child malnutrition

‘India’s Child Stunting Rates Higher Than Sub-Saharan Africa Due to Caste Disparities’: Study

The study by economists Ashwini Deshpande and Rajesh Ramachandran makes it clear that a “large burden of child malnutrition [is] borne by the stigmatised caste groups”.

New Delhi: A new research study has shown that the paradox of India having higher child stunting than sub-Saharan Africa disappears if chronic malnutrition is studied along caste lines.

So far, experts have viewed the higher child stunting rates in India, compared to those in sub-Saharan Africa – one of the world’s poorest regions – as a paradox, given India’s stronger economic position.

However, economists Ashwini Deshpande and Rajesh Ramachandran have found that children from historically marginalised communities like Scheduled Castes (SCs) and Scheduled Tribes (STs) are 50% more likely to be stunted than children from forward castes.

The survey, based on a nationwide household survey conducted during 2019-21, covered 200,000 children under the age of five and estimated a stunting rate of 36% compared with an average 34% across 19 sub-Saharan African countries.

However, stunting in children from forward castes was found to be 27%, significantly lower than than sub-Saharan Africa’s 34% and India’s 36%.

The study also found that forward caste Indian children were 20% less likely to be stunted compared with children in sub-Saharan Africa even after taking into account socio-economic and other factors that can influence child nutrition and stunting levels, the Telegraph reported.

This implies that a ‘broad’ India-Africa comparison overlooks the vast amount of disparity within India when it comes to measuring nutrition outcomes. The researchers have called this the “hidden divide”.

“Our results show that gaps between the groups (within) India dwarf the India-sub-Saharan Africa stunting gap,” said Deshpande, professor and head of economics at Ashoka University, and Ramachandran, an economist at the Monash University Malaysia.

“Much of the academic attention has focused on India versus sub-Saharan Africa,” Deshpande told The Telegraph. “We need to understand the differences in stunting across population groups within India and the reasons why such differences persist,” she added.

While previous studies have tried explain this paradox through other factors like the number of children in a household, access to sanitation and the gender of the children, the study by Deshpande and Ramachandran makes it clear that a “large burden of child malnutrition [is] borne by the stigmatised caste groups”.

“The Indian enigma does not emerge when we restrict the comparison to non-stigmatised caste groups in India,” the researchers wrote. Their study has been published in the Journal of Economics, Race and Policy.

Wasting is the Blind Spot of Child Malnutrition in India

The wasting problem is not as strongly graded across states as stunting is. For instance, there is clear gradation in stunting between districts of Tamil Nadu and Bihar, but it is quite weak when we consider wasting.

While the Indian economy galloped during the last two and half decades to become the fifth largest economy in the world, child malnutrition in India has progressed at a snail’s pace — currently hosting the largest burden of malnourished children in the world. The chronic or stable measure of child malnutrition i.e. stunting declined from 48% in 2005-06 to 35.5% during 2019-21 — a decline of about one percentage point annually. Owing to the slow progress, India has fallen behind many South Asian and sub-Saharan African countries.

India has performed relatively well in child survival, with its infant mortality rates comparable to countries with similar per capita GDP levels. However, the problematic aspect is that this better performance on the mortality front is being used as a pretext to argue that the high stunting rate among Indian children may be overestimated.

The rationale behind such an argument is that it would not be possible for India to do so well in reducing mortality if its stunting rate is indeed that worse because stunting is an important risk factor for child mortality. Based on this logic Professor Arvind Panagariya back in 2013 argued that Indian children are genetically dispossessed for lower heights. Therefore, the World Health Organisation (WHO) child growth standards applied to Indian children would invariably overestimate child stunting for India.

It is to be noted that the WHO standards established in 2006 was derived from a sample survey of healthy breast-fed children from developed and developing countries including India. Of course, there are other factors that may explain India’s competency in stalling mortality rates despite high risk factors such as competent tertiary medical facilities in India.

A collection of research articles from renowned experts immediately refuted Panagariya’s argument with credible logic and evidence. Despite effective countering of Panagariya’s argument by many scholars, it has gained a disproportionate amount of traction within the policy establishment. In fact, India is planning to develop its own ‘indigenous’ standard relating to height-for-age based on this argument.

However, developing an ‘indigenous’ standard for height-for-age measurements could potentially put India in an even more embarrassing situation. This is because India has been topping the world in acute or transient measures of malnutrition i.e. wasting since the early 2000s without any significant dent in prevalence rates ranging between 17 to 20%. Wasting or weight faltering is measured using the weight-for-height standard of WHO. Therefore, the question arises: can India justify introducing a new ‘indigenous’ weight-for-height measure based on the same genetic argument?

In other words, would it be possible to argue that wasting prevalence calculated using WHO standards in case of India must also be an overestimate because India does relatively well in infant mortality as wasting is another important risk factor for mortality. This will be akin to arguing that Indian children are genetically dispossessed not only for lower heights but also for lighter weights. That is, Indian children are capable of growing in a balanced manner with less body mass per unit of height and lower height on an average compared to children of other countries.

Also read: Why Modi Making a Virtue of Vegetarianism Worsens India’s Malnourishment Problem

Prima facie, physiologically it is difficult to buy such an argument without serious scrutiny given that the health and productivity of the entire future generation is at stake. Tweaking these standards without credible scientific evidence and experimentation would mean that India may compromise its labour productivity and competitiveness in the global economy, as well as the quality of life, for a very long period.

It would have been relatively easy for India to advance the genetic argument for a lower height-for-age standard if the country had performed well in weight-for-age measures or wasting prevalence. However, the reality is entirely opposite.

Another complexity to the issue under discussion is that there is umpteen evidence of interdependence between wasting and stunting. Several clinical studies based on longitudinal data of children including from India suggest that children exposed to wasting episodes between six to 24 months have significantly higher propensity of being stunted in later stages of their childhood. These studies also indicate that prevalence rate computed from nationally representative data i.e. the National Family Health Survey (NFHS) is an underestimate by significant factor.

Underestimation of wasting is likely, as a child may experience weight loss multiple times within a year due to frequent exposure to adverse circumstances. However, the NFHS only measures a child’s weight once during the entire one-year reference period. Transient factors that affect access to food or epidemiological environments such as floods, droughts, extreme temperatures, adverse economic shocks and eruption of violent conflicts can immediately manifest in the weight of children. In other words, surveys that measure weight only once during the survey year fail to capture the fact that children may have experienced wasting at any point of time within a year. The height of a child does not respond to such transient factors, so underestimation problems do not arise in measurement of height.

After we consider interdependence between wasting and stunting and the fact that wasting is severely underestimated in NFHS data the high prevalence of stunting and slow progress in it is not as surprising. In fact, the NFHS data also reveals a significant and consistent seasonal pattern in wasting prevalence across all survey years, with the highest prevalence occurring during the monsoon quarter (June to August) and a gradual decline in the subsequent two quarters. Poor households in rural areas may face food grain shortage in the monsoon quarter owing to high prices of food grains during this season. Children may also face additional burden due to adverse epidemiological environments during the same quarter as a result of rains and floods.

The documents and speeches of experts from policy establishments give the impression that stunting is the sole measure of malnutrition that they focus on. However, a policy approach that is blind to the interdependencies between wasting and stunting would invariably fail in addressing stunting in a sustained manner. Longitudinal studies highlight the importance of addressing wasting among children within 24 months of age as these exposures to wasting are strong predictors of stunting in later stages of childhood.

Addressing wasting obviously requires a different set of strategy than the strategy that is currently in place for addressing stunting. If it was not so then current strategies would have addressed the wasting problem by itself. Given the transient nature of indicators, the policy must be sensitive to factors that may adversely affect weight of children such as exposure to floods, droughts, extreme temperatures, adverse economic shocks and eruption of violent conflicts. These events keep affecting one or other regions of India in a sporadic manner.

The number of children affected by such events in India at any given point of time is significant enough for it to become a crisis of national scale for any other country but not for India because it remains so small relative to the country’s population size. Ignoring children exposed to such events limits our ability to combat the wasting rates in a consistent manner which will eventually have its effect on impeding the progress on stunting as well. For instance, the violence in Manipur must have affected a large number of children but it is hardly news.

