Community Health Workers- change agents and mobilisers

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The American Public Health Association defines a community worker as: “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery”. Non-profits working towards improvement of vulnerable population rely on the work of these individuals, to achieve the organization’s mission.

Community health workers (CHW) are therefore fundamental for implementing field-level programming by engaging the community and the beneficiaries through participatory efforts. Carrying out initial work in the community through surveys, house-listing, community mapping, corner meetings, micro-planning etc. are crucial tasks in establishing first contact with the community. Initial community engagement activities carried by CHW(s) include identification of eligible beneficiaries, enrolling them for the sessions, services and trainings. They also mobilize community to participate in group education events and campaigns. Carrying out interventions in the community through group formation, group/community meetings, counselling, information sharing, capacity building, paying home visits, conducting growth monitoring health camps and vociferously following up with individual cases are significant activities carried by them. An important skill that they have mastered over their engagement with the community is customizing the information delivery based on the requirements of the beneficiary. Case management and referrals are other vital tasks carried by them to reach out to the beneficiaries.

A critical area of SNEHA’s research involved analyzing the motivations of these frontline workers, to both take up as well as sustain in this challenging role. As such, a study was created in order to gain insight into the perception of roles and responsibilities by CHWs as well as motivations and challenges they faced. The study comprised of in-depth interviews of the health workers from four NGOs namely: SNEHA, Apnalaya, Foundation for Mother and Child and Shelter Associates, to tap into areas, from background information and training, to personal and organizational factors.

Many themes emerged as to why CHWs decided to join the non-profit sector to begin with. Narratives expressed a desire to contribute to purposeful work, as well as to increase one’s knowledge base from a personal growth perspective. Others expressed support from supervisors as contributing factors to making the decision to join the organization. Another narrative offered willingness to try out work in a new field, and an opportunity to return to the workforce following marriage and motherhood as motivation behind initial association.

Community Health Workers also reported having a positive impact on beneficiaries who engage with trained staff during a critical phase in their growth and development. This, CHWs stated, gave rise to a capacity for self-reflection, increase in knowledge and discernible behavior modification, promotion of healthy relationships through candid conversations between beneficiaries and their parents, and added value through incentivized vocational courses, such as computer literacy and English speaking for beneficiaries. Most importantly, confidence and a personal connection and rapport is built in beneficiaries, and changes seen in youth that push forward that they will go on to produce an equitable society free from gender based or domestic violence.

As for their perceived role, many CHWs believe they served as teachers as well as resource personnel. However, they also believed their responsibilities and scope of influence transcended programming and campaign initiatives. They served as confidants and guides to youth and adolescents by providing them with a safe space, to share their experiences and voice their opinions.

Self-reported characteristics of an ideal CHW included: a strong work ethic, exceptional communication skills, and the ability to generate goodwill through intensive rapport-building efforts in communities. Many front line workers left feeling their own exposure to topics during training left them having not only gained knowledge but also triggering introspection and empowerment within them themselves.

Most CHWs reported having a positive and supportive environment at work and were well satisfied with provisions offered by the organization, including training, timely salaries, flexibility with schedules, as well as staff support and real time feedback.

As for challenges that arose within their work, CHWs expressed the need to juggle multiple responsibilities, thus risking being overstretched. Financial situations also posed a challenge, as did organizational factors.

Perhaps one of the most moving aspects of the study was the participants’ personal account on the changes they had witnessed within themselves, having been part of the organization. While their role was believed to be multifaceted to include serving as a teacher, confidant and guide to the beneficiaries, a significant element that emerged from their personal journey with the NGO was their own process of self-reflection. This manifested in an internalization of knowledge within participants such that through their evolving understanding of themes, empowerment emerged. Affection and respect for working with interacting with children arose as well, contributing to a positive learning environment. Participants also expressed an increase in topical knowledge; skill based competencies, as well as improvements in communication skills and self-confidence. Most importantly, participants saw themselves community resources persons, with one expressing the view of being a change agents, with the ability to empower people in the community.

 

These angels live on the ground – A Women’s Day Special

Ten years ago, Archana Ramesh Mahapade, 50, was out on a fund collection drive when she saw a large group of women.

“When I saw the line and the women waiting patiently, I became curious. I joined them and found out that interviews were being conducted for the position of a community worker at SNEHA. I was selected and that is how my journey began.”

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Archana Ramesh Mahapade, Community Organizer, SNEHA

It is community workers like Archana that help drive the impact of SNEHA, Society for Education, Nutrition and Health Action, an organization that for many decades now, has been working towards improving the health of women and children in slum communities.

SNEHA’s community centres in the vulnerable areas are key to driving the program. The community organizers are drawn from the community itself, and their ease and familiarity with the local population makes them an invaluable asset.

However, as Anupama points out, the familiarity does not guarantee that their presence or advice is always accepted.

“When we first tell people about SNEHA and the work we do, many look tense and turn away. Some women even shout at us and we do feel bad. But we always come back the next day. Eventually their attitudes change when they realize that we are there for good, and not just for a day.”

Once the ice is broken, it takes a few more sessions before they start talking about their lives. “Initially, when we ask them about family planning methods, they are not honest. They say everything is good but as we probe further, we get to know about the situation at home, the pressures they face.”

Building this intimacy is critical given the many levels of SNEHA’s intervention. It goes beyond maternal and newborn health to child nutrition, and sexual and reproductive health, issues that girls and women have never been encouraged to think about. SNEHA offers crisis intervention, counseling, medical and legal help to survivors of violence. It also works on prevention in communities and enables government systems to respond in an effective and sensitive manner.

Access into the homes and lives of women here is vital,  and the community organizers enable that.

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Saira Shaikh, CO, Govandi

“The women in my area come to the city after marriage and they are lonely and unaware”, says Saira Shaikh, 38, a community organizer at Shivaji Nagar in Govandi. Govandi, one of Mumbai’s largest urban settlements, is home to a large population of migrants, who depend on odd jobs to make a living.

“They face violence at home and have no one to turn to,” adds Shaikh. “The violence is made worse by the low unemployment levels. The husbands spend the daily wages on other women or on drinking. We give these women strength by telling them to come forward and seek help so they can start providing for themselves and their kids. We also encourage them to stand up to their husband. Over a period of time, they start to listen and assert themselves. “

Often it can take as long as two years for behaviour change to set in.

Saira brings up the case of a woman in Shivaji Nagar who was pregnant with her fifth child. Her hemoglobin count was just 7.6 and she was always complaining of feeling dizzy and weak.

“The husband would shout at her for being lazy and as we started visiting her we realized that she hadn’t even registered her name at the local hospital”, says Saira. “This was because her husband would not give her money even to go to the hospital. She was a victim of domestic violence. Her husband would even shout at us when we paid a visit. ”

Saira finally took the help of a senior SNEHA staff member to convince the husband. “We were very patient and calm but it still took three months to get him to agree to a hospital delivery. In the meantime, we took the help of the local municipal health staff and started giving her injections and monitored her diet closely. Because she had little money, we encouraged her to eat dates, which are cheap but high in nutrition. She was able to have a healthy baby. “

The episode offers a glimpse into the level of focus and dedication that the community organizers bring to the job.

“In my experience, women and children’s health is an issue everywhere, “ says Archana. “The kids are weak but the mothers don’t think anything is wrong because they compare them with other kids in the neighborhood. They don’t realize that their child has not met important growth indicators. “

Given the sensitivity of such matters, I ask Archana how she speaks to the mothers without making them feel inadequate.

“When we talk to the women, we ask them what the kids eat and the answer almost always is – “I cook but he doesn’t eat what I make”. Then we ask if the kids have been given pocket money that day. The mother realizes that the child has spent the money on buying snacks, and does not want to eat what is cooked at home. We get the mothers to stop doing that. We also show them ways to cook such that the food is to the child’s taste. Like to partially fry an egg and add the roti so the child gets protein and carbohydrates. We have been able to encourage all the women to breastfeed, which was not the practice earlier.”

Ask Archana what difference being a community organizer has made, and her face lights up.

“I am so proud to be a CO. I have helped women who have suffered multiple miscarriages, deliver healthy babies. I have also been able to help couples conceive by telling them about ovulation. The money may not be much but the satisfaction is huge. It has helped to build ties within the community. Now when I don’t go to the community even for a day or two, the women tell me you haven’t come for so many days,” laughs Archana.

SNEHA – A community-based health model that delivers

Public health in urban areas is one of the most persistent, yet neglected, issues facing the developing world. Cities present an especially challenging canvas given the many different factors – migration, inadequate housing, lack of infrastructure, crime, political corruption, pollution, and dysfunctional health systems – that are in play.

Over 50% of the world’s population lives in cities and this number will rise in the next few decades. Due to migration, India’s cities are growing more than three times as fast as the rural areas, and it is likely that more than half of the country’s population will live in urban areas by 2050.

The factors that affect human health are many, ranging from climate change and greenhouse gas emissions to reproductive health and rights. Meeting them is key to India’s success in achieving universal health coverage and improved national health indicators.  96-of-109

The National Urban Health Mission in India aims to enable rightful access to quality health care. This is by setting up an improved public health system, partnerships, and community-based mechanisms. This is to be done with the help of secondary and tertiary institutions, urban health centres, and community outreach. The positive outcomes of such a partnership in Mumbai’s urban settlements, demonstrated by SNEHA, is the subject of a paper recently published in the prestigious medical journal The Lancet.

The interventions of the Society for Nutrition, Education and Health Action, SNEHA, interventions are born out of 16 years of work with women and children in informal settlements. They range from maternal and neonatal health, sexual and reproductive health, childhood nutrition, and prevention of violence against women and children. What makes SNEHA’s model unique and effective is that it integrates these activities, and the model can be replicated in urban settlements across India, perhaps in many developing countries as well, with some tweaks for local, cultural specifics.

SNEHA’s adoption of an integrated approach came after a large neonatal trial conducted in Mumbai. It was felt that this would be an effective method given the multiple health issues faced by women and children, and the belief that communities would be more responsive to an intervention that had both, physical presence and service delivery.

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Every SNEHA centre is equipped with three full-time community organizers with backgrounds similar to the people they reach out to. They are trained to bring together the themes of reproductive, maternal, and neonatal health, child health and nutrition, and prevention of violence against women and children into the community services. They are responsible for home visits, group meetings, organizing day care for malnourished children, and community events, in close association with existing systems.

A survey was done before, and two years after SNEHA’s intervention on three main outcomes – family planning in women (15–49 years), immunization of children, and wasting among children less than five years. The survey looked at secondary outcomes as well, like violence against women or children, number of home births, pregnancies in women younger than 20 years, to name just a few.

There were significant improvements in the met need for family planning, and full immunization. Compared to the NFHS 2015-16 figures of 14% unmet need in Mumbai, the results in the areas of intervention was 22%. Again the NFHS-4 findings showed that 46% of children between 12–23 months in Mumbai were fully immunized. Contrast that with the intervention area rates of 69%. The findings were similar when it came to wasting in children, and diet among children.

There were other positive fallouts seen as well like the use of sturdier material to build homes, building of private toilets and use of safe, drinking water.

The challenges of meeting the health needs of settlements in an urban milieu are many. The shifting nature of the population and specific cultural beliefs can often slow down rates of progress. However, the overwhelmingly positive outcomes demonstrated by SNEHA’s model shows a way forward to city governments across developing countries who are grappling with ways to improve health in informal settlements.

Link to The Lancet paper – http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30363-1/abstract

Innovative approaches to tackling malnutrition

The malnutrition-related deaths of nearly 600 children barely 100 kilometres from Mumbai in 2016 underlines the critical need for various stakeholders to come together to find ways to bring about behaviour change, and ensure that benefits charted out under various government schemes actually get to those who most need them.

The fact is that children do not die of malnutrition but of causes due to malnutrition. Stunting is a better indicator of malnutrition and according to studies 51% of children and adults among tribal populations in Maharashtra are undernourished and stunted. This is a significant figure and one that has not shown sufficient improvement in the last few years.

Across India, the occurrence of wasting among children is serious. Even within the limits of the financial capital Mumbai, NFHS-IV shows that one-fifth of children under the age of five years suffer from wasting. This is very serious indeed given the associated risks of disease, even death, among children who are very underweight.

