Amartya Sen and Jean Dreze wrote in Hunger and Public Action in 1989 that nearly four million people die every year in India from malnutrition and related causes, a number and that “is more than the number that has perished during the entire Bengal famine.” The recent “HUNGaMA” report and the activities of the Citizen's Alliance Against Malnutrition have brought renewed attention to this issue. This report from 112 districts over nine States tells us that 42 per cent of children are underweight and 58 per cent are stunted by the age of 24 months.
In addition to greatly increasing the chances of infant death, child malnutrition has other devastating consequences. Research has established that the damage that begins in the womb and during the first two years of life is irreversible, leading to reduced intelligence and physical capacity. Malnutrition thus has a direct impact on productivity and economic growth. It is also clear that the consequences of malnutrition transcend generations, as stunted mothers are likely to have underweight children.
The solutions to ending malnutrition are not complicated. What is necessary to be done is known and has been achieved in parts of our own country. What is needed are the will and the determination to make this happen.
Why is child malnutrition still so high in India?
The seriousness of the problem is still largely invisible to the families and communities that experience them. This inadequate recognition of the human and economic costs of malnutrition by families, communities and governments is an important reason for the inertia in solving this problem.
Equally important is the fact that adequate nutrition is not seen as a human right and the malnourished have little voice in determining the directions of policy.
There are also problems related to how we deal with malnutrition currently. There are many stakeholders and several agencies that work on the issue. Perhaps there is inadequate consensus on what needs to be done. Politicians and senior officials do not give programmes addressing malnourishment the priority they deserve. There is a tendency to keep repeating programmes that have not resulted in tangible improvements.
There are also some myths that need to be demolished before significant progress can be made. The first is that malnutrition is about inadequate food intake. Many children in food-secure environments are underweight or stunted because of inappropriate infant feeding and care practices, poor access to health services, or poor sanitation. The second myth is that improved nutrition only comes with economic progress and poverty reduction.
Both myths are disproved by experience in parts of India and from other countries. Bangladesh, for instance, is a country with a per capita GNI almost half of India. However, Bangladesh has succeeded in reducing infant mortality, under-five mortality and stunting to rates that are lower than those we have in India in the course of less than 10 years.
What needs to be done?
The experience from all over the world is that food alone does not ensure better nutrition. A range of other interventions is necessary to ensure the health and nutrition of mothers and children.
Following a “life cycle” approach, these should begin with the health of the woman before the pregnancy begins and address all the critical stages of the birth and development of the baby. All these are well known and part of the routine of care in health centres and the Integrated Child Development Centres in the country. In addition, hand washing with soap, use of household filters for purification of water and use of sanitary latrines will ensure the continued good health of the baby and the mother.
A 2006 World Bank publication, “Repositioning Nutrition as Central to Development” evaluates the benefit to cost ratios of some of these interventions. These range from between five to 67 for breast feeding programmes, 15 to 520 for iodine supplementation programmes for women and 176 to 200 for iron fortification per capita. Thus, it is no surprise that the Copenhagen Consensus rated nutrition interventions among the top 17 potential development investments in 2008, outranking others including trade liberalisation.
To make lasting improvements, interventions should go beyond the direct causes of malnutrition, diet and disease burden. Levels of economic development, governance structures including the political will necessary to address this issue, the agriculture and food security situation and women's power in decision-making all influence levels of malnutrition. However, there is no good reason to wait for changes to happen at all these levels before starting to improve infant feeding, sanitation, clean water, and affordable and accessible health services.
What can we do differently?
Integrated Child Development Services (ICDS), the National Rural Health Mission and the Total Sanitation Campaign are some of the major programmes of the government that address the issues relating to child malnutrition. While these programmes each have enormous potential for doing good, the combined efforts of all of them with the power of engagement with the communities who need the help most is the need of the day.
It is essential to ensure that the families and communities know what is at stake. We have experience with Participative Rapid Appraisals and such approaches where the community is part of the planning and execution of development programmes. We need a grass-roots level approach that works with communities in this manner, with a coordinated programme that brings the mainstream interventions to bear upon identified problems.
There is a need for evolving strategies separately for urban and rural areas. Local government agencies — Panchayats and municipalities and other stakeholders like women's groups, NGOs, academic institutions with expertise and interest in nutrition and health need to be a part of this effort. It is necessary that such an effort operates at a sufficiently decentralised level in order that it does not get bogged down in bureaucracy and procedures.
Three key elements should be kept in mind to make such an approach successful. These are Coordination, Convergence and Monitoring. The need for effective coordination and convergence is self-evident. However the potential for monitoring performance much more efficiently by harnessing the power of modern technology is not always realised. SMS on cell phones can provide instant updates, replacing slow paper based reporting forms. Colour coded GIS maps can pinpoint the situation on the ground, down to the nutritional status of individual children in ICDS centres, ensuring the possibilities of rapid responses.
The crucial period for the mother and the child is the period of pregnancy and the first two years of life of the child. This is also the window of opportunity to bring these interventions together in a way that the foundations of good health and nutrition are laid once and for all. It is therefore suggested that decentralised interventions at the district, sub-district, and municipal or urban ward levels be launched to cover these vital “thousand days” that can finally give us the success we seek.
The bulk of infant deaths occur in the neo-natal period of about a month after birth. Neonatology and peri-natal care have made considerable advances and if we can ensure that all health facilities handling deliveries are fully equipped and staffed by trained personnel we can bring about a sharp decline in infant deaths.
What is suggested is possible to be achieved now. It is based on experience in our own country. It is in line with the National Nutritional Council's recommendation for accelerated multi-sectoral action in 200 high burden districts. What we cannot afford is to wait any longer. We cannot anymore accept the shame of standing by when more than half the children of our country are stunted by the age of two.
( The author is a retired civil servant who has worked with UNICEF in several countries .)
