Friday, January 3, 2014

Mal-Nutrition in India


Hunger and under-nutrition are the most persistent challenges for policy makers. According to FAO, 18 percent of India’s population was undernourished in 2012. And worst, children are the most visible victims of under-nutrition, which is the underlying cause of diarrhea, malaria, measles, and pneumonia. Under-nutrition accounts for half of the deaths in children below the age of five years. According to UNICEF, India houses one–third of the Stunted/Wasted (termed malnourished) children of the world and 46 percent of the children below the age of three are too small for their age and 47 are under weight. Under-nutrition can result from critical lack of nutrients in an individual’s diet, weakened immune system and inability to absorb nutrients. A weakened immune system can make people susceptible to diseases which in turn can lower appetite and nutrient absorption. The weakening of the absorptive capacity of the stomach due to gastrointestinal diseases and germs can lead to reduced nutrient intake even when sufficient nutrients are available in the diet. Under nutrition increases the risk of chronic diseases and its impact lasts lifelong.
Malnutrition is a complex multidimensional and intergenerational problem and needs a multisectoral as well as direct and specific interventions. In recent times, as these issues have been worrying global policy makers, there are new indices, different from the popular Global Hunger Index released annually since 2006 that are being developed to illustrate the complexity of hunger and malnutrition. At the outset, it must be mentioned that these indices, cannot capture important national, cultural and political dimensions but are merely tools to highlight the problem.


The Global Hunger Index (GHI) released by the International Food Policy Research Institute (IFPRI) and Welt Hunger Hilfe (WHH) was released recently. The GHI combines three equally weighted indicators into one index - a) under nourishment; b) Child underweight; and c) Child mortality. The multi-dimensional approach to measuring hunger reflects the nutrition’s situation not only of the population as a whole but also of a physiologically vulnerable group, children, who could be sick or stunted because of lack of nutrients. In terms of GHI components, India has the highest prevalence of underweight in children under 5 years;  40.2 percent, only worst country is Timor-Leste at 45.3 percent. The proportion of under nourished in India as a percentage of total population has declined from 21.3 percent in 1999-01 to 17.5 percent in 2010-12. The under 5 mortality rate is the worst in India. It is for the above reasons that the overall GHI for India is very serious and not because of hunger per se.  The other countries which perform worse than India in 2013 on GHI are Burundi, Chad, Comoros, Ethiopia, Haiti, Madagascar, Timor-Leste, Zambia and Yemen. 
Hunger and Nutrition Commitment Index (HANCI), launched in April 2013 for 2012 compares performance of 45 developing countries using 22 indicators of political commitment to reduce hunger and under-nutrition. It looks at government action in terms of policies and programs, legal frameworks and public expenditures. It takes into consideration women’s empowerment, social protection, food and agriculture, and health and nutrition environment. Overall, on HANCI, India is ranked 29th (2 ranks above its per capita GDP rank) while Brazil (4th), China (22nd) and South Africa (23rd). According to HANCI, there is low commitment by the government in India towards addressing the problem of stunting in children below 5 years of age.
A year earlier, Economist Intelligence Unit created the Global Food Security Index (GFSI) in 2012 to deepen the dialogue on food insecurity and measure the associated risks. The 2013 index is comprised of 27 indicators.  In this index, an important contributory factor is quality and safety which takes into account availability of nutrients, micronutrients, vitamin A, iron, protein quality, potable water, and national nutritional strategy. India ranks 70th while Brazil (29), South Africa (39), Russia (40) and China (42) are ahead of us as they are in per capita GDP.


