Children, the hidden victims of Covid-19

Interview with Yasmin Ali Haque, UNICEF Representative in India.

I’d like to start with the global pandemic that has disrupted programmes for delivering food and nutrition to large populations. What would be the impact of this, both in the immediate and long-term?

Directly or indirectly, the Covid-19 pandemic has affected millions of children in India. The costs of the pandemic on children are immediate and lasting. It is a health crisis that risks evolving into a broader child-rights crisis. The longer-term impact could potentially set back developmental gains of past many years. A recent study by Johns Hopkins Bloomberg School of Public Health estimated that globally an additional 1.2 million children under the age of five years could die in just the next six months from preventable causes because of the impact of the crisis. This translates to an additional 6,000 child deaths a day, globally, as the Covid-19 pandemic continues to weaken health systems and disrupt routine health and nutrition services, threatening to reverse nearly a decade of progress on ending preventable under-five mortality.

The Government of India has taken bold steps to protect families and communities from the disease. However, these measures, essential to contain the transmission, have adverse impact on household incomes, food supply chains, health services, early childhood care services, nutrition programmes and education.There are several pathways though which the virus could potentially impact nutritional status of women and children. People who get Covid-19 could also lose weight and become malnourished. The fear of Covid-19 could affect breastfeeding, especially when the mother or baby has the virus. Worsening poverty could further affect the diet and eating habits.

As measures are taken to prevent the transmission of the virus, we see an interruption in community nutrition and care services as well as other key child health services including vaccination and treatment of childhood illness. There could be stock outs of essential nutrition commodities in the health facilities due to disturbance in the supply chain at different levels.

A reduced access to nutritious foods (physical access, increased prices) could occur due to interruption in supply chains and access to Take Home Ration, mid-day-meals, etc. Overall these reductions in access to healthy diets and essential services could lead to an increased vulnerability of children to acute weight loss and severe malnutrition.

Child malnutrition hits early in life. Not only do malnourished children tend to have more illnesses, their brain development can also be irreversibly affected. We must recognize that children are the most vulnerable to some of the most difficult and long-term impacts of the Covid-19 crisis.

 

Do you believe the Covid-19 outbreak could disrupt India’s nutrition goals? How can we stay on course and mitigate the fallout on child health and infant mortality rates?

Children are becoming the hidden victims of this pandemic and are among the hardest hit. The disease itself is largely sparing them, but the socioeconomic impact of the virus and of the containment and mitigation measures around the world is potentially catastrophic for children who are already vulnerable, such as children from resource-poor communities, and girls. In countries with already weak health systems, Covid-19 is causing disruptions in medical supply chains and straining financial and human resources. Visits to healthcare centres are declining due to lockdowns, curfews and transport disruptions, and as communities remain fearful of infection. The current pandemic situation aggravates the difficulties many families already face in terms of access to affordable, healthy diets, access to health and nutrition services, clean water and sanitation.

The Comprehensive National Nutrition Survey (CNNS) 2016-18 estimated that 20.3 million children under-5 in India were suffering from wasting, 40.7 million children were stunted and 39.2 million were underweight,¹ while 53% of Indian women aged 15-49 were anaemic (National Family Health Survey-4, 2015-16). According to the Lancet 2019,² of all the children under-5 that die every year in India, about two out of three have malnutrition as an underlying cause. The country cannot afford to see an increase in these numbers through a Covid-19-induced nutrition crisis. Nutrition is not a magic bullet. Continuity, intensity and quality of services, together with required realignments in service delivery strategies in the context of Covid-19, are essential to stay on course and mitigate the fallout on child health and infant mortality rates. We know that Covid-19 and its prevention measures are likely to continue for a year or beyond, so efforts to prevent and mitigate any possible resulting nutrition crisis would require a one- to two-year planning horizon.

