Despite several schemes, chronic malnutrition persists in Tamilnadu and this is very likely a major cause for continuing poor performance and high dropout rates of children in Tamilnadus government schools. Ironically, the state leads the country in nutritional interventions and has improved its standing in comparison to other states in the last two decades since the scaling up of nutrition schemes. Yet, nutritional status have only marginally improved and in some cases like the anaemia count going up, perplexing activists, policy researchers, and funding organisations.
The state is a study in contradictions: It gave the country its direct nutrition intervention in the form of the Noon-meal Programme (NMP), and yet has alarming levels of hunger. The International Food Policy Research Institute's India State Hunger Index (ISHI) of 2008, gave the state the sobering rating What is the rating? based on the prevalence of calorie-energy deficiency, child mortality and the number of children below the age of 5 who are underweight. One out of every three person did not eat 1632 calories per day? (much lower than the national Below Poverty Line cutoff of 2,100 calories) in Tamilnadu. Every third child below the age of 5 in the state is underweight (low weight for age) and the under 5 mortality rate of is 3.5 per 100 births.
The National Family Health Survey data of 2008, show a similar trend: Almost one-third (31 per cent) of children under age five in Tamilnadu are stunted, or too short for their age, which indicates that they have been undernourished for some time; 22 percent are wasted, or too thin for their height, which may result from inadequate recent food intake or recent illness and 30 per cent are underweight, which takes into account both chronic and acute undernutrition.
Seven out of every 10 children below the age of 5 have iron-deficiency anaemia is this from the NFHS data too? which has actually increased from 69 to 73 percent in the 0-3 age group from the last survey of 1998. Only 40 per cent of the households have access to adequately iodised salt and Vitamin A deficiency persisted despite prevention programmes.
The effects of such acute and chronic undernutrition are well established. In their book The Double Burden of Malnutrition: Causes, Consequences and Solution, Dr Stuart Gillespie and Dr Lawrence J Haddad of IFPRI catalogue increased mortality, poor cognitive and motor development and other impairments in function as fallout of undernutrition. Children who have been severely undernourished in early childhood suffer a later reduction in IQ by as many as 15 points (Martorell 1996), significantly affecting schooling achievement and increasing the risks of drop-out or repeat grades.
Impact of stopping noon meals for over-14
Activists of Right to Food (Tamilnadu) also chalk up a higher drop out rate of close to 40 per cent in the higher classes also to the cessation of noon meal schemes after the age of 14. S Kanniyan, RTF-TN convenor, says with decrease in agricultural work in the villages, more and more women have taken up contract work in construction industry. Many children no longer have breakfast because their mothers need to be at work early in the day. Classroom hunger is a serious cause of concern. When the child comes hungry to school, her learning is going to be impacted. Often teachers do not understand the reasons for poor scholastic achievements and instead punish the students; which only pushes the child into dropping out, he said.
The noon meal is made available in higher secondary classes only to students belonging to MBC, SC/ST castes. Often older children are ashamed of the caste and socio-economic status identification their noon meal plates accord them and prefer to skip the meal altogether, says Aruna Rathnam, Education specialist, UNICEF. Younger children are more enthusiastic about noon meals, especially since the introduction of eggs two times a week, because of hunger. For adolescents, the lunch hour becomes a question of peer acceptance and socialisation. Many students prefer to eat packaged food of poor nutritive value to the prepared meals in schools," she says.
Even in the below 14 category, the efficiency has come under question. A review of Tamilnadu's Noon-meal programme (NMP) implementation shows that the per-day-per-child expenditure is 35 paise, for vegetable, condiments and salt. TN-FORCES, an NGO that works with day cares and crèches, says vegetables or oil or other seasoning are often not present in the Anganwadi centres. Sometimes even salt is brought from the home of the beneficiaries. <Does TN FORCES work through the state or only around Chennai? /
K Shanmughavelayutham, TN FORCES convenor says only two-thirds percent of children who are eligible for the nutritious meal scheme get coverage. Despite that, the nutrition schemes are unable to meet the needs and the government should commit at least 3 percent of the budget for nutrition.
Both Right To Food and TN FORCES have been seeking an improvement in infrastructure and quality of food given to children. After the death of a child in Melvalampettai Higher Secondary School after a vessel holding hot sambar toppled onto him, we sought improvements to NMP kitchens in schools. A committee that inquired into the incident that happened in 2006, said NMP urgently needed upgraded, smokeless kitchen and a safe serving/eating area. The improvements have been slow in coming. Nutritionally too, the scheme needs a re-think. Rice that is used is from the Civil Supplies department and is so heavily processed that it is shorn of all nutrients other than starch. The only other food children get is red gram (masoor dhal) in the sambar, not even oil. The meal, though supposedly provides one third the calorie need of the child, does little else in the form of minerals or vitamins," they say.
