Not everyone in India views malnutrition in the same light. There exists a pervasive idea that the kids are just thin. As one official callously implied,
‘I was skinny when I was growing up, and it never did me any harm’.
You can understand why there has been inertia to seeing malnutrition as a disease. For one thing it means India must start to take responsibility for the eight million children who suffer from it, not a cheap thing to do. Also it draws unwanted attention to why there is such a massive problem in a country with (mostly) no acute crises and 8 mobile phones for every 10 people. It is a politically sensitive subject.
MSF first noticed the problem in Bihar during an emergency intervention during the floods of 2007. Some preliminary surveys revealed the baseline severe acute malnutrition prevalence in under 5s to be roughly 5%, which may in some contexts qualify as a humanitarian emergency and be dealt with as such in, for example, parts of sub-Saharan Africa. This is how our project kicked off, and MSF have been treating children in Biraul ever since. However, there are about 300,000 people in Biraul block (about 20 Roystons), and it is only one of eighteen blocks in the Darbhanga district (population 3.9 million). And there are 38 districts in Bihar state (population 104 million). And in all of Bihar state, all of India even, there is only one nutrition program such as the one MSF conducts. Why then, are MSF in Biraul and not anywhere else?
The main reasons can be boiled down to a combination of opportunistic luck, MSF’s capacity to negotiate access and then generate results, and the political willingness to address the issue on the part of the Bihar State government. What MSF are trying to do here – in Rising India, one day to be the world’s largest economy – is show the government that malnutrition can be treated cost-effectively on a large scale. Inside this contradiction, MSF performs a tight-rope walk, balancing results-oriented, life-saving medical operations and diplomatic negotiations with the government.
So here I am in the Stabilisation Centre, supervising the national staff doctors as they treat the malnourished kids. One two year old, let’s call him George, has that flavour of malnutrition that causes children to start swelling with excess fluid. It is a common cause of those swollen bellies I remember so clearly from the television as a child. I am finally clear as to the cause of the swelling, and contrary to what many sources would have you believe, it is not ascites (an abnormal accumulation of fluid in the abdomen), but in fact a combination of an enlarged liver and overgrowth of bacteria in the intestine, compounded by weak abdominal muscles.
The pathophysiology matters little to George. His skin is flaking off, leaving a mosaic of sores over his swollen body. His mouth is so cracked and infected that he can barely eat. He exudes misery. George does well on treatment though, and within a couple of weeks, he is healing up nicely and I even spot him smiling. He is discharged for follow up in the out-patient clinics.
The day-to-day purpose of the project here is to heal kids like George of their severe acute malnutrition, so that they avoid stunting or, worse, death, and you could no more quantify this benefit than you could put a price on a human life. But MSF are here with an additional, even more ambitious goal: if we can help kids like George with a model of community based nutritional care tailor made specifically for the Bihar State, Indian setting, then we might just be able to convince the government to adopt this model of care, scale it up and then help every sick kid like George.
And that would be quite an achievement!
Luke’s blog post was first published in Spanish in 20minutos.es