Karnataka’s Child Malnutrition Crisis: Mere Survival Is Not the Point

Right to nutrition, and not just the right to food, should have been the premise of policymaking in India.

The National Food Security Act (NFSA) has been in place since 2013 and it was expected to mark a paradigm shift in the approach to food security, transforming it from a welfare to a rights-based concept. However, going by the recent nutritional indicators in the country, questions must be asked as to why the NFSA has not been able to prevent malnutrition. Unfortunately, the law has been reduced to providing the right to mere survival (with the cheapest minimum) rather than the right to a life free of nutritional deficiencies and ill-health. The right to good quality and quantity of nutrition should have been the premise of interventions and policy decisions, not just the right to food.

Data From Karnataka Is Bleak

The nutritional indicators of Karnataka paint a bleak picture. According to the Comprehensive National Nutrition Survey (CNNS) of 2018-19 in Karnataka, only 3.6% of children in the age group of six to 23 months received a minimum acceptable diet; 18.3% of children have minimum dietary diversity; 31.6% have minimum meal frequency; only 8.7% children consume iron-rich foods.

In terms of consumption, among children aged 2-4 years in Karnataka, only 21.9% of children had consumed flesh foods in the previous 24 hours compared to 69% in Kerala. Only 56.7% of children had consumed dairy and 19.1% had consumed eggs. Among children in the age group 5-9 years, 84% had consumed milk or curd in Karnataka, and that was probably because of the Ksheera Bhagya scheme. Iron deficiency is 50.1%, 31.2% and 30.5% in 1-4 year, 5-9 year and 10-19 year age groups, respectively, in Karnataka.

Folate deficiency among children aged 10-19 years is 30.1% in Scheduled Caste groups, 29.9% in Scheduled Tribe, 33.7% in Other Backward Class (OBC) and 27.6% in others. It is 28.2% in the poorest and 42.7% in the richest quintile.

Among children aged 1-4 years, Karnataka has a B12 deficiency of 15.4% and folate deficiency of 36%. Among 5-9 years, B12 deficiency is 15.4% and folate deficiency is 50.5%. Among the 10-19-year-olds, B12 deficiency is 45.5% and folate deficiency is 70.4%.

The state's Arogya Nandana programme had also recently found 7,259 kids having severe acute malnutrition and a whopping 1,05,150 kids having moderate acute malnutrition, out of more than 53.82 lakh children screened. There are 1.5 crore kids in the state.

Malnutrition rarely kills a child overnight. Unlike a plane crash, its impact is not immediate. Malnutrition and its adverse effects develop insidiously, and thus, they don't make for 'sensational' headlines. When news reports mention that children are starving, stunted or under-nourished, there are lukewarm, knee-jerk responses by bureaucrats, the media, civil society, nutritionists and doctors. The responses are neither far-sighted nor sustainable, and do nothing to prevent malnutrition before it occurs. Further, retrospective interventions do not help children who have already fallen into the vicious cycle of malnutrition, poverty and infection.

Vegetarianism Is Not the Way

In a country like India, which has a legacy of casteism, and now, increasingly, communalism, food has always been a political tool. From lynching beef-eaters to treating meat-eating communities as ‘unclean’, ‘polluted’ or ‘untouchable’, from food impositions based on ideology more than sound science to portraying vegetarianism as a benevolent way of life, the passion around food is explosive.

There is a mainstream ideological opinion, often fed by media, researchers, academicians, doctors and others with the ability to influence, that India is a largely ‘vegetarian’ country that is also poor. The effort then, even with the NFSA 2012, has always been to impose cheap vegetarianism on the vast majority of India’s population.

Evidence shows that an important way of preventing nutritional deficiencies and improving overall the outcome is to provide adequate quantities of diverse foods, which include, apart from cereals and millets, recommended quantities of legumes, pulses, nuts, eggs, meat, milk/dairy, fish, poultry, vegetables, fats and oils, as well as other green leafy vegetables.

When a majority of the population is undernourished, it is expected that they will also have multiple nutrient deficiencies. That just a few deficiencies become clinically obvious doesn’t mean that only those nutrients should be replenished. People need diversity by way of the inclusion of different food groups.

For micronutrient deficiencies (iron, zinc, Vitamin A, B12, Folate and calcium) the most nutrient-dense foods based on what is available regionally include chicken liver, ruminant liver, small fish (also a source of Vitamin D and long-chain omega 3 fats), eggs, ruminant meat, dark leafy greens.

Barriers to Availability of Meat

According to the Food and Agriculture Organization (FAO), South Asia has the lowest per capita availability of meat at 19g/day, and India is the lowest in any country at 10g/day. The organisation also adds that In India, green leafy vegetables are moderately available, that fish is consumed only in certain areas, and suggests that the consumption and production of eggs should be increased. The main barriers identified are related to availability, affordability, access, knowledge and cultural preferences. They also suggest that the only real way to address deficiencies is through a multi-system approach involving health, food, water, sanitation and social protection schemes to create micronutrient-adequate diets and adequate feeding practices.