Some of these preventive and mitigation measures could be:

* Ensuring that social protection mechanisms including access to food and feeding schemes are designed flexibly, such that they reach those who are most at risk, while limiting the spread of Covid. Delivery of foods in schemes like Mid-Day Meals (MDM), Integrated Child Development Services (ICDS) programme and public distribution systems (PDS) needs to be adjusted such that they reach the intended individuals.

* Ensuring continuity of critical health and nutrition services delivered through anganwadis, schools, health and community systems to children, adolescents and women, with special care packages for those already at nutrition risk (children with severe malnutrition) and pregnant or breastfeeding women.

* Prioritizing services to protect, promote and support infant and young child feeding (IYCF), including breastfeeding, as a critical component of the health and nutrition response to Covid-19.³ It is recommended that mothers initiate and continue to breastfeed, regardless of their Covid-19 status. The WHO⁴ statement on coronavirus and breastfeeding recommends that a mother with Covid-19 should be supported to safely breastfeed – after reinforcing respiratory hygiene practices, including wearing a facemask, frequent hand washing, and routinely cleaning and disinfecting surfaces and objects. This advice is based on the known benefits of breastfeeding. In cases where the mother is too ill or otherwise unable to breastfeed or express breastmilk, the infant should be provided donor breastmilk or an appropriate breastmilk substitute under medical supervision, with measures to ensure that it is feasible, correctly prepared, safe and sustainable.

* Using alternative strategies and multiple media platforms to provide counselling and advice on feeding, diets and nutrition for mothers, infants and young children, such as telephone and online counselling and advice in places where restrictions on movement interrupt routine services such as antenatal care and immunization/well child clinics.

 

How can nutrition be integrated in pandemic response/prevention strategies, especially since nutrition services are often provided at the community level, and quarantine restrictions and social distancing have forced the suspension of some of these?

The Government of India initiated a high-impact country-wide nutrition campaign, the Poshan Abhiyaan, two years ago, which has led to a strengthening of systems, training of frontline workers, collaboration of several ministries beyond health and nutrition, improved monitoring and reporting and expanded service delivery. To protect the investment made under Poshan Abhiyaan and to mitigate the multiple impacts of Covid-19 on families, a Covid-19-sensitive Poshan Abhiyaan could be envisaged. Nutrition actions that we know are essential and need to be continued can be integrated into the pandemic response strategies in a manner that does not contribute to Covid-19 spread (by maintaining social distancing and using masks). For example: One, supplementary food to pregnant women, lactating women, children and adolescent girls may be provided as take-home rations either to be collected from an anganwadi centre or delivered at home. Two, communication and counselling for caregivers could continue through home visits (observing the local government’s physical distancing norms) and at the time of food distribution, immunization, or antenatal check-up on Village Health, Sanitation and Nutrition Days (VHSND). In addition to standard messages under Poshan Abhiyaan, messages should be delivered on prevention and protection from Covid-19 and continuation of breastfeeding protocols by mothers who may be suspected or infected with the virus.

For instance, in Odisha, with the lockdown and closure of anganwadi centres and community-level activities, children were in danger of moving into severe acute malnutrition, which might have been fatal for some of them. Realizing this, the government decided to continue the counselling and feeding demonstrations with the support of frontline workers at the household level, while following Covid-19 safety measures. In Maharashtra, frontline functionaries decided to communicate nutrition messages to parents through WhatsApp groups. Considering the enthusiasm shown and successes in some areas, the Maharashtra department of women and child development issued directions for state-wide creation of beneficiary-wise WhatsApp groups.

Three, growth monitoring and promotion, including simplified screening of children for severe acute malnutrition. Four, village health, sanitation and nutrition days should continue to deliver services such as immunization, distribution of iron and folic acid tablets, calcium and vitamin A supplementation, deworming, health checkups/screening, antenatal care services, and treatment for minor ailments including diarrhoea, but with an adjusted approach, so that there is no physical crowding. For example, in Bihar, children have started receiving essential vaccines and antenatal services for pregnant women have resumed, with due precautions and maintenance of hygiene. Five, essential adolescent nutrition services that are normally delivered through schools can be integrated into continuing services like VHSNDs, or through home visits or with mobile health teams providing services once a month. For instance, in Assam, anganwadi workers continue their work, using take-home ration distribution visits to simultaneously handover iron and folic acid supplements and reaching out to beneficiaries over the phone to continue the dialogue on nutrition.

