http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60650-3/fulltext

Child malnutrition rises in India despite economic boom

Patralekha Chatterjee

The growth of India's economy during the past decade has had little effect on the nutritional status of its youngest citizens. Even in affluent states, the percentage of underweight children younger than 3 years has risen over the past 10 years. Patralekha Chatterjee reports.

Chandigarh, the joint capital of Haryana and Punjab—two of India's richest states—is an elegant city, with the highest yearly per head income in the country. The signs of affluence are everywhere: glitzy malls, luxury cars, and a high-spending middle class. But on the outskirts of this town, the underbelly of India's booming economy is clearly visible.

In the Azadpur slum, crouched on the floor of her one-room shack, Krishna Devi, twenty-something and 8 months pregnant with her second child, looks listlessly out the door. Her husband, Hriday Ram, a migrant, works as a gardener in middle-class homes. Theirs is a hand-to-mouth existence. But the future holds more promise than in their native village in the under-resourced, over populated state of Uttar Pradesh.

Krishna is anaemic. Kiran, her 2 year-old son, is severely malnourished. Although anaemia can be tackled with iron and folic acid tablets, Krishna is unaware of their importance. A tin of protein supplements and packs of iron and folic acid tablets lie on a shelf in the corner of the room, unconsumed. “I did not like the taste”, she says.

Krishna has had no antenatal check ups to date. A private doctor prescribed expensive protein supplements but did not explain the need for an iron-rich diet during pregnancy. Every morning, Krishna gives her son a cup of milk diluted with water along with a few biscuits. Like most people in the Azadpur slum, Krishna's contact with the public-health system is negligible.

Despite having an economy growing at nearly 10% a year, widespread malnutrition, and its associated health problems, such as anaemia, remain one of India's formidable challenges.

In February this year, UNICEF officials created a stir by telling a gathering of national and international journalists in Delhi that an Indian child is more likely to be malnourished than a child in Ethiopia, the Horn of Africa nation known for its periodic droughts, famines, and long civil conflict and border war with Eritrea.

The comment stemmed from India's 2005-06 National Family Health Survey (NFHS), which reveals that almost half of Indian children younger than 3 years are underweight. The results show that the malnutrition crisis is not confined to migrants huddled in urban shanties like Krishna and her family. Anaemia and undernutrition in small children and pregnant women in their prime is growing, even in India's prosperous states like Haryana.

Life in Dundahera village in the Gurgaon district of Haryana, offers a glimpse of perhaps why economic boom is not translating into better maternal and child health in India. In recent years, Gurgaon has emerged as one of India's hottest outsourcing hubs. Shopping centres, multinational companies, and industrial complexes dot the cityscape. Eager to tap the emerging commercial opportunities, Dunadhera's farmers are selling their land to builders. New houses have been built to accommodate the growing number of migrant families streaming into the area to fuel the economic boom. Many families who have sold their land have suddenly become rich. But within the family and this highly patriarchal society, the status of women has scarcely improved.

Full-size image (50K) Patralekha Chatterjee

A charity worker talks to a family in the Azadpur slum about the basics of a nutritious diet

“Alcoholism is on the rise in Dundahera. The new rich spend their extra cash on beautifying their house, on clothes, and gadgets. The health of the woman is not a top priority for most families. Even if the family owns cattle, they will prefer to sell most of the milk. There is no one really to ensure that an expecting mother eats well. More money in hand does not mean healthy mothers and children”, says Sharda, a village-level anganwadi (child development and nutrition) worker.

The latest NFHS data are preliminary findings. Detailed analyses are awaited, but nevertheless, the current findings have sparked justifiable concern: 41·9% of children under 3 years in Haryana were clinically underweight (too thin for their age) in 2005—06 compared with 34·4% in 1998—99. During the same period, the number of children younger than 3 years who are too thin for their height rose from 5·3% to 16·7%. Disturbingly, the new data also reveal that 69·7% of pregnant women in the 15—49 year age group in Haryana are anaemic compared with 55·7% 7 years ago.

Full-size image (63K) Patralekha Chatterjee

Life on the outskirts of Chandigarh is very different from its bustling financial centre

The discrimination against girls and women in affluent Haryana might explain some of the increase in anaemia. Girls continue to be worse fed than boys in most families, especially in rural areas.

The latest NFHS data also support other recent sample surveys in the state. A community-based study in ten villages in Haryana in 2004—05 found that 25 out of every 100 newborn babies in rural Haryana are low birthweight (less than 2500g at the time of birth). The prevalence of low birthweight babies in rural Haryana has remained nearly constant for the past two decades, despite the state's rapid economic progress.

“The problem of low birthweight is due to inadequate food intake and maternal anaemia. There is little awareness among mothers about what food to eat, how much to eat, and an inability to co-relate the food intake with the outcomes. If this is showing up as low birthweight and child malnutrition, failure to identify maternal anaemia is to blame”, says Arun Aggarwal, one of the researchers on the study based at The Postgraduate Institute of Medical Education and Research in Chandigarh.

“Pregnant women take tetanus toxoid injections. So, there is a contact with the health-care system but this is not translating into awareness about anaemia. Health workers in the villages rarely conduct haemoglobin tests on pregnant women.”

“Other problems on the ground include irregular supplies of the reagent required to conduct haemoglobin tests. Tetanus toxoid has been flagged, anaemia has not. The community health worker is supposed to identify anaemic women on laboratory and other clinical parameters and provide double dose of iron folic tablets but such tablets also are often in short supply. There is an urgent need to make the monitoring and evaluation system for maternal anaemia more rigorous”, Aggarwal told The Lancet. By the time, the anaemia is diagnosed in a pregnant woman, it is often too late.

However, there are signs of change. The Government of Haryana and UNICEF have signed a Memorandum of Understanding to work together to improve social indicators for women and children in the state. Recently, the Haryana Government has set up a state-level steering committee on nutrition. Attempts are finally being made to address the root causes affecting child nutrition. And following the advice of community doctors, health and nutrition workers have begun focusing on the health of the adolescent girl.

“If we want to fight under-nutrition among small children, we have to target mothers before they become pregnant. Today, we are targeting young girls—those who are in the 11 to 18 year age group, who are likely to become young mothers in a few years, through ‘balika mandals’ (support groups of young girls). We counsel them about health and hygiene, about deworming, prepare them for motherhood, sensitise them about the need to take iron tablets. This goes hand-in-hand with our continuing work with expecting mothers”, says Chanchal Dhalwal, who is in-charge of Gurgaon district's Integrated Child Development Services—a nation-wide nutrition and health programme that serves millions of women and children.

The Haryana Government has also decentralised the supplementary nutrition scheme to improve efficiency. Now, self-help groups of women are given cash to procure raw materials locally and make local preparations.

Other attempts to improve maternal health and nutrition include “best mother contests”. Best mothers are those with the best scores in a health education quiz.

“The contests, which began 3 years ago, are intended to get mothers hooked to the health-care system. The initiative is now being taken to other districts in Haryana. It is slow process but women are becoming more nutritionally literate in [the] Gurgaon district and severe malnutrition among children under 6 [years] is going down”, adds Dhalwal.