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COMMENTARY

a decade of economic growth from


The Malnutrition Market 200506 to 201516, a comparison of data
from the National Family Health Survey-3
Let Them Eat Paste (NFHS-3) and National Family Health
Survey-4 (NFHS-4) shows that severe wast-
ing among children in Maharashtra
Abhay Shukla, Shweta Marathe has nearly doubled (IIPS 201516). In
September 2016, the National Human

A
Health activists have critiqued ccording to the classic anecdote Rights Commission issued a notice to the
the Maharashtra governments from late 18th century France, Maharashtra government over reports
on hearing of the demand for of 600 children dying in Palghar dis-
proposal to provide a ready-to-use
bread by the poor of Paris, Queen Marie- trict, many of these deaths reportedly
therapeutic paste to malnourished Antoinette retorted, Let them eat cake! linked with malnutrition.
children across the state, despite In Maharashtra today, we have a situa- Such serious levels of malnutrition are
strong evidence of the benefits tion where, setting aside cheaper, more linked with a deepening agrarian crisis
appropriate and locally produced foods, that constrains the purchasing power of
of cheaper, more appropriate
a state department seems set to impose rural and tribal populations. A weaken-
and locally produced foods. The an expensive form of packaged nutrition ing of public nutrition and health-related
move is one more example of on the children of the poor, defying logic. services compounds the problem. For
how malnutrition, a condition A deeper analysis reveals the possible instance, the current state government
dynamics behind this move. has imposed savage budgetary cuts on the
that results from the widespread
Maharashtras women and child deve- Integrated Child Development Services
deprivation and inequities lopment (WCD) department is currently (ICDS) scheme in the last few years. The
exacerbated by a market-driven proposing a policy for the introduction budget for the concerned WCD depart-
economic system, is being of a packaged nutrient paste, known as ment in 201617 was slashed by a whop-
ready-to-use therapeutic food (RUTF), for ping 62% compared to the previous year
converted into an opportunity to
malnourished children across the state (201516). Following protests organised
expand markets and make profits. (Mahamulkari 2017a). This is a contro- by the social sector platform Jagnyachya
versial decision, questioned from many Hakkache Andolan (Movement for Right
quarters, including ministers and officials to Live) (Rawal 2017) and anganwadi
from other concerned departments. worker unions, this cut was partly
This proposal exemplifies how a com- reversed through increases in the sup-
mon condition (malnutrition), which is plementary budget for 201617. How-
actually the result of widespread depri- ever, the WCD budget for 201718 again
vation and inequities exacerbated by a saw a cut of 22% compared to revised
market-driven economic system, is para- estimates for 201617. Parallel to this,
doxically being converted into an oppor- the programme for village child deve-
tunity to expand markets and push prof- lopment centres (VCDCs) providing spe-
its. In this policy regime, public health cial nutrition and care to malnourished
evidence, developmental considerations, children since 2010, was shut down across
and social preferences all become sec- the state in 201415, the rationale being
ondary to a narrowly technical approach lack of required funds, pegged at roughly
to a complex social problem, which con- `17 crore annually. The VCDC programme
veniently opens the way for the promo- had shown promising results in treating
tion of commercial products. Childrens malnourished children with locally
bodies end up being used to expand the produced foods, but it is now severely
space for capital accumulation, and certain curtailed.
sections of the state are actively colluding In contrast, large-scale finances have
in this process. been made available for certain market-
friendly solutions, such as take home
Starving Public Systems ration (THR) packets. In Maharashtra,
Abhay Shukla (abhayshukla1@gmail.com) is
a public health physician and health activist Maharashtra is a paradoxical state, with while children in the three to six years age
associated with Jan Swasthya Abhiyan. Shweta one of the highest per capita incomes group are provided cooked food in
Marathe (shweta51084@gmail.com) is a health among major Indian states, as well as anganwadis, families of children under
systems researcher. Both work on nutrition high levels of malnutrition (Sardeshpande three are provided packets of THR powder,
and health-related issues in Maharashtra.
et al 2009). Even more seriously, during to be mixed with warm water or milk
18 JUNE 24, 2017 vol lIi nos 25 & 26 EPW Economic & Political Weekly
COMMENTARY

and fed to the child. Although techni- the THR and the cows that are fed the children, even in a closely supervised
cally supposed to be nutritious, there is powdera sign of our times! hospital setting (Jadhav et al 2016).
