My malnutrition better than yours: Why India should still be very ashamed

The issue is not about comparison - whether nutritionally our children look worse than the Sub Saharan African children or not, but about the absolute truth: that a large number of our children are malnourished.

G Pramod Kumar May 06, 2013 10:18:12 IST
My malnutrition better than yours: Why India should still be very ashamed

For a country of 1.2 billion people with a million contradictions, what matters more?

That a large number of its children are malnourished OR that they appear to be more malnourished than the children of Sub-Saharan Africa?

Ideally, it should be the former that even Prime Minister Manmohan Singh is seemingly ashamed of; but for some, it’s the latter that matters.

Super power India compared with a hopeless, darkest part of the Dark Continent?

My malnutrition better than yours Why India should still be very ashamed

Malnourished Indian infant from Madhya Pradesh: Reuters

Impossible!

This is the point that a recent essay by Arvind Panagariya, Jagdish Bhagwati Professor of Indian Political Economy at Columbia University, makes in the Economic and Political Weekly. Of course, his analysis is rigorous, takes into consideration a few counter-arguments and seeks to make a case for the fact that we are certainly better off than sub Saharan Africa and our children only look smaller and thinner because of a flawed methodology.

His argument is that Indians look malnourished because of a measurement issue. Indians are smaller and hence comparing our children’s height and weight with an international yardstick that is used uniformly across the world doesn’t work for us.

Interpreted in simple language, it’s something like this: “We are like this only; let’s cut the cloth according to the coat. Let’s junk the WHO/UN standards - they are unscientific. Let’s have our own yardstick.”

And what do you achieve by doing that?

We can proudly tell the world that we are better than the sickly Sub-Saharan Africans in child malnutrition. Following his 14-page engaging essay, he continued his argument in an op-ed in Times of India as well.

But why take so much trouble to prove that we are better off than sub Saharan Africa? Do we gain anything at all other than perhaps feeling good?

Panagriya's main purpose seems to argue for a revised methodology for measuring child malnutrition, but he also makes a disturbing point on policy and allocation of resources. According to him, the present malnutrition estimates are likely to be excessive and perhaps more money is being allocated to counter it than, for instance, school education.

He also makes a point that “the common impression that India has not made much progress in child nutrition despite economic progress is false.”

The exercise, therefore, is not completely benign and in pursuit of science, but loaded in favour of government policies that include its withdrawal from vital social sectors.

It’s impossible to summarise Panagariya’s argument without losing its air of academic rigor. But for easy comprehension, this is more or less why he says: Indian children cannot be more stunted or underweight than the sub Saharan African children because every related vital indicator such as maternal mortality rate (MMR), infant mortality rate (IMR) and life expectancy in sub Saharan African countries are horribly worse than that in India.

When these indicators, which certainly decide the health of the children, are so much worse than ours, how can their children alone be better nourished than ours?

In other words, Sub-Saharan mothers are so unhealthy, children die in droves as they are born and before they are five years old, and the entire population die much before we die - but the children stay healthier than our children. How is it possible?

This paradox is the basis of Panagariya’s argument.

To be fair, he also discusses some of the possible counters to this intuitive enquiry.

But his paper doesn’t look into these two situations that can make the paradox eminently possible:

Survival of the fittest - the possibility of natural selection in Sub Saharan Africa: Our children are indeed malnourished, but our health systems ensure that they survive and live longer. Low birth weight is still a chronic problem for us, but even a sub-1000 gm. child survives because of our health infrastructure (mostly in better governed states).

On the other hand, in sub Saharan Africa, underweight children perish because of a lack of supporting health infrastructure leaving only healthy children to survive. The extremely poor maternal and child health as indicated by terrible MMR, IMR as well as life expectancy corroborates this possibility.

The possibility of children dying later because of illnesses such as diarrhea, malaria, acute respiration infections (ARI), tuberculosis and HIV: The gravity of the burden of these diseases is borne out by a single disease - 20 percent of all under-five mortality in Sub Saharan Africa is caused by diarrhea. The region also has a huge burden of the other diseases mentioned.

Therefore it is highly possible that a large number of children born to sick and unhealthy mothers (poor maternal health as indicated by MMR) die soon after birth (as indicated by extremely poor IMR) and only healthy children (born to healthy mothers) with good nourishment survive.

However, even those well nourished children, and those who survived death immediately after their birth, might die before the age of five because of the illnesses mentioned above (as indicted by very poor under-five mortality rate of children).

So, the summary is that it is highly possible that a good number of Sub Saharan African children, who survive to be measured, can indeed have better nutritional status than their average Indian counterparts. And they can look healthier than our children because they survived every possible adversity.

Panagariya goes at length to argue that standard WHO/UN global references of height and weight to measure malnutrition is not appropriate for our size and weight because of genetic and other factors.

Although desk-top formulations of international standards need to be scrutinised, particularly by multilateral institutions such as WB and IMF, the standard for malnourishment is based on the average weight and height of healthy children from Brazil, Ghana, India, Norway, Oman and the US. According to Panagariya, we are smaller even for the average measurements of children from these diverse countries, which include all regions, and India.

The issue is not about comparison - whether nutritionally our children look worse than the Sub Saharan African children or not, but about the absolute truth: that a large number of our children are malnourished.

According to the National Family Health Survey (NFHS-3), which Panagariya disagrees with, 47.9 per cent of our children are stunted (means they are too short for their age) and 43.5 per cent of our children are underweight (means they are too light for their age). Panagariya says the figures are bad because we use a reference that is too high for us and we should bring it down because we are diminutive.

Is Panagariya’s argument that we are genetically diminutive convincing? Author of Poor Economics, Harvard economist Esther Duflo, who says that the NFHS data is devastating, asks: “Why are the poorest in India so small? Indeed, why are all South Asians so scrawny?”

She goes on to argue that it could be the inter-generational nutritional deficit and impact because South Asian immigrants gain the same height and weight as that of the Caucasians after two generations of living in the West.

For argument’s sake, even if we agree with Panagariya and are willing to cut our figures by half, it’s still a national shame.

It’s not just these two nutritional measurements that make our children look crippled and unhealthy. About 23 percent of our children are wasted too. This is a measurement that compares weight for a given height and hence one cannot use the excuse of our small size for our children’s crippled look.

In fact, there is more to prove Panagariya wrong.

Look at the data on anaemia (NFHS-3): about 79 per cent of our children suffer from some form of anaemia, which is actually worse than the situation earlier (NFHS-2). Anemia prevalence is more than 70 percent in eight states. And even developmentally sparkling states such as Kerala, Goa, Manipur and Mizoram are not spared. Similarly our breast-feeding standards are very low.

Do we have to devise new standards for anemia measurements?

Now look at the nutritional status of women, which have a direct correlation with the health and nutrition of infants and children - more than one third of our women have a BMI (body mass index) of less than 18.5, the international minimum (again, this is a weight-to-height measurement and hence the excuse of our genetic scrawniness does not hold)

Among the malnourished women, about 44 percent are moderately or severely thin and nearly half the girls of 15-19 age group are undernourished. Of the undernourished, 42 per cent are uneducated and 56 per cent are anaemic.

So, what’s the story?

That these women are figure-conscious and don’t eat well? That our children are in fact healthy, but since we are scrawny and because our ancestors have been scrawny, our children may look scrawnier than the children of Sub Saharan African children?

Sometimes, one wonders what the purpose of scientific pursuit is - even if it is rigorous.

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