Endemic deprivation

The malnutrition paradox is that there are some countries that have become economic powerhouses with persistently high numbers of malnourished children, while other countries with low levels of national income have shown an appreciable progress in combating malnutrition by investing in cost-effective, proven interventions that ensure children’s access to proper nutrition.

Endemic deprivation

Globally, nutrition -related factors contribute to about 45 per cent of child deaths below the age of five.

As Amartya Sen once observed, ‘While there is evidence enough to indicate that more people die from undernutrition than from famines (and also that many people lead severely constrained lives as a result of it), nevertheless it is very difficult to derive definite estimates of the exact magnitude of people affected by the endemic deprivation.’

Moreover, the exact magnitude and intensity of malnutrition in different countries remain obscure from public view. India is no exception.


Article 47 of the Constitution states that ‘the State shall regard raising the level of nutritional and standard of living of its people and improvement in public health among its primary duties.’ Indeed, we have failed our Constitution.

Indian policy-makers have always given priority to ensuring health and food safety. Successive five-year plans have dwelt on policies and multipronged strategies to improve food security and nutritional status of the population in a specified timeframe while also providing requisite funds.

Given its intrinsic and instrumental relevance, the union and state governments have launched important nutrition-specific programmes starting from the Balwadi Nutrition Programme (BNP) in 1970, the massive Integrated Child Development Services (ICDS) in the late 1970s and the Mid-day Meal Scheme (MDMS) in 1995. However, despite considerable efforts, India is yet to witness meaningful reductions in the burden of child malnutrition.

The country has the largest number of malnourished children in the world and one-third of all the stunted children globally. The low levels of under-nutrition, coupled with increasing levels of over-nutrition, are the twin problems. According to the latest National Family Health Survey ~ 4 (NFHS-4, 2015-16), around 35.7 per cent children below five years are underweight, 38.4 per cent are stunted and 21 per cent are wasted.

Every second child in India continues to suffer from some form of Anthropometric failure (either stunting, or underweight, or wasting). In 2017, some 1.04 million under-five children died in the country.

Over 68.2 per cent of the deaths were due to malnutrition. Malnutrition has an irreversible effect on health and cognitive abilities in children.

Indeed, malnutrition is one of the India’s most serious development challenges. That challenge can occur at all stages of the life cycle.

Malnourished women or adolescent girls give birth to babies who are born stunted and thin. In this way, malnutrition is handed down from one generation to another as a terrifying inheritance.

Increasingly a large body of evidence from epidemiology and economics had shown that the mortality aside, poor nutrition in the first 1000 days ~ from a woman’s pregnancy to the child’s second birthday ~ can lead to stunted growth. Growth stunting in childhood is a risk factor for increased mortality, poor cognitive and motor development, and other impairment.

Children who have been severely malnourished in early childhood suffer a later reduction in IQ by as many as 15 points, significantly affecting their achievement in school and increasing the risk of drop-out. Moreover, stunting persists and stunting along with Low Birth Weight (LBW) is also a risk factor for adult chronic diseases.

Why are levels of child malnutrition so high in India? Many believe that India’s low per capita income is the major factor. As expected, income and economic growth influence nutrition in many ways.

Wealthier people can afford to buy more nutritious food, while the poorer section often lacks access to the right quantity of variety of food leading to inadequate nutrition. Moreover, in the words of Nobel Laureate Abhijit Vinayak Banerjee: ‘The peculiar evil is that, the less money you have the less you are inclined to spend it on wholesome food. When you are unemployed, you don’t want to eat dull wholesome food. You want to eat something a little tasty.

There is always some cheap pleasant thing to tempt you.’ [Poor Economics]. The malnutrition paradox is that there are some countries that have become economic powerhouses with persistently high numbers of malnourished children, while other countries with low levels of national income have shown an appreciable progress in combating malnutrition by investing in costeffective, proven interventions that ensure children’s access to proper nutrition. The disconnect between wealth and malnutrition is so stark that economists have concluded that economic growth does nothing to reduce malnutrition.

A UNICEF report, Rapid Survey on Child (RSOC), stated that Gujarat, the most developed state, has the worst rate of malnutrition than the national average. According to NFHS-4, 38 per cent children in the state are stunted, 26 per cent are wasted, 39 per cent are underweight and 9.5 per cent are severely wasted.

The Food and Nutrition Security Analysis for 2019 had stated that Gujarat along with Jharkhand, Bihar, UP and MP for the highest stunting and underweight categories. While India has become one of the world’s largest economic markets, almost half of its children are stunted. Remarkably, although most countries in sub-Saharan Africa have lower per-capita income than India, the majority of these countries have lower levels of child malnutrition.’

Again in contrast to India, Senegal, the westernmost poor country in Africa, is making considerable progress in reducing malnutrition.

The number of stunted children in Senegal has decreased dramatically over 20 years. This puzzling reality is known as ‘Asian Enigma’, that can hardly be explained in terms of genetic differences.

Experts have linked this enigma to the practice of widespread open defecation (OD), rather than scarcity food. ‘The difference in average height between Indian and African children can be explained entirely by differing concentrations of OD. There are far more people defecating outside in India than there are in Africa and anywhere else in the world.’ said Dean Spears, the Executive Director of RICE (Research Institute for Compassionate Economics).

Indeed, India’s growth story vis-à-vis its nutritional security does not hold much water when one analyses its sanitation status. Amartya Sen has expressed the situation in remarkably succinct terms: ‘This is India’s defective development.’ Data with the Department of Drinking Water and Sanitation show that in October 2014, when the Swachh Bharat Mission (SBM) was launched, sanitation coverage in rural areas was just 38.7 per cent. Some 550 million people, or almost half of the country’s population, were defecating in the open. However, the country has now become free from open defecation. Its impact on the status of nutritional security is yet to be revealed.

Poverty has amplified the risk of, and risks from, malnutrition.

People who are poor are more likely to be affected by different forms of malnutrition. Also, malnutrition increases healthcare costs, reduces productivity, and slows economic growth, which can perpetuate a cycle of poverty and ill-health.

Hence for combating malnutrition we need, more than income growth, strong political will, government and partner support, and the right strategies. Low birth weight (LBW ), defined as weight less than 2500 grams at birth, is the main reason why over 50 per cent of the children in Asia are underweight. The majority of LBW infants are born small as a result of intrauterine growth retardation (IUGR) which is attributable to small maternal size at conception (low weight and short stature) and low gestational weight gain. About 60 per cent of women in South Asia and 40 per cent in South-east Asia are underweight (weight below 45 kg).

Indian mothers are under weight prior to conception (BMI less than 18.5) and less weight during pregnancy. Hence, there is a deficit in maternal nutrition during pregnancy, and the deficit tends to affect the baby even after birth. This explains the ‘Asian enigma”. According to a paper published recently in the journal proceedings of the National Academy of Sciences, 42.2 per cent of prepregnant Indian women are underweight compared only 16.5 per cent in the case of sub-Saharan African mothers.

With a score of 30.3 on a 100-point ‘severity scale’, India suffers from a ‘serious’ level of hunger. The Global Hunger Index (GHI) of 2019 ranked India 102nd out of 117 countries. A review of GHI since 2000 reveals a grim picture ~ India has not made progress in eliminating hunger over the past two decades.

(The writer is a retired IAS officer)