Unexpected Lessons In Nutrition

‘Malnutrition’ was just another word I had heard years ago.  I don’t remember the last time this word passed my lips until I landed in Basic Healthcare Services (BHS), an organization in Southern Rajasthan, which I will be part of for the next year. Now, words like malnutrition are part of my everyday vocabulary along with, ‘Severe Acute Malnutrition (SAM)’, ‘Wasting’, ‘Anthropometry’, and the list goes on … It didn’t take much time for this change in conversations I have begun to have.

BHS is a non-profit organization providing primary care services to under-served communities in Udaipur district. It runs a chain of low-cost clinics called ‘AMRIT’ in remote villages where government and other private healthcare facilities are close to non-existent or are not affordable for the local population. On my second day at BHS, I accompanied a few guests to one of the clinics in Manpur, a village about 100 kms South of Udaipur city. The journey was very pleasant, it being the monsoon. There was a look of relief on every man, woman and child’s face from what I was told was a harsh summer. I had planned to spend my day keeping a low profile, observing and soaking in all I could. My visit coincided with the doctor’s weekly visit for which a larger crowd was expected.

My first observation point was the nurse’s station, where two nurses were working harmoniously to elicit the history and presenting symptoms of illness from those waiting for a doctor’s consultation. They weighed, checked the blood pressure, pulse and breathing of every patient before they could ask them why they had come to the clinic. While I stood there keenly watching, people came with different complaints- fever, cough, headaches, weakness, diarrhea, what caught my attention was that the needle of the weighing scale had barely made it to 45kg that day until I stood on it. One after the other fully grown adult men and women weighed 42, 38, and 35kgs! I distinctly recall Sita*, a woman in her early forties who was visiting Manpur clinic for the first time. One could see that with every step she took she gathered up all her energy, then did it again, and again. The scale confirmed what her frail body already conveyed, 33kg! The blood pressure cuff tightened on her skinny arm was even more alarming.

Sita’s is not an isolated case. A quick look around those in the waiting area spoke of a similar reality- Men in their prime and pregnant women with similar body frames. Toddlers in their parent’s arms had hollow eyes and visible wasting. Among the school children who came for a refreshing drink of water at the hand pump outside most had streaks of flaxen hair, which I learned later, is a mark of malnourishment. After another hour at the laboratory area, and a few conversations later I discovered that the iron levels of the population are so shockingly low that they would have been rushed for an immediate blood transfusion in any other setting. I went back with enough food for thought.

Over a month since that day, and patterns have begun to emerge in conversations with other BHS members and the community itself. I learned some hard facts.

1. The tribal community that inhabits hamlets scattered across the semi-arid, hilly terrain faces a lack of availability of food through the summer months. While the monsoons and winters bring in green, leafy vegetables, rice, maize, and pulses into the house, the summers are long and dry.

2. Out of what is harvested, a substantial amount gets sold to pay for other household expenses without much thought of how much will be needed to feed the usually large family all around the year.

3. The agricultural produce cultivated on land that has got divided and sub-divided into smaller plots over generations is meager and does not suffice.

4. This pushes young boys and girls to work at construction sites, soap-stone and marble mines exposing them to an array of respiratory illnesses.

5. A still greater portion of adolescent boys as young as 12 years travel to the surrounding cities of Ahmedabad and Mumbai in search of any odd job. As a migrant in a big city, their accommodations and work environments are a hot-bed for infections like tuberculosis. In the constant effort to earn as much as possible while away from home, their nutritional needs are not adequately met. Weak and unable to afford treatment in the city they return to their village to accept their fate.

Though unavailability of food and meager income are obvious contributors to the low nutritional status of the population, I was surprised to learn that baseless myths play a significant role as well. Old wives’ tales surrounding pregnancy and child care affect a life in it’s formative and most crucial years of development. At a community meeting, when the health worker explained how pregnant women have more nutritional needs and should eat three meals a day instead of the usual two, a six month pregnant Manju* said, “If I eat more my child will be too big to be born by a normal delivery.” The outreach worker who goes door-to-door and weighs children, had a worried look on her face when she shared, “Didi, I just weighed a one and half year old child today. Her body is so shriveled up I fear she will not survive long without medical attention. Her mother does not feed her anything, only breast-milk. She very adamantly told me that children cannot eat until the age of two.”

This is in contradiction to the WHO guidelines that recommend complementary feeding after six months. A team member at BHS added, “When we began Phulwaris (crèches) the parents opposed the inclusion of eggs in the meals served especially to girl children because they believe it results in the early onset of menses.” Beliefs as these invariably lead to weaker adolescent girls, pregnant women and ultimately a malnourished new generation of their children, thus continuing the vicious cycle of malnutrition and disease.

Some terms mentioned in the article are explained below:

• Anthropometry – A science that involves the quantitative measurement of the human body. It is used to evaluate both under and over nutrition.
• Wasting – Loss of strength and muscle mass.
• Severe Acute Malnutrition: It is a more serious condition defined by a very low weight as compared to height, or by visible severe wasting.

*Names changed to protect identity