The Sorry Saga of Bhutan's North

The Sorry Saga of Bhutan's North
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Friday, March 16, 2012

Students die from malnutrition in A GNH school.

Vitamin deficiency confirmed                

«The Orong HSS: A GNH school?
The school had outsourced its mess for a year
Update The Guwahati neurological and research centre confirmed that students of Orong high school were deficient of vitamin B1, thiamine, in its report that the ministry received on Monday.
Four of the 34 students, who were admitted to the Samdrupjongkhar hospital for vitamin deficiency, were sent to Guwahati on December 20 to be further checked by a neurologist.
There had been few cases since July in Orong high school where the lower limbs of students were swollen. It however went unreported to the school authorities because the number of cases was very few.How the school authorities couldn’t know about this condition or the first death remains to be known. Kuensel learnt that the school authorities learnt about it only after they were informed by the students after the second death.It was also learnt that the school mess was outsourced for the last one year, between July 2010 and June 2011 but following complaints, it was taken over by the school.
Health ministry’s director general Dr Dorji Wangchuk said meat, unpolished rice and vegetables are good sources of thiamine.
“Those deficient of this vitamin were found to be physically active and above 10 years,” he said.
That very few girls were affected could be because of the folic acid supplements they get, the DG said.
It was found during investigation that boarding girls were given iron tablets once a week, from where they could be getting some amount of vitamins.
A team led by the nutritionist has also been formed to do a study on nutritional adequacy in school diets. The investigation team, which was in Orong, recommended multivitamin supplements in all schools following a study.
A preliminary report from the investigation team found that the food menu for all meals had below the recommended daily allowance (RDA) for most of the vitamins and micronutrients.
“For instance, the recommended RDA for thiamine is 1.2, but the nutritional assessment showed only 0.7,” the report stated.
Most students, who were admitted were from far flung places such as Gomdar, Shingkhar Lauri, and Samdrup Choling (Bangtar), and had no other alternative food that could possibly provide nutritional supplements.
While most students, who showed no symptoms of peripheral neuropathy like swelling limbs and numbness, are from nearby localities, and day-scholars.
The findings by the investigation team supplemented the findings of a study that was done in July last year, which reviewed the nutrition aspects of food basket in middle and higher secondary schools in Bhutan.The joint study by World Food Program and the education ministry had however remained stacked and no recommendations implemented.It recommended that in order to meet the daily nutritional and kilocalories requirement, the stipend of Nu 700 a student a month should be increased to Nu 1,000. The increase should not increase the cost of firewood, cooks’ salary, utensil costs and electricity.
The review found that the current national education policy does not include school feeding as an integral part of the sector policy. Sanitation and hygiene in the kitchens was a major concern.
“Use of black tea with meals inhibits absorption of iron,” the study stated. “This practice should be discouraged.”
Nutritional guidelines recommend 2,420kcl for 15 – 19 year olds. But it was found that the food basket was low in calcium, iron and vitamin A, Vitamin B1 and B2.
Micronutrients from the current school feeding program had 80 percent carbohydrates, 11 percent fat and nine percent protein.
feeding as an integral part of the sector policy. Sanitation and hygiene in the kitchens was a major concern.
“Use of black tea with meals inhibits absorption of iron,” the study stated. “This practice should be discouraged.”
Nutritional guidelines recommend 2,420kcl for 15 – 19 year olds. But it was found that the food basket was low in calcium, iron and vitamin A, Vitamin B1 and B2.
Micronutrients from the current school feeding program had 80 percent carbohydrates, 11 percent fat and nine percent protein.
“It’s therefore evident that they had access to home food or nutritional supplements, which could have probably prevented them from this condition,” the report stated.
From the information gathered, the investigation team concluded that most likely the students had chronic nutritional deficiencies that eventually led to peripheral neuropathy.
Of the 34 admitted by mid December, eight were kept back for further treatment and the rest discharged. Four were sent to Guwahati for clinical assessment, three were kept in Samdrupjongkhar, and one was referred to Mongar hospital for renal function test and echo test.
By Sonam Pelden


