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Resource centre on India's rural distress
 
 

A nutrition crisis amid prosperity by Pramit Bhattacharya

As a national debate rages over the Indian poverty line, in the heart of Bandra, one of Mumbai’s richest suburbs, in a shanty with barely enough standing space for two adults, three-year-old Priya Doiphode, clad in a red tee shirt, lies listless on a string bed. Priya is one of the 83,243 children in Mumbai who are malnourished, according to government data, a statistic that makes Mumbai the most malnourished city in India.

Priya weighs less than 10 kg, perilously close to being severely underweight. According to classification used by the World Health Organization that India also uses, Priya is malnourished or more specifically under-nourished.

Here in this illegal wood-brick-and-sackcloth settlement of Indira Nagar, or "Pipeline", as the locals call it, a well-nourished child is as hard to find as a toilet. Like many Mumbai slums, "Pipeline" is a breeding ground for infectious diseases, which strike children more than adults.

Houses in "Pipeline" are built on wooden planks placed on a giant pipeline ferrying water to the city. Close by, an open gutter flows. Many children are born at home, and the squalor strikes them hard, says resident and railway coach attendant Dilip Shantaram Satpal, (33), whose nephew Ritesh (8) has not grown in height over the past three years.

Bandra is where the brightest and richest of Mumbaikars live, where expatriates live and party, where many of India’s largest corporations have their head offices and where India’s main stock exchange, the National Stock Exchange is based. The heaving, bustling suburb represents to Mumbai what Mumbai represents to India and India to the world: a striking contrast between rising economic prosperity and stagnating rates of malnutrition.

A third of Mumbai’s children are under-nourished. Not only is it the second highest in Maharashtra, it is higher than the neighbouring tribal lands of Thane and Nashik, infamous for grinding poverty and malnutrition deaths.

The bad news is that malnourishment in Mumbai could actually be worse than India believes it is.

Official statistics likely underestimate malnutrition, based as they are on data provided by Integrated Child Development Services (ICDS), a government child-care programme that reaches only a quarter of children in the city’s slums.

Despite three decades of economic growth averaging around 6%, India still has the highest number of malnourished children in the world. Nearly half of the world’s underweight children are Indians.

"With rapid economic growth and little progress in banishing under-nutrition, India is an economic powerhouse and a nutritional weakling," wrote Lawrence Haddad, director, Institute of Development Studies (IDS), UK, in a 2009 paper on under-nutrition in India.

India’s neglect of public health since independence is a major reason why health and nutrition indicators in lag behind the decline of poverty. With public health expenditure at roughly 1% of GDP, India ranks a lowly 171 in the world.

If India leads a Dr Jekyll and Mr. Hyde existence, as Haddad put it, Mumbai presents the most vivid reflection of such two-faced economic development.

Per-capita health expenditure in Mumbai is Rs 210 per year, less than the national average of Rs 245. While there is a universal health scheme for rural areas, there is none for urban slums.

A proposed National Urban Health Mission, the urban counterpart of the rural mission that could take care of such needs in urban slums is still to see the light of day. The 150-odd health outposts in Mumbai today serve little purpose other than as immunization centres. Family visits are rare.

Increasingly recognized as a leading national malnutrition hub, Mumbai is the only metropolitan city to figure in a list of 158 high-burden districts affected by malnutrition nationally, according to the Women and Child Development ministry.

The problem with achievement
 
But this is not a story about grinding poverty. 

The city of gold, as Mumbai is often called, offers employment to locals and migrants, who accepted a hard life in return for a decent income. Many are part of India’s growing informal sector, offer a variety of services — as taxi-drivers, cooks, domestic servants and housekeeping staff — and have, statistically at least, clambered into the growing middle-class. 

In slums like "Pipeline", the average daily wages are more than Rs 200, which means the daily per-capita income of a family of five is Rs 40 or Rs 80, depending on whether there are one or two wage-earners. At Rs 80, the average income is 100% higher than the official urban poverty line of Rs 32. That slots them just below the lower middle-class, which consumes $2 (Rs 98) to $4 (Rs 196) per person per day, according to a 2010 Asian Development Bank report.

