Dr. Fabian Toegel addressing men and women representing over 40 tribal villages in malnutrition identification, treatment, and prevention. April 25th, 2009
After almost two months of planning, field assessments, and speaking to everyone from mothers of malnourished children to politicians we launched the first phase of our malnutrition eradication program in Jhabua, Madhya Pradesh with two trainings in malnutrition identification, treatment, and prevention over the past week. Our intervention will be a long-term, holistic initiative, with not just trainings but consistent onsite activities and follow up over the next two years, but this past week we started with the first step, a training to create awareness and to increase referrals of severe acute malnutrition to government centers.
On Saturday April 25th we called men and women from over 40 villages in the Jhabua district for our first awareness and training session. These participants, all from Jhabua’s Bhil tribe, represented self-help group animators, parents of children enrolled in the Bhil Academy, and active community leaders.
Fabian, Jimmy, and other RMF folks addressed the crowd, in Hindi, and engaged them about issues pertaining to malnutrition. We discussed what causes malnutrition, what it looks like, and how to treat and prevent it. We taught the group simple methods of identifying malnutrition and gave them guidelines on where, within the government system, they can go for treatment.
Standing room only — RMF’s first malnutrition training session for tribal community leaders
Teaching local communities to identify malnutrition is one method to ensure that children are referred for treatment, but also is a strong method of creating awareness, one step towards prevention. Everyone in this audience had heard about malnutrition to some degree and were aware that it is a threat, but most were not aware of the scale and immediacy of the problem in their communities. In a village where between 60-100% of the children have some degree of malnutrition, malnutrition becomes invisible. Emaciated bodies, lethargy, sickliness, these symptoms become a way of life, banal compared to the other daily challenges these families face to survive.
The training was a lot of fun, even though I felt a little out of shape: After comparing upper arms while explaining the MUAC method (measurement of upper arm circumference, an easy way to identify malnutrition in children) with all the women in the group who do manual labor all day, carrying kilos of water on top of their heads, impossible mounds of firewood, and children big enough to walk and run on their own, my biceps are pathetic. These women are tough and will do whatever it takes to care for their families. They just need the resources and knowledge and they’ll take care of the rest.
On Monday May 4th, we had our second training session for 30 men and women representing 10 NGOs who, put together, work in over one hundred villages throughout Jhabua and Dhar districts. During this session we not only trained the trainers – NGO workers who will go out into the field and train the groups they work with – but also received a training ourselves on the challenges that these NGOs face in the field. Elections, drought, migration, and even weddings pose serious challenges to identifying malnourished children and getting them the treatment they need. In their experience malnutrition is caused by lack of information about best feeding practices, migration, lack of proper hygiene, improper weaning practices, not enough space in between children, and lack of vaccinations – all root causes that we see time and again. No one mentioned lack of enough food as a cause for malnutrition.
Out to the villages with the trainees
After both training sessions, we then followed some of the women we trained and their children home to their villages to show them malnutrition identification in practice and to see what they would encounter in their homes.
On Saturday we visited one rural tribal village of 3,000 people where we went on a wild goose chase trying to find the local “anganwadi,” government village health worker. According to the government of India, one anganwadi worker is supposed to be present for every 1,000 people and is supposed to be the “frontline” health worker, the rural communities’ first contact with medical services. Anganwadi workers provide basic medications, basic health awareness, antenatal services, weekly immunizations, and food and preschool education to children under 6. In some areas, these health workers are the linchpin to making dozens of government interventions and services work.
We found 4 schools in the town which the locals said were staffed by teachers seldomly. The local health sub-centre is open a few times a month instead of daily. Locals don’t even bother visiting these education and health facilities because when they get there, there are no services worth their trip. When we finally found the anganwadi centre, we found that the health worker had long since left and the building had been taken over by a family and their cattle: A family with two children suffering from malnutrition in the former/still official anganwadi building.
Even in this town, relatively close to a large town (the locals visit the weekly market in town) with a tribal population which is known to be the better off and more educated of tribal groups, we still found around 6 cases of severe acute malnutrition in the roughly 50 children we saw.
Umri government sub-center and village behind. The locals don’t visit these centers, even though they’re well located because once they arrive there are no services available.
Umri, Madhya Pradesh
We visited another set of villages after our training session on Monday May 4th. Kauwa, in the Alirajpur district, was a village so remote that I had a hard time even fathoming how they get their basic supplies. As we were speaking to the local anganwadi worker and village mothers, children seemed to pour out over every hilltop, water pump, and shed. There were about 200 children in this farming village. We found another 30 or so shy children who were camped out with their families on the side of the road. These families, migrants from Gujarat, are day laborers for the new road they are building through the district and follow the road as its being built, camping alongside the current construction sites.
Out of the children who we were able to measure, we found that most children were underweight, with a few suffering from severe acute malnutrition. These children, who need expert medical care, were children of the migrants following the road construction. Their parents will not take them to NRC because they have to follow the construction path and are unwilling to spend 14 days in a hospital in a different state.
With so many children in such a remote village which only has one one-room health center staffed by one local woman, it’s hard to imagine that the children can possibly have access to the health services they need. The anganwadi center lacked the scales and measuring tapes to measure height and weight of children and also lacked many of the basic medicines necessary to treat common ailments that the centers are supposed to always have.
We left our MUAC tapes with the anganwadi worker and a promise to follow up with the Women and Child Development Ministry and UNICEF to ensure that this center is restocked with the proper medicines and equipment.
Training mothers, health care workers and NGOs is just the beginning. Once the children are identified as malnourished, they then need to be treated. We made sure during our trainings to speak to each participant individually to make sure they know where the nearest government facility to send a child for malnutrition treatment is located. We will also be following up monthly, if possible more often, with the people we have trained to reinforce the lessons, do onsite training, and to keep updated on the challenges they face.
Jimmy demonstrating MUAC in Kauwa. May 4th, 2009. Photo credit: Kim McGowen
This isn’t enough. As we’ve seen time and time again during site visits, for many children government Nutrition Rehabilitation Centers are not an option. Parents are working, mothers unable to leave husbands for blocks of time, migrants are unwilling to visit these centers in a different state, family weddings prevent others from spending 14 days at a government health facility. These patients, with uncomplicated malnutrition need the chance to get outpatient care. Our next step is to bring treatment for severe acute malnutrition directly to the patients so that they don’t have to travel to centers. With proper oversight and stringent follow up, we will be able to treat children with non-complicated malnutrition at home.
This is part of our larger strategy to tackle malnutrition from both the community and facility angles, focusing on the continuum of care in between. The causes of malnutrition are so varied and the problem is so complex, that we need to look at each village as a separate challenge and an individual community to celebrate. RMF, our field staff, and village volunteers will tailor our long-term interventions to the individual communities we’ll serve.
Stay tuned and please continue to give us your feedback and ideas as we develop and evolve this initiative.
Family from the Baiga tribe, classified as a "primitive tribe" by the government, Mandla, Madhya Pradesh
Demonstrating MUAC in the field
Dr. Fabian Toegel demonstrating MUAC — measurement of the upper-arm circumference — method of malnutrition identification
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