widespread experience that children Studies in other countries (Tadesse
under three find THR unpalatable, mak- Medicalising Malnutrition et al 2015) have documented many con-
ing it ineffective. Two rounds of study Given the abysmal failure of THR as cerns and adverse impacts related to the
by the Nutrition Rights Coalition in four commercial packaged food, what evi- adoption of RUTF, which include shaping
districts of Maharashtra in August 2013 dence from the Indian context justifies young childrens preferences towards
and October 2014 showed that 88% and the introduction of another packaged the sweet taste, developing a resistance
95% respectively of children under product in the form of the centrally pro- to healthy foods, and even the possibility
three years of age were not consuming duced RUTF for treating malnutrition? of permanent alteration of metabolic
THR regularly (Marathe et al 2015). Of Studies from India show that there is functions. A series of case studies on 14
those families that were not feeding hardly any added value in centrally pro- children who had experienced a trial of
this powder to their children due to lack duced RUTF compared to locally pre- RUTF in Nandurbar district, recently car-
of acceptability, 78% opted to feed it pared foods, and any higher impacts on ried out by Jan Arogya Abhiyan, Maha-
to cattle and other domestic animals! increasing the weight of children are at rashtra, revealed disturbing findings after
Following civil society activism and best transient. the conclusion of the trial. One of the
orders from the Bombay High Court, in The findings of one of the larger and parents stated that the anganwadi worker
the Melghat area of Amravati district, more recent trials on RUTF in India had strictly told us not to offer any food
THR was officially replaced by hot (Bhandari et al 2016) show that com- to the child other than paste, unless all
cooked meals for children under three pared to centrally produced RUTF, locally the required paste packets were con-
years. The study by the Nutrition Rights prepared RUTF emerges as slightly better, sumed by the child. The child has now
Coalition (mentioned above) showed while home-prepared foods with the become addicted to the sweet paste and
that the level of severe malnutrition addition of nutrients show comparable after its discontinuation continuously
among children under three years in results. Rates of recovery from malnu- cries for paste, and refuses to eat home-
villages in Amravati where cooked trition among groups receiving locally cooked food (Jan Arogya Abhiyan 2017).
meals are given was 2.8%. This is half prepared RUTF were 56.9%, 47.5% for Even UNICEF has expressed caution on
of the average level of 5.7% in other dis- those receiving centrally produced RUTF, RUTF, especially its potential for com-
tricts where THR packets are being pro- and 42.8% for augmented home-prepared mercial exploitation and risk of under-
vided, strengthening the evidence in foods. Importantly, 16 weeks after the mining existing good practices for child
favour of hot cooked meals compared intervention, overall improvement dec- feeding (UNICEF 2013). Studies have noted
to THR. lined to just 15%, and much of the that RUTF-based standalone progra-
However, despite Supreme Court orders improvement could be attributed to mmes usually have very weak links with
prohibiting the involvement of contra- extra support for feeding by local peer existing food security and nutrition pro-
ctors in the supply of food for children supporters, who enhanced the engage- grammes, compromising their sustain-
in anganwadis, THR packets continue to ment and skills of the mother in child ability (Greiner 2014). Overall, RUTF is
be manufactured and distributed across feeding (Bhandari et al 2016). embedded in a problematic paradigm that
Maharashtra by selected companies The only published trial on RUTF in views malnutrition as a disease that
operating under the guise of womens Maharashtra is hospital-based rather than must be treated with nutrients as medi-
organisations. A few resourceful, mutu- community-based, dealing with a more cines with extremely demanding speci-
ally connected businessmen reportedly controlled and supervised environment. fications, which can only be produced by
run these organisations. The total budget This study shows that after eight weeks, technically sophisticated corporations.
planned for purchase of THR in Maha- 82.8% of children on medical nutrition
rashtra over seven years is estimated at therapy (MNT, similar to RUTF) moved out Poor System, Costly Product
around `5,300 crore, indicating the lucra- of severe acute malnutrition (SAM) status, According to available information, the
tive nature of the malnutrition market. compared to 64.4% of children on stand- current proposal for RUTF is linked with
THR has continued despite protests by ard nutrition therapy (based on nutri- restarting VCDCs across Maharashtra.
