Malnutrition. and Mortality - Nutrition Foundation of India focusses primarily on nutrient intake. not anthropometry. to define malnutrition (Chen. L.C .. E. Huq. and S.L. Huffman.

Malnutrition. and Mortality

Lincoln C. Chen, M.D.Ford Foundation, New Delhi

Recent scholarly exchanges inIndia on the magnitude and nature ofthe malnutrition problem have madeseveral enquiries and referenceswith regard to my research papers,"Anthropometric assessment ofenergy-protein malnutrition and

subsequent risk of mortality amongpreschool aged children" and "Theuse of anthropometry for nutritionalsurveillance in mortality controlprogrammes.

The paper and the letter to the edi­

tor, respectively, were both pub­lished in the American Journal ofClinical Nutrition (Chen, L.C.,AK.MA Chowdhury, and S.L Huf­fman. Anthropometric assessmentof energy-protein malnutrition andsubsequent risk of mortality amongpreschool aged children.Am. J. Clin.Nutr. 33: 1836-1845, 1980; ChenL.c, AK.MA Chowdhury, and S.LHuffman. The use of anthropometryfor nutritional surveillance in mortal­ity control programmes. Am. J. Clin.Nutr. 34:2596-2599, 1981). Thesenotes are intended to summa rise the

published evidence and to clarifywhich conclusions are (and are not)supported by the reported findings.

The paper cited is an epidemio­logic investigation of the relation­ship between various anthropometricindicators of energy-protein malnu­trition and the subsequent risk ofmurtality among children in a ruralarea of Bangladesh

Cross-sectional anthropometricmeasurements of 2,091 childrenaged 13 to 23 months were under­taken in an earlier study on nutritionand fertility. These children were allresiding in an area which has beenunder independent longitudinaldemographic surveillance (registra­tion of birth, death, and migration)for 15 years. (Chen L.C., M. Rahman,and AM. Sardar. Epidemiology andcauses of death among children in arural area of Bangladesh. Intern. J.Epidem. 9:25-33, 1980).'

By linking the cross-sectionalanthropometric data with the mor­tality experience of the same studychildren over the following 24months, the relationship of anthro­pometry and the subsequent risk ofmortality was examined

24 Months Comparison

Children were grouped accordingto standard anthropometric classifi­cations (weight-for-age, weight-for­height. height-for-age, armcircumference-for-age, and armcircumference-far-height) and theirmortality experiences over the sub­sequent 24 months were compared.

The major findings were that: allclassifications were able to prog­nosticate subsequent mortality risk;weight-far-age and arm circum­ference-far-age possessed thehighest discriminatory power: and

the discriminatory capacity wasenhanced with maternal nutritionalstatus and socioeconomic indica­tors were also included.

The results showed that severelymalnourished children according toall indices, experienced markedlyhigher mortality risk whereas nor­mally nourished and mildly andmoderately malnourished childrenall experienced lower but similarrisks (Table 1).

It is this last finding, graphicallydepicted in Figure 1, that has gener­ated widespread interest. Theremainder of this note elaborates onthis key finding and discusses thevalidity of various. interpretations

It is important to recognise at theoutset that the study's objective wasepidemiologic; to determine theusefulness of anthropometric classi­fications for screening of high mor­tality risk children to facilitatepreventive nutritional interve·ntions.The study design did not address thedefinition of malnutrition, and the

analysis used the epidemiologicconcept of "risk". Risk connotesassociative relationships, and is onlyone component of proving directcausal links (Lilienfeld, A.M. Foun­dations of Epidemiology. New York:Oxford University Press, 1976).Thus, while the study showed astrong association between severemalnutrition and mortality, it doesnot prove necessarily that the formercaused the latter. In fact. the analysisshowed that othervariables, such asmaternal nutritional status and thesocioeconomic condition of thefamily, were also powerful predic­tors of mortality.

The study used anthropometryexclusively as an indicator of nutri-

Mortality rate (per 1000) 0 to 11 and 12 to 23 months after nutritional assessmentclassified by percentage wt/a'ge, wt/ht and ht/age of the Harvard standard.

Table I

NUTRITIONAL STATUS

NO. OF CHILDRENFOllOW-UPMORTALITYRATE

Degree

%0-11 mo12-23 mo0-23 moStandard

Wt/age

Normal/mild75 ,54623.812.836.6

Moderate60-74104626.815.342.1

Severe

6042746.865.6112.4

WtI HtNormal

9039935.117.552.6Mild

80-8997926.626.653.2Moderate

70-7956628.321.249.5Severe

707566.780.0146.7

Ht/ageNormal

9518216.516.533.0Mild

90-9465622.916.839.6Moderate

85-8971328.09.837.9Severe

8546851.362.0113.2

All

201930.225.355.5tiona I status. The current debate in

India focusses primarily on nutrientintake. not anthropometry. to definemalnutrition (Chen. L.C.. E. Huq. andS.L. Huffman. A prospective study ofthe risk of the diarrhoeal diseasesaccording to nutritional status ofchildren. Am. J. Epidem. 114:284­292. 1981). The concept of malnu­trition is elusive and controversial. Itmay be reflected in many indicators,including dietary. biochemical. clini­cal. and functional performanceparameters. Each parameter con­tains inherent strengths and wea­knesses. There is unfortunately littleempirical data b.etween populationsor amongst individuals on thedegree of congruence betweenthese various measures.

