FACTS againest MYTHS V0L-VII-11-2001.pdf
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VIKAS APHYAYAN KENDRA
Vol VII #11/2001
INFORMATION BULLETIN
Paradox of Hunger & Overeating;
The Myths behind the Nutrition-Malnutrition Complex - Part I
“You can have a mandatory 2,400 or 2,100 calories a day and yet be very poor. India’s
problems differ from those of a Somalia or Ethiopia in crisis.
Hunger...is far more complex here.
It is more low level, less visible..."
— P. Sainath, “Everybody Loves A Good Drought” (1996)
COMMENT
ince Independence, India
S
has made impressive
strides in terms of material
and social progress. One
major gain has been in
overcoming famine which,
in the past, especially
towards the end of the
colonial era had brought
untold misery to millions at
frequent intervals e.g. the
famines of Madras (187678) and Punjab (1896-97).
Today, famines are a
phenomenon of the past. In
stark contrast, however,
are the persistent famines
in Africa and currently
famine in South Africa is
already taking millions of
lives. Ironically, India and
South Asia, in spite of
overcoming famine, is way
behind Africa fn terms of
improvement of human
nutrition! Calculations of
general undernourishment
-what is sometimes called
‘protein-energy malnutrition’
- is nearly twice as high in
India as in Africa.
Multifactoral Aetiology of Malnutrition
Trancegenerational Cycle of Malnutrition
Q FACTS against MYTHS
FOR PRIVATE CIRCULATION ONLY
Despite famine, however, Africa succeeds in managing
a much higher level of regular nourishment for its
people than does India1 where almost half of all are
chronically undernourished, and over half of all adult
women suffer from anemia. In maternal
undernourishment as well as the incidence of
underweight babies, and also in the frequency of
cardiovascular diseases in later life, India’s record is
among the very worst in the world.
This paradox apart, misconceptions on hunger (Cf.
earlier issues of FAM) are also commonplace. It
continues to be viewed as resulting from a desperate
scarcity of food; occurring only in poor countries and
among the poor! Hunger in the South is indeed most
severe but the problem is not of food scarcity.
Government godowns are over-flowing with food grains.
In 1998, stocks were around 18 million tonnes and
since then there have been a 7% increase. According
to the daily, the Economic Times (15/7/02) stocks have
risen to 649.3 lakh on May 31,02 comprising of 233.3
lakh tonnes of rice and 416.1 lakh tonnes of wheat. So
high are the stocks that the Government recently
decided to distribute a small amount as relief to
Afghanistan. Thus, on the one hand there are huge
food mountains side-by-side the largest number of the
undernourished and on the other, are increasing number
of overfed people in the South and the underfed in the
North.
The concept of malnutrition today, therefore, includes
both access and deficiency with the North seeing rates
of malnourishment that rival those in the South.
Overweight has indeed become a major health problem
in the world today. The Times of India (16/8/02) reported
a new WHO finding that Asians today are more prone
to obesity than citizens in the West and are at risk of
heart diseases. The Commission on Nutrition
Challenges of the 21st Century also noted in its report,
“Ending Malnutrition by 2020: An Agenda for Change
in the New Millennium” that overeating is increasing in
the South, a phenomenon that is becoming the fastest
growing form of malnourishment and an emerging
nutritional concern providing a whole new dimension
to the so-called nutrition-malnutrition complex.
Malnutrition implies imperfect nourishment (‘malus’ bad, ‘nurture’ - to nourish) and occurs when the
demands of the body for certain nutrients are not met
(under-nutrition) or are met in excess (over-nutrition).
While nutrition refers to the lack of quality, under
nutrition refers to lack of quantity. Thus, it is defined
as any nutritional disorder caused by an insufficient,
unbalanced, or excessive diet or by the impaired
absorption or assimilation of nutrients by the body. The
most glaring nutritional disorders in India are protein
energy malnutrition (PEM) defined as a range of
pathological conditions arising from deficiency of
proteins and calories and disorders resulting from
deficiencies of iron (iron deficiency anemia, vitamin A
(keratomalacia or nutritional blindness), iodine (goiter),
0FACTS against MYTHS
and vitamin B (Angular Stomatis, Gossitis). Data from
the National Nutrition Monitoring Bureau of the Indian
Council of Medical Research (ICMR), the agency
monitoring the nutritional status in various States,
revealed that nearly half the households surveys, diets
were deficient even on the basis of lowered yardstick
of adequacy (m-2SD) of mean requirement.
