By Meera Shekar

Senior Nutrition Specialist

The World Bank

Washington

Oped Special to Hindustan Times India

February 22, 2008

More on Malnutrition

The long-anticipated series on nutrition just published 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: the high percentage of malnourished children.

Last year’s release of the National Family Health Survey data showed that 45 percent of Indian children are underweight and 70 percent are anemic.  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, socioeconomic 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 percent of GDP. All this places India’s large young population – the basis of its much-awaited demographic dividend – at a growing disadvantage in today’s globalizing 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 health care; 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 percent of India’s population, more than one in four children are underweight and nearly two out of three are anemic.

Another myth relates to the programs 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 programs 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 percent 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 nation-wide 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, after which appropriate complementary foods would be introduced. 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 by way of food and vitamin supplementation, as well as assistance to prevent common child-hood diseases like diarrhea. 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 anemia (salt fortified with iron, as well as iodine), and possibly cash transfers to poor mothers, conditional on their participation in programs 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 the international growth standards that are used to assess nutrition overstate the problem in India. They contend that our children grow differently from children in other parts of the world. A few have put something of a political spin on the issue by questioning the validity of the alarming nutrition data published about India. They say these stark conclusions are the work of “outsiders,” who either don’t know India or have another agenda. True, the unpalatable information sometimes appears in reports of international organizations such as WHO and the World Bank. 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.

Dr. Meera Shekar is the lead author of "Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action."

She is also the co-author of “India’s Malnourished Children: A Call for Reform and Action”.