The use of mortality also hasstrengths and weaknesses. The defi­nition of mortality is unambiguous.and quantitative measurement ispossible. Because it reflects the ulti­mate consequence of ill-health,mortality is affected by multiple,simultaneous, and inter-active pro­cesses (Chen. L.C., M. Rahman, a'ndA.M. Sardar. Epidemiology andcauses of death among children in arural area of Bangladesh. Intern. J.Epidem. 9:25-33. 1980). As such,measurement of mortality can detectindirect and difficult-to-predicteffects. Attempts to dissect the uni­directional impact of any single fac­tor on mortality. however, may bedifficult and subject to high "back­ground noise" of other importantfactors.

There are at least three possiblehypotheses to explain the centralfinding (Figure 1) that the severelymalnourished experienced signifi­cantly higher mortality risk while thenormally no.urished and mildly andmoderately malnourished all expe­rienced the same but lower risk:

The reported findings are incor­rect. There is indeed a difference ofmortality risk between the normallynourished and the mildly and mod­erately malnourished. but the differ­ences are small and thus were not

detected because of methodologicalconstraints.

The reported findings are correct,but the explanation lies in the asso-.ciative. not necessarily causal. linksbetween nutritional status and mor-

tality and on the complex interactionbetween nutrition and infection.

The reported findings are correct.Mortality risk is indeed similarbetween the normally nourished andthe mildly and moderately malnour­ished. This is due to "homeostasis"

or "adaptation," which imply physio­logic normality.

Let us deal with each in turn. The

first hypothesis seems unlikely. Itshould be noted that the demogra­phic registration system in this studypopulation is one of the most accu­rate and reliable in the world. (Chen,L.C., M. Rahman, and A.M. Sardar.

Epidemiology and causes of deathamong children in a rural area ofBangladesh. Intern J. Epidem. 9:25­33, 1980).

All children aged 13-23 monthsresiding in 86 ,villages weresampled, and the age of the studychildren was known with precisionbecause all births were registered.However, as described in the paper'smethods section, about 450 child­ren were excluded from the final

analysis because of infant mortality(deaths from birth to the study agel.unavailability for anthropometrymeasl)r'emnt. or mis-linkagebetween anthropometry and mortal­ity records. (C.hen, L.C., A.K.MAChowdhury. and S.L. Huffman.Anthropometric assessment of

2

energy-protein malnutrition andsubsequent risk of mortality amongpreschool aged children.Am. J. ClinNutr. 33: 1845, 1980).

The final study cohort. therefore.may contain hidden biases; thisexclusion may have implications forthe interpret~tion of the data. Thereare no reasons to suspect. however,that had all children been included,the pattern of mortality risk wouldhave differed from the observed.

The second hypothesis is moreplausible. Although the analysisdemonstrated an associative rela­

tionship between anthropometryand mortality, many other factors(which are also associated with poorgrowth) could be importantdetermi­nants of mortality as well.

The study, in fact. showed thatmaternal nutritional status and the

economic condition of the family aretwo such variables. These collinear

determinants could generate high"background noise", which couldobscure whatever modest differen­

ces actually exist. In this regard, therole of parental child care and par­ental response to illness may beimportant. Children who 'areseverely malnourished may consti­tute a subgroup for whom maternalcompetence or family social factorsmay playa critical role. (Chen, L.CWhere have the women gone:

Figure 1

Mortalitv rates (per 1000) according to percentage of Harvard standard

3

insights from Bangladesh on the lowsex ratio of India's populationEcon. Polit Weeklv. Vol. XVII. No 10.1982 I am also indebted to Prof.Gopalan for these observations)

When infections strike. these

same children are more likely toreceive inadequate health care. ther­eby resulting in high mortality. Forthe normal. mild. and moderategroups. nutrition may also be impor­tant. but social behaviour such ashealth care could reduce whateverdifferences of mortality would beexpected.