There are a few more facts that need due attention in the context of child malnutrition. The wasting problem is not as strongly graded across states as stunting is. For instance, there is clear gradation in stunting between districts of Tamil Nadu and Bihar, but it is quite weak when we consider wasting. Further, gradation in wasting across economic status is quite weak compared to the economic status-based gradation that we see in case of stunting. Given the interdependencies between wasting and stunting, the lack of robustness in ranking of wasting across economic class and human development at state level signals the vulnerability of gains that have been made so far in malnutrition.

Md Zakaria Siddiqui researches and teaches Economics at Jamia Millia Islamia, New Delhi.

What Impacts Child Malnutrition in India and Why We Need to Be Aware of These Factors

India loses 4% of its GDP annually due to malnourishment and hence, the objective of economic development cannot be met without addressing the issue of child malnutrition.

India has achieved remarkable levels of economic growth, and yet, despite all the progress, it continues to host the highest number of malnourished children in the world.

Child malnutrition is classified as ‘undernutrition’ (inadequate consumption of calories) and ‘overnutrition’ (excess consumption of calories). Of these, undernutrition leads to low height-for-age or stunting. It is known as the most sinister form of child malnutrition because unlike the loss of weight, height cannot be readily gained back. Hence, it is an indicator of chronic childhood malnutrition, which can lead to irreversible mental and physical damage that is even transmitted to the next generation.

To understand the gravity of this problem, we note one-third of stunted children, globally, are Indian. The implication is that India loses 4% of its GDP (gross domestic product) annually, and hence the objective of economic development cannot be met without addressing the issue of child malnutrition.

The research suggests that tackling child malnutrition requires a multi-faceted approach, for example, improving the quantity and the quality of dietary intake, levels of sanitation, maternal health and education, access to social safety net programmes etc. Based on these important findings, the government had established programmes like Integrated Child Development Services (ICDS) that provides comprehensive health and nutrition services to children under six and pregnant and lactating mothers, mid-day meals to school-going children, Swachh Bharat Mission that is aimed to eliminate open defecation, among others programmes.

And yet, despite these measures, the NFHS-5 data revealed that child malnutrition in India is worsening (see figure 1). Thirteen out of the 22 states have witnessed a reversal in stunting outcomes. Experts have commented that this is due to a decline in budgetary allocation towards children’s health and nutrition schemes (here), while others suggest that it could be due to the slowdown in economic growth (here).

Also read: An Overlooked Strategy to Remedy Malnutrition

Given the rising burden of child malnutrition and budgetary concerns, there is substantial merit in understanding the relative importance of the factors impacting child malnutrition. This can help the policymakers redirect their focus on interventions that will yield the maximum benefits to child health.

Figure 1: Percentage of stunted children below age 5 in NFHS-5 (2019-20) and NFHS-4 (2015-16)

We use data from the NFHS-4 survey for almost 90,000 children below five. Further, we use NHFS-4 variables to construct ten groups that are used to explain the child malnutrition under UNICEF’s framework: age of the child (in months; from 0-5 years), gender, occurrence of infections, medicinal intake, birth characteristics (size and weight at birth), their food intake (breastfeeding and dietary diversity), child environment (open defecation level at the village, access to benefits from welfare schemes, improved drinking water, household size), mother’s characteristics (height, BMI, education, and age at marriage), her environment (access to benefits from ICDS centres during pregnancy, health insurance) and socio-economic controls (wealth, place of residence, etc.).

Our outcome variable is height-for-age z-scores (HAZ scores), i.e. the height gap of a child from the median child with the same age and gender. HAZ score below (above) zero means that the child is worse off (better off) than the median child (here).

To estimate the relative contribution of these ten towards the HAZ scores for our analysis, we use an econometric technique called the Shapley-Owen decomposition, which is useful to calculate the marginal contribution of variables, especially when all the variables are interlinked.

Also read: How Caste Discrimination Impacts Child Development and Stunting in India

After running the decomposition on ten groups, we find that the child’s HAZ scores, child’s age is the most important followed by mother characteristics (and within this group, mother’s height), and socio-economic controls. Our results are in line with the well-established finding in the literature that stunting happens in the first 24 months, and hence it holds the maximum contribution.

In a similar vein, it is unsurprising that the next most important variable is the mother’s height as genetics always had an important role in determining heights. This leads us to recommend that additional efforts should be expended to provide adequate nutrition to children from conception till two years (i.e. the first 1,000 days of life). Next, prioritising the nutritional needs of girls among these children will help India break the pattern of inter-generational transfer of stunting, as mothers who faced stunting in childhood are shown to have under-developed uteruses, which leads to the reproduction of stunted children.

Figure 2: Relative contribution of the determinants of child malnutrition towards children’s height-for-age z-scores

While ICDS’s POSHAN Abhiyaan mentions the importance of adequate nutritional intake during the first 1,000 days of the child’s life, the programme, much like other welfare schemes for children and women, have been receiving budgetary cuts for the past few years. This issue has been raised by noted economists, and our findings also provide rigorous evidence to support the call for enhancing the budgetary allocation for programmes like ICDS which are responsible for providing requisite antenatal healthcare to the mothers and optimal quantity and quality of diets to the children.

Similarly, our analysis also echoes the recommendation of economists who have attributed the rise in child malnutrition to the slowdown in economic growth in recent years. Socio-economic controls are the third most important determinant of HAZ scores. It represents the ability of the household to access diets that are optimal in calories and nutrition, healthcare and general living conditions, all of which, jointly determines children’s health. Therefore, while the supplementary nutrition programmes should be strengthened, their impact on the child health outcomes will be most effective when India is also witnessing a faster economic growth.

Payal Seth is a consultant at Tata-Cornell Institute, Cornell University and a research scholar at Bennett University. Palakh Jain is an Associate Professor at Bennett University.

How Caste Discrimination Impacts Child Development and Stunting in India

The child height gaps between caste groups is so wide that variation in the practice of untouchability does not affect the height of upper-caste children, but higher spread of untouchability is linked to lower heights of Dalit children.

Note: This article is based on a data narrative written for the Centre for Economic Data and Analysis (CEDA). The original piece is modified to address some questions raised by readers after the CEDA piece was published.

India is home to nearly one-third of all stunted children in the world, i.e., children under five years whose height relative to their age is below the acceptable range of global variation. Stunting is defined as “impaired growth and development that children experience from poor nutrition, repeated infection and inadequate psychosocial stimulation”.

Why does this matter? Because early childhood indicators of poor health persist into teenage and often adulthood. Stunting is associated with adverse consequences in later life for morbidity and mortality, non-communicable diseases, learning capacity and productivity.

With one in four children worldwide classified as stunted, it is seen as a global health challenge.

This raises three key questions of immediate interest. One, what is the likelihood that a child stunted at a young age, say age one or five, can grow out of stunting by adolescence? In other words, to what extent is stunting persistent? Two, while stunting is an objective indicator of poor health, what are its other consequences? In particular, what are the implications for human capital and subjective well-being? Three, what are the set of factors associated with stunting? Is the likelihood of stunting simply a result of wealth and income or can other factors be identified, which are more amenable to policy interventions?

We have examined all these questions in our recent research. The short answers are: one, children who are severely stunted at age five are 74% more likely to be stunted at age 15 in India, i.e. early childhood stunting is highly persistent. Two, early childhood stunting affects grade attainment and cognitive abilities in mathematics and vocabulary, as well as subjective well-being at ages 15 and 22. Research from developed countries shows that early childhood stunting can affect employment outcomes and wages.

We focus on the third question in this piece. But before we turn to that, we need to place the stunting issue in an international context.

Also read: Reimagining a Post-COVID School for India

The Indian Enigma

Not only does India have a high incidence of stunting, the average incidence of stunting in India is higher compared to the average of 30 countries in Sub-Saharan Africa.

Child height is typically negatively correlated with poverty, as stunting is one of the manifestations of chronic malnutrition. Therefore, the fact that Indian children are shorter than their counterparts in Sub-Saharan Africa is counter-intuitive, as India is a richer country. This puzzle, called the “Indian Enigma”, has led to serious enquiry in the form of significant academic papers that have tried to solve this puzzle (Deaton, 2007).

The predominant explanations for this phenomenon are birth order and son preference (Jayachandran and Pande, 2017): first-born children are not shorter but the height gradient kicks in from the second child onwards, especially if the child is a girl; the high prevalence of open defecation, i.e. the disease environment (Spears, 2018); and genetic differences (Panagariya, 2013). Note that the evidence presented by Jayachandran and Pande as well as by Dean Spears raises a serious question mark against genetic explanation.

Our first look at the child height data revealed a picture that, we were surprised to find, had been overlooked in the literature (See Figure 1).

Figure 1 includes data from 30 countries in sub-Saharan Africa, which have a combined under-five population of 132 million and India with under-five population of 121 million. These data are from the latest round of the Demographic and Health Survey (DHS); with data for India from 2015-16 and for sub-Saharan Africa from the latest round later than 2010.

Panel A of Figure 1 plots the average height-for-age Z score *(HFA Z-score). Indian children have an HFA Z-score of -1.48, which is an additional 0.16 standard deviation units less than the sub-Saharan Africa average of -1.32. The rate of stunting is plotted more directly in Panel B: the proportion of children who are more than 2 standard deviations below the world reference median. This panel shows that childhood stunting is 13% higher in India than in sub-Saharan Africa (36 versus 31%). This part of the picture is well known and widely analysed by the literature referred to earlier.

* This is the number of standard deviations of the actual height of a child from the median height of the children of his/her age as determined from the World Health Organization child growth standards (WHO Multicentre Growth Reference Study Group, 2006).

Also read: India’s Towering Food Inflation Will Make Child Malnutrition Worse

The missing link: the role of social identity

The India-sub-Saharan Africa comparison, however, elides over the crucial inequalities that exist within Indian society. In Panel C and D of Figure 1, we plot the average HFA Z-score and rates of stunting for sub-Saharan Africa and the four major social groups in India: the upper-caste Hindus (UC-Hindus), Scheduled Castes and Tribes (SC-ST), Other Backward Classes (OBCs) and upper-caste Muslims (UC-Muslims, i.e. Muslims that don’t identify themselves as SC or OBC). The four-way classification accounts for the two key cleavages in Indian society: caste and religion.

Panel C of Figure 1 reveals a pattern that had hitherto been missed in the stunting discussion: the height disadvantage for all groups, other than UC Hindus, is higher compared to sub-Saharan Africa children. Panel D shows the same thing differently: rates of stunting are far lower among UC children. Thirty-one percent of children in sub-Saharan Africa are stunted. With a stunting incidence of 26%, UC-Hindu children are 5 percentage points less likely to be stunted than children in sub-Saharan Africa.

Nearly 40%, 36% and 35% of the SC-ST, OBCs and UC-Muslim children, respectively, are stunted. Thus, the SC-ST, OBCs and UC-Muslim children are 14, 10 and 9 percentage points, or 35-50%, more likely to be stunted compared to the UC- Hindu children.

In other words, the gaps in child heights between the social groups in India are two to three times greater than the India-sub-Saharan Africa child height gap. The entire India-sub-Saharan Africa child height gap is accounted for by the lower child heights of disadvantaged groups.

The patterns shown in Figure 1 indicate that the question “why are Indian children shorter than African children” needs to be rephrased to “why are the gaps in child height between social groups within India so high?”

We address this in our latest paper. In this data narrative, we present some of the salient features of childhood stunting in India.

Also read: Child Nutrition Levels in India Worsened Over Last Five Years, Finds NHFS Survey

Variation in stunting across districts and social groups

When we examine the sub-national variation in incidence of stunting, we find both regional and social group variations. We present estimates from the National Family and Health Survey for 2015-16 (NFHS-4).

Table 1 shows the number and share of districts by social group by the incidence of stunting. These are also shown in Figure 2, which plots colour-coded heat maps showing the spatial distribution of the average proportion by district and social group, where the thin black lines depict the district boundaries and the thick black lines the state boundaries and the prevalence of stunting is increasing in the intensity of the colour.

Figure 2. The four panels in Figure 2 show the regional variation in stunting incidence for SC-ST, Upper Caste Hindu, OBC, and Upper Caste Muslim children.

Table 1: Prevalence of stunting by social groups

Prevalence rate	Number and Share of Districts
	SC-ST	UC-Hindus	OBCs	UC-Muslims
0-20	15 (2.65%)	65 (17.62%)	39 (7.66%)	6 (5.41%)
20-30	90 (15.93%)	136 (36.86%)	113 (22.20%)	15 (13.51%)
30-40	171 (30.27%)	111 (30.08%)	168 (33.01%)	32 (28.83%)
40-50	157 (27.79%)	47 (12.74%)	148 (29.08%)	44 (39.64%)
>50	132 (23.36%)	10 (2.71%),	41 (8.06%)	14 (12.61%)

Source: authors’ calculations based on NFHS-4 data, 2015-16

Table 1 shows that for SC-ST children, in 15 districts (2.65%), the average incidence of stunting is between 0 and 20%; in 90 districts (15.93%) it is greater than 20 and less than equal to 30%; in 171 districts (30.27%) it is greater than 30 and less than equal to 40%; in 157 districts (27.79%), it is greater than 40 and less than equal to 50%; and in 132 districts (23.36%), it is greater than 50%. The corresponding number and share of districts showing the spatial variation in incidence of stunting for other social groups can be seen in Table 1.

Summing up, the proportion of districts where rates of stunting are more than 40% (i.e. extremely high) are 15% for UC Hindus; 37% for OBCs; 51% for SC-ST and 57% for UC Muslims.

In terms of regional patterns, the Figure 2 shows a very clear pattern in the areas with the highest prevalence for SC-ST concentrated in the states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Rajasthan and Uttar Pradesh, as can be seen by the northern and central plains being largely red in colour. More specifically, for the SC-ST children in the BIMARU region, in 195 or 84% of the districts, the prevalence of stunting is greater than 40%; and in 105 or 44.49% of the districts more than half the children are stunted.

The BIMARU region stands in stark contrast to the southern and northern regions; not only is the prevalence of such extreme levels of stunting lower across all caste groups but also the extent of differences across caste groups are much smaller. For the upper castes, in the BIMARU region, in only 38 (16) percent of the districts, the prevalence of stunting is greater than 40 (50) percent.

For the OBCs and upper-caste Muslims, in the BIMARU region, the prevalence of stunting in 61% and 71% of the districts, respectively, is greater than 40%.

What accounts for the gaps between social groups and regions?

Many readers asked if what we were characterising as caste gaps were simply differences in socio-economic attributes. If this were true, differences in circumstances should explain the child height gaps between caste groups.

In our research, we start by examining these factors first.

We identify five important categories of factors that affect child height, namely: (i) lack of access to sanitation, captured by two variables: no household access to toilet facility and household members defecating in a bush/field; and the exposure of a household to open defecation at the primary sampling unit level; (ii) the mother’s human capital, measured by two indicators: years of schooling and ability to read, measured by an actual test; (iii) mother’s anthropometric status as captured by the HFA Z-score, the weight-for-height (WFH)-Z score and age; (iv) asset differences as captured by the wealth index factor score; and (v) intra-household allocation and fertility decisions, proxied by birth order and sibling size.

We find large intergroup differences in the covariates that affect child height, especially between UC-Hindus and SC-ST. To highlight a few, 58% of SC-ST households have no access to a toilet facility and defecate in a bush/field, compared to 23% UC-Hindus; maternal literacy is 83% for UC-Hindus compared to 51% for SC-ST; SC-ST mothers have 5.26 years of schooling compared to 9.47 for UC-Hindu mothers; and the average HFA Z-score of UC-Hindu mothers is -1.82 compared to -2.15 for SC-ST mothers.

