Fighting for family health in the developing world
This essay was written by Michael G. Sargent and was first published in the 2008 Mill Hill Essays. An updated version was published in the Mill Hill Essays anthology.
How were the public supposed to respond when world leaders decided to mark the start of a new millennium by pledging “to free the world from the abject and dehumanising conditions of extreme poverty”? Were such ambitious proposals as the “Millennium Development Goals” credible? Could child and maternal mortality be halved by 2015, relative to the benchmark year of 1990? With a proposal so grandiose and the targets and promised financial support so elusive, we should be very curious about how such miracles are to be performed. As a Winston Churchill Travelling Fellow during the winter of 2006, I travelled in India and Ethiopia and was able to meet a wide range of people who know something about what makes early life so precarious in their countries.
About one in fourteen children in India and one in six in Ethiopia will die before they are five years old. In India, about one in 200 pregnancies end with the death of the mother and in Ethiopia one in 120. Such statistics relate directly to the state of hygiene, nutrition, water supplies and medical care in both countries and the meagre incomes that trap people in a life of chronic poverty. The latest instalment of India’s recent National Family Health Survey casts a sombre shadow that is not dispersed by the emerging economic dynamism. The prospects for children and women of the lower social strata are clearly not improving; the proportion of under-nourished Indian children (46%) has barely changed since 1998.
I learnt more about this at the Centre for the Study of Social Change (CSSC) in the slums of Mumbai at East Bandra where I was to meet Ramesh Potdar, the honorary director. CSSC evolved from an organisation started in the 1960s by Indumati Parikh, a paediatrician and humanist greatly honoured in India for her pioneering work for women of the slums. Her mission started with a plan to introduce family planning to such places, but this began to change when she realised that women were not interested because they feared their babies might die. Dr Parikh saw that women of the slums were trapped in a vicious cycle of ignorance and poverty, imposed by religion and ancient tradition that would be broken only by sound advice and practical services. To help them secure the survival of their children, she believed women should examine their lives and the issues affecting their situation through self-help groups formed with the guidance of CSSC.
Ramesh Potdar, also a distinguished paediatrician, introduced me to the complex and subtle social problems of his country. He and many Indian doctors echo Dr Parikh’s opinion when they say that the profoundly patriarchal culture of much of India insidiously influences and undermines family health in the lower social strata. Girls generally enter the world to an unenthusiastic reception. Starting with inauspiciously low birth weight, their growth becomes stunted. Later, inadequate education, arranged marriage and early pregnancy — often while not full-grown — shapes the fate of another generation. In the patriarchal tradition, in city slums or the country, the care of pregnant women tends to be neglected. This is vividly illustrated by the exceptional situation in the relatively poor southern state of Kerala, where infant and maternal mortality are comparable to Europe although malnutrition is still prevalent. The crucial issue is the existence of good antenatal care and medical facilities in high density throughout the state. This reflects the strong political support for such services by males and females and the high levels of female literacy that have existed there for a century.
Following the precepts of Dr Parikh, CSSC is pioneering practical ways of reaching women of the slums through improvised clinics. Sympathetic young female doctors, in a few sessions each week, respond to the primary concerns of their many patients and quickly evaluate general health. Weights of babies are plotted on growth charts, to establish whether the child is thriving or whether the child needs the attention of a nutritionist. Words and pictograms on the charts demonstrate the developmental expectations for each age and the actions required of a mother. Neighbourhood clinics around Bandra are now highly regarded by their clientele, who are themselves becoming increasingly competent at managing the welfare of their families.
Low birth weight is an important issue; Indian babies are on average among the smallest in the world — at normal term, they are 0.8 kilograms less than the British average. Babies weighing less than 2.5 kilograms at birth are notably vulnerable to sickness or death and in India, one third of babies fall into this category compared with just one sixth of babies in sub-Saharan Africa. In part, this has an obvious explanation: Indian women increase in weight by only five kilograms during pregnancy compared with the ten kilograms considered optimal for a successful pregnancy. In contrast, in sub-Saharan Africa, where food is usually much less plentiful, most mothers approach the optimal weight gain. The problem is profoundly difficult to solve. Diets lacking in critical micronutrients is one factor, but curious cultural factors of a different kind are also at work; many pregnant women believe eating less during pregnancy will make the birth more comfortable.
Ramesh believes such problems need evidence-based investigations. He manages a venture called the Mumbai Maternal Nutrition Project, financed by a consortium of organisations including the UK Medical Research Council. This aims to establish whether a food supplement rich in micronutrients (vitamins and minerals) taken before and during pregnancy increases the birth weight of babies. The food supplements are green leafy vegetables prepared in samosas, consumed three times a week in addition to the subject’s normal diet. The trial is a comparison of subjects who anticipate getting pregnant during the trial, allocated randomly either to a highly or minimally supplemented diet. The benefit of participating in the trial for the 4,000 young women was prenatal care, help in arranging the delivery in hospital and post-natal check-ups for five years. In return, they agree to follow the experimental protocol exactly and submit to necessary scientific investigations. In a world where inadequate prenatal care undermines the health of mothers and babies, the publicity associated with the trial promotes awareness of better ways to achieve a satisfactory pregnancy.
