All is not well – The Indian Express

Written by Chahat Rana | Chandigarh | Updated: December 30, 2019 5:51:31 am Arguably the greatest challenge faced by Chandigarhs residents when it comes to their health, is alleviating the burden of anaemia.

When it comes to the health of Chandigarh, there is an abundance of government schemes and policies, but the condition remains almost the same, says Rachana Shankar, a scientist at the PGIMER Department of Community Medicine and School of Public Health, who is currently surveying women and childrens health in various parts of the tricity. Shankar says there are times when her work seems futile and her advances in community engagement and health awareness bring no fruition in terms of changing health parameters. Everything begins with women, who bear children as healthy or unhealthy as they are, so the idea is to focus on women and early childcare, explains Shankar, before adding but there is already so much work being done to aid them, so there must be a deeper issue we are not able to solve.

Chandigarh, which ranked second in the composite good governance index for Union Territories in India, boasts not only of some of the most reputed public health institutes, but of an administration which has been commended for its dedication to timely implementation of health-related schemes and policies. Under the Poshan Abhiyan or the National Nutrition Mission, the Chandigarh administration received four awards, including one for effective implementation of the scheme in the city; the city also flagged off three mobile anganwadis which aim to reach children who are otherwise unable to access the anganwadis. The administration has almost completed its goal of establishing 52 Health and Wellness Centers (HWC) in their attempt to fortify primary healthcare in the city and furthermore, many from the health field, including nurses and anganwadi workers, have received national awards for their work in 2019. Yet, as Shankar rightly pointed out, chronic health ailments mostly driven by lifestyle choices are rampant across residents, regardless of their socio-economic background.

The burden of anaemia

Arguably the greatest challenge faced by Chandigarhs residents when it comes to their health, is alleviating the burden of anaemia. According to the last National Family Health Survey, 73 per cent children and 75 per cent women in the city are anaemic. Apart from anaemia, with more than 20 per cent children lacking adequate levels of vitamin A, according to data from the Comprehensive National Nutrition Survey (CNNS) 2016-18, Chandigarh also falls in the danger zone for high rates of vitamin A deficiency.

Director Health Services Dr G Dewan ascribes the high rate of anaemia to inaccurate methodologies used to collect data by the agents sent by the NFHS team. A team of doctors from PGIMER conducted the same research again and found the rate closer to the national average of 50 per cent anaemic women and children, claims Dewan. However, even if the number of anaemic women is around 50 per cent of the population, the statistic is classified as a major health concern under the guidelines of the CNNS. The nutrition survey, which was released this year, classifies anaemia as a major public health concern in regions where more than 40 per cent women and children are anaemic.

Since last year, various officials working under the Integrated Child Development Scheme (ICDS) and the Women and Child Welfare Department of the administration have come together to tackle the epidemic. Poshan Abhiyan has united different government agencies under the Anaemia-Free Campaign or the T3 campaign which was launched in September 2019. Though under the ICDS scheme, children and women across the country were given folic acid to treat anaemia for several years, the T3 campaign hopes to make a consolidated effort using a test, treat and talk approach to address the issue from all fronts. The idea is to engage with the community and counsel them on why they need to treat their anaemia and then provide them with long-term solutions including lifestyle changes, rather than just giving them a tablet that they often refuse to take, says Sarita Godwani, a consultant for the Poshan Abhiyan in Chandigarh.

However, according to some doctors and nutrition experts, efforts to alleviate anaemia have been made too late by the authorities, and hence getting quick results will be next to impossible. These things cannot be done in a jiffy, it takes a lot of time to change the dietary and lifestyle habits of a population. We knew the rates of anaemia had been high since 2017, but work has truly begun only now, says a nutrition expert from the city who wishes to remain unnamed. So even though in name and writing we have all these provisions for health, there has been no thorough investigation and implementation of effective ways of impacting the health of our citizens. These efforts, including counselling, have just come into being now, so it will take a lot of time for things to change, i.e. if they change at all, says the expert.

