Who will uphold the inviolable rights of children to nutrition?

Adv. Jerald Dsouza and Dr. Sylvia Karpagam

(An edited version of this article first appeared in The Quint on 4th May 2022)

The National Food Security Act (NFSA) has been in place since 2013 and was expected to mark a paradigm shift in the approach to food security from welfare to a rights-based approach. However, going by the recent nutritional indicators in the country, questions need to be asked on why the NFSA has not been able to prevent malnutrition, what the gaps are and how these can be addressed. Unfortunately the law has been reduced to right to survival (with the cheapest minimum) rather than to a life free of nutritional deficiencies and ill-health. The Right to good quality and quantity of nutrition should be the premise of interventions and policy decisions and not just the right to food.

Devastating malnutrition in children of Karnataka

There is no need for a scientist from Harvard to explain to us that the nutritional indicators of Karnataka present a bleak picture. According to the Comprehensive National Nutrition Survey, CNNS (2018-19)^[1] in Karnataka, only 3.6% of children in the age group 6-23 months received a minimum acceptable diet, 18.3% children have minimum dietary diversity, 31.6% have minimum meal frequency and only 8.7% children consume iron rich foods.

In terms of consumption, among children aged 2-4 years in Karnataka, only 21.9% children aged 2-4 years had consumed flesh foods in the previous 24 hours compared to 69% in Kerala. 56.7% children had consumed dairy and 19.1% had consumed eggs. Among children in the age group 5-9 years, 84% had consumed milk or curd in Karnataka and that is probably because of the Ksheera Bhagya scheme. Iron deficiency is 50.1%, 31.2% and 30.5% in 1-4 year, 5-9 year and 10-19 year age groups respectively in Karnataka. Folate deficiency among children aged 10 – 19 years is 30.1% in Schedule caste, 29.9 in Scheduled tribe, 33.7 in Other Backward Class (OBC) and 27.6 in others. It is 28.2% in the poorest and 42.7% in the richest quintile

Among 1-4 years, Karnataka has B12 deficiency of 15.4% and folate deficiency of 36%. Among 5-9 years, B12 deficiency is 15.4% and folate deficiency is 50.5%. Among the 10-19 year old, B12 deficiency is 45.5% and folate deficiency is 70.4%.

The state’s Arogya Nandana programme had also recently found 7,259 kids to have severe acute malnutrition and a whopping 1,05,150 kids to have moderate acute malnutrition out of more than 53.82 lakh children screened. There are 1.5 crore kids in the state. (Reference)

According to the National Family Health Survey,

Children under 5 who are stunted 35.4%
Children under 5 who are underweight 32.9%
Children age 6-59 months who are anemic (<11 g/dl) 65.5%

Source: Ministry of Health and Family Welfare, National Family Health Survey – 5

Short and long term effects of malnutrition

Malnutrition is a broad, all-encompassing terminology that doesn’t give a complete picture of what is really happening to a child. If hunger is acute and occasional, the child may cry incessantly, be irritable and cranky. In most families, there is a response to the hunger and the child that is fed adequately can go back to its regular activities till the next bout of hunger sets in. If the child is not fed adequately, she can experience frequent bouts of hunger making her mostly irritable and demanding. However, if hunger is chronic over a period of time, there are several changes that can take place in the child. She can become withdrawn, reducing her usual activities, there may be reduced body activity, she may feel cold and tend to huddle in corners. If hunger is also associated with dehydration, then the child’s skin can be pinched. Over time, the typical “monkey-face” or marasmic appearance may start manifesting. While these are the visible signs it is important to understand that there are many other changes happening in the body that health workers can pick up. Bitot spots in the eye, night blindness and toad skin or phrynoderma may be the first few signs of Vitamin A deficiency. There could be night blindness where the child bumps into things as the evening draws near. Toad skin can also be a feature of fat deficiency. The bones of the child can change shape into bow legs or rickets, hair becomes sparse and falls off, the tongue becomes red, the corners of the mouth may show ulcers. That apart the child can become much more prone to gastrointestinal and respiratory disease. Whereas a healthy well nourished child could have 2-3 episodes of illness a year, the malnourished child can have upto 7-8 or more with increased duration as well as frequency. This pushes the child into a vicious cycle of infection and malnutrition with each aggravating the other. It is difficult for the child to come out of this. In response to malnutrition, children may withdraw, under-perform, sleep more, become slow or sick and die. They disappear from public consciousness as quietly as they enter the world. At best they may be a statistic, at worst, even that may not be recorded.

