Monday 31 August 2020

India: Malnutrition and Sanitation

 

Dr. Devendra Kothari

Population and Development Analyst

Forum for Population Action

 

 

India is one of the hungriest and malnourished nations in the world.

 

 

Malnutrition is a major health problem in India.  Water, sanitation and hygiene (WASH), given their direct impact on infectious disease, especially diarrhea, are important for preventing malnutrition.

 

It is said that food grows in abundance in India, but every year, India makes headlines for being one of the hungriest major countries in the world. India ranked 102 out of 117 countries in the Global Hunger Index (GHI) 2019 that is much lower than below to its South Asian neighbours such as Sri Lanka (world rank:66), Nepal (73), Bangladesh (88), and Pakistan (94). The index is calculated using four indicators that are - child mortality, undernourishment, child wasting (weight for age) and child stunting (low height for age).

 

 

The GHI report pointed out that "India is suffering from a serious hunger problem", and the situation is deteriorating very fast, as shown in Table 1. As a result, most of its children suffer from acute malnutrition. The chapter argues that improving Wash (Water, Sanitation and Hygiene) practices could be an effective strategy in reducing the level of   malnutrition and its related issues. 

 

                    Table1 India's GHI performance since 2014

Year

World GHI Ranking

Total Countries

2014

55

76

2015

80

117

2016

97

118

2017

100

119

2018

103

119

2019

102

117

Source: GHI reports

 

Malnutrition is the primary reason behind 69 per cent of the deaths of children below the age of five in India, according to the State of the World’s Children report, released by UNICEF in 2019. The report goes on to say that every second child in India, belonging to that age group, is affected by some form of malnutrition (54% or 63 million out of 118 million children in 2018). This includes stunting with 35 per cent of the children, wasting with 17 per cent, underweight with 36 per cent and 2 per cent overweight. [1]

Chronic malnutrition, referred to as stunting, is one of the most serious health and human development problems in India. The country has the maximum number of chronic malnourished children in the world – 1 in every 3 children is stunted. The most direct causes of stunting are inadequate nutrition (insufficient food intake or consumption of foods lacking in essential growth-promoting nutrients) and recurrent infections or chronic diseases (which cause poor nutrient intake, poor absorption and utilization, or other forms of nutrient loss), as per WHO.[2]

The real-world impacts of stunting ripple well beyond linear growth. A stunted child may also have a poorer immune system, brain function, and organ development. Performing below average in these areas may also limit their future productivity and threaten the health of their future children. In short, stunting has lifelong consequences on human capital, poverty and equity. It leads to less potential in education and fewer professional opportunities,” as per Sobha Suri, Senior Fellow, Health Initiative, Observer Research Foundation. [3]

 

And, there is no wonder that the World Bank ranked India at 115th out of 157 countries on the Human Capital Index in 2018. [4] HCI seeks to measure the amount of human capital that a child born today can expect to attain by the age of 18. According to its parameters a child born in India today will only be 44 per cent as productive as she could have been if she had enjoyed quality education and full health as well as better living environment including water and sanitation.  In other words, there are grave deficiencies in India’s human development inputs that are preventing children from reaching their full potential. As such, the productivity, measured as per capita GDP,   is very low. India became the fifth largest economy in the world in terms of GDP in 2018 but still it has a very-very low per capita GDP, as per IMF. It is placed at 119th position among 185 countries.

A study by the International Food Policy Research Institute shows that stunting prevalence varies across districts of India  (12.4-65.1%), and almost 40 per cent districts have stunting levels above 40 per cent. Such high prevalence of child malnutrition in India defies logic. 

After all, the country’s economy has doubled since 1991, when the government started counting the malnourished children. Further, the world’s largest programme to tackle child malnutrition, the Integrated Child Development Services (ICDS), has been in force in the country since 1975, much before any country, other than the US, introduced measures to tackle the problem. The Mid-day Meal Scheme was launched in the year 1995 as a centrally sponsored scheme, it provides every child within the age group of six to fourteen years studying in classes I to VIII who enrolls and attends the school, shall be provided hot cooked meal having nutritional standards of 450 calories and 12 gm of protein for primary (I-V class) and 700 calories and 20 gm protein for upper primary (VI-VIII class), free of charge every day except on school holidays. The scheme covers all government and government-aided schools and also madarsas.