The question is are there people hungry and starving in India? Banerjee and Duflo (2011), find that typical poor household could spend up to 30 percent more on food than it actually does and if it completely cut expenditures on alcohol, tobacco and festivals. Further, even the money that people spend on food is not spent to maximize the intake of calories or micro nutrients.  To illustrate, the poorest group in Maharashtra in 1983, would prefer to buy better tasting, more expensive calories rather than millets which provide calories but may not be good in taste. It is widely documented that poor people spend large amounts of money on weddings, dowries and christenings probably in part as a result of the compulsion not to lose face. In Udaipur, illustratively poor spend 14 percent of their budget on festivals.  According to Banerjee and Duflo the poor like subsidized grains but giving them more does not persuade them to eat better especially since the main problem is not calories but nutrients. On nutrition, it needs to be debated whether India distribute vitamin A and iron supplements or adopt bio fortification of crops with essential micronutrients as researched under Harvest Plus initiative? Pritchard, Rammohan, Sekhar, Parasuraman and Choithani in Feeding India (2013) argue that the problem of under-nutrition in India represents the inability of different institutions to deliver resources to individuals to adequately feed themselves.  They also flag another important issue pertaining to gender-based differences in under-nutrition between girls and boys.


     Virmani (2007)[i] showed that much of the inter-state variation in Child malnutrition (more prcecisely wasting and stunting) in India, could be explained by difference in availability of clean water and access to toilets. Other causal factors were related to information, education and nutritional knowledge particularly of mothers. The role of the PDS system was ambiguous (positive/negative but non-significant), suggesting that the availability of cereals was not per se an important causal element in child malnutrition! Virmani (2012)[ii] showed that the same was true of cross-country differences in child malnutrition (stunting & wasting). Thus much of the outlier status in terms of Child malnutrition was attributable to lack of sanitation with lack of clean drinking water and female education playing a supporting role. In both the Inter-State (India) and the cross-country study, poverty rates were not separate determinant of ‘malnutrition’ once these factors were accounted for! 
      Other studies have also shown that hygiene, clean drinking water, level of mother’s education and dietary diversification positively impact balanced nourishment of the child. Angus Deaton (2013, The Great Escape), observes that in countries like India it is malnutrition, lack of clean water and prevalence of poor sanitation that is the main cause of high child mortality. In fact, according to Deaton, net nutrition, more than food, after making allowance for nutrition lost to diseases like diarrhea, fevers and infections is important. The other cause of high mortality is unhygienic disposal of human waste, lack of protein, energy insufficiency, and lack of vital micro nutrients such as iron. There is a need for better pest control in countries like India.

Open Defecation

Dean Spears and Lamba (2013), undertook a study for India and their results suggest both that open defecation is an important threat to the human capital of the Indian labor force, and that a program feasible to low capital governments in developing countries could improve average cognitive skills. One of the largest sources of early disease worldwide is unsafe disposal of human feces. Over 600 million people in India – 53 percent of Indian households- defecate in the open, without using a toilet or latrine (UNICEF and WHO 2012). This open defecation is an important cause of infant and child disease and mortality. Spears (2013) observe that open defecation can statistically account for much of the variation across poor countries in average child height.  The first year of life is a critical period for the effects of health and net nutrition on subsequent development. Children above the age of one year are stronger and able to withstand the exposure to disease. The study finds that there is an effect of exposure to India’s sanitation drive in the first year of life on cognitive skills. Their finding suggests that even a low capacity government can implement a relatively inexpensive program that will cause an important improvement in cognitive skills given the context of widespread open defecation.


    On the basis of expert opinion, India needs a focused public health and nutritional policy with a concerted public campaign that would help in successfully achieving positive nutritional outcomes. The quick-fixes may not be sufficient and the need is providing cleaner water and better sanitation. India can dramatically close the gap in child malnutrition (wasting) if sewage and sanitation is brought on par with other countries, at least those with similar per capita income levels.
This article is co-authored with Prof. Charan Singh of IIM, Bangalore. A version of this article appeared in the Tribune on January 4, 2014:

[i] Arvind Virmani, “The Sudoku of Growth, Poverty and Malnutrition: Lessons For Lagging States,” Working Paper No. 2/2007-PC, Planning Commission, July  2007.
[ii] Arvind Virmani, "Undernurishment of Children: Causes of Cross-country Variation," Working paper No.WsWp 4/2012, October 2012 .

No comments: