Introduction
Historically
the greatest advances in longevity and mortality reduction have come not from
treatment of individual disease but from public health. This includes modern drainage and sewerage
systems (sewage treatment plants), drinking water systems that produce and
deliver disease free water and solid waste disposal systems. The current
position is illustrated by the low proportion of the population with access to improved
sanitation facilities. The impact of this neglect is reflected in two well
known facts; One, ‘Delhi belly’ is infamous throughout the World and the Delhi
middle class has to use water filters to protect itself from tap water borne
disease. Two, India is still home to communicable and vector borne diseases
that have been eliminated in most countries outside sub-Saharan Africa.
Malnutrition Facts
According
to the National sample survey of 2004-5, 1.9% of Indian households defined
themselves as hungry for some part of the year.
Based on the same survey, the Planning Commission determined the
proportion of poor according to the then prevailing national poverty line in
2004-5 was between 21.8% and 27.5%.
Malnutrition in children under 3 years of age as measured by the
National Family health survey 2005-6 (NFHS 3) was much higher. Stunted and Underweight children constituted
38.4% and 45.9% respectively of children under 3. The cross State correlation between poverty
rates and malnutrition rates was around 0.7 (using either MRP or URP based
estimates). At least 30% of this
cross-State variation in nutritional status of children was therefore totally
uncorrelated with the variation of poverty rates across States.
The
improvement in the nutrition status of children has also been disappointing.
Over the seven years between 1998-9 and 2005-6 malnutrition has declined by
only 1.1 per cent points while stunting has declined by 7.1 per cent
points. This compares with a 4.3 per
cent point decline in the poverty rate between 1999-2000 and 2004-5 (MRP).
Though stunting has declined at a marginally faster annual rate (1.0%) than
poverty (0.9%), the decline in percentage of underweight children is
minuscule. The implication is drawn that
existing policies and programs are not making a significant dent on
malnutrition and need to be improved. To
do this, however, we need to first find out what are the important factors
responsible for malnutrition.
Malnutrition: Potential Causes
Mixing
up issues of Hunger, average availability of food/cereals (or Calorie
deficiency), poverty and malnutrition, can lead to serious diagnostic errors
and ineffective policies that make little dent on these problems. Das Gupta et
al (2009)[i] argued that
the fact that 25% of stunted Indian children were in the highest wealth
quintile reflects the burden of morbidity even among the affluent. The WHO
estimated that half of malnutrition is attributable to infections arising from
poor sanitation, not lack of food.
There are three broad aspects of
malnutrition that must be kept in mind when devising strategies for dealing
with it. One, the ability to access such food items. This depends on household income or ability
to sustain certain levels of consumption.
The rate of Poverty (Head count ratio) is the standard indicator. Other possible indicators could include assets
such as land and housing.
Two, household/family knowledge and
information about good nutrition. This
includes knowledge about the locally available foods that are good from the
nutrition perspective. This can be based
on, (a) traditional age old knowledge (old wives tales). (b) Ability to read
coupled with availability of appropriate reading material on nutrition. (c) Access
to media such as newspapers, radio and TV, coupled with propagation of such
information on the radio (d) Special programs that directly educate mothers
about child rearing and nutrition such as ICDS.
Three the state of health. Even if the right kind of food and nutrition
is available a child may not be able to consume and/or absorb it properly due
to ill health or sickness. For instance
a child suffering from diarrhea much of the time is unlikely to be able to
ingest much good and healthy food and absorb the nutrition, even if it is
freely available and provided to the child by the mother/parents. Historically
it has been demonstrated across many countries that public health measures like
clean drinking water, sanitation, sewerage, control of communicable and
epidemic diseases and public health education play an important role in
reducing mortality rates at every age and across gender. In the Indian environment access to water and
toilets, breast feeding (to impart immunity in an unhealthy environment),
access to sound health advice/treatment, prevalence of vaccination and
availability of vitamin supplements are possible indicators.
Malnutrition Across States
Virmani
(2007)[ii] analysis showed
that household access to toilets, breast feeding of infants and vaccination of
children have a significant effect in reducing child malnutrition. These variables explained 85% of the
cross-State variation in malnutrition. Nutrition variables were either not
significant or had the opposite of the expected effect, indicating problems
with the programs. Expenditure on the
Integrated Child Development program (ICDS) appeared to have an uncertain
effect, probably because it was effective in some states and not effective in
others.
