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Developmental Issues

To tackle child malnutrition effectively, all aspects of household deprivation need to be addressed to improve maternal health. File   | Photo Credit: K.K. Mustafah

The story so far: India has been ranked 94 on the 2020 Global Hunger Index (GHI), lower than neighbours like Bangladesh and Pakistan. The GHI showed that nearly 690 million people in the world are undernourished; 144 million children suffer from stunting, a sign of chronic undernutrition; 47 million children suffer from wasting, also a sign of acute undernutrition. The number of young children in India who are very short and thin, reflecting severe undernutrition, puts it alongside the poorest African nations, with some indicators showing actual declines over the last five years.

The GHI is an annual peer-reviewed publication by Concern Worldwide and Welthungerhilfe. It aims to track hunger at global, regional and national levels. It uses four parameters to calculate its scores.

Editorial | No great escape: On India’s low rank on nutritional indices

One third of the score comes from the level of undernourishment in a country, which is the share of the population with insufficient caloric intake, and uses Food and Agriculture Organization data. The other three parameters are based on children under the age of five years. A third of the score comes from child mortality rate, which often reflects the fatal mix of inadequate nutrition and unhealthy environments. The remaining third of the score is based on child wasting, which is the share of children who have low weight for their height, reflecting acute undernutrition, and child stunting, which is the share of children who have low height for their age, reflecting chronic undernutrition.

These parameters use information from the World Health Organization, the World Bank and the United Nations, although all these international organisations draw from national data, which, in India’s case, includes the National Family Health Surveys (NFHS). There is always a time lag in such data, so the 2020 scores are based on data from 2015-19.

This results in a 100-point scale, with zero meaning no hunger at all. Countries scoring 9.9 and less are classified as having a low severity. A score between 10 and 19.9 is considered moderate, that from 20 to 34.9 is serious, and a score of 35 or more is alarming. These classifications are comparable over time, but the rankings themselves are not comparable, as the number of countries included in each particular year varies.

Also read | Need a different approach to address child malnutrition

In 2020, India falls in the ‘serious’ category on the Index, with a total score of 27.2. This is a definite improvement from the situation two decades ago, when it scored 38.9 and fell into the ‘alarming’ category. However, its scores are abysmal when compared to its peers in the BRICS countries. China and Brazil both scored under five, and are considered to have very low levels of hunger. South Africa is ranked 60 with a score of 13.5, indicating moderate levels of hunger. In the serious category, India stands with some of the poorest African nations, as well as its own South Asian neighbours, all of whom have better scores except Afghanistan. India is tied at the 94th rank out of 107 countries, sharing the rank with Sudan.

In terms of overall undernourishment, 14% of India’s population does not get enough calories, an improvement from almost 20% in 2005-07. The child mortality rate is 3.7%, a significant drop from 9.2% in 2000. Many countries fare worse than India on these two parameters.

Also read | India’s child mortality rate declined between 1990 and 2019: UN

India’s poor score comes almost entirely from the child stunting and wasting parameters. Almost 35% of Indian children are stunted, and although this is much better than the 54.2% rate of 2000, it is still among the world’s worst. Also, 17.3% of Indian children under five are wasted, which is the highest prevalence of child wasting in the world. There is no change from two decades ago, when it was 17.1%. In fact, the situation improved to 15% in the 2010-14 data period, but worsened again by 2015-19.

However, experts say this decline may also be partially due to vagaries in data collection. Hunger is a seasonal phenomenon in many parts of the country, with families dependent on agriculture for their livelihoods, facing lean periods based on the sowing and harvesting cycle. There are seasonality differences between NFHS’s third and fourth rounds, meaning that higher levels of wasting may have been seen in the fourth round, on which the latest scores are based, because field data was collected after a lean period. However, even the Comprehensive National Nutrition Survey (2016-18) shows the same 17.3% rate of wasting.

Also read | India’s under-5 mortality of girls exceeds that of boys, unlike global trend, says report

There is an interesting difference observed between child wasting in South Asia and the poorer nations of Africa, according to researchers. African babies are usually healthy at birth, but as they grow up into their toddler years, undernourishment starts to kick in. South Asian babies, on the other hand, show very high levels of wasting very early in their lives, within the first six months. “This reflects the poor state of maternal health, more than anything else,” says Purnima Menon, a senior nutrition researcher at the International Food Policy Research Institute. “To talk about solutions, we must recognise that this is the root cause. Mothers are too young, too short, too thin and too undernourished themselves, before they get pregnant, during pregnancy, and then after giving birth, during breast-feeding. It is more than a health issue, there are social factors like early marriage … If so many young women are starting their pregnancies so badly, then everything else you may do to help child nutrition later is like simply putting a band-aid on a serious wound.”

Also read | 68% of under-5 deaths in India due to child, maternal malnutrition

Almost 42% of adolescent girls aged 15 to 19 have a low body mass index (BMI), while 54% have anaemia. Almost 27% of girls are married before they reach the legal age of 18 years, and 8% of adolescents have begun child bearing in their teens. Almost half of all women have no access to any sort of contraception. These poor indicators of maternal health have dire consequences for the child’s health as well.

Poor sanitation, leading to diarrhoea, is another major cause of child wasting and stunting. At the time of the last NFHS, almost 40% of households were still practising open defecation. Only 36% of households disposed of children’s stools in a safe manner. One in 10 children under the age of five suffer from diarrhoea.

The Comprehensive National Nutrition Survey shows wide variability across States. Almost one in three children in Jharkhand show acute undernutrition, with a 29% rate of wasting. Although this is the worst State by far, other large States such as Tamil Nadu, West Bengal, Madhya Pradesh, Chhattisgarh and Karnataka also have one in five children who are wasted. Interestingly, other States that usually fare poorly on development indices, such as Bihar, Rajasthan and Odisha, actually do better than the national average, with 13-14% rates of wasting. Uttarakhand and Punjab, along with several north-eastern States, have levels of child wasting below 10%.

Also read | Education for mothers directly linked to better nutrition for children: survey

In terms of stunting, Bihar performs the worst, with 42% of children too short for their age. Other populous States like Madhya Pradesh and Uttar Pradesh also have stunting rates just below 40%, and so does Gujarat. At the other end of the scale, Jammu and Kashmir has only 15% stunted children, while Tamil Nadu and Kerala are around the 20% mark.

Experts caution that there is no magic bullet. Food insecurity, poor sanitation, inadequate housing, limited access to healthcare — all result in maternal distress that leads to the kind of slow, chronic wasting seen in Indian children.

Comment | The double burden of malnutrition: need for urgent policy action

Although India has overall food security with record levels of foodgrain production in recent years, access to healthy food is still difficult for poor households. A recent study showed that three out of four rural Indians cannot afford the cheapest possible diet that meets the requirements set by the government’s premier nutrition body. Over the last five years, the Swachh Bharat Mission’s push for toilets for all and ending open defecation may have resulted in better sanitation outcomes which could reflect in better maternal and child health in the NFHS round five, which started collecting field data in 2018-19. The Integrated Child Development Services programme aims to provide food, primary healthcare and immunisation services to young children and mothers.

“There is no single solution. Every kind of household deprivation that makes life difficult for women needs to be dealt with. The focus needs to be on healthy mothers,” says Dr. Menon.

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