Since 2011, a program introduced and managed by SNEHA and CRY has shown the way forward when it comes to tackling urban malnutrition, especially wasting. Over a period of two years, the percentage of wasting in children reduced sharply from 18% to 12% in the slums of Mankhurd, Govandi and Kurla situated in the suburbs of Mumbai. SNEHA’s intervention in child health and nutrition in Dharavi showed equally encouraging signs – a fall of wasting from 18% to 13%.

The percentage of children who received full immunization rose from 66% to 73% in the three areas mentioned earlier. There were also other positive changes, like rise in hospital deliveries (12 up to 15%), adoption of family planning methods (34% up to 59%) and a dramatic drop in pregnancies among women below the age of 20 years. (17% up to 4%).

The changes took place because of a sustained merging across different sectors at the community level to enhance child under-nutrition. This was backed up with enabling behaviour change through home visits, one on one counseling, awareness campaigns, and community meetings. This led to greater adoption of FP methods, immunization and better nutrition practices.

Urban malnutrition is a challenge not just peculiar to world cities like Mumbai. Tackling it requires innovative and creative approaches that take the community’s needs and pressures into account. The program by SNEHA and CRY offer a window into an approach that could show results in many parts of India to reduce malnutrition rates.

 

 

 

Need to rethink approaches to infant & maternal healthcare

The figures reporting the decline in infant deaths in India is something to celebrate. Data for 2015 shows that 27 babies died for every 1,000 births, which is two better than the government’s own projected figures.

That is a drop of 53%, which is still far short of 67%, which is what India had promised to achieve under the MDGs. But it is promising in that it shows government programs to reduce baby deaths like incentivizing institutional deliveries, providing supplements to pregnant women, etc., is having some impact.

Data from states like Goa, Manipur and Punjab, which have reported a drop of over 60% in IMR is especially promising. However, compare this to the high rates in Uttarakhand and Madhya Pradesh and one gets a picture of just how patchy and uneven the quality of healthcare services remains.

This is a critical lack and needs to be addressed, as high IMR is a report card of the health of the country and an indicator of the future growth potential. Clearly policies aimed towards maternal and infant health need a rethink given the huge gaps that exist.

While widespread illiteracy, poor nutrition and sanitation, and lack of awareness are key factors that explain the high rates, the poor healthcare infrastructure on the ground is evident in the high number of deaths reported from states like Odisha, which witnessed the deaths of over 50 children in just two weeks in a state-run children’s hospital. 151 deaths were reported across hospitals in Kendrapara in Odisha in just 4 months.

There is a need to address the system on the ground and look at what the shortfalls are. Maternal and child health policies cannot work in isolation. There are important connections between these groups and there is a need to strengthen the continuum of care to ensure that an unbroken curve spans the home, community, health center, and hospital. This would help manage the maternal-newborn-child health scale of care in a more unified way.

Putting Health at the Heart of Urban Planning

The recent series by the Lancet on urban slums highlights the importance of placing health at the heart of all interventions.

Over 800 million across the world live in slums; areas where expansion happens with not enough planning or infrastructure. This is despite the many specific challenges that come with slums, like poor housing, unsanitary living conditions, overcrowding, lack of basic health and social services.

These are serious, crippling challenges that need to be addressed and planned for as they are preventing millions from reaching their full potential.

There is a need to put health at the heart of urban planning, argues the Lancet series, an approach that organizations like SNEHA are consistently working towards. Urban public health is one of the most persistent yet disregarded issues facing the developing world. However, there has been no inclusive plan for dealing with India’s rapidly urbanizing population.

The primary focus remains rural health, and while this is important, there is a need for an urban health agenda given the many challenges in our cities.

Take Mumbai’s slum population. They are regarded as a homogenous, indistinguishable presence, although they are a vital component of the financial capital’s economic productivity. Many of them live day-to-day, rather fragile existence with poor access to amenities like drinking water.

The World Health Organization’s report – Health as the Pulse of the New Urban Agenda also reinforces the need to put health at the heat of urban planning. Urbanization, it says, comes with opportunities for mobility and economic growth but has a negative impact on health and the environment. For urbanization to become sustainable, measures have to be put in place for disease prevention and health improvement.

 

 

 

 

State of India’s Children

In less than two weeks, India will celebrate Children’s Day. There will be programs held and speeches made on the treasures that our children are and the tremendous potential they hold for our country’s future.

It is also a good time to take a hard look at the plenty we don’t seem to get right when it comes to our children. Recent Census 2011 data says over 77 lakh Indian children are forced to earn a living as they attend schools, while over eight crore kids don’t go to school at all.

The fact that so many children are still forced to work is troubling, because it is an indication of the low priority education receives among so many. It is also an indicator of just how unaffordable education is for so many in our country.

India’s under-18 population is the highest in the world, what we pride as our demogrpahic dividend. Then why do they get such low priority when it comes to education and health?

A large percentage is marginalized for reasons like poverty, disease, malnourishment and conflicts. States like Assam, Madhya Pradesh, Bihar, Haryana, Uttar Pradesh and even prosperous Gujarat lag far behind some African countries when it comes to infant mortality. Over 16 million girls between 10 and 19 years are married, many of them to older men.

When it comes to investing in this fragile and critical age group, we are severely wanting at many levels.

 

Malkangiri deaths: The deadly link between malnutrition & disease

The deaths of 61 children due to an outbreak of Japanese Encephalitis in Odisha’s Malkangiri district brings home the gaps that lie in the health care system in large parts of rural India. Over 100 villages across seven blocks in this region have been hit and unofficial reports are that the number of children who have died is much higher than 61.

Japanese Encephalitis, which affects mostly children, derives from pigs and spreads to humans through mosquitoes. The population in this part of Odisha is especially vulnerable as people here depend on pigs for livelihood.

There was an outbreak of Japanese Encephalitis in 2012 as well that led to many deaths. Despite that, the community remains unaware of the dangers of rearing pigs so close to their homes. The administration has also failed to carry out door-to-door monitoring for fever and monitoring.

The apathy is even more shocking when one looks at the data. Malkangiri ranks among India’s top 15 districts when it comes to child wasting, stunting and underweight. One-third of children here below five years of age suffer from wasting, stunting and underweight, mainly due to under nutrition.

The infant mortality rate is reported to be 48 as against Odisha’s average of 56, while the maternal mortality rate is 245 as against the state average of 230.

Given the prevalence of so many red flags, it is shocking how poor the health system on the ground is. Malkangiri district has only one pediatrician while the community healthcare centre at Korkunda, the most affected area, has no doctors. In all, 2,000 posts for doctors are lying vacant in the state.

Reports are that vaccinations are very rarely given even if the government has declared a program. Vaccination for JE in India was launched in 2013, but Odisha is yet to receive it share. According to the government’s reports, less than one-third of Malkangiri’s population is covered under the immunization programme.

Regions like Malkangiri show how far we are from providing equitable development across India. Unless steps are taken to strengthen healthcare infrastructure and enable the poor to take care of the nutritional needs of their children, routine epidemics will continue to take away lives.

 

Giving Girls a Voice

Just how distant a dream going to school remains for girls in India is borne out in the new data on female literacy.

According to this study, the proportion of girls who finished five years of primary school in India is 48%, which is far lower than Nepal (92%), Pakistan (74%) and Bangladesh (54%). The data also shows that only 15% of Indian women who studied till Class II can read a sentence.

Gender, location and poverty remain such huge barriers for a majority of girls in India today. The bias against educating girls keeps them vulnerable to female infanticide, early marriage, gender violence, and sex trafficking.

This can only change when education comes to be seen as a vital necessity for everyone, regardless of gender, rather than an advantage that only the privileged have.

Investing in every girl’s education has to be seen as critical for social and economic development, for lifting households out of poverty.

Educating girls is necessary to reduce the number of child marriages, which remain high in large parts of India even today despite being against the law. Studies show that women who get a secondary school education are 92% less likely to be forced into an early marriage. This in turn makes them vulnerable to early pregnancies, domestic violence, HIV and depression.

Education also has a direct link to lower maternal and infant mortality rates. It helps build awareness about better hygiene, vaccinations and nutrition. It enables more informed choices on matters like family planning and employment. Studies show that women who have had the opportunities to go to school are two times more likely to send their own kids to school.

All of which make compelling arguments to ensure we do more to send every girl in India to school.

 

 

 

Junk food and its health implications

We are all vulnerable to junk food. It’s so much easier to cook and eat a two-minute packet of noodles, or pop some biscuits into your mouth than have to think about what to cook everyday. And with the large varieties of so-called healthy alternatives available, it is easy to get sucked in.

Just how all pervasive junk food is, hits you most outside schools and college. Take a walk around lunch break or after school hours, and you will inevitably find kids clutching packets of chips, or wolfing down vada pavs.

An occasional indulgence is fine, but if eaten on a regular basis, junk food has enormous health consequences, even more so for kids. The World Obesity Federation warns that unhealthy eating, and this includes the consumption of sugary drinks, is leading to a rising number of children becoming obese. Millions are getting affected by Type 2 diabetes and high blood pressure, earlier seen in adults only.

About 13.5 million children have weakened glucose tolerance, which is a sign to diabetes. Over 20 million have high blood pressure while over 30 million have fatty liver disease. This is a condition that is linked to alcoholism and can lead to cirrhosis and liver cancer.

This is bad news for kids the world over. For poorer countries like India, where the health system is already overburdened, it spells disaster.

As an IndiaSpend report pointed out, obesity exists alongside stunting in India and there are serious implications if action is not taken to correct this. Childhood obesity, says the study, is high among the affluent and urban, upper classes. However, there is are not enough studies done on the prevalence. According to one report, India sees 10 million cases of childhood obesity every year.

There is also an alarming rise in cases of childhood diabetes, which needs to be addressed. Clearly an action plan is called for to deal with the WHO has called “an exploding nightmare”.

 

Need for new approaches to end stunting

The start you get in life determines the future course not just for an individual but for a country.

Just how critical that is, is brought home in a series of research papers published in the medical journal Lancet earlier this month.

The research says that children who lose out on that early start, that is, they are deprived of the required nutrition and care, go on to earn 26% less on average than others. This applies to 250 million children across the world, over 40% of them under the age of five years. This is because stunting and acute poverty will act as a barrier in the way of them realizing their full potential.

Just how critical the need to invest in the first two years of a child’s life has been shown time and again in many studies. The nutrition children get in these years determines not just physical, but also mental growth. Addressing those shortfalls at a later stage is not possible, especially when it comes to cognitive or reasoning abilities. The human brain develops faster at conception and through the first 2-3 years of life.

In terms of numbers, we are looking at 250 million adults unable to realize their full potential. Economically, this translates into income loss and low productivity.

India needs to act quickly if it wants to halt this social and economic loss. The cost of not taking steps to reduce stunting in children, is said to be 8.3% of India’s GDP. We are looking at this lack of action affecting future generations.

A change in approach is called for. Perhaps there is a need to look at programs followed in countries like Peru where under a World Bank-supported program, conditional cash transfers were given to mothers of stunted children. They were also educated about the importance of giving nutritious foods to their kids. Incentives were given to health clinics to support them. The monthly payments depended on how the children progressed.

There is a need for a relook at early childhood and maternal care programs because clearly they are not doing a good enough job of reaching thousands of mothers and babies, especially in large parts of rural India.

 

Build a conversation on mental health

The recent countrywide survey by the reputed National Institute of Mental Health & Neurosciences, Nimhans, is a wake up call to how lifestyle changes are having an impact on the mental health of Indians.

The report says that a shocking 13.7% of India’s general population suffers from some form of mental illness. A majority of them, over 10% are in need of urgent medical intervention, which translates to about 150 million Indians.

Nearly one in 20 people suffer from depression. Women between 40-49 years are especially vulnerable and report high rates.

Despite being among the first countries to develop a national mental health policy, this is the first time that a proper, in depth study has been done to understand the spread of mental illness in India. Earlier studies at the state levels had several loopholes.

The incidence of mental illness is especially high in urban areas, which is perhaps only too obvious given that is here that the impact of lifestyle changes, changes in family support structures and issues related to job stress are most apparent.

The report raises red flags on many fronts. One is the sheer scale. The other is the huge gap in terms of treatment. This extends to both mental health specialists as well as institutions.

