On January 30, Ajit Kasdekar died. He was two years old. Ajit was afflicted with severe wasting (loss of muscle fat and tissue) and acute malnutrition.
According to growth charts released by the government, Ajit should have weighed 12 kg. He was just four kg when he was admitted to the nutritional rehabilitation centre of the Dharni sub-district hospital in November. When he died, he weighed six kg.
Ajit’s mother, Sharmila, 22, is a Korku Adivasi from Berdabarda village in Dharni taluka of Amravati, Maharashtra. “I don’t understand, it happened all of a sudden. We were happy that he had gained some weight,” she said. “He had developed a small ulcer in his mouth and was a little fatigued when we brought him back from the hospital on the evening of January 30. He ate only a small portion of cooked rice, like he always does, for dinner and slept. It was hard for us to see him not waking up from his sleep the next morning.”
The immediate and exact cause of Ajit’s death is not known since Sharmila didn’t take him back to the hospital.
According to data from the health department of the Amravati Zilla Parishad, 388 children under six died in the district between April 2018 and March 2019. As many as 247 were from the Melghat region.
Melghat comprises the two talukas of Dharni and Chikhaldhara. Nearly 78 percent of Amravati district’s Adivasi population lives in Melghat. Most of them are Korkus.
In 2019, at least 409 children died in Melghat alone, according to data from the health department and a response to an RTI application.
In Palghar some 585 km away, the situation is similar. According to data from the district’s health management information system, out of 210 infant deaths in 2018-19, at least 114 were from the Adivasi-dominated talukas of Jawhar, Mokhada, Vikramgad and Palghar. Most Adivasis in Palghar belong to the Warli, Koli Mahadev, Thakur, and Konkana tribes.
According to an RTI response received by this reporter, around 348 children below the age of six died in Palghar district in 2018-19. Of this, 122 were from Jawhar, 27 from Mokhada, and 32 from Vikramgad.
A in Palghar revealed about 59 percent of its Adivasi children are stunted, 20 percent wasted, 53 percent underweight.
These official figures invite the obvious question: why are Adivasi children more susceptible to malnutrition? There are multiple reasons, including a lack of awareness and quality education, socioeconomic conditions, geographical isolation, early pregnancies, maternal undernutrition, access to healthcare and other government interventions and outreach programmes.
Nuclear families and literacy rates
Dr D Jawarkar, a Korku Adivasi and paediatrician at Dharni sub-district hospital, said, “It all starts with lack of quality education and awareness.”
According to Jawarkar, malnourished children in Adivasi communities are mostly found in nuclear families, or among parents who haven’t completed their secondary or higher secondary education.
“There is an abundance of food — Adivasis are natural agriculturalists — but they are not aware of how to make the most out of their indigenous food cuisine, especially the younger generation,” he said. “These days, children are more inclined towards consuming junk food which is extremely low in nutrition. This needs to be resolved first.”
Their indigenous food includes seasonal leafy vegetables, fruits, roots, tubers, mushrooms, sabji made of dried flowers and wild plants. Instead, families are dependent on the public distribution system. They feed their children wafers with high salt content, biscuits dipped in milk, sev, fried foods, even Maggi.
Ajit would have turned three years old in February. Following the monsoon last year, he had a high fever and severe diarrhoea. According to Sharmila, he was underweight but still doing better — he weighed 8.5 kg and could walk around.
Ajit and his grandmother, Savitri, at the Dharni sub-district hospital.
Ajit weighed six kg when he died.
But by summer, the diarrhoea, fever, and frequent coughs and colds made him drastically lose weight. He had severe muscle wasting and lost his ability to walk. Sharmila herself was preoccupied as she had just given birth to a baby girl. Furthermore, she said, she was clueless on how to take care of Ajit.
