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Dr Samir Chaudhuri: ‘Malnutrition needs to be tackled in an integrated and convergent manner’

‘Poor families need balanced home cooked food first’

Civil Society News, New Delhi

In 1974, Dr Samir Chaudhuri, a paediatrician working in Kolkata’s slums, founded Child in Need Institute (CINI) to tackle the many dimensions of child malnutrition. It struck him at the time that malnutrition wasn’t just a clinical problem but a complex phenomenon rooted in gender issues.

Over the years, led by Dr Chaudhuri, CINI developed deep understanding of the social, economic and political underpinnings of malnutrition and developed strategies to combat it.  CINI is today one of India’s most respected voices on malnutrition and child protection. It works on access to healthcare and education with the government and has twice been the recipient of the National Award for Child Welfare.

CINI has also developed Nutrimix, a simple combination of lentil and local cereal which can be blended into traditional foods and corrects nutritional deficiencies. It has developed a business model around Nutrimix which provides employment to women in villages.

Yet, despite government and non-profit efforts, India continues to lag behind smaller countries in its vicinity like Bangladesh and Sri Lanka in tackling malnutrition. Although famine is history and starvation deaths are rare, stunting and wasting of children along with low birth weight continue to dog the nation especially in India’s poorer states — Bihar, Madhya Pradesh, Odisha and Rajasthan.

In Delhi to attend a workshop at FICCI on best practices in tackling maternal and infant health, Dr Chaudhuri was optimistic that India was on the right path. Governments, he said, had woken up to this issue and were doing a whole lot more. CSR funds, technology and convergence could all be deployed to help women and babies achieve better health.

Extracts from an in-depth interview with Civil Society:

Why have countries in South Asia like Bangladesh, for instance, done much better than us in combatting child malnutrition?

The reason is that they tackled malnutrition in a very integrated and convergent manner. They looked at women’s issues, gender, and they improved crèche services. When a woman works, the child needs to be cared for. It is only recently that we have started converting some anganwadi centres into crèches since the focus on 0-3 years is missed in many Integrated Child Development Services (ICDS) centres. But governments are now becoming more sensitive. They have started providing crèche services to working women. So hopefully things will improve.

We now have a framework in place at the grassroots. We have Ashas (Accredited Social Health Activists), anganwadi workers and so on. Is there something missing?

The most simple and effective tool we have right now is the Mother-Child Protection Card. But if you look at the cards you will notice that growth monitoring and weight for age is not being assessed because they say it’s the work of the ICDS. The Asha workers won’t do it. The ICDS workers do their own monitoring. The left hand and the right hand don’t meet.

But things are improving. There are convergent platforms like the Village Health Nutrition Day (VHND) where Ashas, anganwadi workers and health workers all come together. We need more such convergent platforms. The health system and the Women and Child Development Ministry work hand-in-hand because their focus is on mother and child. Why should they work vertically? CINI’s role is to facilitate this convergence. In fact, convergence works better at the grassroots than at state or national level.

What is required for this kind of convergence to happen successfully? Is it better training?

It is mindset. NGOs also need to change their mindset. We should work in partnership with the government and add value to ongoing government programmes. I feel very strongly that if we can add even 10 percent to that programme the impact is immense rather than one small NGO running one small programme in a block.

The government is also looking desperately for assistance. It is all taxpayers’ money so why don’t we pool our resources? NGOs can facilitate. Instead of putting out a lone worker why don’t we work with anganwadi workers, Asha workers, elected representatives, the panchayats, block-level committees and see that everybody focuses on benefitting the poor mother and child?

We need to improve the capacity of the mother to look after the child better because she doesn’t know where to access these services. I am not just nailing the government but NGOs too. When a woman comes very poorly dressed we don’t address her with respect. She is just shooed away. So that is where we should step in and tell the mother the government has so many programmes to help her and we must help her get access. 

They don’t know their entitlements?

Exactly. It has to be a rights-based approach. This is the world’s largest democracy. The Aadhaar card is helping the poor. Most services have gone online. Smartphones have become available. So use these technologies to help the poor get services.

But there are issues with the Aadhaar card and Direct Benefit Transfer. Poor people are being left out.

Cash transfer is good because it gives choice to the poor. Don’t treat them as illiterates. Let them buy services. The problem is that private healthcare and schools are not regulated. There is no quality control and that is why the poor get ripped off. You need regulation and control.

Empower the poor on how to use that money. Cash transfer does not mean that the money should be spent by the man on liquor. It should go to the mother and for food for the family. That’s where NGOs and frontline workers come in.

District hospitals are now being proposed to be partially privatised. Rural healthcare facilities are in a shambles. How can these be best improved?

It’s a question of money. How much of GDP do we spend on health? About 1.2 percent. It’s very little. Technically, we should be spending 3-4 percent of GDP on healthcare and another 3-4 percent on education. It does not happen. There should be investments in the health system, education, training and making poor people conscious of their rights and entitlements.

Are you in favour of private players coming into district hospitals and PHCs?

Why not — but provided minimum standards are followed. Any idiot can work out costs. We know how much it costs, for instance, to deliver a baby. So regulate prices and ensure quality. 

This is a free economy. We should not say that only government or only private can provide the best care. Make investments in government health systems. We can do both. But they are not making those investments.

We have one doctor for 1,500 to 1,700 people. We don’t have adequate nurses. We invest in medical colleges but not adequately in training except for AIIMS and central institutions. What is the quality of private medical colleges or engineering colleges? Does anybody monitor them?

In recent years there has been a controversy over reinforced foods and packaged foods being given to children. In a sense CINI’s Nutrimix is also a reinforced food. Maharashtra is going in for reinforced foods. You have devoted your life to combatting child malnutrition. How do you see this matter?

