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Nutrition is India’s next big headache
25 Aug 2020
Amir Ullah Khan, Saleema Razvi
Covid could leave behind a silent food crisis that will put the demographic dividend at risk. What can be done?
Food insecurity must be closely monitored in the months ahead. Data sets generated by the national sample survey should include questions on people’s food and nutritional distress
Several months into the pandemic, the long-term effects of covid-19 are only just beginning to surface. In at least a small subset of patients, symptoms persist for months, resulting in fatigue and even permanent damage to the lungs, heart or the brain. The long shadow of the pandemic may thus stay with us for many years to come.
But it is in the realm of nutritional deficits—amplified substantially by the economic fallouts—where this shadow may be the most pronounced and have the most far-reaching effects. Hunger and malnourishment is tragic in any case, but in the long run, they also strike at the root of the demographic dividend that India has been banking on.
Even if the eventual covid death toll is low, the disease could still play havoc with India’s prospects if it triggers a rise in the share of the population that grows up without adequate nutrition, resulting in an inevitable spike in wasting and stunting. That eventuality would also damage the handsome gains that the country has made in the recent past fighting widespread malnutrition among children and women.
The roughly 12 million new entrants into the workforce every year and the 26 million new babies need quality education and, more importantly, adequate food and nutrition to be productive and independent. Neglecting these two requirements will turn the dividend into a disaster.
In the aftermath of the pandemic, Oxfam estimates that an additional 100 million Indians are vulnerable to food distress. Those particularly hard hit are women and women-headed households. Many of them will go hungry soon, if not already. The neo-poor, those who had earlier earned decent wages as taxi drivers and hotel workers, are now unable to buy wholesome food.
Surveys and estimates indicate that 30% of urban India has run out of all savings, which means that their food distress will only grow substantially in the months ahead. Rural India, covered by the PM-Kisan and MGNREGA, has fared relatively better. But with the relentless growth in infections, and the acceleration in the number of job losses, the food crisis striking the country is eerie and silent.
In the patriarchal family structure that India has, children (and the girl child in particular) and women will bear the brunt of this calamity. At least 21 million women underwent pregnancy under the shadow of covid. The ripple effects could emerge in various horrifying ways in the future and needs to be addressed right away. The country’s stimulus package promised large amounts of money as loans that will take time to reach the poor, but hunger is an immediate problem as former Reserve Bank of India governor Raghuram Rajan also pointed out recently.
The current reality
Why did malnutrition and malnourishment go up even as the economy started growing at a steady pace after 1991 and at a fast clip after 2004? If per capita incomes were growing all around, and consumption levels were increasing dramatically, why would the average Indian not spend on food and nutrition? The paradox is even more baffling in urban areas. High malnutrition rates are common even in urban India, with nearly 25% stunted.
India’s children consume large amounts of carbohydrates, very little protein and almost no fruits or vegetables. The uninformed nutrition debate remains a shouting match between animal versus plant-based food advocates, and what we end up with is a situation where less than 15% of children get eggs to eat and only the rich get to consume dairy products.
It is rare for parents to understand that a balanced diet for a child is at least as important as the quantity and quality of food consumed. The dietary quality of the India population is marked by a declining demand for fruits, vegetables and animal proteins, which are the main source of essential micronutrients in the diet. Disruptions in supply chains during covid also mean limited access to perishable foods particularly. This shortage in supply would automatically lead to households shifting to nutrient-poor diets.
Efforts made through public food distribution programs typically deliver non-perishable staples, oils, and pulses, which could only increase the inclination toward poor-quality diets. The International Food Policy Research Institute’s studies show that nutrient-rich non-staple foods are up to ten times more expensive than staple foods in most poor countries. With reduced incomes, households very quickly move to buying the cheapest calories to eat—the aim being to maintain quantity and not quality. As a result, anaemia, stunting, wasting and other nutritional deficiencies are bound to increase.
And in a country like India, which is already home to the world’s largest population of malnourished children, this effect is going to be even more pronounced. In the 2019 Global Hunger Index, India ranks 102 out of 117 qualifying countries. Even Bangladesh at 88 and Pakistan at 94 perform better than India.
How did India get left behind in this race? Why does India have the highest number of undernourished people in the world (almost 24% of the total)? A comparison among countries in the emerging world shows that China which was at the top at the turn of the century rapidly reduced the numbers of undernourished, while India’s numbers have simply plateaued (see Chart 1). One of the most worrying fallouts of 2020 may be the reversal of even this modest progress in maternal and child health.
