THERE is an ongoing transformation in India which would have been unthinkable only fifteen years ago. Before the era of mobile phones, outsourcing, and nuclear deals, India’s image – both abroad as well as in the eyes of Indians – was very much that of a developing country. The benefits of economic liberalization had yet to kick in, and our vast population was considered much more of a liability than an asset. The issue of malnutrition in the country – including starvation related deaths in some of the poorest parts – was reported far more often in the media.

In the intervening decade and a half, India’s image has undergone a sea change. It is seen by the world as a major emerging economy with a burgeoning middle class. More importantly, many Indians too now see the country and its place in the global pecking order differently. It has been several years now since talk of India being ready for a place at the world’s high table gained currency. This is corroborated by a newfound confidence in the country’s corporate sector, as well as among millions of young, empowered Indians. Moreover, an even vaster population is now considered to be a distinct advantage, its preponderance of the young often described as a demographic dividend in the making.

Yet, India today is home to 40% of the world’s malnourished children, and more than a third of the developing world’s low-birth weight infants. A little more than two years ago, I joined an advocacy group on malnutrition in India that is supported by Unicef and includes Bollywood and society personalities as well as members of parliament from across the political spectrum. The shocking statistics show that while the new India is surging ahead, it is leaving half the young population behind. The statistic that invariably grabs everyone’s attention, the one that clearly undermines the potential demographic dividend, is that almost one out of every two children in the country is malnourished!

Malnourishment is not just about hunger or the lack of access to calories – though, despite much progress over the decades, those remain serious concerns – but rather an overall lack of nutrients, which has far reaching consequences. This is particularly important to keep in mind when we sometimes bask in the glow of achievements like the green and white revolutions over the past few decades. Malnourishment stunts growth, negatively affects IQ, undermines the immune system, and generally has a viciously cascading effect on the lives of the poor and, particularly, females.

The reason malnourishment has a cascading effect is because it leaves its grim mark across generations. The problem starts with malnourished adolescent girls – again, by one measure, a shocking 80% of whom are affected in India! – and is compounded by early marriage and childbirth. Many Indians’ preference for having male offspring also extends to discriminatory attitudes towards the daughters they do have, with one common behaviour being step-motherly treatment at mealtimes. Millions of young brides, whose anaemic bodies are barely able to provide them a minimum level of sustenance and health, are then further stressed by societal compulsions to prove their fecundity by quickly having babies, preferably male, of course.

 

Thus millions of babies, both male and female, are born malnourished every year, and in circumstances which worsen rather than correct the problem. Due to both the malnourished condition of the mother, as well as cultural evolution that sacrifices proven traditional practices in favour of heavily marketed modern conveniences, the child often rapidly goes from bad to worse. A major example is the lack of reliance on breastfeeding. Decades of switching away from breastfeeding – due to both easy availability of baby formula as well as relentless marketing to make it the preferred option – has left its mark. Studies conclusively prove the vital contribution to a newborn’s immune system by being breastfed within an hour of birth, as well as being breastfed for the first six months.

The much vaunted demographic advantage – more than 50% of India’s population being less than 25 years old and a large percentage of the population being in their prime productive years – is a real window of opportunity for the next few decades, particularly when seen against the backdrop of many countries’ demographic burden. But it is an opportunity only if it is tapped quickly, which will require far greater investment in education, health and infrastructure than we have been used to. More urgent than any of these priorities, however, is to tackle the far more fundamental challenge of child malnutrition.

 

In terms of trends, child malnutrition in India is declining, but at a glacier’s pace. It is generally accepted that the single biggest contributor to malnutrition is poverty. What is less understandable is the slower reduction of malnutrition than of poverty. The World Bank calls this ‘A South Asian Enigma... While poverty is often the underlying cause of child malnutrition, the superior economic growth experienced by South Asian countries compared to those in Sub-Saharan Africa, has not translated into superior nutritional status for the South Asian child. Income inequality could help explain what average economic growth figures may conceal, yet inequality is not significantly worse in South Asia than in Africa.’

It may come as a surprise to many that South Asia in general, and India in particular, compares so unfavourably to Sub-Saharan Africa on this most basic of measures. Yet the data is clear. ‘Approximately a third of all children born in South Asia are of low birth weight (LBW) compared to 15% in Sub-Saharan Africa’, states the World Bank, and then touches on a crucial reason: ‘Evidence in South Asia indicates that women eat fewer meals per day than men, and eat last in their households. In India, about a third of the women are undernourished and about 56% are anemic.’ Other reasons it cites are infant and child feeding practices, poor household hygiene, and the financial and general status of women.

