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TOWARDS A FOOD RIGHTS CODE:
The State, Food Denials and Food Rights
This volume will try to argue for and outline a proposed Food Rights Code, that lays
down statutory duties for public authorities to secure the right to food of all people at all
times, normal and emergent.
It will begin with a discussion of the only food related official Codes that currently exist,
a range of Famine, Drought and Scarcity Codes. It will trace briefly the historical context
of these Codes, and argue that they need to be completely rewritten for the
contemporary context of a democratic polity. These Codes, but even their successor
Scarcity and Drought Codes of independent India come into force only after people in a
region are ravaged by major natural disasters, mainly failures of rainfall and consequent
disruption of agricultural production. They have rarely dealt with starvation and the
duties of the State to prevent and mitigate it, and also do not aim to help realise people's
right to food in normal times, and the duties of public authorities to people who live
with prolonged denials of adequate food.
In the light of this initial review of Famine Codes, past and present, this volume tries to
suggest an alternative Food Rights Code, which delineates duties of public authorities to
a) ensure the right to food of all people in normal times; b) acknowledge, verify and
address individual and mass starvation; c) identify people and groups which Eve with
chronic hunger even in normal times and take special measures to protect them from
starvation and secure their rights to food; and d) address emergent situations of food
scarcity arising from extraordinary natural, human made and economic situations.
The volume compiles and draws from many sources. It contains contributions form
many sources. The segment on food rights in normal times is based on 'Supreme Court
Orders on the Right to Food: A Tool for Legal Action originally written by Yamini
Jaishankar and fean Dreze for the Right to Food Campaign Secretariat in 2005. It has
V
1
been subsequently revised by Biraj Patnaik and Spurthi Reddy in September 2007. The
segment on starvation and the detailed annexures on verbal autopsies and other
methods to verify starvation are drawn entirely from an excellent document 'Guidelines
for Investigating Suspected Starvation Deaths', prepared by the Jan Swasthya Abhiyan s
Hunger Watch Group, based on a consultation organized in Mumbai in 20031. In writing
the segments reviewing famine and scarcity codes, past and present, I have received
valuable research support from M.Kumaran and learnt much from the painstaking
reviews undertaken of some of these Codes by Sana Das2. The research in preparing this
volume is supported by a research grant from Dan Church India.
This is only a preliminary discussion document, and will no doubt be refined and
greatly improved by extensive consultations.
Harsh Mander
Centre for Equity Studies
December, 2007
1 This conference was attended by and attended by Veena Shatrughna (Deputy Director, National
Institute of Nutrition, Hyderabad), Vandana Prasad (Paediatrician), Narendra Gupta (Prayas),
Sunita Abraham (Christian Medical Association of India), Sarojini (SAMA and Convenor of
MFC), C. S. Kapse (Professor, Department of Forensic Medicine, D. Y. Patil Medical College),
Neeraj Hatekar (Professor, Department of Economics, University of Mumbai), Sanjay Rode (Ph.
D. student, Department of Economics, University of Mumbai), Abhay Shukla (Co-ordinator,
SATHI Cell, CEHAT), Neelangi Nanai, Amita Pitre and Qudsiya (all researchers at CEHAT).
2 Sana Das undertook these reviews for Action Aid India in 2001
1
Contents
Chapter 1
Famine Codes, Past and Present: A Review
In contemporary India, there remain large gaps in the statutory codification of the claims
and entitlements of people from the State for realising their right to food, in normal
rimes, but also in periods of both acute food distress and in situations of chronic food
deprivation, acute denials being the result of natural and human disasters, and chronic
deprivations the more routine denial of sufficient food for a healthy and active life even
in normal times.
During episodes of food scarcity caused by drought and failures of the rains, district
authorities in many regions of the country are still substantially guided in crafting their
responses by locally updated, adapted and amended versions of the Famine Codes that
were initially developed i by colonial administrators. These Codes detail the duties of
governments in such times of great human distress, and the operational strategies that
should be adopted by them when confronted by these challenges. These remarkable,
almost legendary documents were compiled by colonial rulers to regulate the
declaration of food scarcity and famines based mainly on sample field crop assessments,
and to inform the range of subsequent administrative measures required to be taken by
local administrations to address the impacts of food scarcities as and when they
occurred.
However, an enormous amount of water has flowed through the Ganga in over a
century since many of these Codes were written. Among the epochal changes that have
occurred in the context of these Codes, some of the most significant include that India
has since become an independent democratic socialistic republic. fiiejnaMe-Sfefe^
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The Indian Constitution recognises the right to life as a fundamental right, and many
regard this to include the right to food and work with dignity. A conditional statutory
guarantee to the right to work has been created by the National Employment Guarantee
Act, 2005. India is also signatory to a number of international covenants, including those
of economic, social and cultural rights and those related to gender justice and child
rights. The realisation of these rights is closely monitored by activist people's
organisations, often in alliance with an activist judiciary. The State is committed to
affirmative action for most vulnerable groups, such as SCs, STs and women, to
decentralisation of governance to local bodies, and transparency and accountability
through powerful right to information legislation. The Indian government runs some of
the largest food assistance programmes in the world, including direct food and income
transfers; procurement of foodgrains at support price, storage of buffer stocks to prevent
shortages and shocks, and sale of subsidised grain in a nation-wide network of shops;
and wage employment through public works, which as observed was recently converted
into a qualified legal guarantee.
This paper will try to briefly summarise some of the major policy debates relevant to this
vastly altered context of Famine and Scarcity Codes, and track both the continuities and
departures in these discussions and practices from colonial to present times. It will argue
in favour of the careful and comprehensive codification of statutory and judiciable
duties of public authorities to secure the right to food of all citizens at all times. These
should apply firstly to spells of acute food crises caused by periodic local scarcities
(spurred by monsoon failures or natural and human made disasters), but also other
caused by other adversities for farmers such as large unfavourable fluctuations in
agricultural prices, or failures of forest produce which could be critical for tribal and
other forest dwelling communities. However, it will contain measures to address
endemic hunger and starvation, unlike both colonial and contemporary Codes (also
called manuals or handbooks), all of which exclude responding to everyday hunger
5I
endemic to the lives of many dispossessed communities, social categories, households
and individuals. It will propose some principles that it suggests should inform the
codification of State duties, practices and procedures for assessing and dealing with food
scarcity and endemic hunger, in conformity with democratic values, a rights based
approach, gender, social and class justice, and accountability and right to information.
Famine Codes: Continuities and Changes from Colonial Times
During the eighteenth and nineteenth centuries, the people of India were ravaged by a
series of cataclysmic famines, precipitated less by failures of nature and more by colonial
policies, such as of rack-renting, both legal and illegal, neglect of agriculture, 'free-trade'
policies and additional levies for wars. There are terrifying contemporary accounts of
these famines, such as of rivers 'studded with dead bodies'3, of whole settlements being
wiped out by hunger and epidemics that followed in their wake, of desperate loot and
plunder, and the cumulative tragic loss of a numbing 15 million women, men and
children4. Initially the colonial government had no cohesive policy to deal with these
emergencies, except to prevent hoarding and crime, which was followed by ad hoc relief
measures such as stray food kitchens, poorhouses and public works5. It was the Famine
Commission appointed in 1878 which resulted in the first Famine Code (based
substantially on one which had been written by Elliot in 1883 for Mysore) being adopted
as a national model6, and to be suitably adapted in different regions of British rule.
These Codes evolved unOder the influence of 2 subsequent Famine Commissions in 1898
to provide comprehensive institutionalised
guidelines to colonial
administrators. These included instructions to anticipate famines, and to save life but
3 Alamgir, mohiuddin, “Famine in South Asia, Political Eeconomy ofMass Starvation ”, Cambridge,
Massachusetts, Oelgeschlager, Gunn & Hain Publishers Inc, 1980, p 48,64.
4GoI, “The Drought of 1987. Response and Management, Volume 1, National Efforts”, Edited by D.C.
Mishra, Dept. New Delhi, of Agriculture and Co-operation.
5 Alamgir, mohiuddin, “Famine in South Asia, Political Eeconomy of Mass Starvation ”, Cambridge,
Massachusetts, Oelgeschlager, Gunn & Hain Publishers Inc, 1980, p 63-65.
6 Ibid, p 73
explicitly at the lowest possible cost to the exchequer, by providing employment at
subsistence wage, and 'gratuitous' retief to the 'unemployable'.
In independent India, state governments variously adapted and amended these Famine
Codes. In states carved out of the former Bombay and Central provinces - Maharashtra,
Gujarat, Madhya Pradesh and Chhatisgarh - these were renamed Scarcity Relief
Manuals, scarcity being defined as a marked deterioration of the agricultural season
dues to failure of rains or floods, or damage to crops due to insects resulting in severe
unemployment and consequent distress among agricultural labour and small
cultivators7. Orissa wrote and adopted its Relief Code in 1971, updating the Orissa
Famine Code of 1930, and further updated it in 1996. The Madras Famine Code has
remarkably not been amended since 1901. In many states, these exist in the form of
administrative circulars and government directives, which have tinkered with the Codes
but not substantially rewritten these to reflect the imperatives of a democratic polity.
The Andhra Pradesh government used the colonial Madras Code to guide its district
officers until 1981, when it drew up its own Handbook on Droughts, which builds
substantially on the Madras Code. The Andhra Pradesh Handbook was further updated
in 1995.
In their objectives, many of these Codes, manuals or handbooks make significant
advances on their colonial predecessors. The Orissa Code expands its mandate to go
beyond mere relief in crises to the 'maintenance of a certain standard of economic health
of the people', whereas the Madhya Pradesh Code aims to prevent physical
deterioration and loss of morale of its people because of unemployment, to enable them
to restore their ordinary pursuits when better times return9. But as we shall observe,
most Codes do not live up to such aspirations, let alone to the duties of a democratic
State to its vulnerable citizens as pledged in its Constitution, and are severely
7 Gol, "The Drought of 1987. Response and Management, Volume 1, National Efforts”, Edited by D.C.
Mishra, Dept. New Delhi, of Agriculture and Co-operation.
8 Ibid
9 Das Sana, A Critique ofFamine Codes in India: A study of the Orissa Relief Code & Vulnerable People s
Entitlements”, New Delhi, Action Aid, 2001, p 22.
handicapped also because they are not backed by consistent and sufficient fiscal and
administrative arrangements. I believe that the shadow of the values of colonial
administration continues to fall long on the culture and practices of the bureaucracy,
even 60 years after freedom. In this section, it is these many paradoxical and
unacceptable continuities in public policy and practice related to drought and scarcity
relief from colonial times that I will try to trace here, while acknowledging also the
many ways in which we have traversed in more progressive directions in the journey of
protecting our people from want.
(i)
Codes are non-enforceable: All famine, drought and scarcity Codes, both
colonial and contemporary, cannot be enforced in any court of law. They lay
down duties of various public authorities, but contain no provisions that
enable citizens (or subjects) to take these authorities to court, or to penalise
them, if they fail in performing these duties, even if this leads to the
preventable death and suffering of people. In other words, the Codes are not
rights based, in that they do not create legal entitlements, and still depend in
the last resort on the will of the State to act in specific ways. In colonial times,
the timing, nature and extent of State support of people affected by drought
and famine, depended on the 'benevolence' of the State, which was guided
by considerations of doing the least that was necessary for containing unrest
and crime born out of the desperation of mass hunger. It may be argued with
merit that democratic polities hold State authorities accountable through the
electoral process, and this binds them to their duties. But it is also true that
the permanent bureaucracy that continues to be charged with most
responsibilities under these Codes never faces elections, and further the
people who are most in need of State assistance are often also most powerless
and often practically disenfranchised, and therefore cannot influence
electoral outcomes in any substantial way.
In recent times, some related rights have been turned into legal entitlements,
most importantly by the National Rural Employment Guarantee Act, 2005
(NREGA) which provides a statutory guarantee to every rural family that
demands 100 days of wage employment at statutory minimum wages a year.
The State cannot plead fiscal or administrative constraints in providing such
employment, and there is even a token fine on the public exchequer for
failures to provide work in the legally prescribed time. The Supreme Court
has also converted government schemes of school meals and supplementary
nutrition for infants, small children and nursing and expectant mothers into
legal entitlements in the writ petition 196 of 2001, PUCL vs. the Union of
India and others. But the entire Code should be legally enforceable to create
legally binding duties of State authorities towards people who are living with
threats to their lives because of denials of food and livelihoods, including
clear accotmtability lines and penalties for failures.
(H)
Minimalising Relief Expenditures: British Codes were explicit in casting a
duty on public officials to spend the minimum that was necessary, only to
prevent the loss of lives, and nothing beyond that. The 1941 Bengal Famine
Code, for instance, puts it starkly: 'Government is obliged to limit its
assistance to what is absolutely necessary for the preservation of life. When
life is secured, the responsibility to the afflicted ceases and the responsibility
to the tax paying public begins'10. Administrators were warned not to
undertake relief works on such a lavish scale as to impair thrift and self-
reliance among the people and the structure of society11.
This minimalising of relief was accomplished in part through a series of stern
'tests' of the desperation and urgency of want, to discourage all but those
unfortunate persons who were most in most drastic need to report for work,
the first of these so of distance, that the work should be far away from one's
home so as to make it unattractive; the 'residence' test, under which they
were required to live at the work site for the duration of their employment
away from their families; and the 'labour' test, by which the work was
10 Govt of Bengal, ^Famine Manual”, Bengal, Revenue department, 1941, p 3
11 Das Sana, A Critique ofFamine Codes in India: A study of the Andhra Pradesh Handbook on Drought
management & Vulnerable People’s entitlements ”, New Delhi, Action Aid, 2001, p 21.
required to be monotonous, arduous and compensated at very low wages,
carefully calibrated to ensure that it enables nothing more than the purchase
of bare essential food12. Men engaged in hard labour were paid enough to
buy 1.5 pounds of food grains a day (and little else) which amounts to 2500
calories, women 'a little less', and working children from 7 to 12 years half
the male rate. (Paper 1, 6) Despite the fact that children laboured even at such
a young age in famine works, British commentators like Blair describe the
multitude of children "the bugbear of famine relief-works'13, even though
most children above 7 years were also required to work. One result of this
minimalist approach to levels of relief meant that households could not save
anything from their wages, and therefore suffered 2 or 3 months of negligible
access to food between the closure of relief works and the next harvest (Paper
1, 6). All efforts to expand the wages and duration and improve and
humanise the conditions of work were rejected peremptorily as wasteful.
At one level, much has improved since Independence. There is a positive
continuity with the past in the reliance on public works for ensuring
adequate food to households in such trying times. Enduring small public
works closer to the homes of people affected by scarcity are now
recommended (Most Codes require the works to be located at less than 5
kilometres from the place o residence), and there is legislation to ensure equal
wages for men and women and for banning child labour (although some
field studies report that children continue to be observed in some relief
works, helping their parents14. Test works to verify need are discontinued in
states like Andhra Pradesh and Orissa, although the colonial practice persists
in Rajasthan.
12 Singh, K.S, “Famine and Society” in ''Water Project Series ”, Edited by Jean Floud and Amrita
Rangasami, New Delhi, The Indian Law Institute, 1993.
Dubhashi, P.R, "Drought and Development”, EPW, March 28, 1992.
13 Blair, Charles, "Indian Famines their Historical, Financial & Other Aspects”, New Delhi, Agricole
Reprints Corporation, 1986, p. 170.
14Das Sana, A Critique ofFamine Codes in India: A study of the Andhra Pradesh Handbook on Drought
management & Vulnerable People’s entitlements ”, New Delhi, Action Aid, 2001, p 70
But wages are still fixed at bare subsistence levels, just sufficient for survival
of the person and dependents. Scarcity and Drought Codes of most state
governments today still contain no provision for raising wage rates in times
of great dish-ess. Instead they actually reduce it on the specious grounds of
reaching larger numbers13. The Rajasthan Code (paragraph 83) explicitly
states that tire principle of tire famine wage scale is to pay the lowest amount
that is sufficient to maintain a healthy person in health. The Orissa
government is an exception, and it has authorised CoUectors to enhance
wages up to 20 per cent in times of dire need.
Workers in practice (in relief and even NREGA works in most locations in the
country) are paid on not just the basis of daily attendance, but on the amount
of work done16, an illegal and exploitative 'double whammy'. The worker
cannot leave if the work required is completed early, and is not paid more if
more work is done; in effect, the minimum wage is also the maximum
wage17. Workers are in practice found to be paid less than minimum wages in
public relief works, which has been challenged in a series of public interest
petitions in the higher courts. A landmark case was Sanjit Roy vs. the State of
Rajasthan (1983), in which the Court held that payment of wages that were
lower that statutory minimum wages to people in famine relief works
violated the Constitutional right to equality, and the state government should
not take advantage of the helplessness of people living in conditions of
drought and scarcity. It deemed such work at wages lower than minimum
wages to be forced labour, punishable under law.
Standards such as shades and crdches for children and clean drinking water
at work sites continue to be mostly neglected, although the Rajasthan Code
15 Ibid p 46
16 Singh, K.S, “Famine and Society” in “Water Project Series ”, Edited by Jean Floud and Amrita
Rangasami, New Delhi, The Indian Law Institute, 1993.
17Das Sana, A Critique ofFamine Codes in India: A study of the Andhra Pradesh Handbook on Drought
management & Vulnerable People’s entitlements”, New Delhi, Action Aid, 2001, p 158.
lists a number of required on-site facilities and workers benefits. These
include the right to a healthy and sanitary environment, shelter if the site is
distant from the village, clean water and even 3 weeks of maternity
allowance.
In no Code is work guaranteed to all who seek it, and in fact it the Rajasthan
Famine Code actually applies ceilings. NREGA is a great step forward, but it
is still a conditional and not open ended guarantee, which applies to one
person in each rural family, with an upper limit of 100 days. Public works
continue to be closed before the onset of the rains, rather than with the
reaping of the harvest, as in colonial times, and these can be times of the most
severe food deprivation. This timing is specifically laid down in many Codes,
such as the Andhra Pradesh Handbook. Indeed, it has been observed that
even NREGA works are closed when rains start (and many state
governments have issued written orders to this effect, even though these
contravene the law, which requires works to be run whenever there is a
demand by workers for them). It can be speculated that this is done in order
to keep agricultural wages depressed during the agricultural season, to
benefit larger farmers. Agricultural wages are typically well below the
statutory minimum wage, and if workers have options to higher wage
employment in public works, it would force farmers to offer higher wages.
In some of the major scarcities and droughts from the 1960s to late 1980s,
there was relatively greater fiscal freedom to local officials to respond to
actual demand for work, but from early 1990s, relief works are seriously
constrained by resources, and only minimalist interventions are permitted.
The NREGA rectifies this with its significant scale and recent expansion to all
districts of the country, but it still is not an open ended guarantee, ensuring
not more than 100 days of work for one person in each rural family a year,
regardless of the specific exigencies of emergency situations.
(Hi)
Culture of Denial: In colonial times, there was a culture of official denial, of
'masking famines' and indeed of often blaming the victim. I would suggest,
maybe provocatively, that such a culture survives in milder and disguised
forms even in contemporary India. A drought or failure of monsoon may
trigger famine, but it is not in itself the cause of the famine. Students of
famine suggest that bureaucracies tend to 'mask famines first as separate
episodes of mass deaths rather than ongoing processes of pauperisation,
denial and inequality; and second see these as the unfortunate outcome of
rainfall shortfalls, floods or other production failures, as acts of nature for
which there is little human responsibility. These create the normative
framework of minimalist interventions, mainly in the short-term character of
crisis management18.
Droughts may not result in serious food scarcity situations and famines if
people have enough food reserves and opportumties for employment at fair
wages19. IFPRI, in a major study of food scarcity in sub Saharan Africa
concludes that 'production failures caused by drought, even those lasting
several years, do not translate into famines unless other socio-economic
conditions are prevalent' that are usually the direct result of failures of public
policy. These include policies on agricultural technology, the scarcity of non
farm technologies, lack of savings, poor public health facilities and lack of
infrastructure20. It is therefore appropriate to describe the Codes not as
..
,. .................... 2.___ ■_.
drought manuals (as is done, for instance in Andhra Pradesh), but as scarcity
manuals (which is the name in Maharashtra and Madhya Pradesh) because
this at least tacitly admits to scarcity that occurs due to factors that may
extend beyond natural failures like drought and floods. New forms of
agrarian distress have also surfaced in the form of farmers' suicides, which
18 Floud and Rangasami, “The Masking of Famine: The Role of the Bureausracy”, in Famine and Society ,
Edited by Jean Floud and Amrita Rangasami, Water project Series, New Delhi, The Indian Law Institute,
1993.
19 Das Sana, A Critique ofFamine Codes in India: A study of the Andhra Pradesh Handbook on Drought
management & Vulnerable People's entitlements ", New Delhi, Action Aid, 2001, p 16
20 Von, Braun, “A policy Agenda for Famine Prevention in Africa", Washington D.C, IFPRI, 1991.
have spread like an epidemic through many parts of rural India, resulting
from exploitative private credit, cost intensive agricultural technologies and
forced unprotected integration into global markets. Codes provide for
remission of loans from the formal banking sector, but leave untouched
usury by the private moneylender.
Blaming the victim was explicit, even racist, in many colonial records. I can
do no better than quote Charles Blair, an Executive Engineer of the Indian
Public Works Department who writes in 1874 of the 'bigotry, fatalistic
attitudes, apathy, or any of the other subtle influences that prevail in the East
(which) was the cause of the sufferers concealing their necessities, or of
refusing proffered work, wages, or food../21. He quotes a journalist of the
Daily News covering the great Orissa famine of 1866, who wrote, 'Kismet! It is
their fate: it has been the fate of their forefathers, of their caste, from times
immemorial, to toil when toil and wage are offered; to hunger and to starve
when wage and food failed them22.'
He even suggests duplicity, 'Able-
bodied men who were offered work would refuse it, and would sit under a
tree till they got thin enough to get gratuitous relief'23.
Denials of starvation by public officials today are not often so openly racist,
but they still routinely blame the alleged wanton neglect of their health of
especially tribal folk due to superstition and ignorance as the cause of many
deaths which activists and journalists claim are starvation deaths, and claim
an indolent preference for relief rather than self-reliant and self-respecting
honest toil. The Bombay Sanitary Commissioner of 1880 attributed mass
deaths to cholera, measles, small pox, malaria, diahorrea but tellingly left out
starvation. The same happens today when starvation deaths occur. Census
data also is never allowed to reflect deaths due to starvation or migration due
21 Blair, Charles, “Indian Famines their Historical, Financial & Other Aspects”, New Delhi, Agricole
Reprints Corporation, 1986, p.85.
22 Ibid, p.107.
23 Ibid, p. 106.
to intense food scarcity24. There is also a neglect of psycho-social care, as well
as rehabilitative measures for survivors in Codes, past and present,
suggesting an indifference to the enormity of human suffering associated
with mass and individual hunger.
