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.

103-of-109

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.

 

 

 

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.

 

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.

 

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.

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.

 

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.

Maternal deaths in Mumbai down but there are areas of concern

 

The recent data released by the Brihanmumbai Municipal Corporation showing a drop in maternal deaths in Mumbai is good news. According to the report, maternal deaths in the city fell to 311 in 2015-16. This is welcome given that the figures on this front have seen a steady rise over the last few decades, except for 2013-14.

One of the main factors is that anaemia, which has been the single largest contributor to the high maternal deaths, has seen a major fall. According to the report, anaemia is behind less than 2% of the maternal deaths in 2015-16. Until a few years ago the figure was as high as 25%. This shows that interventions by the BMC alongwith various organizations like SNEHA in slums have paid off. There is greater awareness about the importance of taking folic acid tablets, calcium and iron from the early stages of pregnancy.

As women I spoke to in Dharavi point out, they would rarely remember to take these supplements during pregnancy. And even when they did, they had no idea how to. They would simply club them together.

“Now I am aware that I have to space them out through the day so they are effective,” says Vandana, who is pregnant with her second child. “These are things that I learned from counselors who visit the area”.

Another positive is that the fight against tuberculosis is showing results. It contributed to 6% of maternal deaths in 2015-16 compared to 11% in 2015-16. Proof that DOT centres in the slums and awareness campaigns by the BMC is paying off.

However, what is worrying is the threat posed by poor sanitation and hygiene. The BMC data shows that a majority of maternal deaths are due to hepatitis – both A and E. Both strains are directly attributed to poor hygiene and the lack of clean water. Around 14% of the deaths in 2015-16 were due to hepatitis.

Experts say the figures highlights the lack of clean water in the slums, Most of the slums, especially in the tertiary areas like Govandi, rely on water from tankers. Lack of safe water is a major risk factor during and post pregnancy.

Apart from ensuring clean water supply, there is also a need to strongly promote better hygiene and sanitation practices like boiling water, washing hands and using public toilets to reduce infections. The solutions are many and entirely in our hands. Like the fight against anaemia, this too is a battle that can be won.

 

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.

 

Tackling the diabetes challenge

That the Indian government is thinking on the lines of imposing a tax on sugary drinks and junk food is welcome news. Given the alarming rise of diabetes in India, there is active intervention needed to control the rise.

A WHO report says that the number of people with diabetes in India is likely to cross 101 million by 2030, while Lancet published a study  just a day before World Health Day that said there has been a fourfold increase in the number of diabetics from 1980 to 2014 – from 108 million to 422 million. It ranks China, India and the US are among the top three countries with the most number of people with diabetes.

Prevalence has more than doubled for men in India and risen 80% among women. While the incidence is higher in urban areas with states in the South reporting especially high rates, what is worrying is the rise in rural India, a result of rapid urbanization.

Of special concern is Gestational Diabetes Melitus (GDM), which remains neglected in India and has a severe impact on child and maternal health. India has one of the highest rates of GDM in the world, with over five million women affected every year. While the worldwide prevalence figure is 15%, in India it is 22 to 25%.

The increasing prevalence of GDM is linked to growing urbanization, reduced levels of physical activity, and changes in dietary patterns and rising obesity

Women with gestational diabetes report pregnancy-related complications like high blood pressure, large birth weight babies and obstructed labour. They are also more likely to develop Type 2 diabetes in the future and therefore special attention needs to be paid to this population in India.

A 2013 study by the Kerala-based Achutha Menon Centre for Health Science Studies found that women diabetics are even more vulnerable as they cannot abandon their role of looking after the family and are expected to put the health of other family members above their own. This leaves them with far less time and resources for their own health.

One major reason for the rapid rise in India is lack of awareness. A 2012 study by the Brussels-based International Diabetes Federation found that over 60% of diabetics in India had never been screened or diagnosed because of this, while over 63% were unaware of the complications that arise from the disease.

A combination of food patterns, sedentary lifestyles, obesity and genetics makes Indians more vulnerable to diabetes. It is time we acknowledge that and tackle the problem at a war footing.

Apart from nationwide screening programmes, early detection and treatment must become a part of primary health services. Awareness has to be created about dietary habits as well, with greater emphasis on fiber rather than sugar and starches.