“I used to feed him the usual rice, dal and other pulses. He also ate chips and biscuits dipped in milk most of the time,” she said. “After the monsoons, he fell ill and became very cranky. I also had to take care of my newborn daughter then. It was difficult for us to make rounds to the hospital which was about 18-20 km from Berdabarda village and we had to switch buses. So, my mother took Ajit to Mandu village which is closer to the Dharni sub-district hospital [about 10 km away].”
Ajit’s father, Arvind, 22, studied till Class 10 before dropping out to work with his father in farming. Sharmila’s studies ended after Class 8, since her parents couldn’t afford it. “We are not literate enough to know much,” Arvind said, “but we tried all possible means [to save Ajit].”
Data from the 2011 census highlights the difference in literacy rates between other communities and Scheduled Tribes in Adivasi-dominated talukas.
The literacy rate of the members of Scheduled Castes in Dharni and Chikhaldara are 82.46 percent and 78.34 percent, respectively, while that of the Scheduled Tribes in both the talukas is 73.02 percent and 73.92 percent, respectively.
In Palghar, the difference is greater. For instance, in Dahanu and Jawhar talukas, the literacy rate of the SC community is 88.05 percent and 79.17 percent, respectively, while that of the ST population is 46.39 percent and 53.84 percent.
Changing food habits
Sharmila admitted that it didn’t bother her that her two-year-old toddler would eat chips. “As long as that made him less hungry when my husband and I worked in our field,” she said.
The Kasdekars are a nuclear family and own a two-acre plot of land where they grow jowar, toor, and cotton. Their daily meal consists of roti, one sabji [moong, tomato or sev], rice, dal and occasionally meat.
“Jowar and toor are used for personal consumption,” Arvind said. “We also avail rations with our yellow Below Poverty Line card.”
Sharmila’s mother Savitri, 58, fed Ajit only rice as he was not eating anything else.
“This worried me a little,” said Savitri. “In August, our anganwadi worker gave me liquid food which comes in a yellow packet to feed Ajit. This helped initially as he even gained weight.” This is the energy-dense nutritious food packets, given especially to severely malnourished children, every two hours for a few days.
However, Ajit’s health soon deteriorated after another bout of diarrhoea and a cold. “The monsoon really affected his health. We were not sure what to do,” Sharmila said. “In October, we went to our bhumka [traditional healer] in the village. He blessed Ajit, tied a thread around his waist, and told us he will recover once the rains subside. But Ajit didn’t show any signs of recovery.”
So, in November, Ajit was admitted to the nutritional rehabilitation centre at the sub-district hospital. “It was painful to see him die as we thought he was recovering,” his mother said.
Sharmila’s daughter, Shubra, is now nine months old. In addition to breastfeeding, she takes complementary foods as well.
“I will see to it that she gets proper attention. I have been breastfeeding her exclusively for six months and now have been giving her rice and dal, following the doctor’s advice,” Sharmila said. “I will not lose her like Ajit.”
The lack of indigenous food
In Deharje of Vikramgad taluka, Palghar district, about 100 km from Mumbai, Radhika Jadhav, 23, feeds her daughter sev, a deep-fried crispy snack made of flour, for breakfast.
“Rutiksha wakes up every morning and craves this snack. She keeps crying until she gets it so I give it to her,” said Radhika resignedly.
Rutishka is two years old. According to growth charts, she should weigh 12 kg but she only weighs 8.9 kg.
Urmila Patil, the local Accredited Social Health Activist worker, said: “She is gaining weight, but Radhika should be mindful of giving her proper food. Despite us educating them and making them aware of the importance of consuming leafy vegetables and their local food, it’s difficult to follow up because most of the mothers don’t listen.”
Unlike the Kasdekars of Melghat, the Jadhavs work as labourers with no land of their own. They live in a house they built themselves, using clay, bricks and bamboo, with plastic and metal sheets for the roof.
Radhika and Rajesh have been married for three years and live alone with their daughter. Radhika, who is seven months’ pregnant, left school after Class 5. Her husband, Rajesh, studied till Class 7.