Clearly there are large and significant differences in the environment that upper-caste and Dalit children grow up, with the circumstances being much more adverse for Dalit and Adivasi (SC-ST) children. Do these differences in socio-economic characteristics explain the child height gap between social groups?

Using Entropy Balancing, a methodology that enables us to compare like-with-like, we examine differences in stunting in “matched” samples of upper caste and Dalit children, i.e. children whose socio-economic characteristics are matched along major dimensions. We find that in our matched sample in BIMARU states, SC-ST and OBC children are likely to be shorter than upper-caste children. This suggests that the greater stunting among children of low-ranked castes is not only because of their relatively more disadvantaged circumstances.

We suggest that the gaps between Hindu UC and Dalit (SC) children is affected by societal discrimination, manifested in the illegal but widespread practice of untouchability. Dalit children’s height disadvantage increases in districts where the self-reported practice of untouchability is higher. We use data from India Human Development Survey (IHDS 2012) to estimate the association between the practice of untouchability and child height.

Figure 3 shows that Dalit children’s HFA Z-score sharply decreases in areas where the practice of untouchability is more prevalent. In contrast, there is a much weaker association between height/chronic malnutrition levels and the proportion of households reporting practicing untouchability, for upper-caste children.

We also explore the impact of the practice of untouchability on the whole pathway of child development. Our results show that the areas where households are more likely to engage in the practice of untouchability are the same areas as those where SC mothers and children are less likely to be able to access or use a whole range of antenatal and postnatal health inputs.

Also read: To Fix Childhood Stunting in India, Focus On Women’s Health: Study

Conclusions

Our results on caste-as-a-missing-link show that the caste gaps in child height are not entirely a reflection of class or socioeconomic status (SES) differences. While caste groups differ on an extensive set of covariates that are determinants of child height, we show that sizable gaps remain even when comparing samples that are balanced on the same set of covariates.

The evidence shows that the illegal, but widespread, practice of untouchability is positively associated with height gaps between upper and lower-caste (Dalit) children. In particular, variation in the practice of untouchability does not affect the height of upper-caste children, but higher spread of untouchability-related practices is associated with lower heights of Dalit children. The results, moreover, suggest a role for discriminatory practices in affecting service delivery to pregnant and nursing mothers from stigmatised groups and consequently the health outcomes of lower-caste children.

Ashwini Deshpande is professor of Economics at Ashoka University. Rajesh Ramachandran is a post-doctoral researcher at University of Heidelberg.

This Year’s Budget Is Critical to Ensure a Comprehensive Nutrition Response

One of the most disturbing effects of the pandemic has been on the nutritional needs of the disadvantaged. The Budget needs to prioritise addressing this issue.

The pandemic led disruptions of nutrition services have exacerbated India’s existing burden of undernutrition. Children did not get the mid-day meals and supplementary nutrition under the anganwadi services scheme they were registered under. Critical health services like immunisation, iron-folic acide and calcium supplementation, treatment of acute malnutrition, antenatal and postnatal check-ups, other reproductive child health checkup were halted due to restricted mobility.

Several surveys have shown that many had not earned any income during the lockdown, and the food intake by vulnerable communities significantly decreased. Quantity and quality of food consumption decreased for about 74% of the surveyed Dalit families and for about 54% of the surveyed Adivasis. Rampant exclusion errors in the targeting of welfare schemes were magnified. Though state governments instituted measures for home delivery, there were many gaps.

This negative impact of the COVID-19 crisis on nutritional indicators is over and above the reversals reported in the recent data of NFHS-5 (2019-20). The survey results covering 22 states and Union Territories present a vivid demonstration of stagnation in key child malnutrition outcomes – stunting, wasting and share of underweight children across several states. Thirteen states and UTs registered a surge in the percentage of stunted children under five years of age as compared to NFHS 4 (2015-16), whereas 12 states reported an increase in wasted children under the age of five, and 16 recorded a rise in underweight children.

One of the most disturbing effects of the pandemic has been on the nutritional needs of the disadvantaged. Though the government has been pointing to minimal disruption in the meals progarmmes due to its ‘timely interventions’, the acute need to overcome the challenges and ensuring that these do not exclude anyone remains high. At this critical juncture, when the Budget is about to be presented, we have the opportunity to adopt transformative approaches and make significant investments towards addressing the adversities and challenges that many of the country’s citizen’s face.

Also Read: Once in a Century Budget: Statement of Fact or Hope?

Direct nutrition interventions need greater public funding

The Centre and state governments share the funding required for programmes that deliver nutrition interventions. Those schemes focusing on direct nutrition interventions fall under the aegis of the Ministry of Women and Child Development (MWCD), and Ministry of Health and Family Welfare (MoHFW). The pattern of expenditure under ICDS has shown the need for higher allocation. The last Parliamentary Standing Committee report has pointed to consistent shortfalls between demands made by the nodal Ministry of Women and Child Development and allocations made to it. Considering the intensity of the problem of undernutrition in India, the design of Supplementary Nutrition Programme (SNP) needs a correction for provisions for additional measures for marginalised children, also, the government needs to budget at scale. All this necessitates that schemes important for nutrition are given a much higher priority in the upcoming budget.

Shortfalls in Allocations for Schemes of MWCD (2020-21) [In Rs crores]

Scheme	Projected Demand	Actual Allocation BE	Percentage of demand not met
Anganwadi Services	24810	20532	17%
POSHAN Abhiyan	2500	3700	48% (additional)
PMMVY	2875	2500	13%
Scheme for Adolescent Girls	350	250	28%

The proportion of total eligible population covered under the anganwadi services has been very low. It includes 48% of children, 51% of pregnant women and 48% of lactating women. To address the disruptions in food supply, additional measures must be instituted on top priority and backed by adequate resources to ensure expanded coverage and better targeting.

A stronger public health nutrition workforce

The share of the Centre’s contribution to the salary component under anganwadi services has been declining since 2017-18, when it cut down a big number of sanctioned posts. Additionally, the share of the salary component in total Central funding for the scheme has been going down consistently. This is a glaring systemic issue under the scheme, and even fiscally stronger states have vacancies at different levels. This is so as the states are not in a position to fund these posts, they have been asking for higher fiscal support for salaries in their annual programme implementation plans (APIPs). When crucial positions like that of a child development project officers (CDPOs), lady supervisors remain vacant, it hinders the implementation of the scheme and the quality of service delivery.

The institutionalised presence of AWWs, AWHs, ASHAs, ANMs proved a vital resource in our fight against the pandemic. Concerns related to their working conditions are well known: they work under a lot of pressure, do not get compensated adequately for their work. The gaps merit immediate action by the government, most importantly, their honorarium needs to raised, and tied up with adequate social security benefits.

Invest in sectors providing nutrition-sensitive programmes

Optimal nutrition is the result of the inter-connected factors relating to immediate, underlying and basic determinants. Nutrition sensitive interventions address the underlying determinants of undernutrition, and are critical in the overall policy framework for nutrition. Stagnation in nutrition outcomes occurred at a time of rapid improvement in underlying indicators of health such as sanitation and LPG access, which raises some fundamental questions. The overall assessment is that the approach of relying on programmes supporting direct nutrition interventions is not enough to deliver on targets of nutrition.

We certainly need a deeper analysis to understand the factors behind these outcomes, since the period when the survey was conducted was marked by an economic slowdown. These results are likely to have a correlation with the changes in levels of family income in that period. After all, the adverse effects of falling income have the greatest impact on the food bowls of the most vulnerable.

Also Read: Watch | Seven Things to Watch Out for in Budget 2021

The pandemic has underlined the importance of strengthening public provisioning for nutrition, health, sanitation and other interventions. The threats surrounding nutrition would continue to exist beyond the pandemic. In low-income countries, calories from nutrient-rich, non-staple foods such as eggs, and vegetables can be 10 times more expensive than calories from rice, maize and wheat (Headey and Alderman (2019).

