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.
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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.