(iv)
Weak Early Detection Systems: The persisting view of scarcity as the
outcome mainly of natural failures, especially of rainfall, is that Codes today
as in the colonial past, continue to depend on diagnosing 'scarcity'
principally on the basis of sharp shortfalls in total rainfall, and in agricultural
production. The latter is measured by processes prescribed in the Codes and
variously described by terms such as annawari or paisawari. Crop-cutting data,
or sample checks of production compared with the average production, is
required, for instance, in Rajasthan, Andhra Pradesh and Orissa. In Orissa,
drought is declared when there is 50 to 75 per cent damage loss in paddy, ragi
and maize crops, which are the basic cereal crops of the area. Unlike Andhra
Pradesh, the Orissa Code does not recognise irregular spacing of rain as
contributory to drought.
The complicated and long drawn out administrative procedures (sometimes
called 'crop-cutting experiments') seek to assess whether crop production in
particular regions of specific mainly food crops are alarmingly below the
average for that region and crop. These tests are possible only at the time
when crops are ready for harvest. One outcome of this is that drought is
declared well after the neediest people have migrated and pulled back on
their food intake, usually only late in December of the year in which rains
have failed, or even later. The Orissa Code contains a very progressive
provision, that allows government to start labour intensive works even
before drought is formally declared, but this is rarely acted upon.
24 Rangasami, “The Masking of Famine: The Role of the Bureausracy”, in Famine and Society”, Edited by
Jean Floud and Amrita Rangasami, Water project Series, New Delhi, The Indian Law Institute, 1993.
Up to the late 1980s, when large scale scarcity relief works, employing
sometimes more than one lakh persons daily in a district were still the norm
in many regions like Chhatisgarh and Rajasthan, the declaration of scarcity
used to be an intensely politically fraught process, and District Collectors
were frequently placed under great informal pressure even to fudge these
statistics, in order to entitle the district to large funds for relief works. I have
observed first hand that such political pressure frequently arose from lobbies
of contractors, bureaucrats and politicians, rather than from impoverished
people.
There are many problems with these outmoded methods of early diagnosis of
impending food scarcity. Not only do they lend themselves to manipulation,
but they establish scarcity only when it is well on the way, and therefore is
less preventive and more enabling of fire fighting after much avoidable
suffering is already under way. They neglect many early signals of distress
and decline into destitution, such as changes and reduction in food intake,
distress migration and sale of assets, distress wages and so on. They
overemphasise rainfall failures, and neglect rainfall variations which may be
more damaging to crop production, but also price fluctuations that can be
devastating for farmers producing for an increasingly globalised market,
damage to forest produce such as mahua or tendu leaf, on which local
populations may be more dependent, or the flowering of bamboo, or fall in
water table and consequent drying up of sources of drinking water25.
The Andhra Pradesh Handbook includes not only unusual migration of
people and herds but also many offbeat and socially insightful early signs of
scarcity, such as decline in rail travel and festival participation, increase in
crime and consumption of liquor. But in practice, relief works are still linked
25 GOI “The drought of 1987, Response management, Volume 1, National Efforts” , Edited by D.C.
Mishra., Newdelhi, Dept, of Agriculture and Co-operation, Ministry of Agriculture.
only to rainfall failures or aberrations26. A 3 year average is taken as the
baseline, but this is misleading in chronically drought prone districts, where
the baseline is itself too low to secure rural well-being. The Handbook does
not recognise failure of non timber forest produce as a source of drought,
which discriminates against the food survival needs of the poorest forest
dependent communities.
(v)
Neglect of non-farm rural poor, nomadic and migrant workers: The Famine
Codes of the past recognised that non-farm rural poor persons, like artisans
and weavers, may be very hard hit by famine, but did little to address their
food needs, even while recognising that they were not equipped physically
and culturally to participate in the kind of manual labour that is required in
public relief works. This required the design of public works that catered to
their specific skills. This was never done, except for casual references in some
public documents of those times to the effect that the distribution of cloth as
part of gratuitous relief would hopefully create some opportunities for work
for weavers. Although weavers and other artisans continue to suffer
enormous setbacks today, even more so because of their highly unequal
integration with global markets, and reports pour in of both starvation and
suicides by weavers, they are neglected in even in contemporary Codes. The
Andhra Pradesh Handbook, for instance, contains just one section that
requires the listing of village artisans affected by drought, but follows this
with no specific relief. The Rajasthan Code provides for loans against
collateral for ambar charkhas (or modified spinning wheels) for weavers, with
no provision for marketing or to ensure them a daily living wage during the
period of scarcity.
In many regions like Rajasthan, nomadic pastoral communities migrate to
survive scarcity. British administrators were averse to what they saw as
26 Das Sana, A Critique ofFamine Codes in India: A study of the Andhra Pradesh Handbook on Drought
management & Vulnerable People's entitlements ”, New Delhi, Action Aid, 2001, p 68.
'aimless wandering' and found it potentially socially disruptive, therefore
they discouraged it. These attitudes persist, and efforts are constantly made
to 'setde' these communities27. The shrinking of commons and curbing of
forest rights and access have led to reduced pastures and fodder availability
to pastoral communities dependent on livestock. This has led to still greater
dependence of these communities on State support for their fodder needs,
and various Codes include provisions for cattle camps and gaushalas for
starving cattle in times of acute scarcity28, but the scale remains small, and the
needs of these communities remains substantially unaddressed both in
situations of crisis. The Andhra Pradesh Handbook, for instance, provides for
cattle camps where starving cattle are fed at government expense, and fodder
banks which supply farmers cattle feed at half cost, but there is no special
focus in any of this for the specific protection of the small pastoralist and
farmer. Besides, there is no assurance that these camps will actually be
started, and if so when, therefore affected people do not know whether or not
they should migrate29.
Distress migrants to cities, both in normal times of want and in extraordinary
emergent situations of food scarcity, are again neglected both in Codes and
contemporary food schemes. Because they are not of local residence in places
where they migrate, they are routinely deprived of ration cards; they have to
buy food from private shops in an unfamiliar market, and they have been
found to buy broken rice fit only to be fed o cattle; their children are debarred
entry into ICDS feeding centres, and from schools both to access education
and mid day meals; women are denied maternity benefits as well as the
services of ICDS, and aged and disabled people their pensions. These
problems are aggravated in instances of migration between states, where the
27 Kavoori, Pumendu, kiThe social Distribution ofLand and the Variable Significance of Migratory
Pastoralism in the Ecological context ofDrought: Interpreting Some Evidence from Western Rajastan
Jaipur, IDS.
28 Singh, K.S, “Famine and Society” in “ Water Project Series ”, Edited by Jean Flood and Amrita
Rangasami, New Delhi, The Indian Law Institute, 1993.
29 Chattopadhaya, Boudhan, “ Food Security and the Social Environemnt-Food Systems and the Human
environment. Vol 1, Calcutta, Cressida Research Team, K.P Bagchi Co, 1991.
host state refuses to expend its resources for migrants who have come to it in
search of work, often in semi-bonded conditions. The Andhra Pradesh
Handbook, as well as the Rajasthan Code, is silent about the food needs of
migrants from other states. At the same time, their rights and those of their
dependents need to be protected at the places of their origin as well. The
Andhra Pradesh Handbook assures entitlement to women, children and the
aged who are left behind when able bodied members migrate, to gratuitous
relief and supplementary nutrition.
(vi)
Gratuitous Relief and Social Security: Gratuitous relief is the provisioning of
food, cash or other life needs like clothes without requiring labour or
collateral from the people who receive this form of relief. British relief policy
haltingly incorporated programmes of gratuitous relief for persons who were
physically incapable of working on relief sites (or were culturally barred
because of purdah and 'high' caste). There was provision in the Bengal Relief
Code30 for instance, to "distribute such gratuitous relief, in the forms of
money or food, as may be necessary" and to "open and maintain such
temporary hospitals, poor houses, orphanages, and places for the gratuitous
distribution of food as may be necessary". The quantum of assistance and
numbers thus served, however, were severely restricted.
In independent India, in some major scarcities, large community kitchens
were set up and dry rations distributed, but by and large these have been
found inessential in the changed nature of mass food scarcity. The Andhra
Pradesh Handbook contains provisions for gruel kitchens and relief camps,
but the quantum of assistance is not specified, and these are rarely set up.
The rules themselves exclude those who benefit from pensions and other
schemes, neglecting their enhanced needs in such times, and there is no
special targeting of single women and children. An excellent feature is to feed
dependents such as children and old people of those who migrate, which is
30Govt of Bengal, ^Famine Manual”, Bengal, Revenue department, 1941, p 4
sorely needed but not found in Codes like Orissa, but there are no
operational details and much of this remains on paper31. The Orissa Code
also specifically includes out of school children for feeding, and people who
may have migrated from other district or place. The Rajasthan and Orissa
Codes continues to use outdated and politically incorrect derogatory terms
like idiots, the insane, the crippled and women of 'respectable birth, (as
though those born into disadvantaged castes are not respectably born!) to list
those entitled to gratuitous relief, but more gravely they leave large gaps in
coverage of people in need, and frequently do not in practice provide such
assistance at all32.
It may be argued that 'gratuitous' relief as a form of State charity has given
way gradually to social security as rights, the public distribution system
(PDS), to entitlement feeding programmes like the ICDS, mid day school
meals and pensions for aged and disabled people and widows. However,
these are rarely adapted to the special needs created by situations of food
scarcity, except for stray instances such as recent orders to distribute meals to
school going children at schools even during vacations, in districts reeling
under drought. But even this was not by executive order, but by intervention
by the Supreme Court in the writ petition 196 of 2001, PUCL vs. the Union of
India and others. A large emergency feeding programme introduced in the
ZKBK' districts of Orissa infamous for endemic hunger, again at the
intervention of the statutory National Human Rights Commission. The
Andhra Pradesh Handbook directs that care should be taken to ensure
adequate stocking and functioning of PDS shops in drought areas, and
doubles the allocations for drought affected populations. But PDS targeting
introduced from 1996 excludes many needy persons, and even the double
allocation is less than the minimum prescribed by the Supreme Court even
for normal times, namely 35 kilograms per family per month. It ranges
31 Das Sana, A Critique of Famine Codes in India: A study of the Orissa Relief Code & Vulnerable People's
Entitlements ”, New Delhi, Action Aid, 2001, p 76.
32 Das Sana, A Critique ofFamine Codes in India: A study of the Rajasthan Relief Code & Vulnerable
People’s Entitlements”, New Delhi, Action Aid, 2001, p 16
instead between 10 and 16 kilograms. It does not place a discretionary stock
of 2 quintals of grain with the Sarpanch for immediate intervention to
prevent starvation, as is provided for in both Orissa and Rajasthan (one
quintal). But even in these states, this amount is token, barely sufficient to
meet the scale of need.
The Andhra Pradesh Handbook33 describes drought as a 'creeping disaster',
leading to invariable food shortage, and especially high infant mortality. It
provides for supplementary feeding to children below 15 years, to pregnant
and lactating mothers, and old people. The Orissa Code excludes the last. The
Rajasthan Code mentions only 'famine orphans' for special feeding. \\ itlr Lhi.
universalisation of ICDS and mid day meals, there is need now for greater
convergence with food schemes of normal times, and for augmenting these
with higher allocations per head in times of scarcity, and inclusion of left out
groups like out of school children for mid day meals. The Andhra Pradesh
Handbook also is sensitive to the exclusion and higher food vulnerability of
SC ST populations, and therefore directs that these are located in SC ST
villages, as well as slums. The Orissa Relief Code provides for 3 kinds of
gratuitous relief: emergent (in natural disasters like cyclones but not
droughts), ad-hoc (food and clothes for a maximum of 15 days); and 'on
cards' (where crop loss is more than 50 per cent). The last is amore enduring
entitlement, enabling them to access cooked food from on-going feeding
programmes, but studies have shown that in practice large numbers are
excluded from these schemes like emergency feeding34. The Rajasthan Code
does not provide for emergent relief, but gratuitous rehef can be given to
those unable to work who are not getting pensions. But like in other states,
this is rarely operated. This was a spur for the PUCL to file a petition on the
right to food in the Supreme Court in 2001, to which reference has already
been made (196 of 2001, PUCL vs. the Union of India and others).
33 Das Sana, A Critique ofFamine Codes in India: A study of the Andhra Pradesh Handbook on Drought
management & Vulnerable People’s entitlements ”, New Delhi, Action Aid, 2001, p 68.
34 CENDERET ‘‘The Murky twilight: An Unending Questfor Survival, Bolagir Drought-2001 ”, Orissa,
Western Orissa Resource Centre, Xavier Institute of management.
The State also mostly persists in the characterisation of vulnerable people
with special needs as, in effect, unemployable. It overlooks the fact that most
disabilities are social rather than biological constructions, and schemes can be
sensitively designed for the dignified employment of disabled people, single
women and aged people, but these have to break out of the overarching
model of conventional public works. The Rajasthan Code specifically debars
disabled people from employment in relief works, and at the same time (in
violation of the law) permits children to labour in relief works35.
There is also the continuous preoccupation in separating out the 'deserving'
from the 'undeserving' poor. This finds echoes in even in the mandate of free
India's Constitution (article 41) which enjoins the State to secure the right to
work, to education, and to public assistance in cases of unemployment, old
age, sickness, disablement, and in other cases of 'undeserved want'. The
notion that some bring penury and destitution upon themselves or that they
somehow deserve it is, however, questionable, because of the complex ways
in which social inequities come to bear on individual actions.
(vii)
Neglect of Starvation, Malnutrition and Chronic Hunger: British famine
policy limited itself to preventing mass starvation deaths, but ignored the
consequences of malnutrition from prolonged food denials, such as
succumbing to eminently curable ailments. Today bureaucracies again deny
starvation deaths, and do not hold themselves accountable for the deleterious
effects of prolonged food denials. Indeed, it is again reiterated that with the
end of large scale famines, the most important manifestation of hunger is not
in the acute denial of food, associated with famines and scarcities, but with
endemic chronic denials as a way of life even in ordinary times, but even
more threatened in times of personal, local or larger emergencies. These are
35 Das Sana, A Critique of Famine Codes in India: A study of the Rajasthan Relief Code & Vulnerable
People’s Entitlements ”, New Delhi, Action Aid, 2001, p 9.
people who may not always die of starvation, but they live with it, as an
element of daily living. Codes, past and present, do nothing to address these.
In fact, in the past. Codes have strictly warned against the zmisuse, of relief
by people who live even in normal times with denial.
Many contemporary Codes, such as that of Rajasthan, do not even admit to
the possibility of deaths by starvation. Even other Codes like that of Orissa
recognise only mass deaths as an indication of famine, and individual
starvation is so difficult to prove36 that in effect it has been banned simply by
official decree! The Andhra Pradesh Handbook requires that the Collector
gives weekly reports of starvation deaths, but it is completely silent about
how such deaths are defined and verified, and the responsibilities to the
victim family, psychosocial counselling and rehabilitation of survivors, and
the accountability of public officials. The Orissa Code is even more stringent,
requiring Collectors to submit a report within 48 hours of a starvation death,
but there are no penalties for their failures to do so (despite the fact that such
lapses remain the rule rather than the exception). In a landmark judgement in
the Kishan Patnaik vs. the State of Orissa case in 1989, the Supreme Court
confirmed the veracity of complaints of starvation deaths, but held that it had
no reason to disbelieve that the state government was doing ah it could to
deal with the unfortunate situation.
Government programmes are woefully inadequate to prevent starvation and
address destitution. Our evidence is that apart from major leakages and
corruption, the coverage of these schemes is so meagre that they leave huge
gaping holes in the social security net through which large numbers of most
destitute women and men, girls and boys slip through measures to prevent
and reverse starvations, or the persistence absolute hunger. It is stressed that
this is a duty not to the dead, but to the precariously living. It requires public
36 Das Sana, A Critique ofFamine Codes in India: A study of the Rajasthan Relief Code & Vulnerable
People’s Entitlements”, New Delhi, Action Aid, 2001, p 38-39.
vigilance about individuals, conununities and several categories living with
starvation and absolute hunger.
Central and state governments do rim some of the largest entitlement feeding
programmes, distribute subsidised foodgrains through a massive network of
fair-price shops, and support vulnerable groups like old people, widows and
disabled people, with pensions, and mothers with maternity benefits.
Famines in British India were seen as famines of 'work' rather than of 'food',
assuming that there was enough food and this could easily be transported to
places with scarcity through the network of railways. But the enormous
devastation of the Bengal Famine of 1943 exploded this myth, and this
contributed in India to the creation of an impressive Public Distribution
System, although government has limited it coverage through targeting since
1996. It required the mediation of the Supreme Court in the writ petition in
the writ petition 196 of 2001, PUCL vs. the Union of India and others, to
convert some of these measures into universal entitlements, such as noon day
school meals and supplementary feeding of infant, small children and
expectant mothers. 60 years after Independence, a modest pension has been
converted into an entitlement of all aged people who are designated poor.
These schemes still fall short of addressing hidden hunger in 3 main ways: a),
gender, caste and other social barriers, as well as governance failures such as
of corruption and leakages, exclude large numbers of the most needy from
accessing these schemes; b) even in times of declared food scarcity, there is
no augmenting of these food schemes and entitlements; and c) in the
background of denial of a situation of large numbers of people living with
starvation even in normal times, they do not recognise the need for special
intensive interventions for households that live in conditions of chronic
hunger, and of fully excluded groups. An example of the former is that a
child from a home with absolute shortfalls of food will still receive
supplementary nutrition from ICDS centres, when she actually lacks even
primary nutrition. It is only when she slips into third or fourth grade
malnutrition will she be entitled to additional food, but by then her body and
brain has already been irreparably damaged. And of the latter, an example is
of working, street and disabled children, and children of migrant working
families, who are out of school, and therefore denied access to mid day
school meals.
(viii)
Governance Failures: It is remarkable that contemporary scarcity manuals
and codes, continue to rely principally on the permanent bureaucracy at
village, block, district and state government levels, to manage situations of
food scarcity, very tittle different from colonial times. It is not surprising that
many state governments therefore face tittle difficulty in applying Famine
Code procedures developed by colonial administrators to a democratic
polity. This bureaucracy is not directly accountable to the people
democratically; therefore matters literally of life and death, and the onerous
responsibilities for preventing enormous human suffering and loss of life,
cannot be left alone to the non-elected executive. Panchayats today at best
have some role in implementing local relief (as in Madhya Pradesh, Gujarat,
Rajasthan and Orissa) but decision making remains in the hands of the
bureaucracy. Panchayats and other local bodies need to be drawn into the
leadership of all aspects of the management of scarcity, from its early
detection to its withdrawal and further prevention. This is not to deny the
powerlessness and frequent disenfranchisement of most people who are
condemned to live with hunger. But the creation of legal justiciable rights,
and organised civic action around these, have been found to slowly build
democratic sinews of even the weak in securing their rights, especially to life
with dignity.
The procedures and rules under the Codes also remain completely opaque,
another continuity with the past. The Codes need to be rewritten in ways that
inform and engage with affected people at every stage, from the early
detection of food scarcity, its diagnosis, mitigation and relief strategies
including relief works, emergency feeding and other food and survival
support to the vulnerable, fodder camps, arrangements for drinking water,
and the ending of relief and preventive strategies. All these should be
transacted in participatory ways, such that people have the required
information and the spaces to be consulted at every turn, to be informed of
their rights such as to wages and how they are to be calculated, and to
socially audit not just expenditures but also the adequacy of the actions of
elected and permanent public officials to deal with the enormous challenges
posed by the conditions of food scarcity and denial.
Chapter 2
A Scarcity Code for Contemporary Times:
Suggested Features
The persisting culture of vigorous official denial that surrounds living and dying from
hunger and destitution requires a decisively new Scarcity Code that breaks away
decisively from the colonial legacy of Famine Codes, which still influence State response
to food scarcity in a range of ways described in the first chapter of this volume. The
objectives of such a Code would need to need to surge much beyond the minimalist
agenda of the Codes of the past, aiming just to prevent the outbreak of mass deaths due
to starvation in famines at minimum cost to the State exchequer. It would need to
contain cast-iron provisions to protect all men, women and children from short and long
term food denials, hunger, malnutrition and starvation, both in times of unusual
emergency and in more normal times, to enable each of them to secure with dignity their
right to assured and adequate food required to lead a healthy and active life.
We have observed that Codes in the past came into force only after major natural
disasters, mainly failures of rainfall and consequent disruption of agricultural
production. They rarely dealt with starvation and duties of the State to prevent and
mitigate it, and also did not deal with right to food in normal times, and the duties to
people who live with prolonged denials of adequate food. The relief and protections
they afforded to the unfortunate people who lived with acute food denials depended on
the will and benevolence of the State, and was severely constrained by budgetary limits,
and a limited agenda to prevent mass starvation.
In the light of this discussion, this volume tries to suggest an alternative Food Rights
Code, which delineates duties of public authorities to a) ensure the right to food of ah
people in normal times; b) acknowledge, verify and address individual and mass
starvation; c) identify people and groups which live with chronic hunger even in normal
times and take special measures to protect them from starvation and secure their rights
to food; and d) address emergent situations of food scarcity arising from extraordinary
natural, human made and economic situations.
Legal Binding:
The first feature of this Code is that its provisions should be binding on the State: on all
governments - central, state and local. It should carry the force of law. This may be
achieved through two paths, either by acts of Parliament and state legislatures, or by
direction of the Supreme Court of India. It should create not just legal but also moral
rights for all people. It must contain measures of enforceability, such as the right to
information, grievance redressal mechanisms, participatory monitoring mechanisms
such as social audits, and clear lines of accountability of public officials at various levels,
including of penalty for failures. It would be appropriate, therefore, to describe these not
as Famine, Drought or even Scarcity Codes but as Food Rights Codes.
Objectives:
The proposed objectives of the Food Rights Code are as under:
1. To ensure that all people at all times have assured have physical, economic and
social access to sufficient, safe and nutritious food to meet with dignity their dietary
needs and food preferences for an active and healthy life.
2. To establish processes of investigating starvation that are transparent, reliable and
respectful of the dignity of the survivors; and mandatory protocols for intervention
for relief, prevention and accountability.
3. To identify individuals, dispossessed communities, classes and social categories of
people who live with prolonged hunger, malnutrition and starvation, and to
intervene with short, medium and long term measures to mitigate, prevent and
sustainably reverse this situation of chronic hunger.
4. To ensure that emergent situations that threaten mass access to food, such as natural
and human made disasters are anticipated, mitigated and addressed with equity and
speed, without consequences of mass food scarcities.
In subsequent chapters, each of these objectives will be clarified, including the duties
and rights that they create, and the ways in which they can be realised.
Chapter 3
Securing the Right to Food of All People at All Times^
Objective 1 of the Food Rights Code:
To ensure that all people at all times have assured have physical, economic and social
access to sufficient, safe and nutritious food to meet with dignity their dietary needs
and food preferencesforan active and healthy life.
The Code must first lay down the duty of government at all levels to ensure that all
people are able to realise at all times their right to food. The right to food is a human
right, inherent in all people, to have regular, permanent and unrestricted physical,
economic and social access with dignity, either directly or by means of financial
purchases, to quantitatively and qualitatively adequate, assured and sufficient, safe and
nutritious food corresponding to the cultural traditions of people to which the consumer
belongs, for an active and healthy life38.