The allocation for a set of nutrition-sensitive schemes including mid-day meals and the public distribution system was found to have reduced by 19% in the last Union Budget, compared to the previous year. Expansion of public services through investments in a range of important schemes under health, nutrition, food security, drinking water is necessary for achieving improved nutrition outcomes. Equally important is securing income through employment opportunities, and strengthened poverty alleviation programmes. The government’s response provided through the first pandemic Budget can be a good beginning to initiate steps for scaling up these programmes.

A helper assists children as she performs her duty at an Anganwadi Centre, in Kancheepuram district in Chennai, India, on Thursday, December 12, 2019. Photo: Burhaan Kinu/Public Services International/Flickr, CC BY 2.0

Revising unit costs for ICDS components is needed

The cost norms for the Centrally-sponsored schemes are fixed by the Union government. Unit costs for the different categories of beneficiaries under the supplementary nutrition programme (SNP) component of the scheme was last revised in 2017, and though the government also approved annual cost indexation for an increase in rates in future, but the rate has been stagnant since then. In line with the first report of the 15th Finance Commission (applicable for 2020-21), it is expected that this Budget factors in increased cost norms for SNP.

Further, for anganwadi centres to play their role in quality service delivery efficiently, they require proper facilities, improved power supply and adequate physical space. Towards this, the unit cost of constructing new centres needs need to be relooked. Budgetary support towards cost of construction being provided in convergence with the Ministry of Rural Development under the MNREGA must go up from Rs 7 lakh per building, as the scheme has completed four years of implementation. In recognition of this, the state governments have already been demanding that the unit cost per building be increased.

Happy Pant is with the Centre for Budget and Governance Accountability, New Delhi and can be reached at happy@cbgainmdia.org . Views expressed are those of the author, and don’t necessarily reflect the position of CBGA.

India’s Towering Food Inflation Will Make Child Malnutrition Worse

In the face of higher food prices, the subpar allocation in the 2020 Union budget for midday meal, PDS and ICDS projects are likely to worsen the health of families already on society’s margins.

For a year now, food prices have been increasing rapidly. This trend could lead to a sharp increase in malnutrition among children in India, especially those from the most marginalised families.

A large proportion of children in India are malnourished; in fact, child malnutrition in India is higher than in most countries of Sub-Saharan Africa. And even though the extent of undernutrition and stunting has decreased over the last decade or so, severe wasting – which carries the highest risk of mortality – didn’t change significantly between 2005-2006 and 2015-16, the two years in which National Family Health Survey was conducted.

Food and nutrient intake has been declining in rural India, and has been quite inadequate for optimal growth and development for some time now.

In the first decade and a half of the millennium, food inflation increased steadily in India, peaking at 14.72% in November 2013, then reaching a low of negative 2.24% in January 2019. Since then, food inflation has been rising again and was 14.12% as of January 2020.

In general, food prices have been climbing faster than the prices of other commodities. So even when one’s income rises enough to offset retail inflation (although not for the vast majority of people working in the informal sector), a family will still be able to afford less and less food every year.

Further, the price of nutritional food items in India has been increasing faster than the price of a typical food basket, with the gap only widening over time. So without an increase in incomes, families become less able to buy and eat nutritious food.

Poorer people spend a higher proportion of their income on food and have a lower capacity to adapt to price rise. As a result, it is not surprising that food inflation and child malnutrition levels are closely related.

For example, a study published in August 2015 reported evidence that food inflation was strongly linked to a 10% increase among 1,918 children in wasting between 2006 and 2009. Another group of scientists concluded, based on a study in Mozambique, that the very high food inflation in the country in 2008 and 2009 was responsible for 39,000 more moderately underweight and 24,000 more severely underweight children being born. A study in Ethiopia, published in January 2017, found that food prices increase, malnutrition could begin in the mother’s womb itself.

The authors (of this article) have registered increasing malnutrition on a monthly basis since July 2019 in South Rajasthan, where they have been monitoring the growth of children under three years of age in select villages.

Allocations for PDS and midday meals

In the 2020 Union budget, the allocation for the midday meal scheme has stagnated at Rs 11,000 crore; that for the public distribution system has been cut from Rs 1.84 lakh crore in 2019 to Rs 1.15 lakh crore. The budget for the Integrated Child Development Scheme (ICDS) increased moderately from Rs. 27,584.37 crore to Rs 28,557.38 crore.

In the face of higher food prices, these figures are likely to exacerbate the living and health conditions of families already on society’s margins.

Aside from policy measures to reduce the price of food items, the government also has to urgently avail more types of nutritious food, such as pulses and eggs, through the public distribution system and through anganwadis and the midday meal scheme. And to make up for cuts in the Union budget, state governments should set aside higher sums for ICDS, midday meals and food subsidies. Andhra Pradesh, Karnataka and some other states already have systems in place to provide nutritious food to expectant mothers; other states should also follow suit.

Finally, civil society should be vigilant and monitor the availability of food at the household level, ensure strong links with public entitlements and continue to advocate for higher allocations on schemes that ensure availability of good food at difficult times.

Dr Pavitra Mohan is the founder and Dr Sanjana Brahmawar is the director of nutrition, both at Basic Healthcare Services.

Promoting Edible Insects to Improve Nutrition and Protect Lemurs in Madagascar

One programme is testing the farming of sakondry – a little-known hopping insect that tastes a lot like bacon – as part of broader efforts to boost entomophagy to reduce malnutrition and protect biodiversity.

Masoala Peninsula, Madagascar: It’s a lovely walk from the village of Ambodifohara to BeNoel Razafindrapaoly’s field. Nestled at the foot of the mountains of Masoala National Park in northeastern Madagascar, the rainforest tumbles down toward the sea, a fringe of smallholder plots the only barrier between these two elements. Everything seems to grow here: fruit trees (mango, papaya, guava), cash crops (clove, coffee, vanilla), staple crops (rice, yam, sweet potato). Everything is luminescent green, courtesy of the abundant rain and even more abundant sunshine.

Here, Razafindrapaoly has planted tsidimy, a native bean plant, to attract a small hopping insect called sakondry. Hardly anything is known about this insect, except that it’s edible, and most importantly, delicious.

A juvenile sakondry. Photo: Emilie Filou/Mongabay

That was enough to grab the attention of Cortni Borgerson, an anthropologist at Montclair State University in New Jersey, who has been studying the interactions between ecosystems and human health in Madagascar for 15 years. Her work has included the question of why people hunt endangered species, which conservationists have struggled to remedy. She is now leading a three-year programme titled Sakondry to see whether farming the insect and therefore increasing its consumption, could solve the twin challenges of malnutrition and biodiversity loss.

Also read: Forest Communities Pay the Price for Conservation in Madagascar

For despite the appearance of abundance and the stunning primordial landscapes, Madagascar faces serious human and environmental challenges. Three-quarters of the population live on less than $1.90 a day, and nearly half of children under the age of five suffer from stunting due to malnutrition, one of the highest rates in the world. In desperate times, “people turn to what they have, which is the forest,” said Borgerson. Her studies show that in some villages, 75% of animal-source foods come from forest animals, including lemurs. With 94% of lemur species threatened with extinction, this is unsustainable.

Borgerson also found that child malnutrition was higher in households that hunt lemurs, a strong indication that bushmeat is a last resort for families who have little else to eat. Another study by Christopher Golden, assistant professor at the Harvard T.H. Chan School of Public Health, shows that removing access to wildlife would lead to a 29% increase in the number of children suffering from anemia and a tripling of anemia cases among children in the poorest households.

A white-fronted brown lemur (Eulemur albifrons) on Masoala Peninsula. Photo: Rhett A. Butler/Mongabay

“You can see that there is a clear correlation between malnourishment, food insecurity and lemur hunting,” Borgerson said. “But that also makes it very solvable: we just need to solve what you put on top of your rice. If we can fix this, people will shift off,” she said.

Local people are also becoming aware of the value of wildlife protection for tourism: “It’s important to keep lemurs for tourists,” said Lorien, a resident of Ambodifohara. The village is the gateway to Masoala National Park. Most of the 3,000 or so tourists who make it to Masoala each year, therefore, pass through the village. There are a handful of lodges nearby and the village has benefited from employment opportunities, financial support for the school and even the installation of a micro-hydro turbine, which provides free electricity.

