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Why childhood under-nutrition persists in India — and how to intervene

Recently,Prime Minister Manmohan Singh released a survey on child under-nutrition in rural India in 2010-11 (Hunger and Malnutrition Survey,HUNGaMA).

Recently,Prime Minister Manmohan Singh released a survey on child under-nutrition in rural India in 2010-11 (Hunger and Malnutrition Survey,HUNGaMA). Sadly,the new data reinforced the existence of an India marked by substantially low levels of something absolutely vital for adequate human development. The survey found that 42 per cent of the under-five children were underweight and 59 per cent were stunted in the 100 focus districts. Remarkably,in six districts with the best child development index,the prevalence of underweight (33 per cent) and stunting (43 per cent) among children,while somewhat lower,was still substantially high — suggesting the endemic and persistent nature of the under-nutrition burden. Even though child under-nutrition remains very high,do the data from HUNGaMA suggest an improvement over previous assessments? Data from the district-level health survey (DLHS) of 2002-2004 provide some answers. The DLHS includes data on underweight among children under six from hundreds of districts across India. In the 100 focus districts,the prevalence of underweight appeared to have reduced 11 percentage points from 53 per cent in the DLHS to 42 per cent in the HUNGaMA Survey. A similar comparison of changes in the prevalence of stunting is not possible since DLHS did not measure the height of children. Other aspects of the results from the HUNGaMA survey reiterate older patterns. For instance,under-nutrition is inversely associated with socio-economic status; thus children from low income households or whose mother had low levels of education have higher prevalence of under-nutrition.

The HUNGaMA report appears to emphasise the gender differences in under-nutrition even though the magnitude of these differences may not necessarily warrant an urgent attention. For instance,the gender differences in the focus districts are 0.4 percentage points (41.4 per cent in girls versus 41.0 per cent in boys) for underweight,0.5 percentage points for stunting. Similar figures from NFHS-3 are: 1.2 percentage points for underweight,and 0.1 percentage points for stunting. When examined separately by age group,the biggest gender differences in the focus districts are observed with stunting. Girls,compared to boys,enjoy a 6.4 unit advantage between 0-5 months of age,which reduces to a 2-unit advantage in the 6-35 month group and flips to a 1.3 unit disadvantage in the 36-59 month age group. Since stunting is particularly reflective of nutritional circumstances in the first three years of life,one should be cautious interpreting this as a gender disadvantage.

In summary,the report brings out quite clearly that not only does child under-nutrition remains substantially high,collective progress towards reducing it remains extremely slow. Why? Much of the current explanations to answering this question include: nutritional interventions starting at a much older age than necessary,inefficiencies and ineffective delivery of nutritional interventions,inadequate solutions to the problem of food insecurity,low levels of mother’s educational status and overall low socio-economic status,poor environmental conditions exposing children to infections,inadequate access and availability of primary health care counselling and services (for example,immunisation). In short,all these explanations focus on the post-natal (after the child is born) conditions.

While these are important,and indeed more amenable to immediate policy interventions,we posit that in order for India to reduce child under-nutrition attention will have to be focused around pre-natal conditions,and inter-generational influences on child under-nutrition. Recent research on this issue has conclusively suggested that,regardless of a mother’s educational level,household income or other post-natal environmental factors,a strong and consistent determinant of childhood under-nutrition is maternal and paternal attained height. Height attained by adulthood is considered a useful marker of the accumulated health stock of an individual,starting from early childhood to adolescence,and is extremely sensitive to early life conditions. What this research suggests is that children born to mothers (and fathers) who are primarily not in good health,independent of what their external circumstances are after the child is born,will be at a greater risk of being undernourished. After all,according to the latest NFHS-3 data,36 per cent of mothers are undernourished,11 per cent are less than 145 cm tall and 55 per cent are anaemic. The father’s profile is not considerably different. This intergenerational inertia of poor health is likely to slow down any progress towards reducing child under-nutrition,and is somewhat borne out in the HUNGaMA survey data. For instance,in the six best districts from the focus states underweight declined from 39.5 to 21.9. In the six best districts from best states it declined from 34.8 to 32.6. So even in the best possible scenario the reduction in child under-nutrition is not remarkably different from the reductions observed in the “worst” districts,thus lending some support to the inter-generational inertia to reducing child under-nutrition in India.

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This requires a change in our approaches to tackling under-nutrition. For instance,there is an urgent need to focus on age groups (for example,adolescent girls) for health interventions that have inter-generational payoffs. Intervening during the stage of pregnancy and post-partum is too late to break the vicious link of poor health transferring from one generation to another. In addition,there is an immediate need to move away from the conventional wisdom that economic growth will (directly or indirectly) eventually reduce child under-nutrition. The scientific evidence clearly shows no association between increments in economic growth in India and reductions in child under-nutrition,thus suggesting that direct health investments at the right time are necessary. In summary,India appears to have made substantial progress in reducing infant mortality over time. It is now time to move beyond the survival agenda to a growth agenda where the goal is not only to save the child but ensure healthy growth and development.

S.V. Subramanian is professor of population health and geography,Harvard University. Malavika Subramanyam is research fellow at the department of epidemiology,University of Michigan

First published on: 28-01-2012 at 03:43:06 am
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