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:

DSC_0389
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”

DSC_0393
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”.

 

DSC_0397
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”.

 

Community mobilisation needed to tackle rising cancer deaths

On World Cancer Day, here are some India-specific statistics that need immediate attention.

The incidence of cancer is 70-90 per 100,000 population, with prevalence stated to be about 2.5 million cases. Over 800,000 new cases and 550,000 deaths occur each year, with over 70% of the cases being diagnosed at an advanced stage. That means when a person comes for treatment, their chances of survival are very poor.

ICMR data on site specific cancer burden reveals that in males the  most common cancers are those of the mouth, stomach and lung/bronchi. In females, it is that of the cervix, breast, mouth and oesophagus. After breast cancer, cervical cancer is the second most common cancer among women in India.

More women in India die from cervical cancer than in any other country, according to a 2014 report by the Cervical Cancer Free Coalition.  Cervical cancer kills around 72,000 women in India every year, more than 26% of the 275,000 deaths worldwide.

The report also says that the causes are closely linked to attitudes towards women and unless that changes the deaths will rise. Because it is linked to sexual contact, “cervical cancer is a taboo issue in many places”, said the U.S-based group in a statement. “Unless women’s groups and civil society come together to lead movements that break through stigma, patriarchy and other societal barriers, we will continue to see large numbers of deaths and high mortality rates,”.

Cervical cancer, which mostly affects women between 18-45 years, is linked to human papillomavirus, a sexually transmitted virus.. The virus is believed to be responsible for most cervical cancer cases — more than 80%, according to some estimates. A pap smear can spot the virus at an early stage and HPV vaccines have been developed.  In December 2014, the Indian health ministry announced that it wanted to introduce the vaccine in the universal immunisation programme at the earliest.

What is missing however is a countrywide cancer screening program to catch the disease early. Cervical cancer is a preventable disease but it can also be successfully treated if detected early.

The UNAIDS statement calling for a greater integration of health services to tackle cervical cancer is a welcome one. It says “the relationship between HPV and HIV offers significant opportunities to reduce the impact of both viruses, since existing HIV programmes could play an important role in expanding cervical cancer prevention and treatment services.” It goes on to recommend that every woman who tests HIV positive should be offered screening for cervical cancer and follow-up treatment if needed. And that HIV testing should also be offered during cervical cancer screening.

An effective intervention also calls for delivering age-appropriate programmes for adolescent girls, that includes HPV vaccines and regular screening. Steps India has to accord high priority to to rein in the galloping figures.

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.

 

Time to involve adolescents in FP meaningfully

At 1.8 million, they are a significant component of the world’s population. Yet when it comes to family planning, services for adolescents are patchy in many parts of the world. And ignoring this is a serious violation of their human rights.

This is one of the central messages of the 2016 International Conference on Family Planning currently on in Bali, Indonesia.

There is growing recognition the world over that including adolescents in health services is key to any country’s economic progress. Hence, giving them access to contraceptive services, addressing myths and misconceptions and striking down laws and policies that restrict their ability to exercise choices is critical.

“This is a never before moment in adolescent health” said Dr V Chandramouli, scientist at the WHO Department of Reproductive Health and Research. “We need to ask hard questions now”.

Speaking at the opening session of the second day of the ICFP, Dr Chandramouli said the way forward was to make existing health centers in different countries adolescent-friendly rather than set up specific youth centers.

“Separate centers for adolescents are neither necessary nor sustainable”, he said. “Instead make health workers at these centers adolescent friendly. “ This he said should be done through a package of actions which includes good quality training, supportive supervision and collaborative learning.

How these messages are framed is also important. “Adolescents are discovering their bodies and this is a joyful, exciting process for them. They need health workers to help them and not always frame answers in the context of HIV”.

However, this approach calls for a rethink in how many countries approach sexuality education, which is banned in many states across India.

“The Indian government and policymakers are not seeing sex as a health, development and human rights issue”, says Ramya Jawahar, Vice Chair, International Youth Alliance of Family Planning. “They believe that if sexuality education is taught in schools, it will encourage promiscuity.”

This belief that is not backed by any data; on the contrary, various studies have shown that empowering youth with information on family planning brings down unintended pregnancies by as much as 80%. Denying them this information, on the other hand, puts them at health risk.