“If it’s a good working month, we manage to earn around Rs 10,000,” Rajesh said. “Otherwise, our income fluctuates from Rs 5,000 to Rs 9,000.”
Radhika Jadhav and her daughter, Rutishka.
Radhika and her husband, Rajesh. Radhika is seven months' pregnant.
The family’s regular meal consists of rice, dal and a sabji, made of potato, tomato, sev, brinjal, cowpea, or moong. Chicken or mutton is included on special occasions. The family doesn’t eat leafy vegetables or fruits.
Does the family consume indigenous food? Radhika is clueless.
“We don’t get much time, since we work as labourers. I wake up at 6 am, fetch water from the well, wash clothes, cook food, and head to work,” she said. “I stopped working because of the pregnancy. But it is difficult to eat these things when we hardly manage to scrape by. We rely on rations and one-time meals provided by the anganwadi centre.”
Dr Suparna Ghosh Jerath, who works at the Indian Institute of Public Health, Delhi, led a research project on the indigenous food environment of Adivasi communities in Jharkhand. According to her, Adivasis aren’t consuming as much of their indigenous or forest foods as they once did. “It’s also natural, because societies are transitioning.”
Jerath explained, “Some Adivasis, in the past, used to thrive on millets, but now they prefer wheat and rice. The habit of going to the forest and foraging for traditional foods is gradually dying. Also, the traditional knowledge is eroding with time, as the next generation might not even know about certain indigenous foods that are available around us.”
Even if families possess the knowledge of indigenous foods, Jerath said, this isn’t implemented in their daily diets for nutritional benefit.
“Sometimes, filling the stomach becomes the priority of the community and not nutrition,” she said. “After all, this is hidden hunger. People do not have detailed knowledge about the nutrients that they are supposed to consume.”
In comparison with other communities, Jerath said, “Adivasis are at a disadvantage when it comes to access to food as they live in remote locations; their socioeconomic status; their cultural practices, lack of awareness, and many such problems. Even if you give them nutritious food, it might not help as a holistic and practical approach that mainstreams their traditional foods dietary practices into the current nutrition programs is much needed.”
She added: “Reviving traditional food practices is important and for that, we have to suggest ways which are in sync with their reality.”
Socioeconomic conditions and inaccessibility
In 1998, Dr Ashish Satav founded the MAHAN trust, which provides healthcare services to Adivasi communities in Melghat.
“About 80 per cent of the families here are below the poverty line,” Satav said. “They can’t afford to spend 14 days in an NRC or make the rounds of a hospital, ditching their work. Persistent malnutrition here is the result of a lack of awareness, poor socio-economic conditions, and cultural practices.”
According to Satav, 38-40 percent of adults, especially mothers, are malnourished in Melghat. “When a mother herself is malnourished, how do you expect the child to get nutrition, even through breastfeeding?” he said.
Whether it’s Melghat or somewhere else, Satav said, accessibility to healthcare facilities is a challenge, since most Adivasi communities live in remote areas.
“During the rains, about 20-25 percent of the villages in Melghat lose connectivity due to flooding,” he said. “Emergency medical facilities can’t reach such isolated villages. Primary health centres at the village level should be upgraded to provide almost all required facilities. Policies are often not framed keeping ground realities in mind.”
For example, the Vajes, a Warli Adivasi family from Dhamodi village in Mokhada taluka, Palghar, had a tough time taking their son Jayesh to the nearest primary health centre. Jayesh is four years old, and severely malnourished.
The nearest primary health centre is about 10 km away. Only three buses ply the route every day. The centre is difficult to find even on Google Maps, let alone to traverse 10 kilometres on bumpy roads that have no signboards.
“Whenever we took Jayesh to the primary health centre, we were referred to Mokhada government hospital, which is about 23-25 km away,” said Jayesh’s father Santosh Vaje, 28. “After making a few rounds, we gave up. We couldn’t afford it anymore. We barely manage to bring food to the table. Travelling in a private vehicle itself costs around Rs 300 to and fro, if we missed the bus.”
