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Nutritional and health consequences of seasonal fluctuations in household food availability

P. D. Bidinger, B. Nag, and P. Babu
Institute for Rural Health Studies, Hyderabad, Andhra Pradesh, India

Study objectives

Too little is known about the nutritional and health consequences of seasonal fluctuations in food supply, primarily because of the complex nature of the issues involved and the need for an interdisciplinary approach. Among the exceptions to this general dearth of information is the analysis of the very obvious consequences of severe food shortage in times of famine, which have been especially well documented for Africa.

Anthropologists were among the first to explore the interrelationships between food supply, social organization, and nutrition [7]. Economists and nutritionists, as well as health specialists, have focused until very recently on much narrower issues, in particular the documentation of seasonal patterns in the growth of young children [12, 13, 22, 23]. One must consider the many ways in which income is both acquired and used to offset seasonal aspects of food supply and food consumption. It is easy to point out that one should anticipate seasonal changes in food intake based upon, for example, particular patterns of labour-force participation; it is another thing actually to measure the effects when they are frequently complicated by cash or in-kind payments or such practices as borrowing food during times of need [25].

To further the aim of understanding the complex nature of food distribution, the Institute for Rural Health Studies began a small pilot study of 40 families in which hypothesized determinants of food distribution included information from the following disciplines: demography, economics, agriculture, anthropometry, and health. Food consumption by members of the selected households was measured weekly using the 24-hour recall method. Data were collected either as events occurred, as in the case of harvests of any crop, or in a planned weekly session with respondent household members, as in the case of seven-day recalls of labour-force participation and household monetary transactions.

Study hypotheses were as follows:

1. As harvests are few and widely separated, only larger farmers will have an adequate food supply throughout the year. Smaller farmers and labouring families will face greater irregularities, which will be offset to some degree by internal village mechanisms and opportunities for employment.
2. Nutritional and health status (as measured by anthropometry and morbidity) are related to seasonal aspects of climate and workload as well as energy intake.
3. Poor dietary intake at the family level will be a reflection of allocation of available food and preferences rather than availability to the family.

Overview

The Indian Climate

The Indian subcontinent is a land of tropical monsoon climates, with four distinct seasons. The actual onset of each season, its duration and intensity, are highly variable in the different parts of India. The south-west monsoon from June to October accounts for the bulk of the total annual rainfall and is the chief source of the water supply. Little or no rainfall has been associated with famine conditions since the earliest days of Indian history.

Nutrition and Health in India

During the first two decades after India's independence a capital/intensive approach to development was employed, with the result that newly generated income was poorly distributed and the poor remained poor. Food production barely kept up with population growth; frequent drought caused severe food shortages, even though the central government imported grain and authorized the operation of ration shops. Increases in life expectancy, made possible by decreases in mortality from diseases such as malaria and smallpox, helped to create a labour-force surplus. The government saw little reason to increase health facilities that would, in theory, provide even more labour in what was already a labour-surplus situation. Likewise, the rural power structure provided an inhospitable environment for specific programmes to improve the nutrition and health of the poor [14]. The government seemed to echo the words of Uma Lele, who emphasized that "substantial allocation of central resources to social services frequently occurs at the cost of more immediately productive investments in rural areas and, therefore, may prove self-defeating in the long run" [11].

Health has, however, always been allotted some of India's limited resources. In the more than 25 years since the first of various five-year plans was proposed, health planning has essentially meant allocation of funds to: hospitals and dispensaries; education and research; control of communicable diseases; rural health programmes; training programmes; indigenous systems of medicine and homoeopathy; and other programmer. The bulk of the limited resources has historically gone to those responsible for the development of hospitals and their specialists who, of course, principally serve the urban well-to-do. Although serious doubts have been raised as to the efficacy of adopting a system that emphasizes an urban curative rather than a rural preventative system of health, the last plan (1978-1983) resembled its predecessors. D. Banerji, chairman of Nehru University's Department of Community Medicine, notes [2]:

All these major programmes which were launched with so much fanfare and promise have ended as disastrous failures; social orientation of medical education is still a distant dream; the primary health centres have miserably failed to meet even the most pressing needs of the rural poor; the promise to eradicate malaria by the mid-sixties could not be kept and massive resources are still being allocated to "contain malaria"; other communicable diseases are rampant and continue to cause extensive suffering among the people; and mothers and children continue to suffer very high rates of mortality and morbidity. The account of the family planning movement through the past two decades itself is a saga of most expensive and colossal failures. All these provide a strong enough indictment of the entire system.

