DEEPA KURUP, Bangalore, Jan 5, 2013
Bibi Khadeeja (1 year and 8 months) weighs 6.2 kgs. Her family does not have a BPL card. Her mother Shameem taj, who suffers from mental disability, and her visually-impaired father, are both yet to get their disability pensions. Photo : Deepa Kurup
Ramabai with her grandaughter Rosy (1 year and 9 months), a ‘severly and acutely malnourished’ child weighing just 7 kgs. Her mother is the sole earner, and works as domestic help. They have no BPL card or access to state welfare, apart from some assistance from the anganwadi. Photo : Deepa Kurup
Rajeshri (35), a resident of DJ Halli, has five children. Shivaranjini (5) weighs 9 kilograms and is severely and acutely malnourished. The family does not have a BPL card nor access to any state welfare. Photo : Deepa Kurup
14-month-old Khadeeja Kubra barely touches four kilograms on the scale. Her mother Yasmin (22), who is pregnant, says she barely leaves her house. As a result, her child doesn’t get the rations provided at the anganwadi. Khadeeja hasn’t turned over, sat up or crawled. Photo : Deepa Kurup
Seema (25) has four girl children of which two have been identified as severely and acutely malnourished. The family has not been given a BPL card, and allege they’ve often been denied treatment at DJ Halli’s Primary Health Centre. Photo : Deepa Kurup
Salma, a resident of DJ Halli has collected 250 signatures for a petition that appeals to the government to start new anganwadis in their locality. She says the existing ones are already over crowded. Photo : Deepa Kurup
Khamar Taj (35) is now homeless. She alleges the DJ Halli PHC did not diagnose her child’s medical condition, which complicated her case forcing her to spend as much as Rs. 80,000 over six months to treat her for TB and serious stomach ulcers. She took loans from microfinance institutions, repaying which made this sales worker at a garment shop go broke. Photo : Deepa Kurup
Salma’s children Yasin and Sufian are both malnourished and suffer from severe mental retardation. A resident of DJ Halli, she’s been running from pillar to post for a BPL card and disability pensions. Photo : Deepa Kurup
Murugamma, the mother of six-year-old Meghala, with her elder daughter in their dwelling at Devarjeevanahalli in Bangalore on July 18, 2013 after her child afflicted with malnutrition and further to related disabilities, passed away on the July 17, 2013 of severe pneumonia. Visually-impaired mother Murguma and her older daughter Ruth in their broken roof house, showing the portrait of her dead child. Photo: K. Gopinathan
Living conditions in two wards that comprise DJ Halli in East Bangalore are testament to the city’s skewed development
The public and political discourse around the death of a five-year-oldmalnourished child in July last year had appeared to, at last, shine the spotlight on the dark and poor living conditions in Devarjeevanahalli, a densely-populated low-income pocket of east Bangalore that is stark testament to the IT Capital’s skewed development story.
But, five months later, not only is change elusive but also appears entirely off the radar. Since Meghala’s death two more deaths have been recorded here among children identified as ‘severely and acutely malnourished’ (SAM) — Tharun (4) in October and Jennifer (6) in December — apart from one more who died in an accident. The two children died even as their families, government health ‘link’ workers testify, struggled to access health care and lived entirely outside the State’s welfare net.
This despite the fact that promises were made, on paper and by the government in the State legislature, that all children identified as SAM would be at least given a BPL (below poverty line) card to enable them to access subsidised fuel and rations, under the Congress governments’ flagship ‘Anna Bhagya’ scheme where poor families are entitled to 30 kg of rice at Rs. 1 a kg every month.
Both Tharun and Jennifer were mentally-challenged, however, neither received a disability pension (an allowance of Rs. 1,200/600 given depending on extent of disability) nor did their families have BPL cards. Records with PHC workers show that despite being very sick both families had no help from the state healthcare system, apart from being repeatedly referred by the local Primary Health Centre (PHC) to NIMHANS and another government facility. But, as Asha, the health department worker who visited them says, the families were in no position to afford the hefty auto rickshaw fares to travel frequently to these hospitals.
