The long-anticipated series on nutrition published earlier this month in the British medical journal The Lancet has profound consequences for India. True, economic growth is at an all-time high, literacy is improving, and even infant mortality has shown a decline over the past decade. But on one critical front we continue to have the dubious distinction of being among the worst-off in the world: a high percentage of malnourished children.
Last year’s release of the National Family Health Survey (NFHS) data showed that 45 per cent of Indian children are underweight and 70 per cent are anaemic. Indian children are twice as likely to be malnourished as even those in sub-Saharan Africa, and nearly five times more likely to be so than children in China. Even with its remarkable economic progress, India’s malnutrition levels in the seven years since the last NFHS survey have not been getting any better. What is more, inequalities in nutrition between demographic, socio-economic and geographic groups have intensified during the 1990s. Should we be concerned? Yes. Malnourished children are more susceptible to disease, have a reduced capacity to learn, and are much more likely to drop out of school. Once in the job market, their productivity is low. For the economy as a whole, this translates into losses of nearly 3 per cent of the GDP. All this places India’s large young population — the basis of its much-awaited demographic dividend — at a growing disadvantage in today’s globalising world.
Before malnutrition can be adequately addressed, however, its causes need to be understood. It is primarily an outcome of three interlocking sets of factors: one, inadequate access to food; two, an unhealthy environment and limited access to healthcare; and three, inappropriate and often misunderstood child caring practices. In dealing with the problem, certain common myths also need to be dispelled, for it is not poverty and the lack of food alone that cause malnutrition. In fact, in the richest 20 per cent of India’s population, more than one in four children are underweight and nearly two out of three are anaemic.
Another myth relates to the programmes needed to address the problem. Evidence shows that most of the damage caused by malnutrition happens either when the child is in the womb or in the first two years of life. And most of the impairment to brain development and future productivity in these early months of life is irreversible. Therefore, supplementary feeding through school feeding programmes is, for nutritional purposes, too late, too little and — since nutrition budgets are limited — too expensive.
So, there is a clear need to focus on the nutrition of the very young. As for geographic focus, malnutrition in India is concentrated in a relatively small number of states, districts and villages. A recent World Bank report noted that five states account for about 80 per cent of India’s malnourished children. A follow-on mapping study has identified the districts where the problem is most severe.
A balanced nutrition policy in India would, therefore, review the epidemiological evidence for the causes of malnutrition. It would design a public policy that institutes a strong nationwide information campaign promoting good nutrition practices during pregnancy and the first two years of life. It would promote and support traditional practices, such as adequate rest during pregnancy, and exclusive breast-feeding for every child until six months of age, and the introduction of appropriate complementary foods at about six months of age. Such an information campaign alone could help improve nutrition outcomes among those who are better-off. In addition, the policy would support large-scale fortification of commonly consumed foods with micronutrients such as iodine, iron, vitamin A and zinc and encourage women to take iron supplements during pregnancy.
This would ensure that the limited public resources are conserved for use among the poorest who may need more, for example food and vitamin A supplements, as well as assistance to prevent common childhood diseases like diarrhoea. At the same time, these policies would continue to explore innovative options to improve nutrition. These include the production of double-fortified salt to address the widespread anaemia (salt fortified with iron, as well as iodine), and possibly cash transfers to poor mothers, conditional on their participation in programmes aimed to improve child-care practices.
One of the reasons India has not moved more aggressively to address the malnutrition scourge is the view of some here that global growth standards that are used to assess nutrition overstate the problem in India. A few have put something of a political spin on the issue by questioning the validity of the alarming nutrition data published about India. True, the unpalatable information sometimes appears in reports of international organisations. But those reports are derived from India’s own NFHS data, verified by Indian scientists and demographers. In short, the problem of malnutrition in India is large and real. The launch of the Lancet nutrition series in India will provide a good opportunity to re-visit what needs to be done to address this scourge. This will, in turn, help India to build a well-nourished and strong nation that can make the most of the new opportunities that are coming its way.
Meera Shekar is Senior Nutrition Specialist, World Bank, Washington.