Economic challenges brought on by COVID-19 and social distancing norms will complicate the issue of addressing severe malnutrition . Yet this is a problem that needs more attention now
Nothing in our experience in healthcare had prepared us for what the Coronavirus pandemic had unleashed upon the country, particularly rural India. As the contagion-triggered lockdown suspended healthcare programmes across the country, work at thousands of Anganwadi centres, which served nutritious, cooked meals to lakhs of children, was disrupted. Similarly, food distribution at the Nutrition Rehabilitation Centers (NRCs), which are facilities set up by the Government to treat victims of severe malnutrition, also came to a grinding halt.
Economic challenges brought on by COVID-19 and social distancing norms, which are here to stay, are likely to complicate the issue of addressing severe malnutrition. But ironically, it makes the task of addressing severe malnutrition even more important than before.
Long-term social distancing norms mean that in a post-COVID world, we have to rethink and strengthen elements of community-based management of malnutrition through our frontline workers, who remain the lifeline of programme implementation. This reassessment also becomes relevant considering parents may be reluctant to bring their severely-malnourished children to the NRCs for fear of infection. What makes this task more difficult is the fact that even before the Coronavirus struck the country, NRC was not a place parents preferred to stay in with their children.
The intensity and manifestation of Severe Acute Malnutrition (SAM) in the form of extreme thinness, morbidities and associated high mortality could draw the Government’s attention earlier than stunting, which though looming large, was not so visible. As a response to the crisis, in 2011 the Central Government issued operational guidelines on facility-based management of SAM children within institutional (hospital-based) settings with the use of therapeutic foods.
Subsequently, many Indian States established these centres for in-patient care of severely malnourished children. These units function as per the protocols prescribed by the World Health Organisation and the Indian Academy of Paediatrics (IAP). Children with severe malnutrition are referred to the NRC and on admission, are required to stay at the in-patient facilities for a period of 14 days or more, until the child recovers from infectious disease and gains adequate weight as per the discharge criteria.
However in the practical experience of all Government healthcare workers dealing with SAM and NRCs, a majority of caregivers, especially the mothers, find it unusually challenging to stay at the NRCs for over two weeks.
Hence the caregivers either show tacit resistance to treatment procedures or leave the centre abruptly against medical advice. In either case, finally the child suffers and continues to remain acutely malnourished as the prescribed nutrition treatment is rendered ineffective once the child is back in his/her home environment.
The reluctance to take the SAM child to the NRC and the decision of leaving the facility without completing the treatment can be attributed to a host of parenting challenges that women face. Managing household chores, taking care of their other children and even the elderly become impossible for a woman living in a NRC with her SAM child. Due to the extreme poverty of the families that these children come from, there are times when even livestock, jobs or work in the family farm take precedence over the child’s health for the women of the house.
This is an unfortunate but harsh reality of our country that the primary responsibility of all these tasks lies with the mother of SAM children. In addition to this, the compensation offered by the Government to stay at the NRC is much lower than the perceived opportunity cost incurred by the family for treating SAM children.
This includes the travel cost to the NRC, the loss of working days as women contribute to family income, either by working under the various schemes that come under the Mahatma Gandhi Employment Guarantee Act (MNREGA), or by participating in agriculture. Additionally, women also care for the family, fetch water, wash clothes, cook and clean. Thus, all of their household responsibilities get disrupted if they have to stay with the child at the NRC.
What makes matters worse for parents and children are the living conditions at the NRC. Sometimes ill-treatment by the campus staff further damages parental trust and perception of the quality of public health services. Women are often intimidated by the unfamiliar environment, as for many of them the visit to the centre is their first-ever experience of being so far away from their home or village. They are usually anxious about their safety and face difficulty in communicating with NRC staff. All these factors add to their distrust and discomfort.
The pause COVID-19 has forced upon us should be used to reflect and make the NRCs more sensitive to the needs of parents and children. Adequate staff with technical skills and an empathetic attitude towards the need of the child and the parent are a prerequisite for SAM management at the NRC. This significantly enhances the performance of in-patient facility-based healthcare centres. Attention to these aspects also improves the community’s confidence, trust and builds a positive perception of the healthcare facilities. All of these improve compliance to the treatment.
Another component that helps parents stay longer is the introduction of counsellors at the NRC, who can identify psychological distress and offer emotional support to the mothers, empowering them to care for their own and their child’s nutrition and psychosocial needs. Enhancing the mother’s social network through engagement with other mothers present at the center and facilitating interactions between sub-groups in a way that mothers experiencing similar psychosocial stressors and care-giving issues share and learn from each other’s experiences, have been seen to be helpful in retaining SAM children at the centres. Such supportive sessions help mothers adjust with routine procedures at the NRC and make their prolonged stay relatively comfortable.
Structured and thoughtfully-introduced innovations to improve infrastructure facilities like provision of additional side beds for fathers to accompany the mother, arranging for their meals and providing basic facilities for sanitation, entertainment and safety at the centre can go a long way in extending the stay at the NRC.
A vibrant and child-friendly environment has a magical effect on the listless SAM child. Small changes such as a play area with outdoor activities, toys, games that are age and health-appropriate help to overcome the stress and anxiety of hospitalisation and can help reduce the risk of psychomotor and cognitive impairment in children. The play sessions also help in developing and firming the mother-child bond.
Despite the decline in the percentage of children who are underweight from 42.5 per cent in the National Family Health Survey-three (NFHS) to 35.7 per cent in NFHS-four, the burden of childhood malnutrition in India continues to be significantly high. About 38.4 per cent children under the age of five are stunted. And the number of children under five, who are wasted and severely wasted has increased to 21 per cent and 7.5 per cent in NFHS-four from 19.8 and 6.4 per cent respectively over the decade. These numbers are not likely to improve post the COVID-19 crisis.
Reinventing our facility-based management model, so that our centres are more sensitive, combined with a stronger community-based early identification and follow-up approach for managing SAM will prove effective in ensuring completion of treatment, adherence to follow-up and sustained weight gain for children who are suffering from severe malnutrition.
(The writer is a public health nutritionist who has worked with State health, women and child development departments and specialises in SAM)