 

While dealing with the Covid-19 pandemic, do you feel there is an opportunity for India to fast track changes to health systems, infrastructure and nutrition programmes?

India’s advantage is that it recognizes that a multi-sectoral and convergent approach is needed to address malnutrition. This is evident from the Poshan Abhiyaan, which brings together more than 10 ministries and departments to implement existing and new schemes with a ‘nutrition lens’. For instance, the recently introduced Home Based Young Child Care programme provides for additional home visits by accredited social health activists (ASHAs) to address health and nutrition concerns for the youngest children, at the household level. The Swachh Bharat Mission promotes access to sanitation, clean water and hygiene practices, which helps reduce infectious illnesses like diarrhoea that are major causes of malnutrition in Indian children. And earlier this year, the health ministry launched the School Health Programme under Ayushman Bharat, where students will learn about emotional well-being, interpersonal relationships, as well as maintaining healthy lifestyles through nutritious diets and micronutrient supplements. The initiative is linked with other government initiatives such as the Fit India movement, Eat Right campaign, Anaemia Mukt Bharat and Poshan Abhiyaan for an all-round and holistic development model of health for schoolchildren and others.

Many of these schemes, programmes and campaigns, together with improvements in the ICDS, have contributed tremendously towards improving the health and nutrition status of women and children, as well as significantly lowering India’s under-5 and infant mortality rates. These programmes and schemes are technically very solid – they apply best practices from India and are generally in line with global best programme guidance, practices and standards. However, while India has the right programmes and interventions, full and quality implementation is a major challenge. In order to save lives and help children achieve their full potential, we need full Coverage, Continuity, Intensity and Quality (C2IQ) in the implementation of all programmes and schemes.

Health and nutrition services need to cover all, especially the most vulnerable members of the population, including migrants, women and children living in the poorest urban areas, those living in remote rural areas, or culturally disadvantaged communities. Programmes need to have in-built continuity strategies. The breakdown of service delivery we are now seeing due to Covid-19 puts children at risk of common illnesses and malnutrition. Programmes to promote better health and nutrition practices, including healthy diets, need to have quality and intensity. The key messages need to be disseminated through different channels and in different ways, so parents, families and communities understand them and can act on them. And of course, health and nutrition services need to meet quality standards.

The foundation for excellent health systems, infrastructure and nutrition programmes exists. We need to build on that and not let crisis situations like Covid-19 set us back. We need to invest further in the Coverage, Continuity, Intensity and Quality of these services so that they can withstand the impact of Covid-19 and support young women and children especially in getting through this crisis.

 

Despite multiple initiatives introduced by governments over the years, the burden of malnutrition remains high in India. What do you think are the major gaps in our efforts and what kind of policy change would you like to see happening in India?

Poor nutrition in the first 1,000 days of children’s lives can have irreversible consequences, leaving these millions forever stunted. Globally, at least one in three children under-5, or 200 million,⁵ are either undernourished or overweight. This puts them at risk of poor brain development, weak learning, low immunity, increased infections and, in many cases, death. Progress has been made in India. Between NFHS-3 and 4 (2006 and 2016) stunting, an indicator linked to multiple causes of malnutrition, reduced from 48% to 38.7%. It declined further to 35% by 2018 (as per CNNS). But the way we understand and respond to malnutrition needs to change. It is not just about getting children enough to eat; it is about getting them the right foods to eat. Though breastfeeding can save lives, only 58% of children under six months of age are exclusively breastfed, and less than 10% of children are fed foods adequate in quantity and quality to fuel their rapidly growing bodies and brains.