A 2013 government of India study said that there are 3,800 qualified psychiatrists in the country as against the required 11,500. When it comes to clinical psychologists, the requirement is 23,000. The availability is 850. The figures for psychiatric nurses are equally dismal.

The other alert is the widespread stigma attached with mental disorders. The Nimhans report says that 80% of people suffering from mental disorders had not received any treatment despite suffering for over a year.

A major step towards ending the stigma is to build a conversation around mental health. In this regard, it is encouraging to see celebrities like Deepika Padukone come forward to talk about their struggles with depression. It’s a small step, however, given the sheer scale of the mental health crisis India faces. There is a need to look initiatives by NGOs like Sangath that train workers at primary health centres to counsel patients in the community on dementia, depression and schizophrenia.

Rather than just a top down approach, the government needs to encourage and incorporate community level initiatives to help end the stigma and heal.

Time for a Relook at India’s flagship programs

The findings of the Global Burden of Disease 2015 study are truly depressing. The results, published in The Lancet, lists the main factors behind illness, death and disability in countries.

While deaths of children under five years has gone down between 1990-2015 from 12.1 million to 5.8 million, India still tops the number of child deaths at 1.3 million in 2015.

India is followed by Nigeria, which has over seven lakh deaths, and Pakistan with three lakh deaths. Bangladesh has done better. There were 7663 maternal deaths in 2015 in Bangladesh, which is a dramatic improvement from 21,789 in 1990. Maternal deaths in India dropped by half to 63,861 in 2015 from 1,32,239 in 1990

Neonatal mortality, which is death in the first 30 days of life, remains high. While deaths under five years have reduced, it still remains way lower than the MDG goal.

Some of the main causes given in the study are pre-term birth complications, trauma and respiratory infections. Diarrhea-related diseases are the fourth leading cause.

The study says that while government schemes like Janani Suraksha Yojana have been successful in improving access to institutional births, the reach remains patchy with large parts of rural India unable to access the services. This is the demography that remains most vulnerable. A reality we encounter everyday in news reports of pregnant women dying on their way to hospitals.

Clearly, it is time to step back and take a close, hard look at our flagship programs like JSY and the integrated child development scheme, ICDS. The ICDS was launched in 1975 and is one of the world’s oldest nutrition programs. If after 41 years of ICDS, we are still failing so many hundreds of thousands of children, something is clearly going very wrong.

 

Low contraceptives’ usage, a cause for concern

Despite the range of family planning options made available in India, data from the National Family and Health Survey, NFHS-4, is cause for concern.

The figures released for 14 states shows a fall in the use of contraceptives, compared to the previous NFHS survey done 10 years ago.

With options, awareness, healthcare access and incomes growing, the expectation was that women would exercise more say over their pregnancies, but the data doe not indicate that.

While West Bengal and Meghalaya show an increase in the use of modern contraceptive methods like OCPs and IUDs and a fall in sterilization, the figures for the rest of the state surveyed are not so positive. Over 50% of women prefer female sterilization and there is a decline in the use of contraceptives in some states.

What this means is that a large number of pregnancies continue to be unplanned or unwanted and access to contraceptive methods remains in the hands of a few. In rural areas, women still depend on government health facilities for supply and this is affected by lack of choices, irregular supplies and lack of skilled health providers at the district health centres.

The NFHS data for all the states is as yet not available and therefore a conclusion may be premature. However, the findings from these 14 states, many of which have seen some focused family planning campaigns, is a pointer towards how much more needs to be done.

Ensuring that contraceptive methods are available is a small part of the challenge. Getting women to use them, addressing the myths and empowering them with information about how and when to use these methods is a huge gap which remains unaddressed even in some of the relatively better off states. Tamil Nadu, for instance, shows no change in the use of oral pills. It was 0.20% in NFHS-3 and remains the same in NFHS-4.

Given India’s sizeable youth population and the high prevalence of early marriages, it is critical that resources be invested in making sure that information and access to modern contraceptive methods is made available in rural India.

“There is a need to focus on changing behaviour and the regular, smooth availability of contraceptives”, says Dr Ashok Dyalchand, Director, Institute of Health Management, Pachod. “At the moment, this is lacking”.

 

Child marriages & impact on mental health

The impact of early marriage on the reproductive health of women has been well documented, but the effect on mental health often gets overlooked. Child brides often find themselves struggling to cope with anxiety and depression and find little sympathy or support in their marital home.

A sociological study done by the University of Calicut among 600 women who had married before the legal age found that most of them were in conflict with their husbands and other members of the marital home. They were under pressure to take over the household chores and produce a child early.

Any assertion of right or voicing an opinion was treated as a challenge and often met with ridicule, even physical abuse.

A new India wide study by the Delhi-based SAMA Resource Group for Women and Health is also examining the wider impact of early marriage on a woman’s health. Early findings of the report say that when girls are forced to leave school and marry, they experience a loss of mobility. The immediate result is a loss of companionship as they are no longer free to meet their friends. This is a major cause for distress.

Every aspect of their lives comes under close watch – from what they wear to whom they speak to – so there is a constant feeling of apprehension that they might break the rules.

Any sign of sadness or unduly quiet behaviour is regarded as proper and hence gets ignored. It is only when the signs of mental health become very obvious that outside help is sought and this is not professional help, but from traditional faith healers.

“Whenever there is physical violence, it shows up in scars”, says Praful Kamble, Program Officer of SNEHA’s Little Sisters program which has been working towards bringing addressing domestic violence issues in Mumbai’s Dharavi area. “But the impact on the mind is 25% more. There is depression and a sense of shock. And when there is negative support from the family, the woman feels even more isolated.”

Geeta (name changed) experienced verbal violence from her in laws and husband, as her son was constantly ill. Even her sisters-in-law did not support her. One day she threw kerosene on herself and set herself on fire.

“I did it out of despair”, she says. “Caring for a sick child was stressful as it is and then to be constantly blamed for it was a miserable feeling. I was worried for my child and had no idea where to seek help.”

There are multiple linkages between early marriage and health. Mental health is a key one, and needs greater focus in India’s programs and policies.

 

Tacking malnutrition in Mumbai

The latest data put out by the Integrated Child Development Services highlights what a tough challenge tackling child malnutrition in Mumbai’s slums remains.

The latest data says that the slums have over 50,000 moderately underweight and over 3,000 severely underweight children. Undernourished children account for a massive 17% of the total children weighed in anganwadis across Mumbai until March 2016.

All this shows how tough challenge malnutrition remains despite the various interventions, both by the government as well as NGOs.

Between 2015-16, eight children, who were suffering from malnutrition, died. Five were infants below the age of one year, while the rest were between three to six years.

Experts say that the figures highlight the challenges of dealing with a migrant population.

“The slums that have reported such high numbers are home to a migrant population, people who come from different castes and religions”, says Dr Yogesh Nandanwar, Head, Gynecology, at Lokmanya Tilak Municipal Hospital. “The mothers are anemic and undernourished and they are in no condition to have health babies. “

Dr Nandanwar calls anemia the nucleus of all problems. “Because of anemia, worm infestation becomes an issue. Low hemoglobin is another major issue.”

Given that migrants account for one-third of Mumbai’s population, the numbers are enormous. And the fact that this is a floating population makes the challenge even bigger, underlining the need to have a specific policy to look at nutrition issues among the city’s migrant population.

Millions left behind in India’s public health system

Two news reports in the span of 10 days bring home just how grave the crisis in India’s public health care system is.

First was the report from Odisha of a tribal man who had to carry his dead wife’s body on his shoulders for over 10 kilometres because he was denied an ambulance to go back to the village for her final rites.

Then less than a week later came the tragic story from Kanpur of a 12-year-old boy who died after he was denied admission at a government hospital. His father, who was holding the sick child in his arms, was told to go to a children’s hospital despite his obvious poor health. The man’s pleas for transport to carry the boy to the children’s facility were denied.

These are just two instances that we know of because they got media attention. Imagine the thousands, even millions of people across the country, who are unable to access medical treatment on time.

The World Health Organization says the ideal norm is 1 doctor for a population of 1,000. Going by that measure, India falls short by 500,000 doctors as pointed out in a recent IndiaSpend report. Going by these figures, there is one doctor for 1,674 persons, which is worse than Vietnam, Pakistan and Algeria. Even this, many experts believe does not reflect the reality and that the ratio is closer to 1:2,000.

The shortfall is evident not only when it comes to doctors but also support staff like midwives and ASHA workers who form a critical backbone when it comes to rural health care. Under the National Rural Health Mission, more health centres have come up in our villages but there are simply not enough doctors and nurses to man them.

The shortfall gets reflected in the statistics relating to infant and maternal mortality. Despite interventions at various levels, the figures are not improving fast enough. All the plans and policies remain words on paper because there are not enough people on the ground to see them through.

Fighting gender violence together

A recent IndiaSpend report on crimes against women in the Capital brings home the many promises made in the aftermath of the Nirbhaya rape in 2012 that remain unmet; and how four years after that horrific assault on a paramedical student, the number of rapes in Delhi has tripled.

After the incident, the Verma Commission that was entrusted with looking into reforms proposed many changes to the law. Chief among them was hiring more women in the police force as it was seen as a vital step towards ensuring greater sensitivity towards rape survivors. As the IndiaSpend report highlights, this, like along with many others like hiking expenditure on police training remains on paper.

Police, the world over, handle rape badly. Even in developed countries like the US and the UK where resources are so much more advanced, there is a huge variation in the way rape is recorded and how survivors are treated.

In India, where this is compounded by a crippling shortfall of staff, experts say there is a need to take a more pragmatic approach towards tackling crimes against women.

One that does not put the entire onus on the police, but a multi-sectoral approach that involves different agencies across key sectors – health, psychosocial and justice – working together.

Increasing the number of female cops is not the sole answer, says Dr Nayreen Daruwalla, Program Director for Prevention of Violence against Women and Children, SNEHA. “Women share the same concepts of patriarchy and are not able to shed their deep entrenched attitudes while dealing with cases and survivors of violence”, she says. “We are working towards making violence against women and children a public concern, so should not the responsibility of assisting the survivor lie with all duty bearers, irrespective of being a woman or a man?”

Daruwalla argues that a multi-sectoral approach offers a more effective, long-term solution to bringing down crimes against women, pointing towards SNEHA’s convergence approach in the Mahim and Nehru Nagar police stations of Mumbai.

In September 2013, when SNEHA started an observation and in-house training program in gender sensitivity in these two stations there was some initial discomfort. However, gradually there was an understanding from both sides of each other’s pressures and needs.

While the counselors got to witness firsthand the extreme stress and staff crunch the force faces, the police too realized that SNEHA’s presence and inputs were helping them handle cases related to gender based violence in a better manner. It also helped tone down levels of aggression and the use of abusive language. Gradually the police began to reflect upon their patriarchal mindsets.

A study done before and after the program on the policemen who participated showed significant results. Some of them were –

*Greater understanding of the law against domestic violence

*Greater awareness of stalking, violence and disrobing as forms of violence

*53% decrease in the number of policemen who thought it was important to ask if a woman had provoked an act of violence

*Nearly 70% decrease in the number of police who said a woman’s sexual past was not important while recording a rape complaint

The greatest testament to the changes came from the women in the community who said that they were satisfied with how they were being treated by the police in these two stations.

“Changing mindsets is a longer term process that requires regular follow-up and reinforcement”, says Dr Daruwalla. “We work with the premise that the police are ready to fulfill their role appropriately and adequately if given an opportunity to work in a supportive environment. “

The convergence approach pioneered by SNEHA holds many lessons. Enabling the law system to respond to violence against women and children needs a supportive environment, one where various agencies come together and work in partnership with the police.

Instead of seeing the police as the ‘other’, it brings the community closer to the men in uniform, making the fight against gender based violence, everyone’s battle.

 

 

 

 

Let’s Talk About Periods

She may have missed out on a medal but Chinese swimming star Fu Yuanhui is being hailed as a champion back home and around the world for breaking the taboo that comes attached with periods in sports.

Fu attributed her team’s failure to make it to the top three in the 4x100m medley relay to the fact that she started her periods a day before the event, a remark that the Chinese media was quick to praise, given the silence that surrounds menstruation. Soon athletes and activists around the world picked followed suit.

