Food Insecurity and Malnutrition among Santhal Children in Jharkhand

The United Nations General Assembly had announced 2016–25 as the decade of action on nutrition and, on these lines, our present government is considering setting up a National Nutrition Mission in several states (Chowdhury 2016). The idea of this mission is to give the issue a greater thrust and to facilitate better coordination between the interconnected departments, like women and child development, sanitation, rural development, etc. It is a fact that health policies are directly and/or indirectly influenced by the development policies concerned with areas like elimination of poverty and inequality, and are indirectly linked to the health policy, population policy, education policy, and other social development policies. 

 

It is an acknowledged fact that the presence of hunger on an extensive scale constitutes one of the most serious accusations against economic development. In terms of mitigating hunger and securing food for its citizens, India has consistently had one of the poorest records, and the country’s performance in reducing the number of people afflicted by malnutrition and hunger remains dismal even during periods of rapid economic growth. As the causes of child malnutrition are complex, multidimensional, and interrelated, they range from factors as broad in their impact as political instability and slow economic growth, to those as specific in their manifestation, like respiratory infection and diarrhoeal disease (Smith and Haddad 2000).

 

In 2014, the Second International Conference on Nutrition (ICN2) was held, focusing global attention on addressing malnutrition in all its forms. During the ICN2, Food and Agriculture Organization members, parliamentarians, members from civil society, and the private sector endorsed the Rome Declaration on Nutrition and the Framework of Action. The Rome Declaration on Nutrition enshrines the right of everyone to have access to safe, sufficient and nutritious food, and commits governments to prevent malnutrition in all its forms (FAO 2016). For any country, undernutrition and poor health are manifestations of the failure of the development process to reach some segments of the population, the cause of which covers a broad spectrum, emanating from political, environmental, socio-economical, health, and intra-household factors. 

 

Considering the parameters of economic and social development, India’s undernourished population is continually on the rise and the situation has worsened with the spiralling inflation witnessed with regard to food prices. There still exists a large population suffering from massive undernourishment, starvation and deprivation, making it a country with one of the largest food insecure populations in the world. Given its rank of 55 out of 88 countries on the 2015 Global Hunger Index, there is a serious need to effectively expand the food security policies. The Indian State Hunger Index (ISHI) shows that most of the Indian states are in serious to startling levels of hunger (Menon et al 2009).

 

Soon after the declaration of self-reliance by the poor countries at Alma Ata,1 international agencies were mobilised by the rich countries to let loose “international initiatives” on a global scale: growth monitoring for children, oral rehydration for treating diarrhoea, promotion of breastfeeding of infants, immunisation of children, treating acute respiratory infection, global programmes against AIDS, tuberculosis, malaria, and leprosy, eradication of poliomyelitis, etc (Banerji 1999). Because of vital flaws in the conceptualisation, design and implementation, not one of these high profile and very expensive programmes fulfilled expectations (Banerji 2005). It took a decade and a half for the Government of India to admit in its national health policy of 2002 to confess that these “vertical programmes” were unsustainable, that these were not cost-effective and caused severe damage to other health services (GoI 2002). However, the fact remains that economic growth alone, though remarkable, will not reduce malnutrition sufficiently to meet the Sustainable Development Goals (SDGs) nutrition target. 

 

 

India’s main early child development and nutrition intervention, the Integrated Child Development Services (ICDS), has expanded steadily across the country during the 30 years of its existence and is well designed to address many of the underlying causes of undernutrition in India. But, the ICDS faces a range of implementation complications that prevent it from fully realising its potential (Gragnolati et al 2006). 

 

In 1993, the country evolved National Nutrition Goals for the year 2000. These included reduction by one half of severe and moderate malnutrition among young children, reducing to below one-tenth the incidence of low birth weight, eliminating blindness due to vitamin A deficiency, producing more foodgrains, and improving household food security through poverty alleviation programmes. However, these goals were not well disseminated with the result that the failure to achieve them did not attract criticism. Though there have been some real success stories in states like Tamil Nadu, in most cases there is sufficient evidence to show that the Indian government’s main early child development intervention, the ICDS, has not succeeded in making a significant impression in reducing child malnutrition. The ICDS, the main outlet for public spending on child nutrition, has been in existence since 1975 (Saxena 2005). 

 

The idea of food security plays an important role in deciding the status of malnutrition and has undergone considerable changes in recent years. Food security is defined in its most basic form as access by all people at all times to the food needed for a healthy life at the household level. The food should also be adequate in terms of not only quantity, but also quality, safety, and acceptability for all household members (Gillespie and Mason 1991). Food availability and stability were considered good measures of food security till the 1970s. India achieved self-sufficiency by increasing its food production. It has also improved its capacity to cope with year-to-year fluctuations in food production, though it could not solve the problem of chronic household food insecurity. However, nutritionists argue that energy intake is a poor measure of nutritional status, which depends not only on the nutrient intake, but also on non-nutrient food attributes (Martorell and Ho 1984). 

