Author: Arvind Panagariya
Publication: The Times of India
Date: October 1, 2011
URL: http://articles.timesofindia.indiatimes.com/2011-10-01/edit-page/30230007_1_underweight-children-maternal-mortality-mortality-rate
Introduction: Why does nobody question the
absurdly high numbers cited for India?
In the early 2000s, when the 55th (1999-2000)
round of the expenditure survey showed a surprisingly sharp decline in poverty
over its predecessor survey, the reform critics descended on the finding like
a ton of bricks. Their critique eventually led to a healthy debate, important
new research and eventual downward revision in poverty reduction numbers by
the reform advocates themselves.
In total contrast, almost no objections have
been raised to the absurdly high estimates of malnutrition in India trumpeted
by journalists, NGOs, politicians and international institutions within and
outside India. Not a day goes by without some TV channel or newspaper running
the headline that the world's fastest growing economy suffers worse malnutrition
than sub-Saharan Africa (SSA).
In terms of vital statistics such as life
expectancy at birth, infant mortality and maternal mortality, India fares
better than all except one or two of the SSA countries with comparable or
lower per capita incomes. So it is puzzling that, according to World Health
Organisation (WHO) statistics, it suffers from higher proportion of underweight
children than every one of the 48 SSA countries and higher rate of stunting
than all but seven of them. Such countries as the Central African Republic,
Chad and Lesotho, which have life expectancy at birth of just 48 years compared
with India's 65, have lower rates of stunting and underweight.
If you still do not believe the absurdity
of these malnutrition numbers, compare Kerala and Senegal. Kerala exhibits
vital statistics edging towards those in the developed countries: life expec-tancy
of 74 years, infant mortality rate of 12 per 1,000 live births and maternal
mortality rate of 95 per 1,00,000 live births. The corresponding figures for
Senegal are far worse at 62, 51 and 410, respectively. But nutrition statistics
say that Kerala has 25% stunted children compared to 20% of Senegal and 23%
underweight children relative to 14.5% of the latter. In Punjab, which has
a life expec-tancy of 70 years and is the breadbasket and milk dairy of India,
37% of children are stunted and 25% underweight.
To make sense of this nonsense, we must look
at how the stunting (and underweight) rates are calculated. To classify a
child of a given age and sex as stunted, we must compare his height to a pre-specified
standard. The WHO sets this standard. In the early 2000s, it collected a sample
of 8,440 children representing a population of healthy breastfed infants and
young children in Brazil, Ghana, India, Norway, Oman and the United States.
This "reference" population provided the basis for setting the standards.
As expected, when comparing children of a
given age and sex even within this healthy sample, heights and weights differed.
Therefore, some criterion was required to identify stunting and underweight
among these children. In each group defined by age and sex, the WHO defined
the bottom 2.14% of the children according to height as stunted. The height
of the child at 2.14 percentile then became the standard against which children
of the same age and sex in other populations were to be compared to identify
stunting. A similar procedure applied to weight.
The key assumption underlying this methodology
is that if properly nourished , all child populations would produce outcomes
similar to the WHO reference population with just 2.14% of the children at
the bottom stunted and underweight. Higher rates of stunting would indicate
above normal malnutrition. So the million-dollar question is whether this
assumption really holds for the population of children from which the estimate
of half of Indian children being stunted is derived?
As it happens, the answer to the question
can be found buried in a 2009 study published by the government of India.
The latest estimate for stunting in India has been derived from the third
National Family Health Survey (NFHS-3). The report draws a highly restricted
sample from the fuller NFHS-3 sample consisting of 'elite' children defined
as those 'whose mothers and fathers have secondary or higher education, who
live in households with electricity, a refrigerator, a TV and an automobile
or truck, who did not have diarrhoea or a cough or fever in the two weeks
preceding the survey, who were exclusively breastfed if they were less than
five months old, and who received complementary foods if they were at least
five months old'.
If the assumption that proper nutrition guarantees
the same outcome as the WHO reference population is true, the proportion of
stunted children in this sample should be 2.14%. But the study reports this
proportion to be above 15%! The assumption is violated by a wide margin.
The implication of this and other facts is
that Indian children are genetically smaller on average. A competing hypothesis
- which says that nutrition improvements may take several generations - fails
to explain how, without a genetic advantage, the far poorer SSA countries,
which lag behind India in almost all vital statistics, could have pulled so
far ahead of India in child nutrition. Moreover, the trend of the stunting
proportions based on WHO standards, available for India since the late 1970s,
would suggest that nearly all those born in the 1950s or before - the writer
included - are stunted!
Either way, the statistic that half of Indian
children today are stunted needs to be viewed far more sceptically and investigated
more deeply. The right treatment requires a right diagnosis.
- The writer is a professor at Columbia University.