CSSC seeks to engage with women trying to improve family life in Mumbai’s teeming slums but for a city of 18 million souls, packed at millions per square mile, their efforts seem just a drop in the Arabian sea. The salvation of this great city may well lie in grandiose rehousing schemes and improved infrastructure, but it seems certain the battle for family health will not be won until rational mothercraft becomes ubiquitous.
At the end of the British Raj, life expectancy of Indians was just 27 years. India faced social needs on a scale never previously confronted by any democracy. The nascent Indian Republic had the scientific expertise to address the challenges of food security and disease control, but the really difficult problem was how to make policies effective. The most significant attempt to improve the welfare of people in the underdeveloped world prior to Indian Independence, was carried out in the 1940s at Pholela, in rural Kwazulu-Natal, South Africa. In a region completely untouched by twentieth century public health, a group of idealistic young doctors from Johannesburg created an organisation that, within eight remarkable years, reduced overall and infant mortality three-fold. The scheme was predicated on what is now known as social anthropology, an extension of a European concept of social medicine in which an entire community was introduced to modern ideas of hygiene, nutrition and mothercraft. They recruited and trained local people as health workers, who were expected to make contact with every home in the neighbourhood and to persuade them to participate in the scheme. The team helped the community set up civilising amenities such as latrines and vegetable gardens and ran antenatal clinics and mothercraft classes. Although the scheme was a product of a relatively rich paternalistic organisation, it could have survived to be an inspiring model for many nations, if it had not been dismantled under apartheid.
The framework for the Indian health service created after Independence was based on a network of primary health centres dedicated to preventive medicine — almost certainly inspired by Pholela — plus better-equipped secondary units as referral centres. They were to be well staffed with doctors, with resources for maternity services, managing infection and giving advice on hygienic mothercraft to all, irrespective of capacity to pay. The system has had a chequered career but has survived, developing into facilities to deliver the World Health Organisation (WHO) vaccine program and to deal with acute respiratory infections, diarrhoea, fevers, minor injuries and antenatal care. Rural health centres serve great expanses of farmland peppered with small villages in tenuous connection by country roads. It is said that many of the idealists who set up the rural health program lost their enthusiasm when they realised it was doomed to be chronically underfunded. Jean Drèze, an economist noted for his incisive analysis of Indian poverty, believes the recent gloomy statistics from the National Family Health Survey reflect “a catastrophic collapse of health services caused by a pattern of growth favouring middle class interests”. The problem is all too apparent if one compares the swanky cure-oriented private hospitals in Indian cities with the weather-beaten and dilapidated rural health centres and the excess of highly qualified doctors in the cities relative to the villages. Sadly, it seems, socialist India never found an effective incentive to encourage doctors to work in the villages rather than the city hospitals. Belatedly, the Indian government recognises it must rectify this situation. It has launched an apparently well-funded “Rural Health Mission” to train “accredited social health activists” who will advise villagers on every aspect of preventive medicine in the style pioneered at Pholela so long ago. The social problems of India today are infinitely more complex than those that afflicted Britain in 1906. In those times, British infant mortality was similar to current Ethiopian figures and a system of Health Visitors was established to give advice about hygiene, nutrition and mothercraft to working class mothers. It was an innovation that was probably the most important contributor to the dramatic fall in infant mortality that followed.
When the food needs of tiny children are so small, the discovery of stunted growth is puzzling and suggests a serious and peculiar problem that starts very early. Breast-feeding of babies is almost universal in India; it should guarantee nutritional needs for six months and a normal growth trajectory and protection against infection. An ancient Brahminical stricture guides Indian mothers to disrupt this natural process by expressing and discarding colostrum, the precursor of milk secreted in the first few days after birth. This leaves the baby unfed until the definitive milk appears and deprived of a rich source of maternal antibodies and antimicrobial substances. The transition to weaning foods at six months is another danger point for maintaining the trajectory of growth. Mothers may start too late; traditional foods may not be sufficiently nutritious or palatable and may not be hygienically prepared. Babies afflicted simultaneously by undernutrition and diarrhoea tend to have severely retarded growth that may persist in adulthood.
The calorie intake of about one fifth of the population of India is still close to the minimum necessary for maintenance of the human body. At these intakes, the typical staple foods lack sufficient vitamins A and B12, iron, iodine and zinc for a healthy life or for satisfactory growth and development of children and unborn babies. Early exposure to micronutrient deficiencies will almost certainly affect cognitive abilities and general fitness. Since the 1980s, the Indian government have attempted to improve the nutritional status of children and pregnant women through the Integrated Child Development Service. Unhappily, the outcome has not generally matched expectations through mismanagement at local centres in the poorest states that persists after innumerable investigations. Historical records indicate that the British and French were increasing steadily in stature in an improving economic climate for the last two centuries. In contrast, the average stature of Indians between 1830 and 1945 did not increase significantly, reflecting the poverty and acute famines of those times. Indians in the poorest strata of society are still not escaping from this historic trap.
