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Illustration by Jayachandran/Mint (Illustration by Jayachandran/Mint)
Illustration by Jayachandran/Mint
(Illustration by Jayachandran/Mint)

Coming up short in India

Debates on malnutrition ignore links with sanitation and disease and the burdens these impose on children

Children in India are among the shortest in the world. Widespread child stunting is a human development tragedy. This is not because there is anything wrong with being short or anything inherently good about being tall. The tragedy is because of what makes children short: we all have different genetic potential heights, but children who suffer poor early life health and net nutrition will not grow to their genetic potential. Crucially, children with poor net nutrition in their first two years of life not only fail to grow as tall as they could, their brains and bodies also fail to fully develop.

Short children are a big deal because of what stunting signifies: children’s failure to reach their developmental and cognitive capacities. Evidence is accumulating from India and around the world that taller children become taller adults, on average, who have more cognitive achievement, are more economically productive, earn more money, have better health, and live longer—all because of the better early life health with which height is correlated.

Perhaps the best news about child stunting in India is just how often it is in news these days. Epidemiologists, demographers, and economists have long puzzled over the so-called “Asian Enigma": children in India are shorter, on average, than even children in sub-Saharan Africa who are poorer, on average. But now debating solutions to child stunting in India is mainstream—in blogs and newspapers, in debates and Twitter.

One voice in this discussion has belonged to Arvind Panagariya, a trade economist at Columbia University. His recent article in Economic and Political Weekly suggests that perhaps the stunted growth of Indian children is not a problem. He proposes that Indian children are simply genetically short, and therefore, their heights are nothing to worry about.

It would certainly be nice if this were true. But the main thrust of Panagariya’s views are open to simple scrutiny: his opinion is that because differences in income, mortality, and food cannot account for the average difference in height between people in India and people in Africa, the gap must be made up of differences in average genetic potential.

However, as several commentators before me have observed, this view simply ignores some of the most powerful determinants of early life health in India. And if some other factors can account for Indian stunting, then there is no enigma. One missing piece of the puzzle could be social inequality. For example, average height among women in India has been growing more slowly than average height among men. It is easy to imagine that hard-working, low-ranking daughters-in-law in rural Indian households themselves suffer poor nutrition, and are, therefore, challenged to provide sufficient nutrition for their growing children in utero or while breastfeeding.

Yet, perhaps the most important dimension of health that Panagariya overlooks is one of the most obvious: disease. Different diseases have different effects. Relative to children in sub-Saharan Africa, Indian children are particularly exposed to the kinds of chronic intestinal diseases that prevent bodies from making good use of nutrients in food, and cause lasting stunting. This is because children in India face a double threat of uncommonly poor sanitation and high population density. In India, many children are frequently exposed to germs from their neighbours’ faeces.

Over a billion people worldwide defecate in the open without using a toilet or latrine. More than half of these live in India. Just as India is a global outlier with exceptional child stunting, it is equally an outlier for pervasive open defecation.

My own econometric research suggests that these two facts are linked. Differences among developing countries in the prevalence of open defecation explain more than half of the international variation in child height. The fact that children in India are exposed to more open defecation from their neighbours than children in Africa can account for essentially the entire Indian height deficit. Because poor sanitation can explain the Indian stunting enigma, there is no need to invoke a genetic gap.

If you are interested in the details of this research, you can read more at http://goo.gl/oF6fc. Another recent paper, by Audrie Lin and co-authors, published in May in the American Journal of Tropical Medicine and Hygiene, underscores the threat of open defecation. Children in Bangladesh exposed to worse sanitary environments were more likely to develop chronic intestinal disease and grew notably shorter than children in healthier environments.

Last month’s international High-Level Panel report on the Post-2015 Development Agenda included a clear global target: “end open defecation". This is a worthy goal, and a major challenge. Whether the world meets this target will depend critically on what happens in India. That, in turn, will depend on whether we are able to tinker creatively with solutions to effectively reach hundreds of thousands of villages.

The first step towards solutions is acknowledging the problems—which you can do internally next time you see somebody squatting by the road. Widespread open defecation in India is a human development emergency in our generation, and a looming economic productivity disaster for the next. Unfortunately, many people have a life-long habit of defecating in the open, and local governments have little incentive and few tools to change this behaviour. Such implementation challenges are certainly not unique to sanitation policy. However, finding solutions is necessary if we are to move beyond op-eds, blogs, and Twitter to end the enigma of stunted Indian children.

Dean Spears is a visiting economist at the Centre for Development Economics at the Delhi School of Economics. Comments are welcome at theirview@livemint.com

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