The Slums Of Ludhiana City (Panjab)A Case Study

A. Zachariah and Prema Zachariah

Table 1Immunlsation status of children under five years of age who wereentered into the study during the base-line period (n = 679)Immunisation status

ImmunisationAt entry intoFive months later (30/9/91)

the study N(%) N(%)

BeG

140(20.6) 144(21.2)DPT1

22(3.2) 100(14.7)DPT2

26(3.8) 73(10.8)DPT3

189(27.8) 335(49.3)OPV1

22(3.2) 98(14.4)OPV2

24(35) 72(10.6)OPV3

190(28.0) 336(49.5)Measles

84(12.4) 333(49.0)

Ludhiana in Panjab is a city with anapproximate population of 2 million. Thereare nearly 250 slums in the city with anestimated population of about 3lakhs. Ofthese, only half the slums come under thecategory "authorised" and therefore"identified and recognised" by theMunicipality. The rest are unauthorisedand do not figure in either municipal recordsor in the Registrar-General's surveyoperation. The latter are not entitled to9ven basic amenities such as potablewater, sanitation, electricity and basichealth services.

The Christian Medical College inLudhiana recently undertook a survey ofhealth/nutrition conditions in these slums

as part of its effort to involve its studentsin its teaching programme of re-orientationof its undergraduate medical curriculum,through regular contacts with the slumpopulation. In this article, some of thedata which emerged from the base-linestudy are briefly presented. This studywas supported by the Ministry of Health,Government of India, and was funded byUSAID.

There are 250 slums with an

approximate population of 2-3 lakhs inLudhiana. Of these, less than half are"identified", that is, they are recognisedby the municipal authorities who haveprovided basic amenities such as potablewater, sanitation, electricity and basichealth services.

Some important characteristics ofthe slum population under study need

mention. In a study period extending toabout five months, it was noted that thetotal population number changed frommonth to month because of the influx offresh members, on the one hand, anddeparture of older members, on the other.f\.1alesoutmrnbered females in a proportionof 2:1 and the distortion of the sex-ratio

was particularly pronounced in tbe young­adult age group.This was possiblybecauseyoung men come to the cities leavingtheir families and wives in their originalhomes. Most families were nuclear, beingcomposed of young members who hadcome intothe area leavingtheirdependentsbehind in the villages of their origin. Themean family size was four as against thenational average of 4.7.

What was particularly intriguingwas the low number of adolescents,especially girls between the ages of 10and 20 years (Figure 1). It appeared thatfamilies were reluctant to keep their younggirls in the "unpredictable" environmentof a slum. Most probably girls were madeto remain in their village till they weremarried. The majority were illiterate, withthe females, in particular, having very lowlevels of formal education. The literacyrate (adult over 18 years with more thanfive years at school) amqng females wasas low as six and among males37 percent.

Birth weight: The mean birthweightwas 2.8 kg. Nearly 21 percent of babieswere of low birth weight (less than 2.5

5

kg), this incidence being significantlyhigher in primigravida than in multigravida.

Immunlsation coverage: Theimmunisation status at the beginning ofthe study (base-line) is indicated in Table1.During the five months of the study,intensive efforts was made by the studyteam to encourage immunisation in theweekly polyclinics that had been speciallyset up as part of the study. As a result ofthis drive the coverage with respect to allimmunisation except BCG had improvedsignificantly (BCG immunisation coveragehad not improved presumably because oflack of the timely availabilityof the vaccine).What is, however, noteworthy is that evenwith the best efforts immunisation coveragewas less than 50 per cent of all eligiblechildren with respect to all types ofimmunisation.

Out-reach of health services:

Though regular periodic home visits wereundertaken as part of the studies, overone-third of children under five years couldnot be contacted, as the children were"not at home" at the time of visits by thehealth team. Possibly many of thesechildren were at their mothers' work site.