The dismal state of health of especially women and
children is part of the wider, deteriorating state of the
health sector as a whole precipitated by shifts in the
global economy in the early 90s and the resultant WB/
IMF imposition of the SAP conditionalities and the
liberalization of the economy. With the subsequent
withdrawal of the state of its social welfare obligations
e.g. withdrawal of the PDS scheme, these changes
have led to spiraling food costs and threatened social,
and .especially food security, further aggravating the
situation of poverty and unemployment. As women
bear the responsibility of providing nutrition within the
family, shrinking resources and growing poverty
adversly affects their lives as small-scale producers,
as providers of nutrition to the family, and as
consumers. With commercialisation and tt^£
corporitisation of healthcare treatment is also getting
beyond the means of the poor considered as ‘liabilities’
just as the well off are viewed as “markets” and “billable”
resources. According to a Times of India (August
12,2002) the cost of cardiac surgery, for instance is i)
Rs.35-50, 000 in public hospitals ii) Rs. 1.5-2 lakh in
trust hospitals and iii) 1.2-2.4 lakh in corporate
hospitals. In such a situation, the healthcare system
gutted by the SAP is even less prepared for the rise of
STDs and HIV. Lest we forget: the changes in the 90s
led to epidemics of malaria, diarrhea and encephalitis
and, in recent months there have been starvation
deaths in various parts of the country, directly
stemming from recent policy changes.
Malnutrition is a fact of life. Disease is another.
Malnutrition, however, stands at the root of all diseases
that so violently affect infants viz., measles, infant
diarrhea, polio, whooping cough and neonatal tetani^^
It is both a cause and consequence of poverty and
social inequality. Further, the mechanisms of human
nutrition and human disease are highly complex and
no single health problem can occur without facilitating
another. Nutritional deficiencies seldom exist aS distinct
entities but normally occur as complex malnutrition
syndromes covering a wide spectrum of deficiencies
inter-relating in a complex manner. Disease problems
are equally complex and few villages, can be found
suffering from clear textbook cases relating only to
one specific illness.
As mentioned in earlier issues of this publication efforts
to eliminate hunger, disease and poverty the focus is
often on technological quick fixes aimed at boosting
crop yields and producing more food through so-called
scientific breakthroughs as genetic engineering rather
than addressing its deeper, underlying pauses; indeed,
malnutrition is a culmination of a number of factors
both direct and indirect: availability of food, purchasing
power of the people; level of nutrition knowledge,
healthy consumption pattern, sanitation, etc. and as
well as to crucial issues like meager incomes,
inequitable distribution of land and the
disenfranchisement of women. All these do impact
the nutritional status of people. These cannot be
determined by the criterion of adequate diet alone or
just to one set of factors. Nonetheless, myth and
misconception indeed permeate the world’s
understanding of malnutrition, and policy responses
have been wildly off the mark in addressing the
problem. Confronting this epidemic of poor nutrition
will have widespread benefits, but before that occurs,
the myths that obscure the causes of malnutrition
especially among women and children must be
dispelled.
MYTH: Unlike children in Africa Indian children
are not as malnourished.
FACT: Not so!
£ome 47 per cent of India’s children below the age of
3 years are malnourished (underweight). In Africa, the
proportion is on an average, 30 percent. 30 out of 37
countries in this continent report lower levels of child
malnutrition than India. Bihar (54 per cent) and M.P.
(55 percent) report child malnutrition rates higher than
the maximum reported in Africa by Angola (51 percent).
Evidently, India does much worse than Africa. In
avoidance of endemic undernourishment and hunger,
India has done worse than nearly every country in the
world.
MYTH: Low per capita income of people is also
among the main causes of malnutrition.
FACT: Not so! Worldwide, levels of per capita income
are not correlated to child malnutrition in any predictable
manner. 28 out of 37 countries of the African continent
have a lower per capita income than India - and most
them report lower rates of child malnutrition. Outside
Africa there are also other countries e.g. Vietnam,
Mongolia and Haiti that report lower levels of income
as well as lower levels of child malnutrition than India
itself viz.,
•x
x
x
Manipur reported a per capita income of
Rs.8,114 (in 1997-98) and a child malnutrition
rate of 28 percent Gujarat, on the other hand,
reported a per capita income of Rs. 16,251 and
child malnutrition rate of 45 per cent;
Orissa (50%) and Maharastra (51%) report
similar levels of malnutrition, but Maharastra's
per capita income is almost 3 times higher
than that of Orissa;
Kerela and Karnataka report similar levels of
per capita income. Yet, 27 percent of children
6 FACTS against MYTHS
under age of 3 are malnourished in Kerela. The
figure is 44 per cent in Karnataka;
MYTH: Another factor in the high rate of
malnutrition among children is the inequality in
income distribution rather than the income-level.
