Thursday, May 02, 2013


By M H Ahssan / New Delhi

The problem is likely to be less severe than UN statistics indicate, given faulty yardsticks. If asked to name the state with the lowest incidence of child malnutrition in India, readers will overwhelmingly pick one of Kerala, Goa, Himachal Pradesh, Tamil Nadu, Maharashtra, Punjab or West Bengal. But they will all be wrong by a wide margin: none of these states appears among even the top five performers. 
According to the recent report by the Comptroller and Auditor General (CAG) of India, Arunachal Pradesh walks away with the top prize. Based on 2010-11 data, Nagaland, Sikkim, Manipur and Mizoram, in that order, follow on the top five list. Maharashtra ranks a close sixth but the next four slots again go to northern and northeastern states — Uttarakhand, Meghalaya, Jammu & Kashmir and Assam. Only then do Goa, Himachal Pradesh and Punjab find a place on the list (caveat: I exclude Madhya Pradesh due to possible data inconstancies). 
Nine out of the top ten states are from the northeast or north. Even Tripura, the only remaining northeastern state, scores a tie with Kerala. The rankings are also wildly out of line with the only other vital health statistic for children that I am able to access for all Indian states: infant mortality rates (IMR) per thousand live births. 
Arunachal Pradesh, the star performer in child nutrition, had IMR of 32 in 2011 compared with 11 in Goa and 12 in Kerala. But the CAG report places 34% children in Goa, 37% in Kerala and just two percent in Arunachal Pradesh in the underweight category. Assam does worse than even the Indian average in life expectancy and IMR but beats Goa and Kerala in child nutrition. 
These puzzling inter-state rankings mirror some international rankings. In 2009, 33 countries in Sub-Saharan Africa (SSA) had lower per-capita incomes than India. The same year, India ranked ahead of the vast majority of these countries in life expectancy, IMR, child mortality and maternal mortality. Yet, India had proportionately more underweight children than every one of these 33 countries. 
These paradoxical inter-state and India-SSA comparisons are rooted in the flawed measurement methodology that the World Health Organization (WHO) has aggressively pushed to give substance to one of the key United Nations Millennium Development Goals. This methodology prescribes a single worldwide weight norm for children of a given age and gender to determine whether they are underweight. The underlying assumption is that regardless of race, ethnicity, culture and geography, different populations produce identical weight and height outcomes if provided identical diets. By implication, a larger proportion of children deviating from the prespecified norm in a population represents greater incidence of malnutrition in that population. 
But populations greatly differ in height and weight even absent nutritional differences. Japanese adults remain 12 to 13 centimeters shorter than their Dutch counterparts after many generations of healthy diet. American adults have been having as good a diet as the Dutch for decades but they began falling behind the latter in height during the 1950s and have shown no tendency to catch up. African adults are much taller than their South Asian counterparts despite poorer diets for decades. 
In a 2008 study, Martin Nube compares South Asian adults living in Fiji, South Africa and the United States with their respective native counterparts. He finds “an ethnically determined predisposition for low adult BMI [Bio Mass Index]” in them. He concludes that this predisposition “cannot be explained on the basis of indicators which relate to access to food, social status of women or overall standard of living.” 
Careful studies using extensive data find similar differences between infants born in the United States to Indian and Japanese mothers on the one hand and American mothers on the other. After controlling for maternal socio-demographic and prenatal care factors, newborns of the former groups show much greater incidence of low birth weight and low height for gestation than the latter. Nonetheless, newborns of the three groups exhibit very similar IMRs. 
Using a single weight (or height) norm to determine malnutrition when populations of different races and ethnicities differ in these attributes is bound to result in measured outcomes that defy commonsense. No wonder prescribed nutrition measures show children from Chad and Central African Republic as better nourished than their Indian counterparts and those from Arunachal Pradesh, Meghalaya and Assam better fed than children from Goa and Kerala. 
The government of India needs to carefully review whether the WHO approach to measuring underweight children, adopted uncritically, rests on a sound methodology. If not, it should work with its best pediatricians and nutritionists toward devising a better methodology. Until then, there are good reasons to be skeptical of claims that India suffers from worse malnutrition than SSA or that Goa and Kerala lag behind Assam in combating child malnutrition. 
To end on a positive note, however, even the flawed methodology allows us to reasonably track progress over time within the same population. So have the reforms and growth in India indeed failed to improve child nutrition as widely alleged by the reform critics and growth bashers? Not by a long shot. According to the CAG report, in just four years, the proportion of underweight children in India has declined from 50% in 2006-07 to 41%. This matches India’s achievements in life expectancy and IMR. 

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