This explanation is supported bythe data in Table 1. Severely mal­nourished children experienced notonly hIgher mortality risk but also adifferent mortality trend over time.For the normal. mild. and moderatecategories. mortality risk declinedwith aging (lower risk in the second12-month period of observation incomparison to the first 12-monthperiod)

The mortality risk of the severelymalnourished. however. increasedwith aging (high mortality riskin thefirst 12 months of observation. fol­lowed by even higher risk in thesecond 12-month period). This 'dif­ference in trends suggests that theseverely malnourished consisted ofa distinct population subgroup. atvery high risk and with the riskincreasing over time-a pattern dis­tinctly at variance with the generalphenomenon of declining risk withaging.

Another possible explanation con­sistent with the second hypothesis isthe complex interaction of nutritionand infection. Although it is gener­ally accepted that the malnour­Ished experience more episodes ofinfections because of compromisedhost resistance, a recent studyshowed that the attack rate of diar­rhoea was similar across all nutri­

tional groups (Chen, L.C., E. Huq,and S.L. Huffman. A prospectivestudy of the risk of the diarrhoealdiseases according to nutritionalstatus of children. Am. J. Epidem.114:284-292, 1981). The differen­ces between nutritional groups wasnot in incidence rates but. in theduration and severity of illness, withthe malnourished experiencinglonger diarrhoeas and more deaths

per episode (Chen, L.C, E. Huq, andS.L. Huffman. A prospective study ofthe risk of' the diarrhoeal diseases

according to nutritional status ofchildren Am. J. Epidem. 114:284­292. 1981):

This observation is consistent withrecent advances in the understand­

ing of the transmission pattern of thevarious pathogens responsible fordiarrhoea (Chen, L.C. E. Huq, andS.L. Huffma n. A prospective study ofthe risk of the diarrhoeal diseases

according to nutritional status ofchildren. Am. J. Epidem 1.114:284­292, 1981). If valid, these findingssuggest that the mortality effects ofinfections may be of three types.

Firstly, some children irrespectiveof hutritional status experience mor­tality because of the pathogenicity ofthe attacking agent. Second aredeaths due to nutritionally-relatedimpaired host resistance; thesewould be concentrated amongst themost severely malnourished.Thirdly, amongst the normally nour­ished and mildly and moderatelymalnourished, the primary effect ofinfection could be to nutritionallydeplete the victim, shifting childreninto poorer nutritional states. Butthis shift.within a specified period oftime. need not result in death, espe­cially if health services are available.

If these three inter-relationshipsbetween infection and nutrition

operate simultaneously. the net patt­ern of mortality by nutritional status

could approximate that observed inthis study.

More controversial is the third

hypothesis. In support of thishypothesis is the simple observationof very high mortality risk amongstthe severely malnourished and lowerbut similar risk between the normallynourished and the mildly and mod­erately malnourished This finding isconsistent with the interpretationthat. in terms of subsequent mortal­ity risk. these latter three nutritionalstates are indeed- comparable. Ourknowledge base in the nutritionalsciences is not sufficiently strong todemarcate the "range of normality"or to identify the point in the malnu­trition spectrum at which adverseconsequences of malnutritionbecome manifest or measurable.

There are both knowledge gapsand dangers inherent in the transla­tion of these findings into policy Themajor knowledge gap is that nutri­tion investments need to be weighedbetween the more short-term

urgency of preventi ng marta Iityamongst the severely malnourishedversus longer-term approaches thatimprove the overall nutritional statusof a population-including the mildand moderate varieties.

The root causes of all three formsof malnutrition, however, are well­

substantiated. Among others, theseinclude: economic poverty. highprevalence of infections due tounsanitary environment. and ineffi-

cient uses of household resources.

Any long or short-range attack onmalnutrition must deal with all three

One danger of the third hypothesisis not with.regard to its validity. butto its possible misinterpretation fornutrition policy. Derived conclu­sions may go too far beyond cau­tious hypothesis formulation. If theterms "homeostatis" or "adaptation"are used to imply successful andharmless adjustment to stress. orthat mild and moderate malnutrition

are not a problem. the overwhelmingweight of scientific evidence. in thispaper and in the published litera­ture. is inconsistent with this policyconclusion. for several reasons:

First. the pattern of risk (Figure 1)overshadows the key finding that themortality level reported even for thenormally nourished Bangaladeshichildren is 30-50 deaths per 1.000per year (Figure 1). This level isapproximately tenfold that of moreprivileged children in rich and poorcountries (Chen. L.C .. M. Rahman.and A.M Sardar. Epidemiology andcauses of death among children in arural area of Bangladesh. Intern J£pidem. 9:25-33. 1980) Thus irres­pective of the demarcation between"normal" and "abnormal." the level

of mortality among even "normal"children in rural Bangladesh is stag­gering and largely preventable

Second. privileged children inBangladesh. as elsewhere. attaingrowth standards remarkably similarto their counterparts in rich popula­tions (Institute of Nutrition and FoodSciences. Nutrition Survey of RuralBangladesh. Dacca. University ofDacca. 1978). In other words. stunt­ing and retardation are not the con­sequences of varying geneticpotential. but reflect primarily bio­logic insult-due predominantly toinsufficient nutrient intake andrepeated infections.

