India's malnutrition crisis

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One scene never changes in Rafi Nagar, a sprawling slum settlement situated in Govandi, in the north-eastern area of Mumbai. Monsoon or summer the plastic cans and barrels are at the ready, waiting for the waterman to arrive. In a city where space is at a premium, this settlement sits on top of its refuse.

Every day, hundreds of tonnes of Mumbai's leftovers are dumped here. The garbage pile is regularly flattened to make space for the constant demand for shelter. Rafi Nagar is part of Shivaji Nagar, a resettlement colony that has seen a constant stream of migrants flowing into the city. The floors of the makeshift shacks are covered with cardboard sheets or plastic as if to keep the garbage down. As I enter a narrow alley here to talk to Jayeda Khatun, a mother of six, I am surrounded by some children and a swarm of flies; both keep me company as I walk around.

The residents here are mostly migrants from Uttar Pradesh, Bihar and further away and have lived in Mumbai for more than 20 years. Yet, half the settlement in Part II of Rafi Nagar with 400 households has not been given a legal status despite being promised so.

Hence the eternal wait for the water truck to arrive. When the water arrives, the wallets empty out. Filling up a 25 litre plastic can costs Rs 20-25. Considering the average family income here is around Rs 3000-4000 a month, a sizeable chunk of it goes to buying precious water.

And even then, a family can ill-afford to regularly buy 100 litres a day. According to the Mumbai Human Development Report 2009, Mumbaikars on average get 200 litres per capita daily (lpcd) of water, whereas slum residents get less than 90 lpcd.

In this neighbourhood alone, 18 children under the age of 5 died in 2010 from malnutrition-related causes.

Jayeda has already lost one new-born son. Her 18-month-old daughter Haseena suffers from diarrhoea and worms. The child is also chronically malnourished. However, Jayeda is reluctant to take her to a health care facility. "If I leave the house to take her to the doctor, I am afraid our belongings will be stolen." Her fear is based on past experience. Jayeda's house, like the others in the neighbourhood, does not have a door. A gunny bag covers the entrance. Jayeda delivered all her six children at home.

Her husband is a casual labourer. Most men, women and children in this slum are rag pickers, which is hardly surprising considering they live on the city's refusal site. There is a job to be done all year through.

Even as we talk, I notice Haseena playing with the worms that have passed out of her watery stools. Jayeda is, however, unconcerned. "She does this every day," was the casual answer. There is little awareness that her child is susceptible to diseases because of her malnourished state. In fact, there is little community awareness that malnutrition is a medical problem.

But then, Jayeda and the other women in her community are grappling with a much bigger problem, every day survival. They live under constant threat of being evicted from their settlement; many of them do not have a ration card and if they do have one, all they get is very poor quality rice.

This is hardly enough to feed the large families here, the typical size of which is 7-8. They then turn to the open market where the price of rice is higher. Survival here is indeed a daily battle.

Rafi Nagar is just under an hour's drive from the commercial heart of Mumbai, India's financial capital. It is an incongruous reality that Rafi Nagar can exist in the same city where super speciality hospitals offer the best in medical treatment. It defies imagination that 60 per cent of Mumbai's population lives in slums and makeshift shanties while the city plays host to arguably the world's costliest home.

Large pockets of the population in Mumbai live in sub-human conditions with little or no access to health care. The lack of access to clean, safe drinking water, the unhygienic living conditions, the lack of proper toilets, all make a perfect breeding ground for disease to thrive. Undernourished children have lowered immunity to diseases and are more likely to die from common childhood ailments like diarrhoeal diseases and respiratory infections like pneumonia.

According to government data, 3.5 per cent of Greater Mumbai's slum children under six die every year because of malnutrition related causes. The city has about 7.3 lakh slum children below the age of four, according to NFHS data. This means at least 25,550 - 3.5 per cent of 7.3 lakh - children die of malnutrition and related illnesses every year. This is a scandal!

Almost 50 per cent of children below the age of 5 are malnourished in India. Malnutrition stunts physical, mental and cognitive growth and makes children more susceptible to respiratory and diarrhoeal illnesses. The children who do manage to survive the ravages of malnutrition have lifetime disabilities, weakened immune systems and are intellectually disabled.

A silent epidemic quietly unfolds everyday across villages and towns in India. Close to two million children below the age of five die annually in India mainly from preventable causes: that is, thousands of children dying every single month of diseases that are easily treatable and even preventable. Malnutrition is the underlying cause in over 50 per cent of the deaths. Yet, this news hardly causes a ripple, leave alone a media storm. There is no palpable public outrage at this needless loss of lives. Have we become inured to statistics that we no longer care about them?

The world's largest supplementary feeding programme, the Integrated Child Development Services (ICDS), has not made a significant dent in reducing the numbers of sick and malnourished children over the last 20 years or so. Reiterating his resolve to "root out" malnutrition, Prime Minister Manmohan Singh said: "We will endeavour to extend the benefit of the ICDS to every child below the age of six years in the country by 2012." But as the appalling figures show, good government intentions alone are not enough.

Despite progress in reducing child mortality, India still ranks 1 out of 12 countries that account for two-thirds of under-five deaths in the world.

Saving the lives of children is not rocket science. There are enough examples from within India where home-based low-cost interventions have proven effective. With relatively modest investments in basic training, supervision and support, health workers can promote and deliver low-cost, proven health interventions that can save the lives of thousands of mothers and their children each year.

There are several low-cost interventions to reduce malnutrition that are being implemented successfully in countries like Sri Lanka. For example, support for exclusive breastfeeding is one of the most cost-effective public health interventions and could reduce under-five mortality by as much as 20 per cent.

We do not need a major technological breakthrough to crack the problem of malnutrition. But we do need to push the issue of health and nutrition of mothers and young children higher up national and state agendas and start to take this challenge seriously. If the moral case has not triggered us to act then perhaps economic common sense will inspire us. There is a strong economic case for keeping children alive and well. We all lose out when children are undernourished and vulnerable to sickness and early death, and we all benefit when they are healthier, better nourished and educated.