Is malnutrition in India a myth?
5 min read 16 May 2013, 03:48 PM ISTSome commentators dismiss the seriousness of India’s nutritional crisis as it fails to account for genetic differences
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With one in two children malnourished in India, child malnutrition is considered to be among the biggest challenges facing the country. But are these figures highly exaggerated? The answer is a resounding yes, according to Columbia University economist Arvind Panagariya, who believes that the international standards used to measure nutritional attainments of Indian children are inappropriate, as they fail to account for “genetic differences".
Panagariya has questioned the credibility of malnutrition estimates in his op-ed columns and interviews to Indian publications in the past couple of years. In a recent article in The Economic and Political Weekly, Panagariya has expanded on his arguments. Although Panagariya’s arguments have failed to impress nutritionists so far, it has led some commentators to dismiss the seriousness of India’s nutritional crisis. It, therefore, makes sense to examine the weight of his arguments.
There are several problems with Panagariya’s inferences.
First, malnutrition and mortality are not identical issues and hence it is reasonable to expect variations in the two outcomes. Doing enough to prevent a death is quite different from doing enough to ensure that a child has a healthy life. Also, not all child deaths in Africa are because of under-nutrition. High rates of HIV and malaria play a large role in driving up child mortality in that continent.
Second, while Panagariya emphasizes the difference which we show in table 1, he glosses over the difference which we show in table 2. Nutritionists and paediatricians have published several studies to show that the root of high malnutrition in India (and much of South Asia) lies in the low social status of women. Compared to African women, South Asian women face greater inequity at home, which not only skews the household distribution of food but also raises the burden of household work, affecting time spent on children. The proportion of women with below-normal body mass index (BMI) is significantly higher in India than in sub-Saharan Africa. This, in turn, leads to a greater proportion of low birth-weight children. As the accompanying tables show, children are twice as likely to be under-nourished in South Asia precisely because they are twice as likely to be born with a low birth weight, showing that the cycle of under-nutrition starts in the womb.
Third, malnutrition in Asia may not always lead to mortality, but that does not mean it is benign. Panagairya does not see low birth weights or lower BMI of women as a problem in itself. But a growing body of medical evidence points out that low birth weights raise the risk of obesity-related disorders, much later in life. Although the exact mechanisms of how this happens is still being studied, one widely cited (‘thrifty genotype’) hypothesis postulates that under-nutrition in the pre-natal stage programmes the foetal tissues to utilize food efficiently, making it difficult for low birth weight babies to deal with an abundance of food in later life. The double malnutrition trap can be particularly dangerous for South Asian economies such as India.
Fourth, contrary to Panagariya’s claim that the World Health Organization’s (WHO’s) nutritional standards are based on an assumption that there are no genetic differences between India and other countries, this is actually the conclusion of a scientific study involving several teams of independent experts based on field trials across six countries, which included India.
Fifth, the claim that Panagariya advances about genetic differences (and which was rejected in the WHO study) is a very old one, as this blog post points out, and the weight of medical evidence has been against this hypothesis so far. This does not mean that the hypothesis should be rejected out of hand. This merely means that the conclusions of the WHO study align better with the scientific consensus on the subject compared to Panagariya’s hypothesis.
Sixth, Panagariya’s use of the statistics cited in the CAG report to justify his hypothesis is baffling, given that they are based on figures reported by the respective Integrated Child Development Services (ICDS) departments of states. As anyone in India knows, ICDS figures are unreliable and unsuitable for any analysis other than an intra-state comparison. Laggard states with weak ICDS coverage are known to present gross under-estimates of malnutrition. The CAG has also highlighted some of the data discrepancies. As such, despite the monthly frequency of ICDS data, official estimates of malnutrition still rely on the eight-year-old figures of the National Family Health Survey (NFHS), considered much more credible compared to the ICDS data.
Looking at the evidence with open eyes therefore makes one sceptical about most of Panagariya’s arguments. To be sure, there is merit in Panagariya’s argument that we ought to better target children who are at the greatest risk of death. But there is no need to revise standards for this alone. Using existing standards, we can and do distinguish between the severely and moderately malnourished. In India, severe malnutrition is a third of overall malnutrition and is highly concentrated among the less affluent, tribals and dalits, who also happen to face the brunt of child deaths. Special care for them does not preclude cost-effective investments in preventive public health systems to fight malnutrition.
Finally, even if we were to grant, for argument’s sake, that Panagariya’s hypothesis could be vindicated by scientists at a later stage, a new measuring rod won’t change the sorry state of India’s nutritional outcomes. And we need not look as far as sub-Saharan Africa. In our own neighbourhood, poorer countries such as Bangladesh and Nepal have outpaced us in improvements in several social indicators including child health outcomes.