All Tharun, Jennifer and Meghala — like scores of SAM children in the area — got from the State was a small portion of weekly ration, four eggs and two glasses of milk from the anganwadi. These deaths indicate that Meghala’s death, which unlike the others received media attention, was no case in isolation. Like her mother Murugamma (37) — who has since received an AAY card and became eligible for disability pension 30 whole years after a fever claimed her eyesight — thousands of working poor here live with no access to a majority of state benefits/welfare schemes.
Below district average
In fact, at last count, government records show that 77 children have been identified as SAM here, out of which at least 50 households do not have BPL cards. These households are thus unable to access their entitlements in food, fuel or healthcare subsidies. The two wards — DJ Halli and Muneswaranagar — with a population of 77,707 have 2,610 children below the age of six. In all, Bangalore Urban district has 1,550 ‘severely underweight’ accounting for 1.4 per cent of children under 6, and 18,339 falling under the ‘moderately underweight’ category. Given that according to records the percentage of SAM children in the DJ Halli area stands at 2.95 per cent, well above the district average, officials concede that this is a “problem area with conditions worse than elsewhere”. However, the BBMP Health official concedes that most “special measures” have failed to reach the needy and have so far remained on paper.
Take for instance, 35-year-old Rajeshri, a single mother of four boys and two girls, living in a cramped one-room tenement in Srinivasapura. Her youngest Shivaranjani has been identified as SAM – at five years, she is a mere 9 kilograms, too short for her age and lags several developmental milestones, her anganwadi in-charge says. Though Rajeshri has applied repeatedly for a BPL card, she has been turned away for not having proper residence proof.
Rajeshri works four times a week as a cleaner with an event caterer and is paid Rs. 100 for 8 hours of “back-breaking work”. She barely manages to pay rent – her landlord won’t give her stamped residence proof unless she pays a hefty advance. When asked how she makes ends meet, she replies: “It sounds horrible when I say it, but we eat once a day. I ensure the children go to school/anganwadi so they at least get lunch there.” She says she dreads weekends and holidays as she can’t afford to feed them two full meals, but off-late her 14 and 13 year-old sons have started finding odd jobs, which help supplement income. No government official has ever visited her or offered any support, three years after her youngest was identified as SAM; instead, she’s been spurned away at each stage. “Anyone can see that I’m barely getting by; yet they keep asking me for all sorts of documents to prove my poverty,” she says.
In Shivaranjani’s locality Srinivaspura, a majority of the SAM children do not have BPL cards. Also enrolled in her anganwadi is Bibi Khadeeja (1.8 years and all of 6.3 kgs). While her visually challenged father sells pens on the footpath nearby, her mother, who suffers from mental illness, stays at home. Neither parents get disability pensions. Khadeeja’s 55-year-old grandmother, who works as domestic help to run her daughter’s family, says their application was rejected last year, when the government, in an attempt to crack down on bogus cards was ‘weeding out’ hundreds of beneficiaries across the State. “When they were cutting everyone’s name from the list, we got the message that there’s no point applying,” her grandmother says. Their BPL applications has been pending for a few years now.
Many testify to having paid bribes to get the much-coveted BPL card. Fresh applications for BPL cards have been in a limbo, with one round of card allotments having been cancelled. Though not complicated, the applicant requires an ‘introducer’, a ration card holder in the same area. This, residents say complicates matters as it’s tough to find someone to forego a day’s work to come along, and in the absence of which touts charge between Rs. 500-1,000 for the service. Last month, this provision has been scrapped for Above Poverty Line cards, but continues for BPL.
Seema (25), a resident of Eidgah Mohallah who automatically qualifies for a BPL card given two of her four girls – Firdaus (3) and Fazleen (1.5) – are identified as SAM, paid Rs. 300 as bribe for an identity card and Rs. 150 for an application twice this year. A BPL card won’t just get her ration but is also requisite for other benefits such as the Bhagyalakshmi Bond for girl children and fee waivers for diagnostics and medicines at state-run hospitals.