The cycle of poverty and ill health in India appears to continue unabated. Numerous researchers have pointed out that mortality and morbidity are higher among the lower paid workers and their families than among the better-paid semi-skilled and skilled groups; both factors are also higher among the badly paid rural agricultural labourers [6, 31 ]. Levinson found frequent cases of malnutrition and ill health among all rural income groups and caste groups; however, morbidity was considerably higher among the landless labour groups [9, 12, 30].

The causes are complex although the major factor is insufficient income to obtain an adequate diet; over one third of all rural people cannot purchase or obtain a minimum diet [5]. Over 36 per cent of the women in India are in the labour force, thus reducing their ability to provide adequate child care; this, in turn, may lead to malnutrition and ill health for their children [14]. This percentage is higher in rural areas and may vary sharply with agricultural seasons. Also, the ability to earn higher wages appears to be dependent not only on the favour of large landowners or the village elite, but, for males, on height and weight as well [24, 25].

Numerous studies on the health and nutritional status of Indians have been conducted, particularly during the last two decades. The majority of these studies has been on residents of larger Indian cities, on rural residents in villages in close proximity to the urban centres, or on tribal peoples in remote regions [26]. Many of the nutritional studies have been carried out by the staff of the National Institute of Nutrition (the Indian Council of Medical Research) located in Hyderabad, Andhra Pradesh; others have been conducted by the staff of various medical colleges. Nearly all the studies reveal similar findings, although the degree to which the populace is affected may differ depending on the year, the season, or the agro-climatic zone in which the study was conducted.

The following discussion summarizes the results of several of the more typical surveys and illustrates the basic nature of the health problems of most rural communities in India. These studies have been selected as representative of the semi-arid tropics of peninsular India on which this report focuses.

The most commonly reported signs of nutritional deficiency are protein-energy malnutrition (PEM), vitamin A deficiency, vitamin B-complex deficiency, and anaemia [21]. Most studies report that from 0.6 to 2 per cent of the children from one to five years of age present overt signs of kwashiork or marasmus [17, 19,28]. Moderate PEM, classified by the National Institute of Nutrition as any case with one or more clinical signs of malnutrition, has been found to range between 4 and 11 per cent. The sample size in each of these studies was large; the smallest study covered 1,470 children and the largest study 4,536. Geographically the studies covered all the states in south India: Andhra Pradesh, Tamil Nadu, Karnataka, and Kerala. Although the studies covered the period from the late 1950s to the early 1970s, it is interesting to note that the number of young children with signs of PEM changed little over the years, as did their reported mean energy intake (including breast milk), which ranged from 725 to 930 Kcal per day for the one- to five-year-old age group.

Vitamin A deficiency is also a widespread problem in India; however, it appears to be most prevalent among the rice eating peoples of the south and the north-east. In the peninsular states, between 8 and 13 per cent of the children exhibited ocular signs of vitamin A deficiency [17, 19, 20]. Clinical signs ranged from mild conjunctival lesions to keratomalacia. In Reddy's survey, 40 per cent of all children with protein-energy malnutrition also manifested signs of vitamin A deficiency. Signs of vitamin B-complex deficiency (angular stomatitis, cheilosis, and glossitis) were also cited as highly prevalent by the above researchers. Bamji and her associates point out that with supplementation of B-complex vitamins, principally thiamin and riboflavin, the deficiency symptoms do not uniformly disappear, and blood levels fail to rise appreciably, thus giving rise to speculation concerning the true nature of the signs [1].

