declining malnutrition in maharashtra-6-the tribal issues

Child Malnutrition in Child Malnutrition in

Maharashtra (India) Maharashtra (India) August 2013August 2013-- January 2014January 2014

Situation, Efforts, Decline and Challenges

A Review A Review

1

A Review A Review For the State Nutrition MissionFor the State Nutrition Mission

P o w e r P o i n t 6 / 6P o w e r P o i n t 6 / 6

Malnutrition in Difficult Tribal AreasMalnutrition in Difficult Tribal Areas

Dr Shyam Ashtekar, MD (Community Med)

[email protected] feed--Dr Shyam ashtekar jan 2014

Persisting Malnutrition Persisting Malnutrition

Problem In The Difficult Problem In The Difficult

Tribal Blocks of Tribal Blocks of

MaharashtraMaharashtra

PowerPoint 6/6PowerPoint 6/6PowerPoint 6/6PowerPoint 6/6Dr Shyam Ashtekar 2014Dr Shyam Ashtekar 2014

This Photo belongs to year 2000 there is less of this

B U T T H E I S S U E R E M A I N S

Some Pockets of Some Pockets of

Malnutrition in MaharashtraMalnutrition in Maharashtra3

Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014

Maharashtra has 9% tribal population and ..Maharashtra has 9% tribal population and ..

15 blocks15 blocks have more malnutrition have more malnutrition , ,

Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 4

> 30% children malnourished.> 30% children malnourished.

� In some tribal blocks child malnutrition (-2SD) rates are 30-40%

� In this 4-5% is severe malnutrition (-3SD)

� In Maharashtra 9% tribal population implies about 1 crore people

� The U6 child population is about 10-12 lakhs.

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� The U6 child population is about 10-12 lakhs.

� Of these 3-4 lakh U6 children belong to the difficult tribal blocks.

� Possibly 1.5 to 2 lakh U6 children are malnourished.

� Hence about 15-20 thousand U6 children may be severely

malnourished or perhaps more.


The 15+ difficult Tribal BlocksThe 15+ difficult Tribal Blocks

� Jawhar, Mokhada, Wada

� Dhadgaon, Akkalkuwa,

Shahada

� Dharni-Chikhaldare

� Bhamragarh, Armori,

Korchi

� Peth, Surgana,

Trimbakeshwar

� Rajur

� Some blocks have more

pop, so more children in

MN


Contributors Contributors of tribal of tribal

Malnutrition Malnutrition

Child

Poverty and

Migration Roads and Power Problems

Forest restrictio

ns

More illnesses

Ignorance and blind faith

Malnutrition in Tribal blocks- Dr. ShyamAshtekar, Jan. 20147

Child Malnutrition Weak

Governance

Weak Health System

Malnourished

Women

Less Birth weight

Poor Breast feeding

Unclean condition

s

The malnutrition The malnutrition (MN)causes(MN)causes--in a in a pyramidpyramid

Resulting Child deaths

Child MN & illness cycle 0-5Y age group 40-50% MN, 10% U6 children severely wasted.


MN anemia and less BMI in women and adolescence, many reasons for this---early marriage, child birth, weak ANC, Less Birth weight Neglect of breast feeding and complementary feeding,

Lack of hygiene. poor nutrients, weak health system, lack of awareness, blind faith, gender

bias, migration, terrain, no employment, inflation, PDS problems etc.

Govt. Schemes and ServicesGovt. Schemes and Services

� Many Schemes and services are weak in tribal areas.


Scattered Habitats in Tribal Blocks

Google map of Molgi in Nandurbar-

major weekly market, village spread on 4-5 Kms distance

And a typical Non-tribal village


Forest and Animal Sanctuaries, Forest Forest and Animal Sanctuaries, Forest

zone laws, zone laws, Lack of Transport…Lack of Transport…


Seasonal Migration is a Fact ofSeasonal Migration is a Fact of lifelife

◦ Many families migrate for 6-

8 months leaving the AWC

little scope for help.

� Construction and agriculture are

major sectors for migration.� Migration for 6-8 months

◦ Construction and

agriculture sectors attract

most migration-both cause

stress

◦ Migration worsens

malnutrition ..or does it ?


Hard Work and Hilly Terrains Hard Work and Hilly Terrains

� Hard labor and less food lives

little flesh in the body.

� BMI less than 18.5 affects 40-

80% women

� Hilly roads and head loads

� Famished women bear weak

children

� Low BMI reflects poverty.


Blind faith, Faith Healers and Black MagicBlind faith, Faith Healers and Black Magic

� Blind faith and lack of

awareness are major

� Deep rooted problems � Blind faith and Bhagatscarry on..

awareness are major

issues.

� This is a major impediment

in scientific treatment.


LiquorLiquor--struck struck

� For Tribal societies

liquor has a traditional

� Home distilled liquor� A livelihood for some

tribes

liquor has a traditional

value.

� But some tribal

communities are hard

hit with liquor problem


Water and Firewood take so much of Life and LaborWater and Firewood take so much of Life and Labor..


Back Breaking Farm Labor and Little ReturnsBack Breaking Farm Labor and Little Returns

� The tribal agriculture is mainly rice and

millets, of little value in the market.

� The PDS rice comes at 3Rs. a Kg.

� Home grown rice costs about 20Rs. a � Home grown rice costs about 20Rs. a

Kg.

� One season crop and almost no water

thereafter.

� Farming only for staying alive not for

prosperity.


Public Distribution System and Food Public Distribution System and Food SecuritySecurity

� The door step PDS scheme

offers 35Kg. for each family

every month.

� Hence about 100Kg. For 3

months.

� Food supply is a problem in

some parts.

� Some tribes can not use

wheat and rice may be too

bad to use.


Many Homes have Stocks for 2 YearsMany Homes have Stocks for 2 Years

� Currently the doorstep

PDS, farming and wage

labor bring home enough

food for most homes food for most homes


But Proper Nutrients in Good Measure are But Proper Nutrients in Good Measure are

missing. missing.


High fertility: 7High fertility: 7--8 children is a common 8 children is a common scenescene

� More children

� Rapid succession

� No spacing of births� No spacing of births

� Hence neglect of

children and mothers


Early Marriage and ChildbearingEarly Marriage and Childbearing

� More than 50% early

marriages

� Under-age pregnancies � Under-age pregnancies

also common.

� Many unwed mothers get

pregnant and bear children

that may get neglected


Low Birth WeightLow Birth Weight

� 40-50% babies weigh

less than 2.5KGs.

� One in three of these

babies are premature

� These babies do not

thrive well without

really good efforts.


Faulty Feeding PracticesFaulty Feeding Practices

� Just about 50% babies are

breast fed within the first hour

of birth.

� Exclusive breast feeding till 6

months is also barely 50%---

there are also lifestyle causes

for this.


Faulty Complementary Feeding Faulty Complementary Feeding

� 6-8 semi solid feeds necessary after 6

months. Barely 10% babies get this.

� diversity, vitamin A and iron rich feeds

often missing .often missing .

� There are difficulties like work and

migration but the result is the same-

Malnutrition


Sanitation and HygieneSanitation and Hygiene

� The spread of illnesses � Toilet is necessary, but

atleast a hand wash is a must


Less of Immunization Less of Immunization

� < 50% full immunization rate.

� Many reasons for this.� Many reasons for this.


Illness cycleIllness cycle

� Diarrhea pneumonia major illnesses

� IMNCI program trained AWC sevikas for this

� But Govt. of India change this policy.

� Now they expect NRHM-ASHAs to do this.


The Intergenerational Cycle of The Intergenerational Cycle of MalnutritionMalnutrition

� Malnutrition carried to next generation.

� Quick birthing is part of the problem.


Anemia in 60Anemia in 60--70% Women and Children70% Women and Children

� Low hemoglobin invites

several problems.

� Causes maternal

morbidity and mortality.

� Causes Infections,

malnutrition for children.


55--10% Children Suffer from Sickle Cell 10% Children Suffer from Sickle Cell AnemiaAnemia

� Genetically faulty hemoglobin causes many

health problems.

� Infections, malnutrition, pains and growth lag.

� 5-10% children suffers from this disease


Weak Health SystemWeak Health System

� Doctors unwilling to go

and work in tribal areas.

� There are many

administrative hindrances

� Many specialist positions

remain vacant.

� This is a recent news from

Gondiya district in Daily

Loksatta about vacant

positions


InfrastructureInfrastructure--Leaking Roofs are CommonLeaking Roofs are Common


Lack of FacilitiesLack of Facilities

� Many projects have no vehicles.

� Lack of support staff in most projects


Weak Health system

50% childbirths happen at home. Barely 50% women get some ANC care


Getting help from NGO & CSRGetting help from NGO & CSR

� Very few NGOs especially in Nandurbar

� In Melghat, we have some NGOs..no study on

their impact on general situation

� NGOs can undertake some assignments in the

affected areas, with a flexible approach.

� CSR can help in special interventions like

RUTF.


