December 30, 2012
By Deepankar Basu and Amit Basole
In a recent interview given to TEHELKA about his forthcoming co-authored book (“Tryst with Destiny: Debunking Myths that Undermine Progress and Addressing New Challenges”), Professor Arvind Panagariya argues that child as well as adult malnutrition statistics for India is exaggerated. We argue below that Professor Panagariya is mistaken and that India should indeed be concerned about these figures. In fairness we should add that we base our arguments on the assertions made in the interview. This leaves open the possibility that in the book Professors Panagariya and Bhagwati have addressed some of the points raised here. If that is the case, we look forward to engaging with these issues once the book is published.
Let us start by restating some widely understood facts about child malnutrition. Undernourished children have lowered resistance to commonly prevalent infections, especially in developing country contexts. Due to lower resistance, they are much more likely to die from common childhood diseases caused by gastrointestinal and respiratory infections. Malnourished children who survive these childhood ailments are nonetheless worse off than their well-nourished counterparts because they fall sick more often. Recurring sickness reduces their ability to learn and grow as normal children do, often resulting in long term disadvantages in terms of productivity, income, wealth and well-being.
The seriousness of the problem of child malnutrition can be gauged from the fact that it is associated with between half and one-third of all child deaths worldwide. It is also considered to be one of the most important obstacles to fulfilling many of the Millenium Development Goals (MDGs) of the United Nations, especially those related to ending extreme poverty, hunger, and child mortality.
Two of the commonly used anthropometric measures of child malnutrition are height-for-age, and weight-for-age. The basic idea behind the construction of these measures is simple and intuitive. If a child is “much shorter” than the “average” child of her age in a suitably constructed reference population of children, then she can be said to be stunted; if she has “much lower weight” than the “average”, then she can be said to be underweight. We can be more precise: for any given country (or region), the proportion of children who fall below two standard deviations of the median height-for-age for the reference population is said to be stunted; the proportion who fall below two standard deviations of the median weight-for-age for the reference population is said to be underweight.
Using these measures, India emerges as one of the worst performing countries in the world with 43 percent of children underweight and 48 percent of children stunted. These figures are worse than for many sub-Saharan countries that are much poorer than India. How do we know this? Between 2003 and 2007, nutrition status of children under the age of 5 years was measured through data collected by the Demographic and Health Surveys (DHS) in 41 developing countries (the relevant DHS survey was conducted in India during the period 2005-06 and is known as the third wave of the National Family and Health Survey, or NFHS-3). This DHS data revealed that the prevalence of underweight children in India was higher than in any of the other 40 countries. Moreover, the prevalence of underweight children in India was about twice as high as the average prevalence in the 26 sub-Saharan African countries for which data was collected by the DHS (Arnold, et al., NFHS-3, 2005-06: Nutrition in India, August 2009). This widely known finding has shaken even the phenomenally insensitive Indian establishment and led the Prime Minister of the country to admit that malnutrition is a matter of national shame.
Professor Panagariya disputes these well-known facts. The burden of his critique rests on a genetic argument. According to him applying a uniform World Health Organization-specified height and weight for children of a given age and gender is problematic. This is because Indian children might on average be genetically shorter and lighter than the reference population from which the World Health Organization (WHO) standards are derived. Thus, “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.” Therefore, using a uniform WHO-specified measure (derived from a reference population) would overestimate the proportion of stunted and underweight children in India.
Is this claim correct? To answer this question, one needs to understand how WHO constructs the reference population that give it the “uniform” measures that Professor Panagariya suspects would be inapplicable in India.
Prior to 2006, the “uniform” measures were those provided by the National Center for Health Statistics (NCHS)/WHO based on a limited sample of children drawn from the United States of America. In a 1993 review of the use of anthropometric references, the WHO had concluded that the measures “which had been recommended for international use since the late 1970s, did not adequately represent early childhood growth” and so “new growth curves were necessary”. Accordingly, the WHO Multicenter Growth Reference Study (MGRS) was implemented between 1997 and 2003 “to develop international growth standards for children below 5 years of age”. In April 2006, the World Health Organization (WHO) released these new standards to replace the old figures.
Whereas the old reference population was an extremely limited sample of children drawn from the USA, the MGRS project involved more than 8,000 children from Brazil, Ghana, India, Norway, Oman and the USA. The MGRS study was designed to address the “technical and biological drawbacks of the old reference population” by selecting the sample of children in the reference population from a wide variety of ethnic, regional, and genetic backgrounds. As the executive summary of the WHO Child Growth Standards report notes: “The MGRS is unique in that it was purposely designed to produce a standard by selecting healthy children from diverse ethnic backgrounds living under conditions likely to favour the achievement of their full genetic growth potential. Furthermore, the mothers of the children selected for the construction of the standards engaged in fundamental health-promoting practices, namely breastfeeding and not smoking.” Thus, “the new standards confirm that children born anywhere in the world and given the optimum start in life have the potential to develop to within the same range of height and weight.” This has an important implication: differences in children’s growth to age five as measured by deviations from the “average” (i.e., two standard deviations below the median) for the reference population are influenced more by “nutrition, feeding practices, environment and health care than by genetics or ethnicity”.
So, it turns out that Professor Panagariya’s genetic argument has already been addressed by the WHO (as regards it’s method for constructing a reference population of children below age 5). Since the figures for stunted and underweight children have been derived with the new “uniform” measures, his critique of those numbers is invalid.
