In Jharkhand, an Indian state known for its diverse tribal communities, the number of people that are malnourished is persistently higher than the national average. Since June 2017, Doctors Without Borders/Médecins Sans Frontières (MSF) has been treating severe acute malnutrition in the town of Chakradharpur, in Jharkhand, using an innovative community engagement model. Subashini Deb Mahto, from one of the local communities, works for MSF as a Community Health Educator. Here she shares her experiences, both her work with MSF and her first-hand experience of malnutrition.
“I begin my day before the sun rises. Once the chores are done, the cooking finished and my children are on their way to school, I start a pot of lal cha (black tea) boiling on the stove and get ready for work. My cycle gets me to the MSF office, 3 km away, by 8.30 every morning.
I’ve been working with MSF since the malnutrition project started here in 2017. I began as a Community Health Worker, visiting communities with the Sahiya didi (a village health worker employed by Jharkhand state) to identify malnourished children in need of urgent care and to convince their parents to take them to an MSF health centre. Now I work as a Community Health Educator. I provide counselling to mothers who visit our health centres and organise awareness activities in the surrounding villages.
Malnutrition is an issue close to my heart. When I talk to mothers in the villages, I understand how they feel. I was a teenage mother with the same story. I had a daughter soon after I married. I was 17 and did not know how to take care of my new baby. My daughter weighed only 2 kg when she was born. In our community, there are cultural beliefs and misconceptions around pregnancy that restrict what expecting and new mothers and their children can eat. These can cause both to become malnourished.
People believe that a rich diet for pregnant women will make their unborn child very fat and lead to a difficult delivery. After pregnancy, women are only allowed to eat once a day, though sometimes my husband would secretly give me food. In some cases, children are not given meat or milk until they can walk by themselves. My daughter had a very limited diet restricted to dal (lentil soup) and rice; no eggs or meat were allowed for the first few years.
Women also have to juggle working in the fields and doing household chores, leaving very little time for bonding with their children. I was the only one managing our household chores, with no-one to support me in taking care of my child. By the time my second child was born, I had learned to take better care of myself and my children. I found a job in a women’s reproductive health NGO and then later I joined MSF.
Chakradharpur, like most of Jharkhand, is an Adivasi area with many indigenous communities and a lot of diversity. For example, four languages are spoken in just one of the villages I work in. Our role as health workers is to build bridges between MSF and the communities. Members of the team who work on health education and community outreach are all locals. When we were trained by MSF’s doctors to understand malnutrition, we also shared our knowledge of the ancient culture, history and practices of the Adivasis with the rest of the team.
Many people in the village do not understand that malnourishment is a condition that requires medical care. Known as puni or dehna locally, it is often attributed to possession by spirits or bad omens. As a result, traditional healers are the first point of contact for most families and may prescribe natural herbs, or performing some ceremonies to drive away the spirits. It is important to show community members the importance of identifying malnutrition and seeking appropriate medical treatment. There is no lack of food in the forests where these communities live.
We need to teach young mothers and their families about the importance of correct breastfeeding techniques, a diverse and nutritious diet, and maintaining proper hygiene.
In the beginning, it was extremely hard to convince mothers and their families of the causes of malnutrition and to seek treatment. Some tribal communities live deep in the forests where there is no public transport. The mothers walk with their children over hilly terrain for more than 2-4 km to reach the nearest health centres. Often older siblings bring sick children to the MSF health centre after school. Last month, our clinic was empty for a few days because it was the harvest season and all parents were at work.
After months of hard work, we have gained the trust of the community. Sometimes our health centre gets so busy and crowded that there isn’t a moment to rest. At those times, I push myself – I feel like we are doing important work here. Watching a young child waste away is the most painful thing for a mother. During one of my visits, a mother grabbed my hand, and told me she had referred someone else to our Pusalota health centre! The project has treated more than 600 children from these communities and while there is a lot of work still to be done, I get to experience the joy of families as their children return to health and happiness.”
Photographs by Nikhil Roshan
MSF has worked in India since 1999, providing medical treatment to thousands of patients in Andhra Pradesh, Bihar, Chhattisgarh, Delhi, Jammu and Kashmir, Jharkhand, Maharashtra, Manipur, Telangana, Uttar Pradesh and West Bengal.