Now, the country aims to achieve a malnutrition-free India by 2022, as per the National Nutrition Strategy 2017.  The plan is to reduce stunting prevalence in children (0-3 years) by about three percentage points per year by 2022 from NFHS-3 (2005-06) levels, and achieve a one-third reduction in anemia in children, adolescents and women of reproductive age.

As the stage is set for the onslaught of malnutrition, it is time to critically look at the not-so-obvious reasons for its high prevalence in the country.

The debate over the measurement or prevalence of malnutrition ignores some of the crucial determinants of childhood health. Wash (Water, Sanitation and Hygiene) is a missing link. Consider this. Malnutrition is more common in India than in sub-Saharan African countries where per capita income is much lower than that of India. This discrepancy has sparked a debate over the WHO formula which is mainly based on the intake of calories, which is usually used by countries, including India, to measure malnutrition since 2006. 

Today, India lags behind sub-Saharan Africa in terms of sanitation practices. About 56 per cent people defecated, in the open across the country before the Swatch Bharat Mission (SBM) was launched in 2014. In sub-Saharan Africa, on the other hand, only 25 per cent of the people defecated in the open in 2010, according to UNICEF and WHO. Recent health surveys in the largest three sub-Saharan countries show that 31.1 per cent of households in Nigeria, 38.3 households in Ethiopia and 12.1 per cent households in the Democratic Republic of Congo defecate in the open. This difference in sanitation practices between India and African countries explains the difference in the level of malnutrition rate.[5] 

Even in India, good sanitation practices have helped curb malnutrition, as shown in Table 2. Kerala and Tamil Nadu have higher households using toilet facilities in   comparison to other states. Madhya Pradesh and Uttar Pradesh have very high rates of under-nutrition. States with low levels of under-nutrition include Kerala, Tamil Nadu and Maharashtra, although the rate is still considerably higher than that of developed nations.

                       Table 2 Uncomfortable facts: Malnutrition and use of latrine

State

Level of malnutrition (in  %)

Households where latrines in use (in %)

Kerala

20

96.5

Tamil Nadu

26

61.2

Maharashtra

28

45.1

Andhra Pradesh

32

24.9

Karnataka

33

32.1

West Bengal

35

33.7

Odessa

36

18.0

Uttar Pradesh

43

14.0

Madhya Pradesh

44

11.9

Source: National Nutrition Monitoring Bureau, Government of India.

A survey by the National Nutrition Monitoring Bureau (NNMB), which conducts surveys in rural and tribal areas to find out the nutritional status of people, also brings out this aspect. The   Bureau was established under the Indian Council of Medical Research in the year 1972, with a Central Reference Laboratory at the National Institute of Nutrition (NIN), Hyderabad. One of the surveys 

by the Bureau found that malnutrition level among children reduced over a period of time despite less intake of food. “The improvement in nutritional status could be due to non-nutritional factors, such as improved accessibility to health care facilities, sanitation and protected water supply,” the survey concluded.

Most children in rural areas and urban slums are constantly exposed to germs from their neighbors’ faces. This makes them vulnerable to the kinds of chronic intestinal diseases that prevent bodies from making good use of nutrients in food, and they become malnourished. And that explains that in spite of poverty as compared to India, Sub-Sahara Africa has lower malnourished children as compared to India. 

That could be the reason why Narendra Modi said in a pre-election speech to mark the birthday of Mahatma Gandhi in 2013 that: India should build “toilets before temples.” To accelerate the efforts to achieve universal sanitation coverage and to put a focus on hygiene, Prime Minister Modi launched the Swachh Bharat Abhiyan (Clean India Mission) on October 2, 2014. In addition, to cleaning the streets and roads, its main objective is to reduce or eliminate open defecation through the construction of individual, cluster and community toilets by 2019, as a fitting tribute to the 150th Birth Anniversary of Mahatma Gandhi.

