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Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
Declining Malnutrition in Maharashtra-6-The Tribal Issues
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Declining Malnutrition in Maharashtra-6-The Tribal Issues

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Moderate malnutrition (>30%) still lingers in 15-20 tribal blocks, including some severe grade MN calling for rehab effort. The tribal Malnutrition is a complex web--poverty, culture, migration, …

Moderate malnutrition (>30%) still lingers in 15-20 tribal blocks, including some severe grade MN calling for rehab effort. The tribal Malnutrition is a complex web--poverty, culture, migration, terrain, services, lack of awareness, supply gaps etc. We need a roadmap, a practical and pragmatic agenda.

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  • 1. Child Malnutrition in Maharashtra (India) August 2013- January 2014 2013- Situation, Efforts, Decline and Challenges A Review For the State Nutrition Mission PowerPoint6/6 Malnutrition in Difficult Tribal Areas Dr Shyam Ashtekar, MD (Community Med) shyamashtekar@yahoo.comnganwadi-supplementary feed--Dr Shyam A ashtekar jan 2014 1
  • 2. Persisting Malnutrition Problem In The Difficult Tribal Blocks of Maharashtra PowerPoint 6/6 Dr Shyam Ashtekar 2014 This Photo belongs to year 2000 there is less of this BUT THE ISSUE REMAINS
  • 3. 3 Some Pockets of Malnutrition in Maharashtra Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014
  • 4. Maharashtra has 9% tribal population and .. 15 blocks have more malnutrition , Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 4
  • 5. > 30% children malnourished. 5 In some tribal blocks child malnutrition (-2SD) rates are 30-40% In this 4-5% is severe malnutrition (-3SD) In Maharashtra 9% tribal population implies about 1 crore people The U6 child population is about 10-12 lakhs. Of these 3-4 lakh U6 children belong to the difficult tribal blocks. Possibly 1.5 to 2 lakh U6 children are malnourished. Hence about 15-20 thousand U6 children may be severely malnourished or perhaps more. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014
  • 6. The 15+ difficult Tribal Blocks Jawhar, Mokhada, Wada Dhadgaon, Akkalkuwa, Shahada Dharni-Chikhaldare Bhamragarh, Armori, Korchi Peth, Surgana, Trimbakeshwar Rajur Some blocks have more pop, so more children in MN Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 6
  • 7. Ignorance and blind faith Contributors of tribal Malnutrition Poverty and Migration Roads and Power Problems Forest restrictio ns More illnesses Child Malnutrition Unclean condition s Poor Breast feeding Weak Health System Malnouris hed Women Less Birth weight Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 Weak Governan ce 7
  • 8. The malnutrition (MN)causes(MN)causes-in a pyramid Resulting Child deaths Child MN & illness cycle 0-5Y age group 40-50% MN, 10% U6 children severely wasted. MN anemia and less BMI in women and adolescence, many reasons for this--early marriage, child birth, weak ANC, Less Birth weight Neglect of breast feeding and complementary feeding, Lack of hygiene. poor nutrients, weak health system, lack of awareness, blind faith, gender bias, migration, terrain, no employment, inflation, PDS problems etc. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 8
  • 9. Govt. Schemes and Services Many Schemes and services are weak in tribal areas. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 9
  • 10. Scattered Habitats in Tribal Blocks Google map of Molgi in Nandurbarmajor weekly market, village spread on 4-5 Kms distance And a typical Non-tribal village Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 10
  • 11. Forest and Animal Sanctuaries, Forest zone laws, Lack of Transport… Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 11
  • 12. Seasonal Migration is a Fact of life Construction and agriculture are major sectors for migration. Migration for 6-8 months ◦ Many families migrate for 68 months leaving the AWC little scope for help. ◦ Construction and agriculture sectors attract most migration-both cause stress ◦ Migration worsens malnutrition ..or does it ? Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 12
  • 13. Hard Work and Hilly Terrains Hilly roads and head loads Hard labor and less food lives little flesh in the body. BMI less than 18.5 affects 4080% women Famished women bear weak children Low BMI reflects poverty. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 13
  • 14. Blind faith, Faith Healers and Black Magic Deep rooted problems Blind faith and Bhagats carry on.. Blind faith and lack of awareness are major issues. This is a major impediment in scientific treatment. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 14