The last major nutritional problem commonly cited by workers in India is anaemia. Whereas PEN, hypovitaminosis A, and vitamin B-complex deficiency appear principally to affect the young, anaemia is found in severe forms among adults as well. Pregnant and lactating women are most frequently affected. Srikantia and his colleagues [28] studied multiparous women in their third trimester of pregnancy. Nearly 12 per cent had haemoglobin levels of less than 8 g per 100 ml of blood and nearly 45 per cent had levels between 8 and 10 g per 100 ml of blood. Prahlad and Rao et al. report that half of 3,000 rural children studied had haemoglobin levels of less than 10.8 g per 100 ml [17, 19]; 5 per cent of these fell below 5 g per 100 ml. The actual measurement of haemoglobin is rare; most reports from India use such signs as pallor, pale nails, and koilonychia to diagnose anaemia.

That the health problems of the poor are pensive is emphasized by data from several surveys made at different geographical locations throughout India. Although most of the studies focus on diet and income, data on morbidity dearly demonstrate the difficult conditions under which the poor live. In a rural area of Pondicherry in Tamil Nadu, Prasada and Gupta, as well as Rao et al., determined the four most common causes of morbidity in young children, giving the percentages of children with each malady as follows: upper respiratory infection (32 per cent); gastroenteritis (16 per cent); scabies (16 per cent); and ascariasis (11 percent) [18, 19].

In Haryana, 28 miles south of Delhi, a similar rural study was undertaken. Patnaik and Sugathan [15] recorded the principal causes of morbidity as acute upper respiratory infection, diarrhoea, and gastroenteritis. Although no prevalence figures were supplied, the authors noted that "infants and toddlers constituted 13 (1/2) per cent of the population, but contributed 28 per cent of the morbidity."

The reporting of morbidity data fails to emphasize the interaction of nutrition and infection, which first gained attention through the efforts of Scrimshaw, Taylor, and Gordon [27]. Common infections such as those of the upper respiratory tract, or gastrointestinal infections causing diarrhoea, interact with poor nutrition to create a synergistic and vicious spiral leading to a far more serious impact on the victim than the impact of either one considered separately. Poor nutrition decreases resistance to infection, especially among children; infection leads both to decreased food intake (through loss of appetite or food beliefs that emphasize restriction of food during illness) and to decreased absorption of food in the gastrointestinal tract (due to diarrhoea or the competing effects of intestinal parasitism). The result is a further impaired nutritional status, which lowers resistance to infection still more. Commonly accepted indicators of nutritional status, such as weight for age, height for age, and skinfold thickness, may be as much influenced by non-nutritional health considerations, such as disease and parasitism, as they are by food intake.

The village of Bokur: characteristics and organization

Dokur has characteristics representative of the much wider area defined as the semi-arid tropics. The long hot season (February to mid June), when temperatures regularly reach 40°C and the relative humidity is 8 to 10 per cent, is abruptly terminated by the monsoon rains which bring down the temperature by 5 to 10 degrees. The winter season (November to January) is generally rainless and cooler still, with maximum daytime temperatures ranging from the mid 20s to low 30s Celsius.

Monthly rainfall in millimetres for each month of the study year, as well as the average rainfall for an earlier five year period from the Taluka headquarters, is shown in table 1. Agro-climatically, Dokur represents an area of relatively assured rainfall with shallow to medium-deep alfisols (red soils). Rainfall averages 760 mm.

TABLE 1. Rainfall in mm, monthly totals^a

a Although only 90 per cent of ''normal" for the year the Pattern of rainfall was quite advantageous for farmers In that heavy June rains at the beginning of the rainy (kharif) season meant that dryland crops were planted sufficiently early to assure their reaching maturity, provided the remainder of the monsoon was adequate As the monsoon was adequete, and even lasted slightly longer than normal, the year's rainfall could be considered within normal expectations .

A distinguishing feature of Dokur and of the larger area it represents is the system of small lakes (tanks) that collect run-off water during the rainy season. The extra water permits cropping in both the rainy season (kharif) and the post-rainy season (rabi). It has been estimated that over half of the total cropped area is irrigated in Dokur because of its tanks and a number of wells.

Dokur is located in Mahbubnagar District, Andhra Pradesh, approximately 130 km from Hyderabad, the state capital. The nearest market community, Devarkadra, is located 5 km from the village and is connected to it by a simple dirt road. Devarkadra has a population of approximately 5,000 people and is on a paved road that connects two district capitals.