The legal basis of the right to food has been helpfully spelt by the National Human
Rights Commission (NHRC) in the proceedings of a hearing held on 17 January 2003:
"Article 21 of the Constitution of India guarantees a fundamental right to life and
personal liberty. The expression 'Life' in this Article has been judiciahy interpreted
to mean a life with human dignity and not mere survival or animal existence. In the
light of this, the State is obliged to provide for all those minimum requirements
which must be satisfied in order to enable a person to live with human dignity, such
as education, health care, just and humane conditions of work, protection against
exploitation, etc. In the view of the Commission, the Right to Food is inherent to a
37 This booklet has been adapted from "Supreme Court Orders on the Right to Food : A tool for
Legal Action" originally written by Yamini Jaishankar and Jean Dreze for the Right to Food
Campaign Secretariat in 2005. It has been subsequently revised by Biraj Patnaik and Spurthi
Reddy in September 2007.
, .
38 This definition of the right to food derives from and build upon a definition suggested by the
UN Special Rapporteur on the Right to Food, 2002
life with dignity, and Article 21 should be read with Articles 39(a) and 47 to
understand the nature of the obligation of the State in order to ensure the effective
realization of this right. Article 39(a) of the Constitution enunciated as one of the
Directive Principles, fundamental in the governance of the country, requires the
State to direct its policy towards securing that the citizens, men and women equally,
have the right to an adequate means of livelihood. Article 47 spells out the duty of
the State to raise the level of nutrition and the standard of living of its people as a
primary responsibility. The citizen's right to be free from hunger enshrined in
Article 21 is to be ensured by the fulfilment of the obligation of the State set out in
Articles 39(a) and 47. The reading of Article 21 together with Articles 39(a) and 47
places the issue of food security in the correct perspective, thus making the Right to
Food a guaranteed Fundamental Right which is enforceable by virtue of the
constitutional remedy provided under Article 32 of the Constitution."1
The relevant Arttele. of .he Constitute are as follows:
Article 21: "No person shall be deprived of his life or personal liberty except
according to procedure established by law."
Article 39(a): "The State shall... direct its policy towards securing that the citizen,
men and women equally, have the right to an adequate means of livelihood.
Article 47: "The State shah regard the raising of the level of nutrition and the
standard of living of its people and the improvement of public health as among its
’
A 4
pniiuuy
u
*
*
. ■
Note: Article 32(1) applies to the rights conferred in Part III of the Constitution, known
as "fundamental rights". Article 21 appears in Part III, but not Articles 39(a) and 47.
These appear in Part IV, under "Directive Principles of State Policy".
Ensuring Specific Rights to Food in Normal Times
The Supreme Court of India has elaborated many specific on-going rights to food of
specified segments of people in the Civil Writ Petition, PUCL vs. Union of India and
Others (No. 196/ 2001).
The schemes that have been covered as food entitlements under this case can broadly be
divided into the following categories:
Entitlement Feeding Programmes
Integrated Child Development Services (ICDS): Covers all Children
under the age of six, pregnant and lactating mothers and adolescent girls.
Six essential services are provided as part of the ICDS. These are.
Mid Day Meal Scheme (MDMS): Covers all primary school children
Food Subsidy Programmes
-
Targeted Public Distribution System (TPDS): Provides 35 kgs/ month
of subsidised food grains at half the cost of the economic price to all
famihes identified as living below the poverty line (BPL families)
Antodaya Anna Yojana (AAY): Provides 35 kgs of rice / month @Rs.3
per kilo or 35 kgs of wheat / month @Rs.2 per kilo. This is to around 40%
of the poorest of poor families.
•
Employment Programmes
-
National Rural
Employment
Guarantee
Scheme
(100
days
of
employment at minimum wages)
-
Sampoorna Gramin Rojgar Yojana (Food for work programme that is
being phased out and replaced by the NREGS)
Social Assistance Programmes
-
National Old Age Pension Scheme (Monthly pension to all BPL adults
above the age of 65)
-
National Family Benefit Scheme (Compensation of Rs.10,000 in case of
death of bread winner of BPL families)
-
Annapurna Yojana: Provides 10 kgs of free food grain for destitute poor
who are not covered under the National Old Age Pension Scheme
(NOAPS)
The Public Distribution System
Background
The Public Distribution System (PDS) is a means of distributing foodgrain and
other basic commodities at subsidised prices through fair price shops . Every family is
supposed to have a ration card. In 1997, the PDS became "targeted": wherein different
ration cards were issued to households "Below the Poverty Line
(BPL) and those
"Above the Poverty Line" (APL), and each category has different entitlements. Today,
both BPL and APL households are entitled to 35 kgs of grain per month, but the issue
price is higher for APL households. In fact, it is so high that most APL households do
not buy grain from the PDS. Thus, in practice the PDS is restricted to BPL households.
Even in years when the APL prices correspond very closely with the market prices, the
offtake of APL has remained very low since State Governments are not lifting their APL
quotas. The Government of India has now reduced the APL quotas for all States and
restricted it to the average of the last three years of APL offtake for that particular State.
In 2001 Antyodaya cards were introduced as a sub-category of BPL cards.
However, the Supreme Court later stated that the Antyodaya programme should not be
restricted to those with a BPL card (see Section 2.3). Thus, Antyodaya cards have
become a separate card, distinct from either BPL or APL. Some households also have
other cards, such as Annapurna cards (see Section 2.9).
The PDS, like many other large scale food and employment scheme is also confronted
with many governance related issues including wide spread leakages and corruption at
all levels of operation. The Supreme Court has taken notice of this and formed a Central
Vigilance Committee on the Public Distribution System in its order dated 12 July 2006.
The CVC (PDS) is chaired by Justice (Retd.) DP Wadhwa with the Commissioner of the
Supreme Court, Dr.NC Saxena as the Member-Convenor. The Committee is presently
looking into the maladies that are affecting the proper functioning of the Public
Distribution System and suggesting remedial measures. The CVC has since submitted
its report (August 2007) and it will be taken up by the Supreme Court shortly.
Supreme Court Orders
1. Identification of BPL families: On 28* November 2001, the Court directed the State
Governments "to complete the identification of BPL families, issuing of cards and
commencement of distribution of 25 kgs. grain per family per month latest by 1st
January, 2002". Note that the entitlements of BPL families were subsequently raised
from 25 kgs of grain per month to 35 kgs.
The Planning Commission announced (in 2004), the BPL percentage population to be at
26%, which would have meant a drastic reduction in grain allocation by the Central
Government. However the order of 14th February 2006, directed the central government
to allocate food grain on the basis of Planning Commission estimates
poverty rations, which is at 36%. On the BPL list, see also para 6 below.
of
1993-94
2. Accessibility of ration shops and regular supply of grain: On several occasions, the
Supreme Court directed the government to ensure that all ration shops open regularly.
For instance, one of the very first interim orders (dated 23 July 2001), states: "We direct
the States to see that all the PDS shops, if closed, are re-opened and start functioning
within one week from today and regular supplies made." Similarly, an interim order
dated 8 May 2002 states: "The respondents shall ensure that the ration shops remain
open throughout the month, during fixei hours, the details of which will be displayed
on the notice board."
3. Accountability of PDS dealers: The licenses of PDS dealers and shop-keepers should
be cancelled if they: "(a) do not keep their shops open throughout the month during the
stipulated period; (b) fail to provide grain to BPL families strictly at BPL rates and no
higher; (c) keep the cards of BPL households with them; (d) make false entries in the BPL
cards; (e) engage in black-marketing or siphoning away of grains to the open market and
hand over such ration shops to such other person/ organizations .
Further,
the
concerned authorities/functionaries would not show any laxity on the subject .39
4. Monitoring of the PDS40:
A Central Vigilance Committee has been constituted to investigate the maladies
affecting the proper functioning of the public distribution system, and
suggest
remedial measures. "For this purpose, the Committee shall, amongst other things, focus
on: - a) The mode of appointment of the dealers; b) the ideal commission or the rates
payable to the dealer and; c) modalities as to how the Committees already in place, can
function better, d) Modes as to how there can be transparency in allotment of the food
stock to be sold at the shops."
Apart from this the Committee shall also suggest a transparent mode of appointing
PDS dealers; and ways to make the existing vigilance committees more effective.
39 Supreme Court Order dated 2nd May, 2003.
40 Supreme Court Order dated 12th July 2006
4. Permission to buy in instalments: Arrangements must be made to "permit the BPL
household to buy the ration in instalments".41
5. Awareness generation: "Wide publicity shall be given so as to make BPL families
aware of their entitlement."42
6. BPL list: Orders relating to the "BPL list" are also relevant to the Public Distribution
System, since the BPL list is the basis on which BPL and APL ration cards are
distributed. These orders are discussed in Section 2.12. Note in particular that (1) the
Central and State Governments have been directed to "frame clear guidelines for proper
identification
of
BPL
families"43
in
consultation with
the
Supreme
Court
Commissioners44 and; (2) no-one is supposed to be removed from the BPL list until such
time as the Court deliberates this matter.45
Comments
1. The Supreme Court orders on the PDS should be read together with the Central
Government's "PDS (Control) Order" of August 2001. This Order contains sweeping
directions for holding FPS managers and others accountable,and should be read in
conjunction with the Essential Commodities Act. Taken together, these three sets of
orders (Supreme Court orders, PDS Control Order and Essential Commodities Act) can
be used quite effectively to ensure that people get their due.
2. BPL targeting has attracted widespread criticism. There is much evidence that the
"BPL list" is highly unreliable: well-off households often have a BPL card while poor
households have an APL card, if they have a card at all. This is partly because the BPL
41 Supreme Court Order dated 2nd May, 2003.
42 Supreme Court Order dated 2nd May, 2003.
43 Supreme Court Order dated 8th May, 2002.
44 Supreme Court Order dated 14th February 2006.
45 Supreme Court Order dated 5th May, 2003.
survey" used for identifying families below the poverty line is fundamentally flawed.
This issue has been taken up in Supreme Court hearings from time to time - see Section
2.12 for further discussion.
3. Orders relating to Antyodaya Anna Yojana and Annapurna (see below) are also
relevant to the Public Distribution System, since these schemes are implemented
through the PDS.
Antyodaya Anna Yojana
Background
The aim of this scheme, launched in 20004 is to provide special food-based assistance to
destitute households. These households are given a special ration card (an "Antyodaya
card"), and are entitled to special grain quotas at highly subsidised prices. Today,
Antyodaya cardholders are entitled to 35 kg of grain per month, at Rs 2/kg for wheat
and Rs 3/kg for rice. Initially, the Antyodaya scheme covered 1 crore families, but this
was later expanded to 1.5 crore families and then 2 crore families. Currently, around
40% all BPL families are included in the Antyodaya category.
Supreme Court Orders
1. Orders related to the Public Distribution System also apply to Antyodaya Anna
Yojana (AAY), since AAY is a component of the PDS. For instance, the order of 23rd July
2001, directing State Governments to ensure regular supply of grain to the ration shops
applies to AAY also.
2. The State Governments were requested to consider providing grain free of cost to
those who are so poor that they are unable to lift their quota, even at the highly
subsidised AAY prices.46
46 Supreme Court order dated 28th November 2001.
3. The Central Government "shall formulate the scheme to extend the benefits of the
Antyodaya Anna Yojana to the destitute section of the population".47
4. On 2nd May 2003, the Supreme Court declared that all households belonging to six
"priority groups" would be entitled to Antyodaya cards.
More precisely, the
Government of India was directed "to place on AAY category the following groups of
persons:
(1) Aged, infirm, disabled, destitute men and women, pregnant and lactating
women, destitute women;
(2) widows and other single women with no regular support;
(3) old persons (aged 60 or above) with no regular support and no assured means
of subsistence;
(4) households with a disabled adult and assured means of subsistence.
(5) households where due to old age, lack of physical or mental fitness, social
customs, need to care for a disabled, or other reasons, no adult member is
available to engage in gainful employment outside the house;
(6) primitive tribes."
5. Possession of a BPL card is not necessary for inclusions in the AAY category. The
Central Government was directed to issue guidelines to this effect.48
47 Supreme Court order dated 29th October 2002.
48 Supreme Court Order dated 20th April, 2004.
6. In April 2004, the Court asked the Central Government to direct the State
Governments to “accelerate the issue of Antyodaya cards especially to primitive tribes .
Further, "the guidelines issued to State Governments shall be implemented in letter and
spirit".49
7. In the order dated 17th October 2004, the State Governments were directed to
complete the identification of AAY families and the distribution of AAY cards "by the
end of the year", and to begin the distribution of grain to AAY cardholders
"immediately". Further, the AAY cardholders "should not be made to pay, directly or
indirectly, any amount other then what they are liable to pay for the supply taken .
Comments
The most important order here is the order of 2nd May 2003, whereby six
"priority groups" are entitled to Antyodaya cards as a matter of right. However, the
government is yet to devise (and implement) an effective procedure to ensure that all
households in these priority groups are identified and covered under AAY. In the case
of (so-called) "primitive tribes", the task is relatively easy, and in some states at least
Antyodaya cards have been distributed to most famihes in this group.
The other
groups, however, by and large do not have universal access to the AAY scheme.
Mid-day Meal Scheme*
Background
As mentioned earlier, the Supreme Court order of 28th November 2001 directs
State Governments to start providing cooked mid-day meals in primary schools. Every
child who attends a government or government-assisted primary school is now entitled
to a cooked, nutritious mid-day meal every day.
49 Supreme Court Order dated 20th April, 2004.
* For a more detailed discussion of mid-day meals, see Mid-Day Meals: A Primer, available from
the secretariat of the Right to Food Campaign as well as from the office of the Commissioners of
the Supreme Court (the addresses are given in Appendix 2).
The provision of cooked mid-day meals in primary schools is an important step towards
the right to food.
Indeed, mid-day meals help to protect children from hunger
(including "classroom hunger", a mortal enemy of school education), and if the meals
are nutritious, they can facilitate the healthy growth of children. Mid-day meals also
serve many other useful purposes. For instance, they are quite effective in promoting
regular school attendance, and in that respect mid-day meals contribute not only to the
right to food but also to the right to education. Mid-day meals also help to undermine
caste prejudices, by teaching children to sit together and share a common meal. They
reduce the gender gap in school participation, provide an important source of
employment for women, and liberate working women from the task of having to feed
children at home during the day. Aside from this, mid-day meals can be seen as a
source of economic support for the poorer sections of society, and also as an opportunity
to impart nutrition education to children. For all these reasons, the Supreme Court
order on mid-day meals has been widely welcome, especially among disadvantaged
sections of society.
Supreme Court Orders
So far, there have been two crucial Supreme Court orders on mid-day meals: on 28th
November 2001 and 20th April 2004, respectively. Further orders have been issued from
time to time also. The landmark order of 28* November 2001 clearly directed all State
Governments to introduce cooked mid-day meals in primary schools:
"The State Governments /Union Territories to implement the Mid Day Meal Scheme
by providing every child in every Government and Government assisted Primary
Schools with a prepared mid day meal with a minimum content of 300 calories and
8-12 grams of protein each day of school for a minimum of 200 days."
This was supposed to be done within six months. But most State Governments
took much longer, prompting the Supreme Court to issue stern reminders to them from
time to time (e.g. on 2nd May 2003). A series of important follow-up orders were issued
on 20th April 2004, to speed up the implementation of earlier orders, improve the quality
of mid-day meals, and address various concerns raised in the Commissioners' reports.
These orders include the following:
1. Timely compliance: "All such States and Union Territories who have not fully
complied with the order dated 28th November, 2001 shall comply with the said
directions fully in respect of the entire State/Union Territory... not later than 1st
September, 2004."
2. No charge: The meal is to be provided free of cost. Money for the meal is not to be
collected from parents or children under any circumstances.
3.
Priority to SC/ST cooks and helpers: 'Tn appointment of cooks and helpers,
preference shall be given to Dalits, Scheduled Castes and Scheduled Tribes.
4.
Extension to summer vacations in drought-affected areas: "In drought-affected
areas, mid-day meal shall be supplied even during summer vacations."
5. Kitchen sheds: The Central Government was directed to "make provisions for
construction of kitchen sheds" and also to contribute to the cooking costs.
6. Quality improvements: "Attempts shall be made for better infrastructure, improved
facilities (safe drinking water etc.), closer monitoring (regular inspection) and other
quality safeguards as also the improvement of the contents of the meal so as to provide
nutritious meal to the children of the primary schools."
7. Fair quality of grain: In the order dated 28fh November 2001, the Supreme Court
directed the Food Corporation of India (FCI) to "ensure provision of fair average
quality grain" for mid-day meals. Joint inspections of the grain are to be conducted by
the FCI and State Governments. "If the food grain is found, on joint inspection, not to be
of fair average quality, it will be replaced by the FCI prior to lifting.
8. Extension to Class 10: On 20th April 2004, the Government of India was directed to file
an affidavit within three months, " stating as to when it is possible to extend the scheme
up to 10th Standard in compliance with the announcement made by the Prime Minister."
In response to this, an affidavit was filed by the Department of Elementary Education
(Ministry of Human Resources Development) in 2004, but the Court is yet to examine it.
In October 2004, the Court noted that some progress had been made with the
implementation of earlier orders on mid-day meals. However the feedback received
from the States made it clear that implementation was being held up by a lack of funds
in many cases. The Court then directed the Central Government to provide financial
assistance of "one rupee per child per school day" to meet cooking costs. The Court also
clarified that the responsibility to monitor the implementation of the mid-day meal
scheme "essentially lies with the Central Government" .so Again, the Court stressed the
urgency of the situation and directed that "every child eligible for a cooked meal under
the Mid-Day Scheme in all States and Union Territories shall be provided with the said
meal immediately".
Comments
Although the MDMS is now one of the relatively better performing schemes as
compared to other schemes, the implementation of these orders has been a long and
arduous process, but over time, most State Governments have fallen in line. Today,
about 12 crore51 children are getting a cooked mid-day meal at school every day.
However, the quality of mid-day meals remains quite poor in many states: the content of
the meal is inadequate, health safeguards are lacking and social discrimination is
common. Also, nothing has been done to extend mid-day meals beyond the primary
stage. Further action is required to consolidate the gains that have been made and to
ensure that mid-day meals live up to their promise.
50 Supreme Court Order dated 17th October 2004.
51 Official figures available on the website of the Ministry of Human Resource Development
www.education.nic. for the year 2005-06
Integrated Child Development Services
Background
ICDS is the only major national programme that addresses the needs of children under
the age of six years. It seeks to provide young children with an integrated package of
services such as supplementary nutrition, health care and pre-school education. Because
the health and nutrition needs of a child cannot be addressed in isolation from those of
his or her mother, the programme also extends to adolescent girls, pregnant women and
lactating mothers.
These services are provided through ICDS centres, also known as anganwadis . Today
there are 8.44 lakh anganwadis in the country, covering 5.8 crore children in the age
group 6 months to 6 years.52 This is less than half of ah children in the 0-6 age group
53[check]. The coverage of ICDS is therefore far from universal. Further, the quality of
ICDS services is very low in most states. The Supreme Court orders on ICDS are
essentially aimed at achieving "universalisation with quality within a reasonable time
frame.
Supreme Court Orders
Here again the crucial order goes back to 28th November 2001, when the Supreme Court
directed the government to "universalize" ICDS:
52 Seventh Report (March 2007) of the Commissioner appointed by the Supreme Court in the
'Right to Food' case. To read the full report please visit www.righttofoodindia.org.
53 It is estimated that population of children in the 0-6 years age group is about 14 crores. Source:
Government of India (2007), "Sarva Baal Vikas Abhiyan", draft. Ministry of Women and Child
Development, page 1; based on 2006 Population Projections from Census data
"(i) We direct the State Govts. / Union Territories to implement the Integrated
Child Development Scheme (ICDS) in full and to ensure that every ICDS
disbursing centre in the country shall provide as under:
(a) Each child up to 6 years of age to get 300 calories and 8-10 gms of protein;
(b) Each adolescent girl to get 500 calories and 20-25 grams of protein;
(c) Each pregnant woman and each nursing mother to get 500 calories & 20-25 grams
of protein;
(d) Each malnourished child to get 600 calories and 16-20 grams of protein;
(e) Have a disbursement centre in every settlement/'
This order, however, received very little attention for several years, Virtually nothing
was done to implement it. In April 2004, several marathon hearings on ICDS were held
in the Supreme Court and detailed orders were issued, followed by further orders on 7
October 2004. This was followed by a landmark judgement regarding the ICDS scheme
on 13 December 2006. However before, detailing the 13 December orders, we shall look
at a few key directions of the 7 October 2004 order. The key orders in this series are as
follows:
1. The Supreme Court directed the Government of India to increase the number of
anganwadis from 6 lakh to 14 lakh habitations, and to "file within three months an
affidavit stating the period within which it proposes to increase the number of
anganwadi centers (AWCS) so as to cover the 14 lakh habitations.
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2. "All the State Governments/UTs shall allocate funds for the ICDS on the basis of one
rupee per child per day, 100 beneficiaries per AWCS and 300 days feeding in a year, i.e.
on the same basis on which the centre makes the allocation."*
4. All SC/ST habitations should have an anganwadis "as early as possible". Until the
SC/ST population is fully covered, all new anganwadis should be located in habitations
with high SC/ST populations.
5. "All State/UTs shall make earnest effort to cover the slums under the ICDS."
6. ICDS services should never restricted to BPL families ("BPL shall not be used as an
eligibility criteria for ICDS").
7. "Contractors shall not be used for supply of nutrition in Anganwadis and preferably
ICDS funds shall be spent by making use of village communities, self-help groups and
Mahila Mandals for buying of grains and preparation of meals."
8. ICDS funds provided by the Central Government under the Pradhan Mantri
Gramodaya Yojana (PMGY) should be fully utilised by the State Governments. Further
these funds supplement, and not substitute for, ICDS funds provided by the State
Governments. Hmoever the PMGY has been discontinued since 2005/06 and the programme
has been closed.
9. "The Central Government and States/UTs shall ensure that all amounts allocated are
sanctioned in time so that there is no disruption whatsoever in the feeding of children."
I
* Note:This order effectively raises the budget norm for supplementary nutrition under ICDS to
"two rupees per child per day". On 7th October 2004, when the above order was issued, the
Supreme Court also stated that "the aspect of sanctioning 14 lakhs AWCS and increase of norm of
rupee one to rupees 2 per child per day would be considered by this Court after two weeks".
However, this follow-up discussion is yet to take place.
10. "All State Governments/UTs shall put on their websites full data for the ICDS
schemes including where AWCS are operational, the number of beneficiaries category
wise, the funds allocated and used and other related matters."
11.The entitlements of children under six have been further strengthened in the Supreme
Court judgement of 13 December 2006. This can be considered a landmark judgement
because in general, the judiciary refrains from imposing a financial responsibility on the
state. The directions contained in this order are seminal and are presented below.
"(1) Government of India shall sanction and operationalize a minimtun of 14 lakh
AWCs in a phased and even manner starting forthwith and ending December
2008. In doing so, the Central Government shall identify SC and ST
hamlets/habitations for AWCs on a priority basis.
(2) Government of India shall ensure that population norms for opening of
AWCs must not be revised upward under any circumstances. While maintaining
the upper limit of one AWC per 1000 population, the minimum limit for opening
of a new AWC is a population of 300 may be kept in view.
