In a Mint article last week (http://bit.ly/14sYhoQ), economist Dean Spears pointed out that the double whammy of high population density and unsanitary conditions in India stunts the growth of children, who bear a disproportionate burden of infectious diseases and lose their ability to absorb nutrients. Unless India ramps up its public health system, providing extra food will mean little for such children.
Poor sanitation and high morbidity are two key factors explaining India’s high malnutrition burden. India’s flawed food policy—which has focused solely on cereals such as rice and wheat at the expense of pulses, fruits and vegetables—and stark gender inequality, which causes Indian women to be far more under-nourished than men, are the other key factors that explain why India has struggled to combat malnutrition despite giant strides in reducing poverty. Unfortunately, the food security ordinance which was hurriedly pushed through by the United Progressive Alliance (UPA) government does not address any of these issues. It exacerbates the food policy mess by continuing to emphasize access to foodgrains despite mounting evidence that barring a tiny fraction, even the poor can afford to have the cereals they need. What they can’t afford is more nutritious food items. Besides, for the very young, the quantity of food served is immaterial. What matters is the provision of right food at the right time, and a disease-free environment. Conflating hunger with malnutrition has given the UPA government the political opportunity to score a populist goal, without addressing the root causes of India’s nutritional crisis.
While India’s dismal child malnutrition statistics have been receiving greater attention of late, the lack of adequate public health interventions which drive such poor nutritional outcomes, often escapes attention. Spears’ research lends weight to what epidemiologists and health economists have been arguing for long: the absence of an effective public health system makes the country an ideal breeding ground for communicable diseases, imposing debilitating costs on the Indian economy.
Preventive public health services are distinct from curative medical care and include interventions in areas such as food safety, water systems, waste management, vector control and health education. The absence of an effective public health network in a densely populated country like ours has resulted in an extraordinarily high disease burden. Water-borne diarrhoeal diseases alone result in the annual deaths of about 200,000 children below four years of age in the country, according to a recent study published in the medical journal The Lancet. Many more manage to survive the attacks from microbes but suffer from under-nutrition in early life, which has life-long impact. Malnutrition in early life lowers the cognitive skills of children and makes them susceptible to obesity-related disorders in later life. The productivity losses associated with malnutrition are estimated to be in the range of 5-11% for a country such as India, according to experts.
True to the adage of prevention being better than cure, preventive public health services are much more cost-effective than medical services. By reducing the disease burden, they can save healthcare costs, which are a major drag on developing economies such as India. While the poor pay the biggest price of an ineffective public health system in terms of increased health expenditure, reduced earnings and death, even the rich are not spared. Children of wealthy families suffer high levels of morbidity and although deaths are rare, stunting is common. If there are few deserving claimants for the scarce public resources of a developing economy, public health must be one among them. Investments in preventive public health are both pro-poor and pro-growth, as World Bank economist Monica Das Gupta points out in her writings. Owing to the public good nature of such services, the market has little incentive to provide them, leaving the state to take up the baton.
In India’s case, the state has consistently refused to take up the baton. Despite transient and sporadic successes in tackling individual diseases, our public health system remains largely dysfunctional. The state has very limited means for disease surveillance, and even lesser ability for a timely response. While investments in public health score on grounds on efficiency, they are not among the safest electoral bets. And the UPA realizes that. It will perhaps take a while before any Indian politician musters the courage and imagination needed to sell public health investments to an electorate which may often value private goods (such as foodgrains) over investments in public health, which by definition is measured in negative terms: so many cholera deaths avoided or so many flu outbreaks averted.
Till then, India will continue to be a happy hunting ground for communicable diseases.
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