A Healthy Meal
This is an article by Ashwin Parulkar a researcher at the centre for equity studies a New Delhi think tank that is researching starvation deaths and advocating food policy reform and was published in the Wall Street Journal. Gaya District is our area of work but this village is not in the areas our health team covers otherwise this would not have happened.For all you read about the economic miracle in Bihar , on the ground believe us, not much has changed.
BANWARA, India Gaya District In the fall of 2006, Gita Devi was pregnant with her sixth child when her family fell on hard times. A severe drought made it more difficult than ever to find farm work here in India's northeastern plains. The family couldn't afford food. It was unable to get a government ration card to buy grains and rice at steep discounts, even though it clearly was poor enough to qualify. Eventually, Ms. Devi and her children were going without any food for days at a time. The 42-year-old grew too weak to walk or talk. On Sept. 26, 2006, she delivered a baby girl, Muniya. Villagers recall Ms. Devi losing weight rapidly and say they couldn't help because they didn't have sufficient food either. Her husband, Tulsi Manjhi, recalls laying silently next to her on a khattiya, a cot made of bamboo and coconut fiber. The hours passed. "I was hungry too but she couldn't even get up," Mr. Manjhi recalled. "I tried to feed her jinghi (leaves from trees) once." On Oct. 4, eight days after giving birth, Ms. Devi died. An activist who advises India's Supreme Court on food security issues deemed Gita Devi's a starvation death. I traveled to Banwara, a village in Bihar state, to investigate the matter in September and November 2011 with my colleague Ankita Aggarwal from the Centre for Equity Studies, a New Delhi think tank. It is part of a broad study we are conducting of government responses to starvation deaths as India debates sweeping reforms to its food policies. We wound up uncovering a tragedy even more heartbreaking than we anticipated. Ms. Devi's family is part of the Bhuyia community, a low-caste group that historically was socially and economically marginalized from society. They weren't allowed to intermarry with other castes, were segregated in their own villages and were barred from many work and educational opportunities. Such discrimination is still prevalent today, even though it is illegal under India's Constitution. These days, the Bhuyias are recognized by Bihar's government as among the poorest people in the state. One of Ms. Devi's sons, Vilas, reluctantly opened up to us about his family's story and the horror of his mother's death. The 28-year-old quit school after the fourth grade to help support the family. With a small build, clenched-jaw and vacant eyes, he has the look of a young man who has already withstood too much. In the months leading up to his mother's death, Vilas helped his father, Tulsi Manjhi, on the few farm jobs they could find. They typically earned a daily wage of three kilograms of rice. They would sell a share of it at a local market to buy other items, but could never afford dal (lentils) or atta (flour). Family meals consisted of a small ration of rice and salt. Sometimes, they'd make a dish out of local flora, mixing ninua (a local, wild spinach), jinghi (tree leaves), and mungha, a green sickle-shaped fruit that grows on the trees outside their hut, distinguishing it amid rows of dry fields. Aside from farm labor, Tulsi found some work building houses in neighboring villages throughout June and July, during the monsoon rains, but it was never enough for the family to survive on. In the month leading up to Ms. Devi's death, Vilas and Tulsi couldn't find any work at all. In her final days in October, Ms. Devi complained of chest pain and was losing weight rapidly. Family members gave her water from a grimy well near their house that was full of frogs and flies. Ms. Devi had barely any energy to tend to her newborn. Vilas's story then veered off in a direction that caught us off guard. "My own wife had also given birth to a girl at that time," Vilas said. "While your mother was dying?" I asked. "My mother died in the morning after drinking water," he said. "The same night, my daughter passed away. The next morning, my wife also died of starvation," he added, straight-faced. In my notebook I wrote: "HIS WIFE AND CHILD DIED TOO???" It was too much information to process. Did he really just tell us that three people - two adults and one baby - died in the same family in a 24-hour span? It turned out we were investigating a family catastrophe. Phool Kumari was Vilas's wife. The food shortage compromised her pregnancy as it had Ms. Devi's. Ms. Kumari lost large amounts of blood during childbirth and since she had no food, she was unable to feed her day-old, unnamed daughter, who died the day she was born, Vilas recounted. Despite our attempts, we weren't able to ascertain the official cause of death of the child. Local newspapers reported at the time that local officials concluded the infant died because her mother was too sick to breastfeed. Vilas wasn't done with the surprises. "Now my second wife is ill," he said. "And we don't have enough food to give her." "Where is she?" I asked. "At home," he said. "Can we see her?"