Across the world, and more so in countries like China and India, there are a deep-rooted cultural resistance, even stigma, attached to periods. There is indignity and even a certain revulsion attached to it, which prevents open discussion. Which makes statements like Fu’s, or American musician Kiran Gandhi who ran the 2015 London Marathon while she had her periods, welcome.

For those who might think them over the top, consider this. Menstruation remains a major barrier to achieving gender equality in many parts of the world today.

Adolescent girls in developing countries miss five days of school in a month due to lack of access to sanitary pads and hygienic toilets in schools. This makes them fall back in education.

Menstruating women in countries like Nepal and India are seen as impure and a sign of bad luck. They are made to sleep outside their homes and eat out of different utensils.

If talking about periods openly and scientifically can help end this damage of a million lives, then by all means let us all start.

We Have the Act. Time to Create the Awareness

The provision of the Maternity Bill extending maternity leave to mothers The provisions of the bill will apply to all organizations that employ 10 or more persons and is expected to benefit over one million women working in the organized sector.

Given the majority that the ruling government enjoys, its passage in the Lok Sabha is guaranteed, after which the Labour Ministry will notify the changes.

As per the amendments, maternity leave for women in the private and public sector will be increased to 26 weeks as against the present 12 weeks. However, those who already have two or more children will get 12 weeks of leave only.

The bill also proposes 12 weeks maternity leave to mothers who have children through surrogates as well as working women who adopt a baby below the age of three months. The Act will also allow nursing mothers to work from home after the 26-week maternity leave ends, depending upon the nature of their job.

However, the real work starts now. While the provisions are a progressive measure, there needs to be awareness created for the benefits of this to come through. The period after birth is critical for both the mother and the child’s health and the root of the amended act lies towards preventing malnutrition. That is the primary purpose of the Act, which is not to be treated as a holiday.

Passing the Act has to go along with creating awareness about breastfeeding and other measures that are to be taken to secure the health of the child and the mother. There needs to be a well thought out policy to promote breastfeeding, which is still lacking in India. Various studies show that less than 25% mothers in India initiate breastfeeding in the first hour after birth.

The WHO says that initiation of breastfeeding within an hour after birth could bring Infant Mortality Rate by as much as 22%. Nearly 77% of child deaths worldwide are attributed to non-exclusive breastfeeding during 0-6 months of life.

Both the WHO and UNICEF recommend breastfeeding within an hour of birth, only breast milk for the first six months, and continued breastfeeding up to the age of two years, along with appropriate complementary food.

 

 

 

 

 

New Mental Health Bill is a much welcome step

The Mental Health Care Bill 2013, is welcome as it a step towards acknowledging the huge shortage of infrastructure and psychiatrists in the country. The bill aims to protect and promote the of rights of people with mental illness and offer better support and facilities to people suffering from various types of mental illnesses.

In India, mental health problems are more common than cancer and heart diseases. There is a high prevalence of mental disorders, from 58.2 to 73 per 1000 population.

However, research says that over 80% of people suffering are not getting the required treatment due to shortage of mental health experts, stigma, inadequate facilities and the high treatment costs. At present, there is only one psychiatrist for every 343000 people.

The new Bill is progressive because it acknowledges these glaring shortfalls and also calls for greater support for caregivers who are largely neglected. The move to decriminalize attempted suicides also recognizes the rights of the mentally ill. The focus on compassion and responsibility is also a welcome shift away from socially stigmatizing those who suffer from mental illnesses.

However, how effective this Bill will be depends on the implementation and this is a big question mark. Since health is a state subject, different states are left to their own devices when it comes to bringing the various provisions into force and this could undermine many of its positives.

Time to End the Shame Around Breastfeeding

Last week, protests were witnessed across Argentina by groups of women who breastfed their babies in public. They were agitating against the police’s move to throw out a mother from a square in Buenos Aires for nursing her infant in public.

Carrying signboards that said, “Nursing is not up for discussion” and “My breasts, My rights”, over 500 women took to the streets in different parts of the country demanding respect for mother’s rights.

Breastfeeding is a simple, no-cost intervention that boosts the health of children and women substantially, in rich and poor countries. Yet there is little awareness about this. And as we get set to observe World Breastfeeding Week (August 1-7) around the world, experts are calling for programs that encourage ideal breastfeeding practices.

Studies in The Lancet point out that increasing breastfeeding to optimum levels could save over 800, 000 lives every year, most of them children under six months. Also, nearly half of all diarrheal diseases and one-third of respiratory infections in children in low- and middle-income countries could be prevented.

Babies who get no breast milk at all are seven times more likely to die from infections than those who get some in their first six months.

Children who are breastfed also do better at intelligence tests, are less likely to be overweight and less likely to get diabetes later in life. The benefits to mothers are also huge. They show lower risk of developing breast and ovarian cancers.

The awareness is especially abysmal in low-income countries, like India. And it does not help that the government has not aggressively promoted breastfeeding. The focus on bringing down maternal and child deaths has been heavily directed towards promoting institutional deliveries, antenatal check-ups and neonatal care.

There are many barriers that come in the way of early breastfeeding in India and this helps explain why signs of childhood malnutrition like stunting (45%) and wasting (20%), that depend significantly on early breastfeeding, remain high.

According to studies, only one in four mothers are able to start breastfeeding within one hour of giving birth and less than half of all mothers are able to exclusively breastfeed their babies for the first six months after birth.

Supportive health-care systems, workplace interventions, counseling and educational programs are needed to improve breastfeeding. The government’s recent moves to bring changes to the Maternity Benefit Act of 1961 are welcome steps.

There is also a need to break the wider social shame that exists around breastfeeding in public, something the UN has also acknowledged by backing the social trend of belfies – mothers sharing pictures of themselves breastfeeding. It is a welcome step towards ending that stigma and spreading the word about the importance of a mother’s milk.

 

 

 

No Country for Children

It’s been a damning week for India.

A series of reports from different parts of the country brings home just how poorly our children are doing when it comes to access to basic nutrition, sanitation and health.

First Odisha, where according to official figures, 15 children have died of malnutrition-related illnesses in the tribal Nagada village since January. Village authorities say the actual figure is much higher. The news finally made it to the headlines only when five children died in a span of 20 days.

The children in Nagada and nearby villages all show signs of severe malnutrition. The bad roads’ leading to these villages has meant lack of access to basic health care and clean drinking water. It took several newspaper TV reports for authorities to organize a kitchen and a health camp.

The fact that so many deaths have taken place in a mineral rich region of the state has exposed just hollow Odisha’s development claims are. The several flagship schemes for children of vulnerable tribal groups remain on paper and don’t seem to reach those who most need it.

And then this week we also had the results of a combined study by experts from the Johns Hopkins Bloomberg School of Public Health in the US and School for Applied Studies, Delhi, found that diarrhea kills nine children under the age of five in Uttar Pradesh every hour, which 71, 000 deaths in a year.

The study found that just over 15% of private doctors in UP prescribe zinc, which strengthens the ORS. Even the most basic treatment of childhood diarrhoea is a problem across large parts of the state. This explains the huge numbers as since most families opt for private over public health care.

Again, diarrhea is easily preventable with safe drinking water, sanitation, nutrition, to mention just a few.

Finally this week, we have the most recent WaterAid study that says India has the largest number of stunted children in the world, ranking higher than smaller economies and conflict-ridden countries like Pakistan and Nigeria.

Two in every five children under the age of five years in India are stunted, a condition that affects not just physical growth but emotional and cognitive development.

The report points to sanitation as a major cause, citing the practice of open defecation, which is widespread in India.

A country cannot lay claim to be a global economic superpower when it’s children are dying for lack of access to basic amenities; amenities linked to basic rights enshrined in the Constitution, but remain a mirage nearly 70 years after Independence.

 

Worrying State of Mumbai’s Health

The NGO Praja Foundation’s latest report raises many, many red flags on the state of health of Mumbai. Despite being the financial capital, Mumbai ranks poorly on many key health indicators.

The number of dengue cases has gone up by nearly 117% from 2011 to 2015 and the number of people dying of dengue has also doubled in the same period. TB continues to be a major threat with the disease claiming 7000 lives a year.

This is despite the fact that the Brihanmumbai Municipal Corporation spends nearly Rs 220 crores every year on public. Clearly there is little to show given the enormous sums spent.

Some of BMC’s initiatives like the fight against malaria are showing results. Malaria figures have stabilized due to the Fight the Bite campaign but a lot more needs to be done to eradicate the disease. Most critical is to look at improving the BMC’s surveillance system. BMC records for 2015 show just 16 malaria deaths. On the other hand, the Public Health Department issued death certificates in 92 cases where the cause of death was malaria. There is a similar discrepancy in TB figures within the BMC departments.

Apart from revamping the surveillance and reporting systems, the report also highlights the need to strengthen the public health system, which is hopelessly inadequate to meet the needs of the city’s population. Most people opt for public hospitals as they are affordable but there is a severe shortage of staff, from doctors to nursing staff.

One of the UN’s sustainable development goals (SDGs) is to end the spread of water-borne and communicable diseases by 2030. It’s a commitment that India too has made. And if this is the state of health in a city that is considered to have the best public health system in India, then the government needs to take a relook at its health priorities.

 

Strong case for a nationwide “fat tax”

For the first time in India, the Kerala government plans to impose a “fat tax” of 14.5% on branded food chains and restaurants selling food like pizzas, burgers etc.

The announcement has evoked strong reactions.

Some have dismissed it a meaningless move that will not help achieve the stated goal of reducing the consumption of junk food and cutting down obesity-related illnesses. Others have called it yet another excuse to tax the middle and high-income groups.

The argument in favour of such a tax in Kerala is compelling. National Family Health Survey figures show that after Punjab, Kerala has the second highest number of people suffering from obesity.

How far the fat tax will change this scenario, only time will tell. There is no denying, however, that the move has helped focus attention to the growing epidemic of obesity and lifestyle diseases in India.

As the 2016 Global Nutrition Report highlights, the number of overweight or obese people is rising everywhere, leading to a spike in diabetes and other lifestyle-related diseases. One in 12 people worldwide have diabetes while nearly two million are obese or overweight.

Some health experts in Karnataka are calling for the state government to follow Kerala’s move and impose a fat tax as well. But they are asking for the tax to be extended to Indian snacks and foods like puris, bhajiyas and namkeen as well. Experts also say that while the tax can change behaviour by pushing people towards healthier options, tacking obesity calls for a larger behaviour change that can only be achieved through greater awareness of nutrition and healthy routines.

 

Pregnancy prevention is still a woman’s problem

An RTI report has uncovered that a total of 26 women died while undergoing sterilization in Mumbai over the past five years, ten in 2015 alone. They went through a tubectomy, which has been the mainstay of India’s family planning program since Independence, a method that the government has promoted as safe, reliable and effective.

Yet time and time again, come reminders like this one of how perilous the procedure can be, especially when the women have persistent and deep-rooted health problems. The most heartrending was the aftermath of a government sterilization camp in Bilaspur, Chhatisgarh in 2014. Thirteen women died and over 120 left with serious health problems after the procedures were botched up due to poisonous medicines and medical negligence.

Be it a rural health camp or a thriving metropolis like Mumbai which reportedly has better access to healthcare, the point is that female sterilization is fraught with risk and there has to be a move away from pushing this. Since April this year, the Ministry of Health has finally introduced the much talked about basket of choices in family planning methods across district hospitals, an acknowledgement that a move away from female sterilization is long overdue.

However, making those choices available is a challenge, especially in rural areas. Making sure that stocks of contraceptives are made available at hospitals and primary health centres is just one part of the challenge. Creating awareness and counseling is also an important aspect.

These are demands that cannot be met adequately given the huge shortage of health workers and doctors across urban and rural areas. The main reason why sterilization continues to be used so widely is because it is a gunshot intervention. It requires no follow up, any check ups or counseling over a period of time, which makes it a popular choice with the medical staff.

The same BMC data for Mumbai also tells an interesting story. Between April 2015 to March 2016, 18,910 women in Mumbai underwent a tubectomy, as opposed to just 810 men who opted for vasectomies in the same period. This is despite considerable evidence that vasectomies are less invasive and require less post surgery care.

