Why India remains malnourished

Despite a fast-growing economy and the largest anti-malnutrition programme, India has the world’s worst level of child malnutrition. The government plans to pump in Rs 1,23,580 crore over the next five years to tackle the problem. Jyotsna Singh travels to highly malnourished districts in Madhya Pradesh and Rajasthan, while Kundan Pandey quizzes experts across the globe to unravel the enigma

Photo: Reuters
Two-and-a-half-year-old Rabina weighs 6.5 kg. A healthy child of her age should weigh at least 8 kg. But Rabina could not escape the curse of being born in Shivpuri district of Madhya Pradesh—ill-famed as one of the highly malnourished districts of the country for the past 30 years.
Rabina was not always so. At birth, she was healthy and weighed just right—a little more than 2.5 kg. But something went wrong and she did not grow at a healthy pace. At nine months, the anganwadi worker of her tribal-dominated village Udvaya declared her severely acute malnourished, a condition that could stunt her physical growth and cognitive development forever. She referred Rabina to the Nutrition Rehabilitation Centre (NRC), some 20 km away. Doctors there put her through intense nutrition supplement for a fortnight and managed to bring her out of the malnourished state. But back home, in the absence of a regular healthy diet, her condition worsened again. She is now categorised as chronically malnourished in the anganwadi worker’s register.
Shivpuri has 11,392 severely acute malnourished children, show the district administration’s records of 2012. But very few—2,629 in 2012—get admitted to NRCs. Of those admitted, less than a quarter are nursed back to health. Shivpuri’s Sahariya tribals, once known for their lion-like physical strength and often made to fight wild animals in the king’s courtyard for entertainment, are now fighting a losing battle against malnutrition. “I do not remember any child from my generation or previous generations being so thin or unable to perform daily chores due to lack of energy,” says Ram Avatar, resident of Udvaya, as he wonders what ails the children of his community.

MEASUREMENT EFFORTS WORLDWIDE

1970s: Countries do not have measures for malnutrition. Towards the late 1970s, the National Centre for Health Statistics (NCHS) of the US develops a standard for monitoring child growth. WHO adopts this and recommends it to other countries for measuring malnutrition among children
1980s: The NCHS measure runs into controversy. Experts complain that breastfed infants grow taller than the standard set by NCHS
1990s: WHO’s Department of Nutrition sets up a working group to assess the growth pattern of breastfed infants. Its report published in 1994 highlights a number of problems with the NCHS standard. WHO begins work for a new measure. Experts propose that the standard should suggest “how children should grow” instead of “how children are growing”
2000s: WHO begins survey in six countries, including developed, developing and under-developing economies. In 2006 it publishes its new growth reference. All countries adopt the model the same year

More than 100 districts in the country share the fate of Shivpuri, making India home to the largest number of malnourished children. In the absence of latest government figures, estimates by the National Family Health Survey (NFHS) in 2006 show that 48 per cent, or 61 million, under-five children in the country are stunted (they have low height for their age); 43 per cent, or 53 million, are underweight; and nearly 20 per cent, or 25 million, are wasted (low weight for height).

