“Njan vishwasichila. Oru kozhapum illatha kutty aayirunnu (I didn’t believe it. The child was perfectly okay),” said Raman as he recalled trembling with shock when a nurse at the Government Tribal Speciality Hospital (GTSH) in Kottathara informed him that his child was no more. His baby boy, for whom he hadn’t even thought of a name, lived all of three days before he died unexpectedly on November 22, 2018.
On November 19, Raman’s wife Bindu had given birth to a perfectly healthy boy who weighed 2.86 kgs at birth. As a precaution, the mother and child were advised to spend a few days at the hospital, mainly to improve Bindu’s haemoglobin levels (doctors said she was anemic) and monitor the infant’s health. His son was behaving like any other newborn would, Raman said, drinking milk at regular intervals, sleeping for long hours and showing no signs of discomfort. On the morning of Nov 22, when Raman was outside somewhere, he said a nurse took the baby to check his weight and returned a few minutes later with the baby in tears. Immediately, Bindu was asked to feed him, but as he was being fed, she noticed the infant shivering. The nurse was called and informed of the baby shivering, upon which he was transferred to the Intensive Care Unit (ICU).
“Twenty minutes later, they returned to say that my son had died. At first, they did not specify a reason, but later said the death was due to milk aspiration. But when we checked the baby’s nose, there was no presence of milk,” said Raman.
At the time of his son’s death, Raman maintains that there was no paediatrician or gynaecologist present at the hospital, or even the head-nurse. “If a doctor was there on time, probably my son could have been saved. They (the hospital) are answerable for this.”
Raman’s son was the 11th of 13 infant deaths documented by government authorities last year in Attappadi, Kerala’s only tribal block panchayat located in the frontiers of the Nilgiri Hills in the Western Ghats. It serves as a gateway to the Silent Valley National Park, one of the last undisturbed tracts of the Ghats, home to several rare flora and fauna species. However, in recent decades, Attappadi has hit headlines for an altogether different reason: it’s notorious record of infant mortality and dangerously-low nutrition levels among pregnant women. In many ways, it has presented itself as a cryptic case of contrast in a state hailed for its rapid progress on reducing infant mortality rate.
The fate of Attappadi’s infants has been archived extensively in the local and national press, and yet it remains a story that begs to be written again and again. In 2013, when over 55 infants died in Attappadi, it mortified health observers and rang alarm bells in the corridors of the state’s health department in faraway Thiruvananthapuram. Ministers, bureaucrats and activists swooped in to quell the crisis, steamrolling programmes aimed at improving malnutrition and anemia levels among the large tribal population. But the stagnant incidence of deaths in 2017 and 2018 prove that the crisis is in fact festering and is far from over.
Is milk aspiration killing kids?
The cause of milk aspiration, when milk accidentally enters the infant’s windpipe rather than the food pipe or oesophagus, was attributed by doctors at GTSH for five of the 13 infant deaths last year. In normal circumstances, if a small portion of food or liquid enters the windpipe, the natural reaction is a cough. But in case of infants, especially when they are unwell, if a large amount of milk enters the windpipe during breastfeeding, it can lead to severe choking and ultimately death. Optimum breastfeeding methods involve the mother feeding her baby in an upright position and then, at the end, lightly tapping the baby on the back to induce a burp.
Officials at the GTSH, Attappadi’s biggest hospital that accounts for over 95% of the institutional deliveries there, say four of the five deaths due to milk aspiration occurred at home. This, they say, points to the manner in which the mothers breastfeed their baby, often not giving proper attention to the child.
“While feeding, the baby must be given all attention, the mother must look at it’s face and monitor it’s expressions. Many of them use betel leaves while breastfeeding, which can induce sleep. Some of them may mix their husband’s chewing pan masala along with the leaves. Some mothers may drink alcohol. In most of the cases where the deaths occurred, a post-survey indicated the baby was made to lie on its back, which can cause the milk to accidentally flow into the windpipe. Two of the initial post-mortem reports showed milk clot in the windpipe,” said R Prebhudas, Medical Superintendent, GTSH.
