The recent death of children that happened in Bihar due to improper management of the mid day meal scheme opens up another Pandora’s box of the problems related to one of the largest government schemes in India. One such issue is the use of modern technologies, such as food fortification and ready-to-use therapeutic foods, as a “magic bullet” solution to solve the problems of malnutrition in India. However, this food technology-dependent, single-solution approach fails to understand the complex and multiple linkages of the problem of malnutrition as it occurs in the rural areas and urban slums of the country.
It is obvious to everyone that the major determinants of childhood malnutrition include inadequate food availability, high rate of infections and lack of awareness. In the global context, it has been established that half of malnutrition load is due to those infections caused due to poor water supply and sanitation. The case of India cannot be any different as water supply systems are poor and inadequate in the country and diarrhoea is still one of the leading causes of child mortality.
In India the problem of malnutrition is predominantly viewed as the responsibility of the Integrated Child Development Services (ICDS) programme, which has been responsible for supplementary feeding and growth monitoring of children. The current ICDS programme, which is under the Ministry of Women and Child Development, has neither the mandate nor the machinery to address the prevention of infection among children or to treat them during illness, which is in fact contributing significantly to the problem of malnutrition. This was obvious when it was found that a quarter of those children who were treated for malnutrition at a Nutrition Rehabilitation Centres (NRCs), a new institutional setting under the health department which combines feeding, treatment and awareness creation to severely malnourished children to prevent malnutrition deaths, were readmitted to the same centres within a duration of one year.
Here, two aspects are important; first, initiatives like NRCs are only a crisis management initiative which can only prevent deaths due to malnutrition and not the problem of malnutrition per se. Drawing from this is the second aspect, which is that any intervention to address the problem of malnutrition should have potential to prevent occurrence of illness among children, which calls for ensuring safe water supply and sanitation, a widely ignorant sector in rural areas and urban slums.
Closely related to it is the access to health services system so that disease and infections do not interfere with the growth of the child. In one of the tribal blocks of Madhya Pradesh, it was found that there were around five to seven episodes of illness with durations of 12-16 days reported in a year among those children who are poorly nourished. This means that several children remain ill for almost 70 to 80 days in a year, a duration that restricts normal growth further, making them more susceptible to malnutrition-infection cycle. The solution to address the problem of malnutrition hence calls for not only better feeding programme, but ensuring safe drinking water and sanitation together with access to health care for treating minor illnesses.
In short, the problem of malnutrition has to be understood in its broader dimension as it is just the tip of the iceberg of the underlying social development of a nation that fails to ensure basic employment, safe water supply and sanitation and primary health care. Any attempt to project the problem of malnutrition as a techno-managerial inadequacy not only will divert the focus leading to the adoption of unsuccessful strategies but also hamper the opportunity to correct the basic services that are faulty at the grassroots level. A proper public health approach to malnutrition calls for ensuring food security, prevention of illness and better treatment facility along with the need to provide opportunities for safe livelihood.
Dr. Mathew George is an Assistant Professor at the Centre for Public Health at the School of Health Systems Studies at the Tata Institute for Social Sciences in Mumbai, India.