Yet, most cannot think of owning a house and are forced to live in congested slums without sanitation. Slums account for 78% of the city’s population, according to the latest census figures.

Studies show how women and children bear the brunt of this darker side of urbanization. Children under five years in slum areas of Mumbai, compared with children in non-slum areas, are 40 percent more likely to be underweight and 14 percent more likely to be stunted, according to NFHS data. These are figures that match those in deepest Jharkhand and sub-Saharan Africa.

The parents of "Pipeline" may be lower-middle class, but they work long hours to stay there. They are ignorant of the right feeding practices and endure unsafe water and limited sanitation, which spread infectious diseases and exacerbate the effects of under-nutrition.

Priya’s father, Santosh Ramdas Doiphode, is an electrician and her mother a maid. Together, they earn more than Rs 8,000 a month. Like most people in "Pipeline", they are not officially poor and do not have ration cards to buy subsidised food. Doiphode says they can afford food but not health care.

Like many other malnourished children in the city, Priya frequently suffers from diarrhea. "Jab mitti khati hain, bimar parti hain (she falls ill whenever she eats mud)," says Doiphode nonchalantly.

When both parents are out at work, Priya’s elder sister Neha (8), looks after her. Consequently, ‘mitti khana (eating mud)’ and diarrhea are both quite common.

Girls like Priya need medical examination and a nutrient-rich diet so she can catch up with her peers. There is no effective state agency that takes care of such needs.

Doiphode says his daughter has ‘sukha’, or dryness. He relies on the powers of a ‘vaidya (traditional medicine practitioner)’, who advised a garland of garlic.

Recourse to quacks is a testament to inadequate health care in a city famous for its super-specialty hospitals.

There is an overburdened public hospital in Bandra, with long, snaking queues. For common ailments, locals frequent quacks and ‘bees-wallah doctors’ (doctors who charge a fee of Rs 20).

Parveen Sheikh, the mother of Faizaan, another malnourished child of "Pipeline", prefers to consult such ‘bees-wallah doctors’ in neighbouring Naupada when Faizaan is ill, which is often enough.

Some of the ‘bees-wallah doctors’ in Naupada have been trained in alternative medicine practices such as ‘unani’. Others are "self-trained"!

"Koi bhi normal weight ka bachha nahi hain yahan (every child is underweight here)," says Aziz Mulana, one such unani doctor. Mulana blames poor feeding habits and inadequate care as the main reasons for malnutrition in the slum.

In many families, children are fed only twice a day although younger children need to be fed small meals 4-5 times.

"Parents are willing to spend Rs 30-40 a day to buy snacks for their younger kids, an amount which they can use to provide healthy food," says Mulana. But no one has the time to attend to his or her kids, he adds.

Doiphode says his daughter likes to have tea and bread pakoda from a nearby stall but has little appetite for home-cooked food, a story repeated in several other families.

Street food is not just unhygienic but suffers from a pathetic lack of variety in Mumbai’s slums. ‘Bhajiya’, the famous ‘vada-pav’ and ‘bread-pakoda’ are all they serve.

The high prevalence of infectious diseases and child malnutrition are connected in a vicious circle. Undernourished children have lower immunity, making them more susceptible to infectious diseases. Ill children suffer from low appetite and have limited ability to absorb nutrients, which raises the risk of under-nutrition.

The burden of infectious diseases per person in India is extra-ordinarily high and 15 times the burden in UK, contributing to a third of the disease burden in India, according to a research paper by Indian epidemiologist T Jacob John and others, published in a 2011 Lancet special series on health in India.

John, a former professor at Christian Medical College, Vellore, said that India’s failure to stem the prevalence of such preventable diseases is because of inadequate public health facilities, which include safe drinking water, sanitation, vector control and waste disposal.