Malnutrition has been one of the enduring enigmas of contemporary India. Despite years of rapid economic growth, child malnutrition rates remained unchanged for years. After years of stasis, there seems to be some sign of progress in India’s battle against malnutrition, although malnutrition rates remain high.
A Mint analysis based on provisional state-wise data from a recent national survey shows that some of the most malnourished states of the country have witnessed the sharpest fall in the proportion of underweight children. But when it comes to stunting (low height for age), considered an indicator of chronic undernourishment, the ranking of states remains precisely the same as it was a decade ago.
While improvement in poverty rates could have played a role in reducing the burden of malnutrition, there is very little evidence to suggest that state interventions, either in the form of broad-based programmes such as the public distribution system (PDS) for foodgrains or targeted child nutrition programs such as the Integrated Child Development Services (ICDS) played a major role in fighting child malnutrition, as the charts given indicate. The recent data seems to corroborate earlier research on malnutrition in India that highlighted two key drivers of malnutrition in: the absence of sanitation, which leads to rampant spread of diseases, and the low social status of women, which is reflected in low birth weights.
A nationwide survey called the Rapid Survey on Children (RSOC), conducted by the ministry of women and child development in 2013-14 in league with Unicef, showed that the proportion of underweight children in India was 29.4%, and that of stunted children 38.7%. While these figures indicate high levels of under-nutrition, they show a marked improvement over what the last nationwide survey, the National Family Health Survey (NFHS), had reported in 2005-06: the ratio of underweight children at 42.5%, and the ratio of stunted children at 48%. While the aggregate figures were reported by the government to the International Food Policy Research Institute (IFPRI) last year, leading to a dramatic improvement in India’s rank on the hunger index released annually by the institute, the ministry did not publish any details relating to the survey for a year after it was completed.
After The Economist published provisional state-wise results of the survey, the ministry of women and child development put up a fact sheet about the survey on its website earlier this month. The Union government also said that the state-level estimation methodology is still being examined.
The fact sheet seems to suggest that the RSOC survey had a large sample size, and a sampling methodology similar to the NFHS. It is, therefore, worthwhile to compare the trends revealed in the latest survey (sourced from The Economist) with the trends reported by NFHS nearly a decade ago.
Like almost everything else in India, malnutrition rates vary widely across states and income groups. But it is heartening to note that some of the most malnourished states of the country saw the biggest gains in underweight rates over the past decade. Madhya Pradesh and Bihar, the states with the highest rates of underweight children, saw the sharpest fall in underweight rates over the past decade.
Most states in the North-East saw big improvements in rates of stunting, albeit on a high base. The ranking of states in 2013-14 was identical to the ranking in 2005-06. Inter-state variations in rates of stunting are as pronounced as they were a decade earlier.While poverty is not the only cause of malnutrition, it is an important cause, not just because poor people may lack adequate food but also because the poor often have less time and resources to care for their children. Not surprisingly, the proportion of malnourished children among the lowest wealth quintile is significantly higher than the proportion of malnourished children among the highest wealth quintile. But the difference between the two extreme wealth quintiles seems to have narrowed over the past decade, the latest data suggest. The proportion of underweight children among the lowest wealth quintile declined 14.5 percentage points to 42.1% while the same proportion among the highest wealth quintile fell 1.1 percentage points to 18.6%, compared to the previous decade.
The past decade saw the biggest decline in poverty rates in the history of independent India. And it is likely that nutrition levels improved as even the poorest had access to greater resources than in the past.
While there is a clear link between wealth and nutrition at the household level, the link is much weaker when one looks at countries or states. India, for instance, has higher malnutrition rates than many poorer countries, such as those in Africa. Within India, some of India’s richest states, such as Maharashtra and Gujarat, have higher proportions of underweight children than some of India’s poorer states such as Assam and Uttarakhand.