 

In policy design, a distinction is made between transient and chronic food security, wherein the former is associated with the risks related to either access or the availability of food during the off-season drought and inflationary years. Policies such as those relating to price stabilisation, credit, crop insurance and temporary employment creation are initiated for stabilising the consumption of vulnerable groups. In contrast, the problem of chronic food insecurity is primarily due to a continuously inadequate diet (Radhakrishna and Reddy 2004).

 

The Food Security Bill, 2011 states that every person shall have physical, economic and social access, at all times, either directly or by means of financial purchases, to quantitatively and qualitatively adequate, sufficient, and safe food, which ensures an active and healthy life. The state government is directed to provide nutrition, take-home rations and/or local and freshly cooked meals throughout the year through the local anganwadi that meet the nutritional standards for all children in the three to six age group. Services including, but not limited to, supplementary nutrition, immunisation, health check-ups, referral services, growth monitoring, and preschool education are to be provided to all children in the 0–6 age group. However, in spite of being a country with so many constitutional safeguards, children are starving to death.

 

India has a large programme of public food distribution through fair price shops, accounting for a significant part of the government’s budgetary subsidies. The public distribution system (PDS) in its present form, a producer price support cum consumer subsidy programme, has evolved from the foodgrains shortages of the 1960s. The welfare dimension of the PDS gained importance since the early 1980s and its coverage has been expanded to rural areas in some states as well as to areas with high incidence of poverty. The ICDS stipulates that there should be one anganwadi centre per 1,000 population, with a more intensive placement of one per 700 population in tribal areas, where poverty tends to be more prevalent. While this policy aims to promote an equitable distribution of centres, the ICDS is rather poorly targeted. The poorest states and states with the highest levels of undernutrition tend to have the lowest coverage by ICDS activities and the lowest government budgetary allocation per malnourished child.

 

According to Aiyar (2010), in national sample surveys, the percentage of people claiming to be hungry has fallen steadily from 15% in 1983 to 2% in 2004–05. According to Deaton and Drèze (2009), with the rise in income, poorer Indians opt for superior foods rather than more calories; only non-hungry people will prefer quality over quantity. Poverty is still substantial, but hunger is now marginal. Deaton and Drèze (2009) have shown that targeting the needy can lead to the exclusion of the non-poor because targeting the poor can be socially divisive and can create poverty traps; as a poor person becomes non-poor, they lose their subsidised food and slip back into poverty. Micronutrient deficiencies are widespread with more than three-fourths of preschool children suffering from iron deficiency anaemia (IDA), while more than half of preschool children have subclinical vitamin A deficiency (VAD) and iodine deficiency in a majority of the districts (Bellamy 2002).

 

The Antyodaya Anna Yojana, which started in December 2000, reflects the commitment of the government to ensure food security for all, to create a hunger-free India, and to reform and improve the PDS so as to serve the poorest of the poor in rural and urban areas. This scheme was further expanded in 2004–05 and again in 2005–06, by covering another one crore below poverty line families by including all households at the risk of hunger, increasing its coverage to two and a half crore households.

 

 

The effect of malnutrition is enormous as it causes a great deal of human suffering, both physical and emotional. It is a violation of a child’s human rights (Oshaug et al 1994), a major waste of human energy, and associated with more than half of children’s death worldwide (Pelletier et al 1995). Adults who survive malnutrition as children are less physically and intellectually productive and suffer from higher levels of chronic illness and disability (UNICEF nd). The personal and social costs of continuing malnutrition on its current scale are immense. Children, being the group mostly affected by this problem, are the first call on the agenda of development. The foundation for lifelong learning and human development happens in the crucial early years, and it is now globally acknowledged that investment in human resource development is a prerequisite for economic development of any nation.

 

Looking at the poor nutritional health status of the tribal population in India, mainly central India, of late, there has been growing realisation and acceptance of the fact that tribal and such similar groups living in the resource-rich regions have been the worst victims of the model of political governance, state apparatus and the development strategy pursued especially in the post-independence period. The tribal areas and its people had to suffer the exploitative structure of governance symbolised in police, excise and forest departments, exploitative market structure, rural stagnation, and mass poverty and “pauperisation” (Sharan and Singh 1999). They had little gains from the industrial and development projects, and poor access to education and health projects. 

 

A civil society organisation (CEFS 2008) covered a sample of 1,000 randomly selected tribal households from 40 sample villages in Rajasthan and Jharkhand, and found that 25.2% of them reported of not having two square meals a day in the week before the survey, and around 99% had not been able to manage two square meals a day at some point of time (at varied levels) during the previous year. From a policy perspective, it is important to understand that tribal communities are vulnerable not only because they are poor, asset-less, and illiterate compared with the general population. Often their distinct vulnerability arises from their inability to negotiate and cope with their consequences of their forced integration into the mainstream economic, social, cultural, and political systems, from which they were historically protected as a result of their relative isolation (Saxena 2005).

