Mal-Nutrition in India

Introduction

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.

Indices

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 (4^th), China (22^nd) and South Africa (23^rd). 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 70^th while Brazil (29), South Africa (39), Russia (40) and China (42) are ahead of us as they are in per capita GDP.

Hunger

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.

Sanitation

     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.

Conclusion

    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.

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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:   http://epaper.tribuneindia.com/c/2163212

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[i] 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

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