UNICEF strongly believes that investing in the first 1,000 days from conception to a child’s second birthday shapes the future of the nation. Ending stunting and other forms of undernutrition saves lives, improves health and prospects for children and impacts overall development progress. In this context, the new Home-Based Care for Young Child (HBYC) programme is a very important. It is an extension of the Home-Based New-Born Care (HBNC) programme to provide nutrition, health, childhood development and WASH (water, sanitation and hygiene) services through additional home visits by ASHAs. Besides the original HBNC home visits to newborns up to 42 days, the ASHA will now make an additional five home visits till the child is 15 months old, to promote early initiation of breastfeeding, exclusive breastfeeding till six months, and continued breastfeeding till the second year of life. The ASHA will also counsel on adequate complementary feeding, prevention of childhood pneumonia and diarrhoea and ensure age-appropriate immunization and early childhood development. When fully implemented and reaching all the children that need it, these programmes have tremendous potential to prevent and address young child malnutrition.

 

UNICEF played a major role in launching the ICDS. Today, via 1.3 million anganwadi centres, India is delivering preschool services to 33 million children, and nutrition and health education to families as well as regular food rations to young children, pregnant women and breastfeeding mothers. Despite all this, India continues to bear nearly one-third of the global malnutrition burden. How can we strengthen the ICDS to make it more impactful?

ICDS is a tremendous programme, combining many aspects from health and nutrition promotion, helping caregivers provide care for children, supplementing home diets and promoting early childhood care. Not many countries in the world have a system like the ICDS. Under Poshan Abhiyaan, the strengthening of the ICDS system has begun. There is, for instance, a greater emphasis on the frontline workers, improving their knowledge and skills through an incremental learning approach as well as equipping them with additional tools like mobile phones to assist them in providing guidance and support to mothers and to report on their situation.

When the prime minister launched the Poshan Abhiyaan, he also added a very important component of a people’s movement or Jan Andolan. The overall awareness and understanding of the importance of malnutrition among many, across all socioeconomic groups, is limited. That is why we see malnutrition among the rich and the poor, the urban and the rural. While government provides essential services, it is also important that communities, families and parents be engaged and educated about nutrition, healthy eating, good hygiene practices, and the health and nutrition services provided by government. Their involvement in the fight against malnutrition is critical.

UNICEF and other partners support the government’s efforts around Jan Andolan by assisting with social and behaviour change communication. We develop strategies and support the development of educational materials, videos, radio messages and social media tools to spread knowledge and encourage effective community engagement. During the Poshan maah and Poshan pakhwadas over the last two years, we have seen the reach and magnitude of people’s engagement on these issues, with hundreds of millions of Indians joining in to learn, apply and share learning towards ending malnutrition. However, the work under Poshan Abhiyaan is not yet finished. It is hoped that the tremendous leadership at all levels to improve the ICDS systems during the last years is continued so that the Poshan Abhiyaan is fully implemented. That, together with an emphasis on the C2IQ of services we referred to earlier, is likely to accelerate the reduction of child malnutrition in the country.

 

Breastfeeding is considered one of the most important interventions for improving the nutritional status and chances of survival of children, and yet, only 57% of infants are breastfed within the first hour of life and 58% of infants under six months are exclusively breastfed (findings of the CNNS, 2016-18). What are some reasons why early and exclusive breastfeeding is not more common, and how can we address this better?

Each year, millions of newborn children miss out on the benefits of early breastfeeding, and the reasons, all too often, are things we can change. This includes prevalence of cultural practices and lack of skilled counselling support that mothers may need to enable them to successfully breastfeed. An increasing number of caesarean sections also results in delayed initiation to breast-milk. The promotion and marketing of infant food or drinks, including infant formula, are among the other factors impacting early and exclusive breastfeeding in India.⁶

Infants can receive early and exclusive breast-feeding by involving the family, community and service providers, coupled with policy changes. Increasing awareness⁷ among mothers and families is essential to raise breastfeeding rates from birth through the age of two. Mothers should receive skilled breastfeeding counselling at health facilities in the very first week after delivery. Implementation of the 10 steps to successful breastfeeding at maternity facilities and providing breastmilk for sick newborns is also important. Strengthening the links between health facilities and communities is important to assure mothers of continued support for breastfeeding.