On allegations of the hospital authorities not being able to provide satisfactory reasons for the deaths of the infants, Prebhudas responded saying, “What answer can we give for a baby’s death? In case of sudden death, children won’t get heart attacks so aspiration is the only cause, or suffocation, that can happen too. That’s why, as the sub-collector ordered, we’re sending all milk aspiration cases for post-mortem.”
After the death of Raman’s son, public protests erupted outside the hospital demanding why authorities failed to provide doctors at critical moments or quite simply, explain to them why their children died.
“When kids die at home, they inquire why we didn’t bring them to the hospital, but my child, who was healthy, died at the hospital. Kids, who were born less healthy than my son are still living in Attappadi. So when everything was normal, it’s very surprising (when my son died),” said Raman, sitting on the bare, uncemented porch of his humble home in Pudur panchayat.
To quell the protests, the Palakkad district sub-collector ordered an inquiry into the deaths, promising answers for the tragedy. But two months on, Raman claimed, not one member of the inquiry team has landed at his doorstep asking questions. The post-mortem reports of previous infant deaths in the year haven’t come out either, he said.
The reasoning of milk aspiration behind some of the deaths has not gone down well with several activists and health practitioners working in the tribal sector in Attappadi. It’s a clever ruse to hide the real underlying deficiencies of the hospital, they allege, and more importantly an attempt to pin blame on the tribal community by saying that mothers don’t know how to breastfeed their kids.
“Which mother doesn’t know how to breastfeed her baby? That’s injustice to their people. These are flimsy excuses,” said Rajendra Prasad, president of Thampu, an outfit that works for the welfare of the tribal community in Attappadi.
TR Chandran, a retired health inspector in Attappadi, concurred. “It’s invented to avoid a lot of questioning. Mothers are not so foolish. They are increasingly coming to hospitals to get immunised. There could be other underlying causes. The government has just invented a reason to hide their failures,” he said.
A paediatrician, working with a private hospital who did not want to be identified, instead blamed the deaths on the lack of strict protocols that must be followed with tribal children who are naturally susceptible to diseases. “Instead of taking the community into confidence, if you blame the community, it will backfire. This is antagonistic in nature. Tribals have communication problems with outsiders, so you have to communicate more. Doctors at primary health centres (PHCs) have to be empowered and they have to be tribal friendly,” the paediatrician said.
Malnutrition-anemia rampant in tribal women
The height of the tragedy in 2013, when infant casualty figures went beyond 50, forced the Centre and State governments to proactively work on reducing malnutrition and anemia levels among tribal women, cutting down on home deliveries, empowering the primary health centres and anganwadis and creating a system where every pregnant woman in each of the 192 ‘oorus’ (hamlets) could be tracked on time by ASHA workers and doctors at GTSH, Kottathara. The idea of community kitchens, where food would be prepared for starving families, took shape. The facilities at GTSH itself were strengthened with a special newborn care unit set up and a high-nutrition regimen designed for pregnant women to prevent the birth of underweight babies. Authorities stepped up monthly field camps, especially in far-off tribal settlements, to gauge the health of the women. Moreover, to economically support the women, the Janani Janmaraksha scheme, that guarantees every pregnant woman the cash assistance of Rs 1000 per month for 18 months, was put into effect.
The remedial measures, largely seen by activists as a knee-jerk reaction, helped put a lid on the boiling issue, drastically reducing mortality rate in the subsequent years and bringing more women under the ambit of the block’s health apparatus. But they still do not come close to tackling the problem in the long-term, experts pointed out.
An ongoing socio-economic survey, carried out by the Kerala Mahila Samakhya Society (KMSS) among 48 mothers in Attappadi who have lost their children, showed how none of them followed traditional food habits and an overwhelming number among them rarely eat eggs. Sixty per cent of the mothers surveyed had their haemoglobin count below 10, half of them having lost their first child. The findings confirmed that sickle-cell anaemia, a condition due to the lack of healthy red blood cells, is prevalent among women.
“This is not a linear issue, this is a developmental issue. There are severe problems with reproductive health. At the same time, we looked at their social aspects, their backgrounds, how much they studied at school, problems of domestic violence or drug abuse,” said PE Usha, project director, KMSS.