The question of nutrition

If given an option, 10-year-old Sumit, a resident of a construction site in Dhanas whose parents work as daily wage labourers, would eat a packet of chips over the kadhi-chawal served by anganwadi workers to all the women and children living at the site. If I could get my hands on some change, I would buy chips every day, says the boy with a sheepish smile, clutching the hand of his severely malnourished younger sister, who has come under the radar of frontline health workers due to her developmental retardation. They all flock to buy junk food, it is no wonder all our efforts seem futile sometimes, says the anganwadi helper at the site. At another slum near Panchkula inhabited by scores of malnourished kids, a small store next to the slum is filled with kids of all ages buying chips and other junk food.

The junk food addiction is not just a problem of the socio-economically backward of Chandigarhs population. The packet of chips connects Sumit and the slum children to their more privileged counterparts in the city as well, who if given the option will tear into the transfat-laden packaged food before touching the hot nutritional food otherwise prepared for them. The nutritional deficiency on the one hand of course is aggravated by your socio-economic background, but on the other it goes beyond that and reveals our complete lack of awareness when it comes to dietary choices we need to make for our health even if we have the means to afford all kinds of food, says Raveesh Grewal, a nutrition consultant for Poshan Abhiyan, whilst on his way to a site for a regular checkup of those diagnosed with severe malnourishment. At the site, the nutritionist quickly spots a child with Severe Acute Malnourishment (SAM) by her significantly bloated belly caused by water retention. Every day we spot someone new with severe malnourishment, almost every day, says Grewal.

Though there is no recent study published on the prevalence of malnourishment in Chandigarh or the rest of the tricity, the rampancy of the issue is not only vouched for by the research conducted by doctors and health workers in their individual capacity, but also by high rates of occupancy in Nutrition Rehabilitation Centers (NRC) in the city. In November, Newsline reported on the over-occupancy of the NRC at civil hospital Panchkula, which treats children from across the tricity and the neighbouring states of Punjab and Haryana. The centre, which aims to rehabilitate severely malnourished children by giving them essential carbohydrates and increasing their weight at least by 15 per cent, is perpetually over-occupied. Hence, the doctors stationed at the centre are forced to let go of those that have improved a little in a shorter than stipulated time period, to make space for cases that require more urgent care. We do our best with whatever resources we have, and we also provide counselling to mothers so hopefully people improve their nutritional intake and lifestyles when they go back home instead of falling to the same debilitating condition again, says Dr Rohit Sharma.

This short-term approach will do nothing in terms of getting out of the vicious cycle of malnutrition, especially for those who do not have the means to give adequate time to their children, says Dr Poonam Khanna, nutrition expert from PGIMER school of public health, who has conducted extensive research on women and child health in the region. According to Khanna, for those who come from weaker economic backgrounds, especially those who live hand to mouth, productivity is the key to survival. So it becomes almost impossible for them to focus on their childrens health enough to make sure they remain out of the red zone of malnutrition, says Khanna, referring to the stratification of levels of malnutrition provided by the World Health Organization, with red zone being the most life-threatening.

Apart from hindering mental development, one of the biggest effects of malnutrition is stunting. Stunting is not limited to the underprivileged. For example, I too am stunted, we dismiss stunting as something that is just in our genes, but I am stunted because my protein intake was not adequate despite my mother being privileged enough to give me attention and adequate amounts of food, says Shankar, the woman scientist at PGIMER. According to her, there is an acute lack of awareness and hesitation in changing our lifestyles no matter our socio-economic background. We all need 55 grams of protein a day, how many of us truly follow that? says Shankar, before adding, No matter what treatment is provided by the government, unless preventive measures are put in place through awareness and lifestyle changes, we will continue to accumulate chronic health issues which will affect us for the rest of our lives, says Khanna.

Integrating AYUSH and Yoga

Apart from focusing on womens health and early child development, the UT Administration is working in line with the Central governments National Health Mission (NHM) to promote more indigenous forms of alternative medicine and treatment such as Ayurveda and Yoga. Under the National Health Mission and as prescribed under the National Health Policy of 2017, regions across India have to develop Primary Healthcare Centres known as Health and Wellness Centres (HWC).

