Nepal’s epidemic of hunger

Malnutrition among Nepali children pre-dates Covid-19, but the pandemic has made it worse


There are 34 households in Mohattarai’s Anaita neighbourhood, most of them have at least four children eachIn the last three years, three children in the community have died due to complications from the lack of food.

Raju Devi Sada first lost her three-year-old daughter, already weakened by malnutrition, who died a week after she caught pneumonia and diarrhoea.

“We spent quite a bit of money for her treatment in hospital, but we couldn’t save her,” says Raju Devi, wiping a tear with the hem of her sari. A year later, she gave birth to another daughter. But she died soon after being born.

“I don’t even know why she died,” says Raju Devi, who is now raising her third daughter.

The little girl is underweight and local health workers have recommended nutritious food. But Raju Devi cannot afford the vegetables, eggs, milk and meat, and what she earns as a daily wage labourer is barely enough to feed the rest of the family.

“What we make is not sufficient to pay for food, let alone medicines,” adds Raju Devi, looking at her youngest girl, who reminds her so much of the other two daughters who did not make it. “A mother never forgets her children, even if they are dead.”

Hunger has always stalked the land here in the backwaters of the eastern plains of Nepal. State neglect, inequality and injustice have unleashed a vicious cycle where families are too poor to eat enough, which makes them sick, and having to spend on medical treatment drives them deeper into poverty and that means they can afford less food.

The first and second waves of the Covid-19 pandemic arrived in these districts bordering India before it spread across Nepal. Four months of lockdown in 2020, and two months so far this year have meant that subsistence farmers like Raju Devi’s family have lost what little they could earn to buy extra food for the children.

At the nearby Manorasisuwa neighbourhood, Sagar Devi Sada spends her day caring for her grandchildren, both of them visibly malnourished. Her eldest grandson is four-and-half years old and is so weak he cannot even stand on his feet. He has poor eyesight and is mute, but the family can afford neither more food nor treatment.

A few weeks ago, a community health worker gave Sagar Devi some packets of the supplementary food, Balvita, but she has run out of those by now.

“We built this house, but we haven’t paid our loans, we don’t have money for anything else, it’s up to the gods now,” says Sagar Devi in a resigned voice. “Their father makes some money but doesn’t provide for them, and their mother abandoned them. If not for me, these boys would be dead.”

In Manorasisuwa alone, 17 children have so far been diagnosed with severe malnutrition. And this is just one neighbourhood of one village in Nepal -- a microcosm of what is happening across the country during this pandemic.

Even before this crisis, the lack of food was already the biggest cause of childhood illness and death, and parts of Nepal have rates of malnutrition that are highest in the world. Complications due to malnutrition cause more than half the childhood deaths in the country, according to a UNICEF report.

In addition to the risk of losing their lives, children with malnutrition have stunted physical and mental growth, are severely underweight, and their immune system is compromised.

Nepal’s hunger hotspots are these districts in Province 2, and Sudur Paschim Province in Nepal’s far-western mountains. The 2019 Nepal Multiple Indicator Cluster survey found that 41% of children in Sudur Paschim Province are short for their age, and 34% of children in Province 2 are similarly stunted. The survey showed that a third of Nepali children show signs of stunting due to lack of food, and 12% are wasted, and 24% low weight.

“We have found that up to 70% of children who die every year in Province 2 do so due to malnutrition, and the main reason for that is extreme poverty,” says Kedar Parajuli at Nepal’s Family Welfare Division. “Without alleviating poverty, we can’t solve malnutrition. And to do that these families need more land to farm, or a means of livelihood.”

But malnutrition is not just about food availability. Many children even from better off families suffer from poor nutrition because of chronic diarrhoea caused by contaminated water, poor sanitation and hygiene.

In October 2019, amidst much fanfare, Nepal was officially declared the first open defecation-free country in South Asia. But here in Ramdaiya village of Dhanusha district that is noticeably not true.

There are 150 households from the Musahar community in the village, and half of them malnourished children. None of them have a proper latrine, with villagers using nearby fields. The village pond is used for drinking, washing, bathing and cleaning utensils, as well as a buffalo wallow.

But Ramdaiya was declared open defecation-free two years ago after distributing toilet sets to all the wards. No latrines were built.

Sri Narayan Sada is daily wage labour, and has a family of seven but no land. His two-year-old son is scrawny, and has all the symptoms of severe malnutrition: frequent diarrhoea, swollen stomach and skeletal limbs. “I don’t know what’s wrong with my son, only the gods know,” he says.

Assistant health worker Aruna Yadav says the child is underweight and is mentally retarded. She says the father earns Rs500 a day but spends half of it on alcohol, the rest goes to buy food, but it is not enough for the whole family.

Poverty, hunger, patriarchy, caste and gender discrimination make a dangerous concoction in these villages. As a result, most girls are married before pubescence. By the time the severely undernourished girls are in their mid-teens, they have already given birth to their first child – making it risky for both mother and baby.

The young mothers have never been taught about taking care of their health, or that of their children. Most do not know the kind of diet and supplements that pregnant and lactating mothers need, and even if they did, cannot afford them.

The Nepal government is supposed to provide Rs400 per Dalit family as a ‘nutrition allowance’. But the families in Ramdaiya in Dhanusa and Monorasisuwa in Mahottari interviewed for this report had not got even that paltry amount for the past two years because they did not know how to work the system.

The government also implemented a Multi-sector Nutrition Plan to revive a successful program that saw dramatic strides in the last 20 years in raising family food intake the first two decades before the progress stalled. But the plan has got tangled up over jurisdiction under Nepal’s new federal structure.

If things were not serious enough, the Covid-19 pandemic has set back even the few inroads Nepal had made in tackling malnutrition. According to the Nepal Planning Commission, last year’s pandemic-induced lockdowns pushed 4% of Nepalis back below the poverty line.

A recent John Hopkins School of Public Health study concluded that severe malnutrition among children under five during the pandemic could kill up to 4,000 children a year in Nepal due to insufficient food caused by lost family income.

This is already visible at the community level. Nutrition Rehabilitation Centres across Nepal is seeing an alarming rise in severely malnourished cases, much higher than the yearly average.

“We recently admitted five cases of underweight children with very severe malnutrition, we rarely used to see such children,” says Karuna Yadav at a Nutrition Rehabilitation Centre in Janakpur. “And these are just cases that come to us, we have not even conducted camps or gone house-to-house yet.”

There are 21 centres like this one in Janakpur that treat severe malnutrition across Nepal, but they are not easily accessible to poorer families who usually live out of the way.

The UN’s Sustainable Development Goals (SDGs) require Nepal to reduce wasting to less than 5% by 2030. Stunting needs to be well below 15% in 10 years to meet the global target. Even the little progress Nepal has made in this regard is now jeopardised by the pandemic.

Says Kedarraj Parajuli of the Family Welfare Division. “Given inter-generational nature of malnutrition, we are focusing on what we call the 1,000 golden days after birth by promoting supplementary food and creating awareness.”

But it is easy to see that malnutrition is a structural problem that has deep political and socio-economic factors that are rooted in poor governance, corruption and ingrained cultural inequities. A piecemeal approach that just addresses nutrition, sanitation, environment and development must be replaced with more accountable national, provincial and local government. But given the chronic political instability and lack of political will, that is a tall order.

Says nutrition policy expert Atmaram Pandey: “Nepal doesn’t lack resources, but they are taken up by a faulty development model that wastes it all on viewtowers and unnecessary roads. Nepal’s chronic malnutrition can only be reduced with a more responsive state that generates jobs so the poorest have more money to buy food for their children.”