bhajiya pav, which she eats almost daily, going by herself to the local vendor in a Dharavi bylane."She is pampered silly by everyone in the house. She refuses to eat any home-cooked food," Prachi says with an indulgent smile.“I tried giving her khimti (dal-rice porridge) when she was about one-and-a-half years old. She wouldn't touch it.” To varying degrees, this might sound like a familiar situation, but here are two surprising details.Two-year-old Ritu’s* first real solid food, according to her mother Prachi, was a plateful of Maggi noodles. Soon after, she graduated to eating roadside ‘Chinese bhel’ and biscuits. For about a year now, Ritu’s been snacking on packaged potato wafers, Kurkure, and other junk food. Her latest obsession is deep-fried
One. In May 2014, Ritu was detected not with the conditions that you may associate with highly indulged, junk-food eating children – obesity. Instead, she was detected with Severe Acute Malnutrition (SAM), a life-threatening condition marked by a very low weight-to-height ratio and visible, severe wasting of muscle and fat.
Ritu’s family lives in Dharavi. But – and here is the second surprising detail – the family doesn’t live in abject poverty, nor is access to food a problem, but she is one of approximately 3,000 children who suffer from malnutrition in Dharavi. In urban slums such as Dharavi, however, barely 5 percent of its malnutrition cases can be attributed to abject poverty and lack of food. The newest cause of malnutrition among children in urban slums like Dharavi is the widespread consumption of junk food.In 2013, nearly 25 percent of the approximately 44,000 children between 0 and 6 years of age in Mumbai were found to be suffering from Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM), (according to figures supplied by the Integrated Child Development Services (ICDS), the central government’s initiative to tackle malnutrition in children below 6 years of age and their mothers). In Dharavi, the figure stands at 12 percent. But experts in the area paint a darker picture; they say the figure is actually around 50 percent.
While Dharavi in the popular Indian imagination is a metaphor for abject poverty, today this 557acre Mumbai neighborhood is a center of profitable small-scale industries – including textiles, leather-making, manufacturing of food products and pottery – that are said to beworth $650 million; around Rs 3,981 crore. Dharavi is crucial to the Mumbai economy. A vast part of Dharavi is – no question about it – a slum. The squalid living conditions, the common toilets and tiny, muggy rooms barely touched by sunlight have not changed. But today the people who live here have to pay rents ranging from Rs 4,000 to Rs 6,000 per month, even for houses as tiny as 250sq meters. Most houses have a television set, a mixie, a scooter. Sometimes even a gas connection. So under these conditions children are not malnourished because they are not eating enough food. They are malnourished because they are eating only food with no nutrients in them.
Parents spend up to Rs 25-30 per day on packaged food or other kinds of junk food for their children, say ICDS officials in Dharavi. “About 45 percent of infants in Dharavi probably consume sweet snacks and 25 percent consume salty snacks and this increases with age,” says Neena Shah More, Director of the Aahar project of the SNEHA, an NGO that aims to improve the health and nutrition of children under three in Dharavi.
The promise in the packet
Around 12.30pm on a school day, the local nursery school at Matunga Labor Camp has just ended. Soon around 40 children throng the store opposite the school. Most buy wafers, biscuits and chocolates, all of which cost less than Rs 5 each. Sadiq Hussain, who runs a store in one of the bylanes near Dharavi’s 90 Feet Road, says, “When I started 25 years ago, the children would buy things for 25 paise. Now, they have Rs 10 in their hands.” Hussain claims that a decade ago, the distributors of major companies also started showing up in Dharavi. It was also a decade ago that CK Prahalad’s seminal book The Fortune at the Bottom of the Pyramidwas published. Prahalad argued that the basic economics of the bottom-of-the-pyramid market is based on “small unit packages, low margin per unit, high volume, and high return on the capital employed.”
After Indian companies successfully startedselling shampoos in Re 1 sachets in the 1990s, the principle of selling products in small unit packages proliferated across other categories of products, including food. Many companies, including Parle Products,PepsiCo, Nestle and others have diversified their products with this market in mind. They have products priced between Re 1 and Rs 5. They advertise with posters, danglers, house-to-house campaigns and give sops to retailers. In cities where television has proliferated in all sections of society, residents of urban slums too aspire to consume packaged foods and to consume brands.