Apart from this, chronic malnutrition can have several long term complications. There can be cognitive and behavioural impairment during childhood and adolescence. Previously malnourished people may show more anxiety, shyness, less intellectual curiosity, greater suspiciousness and lowered sense of efficacy or competence.^[2] There can also be attention deficits even when the nutritional deficiency is addressed. ^[3] Adolescents who were malnourished as infants are likely to have conduct problems.

Research and data from India is mostly retrospective in nature, so the consequences, including inter-generational ones, of malnutrition become evident only after they have occurred, and are therefore mostly irreversible. For instance if a girl has undernutrition and stunting in her childhood this can affect her pregnancy outcome and the weight of the baby as well. The lower the weight, the less developed the organs are, which means poorer function. Again this can leads to diabetes, hypertension and heart diseases which can lead to other organ damage. This further burdens the healthcare system which cannot even handle existing diseases, leave alone these emerging ones.

Malnutrition rarely kills a child overnight unlike a plane crash, and therefore it may not receive the attention that a plane crash does. Both still kill the child – while one is immediate, the other stretches on sometimes even across generations. Malnutrition and its adverse effects develop insidiously so it is not sensational. When headlines mention that children are starving, stunted or under-nourished, there could be a lukewarm, knee jerk response by the bureaucrats, the media, the civil society, nutritionists and doctors. This is neither far-sighted nor sustainable and does nothing to prevent malnutrition before it occurs. Retrospective interventions do not help children who have already fallen into the vicious cycle of malnutrition, poverty and infection.

What is nutritious food?

This question may seem banal and one may wonder why this even needs to be asked. Many of us are self-appointed experts on nutrition and are ready to throw advice around, irrespective of whether it is accurate or evidence based. In a country like India which has a legacy of casteism, and now increasing communalism, food has always been a political tool. From lynching beef eaters to treating meat eating communities as ‘unclean, polluted and untouchable, from food impositions based on ideology more than sound science to projecting veganism as a benevolent way of life, from projecting India as a vegetarian country to assertive beef festivals, the passions around food become well established.

There is a mainstream ideological opinion, often fed by media, researchers, academicians, doctors and others with ability to influence, that India is a largely ‘vegetarian’ country that is also poor. The effort then, even with the NFSA 2012, has always been to push cheap vegetarianism on the vast majority of India’s population.

Evidence shows that an important way of preventing nutritional deficiencies and improving overall outcome is to ensure adequate quantities of diverse foods that include, apart from cereals and millets, recommended quantities of legumes, pulses, nuts, eggs, meat, milk/dairy, fish, poultry, vegetables, fats and oils as well as othe green leafy vegetables.

UNICEF has recently released a child nutrition report 2021 from 135 countries where they recommend diverse foods/animal source foods/vegetable and fruits/breastmilk etc. When a majority of the population is undernourished, it is expected that they will also have multiple nutrient deficiencies. Just because one or two deficiencies become clinically obvious it doesn’t mean that only those nutrients should be replaced. People need diversity by inclusion of different food groups – namely vegetables and fruits, cereals and millets, legumes and pulses, meat, fish and poultry, eggs, milk and dairy products as well as fats and oils.

For micronutrient deficiencies (iron, zinc, Vitamin A, B12, Folate and calcium) the most nutrient dense foods based on what is available regionally includes chicken liver, ruminant liver, small fish (also source of Vitamin D and long chain omega 3 fats), eggs, ruminant meat, dark leafy greens.

According to FAO, South Asia has the lowest per capita availability of meat @19g/day and India is the lowest in any country @10g/day. So they say campaigns should encourage increased consumption of chicken liver, ruminant liver, ruminant meat for children 6-23 months. They say that Green leafy vegetables are moderately available, that fish is consumed only in certain areas, and suggest that the consumption and production of eggs should be increased. The main barriers that they have identified to consuming these foods are related to availability, affordability, access, knowledge and cultural preferences. They also suggest that the only real way to address deficiencies is a multi system approach involving health, food, water, sanitation and social protection schemes to create micronutrient adequate diets and adequate feeding practices.

In India, the Comprehensive National Nutrition Survey (2018-19) specifically mentions that iron rich food includes “any liver, kidney, heart or other organ meat; any chicken, duck, or other poultry; any fresh or dried fish or shellfish; or any other meat during the previous day”.

