Case History

Malathi, a one and half year-old female child has been brought to the Primary Health Centre
(PHC) by a female health worker. She weighs only 6kgs has an emaciated look with swollen
legs and abdomen and sparse discoloured hair. She is very irritable but not able to cry and
refuses to eat anything. It is a pathetic sight to look at.

Malathi was born in Kottakuppam, a remote village in Tamil Nadu to Shankar and Lakshmi. Both
are illiterate. Shankar is a daily wage manual labourer earning about Rs 100 per day on the
days he gets job. Laksmi is a house hold maid earning Rs 500 per month. She got married at
the age of 17 years and had her first child within a year. Malathi is their 5th child. The other
three living children are Sumathi 8 years, Ramayee 6.5 years and Mangammal 4 years. The
fourth child had died of Pneumonia at the age of 10 months. Malathi was delivered at home by a
female relative of Shankar. Her birth weight was 2 kgs. She was given sugar water for the first
two days. Breast feeding was initiate only on the third day so she did not receive colostrum.

Lakshmi's health was poor. She weighed 36 kgs, which is very much less than what is expected
for her height and is severely anemic. She did not go for any ante-natal care for any of her
pregnancies and so did not receive any advice regarding her own care and the care of the new
born child. During her pregnancies she was advised by the elderly women in the village to avoid
foods like papaya and some food which were considered hot and cold. She was also advised to
take less food so that the baby will not become big and the delivery will be easy. This worsened
her health status. But to earn and feed her children she started going to work within one month
of Malathi's birth. Hence Malathi though breast fed, did not receive as many feedings as
needed. Weaning was started after nine months of age and breast feeding was stopped
abruptly. Only very small quantities of plain rice and highly diluted cow's milk were given.

Sumathi looks after her siblings including Malathi when their parents are out at work. She is not
aware of the need to wash hands before feeding and the need to use clean utensils, Hence
Malathi had repeated attacks of diarrhea. Food was withheld during these episodes because of
Lakshmi's belief that food would worsen the condition. Malathi as well as the other children were
not completely immunized as Lakshmi and Shankar did not have faith in immunization and were
not willing to lose one day's pay to take their children to the PHC to get them immunized. When
Malathi was 15-month-old, she had an attack of measles. Her parents thought it to be due to the
curse of Goddess Mariamman. They offered prayers at the temple and kept neem leaves
outside their house. A native healer advised to tie a "religious thread" around the wrist of the
child. After recovery from measles the child kept on having respiratory infections but was not
taken to any health facility.

Malathi's family lives in a small thatched hut without any drainage facility. Cooking is usually
done outside the house but in rainy season it is done indoors. Sullage flows to waste land
nearby and becomes stagnant. The surrounding is full of rubbish and garbage thrown by the
residents of all the nearby houses. The children go for open air defecation to a field behind the
house not far away from the place where they play. They are heavily infested with intestinal
worms. There is no proper water facility nearby. All of them have to go to a well about 15 km
away for bathing and washing purposes, so bathing and washing are quite infrequent. Drinking
water is collected from a panchayat tap 1 km away and stored in vessels, which are not properly
cleaned or covered. Children dip their tumblers into the vessel every time they take water.

Shankar is addicted to alcohol and smoking bidis. He spends most of his earnings towards
these habits. The family is hardly able to subsist on the meager income of Lakshmi. They
already have a debt of Rs 20,000. None of the children attending school as their parents want
them to look after the house, and the younger siblings when they go out to work. They are not
registered in the under-five clinic in the nearby PHC which 10 Km away. It takes about 1 hour to
travel to the PHC because of the poor transport facility. The Anganwadi worker had visited their
house many times but could not meet Lakshmi as she used to be out for work. Thus, Lakshmi
never received any advice regarding the care and nutrition of the children. She also did not
receive the supplementary nutrition provided by the Anganwadi Centre neither for herself nor for
her children because she could not find time to go and collect the food.

As Malathi's condition worsened, Lakshmi and Shankar became aware of something being
wrong but were not able to do anything. At that time during one of her visits to the village, the
health worker met Lakshmi and encouraged her to take Malathi to the PHC.