Professor Aravind Panagariya’s recent paper, Does India Really Suffer from Worse Child Nutrition than Sub Saharan Africa, [Economic and Political Weekly, May 4, 2013] has engendered a lively debate on the appropriate methodology for calculating the incidence of child malnutrition in India.
In a paper, reminiscent of Lalit Dandona’s paper that led to massive downscaling of the estimates of the number of persons at risk of HIV/AIDS in the last decade [Lalit Dandona, HIV/AIDS Control in India, Lancet, 2002], Panagariya’s paper argued that the claims that India lagged behind even much poorer Sub-Saharan Africa in eradication of child malnutrition were based on flawed measurement methodology.
The paper averred:
“The central problem with the current methodology is the use of common height and weight standards around the world to determine malnourishment, regardless of differences that may arise from genetic, environmental,cultural and geographic factors ...Malnutrition is a multidimensional phenomenon. In broad terms, it may be divided into protein energy malnutrition and micronutrient defi ciency...Given these many dimensions involved in identifying malnutrition, only a thorough medical check-up can properly determine whether a child is malnourished or not.”
Panagariya further added:
“The height of an individual can vary for both genetic and nutritional reasons. Without detailed medical examination, one cannot conclude whether an individual is short because of malnourishment or because of genetic factors. This makes identifying stunting by referring to just height, an imperfect exercise. Nevertheless, this is the current practice. Without genetic differences, there is no empirically plausible explanation for the signifi cantly higher levels of stunting and underweight among Indian children than their Sub-Saharan African counterparts.”
In addition to this conceptual critique, Panagariya also emphasised on the mismatch between malnutrition and mortality figures. Comparing the rate of malnutrition and infant and child mortality in India and Sub-Saharan African countries, he found prevalence of lower rates of infant and child mortality in India relative to Sub-Saharan Africa despite higher malnutrition rates. In view of the fact that declining rates of malnutrition typically accompany declining infant and child mortality rates and maternal mortality ratios, he questioned the official figures on the rate of child malnutrition in India .
This paper has however resulted in a series of rejoinders from nutritionists, public health experts and economists in the pages of Economic and Political Weekly.
Gargi Wable, has come out in support of the use of height-weight matrix for the measurement of malnutrition. In her paper, Methodologically Deficient, Ignorant of Prior Research [Economic and Political Weekly, Aug.24], she argued:
“First, countries have historically used anthropometric measures such as height and weight alone when assessing child under-nutrition. The Lancet 2008 Series on Maternal and Child Under- Nutrition provides substantial evidence on the relationship between chronic and acute undernutrition and poor height and weight gain in children under five, as well as the risk to morbidity and mortality among children who are stunted (too short for their age) and wasted (too thin for their height)...Second, since the author insists on medical assessment, gross levels of undernutrition among Indian women and children have been reported from the serum testing performed periodically by well-regarded national surveys, such as the National Family Health Survey (NFHS) and the National Nutrition Monitoring Bureau (NNMB). In fact, even the latest round of the NFHS (2005-06), which tested haemoglobin levels pointed to a prevalence of iron defi ciency anaemia among as many as 70% of young children (6 to 59 months age) and among 55% of women in the child-bearing age group (15-49 years).Similarly, measurement of serum retinol levels in the NNMB 2003-06 rural surveys showed a 60% prevalence of Vitamin A deficiency among children of age one to six years. Obviously, such pervasive levels of micronutrient deficiencies would not occur in well-fed/well-nourished populations. Thus, using medical assessments instead of weight and height will not help to underrate India’s malnutrition burden.”
Several scholars have questioned Panagariya’s use of genetics as an explanans for deficiency in height among Indian children. Rakesh Lodha, Yogesh Jain and C Sathyamala note in their paper, Reality of Higher Malnutrition in India, [Economic and Political Weekly, August 24] that:
“The central question is whether the Indian genetic make-up is so distinct that it warrants separate charts. There have been multiple studies on the genomic diversity in India of which the Indian Genome Variation Consortium (IGVC) initiative has been the most comprehensive one (Indian Genome Variation Consortium 2008). Recently, the genetic origins of Indian population have also been reviewed (Tamang et al 2012). These papers highlight that the Indian population is a genetically diverse population with significant overlaps with other populations of the world, chiefly European and African. Very few groups are genetically distinct…The available genomics data does not suggest a unique genetic make-up of Indians and thus supports the use of a universal standard for comparing the burden of childhood undernutrition across countries.”
In the same vein, Coffey, Deaton et al, state in Stunting Among Children: Facts and Implications [Economic and Political Weekly, August 24] that:
“Panagariya discusses a number of puzzling facts about child and adult anthropometrics. Most, although not all, of these have been known for a long time. Scholars who have written about these puzzles have indeed noted that some of the facts have no ready explanation, for example, that Indians have higher average incomes and lower infant mortality rates than most of Africa, but that Africans are taller. What Panagariya claims to contribute is the answer to these puzzles: that they can all be explained by “genetics”. All of his argument about the role of genetics is by residual: if we cannot think of anything else, it must be genetics. There is no direct evidence on genetics anywhere in the paper.Genetics might be the answer, or part of it, but any argument by residual is obviously sensitive to having missed something, or to having overlooked some evidence.”
Panagariya’s claim that lower infant and child mortality rates indicate a lower rate of malnutrition has been questioned by Arjun Gupta, Biraj Patnaik et al, Are Child Nutrition Figures for India Exaggerated? [Economic and Political Weekly, August 24]. The paper notes:
“One of Panagariya’s central arguments is that Indian malnutrition figures are much higher than would be expected, given its child and infant mortality levels. This he shows using data related to every conceivable parameter such as life expectancy, neonatal mortality rates, and infant, child, and maternal mortality rates, very often out of context, and attempting to shock readers into rethinking India’s performance on nutrition.
However, it is important to note that not all undernutrition leads to death. Death is dependent on many factors such as the nature and duration of illness before a child dies, and access to healthcare and health facilities, especially emergency care. Public health measures such as the state of immunisation, and water supply are also important. It is an unfortunate truth that while curative care in India does not address the problem of malnutrition, it does save malnourished children if they land up at a hospital in time. In his article, Panagariya does not appreciate the importance of medical facilities in explaining better mortality figures. Surely he knows that India is a nation in transition, with poor food intake and widespread hunger on the one hand, and relatively well-established healthcare services, especially emergency care, on the other.”
There is a certain intuitive appeal to Panagariya’s argument that when almost all of the statistics suggest that India’s doing better than sub-Saharan Africa and there’s one statistic going the other way, one has to look closely at that one errant statistic. Yet, as Gupta, Patnaik et al claim, the answer to India’s failure to combat malnourishment in face of its substantial success in bringing down infant and child mortality may be rooted in the peculiar features of its public health system. contours
This view finds support in Dean Spears’ Coming Up Short in India in Mint, poor sanitation and resultant chronic intestinal infections could explain the persistence of child malnutrition in India.
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