The Chandigarh Administration is actively working towards creating 52 such HWCs by March 2020, which will provide a more comprehensive approach to primary healthcare, providing not only basic health services, but also treatment for women and child health, non-communicable diseases, emergency care and free medication for certain diseases. Apart from this, the HWCs are guided by the principle to enable the integration of Yoga and AYUSH as appropriate to peoples needs. AYUSH is an acronym which stands for a conglomeration of alternative medical practices, including Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy. After coming to power, the current government promoted AYUSH treatment in the country by setting up a separate AYUSH ministry and dedicating ample funds to work towards strengthening the practice of AYUSH in the country.

According to NHM, the need for integration of AYUSH and yoga in the mainstream is fuelled by a comprehensive, rehabilitative and preventive approach to primary healthcare. Dr Dewan, the Director of Health, says the HWCs will decrease the burden of providing treatment in tertiary healthcare centres such as PGIMER and other public hospitals in the city. Furthermore, this push towards holistic and alternative treatment will be particularly effective for those suffering from chronic conditions which allopathic medicine alone cannot tackle. This comprehensive form of treatment is what we aim to achieve at the primary level. In Chandigarh, the HWCs will be staffed by not only an ANS and an MBBS medical doctor, but also an AYUSH practitioner, says Dewan.

Medical Superintendent at GMCH 32, Dr Ravi Gupta, also welcomes the shift towards alternative treatment. I myself am a big believer in yoga, I have also prescribed yoga to some of my patients who have been suffering for long with chronic illnesses, says Gupta, who adds that the hospital is also working towards building a separate department for AYUSH-related medical therapy. Earlier in 2019, even PGIMER had announced its decision to start prescribing yoga asanas as treatment to its patients. By March, the reputed tertiary health care centre had signed a memorandum of understanding with Swami Vivekananda Yoga Anusandhana Samsthana, a university in Bangalore, for facilitating research collaborations on yoga at the hospital.

Furthermore, yoga has been made a part of the curriculum of city schools, and is also prescribed under the Poshan Abhiyan for adolescent girls, pregnant women and children. Under the Fit India Programme, schools have been asked to conduct at least 20 minutes of yoga for students almost every day. Some schools have had to follow the directive even if that means making the children sit at the playground in the cold. Officials from Poshan Abhiyan have been distributing pamphlets that prescribe yoga exercises for women and children in different age groups, according to their physical and mental health needs. For example the booklet for pregnant women will have those asanas that will benefit her during her pregnancy, without compromising on her and her childs health, says Godwani, the consultant for Poshan Abhiyan at Chandigarh.

PGI prescribes caution

Though a comprehensive approach to healthcare and a dedication to universal health coverage in the city is welcomed by all, medical professionals have voiced their contentions with the focus on AYUSH. At the end of the day, we all have to turn to allopathic treatment, which is our first and primary line of defence, says a senior PGIMER doctor who wishes to remain anonymous. We welcome the approach, and we should expand the ambit of treatment, especially when it comes to chronic and lifestyle-related issues, but at PGIMER for one, people come here in the most precarious condition, and these patients can be helped only through modern medicine, says the doctor. The doctor also believes that the burden of treatment at PGIMER will not be lightened by an increasing focus on alternative treatment, but through a fortification of existing primary healthcare infrastructure. For example the local dispensaries need be stocked with basic medicine and a good MBBS doctor at all times. We should ensure that before we expand into this whole wellness fad, adds the doctor.

Even Dr Ravi Gupta, who has great faith in yoga and its myriad health benefits, is skeptical of the extent of its effect when it comes to primary health care in the city. Unfortunately, though there is anecdotal evidence of the benefits of alternative medicine and yoga, there is no thorough scientific research conducted about its actual benefits, says Gupta. So allopathic practices can never be replaced, and I dont think that is what the administration is attempting to do anyway, but still the focus on AYUSH and yoga has a separate place in medicine, which can never challenge the benefits of modern medicine, Gupta sums up.

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All is not well - The Indian Express