Further, rural communities and slum dwellers should be entitled to an
" Anganwadi on demand" (not later than three months) from the date of demand
in cases where a settlement has at least 40 children under six but no Anganwadi.
(3) The universalisation of the ICDS involves extending all ICDS services
(Supplementary nutrition, growth monitoring, nutrition and health education,
immunization, referral and pre-school education) to every child under the age of
6, all pregnant women and lactating mothers and all adolescent girls.
(4) The order also specifies the monetary allocation to be made per beneficiary
under the ICDS scheme. The court instructs all State Governments and Union
Territories to fully implement the ICDS scheme by, interalia.
(i) allocating and spending at least Rs.2 per child per day for
supplementary nutrition out of which the Central Government shall
contribute Rs.l per child per day.
(ii) allocating and spending at least Rs.2.70 for every severely
malnourished child per day for supplementary nutrition out of which
the Central Government shall contribute Rs.1.35 per child per day.
(iii) allocating and spending at least Rs.2.30 for every pregnant women,
nursing mother/adolescent girl per day for supplementary nutrition
out of which the Central Government shall contribute Rs.1.15.
(6) Chief Secretaries of all State Governments/UTs are directed to submit
affidavits with details of all habitations with a majority of SC/ST households, the
availability of AWCs in these habitations, and the plan of action for ensuring that
all these habitations have functioning AWCs within two years.
(7) Chief Secretaries of all State Governments/UTs are directed to submit
affidavits giving details of the steps that have been taken with regard to the
order of this Court of October 7th, 2004 directing that "contractors shall not be
used for supply of nutrition in Anganwadis and preferably ICDS funds shall be
spent by making use of village communities, self-help groups and Mahila
Mandals for buying of grains and preparation of meals". Chief Secretaries of all
State Governments/UTs must indicate a time-frame within which the
decentralisation of the supply of SNP through local community shall be done."
Comments
The Supreme Court orders of April and October 2004 gave a useful wake-up call to the
government, as far as the universalization of ICDS is concerned. The universalization of
ICDS was included in the National Common Minimum Programme of the UPA
Government in May 2OO4.The judiciary's continued focus on ICDS starting with the
December 2006 judgement promises to keep the issue alive till universatisation of ICDS
is effected. The National Advisory Council submitted detailed recommendations for
achieving ^universalization with quality,, in October 2004, and some
recommendations" in February 2005 (see www.nac.nic.in).
follow-up
The expenditure of the
Central Government on ICDS was roughly doubled (from Rs 1,500 crores to Rs 3,000
crores) in the Union Budget 2005-6.
However, according to conservative estimates, the recent judgement (13 December
2006) necessitates a budgetary allowance of Rs 9000 crore per annum. In this tight the
2007-08 Union Budget allocation of Rs 4,761 crores is minimalistic. This allocation has
barely increased in real terms, and remains virtually unchanged as a proportion of GDP.
As far as the situation on the ground is concerned, the issue of entitlements of children
under six, as embodied by ICDS, has attracted the attention of civil society
organisations. A Childrens Right to Food Convention, held in April 2006, helped build
consensus on the issue of universalization with quality. Since the convention many
activities have been held across the country to highlight the social importance of
anganwadis; and the issue has also broken into the public consciousness.
National Old age Pension Scheme
Background
This scheme was launched in 1995 to provide "old age pensions" to senior citizens (aged
65 years or more). It is part of the National Social Assistance Programme, which also
includes two other schemes: the National Family Benefit Scheme (NFBS) and
Annapurna.54
54 The National Social Assistance Programme also included the National Maternity Benefit
Scheme (NMBS) till it was transferred to the Ministry of Health and Family Welfare in 2001-02.
The National Old Age Pension Scheme (NOAPS) is primarily addressed to old men and
women with no assured means of subsistence, but the eligibility conditions vary from
state to state, and so does the coverage of the scheme. The pensions are given in cash,
with the Central Government contributing Rs 75 per month, often supplemented with a
contribution from the State Government (e.g. in Rajasthan the old age pension is Rs 200
per month). The Central Government enhanced its contribution to Rs. 200 per month, in
March 2006. One of the main problem with this scheme is its small coverage: there are
plenty of applications, but funds are limited to 50% of the BPL individuals above the age
of 60. Even within this, the conditionality imposed by the scheme of the individual not
being "supported" by other family members further restricts the outreach of the
programme.
In 2002-3, NOAPS was "transferred" to the State Governments (along with other NSAP
schemes): from a "Centrally Sponsored Scheme", it became part of the State Plans. This
is meant to be a relatively minor administrative reform, whereby the Central
Government gives a cash grant to the State Government (under "Additional Central
Assistance") and lets it run the scheme, instead of co-implementing the scheme with the
State Government. In practice, however, this "transfer" tends to have an adverse impact
in several ways. First, the cash grants disbursed by the Central Government are often
"diverted" by State Governments for other purposes, or released after long delays.
Second, after a scheme is transferred to the State Plans, the Central Government stops
monitoring it. Third, the transfer has also terminated the payment of administrative
charges by the Central Government, and State Governments often fail to make up for
this.
Aside from NOAPS, other schemes under the National Social Assistance
Programme (i.e. Annapurna and the National Family Benefit Scheme) have also been
transferred to the State Plans.
Supreme Court Orders
1. State governments have been directed to complete the identification of persons
entitled to pensions under NOAPS, and to ensure that the pensions are paid regularly.55
55 Supreme Court Order dated 28th November, 2001.
2. Payment of pensions is to be made by the 7th day of each month.56
3. The scheme must not be discontinued or restricted without the permission of the
Supreme Court.57 This actually applies to all the schemes covered by the interim order
of 28th November 2001 (see Section 2.1). However it is particularly relevant to schemes
such as NOAPS, because these schemes are quite "fragile": there are no strong lobbies to
defend them, and they often come under the financial axe when State Governments face
a financial crisis.
4. The NOAPS grants paid by the Central Government to the State Governments under
"Additional Central Assistance" should not be diverted for any other purposes.58
Comments:
Even though the enhancement of the contribution of the Central Government for the
pension amount was announced in the budget speech of the Finance Minister in March,
2006, the funds reached the state only by September. Many states therefore did not
enhance the pensions for the financial year 2006-07. A recent announcement by the
Prime Minister has enhanced the entitlement under this scheme to Rs.400 per beneficiary
per month. More significantly, the cap on 50% of BPL has been removed and BPL
persons who are 65 and above have been brought within the ambit of this scheme. It is
hoped that this will go a long way in ensuring more secure entitlements to one of the
most neglected and marginalized section within out society.
There are many implementation issues in the States of this programme. For instance, in
many states, old people are forced to walk long distances to collect their pensions from
the Block headquarters and often do not get it on time - with the pensions reaching once
56 Supreme Court Order dated 28th November, 2001.
57 Supreme Court Order dated 27th April 2004.
58 Supreme Court Order dated 18th November 2004.
in six months rather than monthly. There is a possibility of streamlining distribution of
pensions through bank accounts, money orders or transfer through panchayats.
Even with all its flaws, this is the only programme which provides a chance for a
dignified living to old people living below the poverty.
National Family Benefit Scheme
Background
This scheme, like NOAPS, is part of the National Social Assistance Programme.
It
provides for lump-sum cash assistance of Rs 10,000 to BPL families on the death of a
primary breadwinner, if he or she is aged between 18 and 65 years.
A primary
breadwinner" is a household member whose earnings contribute substantially to
household income. The amount of assistance is Rs 10,000 for accidental deaths and Rs
5,000 in the case of death due to natural causes. The payment is to be made to the
"surviving head" of the household, after a local enquiry.
Supreme Court Orders
1. As with other food-related schemes, the Supreme Court order of 28th November 2001
(7311s for prompt impl ementation of the National Family Benefit Scheme. BPL families
are to be paid Rs 10,000 within four weeks through the local Sarpanch when the
breadwinner dies?
2. As with NOAPS, this scheme is not to be discontinued or restricted in any way
without the permission of the Supreme Court.59
4. None of the benefits should be withdrawn from this scheme as a result of this order
till further orders, by any of the State Governments or Union Territories.60
59 Supreme Court Order dated 27th April 2004.
60 Supreme Court Order dated 18th November 2004.
Comment
So far, the National Family Benefit Scheme has not received much attention in the
Supreme Court hearings, interim orders. While information available from the field as
well as the analysis of the macro-data on the utilization in this scheme, brought out by
the Commissioners Office point out to glaring gaps in the way the scheme is
functioning, the scheme has not received the attention it deserves from the Campaign
groups.
Annapurna
Background
The Annapurna Scheme was launched on 1st April 2000. The target group consists of
"senior citizens" who are eligible for an old age pension under the National Old Age
Pension Scheme (NOAPS), but are not actually receiving a pension. The beneficiaries, to
be identified by the Gram Panchayat after giving wide publicity to the scheme, are
entitled to 10 kgs of grain per month free of cost through the Public Distribution System
(special ration cards are issued to them for this purpose). The intention appears to be to
provide some sort of emergency food security to elderly persons who are waiting for a
pension to be sanctioned to them under NOAPS. However, the coverage of Annapurna
itself is very limited. In 2002-3 this scheme was "transferred" to the State Plans, like
NOAPS.
Supreme Court Orders
1. As with other food-related schemes, the Supreme Court order of 28* November 2001
calls for prompt implementation of Annapurna ("the States/Union Territories are
directed to identify the beneficiaries and distribute the grain latest by 1st January,
2002,,).6i
2. As with NOAPS and NFBS, this scheme is not to be discontinued or restricted in any
way without the permission of the Supreme Court.62
Comment
The status of Annapurna is not very clear. Field reports suggest that the coverage is
very limited. Also, there are occasional reports of the scheme being discontinued in
particular states, in violation of Supreme Court orders. Ideally, those who are eligible
for Annapurna should be promptly covered by the National Old Age Pension Scheme.
As mentioned earlier, with the upward revision of the central assistance for the NAOPS,
there is an urgent need to upwardly revise the entitlements under the Annapurna
scheme as well.
National Maternity Benefit Scheme
Background
This scheme is a timid attempt to introduce "maternity benefits" in India's social
security system. It was introduced in 1995 as part of the National Social Assistance
Programme, and later transferred to the Health Ministry.
Under NMBS, pregnant
women from BPL families are entitled to lump-sum cash assistance of Rs 500, up to two
Eve births. The payment is to be made 8-12 weeks before delivery, but in practice there
are long delays, partly due to the complex application procedures. Women are often
paid months if not years after dehvery, and this defeats the purpose of the scheme.
Further, the coverage of this scheme is very low: according to official figures, the
number of women who actually received cash payments under NMBS in 2003-4 was as
low as 4.3 lakhs - less than 2 per cent of the total number of births in that year.
Supreme Court Order dated 28th November 2001.
62 Supreme Court Order dated 27th April 2004.
Supreme Court Orders
1. As with other food-related schemes, the Supreme Court order of 28th November 2001
calls for prompt implementation of the National Maternity Benefit Scheme.
2. As with NOAPS, this scheme is not to be discontinued or restricted in any way
without the permission of the Supreme Court.63
3. On 9th May 2005, the Supreme Court refused to allow the Government of India to
phase out NMBS and provide maternity benefits under a new scheme, Janani Suraksha
Yojana (JSY). The reason for this refusal is that it is not clear whether the new scheme
preserves all the benefits available under NMBS, as the government claims. The Court
requested the government to submit further information on JSY, and asked the
Commissioners to "examine the matter in depth and file a report". "Meanwhile, the
existing National Maternity Benefit Scheme will continue."64
Comments
This scheme is in very bad shape. The procedures are complicated, the quantum of
benefits is small, payments are often delayed for months if not years, and the coverage is
very limited. The government has merged this with the Janani Suraksha Yojana (JSY),
but JSY itself has many flaws. In fact, the main focus of JSY is not maternity entitlements
but the promotion of institutional deliveries and safe motherhood. Also, it is not clear
whether this new scheme preserves the earlier NMBS entitlements, in particular
maternity benefits in cases of a delivery at home. Despite unambiguous instructions
that Rs.500 needs to be paid, even in the case of home deliveries, this message does not
seem to have been communicated adequately to the State Governments and there are
multiple field reports from across the country about the non-implementation of this
scheme.
63 Supreme Court Order dated 27th April 2004.
64 Supreme Court Order dated 9th May, 2005.
Sampoorna Grameen Rozgar Yojana
Background
The initial PUCL petition, submitted in April 2001, argued that assured
employment at a living wage is the best protection against hunger. In this and other
ways, the right to food is closely connected to the right to work. Employment issues
have figured in the Supreme Court hearings from time to time.
Sampoorna Grameen Rozgar Yojana (SGRY) is a centrally-sponsored employment
scheme. It was initiated in August 2001, and officially aimed at generating 100 crore
person-days of employment each year. According to the official guidelines: The SGRY
is open to all rural poor who are in need of wage employment and desire to do manual
and unskilled work in and around his/her village/habitat. The primary objective of the
scheme is to provide additional wage employment in rural areas, thereby provide food
security and nutritional levels. The secondary objective is the creation of durable
community, social, economic assets and infrastructural development in rural areas.
While providing employment preference shall be given to agricultural wage earners,
non agricultural unskilled wage earners, marginal farmers, women, members of the
Scheduled Castes/ Scheduled Tribes and parents of child labour withdrawn from
hazardous occupations, parents of handicapped children or adult children of
handicapped parents who want to work for wage employment. 65
This scheme however is being gradually replaced by the NREGA. Unlike the SGRY, the
NREGA provides for a right to a hundred days of employment and has in addition a
compensatory mechanism in case employment is not provided. It is therefore a far
more robust means of ensuring entitlement than the SGRY.
65 Government of India (2002), Guidelines for Sampoorna Grameen Rozgar Yojana (New Delhi:
Ministry of Rural Development), page 1.
Supreme Court Orders
Important orders pertaining to SGRY were issued by the Supreme Court on 28th
November 2001, 8th May 2002, 2nd May 2003, and 20th April 2004. These include:
1. Speedy implementation: Several directions were issued (notably on 8th May 2002, 20th
April 2004 and 17th October 2004) to the effect that SGRY should be implemented
"expeditiously" by the Central Government and State Governments. In particular funds
should be released on time and fully utilised, and SGRY funds should not be diverted
for other purposes.66
2. Priority groups: "The respondents shall focus the SGRY programme towards
agricultural wage earners, non agricultural unskilled wage earners, marginal farmers
and, in particular. SC and ST persons whose wage income constitutes a reasonable
proportion of their household income and to give priority to them in employment, and
within this sector shall give priority to women."67
3. Doubling of SGRY: On 2"d May 2003, the Court directed the government to "double"
the scale of SGRY, in view of drought conditions prevailing in large parts of the country:
"The present SGRY system should be expanded, at least doubled, both in terms of
allocation of food-grain and cash for the months of May, June, and July . On 20th April
2004, this direction was extended: "The directions for doubling the food grains as also
cash in terms of the order dated 2nd May, 2003 shall be applicable this year also.
4. Timely wage payments: Wage payments under SGRY are to be made on a weekly
basis.68
5. Ban on contractors: The use of contractors is z/prohibited".69
66 Supreme Court Orders dated 8th May, 2002.
67 Supreme Court Order dated 8th May 2002.
68 Supreme Court Order dated 8 May 2002.
69 Supreme Court Order dated 8 May 2002.
6. Minimum wages: "The State Governments/UTs are directed to pay minimum wages
to the workers under the Scheme."70
7. Ban on labour-displacing machines: The State Governments were also directed to
"stop use of labour displacement machines" under SGRY.71
8. Role of Gram Panchayats: Gram Panchayats are entitled to "frame employment
generation proposals in accordance with the SGRY guidelines for creation of useful
community assets that have the potential for generating sustained and gainful
employment". Further, "these proposals shall be approved and sanctioned by the Gram
Panchayats and the work started expeditiously".72
9. Social audits: Gram Sabhas are entitled to conduct social audits of SGRY (and indeed
of all food-related schemes). On receipt of any complaint of misuse of funds from the
Gram Sabhas, the implementing authorities shall "investigate and take appropriate
action in accordance with the law".73
10. Transparency: "Access to all public documents including all muster rolls shall be
allowed to such persons who seek such access and the cost of supplying documents
shall not be more than the cost of providing copies of the documents."74
Comments
Field reports suggest that most of the above orders are routinely violated in most states.
Some specific instances, such as the violation of Court orders on SGRY in Badwani
District (Madhya Pradesh), have been taken up by the Commissioners or even referred
to the Supreme Court through Interim Applications. But even there, attempts to seek
redressal have been partially successful at test.
70 Supreme Court Order dated 20th April 2004.
71 Supreme Court Order dated 20th April 2004.
72 Supreme Court Order dated 8 May 2002.
73 Supreme Court Order dated 8 May 2002.
74 Supreme Court Order dated 20th April 2004.
The National Rural Employment Guarantee Scheme is set to replace the SGRY in all
districts of the country.
The National Rural Employment Guarantee Scheme
The National Rural Employment Guarantee Act 2005 (NREGA) was unanimously
passed by the Indian Parliament in August 2005. So far, the implementation of this Act
has not come under the scrutiny of the Supreme Court, since the Act is yet to come into
force. In particular, the Employment Guarantee Act is not mentioned in any of the
Interim Orders. However, public works programmes are often mentioned, and the
directions relating to these programmes (e.g. regarding prompt payment of wages) can
be regarded as applicable to the NREGA also.
Further, it is very likely that the
implementation of the Employment Guarantee Act will figure quite soon in the Supreme
Court hearings. Thus, employment guarantee is an integral part of the agenda of "legal
action for the right to food".
Chapter 4
Starvation: Definition, Verification and Response
Objective 2 of the Food Rights Code:
To establish processes of investigating starvation that are transparent, reliable and
respectful of the dignity of the survivors; and mandatory protocols for intervention for
relief, prevention and accountability.
Definition of Starvation
It is remarkable that Famine Codes of the past, and contemporary Codes, do not contain
an agreed definition of starvation. The Code must define starvation carefully and
rigorously, and yet in ways that are accessible to the lay public.
Hunger may be understood as the denial of adequate food to ensure active and healthy
life. If hunger is prolonged to an extent that it threatens survival, or renders the person
amenable to succumb because of prolonged food denials to curable ailments, then the
person is living with starvation. If these conditions actually lead to death, then this is a
starvation death, even though the proximate cause in every case would be a medical
failure. But the cause of death is not the medical failure, but the prolonged denial of
nutrition that led to a person succumbing to medical conditions which a well fed healthy
person would easily be able to combat and survive.
This definitions of starvation and modes of verification in this chapter and its annexures,
are derived very substantially from an excellent document 'Guidelines for Investigating
Suspected Starvation Deaths', prepared by the Jan Swasthya Abhiyan) Hunger Watch
Group, based on a consultation organized in Mumbai in 200375.
75 This conference was attended by and attended by Veena Shatrughna (Deputy Director,
National Institute of Nutrition, Hyderabad), Vandana Prasad (Paediatrician), Narendra Gupta
(Prayas), Sunita Abraham (Christian Medical Association of India), Sarojini (SAMA and
Convenor of MFC), C. S. Kapse (Professor, Department of Forensic Medicine, D. Y. Patil Medical
The document points out firstly that 'starvation is ultimately not primarily a technical
issue, but is rather related to deep-rooted socio-economic inequities, which require
radical and systemic solutions'. It adds that 'while approaching the issue of hunger
related deaths, we should start with the basic fact that starvation and malnutrition
related deaths are public health problems requiring community diagnosis. In this sense they
differ from classical "disease related mortality". The diagnosis of a death due to
tuberculosis may be approached as an individual diagnosis. But the diagnosis of a
"malnutrition death" cannot be just an individual diagnosis; we have to document the
circumstances prevailing in the family and community along with the individual to
reach such a conclusion'.
It adds that the dilemma is deepened because 'generally prevalent "baseline"
malnutrition, gradually worsening severe malnutrition and definite starvation merge
with each other along a seamless continuum. In a community which is used to barely
subsistence intake, three years of drought reduces this further and then some families
start eating once a day, a few poorest families eat on alternate days ... where exactly is
the dividing line between malnutrition and starvation? When exactly does the situation
change from "a chronic problem" to "an alarming situation"?'
Public officials, the lay public and sometimes even professionals believe that starvation
requires no intake of food. This underlies some of the denials when post mortems of the
corpses of the deceased show some grains of food, or investigators are able to find some
foodgrains in the homes of the person who recently died, and the cause of whose death
is being contested. The Hunger Watch group defines starvation as levels of food intake
College), Neeraj Hatekar (Professor, Department of Economics, University of Mumbai), Sanjay
Rode (Ph. D. student. Department of Economics, University of Mumbai), Abhay Shukla (Co
ordinator, SATHI Cell, CEHAT), Neelangi Nanai, Amita Pitre and Qudsiya (all researchers at
CEHAT).
that are unsustainable for the continuance of life itself. In assessing this, one challenge,
as already observed, is that 'malnutrition, starvation and starvation deaths seem to lie
along a continuum. How is it possible to demarcate one from the other?'
An adult who eats 850 kilocalories of food daily or less may be presumes to be starving.
This cut-off is based on research that shows that a person who weighs 50 kilograms, if
she or he engage in no physical activity altogether, they require at least 850 kilocalories
merely to stay alive, even though they perform no work at all. Thus if it is established
that the adult had access to less that 850 kilocalories, then this is not compatible with life
itself, and the person is undoubtedly starving76.
Another reliable physiological indication of starvation is a BMI (Body Mass Index) of 16
and less. Body Mass Index or the BMI is the ratio of the weight of the adult in kilograms
to the square of her height in metres. This is a very good indicator of adult nutritional
status as it is age independent. Values of BMI that fall between 20 and 25 are deemed to
be normal. On the other hand, significant research finding is that in adults, if BMI is
below 19, mortality rates start rising. Mortality rates among adults with BMI below 16
are nearly triple compared to rates for normal adults77. Thus in adults a BMI of 16 and
less should be used as a cut off point to demarcate starvation from under-nutrition.
The nutritional status of children is easy to derive from the child's weight and age, and
most ICS workers are trained in assessing this. NCHS standards for ideal body weights
for children, both male and female are available. Classification systems based on these
standards enable us to decide from the age of the child and its weight if the child has a
normal nutritional status or is either undernourished or overweight. The weight of the
child should be compared to the ideal weight for that age mentioned in the NCHS
standards. A percentage of up to 80 per cent is deemed normal, 60 to 80 percent is
76 In the word of the hunger watch group (mimeo, 2003), 'Based on a requirement of 0.7 Kcal / kg
/ hour, a 50 Kg person needs about 850 Kcal per day to maintain oneself at Basal Metabolic Rate,
without any physical activity'. Thus any food intake that is sustainedly lower than 850 Kcal per
day would be incompatible with life in due course and is an indication of starvation .
77 'Guidelines for Investigating Suspected Starvation Deaths', by the Jan Swasthya Abhiyan)
Hunger Watch Group (mimeo, 2003)
deemed mild to moderately malnourished, and below 60 per cent the situation is severe,
below 50 per cent alarming.
How is starvation definedfor children? To add.