From the policy perspective, enactment of paid family leave and workplace breastfeeding policies, including paid breastfeeding breaks, is recommended. Strong legal measures to regulate the marketing of infant formula and other breastmilk substitutes as well as bottles and teats are also essential. Lastly, we need to emphasise monitoring systems to track improvements in breastfeeding policies, programmes and practices.

 

Our social norms can lead to gender inequalities when it comes to nutrition. Adolescent girls are especially vulnerable to malnutrition. Is there an adequate gendered lens to nutrition programmes like the Poshan Abhiyaan?

Poshan Abhiyaan has a key focus on the welfare of women and adolescent girls. It has fixed goals to reduce low birth weight, stunting and undernutrition in children up to six years of age, anaemia in children, adolescent girls and women (up to 49 years of age) as well as reducing undernutrition among adolescent girls and women in the 15-49 age group. One of the important goals of Poshan Abhiyaan is to reduce low birth weight. The only way this can be done is by supporting adolescent girls and young women to be healthy, well nourished and well informed about the importance of their health and nutrition. Addressing the health and nutrition of women before they conceive is critical to reducing low birth weight and young child malnutrition. Educating girls, delaying child marriage and programmes to empower women are essential components of a comprehensive response to maternal and child malnutrition in India.

 

UNICEF works closely at the community level. The community framework has always been crucial to outcomes on nutrition, even more so in these times. Are there some lessons from successful local interventions for the entire country?

Involving the community is critical to achieve any results related to nutrition and healthcare. If community members are aware and motivated, then the challenges can be met. After the announcement of the countrywide lockdown to fight the Covid-19 pandemic, the Andhra Pradesh government devised novel ways to deliver take-home rations to pregnant and lactating mothers, while following social distancing and hygiene protocols. Anganwadi workers came up with multiple innovations to ensure timely delivery of supplementary nutrition in their catchment areas. For example, some specially abled anganwadi workers delivered the rations using their tricycles. Community members appreciated this innovative use of tricycle by workers and acknowledged their help at a critical time.

 

Footnotes:

1. Ministry of Health and Family Welfare, Nutrition Dashboard. https://nutritionindia.info/dashboard/nutritionINDIA#/

2. India State-Level Disease Burden Initiative Malnutrition Collaborators, ‘The Burden of Child and Maternal Malnutrition and Trends in Its Indicators in the States of India: Global Burden of Disease Study 1990-2017’, the Lancet Child & Adolescent Health 3(12), 2019.

3. UNICEF, Global Nutrition Cluster, Global Technical Assistance Mechanism for Nutrition, ‘Infant and Young Child Feeding in the Context of Covid-19’, Brief No 2 (v1), 2020. https://mcusercontent.com/fb1d9aabd6c823bef179830e9/files/ffa 9cdc1-17de-4829-9712-16abe85c2808/IYCF_Programming_in_the_context_of_COVID_19_30_March_2020.pdf

4. WHO, ‘Frequently Asked Questions: Breastfeeding and Covid-19 for Health Workers’, 7 May 2020.

5. UNICEF, State of the World’s Children 2019: Children, Food and Nutrition: Growing Well in a Changing World. https://www.unicef.org/reports/state-of-worlds-children-2019

6. Hindustan Times, ‘3 in 5 Babies Not Breastfed in 1st Hour of Life: Report’, 31 July 2018. https://www.hindustantimes.com/health/3-in-5-babies-not-breastfed-in-1st-hour-of-life-report/story-s6R0VVu07xRPkAMBnOFndP.html

7. UNICEF, ‘On Mother’s Day UNICEF Calls for the Narrowing of "Breastfeeding Gaps" Between Rich and Poor World- wide’, press release, 10 May 2018. https://www.unicef.org/india/press-releases/mothers-day-unicef-calls-narrowing-breastfeeding-gaps-between-rich-and-poor