The major crops grown in Dokur are paddy and groundouts (peanuts), which, owing to irrigation, can be grown in both seasons. Substantial amounts of sorghum (jowar) are also raised, but only small quantities of pulses. Of the pulses, pigeon pea (red gram) is the most frequently planted. This particular planting is to be found wherever tanks exist. In the drier areas, a pattern of less paddy and groundnuts and more sorghum predominates.

Village Characteristics

Dokur is not a picturesque village; houses of stone covered with mud are grouped in a rather random fashion. The streets (such as they are) are basically what has remained between the houses. Most houses consist of one or two rooms with perhaps one small barred window for ventilation. Mud floors are the norm, but wealthier residents have shabad stone floors. Roofing ranges from thatch to a sturdier wooden framework covered with thatch and mud. Sanitation levels are poor; only one house in Dokur possesses a latrine (out-of-doors). The common practice is to defecate in specified fields outside the village boundaries. Kitchen waste is customarily poured out from the cooking area in the house through a small hole in the wall; some people simply pitch their refuse out the door. Thus, the passageways of Dokur are crossed by rivulets of putrid water.

Another characteristic of the village is that only 5 to 10 per cent of the houses and shops, as well as the pump of a protected water supply, are supplied with electricity. Previously, Dokur water came from public wells that had been hand-dug and lined with local stone, and an annual cholera outbreak was a feature of village life. Several years ago, a protected water supply was constructed in the centre of the village. As it has numerous outlets, the harijan community asked for, and received, the rights to draw their water from the same source. Many villagers still use the older hand-dug wells routinely, and all villagers use them during the frequent power cuts that render useless the protected water supply.

Demographic Characteristics

In 1980, it was estimated by the sarpanch (elected village head) that the population of Dokur was about 2,600 or slightly more than 400 households. In the mid 1970s a survey of household heads revealed that nearly 25 per cent were basically labourers, although they nearly all owned tiny plots of land (less than 0.2 ha). Slightly more than 70 per cent were cultivators and the remainder (between 3 and 4 per cent) were listed as owning shops or having occupations such as teachers and construction workers [3]. Approximately one-third of the farming households have an operational landholding size of less than 1 ha, while another third have between 1 and just over 2 ha. The upper one third, or large farmers, have from just over 2 ha upwards; a few of the largest of these have as many as 20 ha. Operational landholding was defined as the area of owned land, minus the area leased out or share farmed to someone else, plus the area leased or sharefarmed from someone else.

Health Care

As in the vast majority of rural Indian villages, health care is virtually non-existent. The nearest primary health centre is 12 km away and there is no bus service in Dokur. Should one manage to get to the centre, the probability of finding a doctor there is virtually nil, the centre has a long history of absentee doctors. In the other direction, Devarkadra does have one doctor who holds the standard MBBS degree given to Indian doctors; however, his clinic is a private one, and thus a luxury for most of the villagers. For less money, they may turn to the available homoeopathic doctor, who is frequently unable to deal with the major illnesses and injuries presented to him. In Dokur itself, there is a registered medical practitioner (REP) who practices a combination of homoeopathy and allopathy part time (he has a large farm). Many of the villagers appear to have great confidence in him, as he freely gives them the injections many so fervently believe will cure virtually everything. Our observations indicate that often the injections consist of plain water; however, his fees for service are always within the reach of the poorest villagers as he charges as little as one or two rupees for an injection.

Diet

Throughout the year polished boiled rice is the staple food for virtually all families; sorghum, used less frequently, is made into chappatis or a gruel (ambali). Small quantities of pulses (pigeon peas) are eaten irregularly as a thin soup (dal) with the rice. The quantities of dal consumed relate directly to farm size [4].

Tamarind extract mixed with jaggery and ground sesame seeds (pulsu) is widely used by all for about half the year (from February to July) and is served with rice. This, or a chutney of green chillies (from January to June) is one of the most commonly eaten foods. The consumption of seasonal vegetables is related to both income and taste. As recently as 1977, few vegetables were grown in Dokur; the small amounts eaten were grown in neighbouring villages. Both domestic species as well as the currently termed "common property resources" (custard apple, zizyphus berries, and wild greens) are eaten. Onions, eggplant (brinjal), gourds, beans, tomatoes, and greens (gogu) are the most popular; however, with the exception of onions, they are nearly always eaten infrequently and in rather small quantities. Mangoes are also eaten in season.