All this points to how women are so disempowered when it comes to childbirth. She has no say on when, or how many children to have; yet when it comes to preventing a pregnancy, it remains entirely her problem.

“Vasectomy and safe family planning methods need to be aggressively promoted if we care about women’s health”, says Dr Vijaya Sherbet, a gynecologist at Bengaluru’s Columbia Asia Hospital. “That sense of empathy, of political will has been largely missing.”

Signs of a change are evident. Tubectomy rates are down and doctors at government hospitals are promoting alternate FP methods. But this is in Mumbai, the financial capital. Rural India, or even the outskirts of Mumbai city offer an entirely new set of challenges.

 

 

Why are so many children dying in India?

Around 1.2 million children under five years died due to reasons that were entirely preventable according to the latest Unicef report released today.

The report says that most of the deaths were due to diseases that could have been treated and that India is among five countries that account for half of the nearly six million under-five deaths reported worldwide in 2015.

The other four countries are Democratic Republic of Congo, Ethiopia, Nigeria, and Pakistan – all of which have economies much smaller when compared to India’s.

The biggest killers In India are premature and neonatal birth complications, followed by pneumonia, diarrhea and sepsis.

What is disturbing is that two of the countries in the list, India and Nigeria, are on the fast track of growth economically, but are poor performers when it comes to reducing child mortality.

While India’s under-five mortality rate has improved to 48 per 1000 deaths from 126 deaths in 1990, there is a lot left to do.

Even Nepal and Bangladesh have a better under-five mortality rate compared to India.

Diseases like diarrhea can be prevented if sanitation measures are improved. As the Unicef report says, while 94% of India’s population has access to clean drinking water, toilet facilities are available to just 40%.

There is also a need to relook at how schemes like ICDS are performing on the ground to address the loopholes that come in the way of bringing down child deaths. In many states, the functioning of anganwadis has been crippled due to the lack of resources, staff and theft. This is true not just for remote villages but even areas in suburban Mumbai.

While worldwide, under-five mortality rate has come down dramatically, there is need to focus on those who slipping the net. Unless that is done we are looking at 69 million children dying of preventable causes by 2030, many of them in India.

An app that is saving women’s lives in Dharavi

One of the most positive fallouts of the rapid mobile phone penetration in India has been the impact on education and health in rural India. These are parts of the country that have been left out of the benefits of the economic boom and progress seen in urban parts, either due to poor infrastructure or lack of political will. Be it apps that provide health updates or learning tips, start ups are coming up with creative, innovative ways to reach a constituency that was regarded as difficult to access for the longest time.

One such initiative that has received much attention, and for the right reasons, is SNEHA’s Little Sister project that deals with the sensitive subject of domestic violence. DV is rampant in India but has never been given the attention it needs given the scale as most women do not report it. Many of them don’t even see it as an issue as a nationwide survey in 2013 found out. Over 50% of women said it was justified on many counts.

Apart from being a human rights issue, DV is also a health issue. It impacts women’s health in a myriad ways – from causing Post Traumatic Stress Disorder to depression and even affecting maternal health outcomes. Also think of the impact on a child who watches his mother get verbally abused or physically beaten up? You are looking at a generation that will grow up to be either abusers or victims of abuse.

SNEHA’s Little Sister app works by offering women in Dharavi a safe space to seek help. It is private, non intrusive and effective. Most victims of DV are not looking to walk out when they seek help. Often they want a shoulder to cry on before deciding what to do next. Little Sister does just that. It allows the woman to set the pace. Its the comfort of reaching out to someone who you do not have to see again if you don’t wish to and who will not judge you, or your situation.

To find out more about the Little Sister project click here. There is a video link about the project as well. 

 

 

 

Telangana polio scare indicates flaws in immunization program

This week Telangana declared a global health emergency after an active strain of a polio virus, but one derived from a vaccine, was detected in water collected from a drain in Hyderabad. Two lakh vaccines from Geneva were flown in to vaccinate children in Hyderabad as a preventive measure.

The scare is unlikely to make a dent on India’s claim to be polio-free since 2011 as this is not a direct case of polio.The strain found is from the oral polio vaccine, which contains a small amount of the weakened virus that stays in the child’s intestine and helps develop immunity. India can justifiably feel proud of its campaign to end polio, which was a long and tough battle to win.

However, there are concerns about the larger immunization program, as a recent study by the University of Michigan has found. The study says that two thirds of children under five years of age in India had not been vaccinated at all, or had not received the dose prescribed on time.

Every year, in India, over 1.5 million children die due to diseases that can be prevented by vaccines. While the Universal Immunization Program has helped reduce the numbers substantially from the figure of 120 in the nineties, the current figure of 48 is still high. And one possible explanation could be that vaccines are not being given on time.

Experts say that typically a child’s natural immunity after birth starts falling by the time it is  nine months old and it is critical to administer crucial vaccines like measles and rota virus in this period. Delaying this even by a few weeks, not only makes the child vulnerable to the disease, but also other infants in his or her proximity.

Ignorance among new mothers and poverty are major factors for the delay as is the lack of immunization records. Issues that initiatives like mMitra and Immunize India are attempting to address by taking rising on the mobile technology spread across India. Initial results from these initiatives show a lot of promise and given the many challenges of providing healthcare to a country as vast as India, technology innovations like these show the way forward.

Global Nutrition Report paints a dismal picture of India

The Global Nutrition Report, is the annual report card on the the world’s nutrition levels, and documents how every country is doing in its efforts to improve it. It looks at how each country is going about meeting the targets established as well as the steps taken that have proved to be effective in fighting malnutrition.

Nutrition is key to meeting all the 17 sustainable development goals (SDGs) and having a population that is stunted or undernourished can have a crippling effect on a country’s economic progress and social development.

Which makes the 2016 Report a major cause for concern for India. It says India is way off the mark when it comes to meeting the targets set for reducing stunting,  anemia and diabetes. India stands at 114 for under-5 stunting out of 132 countries, 120 out of 1320 countries for under-5 wasting and 170 out of 185 countries for anaemia. The report says that India needs to increase expenditure on nutrition by $700 million if it wants to meet targets.

Not all the news coming from India is bad. Breastfeeding rates are up and India has reduced child malnutrition rates considerably. Stunting, which is linked to frequent infections and insufficient nutrition intake, is also falling at twice the rate it was 10 years ago. but the reports are disparate across the country. Uttar Pradesh and Bihar have made the least progress when it comes to stunting.

Another factor for concern in the report is the rise in diabetes and overweight conditions among adults, which are also indicators of malnutrition. What is lacking is a national strategy that aims at combating all the indicators of malnutrition.

Experts say India’s stunting problem stands for the largest loss of human potential in any country and the crisis is growing with under-nutrition coexisting with over-nutrition and the rise of non-communicable diseases.

Not enough in this budget for Family Planning

Among the most widely reported statements at the International Conference on Family Planning held in Indonesia in January this year was that of the Indian Health Minister JP Nadda who said that the country was committed to meeting the FP2020 goal of providing 48 million additional women and girls with access to modern contraceptives by 2020.

A global partnership, Family Planning 2020, works with governments, civil society and the private sector to enable women and girls to make decisions regarding if, when, and how many children they want.

The Indian Health Ministry team also announced that women would have access to better quality family planning services. A promise that is being met with. Since April, injectable contraceptives and pills are being supplied to all district hospitals across the country.

However, the recent report by the Population Foundation of India points out just how distant that goal of recahing 48 million women and girls is.

While the provision for health in 2016 has grown by 22% over 2015, with FP seeing a substantial increase of 67% compared to previous years, health remains hugely underfunded in India. The rise this year, it points out, is insufficient to compensate for the whopping 54% decline in allocations to family welfare between 2013-14 and 2015-16.

Meeting the 48 million number needs more than simply expanding the basket of choices. It needs awareness campaigns and better rural health facilities to ensure that babies and mothers survive. Campaigns have to be tailored to meet the specific challenges that a country as varied as India throws up.

While the shift away from female sterilization is welcome, there seems to be widespread official myopia in acknowledging just how deep the links between family planning and broader development goals go, and this is disturbing.

Making girls count: Why open data matters in gender development

“Closing the gender gap is not possible without closing the data gap.” – Melinda Gates

One of the key announcements to emerge from the ongoing Women Deliver 2016 at Copenhagen is the launch of a new data and research partnership to monitor and drive progress on gender targets outlined in the Sustainable Development Goals.

Key to meeting these new gender targets is reliable and up to date information on women and girls to help ensure transparency, accountability and citizen engagement. In most countries, this data is largely missing or incomplete, be it on child marriages, dowry deaths, domestic violence, the wages women are paid, or why and how many girls are dropping out of schools. Having the data helps set concrete plans and goals and hold governments accountable.

This is especially critical in these times given the global financial crisis, natural disasters and widespread political instability. Take climate change related disasters for instance. There is evidence to show that every such crisis affects men and women differently. This is especially the case in developing countries where women face greater risks to life and health due to social structures. However the lack of adequate data to support this differentiated impact means they don’t get taken into account at the policy level.

“Making all girls visible in statistics is a critical first step towards holding governments to account and implementing the girl-focused global goals”, believes Anne-Birgitte Albrectsen. CEO of Plan International, which is one of the groups leading the joint research initiative. Progress on gender equality goals are slow because there are no numbers to track it. “We do not adequately measure the number of girls who leave school due to marriage, pregnancy, or sexual violence, simply the number in school. Millions of girls are left invisible”, adds Albrectsen.

This invisibility supports the attitude that girls and women simply do not count. Having hard numbers for where they live, what they go through and what they want will help bring down that wall.

 

Water crisis has links to women’s rights & economic progress

Just how grave the water shortage in India is brought out in IndiaSpend’s latest report, which says that India is facing the worst crisis in a decade, with the shortage likely to create drought-like conditions in many parts of the country.

We are already seeing the worst of it in many regions. Farmers in Bengaluru led a protest over water scarcity that lasted days. The water crisis in Karnataka is affecting Tamil Nadu and Andhra Pradesh, which are among the states that will be worst hit this year.

The impact of this scarcity will be felt most by women and children, especially girls, on every count, be it health, education or nutrition.

In Bundelkhand, Uttar Pradesh, the acute drought has led to an alarming drop in nutrition levels. 86% homes have cut down on dal intake, while 84% have cut down on milk for their children.

The threat of food scarcity is not limited to Uttar Pradesh alone given that there is not enough water to irrigate farmlands. So we are looking at a potential food shortage across the country.

Clean water affects education. It helps keeps children in schools. This is especially true of girls because in rural India, the task of fetching water still remains the primary responsibility of women. Families in Marathwada, in rural Maharashtra, which is facing severe water scarcity, are pulling their children out of school so they can help fetch water.

Perhaps the biggest concern is the impact on health. The acute shortage of safe, drinking water will lead to a spiralling of diseases like diarrhoea. There are over 300,000 diarrhoea-related deaths in the world every year. 45% of them are from India.

Access to clean water is not just a supply and demand issue. It has links to women’s rights, maternal and infant health and overall economic progress. Its time we looked at water from a larger perspective rather than battling it from season to season.

 

Quiltessentially SNEHA – Threads that bind and empower

As you walk into the exhibition of Quiltessentially SNEHA, the thought that strikes you is how the sea of rich patterns and intricate weaves is such a powerful expression of SNEHA’s work; conveying both the range of its outreach work and the ties it builds in the communities it works in.

Quiltessentially SNEHA, the livelihood project started in 2009 by the Society for Nutrition, Education and Health Action, aims to equip women in slums with various skills that will strengthen them financially

“I was supervising a tailoring class for adolescent girls and women and that’s when the idea came about. We thought why not start a small unit that makes patchwork quilts”, says Naina Fernandez, project director.

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Naina Fernandez, Project Director & Seema Singh, Volunteer

Initially she relied on fabrics donated by clothing and furnishing stores that usually have large swatches left over.

“We taught the women basic stitching skills and we had some sewing machines and we were set to start”, she says.

The women would put the pieces together guided by creative inputs from Fernandez.

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This is how it all started, with patchwork quilts

Some families took a little convincing at the start.