Yogita Vaje, the anganwadi worker in Dhamodi, said she tried to convince the family to continue Jayesh’s treatment. “But what can they do when they can’t afford it? I had begun feeding Jayesh with energy-dense nutritious food, but he showed very little signs of recovery.”
Jayesh has been severely malnourished for the past year. At four, he should ideally weigh about 16 kg. During my interview with his family, he weighed 7.8 kg.
Jayesh’s mother, Sangeeta, is 26. She and her husband work in the fields during the day while Priyanka, their six-year-old daughter, looks after Jayesh and two other siblings: Kareena, 3, and Pratiksha, 1. Sangeeta either feeds the children dal and rice at home, or takes them to the anganwadi centre.
“It’s not possible to take kids with us to work,” Sangeeta said. “Besides, they get food at the anganwadi centre where they get khichadi, eggs and snacks, so we are a little less worried about them being hungry.”
Jayesh Vaje, 4, and his mother Sangeeta.
Priyanka, 6, shows the meal prepared by her mother before she left for work.
Dr TD Shinde, a paediatrician who works with MAHAN trust, said the onus of the problem lies on the family.
“Priorities change once the child becomes sick. The child is brought to the hospital or a medical facility when it is in critical health,” Shinde said. “The brain of a child develops up to two years, and the children here are so malnourished up to that age that they lack the required IQ. Birth spacing, family planning is not what they think of consciously. They don’t know the techniques of complementary feeding, which is also a loss for the child.”
Several government and non-government interventions provide parents with services, Shinde said, but it’s up to the family to make the most of it.
“Interestingly, if you ask any Adivasi family, they are happy with their simple life,” he said. “Increasing awareness, improving quality education, and stringently guiding them against early marriages and early pregnancies can help them come out of this rut.”
When Jayesh first fell ill, his parents were reluctant to interact with doctors since they are both illiterate, Sangeeta explained.
So, like the Kasdekars, the family went to their bhagat, or traditional healer. “He told us that Jayesh and our family are under the influence of some evil energy. Once that is taken care of, Jayesh will recover.”
Bhagats or bhumka parihars provide traditional medicines to all sorts of ailments. Many Adivasi families prefer to visit them: access to healthcare is difficult, the bhagat belongs to the Adivasi community, and speaks their language.
Raju Mahale, a traditional healer from Palghar’s Jawhar taluka, said he treats underweight children with powder made by crushing certain herbs, or powders made from the barks of specific trees.
“Apart from our mantras, the indigenous herbs which we handpick from the forest help the child recover,” Raju said. “However, these days, people prefer to go to doctors as well if they run out of patience.”
Raju has been a bhagat for 35 years; he’s the eighth generation of his family to do so. “We don’t charge them money,” he added. “It’s up to them what they want to give us. Sometimes, they don’t even pay.”
Proper implementation of government interventions
Bandya Sane, an activist and the founder of Khoj, an NGO in Amravati, said there’s a need for collective effort to tackle child deaths across Adivasi regions in Maharashtra.
“There are several reports and action plans submitted by experts and medical practitioners, like Dr Abhay Bhang, Dr Ashish Satav, UNICEF, the Tata Institute of Social Sciences, Rajamata Jijau Maternal Health, and Child Nutrition Mission, to control child deaths in Adivasi regions,” he said. “However, the recommendations are not implemented by the government.”
Sane lists several aspects that need attention.
“For instance, paediatricians and gynaecologists should be regularly appointed in Adivasi regions after monsoons, as the number of child deaths shoots up between June and December,” he said. “There’s also a need to create employment opportunities to stop the migration of Adivasis — this is also one of the main reasons why an Adivasi child falls prey to malnutrition. With migration, the child or family loses access to healthcare. A comparative and scientific study should be instituted to understand why only Adivasis are more susceptible to the vicious circle of malnutrition over several decades.”
This story was supported by the as a part of its Public Health Fellowship 2019.