In biologic terms. the human orga­nism. appears to recognise theabnormality of stunting and retarda­tion During the convalescent phaseafter acute nutrition insult. for exam~pie. the phenomenon of "catch-up"growth is well documented (Rohde.J.E. Preparing for the next round:convalescent care after acute infec­tion. Am. J Clin. Nutr. 31: 2258.1978)

Catch-up growth involves physio­logic adjustments of increasingappetite and enhancing efficiency inthe deposition of body mass. Liketissue repair after injury. the bodyappears to recognise growth slow­downs as abnormal and attempts toadjust b'y more-rapia-than-normalgrowth recovery. After a child attainsnorma I weight for height. "catch-up"growth ceases.

Third. the study examined only thesurvivors Those who died prior tothe study period are excluded. InBangladesh. the infant mortality rateis about 140 per 1.000 live births(Chen. L.e. M. Rahman. and A.M.Sardar Epidemiology and causes ofdeath among children in a rural areaof Bangladesh. Intern J Epidem. 9:25-33. 1980).

Low Birth Weight Mortality

For a study beginning with 13-23months old children. at least 14 per­cent of the same birth cohort have

already died. One effect of this biasis illustrated by low birth weight. Lowbirth weight babies possess signifi­cantly higher mortality risk than theirheavier counterparts (Habicht. J.P ..A. Lechtig. C. Yarborough. and R.E.Klein. Maternal nutrition. birthweight. and infant mortality in Size atBirtf). CIBA Foundation Symposium27. Elsevier. London. 1974).

The risk is highest immediatelyafter birth and. with aging. tends tomove towards the population mean.Surviving low birth weight babiesoften follow growth tracks thatparallel. but remain lower at eachage than. their heavier counterparts(Yarborough. C.. J.P. Habicht. A.Lechtig. and R.E. Klein. Length andweight in rural Latino children.Phys.Anthropol. 42: 390. 1975).

Thus. mildly and moderately mal­nourished children at 13-23 months

would consist of disproportionatelymore surviving low birth weightbabies than normally nourishedchildren. Even if the subsequentmortality risk of the malnourishedapproached that of normally nour­ished children. the high mortality tollof low birth weight babies in theearly years should be an integralconsideration in interpreting thestudy

4

Fourth. mortality is only one of themany well-documented adverseconsequences of malnutrition. Thepattern of function'al impairmentdue to malnutrition will vary accord­ing to the parameter examined.Some of the more important effects.in contrast to mortality. may be themost difficult to measure and quan­tify. Of possible relevance here aresubtle. less-discernible. anddifficult-to-measure changes ofexploratory activity. initiative. crea­tivity. learning.and social interaction(Calloway. D.H. Functional conse­quences of malnutrition. Paper pre­pared for the Workshop onInteraction of Parasitic Diseases and

Malnutrition. Bellagio. Italy. Sep­tember 27 -October 1. 1980).

Fifth. even if mildly and moder­ately malnourished children expe­rience the same mortality risk asnormally nourished children. thephenomenon does not assess thehuman cost of the adjustment pro­cess High mortality at younger agesis one such cost. Other possiblecosts include hunger and dietaryinsufficiency. repeated onslaught ofinfections. other morbidities. com­promised exploration and learning.

Take as a parallel example. notmalnutrition. but contaminated

drinking water. Repeated exposureto pathogens from contaminatedwater leads to gastrointestinal infec­tions. With each episode. somechildren die while others experiencetransitory illness. Among the survi­vors. each infectious insult alsostimulates an immune response.

Thus. at some future time. one mayobserve surviving children with noapparent problems (and even pos­sessing immunity against manyinfections). It would be fallacious toconclude that since children

exposed to contaminated waterappear healthy (even healthier thanothers). contaminated drinkingwater is not a problem.

These notes have summarised thesalient features of the relationshipbetween malnutrition and mortality.Particular attention was devoted to

three alternative hypothesesexplaining the reported findings. Ifthe hypotheses are extended too farto derive the conclusions that mildand moderate malnutrition does not

C. Gopalan

The Nutrition Policy ofBrinkmanship

constitute a problem, the interpreta­tion is fallacious.

Too much attention may be paid tothe future risk of those who arealready mildly, moderately orseverely malnourished. The centralquestion ought to be to the past aswell. All forms of malnourishmentare due to antecedent root causes,such as lack of income and infec­

tions. These deserve the highestpriority in any nutrition policy.