Not surprisingly today, though there are many small-scale food industries in Dharavi, packaged foods sells far more. “The locally made chivda and laddoos hardly sell. We only stock biscuits and wafers worth Rs 5,” says Parthiv Fan, a wholesaler in Dharavi. Children routinely ask for new products based on the new ads they see, says Manoj Mogawe, a shopkeeper at Matunga Labor Camp, while handing chocolate over to a three-year-old boy. He sells about 25 packets of wafers priced at Rs 5 every day. “Children as young as one crawl to the shops,” says SNEHA’s Shah More.
In the particular conditions of Dharavi, parents often see the packaged foods as clean, unadulterated, healthy options. Harried parents are lured by the promise of nutrition in advertisements. “Glucose biscuits” are seen as providing “taakat” to the children. Juice packets with pictures of apples are seen as nutritious. “The mothers feel that if [companies are] making food in a factory and packing it so well, it must be good,” says Shah More.
It must be good, thinks the Dharavi customer. And like the customer anywhere else, she thinks, it must be cool. Damodar Mall, CEO, Value Retail at Reliance Retail and author of Supermarketwala: Secrets to Winning Consumer India, says that the aspirations of people across classes are now distinctly democratized. “Modern products stand for small joys of life. In urban areas, all classes consume the same television media and absorb the same aspirations. Incomes have also grown. The companies are selling products tuning into the earnings and cash flow cycle of these people who earn by the day and aspire by the day.”
As Mall says, there’s more facilitating the consumption of junk food in Dharavi than its mere presence – there’s the sense of having moved up in life associated with it.
Sanjana is a Dharavi resident in her twenties. “I remember my father who had migrated to Mumbai for work would send biscuits and chocolates to Mahad [175km from Mumbai] where we were growing up. We couldn't get all these foods in Mahad,” she said. They grew up eating dal, rice and vegetables.
Sanjana’s two-year-old (and severely malnourished) daughter Priyanka is growing up in a different world from her. Not only are those treats readily available, the food her mother grew up on is distinctly uncool. And not just among little children. The mother of a three-year-old buying a sweet and rice crispies at a small Dharavi store tells me she sometimes buys the child a packaged snack for school lunch. “The teachers say that they don’t want the children to eat sticky food.”
What’s cooking in Dharavi
Under most conditions working mothers do not have it easy raising children, but in a slum like Dharavi, it is exceptionally tough. Many working mothers in Dharavi find it difficult to adequately breastfeed their children or cook for them. In addition to their jobs as cleaning or cooking maids, workers at small scale industries, or selling knick-knacks, the women must store water, cook meals, feed the children, buy provisions from the ration shops, send their children to school, and pick them up and take them to the doctor when they fall sick. The pressure to feed children and to actually create the food the children eat has always been on the women of Dharavi. Fathers are rarely involved. Many of these women do not have the time to sit down with their youngest children and feed them by hand. They expect their children to eat on their own, even if they are a year old.
Grassroots-level social workers say that many women in Dharavi – leaving home at 8am as they do – can only cook once a day, for dinner. Packaged food then becomes the obvious solution. Most mornings, children here eat khari (a biscuit made of refined flour and vanaspati or refined vegetable oil loaded with trans fats) and tea, or biscuits and tea. Little children in Dharavi are adept – like children everywhere else – at seeking Rs 5 or Rs 10 from their parents to buy snacks from nearby stores. Unlike children elsewhere though, these biscuits may be the only thing they eat all day.
Sanjana’s daughter Priyanka, who is two, weighs barely 7.5 kg. Priyanka has been suffering from SAM for the last three months and catches infections at least twice or thrice a month. Their home is clean, with an old television, a washing machine and a gas stove laid neatly in different corners of her family’s living room. Sanjana, who introduced her to biscuits when she was barely a year old, says Priyanka snacks on junk food all day. The house has two large containers full of snacks set aside for Priyanka, who finishes them all off in two weeks. While her parents try to feed her two small bowls – just about 150g each – of rice, dal and vegetables (which she sometimes takes two whole hours to finish), this quantity is much less than what an average two-year-old should consume.
Why no one can stop with just one
Two-year-old Divya can barely talk but she easily negotiates the narrow alleys outside her house to the nearby corner shop to ask for her favorite item. “I have to make her a pack of Maggi noodles at least once a day. She has a hole in her heart and needs surgery. The doctor has told us to ensure she puts on weight. But she barely eats two small bowls of rice a day,” says Nanda, her mother.