“There was this young girl who was really talented but in the early stages, the earnings weren’t that good”, says Fernandez. “Her family pulled her out because they felt she was better off working as a domestic help. I stepped in and insisted that she had a gift and they should not stop her from coming to the center”.

From quilts, the range of products has expanded way beyond to dupattas, bathroom mats, bedspreads and cushion covers. And then there are the small and thoughtful items like pouches for sanitary pads, an idea that Fernandez says came from school-going adolescent girls that SNEHA works with.

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Pouches for sanitary pads

The designs are never repeated so each product is unique. The demand for the products is huge, especially among corporate houses.

The project employs about 40 girls and women, with 13-15 working on a shift basis. The timings are flexible as many have young children or elderly in-laws to look after. On an average, each person earns upwards of Rs 5000 a month.

Income that Manali, one of the earliest members, says comes in handy, especially when finances run low.

“My husband is a BEST driver and he earns decently but we used to feel the pinch when my children needed books or clothes. Now I contribute and ease the financial burden which makes me feel great”, says Manali. “I am able to support my family”.

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Manali (right), among the early members

Above all, the project offers a safe space for women to get together and bond over shared experiences and issues.

“We stitch together, we share, laugh, chat, give each other advice and in the process feel lighter”, says one of the project members.

 

“I can often hear them giggling loudly as they work” laughs Fernandez. “People in the nearby units tell me these people make such a racket. So I know they are in a happy space.”

 

 

How Climate Change Impacts Women More

Amidst the stream of news reports on the severe drought across India, here is one that didn’t make it to primetime.

It’s the story of Yogita Ashok Desai from Maharashtra’s Beed district who died of a heat stroke. The 12-year-old was dehydrated and collapsed after her fifth trip to the village hand-pump to fetch water. Just last month,  a 10-year-old girl from Pimpalgaon village, also in Beed district, died after she fell into a well while trying to draw water.Both girls had been pulled out of school to help their families cope with the severe water scarcity.

The reasons for the worsening drought are many; many of them manmade like the indiscriminate digging of borewells and the cultivation of water guzzling crops. Decisions that women had little to do with. excluded as they are from choices relating to irrigation systems or what crops to grow. However, they are facing the worst impact.

A recent World Bank report, Shock Waves – Managing the Impacts of Climate Change on Poverty, highlights how ending poverty and addressing climate change is key to achieving sustainable global development. Addressing climate change is critical as it directly impacts availability of food and heightens health risks.

Most vulnerable are the poor and marginalized, and within that group, women and children. There are various studies that show that women, especially in developing countries like India, suffer the impacts of natural disasters and climate change more due to cultural norms.

In rural areas, women rarely work and are economically dependent on their husbands for survival. Faced with a severe drought, men have the resources and the independence to find ways to adapt. Women are denied those options.

Faced with a shortage of food, women place their husbands’ and sons’ needs above theirs or their daughters’, making them vulnerable to diseases.

Faced with income or food crunch, girls’ get hit the hardest. They get pulled out of school and are expected to help with the household chores. Their nutrition and health gets neglected. Climate change also affects availability of water. Women and girls’ are expected to fetch water for the family, often traveling long distances to do so.

As Rachel Yavinsky points out in her 2012 study, their secondary role and lack of decision-making power severely limits women’s ability to adapt to climate change.

“Without participation by women, programs to replace traditional crops with those better suited to the changing environment might focus only on the needs of men’s fields and not address the problems women face with household gardens’, says Yavinsky.

She points to various studies that demonstrate how women can be effective agents of adapting to climate change if equipped with information and power. In Bangladesh, for instance, women farmers switched to raising ducks because they kept losing their chickens to frequent floods.

Empowering women, especially rural women, is necessary to address climate change effectively. Climate change will affect all os us, most of all women, and unless we empower them, building a sustainable future will remain a distant dream.

Pyaari Meenu -Telling SNEHA’s story through the letters of a young girl

How does one even begin to express why investing in women’s health is so vital?

Be it reducing maternal deaths, improving infant and maternal health, family planning, or tackling domestic violence, a healthy woman is at the core of a prosperous urban world, and this is effectively conveyed in Pyaari Meenu, the film by Social Access on SNEHA’s efforts to build strong, healthy and secure urban communities.

Bringing together SNEHA’s various community interventions is not easy. However, Pyaari Meenu weaves those strands together quite beautifully.

“Our challenge was to convey all the program interventions they undertake in one central thought” says Lynn De Souza, founder, Social Access, “and we did this by stepping back and driving home the underlying premise, the belief that empowers all their work. This came through in the tag line “A healthy world begins with a healthy woman”. Even men get included in this thought!”

Pyaari Meenu uses the form of letters written to an unborn child to convey these ideas. “Letters are always a nicely emotive way to tell a story from a personal point of view. They draw the viewer into the experience, as observer and participant,” adds De Souza.

Shooting the film came with its own set of challenges as the milieu had to be real to bring home a sense of the community that SNEHA works in. Pooja Das Sarkar, who directed the film, says it was shot in just one day over 17 hours, remarkable given the noise and chaos that is present in any urban settlement.

“We chose a two-storied house – one to show the life stage of a younger girl, and another to show the older woman”, says Das Sarkar. But the challenges remained. “We chose lights that were small and could be used in a smaller space. At night, people were very curious and stood outside the house commenting on “Who is the heroine”? etc. It was funny but natural and we did not let it affect the shoot.”

Helping to make the process smoother were SNEHA workers. They explained to local residents what the film was about. “We sourced the kitchen, a baby’s cot and even a baby from the community”, adds Pooja. SNEHA staffers were also roped in to act, with Nasreen playing the key part of Bharati Didi.

The result is Pyaari Meenu – a haunting, evocative film that helps the audience understand SNEHA’s work and makes an emotional connect.

 

 

 

International Day for Maternal Rights – Time to Act

This week the world marked the second International Day for Maternal Health and Rights. High time the world paid attention to maternal health given that even today, in circa 2016, a woman dies in childbirth every two minutes. Clearly there is a need to promote and set up a comprehensive and rights-based approach to maternal health.

These rights are abused in many different ways, be it in terms of lack of access to quality health care during pregnancy, lack of information on birth control and availability of methods, or the abuse and disrespect that women are subject to during pregnancy and childbirth in hospitals and primary health centres.

Applying a human rights-based approach requires policy makers and health care providers to see women not as clients or patients or victims, but as those whose rights should be maintained and upheld in the context of health care.

It’s an approach that has been missing in the Indian government’s single-minded focus on increasing institutional deliveries. Broader sexual and reproductive health issues like access to safe abortion, setting up of adolescent friendly services, access to pap smears and mammograms, and promoting gender equity in family planning have been mostly neglected.

While nationwide surveys may show the maternal deaths rate declining, the statistics bury some hard realities. Anemia, which has a direct bearing on maternal health, continues to affect over 55% of Indian women. The poor and the marginalized face discrimination from healthcare providers. Caste continues to dictate access to immunization and other factors that help determine safer pregnancies.

These are factors that cannot be addressed by simply increasing the number of hospitals, healthcare providers or contraceptive choices. While structural changes like building stronger health systems makes a difference, maternal mortality is closely linked to development and cultural factors that are harder to change. Parts of the bigger picture may have shown some improvement, but what is missing is a rights based approach.

Addressing the nutrition challenge

Just how poor nutrition levels are among Indian children has been highlighted yet again; this time in IMRB’s recent survey across ten Indian cities.

According to the report, one in three children in these cities misses school for about 50 days a year due to persistent health issues, ranging from cold, cough or skin irritation – a telling sign of poor immunity levels.

The children surveyed were between the ages of 6 to 14 years. Many had even missed exams due to a nagging health issue.

Apart from the health concerns, the findings throw light on the financial implications. Three out of ten mothers said they went to the doctor at least once a month to get their child treated and spent about Rs 850 a month on medicines.

This comes just a few months after The Lancet published a report on how despite its economic progress, India continues to do poorly across health indicators. The report rated India’s performance as the worst among the BRICS nations (Brazil, Russia, India, China and South Africa). Not just that, it is far behind poor countries like Nepal and Bangladesh.

The Lancet report specifically highlighted how low body weight and stunting remains a serious concern in India.

Lack of awareness about what the link between nutrition and immunity levels is a big part of the problem. Parents, in both middle class and lower middle class homes, rely on processed foods, unaware of just how harmful they are for health. Consumption of fruits and vegetables is practically non-existent. There is emphasis on the quantity eaten, rather than quality.

All this points to a need to implement programs like AAHAR aggressively on a national scale. Under this program started by SNEHA, yearly camps are conducted across Mumbai slums where counsellors talk to mothers and grandmothers in the community about why cooking food fresh and fruits and vegetables matter. Healthy cooking practices are also demonstrated.

Given the low level of understanding of nutrition and the attractive, overwhelming presence of junk food, there is a need to find creative ways to address the nutrition challenge effectively.

Even rich countries are battling this, even if its from a different spectrum. In the US, for instance, no less than First Lady Michelle Obama has taken up the nutrition challenge, demonstrating cooking methods and exercise techniques on TV and social media. Her goal, is specifically children and the youth. Its high time India’s leadership showed similar commitment to the health of our children.

Zika outbreak: Lessons for India

The fear and panic over the spread of the Zika virus disease has helped highlight the inadequacies many countries face in providing family planning and reproductive health services. The outbreak may be far from India’s shores, but those lessons hold true for us as well.

Zika has been declared a global public health emergency. There are fears, not entirely proven, that it is linked to birth defects in babies whose mothers contract the virus during pregnancy. Over 3000 cases of microcephaly—an oddly small head and an immature brain—have been reported in Brazil.

Given that the virus is spreading rapidly, with no proven vaccine in the horizon, women who are pregnant, or are likely to become pregnant, are in a spot.

In many of the countries affected, abortion is illegal. In some regions, contraceptives are in short supply. But going by the statements coming from political leaders, the onus seems to be entirely on women.

In El Salvador, women have been told to postpone getting pregnant for up to two years. How will they given that it’s not always accessible?

The public health system in many of these countries is in a poor state, much like in India. Rural areas, which are understaffed, are worse off. Again, much like in India. There is also great stigma attached to contraception.

Like India, the societies in many Latin American countries are deeply patriarchal. Cases of rape, including marital rape, are high. So where is the question of women exercising the choice to not get pregnant?

Zika is already out of the headlines, swept away by another crisis in another part of the world. But the outbreak has thrown up relevant questions. Like the need to build a strong public health infrastructure, make available a range of contraceptive choices, and most important, empower women to exercise those choices.

 

 

How Aahar is making a change: A community speaks

Approximately 50% of children under 5 years are malnourished in India. Nearly 39% are stunted, that is low in height for their age. And in the financial capital Mumbai, 26000 children die every year because of malnourishment.

Aahar, which means food, is a program that combines home-based and facility-based care to reach out to a large number of vulnerable children in need of monitoring. In order to make maximum impact, it reaches out to mothers when they are pregnant and  addresses nutrition and feeding practices throughout the first 1,000 days of child’s life. The program was launched in Dharavi, Mumbai’s largest slum colony in 2012 by NGO SNEHA, and works in partnership with the Centre’s Integrated Child Development Scheme, the Municipal Corporation of Mumbai and the Lokmanya Tilak Municipal General Hospital.DSC_0395

This week SNEHA will felicitate the many champions that help Aahar make a difference. A series of events will be held to honour the dedication and commitment of mothers, the municipal staff and community workers.

 

Here are some of those voices:

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Mukesh Kumar Jaiswal

Mukesh Kumar Jaiswal, 25

“I was 21 years old when I got married and I have two young children. My children used to fall sick very often when they were babies and my wife and I struggled to cope. We gave them whatever was cooked in the house, sometimes we fed them chips and biscuits. It was only when my youngest was nearly 6 months old when we realised that what they eat makes a substantial difference to their health. This was after SNEHA workers came to our area and held camps. They talked about the importance of breastfeeding and immunisation and it made a big difference to our children’s well-being and those in the neighbourhood as well. 

It is not like children don’t fall sick now. They do but not as often as they used to. We not only feed our children green vegetables, dal and fruits, but we eat healthy too”

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Renuka Kadam

Renuka Kadam, Community Organizer, SNEHA

“I started working in Dharavi 4 years ago and it was initially very hard to convince the families here to change their habits. They did not understand the importance of eating green vegetables, fruits and protein. We received a lot of support from the local anganwadi where these women would gather. Gradually they started to trust us and attend our sessions.

There was no awareness of the importance of breastfeeding. Most women would not nurse their babies due to misconceptions and myths so we had to work a lot on that aspect. They did not understand how important it is to take adequate rest, eat regular, nutritious meals while pregnant or take vitamins and supplements so their babies are healthy. They are so busy taking care of their families that they forget to look after themselves. They forget to eat. So we draw a clock on a sheet of paper and mark out the hours when they should eat. 

We hold camps twice a month when babies are weighed and their growth is recorded in charts. As the mothers see the improvement they are convinced. We also advice them about spacing babies and the various contraceptive methods.

From the time we started Aahar, there has been a big improvement in baseline indicators. But the challenge remains. Dharavi is home to a large migrant population so we have to monitor constantly”.

 

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Sangeeta Gupta

Sangeeta Gupta, 30

“I have three children and earlier I would never bother too much about what I fed them. If I could cook a meal I would. Otherwise I would give them some money so they could eat chips or biscuits. After SNEHA’s camps I have changed. I always give them a dabba for school with vegetables and roti or rice. I have seen what a major difference it has made to my children’s health”.

 

Breastfeeding: Promotes a smarter, healthier, equal world

The lives of over 800, 000 children and 20 000 mothers could be saved each year with universal breastfeeding says a new series by the respected medical journal The Lancet.

Breastfeeding leads to fewer infections, enhanced IQ, probable protection against obesity and diabetes, even breast cancer prevention in mothers, says the series which has been hailed as the most in-depth analysis done so far into the health and economic benefits that breastfeeding can lead to. It also highlights that breastfeeding leads to economic savings of 300 billion dollars

The data published is based on analysis led by scientists at the Federal University of Pelotas in Brazil who looked at data from previous research.

Reporting on the findings, The Independent,  a UK daily, quotes the study head Professor Cesar Victora as saying, “There is a widespread misconception that breast milk can be replaced with artificial products without detrimental consequences…. The decision not to breastfeed has major long-term negative effects on the health, nutrition and development of children and on women’s health.”

However, globally, only 37% of children under the age of six months are exclusively breastfed in low and middle-income countries.

Women avoid or stop breastfeeding due to many reasons ranging from medical, cultural, and psychological, to physical discomfort. Turning to formula milk, which is heavily pushed by multinational companies and many hospitals, becomes a convenient option.

There is a need to create a supportive environment for a mother who is breastfeeding says Dr Armida Fernandez, Founder, SNEHA. This includes addressing the many myths and misconceptions that are still widely prevalent.

“Mothers, and this includes women from poor backgrounds, want to breastfeed their babies. But if their baby keeps crying, and this happens due to many reasons, they feel it’s because they are not producing enough milk and so they resort to formula or diluted cow’s milk leading to malnutrition”, says Dr Fernandez.

She believes that doctors need to aggressively and consciously encourage breastfeeding.

“I find many doctors do not support it at all. The moment the baby is a little underweight they tell the mother to start a top feed. “ Dr Fernandez suggest that health centres and clinics must have counsellors on their staff who actively encourage women to breastfeed.

Currently India is still some distance away from reaching its targets on improving infant nutrition as per an assessment report by the Breastfeeding Promotion Network of India (BPNI) and Public Health Resource Network (PHRN) published in late 2015.

The report says that nearly 15 million babies, who comprise of 55% of newborns in India annually, are deprived of optimal feeding practices in their first year after birth.

The assessment also points to gaps in policies and programmes outlined for enhancing breastfeeding rates. Countries like Afghanistan, Bangladesh and Sri Lanka fare better than India in comparison.

Aggressive promotion of baby foods by companies, lack of support to women in the family and at work places, inadequate healthcare support, and weak overall policy and programmes were some of the reasons identified as responsible for lack of improvement in infant and young child feeding practice indicators.

 

No quick fix solutions for child stunting in India

Why despite years of economic progress India continues to report high rates of child malnutrition has been a matter of endless discussion. One that has received renewed attention following the announcement that the 2015 Nobel for economics has gone to Angus Deaton.

Much of Deaton’s work has revolved around India, covering issues like nutrition, poverty and health gaps. Alongwith fellow welfare economist Jean Dreze, Deaton has analyzed the reasons why under nutrition levels in India are consistently higher than far poorer countries in sub Saharan Africa.

Nearly 39% of children in India are stunted due to poor nutrition. Two of five stunted children in the world are in India, making it the epicenter of global malnutrition. India reports a far higher figure than Burkina Faso or Haiti.

Stunting, which is the fallout of chronic malnourishment, has permanent consequences. It is accompanied by a host of problems – poor immunity, risk of disease and a greater risk of dying before the age of five. On the whole Indians are stunted compared to people in most countries, including Africa and China.

It’s not just a question of a shorter height than normal, but is a marker for an array of developmental problems, explains Dr Armida Fernandez, former dean at Lokmanya Tilak Municipal Hospital, one of Mumbai’s largest public health facilities.

“When you are short there are many things that are affected”, says Dr Fernandez. “The brain is not developed and as the child grows older, there is the risk of early onset of diseases. Children who are born small run the risk of hypertension and diabetes.”

The impact on brain development is a cause for great concern and is seen as an explanation for why stunted children drop out of school early.

There are many factors responsible like poor maternal nutrition, poor feeding practices, substandard food quality as well as frequent infections. However, nutritional interventions are only a part of the solution because stunting also occurs among well-fed children. Lack of access to adequate hygiene sanitation and clean drinking water are compelling factors as well. The WHO estimates that 50% of malnutrition is associated with repeated diarrhea or intestinal worm infections from unsafe water, poor sanitation or hygiene.

Studies have also shown that women’s roles play a strong role. The low status of women in India means poor levels of maternal nutrition. Many children are therefore malnourished in the womb itself.

“We need to look beyond just the lack of toilets”, says Dr Fernandez. “We need to look at the quality of food girls are given, women’s health, domestic violence and what a mother undergoes during pregnancy. There is no simple cause and effect factor for stunting”.

Tackling child malnutrition the Aahar way

A few months short of his first birthday, Sushma’s firstborn died. Underweight at birth, Vicky was always sickly and suffered from frequent diarrhoea.

A ragpicker, Sushma lives in Govandi, home to one of Mumbai’s largest slum colonies and an area that reports a large number of malnutrition-related deaths.

According to a recent study, 6000 children die everyday in India and nearly half of them are malnutrition-linked. Mumbai alone reports 26000 deaths every year.

“The maximum deaths due to malnutrition take place between six months and two years”, says Dr Armida Fernandez, founder-trustee, SNEHA, the Society for Nutrition, Education and Health Action, a Mumbai-based non-profit which seeks to address the needs of women and children in urban, underprivileged communities by working with the public health system. “The problem is that the ICDS program takes on children after they turn three years old and by then the damage is done”.

ICDS or the Integrated Child Development Scheme is a government welfare program that provides food and health facilities to children below the age of 6 as well as their mothers.

The problem, experts say starts as at a very early stage.

SNEHA at a home in Dharavi, Mumbai
SNEHA team at a home in Dharavi

“Girls are often treated as less valuable and their health and nutrition is accorded low priority,” says Shreya Manjrekar, a program coordinator with SNEHA. “When she gets pregnant, her poor nutrition level affects the baby.”

Early marriage and high teenage pregnancy rates add to the problem. And compounding it is the lack of awareness about exclusive breastfeeding and nutritious diet.

Exclusive breastfeeding for six months after birth is widely established as an effective way to reduce malnutrition and ensure that every child has a fighting start in life.

Not only does early and exclusive breastfeeding help children survive, it also supports healthy brain development, improves cognitive performance and is associated with better educational achievement at age 5. Breastfeeding is the foundation of good nutrition and protects children against disease.  In this and many other fundamental ways, breastfeeding allows all children to thrive and develop to their full potential

Breastfeeding also contributes to maternal health because it helps reduce the risk of post-partum haemorrhage after delivery.  In the short term, it delays the return to fertility and in the long term, it reduces type 2 diabetes and breast, uterine and ovarian cancer.

SNEHA frontline workers in action
SNEHA frontline workers in action

Yet myths and misinformation regarding breastfeeding are plenty.

“I did not nurse my children but fed them cow’s milk because that is better for health. I told my daughter-in-law to do the same” says Alka, Sushma’s mother-in-law.

Her neighbor Usha adds, “I started nursing my daughter three days after she was born because the first milk is dirty and it should be thrown out”. She has never been told that the first milk or colostrum contains antibodies that are essential to build immunity.

The impact of this lack of awareness finds reflection in India’s infant mortality rate. At 1.34 million under-five deaths, India reports the highest IMR according to a 2014 UN report. Many of these deaths can be prevented with breastfeeding.

“A major problem we see is that of stunting”, says Dr Fernandez. “Babies in India are getting shorter”. This too is attributed to under-nutrition in the first 1,000 days of a baby’s life, including during gestation.

To bust such myths and promote nutrition in this crucial 1000 days period, SNEHA holds yearly camps called Aahar in areas that are home to a large number of informal settlements or slums.

One in six of Mumbai’s population lives in slums, and many of them live under the threat of constant displacement. Like Sushma, they have no fixed means of income and often travel long distances for work. In such a scenario, food takes the lowest priority.

Pitting two food options against each other
Pitting two food options against each other

By using innovative strategies and tools like flash cards, puzzles, games and videos SNEHA counselors work with the ICDS staff to promote awareness about breastfeeding techniques, complementary feeding, and healthy cooking practices.

What makes for a nutritious diet?
What makes for a nutritious diet

Apart from this, SNEHA also holds workshops and sessions where they directly engage with the communities. “We do this through home visits and group meetings where we demonstrate healthy methods of cooking”, adds Manjrekar.

“We reach out to not just mothers, but all the women in the community because the decision on what to feed is not entirely in the mother’s hands. The in-laws play a big role”, says Anagha Waigankar, associate program director, Aahar. “We also educate the mothers about immunization, hygiene and care during illness because if the women change their habits about cooking and child care, it benefits the entire family.”

An internal impact assessment report by SNEHA shows a 35% reduction in wasting through 2 ½ years of intervention.

India’s urban population is estimated to double to over 800 million over the next five years. A quarter of them, nearly 200 million, will live in poverty, in slums like Govandi.

The solution to tackling child malnutrition lies in models like Aahar that can be scaled up to tackle a critical public health issue that has direct economic implications on India’s national growth.

Promoting breastfeeding

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On the occasion of World Breastfeeding Week, SNEHA organised three rallies at Dharavi on August 2. All the 79 community organisers, and others who work with the Aahar project of SNEHA, came out in support of the message. Nearly 150 people attended the rallies

“We spread the message of breastfeeding in the rallies. We told women that it is very important to breastfeed the first half hour of birth, and then exclusively for the first six months. There were some women from the community too who came and asked us questions. Our staffers counselled them on the issue, “said Dr Ganesh Mane, programme co-ordinator, Aahar.

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The rallies had the support of our civic officials, and especially the doctors of Lokmanya Tilak Municipal General Hospital. In fact, Dr Alka Jadhav, professor of department of Paediatrics, with Dr Neeta Naik at LTMG Hospital, Mr Nandepalli, an ex-corporator from BMC, and Mr Gaikwad, CDPO, Dharavi block inaugurated the three rallies.

Iron boost

After being told that both her children- Rahul, 13, and Pratik, 11, are anaemic, Meena Shukla is now constantly looking for iron-rich foods to feed them. Through a SNEHA programme at Janata Colony, Kandivali west, Shukla found out that both her children’s condition, especially about her younger son’s severe anaemia problem.

“My husband is a driver and I have to run the household on a tight budget. I worry about them. The younger one is so thin,” said Shukla.

Shukla was visibly excited when the programme co-ordinator, KK Jayalakshmi told her she could opt for cheaper iron-rich foods such as nachni, drumsticks among others. “I will try out the recipes at home,” she said.

Both children are on iron tablets since February. Since then, Shukla has made some changes in the diet at home (more vegetables and less junk food) and claims that the programme has helped Pratik has gain some weight.

