Is Malnutrition a Matter of ‘National Shame’?


The HUNGaMA Survey Report 2011 has revealed that 42 per cent of Indian children were malnourished and 59 per cent were stunted – the prevalence of stunting increasing sharply from birth through the first two years of a child’s life. It famously caused Prime Minister Manmohan Singh to comment that malnutrition is a matter of “national shame”.

Here is one set of figures that pierce the mind from the HUNGaMA Survey Report 2011 that covered 109,093 children under five in 3,360 villages across nine states: 66.3 per cent mothers interviewed in the 100 districts that reported the lowest levels of child development have never been to school.

“To my mind, we are in an emergency situation. As a nation, we need to be made more conscious of nutrition. If children aged from 0 to 6 could speak, if women had education, decision making powers and entitlements, the scenario would have been totally different,” says Survey team leader Rohini Mukherjee of Naandi Foundation, which had anchored the document. This was why a section, entitled ‘Mother’s Voice’, was included in the Survey. It put together for the first time data on whether the mother went to school, had an institutional delivery, had decision making powers about their children’s welfare, and so on. As each number told its story it only went to underline a tragically familiar reality: Women’s low status and appalling social disparities lay at the heart of one of India’s most formidable challenges.

The Survey zeroed in on 100 districts that ranked at the bottom in terms of the Child Development Index developed in 2009 by Indicus Analytics for UNICEF India, which fell in six states. Six rural districts that did the best in those very states were also surveyed as were six top-ranking rural districts in the three best performing states of the country.

There are three traditional ways to measure child malnutrition: underweight, stunting and wasting. All three measurements were collated in this exercise that brought striking gaps and contrasts into view. In the six rural districts that did the best in terms of child development, for instance, only 4.3 per cent mothers had not been to school and, in fact, most of them had studied at least up to Class Ten.

The intimate link between a woman’s physical well-being and her child’s nutritional profile also came through. Birth weight, crucially dependent on the health of the mother, was clearly an important risk factor for child malnutrition: Its prevalence among children born with a weight below 2.5 kilograms was 50 per cent, while among children born with a weight above 2.5 kilos, prevalence declined to 34 per cent.

Similarly, the close connection between malnutrition and the educational profile of the mother, her lack of agency, and her low levels of awareness was highlighted. For instance, less than half the mothers in the 100 focus districts reported giving breast milk as the first intake. In contrast, 87.2 per cent mothers in the best districts had done so. Moreover, 58 per cent mothers fed water to their infants before they turned six months old – a dangerous practice given the poor quality of the drinking water available. Also, exclusive breastfeeding was clearly not practiced widely. While soap had made its way into almost every home, only 10.8 per cent in the focus districts said family members used soap to wash their hands before a meal and only 19 mothers said that soap was used after going to the toilet.

What was most striking was the lack of not just an understanding of malnutrition, but a complete unawareness that it existed. While 81.6 per cent of mothers in the six best districts had heard the word “malnutrition” in their own language, among the 100 focus districts this was just 7.6 per cent. “Malnutrition does not have any symptoms like malaria, it is not contagious like influenza, there is no vaccine for it like polio – and that’s what makes it so difficult to address,” observes Mukherjee.

In fact, when she travelled to some of the surveyed districts, she didn’t encounter a single mother who said that her child was malnourished. “It is easy to understand this. After all, every child in the village is more or less uniformly malnourished and the presumption is that ‘all kids are like this’. The mother also believes that she is feeding her child, although most of this food is just carbohydrates,” adds Mukherjee.

This is where poverty levels and the striking inequalities that mark India came into focus. Mothers in the Survey expressed helplessness about not being able to feed their children better foods. Only 47.8 per cent mothers reported that they were satisfied with the amount of non-cereal foods they were able to give their children, and when asked why they did not give their children more non-cereal foods, 93.7 per cent said that such foods were beyond their means.

Given this situation, the government should seriously consider providing non-cereal items through is public distribution system (PDS), feels Mukherjee. She also strongly argues for a renewed focus on children in the 0-3 age group, as well as for maternity leave for rural women. “We recognise that urban working women are entitled to maternity leave, so why not rural women? Perhaps, we could use a mechanism like MGNREGA to ensure that she gets a paid break after child bearing. This will pay enormous dividends, because if two things are followed – breast feeding after birth and exclusive breast feeding – it will make a huge difference to the country’s nutritional profile,” says Mukherjee.

Will the emerging generation mark a change? Not if one went by the data from the Survey that revealed that biases and neglect mark out the girls in the family from early childhood. Development economists Abhijit Banerjee and Ariel Zucker, who went through the Survey data, highlighted the fact that “girls start with a nutritional advantage over boys, which they lose as they grow older, to the point that by age four they have fallen behind.” The inter-generational transfer of gender disempowerment disturbingly carries on apace.

Mukherjee points out how a country like Thailand has been able to dramatically improve the nutritional profile of its children by adopting primarily two strategies: A massive multi-ministry effort backed by resources; and good outreach services and counselling, where one woman counsels 10 mothers. Although India may never be able to achieve that ratio given its population, she believes the institution of the anganwadi needs to be brought into the centre of the conversation. “Anganwadi workers could do better. But we also need to help them do better. We are not monitoring the right things in the anganwadi. We are not monitoring, for instance, how many women are doing exclusive breast feeding. Right now, anganwadi workers have to fill 119 columns of data. In an ideal scenario, they should not have to fill more than 20. But this data should be taken seriously, analysed and sent back to them, so that this is not just a bureaucratic exercise but a way to improve their interventions,” she says.

The Survey iterates the need for a convergence of many key concerns to tackle malnutrition – from water, health, sanitation to the PDS and anganwadis. But with this it re-emphasises that women’s status, not just as mothers but as productive human beings in their own right, is the surest foundation for lasting and sustainable change.

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