Asia | Nutrition in India
Of secrecy and stunting
The government withholds a report on nutrition that contains valuable lessons
Jul 4th 2015 | DELHI
A REMARKABLE story has been unfolding in the past decade in India. A new study—conducted by the government and the UN agency for children, Unicef—offers evidence of a steady and widespread fall in malnutrition. But the picture is still grim. Judged by measures such as the prevalence of "stunting" (when children are unusually short for their age) and "wasting" (when they weigh too little for their height), India is still vastly hungrier than Africa.
India's government has been sitting on the report for months, though it has been ready since at least October. One rumour suggests official concern about the quality of the data, but Unicef has voiced no such worry. Another possible reason is the pride of India's prime minister, Narendra Modi, who ruled Gujarat for a dozen years. The new data indicate his relatively prosperous state performed worse than many poorer ones. The Economist has obtained the report, known as the Rapid Survey on Children (RSOC). It shows gains at both national and state levels.
Much of what hitherto was known about nutrition in India came from the National Family Health Survey (NFHS) conducted by the government in 2005 and 2006. Work on a follow-up is under way. Unicef and the government agreed in the meantime to conduct the RSOC. It involved 210,000 interviews across 29 states and territories in 2013 and 2014; more than 90,000 children were measured and weighed, as well as 28,000 teenage girls.
Unicef's nutrition adviser for South Asia, Victor Aguayo, says India's overall gains have been "unprecedented". A decade ago 42.5% of all children under five were underweight. Now the reported rate is just below 30%. That improvement coincided with a period of rapid economic growth, rising household incomes and more spending on welfare such as free cooked midday-meals in schools. Madhya Pradesh in central India cut the proportion of its children who go hungry from 60% to 36%; Bihar in the north, from 56% to 37%.
The case of Maharashtra, a wealthy state on the western coast, is revealing. The proportion of children there who are underweight fell from 37% to 25%. Mr Aguayo cites Maharashtra as a "good example" of how to deal with malnutrition, identifying four crucial changes there: better and more frequent feeding of infants, more care for pregnant women, higher household incomes and a rise in the age at which women begin having babies. Officials and politicians in Maharashtra played a crucial role by helping to target worst-afflicted groups such as tribal people known as adivasis.
Other national trends follow similar patterns. The RSOC suggests that the proportion of children who are wasted fell from nearly 20% to 15%, and the stunting rate fell from 48% to nearly 39%. Yet still, more than half of children in Uttar Pradesh, a massive northern state, are below normal height. And amazingly, even among the wealthiest fifth of Indian households, more than a quarter of children are stunted. This may be because of sexism: mothers and girls get less food, health care and education than males. Over half of all girls aged 15-18 had a low body-mass index, meaning they were likelier to produce undernourished babies.
The RSOC highlights several failures. A deworming campaign has achieved little: not even 28% of under-fives had been given a recent dose. And though many women gave birth in institutions, fewer than half of babies were, as the WHO recommends, breastfed within an hour of birth.
India's age-old habit of defecating in the open—which distinguishes it from many other developing countries—makes matters worse. The proportion of Indians who do this has fallen from 55% a decade ago to 45%, but that is more than enough to help spread diseases, worms and other parasites that make it more difficult to absorb nutrients even when food is abundant. Poor public hygiene may account for much of India's failure to make faster improvements in nutrition. There is a clear correlation between open defecation and hunger (see chart).
Coincidentally or otherwise, states run in the past decade by Mr Modi's Bharatiya Janata Party (BJP) appear to be laggards compared with several states that are (or were) under the control of rivals. The most sensitive example is Gujarat, which Mr Modi has touted as a model because incomes there are high. The RSOC shows that the proportion of hungry children in the state fell from 44.6% to 33.5%, but that remains worse than the national average. Maharashtra next door has similar incomes and has fared much better. Gujarat is also worse than average for stunting (42%), severe stunting (18.5%) and wasting (18.7%). Nearly two-fifths of its population defecate out of doors.
India's malnourished children: Explore India in our interactive map
Asked about child malnutrition in Gujarat in 2012, Mr Modi told the Wall Street Journal that it was a middle-class, vegetarian state, and that: "The middle class is more beauty conscious than health conscious...If a mother tells her daughter to have milk, they'll have a fight. She'll tell her mother, 'I won't drink milk. I'll get fat.'" Some found that answer about as satisfying as a cardboard biryani. Amartya Sen, an economist and Nobel laureate, says Mr Modi does not provide strong leadership on health policy. He notes that spending on health care fell in this year's national budget. India devotes barely 1% of GDP to it, far behind China, for example.
In African countries, the proportion of children who are underweight is 21%—well below India's level. For India to match that, more states will have to act like Maharashtra. Growth alone is not enough. Politicians also need to help women and other vulnerable groups get the food, medicine and toilets they need.
This article appeared in the Asia section of the print edition under the headline "Of secrecy and stunting"
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