Virmani
(2007)[iii] concluded
that the most important determinant of the variation of malnutrition across
India States was public health deficiencies as measured by access to
improved sanitation and drinking water. That is, the weakening of the absorptive
capacity of the stomach due to gastrointestinal diseases and germs played a
much more significant role in malnutrition than the availability of cereals
which are the focus of the PDS system and ‘right to food’ advocates. The paper also suggested that basic public
health information, nutritional knowledge and availability about nutritional
foods may also play a role.
Dean
Spears and Lamba (2013),[iv] village
level study in India, showed the negative effect of open defecation on child
stunting and wasting, thus confirming the importance of Household access to
toilets on the nutrition status of children. Jeffery Hammer et al have carried
out micro-experiments that confirm these findings for the high income city of Delhi.
Malnutrition: India In World
India is an outlier in terms of
malnutrition in cross-country plots of malnutrition against per capita GDP. Correspondingly India is way significantly
worse than countries at its level of per capita GDP in terms of household
access to toilets. It is however close to the trend line with respect to access
to improved drinking water sources. Inadequacy
of public health measures, results in prevalence of gastro-intestinal
infections (even if they do not manifest themselves in a visible disease or ill
health), that inhibit the absorption and use of food in the body. Even if
enough food is available, the child may not be able to ingest or absorb it
properly, resulting in under-nutrition.
Virmani (2012)[v]
analyzed cross-country variation in child malnutrition. The quality of public
health, as measured by variables such as access to better sanitation and
improved water sources, is an important factor in explaining cross-country
variations in the prevalence of malnutrition and inter-state variations across
India. It also confirms the importance of primary education, particularly of
females, in helping spread information and knowledge about personal hygiene,
sanitation and nutrition. Much more
could however be done through appropriate school curricula and media campaigns
to promote public health education.
The analysis suggests that poverty is not
an independent cause of malnutrition, but may provide an additional explanation only to the extent that it is
over & above that of unsanitary living conditions. The
proportion of adults having primary education also tends to reduce
malnutrition, probably by increasing understanding of the effect of unsanitary conditions. The primary completion
rates for females is however, more significant than for both male and female together,
suggesting the relatively greater importance of female literacy. This is because females play a greater role in creating and maintaining a clean home environment than males.
Conclusion: Sanitation
A toilet is not just a room with a hole in it. The
toilet has to be backed by or connected to, a system for collecting and hygienically disposing
of human excretions, so that they don’t contaminate the water supply or the environment
our children play and study in and we all live and work in. Effective systems of sanitation in our urban
and rural areas, by cleaning up the environment in which harmful germs and
bacteria thrive, can have a major effect on malnutrition and disease. Public education campaigns that increase
understanding of this hidden menace (invisible to many) can accelerate the process. The improvement
in cleanliness and sanitation as envisaged by the Government’s “Swach Bharat” program, can eliminate most
of the difference in malnutrition (stunting, wasting) between India and the
rest of the World and across Indian States. The increased subsidies envisaged
under the Food Security Act would reduce malnutrition more effectively if spent
on toilets, sewers, sewage disposal and garbage processing.
[i] Das Gupta,
Monica, Rajendra Shukla, T.V. Somanathan, and K.K Datta, 2009. “How Might
India’s Public Health Systems be Strengthened?”, Washington DC: The World Bank
Policy Research Working Paper 5140.
[ii] Virmani,
Arvind, “The Sudoku of Growth, Poverty and Malnutrition: Lessons For Lagging
States,” Working Paper No. 2/2007-PC, Planning Commission, July 2007.
[iii] Op cit
and “Causes of Child Malnutrition In India,” Working Paper No. WsWp 1/2007, July 2007. MalnutritionChild07July.docx at https://sites.google.com/site/drarvindvirmani/working-papers
[iv] Spears, Dean
and Sneh Lamba, “Effects of Early-Life Exposure to Sanitation on Childhood
Cognitive Skills: Evidence from India’s Total Sanitation Campaign”, Policy
research Working Paper, 6659, World Bank, October 2013.
[v] Virmani,
Arvind, "Under-nurishment of Children: Causes of Cross-country
Variation," Working paper No.WsWp 4/2012, October 2012 [ Nutrition12oct.docx at https://sites.google.com/site/drarvindvirmani/].
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A version of this article appeared in The
Hindu on July 28, 2014 under the banner, “Investing in Health Through Hygiene.”
http://www.thehindu.com/todays-paper/tp-opinion/investing-in-health-through-hygiene/article6255543.ece
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