civil society organisations, representa- tious local food ingredients). However, The latter would be a welcome and long
tions in the Supreme Court, and resist- the difference between the two groups overdue step, and can definitely improve
ance from many anganwadi workers concerning rate of weight gain was sta- care of malnourished children across
who are compelled to impose THR pack- tistically insignificant after four weeks. the state. However, the economics of the
ets on reluctant beneficiaries. While At the end of six months, there was no proposal seem to be weighted towards
the intended beneficiarieschildren in statistical difference in nutritional sta- providing substantial resources for pur-
poor familieshave hardly benefited tus of both groups, showing that RUTF chase of the commercial paste, while the
from THR, the two main gainers from had only a minor and temporary advan- ICDS system delivering the product
this political decision seem to be the tage over locally produced food in remains under-resourced. If ready-to-
disguised companies that manufacture improving the nutrition of malnourished use foods are provided to both severely
Economic & Political Weekly EPW JUNE 24, 2017 vol lIi nos 25 & 26 19
COMMENTARY

and moderately malnourished children of this company carries the following normalcy was fairly well maintained.
across the state, the budget would be in enigmatic statement: Another trial of local therapeutic food,
the range of `100 crore per year. Here India as production site is strategically im- accompanied by community-based inter-
we would focus on severe acute mal- portant as it is the worlds largest democracy ventions by MAHAN Trust in Maharashtra,
nourished children, who officially num- and has a population which counts for 1/6th showed significant reductions in the prev-
ber around 83,000 in Maharashtra of the world population. The population alence of SAM and severe underweight
growth creates challenges regarding dis-
(Ministry of Women and Child Develop- children at the end of the study, demon-
tribution of wealth and services. Adequate
ment 2017) (a grossly under-reported fig- and correct nutrition supplies are in high strating the efficacy of locally produced
ure compared to more reliable NFHS-4 demand, and therefore India is an important foods, and the effectiveness of commu-
data). Each SAM child would be provided place to be present as the challenges develop nity-based models to tackle acute and
three packets of paste every day, for a further. (G C Reiber Compact 2017) chronic malnutrition (Dani et al 2016).
period of 72 days. Each packet provides Apparently, Indias population growth
500 calories, so three packets would (not its socio-economic system) is respon- More Profitable Than Prevention
provide 1,500 calories, while the daily sible for its challenges regarding distri- Malnutrition is an embodiment of
energy requirement of a child in the age bution of wealth (that is, major inequi- poverty and deprivation, linked with
range of 16 years is 9001,400 calories. ties and poverty). More importantly for deepening agrarian distress, limited house-
This implies that if the protocol were fol- G C Reiber Compact as a multinational hold incomes, and large-scale seasonal
lowed, each child would be expected to company, as these challenges develop migration, especially in tribal areas of
eat only RUTF paste from morning to further there is high demand for cor- Maharashtra. However, going by ongoing
night, with practically no consumption of rect nutrition supplies (that is, packa- policies for the agricultural sector, as well
normal food, continuously for over two ged nutrients). In short, growing pov- as recent state budgets for key areas like
months! The advisability and feasibility erty is good for business, since presuma- ICDS and food security, the state is weak-
of such an artificial form of dietary bly we have no choice but to depend on a ening its emphasis on prevention of mal-
intake, especially in community condi- multinational corporation to feed our nutrition through wider socio-economic
tions where the child would be weakly malnourished kids correctly. (Did any- measures and programmes. Even focus-
supported in case of adverse effects, is one mention Make in India?) ing on the short-term need to tackle exist-
seriously questionable. ing malnutrition, locally anchored and
Since each RUTF packet costs `25, with Ignoring Alternatives empowering options such as promotion
three packets provided daily, the cost per Nutrient paste is obviously not the only of improved nutrition practices with
child per day would come to `75. Given solution available to treat malnourished womens groups, individualised counsel-
such significant amounts, imagine the children. There is ample scientific evi- ling of caretakers of malnourished children
alternative nutritious foods that could be dence on the effectiveness of approaches for dietary improvements, and organi-
locally provided, socially rooted and cul- based on locally produced, culturally sation of publicly supported crches, are
turally appropriate, encouraging the local acceptable nutritious foods, which are being ignored. However, once certain
economy and helping to reshape house- far more appropriate than centrally children inevitably fall into severe mal-
hold dietary practices in a sustainable manufactured RUTF. These approaches nutritionone extreme of the wide
manner. We outline an example of such need priority, instead of the large-scale spectrum of ongoing deprivationthe
locally provided food from Maharashtra promotion of commercial packaged foods. state seems eager to rescue them, per-
in the next section. The proposed RUTF Significant initiatives have been intro- haps for a few months, through provi-
provision can also be compared to the duced in India which have reduced mal- sion of commercially manufactured paste.