Three National Family Health Surveys (NFHS) have been conducted in India, in 1992-93, 1998-99, and 2005-06 under the aegis of the Ministry of Health and Family Welfare. NFHS-3 was funded by USAID, DFID, the Gates Foundation, UNICEF and UNFPA, with support from other agencies, and involved as many as eighteen research organizations for its fieldwork. While it indicates progress on some fronts, there remains much cause for despair. Take for example the statistics on women aged 20-24 who were married by the age of 18. The good news is that the overall national trend has been declining from 54% (1992-93) through 50% (1998-99) to 45% (2005-06). The bad news is that even as late as 2005-6, the figure for rural India was 53%. In other words, more than half of all girls in rural India are married by the age of 18.

 

The latest NFHS is full of both positive and negative nuggets. Like the positive trend in child immunization, but the negative trend in anaemia among children. Infant mortality has been steadily dropping; it is better than our neighbours Pakistan, Bangladesh and Nepal, but twice as bad as in China, and far worse than Sri Lanka. As a predictor of child malnourishment, the percentage of adults affected, particularly women, is of concern. If only low bodyweight is compared, there is hardly any difference by gender, with 34% men and 36% women being underweight. That is bad enough, but the dead giveaway is the stark difference in anaemia figures: in the age group of 15-49, a quarter of the men, but more than half the women are anemic.

 

The advocacy group I am a part of has visited several states, seen the grassroots reality firsthand, interacted with experts, met executive office holders at both national and state levels, and urged the media to cover malnutrition more vigorously. Some aspects of how this scourge is being handled are encouraging, others troubling.

What is encouraging is that while the nationwide decline in child malnutrition is slow – an overall reduction of only 1% between 1998-99 and 2005-06 – some states, including a couple of former laggards, have outstripped the national performance. These include Maharashtra, Orissa, Himachal Pradesh, Jammu and Kashmir, and Chhattisgarh, which have achieved the maximum reduction in child malnutrition during this period.

What is not encouraging is the number of other issues, major and minor, that malnutrition has to compete with to get the attention of opinion and decision-makers. The media is sometimes intrigued, but more often skeptical, of a group of Bollywood celebrities, politicians and activists, urging it to give malnutrition as much space as it does to page three or cricket. When it comes to decision-makers, there is recognition of the seriousness of the problem, and willingness to deal with it, but often an indirect acknowledgment of the limited time at their disposal to regularly go deep into the subject.

Over the past three decades, programmes like the mid-day meal schemes at schools, and the establishment of aanganwadi centres for infants and toddlers, have given a boost to tackling child malnutrition. The former in getting and keeping students at school and providing them at least one meal a day, and the latter in correcting early malnutrition as well as educating mothers about better nutritional and hygiene practices.

Both these huge, countrywide programmes are nevertheless handicapped by inadequate resources, but more importantly, by inconsistent implementation. If only throwing money at this problem could solve it, we may not be far away from a solution, with a rapidly growing economy, rising governmental revenues, and a willingness to spend more on the social sector. But clearly, it is going to take more than that. Increasing budgets will help, but much more will be required to overcome endemic problems like infrequent attendance of teachers, aanganwadi workers, and doctors at rural health centres, and the like.

 

Where more has been done is where more has been achieved. There seem to be some common features among the success stories that stand out among the states that have started improving faster: state governments being willing to benchmark their efforts with successful practices in other states, and being open to involving outside agencies and NGOs with cross-state and transnational experience. A particularly successful initiative that has been emulated across state borders involves overcoming the lack of indoor toilets. Going outdoors is fraught with risk, particularly for children, of infections leading to dysentery, dehydration and worse. While a governmental programme to build indoor toilets in villages is a long term effort, a simple interim alternative – teaching mothers to ensure that children wear slippers when going to the fields – has led to spectacular drops in infection, and thus malnutrition, rates.

Both the mid-day meal and the aanganwadi programmes have evolved over the years, now often involving the participation of NGOs and women’s Self Help Groups (SHGs). The informal feedback we could glean during our field visits was that NGOs often do a better job of running an outsourced school-meal programme than the government-run schools themselves – though not all NGOs and not always – and that local SHGs usually do even better. So why not just outsource these programmes in their entirety to NGOs and SHGs? That is easier said than done, for the availability and capability of NGOs and SHGs is not uniform. And in any case, a bigger bottleneck than the actual implementation may be the supply chain, in other words the notoriously creaky public distribution system (PDS).

In trying to improving the efficacy of these flagship programmes, there are fundamental policy choices that decision-makers have to grapple with. Two of the most highly debated are the issues of food fortification, and hot vs. packaged food. The former is the longer running discussion, with most experts weighing in favour of fortification, but a few with influence at the highest levels of government opposed. The latter raged brightly but briefly last summer in the national media, although shrill allegations of vested interests crowded out any semblance of a rational discussion.

