"Public Health" is key to Malnutrition

Introduction

    Every time a "Hunger Index" comes out, it attracts wide publicity & discussion. Nobody seems to notice, that the "Hunger index" doesn't measure "Hunger" at all. When this author found objective survey data on "Hunger" in India, both the Planning Commission and EPW vetoed its publication. Why? Possibly because it threatened too many intellectual vested interests.

    The author and consultant for the Indian part of the "hunger index" admitted, that the index is mostly about Child stunting, wasting etc, which have collectively come to be called "child malnutrition". If the real problem is Child Malnutrition, then we need to understand this problem and find solutions to it as we did over last decade.

 India's under 3 year old Child malnutrition rate(%) was double the poverty rate (%) and 20 times the per cent of hungry in India (% of households in which any member had less than two (2) full meals, on any day of the month (i.e. even one day without 2 square meals, counts as hungry) .

Child Malnutrition

There are three broad aspects of malnutrition that must be kept in mind when devising strategies for dealing with it. [i]   

1)    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. 

2)    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.

3)    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.

Poverty

Poverty affects cross State differences in Child malnutrition, it has to be addressed through economic growth, reform of welfare programs etc. Our research confirms that average per capita GDP is an important  determinant of poverty.[ii] It also showed that higher agriculture growth has an impact on poverty reduction in addition to its normal contribution to overall GDP growth. A special focus on agricultural growth in poorer states and in States with opportunities for productivity improvement can therefore be justified in terms of poverty removal even though it may not have any impact on overall growth. The empirical results also justify an added focus on rural roads and telecom connectivity (in addition to the general effects found earlier) to the extent that they promote the development of agriculture. Development of rural connectivity also improves market integration and labor mobility, which in turn will remove the differential and segmented impact of growth on rural and urban poverty. The research also showed that the consumption share of bottom 40% of the population is an important determinant of poverty. Targeted benefit programs should therefore focus on the bottom 40% of the population. It is essential to set up a comprehensive data base with unique IDs, photographs and Bio-metric identification, that will eliminate fraud and help identify the poorest 30% to 40% of the population.[iii]

Malnutrition Solutions

The research on cross-State differences in child nutrition outcomes shows, that the greatest social welfare benefits from direct intervention by government to improve the lot of the bottom 40% can come if it focuses on two long neglected quasi-public goods.[iv]  First, Public health including communicable disease and vector control, quality drinking water, drainage, sewerage and solid waste disposal in every city, town and village in the country. Second universal primary education and literacy to a global standard that is visible in outcomes. 

Improvement of public health education and public health facilities clearly has a positive effect on nutrition outcomes.  The ICDS program seems to have helped in providing public health education to mothers and thus contributed to the outcome.  The policy implications, however, extend beyond nutrition to other health outcomes. A comprehensive program for improving civic amenities of a public health nature to a defined standard is necessary to remove visible symbols of divide between rich and poor that slums and other neighborhoods with poor drainage and sewage create.

For every existing town, States must plan and install a modern drainage, sewerage and water supply system with water storage and purification, sewage treatment plants and garbage disposal sites.  The impact in terms of economic activity, health and nutrition can be enormous.  Government should help develop consultancy firms that can Plan and organize such systems and organizations that can compete with each other to build these systems across the country.  Once 100% coverage of towns is attained, we should extend the planning effort to semi-urban areas and villages in co-operation with Panchayti Raj institutions and NGOs.  We may not be able to match the quality of public health  and civic services routinely found in the villages of High income country’s, but we must target a quality level equal to that of middle income countries.

    This brings us back to the broader question of other quasi-public goods that are of critical importance to the poor.   Literacy can help in acquiring knowledge about hygiene, nutrition and sanitation.  Government must ensure that every citizen, has the education that (s)he is supposed to acquire with the completion of Primary education.  But this education must also be made more relevant by providing information on matters that will improve their lives (health, hygene, nutrition) and equip them to find useful information.

