Excerpt from MFC e-group discussion

Background: In India, around half the children under five are underweight and stunted, 30% of newborns have low birth weight, and over 70% of the women and children in the country are anemic.  Undernutrition among the SC and ST community is around 60%.  These figures are worse than the current malnutrition figures from Sub-Saharan Africa.

 

This essay juxtaposes two different views of child undernutrition and health indices in India. One is a neoliberal economist’s view on how the much-publicized view of child undernutrition is simply a wrong reading of statistics, and how we must now put this fetish behind us.  The other is a narrative arguing that the reality on the ground is in fact worse than the bare statistics suggest.

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Extract from Tehelka Interview of Arvind Panagariya by Akshai Jain (End November, 2012)

 

http://tehelka.com/once–we–do–our–malnutrition–numbers–correctly–we–will–find–that–india–has–no–more–to–be–ashamed–of–its–malnutrition–level/

 

It’s a series of statistics that have been repeated so often that they are now accepted as fact — nearly half of Indian children under five are malnourished, a proportion that is higher than that of most countries in Sub-Saharan Africa. And, more than a third of the world’s malnourished children under five live in India. These statistics have been reinforced recently by the 2012 Global Hunger Index, according to which India ranks second to last on the number of underweight children — below Ethiopia, Niger, Nepal and Bangladesh. Arvind Panagariya, professor of Economics at Columbia University and former chief economist at the Asian Development Bank, has been arguing that though malnutrition, both child and adult, is a problem in India, these figures are highly exaggerated. Ahead of the publication of his book India’s Tryst with Destiny: Debunking Myths that Undermine Progress and Addressing New Challenges (co-authored with Jagdish Bhagwati), the economist elaborates on these claims and more in an exclusive interview with Akshai Jain. See below:

Question: In a series of papers over the past year, you have argued these statistics are a complete myth, a gross exaggeration at the very least. Why do you think so?

 

Answer: When two sets of indicators [mortality rates and undernutrition figures] lead to diametrically opposite conclusions, you either have a reasonable explanation for it or must reject one set of indicators. When we compare Indian children to those from Sub-Saharan Africa (SSA) in terms of life expectancy, infant mortality rate (IMR), under-five mortality rate and maternal mortality rate (MMR), they look significantly healthier than the latter. But the picture of India’s development turns on its head when we compare them in terms of incidence of stunting (low height for age) and underweight (low weight for age). The contrast is nothing short of dramatic. Compare India with Chad, which has half of India’s per capita income. Using 2009 data, Chad has life expectancy at birth of 48 compared with India’s 66, IMR of 124 per 1,000 live births relative to India’s 50, MMR of 1,200 per 1 lakh live births in relation to India’s 230 and under-five mortality rate of 209 per 1,000 live births in contrast to India’s 66. Every one of these indicators places the health of Indian children miles ahead of those from Chad. Yet, child malnutrition indicators say that the proportion of children stunted and underweight is higher in India than in Chad!

Even more shocking is the comparison between Senegal and Kerala. With life expectancy of 74 years, IMR of 12 and MMR of 95, Kerala is the crown jewel of India when it comes to health. In comparison, Senegal exhibits a life expectancy of 62 years, IMR of 51 and MMR of 410. Yet, we are told that Kerala has a higher proportion of stunted and underweight children than Senegal. It cannot get more absurd than this.

Question: Where are we going wrong?

 

Answer: We have been applying a uniform World Health Organisation (WHO)-specified height to decide whether or not a child of a given age and gender is stunted. And similarly, a uniform WHO-specified weight to decide whether or not the child is underweight, regardless of the child’s race, socio-cultural background, geographical location or time or vegetarian versus meat diet. Any failure to meet the WHO-specified standard is attributed to malnutrition and the child classified as malnourished. But what if Indian children are on average genetically shorter and lighter than the population from which the WHO standards are derived? Then, even perfectly healthy Indian children would be classified as malnourished just because they fail to meet the height and weight standards derived from the WHO population that is taller and heavier on an average.

Question: So well-nourished populations may not be similar in height and weight?

 

Answer: My reading of the evidence is — not by a long shot. Japanese men and women are about 12 cm shorter than their Dutch counterparts. The differences are not limited to adults. A 2006 study of infants born to Indian mothers in the US during 1995 to 2000 finds higher incidence of low birth weight and small-for-gestational age, and yet lower infant mortality rates for most part than the children of white mothers. A study of Moroccan children in the Netherlands show that the height gap between the latter and the Dutch children can be observed as early as two years of age. The gap eventually rises to as much as 9 cm.