Verifying Starvation
The duty to investigate and verify complaints of starvation must be shared by public
officials, elected representatives, affected people and local communities, and
professionals. Each must have clear and well defined roles.
In practice, if large numbers of people die of starvation, it occasionally captures media
attention, and there is transient public outrage. Government officials in every part of the
country, hotly deny allegations of starvation deaths. Most claim that the deaths result
from illness, some even quibble that people were just chronically malnourished, but not
starving. Issues of food security and hunger surface briefly in public consciousness,
whenever there are media reports on starvation deaths. The brief public outrage that
follows such reports lead almost invariably to unseemly wrangles about whether this
was indeed a starvation death, with angry denials by officials, post mortems and other
evidence being mustered to establish that there was indeed some grain in he stomach of
the diseased or available to the family and therefore this does not constitute a starvation
death.
Apart from this, even the media and political establishment tend to react only when
reports emerge of actual starvation deaths surface; reports of destitution that led to this
final collapse fail to stir interest or action. There is in this sense, in both State and non
State circles a certain 'normalisation' of destitution, of conditions in which people are
forced to live with starvation. They can expect the State to act or public opinion to be
outraged only when people begin to die.
t
L
Few people die directly and exclusively of starvation. They live with severe food deficits
for long periods, and tend to succumb to diseases that they would have survived if they
were well nourished. Official agencies do not recognize these as conditions of starvation,
and instead maintain that the deaths were caused by the proximate precipitating factor
of infection. We have also seen that starvation does not require absolutely zero food
intake, but rather prolonged periods of such low food intake as to be incompatible with
survival.
In the aftermath of media complaints of starvation deaths, while analysing deaths due to
starvation, the official investigator usually conducts a conventional enquiry in which he
or she fires a series of humiliating questions soon after the death has taken place to the
victim's. This would only leave scars on the family of the deceased. The usual line of
questioning is about whether the individual or family had access to any food at all in the
period immediately preceding the death, or whether the death was due to illness or
natural causes. There are sometimes post mortems to show even a few grains or wild
leaves and tubers on the stomach, to demonstrate spuriously that the death was not due
to starvation.
Investigating the Living by Public Officials
The National Human Right Commission in its investigation into alleged starvation
deaths in Orissa78 some important and human principals have been established. First of
these is that death is not necessary as evidence of starvation. In the words of Mr.
Chaman Lal, former Special Rapporteur of The National Human Rights Commission
(NHRC)79,' A person does not have to die to prove that he is starving. This insistence on
death as a proof of starvation should be given up. Continuance of a distress situation is
enowgh proof that a person is starving'. We agree that medical post mortem inquiries do
not serve much in the process of preventing starvation deaths and in assuring the right
to food. Indeed, it hurts and humiliates those families and communities who have lost
78 'Feedback from Dr. Amrita Rangaswamy on Starvation deaths', Tanushree Sood, CES, Mimeo,
2005.
79 Personal communication
people painfully to starvation. Citizens, especially the ones who are starving, have a
right to dignity. Starvation is also rarely an isolated instance, but reflects instead
prolonged denials of adequate nutrition to households, communities, or social
categories. Such people are usually very impoverished and dispossessed or destitute.
The discourse around starvation, especially among public officials and the media,
should shift in such times from not just those who died, but those who survived but are
deeply threatened. They need to recognise starvation to be a condition not just of the
dead but also of the living. It is crucial to understand and accept that death or mortality
is not a pre-condition for proving the condition of starvation. Long-term unaddressed
malnutrition and endemic prolonged phases of hunger must be recognised as situations
of starvation, and the duty of the state to prevent deaths of persons who are living with
starvation.
There are many ways that allegations, complaints and fears of starvation arise. In any
such situation, the focus of the investigations by public officials must focus not on the
dead, but on the living survivors, and people of the family, class or community who
may be similarly threatened. This would ensure that the survivors of the deceased are
not traumatised further, and measures for relief and prevention are put in place without
delay.
But it is important also to establish the veracity of complaints of starvation deaths. This
should be done by processes of community investigations and verbal autopsies by
public health officials in collaboration with local people. Both these processes may
proceed
In the event of complaints, through application or verbal, made in the media, by affected
people or activists or any other source, local panchayat representatives and revenue
official must inform the District Panchayat head and the District Collector immediately,
who in turn will inform each other, the local officials, and panchayat functionaries at
various levels. They would be debarred from issuing denials, in the absence of
investigation by public health functionaries, and instead the effort should be to identify
the sources of distress, and respond to mitigating and ending these.
It would be the duty of the District Panchayat head, with the District Collector, the Chief
Medical Officer, heads of departments of civil supplies, women and child welfare, social
welfare and forests, to personally visit the location expeditiously, and in nay case not
later than 48 hours after receiving the complaint or information is received. They should
investigate the overall field situation in the family and community: not whether there
was a starvation death, but whether the specific family, as well as in that location the
local community (such as Musahars) and the social (such as single women) and class
(such as landless workers) categories to which she or he belongs, subsist in conditions of
prolonged deprivation of adequate food with dignity, or in continuous uncertainty
about the availability of food, or dependence on charity or debt bondage for food. On
receiving reports of people living or dying of starvation, may be analysed, by a process
described sometimes as verbal autopsy. They should meet the family of the victim, and
learn from them about their general food and livelihood situation, and with the
neighbourhood, and the local community, tribe, caste, class, gender or age group to
which the affected people belong, and the village (or urban settlement) at large.
This public investigation should be conducted in consultation with and seeking the
support of the affected people. It may occur in two phases. In phase one, discussions are
held with the family of the victim and some neighbourhood families. During these
discussions, the victims' families may be asked questions about the food and livelihood
conditions and deprivations of the individual and the household, access to food and
work, periods of hunger, and so on. The idea is not only to probe death and its causes
but only to understand the poverty and destitution faced by the families and by
similarly affected people. Attempt should also be made to understand the root cause of
poverty such as livelihood crisis, heavy debt, crop failures etc.
In the second phase of investigation, discussions should be carried forward with the
other members of the tribe, caste, class, gender or age group to which the affected people
belong. During these discussions, questions may be posed about the food and livelihood
conditions and deprivations of the class and communities of deprived people, their
access to food and work, and periods of hunger. Broader questions regarding
functioning of the food and livelihood schemes may be asked, such as (i) is there an
operational anganwadi centre running in the village, (ii) is the nearby government
school providing midday meals to the children, (iii) does the ration shop provide
foodgrains in the right quantity, price and on time, (iv) how many elderly persons in the
village obtain social security benefits or pensions from the state and so on. At the same
time, the people should be provided enough space to reveal situations on their own.
They should not be crowded out by questions from the investigator. It may also be
worth asking if any change has occurred in their way of living over the years. In other
words, have the government policies brought about a change in the way of living of the
people? There is a need to document the circumstances prevailing in the family and
community at large special focus needs to be laid on tribal and backward rural areas.
Also there may be cases of starvation of individuals who for one reason or another are
without families, or abandoned by their families and excluded from their communities.
The investigations should be sensitive to these as well.
These findings should be recorded by the District Panchayat head and District Collector
in writing, and their report shared and explained in the local language to affected people
and conununities, local elected leaders and local officials. The report should contain a
clear time bound action plan for intervention.
Investigating the Causes of Death to Verify Starvation
Even as measures to mitigate and address the deprivation and prevent further
deprivation, destitution, under-nutrition and starvation are undertaken (and these will
be outlined in the next section), it is important that the examination of whether the
deaths were of starvation also proceeds side by side. The Hunger Watch Group of the
Jan Swasthya Abhiyan80 suggests 4 parts to this investigation. These are as follows:
1. Assessing whether there is an abnormally high death rate in the villages: A cluster of
such villages, from where there have been reports of suspected starvation deaths,
may be taken up for investigation. All the deaths that have taken place in these
villages during the period of serious food deficit (say a period of at least three
months, may be six months or one year) would need to be documented. Details
would be collected by visiting families of the deceased, the mortality records
maintained by the ANM, and other local enquiries. In parallel, the exact population
of all the villages and hamlets in the cluster would be ascertained from census and
voter lists and local enquiries. We need to ascertain whether the number of deaths in
this particular area is significantly higher or not. This is done by comparing (bearing
in mind seasonal variations). To see whether the number of deaths in the area we are
investigating are significantly higher than the previous year in the same area or than
that of deaths in nearby villages in the same year, or in the same area in the same
period in the previous year, or the average deaths for the district in that period.
The detailed methodology is given in annexure 2.
2. Anthropometry to assess nutritional status of the community/The second method is
to use physiological measures of height and weight to assess the nutritional status of
the community. One needs to take a representative sample of hamlets, villages, and
within then of various age, gender, occupational and identity groups, and measure
the BMI of adults, and the nutrition levels of children. Once again, the detailed
methodology is given in Annexure 3.
3. Assessing malnutrition deaths among children. For children, the following criteria
80 'Guidelines for Investigating Suspected Starvation Deaths', by the Jan Swasthya Abhiyan)
Hunger Watch Group (mimeo, 2003)
may be used to establish malnutrition deaths:81
Increased death rates among under-five children compared to state U5MR. An
•
exercise must be done to calculate age specific death rates, and compare this with
the state averages to define increased death rates.
Siblings of children who have died of suspected malnutrition can be assessed.
•
Their anthropometry may show very poor nutritional status and this would be
supportive evidence.
•
Access ICDS records and records from other sources for weight of the deceased
child shortly before death if possible
•
High mortality from minor infections (e.g. diarrhea, measles) is itself an indicator
that the underlying cause of death is malnutrition. We need to compare mortality
rates due to the infection in the sample community with 'standard mortality
rates for that illness. If say the case fatality rate for measles in a community is
20% compared to the known case fatality rate of 2% then the 'measles deaths' in
the community are actually malnutrition deaths in which the terminal event is
measles.
4. Verbal Autopsies: Verbal autopsies are individual investigations to reveal whether at
least a few deaths in which starvation is suspected to be an underlying cause of
death (irrespective of the immediate cause, which may often be infections etc.)Verbal
autopsies should be used only in conjunction with the other methods outlined
above, to document specific starvation deaths. It is reiterated that 'individual
starvation deaths are only extreme examples of the severe nutritional deprivation
being suffered by the entire community, and should always be presented in the
larger context of community starvation'.
Verbal Autopsy is a scientific method of proven validity used for establishing the
cause of death of individuals in a community, where forensic autopsies have not
8^ 'Guidelines for Investigating Suspected Starvation Deaths', by the Jan Swasthya Abhiyan)
Hunger Watch Group (mimeo, 2003)
been or cannot be conducted for any reason. These also less distress o the bereaved
family than forensic autopsies. This method has been successfully employed in
India, Bangladesh, Kenya, Nigeria, Philippines, Indonesia, Egypt, and several other
countries to determine the cause of death of individuals in various circumstances,
especially to identify causes of maternal and infant mortality. It should look into a
sample of 'suspected starvation deaths', or any death where family members report
that the deceased had significantly reduced food intake due to non-availability of
food, during the month prior to death. The questionnaire to conduct a verbal
autopsy is somewhat medicalised in nature, hence a person with some experience of
health work may find it useful, but for transparency local field workers can and
should be given appropriate training to administer it. It begins with the care giver or
family member (or any one lese most familiar) explains what happened in their own
words, details of food security, subsequent illnesses, and responses to treatment
received till the death of the deceased. The statement is recorded verbatim,
supplemented by questions in the attached questionnaire (Annexure 4). A special
section is devoted to collecting information concerning family food security. Another
section elicits the dietary history relating to the deceased, during the week and
during the month prior to death. The filled questionnaire is then sent to a panel of
three independent physicians along with available medical records of the deceased,
who do not communicate with each other.
The detailed methodology and questionnaire is given in Annexure 4.
State Interventions in Situations of Suspected Starvation.
Even without awaiting the outcomes of the community investigations and verbal
autopsies to establish starvation deaths, public authorities of the Panchayat and district
administration must implement a range immediate measures, as soon as they are
convinced that conditions of grave and threatened food and scarcity prevail in a local
area of community, which result in people being forced to live in conditions of
prolonged under-nutrition and even starvation.
Once it is established that there exist conditions of people of a dispossessed community,
class or social category who live with starvation or grave threats to their food and
livelihoods security, it is the duty of the State (jointly of the District Panchayat and
district administration led by the District Collector) first to provide relief in case of
conditions of starvation or long term unaddressed under-nutrition and failure of food
schemes to prevent or remedy this. In its current form, 'gratuitous relief is in the nature
of charity. Such an ideology cannot bring about long term and permanent change in the
condition of people who are vulnerable to starvation or the system of administration.
Thus, such kind of an ideology needs to be converted into a system of entitlements. In
other words, relief needs to be in the form of entitlements and not charity.
If a certain region has been diagnosed as suffering from intense hunger, the state should
be alarmed immediately, and be asked to place systems of relief, immediate, short term
and the long term.
1. Relief for Family of Deceased: The first immediate relief must be for the affected
family itself that has suffered the loss of persons for reasons associated with prolonged
deprivation of adequate and assured food with dignity. Some of the measures that may
be relevant include:
a) ensuring immediate food availability to the family, free of cost for at least for a period
of six months and then continuously on a more permanent basis at highly subsidised
rates. This would be by the distribution to them of special AAY cards with the specific
provision that they would get their food entitlement without any cost for the initial six
months;
b) ensuring early sanction and release of insurance under NFBS, and release of an ad hoc
amount of the same amount for all dead as compensation regardless of whether or not
they were adult bread earners;
c) identifying in consultation with the survivors in the family, the reasons for livelihoods
denial, collapse or insecurities and assisting them to build a secure livelihood through
measures like land allotment and restoration in case of alienation;
d) ensuring their coverage of all food and livelihood schemes for which they are eligible
such as ICDS, MDM, NREGA and old age, widows and disability pensions;
e) for children, ensuring their admission to SC ST hostels if they choose, so that their
education, food and protection is secured;
e) organising psycho-social support through professional and trained lay counsellors to
the survivors of the deceased;
and (f) for infants, small children, expectant and nursing mothers, doubling their quota
of food entitlements, hospitalisation where necessary, arrangements for nutrition
rehabilitation, and health-care including immunization.
2. Relief for others identified to be similarly threatened: The next stage of intervention
would be for the community, class or social category to which the family of the affected
person belongs. This must begin with publicising and opening NREGA works for all
those who seek it, within a week of the receipt of the information. The ceiling on 100
days for one member of each family must be relaxed for the affected people for a period
of 2 years from the time a situation of starvation is identified. Simultaneously the mid
day meal in the school will be extended to all days in the year, and open to all children,
even if out of school, and old and disabled people and single women who seek it. The
ICDS centre will also provide children of 3 to 6 years hot cooked meals twice a day
instead of once, and this will be open also to pregnant and lactating mothers, and single
women.
This must be followed with a careful official as well as well publicised affected people s
social audit of why they could not access their food rights from the food and livelihood
schemes relevant for them. For instance, were their small enrolled and regularly availing
of the services of ICDS, and was their decline of nutritional status identified and
addressed on time; if not, why not? Were the older children in school, and did they
access regular and nutritious mid-day meals? Did they have ration cards, AAY or at
least BPL, and did they regular receive the prescribed quota of 35 kilograms of
subsidised food grains from the ration shop; if no, again why not? Did all old people
receive pensions, and were these distributed at their doorstep on time every month? The
sarne questions would apply to widows and disabled people in states with schemes for
pensions for these groups. Did they seek job cards and work, and was this given to them
in accordance with their legal entitlements under the NREGA?
From such an enquiry, the reasons for failures of food and livelihood schemes, and the
exclusion of these most food vulnerable people from their reach, should be clearly
diagnosed. The District Panchayat and Cohector should clearly fix responsibility at all
levels, punish those found guilty, remedy gaps of funds, resources and personnel, and
address issues of discrimination and social exclusion. There should then be a time
bound coverage of all affected and threatened people by AAY ration cards, job cards
under NREGA, old age, widow and disability pensions, and ICDS services, including
nutritional rehabilitation and hospitalisation where found necessary, within a period of
one month from the date of initial information. Failures to do so, if they result in further
loss of life or deterioration in people's nutritional condition, will be the personal
responsibility of the district leaders of the Panchayat and administration.
In the long run, local structural sources of pauperisation will be identified and local
solutions developed in consultation with the gram sabha and village panchayat. These
may include failures to implement land reforms, tribal land alienation, caste
discrimination, micro minor irrigation and watershed development, availability of
formal credit for agriculture and artisans, access to forests and choices of agricultural
technology and cropping patterns.
Chapter 5
Addressing Chronic Hunger
Objective 3 of Food Rights Code
To identify individuals, dispossessed communities, classes and social categories of
people who live with prolonged hunger, malnutrition and starvation, and to intervene
with short, medium and long term measures to mitigate, prevent and sustainably
reverse this situation of chronic hunger.
Once again. Codes in the past did not address and often did not even admit to certain
segments of the population who live with critical hunger and chronic food denials even
in normal times. This links closely with the neglected phenomena of destitution. What
usually goes unrecognised is that death by starvation is only the outcome of a much
more chronic, invisible, malaise of destitution. There are large numbers of forgotten
people who live at the edge of the survival. Each day comes afresh with the danger of
one push that will hurtle them down the precipice. This may come from an external
emergency, like a natural disaster, epidemic or riot, but even from local crises: a sickness
in the family, a sudden untimely death of a bread earner, or a brush with the law. The
problem of starvation and hunger can be overcome only when people who live on a
regular basis in constant peril of slipping into starvation, or at least chronic, long term,
unaddressed hunger - people who may be described as destitute are protected from
destitution.
Government programmes are woefully inadequate to address destitution. Our evidence
is that apart from major leakages and corruption, the coverage of these schemes is so
meagre that they leave huge gaping holes in the social security net through which large
numbers of most destitute women and men, girls and boys slip through measures to
prevent and reverse starvations, or the persistence absolute hunger. It is stressed that
this is a duty of the State not to the dead, but to the precariously living. It requires public
vigilance about individuals, communities and several categories living with starvation
and absolute hunger. It requires the State to act, not after there is an emergency like a
drought or flood, not even after people die of starvation, but pro-actively before people
sEp into destitution, and fad to access in an assured and retiable manner, with dignity,
the nutritious and culturally appropriate food they require to lead healthy Eves.
In a sense, this set of duties are of pro-active measures by the State to prevent hunger
and starvation and to promote well being and the right to food of aU people, to
anticipate and forestaU starvation, by recognising and arresting destitution weU in time,
before it pushes hapless people into starvation. The previous chapter on starvation was
reactive, whereas this is actively protective and deterrent. The extent to which public
authorities are able to implement the measures in this chapter, to that extent the
interventions listed in the past chapter wtil become in fructuous, and an enormous
amount of human suffering avoided.
This requires local authorities, mainly panchayats and local bodies, to identify those
classes, social categories and local communities, who are destitute in normal times, who
lack the resources, financial and material, the employment, assets, access to credit, and
social and family support and networks, to secure sufficient and assured food for
themselves and in many cases for their dependents. These are people who are frequently
powerless and disenfranchised, sociahy isolated and devalued, sometimes stigmatised
and even Elegalised, and often with special needs born out of disability, illness, social
standing and age.
Even in the more intimate context of a vihage, many of these socially excluded groups
are invisible, barely known and acknowledged, therefore the panchayats wih have to
take special steps to identify them. In diverse cultural and socio-economic contexts,
these may vary widely, such as certain denotified and nomadic tribes in one place, some
speciaUy disadvantaged daht groups like Musahars or Madigas in another, weavers,
artisans and particularly disadvantaged minority groups in yet another, ah designated
'primitive tribal groups', and so on. In addition, studies have estabhshed that in aU
cultural contexts, the following rural social categories consistently tend to be very
dispossessed and vuhierable in their access to food: disabled people, both as bread
winners and dependents, single women and the households that they head, aged people
especially those who are left behind when their families migrate or who are not cared for
by their grown children, people with stigmatised and debilitating ailments such as TB,
HIV AIDS and leprosy, working and out of school children and bonded workers.
In the bridge between rural and urban destitute are the distress migrants, at the bottom
of the heap both where they move for work, and from where they come. In urban
contexts are street children, with or without responsible adult caregivers, urban
homeless people, slum dwellers and a wide range of unorganised workers, both
seasonal migrants and settlers, such as rickshaw pullers, porters, loaders, construction
workers and small vendors, and people dependent on begging.
It is impossible for a Code like this to list all the measures that need to be taken for each
of these groups. These would have to be locally evolved. But the extent to which these
are instituted and implemented, and the extent to which destitution is effectively
combated, hunger and starvation would be prevented. This Code will list a few
illustrations:
a.
The Panchayat may consult with special assemblies of single women, disabled
people, bonded workers, stigmatised communities and distress migrants, and
identify all families among them with children which live with chrome hunger. It
would ensure that all these children are enrolled in the nearest ICDS centre, and
even before they slip into advanced stages of malnutrition, they are given as a
preventive measure higher levels of nutrition which would have been given to them
of they were identified to be in fourth grade malnutrition.
b. The same assembly would also include old people, and they would be organised to
demand work under NREGA. Special plantation works that require less hard labour
would be opened specially for these groups, and care would be taken to mclude all
adults from these categories in these works, and also people from such occupations
as weavers and artisans who cannot cope with conventional manual works.
c. All households would be covered by AAY cards, and for all persons who are of the
required age or social category such as widows and disabled people would be
covered by pensions. The Panchayat would ensure systems of doorstep delivery of
pensions in the first week of every month.
d. All children who are out of school would be identified, and a residential bridge
course organised in order to secure their bridge education as well as adequate
nutrition. If parents such as single mothers and disabled people are unable to feed
these children, and this is what pushes them into work, then the Collector would
ensure their admission in the nearest government hostel.
e. All seasonal distress migrants would be organised to demand work under NREGA,
especially if it enables them to stay back from migration. But even if still choose to
migrate. The Collector should establish camps, and vigilantly ensure that all are
registered to get the protection offered by the Inter State Migrant Workers Act.
f.
All children and women would be eligible for all services in the ICDS, regardless of
whether or not they are residents of that village. This would enable children and
mothers of migrant families to access supplementary nutrition and immunisation.
g-
Old people should be permitted to eat at the school mid day meals, with no
questions asked. This would act as the last defence against starvation for the
destitute aged people of the village, at no additional cost except the cost of
additional food.
h.
For children of migrant families and aged people left behind when they migrate, the
local school should be coveted into a community based hostel. The aged people
would be the caretakers of the children, and both the aged people and the children
would be entitled to all 3 meals. This would ensure dignified survival of old people,
even while it enables children of the poorest distress migrant workers to continue
their education, while also securing their nutrition.
An illustrative list of measure for urban areas is:
a. For children on the street, both without parental support and those with parents
who are also homeless, a series of community based residential schools should
be created in existing government schools, in the nature of an additional shift
after regular school hours. This is the only way that tens of thousands of such
children in most cities, can be assured nutritious food, as well as protection and
their right to education, at very little additional cost. The children can be bridged
to eventually get admission in the same school.
b.