Cross-country Lessons

Our cross-country results show that 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.[v]  It indicates that improvements in environmental sanitation could have a significant impact in reducing malnutrition in 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.

Conclusions

  Once the current targets of the Swach Bharat Mission are met it should be raised to a broader and more comprehensive level: A comprehensive end-to-end water-sewage-sanitation system for the country. One that starts with clean drinking water and unpolluted irrigation water and ends in fertilizer and usable water. Similarly Union government health initiative must be focused on classic public health and public health education in schools and family health programs (like ICDS).

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A version of this article appeared in the Indian express OP ed page on October, 2017 under the banner "What schools have to do with health" http://indianexpress.com/article/opinion/columns/global-hunger-index-india-child-mortality-poverty-what-schools-have-to-do-with-health-4897121/

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[i] Virmani, Arvind, “Causes of Child Malnutrition In India,” Working Paper No. WsWp 1/2007,  July 2007. MalnutritionChild07July.docx .

[ii]  Virmani, Arvind, “The Sudoku of Growth, Poverty and Malnutrition: Lessons For Lagging States,” Working Paper No. 2/2007-PC, Planning Commission, July  2007. http://planningcommission.nic.in/reports/wrkpapers/wp07StJl12.pdf , http://planningcommission.nic.in/reports/wrkpapers/index.php?repts=wrkpap.

[iii] Virmani, Arvind, “Poverty And Hunger In India: What is needed To Eliminate Them,” Working Paper No. 1/2006-PC, Planning Commission, February 2006.  http://planningcommission.nic.in/reports/wrkpapers/wk_pov106.pdf .

[iv] Virmani, Arvind, “Causes of Child Malnutrition In India,” Working Paper No. WsWp 1/2007,  July 2007. MalnutritionChild07July.docx .

[v] Virmani, Arvind, "Undernurishment of Children: Causes of Cross-country Variation," Working paper No.WsWp 4/2012, October 2012 [WsWp 4/2012. Nutrition12oct.docx . 

Food Security Bill: What Will it solve?

PDS and FCI 

  In the decade or so that I spent in the Planning Commission, the Food Ministry, under which the Public Distribution System (PDS) and the Food Corporation of India (FCI) run, was always one among other Advisory responsibilities on Development Policy.  It did not take very long to find out that the fundamental problem with the system was about so called “leakages” abetted by corruption:  One soon learnt that FCI was one of the most inefficient and corrupt organizations in the government. At that time available estimates of leakage plus administrative costs ranged between 40% and 55%. The other problem was of exclusion – some poor people did not have access to a ration card or subsidized food, whence the horrifying reports of starvation in remote and tribal areas of the country.  This led me to propose the introduction of a Food credit/debit card using smart card technology, which could be integrated with the food for work program and also have the inbuilt flexibility to change over to an income transfer system if desired (Planning Commission Working paper 5/2002).[1]  Instead of dealing with the very difficult political and bureaucratic problems that have stymied genuine reform of the food system, the “Food Security Act,” proposes to deal with these problems with, ”A stroke of the pen.” Unfortunately very little will change, besides providing lucrative new opportunities for bureaucratic and political corruption!

Hunger & Malnutrition

What are the real problems that are still awaiting serious government and NGO attention?  In 2004-2005, 2% of households suffered from hunger at some point during the year and about 25% of people were below the poverty line, but as many as  45% of children below the age of 3 (5) years were malnourished.  If we leave philosophy and politics aside, these facts suggest that,

(a) As hunger affects only 8% of the poor, the food security bill and anti-poverty programs are not the best way of reaching the hungry, who are dispersed across the country and in tribal and remote areas.  The hungry have to be individually and geographically identified/ located. Once this is done it would not cost much to eliminate this hunger through direct cash or food transfers, depending on whether there are or are not competitive food markets in the area where they live.  Thus in remote or hilly areas it is probably necessary to supply food.

(b) Malnutrition is a much bigger problem than poverty and the causes are unlikely to be the same, even though there may be some overlap.  Anti-poverty measures/programs are unlikely to solve the malnutrition problem.