By the end of the study, despite

Figure 1Baseline population distribution by

age and sex

Age group (years)

50+ • Femaleso Males45-49

35-39

25-29

20-24

15-19

10-14

5-9

0-4

500 400 300 200 100 0 100 200 300 400 500

Number

Table 2Effect of accessibility on immunisation coverage

Children who

Children whowere accessible

were not accessibleImmunisation

as of 30/9/91as of 30/9/91

Percent immunised (%)(%)

BCG

23.215.2

OPT116.78.8

OPT213.62.3

OPT358.721.6

OPV116.38.8

OPV213.42.3

OPV358.921.6

Measles60.215.8

Table 4

Prevalence of malnutrition among infantsSeverity of

Agemalnutrition <6 MOS

>6 MOS

N(%) N(%)

None

33(50.0) 15(23.8)1 degree

20(303) 24(38.1)2 degree

7(10.6) 16(25.4)3 degree

6(91) 8(12.7)

Table 5

Prevalence of malnutrition by ageSeverity of

malnutritionAge

<1yr

1-2 yr2-3 yr3-4 yr4-5 yrN

(%)N(%)N(%)N(%)N(%)

None

48(37.2)18(18.6)19(24.4) 8(23.9)8(21.6)1degree 44

(34.1)35(36.1)28(35.9)10(38.0)10(27.0)2degree 23

(17.8)25(25.8)16(20.5)14(19.7)14(37.8)3degree 14

(10.9)19(19.6)15(19.2) 5(18.3)5(13.5)

Table 6Prevalence of malnutrition by sex

Severity of

Females MalesRelative riskmalnutrition

N(%)N(%)

None

38(18.3)72(35.1)0.52

1 degree

67(32.2)78(38.0)0.85

2 degree

59(28.4)33(16.1)1.76

3 degree

44(21.1)22(10.7)1.97

best efforts, only 75 per cent of the childrenoriginally registered at the start could becontacted. At the end of the study period,771 children who were not accessible and

who could not be contacted regularly duringthe study period were identified and theirimmunisation status recorded. The strikingdifference in immunisation coverage asbetween the children who were regularly"accessible" and those who could not becontacted is indicated in Table 2. These

data show that in spite of their closeproximity to health centres, a significantproportion of slum children do not getthe benefit of basic immunisationcoverage.

Nutrition status: The overall

prevalence of malnutrition in childrenless than five years of age is shown inTable 3. Only children who had had theirweights recorded within one month of

6

Table 3Overall prevalence of malnutrition*

Severity of

malnutritionN(%)

None

110(26.6)

1 degree

145(35.1)

2 degree

92(22.3)

3 degree

66(16.0)Total

413

• Degree of malnutrition using lAP standards:None: weight> 80 percent of 50th percentile HarvardStandard weight-far-ageFirst degree: weight between 70 percent and 80percent of 50th percentile Harvard Standard weight-for-ageSecond degree: weight between 60 percent and 70percent of 50th percentile Harvard Standard weight-for-ageThird degree: weight <60 percent of 50th percentile.Harvard Standard weight-far-age

the start of the study have been includedin the table. Itwiil be noted that nearly 40percent of the children were at "second"and "third" degrees of malnutrition. Thelevels of third degree malnutrition observedin the present study appeared to be higherthen those earlier reported forlow incomegroups in urban areas in the country byNational Nutritional Monitoring Bureau(NNMB).

In Tables 4 and 5, the prevalence ofmalnutrition in infancy and at differentages has been indicated. In Table 6, theprevalence of malnutrition in boys andgirls has been indicated. It is noteworthythat contrary to the data of the NNMBwherein no significant gender differencewith respect to childhood malnutrition isobvious, the data here show that girls are _worse affected than boys. It must be notedin this connection that the NNMB data do

not cover Panjab. It may be argued thatthe gender difference is most pronouncedin Panjab than in the slums covered bythe NNMB operations.

The prevalence of malnutrition wasleast in children less than one year of age,reflecting the protective effect of breast­feeding. When those less than one yearof age are further stratified, it can be seenthat significant malnutrition begins aftersix months of age, presumably reflectingthe usual weaning period (Table 4).

There were six under-five deaths

during the five months of the study. Allwere females, two neonatal, two post­neonatal infant and two toddler deaths.

The delivery of comprehensivehealthcare to slum dwellers presented problemswhich cannot be ignored sincethese peopleconstitute an ever-increasing proportion

NFl National Workshop On Combating Vitamin ADeficiency Through Dietary Improvement

Subadhra Seshadri

of India's population. In order to achievethe goal for which they migrated fromrural areas -- more income -- they areprepared to overlook all hardships and tolive in congested settlements of makeshifthuts Uhuggis). Health measures are oflow priority to the slum dwellers; they arefar too busy trying to make ends meet tobe able to attend clinics; home visitingevery eight to 10 weeks by health teamsfail to capture many of them since theyare out working. Missing contacts on twosuccesive visits could mean that the health

worker and the family do not meet forabout six months, thus there is often noopportunity for effective home-based healtheducation.

Most medical colleges have slums

"'-- ,·,t their doorstep; and these present aneasily accessible site for community­oriented medical education. The weeklyor fortnightly exposure of students to agroup of families over a period couldfacilitate contact and compliance. Thiswas demonstrated in the present study. Alarge majority of 3,503 contact attemptsto under-five children were made bystudents. Two-thirds of their attemptsresulted in actual contacts. However, nostudent visit to the slum was unprofitablesince all students met at least six of 10assigned families on a single visit. Thefrequency of contact resulted in increasingrapport with, and trust by, families whobegan to comply with the health measuresrecommended. This was most obvious in"short-term" activities such asimmunisation of under-fives and referral

"-...--0f the sick to the polyclinic. However, littleattitude change regarding the feeding oftoddlers, prevention of diarrhoea or theuse of oral rehydration fluids could beachieved in such a short time.

Dr. A. Zachariah is principal, and Dr. PremaZachariah is professor of Preventive Medicine at the

Christian Medical COllege, Ludhiana, Panjab.

Reference

1. Report on Urban Population. NationalNutrition Monitoring Bureau, National Institute of

Nutrition, Hyderabad, 1984.

We are grateful to UNICEFfor a rnatching grant towardsthe cost of this publication.

Vitamin A deficiency, in its milder forms,continues to be a major problem in India,although fortunately, there has been asteep decline in keratomalacia, the moreserious and crippling form of this nutri­tional deficiency. The massive dose vita­min A prophylaxis programme was intro­duced in India 20 years ago, purely as atemporary expedient to tide overthe prob­lem of nutritional blindness due to vitaminA deficiency. However, despite the sharpreduction in the prevalence of keratoma­lacia (not all of which was due to themassive dose programme), there is ap­parently a concerted attempt to perpetu­ate the synthetic vitamin A massive doseprogramme with its ramifications of de­pendence on external donors.

Few attempts have so far been madeto promote altemative (physiologic ratherthan pharmacologic) options based onindigenous, inexpensive resources. Thewide variety of B-carotene-richfoods (con­ventional and unconventional) availablewithin the country provides an obviouslogical means of combating vitamin A de­ficiency; serious attempts to promote theproduction and effective utilisation of theserich food resourcesare now urgently calledfor. Therefore, it is timely and appropriatethat the Nutrition Foundation of India,which has been consistently arguing infavour of technologies that are sustain­able in the long term with local resources,organised a national workshop on"Combating vitamin A deficiency throughdietary improvement".