The disruption of the cooked meal programme, in particular, could worsen the already existing under-nutrition in children. With schools closing, access to the mid-day meal scheme—a free nutritious meal for approximately 100 million children between the ages of 6-14 years—was also halted.
The Centre had earlier advised states to distribute dry rations to the beneficiaries of the Integrated Child Development Services (ICDS), but national and local lockdowns have led to the closure of many manufacturing units which make the raw materials for the mid-day meal scheme.
Roots of a slide back
Ever since the nutrition crisis was highlighted by the HUNGaMA report and termed a national shame in 2012 by the then Prime Minister Manmohan Singh, India has seen significant improvements in the indicators. Over the last fifteen years, after the District Level Health Survey in 2004 showed that 53% of children in India’s worst-affected 100 districts were underweight, there has been a steady decline in these numbers.
The mid-day meal scheme, the national health mission, MGNREGA, the rise of women’s self-help groups and a decisive movement by the government toward setting up the POSHAN Abhiyan have all resulted in tangible improvements. Nutrition had finally gotten its due, with rigorous efforts from the government to reduce child mortality and improve nutritional interventions.
The wins have been fairly substantial. In the north-eastern states, where two-thirds of infant deaths occur, persistent communication and outreach have resulted in a significant increase in early initiation of breastfeeding. The percentage of stunted children under 5 came down from 48% in 2005-06 to 38.4% in 2015-16 (see Chart 2).
However, at the same time, there has been a rise in the national share of children who display symptoms of wasting—from 19.8% to 21%. A high increase in the incidence of wasting was noted in Punjab, Goa, Maharashtra, Karnataka, and Sikkim. Wasting refers to a process by which a debilitating disease causes muscle and fat tissue to “waste” away. Apart from India, only three countries in the world have wasting above 20%—Djibouti, Sri Lanka, and South Sudan.
Give this mixed progress report and the threat of a pandemic-induced slide back, there are at least some steps that India can take to protect and preserve its demographic dividend.
Firstly, we need to monitor food insecurity closely in the months ahead. Large datasets generated by the national sample survey (NSS) should include detailed questions on people’s food and nutritional distress. We should also carefully record antenatal visits, anganwadi worker outreach and the impact on women’s health. In a situation where we cannot supply mid-day meals, the anganwadi centers should ramp up the provision of dry food ration, and maybe even double or triple the quantity. Cash transfers have been known to have a positive impact on nutritional outcomes and that is what India has not used effectively until now in its pandemic support policy for the poor.
Secondly, the Integrated Disease Surveillance Program (IDSP) is our central disease monitoring network. Curiously, the IDSP’s weekly updates have disappeared after the twelfth week of 2020. The IDSP must continue to publish weekly updates to help keep a check on future disease outbreaks.
Thirdly, on the agriculture front, our godowns are stocked and overflowing with 77 million tonnes of food grains. If not now, when are we going to use this reserve?
Fourthly, immunisation, public health screening, family planning and other such programmes should be resumed fully with physical distancing and other safety protocols in place. The prevention of wasting in children can also be easily integrated into the mandate of the existing health infrastructure, especially in cities.
Finally, given the importance being given to the new National Education Policy (NEP), it is important to underline the fact that it fails to acknowledge the importance of school education in the healthy development of a child. We have 159 million children below 6 years of age and they are so much more vulnerable today that they were last year, with the prospect of high nutritional and learning deficits. We often ignore the strong correlation between educational outcomes and the level of nourishment.
Undernourished children have learning difficulties, are inattentive in class and, in today’s context, have lower immunity levels making them vulnerable to infections. The ICDS should have been underlined in the NEP and financed sufficiently to provide balanced diets, supplements and physical exercise for India’s children.
The economics behind the impact of undernutrition and malnutrition on the demographic dividend needs to be reiterated. Substantial economic returns from investing in interventions to improve the nutritional status are proof that poor nutrition is bound to cause economic losses, especially in India which is a young country. Under-nourished children score poorly on tests of attention, fluency and memory, which is important to consider given the strong linkages between cognitive skills and earnings and income in adulthood. A malnourished workforce, which is unable to work with full efficiency, will keep India’s productivity low and will severely hurt our long-term economic competitiveness.
Amir Ullah Khan is professor of development economics at the MCRHRDI and Saleema Razvi is a senior research economist at the Copenhagen Consensus Center.