Stuart Gillespie, CEO of Transform Nutrition, comments on the view held by Dr Arvind Panagariya that India has no reason to be ashamed of its child malnutrition levels.
In the 1 December 2012 issue of India’s Tehelka magazine, Dr Panagariya of Colombia University reiterates his belief, first aired in an October 2011 Times of India op-ed, that “once we do our malnutrition numbers correctly, we will find that India has no more to be ashamed of its malnutrition level or the progress made in combating it than of other vital statistics such a life expectancy, IMR and MMR”. Drawing on a recent paper (Panagariya 2012) he claims that India’s nutrition data are flawed and high levels of child malnutrition in India are myth, not reality. But he makes several basic errors, of which we highlight four below (italicizing his statements in Tehelka).
1. First, he is mystified by the differences in the relationships between mortality and anthropometric indices between African countries and India.
“When two sets of indicators lead to diametrically opposite conclusions, you either have a reasonable explanation for it or must reject one set of indicators…..when we compare Indian children to those from sub-Saharan Africa (SSA) in terms of life expectancy, infant mortality rate (IMR), under-five mortality rate and maternal mortality rate (MMR), they look significantly healthier than the latter. But the picture turns on its head when we compare them in terms of incidence of stunting (low height for age) and underweight (low weight for age). The contrast is nothing short of dramatic”
This is a slightly strange statement — why should apples look like oranges? Mortality data measure mortality and anthropometric data measure child growth. India may be significantly better than many sub-Saharan African countries at keeping children alive, but survival does not automatically equate with adequate nutrition and growth.
2. Second, he exaggerates the actual differences between India and Africa
What do the current data show? According to the WHO nutrition database of nationally representative stunting data, the latest data (now 7 years old) puts India at 48%, while five years later – in 2010 — Chad was at 39% child stunting. In his 2011 Times of India article, Panagariya compares India with the Central Africa Republic and with Lesotho in a similar vein, and yet all three countries have similar levels of stunting (CAR 43% in 2006, Lesotho 45% in 2005, India 48% in 2005). The WHO (which does not actually produce national estimates, as claimed by Panagariya – just regional and global estimates) has pointed out in several publications that the prevalence of child undernutrition (whether underweight or stunting) is improving in Asia (where India drives the trends given its size) while stagnating or deteriorating in Africa. (de Onis et al 2011).
3. Third, he argues that India needs it own growth standard and should not be using the international standard.
“what if Indian children are on average genetically shorter and lighter than the population from which the WHO standards are derived?”
There is no genetic reason for higher rates of stunting among children anywhere. This has been repeatedly shown for many years – ever since the “small but healthy?” hypothesis of David Seckler was roundly rebutted back in 1980. Among the many studies published on this topic (most recently WHO 2006), there is a classic one from the Nutrition Foundation of India published in 1991 (Agarwal et al 1991) that concluded that Indian children properly cared for grew similarly to the international (NCHS) reference population. Indeed, based on this study; India decided to start using the NCHS reference population.
The current WHO (2006) growth reference is derived from healthy children in Brazil, Ghana, India, Norway, Oman and USA. Panagariya claims “as expected, when comparing children of a given age and sex even within this healthy sample, heights and weights differed.” But this is not correct, as WHO (2006) show – there were striking similarities with regard to linear growth across growth reference sites (e.g. India versus Norway, etc).
4. Fourth, Panagariya argues that the trend in stunting and underweight is actually quite positive in India
A decline from 43% to 40% underweight over a seven year period (1998-2005) for a country in the midst of an economic boom is NOT a positive trend.
The reality is…
That many, many studies have shown that a key issue in India is that infants begin life with a disadvantage due to poor intrauterine growth. At birth one third of Indian infants and underweight and 20% are stunted (Mamidi et al 2011, Ramachandran and Gopalan 2011). Combining the nutritional deficits already suffered at birth with those that develop within the first two years of life will account for most undernutrition in Indai. What happens, or does not happen, in the crucial 1000 day “window of opportunity (pregnancy plus first two years of a child’s life) will continue to drive the nutritional statistics in India or elsewhere.
Agarwal, K.N. et al (1991) Growth Performance of Affluent Indian Children, Nutrition Foundation of India, Scientific Report No. 11.
De Onis, M., Blossner, M and Borghi, E. (2011) Prevalence and trends of stunting among pre-school children, 1990–2020. Public Health Nutrition, p1-7.
Mamidi, R.S et al (2011) Pattern of Growth Faltering and Recovery in Under Five Children in India using WHO growth Standards – A stuidy on first and third national family Health Surveys. Indian paediatrics, March 15, pages 1-6.
Some further responses to Dr Panagariya:
- Purnima Menon was quoted in an article in the Washington Post ‘Is India’s malnutrition crisis a myth?’, December 2012 about this issue
- Deepankar Basu and Amit Basole wrote an article ‘Is Child Malnutrition Overstated in India? A Reponse to Arvind Panagariya’ in Sanhati.com December 2012