State of the nation’s health – Nutrition

Dr. Sunil Kaul, our Executive Director and Founder Trustee, in this series of writings, critically analyse various illness that plague the health of the nation and how as a state we have failed to address these important social issues. This is a narrative of a social worker in a rural corner of Assam, calling out for collective action.


The death of children due to the lack of oxygen in a medical college in Gorakhpur created an uproar in the media. Deservedly so. But what about when children starve or are starved in India in broad government and media daylight with no one lifting a finger to do anything? To me, that is a much bigger scandal. To me, THAT is a shame! To keep our children malnourished, worse than what sub-Saharan Africa manages to do with much worse poverty must take special levels of insensitivity or callousness for a country like India which has enough money to be the largest importer of weapons for almost a decade and having an arsenal of nuclear weapons!

But let me start with how malnutrition is measured in children. In the last decade or so, WHO measured the height and weight of hundreds of thousands of children – from birth to 5 years (60 months) – in many parts of the world, including India keeping in mind the fact that all such children had been given nothing else except breastfeeds in the first 6 months, had been fully immunised and hadn’t taken seriously ill in the 5 years of the their life. Assuming that such children had not been hindered by any other factor and could hence achieve their inherent potential, their weights and heights were measured until the completion of 60 months and these were called as standard heights and weights for the entire world, having thousands of observations for each day of the 5 years. Studies in India and abroad had meanwhile convincingly proven that children in the higher socio-economic strata of any ethnicity had similar weight and height all over the world, thus disproving that height and weight was based on geography or ethnicity. Now, malnutrition is universally measured the world over by comparing the height and weight of children from birth to 60 months against these WHO Standards described above.

If we were to plot the height (or the weight) of a population in kgs (or for that matter, BP or Blood sugar or whatever) and try to measure it statistically, we find that the natural distribution would cluster almost 95% of the heights and weights in a neat dumbbell shaped curve, the average right in the middle and only 2.25% remaining outside the curve on either side of the curve, some more and some less. Plotting the heights and weights of children against the accurate age in days when compared with WHO standards can indicate the proportion of children faring poorer or much poorer than the standard children. But only if the weights when measured are outside the 95% limits of the standard dumb-bell curve, do we call a child malnourished.

In medical science, it is also well known that the physical, mental and social infrastructure of a child is built in the first 24 months of life, and responding later than 24 months to correct is usually seen to be too little and too late. In fact, if a child is stunted or underweight until the 2nd year, it faces a higher risk of diabetes or heart disease if its parents try to feed it more after the 2nd or 5th year. Though malnutrition makes a difference to mental and social faculties too, it is height and weight that can be easily measured, and hence this discussion.

So, what is the scandal and the shame about? The fact that the latest National Family Health Survey shows that 38.4 percent of our children under the age of 5 years are stunted and 35.7 percent of children are underweight when instead of the standard of only 2.25% of standard WHO children.

A few Assam based NGOs conducted a nutritional survey in 2013 which showed that more than 40% of 2 to 5 year rural children were underweight for their age when compared to the WHO standard. The stunted children fared even worse. Almost 50% of children between 3 and 5 years of age were stunted for their age, much worse than what the NFHS showed. What the study also showed us was that the difference between the height and weight of children in our study and the height and weight of the standard children kept worsening as the age increased from 3 to 5 years.

In another study, which was restricted to children below two years of age and was carried out only amongst the children of tea garden labourers, 58.2% were underweight while 70 percent of the children were stunted! The study also showed that 36.2 % children were severely stunted (worse than 3 standard deviations of the average, the normal for standard children being only 0.15%). Such children could be said to be condemned for good, for any help after may actually be worse for their health!

Is or isn’t this shameful for all of us? The tea gardens in Assam pay only Rs 126 a day to the labourers, almost half the minimum wage that Assam Govt decrees for its other residents! When questioned, the tea companies get away by talking about other items that they give, like 35 kg rice to the family at around 50 paise a kg, which may add their income by not more than 5 rupees a day! At such meagre wages, the labourers don’t get enough to eat a healthy square meal, and it is no wonder that their children are also so malnourished! While every state now has the ICDS Anganwadis to help children with supplementary feeds, these services are usually given only to children above the age of 3 years and upto 6 years. If the NGO study on 3 to 5 year olds tells us anything, it is that the Anganwadi system hasn’t been able to make a dent into malnutrition. But worse is about children below 2 years of age – in most of the states of India, there is no supplementary food available for children below the age of 3 years! Governments of the day are insensitive enough not to pressure the owners of the tea garden to increase the labourers wage rates. They don’t even provide any supplementary nutrition to such under-2 year children, maybe because we cant spare funds for them since they are not elegible to vote for them!

Isn’t it a shame when we proclaim our love for our children and then create such a large mass of children that is underweight and stunted! Isn’t it a shame that we don’t get outraged at looking at the walking corpses that go by the name of tea garden labourers.

UNICEF, the children’s agency proclaims that the key to India’s enigmatic malnutrition is to exclusively breastfeed the children in the first 6 months, fully immunise them, give them more and better feeds, and to improve hand hygiene and sanitation in the house. They also recommend the increased participation of men in household work so that women can find more time to look after their children!

For the time being, to expect all this seems a tall order. Of course we also have great people in high places who do not believe what WHO and UNICEF or our scientists say and feel that Indians are short and thin because of the climate and genetic makeup – one such person recently resigned from the top of the NITI Ayog!  Maybe that is why we as a nation are allowing our children to starve.

But we must be aware that combating malnutrition would take us decades to recover from, even if we start all the above steps from today itself. We need to start NOW. For the sake of our children. Shame on us!

(photo credits: India Today)

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