FACT; Child malnutrition rates are lower than India’s
among many countries that report similar levels of
income inequality. Income inequality in African
countries like Botswana, Mozambique and Cote
d’Ivoire, for instance, is similar to India’s [measured
by the ‘gini index (that is, the index that measures the
extent of equity in the distribution of income (or
consumption) among individuals or households within
a country. A value of 0 represents perfect equality; a
value of 100 perfect inequality) of income distribution].
Yet child malnutrition in these three countries ranges
between 24 and 29 per cent, as against 47 per cent in
India.
Moreover, compared to India, child malnutrition is lower
among many countries in Africa, with not only greater
income inequality but also lower per capita incomes.
West African counties of Gambia, Mali, Nigeria and
Guinea-Bissau, for example, report both lower levels
of income and greater income inequality, and yet levels
of child malnutrition in these countries are lower than
in India.
M YTH: Income poverty is a major underlying cause
of malnutrition.
FACT: Not entirely true.
At a national level, the linkages between income
poverty and child malnutrition are not obvious. Most
countries of Africa report higher levels of income
poverty than Indian even though levels of child
malnutrition in India are significantly higher than in the
former.
Within India, too, the link between poverty levels and
child malnutrition is not obvious. In 1993-94, Tamil Nadu
and W. Bengal reported similar levels of income poverty
(35-36 per cent levying below the poverty line), and
yet in 1998-99, only 37 percent of Tamil Nadu’s children
below 3 years were malnourished as against 49 in West
Bengal. Haryana (35 percent) and Assam (36 percent)
reported similar levels of child malnutrition despite the
fact that in 1993-94 only 25 percent of Haryana’s
population lived below the Poverty Line as against 41
per cent in Assam.
MYTH: Indian children are malnourished because
poverty prevents their families to feed and nourish
them.
FACT: No so!
At a very young age, between 6-18 months, when most
infants begin to experience growth faltering, food
availability within the household is usually not the
critical factor causing malnutrition. It is very often
3
inadequate knowledge about feeding practices that are
in the best interest of the child. The denial of as little
as 200-300 calories in a young child’s daily diet is what
makes the difference between normal growth and the
faltering that starts the descent towards illness and
death. We are talking of half a ‘chapatti’ dipped in ‘dal’.
Equally critical for preventing malnutrition during early
infancy is the quality of care and attention that young
infants receive when being fed. Infants do not eat by
themselves, and feeding them takes time - a luxury
few rural women can afford, and a chore those older
siblings can perform satisfactorily.
2.
half of the women (48.5%) are anemic. This
is not very different from the national
prevalence of anemia at 51.8%. However, two
features are striking,this study notes. Firstly,
the prevalence of ‘severe anemia’ is very high
in this State i.e. almost 3% of women have
severe anemia (hemoglobin less than 7 gms/
100 ml), placing it among the two worst states
of the country in this respect. Besides, certain
socio-economic groups of women within the
State have a higher level of anemia. Adivasi
women are much more frequently (64.2%)^t
anemic. On the other hand, non-slum women®
MYTH: Reports of deaths of children by
malnutrition are not as alarming as made out be
by the media, etc.
FACT: The source of this false claim is the report by
the Maharastra Government’s Tribal Department,
presented on April 24,2001. Independent institutions
have strongly challenged the government’s claim
maintaining that the Governments figures were
misleading. For instance,
1.
The Tribal Research Training Institute (TRTI),
Pune, maintained that malnutrition was the
cause of 71.5 per cent deaths among children
in Nashik Division in the period 1999-2000 and
2000-2001 respectively. It held that the
Government tribal department had combined
and generalized the cause of death of children
by including cultural factors, poor social
infrastructure, etc., without attempting to
examine or focus on malnutrition as the
harbinger of death. The Department had taken
a sample survey of 143 families who lost
children below the age of 6 years, in 24 villages
of Dhadgaon, Akalkuwa and Navapur blocks
in Nandurbar District of Nashik revenue
division. A total of 158 children had died in
143 families surveyed. The deaths comprised
94 males and 64 females. 42 per cent of the
deceased children were in the age group of 1
to 6 years. That nutrition related deaths
accounted for 71.5 per cent of the deaths was
also confirmed by verifying the nutrional status
of the siblings of the deceased children where
the extent of malnutrition was 76.5 per cent.