If one considers the MDM in Karnataka, a primary school child is entitled to 450 cal and 12 gm of protein, while an upper primary child is entitled to 700 calories and 20 gm of protein. Each meal is expected to provide at the primary level 100 gm of food grains, 20 gm of pulses, 50 gm of vegetables, 5 gm of oils and fats.An upper level (Class VI – VIII) child is expected to receive 150 gm food grains, 30 gm of pulses, 75 gm of vegetables and 7.5 gm of oils and fats. This diet is inadequate to meet 1/3rd of the protein, mineral and vitamin needs of the child and certainly cannot be called diverse. Eggs are being denied to children inspite of these foods offering superior nutrition and the reasons are primarily caste-related, ideological or political. While the NFSA guarantees food security, it doesnt promise nutrition security. Therefore, policy making has to necessarily go beyond the NFSA if it is serious about addressing malnutrition in India.

Legal rights of children to food

The Supreme Court of India has established that the right to food is a Constitutional right in its landmark decision in the Public Interest Litigation petition of the People’s Union for Civil Liberties vs. Union of India and Others.^[4] Several government food security schemes were converted to legal entitlements, with special provisions for vulnerable groups such as pregnant and nursing women and children from 6 months to 14 years through the Integrated Child Development Services (ICDS) scheme and the Mid-day Meals (MDM) scheme in government and government aided children. Malnourished children receive additional food. The Act also legally entitles upto 75% of the rural population and 50% of the urban population to receive subsidized food grains under the Targeted Public Distribution System, thus expecting to cover ⅔ of the population. In case the entitled food grains or meals cannot be provided (as happened during the Covid pandemic and lockdown), such persons are entitled to a food security allowance from the State government as governed by the Food Security Allowance Rules, 2015.

The National Human Rights Commission had also taken a position^[5] in February 2003, that Right to Food is inherent to a life with dignity and that Article 21 of the Constitution (which guarantees a fundamental right to life and personal liberty) should be read with Articles 39 (a) and 47 to understand the nature of obligations of the State to ensure the effective realization of this right. Article 39(a), one of the Directive Principles, requires the state to direct its policies towards securing that all citizens have the right to adequate means of livelihood, while Article 47 spells out the duty of the State to raise the level of nutrition and standard of living as a primary responsibility. The commission importantly held that ‘the right to food implies right to food at appropriate nutritional levels and the quantum of relief to those in distress must meet those levels in order to ensure that this right is actually secured and does not remain a theoretical concept.”

This clause is of particular significance because it draws attention that food ‘at appropriate nutritional levels’ is crucial. It means that it is not just the quantity of food that one eats, but importantly, the quality. Quality of food determines how much access one has to bioavailable, nutrient dense foods as a first step to addressing malnutrition and multiple nutritional deficiencies.

What is the way forward?

Children are unique in that they cannot themselves articulate serious violation of their fundamental rights. Just as a child who is abused is often unable to communicate why it is a violation of her human rights, similarly a hungry, starving or malnourished child cannot put into words, make demands, organise protests or submit petitions and memorandum. The children therefore need people to speak for them.
Who are these people? Sometimes it can be parents or families. They share the distress experienced by the child and/or family with a larger community and often seek respite. The larger community can either be sensitive or ignore/deny calls for help. Those who come in contact with the child or family can often be the first point of contact to raise the alarm that the child’s basic needs are being violated. A doctor, an ASHA worker, and anganwadi teacher, an ANM can pick up gaps in the child’s development and either link them up to a support system or escalate the issue to a higher authority. If the system is responsive, the child will be provided additional nutrition or health support, and attempts will be made to ensure that the child is more protected going forward. Civil society can play a role in documentation, research and advocacy to ensure that authentic ground level data is made more publicly available. The media can highlight both localised as well as policy level barriers to addressing children malnutrition and hold the service providers accountable.

Food Diversity

For a start it is important to acknowledge that nutrition is much more than food security. Providing cereals and millets 24/7 even if it is 3 or 10 meals a day, will fail to meet the nutritional requirements of the child. Diversity is crucial. Diversity means that there is food from at least 4 or more food groups namely cereals and millets; pulses and legumes; milk and dairy; meat, fish and poultry; vegetables and fruits; fats and oils to meet the recommended dietary intake. The RDA is calculated assuming that the person has no deficiency, so in the presence of deficiency, the RDA of different nutrients may change based on the availability of other nutrients. For instance, if there is anemia, replacing the RDA of iron will not help to resolve the anemia because there are several other nutrients and proteins that have to be replaced as well.

Accountability

The child is unable to articulate his or her needs, so it is the moral responsibility of the bureaucrats, the politicians, researchers, academicians, teachers, parents, civil society to hold the state accountable for any denial of the child’s nutritional needs.