Vilas's second wife, Sunita Devi, lay outside their mud-walled house on a khattiya. Waist down, she was covered by a woolen blanket. She wore a red sari. Flies buzzed about her face. Her eyes were liquid. The pupils darted back and forth, but the tears didn't drop. They pooled around the rims. Her mouth stayed open so that her teeth showed. She was moaning. She was bloated at the belly and cheeks but the flesh on her arms had withered to a tight, dry, wrinkled sheet of skin outlining her bones. Every now and then she would rest the back of her hand on her forehead and make a gagging sound. She was trying to breathe. Though she was 24 years old, her swollen face made her look like a child, confused and sad. My God, I thought. It's not clear when Sunita Devi first fell ill, but in August 2011 her condition deteriorated quickly. She went to get checked up at Magadh Medical College in Gaya, the largest city in a district with the same name, about an hour's bus ride from Banwara. An ultrasound revealed an abscess of the liver - a thick, liquefied material filled with blood and micro-organisms that is caused by infection and can result in organ failure. Sunita's parents stayed with her in the hospital as she underwent treatment during an approximately two week stay in late August and early September. Doctors gave her antibiotics, vitamins, and medicines for fungal skin disease, worms, and bronchitis. Tulsi Manjhi says the family paid for its medical expenses by taking out a loan of 15,000 rupees (about $300) from Sanjay Singh, a local sub-contractor who rounds up laborers from Banwara and other neighboring villages to work in brick kilns. Vilas and his three younger brothers, Umesh, Arjun and Sarjun, worked alongside their father Tulsi in the brick kilns to pay off the loans. Vilas and Tulsi told us the doctors discharged Sunita Devi in early September even though she was still ill, because they did not have necessary medicines. They said the doctors told them to seek additional treatment elsewhere, but they didn't have the money. "Bhaiya," Vilas said, addressing me as "brother" in Hindi. "We don't know what to do." According to hospital records, Dr. Rahul Kumar, the physician that supervised Sunita Devi's case, indicated that the family requested her discharge before she was healthy enough to leave. I called Dr. Kumar to confirm that, but he declined to comment. Tulsi Manjhi denies that the family urged her release. "No, no. Why would we ask her to be discharged?" he said. We stood silently with Sunita for ten minutes. Her eyes kept darting back and forth, her mouth open in pain. "Is it okay to talk to her?" I asked. Vilas nodded. A group of curious young men from the village formed a circle just behind us. I got on my knees, dropped my notebook in the dirt, and took her hand in mine. It was cold and dry, her fingers searching my palm, my wrist. Vilas stood nearby, one hand on his hip, looking down. "What do you feed her?" I asked him. "We can only give her this much rice, once in the morning," he said, cupping his empty hand. She started to cry. She was saying something but I couldn't make out what. I put my free hand on her shoulder, then atop her head. "Are you in pain?" I asked. She nodded. She started to cry large tears. "I'm hungry," she said. "Please give me something to eat." I looked up at Vilas. He was broken. I was lost. "When we come back tomorrow," I said, "we'll bring food."