The Workshop: The Workshop whichtook place at the India IntemationalCentre,New Delhi on January 9 and 10, 1992was unique in that it brought together, forthe first time, experts from different disci­plines such as home science, agriculturalsciences, food technology and nutritionas well as senior administrators belong­ing to different sectors in order to findpractical and feasible solutions to theproblem of vitamin A deficiency, withinthe framework of dietary improvement.Participants in the workshop were scien­tists with considerable experience withrespect to the problem of vitamin A defi­ciency, and production and consumption

7

of carotene-rich foods. They agreed thaiconcerted and co-operative efforts werEnow needed to achieve the elimination 01

vitamin A deficiency in the country througrthe optimal use of available food resources

The Workshop opened with introduc·tory remarks by Dr Gopalan who de·scribed it aptly as "an attempt to impart anew thrust and direction to programme~for combating vitamin A deficiency in thEcountry". The Workshop was supportecfinancially by UNICEF; the enthusiasticparticipation of senior officers of Indiaoffered promise that the recommenda­tions of the Workshop would be trans­lated into action. Itwas noteworthy that allimportant government agencies and na­tional institutes as well as international

organisation such as WHO were repre­sented at the Workshop. The ministries 01

health, agriculture and food were repre­sented by their senior technical execu­tives. The Central Technical Committee

of ICDS was represented by its Chair­man and his senior colleagues. Scien­tists from the Central Food TechnologiesResearch Institute , Mysore and theRegional Research Laboratory, Thiruva­nantapuram ( of the CSIR system) en­gaged in studies on carotene-rich foodsparticipated. Leading home science col­leges were active participants. A notablefeature was the participation of privateentrepreneurs and non-governmentalvoluntary agencies. The National Insti­tute of Nutrition, the leading nutrition re­search centre in the country, was repre­sented by its Director and four other seniorlevel scientists.

Dr. E. Watanabe, Chief of UNICEF,India Office, in her introductory remarksobserved that the them of the Workshopfitted very well with India's recognition ofthe resolution adopted at the 'GlobalSummit for Children' to virtually eliminatevitamin A deficiency by the turn of thecentury. She emphasised that colostrum­feeding and breast-feeding should bepromoted along with other measures andthat strategies for the elimination of vita­min A deficiency must pay particular at­tention to landless labourers in rural ar­

eas and the urban poor. The pivotal roleof Government of India and the Integrated

Child Development Services Scheme inimplementing these strategies was alsohighlighted by Dr. Watanabe.

Specific aspects discussed in suc­cessive sessions were:

• Production and consumption of greenleafy vegetables and fruits in the country:current status and proposed program­mes,• Content and bioavailability of carotenesfrom locally available foods (conventionaland unconventional): currently availabledata,• Studies on spirulina : prospects andproblems,• Carotene from red palm oil: currentstatus and future possibilities,• Field experience in the promotion ofproduction and consumption of carotene­rich foods at home and the communitylevel,• Technologies for preservation and stor­age of carotene-rich foods,• Incorporation of carotene-rich foodsand weaning dietaries: current depend­ence and possible approaches.

Each of these aspects was briefly in­troduced by a speaker and the discussionthat followed generated ideas with re­spect to future research and action. Theemphasis was on strategies that can beimplemented and on research which willpromote their implementation.

The technical session on "productionand consumption of B-earotene-rich vege­tables and fruits" focused on the mostrecent Indian data. Horticulture, whichhad been a relatively neglected area tillrecently was given a better resource allo­cation in the recent five-year plans whichhelped in boosting production. Althoughconstraints to increased production, suchas insufficient quantities of breeder seedsand planting materials existed, attemptswere underway to use new bio-technol­ogy techniques to augment productionand evolve high yielding, high nutritivevalue varieties. As a result, several highyeilding varieties of papaya, tomatoesand carrots have now been developed. AB-gene has been identified that can in­crease the B-carotene content of toma­toes. Unfortunately green leafy vegetables(GLVs), which are the most importantsource of B-carotene have been sadly ne­glected. Itwas noted that future researchmust build a data-base indicating trendswith respect to the production of GLVs inthe country.