Also read: Meet the Professor Who Thinks Dinners of the Future Should Include Insects

Insects are widely eaten in Madagascar, locusts and beetles being the most popular. In Masoala, Borgerson found that 60% of households have eaten insects in the last year, with sakondry the favourite. Insects also happen to be incredibly nutritious, containing high levels of protein, minerals and vitamins (see graph).

insect_nutrition
Infogram

Borgerson’s project, which is funded by the IUCN’s Save Our Species initiative, will, therefore, plant tsidimy, the sakondry host plant, hone farming techniques and monitor nutrition indicators as well as wildlife hunting at three test sites on the Masoala Peninsula. Its stated goal is to improve rural nutrition and food security in ways that reduce targeted lemur hunting by at least 50%. The project started last December, with villagers at the test sites planting more than 4,200 tsidimy plants. Early estimates suggest that more than 52,000 sakondry have now taken up residence among their leaves.

Borgerson said the priorities over the next few months are to understand the limitations of the current traditional farming system and to study the insect. “It’s amazing how much we don’t know,” she said. “We’ve established the genus, a Fulgorid planthopper, but we can’t tell male from female; we don’t know when females lay their eggs. We want to look at the life cycle, parasites, diseases etc.”They don’t even know what it eats: although sakondry lives on the native bean plant, it doesn’t feed on it. All this information will help Borgerson and her team develop and test enhanced farming techniques.

Female crickets lay their eggs at Valala Farms. Photo: Emilie Filou/Mongabay

Other insects

The Sakondry programme is part of broader efforts to boost entomophagy in Madagascar to reduce malnutrition and protect biodiversity. In Antananarivo, Madagascar’s capital, Valala Farms has been selling its cricket powder since 2018 to humanitarian organisations that provide free school meals in the capital and famine relief in the south of the country

The farmhouses about a million crickets at any given time, and produces around 60 kilograms (132 pounds) of powder per week, in a facility of just 100square meters (1,076 square feet).

If this sounds like a small footprint, it is pound for pound, insects require less land, less water and less feed than other meats (see graph). They also produce fewer greenhouse gases.

A staffer shows off a cricket at Valala Farms. Photo: Mongabay

Brian Fisher, an entomologist at the California Academy of Sciences and one of Valala Farms’ founders, said that although the farm’s cricket powder will ultimately serve a predominantly urban market, the community element is fundamental to its work.

“You need breakfast before conservation,” he said. “We want to provide tools for conservation activities … We are thinking about replicability for local people, about community initiatives like Sakondry. Perhaps they could raise crickets for us to process or for their own consumption. It’s a much more powerful story if we can get local people involved.”

Back on the rolling fields of Ambodifohara, Razafindrapaoly, who is Borgerson’s project manager, is head-deep in his tsidimy (“never five” in Malagasy, because you only ever find four or six beans in the pod) looking for sakondry. These “wild fields” currently produce around a cup of insects per household every few days, but Borgerson reckons this could increase significantly once the plants get bigger and they tweak the rearing system.

Razafindrapaoly picks juveniles (the tastiest, he said), which are covered in a bizarre-looking plume of white dust. Once home, he washes off the dust, pinches their head to kill them and pops them in a pan with a little water and salt. “You can eat them in sauce, fried, with leaves or with rice but this is the best way,” he said. To Western palates, sakondry tastes like bacon or peanuts.

Virtually every household in the village is taking part in the programme. Lorien said he liked the idea of planting tsidimy to attract sakondry. “It’s food growing over food,” he said.

Be Denis with his chicken in front of a large tsidimy plant. Photo: Emilie Filou/Mongabay

Be Denis, a neighbour, said that although he’s eaten sakondry before, it’s always been quite opportunistic. “It’s not like fishing where you think, ‘the sea is calm, let’s go out,’” he said. “But it will become a bit like [fishing] with tsidimy because you go pick beans and you look for insects at the same time.”

Borgerson’s goal is to develop a system that is productive but doesn’t require much money or monitoring. “We’d like to produce a pictographic user manual, maybe one in the local language, with everything from best practice to troubleshooting,” she said.

A new chicken vaccine

Ambodifohara is also the test site for another conservation and nutrition initiative: a new poultry vaccine against Newcastle disease, a virus that decimates chickens. The vaccine is the brainchild of Madagascar Health and Environmental Research (Mahery), a research organisation set up by Golden.

Golden, like Borgerson, has been working on the intersection of human health and the environment in northeastern Madagascar since 2004. Over the course of his research in Makira Natural Park, another protected area in northeast Madagascar, Golden found that wildlife was widely hunted, with 16% of the population hunting bats, 23% hunting bush pigs, 40% hunting endemic carnivores like mongoose, 49 % hunting lemurs and 91% hunting tenrecs, small mammals that resemble shrews or hedgehogs. Golden also ran taste preference studies and found that although bushmeat ranked high, people’s favourite meat was, in fact, chicken.

BeNoel Razafindrapaoly feeds his chickens. Photo: Emilie Filou/Mongabay

Yet because of the presence of a virulent strain of Newcastle disease, chickens were not readily available. A vaccine does exist, but it requires a cold chain and a trained veterinary technician to inject it, two major obstacles for its use in remote areas such as Masoala or Makira. Mahery, in partnership with the Malagasy Institute of Veterinary Vaccines and vets from the US and Australia, therefore developed a vaccine tailored to the realities of rural Madagascar. The new vaccine, called I-2, is thermostable and administered as an eye drop.

“Thermostable doesn’t mean you can keep it in a hot truck for days, but it’s definitely better than the other one,” said Golden. Its big advantage is that eye drops can be administered by community vaccinators, basically local people who have been trained in the procedure. “That’s a gamechanger when there are only about 100 vets in the whole of Madagascar,” said Golden. Unlike its competitor, I-2 offers the potential for herd immunity, meaning that if a high enough percentage of animals are vaccinated, even those that aren’t vaccinated are protected.

Also read: Why Are so Many People Getting a Meat Allergy?

Mahery has been vaccinating chickens at eight test sites since 2016. Razafindrapaoly is a master vaccinator for the programme: he vaccinates and also trains community vaccinators. He said that although some families were initially reluctant to get their birds vaccinated, they quickly came around when they saw that immunised chickens didn’t succumb to the disease.

His only concern is the price. During the trial, the vaccine was sold at just 100 ariary (three US cents) per chicken, but its real price is likely to be 600 to 900 ariary (16 to 25 cents). With families having on average 15 chickens and the need to vaccinate every four months, it adds up quickly. “Livelihood is low around here; if the price increases, perhaps fewer families will vaccinate, or they won’t vaccinate all their chickens,” Razafindrapaoly said.

Lorien with one of his chickens. Photo: Emilie Filou/Mongabay

Golden said that one of the ways they’re trying to mitigate that is by embedding the vaccine into a larger chicken husbandry program that will give people a better understanding of how best to rear chickens.

Ambodifohara residents aren’t concerned, however. “Nine hundred ariary is nothing compared to losing a chicken,” when a fully grown bird sells for 20,000 to 25,000 ariary ($5.50 to $7), said Lorien, who lost ten chickens to Newcastle disease a few years ago. Be Denis agreed, going so far as suggesting that “people might forget to eat sakondry if chicken becomes plentiful.”

Razafindrapaoly said he thinks both initiatives are important: “Sakondry and chicken are parallel because you can’t eat chicken every day, they need time to grow,” he said. Both also offer income-generating streams on local markets, with the sale of eggs, beans, and insects.

The question is whether these initiatives will have an impact on bushmeat consumption. It is too early to tell with empirical data for Mahery and Sakondry. But the villagers, for their part, are convinced. “The reason people look for bushmeat is that there is nothing to eat: if there is bad weather, you cannot go fish,” said Razafindrapaoly. “But if there is sakondry and beans, you’re OK, and you don’t need to go to the forest.”

Lorien agreed. “People eat lemur to put on top of their rice; if there was plentiful meat through sakondry, chicken and fish, people would not need to eat lemur,” said Lorien. “Eating lemur is a sign of poverty.”