Food for thought
The neurology centre in Guwahati, India has confirmed that vitamin deficiency caused the death of two students in Orong. While this is not a big surprise, the Orong incident has opened a window to look deeper and beyond the school feeding programme.
Most rural schools depend on the programme, and the first question that arises is: why only in Orong? Why only male students and why the deficiency? Bhutanese, who grew up eating school meals, would remember that the food school messes served is not the best. The monotonous diet of rice, potato and dal is still the most common diet even today.
The school feeding programme benefitted thousands of students, especially in rural Bhutan, and it is one reason why many students from disadvantaged families are able to continue their education despite problems at home. But if what is fed to students is causing problems, it may be a good time for decision makers to look closer into the programme. The stipend of Nu 700 for students, who depend on the school mess for all three meals, may be not enough to buy the same basket of food, like when it was decided years ago. Nutritional content can be improved only if the menu is improved. The education ministry is aware that 80 percent of the energy supplied by different macronutrients in school menu is carbohydrate. Protein composes only nine percent.
However, money alone will not solve the problem. Educationists, as they talk about wholesome and GNH education, could re-look into the school agriculture programme. We have some schools in rural Bhutan, where students not only supplement the school mess menu, but also make income for the school from their agriculture programme. Some even have fisheries and poultry, and students are proud of what they do. All schools may not have fertile backyards, but each school, with good leadership, could look into their strengths. A good example schools can learn from is the voluntary feeding programme initiated by the Chubachu school in Thimphu.
A school mess outsourcing to private business people could jeopardise what students consume. Business people are concerned with profits and not the quality of food they supply. The school should have the authority of tendering of food supply, as they know best and not the dzongkhag administration. A review report on nutrition of food basket in middle and higher secondary schools in Bhutan has already recommended what needs to be done in the school feeding programme. For whatever reasons, the report has just remained on paper.
If the programme aims at improving the cognitive capacity of rural students, it is high time to change the menu they consume day in day out for 10 months every year.


Almost a case of involuntary manslaughter: minister
Orong HSS IncidentThe recent incident in Orong higher secondary school, where two students died of complications arising from chronic nutritional deficiencies, was like involuntary manslaughter, education minister Thakur S Powdyel said, during the annual education conference that ended in Gelephu yesterday.
“For students’ safety, and to avoid such embarrassing situations, it’s vital for the ministry, dzongkhag education officials, principals, teachers and parents to work together and ensure to provide better feeding and nutritional foods to every student,” the education minister said.
He urged the of school feeding program division, the agriculture club of schools, the dzongkhag administration and the public health to work cooperatively and find out the availability of food (vegetable) items in the district, based on the nutrition value, and circulate them with immediate effect to schools.
Some principals told Kuensel that to coordinate and take care of fresh feeding items for a huge number of boarding students in the midst of heavy teaching schedule is no easy task. “Managing informal boarders was a huge burden, as parents leave everything up to the school management and never show up for months on end,” another principal said.
Presenting the school feeding and nutrition report, the chief program officer, Chador Wangdi, said that, because of the limited availability of food commodities in remote schools, feeding often lacks essential macronutrients and other nutritional requirements, whereby resulting in monotonous diet.
“Lack of adequate storage is a major concern, especially for perishable items, such as vegetables, meat and eggs, which could further result in health hazards,” he said.
In some case, schools outsource the catering of food commodities, whereby the contractors, for their convenience, supply a month’s stock at one go. In such cases, he said, the food items either get rotten, or become likely to cause food poisoning. “Therefore, if catering is outsourced, contractors should be closely monitored by school authorities,” Chador Wangdi said.
He also said that, despite providing agricultural training to 20 teachers annually, none of the female staff initiate programmes or participate as mess in-charge, except for one female teacher in Sarpang.
“Lack of female staff participants, sanitation and hygiene in kitchen and surrounding areas were some of causes of health problems, education officials said, adding that school feeding should be set as an integral part of education sector policy.
Meanwhile education officials reminded the teachers that “boarding isn’t a choice but a necessity, therefore, the hostel seats should be fixed, based on the number of students who could comfortably fit, and the admission should be given to students, whose parents reside outside an hour’s walking distance from school.
Principals and teachers requested the ministry to revise the monthly stipend rate to Nu 1,000 from Nu 700 a student. They also asked for a separate transportation charge and an additional Nu 300 a student a month to buy vegetables, meat and eggs.
By Dawa Gyelmo, Gelephu

