Why do we show interest only in post-mortems? Only to know about the type of crime, how it was committed, what caused the death, and any evidence that may lead to the conviction of the criminal? Why are we not doing enough to prevent crime in the future?
This analogy is in response to the series of ritualistic channel discussions, webinars and virtual meetings on the customary nutrition month in September. The National Family Health Survey-5 (NFHS-5) results for states are out and the spotlight is on Bihar, which has shown persistently high figures for under-5 infant and neonatal mortality. Life starts quite adversely for a baby born there. Early initiation of breastfeeding within one hour of birth has come down from 35% to 31% this time around compared to NFHS-4. The figures for severely wasted children have increased from 7% to 8.8%.
When a hungry child eagerly looks into your eyes, you turn your face away and lecture about the gravity of stunting as a sign of chronic hunger and malnutrition. The harm is done. Academically, it is true that we need to monitor data for programmatic evaluation and corrections. But the ethical question is: What type of data do you need to help starving children in India? Is it the current data on what is happening in the field, how much food is supplied, served and consumed or the data on what went wrong, how many have become worse, what is the prevalence of weight loss and growth stagnation as evidence of recurring and perpetual denial of food? Do we need output or impact data or input and process data and their quality parameters?
When children are weighed monthly and, in many anganwadis, meticulously marked on the growth monitoring chart, is there an effort to counsel parents or to monitor the number of days the centre was opened, the days when hot cooked meals were served, the monthly ration supplied to the centre, or to check whether 'take-home rations' (THR) were distributed or not? Also, was there any attempt to diversify the menu and procure locally cultivated millets, vegetables, pulses and oilseeds for cooking mid-day meals in schools or anganwadis? Was there any attempt at value addition by provisioning eggs or milk for children? Or, is egg denied or stopped for sociopolitical reasons or forced vegetarianism? These data on the work process and its active monitoring will help growing children. Data on severe malnutrition and the death of children is for academicians, bureaucrats and government policy formulators, not for the suffering children. Mere surveys and their results will proclaim one's apathy and heartless inaction.
Our Public Distribution System (PDS) and Integrated Child Development Services (ICDS) have not attained the status of recognising and enabling a mechanism for nutrition security. It still remains at the food security level, even after the Supreme Court's intervention. The National Food Security Act 2013 (also the 'Right to Food Act') aims to provide subsidised food grains to approximately two-thirds of the country's 1.2 billion people. The prime concern is not to allow anybody to go to bed hungry. So, as a hunger mitigation method and prevention of starvation, the PDS focused on procuring cereals, especially wheat and rice, through the Food Corporation of India and distributing them to families.
Rice and Wheat, as staple foods, filled stomachs and averted hunger, so also starvation deaths. But not malnutrition — because cereals alone are not nutrition. Nutrition security can be achieved only by supplementing cereals with protein-rich items like meat, fish, eggs, milk, pulses, fats and oils in addition to vegetables and fruits in the family pot. Nutrition is wholesome, where carbohydrates, proteins, fats, oils, vitamins, minerals and micronutrients all have a role in the right proportions. Diet diversity with a culturally acceptable menu, cooked from locally cultivable and available cereals, vegetables, fruits, nuts and oil seeds will be the natural and sustainable strategy to ensure nutrition security and prevention of malnutrition.
Ever since the monoculture dominant “green revolution”, India produced enough and surplus grains to feed, but the irony is that famine, starvation deaths and seasonal migration for survival due to abject poverty continued. Supplementary nutrition through ICDS did make a dent on severe acute malnutrition. Micronutrient deficiencies were tackled through Vitamin A concentrate biannual supplementation and iodine deficiency through fortification of salt before supply for marketing. Iron supplementation had many limitations of inadequate absorption and storage in the body. But the quick solution of iron-fortified rice, promoted mainly by the corporate food industry lobby, is severely criticised by scientists and health activists for lack of evidence of impact and sustainability.
Back to basics is to promote diet diversity and promotion of locally cultivable cereals, millets and pulses. Procure them and cook them according to traditional recipes and serve as per acceptable menu. The minimal intervention must be limited to imparting knowledge about a few practices that will have nutritive value addition.
1. Mothers are not aware of “calory densing” in weaning diet or complementary feeding by addition of two or three spoons of cooking oil, if butter and ghee are not affordable. It can make a major difference in the small frequent quantity of semisolid diet the infant takes.
2. Fermented foods enrich cereals by amylisation of carbohydrates. Overnight fermentation makes complex starch easily digestible for the baby as in idli, dosa, sanna, dhokla etc.
3. Sprouting of pulses and grains generates many vitamins and adds nutritive value for infants and young children.
4. Adding tangy fruits like lemon and tamarind will provide Vitamin C, enabling iron absorption.
5. Coloured vegetables like green leaves, beetroot, carrots and pumpkin will give Vitamin A.
The above messages are not adequately focused on our interpersonal communication or in the media. Even counselling on those messages will not result in changed practices unless it is demonstrated in anganwadi kitchens and Poshan Vatikas promoted through ICDS in this Poshan Mah. Sustainable nutrition security is assured more through such small interventions at the community level than policies and programmatic directives nationally.
(The writer is a paediatrician, public health consultant and Independent Monitor, National Health Mission, based in Kochi)
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