In India, the Comprehensive National Nutrition Survey (2018-19) specifically mentions that iron-rich food includes “any liver, kidney, heart or other organ meat; any chicken, duck, or other poultry; any fresh or dried fish or shellfish; or any other meat [eaten] during the previous day”.

If one considers the Mid-Day Meal (MDM) programme in Karnataka, a primary school child is entitled to 450 cal and 12 gm of protein, while a child in the upper primary section is entitled to 700 calories and 20 gm of protein. Each meal is expected to provide, at the primary level, 100 gm of food grains, 20 gm of pulses, 50 gm of vegetables, and 5 gm of oils and fats. An upper primary level (that is, Class VI-VIII) child is expected to receive 150 gm of food grains, 30 gm of pulses, 75 gm of vegetables and 7.5 gm of oils and fats.

But this diet is inadequate to meet even a third of the protein, mineral and vitamin needs of the child. Eggs are being denied to children due to caste-related, ideological or political reasons.

While the NFSA guarantees food security, it doesn’t promise nutrition security.

Not Just Quantity, But Quality, Too

The Supreme Court of India has established that the right to food is a Constitutional right. Several government food security schemes were converted to legal entitlements, with special provisions for vulnerable groups such as pregnant and nursing women and children from 6 months to 14 years of age through the Integrated Child Development Services (ICDS) scheme and the Mid-day Meals (MDM) programmes. Malnourished children receive additional food. The Act also legally entitles up to 75% of the rural population and 50% of the urban population to receive subsidised food grains under the Targeted Public Distribution System, thus expecting to cover two-thirds of the population.

The National Human Rights Commission had said in February 2003 that the Right to Food is inherent to a life with dignity and that Article 21 of the Constitution (which guarantees a fundamental right to life and personal liberty) should be read with articles 39(a) and 47 to understand the nature of the obligations of the state. Article 39(a), one of the Directive Principles, requires the state to ensure that all citizens have the right to adequate means of livelihood, while Article 47 spells out the duty of the state to raise the level of nutrition and standard of living as a primary responsibility.

The commission importantly held that “the right to food implies the right to food at appropriate nutritional levels and the quantum of relief to those in distress must meet those levels in order to ensure that this right is actually secured and does not remain a theoretical concept”.

This clause underlines that it is not just the quantity of food that one eats, but importantly, the quality. Providing cereals and millets even ten times a day will fail to meet the nutritional requirements of the child. Diversity is crucial. Diversity means that there is food from at least four or more food groups.

Further, the Recommended Daily Allowance (RDA) is calculated assuming that a person has no deficiency. So, in the presence of a deficiency, the RDA of different nutrients may change based on the availability of other nutrients.

When Politics, Ideology and Society Define Nutrition Choices

Children are unique in that they cannot themselves speak against serious violations of their fundamental rights. They need people to speak for them. Who are these people? It can be parents or families, doctors, ASHA workers, anganwadi teachers, auxiliary nurse midwives (ANM), etc. Civil society can play a role in documentation, research and advocacy to ensure that authentic data is made publicly available. The media can highlight both localised as well as policy-level barriers in addressing child malnutrition.

Importantly, the government should be held accountable by all stakeholders for malnutrition in the state. Civil society, media and academia have to understand that food security is not equivalent to nutrition security. Preventing starvation is one thing, but ensuring that there are no nutritional deficiencies and that there are systems in place to identify and respond to the looming crisis should be one of our foremost efforts.

The decision to give eggs and bananas as part of mid-day meals in seven backward districts of Karnataka is a step in the right direction, but it is inadequate in its scope and scale. To reiterate, malnutrition has to be prevented, not managed retrospectively. It is, therefore, irrational to provide eggs only in backward districts that have seen high levels of malnutrition.

More importantly, the Public Distribution System (PDS), the ICDS and Mid-day meal programmes have to move away from the realm of ideology and politics. There is a need for the inclusion of nutrient-dense foods and animal-source foods (ASF) like dairy, meat, poultry and eggs in the regular diet. These foods then have to be made available through social security schemes and/or at subsidised costs. Ideological opposition to all forms of ASF, including the call to ban halal meat, the economic boycott of Muslim vendors, resistance to eggs in mid-day meals, cattle slaughter bans, etc., need a rethink in Karnataka.

The Case for Food Sovereignty

The importance of kitchen gardens, poultry and livestock-rearing, and sustainable agriculture, needs to be emphasised. This can help families become self-sufficient, which is also environmentally and ecologically sustainable and preserves food sovereignty.

That brings us to the question of whether a social problem like malnutrition can be left unaddressed.

What does it say about society as a whole? Can the state and those wielding power over a child’s nutritional status be absolved of responsibility?

Children cannot wait for us to address other issues, nor can they access justice themselves. They just disappear or become less-than-average citizens. And for that, all of us are responsible.

(Adv Jerald Dsouza Director, St Joseph's College of Law (SJCL), Bengaluru. Dr Sylvia Karpagam is a public health doctor and researcher. This is an opinion article and the views expressed are the author's own. The Quint neither endorses nor is responsible for them.)