Of the two "unconventional" sources

of B-carotene, namely spirulina and red

palm oil, the latter emerged as the imme­diately more feasible alternative. Suitableagro-c1imatic regions for the cultivation ofthe red palm have already been identifiedin India, the technology for processinghas been developed successfully and thecost of the oil is relatively low. Besides,the B-carotene in the red palm oil is stableup to four months when left on the shelf.Just half a teaspoon of oil per day ( 2 gproviding about 1,400 mcg of carotenes)is sufficient to meet the vitamin A require­ments of young children. The only pre­caution needed is that the oil should not to

be used for deep frying as the carotenescan then be substantially destroyed.

Spirulina, a blue green algae, is also agood source of B-carotene. Itlends itselfto both low and high technology cultiva­tion. The presentation and discussion onspirulina once again highlighted recenttrends. The B-earotenecontent is reportedto be 3,000 mcg/g, the highest availablefrom any natural source. The sun driedspirulina was reported to retain 20 per­cent of its B-earotene,thus providing about600 mcg/g. It was acknowledged thatspirulina holds great promise as a supple­ment in large-scale feeding programmes.The production of spirulina is also beingattempted on a large scale in Tamil Nadu.An issue that needs to be studies is theextent of retention of B-carotene, whenspirulina is dried using different methods.The limited trials using spirulina havesuggested that it can find wider use, if itscultivation is actively promoted and thecost of production can be kept low.

Field experiences presented in pro­moting household production of vege­tables and fruits were very encouraging.Horticultural experiments at the villagelevel showed that if a critical mass of

people (about 100 households in a vil­lage) were imparted the skills, the pro­gramme had greater chances of becom­ing self-sustaining and production becamesignificant. These experiments also re­vealed that several practical problemsmight be encountered initially in the firstyear and that positive results would beseen only in the second or third years.The bio-intensive gardening approachappeared promising as it apparently re­quired low-input technology and couldhelp in the propagation of varieties.

An issue that merits attention, how­ever, is how far small-scale experimentsin horticulture or bio-intensive gardeningcan be scaled up to larger ones and withwhat success.

The presentation and discussion onpreservation of vegetables and fruitsrevealed that there were many effectivetechniques currently available. However,the point was made that the informationavailable on the retention of B-carotenewhen fruits and vegetables were proc­essed by different methods were scantyand scattered and needed to be compiledand critically evaluated. Simple process­ing methods that result in minimal lossesof B-carotene needed to be identified and

advocated. The participants were of theview that this would also help in initiatingresearch to bridge the gaps in knowledgeconcerning processing effects.

There was a general agreement thatfor introducing GLVs, fruits and othersources of B-carotene into weaning di~taries, an intensive and extensive pru­gramme of information, education andcommunication was called for.

The two days of discussion at theWorkshop generated a broad consensusthat the approach to combat vitamin Adeficiency must be based on dietaryimprovement and that it should be pos­sible to achieve this within a specifiedperiod of time by promoting the produc­tion and consumption of a whole range offoods rich in B-carotene. A definite policydecision to taper off the current near­exclusive reliance on synthetic vitamin Amassive dosage approach within a pe­riod of five years, in a phased manner, willinject the necessary sense of purposeand urgency in this regard. This will alsoimply that the present ill-conceived ef­forts to further expand the use of synthetic vitamin A in public health program­mes are misplaced and unwarranted.

It is understood that NFl will shortlypublish the proceedings of the Workshop.The publication will doubtless provide animportant scientific basis for the implem­entation of a policy for combating vitaminA deficiency in the country through betterdiets rather than drugs.

Besides providing data for a series ofnational action plans to combat vitamin Adeficiency, the Workshop proved to bevery rewarding as it provided an opportu­nity for exchange of the latest availableinformation among Indian scientists andgenerated several ideas with respect tofuture research.

The author is a Senior Member of the Facuity of the

Department of Home Science, M.S. University, Baroda.

Edited by Manpreet Sharma of Nutrition Foundation of India, B-37, Gulmohar Park. New Delhi. Designed and produced by Media Workshop. Printed at Vash,ma Printers.