In measles hotspots, hunger, an older malaise, is hastening fatalities

Mumbai: Just when we had stopped obsessing about daily Covid caseload, there is a new cause for worry. Measles, that common outbreak which routinely afflicts schoolkids, has turned deadly. 12 infants below the age of 5 have died in the Mumbai Metropolitan Area in the last 3 weeks.

On Friday, the Navi Mumbai Municipal Corporation identified 4 measles-affected areas while a newly formed state task force grapples with vaccine hesitancy in large pockets. But in the worst-affected areas, it is hunger, that older malaise which is hastening measles fatalities. Death analysis of the children who succumbed to the viral infection indicates that malnourishment in combination with the children not being vaccinated is having fatal consequences.

These indicators, and their presence in the slums of M east ward is not new though. In 2010, sixteen children in the rag pickers’ community in Shivaji Nagar had died of malnutrition related illnesses. A 2012 study conducted by Dr Saiprasad Bhavsar, then a junior resident at the Topiwala National Medical College and BYL Nair Charitable Hosptial in Rafiq Nagar, also speaks about the widespread malnutrition and the low immunisation rate in the locality. According to the findings of this study, 116 (59.8%) of the 194 children who participated were malnourished and only 90 (46.4%) were completely immunised.

The newly-appointed state-level measles task force also acknowledges the problem. Dr Subhash Salunke, former Director of Health Services for Maharashtra who heads the task force said, “Malnourished and not being vaccinated can land a child into serious trouble in terms of measles. A child with no access to good nutrition has to be hospitalised if they develop complications due to grade 4 malnutrition.”

Senior pediatrician and former vice-chancellor of Maharashtra University of Health Sciences (MUHS), Dr Mrudula Phadke, who has done several researches on nutrition said the pandemic has left a deep impact on the health and nutrition levels of vulnerable communities. “Job losses and insufficient savings in these families have led to nutritional deficiencies,” she said.

She also referred to the National Family health Survey 5 conducted in 2019-2020, according to which the percentage of urban children in Maharashtra with stunted growth (height of a kid being low for its age) and wasted growth (child being underweight for its height) is very high. While 35% of urban children under 5 years of age were found to have stunted growth, 23% of them had wasted growth. “Covid would have significantly increased the proportion of malnourished children, especially in the vulnerable communities. Even children whose growth factors may look normal can still be suffering from what is called as hidden hunger which is the deficiency of micronutrients like iron, vitamin D,” she said.

Talking about why the infection has led to so many deaths, Dr Phadke said that combination of not being vaccinated and malnutrition makes the kids more susceptible to infections as they become immunologically weak. “Even a well-nourished child stops eating for over a week due to measles. A malnourished child can go into severe acute malnutrition. As such malnutrition is a complication of measles. No wonder than that the disease affects malnourished children more severely,” she said calling it a vicious cycle.

Her fears are corroborated by a 2021 study conducted by NGO Apnalaya that works in the M-East ward. As per the survey of 433 families, only 17 per cent ate one or two meals a day. The rest couldn’t manage one meal a day.

In its report, the NGO also analysed daily expenditure on water for families who reported either food insecurities or unavailability of food. It found that over 40% of families who face food insecurities spend over ₹50 per day on drinking water and 17.2% pay ₹100 or more. Their report said that this additional expenditure places a significant pressure on families who are already struggling with food insecurity.

“Malnutrition and vaccination are interconnected and needs special attention. The living conditions of these people needs to be seen in totality,” said Praveen Singh, CEO of Apnalaya.

Besides malnutrition, the ward faces several difficulties including lack of access to good and affordable healthcare services. Razia Khatun, who stays in one of the bylanes of Rafi Nagar took her two and half year-old son to Rajawadi Hospital last week after he developed symptoms of measles - redness of eyes and boils. She soon returned home with her sick child without having met a doctor. She had to eventually seek a private practitioner even though it entailed buying medicines worth ₹500.

“I have three children and my husband is a daily wage earner. I can’t leave my daughters aged 3 and 5 all alone at home,” she said. Razia agreed that she did not vaccinate the son as he was born in the village during the lockdown. While the scabs are coming off, Razia’s concern is the wheezing cough her son now has. “I had asked for medicines for the cough at Rajawadi Hospital, for which they asked me to go to Kastruba Hospital,” she said.

In the lane next to hers Sehrunisa Khan whose two children - a five-month-old daughter and a three-year-old son - recovered from measles recently said they initially took their daughter to Rajawadi Hospital but returned home when they were referred to Kasturba Hospital instead. “I have four other children at home to care for. It was impossible to take my daughter to Kasturba Hospital, which is 16 kilometers away,” she said. Sehrunisa said a good government facility closer to home would help solve most of their health woes.

“The nearest health post is more than 2 km away. Often, it’s not stocked with medicines. We are referred to Rajawadi Hospital in Ghatkopar. It just means running from one hospital to another. Going to a private practitioner seems easy even if it is not affordable for us,” she said. The monthly income of her family of 6 is less than ₹7000.

The Apnalaya report also found a majority of the respondents saying it takes them 30-60 minutes to travel to the nearest government hospital. It also said that only 20% respondents had access to primary health clinic or health post. In fact, 50% respondents paid more than ₹5,000 per year on treating chronic illnesses while 37% paid more than ₹10,000 per year for the same.

It is not just the inadequacy of health posts that created this health crisis in M east ward, according to Professor Amita Bhide from Tata Institute of Social Sciences (TISS). The problem, she said, is exacerbated by the number of vacant positions in these health posts which puts extra pressure on the existing outreach staff. “Primary health system is also not oriented to the needs of migrant families, nor does it provide a full range of services from prevention to treatment, diagnostics and awareness,” she said. These lead to the several gaps which then surface when there are disease outbreaks.