Importantly, the government should be held accountable by all stake holders for malnutrition in the state. At no point should the government be able to wriggle out of its essential responsibilities. An informed media and civil society can go a long way to ensure that children of the state are able to function in good health and nutrition. For this civil society, media and academia have to understand that food security is not equivalent to nutrition security. Preventing starvation is one thing, but ensuring that there are no nutritional deficiencies and that there are systems in place to identify and respond to the looming crisis should be one of our foremost efforts.

Co-ordination with other systems and departments

The health system plays a crucial role in identifying those health conditions that have caused or been caused by malnutrition. A close link is required to ensure that children do not fall into inter-departmental gaps and thus become “nobody’s baby”.

Child rights commissions and other quasi-government human rights groups have a role to play in speaking up on behalf of children, even if it means questioning established norms, guidelines or policies.

The educational department has to be trained on proper nutrition based on science rather than ideology. There needs to be a concerted and consultative effort to provide hot, locally cooked nutrient dense foods to children in government and government aided schools. Nutrition education based on evidence should be imparted to children as a life skill.

Concerned bureaucrats can change the ethos of the state by bringing in far reaching policy changes, anticipating problems and addressing them rather than knee jerk reactions once the malnutrition starts manifesting itself. The decision to give eggs and bananas as part of mid day meals in seven backward districts of Karnataka is a step in the right direction, but inadequate in its scope and scale. To reiterate malnutrition has to be prevented, not managed retrospectively. It is therefore not rational to provide eggs in government and aided schools only in the backward districts that have seen unacceptable malnutrition. It has to be provided on 5-6 days of the week in all districts to prevent malnutrition, more than manage.

Scientific temper

The Public distribution system (PDS), ICDS and Mid-day meal scheme have to move away from the realm of ideology and politics to the realm of science. There is a need for inclusion of nutrient dense foods animal source foods (ASF) like dairy, meat, poultry and eggs in the regular diet and to ensure that, these foods have to be made available through the social security schemes and/or available at subsidised costs. Ideological opposition to all forms of ASF including the call to boycott halal, economic boycott of Muslim vendors, resistance to eggs in mid-day meals, cattle slaughter bans etc. need a rethink based on science and nutritional requirements of Karnataka’s population. The introduction of the Ksheera Bhagya scheme in the government anganwadis and mid-day meals is a huge step forward in the right direction by the government of Karnataka. Scientific temper should be the sole criteria for decisions about food for children and not cultural/ideological perceptions.

Health education on sustainable nutrition

There needs to be a concerted effort to bring in scientific evidence based information on nutrition through health education programs. The importance of kitchen gardens, poultry and livestock rearing, sustainable agriculture needs to be emphasised. Encouraging people to have poultry, livestock, kitchen gardens can ensure that families are self sufficient. Pulses, legumes, nuts, vegetables, This is more effective in the long run than corporate driven fortification which leads to change in taste, consistency, increase in cost as well as reducing shelf life. This is environmentally and ecologically more sustainable and preserves food sovereignty.

That bring us to the question of whether a social problem like malnutrition can be left unaddressed. What does it say about the society as a whole? Can the state and those wielding power over a childs nutritional status be absolved of responsibility? Article 15 of the Constitution allows for special laws for the welfare of women and children. This can be the premise for bringing in a new law upholding the inviolable right to nutrition of children. Children cannot wait for us to address other issues, nor can they access justice themselves. They just disappear or become less than average citizens. For that………all of us are responsible.

Adv. Jerald Dsouza Director, St Joseph’s College of Law (SJCL), Bengaluru.

Dr. Sylvia Karpagam is a public health doctor and researcher

References

^[1] Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF

and the Population Council. 2019. Comprehensive National Nutrition Survey (CNNS)

Karnataka Report. New Delhi.

^[2] Galler JR et al., “Malnutrition in the first year of life and personality at age 40.” J Child Psychol Psychiatry. 2013 Aug;54(8):911-9.

^[3] Galler JR et al., “Infant malnutrition is associated with persisting attention deficits in middle adulthood”. J Nutr. 2012

^[4] Birchfield L., & Corsi J., “The Right to Life Is the Right to Food: People’s Union for Civil Liberties v. Union of India & Others’

^[5] National Human Rights Commission “ RIght to food – a fundamental right” 28th February 2003

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ಆಹಾರ ನಮ್ಮ ಹಕ್ಕು/Ahara namma hakku

Our nutrition our right

Who will uphold the inviolable rights of children to nutrition?

Devastating malnutrition in children of Karnataka

Short and long term effects of malnutrition

What is nutritious food?

Legal rights of children to food