India's Supreme Court has ruled that states have a legal responsibility to ensure their people have adequate food. As part of a wide-ranging public interest litigation known as the "right to food" case, the Court in 2002 said that starvation deaths should serve as evidence that something is gravely wrong in the government's food and welfare programs. The state has a duty to address those problems immediately, the Court said, not only to prevent future tragedies but to identify people who are living with chronic hunger and ensure they get the benefits they're entitled to. In Gaya district, where Banwara is located, it was clear the government's safety net had some gaping holes in it. Many benefits the Court says should be guaranteed aren't being provided. Schools are mandated to provide mid-day meals for children, but many still don't. The Integrated Child Development Service, which is supposed to offer supplemental nutrition and care for pregnant women, lactating mothers, and children under the age of six, was closed on a recent visit. Most glaringly, the "public distribution system" - which provides subsidized grains to the poor - was defunct. When the government provided food ration cards to impoverished families in the area in 2002, the landless, share-cropping family of Gita Devi and Tulsi Manjhi surely should have qualified. A "below poverty line" card would have allowed them to buy 35 kilograms of grain per month at half the market price. Indeed, they probably should have qualified for the national Antyodaya Anna Yojana program, which is meant for the poorest of the poor and ensures the same amount of grains at even lower prices. But they didn't receive a ration card and were shut out of those discounts. Despite our efforts, we weren't able to get a clear explanation from local officials of why the family was overlooked. According to official estimates from a 2004-2005 national survey, half of Indian households who should be eligible for such benefits don't receive them. In Bihar that figure is 80%. The office of Bihar Chief Minister Nitish Kumar did not respond to calls and faxes seeking comment for this article. Local officials in Gaya district acknowledged that Gita Devi's family and others had no access to many basic government programs. But they said that doesn't mean Ms. Devi, her daughter-in-law, and the newborn, died of conditions stemming from hunger. Officials said Phool Kumari died due to complications of childbirth. Gita Devi, they said, died from tuberculosis. That struck me as particularly odd, since no medical official had ever diagnosed Ms. Devi with the disease. But it made for a convenient explanation: the disease is rampant in the area. In Banwara alone, about 12 people had it when I was visiting. The Hindi newspaper Dainik Jagran covered Gita Devi's story in the days after her death. The stories detailed the failings of government programs and the destitution of Banwara's low-caste Bhuiya community, of which her family is part. News reports put pressure on government officials to visit the family. Ravi Bhusan, the block-level development officer - a bureaucrat that oversees welfare programs across several villages - gave Tulsi Manjhi 15 kilograms of rice and a check for 10,000 rupees ($200). But according to newspaper reports in Dainik Jagran and my interviews with block officials and journalists, local officials did not investigate whether social welfare programs are working properly, as the Supreme Court's orders in the right to food case say they should do following a starvation death. Ashok Singh, the elected president of the local village council, visited the family two days after the deaths and offered the family 10,000 rupees, 10 kilograms of flour, and 20 kilograms of rice. Mr. Manjhi says the aid was on the condition that he testify that Gita Devi had died of tuberculosis by giving his thumb impression on an official document. (When I later called Mr. Singh and asked for comment on this claim, he hung up the receiver.) Mr. Manjhi told me he complied with that demand and received the money and food, but he says he still believes his wife died from hunger. No postmortem was conducted on any of the bodies since the family had buried Gita Devi, Phool Kumari, and her infant daughter by the time local officials arrived. In 2007, the government did eventually distribute ration cards to Tulsi Manjhi and other households in Banwara. But that didn't resolve the problems the community faced. Many destitute families didn't get the Antyodaya Anna Yojana cards offering the biggest discounts, as they probably should have. Ration shops in the area still only function for six to eight months per year, residents say, and cardholders often don't get their full quota of grains.
The morning after we met Sunita Devi and saw her struggling, we went to meet Ashok Singh, the village council leader. About 10 men sat silently around him on the patio outside his home. He was wearing an undershirt and shorts. It was a two story, fully furnished bungalow with a new coat of white paint. There was a tractor in the yard. We presented the facts we had gathered about Ms. Devi, Phool Kumari and the newborn - how there was no food in the house for days, no access to subsidized grains, no work available. "Gita Devi," he said between a gulp of tea and a bite of biscuit, "died of tuberculosis." "These people are poor," he explained. "They drink. So they have health problems. They get sick. And die." We started to ask him about the conditions that made the three victims and others in the area unable to access Court-mandated government entitlements. Mid-question, he got up, walked inside his house, walked back, and placed a piece of paper in our hands. "See," he said. "These people are poor. They get sick. And die." We looked down at the paper. "Sunita Devi?" we said. "We just saw her last night." "She died this morning," he said, "just before you came here." In our hands was a death notice.
Sunita Devi was under the woolen blanket now. They were going to bury her soon. We placed bags of grain in the middle of a ring of people. Vilas walked up to us slowly with one hand on his hip. "I am in a lot of pain," Vilas said. I thought, "What if my soul was born in his body?" I imagined lunging for him, hugging him. But I just stood there, watching him condemned. Starvation is a brutal but little-discussed reality in India. The Wall Street Journal's India Real Time is publishing a six-part series on starvation, showcasing the findings of an investigation by the Centre for Equity Studies, a New Delhi think tank that is researching hunger and advocating reforms of India's food policies. The series of essays documents the stories of starvation victims, explores the primary causes of their deaths, and argues fiercely that India must overhaul its broken food security system.