Its report on the nutritional status of the 136
siblings also indicated that 76.5 per cent of
these children were malnourished, including
40 per cent suffering from severe
malnourishment. (TRTI derived its conclusions
from actual weight for age measurement.) (See
Box on this page.)
Relatedly, semi-starvation diets have also led
to people becoming more vulnerable to
infectious and communicable diseases like
Malaria, Gastroenteritis, Typhoid, Hepatitis and
. TB.
FACTS against MYTHS
The Health Institute of Management at Pachod
recently highlighted that Indian women also
have the highest prevalence of iron deficiency
anemia.Trained attendants attend only 1 to 3
others at the time of childbirth. As a result
1.2-m. mothers die each at the time of delivery.
This is apart from the problem of gynecological
morbidity that women in both rural and urban
areas experience which was highlighted in a
recent paper on this issue. Another recent
study4 notes that in Maharastra itself almost
in this City have significantly lower levels
(37.4%) of anemia. Of significance too is that
(currently) unmarried women (58.2%) have a
higher level of anemia compared to (currently)
married women. This highlights the fact those
unmarried adolescent women, and also
Officially Recognised Deaths
The administration account of the deaths as on
March 11 is as follows:
Date
Taluka
Village
No. of dead
28.02
Khanpur
Pandunda
1
Divda
1
Ghoganbi
Rinchia
1
Kadana
Devada
1
Khanpur
Pandharwa
21
Halol
Halol
5
Kalol
Kalol
16
Linnawada
Linnawada
1
Khanpur
Limdia
8
Kalol
Aral
7
Halol .
Rameshra
2
3-4
-
-—.
-
5.03
Santrampur
1.03
2.03
Anjanvar
Source: Combat Law, No. 3,2002
8
Explaining Child Malnutrition*
Within India, Sikkim reports the lowest rates of child malnutrition and MP the highest. The explanations
for this differential stems from the following factors:
1.
Low Birth Weight: Birth weights of less than 2,500 grams, are very closely linked with poor
growth right from infancy to childhood. Indian estimates reveal that 20-30 per cent of babies are
born with low birth weight, suggesting that children begin to get malnourished in the womb and
indeed suffer from an inter-generation transfer of malnutrition. Only 13 per cent of Children born
in Sikkim are of low birth weight. The proportion is 24 per cent in M.P.;
2.
Women's Nutrition: The poor Nutritional Status of Women also adversly affects the birth of
babies. Nutritional deficiency among women and mothers is high. Data from the NFHS-2 for
1998-99 suggests that over 173rd (36 per cent) of Indian women have a Body Mass Index (BMI)
of less than 18.5 kg/m2. Added to this, given her inferior status in society, expectant mothers
raily get adequate attention, care, diet and rest let alone time for leisure. Only 11 per cent of
ever-married women in Sikkim suffer from 'Chronic Energy Deficiency' (with a BMI of less than
18.5 kg/m2). The proportion is 38 per cent in M.R
3.
Child Malnutrition: This outcome tends to be better where women enjoy greater freedoms and
more autonomy;
X
Women in Sikkim enjoy far greater freedoms and autonomy than women in M.R as well as better
access to money, greater exposure to the media, and freedoms to go out of the house. The
following are some comparative indicators:
The female-to-male ratio of population 0-6 years in Sikkim is 986; it is 929 in M.P.
The average age of marriage for women in Sikkim is 22 years; it is 19 in M.P
X
In Sikkim, 42 per cent of women do not need permission to visit friends or relatives; in M.P. only
20 per cent of women enjoy this freedom;
X
Close to 79 per cent of women in Sikkim has access to money; in M.P. only 49 per cent do;
X
In Sikkim, 22 per cent of women are not exposed regularly to any media; in M.P. the proportion
is 45 per cent.
4.
Child Care: Failure to introduce supplementary foods at the end of 6-9 months is a major factor
accounting for child malnutrition. Breast milk provides vital nutrients through the first year of life;
but this is alone is not enough. The energy and calories needed for healthy growth can come
only from additional food. Beyond 4 to 6 months, infants must be given solid foods to supplement
breast milk. Data from the National Family Health Survey-2 suggests that only around a third (34
per cent) of children, 6-9 months old receive solid and mushy foods to supplement breast
feeding. It is, therefore, not surprising that a child typically becomes malnourished between 6
months and 18 months of age, and remains so thereafter. In most cases, nutritional rehabilitation
is difficult. Close to 37 per cent of children, 6-9 months old, receive breast milk and solid or
mushy foods in Sikkim. Only 27 per cent of such infants do so in M.P.