Facts and Analysis

Analysis of the state wise 2004-5 NSS and 2005-6 NFHS data led to the conclusion that the most important cause of malnutrition in India was the abysmal state of ‘public health’ in terms of sanitation, pure drinking water and public knowledge about the importance of cleanliness (al la germs in dirty water, dirt and grime) and nutrition (basic food groups etc.).[2]  If this appears surprising, think about the simple act of eating and digesting food and absorbing energy and nutrition from it.  A child or adult who is sick with diahorea or dysentery can eat as much as (s)he wants but will not be able to absorb it effectively.  Recent medical research goes further, to show that even those children who are living in unsanitary conditions, but do not show any symptoms of gastro-intestinal disease, are infected with germs in their intestines that do not allow them to absorb nutrients from the food they eat.

Cross country analysis of malnutrition data confirms the conclusions of the India analysis.[3] The quality of public health, as measured by variables such as access to better sanitation and improved water sources, explains much of the cross-country variations in the prevalence of malnutrition and the high malnutrition in India relative to other countries with similar levels of per capita income and poverty.  Improvements in environmental sanitation are the clearest and most effective policy-program tool for the Central government to reduce if not eliminate the excessively high levels of malnutrition in India.  The cross country compliments the Indian Inter-state study by showing that female primary education, is an important factor in  reducing child malnutrition, by helping spread information and knowledge about personal hygiene, sanitation and nutrition.

Conclusion

     The Food Security Act will have little or no effect on malnutrition, poverty and hunger.   Hunger can be eliminated if and only if the government and/or NGOs identify the 40 lakh affected households and ensure that cash or food reaches the principle female (mother) of the household.  An, “Elimination of Hunger Act”, with severe penalties for officials in whose area a hungry family is found, could do this at a small fraction of the cost.  Child malnutrition can be dramatically reduced, if not eliminated within a decade, through a massive “public health” campaign: This would insure a modern sewerage and sanitation system in every urban, semi-urban and semi-rural area and pure drinking water, septic tanks and lavatories in rural areas.

A version of this note appeared on the Op Ed page of the Times of India, of Feiday 7th June, 2013, under the banner, "What we need is not a Food Security Bill but a Hunger Elimination Act. " http://timesofindia.indiatimes.com/home/opinion/edit-page/What-we-need-is-not-a-food-security-Bill-but-a-hunger-elimination-Act/articleshow/20465002.cms 

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[1] Arvind Virmani and P. V. Rajeev, “Excess Food Stocks, PDS and Procurement Policy,” Planning Commission Working Paper No. 5/2002PC, December 2001. http://www.planningcommission.nic.in/reports/wrkpapers/wp_pds.pdf.

[2]  Arvind Virmani, “The Sudoku of Growth, Poverty and Malnutrition: Lessons For Lagging States,” Working Paper No. 2/2007-PC, Planning Commission, July  2007. http://planningcommission.nic.in/reports/wrkpapers/rpwpf.htm

[3] Virmani, Arvind (2012), “Under Nourishment in Children: Causes of Inter-country variation,”  Working paper number WsWp 4/2012, October 2012. http://sites.google.com/site/drarvindvirmani/working-papers.

India’s Problem is Malnutrition Not Food Security: Public Health (not Cereals) is the Solution

Background

Shri Rahul Gandhi has wisely noted that our society pays more attention to high position than to greater knowledge.  This has emboldened me to present some analysis that seems to go counter to the results expected by the Congress party at the center and BJP in the States, from their respective food security Acts.  In 2004-2005, 2% of households suffered from hunger at some point during the year and about 25% of people were below the poverty line, but as many as  45% of children below the age of 3 (5) years were malnourished. 

