A group of activists from the Jan Swasthya Abhiyan, met on the 22ndand 23rdFebruary 2003, to form a 'Hunger Watch Alert' in the backdrop of the worsening situation of food security in India. Reports of drought, crop failure, suicides by farmers, starvation and hunger deaths are pouring in from various parts of the country. This includes rural areas of Maharashtra like Wada, as well as metropolises like Mumbai. Jan Swasthya Abhiyan, convened this meeting as a response to high levels of undernutrition, growing instances of hunger deaths and government apathy towards them. The aim was to arrive at a scientific protocol to investigate and document hunger related mortality. Those attending the meeting included Dr. Veena Shatrughna (Deputy Director, National Institute of Nutrition, Hyderabad), Dr. Vandana Prasad (Paediatrician), Dr. Narendra Gupta (Prayas), Dr. Sunita Abraham (Christian Medical Association of India), Sarojini (SAMA and Convenor of MFC), Dr. C. S. Kapse (Professor, Department of Forensic Medicine, D. Y. Patil Medical College), Dr. Neeraj Hatekar (Professor, Department of Economics, University of Mumbai), Sanjay Rode (Ph. D. student, Department of Economics, University of Mumbai), Dr. Abhay Shukla (Co-ordinator, SATHI Cell, CEHAT), Dr. Neelangi Nanal (CEHAT), Dr. Amita Pitre (CEHAT) and Ms. Qudsiya (CEHAT)
Undernutrition in children as well as Adults is well documented in various government publications. This data from NNMB (National Nutrition Monitoring Bureau) 'Diet and Nutritional Status of Tribal Population Report on First Repeat Survey' shows extremely high prevalence of malnutrition (92%), and significant numbers of severely undernourished (20%). This situation of silent hunger hardly seems to draw any action for relief, while incidences of suspected starvation deaths send the government machinery into action to vehemently deny their occurrence. Therefore it was thought that efforts must be made to systematically investigate and document starvation deaths, at the same time keeping a focus on a community diagnosis of a starving population and to gain relief for the entire community. The occurrence of a starvation death could be used as an advocacy tool to highlight the omnipresent undernutrition, and a chronically starved population on the brink of death in case of drought or crop failure.
Participants presented their experiences in the context of investigating suspected starvation deaths and the methodological issues that emerged during the exercise.
Abhay Shukla presented the experiences of Badwani, Madhya Pradesh and Wada, Maharashtra. Narendra Gupta presented those of Baran, Rajasthan and Neeraj Hatekar those of Mumbai slums. The reports of these studies were circulated. Veena Shatrughna presented the methodological issues and existing literature regarding malnutrition and starvation deaths.
Verbal Autopsy Forms was an important tool that was discussed. A standardised form available for the children, and the WHO form available for adults were modified to accommodate specific provisions to diagnose the status of food security for the community, family and individual and used in the Badwani study. Also discussed was which would be the best parameters to assess adult and child nutrition. The Body Mass Index (BMI) in adults and the Weight for Age in children, are the best available parameters for use. The group will also be exploring the importance of Post Mortem findings to diagnose a starvation death. The dearth of information regarding this and the reported facts that forensic experts hardly ever diagnosed 'Starvation' as the cause of death was surprising. This again confirmed that while malnutrition could be quoted in medical reports and death certificates, starvation was a taboo word, to be avoided.
The important methodological issue that came up was whether calculation of three monthly death rates as was done in Badwani was a valid tool in assessing death rates. Weekly death rates had been calculated by the British in case of the Bengal Famine. A study should be done to record seasonal variations and the phenomenon of clustering of deaths and if this is a statistically significant phenomenon. Otherwise there seemed no problem with calculating such death rates.
An important suggestion made was that for effective advocacy the weights of the children in the affected area should be compared with those of middle class children in the same age group. This would bring out the differences more sharply than do figures of percentages in the various categories of undernutrition.
Another stumbling block to prove a starvation death is one has to rely a lot on physical appearance as related by close relations, as anthropometry is out of question. An important proxy indicator would be the weights of siblings. The Nandurbar study done by the Tribal Research and Training Institute relied on weights of mother and siblings. This could be an important tool to decide if the entire community was starving.
Another important issue was that malnutrition, hunger and starvation seem to lie in a continuum. How is it possible to demarcate one from the other. One important finding that was told here was that at adult BMI of 19 mortality rates seem to start rising. Consensus was reached that B.M.I of 16 and less should be used as a cut off point to demarcate starvation from undernutrition. A 30 Kg person (~B.M.I of 16) needs 500 Kcal per day to maintain himself at Basal Metabolic Rates, without any activity. Therefore such a low intake is also an indication of starvation.
The following indicators may serve to define an adult starving population-