All homeless people should get AAY cards, and slum dwellers BPL cards. One
reason why these are denied to them in many cities, is that ration cards are also
treated as de facto identity cards. But this will not act a barrier to these most
vulnerable urban residents from getting their right to food.
c. People who live by begging should be carefully surveyed, but from a
rehabilitative perspective. There are any among them who are aged, disabled
with leprosy or polio, or single women. They should be given pensions which
would enable them to give up begging.
d. Areas which are widely populated by migrant workers, particularly single men
who migrate without their families, should be mapped in the city. In these
places, wholesome hygienically prepared food should be distributed with the
help of trade unions and other organisations who work with unorgamsed
workers, with some subsidy from the government. Religious and secular
charitable organisations may be drawn in to contribute both with financial and
management resources, and volunteers.
Chapter 6
Addressing Emergencies with Equity
Objective 4 of Food Rights Code
To ensure that emergent situations that threaten mass access to food, such as natural
and human made disasters are anticipated, mitigated and addressed with equity and
speed, without consequences of mass food scarcities.
We come finally to the more conventional and familiar content of the Food Code, and
this is deals with emergencies. The problems and also the recommendations flow out of
the first chapter which reviews past and existing Famine, Drought and Scarcity Codes.
What is more, if the other objectives of the Code already recounted, namely securing
right to food in normal times, addressing, mitigating and preventing starvation, and
special support for destitute groups who live with chronic hunger even in normal times
is executed, then many of the needs and crises of emergencies are already addressed. We
will therefore only briefly recapitulate what should be the major principles and
measures to deal with emergencies.
1. Declaration of Scarcity: The declaration of food scarcity must break away
from the cumbersome, bureaucratic, opaque and long-drawn out
provisions that still can be fund in most Codes even today, which result
in such delays that the suffering, hunger, distress migration, distress sale
of cattle and other assets, and indebtedness have long set in before the
State takes any ameliorative measures. It needs also to recognise
emergencies that may not be linked to less rainfall.
The District Panchayat and District Collector should be authorised to
identify a range of emergent situations that may result in mass food
scarcity. This could include low or ill-timed rainfall for crops and farmers
who are dependent on rainfall and workers whom they may employ;
sharp slump in prices of agricultural produce; worrying fall in the water
table; failures in such non-tunber forest produce on which local
communities depend substantially for food or livelihoods; flowering of
bamboo; war, riots and ethnic clashes; the sudden closure of a major
industry that employs a large number of workers; and floods, cyclones
and earthquakes.
They should send their report with reasons to the state government. This
should be examined by a small inter-ministerial group which also
includes also the leader of the opposition, and they should be required to
give their decision within 2 weeks of receipt. They should give reasons
for their decision, and in case there are disagreements, there should be
provision for an appeal to the State Human Rights Commission, whose
decision would be final.
2. Public works: After the commencement of NREGA, public works need to
be converged with NREGA, rather than creating a separate machinery
and set of rules for relief works. However, after the declaration of scarcity
in an area, the District Panchayat should be authorised to raise wages by
up to 20 per cent of the minimum wage. Likewise, the limit of 100 days
and employment of only one adult per family should be fully waived for
the period of the scarcity. There should be a certain proportions of works
selected which require less demanding manual labour, and this should be
available to old, disabled and infirm people, as well artisans and weavers.
But there should be a strictly enforced ban on children working in any of
the sites.
3. Gratuitous Relief: Likewise, the provisions for gratuitous relief should
also be converged as far as possible with existing schemes. The
Panchayats at all levels will take special care to ensure that all eligible
aged and disabled people, and members of specially vulnerable
communities like the designated 'Primitive Tribal Groups' are fully
covered by AAY cards, and those who are eligible for pensions also
receive this. The administration of ration shops and pension distribution
should also be streamlined. The entitlement under each of these
(subsidised rations and pensions) should also be raised by 50 per cent
during the period of scarcity.
Likewise emergency feeding should be converged with the ICDS and mid
day meals. ICDS food entitlements should be doubled during the period
of the scarcity, and hot meals for children in the age group 3 to 6 years
provided twice a day instead of once. The timings of the hot meals should
be adjusted in ways that expectant and nursing mothers are able to eat at
least one of the hot meals, of not both. Old and disabled people, and out
of school children, should be encouraged to join the mod day meals,
which should continue during the vacations.
Annexure 1
Assessment of Death Rates82
An important component of investigating suspected starvation deaths is the calculation of
death rates, in a specific area and pertaining to a specified period during which suspected
starvation deaths have been reported.
Identifying the area for investigation - Anecdotal reports may be received about
unusually high number of deaths from certain villages. A cluster of such villages, from
where there have been reports of suspected starvation deaths, may be taken up for
investigation. All the deaths that have taken place in these villages during the period of
serious food deficit (say a period of at least three months, may be six months or one
year) would need to be documented.
Once the villages and the period have been finalised, all the deaths during the
period should be recorded by means of small group enquiries throughout the area
(covering all hamlets and house clusters)/ house to house survey in that area to
document deaths in that particular period of time. The families of all the deceased
would need to be visited, the date / month of death should be verified for all deaths
being investigated. Deaths whose timing falls outside the study period should be
excluded from the calculation.
i
To confirm the timing of all deaths, and in order not to miss any deaths, an
attempt should be made to compare this data with the mortahty records maintained by
the ANM for the area. Our experience is that the ANM may be better at recording
neonatal and infant deaths, since she does antenatal registration, but she may not
record certain deaths esp. of adults in remote hamlets, which she visits infrequently.
82 'Guidelines for Investigating Suspected Starvation Deaths , by the Jan Swasthya Abhiyan)
Hunger Watch Group (mimeo, 2003)
Local calendar, local festivals, phases of the moon and local market days may be
used to ascertain the date of death in case of all deaths in the specified period. The exact
number of deaths in this period should be used for the calculation of death rates. The
shorter the recall period, greater will be the accuracy in assessing the date of deaths.
A parallel important exercise is to assess the exact population of all the villages /
hamlets in the cluster, which would form the denominator. The Gram Panchayat would
usually have figures and voter lists, yet this may be cross-checked by actual estimation
of number of households based on information from local people.
How to check whether the number of deaths in this particular area are significantly
higher or not?
There are two major issues involved if we calculate the death rates for a
comparatively shorter period (e.g. three months) and in a small sample, and then
extrapolate it to the whole year and compare it with the state figures. Firstly, there is
seasonal variation in deaths. For e.g. there may be more deaths in rainy season due to
water bom diseases like diarrhoea. If the death rate we have calculated in our study
coincides with the period in which there are seasonally higher deaths in that region,
and then we extrapolate to the whole year, then definitely the death rate that we have
calculated will be an overestimate compared to the annual death rate. Thus it is
essential to consider the seasonal variation in deaths while calculating death rates for a
shorter period. One way of doing this is to compare death rate in a specific season this
year with the death rate during the same season last year. A higher rate this year indicates
a definite and significant increase.
A second important issue related to calculating death rates in this manner is that
if the sample population we have covered is too small in size, and then if we compare it
with the rates of the state, it will may give an inaccurate estimate of death rates for that
sample population being higher than the total state. For that we need to take certain
minimum population while calculating death rates (to be estimated), and perform a
statistical comparison of proportions, which will take into account the difference in sample
size.
To see whether the number of deaths in the area we are investigating are
significantly higher than the previous year in the same area or than that of the nearby
villages in the same year, we will have to follow certain steps:
1
Document all the deaths in the area we are investigating in the specified period
of time in which we are suspecting that the starvation deaths have occurred.
2
Find out the number of deaths in the same area in the same period in the
previous year through Gram Panchayat data.
3
The data for deaths in that District in the same period can be collected from the
NSS records.
4
Find out the number of deaths for the district in that period.
To overcome the problem of seasonal variation in deaths, here we are
comparing the deaths in the same period during last year in the same population.
To calculate whether the deaths in the area we are investigating are significantly
higher, we can apply the comparison of proportions test or chi-square test. For
comparison, age specific deaths should be compared.
For e.g. total number of deaths in the age group of 0 to 5 years in the village we are
investigating are 17 in the year of investigation and the total number of children in this age
group is 138. In the previous year in the same village the total number of children in the same
age group were 154 and the total deaths that took place were 13. Then to find out whether the
number of deaths is significantly higher or not, apply the proportion test.
Annexure 2
Anthropometry to assess nutritional status of the community83
An effective nutritional survey involves an assessment of nutritional status of
children and adults in the area based on anthropometric measurements, assessment of
specific deficiencies, socio-economic status, along with current sources of income,
availability of food and social security measures such as Fair price shop, Ration shop
and Anganwadis etc. The following strategies could help in an accurate estimation of
nutritional status based on anthropometric measurements. The other parameters could
be tackled with the help of a short questionnaire answered by people in a village
meeting.
At the outset explain what you are going to do to the activists who are helping
you. Repeat this when you go to the actual villages. Explain the procedure patiently to
each person involved in the study. Take their oral consent after informing them about
the nature of the study, what is the objective behind it and where will the results be
used. Assure them that the names of all participants will be strictly confidential m case
they are alarmed about this. Lastly tell them that they can withdraw from the study at
any stage.
Sampling- It is the method of choosing a part of the study population, rather than
the entire population, for participation in the study. It should be representative of all the
strata in the population. Sampling makes the study easier, economical and enables us to
study a larger area.
Various methods can be employed for this according to our needs. In case of the
present study we can study two or three hamlets in the area, which will give us a good
idea of the nutritional status in the whole area.
83 'Guidelines for Investigating Suspected Starvation Deaths', by the Jan Swasthya Abhiyan)
Hunger Watch Group (mimeo, 2003)
In order to take a representation from all the groups in the population we can
select hamlets such that: ♦ Hamlets close to the road and away from road are covered. ♦
Hamlets of different tribes, and or backward castes/ classes/ areas we are interested in
working with are covered ♦ Hamlets with and without an Anganwadi facility are
covered.
We can choose 2-3 hamlets, which cover these aspects. This would be a
representative sample of the people we would like to work with. Within the hamlet we
need not choose a further sub-sample if the hamlet is as small as of 30-40 households. In
case it is as large as that of 100-200 households, we can take a 50% sample, i.e. we can
choose every alternate house. This will give us a good representation of that hamlet. We
can study the children in the age group of 1-5 yrs and adults above the age of 18 years in
the chosen households. This sampling scheme will be repeated in each area we want to
study.
Nutritional survey of children- The weight of a child is a sensitive indicator of its
nutritional status. NCHS standards for ideal body weights for children, both male and
female are available to us. (Annexurel) Classification systems based on these standards
enable us to decide from the age of the child and its weight if the child has a normal
nutritional status or is either undernourished or overweight. The IAP standards (Indian
Academy of Paediatrics) are most commonly used as they are also the standards used by
the ICDS (Integrated Child Development Scheme). In order to use this classification the
weight of the child in Kilograms (Kg) and the age of the child in months should be
available. It is also desirable to measure the height of the child to know the Height for
a;ge and whether there is 'stunting1 which shows chronic/ long term undemutrition.
Tools required-
1
Weighing scale
2
Height measuring tape
3
Indian / local Calendar to ascertain the exact date of birth.
Weighing children above the age of 2 years is not a problem as they can stand on
the weighing scale. To weigh children between the ages of 12 months to 24 months, ask
any responsible adult to hold the child in her arms. Weigh them both together. Then
weigh the adult alone and calculate the difference between the two weights.
Precautions to be taken while measuring weight:
□
(a) The zero error of the weighing scale should be checked before taking the
weight and corrected as and when required.
□
□
(b) The individual should wear minimum clothing, and be without shoes.
(c) The individual should not lean against or hold anything, while the weight is
recorded.
For accurate measurement of height, ask the person to stand against a straight wall.
The position should be as such that both the feet are together, heels to wall and chin
parallel to ground looking straight ahead.
As record of vital statistics is very poor in rural India, many times there is no
reliable record of the child's age. Hence make sure that you are acquainted with the local
festivals or landmark events, and take an Indian Calendar while recording the date of
birth of the child. Make as accurate an estimation in months of the child's age. This is
important for the following calculation.
The weight of the child should be compared to the ideal weight for that age
mentioned in the NCHS standards. Calculate what percentage of the NCHS standard is
the child's weight, using the formula-
Weight of the child x lOOExpected
Percentage of the NCHS standards -
weight for that age (NCHS std)
TAP classification of Nutritional Status
Grade of Nutrition
Weight as Percentage of NCHS
weight stds
Normal
>80%
Mild to moderate undemutrition
71-80% 61-71%
III
Severe undemutrition III IV
51-60% 50% <
Tabulate the number of children falling in each category of nutrition status.
Nutritional Status of Adults-This is assessed based on the Body Mass Index or the
BMI. BMI is the ratio of the weight of the adult in Kgs to the square of her/his height in
meters.
BMI = Weight in Kgs
Height in
meters
2
This is a very good indicator of adult nutritional status as it is age independent. It
measures the person's weight for her height. Values of BMI between 20 to 25 are normal.
Undemutrition is measured using the following parameters.
Nutritional Status using BMI
20
BMI analysis
Grade of undemutrition
1. BMI <16
III degree CED*
2. BMI 16-17
II degree CED
3. BMI 17-18.5
I degree CED
4. BMI 18.5 to
Low normal
5. BMI 20 to 25
Normal
6. BMI >25
Overweight
*CED - Chronic Energy Deficiency
Criteria to define starvation in Adults - An important issue is that malnutrition,
starvation and starvation deaths seem to lie along a continuum. How is it possible to
demarcate one from the other? A significant research finding is that in adults, below
BMI of 19, mortality rates start rising. Mortality rates among adults with BMI below 16
are nearly triple compared to rates for normal adults.
Thus in adults a B.M.I of 16 and less should be used as a cut off point to demarcate
starvation from undernutrition. Based on a requirement of 0.7 Kcal / kg / hour, a 50 Kg
person needs about 850 Kcal per day to maintain oneself at Basal Metabolic Rate,
without any physical activity. Thus any food intake that is sustainedly lower than 850
Kcal per day would be incompatible with life in due course and is an indication of
starvation.
Annexure 3
Verbal Autopsy procedure84
Verbal Autopsy is a scientific method of proven validity used for establishing the
cause of death of individuals in a community, where forensic autopsies have not been or
cannot be conducted for any reason. This is particularly useful in situations where the
proportion of deaths occurring under medical care are low and where no autopsies are
routinely carried out. This method has been successfully employed in India, Bangladesh,
Kenya, Nigeria, Philippines, Indonesia, Egypt, and several other countries to determine
the cause of death of individuals in various circumstances, especially to identify causes
of maternal and infant mortality. At the Bhopal Peoples1 Health and Documentation
Clinic run by the Sambhavna Trust, Verbal Autopsy (VA) was used as a method for
monitoring mortality related to the December 1984 Union Carbide disaster in Bhopal.
Sampling-Ideally, all the recent deaths in the area should be considered for VA, so
there is no sampling involved. All deaths during a specified period (from one to three
months) should be taken. Recall of details becomes poorer with respect to deaths prior
to 3 months before the time of VA, and should be avoided.
A less demanding method is to conduct VA only on suspected starvation deaths
during a specified recent period. However, here a working definition of suspected
starvation deaths' needs to be used, for example 'any death where family members
report that the deceased had significantly reduced food intake due to non-availability of
food, during the month prior to death'. This option would thus involve a two-stage
survey process, first identification of suspected starvation deaths and then VA on the
selected suspected starvation deaths.
84 "Guidelines for Investigating Suspected Starvation Deaths', by the Jan Swasthya Abhiyan)
Hunger Watch Group (mimeo, 2003)
Technique of Verbal Autopsy-This method is based on the assumption that most
causes of death have distinct symptom complexes and these features can be recognized,
remembered and reported by lay people. It involves trained workers administering a
questionnaire to the carer / close family member of the deceased. Information thus
collected on the symptoms suffered and signs observed is given individually and
independently to a panel of experts for ascertaining the probable cause of death.
Steps in carrying out the Verbal autopsy
♦ Training-The questionnaire to conduct a VA is somewhat medicalised in nature and
hence we recommend that a person with some experience of health work be given
appropriate training in administering it, familiarity of the local language would be
necessary. However given the circumstances in which it has been successfully used
earlier, a well-trained fieldworker with good knowledge of the local language can
I
also be suited for the job. The section wise details of the questionnaire will be
provided later. All fieldworkers have to be given the background for conducting this
I
VA, and be trained in interviewing skills, administration of the questionnaire and
signs and symptoms of diseases.
I
♦ Identification of households- The fieldworkers would conduct a survey to identify
and list households where deaths have taken place during the specified time period.
Then for the VA, they would question carer of the deceased on the medical history
and clinical symptoms suffered. It is best to identify a single carer who has been with
I
the deceased and nursed her/him through the illness, and get all the information
through this person. In case of children, the mother is the best person, though this
would depend entirely on the circumstances. Using culturally appropriate language,
the fieldworkers, should apply stringent criteria in the collection and recording of
I
information. Information would be recorded on a questionnaire designed to elicit
details of the last illness, bodily appearance at the time of death, details of food
I
availability in the house, medical examinations and their results, treatment including
duration etc.
I
The VA questionnaire-At the outset, the interviewer must explain to the carer, the
I
I
I
purpose of conducting the VA, and take an informed consent to proceed. This may be
written or oral in case of non-literate carer, but this should be explicitly recorded. The
verbal autopsy questionnaire (VAQ) begins with general, introductory questions to
determine the lifecycle of the deceased. An instruction sheet is used by the field workers
as a guideline for administration of the questionnaire. The instruction sheet should be
translated into the local language where it is to be administered. The health workers
would also confirm which medical records of the deceased are in the possession of the
carer. General questioning familiarizes the carer with the type of information to be
collected and enables the interviewer to create favorable conditions for the carer to speak
openly, regarding personal and often traumatic details concerning the deceased.
The health worker then begins an open section in which the interviewee is invited to
explain what happened in their own words, details of food security, subsequent
illness/es, and responses to treatment received till the death of the deceased. The
statement is recorded verbatim. With the use of filter questions, specific recordings of
the symptoms related to different body systems are then made. While the interviewer
should be cautioned against asking leading questions, the questionnaire consists of all
important symptoms and signs relating to the major body systems, which should not be
left out in case their importance is not realized by the carer. Thus the health worker
identifies a body system, e.g. the respiratory system and encourages the carer to provide
voluntary information on any particular symptoms, e.g. breathlessness, cough,
expectoration tightness in chest etc. Care is taken to ensure that the interviewer does not
provide any direct or indirect suggestions during questioning. Information on medical
treatment received and documents related are also gathered.
A special section is devoted to collecting information concerning family food
security. Another section elicits the dietary history relating to the deceased, during the
week and during the month prior to death.
Assessment of Completed Verbal Autopsy Questionnaires- The filled VAQ is then
sent to a panel of three independent physicians along with available medical records of
the deceased. The physicians in the verbal autopsy assessment panel (who do not
conununicate with each other about their opinions) fill in a VA analysis table for their
convenience, and then write their opinions on the probable immediate, underlying and
contributory causes of death of the individual.
The final opinion is arrived at on the basis of the level of agreement among the three
independent medical opinions. In case all the three doctors in the assessment panel
opine that the underlying cause of death has been 'Starvation', then the final opinion
states that the 'most probable1 cause of death is attributable to 'Starvation'. The final
opinion states 'probable1 in case two of the three doctors agree on the nexus between
starvation and subsequent death and 'possible' if only one of the doctors in the panel
mentions starvation as a probable cause of death. In case all three doctors opine that the
disease or condition of death is not related to 'Starvation, the final opinion states that
the cause of death is unrelated to 'Starvation'.
Validity of the method of Verbal Autopsy in ascertaining cause of death -
Through numerous studies carried out in different parts of the world, the method of
Verbal Autopsy has been found to have a positive predictive value in the range of 70%
to 80% depending on the cause of death and age of the deceased. This range of validity
has been confirmed through comparison of opinions on cause of death as ascertained
through usual autopsies (post-mortem examinations) and that through Verbal Autopsy.
Appropriateness of VA in ascertaining starvation as a cause of death-The areas
where Verbal Autopsy is going to be used to assess starvation as a cause of death are
also the areas where availability of medical care is poor. This includes reasons related to
extreme poverty and physical lack of access to any government or private medical
facility. Also, an overwhelming majority of these deaths occur in people's homes
resulting in autopsies rarely being conducted and often there being no competent doctor
to certify the cause of death. Although some care may have been available, medical
records of the deceased prior to death are often unavailable or where available, these are
often incomplete. Given such a situation, VA appears to be the most appropriate method
to assess the cause of death.
The VA has to be supplemented in these circumstances by a thorough recording of the
conditions of'Food Security' prevailing in the community in general, including natural disasters
of drought, famines, rain and crop failure or conditions of gross/sudden unemployment,
indebtedness etc, similar conditions in the individual household, any signs of desperation to find
food such as borrowing, begging, stealing, consumption of unusual foods and incidents of suicide
etc. Also an analysis of the 'Calorific value' of whatever food is available and eaten should be
undertaken, to see whether the deceased was getting enough calories through food. To further
strengthen the findings anthropometric measurements of the living siblings in case of children
and the Body Mass Index of the living adults in the same household should be obtained.
Dietary Survey and Calorific Value of Locally Eaten Foods
Dietary survey is an essential part of the verbal autopsy process, which gives idea
about whether starvation / insufficient food intake is a cause of death or not.
Whenever a dietary survey is carried out in any community to investigate
starvation deaths, we first identify major local staple foods (basically cereals) eaten in
that community. Then we give a fixed amount (say 1 kg.) of flour or grains of that cereal
in any two houses of that community. We ask them to prepare their usual preparations
out of the raw material given. We then calculate the amount of flour used to make one
roti or amount of pulse used to prepare one Katori of dal. Then prepare a master chart
indicating nutritive value of locally available foods. For eg. In Badwani district of
Madhya Pradesh where verbal autopsies were conducted, one kilogram of maize flour
was given to two famihes each and they were asked to prepare roti. Out of one kg. flour,
six roties were made which means each roti contains approximately 170 gms. of flour.
Since 100 gms of maize gives 342 calories, it was concluded that one roti in this area
gives 580 Kcal approximately.
In case of calculating calorie intake of the deceased, information should be elicited
regarding the food eaten by the deceased one week and one month prior to death. Note
the number of meals eaten by him / her in a day. List the food items and their
ingredients in details. In case of children, note the..We^pf fppd intake up to three
v7
months prior to death. With the help of the master chart of calorific value of locally
available foods, then calculate the total calorie intake of the deceased per day prior to
death.
Based on a requirement of 0.7 Kcal / kg / hour, a 50 Kg person needs about 850
Kcal per day to maintain oneself at Basal Metabolic Rate, without any physical activity.
Thus any food
intake that is sustainedly lower than 850 Kcal per day would be incompatible with life
in due course and is an indication of starvation
It may be noted here that the intake during the week prior to death may be reduced
due to the illness itself, and is less significant to identify starvation compared to the
intake one month prior to death. The data on intake has to be combined with data on
Food availability for the family to come to a conclusion about lack offood intake due to non
availability offood, in other words, starvation.
History of consumption of unusual or 'famine' foods like toxic roots, leaves, tubers
etc. or consumption of substances eaten to suppress hunger should also be noted. It
indicates the non availability of other edible food items like pulses, grains etc.