Small quantities of fish from the nearby irrigation tank are eaten during the monsoon and post-monsoon seasons. Chicken and, rarely, goat are more often eaten by large farm families, or for celebrations, such as festivals and weddings, by others. Milk is used principally in tea purchased in neighbourhood tea-shops. Large-farm families who own milch animals serve tea with milk at home and may also make it into curds or buttermilk. Alcohol, in the form of palm toddy, is regularly drunk by nearly everyone, including children.

There is a considerable discrepancy between the diets of rich and poor villagers. The poor householders' diets all too frequently consist of nothing more than rice and chill) powder (cayenne pepper) or tamarind chutney supplemented by sorghum chappatis pats in place of rice, and, of course, toddy and tea. The diets of those who are better off are based on a much wider variety of foods.

Infants are breast-fed exclusively until the age of six or seven months, after which nearly all are occasionally fed glucose biscuits, toddy, and tea, while some also receive small amounts of cow's milk. When the child is between the ages of 12 and 15 months, rice and sweets, and sometimes seasonal fruit, are irregularly fed. After about the age of 15 months the child is given the adult diet on a regular basis. Breast-feeding continues throughout this period and frequently continues until three or four years of age, when the child is gradually weaned.

Education

A government-sponsored village school for children in the first seven grades is the focal point for the education of both boys and girls. There are generally four teachers available throughout the year. Although the number of pupils

fluctuates widely according to the season, nearly 170 children are registered. A good many of them are called upon to help with agriculturally related tasks during the year and, as a result, many of these pupils are forced to repeat certain years. As a rule, the emphasis upon education in the village is minimal, and has been for a long time.

There are a few small private "tutorial" schools in the village, but the people running the "tutorials" are frequently minimally educated themselves. Some of the pupils attend the government school and go to a tutorial after school. These are most frequently the children of the wealthier villagers, as fees must be paid.

Few villagers are formally educated. Of the 200 (57.3 per cent) respondents who were over 12 years of age, only 19 (9.5 per cent) had gone beyond the seventh year in school. All but three of these were males; the three females were teenagers.

Religion

Almost the entire population of Dokur is Hindu; there are no more than six Muslim households in the village. The minority Muslims live in harmony with the Hindu majority and each group appears to practice its religion unhampered by the other. Festivals such as Divali, a major Hindu festival, are celebrated with much enthusiasm by all the villagers. A small but devoted group of Hindus worship during the late hours of each Thursday night, and forms a procession that winds its way through the village paths. Although there is a proper temple, it appears to be a minor focal point of religious life. Worship in individual homes is also practiced; many have areas set aside for the worship of the goddess Nagamma, who is thought to inhabit clay pots.

Household Characteristics

A survey of the entire village identified forty households (or approximately 10 per cent of the total) that had the following characteristics:

1. The families had at least one child under the age of five who was a full-time resident.
2. The families were principally agrarian, i.e. either landless or farm families, although families with small subsidiary occupations were considered acceptable.
3. The adult female members had to work principally as hired labourers on other farms or on their own family farms.
4. The families had to be willing to spend time weekly with the investigators for the next 15 months and be willing to permit the physician to examine them physically at periodic intervals.

Two lists were then prepared: one of families whose adult female members worked principally on their own family farms and another of those whose adult females routinely sought employment as paid agricultural workers. Each list was ranked by landholding size, and then a random sample of twenty families from each group was selected.

The study population, which totalled 349, was chosen to reflect the fact that young children constitute a sizeable part of the Indian population and are at risk from the effects of any food shortage. The stratification of the respondents based upon female work pattern reflected the need to learn more about the constraints placed upon women and their families in villages where female labour-force participation is particularly high, i.e. irrigated villages. In Dokur, nearly all village women work, either on or off the farm in about roughly equal proportions.

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