5.
Education: This is also an important factor in child malnutrition. The linkage is striking:
Chronic energy deficiency drops significantly with improvements in the levels of education. And
it is well known that higher the levels of chronic energy deficiency, the higher will be the levels of
child malnutrition.. Chronic energy deficiency among illiterate women is 43 per cent whereas it is
only 18 per cent among women who have finished high school.
The lower the level of mothers’ education, the higher is the level of child malnutrition. Malnutrition
among Indian children below 3 years bom to illiterate monthers (55 per cent) is more than twice
the levels Reported among mothers who have com pleted high school (27 per cent).
* Little Magazine, 2002
Q FACTS against MYTHS
No|l|.girlsfosSerOfiiKl
Nutritional Status
Mil
Severe Malnutrition
1,352
72.96
less than 16
Moderate Malnutrition
186
10.04
16 to 16.9
Mild Malnutrition
183
9.88
17 to 18.4
Normal
130
7.02
18.5 to 24.9
2
0.11
25 to 29.9
1,853
100.00
Overweight
GRAND TOTAL
deserted (‘parityakta’) and single women are
likely to have poor nutrition and higher levels
of anemia.
Yet, another survey, conducted in 1996, by the National
Family Health Survey (NFHS) in Mumbai reported that
half the children in Maharastra suffered variously from
acute and chronic malnutrition, growth retardation and
wasting (i.e. a deficit of weight for height greater than
20 percent)5 Between April and August 1996,25,000
Adivasi children between the ages of 6 months to 6
years suffered severe malnourishment and 336 children
died of secondary causes e.g. pneumonia, low birth
weight, premature birth, dysentery, diarrhea and TB.
Researchers Shobha Rao and Vidya Pitre of the
Aagharkar Research Institute of Pune corroborated this
citing two recent studies carried out in Maharastara
by Dr. Abhay Bang of SEARCH, which noted that there
was gross under-reporting of infant deaths and placed
the figure at 80 percent and that Adivasi hamlets were
not covered by the Government.This revelation is also
supported by the commissioner of the Tribal Research
Institute and that these deaths were due to
malnourishment. Further, studies clearly attribute the
high rate of IMR to malnutrition although in most cases
it may even be due to under-nutrition, or starvation®>
Most disturbing however is the data on malnutrition of
pre-adolescent girls. A women’s resource center in
Mumbai, VACHA, in its study of girls in the age group
9-13 discovered severe undernourishment (based on
body mass index i.e. height and weight) in 1352 girls,
i.e. 72%. Arm circumference can be done only unto 6
years. BMI is body weight in kilograms divided by the
square of his/her height in metres.(See also Box on
page 6) Only 2 girls were overweight. 183 girls were
mildly undernourished.That is, 82-89% is malnourished
which is indeed very alarming.
Millions of People
Overweight
Underweight
Overweight and underweight are not arbitrary terms,
but are defined using Body-Mass index (BMI), a scale
calibrated to reflect the health effects of weight gain. A
healthy BMI ranges from 19 to 24; a BMI of 25 or above
indicates "overweight" and brings increased risk of
illnesses such as heart disease, stroke, diabetes, and
cancer. A BMI above 30 signals "obesity" and even
greater health risks. BMI is calculated as a person's
weight in kilos divided by the square of height in meters.
C FACTS against MYTHS
Balance Sheet of Health
x
47% children under 3 are underweight, 18% are severely underweightji.e^ 46%
children under 3 are stunted and this is due to chronic undernourishment;
X
16% children under 3 are wasted;
X-
«
*
y
36% women aged 15-49 years suffer from chronic energy deficiency;
X
51.8 per cent women suffer from anemia (insufficient iron intake);
X
only 58% of mothers received iron-folate supplements during their pregnancy;
x
Only 30% of children between 1-3 years of age had received at least one doze of
Vitamin A;
X
Only 16% of children are breast fed within 1 hour of birth and only 37% on the first
day;
X
Calorie consumption per capita in rural areas has gone down from 2,266 in 1972/
3 to 2,221 in 1983 and to 2,153 in 1993-4.
Source: Food and Nutrition Security: An Indian Context, VANI, New Delhi, 2002
G&SO
G82O
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Note: References to Africa refers to African countries that lie South of the Sahara.
G3£O
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Please feel free to reproduce material from this publication but with due credit.
r — ——————————————t
I
Facts Against Myths is a monthly bulletin offactual
\
information on a number ofdevelopment myths and
fallacies, etc, including information against alien
development models, paradigms and false concepts
on caste, creed and gender.
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