A study that focuses on only survi­vors. on mortality measurements.and on subsequent or future riskdoes not deal with the central issueof the human cost absorbed in thepast which has resulted in less-than­optimal growth. Clearly. there is aneed to address all forms of malnu­trition, mild to severe. and to workdirectly on the root causes of theproblem.

The role of the nutritional sciences

should be to provide insights thatgenerate more political commit­ment, higher priority. and operation­ally effective interventionson-the-ground that wi II confrontsquarely one ofthe major challengesof contemporary humankind.

While intellectual dialogue on themagnitude of malnutrition is nodoubt stimulating. we should notmiss the main point with which we allconcur. namely that poverty andmalnutrition are massive, and itsprevention and control demand thehighest priority through effective

action on-the-ground.

FOUNDATIONNEWS

A meeting of the task force onstudies on health/nutrition con­sequences of developmental pro­grammes in Punjab and Uttar Pradeshwas held in New Delhi on July 23.under the chairmanship of Dr. Sri­kantia.

A meeting of the task force onstudies on disabilities in schoolchildren related to malnutrition washeld in New Delhi on September 11.under the chairmanship of Dr. V.N.Rao. Director (Research). KEMHospital. Pune.

Brinkmanship is defined as the artof advancing to the very brink ofwar or catastrophe but stoppingjust short of it. It would seem thatbrinkmanship is now being activelypromoted and propagated as part ofthe nutrition policy of developingcountries.

The art of brinkmanship in nutri­tion consists essentially in advocat­ing that children who suffer frommalnutrition of the so-called 'mild'and 'moderate' grades-a classifica­tion devoid of proven physiologicalvalidity-may be left severely aloneto fend for themselves. and "nutri­

tion intervention" need be attemptedonly when they reach the "severe"

stage of impending death. In otherwords, saving children from thecatastrophe of death. rather thanensuring their normal health andnutrition is the essence of the policyof brinkmanship.

Strange Justification

The justification proffered for thispolicy is that children who are not soseverely malnourished as to be onthe verge of death, may somehow"muddle through" and manage tosurvive-in which case they could bedescribed as "adapted", meaningthat they have come to terms with.and have learnt to reconcile them­selves to, their bad lot. Unfortu­

nately, many of those who are usingthe word "adaptation", in the debatedo so rather loo~ely. A person withhigh blood pressure can "adapt"himself to his condition throughhypertrophy of his heart; such"adaptation" helps him to buy sometime before the inevitable disasterstrikes, but he IS by no means normal.The fact that between death and nor­

malcy, there exists a broad twilightzone of morbidity, functional impair­ment of various kinds, apathy. lack ofsense of well-being, poor physicalstamina, low productivity, etc., is lar-

5

gely lost sight of.The policy of brinkmanship­

withholding nutrition intervention tochildren till they reach the verge ofdeath, the so-called "severe" stageof malnutrition, is calculated to

undermine and erode the quality ofour human resources. Intervention

in the last stages of malnutritioncannot help to build a strong andhealthy nation, but will only serve toincrease the pool of survivors of sub­standard physical stamina andproductivity-the scars of childhoodmalnutrition: it will be akin to boltingthe stable door after the horse hasescaped, for many children whohave reached the 'severe' stage ofmalnutrition cannot be restored to

full normalcy

Policy of Bankruptcy

To say this is not to advocate

"triage": for it is not implied here that'severe' cases of malnutrition should

be left alone to d.ie. What is empha­sised here is that a nutrition policywhich consists in apportioning thepredominant part of the NutritionBudget only to saving severely mal­nourished children from the jaws ofdeath, and in according little impor­tance and support to improving thelot of other malnourished children in

the community and in preventingthem from sliding into the 'severe'stage. will be a policy of bankruptcyand brinkmanship.

What is objectionable is theattempt to justify exclusive emphasison 'severely' malnourished childrennot on the basis of lack of adequateresources for a broader coverage,but on the basis thatchildren in poorcommunities. other than those"severely malnourished" and on theverge of death, are all normal and'adapted' in spite of their very signifi­cant growth-retardation In otherwords, we are being persuaded toaccept mild and moderate malnutri-

tion in our children as our normalnational feature.

When it is pointed out to thosewho advocate this policy of brink­manship that malnourished children

who may escape death eventuallygrow into stunted adults of low bodysize and poor productivity. it isargued that low body size is wel­come because the energy require­ment of such subjects will be low;the resultant low productivity andlow earning capacity should notmatter because in any case we are alabour-intensive, cheap-laboureconomy! "Improve the economyfirst. and then talk aboUt improvingnutrition of children and body-sizeof adults. Our labourers have the

body-size suited to our economy," isthe answer. Without questioning thebonafides of scientists who advo­

cate this policy and with all duerespect to them, it must be clear that

this policy will only serve to perpetu­ate the current nutrition scenario~ \

and .the 'underlying povertysyndrome-the vicious cycle of pov­erty, undernutrition, low productiv­ity. poor fncome and poverty. Thisvicious cycle must be broken at sev­eral points and not in an ordainedsequence.