 

Sen (1992) found that undernutrition was relatively higher among the lower socio-economic category of households, such as those belonging to the Scheduled Caste (SC) and Scheduled Tribe (ST) communities, with the maximum number of cases found in the ST communities. Tribal communities in India have their own history of struggles for identity, citizenship, survival, representation and pro-people development. Jharkhand has a history of mobilisation and assertion for ethnic identities and control over resources and self-determination. Tribal groups have their traditional social institutions called traditional self-governance (TSG) institutions with a strong concept of democratic participation and governance. However, with the advent of 73rd constitutional amendment, the scenario changed. 

 

According to the HUNGaMA Survey Report, 2011, out of the total worst performing districts, 15 belong to Jharkhand, and Dumka district has more than 63% stunted children, one of the highest numbers of stunted children (HUNGaMA 2011). An interesting finding of the report was that while girls started with a nutritional advantage over boys, they lost out as they grew older, to the point that by the age of four, they had fallen behind. The survey also found that while 45% children of illiterate mothers were underweight, 27% children of mothers with 10 years’ or more education suffered from the problem. Anganwadi centres were found to be functioning in 96% of the villages covered under the study, though their most important function remained immunisation in most of these villages. Only 6% of these centres had dried rations and only half of them had provided food on the day of the survey. And, among all, only one-fifth of the (mothers) entire population reported that the centres provide nutritional counselling to parents. This report has evaluated malnutrition on three parameters—underweight, stunted growth and wasted—and for the first time includes voices of 74,000 mothers of malnourished children to understand the familial, social, and economic basis of malnutrition.

 

 

The study is essentially an exploratory analysis of interactions among nutrition and a broad range of potential determinants at community, household and intra-household levels to understand the socio-economic factors determining the nutritional health status of tribal children. It aims to study the interrelated factors leading to the issue of malnourishment among children in the 0–5 age group in Giridih district of Jharkhand. 

 

The methodology used for this particular research topic is the mixed method approach, which enquires the combination or association of both qualitative and quantitative forms. It involves philosophical assumptions, the use of quantitative and qualitative approaches, and the mixing of both the approaches in the study. The technique that has been adopted for sampling is the probability proportionate to size (PPS) method, wherein the number of villages between groups has varied, but their combined total households have remained the same. This method has been adopted so that even a small-sized village in the sample represents many small-sized villages in the population, while a large-sized village in the sample represents only a few large-sized villages of the population. This method ensures larger units getting higher chances and smaller units getting lesser chances of being selected so that a higher proportion of larger units and a lesser proportion of smaller units are in the sample. 

 

Mothers of the children belonging to the 0–5 age group are considered as the unit of enquiry of the study, whereas the child is considered as the unit of observation and analysis of this study. The sample size taken was 200 mothers from the tribal communities of 12 villages from Gandey block, Giridih district, Jharkhand. The villages were Badguda, Dadhi Mohua, Dhavatand, Guliyatand, Jamaniyatand, Kaeludih, Kundalwadah, Kusmatand, Lothra, Lutori, Manjhlitand and Matkuria.

 

The research is a combination of both quantitative and qualitative research. For the quantitative part, the interview schedule was prepared, which contained semi-structured questions so that the respondent could give answers to direct as well as indirect questions that needed elaboration. Quantitative data was collected in order to study the nutritional health status of the tribal children in the 0–5 age group, to understand the different factors operating at various levels that affect poor nutritional status at large in the study area, which is considered to be a backward area of the state, and also to substantiate the qualitative data. 

 

The indicator that has been chosen to measure the nutritional status of these children is the anthropometric measurement that calculates stunting, wasting and undernourishment levels of the children using Statistical Package for the Social Sciences (SPSS) for doing statistical data analysis. For the qualitative part, the tool of focus group discussion (FGD), in-depth interview, and non-participant observation have been used. The qualitative data has helped understand the issue holistically as the way socio-economic, cultural and political surroundings of a region affect the nutritional health status of that area.

 

The interview schedule was analysed with regard to relevant variables and SPSS has been used for data analysis. Descriptive statistics was used to describe the various demographic, socio-economic conditions, nutritional status, women’s autonomy, and reproductive and child health, which have physical and psychological variables. The quantitative data has been analysed by using the statistical package of SPSS. Bivariate and multivariate analysis, like logistic regression, was attempted to understand the various factors affecting the nutritional status of children.