Over time, the term junk food has ceased to register the contempt the nomenclature originally contained. We talk of our love for junk food with affection, mild embarrassment or feigned horror at our lack of control when confronted with a packet of chips.
In his 2013 book Salt Sugar Fat, Pulitzer award-winner Michael Moss writes extensively of the research big processed food companies put into creating products that are heavy on fat, sugar and salt – products that make the pleasure centers in our brain addicted. As he says in an interview, “And while we always knew that eating too much of what I like to call “the foods we hate to love” would make us overweight or otherwise ill, we now know from these documents and interviews that the food companies have known this for years and years – even as they continued adding heaps of salt, sugar and fat to their products.”
While we are all vulnerable to the salt-sugar-fat addictions, the empty calories of this addiction affects some populations more than others. The National Institute of Nutrition, Hyderabad is currently researching urban child nutrition across 16 states in India. “The consumption level of children, both from educated and uneducated families, is just 75 percent of the recommended dietary allowance in almost all kinds of nutrients. Of this one-fifth [is junk food]. We also noticed that in school tiffins, the parents regularly put in a packet of wafers, or biscuits,” says N Lakshmaiah, the scientist heading the research.
Can packaged food like glucose biscuits take the place of a home-cooked meal? “As per our investigations, the glucose in these biscuits is nominal. These corporates palm off the product as healthy, but it usually has only maida and sugar. Noodles anywhere in the world cannot be made without maida. The sugar and salt content in these products is addictive and unhealthy,” says Pritee Shah, chief general manager of the Ahmedabad-based Consumer Education and Research Center (CERC).
Adults may recover from actual starvation or even the hidden malnutrition of junk food. Malnutrition in young children has serious long-term effectsincluding diminished motor, sensory, cognitive, social and emotional development. Studies show that malnourished children are less likely to perform well in school and more likely to grow into malnourished adults, at greater risk of disease and early death. Many children here in Dharavi catch infections – particularly frequent or persistent diarrhea, pneumonia and sometimes tuberculosis. The infections are a result of underlying immunity, and in turn make them susceptible to acute malnutrition.Parle Products and PepsiCo refused to comment for this story. A spokesperson for Nestle India, which manufactures Maggi instant noodles, a popular food item among Dharavi residents, says, “Maggi has a portfolio that caters to families across the income pyramid and is not specific to any group.” He adds that their consumer research and other published data shows that a large number of Indian consumers are unable to afford meals that provide the relevant nutrients.
Changing the recipe
Alka Jadhav is the professor of Pediatrics at Lokmanya Tilak Municipal General Hospital, Sion. She says, “For a one-year-old, there have to be five complementary feeds such as rice porridge, dal, fruits and vegetables, apart from breast milk. Junk food compromises their nutritional intake, both in quality and the quantity.” Since this is unlikely for most Dharavi households, the hospital’s Nutrition Rehabilitation Center (NRC) has stepped in to the breach. The Nutrition Rehabilitation Center (NRC) treats most of the malnourished infants from Dharavi. Divya, the two-year-old with a hole in her heart, was diagnosed with SAM a few months ago. She has since been regularly fed a ready-to-use potent mixture of peanut butter, soya and milk powder, and essential micronutrients provided by NRC and distributed by SNEHA staffers. Divya is no longer severely malnourished, but she is still moderately malnourished.
But nutritional supplements are not enough. Sarita, who works as domestic help, lives with her four children (the oldest 6 years old, the youngest 21 months) in a shanty next to a garbage bin. The house is made of bamboo and a tarpaulin sheet with one side open to the sky. All her four children rarely sit inside as there is no space for them.
Mohan, Sarita’s youngest, sleeps in the corner of the house in a cloth cradle. He was never breastfed exclusively as Sarita’s income feeds the entire family. Since he was two months old, Mohan was fed biscuits soaked in milk as a makeshift porridge. Mohan weighs a little over 7kg and was diagnosed with MAM about six months ago. He recently learned how to sit up, but is still not able to walk. Sarita hasn’t given up. She says, “My heart says he will walk. But he falls sick all the time. He suffers from constant attacks of diarrhea, skin rashes and seizures. Sometimes he eats a morsel of dal-rice, but vomits. He is not putting on any weight. I don't know what to do.”
