India is an aspiring superpower. It also has the highest proportion of undernourished children in the world. Why?
That million-rupee question is going to be asked a lot as the country gears up for the National Nutrition Month in September.
Arguably, there has been no dearth of policies and vision statements aimed at addressing the country’s humongous malnutrition challenge, which has inter-generational and long-term impacts. But progress has been slow and patchy as the latest National Family Health Survey (NFHS 4) clearly shows.
One reason why the malnutrition story does not get the attention it deserves in public discourse is because it has been routinised. India has too many undernourished children. Starvation deaths attract instant attention. Disturbingly, slow, grinding under-nutrition, especially during the first three years of a child’s life, is not always seen as an emergency though it impairs physical growth and cognitive development, jeopardising the child’s future.
That the problem is serious enough is evident from Prime Minister Narendra Modi’s reference to the Central government’s Poshan Abhiyan (National Nutrition Mission) in a recent edition of his radio show Maan ki Baat. ‘Poshan Abhiyan’ was launched by Mr Modi in March 2018. One of the key aims of the flagship scheme is to reduce stunting in children aged between 0 and 6 years from 38.4% (2015-16) to 25% by 2022.
On the ground, severe challenges remain
Recently, Nandgaon, a tribal village in Palghar, Maharashtra, where the ruling Bharatiya Janata Party (BJP) is in power, hit the headlines because of a number of children relapsing into ‘moderate acute malnourishment’ (MAM) over the past three years.
Sadly, India’s malnourished children jostle with each other for resources. The system pegs the needs of the ‘moderately malnourished’ below that of the ‘severely malnourished’, often with tragic outcomes.
It is an old story and one that is not confined to any one state or region.
The dramatic progress in India’s economy in recent decades has not been matched by equally impressive achievements in child malnutrition.
On a visit to Kaptipada block in interior Mayurbhanj, Odisha, in 2006, this reporter saw toddlers with pinched visages and wrinkled hands, an image that I can’t forget even after so many years.
This was the face of ‘grade IV’ or severe malnutrition.
The settlement I visited was inhabited by the Mankadias — nomadic food gatherers and hunters. The Mankadia women trudged for over an hour to fetch water from a spring. Most adults were illiterate and lived off forest produce. Little children in this tribal settlement in rural Odisha wandered around, carrying their tiny siblings, while their mothers went to the forest in search of wood for fuel. Typically, the task of looking after the newborns fell to the grandmother or a sibling.
Many children missed out on regular breastfeeding, critical to a child’s first 1,000 days. They were given other fluids, often mixed with unclean water. The lack of clean water, basic hygiene and incorrect breastfeeding practices took a toll on many newborns. Those who survived suffered from severe protein-energy deficiencies. One child who was one-and-half-years old weighed barely 4.2 kilos. A government programme aimed to sensitise the Mankadia community about correct breastfeeding practices.
But on the ground, even the best-intentioned plans ran into challenges. The frontline worker who was tasked to do the job confessed that she did not speak the local dialect and could not fully communicate with the people. Sometimes her efforts worked; she managed to convince the mother about good practices in newborn care, and the child gradually gained weight.
At other times, she was not lucky. Many severely malnourished children from the Mankadia colony had been referred to the nearby hospital for treatment.
Between 2005 and 2015, the proportion of underweight children in India has indeed come down, mainly on account of an improvement in stunting. The percentage of stunted (whose height is below the average for their age) children under 5 reduced from 48% in 2005-06 to 38.4% in 2015-16, according to the official data.
Hearteningly, apart from most of the smaller states, others with populations above 25 million – Kerala, Punjab, Tamil Nadu and Telangana – have stunting rates below 30%.
However, the percentage of children who are wasted (whose weight is below the average for their age) has risen from 19.8% to 21% during the same period. States which have shown a high increase in the incidence of wasting includes Punjab, Goa, Maharashtra, Karnataka, and Sikkim.
Overall, there are more underweight children in rural areas (38%) than in urban areas (29%). But there are big differences between states.
In India, averages don’t tell the story. Even affluent states with reasonable nutrition scores have pockets of acute child malnutrition. Children in rural India fare worse on the whole on the nutrition front than their counterparts in cities, but those living in urban slums are typically worse off than the rural average.
Many slum dwellers in India’s big cities may not be officially poor but do not have access to nutritious food — either through ignorance, changing food habits and time pressure.
What should be done?
The backstory, the underlying problems, need urgent attention. One key factor relates to human resources. India has the world’s largest integrated early childhood programme – ICDS or Integrated Child Development Services (ICDS). It was set up in 1975 when the world at large was not talking that much about a child’s early years.
India was ahead of the curve.
The Anganwadi worker is the community face of ICDS, but over the years, the ICDS scheme has worked patchily on the ground. In some states, it works well and in many others, with weak institutional structures, it fails the child.
Then, there is the matter of coordination. The Anganwadi worker is part of the Integrated Child Development Services (ICDS) system of the women and child development (WCD) ministry; the auxiliary nurse and midwife (ANM) and the Accredited Social Health Activist (ASHA) report to the health ministry. Both sides are critical for child nutrition and health.
These two ministries need to coordinate better to improve the child nutrition story on the ground. As of now, there is inadequate data sharing and weak accountability.
Another area which requires a lot more policy attention is early childhood development. Families get take-home ration for children up to three years under the ICDS scheme, but this helps only physical growth. It does not take into account the vital need for psycho-social stimulation that is critical for cognitive development. The responsibility for that is left to parents and family members.
Nutrition expert Purnima Menon of The International Food Policy Research Institute (IFPRI) points out that ‘The quality of implementation of planned efforts will need attention. Both the health and ICDS face substantial challenges that affect day-to-day functioning.”
The reasons for implementation bottlenecks vary from state to state, she says. In some places it is financial flows and governance, in other places, it is human resources and unfilled posts; then there is the familiar story of overloaded health workers.
All of these should be action points, come September and in the months to come.
Or else, gear up for a severe future shock.
Patralekha Chatterjee is an award-winning journalist/columnist, and photographer focusing on development issues. Currently, her writing focuses on the intersection of politics and public policy on a range of inter-linked development issues for Indian and international media.
(Views are personal)
