By Melari Nongrum and Glenn Kharkongor
On a casual walk through a village in Meghalaya, be it in West Khasi Hills or South Garo Hills, around Nokrek or in the Sung Valley, one cannot help but notice the children. Boys laughing as they run around kicking an improvised football, a group of girls in giggly conversation, a lone child sitting at a doorstep. The ones that specially catch an old pediatrician’s eye is the infant slung over its mother’s back, sometimes asleep, or the toddler safely clutching its mother’s jainsem.
Many of these under-fives have sparse, unnaturally light hair, pale eyes and sores at the angles of the mouth. These are unmistakable signs of malnutrition. A chubby face or a pot belly is deceptive and may actually be indications of low protein levels, a dangerous precursor to compromised immunity and harbinger of life threatening infectious diseases such as diarrhea, measles or pneumonia. Sixty percent of deaths in this age group are related to malnutrition.
Early childhood malnutrition is the greatest threat to the attainment of the full physical and mental potential of the child. It causes a lifelong compromise of growth and development, leaving in its wake a susceptibility to mental deficiency, and propensity to certain diseases later in life. The imprint of malnutrition is tragically transmitted to future generations, so urgent and sustained interventions are needed. A comprehensive approach that includes health, social and economic strategies must be packaged in a coordinated strategy. But some measures need to be taken immediately.
Weight and height are good indicators of malnutrition, and there are different ways of correlating these two indicators. Most children with poor nutrition are underweight for their age. Many look thin, because of wasting. Wasting may indicate weight loss from a recent illness. Some children with low weight may however look proportionate because they are short. Stunting usually signifies chronic malnutrition leading to impaired skeletal growth.
According to the National Family Health Survey 2015-16 (NFHS4), for which figures have been released for 13 states, 29% of children in Meghalaya under the age of five years are underweight. Two out of five children, 43.8% are stunted. More than two-thirds of all children in this age group, 71.6% are anemic (NFHS3). Most of the childhood malnutrition indices in our state are the worst in the Northeast region and comparable or even worse than the so-called BIMARU states.
Adequate nutrition later in life does not mitigate all the harmful effects of childhood deprivation. The effects are lifelong. Predisposition to rickets, delayed puberty, diabetes, stroke, heart disease and even obesity later in life are well-documented. The World Health Organization has devoted much study and analysis to this problem.
The most tragic outcome of severe malnutrition is cognitive deficiency or plainly speaking, mental retardation. In the rural areas, one cannot help but notice the occasional child with a vacant look, a blank stare, an obvious dullard. It is necessary to use crude phrases so that we do not beat around the bush with euphemisms, but squarely face up to the fact that the neglect of our children begets in every generation a higher proportion of these low IQ individuals. No one else will tell us this.
Unfortunately, the matter does not end with this generation. The girl child with undernutrition tends to become even more anemic when she reaches puberty. Half of our girls, 49.2%, in the age group 10-19 years are anemic. Almost two-thirds, 63.9%, of pregnant mothers in Meghalaya are anemic. Just look at the pale eyes and pallid skin of the women pavement vendors when you buy vegetables. So the womb in which the precious baby grows does not provide the nourishing environment which it should. The pregnancy results in a low weight baby, already starved in the womb.
This two-generation link is well-documented. But it goes beyond low weight. The poor nutrition of the mother, before and during pregnancy, has other effects. Her baby’s biological systems become biochemically and physiologically programmed to deal with the chronic undersupply of nutrients. The developing brain is given priority and glucose is diverted from muscles and other tissues so that cognitive potential is somehow maximized, even at the cost of physical growth.
The growing science of epigenetics has found that these adaptive signals are also embedded in the ovaries of the unborn girl baby, which means that the effects of malnutrition in the mother are carried even to her yet unconceived grandchildren, who will be born decades later to her daughters. Some of these epigenetic effects are also expressed through paternal influences so the nutrition of the boy child is also key to the sparing of future generations.
The question that arises is why do a majority of our women have poor health? Good health is largely dependent on consumption of nutritious food. In our context, there are social and economic factors that influence the consumption patterns of food by women and children. Maternal education is a critical factor that determines the choice of specific types of food in the home and contributes positively to the general nutritional status of the children. Education is often narrowly considered to be a formal school education.
But traditional knowledge of food systems have made communities food secure for generations. Therefore, though formal education is important, traditional knowledge should not be looked down upon. These two systems of knowledge are a continuum; one complements the other. Both systems of knowledge need to be acknowledged and promoted among mothers and indigenous people in general.
Other factors that affect health or consumption of food is food availability, food selection practices and biological needs. Food availability depends on production and harvesting processes and also peace and stability in the area. When food is available, food selection is affected by many factors such as cultural preference, affordability, influences of education and the media, and individual biological needs.
An important underlying factor that affects the consumption of nutritious traditional food is land. Patterns of land ownership and use among the Khasis and Jaintias have changed drastically in the recent past. Land is now mostly used for cash crops and monoculture has replaced traditional crop rotations. Privatization of land is on the increase. These forces have left many common people landless. Landlessness has many implications; as people lose access to land, their engagement with land is considerably reduced. This reduced engagement with land leads to decline in the knowledge of the natural environment which would also lead to a decline in the consumption of nutritious traditional foods.
Poverty is closely linked to landlessness and therefore the inability to grow and consume a balanced diet for the family. Poverty is a complex phenomenon in which numerous factors interplay. The number of earning members in the household play a role in the ability of households to be able to afford balanced meals. Smaller families tend to have a better standard of living and are less likely to have children deficient in vitamins. According to the 2011 census, Meghalaya has the highest fertility rate, family size and the largest proportion of children aged 0-6 years in the country.
The underlying social factors described in this article were amply demonstrated in a survey that showed a high prevalence of vitamin A deficiency in Pynursla Block of the East Khasi Hills District. Perhaps the situation is even worse in some other districts of the state. In the NFHS survey, Meghalaya has been clubbed with Bihar and Madhya Pradesh as the states with the highest percentages of stunted children.
Not to single out Meghalaya, most of India has not addressed this problem in a meaningful way. Despite two decades of high economic growth, the rates of child malnutrition have hardly changed. Many well-intentioned schemes have failed to make an impact. Perhaps Meghalaya, with a doctor at the helm, can find a better way.
Melari Nongrum is associate professor of social work at Martin Luther Christian University. Glenn Kharkongor was professor of pediatrics at Manipal and is now at MLCU.