A sensible National Nutrition Pol­

icy should aim at preventing mal­nourished children of poorcommunities from reaching thesevere terminal stage, and not wait·passively for them to arrive there in

oorder to start rescue and repair oper­ations, which, besides being expen­sive, will in any case not restore themto full normalcy.

It is from this point of view that wewelcome Dr. Linc.oln Chen's forego­ing excellent paper; his earlier com­munications in the AmericanJournal of Clinical Nutrition had led

to unwarranted interpretationswhich were clearly not intended byhim.

Dr. Chen's communication clearlyunderscores the need for a nutrition

policy which seeks to· attack thebasic factors that underlie all forms

of malnutrition. including the "mild"and "moderate" degress. His paperrepresents a cogent well-reasonedand forceful plea against the policyof brinkmanship ionnutrition.

REVIEWS ANDCOMMENTS

On Brinkmanshipin Nutrition

I am thankful to Dr. C. Gopalan forsharing with me the draft of hispaper on "The Nutrition Policy of

Brinkmanship". I agree heartily withwhat he has written. and especiallyendorse his objection to attempts tojustify a nutrition policy of exclusiveemphasis on 'severely' malnourishedchildren, on the assumption that allother malnourished children in thecommunity (the so-called mild/moderately malnourished) are normaland ·adapted'. Indeed, I would gofurther and say that in India, a countrywith enough food. no baby shouldbe expected to adapt to deprivationoffood.lnsteadofdevising a nutritionpolicy based on such expectationand consisting mainly of dealingwith severe' malnutrition after it hasset in, the country should embark ona war-footing upon a policy ofpreventing such 'severe' malnutritionin children.

In every village of the countrytoday, all the time, "horses are bolt­ing out of open stable doors"­infants and children, victims of the

. inexorable interaction of chronicstarvation and diseases die. often tobe replaced by the next. with themother progressively worn out andnutritionally depleted. I w0L!ld callthis a progressive spiral of descentinto the state of misery (not just avicious circle). Our .experience inCMC Ludhiana. working with thehealth functionaries in a communitydevelopment block. has shown usthat all this misery can be avoided .. 0

In every village. though the overallcommunity nutrition profile mayshow little change over severalmonths. in individual households itis all the time rapidly changing.New high-risk subjects will haveemerged in families which did nothave them before-new pregnan­cies, new births, and babies who

were in good nutritio,n on exclusivebreast-feeding just a few weeks aqo.now steadily descending into mal­nutrition. Under the circumstances,

6

what is needed for an effective prev­entive programme (as against arepair operation) is a strategy of con­tinuous monitoring of thecommun­ity for rapidly updating the data onchanging nutrition profile in individ­ual house holds and for timely iden­tification of the high-risk su bjects.This cannot be achieved throughelaborate resurveys, following on aninitial base-line survey, each ofwhich resurvey may take at leastthree months for a team of multi­

purpose workers, working fourhours a day, to complete in a sub­centre area. Such resurveys wouldprove as much tiresome and frus­trating to the communities as to thehealth-personnel. for, in the mean­while "several horses would havebolted out of the stables".

At present the MultipurposeWorkers attached to each Subsi­

diary Health Centre (population5,000) in Punjab. visit every homeonce in 6-8 weeks. Their emphasis ison maternal and child health and

family planning but the continuinghigh infant and toddler mortality andthe prevalence of so much malnutri­tion, esp'ecially in the second andthird year. shows that the goals ofthese 0 workers are not beingachieved. In the Community Devel­opment Block allocated in 19BO toour medical college. without disturb­ing the basic working pattern ot theexisting work force. we have simplymore effectively deployed that forceso that they have adopted the "need­based" approach developed by us.

The workers, realising that atti­tudes and long-standing practicescannot be changed during a homevisit lasting 3-5 minutes every 6-8weeks have recognised that allhomes do not need 5 minutes, andthat in the homes of more than halfof the family folders they take outdaily, they need spend only 2 min­utes monitoring any change whichhas taken place.

In these homes there will be no

potentially "at risk" individual andthis allows them 15-20 minutes in

homes where there are pregnantwomen and/or under-five children.

especially when these high risk sub­jects do not attend the local clinicsfor mothers and children. This"intensive care" approach allows the

Dr. P.V. Indiresan, Director,Indian Institute of Technology, Madras

Integrated Rural Development:The Narayanapuram Experience

workers time to teach mothers, no

matter how poor or over-worked,how to make the best use of wha­tever is available in that home.