Safe water is more accessible in India than anywhere in sub-Saharan Africa but the extraordinary population densities and poor sanitation amenities make Indian urban slums much more unhealthy for children than rural communities. Indian commentators fret at the lack of satisfactory progress in sanitary engineering particularly when new installations prove inadequate for the influx of population that occurs when the work is ongoing. Providing safe water on the Ganges plain — one of the most densely populated places on earth — presents uniquely difficult problems as the sacred river is heavily polluted with human excreta and is a notorious source of cholera and dysentery.
Ethiopia, the fourth poorest nation on earth, began building its system of preventive health care relatively recently, like India using primary health centres to deliver elementary care. As in India, the hope is for these units to be leaders in an educative campaign. Addis Ababa University has a centre to develop community medicine at Butajira in the Gurage region of Ethiopia. Attached to a survey team, I was able to see something of the texture of rural life, through visits to several families in their tukuls, the instantly recognisable African roundhouses with a thatched roof. Under the bluest of December skies and brilliant sunshine, the highland settlements are picturesque and neat with breathtaking vistas of mountain ridges and the distant floor of the Rift Valley. Clusters of tukuls sit amid verdant plantations of ensete, the false banana plant — a traditional dietary staple that is used to make an unnutritious porridge. Typically, families live in a single room with an earth floor shared with their animals and no other amenities, but it is surprisingly easy to imagine a sanitised version becoming a charming tourist attraction. Paradoxically, it is a world of unforgiving harshness; where to get sufficient food and water for a family involves extraordinary energy while infectious hazards are hard to avoid. A country in which 85% of the rapidly growing population are peasant farmers is chronically troubled by the consequences of the poor performance of crops. Originating in declining soil fertility, soil erosion, and inadequate water conservation this poor performance causes widespread chronic undernutrition.
As in India, inherited customs can be extremely damaging to the development of children; none more so than the florid examples found in the country. Infant incisors are sometimes removed by “traditional healers” to cure chronic diarrhoea; on the basis of the dubious evidence that the infection and teeth appear together. Newborn babies are often kept covered to protect them from the “evil eye”, but the exclusion of sunlight causes severe vitamin D deficiency. The traditional remedy for respiratory infections is excision of the uvula and usually ends in sepsis. More mundanely, the transition from breast-feeding to weaning foods is often the trigger for bouts of diarrhoea and the dreadful synergy with malnutrition permanently stunts growth. Ethiopian nutritionists, see native crops like ensete to be a menace as a weaning food because it is deficient in micronutrients, seems unpalatable to infants and is not generally prepared hygienically. Most babies are born at home in unhygienic environments assisted by the “traditional healers”, who often put the lives of mother and child at risk. The WHO indicator of progress towards safer childbirth — the proportion of births attended by skilled health personnel — ranks Ethiopia very low; 6% in 2000 compared with 42% in India. Many young girls who are physically immature, undergo prolonged and obstructed labour that usually ends tragically.
Life in rural Ethiopia is dominated by the need to collect water, a burden that falls mainly on the women who in some regions spend up to 6 hours per day — sometimes carrying more than half their body weight. Consequently, people manage on incredibly small amounts, often from contaminated sources. Some Indian commentators wistfully imply that the women of sub-Saharan African are empowered in important ways because they have greater autonomy than those of India. For an outsider, this is difficult to confirm but Ethiopian women are clearly conspicuously overburdened with domestic and agricultural work even in advanced pregnancy and are generally illiterate. Locally, the word is that their position is deteriorating; less time is spent recovering from a birth due to demands of work while the health of older women is being neglected.
With the death rate falling steadily in Ethiopia, population growth is developing an ominous momentum, which thoughtful people believe could negate any economic growth and threaten food security. As in other countries burdened with high infant mortality, couples see no point in contraception even though help is readily available at every health post. Families of six children are typical. I learnt of a specific example of how an unanticipated increase in fertility was precipitated by the introduction of a piped water supply. This dramatically transformed the lives of the women of Arsi, an arid region of South Ethiopia, in the late 1990s. Water collection was reduced to as little as 30 minutes, with important consequences; the interval between births decreased by six months and low birth weight babies survived better. The authors of this study believe the increase in available energy to mothers following the improvements enhanced fertility and improved their capacity to care for their children. Consequently, low-birth weight babies survived better to be an additional threat to food security in the longer-term.
Many infant and maternal deaths in the developing world are avoidable in principle by appropriate hygiene and nutrition; the challenge is to implement such practices effectively. As in Britain in 1906 and Pholela in 1942, the most effective way of intervening in the lives of disadvantaged people still seems to be through the role of trusted advisors, like our health visitors, who can persuade people to abandon damaging customs. Whatever world leaders and attendant celebrities imagine they can do for countries of the undeveloped world, such intimate interventions are manifestly best delivered by their own people. There is an important place for help with the financing of new facilities — clinics, safe water supplies and latrines — that would improve the quality of life but whether this can be done at the speed suggested by the Millennium plan is anyone’s guess. The greatest uncertainty is whether the much-vaunted trickle-down of wealth will actually reach the poorest of the poor.