current amount allocated for regular nutrition based on promotion of improved This seems to be exceptionally myopic,
meals in the anganwadi, which is barely household feeding practices, individu- since the improvements may only last
`6 per child per day. Clearly, priorities alised counselling of caretakers of chil- for a short time, after which such chil-
are skewed, with scarce resources being dren, and better support to children dren may fall into the next round of mal-
made available to prevent malnutrition under three through crches and similar nutrition, given that the underlying
among all children, but lavish resources measures. A multi-strategy intervention causes have remained unaddressed.
provided to purchase commercial products termed Action Against Malnutrition (AAM)
for treating malnutrition. (Prasad and Sinha 2015) has been adopted Critical Voices
Further, the company that may supply in a nested manner, with the running of Although powerful global bodies are
RUTF packets on a large scale in Maharash- crches, mobilisation of the community endorsing RUTF, alternative voices are now
tra (since it has provided the eeZeePaste through structured participatory learn- arguing with evidence that locally pro-
NUT packets used in the recent RUTF ing and action meetings, and systems- duced and socially rooted solutions for
pilot in Nandurbar) is the Norwegian strengthening to improve health services malnutrition are equally effective and much
G C Rieber Compact, which has a sub- and ICDS. This approach demonstrated more sustainable. Recently, a group of 16
sidiary in India with a manufacturing a very significant reduction in severe senior nutrition and health experts from
plant in Gurgaon, Haryana. The website acute malnutrition from 8% to 4%, while across India have written a letter to the
20 JUNE 24, 2017 vol lIi nos 25 & 26 EPW Economic & Political Weekly
COMMENTARY

union health minister,1 cautioning against healthier options must be prioritised, Jan Arogya Abhiyan (2017): Report on Case Studies
of Families after RUTF Trial in Nandurbar,
the introduction of products like RUTF: and public good must prevail. May, unpublished report.
We, the undersigned, make a fervent appeal Mahamulkari, S (2017a): Maharashtra Floats
for framing local evidence based policy that Note `100-crore Packaged Food Plan for Malnour-
1 Letter by 16 nutrition and public health experts ished Kids, Times of India, 26 May, http://
seeks to reduce burden of severe wasting in a timesofindia.indiatimes.com/city/mumbai/state-
to the health minister on Policy for Child
sustainable manner, instead of focusing upon floats-rs-100-crore-packaged-food-plan-for-mal-
Undernutrition: An Emerging Need to Reduce
distractive and uncertain quick fixes Severely Wasted Children Than Just Treat nourished-kids/articleshow/58847349.cms.
Prudent, cost-effective and sustainable strat- Them with RUTF, unpublished communica- (2017b): Now, Tribal Department Opposes
egies to address SAM (severe acute malnu- tion, 19 April 2017. Packaged Nutrition Meals for Malnourished Kids,
Times of India, 6 June, http://timesofindia. india-
trition) should follow the holistic preventive times.com/city/mumbai/now-tribal-depart-
route, instead of diverting funds towards References ment-opposes-packaged-nutrition-meals-for-
distributing nutrient-products with evanes- malnourished-kids/articleshow/59010597.cms
Asian Age (2017): NGOs Question Packaged Food
cent benefits for the mere tip of the iceberg Given to Kids, 8 June, https://www.google. Marathe, S, D Yakundi and A Shukla (2015): Is
co.in/amp/www.asianage.com/amp/metros/ Take Home Ration Really Improving the Nutri-
mumbai/080617/ngos-question-packaged- tional Status of Children? A Study of Supple-
We are concerned that in spite of this evi-
food-given-to-kids.html. mentary Nutrition for Under-3 Children in Four
dence from India, some states are in the pro- States of Maharashtra, Journal of Community
cess of scaling up ready to use therapeutic Bhandari, N et al (2016): Efficacy of Three Feeding Nutrition and Health, Vol 4, Issue 1.
Regimens for Home-based Management of
foods (RUTF) and energy dense food (EDF) Children with Uncomplicated Severe Acute
Ministry of Women and Child Development (2017):
for treating SAM children in partnership Monthly Progress Report on ICDS, Govern-
Malnutrition: A Randomised Trial in India,
ment of India, icds.gov.in/mpr2016_2017.html.
with agencies. This defies evidence-based BMJ Global Health, 30 December.