Confirming the date of death
To determine the exact date of death, local events calendar should be used. A local
events calendar shows all the dates on which important events took place during a past
one year period. It shows the different seasons, months, phases of moon, local festivals
and events in the agricultural cycle.
It is important to accurately determine the date of each death also in the context of
calculation of death rates (section III).
Mode and Causes of Death
Even medical professionals are often not very clear about the
difference between mode of death and cause of death, and types of
causes of death. Hence the need for us to be clear about these terms
when we talk of starvation as a cause of death.
The Death Certificate issued by a doctor should contain the following-
Cause of death: A disease or injury that results in the death of the individual. If
there is a time delay between the onset of the disease or injury and the time of death,
then the cause can be divided into the following categories:
□
(a) Immediate cause of death: This is the disease or injury that developed just
before the death and resulted in the death. E.g. Pneumonia, Diarrhoea, Ischaemic Heart
Disease, Burns, Accident.
□
(b) Underlying cause of death: When there is a delay between the onset of the
disease or injury and the ultimate death, this is the process that started the chain of
events that eventually resulted in the death. E.g Measles could be the underlying cause
of Pneumonia which resulted in death of the individual. Atheromatous or narrowed
blood vessels could be the underlying cause of Ischaemic Heart Disease. In the same
way, severe malnutrition or starvation could be the underlying cause of death in a case
where the immediate cause is diarrhea.
□
(c) Contributory cause of death is inherently one not related to the principal
cause, but it must be shown that it contributed substantially or materially; that it aided
or lent assistance to the production of death. It must be shown that there was a causal
connection.
E.g Undernutition in death due Pneumonia, High blood pressure in Ischaemic Heart
Disease.
To illustrate the difference, take the case of a woman who is severely anemic during
pregnancy. Her severe anemia remains untreated, and immediately after delivery she has
moderate amount of bleeding and dies. (A healthy, non-anemic woman with similar amount of
bleeding may have survived.) In this case, immediate cause of death is post-delivery bleeding,
while underlying cause is severe anemia.
Mode of death: A pathophysiologic derangement that is incompatible with life. It is
a common final pathway to death for a number of disease processes. Modes of dying
include organ failure (e.g. 'heart failure', 'renal failure', multi-organ failure'), cardiac or
respiratory arrest, coma, cachexia, debility, uraemia and shock.
Therefore it is important to recognize that 'Cardio-respiratory arrest', which is often
erroneously mentioned as the immediate cause of death is in fact the mode of death in a
person. To state 'cardio-respiratory arrest' as a cause of death is not only factually
erroneous, it may also be a deliberate subterfuge by a medical official, to avoid
commenting on the actual cause of death, such as starvation.
As a general rule, a number of pathways can be responsible for a mechanism or
mode of death, but causes of death are specific. For example, shock has a number of
causes and therefore is a mode of death. However the post-partum sepsis that resulted
in shock is the cause of death.
Another way of looking at it is, if all dead people have the entity that you would
like to list as a cause of death, then it is likely to be a mode of death. All dead people
suffer from low blood pressure (shock), cardiac arrest and pulmonary arrest.
Starvation and Undemutrition as a cause of death-It is obvious that Starvation and
Undemutrition would generally occur as the underlying or contributory cause of death
in an individual. The final clinical event before death may be a minor infection such as
diarrhea or measles, which may become the immediate cause of death.
As we are going to deal with actual human beings in real life situations, the
individuals would suffer from gradual reduction in the calorie intake while having to
keep up desperate efforts to find work and food for the family. The children would have
to cope with demands for their growth. Rather than an absolute deprivation of food
leading directly to death, we would have a chain of events where starvation (<850 Kcal
daily intake) is the underlying cause, and an infection becomes the immediate cause of
death.
Ethical issues related to conducting VA
There are certain serious ethical issues, which come up during the process of conducting a
verbal autopsy in such a social situation. Some of the issues encountered and how they may be
addressed are outlined below-
(a) Distress to relatives caused by the verbal autopsy procedure
The verbal autopsy process involves a detailed questioning of the relatives about
the illness, food intake, treatment and various other aspects of the deceased prior to
death. This is a process, which is liable to cause distress among the relatives of the
deceased when they are questioned.
To deal with this issue, an attempt should be made to carefully explain the purpose
of the study to the relatives. Also, the option of not participating in the study should be
kept open for the respondents. In some situations, where the respondents are not in a
mental frame to answer the questions, a second visit may be made to conduct the
questioning at a later stage, or the asking of information may be spread over two visits.
Of course, the interviewer must properly introduce himself / herself, state the purpose
of his / her visit, and thank the respondents for their co-operation etc.
(b) Possible raising of false expectations among respondents
Measuring of nutritional status of children and adults and detailed questioning of
relatives of the deceased might lead to generation of expectation of some immediate
benefit to be given by the interviewers to the respondents. This is especially likely if the
interviewer is a person from outside the area, of apparently better socio-economic
background etc.
This problem may be partly avoided if the basis of contact is by means of a local
organisation or person who is already known to the people. If possible, the verbal
autopsy should be done by a person who is known to the community or linked with a
local organisation. People may be already aware of the method of working of the local
organisation and would not expect any personal preferential 'dole' from a person who is
linked to the organisation. Rather it should be made clear that the findings of the survey
would be used to generate pressure for better implementation of relief measures in the
area, which would benefit everyone, provided that such an attempt is planned.
(c) Need to share the results of the study with the people in their language
Such a study should preferably be conducted on the demand of a local orgamsation,
and should help to strengthen their demand for relief facilities. In the same spirit, the
results of the survey should be communicated to the people in their own language, in
village meetings and also by means of a simply written note in the local language.
Method of preparing the final report and drawing the 'Hunger Pyramid'
The methodology of investigation as described in previous chapters has been
devised to ensure a thorough, factual and relatively objective investigation of a death as
well as its context.
However, the report is not a mere collation of the facts thus collected. The report is a
statement of our opinion on the basis of the facts collected along with corroborative
arguments and evidence. It is, therefore, an analytical document carefully arguing a case
once our investigation is complete and has led us to an opinion.
If the investigation convinces us that the death concerned is not a starvation death
we must make our report accordingly if asked to do so by any agency. However,
henceforth, this chapter assumes that we are making the report of what we consider to
be starvation death(s), either of children or adults, in the setting of a starving
community.
The objectives of the report are twofold:
1
To verify and certify starvation death(s)
2
To clearly detail the prevailing community conditions of malnutrition and
starvation leading to morbidity (sickness) and further mortality (death) if action is not
immediately taken.
Such a report can be used for demanding immediate action such as
compensation and appropriate state action to ensure food security for the entire
community, as well as build evidence and pressure for long term policy changes.
The report should have the following sections, at least -
1
Introduction
2
Under five mortality rates of the given community and comparison with state
under-five mortality rates
3
Death rates within the community and comparison with state crude death rates
4
Estimation of malnourished children based on weight for age
5
Estimation of severely malnourished adults based on EMI
6
Details of starvation / malnutrition deaths among children
7
Details of starvation deaths among adults
8
Community situation of food security
9
Hunger pyramid for the community and overall assessment
10
Recommendations
1. Introduction
This section should outline the initial information (press reports, personal
communication), which originally led the team to investigate starvation deaths in this
particular community. It should also contain some information about the area (district,
taluka, villages), organisations and individuals involved in the investigation, and overall
setting of food insecurity in the state / region (drought, failure of food security schemes
etc.)
1
Under five mortality rates of the given community
and comparison with state under-five mortality rates
Death rates within the community and comparison with
2
state crude death rates
These death rates should be calculated and compared with the relevant state
mortality rates. Then the number of excess deaths (actual deaths minus deaths expected
according to state mortality rates) can be calculated. All excess deaths taking place in a
situation of serious food insecurity may be regarded as malnutrition deaths unless proved
otherwise. Here the absence of any major disasters or accidents may be quoted to rule out
other causes of excess deaths.
4. Estimation of malnourished children based on weight for
age
AU children with weight for height less than -3SD should be enumerated and listed
individuaUy also. The number should be expressed as a percentage of aU children and
compared with the state/block average as per ICDS records / NFHSII records,
whichever available. ICDS records are preferable. Increase should be shown as
percentage increase and it has to be argued that according to the WHO any child with -
3SD or less weight for age is considered in need of emergency treatment.
It has been documented that mortality rates among children increase several fold
and drastically when the weight for age is below 60% of the expected weight. Hence
these children are at very high risk of mortality. Any increase in numbers of such
children indicates that the entire community of cluldren is at risk. Therefore, emergency
measures must apply to all children in that particular community.
According to the WHO criteria, if more than 30% of children in a
community have low weight-for-age, it is a very high prevalence
level. Although practically all poor rural communities in India have
higher than this level of malnutrition, this too may be cited as
evidence of very high level of malnutrition.
Prevalence group
% of children with low weight-for-age
(below -2 SD scores)
Low
<10
Medium
10-19
High
20-29
Very High
>30
(Criteria laid down in the WHO expert committee report on Anthropometry - WHO TRS 854,
1995)
For effective advocacy, the weights of the children in the affected area should be
compared with those of middle class children in the same age group. This would bring
out the differences more sharply than do figures of percentages in the various categories
of undernutrition.
5. Estimation of severely malnourished adults based on BMI
The number and percentage of adults with BMI less than 18.5 and BMI less than 16
should be computed and presented. Adults with BMI less than 16 are at high risk of
mortality from starvation. If over 40% of adults in the community have a BMI of < 18.5,
the community may be termed at 'critical risk for mortality from starvation' or a starving
community.
Low prevalence
5-9% population with BMI< 18.5
Medium prevalence
10-19% population with BMI< 18.5
High prevalence (serious
20-39% population with BMI< 18.5
situation)
Very high prevalence
>= 40% population with BMI< 18.5
(critical situation)
(Criteria laid dawn in the WHO expert committee report on Anthropometry - WHO TRS
854, 1995)
6. Details of starvation / malnutrition deaths among
children
This part of the report is based upon
1
Verbal autopsy
2
Anthropometry of siblings and family members
3
Community Situation of Food Security
4
Community Child Death Rates
These are used to argue the following points -
1
Evidence that the dead child was already malnourished ( description of physical
appearance, hair, skin, nails, previous anthropometric / medical records, siblings and
other family members being malnourished - by anthropometry)
2
Evidence that there was acute shortage of food to the individual. This is done by
relating dietary history for the last few days to caloric intake. Since this is relatively
difficult for a child, specially a breast feeding child, this part of the report should be
commented upon by the technical support team (nutritionist / pediatrician)
3
Evidence that there was an acute shortage of food in the household ( dietary
history of other household members, examination of household food supphes, loan
taken recently, recent migration of able bodied family members, eating of unusual food,
recent beggary / crime for food, failure to receive food from PDS, ICDS or any other
schemes due to non availability, illness or debility)
4
Evidence that there is an abnormally raised child death rate in the community
(section 2 of the report). Even if the terminal event in most of the deaths are infections
(diarrhea, pneumonia, measles) if the death rate is significantly higher than the under
five death rate for rural areas in the state, this is evidence of hunger related deaths
provided there is a community setting of food insecurity.
Infection as the terminal event
When the terminal event is an infectious disease, which is the commonest scenario,
such as pneumonia or diarrhoea, the 'diagnosis of starvation death need not change.
This logical progression to disease, which forms the terminal event, is well
documented in cases of starvation. The last two points suffice to call a death a starvation
death.
If there has been an outbreak of a disease (e.g. measles) and all the deaths have been
attributed to the outbreak, the logical argument in the context of starvation would be
that normally speaking the mortality of a disease does not exceed x percent of cases. The
fact that mortality has been so much higher proves that death was due to starvation, not
disease.
7. Details of starvation deaths among adults
This part of the report depends upon 1
Verbal autopsy and dietary history
2
Anthropometry of family members
Verbal autopsy
This is to establish that death did not take place due to
accident or other physical trauma, and to document the clinical
events preceding death, as also dietary history and body appearance.
The dietary history component should be analysed in terms of caloric value by
referring to the charts of caloric values of local food for assistance or taking the
assistance of the technical support group. Caloric intake of less than 850kcal per day for
an adult establishes the diagnosis of starvation.
Food security of the family - substantiating findings of food stores within the
family, recent loans, migration of able-bodied members, eating of unusual foods,
beggary should be documented.
Anthropometry of surviving family members
BMI of less than 18.5 amongst adults of the family, and weight for age less than
3SD in the children is supportive evidence that the whole family is in a situation of
starvation.
8. Community situation of food security
The provision of supplies,access and uptake from PDS, Food for Work
Programmes if any, ICDS, Mid Day Meal, maternity benefit and other schemes should
be described.
9. Hunger pyramid for the community
The above mentioned two objectives are fulfilled by drawing the entire 'hunger
pyramid' that prevails within a community, of which the starvation death/ s are only
the tip.
Starvation deaths
Starving population Severely undernourished
Mild to Moderately
undernourished
Appropriate figures or percentages should be given for each of these categories, to
give a complete idea of the situation, e.g. in a particular village Starvation deaths - 6 persons (4 adults, 2 children) Starving population - 7%
families Severely undernourished - 15% adults, 18% children
Mild to Moderately undernourished - 43% adults, 62%
children
Starvation deaths are those deaths which have been identified as being due to
starvation / malnutrition on the basis of the Verbal autopsy process.
Starving population is the proportion of families where adults have a daily caloric
intake of less than 850 Kcal.
Severely undernourished population is the proportion of adults with BMI < 16 and
in case of children, those with weight for age less than 60% of expected, (deduct the
proportion of starving population from this to avoid overlap)
Mild to moderately undernourished population is proportion of adults with BMI <
18.5, proportion of children with weight for age less than 80% of expected (deduct the
previous two proportions from this to avoid overlap)
The investigating team along with the Hunger Watch group should express an
overall opinion. This should categorically express an opinion regarding the deaths that
have taken place - starvation deaths or not starvation deaths. It should also make a
community diagnosis
- community at risk for further starvation deaths (starving community) or not.
10. Recommendations
Finally, the report should make recommendations for immediate action at the local
level.Recommendations should include compensation for the deceased, measures to
feed and supply food, hospitalization where necessary, arrangements for nutrition
rehabilitation, healthcare including immunization, long term food security measures.
Annexure 5
Verbal Autopsy Questionnaire - Adults
(Above 15 years of age)
Preliminary Information
Name of the deceased: Date of
interview:
Age in years at time of death:
Sex: Male/Female
d. if Female-Pregnant / Lactating/ Neither
Age of eldest living child
Marital status
* Married * Unmarried *Divorced * Widowed
*Others
Address:
Name of the informant(s)
Informant's relation to the deceased Who, among the informants, was present at the time of the
fatal illness?
Occupation (give details of type of work)
i) Working person, active till death
ii) Working person, stopped working for some period before
death (specify period)
iii) Not working person
Family structure -Nuclear / Joint
Total No. of Members
Male adults
Female adults
Children
Income and food supply: (Relates to the family)
Agriculture:
Total Land owned ________________
Irrigated land owned^
Crop from last harvest was sufficient to adequately
feed the family till which month -
Wages: (In the last six months)
Work as agricultural labour -
No. of days in last 6 months
Daily
WageWork on Govt, relief works -
No. of days in last 6 months
Daily
Wage-
Work outside the village (State the type of work)
No. of days in last 6 months
Daily
Wage-
Any other source of income:
Has the total income during last six months been sufficient
to adequately feed all family members?
Yes No
If not then what was the approximate proportionate decrease
(proportion of usual)? -
Which items in the diet specifically were decreased -
Foodgrains (Maize, Wheat, Jowar, Rice etc.)
Pulses
Vegetables
Oil, milk etc.
In the last six months relating to the deceased
and family
Were any unusual or 'famine' foods being eaten
(roots,
tubers, leaves etc.)
Were other members of the family eating such
unusual things ?
Any substances being eaten to suppress hunger?
Was the family purchasing PDS rations ?
Did the family avail of drought relief ? Yes /
No
If so in what form?
Deaths of cattle or other animals
Distress sale of cattle, vessels, implements and other
belongings to obtain food
Borrowing or begging food from neighbours, relatives or
others
Personal habits
i. Smoking Yes No
If yes
Duration
Bidi / cigarette per day
ii. Alcohol Yes No
If yes
Duration
Quantity per day
Date of death
Day Month
Year
Weather at the time of Death:
Extreme cold / Extreme heat /
Neither
Place of Death
□
i. Home
Staying alone / With family
□
b. Families in immediate neighborhood:Yes / No Health centre / Hospital
iii On the way to Health Centre/Hospital
iv. Any other
Whether Death Certificate Available
Yes/No
If not why
___________ If yes
Mention Cause of Death as certified
2. Medical history related to death
2.1 Was the deceased seeing a health care provider before
death: l.yes 2.no
2.2 If yes, specify (name, profession, address.):
2.3 For how long:
years
2.4 For what complaint (specify):
2.5 Was the deceased taking any medication:
l.yes 2.no
2.6 If yes, specify (ask for remaining containers / unused
medicines):
2.7 Was the deceased hospitalized before death:
l.yes 2.no
2.8 If yes, specify where (name, address):
2.9 For how long:
days
2.10 Did the deceased leave hospital (before death): l.yes
2.no
If yes, how many days before death?
days
2.11 Did the deceased undergo any surgical operation during
this hospitalization: l.yes 2.no
2.12 If yes, when (before death):
days
2.13 Do you know what was the operation: l.yes 2.no
2.14 If yes, specify
2.15 Was the deceased or any member of the family ever told
the nature (the diagnosis) of the illness:
l.yes 2.no
2.16 If yes, what was it (specify as clearly as possible):
Was there any accident / poisoning / bite / bum or other
unnatural event shortly before death-
l.yes 2.no
2.17.1 If yes, what was the accident
2.17.2 If yes, specify hours / days before death:
2.18 Where did the accident occur:
1. at work
1
road (vehicular accident)
2
at home
3
other (specify):
2.19 Organs/part of body injured during
accident
2.20 Other unnatural eventsDrowning
Poisoning
Hanging
Bite by snake or other venomous animal
Bums
Violence
Any other (specify)
How long before the death did this event take place?
(Hours / days)
Details of the event (in case of poisoning, what agent was
used; in case of violence, what type of violence etc.)
3. Specific disease related information
3.0 Open ended question about the illness -
According to what you know what did the deceased die of and
how? Please narrate.
(All questions in the sections below pertain to the illness
immediately preceding death unless specified otherwise)
3.1 Cardiovascular system
Did the deceased ever complain of unusual breathlessness? :
l.yes 2.no
If yes, was it on:
Exertion: l.yes 2.no
If yes, how much exertion:
1
Walking on level surface
2
Walking up an incline
3
Climbing stairs
Breathlessness while lying down flat: l.yes
2.no
At night, relieved by sitting up in bed:l.yes
2.no
3.1.2 Did the deceased ever complain of chest pain: l.yes
2.no
If yes:
3.1.2.1 Was it persistent for several hours:
l.yes 2.no
Was it accompanied by excessive sweating: 1. Yes
2. No
3.1.2.2 Was it relieved by rest:
l.yes 2.no
3.I.2.3. Did the deceased ever complain of cyanosis on the
lips, fingers or nails: l.yes 2.no
3.1.2.4 Did the deceased ever complain of swelling on the
body (the lower limbs, foot and leg, eyelids, abdomen, back):
especially if lying down:l.yes 2.no
3.1.2.5 Did the deceased ever complain of an episode of
palpitations (sudden rapid heart beats for one hour or more):
l.yes 2.no
3.1.2.6 Did the deceased ever complain of recurrent sore
throat, joint pain and inflammation (migrating, fleeting and
affecting several joints):
l.yes 2.no
Respiratory system
3.2.1 Did the deceased have cough: l.yes
2.no
3.2.2 Dry cough / Productive cough
If productive, was the sputum:
3.2.2.1 Clear and sticky:
l.yes 2.no
S.2.2.2 Yellowish or greenish: l.yes
2.no
S.2.2.3 Stained with blood: l.yes
2.no
3.2.2.4 Whether large quantity of sputum and offensive
smell: l.yes 2.no
Duration of the cough
Was the cough related to season ? If so, in which season
was it worse?
3.2.5 Chest pain: l.yes 2.no
If yes
3.2.5.1 Was it increased with cough and / or deep breath:
l.yes 2.no
3.2.S.2 Was it localized and tender:
l.yes 2.no
3.2.6 Wheezing:
l.yes 2.no
Digestive system
Did the deceased ever complain of:
3.3.1 Abdominal pain l.yes
2.no
If yes, since when?
Was the pain
3.3.1.1 Persistent:
l.yes 2.no
3.3.1.2 Localized over one area: l.yes
2.no
If yes:
3.3.1.2.1 Central abdomen: l.yes
2.no
3.3.1.2.2 Left upper abdomen l.yes
2.no
3.3.1.2.3.Right upper abdomen l.yes
2.no
3.3.1.2.4 Lower abdomen l.yes
2.no
If yes then - left side
right side
entire lower abdomen
3.3.1.2.5 Loin radiating to the groin (inguinal region)
l.yes 2.no
3.3.1.2.6 Relieved by meals (food):
l.yes 2.no
3.3.1.2.7 Aggravated by meals (food):
l.yes 2.no
3.3.2 Persistent heartburn:
l.yes 2.no
3.3.2.1 Was it sometimes accompanied by water brash
(belching of sour fluid in the mouth:
2,no
l.yes
3.3.3 Diarrhoea:
l.yes
2.no
If yes, was it:
3.3.3.1 Acute (less than 15 days)
3.3.3.2 Chronic (more than 15 days)
3.3.3.3 Accompanied by blood
l.yes
2. no
Alternating with constipation:
2.no
l.yes
3.3.4 Vomiting blood: l.yes 2.no
If yes:
33.4.1 Was the blood:
1.bright red 2.dark brown
33.4.2 Did this vomiting of blood last until death:!.yes
2.no
33.4.3 For how long before death:
month(s)
33.4.4 Was the deceased or any member of the family
informed of the nature or the cause of this
vomiting blood:
l.yes 2.no
If yes:
33.4.5 What was it
33.5 Normal stools with blood in the stools: l.yes
2.no
If yes:
3.3.5.1 Was the blood:
l.red 2.dark brown
l.yes
3.3.S.2 Did the symptoms last until death:
2.no
If yes:
3.3.5.2.1 For how long before death:
months
3.3.5.3 Was the deceased or any member of the family
informed of the nature or cause:
l.yes 2.no
If yes:
3.3.5.3.1 What was it:
3.3.6 Jaundice:
l.yes 2.no
If yes:
3.3.6.1 For how long before death:
days
3.3.6.2 Did jaundice last until death:
l.yes 2.no
3.3.6.3 Was the deceased or any member of the family told
of its nature or cause:
l.yes 2.no
If yes:
3.3.6.3.1 What was it:
3.3.7 Persistent vomiting:
l.yes
2.no
If yes:
l.yes
3.3.7.1 Did it last until death:
2.no
days
3.3.7.1.1 What was the duration: (before death):
_____________ days
Urinary system
3.4.1 Did the deceased ever complain of one of the
following symptoms:
l.yes
3.4.2 Blood in urine:
2.no
If yes:
3.4.2.1 Did blood in urine last until death:
l.yes 2.no
If yes:
3.4.2.1.1 For how long (before death):
month(s)
3.4.2.1.2 Was Blood in urine ever associated with pain:
l.yes 2.no
3.4.2.2 Was blood in urine: l.persistent
2.intermittent
3.4.3 Problems in urination:
2.no
If yes:
3.4.3.1 Decreased volume of urine: l.yes
2.no
3.4.3.2 Complete retention of urine lasting for more than a
l.yes
few hours:
l.yes 2.no
If yes:
3.4.3.2.1 Was this retention:
1.recurrent 2. transient
3.4.3.2.2 Did this retention last until death: 1. yes 2. no
3.5 Infectious diseases
3.5.1 Did the deceased ever complain of fever in the month
prior to death:
1. continuous 2. intermittent 3. never complained
If continuous or intermittent:
3.5.1.1 Did fever last until death: 1. yes 2. no
If yes:
Was the fever on alternate days or every day at a fixed
time?