In the absence of access to any of these, Seema’s family is in huge debt, which she primarily attributes to huge and frequent health expenditure.
Cut off from most formal systems of credit, she and her husband Omar, a daily wageworker at a fruits stall, borrowed heavily from private moneylenders and group-based microcredit from two micro finance institutions, the latter at a cutthroat interest rate of over 35 per cent. Her equated monthly installments total Rs. 4,200; defaulting isn’t an option as group members will “raise hell” and the collection agent will turn up at her doorstep. Now, to help repay these, she spends her mornings – when three of her children are at anganwadi/school – peeling garlic for a meager wage of Rs. 15 a kg of cleaned garlic.
But why did she take such huge loans? Her husband’s daily wage of Rs. 150 barely pays the rent and food bill, and things went out of hand when her fourth pregnancy incurred a huge expenditure last year, and her new-born suffered from neonatal jaundice. Pointing to the poor sanitation and open drains nearby, she says that her younger two take ill frequently. In what she says is a “good month”, their health expenses remain around Rs. 1,000.
Out-of-pocket health expenditure
Ideally, Seema’s delivery expenses, pre and postnatal care should have all been met by the State under the Janani Suraksha Yojana or the newer Janani Shishu Suraksha Karyakram. The government also runs several schemes – primarily under the Integrated Child Development Scheme (ICDS) – that support and monitor women during pregnancies, provide free antenatal care and delivery, early nutrition and healthcare support to new-born and mother, and monitors and manages nutrition levels and education needs of children till the age of six.
But Seema’s experience reveals that these services – accessed through the anganwadis and the PHC – are not always a given. For instance, at the Court-mandated BBMP Health Camps, her SAM child Firdous was prescribed several tonics for which the anganwadi promised reimbursements, but later the medical officer refused. Seema points out that the PHC does not even have a pediatrician, and more often than not medicines are out of stock.
During her previous two deliveries, the PHC frequently referred her to a private hospital; she was not told that scans and tests are free at State hospitals. She was prescribed blood tests to monitor her pre and post-pregnancy anemia, scans and post-delivery injections, all of which she was asked to purchase from outside. Her husband Omar points to the stack of bills and says that he paid for every thing, barring one bottle of glucose. “The government has a thai (mother) card and link workers come asking after our health; but of what use is all the so-called monitoring if they cannot even do a blood test for me at the PHC,” she asks.
These case studies are in line with the dismal findings of the last government health survey, the National Family Health Survey-3 (2005-6), and indicate that little has changed on the ground since. The NFHS-3 found that in Karnataka the percentage of children under 6 who have received any service, supplementary food, immunization or are monitored during health checkups in urban areas is a third of that in rural areas, where anganwadis are able to cover over 45 per cent of the population. Further, 86.8 per cent mothers received no services or monitoring during and after the pregnancy from anganwadis (59.2 in rural Karnataka).
The primary reason for poor implementation of these schemes is that both the PHC and anganwadis lack basic infrastructure and face severe funds crunch. According to the Supreme Court, the government must provide one anganwadi per 800-1,000 population (one per 300 in tribal areas), and one for every 30 children under six. DJ Halli is found lacking grievously on both parameters – there are 17 (23 on record, but six are functioning in the same location) anganwadis here for a population of 77,707. And, given the under-six population is 2,610 the area must have 87 anganwadis. Following Meghala’s death, the BBMP promised 40 more anganwadis, however, these are yet to open.
That little attention is being paid to developing the infrastructure is evident in the “knee-jerk manner” in which authorities have asked anganwadi teachers to identify rooms for new anganwadis “almost overnight”, says Sylvia Karpagam, doctor and member of Jana Arogya Andolana, a community health initiative which recently conducted a public hearing here. She says that official numbers on nutrition levels are at great variance with the situation on the ground; for instance, in Janibai colony area in DJ Halli she says that the anganwadi had a few children listed as malnourished but a survey along one stretch of road found the number closer to 20.