Child Neglect..Child Neglect..

� Causing gaps in child feeding

� Lack of cleanliness and hygiene because

of either an old or too young attendant

There are substantial reasons like a � There are substantial reasons like a

working mother, migration etc..


Some Families are Less ConcernedSome Families are Less Concerned

� Some tribal families feel less

about malnutrition unless it is

a severe malnutrition..

� Problems of daily life more

� Some AWC workers report

that families may starve the

child to get Khavati loans

� Loan amount –Rs 3000- is

important than a malnourished

child.

sometimes wasted

� This is possible and we need

to review this scheme for

better utilization.


Need to Know TribeNeed to Know Tribe Specific Facts Specific Facts in in Malnutrition Stat. Malnutrition Stat.

� Scheduled Castes (SC) and VJNT

communities also have sizable malnutrition, communities also have sizable malnutrition,

some more than others

� Nomadic Tribes needs special attention and

mentorship


Some Tribes are More Malnourished Than Some Tribes are More Malnourished Than

Others in the Same Village. Others in the Same Village.

� Some tribes are backward in cultural and

educational aspects than others in the same region

(e.g. Katkaris as compared to Warlis in Thane)

� Some are afflicted with liquor addiction

� We need to study these differences closely and

take appropriate action.


Food Security and MalnutritionFood Security and Malnutrition

� We cannot link all malnutrition with food

insecurity.

� Many homes have enough stocks of

foodgrain

� Specific causes need to be explored,

proximate factors like nutrients and health

care are often more important.


Community Participation NecessaryCommunity Participation Necessary……

It is difficult to

expect local

participation for

combating combating

malnutrition in

tribal areas at this

stage.


KhavtiKhavti Loan for Affected FamiliesLoan for Affected Families

� Families get 3000 Rs. loan as help if their baby is

malnourished. It is almost never returned.

� Families eager to get this dole even fight to get this.

But the cash is often used for other purposes, even � But the cash is often used for other purposes, even

spent for liquor

� Is Khavti helping for reducing malnutrition?

� Can we promote this as an award scheme? will that

help? Need a review!


Nutrition RehabilitationNutrition Rehabilitation

� The NRHM assistance is

available for nutrition

rehabilitation from village to

district hospital.

� This is expected to prevent � This is expected to prevent

further malnutrition if not cure

the problem.

� Also helps to avert some child

deaths.


Crèche Crèche

� The crèche scheme has

been started in some

tribal blocks. The crèche

attends to pre AWC age

� Crèche is a good social facility.

attends to pre AWC age

group including nutrition.

� The crèche also frees

the mothers from child-

duties for some hours.


Line listing of Malnourished children on Line listing of Malnourished children on

Website ..But These Lists are Rather Old. Website ..But These Lists are Rather Old.


Media Can Help in Fighting Tribal MalnutritionMedia Can Help in Fighting Tribal Malnutrition

� Media.. should focus on comparative statistics,

causes and management options.

� The AWC Sevikas are honorary workers, not

well paid servants.... they are not the causes of

malnutrition themselves. malnutrition themselves.

� Need to be sensitive also to the problems of

staff working in difficult areas.

� Tribal malnutrition is a complex problem and is

bound to take more efforts and time.

� Media can play a constructive role


A Road MapA Road Map

Income Programs

Social Reforms

Administrative Reforms

Health & Nutrition measures

� There is no magic wand

� We need a practical Road Map

� Need for wider collaboration

� Need a rational and realistic program with achievable

objectives.


Need for Balanced EffortsNeed for Balanced Efforts

� Need to balance between

family/social efforts with

administrative measures.

� Govt. cannot do it alone

unless families are also

able to participate.


A Senior Journalist SaysA Senior Journalist Says

� I met a senior journalist who had reported on Bamani--

the ground zero of malnutrition deaths in Nandurbar

which first hit the headline in eighties.

� He says “there is a visible decline in severe


He says “there is a visible decline in severe

malnutrition even in those areas that were worst hit.

We used to see the affected children while passing any

village. We see there is a big difference”.

� I hope another decade will see more change

Best WishesBest WishesDr Shyam Ashtekar (MD, Community Medicine)

21 Cherry Hills Society, Anandwalli, Nashik India

422013

[email protected]

Cell +919422271544

Website:

51

arogyavidya.org,

bharatswasthya.net

A study of Anganwadis and campaign against malnutrition in Maharashtra

for and with support of

Rajmata Jijau Mission,

August to Dec 2013


declining malnutrition in maharashtra-6-the tribal issues

Health & Medicine