Logic vs. Ideology 

 A simple, non-ideological  examination of these facts suggest that,
 (a) As hunger affects only 8% of the poor generalized policies and anti-poverty programs are not the best way of reaching the hungry.  They have to be identified geographically and individually and reached directly. Once this is done it would not cost much to eliminate this hunger through direct cash or food transfers, depending on whether there are or are not competitive food markets in the area where they live.  Thus in remote or hilly areas it is probably necessary to supply food.  
 (b) Malnutrition is a much bigger problem than poverty and the causes are unlikely to be the same, even though there may be some overlap.  Anti-poverty measures/programs are unlikely to solve the malnutrition problem.

Research

Analysis of the state wise 2004-5 NSS and 2005-6 NFHS data led to the conclusion that the most important cause of malnutrition in India was the abysmal state of ‘public health’ in terms of sanitation, pure drinking water and public knowledge about the importance of cleanliness (al la germs in dirty water, dirt and grime) and nutrition (basic food groups etc.).  If this appears surprising, think about the simple act of eating and digesting food and absorbing energy and nutrition from it.  A child or adult who is sick with diahorea or dysentery can eat as much as (s)he wants but will not be able to absorb it effectively.  Recent medical research goes further, to show that even those children who are living in unsanitary conditions, but do not show any symptoms of gastro-intestinal disease, are infected with germs in their intestines that do not allow them to absorb nutrients from the food they eat.

Cross country analysis of malnutrition data confirms the conclusions of the India analysis.[i] The quality of public health, as measured by variables such as access to better sanitation and improved water sources, explains much of the cross-country variations in the prevalence of malnutrition and the high malnutrition in India relative to other countries with similar levels of per capita income and poverty.  Improvements in environmental sanitation are the clearest and most effective policy-program tool for the Central government to reduce if not eliminate the excessively high levels of malnutrition in India.  The cross country compliments the Indian Inter-state study by showing that female primary education, is an important factor in  reducing child malnutrition, by helping spread information and knowledge about personal hygiene, sanitation and nutrition.

Misleading Indices

The misnamed Global Hunger index (actually an average of calorie availability, poverty rates and child malnutrition) has been a major factor in misleading policy makers and advisers that Indians are hungry and starving and if we can assure them enough calories, the problem will be solved.  The World food Program’s single minded focus on cereals availability (and wheat and rice in India), has also contributed by arousing “liberal guilt,” about the declining average calorie intake.   
Those of us who have dealt with food issues for the last few decades, have often cautioned that easy availability of subsidized wheat and rice has driven out coarse cereals and other more nutritious local foods (e.g. wild berries, roots) from the diets of the poor and may thus have had a negative impact on nutrition.  In some cross state regressions the size of the PDS has an adverse effect on malnutrition, thus showing that the intuition s not completely wrong.  As the result is not statistically robust, it suggests that the PDS has had both positive and negative effects and in some cases the first and in others the second dominates.

Conclusion

     Here is my forecast:  The Food security Act will have little or no effect on malnutrition, poverty and hunger.   Hunger can be eliminated if and only if the government and/or NGOs identify the 40 lakh affected households and ensure that cash or food reaches (despite usual problems of leakage-corruption) the principle female (mother) of the household.  An, “Elimination of Hunger Act”, with severe penalties for officials in whose area a hungry family is found, could do this at a small fraction of the cost. 
     Child malnutrition can be dramatically reduced, if not eliminated within a decade, through a massive “public health” campaign: This would insure a modern sewerage and sanitation system in every urban, semi-urban and semi-rural area and pure drinking water, septic tanks and lavatories in rural areas.   The issue of Poverty requires a separate note.

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A version of the above post-appeared as an op ed article in the Economic Times, of February 4th, 2013, under the title, "Focus on Malnutrition, not hunger," http://m.economictimes.com/opinion/comments-analysis/focus-on-malnutrition-not-hunger/articleshow/18327041.cms

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[i] Virmani, Arvind (2012), “Under Nourishment in Children: Causes of Inter-country variation,”  Working paper number WsWp 4/2012, October 2012. http://sites.google.com/site/drarvindvirmani/working-papers.