Tackling the challenge of Anaemia
Another issue that has the child health organisations worried is that of iron deficiency anaemia (IDA). According to NFHS-3, in the below 5 years group, a majority -- 64 percent is anaemic. This includes 27 percent who are mildly anaemic, 35 percent moderately anaemic, and 3 percent with severe anaemia. Children of mothers who have anaemia are much more likely to be anaemic themselves. And in the state, those numbers are also of concern: various health surveys put that between 53 and 69 percent for pregnant women.
Dr Devashish Dutta, Health specialist, UNICEF office for Tamilnadu and Kerala says maternal anaemia impacts maternal mortality. It could lead also lead to pre-term deliveries and growth retardation with blood supply to the uterus being less than sufficient, he says. Anaemia reduces the capacity of the baby to survive, and her immunity. Poor immunity leads to the child falling ill often, which in turn impacts her nutritional status leading to more illness. When the child grows up to have children, the vicious cycle of low birth weight, poor immunity and malnutrition is repeated," says Dr Dutta.
Gillespie and Goddad, in their book, further aver: Infants with low birth weight are born with low iron stores, depleted by two to three months. Because breast milk cannot meet their iron requirements, it should be supplemented with iron starting at two months of age.... Iron supplementation of anaemic preschoolers improves their cognitive and physical development.
Unfortunately, the under-five group is outside the purview of the IDA prevention programme in Tamilnadu, that focus on adolescent girls and pregnant women. Nor have issues like links between poor iron absorption and Vitamin A deficiency and worm infestation been integrated into the scheme. Protein deficiency in the diet can also cause anaemia, given that iron binds with a protein called globulin. Often more than one deficiency co-exists indicating that the nature of food available or feeding practices were poor,'' says Dr Dutta.
Even in the case of adolescent girls who receive the weekly supplementation of Iron and Folic Acid tablets, activists are not happy. A daily supplementation dose will not have as many side-effects as the weekly dosing, which are often accompanied by black stools, gastro-intestinal discomfort, and malaise. Ideally, the supplement is had in the night after dinner with another food with vitamin C like lime juice or sweet oranges. But the government has asked us to ensure that the IFA is taken in our presence, so we give it with the noon meals. Occasionally, some girls feel nauseous or vomit after taking the tablets. Then encouraging others to consume it becomes an issue,'' says S Tamilazhagi (name changed to protect identity), an Anganwadi supervisor in St Thomas Mount Panchayat union, that abuts Chennai Metropolitan area to the west.
Some anganwadi workers who are involved in distributing IFA tablets in neighbouring Kancheepuram and Thiruvallur districts say the supply has been erratic over the past two years and others allege that after initial testing of haemoglobin levels in 2005-2006, the government has subsequently failed to study the impact of the programme. The distribution of tablets or testing for haemoglobin levels depend on the initiative of the VHNs and Anganwadi workers. Often the service delivery is interrupted because of government chooses to implement other non-nutrition related schemes through us. For example, we are also to talk to the adolescent group about nutrition, reproductive health, menstrual hygiene and entrepreneurship development,'' says N Gomathi, a leader in the TN VHN Association. Community-based outreach
Where the juggernaut of the government faltered, voluntary organisations have prevailed. The few of them that have focussed on public health campaigns have had better success in reducing iron deficiency anaemia. Nalamdana Trust's five year project in the fishing hamlet of Urur-Olcott Kuppam in south Chennai has shown that with mere information and without the free supplements it is possible to improve nutritional status.
Nithya Balaji, Nalamdana founder, says her project used the popular medium of theatre to introduce behavioural changes and ownership for health and nutrition projects. At Urur kuppam, initially we got a private organisation to add an additional Rupee per child per day to the ICDS expenditure to add a few locally available vegetables, dhal and oil. The children's growth charts showed an impressive increase in the first two months of nearly 1.5 kg. This scheme is currently being supported by local sponsorship, but can easily be transferred to the parents if the state permits it," she says.
The other target group of the project was adolescent girls. As a pre intervention indicator, we measured the anemia levels of 95 girls and held regular meetings for 8 months. The sessions covered issues of understanding one's body, pre-puberty issues, reproductive health and importance of nutrition. Only accurate information had been given- no doles, no tablets. Their Hb levels had increased from 8 and 9 to 11 and 12, respectively. They had adopted better hygienic practices, started eating breakfast and also included greens, vegetables and one affordable fruit in their daily diet,'' says Nithya. The scheme implemented in partnership with other NGOs is being continued despite Nalamdana withdrawing from the project.