  • 15. LiquorLiquor-struck Home distilled liquor A livelihood for some tribes For Tribal societies liquor has a traditional value. But some tribal communities are hard hit with liquor problem Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 15
  • 16. Water and Firewood take so much of Life and Labor. Labor. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 16
  • 17. Back Breaking Farm Labor and Little Returns The tribal agriculture is mainly rice and millets, of little value in the market. The PDS rice comes at 3Rs. a Kg. Home grown rice costs about 20Rs. a Kg. One season crop and almost no water thereafter. Farming only for staying alive not for prosperity. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 17
  • 18. Public Distribution System and Food Security The door step PDS scheme offers 35Kg. for each family every month. Hence about 100Kg. For 3 months. Food supply is a problem in some parts. Some tribes can not use wheat and rice may be too bad to use. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 18
  • 19. Many Homes have Stocks for 2 Years Currently the doorstep PDS, farming and wage labor bring home enough food for most homes Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 19
  • 20. But Proper Nutrients in Good Measure are missing. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 20
  • 21. High fertility: 7-8 children is a common 7scene More children Rapid succession No spacing of births Hence neglect of children and mothers Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 21
  • 22. Early Marriage and Childbearing More than 50% early marriages Under-age pregnancies also common. Many unwed mothers get pregnant and bear children that may get neglected Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 22
  • 23. Low Birth Weight 40-50% babies weigh less than 2.5KGs. One in three of these babies are premature These babies do not thrive well without really good efforts. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 23
  • 24. Faulty Feeding Practices Just about 50% babies are breast fed within the first hour of birth. Exclusive breast feeding till 6 months is also barely 50%--there are also lifestyle causes for this. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 24
  • 25. Faulty Complementary Feeding 6-8 semi solid feeds necessary after 6 months. Barely 10% babies get this. diversity, vitamin A and iron rich feeds often missing . There are difficulties like work and migration but the result is the sameMalnutrition Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 25
  • 26. Sanitation and Hygiene The spread of illnesses Toilet is necessary, but atleast a hand wash is a must Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 26
  • 27. Less of Immunization < 50% full immunization rate. Many reasons for this. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 27
  • 28. Illness cycle Diarrhea pneumonia major illnesses IMNCI program trained AWC sevikas for this But Govt. of India change this policy. Now they expect NRHM-ASHAs to do this. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 28
  • 29. The Intergenerational Cycle of Malnutrition Malnutrition carried to next generation. Quick birthing is part of the problem. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 29
  • 30. Anemia in 60-70% Women and Children 60Low hemoglobin invites several problems. Causes maternal morbidity and mortality. Causes Infections, malnutrition for children. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 30
  • 31. 5-10% Children Suffer from Sickle Cell Anemia Genetically faulty hemoglobin causes many health problems. Infections, malnutrition, pains and growth lag. 5-10% children suffers from this disease Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 31
  • 32. Weak Health System Doctors unwilling to go and work in tribal areas. There are many administrative hindrances Many specialist positions remain vacant. This is a recent news from Gondiya district in Daily Loksatta about vacant positions Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 32
  • 33. InfrastructureInfrastructure-Leaking Roofs are Common Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 33
  • 34. Lack of Facilities Many projects have no vehicles. Lack of support staff in most projects Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 34
  • 35. Weak Health system Barely 50% women get some ANC care 50% childbirths happen at home. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 35
  • 36. Getting help from NGO & CSR Very few NGOs especially in Nandurbar In Melghat, we have some NGOs..no study on their impact on general situation NGOs can undertake some assignments in the affected areas, with a flexible approach. CSR can help in special interventions like RUTF. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 36
  • 37. Child Neglect.. Causing gaps in child feeding Lack of cleanliness and hygiene because of either an old or too young attendant There are substantial reasons like a working mother, migration etc.. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 37