Archana Kumari, 22, lives in a slum in South Delhi. She is pregnant for the third time in six years and is anaemic. Both her children are malnourished (Photographs: Chinky Shukla) Of the 25 million wasted children, eight million are severely wasted or suffer from severe acute malnutrition like Rabina. India is home to one-third such children. Sixty per cent of them live in six states: Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, Maharashtra and Tamil Nadu.
Such high prevalence of child malnutrition in India defies logic. After all, the country’s economy has doubled since 1991, when the government started counting the malnourished children. The world’s largest programme to tackle child malnutrition, the Integrated Child Development Services (ICDS), has been in force in the country since 1975, much before any country, other than the US, introduced measures to tackle the problem.
All the states with a high burden of malnutrition have the public distribution system in place to ensure that the poor, even in inaccessible areas, get food grains at subsidised rates. Yet, reports regularly appear both within and outside the country, highlighting child deaths due to malnutrition.
According to the Registrar General of India, in 2010, under-five mortality in India was 59 per 1,000 live births, one of the highest in the world. In 2012, British non-profit Save the Children reported that 1.83 million Indian children die every year before they turn five and pinned malnutrition as the key reason for the deaths.
“The child may eventually die of a disease, but that disease was lethal because the child was unable to fight back due to malnutrition,” Victor Aguayo, chief of Child Nutrition and Development at Unicef-India, told the media in New Delhi recently.
All surveys indicate that India is slipping into a vicious cycle of malnutrition. Scientists say the initial 1,000 days of an individual’s lifespan, from the day of conception till he or she turns two, is crucial for physical and cognitive development. But more than half the women of childbearing age are anaemic and 33 per cent are undernourished, according to NFHS 2006. A malnourished mother is more likely to give birth to malnourished children.
The HUNGaMA (Hunger and Malnutrition) Survey across 112 rural districts in 2011 by non-profit Naandi Foundation shows the impact of the world’s oldest anti-malnutrition programme. Eighty per cent of the mothers have not heard the word malnutrition in their local language, says the report.
It seems India is all set to miss one of its key Millennium Development Goals: halving malnutrition by 2015. This is the reason past few months have witnessed a flurry of high-profile public statements and programme decisions to fight malnutrition. In September, Parliament passed the National Food Security Act, which aims at fighting malnutrition by tackling food insecurity. The following month, the Centre declared that NFHS will resume after a gap of seven years. It will begin in February 2014. In 2012, the 12th Five-Year Plan restructured the ICDS scheme immediately after Prime Minister Manmohan Singh termed malnutrition as a “national shame”. The scheme will provide supplementary nutrition, pre-school education, health and immunisation to children under the age of six in 200 high-burden districts by the end of the year by setting up more anganwadi centres. So far, ICDS was catering to the needs of children in the age group of three to six, leaving out the crucial under-three children. By the next year, when the scheme will be expanded to cover the entire country, its scope can be compared with the polio eradication campaign. The Centre has allocated a whopping Rs 1,23,580 crore for the scheme. This is almost thrice the budget allocated to ICDS in the previous Plan period. The government hopes this will help bring down malnutrition among under-three children by 10 per cent and among girls and women by 20 per cent.
But are these measures sufficient to tackle the menace? In popular perception, poverty is synonymous with malnutrition. Reports show a major chunk of malnourished children belong to poor families and traditionally poor states. But rates of malnutrition are also significant among middle- and high-income families.
As the stage is set for onslaught of malnutrition, it is time to critically look at the not-so-obvious reasons for its high prevalence in the country.
Confused over measurement
Analysts say WHO formula is not a standard to measure malnutrition, but a reference
“Malnutrition is not the result of a single problem,” says Umesh Kapil, professor of human nutrition at the All India Institute of Medical Sciences, Delhi. “There are 15 to 20 issues (literacy level, clean drinking water and sanitation, for example) that contribute to the problem,” he adds.
Consider this. Malnutrition is more common in India than in sub-Saharan African countries where per capita income is much lower than that of India. According to Yogesh Jain of Jan Swasthya Sahyog, a non-profit in Chhattisgarh, close to 69 per cent of Indians earns less than US $2 a day. People in half of sub-Sahara Africa subsist with this much earning. This discrepancy has sparked a debate over WHO’s formula, which is usually has been used by countries, including India, to measure malnutrition since 2006.
In May this year, a research paper published in the journal Economic and Political Weekly questioned the applicability of the WHO standard to India. The paper by Arvind Panagariya, economist at Columbia University, US, argued that despite progress in other social indicators India lagged in reducing malnutrition. He attributed this to the WHO formula and called it faulty (see ‘WHO’s standard’).

WHO’S STANDARD

It is based on children from well-off background
In 2006, the world adopted a growth standard developed by WHO to measure malnutrition. These standards were prepared after measuring the growth of 8,500 children from six countries—Brazil, Ghana, India, Norway, Oman and the United States—for two years. Selection of the children was made on the following conditions:

Good economic condition of parents
Access to safe drinking water and sanitation
Low mobility of mother so that children receive regular care
Mothers adhering to breast feeding and other recommended diet patterns
Access to nearby hospitals and total immunisation
Use of micronutrient supplements
One of the parents must have 17 years of education
Mother must be non-smoker

In India, the sample was drawn from 58 affluent families in South Delhi, a plush area of the capital city. In the late 1990s, WHO conducted two surveys of the region to identify 1,000 pregnant women from 111,084 households. WHO officials monitored the growth of their children for close to two years.
At the global level, the survey began with the enrollment of the first newborn in Pelotas, Brazil, on July 1, 1997, and ended in November 2003.
During the survey, WHO officials measured height, weight, and circumference of the head and the mid-upper arm is proportion to the age of under-five children. Based on the survey findings, WHO created the growth chart.
Though these standards show how a child is growing, countries use it as a standard to check malnutrition. Countries measure the growth of children against this WHO chart to identify if a child is malnourished. A child is categorised as underweight (low weight for age or less than 2.5 kg at birth), wasted (low weight for height) and stunted (low height for age). Stunting is an indicator of chronic under nutrition, especially protein-energy malnutrition, and is caused due to prolonged food deprivation and/or disease or illness. Wasting is an indicator of acute under nutrition and is the result of more recent food deprivation or illness. Underweight is used as a composite indicator to reflect both acute and chronic under nutrition.

The formula uses height and weight as yardsticks to measure the growth of a child. Panagariya argued that the height of an individual can vary depending on the nutrition status as well as genetic makeup. For instance, Indians are not genetically programmed to be as tall as WHO expects. But the WHO formula does not take this disparity into account.
A senior official with the Department of Health informed Down To Earth that the government plans to use the WHO formula to estimate the number of malnourished children in the latest round of NFHS, beginning 2014. But medical and community health experts are already divided over its accuracy.
Some say the WHO growth chart, prepared using the formula, is just a reference and hence should not be used as a standard to measure malnutrition. “It tells us the perfect size of children from well-off background, like those born to educated parents and have access to nutritious food, sanitation and medical facilities. It shows how a child should grow in an ideal situation,” says H P S Sachdev, former national president of Indian Academy of Paediatrics.
“India is a vast country with individuals belonging to many ethnic groups. In certain communities, people are of short stature. This does not mean they are malnourished,” says Kapil (see ‘WHO’s to blame’, Down To Earth, October 1-15, 2013) Use of the WHO growth chart as a standard to decide malnutrition level has led to confusion among the ground-level health workers.
At the village level, an anganwadi worker is the first to identify a malnourished child. She registers every birth in her area and monitors the child’s growth at regular intervals. While the WHO formula uses three measures of physical growth—age, weight and height—to judge nutritional status of a child, anganwadi workers usually prepare the growth chart based on weight alone (see ‘Data interrupted’). If a child is detected underweight, which is a measure of malnourishment, the anganwadi worker refers him or her to NRC for intensive nutrition treatment.

DATA INTERRUPTED

1.4 million poorly trained anganwadi workers collect malnutrition data in rural India. Error creeps in here
STEP-I: Anganwadi workers measure weight of the child
REALITY

49% of under-six children are registered for Integrated Child Development Services (ICDS) benefits and go to anganwadi centres. Anganwadi workers monitor weight of only these children

STEP-II: They must check all indicators of growth to get the right sense of malnutrition
REALITY

Anganwadi workers are not trained enough to measure all indicators—weight, height and age—and estimate malnutrition through calculations
Scarcity of equipment like weighing machines and teaching aids in 82 per cent of anganwadi centres

STEP-III: Anganwadi workers refer malnourished children to Nutrition Rehabilitation Centre (NRC)
REALITY

Anganwadi workers measure underweight while NRC measures wasting. This leads to discrepancy in data. Many children are refused admission, thus losing out on the window of opportunity during their first 1,000 days of life, crucial for physical and mental growth
Those who receive treatment need to visit NRC after every fortnight for two months follow-up treatment. Parents usually do not agree

STEP-IV: Supervisor collates data from 100-200 anganwadi centres
REALITY

Due to lack of skills of anganwadi workers, the supervisor does the final data entry. If she finds any inappropriate entry, she corrects it herself, usually without consulting the anganwadi workers. This is where massive data mismatch takes place. As the data moves to state government and then to the Centre, there is no way it can be fixed Source: Planning Commission evaluation report, ICDS

NRCs have different criteria for accepting a child as malnourished. Since they do not have the list of age for each child, they categorise children for wasting, which is measured based on height and weight. This is where discrepancies in measurement creep in, and many a time NRCs send back children referred by anganwadis for rehabilitation. “The problem is that we see malnutrition as a disease. The health department cannot cure it. It is a community issue and people should be given proper food,” an official from the department told Down To Earth. NRCs fall under the health department.
An easier way to avoid these discrepancies is to follow another WHO measurement: the mid-upper arm circumference (MUAC) of a child. A child whose MUAC is less than 115 mm is considered severely acute malnourished, those with 115-125 mm of MUAC are moderately acute malnourished and those with more than 125 mm of MUAC are considered normal. However, this measurement is yet to gain momentum. Few anganwadi workers know about it and even fewer have the skill to measure MUAC properly. One has to first calculate and mark the mid-point of the arm after measuring the arm length; MUAC is determined at this mid-point.
“Our anganwadi workers are not well-literate and their skill is limited. They find it is easier to keep track of a child’s growth by weighing them rather than following other measurements,” says Upasana Rai, district programme officer, Department for Women and Child Development (DWCD), Shivpuri. DWCD supervises anganwadis.

With this confusion and inability to cope with measurement procedures, India’s data on malnutrition may not be accurate. ICDS records as of March 2012 show 62.8 per cent under-six children who were weighed at anganwadi centres were normal. Rest of the 37.2 per cent children were underweight or malnourished. This is almost 10 per cent dip from the estimates by NFHS 2006. The 2011 HUNGaMA report also states a reduction in malnutrition. It found that 42 per cent of under-five children are underweight and 59 per cent are stunted. But no one can say for sure whether the number of malnourished children has increased or decreased since 2006 NFHS survey.
But there are arguments that favour the WHO formula. “The reference was prepared considering all kinds of people including the poor. The standard says even children in poor countries grow similar if they get similar opportunity,” says David Sanders, Emeritus Professor, School of Public Health at University of Western Cape in South Africa. He is also known as the founder of the People’s Health Movement. Arun Gupta, member of the Prime Minister’s Council on India’s Nutrition Challenges, says, “It does not matter which formula one uses to determine the number of malnourished children. We shall have to solve the problem anyway.”
The debate over measurement of malnutrition ignores some of the crucial determinants of childhood health. In the 1990s, these not-so-obvious determinants had prompted V Ramalingaswami, former National Research Professor of India, to term malnutrition as “Asian enigma” . Three decades later, none of the countries are anywhere near to solving the riddle.
Sanitation, a missing link?
Evidence shows malnutrition is high in areas where people defecate in the open

75% of India’s surface water is polluted by human and agricultural waste and industrial effluents. Reports say lack of sanitation is the key reason for child malnutrition
One missing piece of the malnutrition puzzle is social inequality. For example, girl children are more likely to be malnourished than boys, and low-caste children than upper-caste children.
But the most important aspect is sanitation. Most children in rural areas and urban slums are constantly exposed to germs from their neighbours’ faeces. This makes them vulnerable to the kinds of chronic intestinal diseases that prevent bodies from making good use of nutrients in food, and they become malnourished.

According to the Planning Commission’s evaluation report of the Total Sanitation Campaign, close to 72 per cent people in the country’s rural areas still defecate in the open (see ‘Uncomfortable facts’). Every day, an estimated 100,000 tonnes of human excreta are left unguarded along river and stream banks, in open fields, on road sides and farms to contaminate water sources. According to Unicef, each gram of human excreta contains 10 million viruses, one million bacteria, 1,000 parasite cysts and 100 parasite eggs. Given the high population density in the country, this is sufficient to trigger widespread diseases. Children are more susceptible to such diseases.
A visit to Dholpur district of Rajasthan shows how government efforts to provide health and nutritional care to children through ICDS and anganwadi centres have failed due to lack of sanitation. Dholpur is one of India’s highly malnourished districts. Close to 80 per cent of people here defecate in the open. In Sakhwara village of Dholpur, an open drain, carrying human faeces, passes right through the village. Children and expectant mothers cross the drain on foot to reach the anganwadi. “Diarrhoea and pneumonia have always been part of our lives,” says Bhanmati Pitaka, an elderly woman of the village. “Every monsoon at least five to six children suffer from the diseases in the village.” She claims that the village always had thin children.
Lack of sanitation and clean drinking water are the reasons high levels of malnutrition persists in India despite improvement in food availability, says Joe Mediath of Gram Vikash, a non-profit that works on sanitation in India and Africa.
A few recent reports also provide evidence that lack of sanitation could be the key reason for high malnutrition.
A research paper published in science journal PloS One in September this year concludes that lack of sanitation is a potential contributor to stunting in India. The study was done by Dean Spears of Delhi School of Economics along with Arabinda Ghosh, an Indian Administrative Service official, and Oliver Cumming of the London School of Hygiene and Tropical Medicine. The researchers analysed recently published data on the levels of malnutrition and open defecation in 112 rural districts. They found that 10 per cent increase in open defecation resulted in 0.7 per cent increase in both stunting and severe stunting. “The early-life disease environment is poor: over 70 per cent of households defecate in the open and 71 out of every 1,000 babies born alive die before they turn one,” states the report. The researchers point out another missing piece of the malnutrition puzzle: two-thirds of all adults are literate in this region.
In 1999 when the Centre launched Total Sanitation Campaign, its aim was to eradicate the practice of open defecation by 2017. Under the campaign, the government had to provide toilet facilities to schools and anganwadi centres by 2009 and to rural households by 2012. But the Planning Commission report states that the campaign is yet to achieve the targets.
Today, India lags behind sub-Saharan Africa in terms of sanitation practices. About 56 per cent people defecate in the open across the country, including rural and urban areas. In sub-Saharan Africa, only 25 per cent the people defecated in the open in 2010, according to the Unicef and WHO. Recent health surveys in the largest three sub-Saharan countries show that 31.1 per cent households in Nigeria, 38.3 households in Ethiopia and 12.1 per cent households in the Democratic Republic of Congo defecate in the open. “This difference in sanitation practices between India and African countries explains the difference in malnutrition rate,” says Joe.
Even in India, good sanitation practices have helped curb malnutrition. Ahmednagar district of Maharashtra is one such example. In 2004 the government successfully implemented the Total Sanitation Campaign in half of the 60 villages in the district. Following this, open defecation stopped in these villages. A few years later, Spears and his fellow economist Jeff Hammer, who were monitoring the health of an experimental group in these villages, found that the average height of children had increased by about one centimetre compared to that of children in nearby 30 villages where the campaign was not introduced.
The latest survey by the National Nutrition Monitoring Bureau (NNMB), which conducts surveys in rural and tribal areas to find out nutritional status of people, also brings out this aspect. NNMB found that malnutrition level among children reduced over a period of time despite less intake of food. “The improvement in nutritional status could be due to non-nutritional factors, such as improved accessibility to health care facilities, sanitation and protected water supply,” the report notes.
The government should take note of such findings while implementing its anti-malnutrition programme.