This article was republished from Mongabay under Creative Commons.

Global ‘Pandemics’ of Undernutrition, Obesity and Climate Change Are Interlinked

A new report in the ‘Lancet’ describes the intersection of the three issues as the world’s “paramount health challenge.”

New Delhi: The premier British medical journal, The Lancet, has identified a “global syndemic”, or a synergy of epidemics”, approaching human societies, which links the poor management of nutrition with a worsening natural climate.

The original mandate of the commission behind the report was to look only at obesity. Its research and deliberations, however, led to the “reframing of the problem and expansion of the mandate” to these other two, interlinked pandemics.

The Lancet Commission’s report tries to see all these issues as related to each other, and not separately as government policy often views them.

Globally, undernutrition has been declining too slowly to meet any targets. No country has been able to reverse the growing obesity epidemic, and public policies world over are insufficiently countering climate change. The reasons, which the report identifies, include opposition by vested commercial interests, misplaced economic incentives, lack of political leadership and insufficient social demand for change.

Earlier this month, the Lancet’s EAT Commission also released a similar report on different diet choices and their impact on the environment.

How bad is the global syndemic?

Stunting and wasting from undernutrition are thought to affect 155 million and 52 million children worldwide. Eight hundred and fifteen million people are estimated to be undernourished. Taken together, Asian and African states spend about 4.11% of their gross domestic product (GDP) on dealing with the costs of undernutrition.

At the same time, more and more societies are struggling with obesity – excess body weight affects about two billion people worldwide and causes four million deaths. “The obesity pandemic has shifted the patterns of malnutrition,” the report says, as high-income countries have felt the burden of epidemic obesity since the 1980s, while low-income countries have continued to suffer malnutrition.

Also read: Without Tackling Hunger and Malnutrition, India’s ‘Acche Din’ Will Remain Stunted

High-income countries – with their large burdens of obesity and their larger carbon footprints – engage in more environmentally damaging practices of food production and diet, such as the rearing of animals for consumption and the prevalence of packed and processed food.

Bad food-production practices contribute heavily to climate change. Agriculture alone contributes 15-23% of greenhouse gas emissions. Along with land conversion, food processing and waste, that figure goes up to about 29%.

The pandemics in India

“Until now, undernutrition and obesity have been seen as polar opposites of either too few calories or too many,” says Dr Shifalika Goenka, one of the commissioners on the report. “Similarly, climate change has been viewed as separate. In reality, they are all driven by the same systems and policies.”

India has fared poorly on the problem of nutrition for years. The Global Hunger Index ranked India at 103 among 119 countries last year, dropping three spots from 100 in 2017. (The index is based on four factors: undernourishment, child mortality, child wasting and child stunting.) Other South Asian countries do better – India ranks well below neighbours like China (at the 25th spot), Nepal (72), Sri Lanka (67) and Bangladesh (87). Pakistan placed 106th.

The government’s National Family and Health Survey data states that 38% of children under five years are stunted, 21% are wasted and 36% are underweight.

Being overweight is also a risk factor for diabetes and the number of people with the disease in India increased from 26 million to 65 million between 1990 and 2016.

The news on climate change is not much better. The World Bank said last year that 600 million people live in locations that could either become moderate or severe hotspots by 2050 – which will have devastating effects on agricultural output and food security.

The thrust of the Lancet report is how the interactions between these three issues may play out – for example, Goenka explains, climate change increasing food insecurity and thus undernutrition, or fetal and infant undernutrition increasing the chances of adult obesity.

Why the Modi Govt Shouldn’t be so Quick To Dismiss World Bank’s Human Capital Index

The finance ministry can continue to quibble, but the stark fact is that decades of underspending in education and health may result in India wasting its demographic dividend.

On October 11, the World Bank launched the latest of its country rankings: the Human Capital Index (HCI).

The objective of the index is to show how low education and health outcomes – or human capital – impact productivity, growth and prosperity. The ranking of 157 countries is also a way to “name and shame” governments that do not prioritise investments in human capital. India, unsurprisingly given its notoriously poor commitment on both health and education, is amongst the countries that have little to celebrate and much to improve.

The HCI has three main components, which, taken together, compose the overall score. One, survival rates, measured as children’s probability of seeing their fifth birthday. Two, education, both in terms of the average number of years that children can expect to go to school and in terms of how much they are actually learning.

Three, health, as measured by the proportion of children who are not malnourished and the probability of a 15-year old to live through her entire working age and celebrate her 60th birthday.

Also read: India Ranked 131 on Human Development Index; Inequalities Continue

The overall score for India is 0.44, whereas the highest country in the index (Singapore) has a score of 0.88 and the lowest (Chad) has a score of 0.29. What these numbers mean is that, in the case of India, a child born today will become 44% as productive an adult as she could be, had she lived in the country of Utopia where all children enjoy full education and full health (where the score would be 1).

India is ranked 115 out of 157 countries in the index, below the world average and below the average for South Asia. Quite remarkably, much poorer neighbouring countries like Bangladesh and Nepal score better than India. Even compared with its peers in terms of GDP per capita, India’s score is lower than the average of middle-lower income countries.

This should not come as surprise, as India has a long and problematic history of virtually no investment in human capital during the colonial period, followed by greater but still very low commitment to human capital formation by successive Indian governments. India’s combined public expenditure on health and education, for instance, (4.71% of the GDP) is nearly half of that of East Asian countries or Latin America. China, on the contrary, which invested heavily in health and education after the Maoist revolution, despite being as poor as (if not poorer than) India, today ranks 46 in the HCI index.

India is ranked 115 out of 157 countries in the index, below the world average and below the average for South Asia.

Whereas India does not come in the top 50% for any of the indicators, the two most problematic areas – those that bring down the HCI the most – are child malnutrition and the quality of education. Only 16 countries in the index have a higher proportion on stunted children. These are either some of the poorest countries in the world (mostly in Sub-Saharan Africa) or war-torn countries like Afghanistan and Yemen.

The terrible record of India in ensuring the well-being of its children should be treated as a national emergency. According to the latest Family and Health Survey, as many as 38% of the country’s children aged 5 or less are stunted. Malnutrition during the first two years of a person’s life has irremediable consequences in terms of cognitive and physical development and has severe repercussions on their ability to become healthy and productive adults.

A recent World Bank report estimates that about two-thirds of today’s workforce in India earns on average 13% less than what they would have if they had not been stunted during childhood. Another World Bank study calculates that malnutrition costs India between 2 and 3 percentage points of GDP each year. This translates into billions of dollars of lost economic growth and into millions of people not able to escape poverty and deprivations. What the HCI shows is that these losses of productivity will continue to constitute a massive drag on growth and prosperity, severely limiting India’s ability to reap the benefits of its demographic dividend.

The second area that needs immediate policy attention is education. Article 45 of the Constitution stipulates that “the State shall endeavour to provide, within a period of ten years from the commencement of this Constitution, for free and compulsory education for all children until they complete the age of fourteen years”. This was translated into law only in 2009 when the UPA government passed the Right to Education Act – with a delay of almost 50 years. The passage of the RTE Act did make a difference, and today virtually all children (both girls and boys) attend school for at least a few years. However, the quality of education is still very low.

Only 20 countries in the HCI ranking – again mostly in Sub-Saharan Africa – perform worse than India in terms of educational outcomes. While the HCI figures should be taken with a pinch of salt, these results are in line with the findings of the latest ASER report , according to which 25% of youth in rural areas aged 14-18 cannot read fluently a simple text in their own native language and nearly 60% cannot make a simple division.

The bit of good news coming out of the HCI is that, at least in the indicators used to construct the index, differences between boys and girls are negligible. Girls have the same probability of boys of surviving until their fifth birthday and perform better than boys at school. They are also more likely to live up to the age of 60. This does not mean that gender imbalances have disappeared or that boys and girls have the same kind of opportunities in their lives. But it does mean that the Indian state has been able to bridge the gender gap at least in these (very basic) dimensions of people’s lives.