“There are families who cannot afford to eat eggs and meat. They don’t drink milk a lot. Also, there’s a lot of stigma associated with families where infant deaths have occurred. There are problems of migration,” she added.
There were more troubling social factors at play, the survey indicated. Almost 22% of the mothers had married before they turned 18, a whopping 66% had abandoned studies after Xth grade and three-fourths of the fathers surveyed having studied up to Xth grade in school.
KMSS officials, who plan to meet state government bureaucrats after the completion of the survey in March, want greater focus on adolescent girl child health and special policies to be crafted around tribal hostels.
“A clinical study is not enough, but rather one that looks at social and developmental factors. For example, a pregnant woman going to the hospital for check-ups is forfeiting her wages. She must get that day’s wage. Similarly, a mother must be informed by hospital authorities why exactly her child died, she has a right to know,” remarked Usha.
Infant deaths linked to larger problem of Adivasi rights
Experts have regularly pointed out that the scourge of infant mortality in Attappadi cannot be eradicated just by raising the health standards of the tribal block. It has more to do with the gradual degradation of land and water sources and the systematic suppression of Adivasi rights. The 1951 Census showed Attappadi dominated by 90 per cent of tribals, but over the years, their population has dwindled at the cost of their lands being sold to settler communities from Kerala and neighbouring Tamil Nadu in order to repay their debts. Today, the Adivasi population, as per the 2011 Census, in the block is just over 30 per cent, that is around 27,000 people. With Adivasis constantly being swept to the margins with little land and slowing incomes, it becomes increasingly harder for them, economically and socially, to compete with others.
“Land is the main factor. Barren lands must be detected and there must be efforts to bring water supply to these areas. Tribals must be brought back towards agriculture and irrigation practices must be encouraged. They must have their own source of income. They should not have to depend on government ration. When they commit to intensive farming, it will take their mind off alcohol and drugs,” said Rangan, a primary school teacher and secretary of the Adivasi Employee Welfare Organisation of Attappadi.
Chandran, the retired health inspector, said there was a time when Adivasis were economically and socially powerful to bestow gifts and help others, but today they have been forced to beg for basic necessities.
“Give them their land back. They must be brought back to their roots. Every month, they are getting free food grains. Such free stuff should never be encouraged. Return them to agriculture. The sad fact today is that no one is trying to stop the displacement of tribals,” he said.
Health observers say the Adivasis, who earlier used to consume nutritious, traditional food items like ragi, little millet (chama), medicinal herbs and leafy vegetables as part of their diet, have been forced to switch to the often-bland ‘choru-sambar’ (rice-sambar) menu of the community kitchens. Many families even forgo the kitchens due to community rivalries.
It’s this increasing ‘dependence’ on government allowances, loss of autonomy, little or no jobs, ineffective utilisation of tribal funds and the general disregard for Adivasi rights that has made Attappadi susceptible to social disintegration.
“In Attappadi, if you want to recognise the Adivasi settlements from the other, just look at the land adjoining rivers and streams. Adivasis would never encroach on such lands, others would. Adivasis do not exploit nature,” said Usha.
Krishnaprakash, director of the government’s Integrated Tribal Development Project (ITDP) in Attappadi, agreed an ‘appeasement’ policy only results in greater dependence on the administration, but insisted that the state is focusing on programs designed for tribals’ self-dependence.
“The government is running a lot of training programmes and job-oriented vocational courses. It has not reached a grand stage but there are some positive developments. For example, there are self-help groups formed in the construction sector. We are also trying to provide jobs in hospitality and automobile sectors,” he said.
“But a big problem is that many of them are not ready to leave their comfort zone to work outside. Their emotional competence levels are low. That’s also a factor,” he added.
A few kilometres away from Raman’s home, Murugan and Revathy, in their 30s, and Ayyappan and Sivakami, in their mid-20s, are also mourning their children. Many would say their children are luckier than Raman’s, for they had a longer lifespan of 17 days and 143 days respectively. In Attappadi, for some reason, such morbid calculations have become a cruel yardstick of a child’s life.
Revathy, who lost her youngest child in October last year, said, “I can’t cry in front of the other three children so I go outside. The eldest child, who’s 11, knows. But the other two kids don’t know.” “They just think the baby’s gone to the hospital.”