__________
Were there chills / rigors accompanying the fever?
Was there continuous fever for more than one week?
3.5.1.2 Was the deceased or any member of the family ever
informed of the nature of the diagnosis
of this fever:
l.yes 2.no
If yes:
3.5.1.2.1 What was it:
Reproductive mortality
If the deceased is a female aged 12-50 years:
3.6.1 If married and living with her husband OR separated.
divorced, or widowed for less than 3 months,
did she complain before she died of:
3.6.2.1 Continuous fever: 1. yes
2. no
3.6.2.2 Vaginal bleeding: 1. yes
2. no
3.6.2.3 Abortion (up to 42 days (6 weeks) before death): 1.
yes 2. no
3.6.3 Was she pregnant and dehvered before her death (up
to 6 weeks before death) regardless of gestation
age:
1. yes 2. no
If yes:
3.6.3.1 Where did the delivery take place: 1.
hospital 2. home 3. other
(specify)
Any significant symptoms or events related to the pregnancy
or delivery
Unusually large amount of vaginal bleeding before / during
I after delivery
Inability to deliver within 24 hours of onset of labour
Severe continuous pain in the abdomen during labour
Pain in lower abdomen with fever / foul discharge after
delivery
Malignancies
Did the deceased ever complain of:
3.7.1 The presence of any mass or tumour in any part of the
body: l.yes 2.no
If yes:
3.7.1.1 Where: (specify, if a woman emphasize mass in
breast)
3.7.1.2 Did this tumour persist until death:
l.yes 2.no
3.7.2 Continuous loss of weight with no apparent reason
l.yes 2.no
3.7.3 Abnormal vaginal bleeding aside from the menstrual
cycle especially after menopause
3.7.4 Lump in the cheek / tongue
3.7.5 Was the deceased or any member of the family ever
informed of the possible existence of a malignant tumour or
growth:
l.yes 2.no
If yes:
3.7.4.1 Where in the body (specify as clearly as possible)
S.7.4.2 What was the outlook for the patient:
l.not mentioned
2. good
S.reserved
4.bad (fatal)
Did the person have obvious loss of weight in the three
months prior to death?
3.8 Other
Did the person have paralysis / extreme weakness on one
side or a particular part of the body?
Did s/he have severe continuous unremitting headache ?
If yes, was there accompanying fever and inability to bend
the head forwards?
Did s/he have convulsions? If yes, did these last until
death?
Was the body stiff/ arched back for some hours or days
before death?
Was the person unconscious before death? if so, for what
duration?
Specific information related to
malnutrition / starvation
Food intake (semi-quantitative) - here
the interviewer has
to estimate the caloric intake if possible
based on detailed
dietary history.
Daily intake during the week prior to
death
How many meals did the deceased have
in a day ?
Morning
Noon
Afternoon / evening
Night
Other meals / snacks
(Quantify exact amounts of roti, rice,
ghat / rabdi
(porridge), dal etc. as far as possible)
Was this food enough to satisfy his
hunger?
Daily intake during the month prior to
death
How many meals did the deceased have
in a day ?
Morning
Noon
Afternoon / evening
Night
Other meals / snacks
Was this food enough to satisfy his
hunger?
4.2 a. Water intake - Normal / reduced /
increased / do not know
b. Source of Water -
Did s/he complain of
Constant complaint of hunger
Loss of feeling of Hunger
Dizziness on standing up
Extreme weakness and inability to walk
Inability to see at night
What were the observations of the family members regarding
the deceased person:
Eyes:
Sunken/
Skin:
Creases, wrinkles
Normal/
Do not know
over forehead and face as usual
Increased
Do not know
Normal / Scaling or peeling / Do not know Hair: Normal / Dry or discoloured / Do
not know Cheeks : As usual/ very sunken / Do not know Ribs: As usual / very
prominent/ Do not know Limb bones : As usual / prominent/ Do not know Abdomen:
As usual/ very sunken / Do not know Hipbones : As usual/ prominent and projecting
/Do not know Tongue: Dry / coated or fissured / Do not know Normal pink colour /
very pale or whitish / Do not know Lips: Normal / Dry or cracked / Do not know
Gums : normal / loose teeth, bleeding / do not know
Swelling over Ankle : Y/N
If yes -unilateral / bilateral Face : Y/N Upper limbs: Y/N
Palms and nails: Normal pink colour / very
pale or whitish
/ do not know
Body temp : Normal / Cold / Do not know
Bed sores: None
If yes, site : Shoulder blade/ Lower back /
Hip/Calf
/Other part
Behavioral changes: None /Muttering or irrelevant talk /
Unconscious
5. Presumed cause of death
5.1 From death certificate if available:
5.2 From verbal autopsy form:
5.21 Immediate cause of death:
5.22 Underlying cause(s) of death
5.23 Contributory cause(s) of death:
Questionnaire modified from - Mortality and causes of death
in Jordan 1995-96:assessment by verbal autopsy
S.A. Khoury, D. Massad, T. Fardous,
Bulletin of the World Health Organization, 1999, 77 (8)
Verbal Autopsy Questionnaire for
Children
Instructions to interviewer: Introduce yourself and explain the
purpose of your visit. Ask to speak to the mother or to another
adult carer who was present during the illness that lead to death.
If this is not possible, arrange a time to revisit the household
when the mother or carer will be home.
Section 1: Background information on child and household
(To be filled in before interview)
1.1 Address of household
1.2 Name of child
1.3 Sex of child: 1. Male 2. Female
Section 2: Background information about the interview
2.1 Language of interview
day/month/year
Date of first interview
attempt
Date of second interview attempt
Date of third interview
attempt
Date of interview.
Section 3: Information about carer/respondent
3.1 What is the name of the main respondent?
3.2 What is the relationship of main respondent to deceased child? (tick relevant box)
Mother
Maternal Grandmother
Paternal Grandmother
Maternal
Grandfather
Paternal
Grandfather
Paternal Uncle
Maternal Uncle
Maternal Aunt's
Husband
Paternal Aunt's
Husband
Maternal Aunt
Paternal Aunt
Paternal Uncle's
wife
Maternal Uncle's
wife
Elder brother
Elder sister
1. Other male (specify)
17.Other female (specify)_
3.3 What is the age of main respondent (in years)
3.4 How many years of school did the main respondent
complete?
3.5 Were other people present at the interview?
1. Yes 2. No (If "No",go to question 3.5.3)
3.5.1 Of those present at the interview, which were
present at the illness that led to death/hospitalization?
3.5.2 Total number giving information at interview
3.5.3 If mother is not present at the interview, is the
mother still alive? Yes No
Section 4: Information about the child
4.1 Date of birth of child:
/
4.2 What was the date of death?
/
(dd mm yy)
/
/---- (dd mm yy)
4.3 Where did the child die? (tick relevant box)
1
Hospital
2
Other health facility
3
On route to hospital or health facility
4
Home
5
Other (specify
.)
4.3.3 For deaths at hospital or health facility, record
facility name and address:
Section 5: Open history question
5.1 Could you tell me about the child's illness that led to
death?
Prompt: Was there anything else?
Instructions to interviewer - Allow the respondent to tell you
about the illness in his or her own words. Do not prompt except for
asking whether there was anything else after the respondent
finishes. Keep prompting until the respondent says there was nothing
else. While recording, underline any unfamiliar terms.
Take a moment to tick all items mentioned spontaneously in the
open history questionnaire.
5.3 Was care sought outside the home while he/ she had this
illness?
1. Yes 2. No 3. Don't know (If "No" or "Don't know", go to section 6)
5.3.1 (If yes ask:) Where or from whom did you seek care? (Record all responses)
1
Traditional healer
2
Governmental health centre or clinic
1
Government hospital
2
Community-based practitioner associated with health
system including trained birth attendants..
3
Private physician
4
Pharmacy, drug seller, store, market
5
Other provider
8. Relative, friend (outside household)
After respondent finishes prompt: Did you seek care anywhere else?
Keep using this prompt until respondent replies that they did not
seek
care from anyone else.
Note: Above categories should be country-specific.
Section 6: Accident
6.1 Did the child die from an accident, injury, poisoning,
bite, burn or drowning?
1. Yes 2. No. 3. Don't know (If "No" or "Don't know",go to section 7)
6.1.1 (If yes ask): What kind of injury or accident? Allow respondent to answer
spontaneously. If respondent has difficulty identifying the
injury or accident, read the list slowly.
1. Motor vehicle accident 2. Fall
3. Drowning
4. Poisoning
5. Bite or sting by venomous animals 6. Burn
7. Other injury (specify)
6.1.2 How long did the child survive after the injury,
poisoning, bite, burn or drowning?
1. Died within 24 hours
2. Died 1 day later or more
Section 7: Age determination and reconfinnation
7.1 Record the child's date of birth from question 4 _/----/
Record child's date of death from question 4.2
dd mm yy
/— dd mm yy
J
7.2 Take a moment and calculate the age of the child at the time of death. Read out:
I have calculated that the child was
days (or
months or years old as appropriate) at the time of death. Is
this correct?
If the respondent indicates this is not correct, reconcile the
inconsistency by re-checkin the child's date of birth and date of
death. Make the necessary corrections here and in section 4.
If child died within 24 hours from injury or accident,go to
section 10 - treatment and records. If child was less than 28 days old
do not record any details as that is beyond the purview of this study.
If child was 28 days old or more at the time of death, go to section 8 -
post-neonatal deaths
Section 8: Post-neonatal deaths
8.1 During the illness that led to death, did
he/she have a fever?
1. Yes 2. No 3. Don't know (If "No" or "Don't know", go to question 8.2)
8.1.1 (Iffever ask): How many days did the fever last?
.
days
8.2 During the illness that led to death, did
have frequent loose or
liquid stools?
1. Yes 2. No 3. Don't know
8.2 During the illness that led to death, did he/ she
have (local terms for diarrhoea)?
Note: When preparing the country-specific
questionnaire,
include local terms for
diarrhoea.
1. Yes 2. No 3. Don't know
(If "No" or "Don't know", for both questions 8.2 and 8.3, go to question 8.4)
8.3.1 (Iffrequent or loose stools or local terms for diarrhoea ask):
For how many days did he/ she have loose or liquid stools?
days
8.3.2 Was there visible blood in the loose or Equid
stools?
1. Yes 2. No 3. Don't know
8.3.3 During the time with the loose or liquid stools,
did the child drink 'Rabdi' or 'Salt and Sugar solution' or
ORS?
1. Yes 2. No 3. Don't know
8.3.4 During the illness that led to death, did the child
have a cough?
l.Yes 2. No 3. Don't know
(If "No " or "Don't know",go to question 8.5)
8.5 During the illness that led to death, did the child
have difficult breathing?
1. Yes 2. No 3. Don't know (If "No" or Don't know",go to question 8.6)
8.6 During the illness that led to death, did the child have fast breathing? l.Yes
2. No 3. Don't know (1/ "No" or Don't knew",go to question 8.7)
(Ifyes ask): For how many days did the difficult breathing last?------ days
8.6.1 (If yes ask): For how many days did the fast breathing last?
days
8.7 During the illness that led to death, did he/she
have indrawing of the chest?
1. Yes 2. No 3. Don't know
8.8 During the illness that led to death, did he/she have noisy breathing?
(Demonstrate each sound)
8.8.1 Stridor
l.Yes
2. No 3. Don't know
8.8.2 Grunting
1. Yes
2. No 3. Don't know
8.8.3 Wheezing
1. Yes
2. No 3. Don't know
8.9 During the illness that led to death, did his/her
nostrils flare with breathing?
1. Yes 2. No 3. Don't
know
S.lODuring the illness that led to death, did the child
have pneumonia?
l.Yes 2. No 3.
Don't know
Note: When preparing country-specific questionnaires include
local terms for pneumonia here.
S.llDid the child experience any generalized
convulsions/fits during the illness that led to death?
8.121. Yes 2. No
3. Don't know
8.13Was the child unconscious during the illness that
led to death?
1. Yes 2. No
3. Don't know
8.14At any time during the illness that led to death,
did the child stop being able to grasp?
1. Yes 2. No
3. Don't know
(If "No" or Don't know",go to question 8.14)
8.15At any time during the illness that led to death,
did the child stop being able to respond to a voice?
1. Yes 2. No 3.
Don't know
(If "No" or Don't know",go to question 8.15)
8.16At any time during the illness that led to death,
did the child stop being able to follow movements with
their eyes?
1. Yes 2. No 3.
Don't know
(If "No" or Don't know",go to question 8.16)
8.15.1 (If yes, ask): How long before he/she died did the child stop being able to
follow movements with their eyes?
1
Less than 12 hours
2
12 hours or more
8.17 Did the child have a stiff neck during the illness that led to death?
(Demonstrate) 1. Yes 2. No 3. Don't know
8.18 Did the child have a bulging fontanelle during the
illness that led to death?
1. Yes 2. No
1
3. Don't know
8.19During the month before he/she died, did the child
have a skin rash?
1. Yes 2. No 3. Don't know
(If "No" or Don't know",go to question 8.18)
8.18.1 (Ifyes, ask) Was the rash all over the child's body?
1. Yes 2. No 3. Don't
know
8.18.2 Was the rash also on the child's face?
1. Yes 2. No 3. Don't know
8.18.3 How many days did the rash last? ...
days
8.18.4 Did the rash have blisters containing clear fluid?
1. Yes 2. No 3. Don't know
8.18.5 Did the skin crack/ split or peel after the rash
started?
1. Yes know
2. No
3. Don't
8.18.6 Was this illness "measles"?
1. Yes know
2. No
3. Don't
Note: When preparing country-specific questionnaire include
local
term for measles.
8.18 During the illness that led to death, did the child
become very thin?
1. Yes 2. No 3. Don't know
8.20During the illness that led to death, did the child
have swollen legs or feet?
8.21
1. Yes 2. No 3. Don't know
(If "No" or Don't know",^o to question 8.21)
8.20.1 (Ifyes, ask): How long did the swelling last? Number of weeks
8.22During the illness that led to death, did the
child's skin flake off in patches?
1. Yes 2. No 3. Don't know
8.23Did the child's hair change in colour to a reddish
(or yellowish) colour?
1. Yes 2. No 3. Don't know
Note: When preparing country-specific questionnaire, terms
for colour to be locally adapted.
Did the child have "marasmus" during the month before
he/she died?
1. Yes 2. No
3. Don't know
Note: When preparing country-specific questionnaire, local terms
for marasmus should be included.
8.24 During the illness that led to death, did the child
suffer from "lack of blood" or "pallor"?
1. Yes 2. No 3. Don't know
Note: When preparing coun.try-specific questionnaire, local terms for "lack of blood" or
"pallor" should be included .
8.25 During the illness that led to death, did the child
have pale palms?
1. Yes 2. No 3. Don't know
Note: When preparing country-specific questionnaire, local terms
for "pale palms"should be included.
8.2.7 During the illness that led to death, did the child have white nails? (Show
photo if possible)
1. Yes 2. No 3. Don't know
Note: When preparing country-specific questionnaire local terms
for "white nails" should be included here.
8.26 During the illness that led to death, did the child
have swellings in the armpits?
1. Yes 2. No 3. Don't know
8.27 During the illness that led to death, did the child
have swellings in the groin?
1. Yes 2. No 3. Don't know
8.28During the illness that led to death, did the child
have a whitish rash inside the mouth or on the tongue?
1. Yes 2. No 3. Don't know
9. Information about the Nutritional status of the child
9.1 What and how much was the child eating about one week
before death?
9.1.1 How many meals did the child have in a day?
9.1.2 Approximately what and how much was the child eating
in the
Morning
Afternoon
Evening
Night
Other
(Try to quantify approximately how much each of Roti,
Ghat, Raabdi. Etc)
9.1.3 Was this food enough to satisfy the child's hunger?
9.2 What and how much was the child eating about one month
before death?
9.2.1 How many meals did the child have in a day?
9.2 2. Approximately what and how much was the child eating
in the
Morning
Afternoon
Evening
Night
Other
(Try to quantify approximately how much each of Roti,
Ghat, Raabdi. Etc)
I
9.2.3 Was this food enough to satisfy the child's hunger?
9.3 What and how much was the child eating about three
months before death?
9.3.1 How many meals did the child have in a day?
9.3.2 Approximately what and how much was the child eating
in the
Morning
Afternoon
Evening
Night
Other
(Try to quantify approximately how much each of Roti, Ghat,
Raabdi. Etc)
9.3.3 Was this food enough to satisfy the child's hunger?
9.4 Was the child being given any unusual foods apart from
what is usually given? (e.g. leaves, roots, tubers)
Were others in the family also eating such unusual
foods?
Were any foods being eaten to suppress hunger?
9.5 Information about the Income and Food security
of the family.
9.5.1 Agriculture
Total land owned-
Total irrigated land owned
Harvest of the previous year was sufficient to feed the
family for how many months?
9.5.2 Labour
Work in the form of agricultural labourer- No. of
days in the last six months
Work as daily labourer-
• Work obtained in the relief work
started by the Government-How many days
in the last six months-
Daily wages-
• Work obtained outside the village-How many days
in the last six months-
Daily wages-
9.5.6 Was the income in the last six months enough to
adequately feed the family?
9.5.7 If not then how much was the decrease ?
(Approximately estimate what proportionate paise of a rupee)
The decrease was seen in which eatables
1
Main food (Maize, Jowar, Rice, Wheat)
2
Pulses
3
Vegetables
4
Oil. Milk etc
5
Meat, Fish, Eggs etc
9.6 How much water was the child drinking in the
week before death ?
1
Usual quantity
2
Less than usual
3
More than usual
4
Do not know
9.7 Did the child suffer from 'Night Blindness' ?
1. Yes 2. No 3. Do not know
9.8 Were the corners of the child's mouth cracked,
or did he/she have ulcers in the mouth/ tongue?
1. Yes 2. No 3. Do not
know
9.9 Did the child have problems such as bleeding
gums or loose teeth?
1. Yes 2. No 3. Do not know
9.10 Did the child have 'bow legs' ?
1. Yes 2. No 3. Do not know
Section 10: Treatment and records
I would now like to ask a few questions about any drugs the
child may have received during the illness that led to death.
10.2 Do you have any prescriptions, case papers or other
health records that belonged to the child ?
1. Yes 2. No 3. Don't know
(If "No" or Don't know".go to question 10.5)
10.2.1 (If yes ask): Can I see the health records?
1. Yes 2. No 3. Don't know
(If "No" or Don't know ".go to question 10.5)
If respondent allows you to see the health records,
transcribe all the entries within the
12 months before the child died.
10.3 Weights (most recent two)
10.3.1 Record the dates of the most recent weight, two
weights
1
_ /_ /__ (dd/mm/yy)
2
/_ /_ (dd/mm/yy)
10.3.2 Record the most recent two weights .
1 ___________
2
10.4 Medical notes
10.4.1 Record the date of the last note.
(dd/mm/yy)
10.4.2 Transcribe the note
10.5 Was a death certificate issued?
1. Yes 2. No 3. Don't
know
(If "No" or Don't know'^go to question 10.7)
INSTRUCTIONS TO INTERVIEWER - Ask to see the death
certificate and record whether you have been able to see it.
10.5.1 Able to see death certificate?
1. Yes 2. No (If "No",go to question 10.7)
10.6 Record the immediate cause of death from the certificate
Record the first underlying cause of death from the
certificate-
Record the contributing cause(s) of death from the certificate
Now I would like to ask a few questions
about the child's mother.
10.7 Has the child's mother ever been tested for
1. Yes 2. No 3. Don't know
(If "No" or Don't know",go to question 10.8)
10.7.1 (If yes ask): Was the "HIV" test ever positive?
1. Yes 2. No 3. Don't know
10.8 Has the child's (biological) mother ever been
told she had "AIDS" by a health worker?
1. Yes 2. No 3. Don't know
11. From verbal autopsy
form:
___
11.1 Immediate cause of
death:.
11.2 Underlying cause(s) of
death:_
11.3 Contributory cause(s) of
death:
_________
END OF INTERVIEW
THANK RESPONDENT(S) FOR THEIR COOPERATION
(Modified from - WHO/CDS/CSR/ISR/99A; A STANDARD VERBAL AUTOPSY METHOD
FOR INVESTIGATING CAUSES OF DEATH IN INFANTS AND CHILDREN)
Annexure II
Expected Weight for Age
(NCHS Standard)
Weights in Kg.
Age in months
Male
Female
12
10.2
9.5
15
10.8
10.1
18
11.5
10.8
21
12.5
11.3
24
12.6
11.9
27
13.1
12.4
30
13.7
12.9
33
14.2
13.4
36
14.7
13.9
39
15.2
14.5
42
15.7
15.1
45
16.2
15.5
48
16.7
16
51
17.2
16.4
54
17.7
16.8
57
18.2
17.2
60
18.7
17.7
63
19.2
18.1
66
19.7
18.6
69
20.2
19.5
72
20.7
19.5
75
21.2
20
Reference-Weight in Kg are 50h percentiles of Boys and
Girls;
NCHS growth curves for children, Birth-18 yrs. National
Centre for Health Statistics,
Publ No. DHS 878-1650, 1977. Hyattsville MD, USA
Annexure III
IAP classification for weight for age
Weight for Age
A
B
G
ge
oys
iris
1
12
1 0.2
9.5
1.3 m
15
10.8
1
Years
0.1
11/2
18
11.5
1
0.8
1.9 m
21
12.5
1
1.3
2
24
12.6
1
1.9
2.3 m
27
13.1
1
2.4
21/2
30
13.7
1
2.9
2.9 m
33
14.2
1
3.4
3
36
14.7
1
3.9
3.3 m
39
15.2
1
4.5
31/2
42
15.7
1
5.1
3.9 m
45
16.2
1
5.5
4
48
16.7
16
4.3 m
51
17.2
1
6.4
41/2
54
17.7
1
6.8
4.9 m
57
18.2
1
7.2
5
60
18.7
1
7.7
5.3 m
63
19.2
1
8.1
51/2
66
19.7
1
8.6
5.9 m
69
2 0.2
1
9.5
6
72
2 0.7
1
9.5
6.3 m
75
21.2
20
1 Supreme Court Order dated 28th November, 2001.
I
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