 

 

All the respondents belong to the Sarna religious group, who are worshippers of nature, and belong to the Santhal tribe. There were no age criteria for the women but that they should be the mother of child who is five years or less, and hence the parameter of selecting the respondents was the age of their child and not theirs. The respondents were basically tribal married or widowed women from the tribal communities from amongst the 12 villages of Gandey block of Giridih district. A majority of the population (99%) resides in kutcha houses wherein the wall is made up of mud and stones and the roof of the houses were made of the dried paddy stalks. There was just one household each that had a semi-pucca (0.5%) and a pucca house (0.5%). The type of dwellings occupied by these tribal households is a reflection of the socio-economic status of the family. Most of the households obtain water from handpumps (52.5%), many of them draw from the common well (29%), and, for a large number of the study population, freshwater lakes serve as the source of drinking water. There is absolutely no concept of a public tap. With regard to toilets, the data reveals that none of the households had a closed toilet at home or any community toilet in the study area, leaving them with the only option of open defecation. 

 

The educational qualifications of the respondent, whose child’s malnutrition status is to be known, are very important as the relation between the two is a direct one and forms one of the hypotheses of the study. From the data, it is clear that an overwhelming proportion of them (89%) have not attended school at all. Out of the rest of the respondents who attended school for some years—a majority of them (6.5%) had completed their primary education probably till Class 4 or 5 and a handful of them (4.5%) have completed their education till the secondary level—the average years of schooling can be clearly seen to be very low. 

 

 

Respondents were asked about the pattern of food consumption in their families using the 24 hours recall method, wherein they were asked about their food consumption in the last 24 hours. And, each meal was especially categorised to know the quality of food they consume on a day-to-day basis. Considering, on a general scale, eating thrice a day signifies that the people in the study are in a situation where they can at least afford to have two square meals every day, but the question that arises here is the quality of the food that they are consuming. 

 

When we look at the morning meals, majority of the households reported that they eat maadbhaat (78.5%), which is just cooked rice along with some salt, and some of the families have reported that they eat sabji bhaat (12%), which is rice and some kind of vegetable, mostly potato. There are also families who eat rice, dal and vegetables, roti chah (tea and chapatti), saag bhaat (rice and lettuce), and some families also eat baasi bhaat (stale rice). At the same time, there are also families who do not eat anything in the morning. When we look at the afternoon food, more than half of the families (64.5%) have reported that they eat saag bhaat, some families eat bhaat dal (rice and pulses) and sabji (13.5%), while there are a large number of families (15.5%) who do not eat anything in the afternoon. For their evening meals, around three-fourths of the families (71%) reported that they eat sabji bhaat and one-fifth of them eat maadbhaat namak, which can be steamed rice or rice soup sometimes. Hence, the data reveals that there are families who have reported that they eat nothing in the mornings and in the afternoons; probably, they belong to the group of families that eat only twice a day.

 

 

Food consumption of any population is influenced by the availability of resources in that area. To know the efficacy of the PDS in the study area, the respondents were asked the type of ration card they possess which can give them cereals at a subsidised rate. Here, more than half of the respondents (58.5%) reported that they have red-coloured ration cards, while some of the families (16.5%) repor­ted that they have yellow-coloured cards. There were also families who reported that they have other cards like Annapurna and the Antyodaya cards (6%), where the former is for senior citizens and the latter is for families. A considerable number of families did not possess any kind of card.

 

The rationing system and its successor, the PDS, have played an important role in attaining higher levels of household food security and completely eliminated the threat of famines from the face of the country. But, the current scenario of the PDS suffers with lots of loopholes in terms of governance, and just and fair distribution of the cereals and other products. On being asked about the availability of the fair price shops, a majority of the respondents (85.5%) reported that there is a fair price shop in the area, but when it comes to the items that they receive from such shops, out of the many commodities like rice, wheat, sugar, kerosene, and iodised salt, most of them reported getting only kerosene (81%), while a majority of them (51%) can also procure rice from those shops. Apart from these two commodities, there are some families (13%) who get iodised salt from the shops too. A majority of the respondents (80.5%) say that all that they get from the fair price shops is not at all sufficient to meet their family’s needs for even half a month (Figure 1). 

 

 

 

More than three-fourths of the respondents (82%) reported having an anganwadi centre in the proximity of their residence, but some respondents do not have anganwadi centres (15%) adjoining their village, and a few respondents (3%) do not know if there is any anganwadi centre in their area.

 

Out of the respondents who say that they have an anganwadi centre in their proximity, the services received from the anganwadi centre show that the number of children who received vaccination are higher (27.5%) than the number of children who received cooked food (16%) and preschool education (16%) (Figure 2). There were also few families where the children go to the centre sometimes, depending upon two factors: the first is when the anganwadi sahayika comes to take the children, and second, when they get food in the centre. The observation and information from the community also suggests that whenever cooked food is given in the centre, attendance is good, but not when there is no food provided. Also, when the children are too young, they are not sent to the anganwadi centre.