Prasad, V and Dipa Sinha (2015): Potentials, Expe-
programming, and could be resulting from Dani, V et al (2016): Community Based Manage- riences and Outcomes of a Comprehensive
the absence of a clear national policy to ment of Severe Malnutrition: SAM and SUW in Community Based Programme to Address Mal-
guide such interventions. the Tribal Area of Melghat, Maharashtra, nutrition in Tribal India, International Journal
India, Clinical Epidemiology and Global Health, of Child Health and Nutrition, Vol 4, pp 15162.
Recently, the civil society networks Vol 5, No 2, pp 6269.
Rawal, S (2017): Despite Malnutrition Deaths in
Jan Arogya Abhiyan (Peoples Health G C Reiber Compact (2017): http://www.gcrieber- Maharashtra, Child Development Budget Cut
compact.com/locations/india. by 31%, Hindustan Times, 23 March.
Movement, Maharashtra) and Anna Greiner, T (ed) (2014): The Advantages, Disadvan- Sardeshpande, N, A Shukla and K Scott (eds)
Adhikar Abhiyan (Right to Food campaign, tages and Risks of Ready-to-Use Foods, Breast- (2009): Nutritional Crisis in Maharashtra, Sup-
feeding Briefs, No 56/57, Geneva Infant Feeding port to Advocacy and Training to Health Initia-
Maharashtra) released statements to the Association (GIFA), International Baby Food tives (SATHI).
media, sharply critiquing the proposal Action Network (IBFAN). Tadesse, E et al (2015): Perceptions of Usage and
by the WCD department to introduce IIPS (201516): National Family Health Survey Unintended Consequences of Provision of
(NFHS-4), 201516, India Fact Sheet, Interna- Ready-to-Use Therapeutic Food for Manage-
RUTF on a large scale in Maharashtra, tional Institute for Population Sciences, Mumbai. ment of Severe Acute Child Malnutrition:
which led to significant coverage of the Jadhav, A et al (2016): Randomised Controlled A Qualitative Study in Southern Ethiopia,
Facility Based Trial to Assess the Impact of Health Policy and Planning, Vol 30, No 10,
issue (Asian Age 2017). It is notable that pp 133441.
Indigenously Prepared Ready to Use Therapeu-
even Maharashtras minister for tribal tic Food (RUTF) for Children with Severe UNICEF (2013): Ready-to-Use Therapeutic Food
development has publicly expressed res- Acute Malnutrition in India, Pediatric Oncall for Children with Severe Acute Malnutrition,
Journal, Vol 13, No 4. Position Paper 1.
ervations regarding this proposal, while
the state health ministry has also not
supported it (Mahamulkari 2017b). EPWRF India Time Series
To conclude, we feel that there is a
Expansion of Banking Statistics Module
need for large-scale social mobilisation
to resist the weakening of public service (State-wise Data)
systems, and to counter tendencies to
The Economic and Political Weekly Research Foundation (EPWRF) has added state-wise
move from a welfare state to a war- data to the existing Banking Statistics module of its online India Time Series (ITS)
fare state. Linked with this is the need database.
to critique the growing commercialisa-
State-wise and region-wise (north, north-east, east, central, west and south) time series
tion of welfare, which is emerging as a data are provided for deposits, credit (sanction and utilisation), credit-deposit (CD) ratio,
new area of state-assisted accumulation. and number of bank offices and employees.
Seemingly arbitrary decisions that pro- Data on bank credit are given for a wide range of sectors and sub-sectors (occupation)
mote vested interests while ignoring such as agriculture, industry, transport operators, professional services, personal loans
healthier and much more socially sus- (housing, vehicle, education, etc), trade and finance. These state-wise data are also
tainable options are unacceptable in an presented by bank group and by population group (rural, semi-urban, urban and
age that demands evidence-based policy metropolitan).
and democratic decision-making. Just as The data series are available from December 1972; half-yearly basis till June 1989 and
war is too important to be left to gener- annual basis thereafter. These data have been sourced from the Reserve Bank of Indias
als, nutrition is too important to be left publication, Basic Statistical Returns of Scheduled Commercial Banks in India.
to nutrition experts and nutrient manu- Including the Banking Statistics module, the EPWRF ITS has 16 modules covering a
facturing companies. Undue promotion range of macroeconomic and financial data on the Indian economy. For more details,
of commercial interests in the guise of visit www.epwrfits.in or e-mail to: its@epwrf.in
welfare must be exposed, alternative
Economic & Political Weekly EPW JUNE 24, 2017 vol lIi nos 25 & 26 21