PremiumRicher states have taller children and lower levels of stunting on average. But across states, gains in per capita incomes are not linked to improvement in stunting rates, suggesting that other factors matter in improving nutrition
The results of the first phase of the latest round of the National Family Health Survey (NFHS) point to sharp reversals in the gains India had made earlier in batting child malnutrition. A majority of the 22 states and union territories covered in the first phase saw the proportion of stunted children (those with low height for age), wasted children (low weight for height), and underweight children (weight for age) rise compared to the previous round conducted in 2015-16.
The increase in stunting in children under the age of five is the most worrying. The World Health Organization (WHO) describes a stunted child as one whose height is two or more standard deviations below the WHO’s Child Growth Standards median - meaning a substantially lower than expected height for the child’s age.
“It is a largely irreversible outcome of inadequate nutrition and repeated bouts of infection during the first 1000 days of a child’s life," the WHO says. The potential impact casts a long shadow. Research suggests stunting deeply affects cognitive and physical development as well as health outcomes well into adulthood, potentially lowering lifetime earnings for the stunted.
The rise in stunting rates are particularly worrying because Indian children are already among the shortest in the world.
Research by the health economist Dean Spears suggests that much of the difference in heights between Indian and sub-Saharan African children could be explained by the extent of exposure to open defecation.
Spears and his colleagues also found that differences in the levels of open defecation could account for 35 to 55 percent of the average difference in stunting between districts in 2011. “[G]erms from feces cause diarrhea and other diseases, which can consume energy and harm the overall nutrition of growing children and of the mothers who nurture them in pregnancy and early life," Spears said over email.
The social status of women is also associated with the heights of their children: the younger daughters-in-law in rural joint families in India had shorter children on average, economist Diane Coffey and others wrote in a working paper.
First-born Indian boys are taller than their sub-Saharan counterparts, economists Seema Jayachandran and Rohini Pande found, but first-born girls were shorter, and girls with elder female siblings were the worst off. Driving these decreases was likely the desire for a son, Jayachandran and Pande’s research suggested.
Yet, all of these factors are correlated with economic growth and development. Women in richer states are healthier and have healthier pregnancies, sanitation coverage is more widespread and family sizes are smaller. So, should India have expected to see better outcomes in child stunting in the new NFHS round in states which did better economically over the last five years?
A comparison of the NFHS data and official economic data shows that richer states did have lower rates of child stunting, but increases in per capita income over the last five years were not necessarily correlated with reductions in child stunting.
Past research into this issue suggests that the link between rise in average incomes and nutritional outcomes is not always straightforward. In 2005-6, the tallest children were in the richest states - Tamil Nadu, Goa and Delhi - Coffey and others found, and the shortest in Uttar Pradesh and Bihar. There was a difference of nearly 4.5 cm between the average Tamil Nadu child aged 3 and the average Bihar child aged 3. But the relationship with per capita income weakened between 1998-99 and 2005-06, they found. This suggests that where higher incomes were funneled, and how state spending was allocated mattered.
“Money can be used to buy inputs to health, but it doesn’t have to be," said Spears. Even without spending more money, by improving technology, or changing behavior or culture, health outcomes can improve, said Spears.
“If economic growth is achieved by polluting the air or without investing in the health of mothers and children, then it may not be translated into better health for the next generation," he added.
Nikhil Rampal of Mint contributed to this story.
Rukmini S. is a Chennai-based journalist.