An analysis of states where the decline in poverty was faster than the national average between 2004-05 and 2011-12 shows that the link between poverty reduction and improvements in nutrition is at best a weak one. While some of these states, such as Bihar and Madhya Pradesh, saw rapid gains in nutrition, others such as Odisha and Tripura saw only modest gains.
The past decade also saw significant improvements in the PDS, as an earlier Plain Facts column had pointed out. But there does not seem to be any strong link between improvements in PDS and improvement in nutritional outcomes. Improvements in PDS have been calculated as the financial equivalent (at constant prices) of the increased foodgrains people availed of in rural India across states. The implicit income transfer through PDS is based on estimates by economist Andaleeb Rahman of the Indian Institute for Human Settlements, Bengaluru. As the chart below shows, states which have led gains in PDS, such as Chhattisgarh and Odisha, have seen modest gains in nutritional outcomes. Many states with less improvements in PDS have fared better in nutritional outcomes.The past decade also saw rapid expansion of India’s biggest intervention to fight child malnutrition, the ICDS. A 2011 evaluation report of the ICDS by the Planning Commission ranked states on the basis of an index of ICDS performance. The index is a composite one that takes into account factors such as the average number of days beneficiaries received nutritional supplements, the proportion of mothers who consulted ICDS workers when their children fell sick and the average attendance during surprise visits by the evaluating team.
As the chart below shows, there is little evidence to suggest that states that rank high on ICDS performance have improved nutritional outcomes. A high rank on ICDS performance indicates better performance in the chart, while high ranks in stunting and underweight ratio indicate low level of stunting and underweight, respectively. Thus, a rank of 1 on ICDS performance indicates the best performance among all the major states considered, while a rank of 1 on stunting indicates the lowest level of stunting among all states considered.
Two factors that do seem to affect under-nutrition are open defecation and the status of women. States with low rates of open defecation seem to have better nutritional outcomes, while states with high rates of open defecation seem to have worse nutritional outcomes, as the chart below shows. In the absence of sanitation facilities, children face a hostile environment and frequently fall prey to common infectious diseases which reduce their ability to absorb nutrients and grow.
The chart also indicates that states with high proportions of low birth weights tend to have worse nutritional outcomes. Low birth weight babies start life with a nutritional disadvantage, and many of them remain underweight even as they grow up. High incidence of low birth weight babies is a reflection of the low social status of women, who do not receive adequate nourishment or care prior to childbirth. It does not appear to be a coincidence that most states with low ratios of low birth weight babies are also states with relatively higher sex ratios.
3000 Children Die In India Every Day Due To Malnutrition: 10 Hard-Hitting Facts About Hunger
How many of us know that 16th October is ‘World Food Day’? World Food Day is celebrated around the world that day, because it coincides with the establishment of the Food and Agricultural Organization (FAO). It is a day when people get together to declare their commitment to hunger in our lifetime. Hunger not only makes one suffer, it also affects health severely. The statistics of hunger are staggering and shocking. One in nine people on earth is currently under-nourished. Here are ten facts about hunger that you should be aware of:
1. There are currently 795 million people hungry people on earth. India itself is home to the largest under-nourished and hungry population, with 195 million people going hungry every day.
2. Close to 165 million children are stunted as a result of under-nutrition and infection, leaving them physically and intellectually weak. According to the United Nations Children’s Fund, 24 countries with the highest levels of stunted children are concentrated in Sub-Saharan Africa and South Asia alone.
3. Nearly half of all deaths in children under age 5 are attributable to under-nutrition. This translates into an unnecessary loss of about 3 million young lives a year. In India itself, 3,000 children die every day due to malnutrition. Malnutrition also increases a child’s risk of dying from many diseases – most prominently measles, pneumonia and diarrhoea.
4. Around half of all pregnant women in developing countries are anemic, because they lack access to iron-rich foods. Anemia is responsible for causing 110 deaths during childbirth every year.