The idea of just saying no to junk food or even just nutritional supplements is not a solution for this family. While Sarita is away at work, her sister -in-law takes care of her children. She has four children of her own, one of whom is an infant. “When I used to take leave from work early, my employers did not like it,” Sarita says.
The government provides for crèches under the Rajiv Gandhi National Crèche Scheme for Children of Working Mothers. There are 54 such crèches in Mumbai that cater to about a miniscule 800 children in the city. Three of them are in Dharavi. I visited one crèche run by the Community Outreach Program (CORP) situated inside a big hall provided by the Kannada Methodist Church in the middle of the slum at Mukund Nagar, Dharavi. The crèche had around 100 children under the age of 5. Some are a few months old. Nirmal Chandappa, the director of CORP, says, “There is an acute shortage of these crèches in the area. We get as many as 200 applications in all our three centers, when we can admit only 30 to 40 children a year,” said.
Worse, the amount sanctioned for nutrition of the children under the scheme is a measly Rs 2.10 per day, while the caretakers are given Rs 1,000 per month as honorarium. CORP says it gets only 30 percent of the funds for running the crèche from the government – the rest comes from donations. And there are strong indications that the number of crèches are likely to shrink. “With the lack of space and so little money allotted, it is just not feasible for NGOs to apply for a crèche in Mumbai. Over the past 5-6 years, we have not allotted a single crèche in Mumbai,” said an officer from the Maharashtra Social Welfare Board that runs the scheme, on condition of anonymity.
Dharavi has 300 anganwadis under the ICDS program that reach out to nearly 25,000 children. On paper, the scheme is supposed to improve the health of preschool children, pregnant women and nursing mothers by providing supplementary nutrition and education on immunization, nutrition and health education. “The ICDS works well at the level of spot feeding. We provide supplementary nutrition to children in the slums. But, the nutrition counselling is on the [backburner] because of the excessive workload on the anganwadi workers. We are providing for [an additional] worker per anganwadi which may fill the deficit,” said Ujwal Uke, principal secretary of Maharshtra’s Department of Women and Child Development.The weighing of the children is regularly fudged and completely haphazard, experts say (if the children are not weighed properly, or regularly, it is very difficult to determine their malnutrition status). Vandana Krishna, director-general of Rajamata Jijau Mother-Child Health and Nutrition Mission, said that most of the ICDS statistics are completely unreliable. The program, according to experts, lacks a number of things: supervision, clear roles for the anganwadi workers, training, and regular appraisal of the workers, which ensures accountability. Since the Maharashtra state elections have been announced, all the ICDS workers have been working for the Election Commission on various tasks.
How can the problem of malnutrition in children be tackled? “In a situation like Dharavi or any other urban slum, a community kitchen run by trusted, well-established organizations that can cook wholesome food for children for a nominal amount may work. Something on the lines of ‘Amma Canteens’,” says Krishna. Amma Canteens is a government food subsidy program in Tamil Nadu which runs canteens that serve cheap, healthy foods.
SNEHA has a complex, community-based approach to dealing with the problem. In collaboration with the ICDS, local municipality and the Nutrition Research and Rehabilitation Center, they have piloted the first Community-based Management of Acute Malnutrition program. The community organizers measure the nutritional status of all children below age of three, make regular visits to homes of children suffering from SAM and MAM and refer them for check-ups. Their efforts are paying off. “In about 18 months of running the project in 2000 families, malnutrition in 0-3 years children has fallen by 18 percent. However, it is a challenge to sustain this with the constant movement and migration of young children,” says Shah More.
While the context of Dharavi’s hidden malnutrition remains difficult, there is no understating SNEHA’s work has had on individual families.
After Ritu was detected with SAM about a year ago, SNEHA’s community organizer built up a rapport with her mother Prachi and explained that her condition was precarious. It was difficult to feed the child home cooked dal-rice and vegetables when she was completely accustomed to eating junk food. The child was severely malnourished for for nine months. When she gained a little weight, she started walking only a few months ago.
Ritu is now 10kg and her weight gain is normal for her age. “I understand that home-cooked food is good and outside food is not good. I try feeding her a few home-cooked meals now. My child looks healthier now,” said Prachi, smiling.
*Names of children and their mothers have been changed to protect their privacy.
Menaka Rao is a freelance journalist based in Mumbai.