Question: When did you first begin to doubt the Indian statistics? Why?

 

Answer: I’m not an expert on health, let alone child nutrition, by any stretch of imagination. But soon after my 2008 book, India: The Emerging Giant, in which I reported vital health statistics with approval, I began to notice the exceptionally poor child nutrition statistics and felt they could not be reconciled with the former. But I seriously focussed on the issue only when I took upon myself to write the chapter on health in a jointly authored book on the performance of Indian states. That is when I noticed that Kerala showed worse child nutrition statistics than many SSA countries and that, in turn, led me to dig deeper into the methodology leading to these absurd comparisons.[…]

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Dear Friends,

It is interesting how economists like Arvind Panagariya who profess they are not experts in the subject, anyway go ahead to decide that stunting/child underweight and mortality statistics should go hand in hand. When they don’t go hand in hand, these ‘non-experts’ decide to reject one (stunting and underweight) in favour of the other (mortality) simply because they don’t form a neat statistical picture.  You do not find a correlation between undernutrition and mortality in India because of a health care system that has been set up to address acute and critical health problems.  When a child or mother goes to the government health set up with a medical crisis, the system does the minimum job of keeping them alive.  This is done by the curative system established to prevent maternal and child mortality.  Even an undernourished child benefits from this system in so far as it is kept alive.  However, this emergency machinery does not deal with the chronic issue of hunger, undernutrition, underweight and stunting.  Here the poor are left to cope through their own meager resources. For this reason, the cause for death and malnutrition in India do not go hand in hand, and they can’t be counter-posed or mapped on each other.  These two indicators side by side expose the emaciated underbelly of the India Shining story.

The doubts about Indian standards reported by Panagariya have been resolved with the new WHO Standards where India was one of the centers. The data which was generated on child growth in India, showed that given ideal conditions of food etc., Indian children grow tall and put on weight which is on par with other nations.  His examples from Japan and Morocco and of Indians living in the US betray his ignorance of human growth and physiological development.  It takes 30-40 years of elimination of dietary inadequacy for a population to achieve its maximum height potential.

I agree that there is a fatigue caused by looking at this data, and this is because we are looking at the wrong end. For too long we have these figures hammering us, with the UNICEF WHO pictures of clinging starving children making it worse.  I can see that it distracts from the India Shining story. However the struggle of mothers to feed the kid a decent meal with wages that do not allow the luxury of even buying milk, has not been recorded (and some states which will not allow the use of eggs for kids in the ICDS in the name of Indian culture)!

Our economists like clean secondary data where everything is given to them on a platter, and we obliging nutritionists have simplified it for them with the concept of calories.  We have pandered to their discipline, the result is that now these economists cannot be bothered about the starving face of the India Shining story. I think these economists should for once in their lives struggle to look at intakes in empirical descriptive studies (which also permit precise measurement of nutritive components) where the picture is messy.  Read on for an observational, narrative account of what isn’t captured by neat numbers:

7.00AM   Gita wakes up, crying… mother puts her to the breast to pacify her (Gita is 2 1/2 years old and the breast is dry) and mother continues to do housework.

8.00AM   Gita is whining… mother gives her a few sips of tea from her cup… and continues to do her work.  Cleans the kid.

9.00AM   Gita continues to whine… mother places a piece of roti in front of her… rushes to work, elder sibling Manga takes over. The roti is uneaten – in any case it was so dry.

10.00AM   Child is carried around by Manga, and consoled with a packet of Tiger   biscuits (Rs.2). God bless Glaxo, or is it Britannia?

12.00PM   Mother returns, cooks rice and some tomato chutney (Gita is still whining). She sits down to eat, serves Manga, and shoves morsels into Gita’s mouth. Gita eats as long as the mother does.

2.30PM   Mother washes up and leaves for work. Gita is dozing off.

4.30PM   Gita is up and crying, mother is back, scolds her, puts her on her breast, keeps working, hands her over to Manga… who plays with her friends, Gita on her waist.

6.00PM    Gita gets a bun from the tea shop, stops crying, she is beaming and plays with other kids.

8.00PM     Dinner is ready; Gita eats a few morsels as the mother serves rice and rasam to her husband and Manga. Mother eats and tries to give Gita a few more morsels… who has lost interest, and is running away.

10.00PM   Mother washes up, consoles a wailing Gita, puts her to her breast, and Gita is fast asleep.

11.00PM   Mother goes to bed.

Now what do I say?

Warmly,

Veena Shatrugna