Having spent half an hour daily inthe centre recording in appropriatesection of the Master Register, allchanges found on that day's homevisiting, the workers andsupervisor-who may be a medicalofficer or Lady Health Visitor. dis­cuss all priority persons seen thatday and make a plan for each. Thusfor a clinic attender of 18 months.

eating adequately, there may be noneed to see her till the routine visit

However, a female of 10 monthsfrom a poor home, eating inade­quately in spite of earlier advice andwhose mother's pregnancy wasnoted that day, is of very high risk.Even though she is on the "Road toHealth"-she must go on a high risklist so that the home receives visits

every 4 or even 2 weeks until thechild is out of danger as a result ofthe mother's acceptance of the oft­repeated nutrition health education.

Through such a programme, wehave shown that women of poorcommunities can have splendidbabies through encouraging exclu­sive breast feeding for 6 to 7months; and that through timelyadvice on the use of inexpensivelocally available supplements(based just on roti. vegetables andtea) which can be eaten by theseven-month old, even first degreemalnutrition can be prevented inthem, We can ensure that a very highpercentage of children avail offacili­ties for immunisation, and the prac­tice of timely oral hydration ofchildren with diarrhoea is promotedand propagated.

We are convinced from our expe­rience in CMC-Ludhiana that thisstrategy of preventing infants andyoung children from sliding intosevere malnutrition (rather than astrategy of belated repair andrescue-brinkmanship) is perfectlyfeasible, with the existing infrastruc­ture, facilities and resources, andthat this is not a "pipe-dream".

Dr. Betty CowanChristian Medical CollegeLudhiana

Some years ago. the Indian Insti­tute of Technology. Madras,obtained from the' Tamil NaduGovernment a 94 acre tract of land

near the southern boundary of thecity to establish a Rural Develop­ment Project This land, part of a sea­sonal swamp, which gets inundatedby knee-deep water for about fourmonths in a year. was uncultivatedand uncultivable. with not even

water hyacinth surviving on it.On this inhospitable land. the

Institute has established during thepast two years, an integrated devel­opment complex, employing about300 people with monthly wagesranging from Rs 300 to Rs 1200.The main resource available on site

was plenty of subsoil, brackishwater. with salt content as high as30,000 parts per million. It wasdecided that the best way to utilisethis asset was to cultivate the fishthat thrive in brackish water.

From the earth that came out of

digging this fish pond, bricks weremade, and to help make bricks, a bio­gas plant was established, naturallyalong with a dairy farm. To facilitateboth dairy farming and brick making,a rice r1iill was started, the branbeing used for the cattle and thehusk for making bricks. In addition abakery was established to use thebiogas.

As this project involved considera­ble construction work-worth overRs 20 lakh during the past oneyear-a carpentry and a weldingsection, were formed, which haveproved to be profitable industrialactivities in their own right.

It so happened that the ScienceCentre of the liT-Madras had alreadydeveloped kits for teaching electron­ics in schools, and had secured sub­stantial orders from various stategovernments. The fabrication ofthese kits also was taken up by theCentre

During fabrication, a need was feltfor screen printing and for plasticbags. It was found far more conve­nient to have these things done in­house hence a screen printing unitand a small plastic moulding plantwere also started.

As an adjunct to screen printing. aprinting press was also establishedFinally, to utilise the considerableamount of waste paper that is availa­ble from the liT and elsewhere, a

Paper Recycling Plant of one ton'capacity per day was erected.

Thanks to the considerableamount of sludge from the biogasplant. the uncultivable land in whicheven water hyacinth would notgrowis now gradually being reclaimed.Today, there are hundreds of cOCQ­nut plants and thousands of kubabui'trees. Further expansion will be inthe direction of providing varioussocial, municipal and commercialamenities, as well as housing. A dis-_pensary is already in 9peration and abank is about to start Together,these constitute the NarayanapuramIntegrated Development ProJect.

Commercial Venture

There are several novel conceptsin this scheme. Firstly, it is not a wel­fare project but a commercial ven­ture. Most rural development

. projects run mainly with subsidiesfrom Government and other agen­cies. However, this project has.beenfinanced by commercial loans takenfrom the United Commercial Bank atthe usual rates of interest. Most ruraldevelopment schemes were notreplicable because they did notinspire adequate confidence regard­ing their economic viability. The bestway to demonstrate such a viabilityis to .have a bankable project

A bankable project has also theadvantage that. as and when theloan is repaid, there will be funds to

start another similar project. andwhen the loan is repaid with interest.one can actually generate funds tostart more than one such project.Subsidies. on the other hand. tend todry up sooner or later. Thus. only abankable project is self-regenerativeand has the ability to growexponentially

Secondly. most rural projects aimat marginal improvement in the con­ditions of life and the economic sta­tus of the concerned individuals. As

already stated. the salary levels thathave been established. range fromRs 300/ - to Rs 1200/- per month.These are muCh higher than what isnormally obtained in village devel­opment schemes.