A majority of existing anganwadis visited by The Hindu was run out of cramped one-room spaces, many without toilets, clean drinking water or adequate seating area for children. Most did not have separate cooking areas. The anganwadi in Srinivaspura for instance, where 44 children are enrolled, is housed in a rented space no larger than a tiny provision store, where the lunch meal is cooked in the same space, dangerously close to where all the children sit on a mat. To “teach” or address the children, the teacher must either sit with them, taking a few on her lap, or stand outside on the steps. The helper admits that they prefer the children are only brought here for the meals because all 44 children cannot be accommodated here at the same time. Further, anganwadi workers who work from 9 a.m. to 4 p.m. are poorly paid – while the teacher takes home Rs. 5,000 a month, the helper or assistant gets Rs. 2,500.
In 2012, a High Court-appointed committee headed by Justice N.K. Patil found that in Bangalore Urban 97 per cent anganwadis were running out of rented buildings, 66 per cent did not have water facility and a vast majority did not have toilets. The committee’s recommendations, submitted to the High Court October 2012, are yet to be implemented by the government.
The situation is no different at the PHC here, popularly known as Maidan Hospital, where the maternity wing has 17 beds and a total of four nurses – two temporary and two permanent – and one doctor attend to at least 40 out-patients a day and perform at least 70 deliveries a month.
The monthly budget for medicines is Rs. 30,000, out of which Rs. 10,000 is allocated to purchasing anti-rabies vaccine as they attend to around 100 cases of dog bites every month. The stocks, staff nurses say, get over in 20 days, after which they are forced to ask patients to purchase medicines for themselves. A senior staff nurse here says that since there is only one doctor who leaves at 4 p.m., they have no option but to refer complicated delivery cases to other hospitals. Given this densely populated slum settlement is also among the poorest in terms of clean water supply and sanitation, and therefore disease prone, one PHC for a population of 77,707 is inadequate.
That government facilities are unable to cater to the basic healthcare needs of people in the area is reflected in poverty and mounting debt burden among the low-income groups here. Almost all the people interviewed said that a significant portion of their family’s earnings was spent on healthcare, and a majority of them did not depend on state-run facilities.
Debts, mostly micro
Indeed, the lack of functional primary health care often compounds the problem. This is best exemplified in the case of Kamar Taj, whose debts to three MFIs rendered her homeless last month. As of last week, after living on the streets for a month, she raised advance payment for a new room by joining another MFI group. She got the fresh loan after social workers here stood guarantee, but has since taken on an additional job after the eight hours she works at a garment store in Govindpur.
She was chased out of her home after her neighbours turned against her as she failed to pay the EMI for her MFI group loan for two months. “They would come and shout at me every day (because they had to pay my portion) and a month later, the man representing the company came home. I was forced to pay that installment, but couldn’t make rent,” says Kamar, who has four children.
Kamar started borrowing heavily last year when her five-year-old Mehak had to be hospitalised. She alleges that when she first developed a fever, cough and tummy ache, the PHC doctor only prescribed deworming pills and paracetamol. Three months later, a private hospital recommended an abdomen scan to find that “a knot and ulcers” were formed in her stomach, and she had early stages of TB. Both the PHC and the government hospital had missed this, and subsequent treatment and hospitalization cost her over Rs. 40,000. She also incurred huge health expenses when her two sons got dengue, and later her husband had to undergo treatment for kidney stones. During her hour of need, neither the PHC nor the government hospitals were able to help Kamar and her family; without a BPL card, she had no access to medical subsidies.
Six months on, Kamar and her husband now work double shifts to repay her monthly MFI group loans, they’ve sold her mother’s ornaments to repay the local moneylender and struggle to keep their two younger children in school. Her younger child, aged 5, dropped from 20 to 12 kgs as a result of her illness, but her nutrition needs are not top priority for Kamar, neither is this being monitored by the State. And what if someone in the family falls ill now? “We simply can’t afford it,” she says.