Unfortunate view

Sadly, the government of India has dismissed the report with the ministry of finance issuing a statement that criticises its methodology.

The ministry makes three points. The first is that the HCI does not take into account GDP per capita. This would have arguably brought India higher up in the ranking (as it happens with the Human Development Index, where income is one of the main components).

However, it is not clear why the HCI should have included a measure on income. As the data provided on the Human Capital Project’s website shows, income on the one hand, and educational and health outcomes on the other, do not necessarily go hand in hand. India is a case in point, with lower educational and health outcomes than what its GDP per capita would predict. Vietnam, on the other hand, has much better outcomes, relative to the size of its economy. Arguably, one of the objectives of the report was precisely to highlight educational and health outcomes, irrespective of a country’s wealth.

Also read: How Methodology Tweaks, Not Modi’s Magic, Boosted India’s Doing Business Rankings

The second objection to the HCI’s methodology is that the data used for assessing the quality of education is questionable at best. This is a fair point, as comparing test scores across countries is quite a difficult thing to do and the World Bank’s result is far from perfect. But it is not clear why the methodology used should penalise India more than other countries.

It is also a bit preposterous that the finance ministry’s statement complains that the quality of education figures are the result of test scores taken in only two states (Himachal Pradesh and Tamil Nadu). I do not recall the ministry complaining about the Ease of Doing Business Ranking’s methodology which is based on data taken from only two cities (Delhi and Mumbai). Perhaps the fact that India performed really well in the latest ranking might explain why in that case using very selective data was deemed appropriate then. Secondly, Himachal Pradesh and Tamil Nadu are two of the most highly developed states in the country, so, if anything, using these two states should have been over, rather than under estimated India’s performance.

The third criticism is that the index does not take into account recent initiatives like Samagra Shiksha Abhiyan or the Swachh Bharat Mission and even Aadhaar, when calculating the index. It is not clear why it should have.

The HCI is an index that measures outcomes – like virtually all composite indexes – and not the tools to reach the outcomes. As such, it does not say anything about the present government’s effort to develop human capital. What it does say is that decades of underspending and under-commitment to education and health resulted in a situation where India is at serious risk of wasting its demographic dividend. And this is true irrespective of any methodology.

Diego Maiorano is a Research Fellow at the Institute of South Asian Studies, National University of Singapore. Views are personal. He tweets at @diegoemme

Experts on US Opposition to Breastfeeding and What’s Next on the Agenda for Nutrition Advocates

Activists believe Donald Trump has joined an American tradition of opposing policies that encourage breastfeeding in favour of supporting the milk-substitute industry.

The Trump administration came under fire for efforts to undercut guidelines that encourage exclusive breastfeeding at this year’s World Health Assembly (WHA) in May – something Malnutrition Deeply reported shortly after it happened

Trump pushed back on Twitter, insisting that “the U.S. supports breastfeeding but we don’t believe women should be denied access to formula.” Many activists and experts disagree.

They say he has joined an American tradition of opposing policies that encourage breastfeeding in favour of supporting the milk-substitute industry. Malnutrition Deeply asked nutrition experts and practitioners about this history and how the lessons from the WHA will help guide their future approach to this issue.

We are also eager to hear from you about how you think exclusive breastfeeding supporters should respond to this situation. Tell us here.

Aunchalee Palmquist, assistant professor, Gillings School of Global Public Health at the University of North Carolina

Advocates need to be aware that there is a lot of potential for conflicts of interest with commercial industry in the field of nutrition.

When the resolution to adopt the International Code of Marketing of Breast Milk Substitutes was introduced in 1981, the US was the only country that opposed it and voted against it. And in the convening years, there hasn’t been active opposition against similar resolutions. This year was unique in the sort of direct lobbying and pressure on member states who were planning on supporting it, to not endorse it.

The US, according to a 2016 report, has never had and does not have any legislation related to the Code or provisions that offer any kind of enforcement of the Code. And the WHO Code was designed to help strengthen member states’ ability to prevent the predatory marketing of breast milk substitutes and other related infant feeding products. So the WHA resolution provides guidance for member states, but then member states can put in different official legislation and policy around it, but the US doesn’t have anything in place.

Some have argued that these kinds of actions are linked directly to protecting the interests of the multibillion-dollar dairy industry.

Palmquist Aunchalee. Credit: sph.unc.edu

I think the ongoing work for practitioners is reiterating in any way that they can that breastfeeding is a public health priority. It’s a public health nutrition priority, and there need to be supports in place to protect breastfeeding.

And in advocating for breastfeeding, it doesn’t mean that people are anti-formula feeding, and I think clarifying misconceptions around what the WHO Code is, and what the Baby Friendly Hospital Initiative is and what it does, is really important. Nutrition advocates, including those who focus on breastfeeding, can continue to work to ensure that accurate messages are getting out into their communities of practice, to the public and to their government representatives. Governments and healthcare institutions also have the responsibility of ensuring that families are able to make infant feeding decisions based on the highest quality of scientific evidence and are not unduly biased by the commercial and political interests of industry, including unethical marketing. Breastfeeding protects mothers and infants from malnutrition and poverty.

The WHO Code and BFHI provide guidance and implementation recommendations for protecting the right to breastfeed by putting into place safeguards against aggressive marketing of formula companies. These guidance documents are not anti-formula feeding and in no way prevent a parent’s access to formula feeding when it is medically indicated or is a parent’s choice. We need more organisations and advocates to get involved in the WHA resolution process in Geneva since it is dominated by industry and there is high potential for burnout by the few individuals and orgs who represent the public health perspective on Infant and Young Child Feeding (IYCF).

(Palmquist spoke to Malnutrition Deeply in her personal capacity.)

Mary Champeny, programme officer, ARCH Research and Communications

There is a very clear next step: and it’s especially a rallying cry for and middle-income countries.

The November Codex Alimentarius Commission on Nutrition and Food For Special Dietary Uses meeting is, where member states and organisations will be reviewing and hopefully finalising the standard for follow up formula. For the past several years we’ve been involved in a long-standing policy process, revising this food standard. Our advocacy has focused on briefing country advocates on the issue. These are countries in official observer standing with the WHO and the FAO, which make up the Codex Alimentarius.

Mary Champeny. Credit: Twitter

Fundamentally, we believe that the products that function as breastmilk substitutes need to be all defined as breast milk substitutes and then regulated as such, which is really a big policy win that we achieved with the World Health Assembly Resolution 69.9 in 2016, and which was part of why the infant and young child feeding resolution at this past World Health Assembly was so controversial because it made direct reference to that previous policy.

There’s a large, well-resourced coalition of EU countries and other western industrialised nations that have either large dairy industries or powerful formula manufacturers. They have big delegations, and you can expect that they will have a polished and well-articulated argument that these milks for older children are not breast milk substitutes, and that they don’t need to be regulated under the code.

We need to see other countries show up to the meeting, as every country gets a vote. We need to get as many countries as possible to be informed on this issue, to send representatives from their government to this meeting in Germany in November, and be willing to stand together in a united front against what we expect to be strong opposition, based on what we’ve seen in the past. It’s especially a rallying cry for middle-income countries – and it’s time to get there and to speak up.

We want to see this Codex Alimentarius standard for follow up formula; we want to see it aligned with that World Health Assembly resolution, with all of the WHO language that says that a breast milk substitute is any milk-based product that replaces or functions as a breast milk substitute in the diet of children from zero to 36 months of age. That’s a sticking point for many industrialised countries where the formula manufacturers are based.

We anticipate lots of lobbying at this November meeting, and expect to see the same flavour of opposition that we saw at WHA. That’s also because industry is more represented at Codex. Part of the Codex Alimentarius mission to protect public health and consumer interest, and then the other part of it is to act in the interest of trade. They’re setting these standards that are supposed to be applied globally. The World Health Assembly is focused on health issues whereas Codex’s scope is broader, and offers more of a role and opportunity in the conversation for the private sector.

This article originally appeared on Malnutrition Deeply. You can find the original here. For important news about malnutrition and the ideas to end it, you can sign up to the Malnutrition email list.