While even a casual perusal of published WHO reports (e.g., WHO Child Growth Standards: Methods and Development) is enough to discover the fallacy of the genetic argument that Professor Panagariya makes, it is nonetheless interesting to inquire into the reasons that led him to advance the specious argument in the first place. As outlined in the TEHELKA interview, he arrives at his argument by way of comparison between India (or Indian states) and some sub-Saharan countries. In the interview he mentions the result of comparing Chad with India and Senegal with Kerala. In both cases, he finds India (Kerala) performing far better than Chad (Senegal) in terms of life expectancy at birth (LEB), infant mortality rate (IMR) and under-five mortality rate (U5MR) but worse than Chad (Senegal) in terms of height-for-age and weight-for-age. He is puzzled by this discrepancy, and resolves it by advancing the claim that the latter measures are invalid.
We have seen that his claim, which rests on a genetic argument, is invalid. There seems to be an additional conceptual mistake at work here. Height-for-age and weight-for-age are measures of under-nourishment of children, i.e., inadequate intake of energy and protein. LEB, IMR and U5MR, on the other hand, are broader measures of well being of a population which are impacted not only by nutrition but also by other factors like rates of immunization against common infections, access to institutional health care services (for instance, for childbirth), levels of sanitation and hygiene, prevalence of killer diseases like AIDS, and levels of socio-economic conflict and violence. Thus, in a comparison between two countries, it is perfectly possible for one country to have higher (or similar) levels of nutrition for its children but lower levels of LEB, IMR, or U5MR than the other country due to the effect of factors other than nutrition that impacts LEB, IMR or U5MR.
Let us use one of the examples that Professor Panagariya mentions in his interview to clarify this point: a comparison of Chad and India. In 2010, 30 and 39 percent of children were underweight and stunted, respectively, in Chad; in 2004-05, the corresponding figures for India were 43 and 48 percent. In 2009, life expectancy at birth was 48 years in Chad and 65 years in India. This apparent paradox of low LEB and lower under-nutrition of its children (for Chad in comparison to India) must be the result of the operation of factors, other than nutrition, that has led to such a low LEB in Chad.
These factors are not difficult to come by. First, in 2009, whereas India had an HIV/AIDS prevalence rate (among the population aged 15 to 49 years) of 0.3 percent, Chad had a prevalence rate more than 10 times higher at 3.4 percent. Second, only 9 percent of the population in Chad had access to improved sanitation facilities in 2009; the corresponding figure for India was 31 percent. Third, in 2009 the per capita expenditure on health care was 94 and 132 in Chad and India, respectively, measured in PPP-adjusted 2005 international dollars. Fourth, Chad saw a huge influx of refugees from Darfur and the Central African Republic, which has led to a serious pressure on its resources.
While a more rigorous comparative study must pay closer attention to the historical and social context of the two countries, one thing is pretty clear: a combination of all these, and possibly other, factors must have swamped the relatively better nutrition for children and led to lower LEB for Chad in comparison to India. It is hardly surprising that Chad was among those few sub-Saharan countries where LEB has declined over time: between 1990 and 2009, LEB declined from 52 to 48 years in Chad.
Professor Panagariya also does not find declining calorie intake among adult Indians a matter of concern. He offers two reasons for his cheerful take on the matter. First, that the decline has occurred across all consumer classes (that is, not only among the poor); and second, that declining calorie needs are responsible for reduced intake.
In a recent study, we have argued that rather than declining calorie needs, a squeeze on the food budget due to galloping expenses on non-food essentials and a decline in access to non-market sources of food may be the cause of the calorie intake decline. That is, even though incomes have increased in real terms, even among the poor, expenses on education, healthcare, transportation and consumer services (such as purchasing and using cellular phones) have increased even faster, leading people to substitute food spending with spending on non-food essentials. While this is partly a matter of “choice” in that people are choosing to send children to private schools, purchase cell phones or commute longer distances to work, many of these choices are perforce made for the poor by structural factors beyond their control (such as disappearing sources of rural income, dwindling access to non-market sources of nutrition, lack of public schools, lack of public health care services, lack of public transportation and housing, etc.).
As for the calorie intake decline occurring across all consumer classes, it is worth pointing out that declining calorie intake may hold very different implications for those at the top of the expenditure distribution, from those at the bottom. In fact, the NSSO data (which gives us the calorie figures) show that the bottom eight expenditure deciles in rural India (i.e. 80% of rural Indians) reported calorie intake values lower than the 2009 Indian Council of Medical Research (ICMR) norm of 2320 Kcal per capita per day. For these classes, a decline in calorie intake is occurring even before they have had the chance to start consuming an adequate number of calories. Thus we believe that declining calorie needs (or even a desire to limit calories) may be an adequate explanation for the top two classes, but cannot be the whole story for the vast majority.
To conclude, we find the alarming levels of child under-nutrition in India truly a cause for national shame. Professor Panagariya’s argument to dispute the under-nutrition figures for India rest, in our opinion, on a specious genetic argument about WHO-specified measures and reference populations. His basis for arriving at the specious argument, in turn, rests on a possible conceptual fallacy that does not account for determinants of LEB, IMR and U5MR other than nutrition. Moreover, the declining calorie intake of the vast majority of the Indian population is a matter of grave concern, and points, in our opinion, towards some of the perverse aspects of contemporary Indian growth.
(We would like to thank Shiv Sethi for helpful comments on an earlier version of this paper).