Muzaffarpur is emblematic of a hot spot for undernutrition in India. With one in two children stunted, Muzaffarpur lags India’s average by ten percentage points. One in two women is anaemic and one in three is underweight. Although most infants are breastfed and exclusive breastfeeding is high, other aspects of infant diets are abysmal and childhood illness is high. Other social determinants of malnutrition – early marriage, poverty, open defecation and more – offer a case study in what one could call a “perfect storm” of risk factors.
Children here appear to be born and grow up malnourished. This fact, and that some of these children and their families pay a deeper price of a life snuffed out, should be a wake-up call that society continues to allow such inequities to be heaped upon children.
In this cluster of risk factors that contribute to rampant undernutrition, the additional stress imposed on the most vulnerable families has pushed many susceptible children over the edge this year. Unfortunately, the added vulnerability of the season wasn’t a surprise nor this is the first time that so many children have died in this area.
An analysis of the challenges in the acute encephalopathic syndrome (AES) deaths of 2014 outlined the contributors and the possible remedial issues in a paper in the Lancet Global Health some years ago. And indeed, in a thoughtful piece by Jacob John, one of the investigators of that study, asks why recommendations were not followed. These are hard questions, begging immediate answers.
There are many experts on the ground in Muzaffarpur today, aiding in the investigation of this year’s crisis. They will again examine issues related to the health system’s preparedness, its response and assess the nutritional risks.
Is it likely that these current investigations will highlight that the 2019 deaths occurred under different circumstances than the 2014 deaths? No. Is it likely that the most vulnerable families in this district – those doing seasonal work in the litchi orchards – are going to continue to be the worst affected by this health emergency, and is there a risk this will occur again? Yes. Is anyone going to be held accountable for this other than hardworking doctors trying their best to pull children back from the brink of death? Unlikely. Unfortunately, the facets of social inequity that show their face in the mirror of Muzzafarpur are possibly too much to handle.
Identifying solutions will require a deeper social analysis in addition to the health system’s readiness and response. Here are some additional questions that need to be asked from a social epidemiological lens.
What are the social antecedents of the families camping in the litchi orchards to pick the fruit? What do their usual year-round employment and economic conditions look like? What are their other social vulnerabilities?
How food secure are these families on a routine basis? What are the additional seasonal stressors on their ability to feed themselves and their children?
What do meal patterns look like for these families on a year-round basis, and how do they change during litchi picking season?
How vulnerable are the mothers of these young children who died? What does their social safety net for child care look like on a year-round basis? Do they have any support in food procurement, meal preparation and child feeding? How do these change during this season of high vulnerability?
Do these families have any access to the basic social safety net programs of the ICDS and PDS in Bihar? How are those working for them?
What are the social information networks for these families? Had any of them ever heard about the effects of litchi consumption or the need to try to feed their children before bedtime? And if they had heard about it, but weren’t able to act on it, what were their biggest constraints?
Answers to some of these questions will reveal the practical roadblocks that need to be resolved to help build a contextually-grounded food security and nutrition safety net during this season, and beyond. In the context of poorly functioning basic programs like PDS, ICDS and health systems in Bihar, though, non-state solutions might well also need to be explored to deliver such a safety net. Recent experiences with community-run creches in vulnerable tribal districts in Odisha and Jharkhand are well worth exploring.
Solving the child death and malnutrition crisis will require compassion for the most vulnerable. It will also require a reshaping of India’s ability to live comfortably with a remarkable level of social inequity – economic, caste-based, gender-based and more. These inequities play out in myriad small ways daily for those affected by them and contribute to outcomes like stunting and wasting among children.
However, in places like Muzzafarpur, at especially vulnerable times of the year, the consequences of the cluster of social inequities are devastating. Using an epidemiological and ethnographic lens to ask deep questions about these inequities in the context of the ongoing analyses what will bring scientifically sound, compassionate and pragmatic solutions.
Purnima Menon is a senior research fellow in IFPRI’s Poverty, Health and Nutrition Division, based in New Delhi.