Did the school make a mess of the mess?
Outsourced or not made no difference to the poor food quality, say students
Orong HSS UpdateStudents complained of insufficient food and poor quality, when the Orong high school’s mess was outsourced to a grocery shop in Samdrupjongkhar for a year.
They said meat was served once a month, mixed with potato or radish. Between July 2010 and June this year, the 484 students were eating such meals.
After the midterm exams, the school took over the mess. By then, the 34 students, who were admitted to Samdrupjongkhar hospital earlier this month, had started showing signs of vitamin deficiencies, such as swollen limbs.
Seldon grocery shop, to whom the school mess was outsourced for Nu 338,800 a month, bore the cost of ration, transportation, firewood and the cook’s salary, among others. All seven cooks in the school were recruited by Seldon grocery.
Each student gets a stipend of Nu 700 a month from the government. Orong HSS received Nu 338,800 every month for its 484 boarding students.
The shop had never taken up something like this before, nor had the school outsourced its mess before.
Orong high school principal Nima Wangchuk said the school authority had called a quotation, and then given it to the shop.
He said the school mess was outsourced after they were “encouraged” by the education ministry to implement its policy of outsourcing to reduce workload on schools.
It was also discussed during the 9th annual education conference, and first initiated by Bajothang high school in Wangduephodrang, the principal said.
“When they had to bear all costs, the quality could have been compromised,” he said. “They too requested to quit after it was outsourced, as they were running on loss.”
But the school soon learnt that outsourcing in a remote school like Orong was not easy, especially during summer, when roads are blocked frequently.
The complaints from students on the food quality was another issue.
Yet they continued, because of the one-year agreement the school and the shop had.
Seldon grocery however said they were not aware of having received any complaints with food or its quality. “The money wasn’t enough for us to run the mess, as well as meet the other costs and we had to quit,” the shop people said.
The shop paid Nu 6,000 each to the six cooks, and Nu 7,000 to the head cook a month. It also bore the cost of firewood, about Nu 10,000 every month, and between Nu 3,000 to 5,000 for transportation.
The shop spent about Nu 62,000 on these costs from the total budget of Nu 338,800. This means it was spending Nu 276,800 on food.
The school would not have to bear these costs, if it was managing the school mess.
The shop also said it didn’t serve eggs throughout the time it was catering, because of the bird flu, and the ban on poultry products. Instead it served beef twice.
When the school took over the mess, only three of the seven cooks returned to the school. The rest either resigned or were transferred.
Except for rice, tea leaves, milk powder and sugar, which was supplied by the Orong gup, who also runs a grocery shop near the school, the rest of the mess supplies were still supplied by Seldon grocery.
The school’s vice principal Ugyen Namgyel said the school also has a school agricultural program, where they grow spinach, beans, peas, pumpkin and radish, along with maize, on about 50 decimal land.
“Vegetables, harvested once a year, are supplied to school mess, given to students by mixing with potatos,” he said. “Some are also sold to school staff.”
No teachers or principals eat at the school mess.
Students said not much changed after the school took over the mess. The mess diet comprised dal, polished rice, chick peas, nutrella, potato, amul cheese, all cooked in refined oil. They ate dry fish, beef and an egg once a month.
Vegetables were given when villagers brought them to sell. Dry fish, although on the menu, never made it to the plates.
By Nirmala Pokhrel, Samrupjongkhar
Lack of vitamins in diet likely cause
«A dietician collects samples of rations from Orong school’s storeroom on Sunday
Results of tests in Guwahati on 5 students are awaited
Update: Orong HSS Deaths Five of the 34 boarding students of Orong higher secondary school, being treated at the Samdrupjongkhar district hospital for nutritional deficiencies, leave today for Guwahati, Assam, for further medical tests.
Clinical research, done by a medical specialist from the Mongar regional hospital, and a dietician and a public health lab microbiologist from Thimphu referral hospital, suggests the students could be suffering from peripheral neuropathy, an illness arising out of vitamin deficiency.