5. Though women make up a little over half of the world’s population, they account for 60% of the world’s hungry. In India, the nutrition of children is particularly worse because of the state of their mothers. 36 percent of Indian women are chronically under-nourished, from their childhood itself. This can be attributed to the fact that girl children are less wanted in a patriarchal society, where men receive food before women. Data from Bihar and Madhya Pradesh shows that girls represent up to 68 per cent of the children admitted to programmes for the severely malnourished.
6. To prevent hunger, a child needs to be taken care of the most during the first 1,000 days of its life, from pregnancy to age two. According to the World Food Programme, a proper diet during this period can protect children from mental and physical stunting that can result from malnutrition.
7. It costs just $0.25 (INR 16) per day to provide a child all the vitamins and nutrients he/she requires to grow healthy.
8. According to the International Food Policy Research Institute (IFPRI), climate change and erratic weather patterns will push another 24 million children into hunger in the future.
9. There is enough food to feed everyone in the world. If total world food supplies are divided equally – all food grown divided into equal portions – there will be plenty for everyone, with some to spare; in fact, today the world produces 10 percent more food than is needed to feed everyone. But 30% to 50% of 1.2-2 billion tonnes of food produced around the world never makes it to a plate, and gets wasted.
10. Two types of acute malnutrition are wasting (also called marasmus) or nutritional oedema (also known as kwashiorkor). Wasting is characterised by rapid weight loss and can also lead to death.
Eradicating hunger is one of the key Sustainable Development Goals for 2015, and the target is to end hunger by 2030 and ensure food access to all parts of the population. Organizations like UNICEF are helping countries by supplying them with essential micronutrients like iron and Vitamin A which is essential for a healthy immune system. Organizations like Feeding India too are channeling excess food from individuals, corporates, weddings and restaurants to the ones in need. What we call food wastage can be converted into food security for others. Awareness about malnutrition is necessary to tackle this problem and help the world reach its target of reducing world hunger by fifty percent.
INDIA has been growing steadily richer in recent years, but it still has more malnourished people, especially children, than any other country. A big, nationwide study from 2005 and 2006, the National Family Health Survey (NFHS), found that 42.5% of children under five years old were underweight. The region with the next highest proportion of underweight children is Africa, with an average of 21%. Another measure of malnutrition is stunting, when children are unusually short for their age. Again, India’s problems were shown to be unusually bad.
Now comes some good news. In 2013 and 2014 the UN agency for children, Unicef, and India’s government conducted a new study called the Rapid Survey on Children (RSOC). The purpose was to gather up-to-date figures to use in the interim before the next big NFHS survey, which is under way. The RSOC report has unfortunately not been published, but The Economist obtained a copy.
It points to some striking national trends. For example the proportion of underweight children has fallen from 42.5% a decade ago, to just under 30% now. There have been similar improvements on stunting, wasting and other measures of malnutrition. The national immunisation rate has risen and the rate of open defecation is down from 55% of households to 45%.
Really interesting, however, is the breakdown of results by state, presented here. By and large social and health indicators across India follow predictable patterns. In states with higher incomes, those nearer the coast and farther south, most health indicators are better. Typical high achievers are Kerala and Tamil Nadu. In landlocked states, poorer ones and in the north, social and health results are usually worse. Notorious backward states include Bihar and Uttar Pradesh. North-eastern states are often outliers, both poor and landlocked but often with high rates of literacy and better health.
Results from the RSOC mostly bear out these trends. Everywhere has seen a reduction in the share of underweight children and in stunting. But it is striking that on occasion higher incomes do not correlate with the biggest health gains. Maharashtra and Gujarat are both states with relatively prosperous people, but Maharashtra’s nutrition levels are better than Gujarat’s. This is also true for rates of immunisation and of open defecation. It appears that Maharashtra’s government has put more emphasis on tackling nutrition problems, for example among its adivasi, or tribal, population.
Two crucial factors are worth looking at. Lower rates of open defecation correlate well with reduced malnutrition. When children live and play in clean environments they are less likely to be infected with parasites that make it hard to absorb nutrients. And states that focus on helping girls and young mothers probably do better at breaking long-term cycles of malnutrition. Where teenage girls have a low body-mass index there seems a greater likelihood mothers will give birth to undernourished children. Proper nutrition for girls and women should be a priority.