A Quantum Jump

Thus. the attempt is to ensure aquantum jump rather than a margi­nal improvement. In fact. this quan­tum jump is much more substantialthan what may appear from the kindof salaries that are being paid. It isplanned that the people working onthis project will get subsidised mod­ern housing. protected water supply.proper sewage systems. fuel andother amenities such as schools.health centres. commercial andtransportation systems.

The effective income and qualityof life will. therefore. be far higherthan what the salaries indicate.

The reason why we consider itfeasible to establish an improvementin the quality of life as listed above isbecause the main basis of develop­ment is not agriculture but industryAgriculture has the limitation thatthe consumption of agricultural pro­ducts is comparatively inelastic. Onthe other hand. there is an insatiabledemand for industrial goods andhence. the rr.argin of developmentthrough industrial development isimmensely higher.

Most major schemes of rural tech­nology are based on maximisingemployment and mlnlmlslngprod uctivity.

In Narayanapuram. on the con­trary. the aim has been to maxi miseproductivity and to minimise directemployment in every field of activityThe overall employment is madehigh. however. by increasing the

number of such activities. To ensure

high productivity we have to use thebest possible technology in contrastwith the accepted norms of approp­riate technology which usuallyimplies minimum of technology

Such a minimum technology isgenerally advocated because of theworkers' illiteracy and the cost ofsophisticated equipment. Webelieve these arguments to beincorrect.

Firstly. there is a distinctionbetween a sophisticated equipmentand equipment which requiressophistication to handle. QUite alarge variety of modern sophisti­cated production equipment requirevery simple skills indeed In fact. theentire growth of the industry In theWest has been based on the employ­ment of more and more unskilledlabour. as for instance. in the manu­facture of automobiles. Thus.

sophistication in machines actuallydemands less. not more. skill fromlabour and is better adapted tounskilled people than are simpletools

No·doubt. it is true that sophisti­cated equipment is expensive and. ina poor cQuntry like ours. funds arelimited. Strictiy speaking. howeverthe real limitation is not funds forinvestment. but profitable ideas forinvestment. One of the main reasonswhy rural development works arestarved of funds is because of thefear that. in most cases. the loanswill never be repaid. Where theinvestment is profitable. there willbe-in fact. this is our experience­no dearth of funds.

It might have been noticed that the300 workers who have been

employed under the scheme are allwage-employees. This again is indirect contrast to the traditional wis­dom of rural development. whichemphasises self-employment. Toprovide an additional cow. or pig. orloom to help an individual supple­ment his income. is no answer; self­employment requires a standard offoresight and entrepreneurshipwhich even highly educated peoplerarely enjoy. It is far too much toexpect an illiterate villager to 5UC­ceed where even the best educatedfear to tread.

Secondly. self-employment can

never be properly integrated. whe­reas wage employment can be. Thereason why we are able to generate alarge amount of employment isbecause a variety of things havebeen integrated and such an inte­gration is not possible where all theworkers are self-employed with eachone ploughing his own lonelyfurrow.

We were fortunate to get a reason­ably large tract of unoccupied land.Thereby. we have avoided the pitfallsof adopting a village. Adopting a vil­lage implies that we have to come toterms with the internal social. politi­cal and economic structure within

the village. By establishing the pro­ject outside any village. we haveavoided many such problems. Infact. we draw our workers from as

many as five villages in the vicinity.This further diffuses the problem ofinternal rivalries common in villagecommunities.

Ideas for Investment

We have also more or lessexcluded the local leadership fromthe functioning or organisation ofthe project. In fact. apart from thesenior faculty of the liT-Madras whoare working in this project. most ofthe functional leadership is with thehired supervisory staff who had to bedrawn from outside the neighbour­hood.

By insisting on such professionalmanagement. we have. at least sofar. avoided the local caste. groupand political pressures We do notadvocate enlargment of a schemeto obtain growth. but suggest repli­cation instead. Incidentally. replica-

. tion is also the only way a ruralproject remains rural.

Although these projects havedrawn on the expertise of the IndianInstitute of Technology. Madras. thisis not strictly necessary In fact. whatliT-Madras has provided is not somuch technical expertise asmanagerial ideas. There is no reasonwhy the concepts enumerated herecannot be implemented by others.As mentioned already the cost ofinvestment. although substantial. isunlikely to be a. problem. but a min­imum of 100-200 acres is needed totryout such a scheme.

Edited by Dr (Mrsl S Malhan. PhD for Nutrition Foundation of India. B 37 Gulmohar Park. New Deihl. DeSigned and produced by Media Workshlp and printed at Veerendra Printers