The latest edition of the Global Nutrition Report 2015 by the International Food Policy Research Institute, released on Tuesday, brings back the concerns over malnutrition into sharp focus. In July, the government of India, after much avoidable controversy, released malnutrition (used synonymously as undernutrition) figures from the Rapid Survey on Children (RSoC) data that was collected in 2013-14. This dataset was keenly awaited as it provides a nationwide assessment after the third round of the National Family Health Survey (NFHS-3), which is nearly a decade old now. The RSoC data also assumes significance as the world adopts the Sustainable Development Goals. Goal 2.2 seeks to end all forms of malnutrition by 2030, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under five years of age.
The RSoC was conducted by the ministry of women and child development with technical support from Unicef. It found 29.4 per cent of children (aged less than three years) to be underweight (low in weight for their age), while 15 per cent were wasted (low weight for their height) and 38.7 per cent were stunted (low in height for age). On the face of it, this compares well with the NFHS-3 data, in which the corresponding figures were 40.4 per cent (underweight), 22.9 per cent (wasted) and 44.9 per cent (stunted). But in absolute terms, the current levels of underweight and stunted children are abysmally high and former Prime Minister Manmohan Singh’s assertion
that malnutrition is a “national shame” is still valid.
A civil society collective appealed to policymakers in a press release on July 23 to “declare malnutrition as a medical emergency to save India’s children dying of hunger”. The Union minister for tribal affairs on August 4 said that his ministry “will collaborate with Ramdev and Balkrishna to identify and document medicinal herbs helpful in the treatment [emphasis added] of malnutrition”. But ready-to-use therapeutic food was introduced as a “treatment” to combat this medical emergency nearly two decades back.
The moot question is: can malnutrition be “treated”? Current mainstream global notions draw upon African experiences, where severe acute malnutrition (SAM) has been triggered by acute crises, such as drought, crop failure and civil wars. Classical SAM is a medical emergency, carries with it a high risk of mortality, and requires not just therapeutic feeding but other medical inputs. This global wisdom was bought off-the-shelf by national experts and Indian strategies and guidelines continue to be largely clinical, essentially seeking to treat malnutrition.
The predominant form of malnutrition in India is significantly different from classical SAM and standardised protocols for treatment are not as effective in the Indian context, where longer durations are required for achieving targeted weight gains. This is on account of the high levels of underlying stunting. Stunting signifies chronic undernutrition and has no scope for “cure” in a therapeutic mode. Its levels in India are higher than in Africa, and exceedingly so among chronically poor populations. Severe chronic malnutrition (SCM) in children is characterised by stunted growth and is a potentially less serious but continual form of malnutrition. SCM is generally an outcome of latent poverty, chronic food insecurity, poor feeding practices and protracted morbidities, but rarely a direct cause of mortality. In short, stunted children are hungry but not sick.
Chronic malnutrition requires a far wider spectrum of programmatic interventions beyond clinical management. Multi-sectoral actions are needed to combat multi-dimensional deprivations. Simultaneously, there is an urgent need for promoting practices to improve the quality of local diets, improving child-feeding practices, reducing exposure to illnesses, and paediatric care services. This would need a broad-based commitment of resources as well as the creation and nurturing of local capacities and leaderships.
Despite recent gains, malnutrition continues to be a national emergency; though not a medical one. The National Nutrition Mission (a multi-sectoral programme earmarked for 200 high-burden districts) has not taken off in any meaningful manner. The penchant for a magic bullet to treat and cure malnutrition draws attention away from the Indian epidemiological reality. Policymakers and opinion leaders are increasingly impatient with the tardy progress of the current set of interventions. The way forward requires a reorientation of Indian research to inform policy and practice and change the current tenor of policy discussions. The Make in India call should apply no less to research and practice.
The writer is professor and chairperson, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, Delhi