  • 38. Some Families are Less Concerned Some tribal families feel less Some AWC workers report about malnutrition unless it is that families may starve the a severe malnutrition.. child to get Khavati loans Problems of daily life more Loan amount –Rs 3000- is important than a malnourished sometimes wasted child. This is possible and we need to review this scheme for better utilization. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 38
  • 39. Need to Know Tribe Specific Facts in Malnutrition Stat. Scheduled Castes (SC) and VJNT communities also have sizable malnutrition, some more than others Nomadic Tribes needs special attention and mentorship Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 39
  • 40. Some Tribes are More Malnourished Than Others in the Same Village. Some tribes are backward in cultural and educational aspects than others in the same region (e.g. Katkaris as compared to Warlis in Thane) Some are afflicted with liquor addiction We need to study these differences closely and take appropriate action. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 40
  • 41. Food Security and Malnutrition We cannot link all malnutrition with food insecurity. Many homes have enough stocks of foodgrain Specific causes need to be explored, proximate factors like nutrients and health care are often more important. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 41
  • 42. Community Participation Necessary… Necessary… It is difficult to expect local participation for combating malnutrition in tribal areas at this stage. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 42
  • 43. Khavti Loan for Affected Families Families get 3000 Rs. loan as help if their baby is malnourished. It is almost never returned. Families eager to get this dole even fight to get this. But the cash is often used for other purposes, even spent for liquor Is Khavti helping for reducing malnutrition? Can we promote this as an award scheme? will that help? Need a review! Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 43
  • 44. Nutrition Rehabilitation The NRHM assistance is available for nutrition rehabilitation from village to district hospital. This is expected to prevent further malnutrition if not cure the problem. Also helps to avert some child deaths. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 44
  • 45. Crèche The crèche scheme has been started in some Crèche is a good social facility. tribal blocks. The crèche attends to pre AWC age group including nutrition. The crèche also frees the mothers from childduties for some hours. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 45
  • 46. Line listing of Malnourished children on Website ..But These Lists are Rather Old. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 46
  • 47. Media Can Help in Fighting Tribal Malnutrition Media.. should focus on comparative statistics, causes and management options. The AWC Sevikas are honorary workers, not well paid servants.... they are not the causes of malnutrition themselves. Need to be sensitive also to the problems of staff working in difficult areas. Tribal malnutrition is a complex problem and is bound to take more efforts and time. Media can play a constructive role Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 47
  • 48. A Road Map Income Programs Social Reforms Administr ative Reforms Health & Nutrition measures There is no magic wand We need a practical Road Map Need for wider collaboration Need a rational and realistic program with achievable objectives. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 48
  • 49. Need for Balanced Efforts Need to balance between family/social efforts with administrative measures. Govt. cannot do it alone unless families are also able to participate. Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 49
  • 50. A Senior Journalist Says I met a senior journalist who had reported on Bamani-the ground zero of malnutrition deaths in Nandurbar which first hit the headline in eighties. He says “there is a visible decline in severe malnutrition even in those areas that were worst hit. We used to see the affected children while passing any village. We see there is a big difference”. I hope another decade will see more change Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014 50
  • 51. Best Wishes 51 Dr Shyam Ashtekar (MD, Community Medicine) 21 Cherry Hills Society, Anandwalli, Nashik India 422013 shyamashtekar@yahoo.com Cell +919422271544 Website: arogyavidya.org, bharatswasthya.net A study of Anganwadis and campaign against malnutrition in Maharashtra for and with support of Rajmata Jijau Mission, August to Dec 2013 Malnutrition in Tribal blocks- Dr. Shyam Ashtekar, Jan. 2014

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