The latest edition of the Global Nutrition Report 2015 by the International Food Policy Research Institute, released on Tuesday, brings back the concerns over malnutrition into sharp focus. In July, the government of India, after much avoidable controversy, released malnutrition (used synonymously as undernutrition) figures from the Rapid Survey on Children (RSoC) data that was collected in 2013-14. This dataset was keenly awaited as it provides a nationwide assessment after the third round of the National Family Health Survey (NFHS-3), which is nearly a decade old now. The RSoC data also assumes significance as the world adopts the Sustainable Development Goals. Goal 2.2 seeks to end all forms of malnutrition by 2030, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under five years of age.
The RSoC was conducted by the ministry of women and child development with technical support from Unicef. It found 29.4 per cent of children (aged less than three years) to be underweight (low in weight for their age), while 15 per cent were wasted (low weight for their height) and 38.7 per cent were stunted (low in height for age). On the face of it, this compares well with the NFHS-3 data, in which the corresponding figures were 40.4 per cent (underweight), 22.9 per cent (wasted) and 44.9 per cent (stunted). But in absolute terms, the current levels of underweight and stunted children are abysmally high and former Prime Minister Manmohan Singh’s assertion that malnutrition is a “national shame” is still valid.
A civil society collective appealed to policymakers in a press release on July 23 to “declare malnutrition as a medical emergency to save India’s children dying of hunger”. The Union minister for tribal affairs on August 4 said that his ministry “will collaborate with Ramdev and Balkrishna to identify and document medicinal herbs helpful in the treatment [emphasis added] of malnutrition”. But ready-to-use therapeutic food was introduced as a “treatment” to combat this medical emergency nearly two decades back.The moot question is: can malnutrition be “treated”? Current mainstream global notions draw upon African experiences, where severe acute malnutrition (SAM) has been triggered by acute crises, such as drought, crop failure and civil wars. Classical SAM is a medical emergency, carries with it a high risk of mortality, and requires not just therapeutic feeding but other medical inputs. This global wisdom was bought off-the-shelf by national experts and Indian strategies and guidelines continue to be largely clinical, essentially seeking to treat malnutrition.The predominant form of malnutrition in India is significantly different from classical SAM and standardised protocols for treatment are not as effective in the Indian context, where longer durations are required for achieving targeted weight gains. This is on account of the high levels of underlying stunting. Stunting signifies chronic undernutrition and has no scope for “cure” in a therapeutic mode. Its levels in India are higher than in Africa, and exceedingly so among chronically poor populations. Severe chronic malnutrition (SCM) in children is characterised by stunted growth and is a potentially less serious but continual form of malnutrition. SCM is generally an outcome of latent poverty, chronic food insecurity, poor feeding practices and protracted morbidities, but rarely a direct cause of mortality. In short, stunted children are hungry but not sick.Chronic malnutrition requires a far wider spectrum of programmatic interventions beyond clinical management. Multi-sectoral actions are needed to combat multi-dimensional deprivations. Simultaneously, there is an urgent need for promoting practices to improve the quality of local diets, improving child-feeding practices, reducing exposure to illnesses, and paediatric care services. This would need a broad-based commitment of resources as well as the creation and nurturing of local capacities and leaderships.Despite recent gains, malnutrition continues to be a national emergency; though not a medical one. The National Nutrition Mission (a multi-sectoral programme earmarked for 200 high-burden districts) has not taken off in any meaningful manner. The penchant for a magic bullet to treat and cure malnutrition draws attention away from the Indian epidemiological reality. Policymakers and opinion leaders are increasingly impatient with the tardy progress of the current set of interventions. The way forward requires a reorientation of Indian research to inform policy and practice and change the current tenor of policy discussions. The Make in India call should apply no less to research and practice.
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