“Their nutrition level is below the recommended daily allowance (RDA),” dietician Laigden Dzed said. “It’s 0.7 milligram a decilitre (mg/dl), when they’re required to have 1.5mg/dl a day,” he said. “They are lacking vitamins like B1 and B12.”
Vitamin B12 is available from meat, egg and fish only.
Samples of the ration from the school have been collected and will be sent outside the country to find out its vitamin contents. Some Orong students, who did not fall ill and were in Samdrupjongkhar for the National Day celebrations, were also tested for nutritional levels.
Medical specialist Dr Kezang said the cause of illness will be further verified after the five students do the nerve conduction and the electro mayo graph (EMG) test in Guwahati, 90 kms from Samdrupjongkhar. “It’ll give us a picture of the preliminary cause of illness,” he said. “We’ll then be able to further proceed with the investigation.”
He also said that he could not confidently say at this point that peripheral neuropathy led to the death of the two students on December 3 and 12. “Although they had similar symptoms that the 34 students being treated showed, there could have had other infections, which was never revealed,” he said.
The students at Samdrupjongkhar hospital are likely to be discharged today with vitamin supplements, as they have fully recovered fully, but they are required to visit the hospital once a month.
Meanwhile, the school authorities and health officials cannot explain why only students of classes X and XII fell ill, and not students of classes IX and XI, who were taking the same meals served by the school.
The local community believes the dirtying of a small lake by the hostel’s sewerage water outlet might have something to do with deaths and sickness in the school.
By Nirmala Pokhrel
Cause of student deaths not yet known
While 31 students are on treatment
Orong HSS A medical specialist and a nutritionist from Thimphu referral hospital should reach the southeastern border town of Samdrupjongkhar today to investigate the deaths of two students of Orong higher secondary school (HSS), who died on December 3 and 12.
As of now, it’s suspected that chronic multi-vitamin deficiency might be one of the reasons why a 21-year-old class X student and a 19-year old class XII student died at the Samdrupjongkhar district hospital from severe heart failure. Doctors explained that heart failure is different from heart attack. A heart attack is sudden and happens when the heart do not get enough blood. Heart failure happens when the heart is too weak to pump enough blood to meet the body’s needs.
Based on this suspicion, the 31 students of Orong HSS who were admitted to the district hospital on Wednesday and Thursday, with swelling of limbs, face, hands, numbness, irritation of skin and drowsiness, were treated for chronic multi-vitamin deficiency, and are reportedly improving, said the district medical officer Dr Ugyen Wangdi.
Doctors said that if one is suffering from iron deficiency, it would cause anaemia and that chronic anaemia leads to heart failure. These symptoms also occur say doctors when the body lacks vitamin B1 or is deficient of Thiamin.
The 31 students showed the same symptoms as the two students who died, according to hospital doctors.
While 23 cases, of which 14 were severe, were admitted on December 14, another eight students were brought to the hospital last morning. Only one was female. With the 20-bed hospital not able to accommodate all the students, those with less severity have been kept in a classroom of a nearby middle secondary school.
Students at the hospital said they started falling sick and started experiencing slight swollen limbs before the midterm vacation, but started feeling better after taking some doses of vitamin B-complex from the Orong basic health unit.
A class XII student, Chhogyel Rigzin, 20, said the same symptoms started showing again during their trial examinations, and students stopped going to classes and stayed back in the hostel.
“We thought it wasn’t a severe case, so we just took vitamin tablets provided by the BHU and stayed back,” he said. “It was difficult to attend classes and we could not do the trials well.”
The school principal Nima Wangchuk said that, when the second student died, he told the students not to worry, and not to spoil their last board exam paper, so that they did not panic.
Dr Ugyen Wangdi said that, after students were given thiamine injection and multi-vitamin tablets, most showed signs of recovery and the swelling was reduced.
The severely affected students are also being fed with meat, eggs, fish and made to do some exercises. “With lack of facility and medical specialists we aren’t able to diagnose the disease properly,” the DMO said.
By Nirmala Pokhrel, Samdrupjongkhar

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