Nalamdana's findings are anecdotally affirmed by the Anganwadi staff. Tamizhagi says mere supplementation showed only marginal improvement in the moderately anaemic adolescent girls. The eating habits have changed drastically in the last two decades, moving towards a rice-based diet. Traditional iron-rich food like drumstick greens thovaiyal or curry leaf thovaiyal have become devalued and pushing those through the nutrition eduation programme often backfires with adolescents,'' she adds.
Nalamdana circumvented this issues by involving the community in their own nutritional improvement. Recipe clubs were formed in the study area with the women being given basic information about nutrition dense food. With help from nutritionists and students, the women innovated their own healthy recipes, thus making their integration into daily diets an easy affair, says Nithya.
Juxtapose this with a study by the National Nutrition Monitoring Board that came to the conclusion that national nutrition programmes have failed in achieving their goals largely due to lack of nutrition education with poor outreach. A study of Vitamin A deficiency among rural preschoolers done in 2007, established high prevalence of subclinical deficiency largely due to poor nutrition and that nutrition education component covered a mere 14 per cent of the target population. No night-blindness, but Vitamin A deficiency still high
In the rural survey, NNMB, an arm of the Indian Council of Medical Research, found that Tamil had clinical Vitamin A deficiency (night blindness, Bitot's spot and conjunctival xerosis) in less than 0.5 percent of its children below 5, in part due to the massive dose Vitamin A supplementation at birth and near total institutional delivery. But nearly half the children in the age group were found to have sub-clinical VAD or vitamin A level of less than 17 micrograms per decilitre. Explain the significance of VAD for the lay person. What is the impact on the childs health and development? The results linked poor nutritional habits and weaning food choices to the sub-clinical deficiency.
Interestingly, this study linked the higher prevalence of clinical manifestations of Vitamin A like Bitot's spot in the eye to the mother being illiterate and to populations without access to sanitary toilets. Ascaris and hookworm infestation are often leading causes for Vitamin A deficiency and iron deficiency anaemia in the state.
Poor sanitation undermining nutrition thrust (does sanitary toilet simply mean clean toilet?)
All nutrition interventions have to go hand in hand with improvements to sanitation and access to protected drinking water, believes Dr Devashish Dutta of UNICEF. As much as 83 percent of rural homes do not have access to sanitary toilets and defecate in the open. A large percentage of students do not use footwear while going to school. Hookworm enters the body through the feet of the person walking on an area contaminated with faecal matter. The worms anchor onto the small intestine and such on blood, leading to anaemia,'' he says. Though the state has its deworming programme, it could be scaled down and resources used elsewhere if people were to wear footwear before the stepped out of their homes, he adds.
Even in urban areas, the NFHS-3, only 33 percent have access to flush toilets that are connected to sewerage, septic tank or pits. A whopping 40 per cent have seen no improvement since the last survey of 1998 and continue to use toilets which are either shared between households or have no flushes/poured flushes. Twenty-six per cent continued to use open spaces for toilets.
This was no different even in targeted nutrition interventions like the ICDS. According to 2000-2001 study by TN-FORCES of the Anganwadis in 150 areas in Chennai showed that 87 percent of them had no access to toilet, an overwhelming 90 per cent did not have potable water, 90 per cent had no electricity and only 50 per cent were well ventilated with windows. Often, the centres are right next to public toilets or sometimes right next to garbage collection points, making hygienic Anganwadis a rarity,'' says Shanmughavelayutham of TN-FORCES.
And that is why activists, policy analysts and funders alike say nutrition cannot be just a health-sector issue and have been working with the government in bringing about a convergence of various service delivery departments. There is a role for every single government department in providing universal sanitation, highways departments need to plan more number of hygienic public toilets, education department can introduce good practices in the syllabus, the media can weave in the importance of balanced meal through both mass entertainment programmes and educational slots,'' says Dr Dutta.
UNICEF is also working with the government in scaling up projects that link poverty alleviation to better nutrition. The simple fact is a person who is born with low birth weight, goes through childhood being undernourished will do poorly in school and perhaps drop out. When he is not educated, he will make poor choices for his family about nutrition and will perpetuate the cycle,'' he adds.
Others agree. Iron tablets and nutritious mix are welfare-based schemes, and at best they can be a temporary solution to a problem that needs an inter-sectoral solution.