 

Food fortification – the addition of nutrients to publicly distributed food in order to target specific malnourishment issues – remains a debate at the national level, with some influential voices against it. However, the preponderance of worldwide expert opinion seems to favour it, with several documented cases of successful implementation. Fortifying salt with iodine – the deficiency of which is directly linked to both goitre as well as lower IQ – is one of the best-known global examples.

Anaemia being one of the commonest forms of malnutrition in India, it is relevant to note the conclusions of a Canadian study on its economic impact. The paper notes that ‘there are two broad areas in which iron deficiency is considered to have important functional impacts on humans, where economic consequences can be estimated: cognitive ability of children, and work capacity of adults.’ It then goes on to stunningly conclude that ‘illustrative calculations for ten developing countries suggest that the median value of… annual total losses (physical and cognitive combined) are… 4.05% of GDP.’ That is more than half India’s current annual GDP growth rate, and it represents the estimated losses linked only with anaemia!

 

The irony of it all is that fortifying food with iron would likely cost only a few paise per child per month. The story repeats itself with other nutrients. Fortifying PDS food with a few key nutrients, like vitamin a and d, folic acid, and the like – each of them critical to some aspect of malnourishment – is a matter of adding slightly to the cost already being incurred.

While the national debate continues, a few states have decided to plunge ahead on their own. The most notable is Gujarat, which arguably has the most aggressive fortification programme in the country, involving fortifying a range of nutrients in a variety of food aimed particularly at children. While some critics claim that Gujarat’s statistics of malnutrition continue to remain as dire as elsewhere in the country, others argue that fortification programmes cannot be expected to yield instant results, and will need years before they can be evaluated.

The debate over hot vs. pre-packaged food erupted last year when allegations flew fast and furious that the Ministry of Women and Child Development was promoting the idea of prepackaged foods under pressure from private contractors who were keen to bid for contracts that would run into huge sums. Apart from a continuing deep suspicion about the involvement of private contractors, what characterized the mudslinging was a visceral resistance to the idea that locally cooked hot meals would be replaced with industrially packaged, cold and artificial food.

 

Sometimes, locally cooked meals work well. When local women’s SHGs take up the job to cook midday meals at schools, their members are often cooking for their own and their neighbours’ children, and obviously do it sincerely. There are now also several examples of large NGOs who have installed hygienic, district-level industrial kitchens, which provide freshly cooked and nutritious hot meals to millions of schoolchildren. But SHGs are often handicapped by their reliance on the PDS supply chain, and governmental payments, both of whose shortcomings lead to irregular midday meals in many states. Moreover, NGOs’ industrial kitchens are only successful to the extent that they can supplement the governments’ meagre payment for midday meals with large contributions from corporate donors.

While the idea of replacing hot meals with prepackaged food is not at all popular, perhaps there ought to be a few pilot projects to test a mix of both approaches, say an ongoing midday meal scheme to be supplemented (not replaced!) by the provision of nutrient/vitamin enriched biscuits once a week. However, these policy decisions are faced with numerous challenges, not the least of it being legal ones. There is a complicated legal environment around such issues, with an existing Supreme Court ruling banning private contractors from supplying food to aanganwadis, an order that has apparently already seen repeated violations by state governments. Again, while allegations are common that vested interests are behind this, it is hard to see how governments can entirely avoid outsourcing if they are to reach every child in every village.

 

Finally, a growing chorus of resentment against the country’s tardy progress on malnutrition might be breaking out of expert and intellectual circles and into the mainstream consciousness. The past year and a half of the worst global recession in decades, despite India’s claims of having mostly bucked the trend, has once again refocused attention on the bottom of the pyramid. Reports keep popping up even in the popular media to remind us that India still has a long way to go. For example, a just-released Unicef report points out that India has by far the world’s highest number of stunted children, 61 million, with the next highest being China with 12 million, and all other countries have far smaller numbers.

Democracy has given us many dividends. Yet it also clearly extracts a tax from us that goes far beyond what we pay in immediate financial terms. As Indians, we all pay, but particularly the poor, in terms of the years and decades lost, not to mention the hundreds of millions of lives. It took us decades of post-colonial diffidence before we could bring ourselves to take the steps that finally put behind us the low-economic growth rates that were derisively called the ‘Hindu rate of growth’. India’s economic growth rate today, despite being slowed down by anaemia and the like, is the envy of the world. The equivalent challenge at the end of the 21st century’s first decade is to bring about the systemic changes needed to achieve the same kind of rapid improvement in malnutrition.