The programme has identified about 150 adolescents who are anaemic in slum. Almost an equal number of boys and girls have been affected by the condition. Anaemia, or iron deficiency is caused by the lack of iron in the diet among others. Its symptoms include tiredness and lethargy, pale complexion, headache and coldness in hand and feet. The programme provides iron supplements for the children suffering from anaemia (which they are supposed to collect each day), regular check-ups, and counselling about how to improve the diet among others.

Nazreen, 17, for instance, would return from college tired and would go to sleep immediately. Her two other siblings, a brother and sister are also anaemic.

“These children do not eat well. Most of them skip breakfast, and directly eat at lunchtime. They also eat a lot of junk in between meals,” said Jayalakshmi.

The community organisers have to coax the children to take the iron supplements. Many complain of nausea, stomach ache, among other side effects and some have even dropped out of the programme. But the community organisers are persistent and counsel them on how to reduce the chances of side effects with the supplements.

Many children and their parents are also happy with the programme. “Two girls who would get very irregular periods have started getting regular cycles now. One girl said she doesn’t feel dizzy any more after taking the supplements,” said community officer, Najma Shaikh.

(Names of the children and parents under the programme have been changed to protect privacy)

Dharavi diaries: The mystery of Aryan’s malnutrition

Healthyurbanworld will be following a severely malnourished child for a six months and note how the programme helps the baby’s development. 

Aryan (centre)
Aryan (centre) at SNEHA’s day care centre

Two and a half year old, Aryan Kothari is sick yet again. Almost every month, he suffers from a bout of diarrhoea or fever with a cold. Aryan is severely malnourished. He weighs just about 10 kgs and is only 86.8 cms tall. He been malnourished for nearly a year and has been in SNEHA’s day care centre at Matunga Labour Camp, Dharavi since September last year. He has been on medical nutrition therapy (a supplement with essential micronutrients mixed with peanut butter) for a few months.

His mother, Lata Kothari, 22, is at her wits end. “He does not eat well. I try so hard. People also say that since both my husband and me are thin, he is also thin,”said Lata. She shares the misconception of many parents who attribute the child’s malnourishment to genes.

Aryan was breastfed well for six months before his mother tried to give him supplementary food. “He just refused to eat anything. At most he would have one or two bites. I still find it very difficult to make him eat,”said Lata. She spends nearly two hours feeding him a small meal (a few mouthfuls, usually). The day care centre teachers too complain that Aryan is a poor eater.

Aryan's mother, Lata Kothari with the community organiser, Kunal
Aryan’s mother, Lata Kothari with the community organiser, Kunal

Aryan’s case is befuddling as his mother tries hard to follow most of the instructions provided by SNEHA community organisers. She tries to give him a nutritious diet and keep both him and his surroundings as clean as possible.

Recent studies have posited that poor sanitation, despite good diet, is one of the major causes of malnourishment. In all probability, Aryan is being exposed to a lot of germs. His house, though spic and span, is couched between a menagerie of houses. The house, which is on a mezzanine floor, has zero ventilation and no light. They need to switch on the tubelight all day long.

Aryan has to climb this steep staircase to enter the house
Aryan has to climb this steep staircase to enter the house

When we entered the house on a rainy day, the passage leading to the house was submerged in water. One has to climb a steep staircase to enter or exit the house, reducing his chances of outdoor exposure.

“We are trying to counsel these parents about how to feed the children and what is good for them. But if their circumstance is such that that they have to live in such unhygienic conditions, it becomes difficult for us to get rid of the problem of malnutrition in such cases,”said Dr Ganesh Mane, project co-ordinator, SNEHA.

A date with the doctor

While examining a 10-month old child at Matunga Labour camp in Dharavi, Dr Bharati Shanbhag chided the mother for stopping vitamin and calcium tonic for the child. “Please tell your husband that these nutrients are important for your child,” she told the mother.

Every month mothers at Dharavi flock the health camps organised by SNEHA. The camps are held at each beat at least twice a month. The check ups are geared towards treating children with malnutrition as well as children with normal growth rate who fall sick.

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Mothers flock for a health check-up at Dharavi

On Wednesday, 13 children were examined by the doctor mostly with monsoon ailments such as diarrohea and other infections. The community organisers at SNEHA inform the mothers at their door steps about the health camp and are compelled to give reminders when they don’t turn up.

Dr Shanbhag who worked at with a public sector undertaking said that handling children in Dharavi is tough because of the community is migratory. “It is very difficult to follow up with these patients. Parents do not follow up on vaccination and check ups,” she said.

The children at Dharavi usually get recurring diarrhoea and other infections which constantly bring down the weight of the child. This is one of the causes of malnourishment.

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SNEHA’s community organisers check the weight and height of children visiting the health camp

“The children start walking and step out of the house picking anything on dirty corridors between the houses to eat. If there is more than one child in the house, the infection spreads easily, she said.

Dr Shanbhag has been working for over a year. “I feel the situation has improved since the past one year. The community organisers who visit them regularly have made all the difference. The immunisation programme is followed better now. Also, the parents have started understanding the importance of sanitation and nutrition, ” said Dr Shanbhag.

The lure of junk food

 

Dotted all over Dharavi are little stores or selling goodies for children. These stores sell potato chips, biscuit packets, instant noodles, and other snacks for as less as five rupees. Children as young as three years in the area frequent these stores to get their regular dose of junk food.

While the phenomenon of junk food leading to obesity is a well known phenomenon in the US, it also has a role to play in urban malnutrition. The easy availability of junk food is a huge problem, especially in places such as Dharavi.

Women in Dharavi who are pressed for time are not always able to devote time for hand feeding children, especially when they are very young. Giving a piece of biscuit is a good way to get a child to eat on his or her own without worrying about the child being hungry. The understanding of nutrition is scant (many do not know what it means) and mothers are usually satisfied if the child eats, irrespective of the quality of food.

Some are even taken in by the advertising and talk about nutritional value of biscuits in particular. Attributing nutritional value to biscuits, some women refer to biscuits as “glucose biscuits”. Some feel that if there is a fruit illustrated on the cover, it has some additional nutrients.

Children are seen scampering towards shops with five or ten rupees in hand asking for either biscuits or chips. They also go to wada pau or bhajia Chinese food stalls Many forgo regular meals (dal-chawal, vegetables, fish etc) for this kind of food with very low nutritive value. In this context the packaging of products targeted to this sector seems deliberate. Shopkeepers say that they sell over 50 packets of biscuits and chips per day.

Community organisers from SNEHA are working hard towards increasing the knowledge of nutrition in the area and the importance of feeding children home cooked food. Many mothers now understand that “outside food” is not always very good, and should try to cook fresh food at home for the children. Some children who are left at the day care centres at SNEHA also develop the habit of eating fresh food which can be nurtured at home. This may go a long way in educating the community about nutrition.

Need for creches in Dharavi

 

Mohan, about 18 months old spends most of his day in the crib in his dingy slum at Dharavi. The crib is in the corner of the tiny room which has no light. His mother spends hours in the mornings and afternoons working as a housemaid. Almost the whole day, the child eats biscuits soaked in milk.

Apart from gross ignorance about nutrition (many mothers in Dharavi do not even know the word), SNEHA has to deal with the lack of resources that the women face in the area. While many mothers are compelled to work, there is no real solution for lack of caretakers for children. Mohan’s mother says that she leaves her children to her sister-in-law’s care. This sister-in-law who lives a few rooms away already has four children, one of who is just an infant. One can safely conclude that the children are left to their own devices when the mother steps out.

Many such children of working mothers at Dharavi are susceptible to malnutrition. Children need the care and attention of their mother is always not possible. Many mothers are busy with daily chores and are also working to earn a living by doing off jobs such as selling utensils, embroidery, among others. Few of the other major reasons for malnutrition in children are lack of access to healthcare services, lack of quality of care, lack of good hygienic practices and absence of correct feeding practices.

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Sevikas from SNEHA’s day care centres say that approximately 90 percent of the children in the centres belong to working mothers. The day care centres take in children who suffer from severe acute malnutrition and moderate acute malnutrition. In the centre, children learn to eat nutritious food (they are fed milk, fruits and other snacks), and form habits such as hand-washing, toilet training, among others. The children are also taught songs and rhymes and play with each other during the day. Children who stay in day care centres make great improvements in their health and move to their homes with better habits.

Many of these working mothers are not able to breastfeed their children exclusively for six months, let alone feed them breast milk for two years, which is recommended by the World Health Organisation. Many women resort to feeding the children cow’s milk in bottles. The sterilisation of these bottles is also a question. Many working mothers also resort to feeding easy-to-feed food such as biscuits, packaged snacks such as wafers, crispies etc.

​There is an acute need for creches for children in Dharavi with its compromised health and lack of care practices.Creches can help a child not only overcome malnutrition but also mentally stimulate him or her. Children need an environment which is safe and stimulates mental and motor development.

Fighting malnutrition

 

Ruksar Khan, 3, weighed barely seven kgs and was malnourished when she was spotted by SNEHA workers last year. Her family who lives in Mandala slum at Mankhurd believed that Ruksar was just a fussy eater (sirf doodh peeti thi) and she will “grow up on her own” (apne aap badi hogi), like her other three older siblings. Ruksar refused to eat home-cooked foods and was pacified only with a packet of fried snacks. After intervention by SNEHA workers, Ruksar and her mother overcame malnutrition and Ruksar now weighs over 10 kilos now.

On December 31,2013 Ruksar and her mother, Saibunissa were felicitated along with 16 others mother-child duos from Mankhurd-Govandi area for recovering from malnutrition successfully for over six months. Ruksar excitedly accepted her tiffin box handed over by SNEHA team, while Saibunissa was given a mother-daughter framed photograph. More than seventy children have been felicitated for recovering from malnutrition last year.

Three similar functions in different venues were held in the area and were attended by municipality staffers, Integrated Child Development Scheme (ICDS) functionaries and anganwadi staff who are partners with SNEHA.

Every month, in association with ICDS workers, SNEHA staffers conduct anthropometry (measuring child’s height, weight) of children under the age of five. This exercise, funded by CRY and Welcome Trust, takes place in 23 community centres in Kurla, Govandi, Mankhurd and Trombay areas. SNEHA has covered about 20,000 households with 7000 children so far.

SNEHA workers then urge the parents whose children are detected as malnourished to enroll them in the Doorstep Childcare Centres (DCCs). A medical examination is done to check if the child suffers any medical problems or complications. In case of severe complications, the child is sent to the hospital. About 20 children attend the centres daily.

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Convincing parents that their child is malnourished is an uphill task. Health of women and children is low on the priority of residents in such vulnerable slums. Talking to the mothers, Digambar Gaikwad, programme officer who handles two centres in Mankhurd area said,“It is great that you mothers accepted that your child was weak. Then you trusted us to care for your child at our centre where we nourished the child. Now that these children are healthy, we are today celebrating this achievement and felicitating them and you as their mother.”

The enrolled malnourished children are fed medical nutrition therapy (MNT), a peanut based mixture with all the essential micro nutrients, provided under a community based trial on the effectiveness of MNT by the Nutrition Research and Rehabilitation Centre of the pediatric department of Lokmanya Tilak Municipal General Hospital, Sion.

“We first get the mothers to come with their children and do an appetite test to check if they are willing to eat the MNT, as prescribed by our doctor. After a few days, the children can stay in the centre where our workers/sakhis feed them MNT for eight weeks,”said Neena Shah More, programme director for SNEHA centres. The aim is to ensure that the children attains normal nutritional status.

The change in the child’s diet is not possible without roping in the mothers. The mothers are counselled to ensure good eating practices among children.“Many mothers are overburdened with housework and do not make time to cook nutritious food and feed the child nor do they see the value of scheduled feeds. Our trained balsakhis feed them with a great deal of patience and eating in a group of children makes a big difference,”said Anjanatai, a community organiser.

The balsakhis also engage in games with children and try inculcate good habits such as regular sleeping, washing hands. Once out of the centre, the community outreach workers follow up with the child and the mother by making frequent home visits and ensuring that the children do not get sick again because of lack of adequate nutrition.

In the meanwhile, Ruksar, who refused to eat dal rice and vegetables now eats well. “Ruksar now does not throw a fuss and eats well. I am happy that she is healthy now,”said Saibunissa.