In many ways reinforced foods are a quick method because you have to deliver outcomes. From the recipient’s side, I don’t think it’s that easy. Food habits are changing. Maybe the time has come for some packaged foods to go to the community because the poor imitate the rich and they see packaged food being consumed by them.

The question is at what cost. The cost is that they are moving away from their traditional foods. You also pay more for packaged foods. The profits go to the shareholders and not to the poor. Of course, one advantage with packaged foods is that you can add nutrients.

But I have very mixed feelings about this. I see India changing. I would like the poor to have balanced home cooked foods first. Then, as social-economic status rises, you can go for some packaged foods but that brings in the problem of plastics and wrapping and so on. Instead of parathas and rice and other home cooked food, schoolgoing children are being given noodles or Rs 10 to buy a packet of chips.

But are reinforced foods the solution to the nutrition problem we face in this country?

We have a malnutrition problem. Obesity is a type of malnutrition. So is undernutrition. Both are health hazards. But the point is that malnutrition starts from conception. Even now 22 to 25 percent of our children are born with low birth weight.

Around 20 to 25 percent of children are also obese. So India is suffering from the two faces of malnutrition.

Eating habits are changing but you need a balanced diet, not junk food rich in carbohydrates. Lifestyles are changing. Activity is slowing down. You see this in migration patterns. When people move from villages to urban slums they don’t do hard labour. They become obese and hypertensive and their children become obese.

Maybe in 20 or 30 years we will be able to resolve the malnutrition problem. Undernutrition, wasting, malnutrition will come down and obesity, hypertension and lifestyle diseases will increase as has happened in the West. So this is the demographic and lifestyle transition we are passing through. We need to educate people on diet and lifestyle.

What should an industrialised state like Maharashtra be doing? Is something like Nutrimix the answer?

Nutrimix is nothing but a pulse and cereal mixture. It is like dal/roti or khichdi, convenient and adapted to an infant’s tastes. You can’t feed dal/roti to a six-month child.

So you give a variety which is available and traditional. It is a cereal blend. I used to teach women how to make it — you roast the wheat and the dal. You use one fistful of dal and five fistfuls of cereal. Then it becomes a balanced food.

How is Nutrimix being distributed in West Bengal?

It is being purchased for the ICDS by the state. We have got a Self-Help Group (SHG) model too — the local SHG makes Nutrimix and sells it to the local anganwadi centre who buys it for a morning snack or as a supplementary food. The mothers know that it is made from ingredients available at home. See, chips and noodles are an alien food. The mother doesn’t know where it comes from but it is quick and convenient. Here is an option for the mother. She can get Nutrimix from the SHG or make it herself at home.

So this is a model for states but governments will say they don’t know how to do all this.

My answer is that there should be a centralised model where you can supply it to anganwadi centres or make bulk purchases. But there should also be a decentralised model which we promote where a small SHG can produce Nutrimix in their villages and supply it to the local anganwadi centre. There have been a lot of complaints about the quality of food in the anganwadi centre when you purchase centrally. But here mothers know this is going to feed their children so there will be more quality control and consciousness.

How should governments go about doing this?

We have offered this model to the governments of Jharkhand and West Bengal. We are willing to offer it to states where we are going in now — Assam and the northeast. See, packaged food comes from long distances, whereas every state has local grains available. So you don’t spend on transport, you can add value to the cereal mix and you can see local women preparing it for their children. What better solution can you have?

How widely used is Nutrimix in West Bengal?

Well, now we are producing 500 to 600 tonnes a month. It is being distributed through the anganwadi centres. Of course, there is a Supreme Court order that you cannot buy from multinationals or big producers. But we have an SHG model and a small centralised model, where you can make some bulk sales. We employ local women. They are involved in every stage of production and packing. We have both models.

How can the Public Distribution System (PDS) be strengthened to provide a better mix of foods?

The most important thing is low-cost nutritious food for infants, children and pregnant women. This is important because they need the food now. You can get grains, oil, sugar from the PDS but what about eggs? Andhra is a big producer. The state could see that eggs are available in the PDS. Also, eliminate the rich from the PDS.

What are CINI’s most important findings on malnutrition over the years?

The most important finding is that malnutrition can’t be equated only to food. It is linked not only to poverty but to illiteracy, gender, social status… We always say the children of the poor are malnourished. It’s not true. You see bubbling and thriving children even in poor families. So what happened there? They deviated positively. We take that learning and spread it in the community. Those families become our brand ambassadors in the same village.

No amount of ICDS, national programmes, government programmes can eradicate malnutrition until and unless the mother and the families are involved. Mothers are the best caregivers.

They know what to feed — home-cooked food with love and care. They access health systems. Malnutrition and infection are a vicious cycle — the more malnourished you are the more prone to disease you will be. Love, care and strengthening the family safety net is the most important strategy in tackling child malnutrition.

Then come quantity, quality and frequency of food. We think the child is small so we should feed small amounts. Not true. The child needs more food compared to body weight. We tend to feed children three times a day when they need to be fed four or five times a day — green leafy vegetables, fish from the pond, eggs, seasonal vegetables, all this improves the safety net in the family. Up to the first 1,000 days, the child needs food and healthcare.

Then the child needs to go to school or he ends up as a street child. If the child has not been nourished in the first 1,000 days, the attention span is gone and he can’t thrive in school. Girls get married early, in some states nearly 40 to 50 percent of girls marry when they are only 14 or 15 years old. They get pregnant, give birth to low-weight babies. You have to break this cycle. The girl has to stay in school otherwise she becomes a prime candidate for trafficking. Malnutrition must also be seen as a child protection issue.

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