Since its launch on October 2, 2014, more than 86.6 million toilets have been built in India, with 513 districts and 25 states being declared open defecation free (ODF) with 98.6% of Indian households having access to toilets, according to India’s official sanitation statistics.

 

While there is no denying that millions of toilets have been built since the Clean India Mission launched in 2014, experts have skepticism about this claim.

This is in large part due to the fact that a recent WHO report estimated that in 2017, 520 million (39%) people in India were still defecating in the open. Experts wonder how, in just two short years since the report, the government of India could have created toilet access and use for all of those people? This skepticism has also been buoyed by first-hand accounts from people who continue defecating in the open because they still do not have a toilet with water supply, as per Anoop Jain, the founding director of Sanitation and Health Rights in India (SHRI), a non-profit that improves access to toilets and safe drinking water throughout rural India.[6]

Additionally, pit latrines – the government’s recommended sanitation technology in rural areas – must be emptied when full. Tankers are cost-prohibitive and often infeasible in rural areas that lack good road infrastructure. Furthermore, manual scavenging (cleaning out pits manually) has rightfully been outlawed given the myriad dangers associated with handling human feces, leaving families the only option of doing it themselves. However, the social stigma associated with handling human excrement, perpetuated by India’s caste system, deters families from doing so. This causes the pits to fill up, rendering toilets unusable, which leads people to revert to defecating in the open. As a result many of the toilets, especially in rural areas, are lying non-functional. People use these toilets for storing fodder or cow dung cakes, as noted by Jain.

In addition, India is in the midst of a water crisis. Close to half the country, about 700 million people, face high to extreme water stress. A key facet of water policy must be the induction of technology to promote reuse and store the rainwater. 

The government should take note of such issues while planning its anti-malnutrition programme.  It is suggested that the rural employment guarantee scheme (NREGA), which is the responsibility of Panchayats Raj Institutions, should be used to improve the basic amenities like water, sanitation and hygiene in rural areas. The fund allocated to the Smart Cities Mission could be used mainly to develop the basic WASH facilities in urban areas.

While toilets are an important first step for sanitation, they still need to be used. Reducing open defection requires not only the technological inputs but it requires behavioural change at the household or family level.

How to forge ahead?  Based on the available data, it is estimated that around 435 million (31%) people mainly in rural India in 2019 were still defecating in the open. Some of them even have toilets in the household premises but do not using them due to various reasons, as noted above.

 And, without focussing on this population of 90 million families, mainly comprising Dalits, other lower castes including OBCs and Muslims, India cannot think of becoming an ODF country. And, most of these are the people suffering from the incidence of malnutrition, especially stunting. We have to recognise that open defection is a problem of poverty and behavioural change. For this one has to work at the household level, as proposed in the HDPlus strategy. 

For this one has to work at the household level for behavioural change, as proposed in the HDPlus strategy.[7] 

In short, clean water, sanitation and hygiene form the backbone of an effective human development agenda, as argued by the Johns Hopkins University Water Institute. However, the challenges of providing these services in a large and heterogeneous country can be vast. Clean drinking water and sanitation are certainly not cheap. The cost of implementing these for all of India will be very large. Of course, not doing it will also have huge financial implications in terms of health and socio-economic development costs. But the big question remains – will the policymakers acquiesce?

 


 [4] Refer  2018 Human Development Index (HDI) at: https://www.onlinegk.com/news-and-tips/2018-human-development-index-(hdi)

 [5] Singh, Jyotsna and Kundan Pandey (2018).  Why India remains malnourished, DownToEarth. Read more at: https://www.downtoearth.org.in/coverage/health/why-india-remains-malnourished-42697 

[6] Jain, Anoop (2020). The end of India’s sanitation crisis? Stanford Program on Water, Health & Development. Read more at:  https://water.stanford.edu/news/end-india-s-sanitation-crisis 

[7] Kothari, Devendra (2019). Nurturing Human Development: A Strategy for New India, New Delhi: Paragoan International Publishers.


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