Malnutrition: poor economics with poor humanity

In the last year, several reports of deaths of tea workers in North Bengal went largely unnoticed -- till November 7, 2015, when the Chief Minister of West Bengal finally admitted at a meeting she chaired with the GoM (Group of Ministers) that “malnutrition” was indeed a factor in these deaths. She also created a task force to address the issues of poverty among workers of “distressed tea estates”, who are paid a pittance, leading to lack of food, nutrition and death in several cases. Out of the approximately 800 million people in the world who go to sleep hungry, over a quarter live in India.

One of the earliest studies on malnutrition, was conducted, quite ironically, in the tea estates of Sri Lanka. It established that there were significant differences in productivity (per day), between those workers whose diet was supplemented with micro-nutrients to address iron deficiency anemia and those who were given a placebo. Studies have since established beyond doubt that malnutrition inhibits physical and cognitive growth, leading to premature death, disability, low productivity and poor learning outcomes. Even though the effect of poor nutrition in the first 1000 days of life – from conception to 2nd birthday is irreversible, malnutrition is preventable. At the Copenhagen Consensus, Nobel laureates have voted twice for investing in malnutrition as the number one priority.

The United Nation’s Millennium Development Goals culminated in 2015 and the world adopted Sustainable Development Goals, where goal 2.2 is eliminating malnutrition by 2025. India lagged behind on four of the seven MDGs – achieving universal primary school enrollment and universal school literacy - goal 2, empowering women through wage employment and political participation – goal 3, reducing child and infant mortality – goal 4, and ensuring access to adequate sanitation to eliminate open defecation – goal 7. It is interesting that each of these is also a nutrition sensitive intervention and an improvement in achieving these goals would have lead to an improvement in nutrition.

Despite this knowledge and the presence of programs to address under-nutrition like ICDS, Mid Day Meals in schools etc., our record of dealing with hunger and chronic under-nutrition is inadequate. India remains home to a quarter of the world’s under-nourished people, a third of the world’s under-weight children and a quarter of the world’s hungry. The situation is exacerbated by the poor social status of women. Under-nourished adolescent girls are married before the official age of 18 (nearly 50%) and end up with multiple pregnancies very quickly, giving birth to low weight infants (one out of every three), and the inter-generational and vicious cycle of under-nutrition continues.

Having said this, there has been some welcome progress in stunting (low height for age) as is evident in the RSOC (Rapid Survey on Children, a collaborative effort of the Ministry of Women & Child Development and UNICEF) with the field work done over 2013-14. Among children less than 5 years, stunting has reduced from 48% to 39%, and under-weight from 43% to 29%. RSOC data also challenges the belief that rising incomes naturally lead to rapid social and health gains as evident from state level data and the fact that even among the wealthiest households, 25% of children are stunted.

Nutrition is multi-faceted and complex and requires coordinated action on several fronts - access to food, micro-nutrients, education, sanitation and health care, at a minimum. Additionally, there is no ongoing and real time data to measure the prevalence of under-nutrition. RSOC is the most recent large-scale data base and has updated information that was collected by the NHFS in 2005-06. Imagine running the country with economic data that is updated once every 5-10 years! For comprehensive, equitable and sustainable growth, it is imperative that we assign the same value to indicators of human development as we do to indicators of economic development.

Interestingly, right now there is huge convergence between SDG goals (to end poverty and deprivation in all forms, making development economically, socially and environmentally sustainable), and the idea of “sabka saath, sabka vikas”. One of the foundations of health, growth and development is nutrition. This arena contains three broad parameters for action – supplements, dietary diversification and large-scale staple food fortification, of which the last is the most efficacious in the short term. One example of this is the hugely successful (almost) universal salt iodization in India. This model can be emulated to fortify other staples like oil, milk and flour to begin with. A starting point would be to mandate this for all packaged and branded food sold in the country as the supply chain is easier to control and manage, and, like with salt iodization, simultaneously work with the large numbers of other players, like local millers for instance, to include micro-nutrients (vitamins & minerals) into their supply chain. It is one of many interventions where empirical data and cost of doing so make it a most compelling choice.