Comparing India's child malnutrition with Sub-Saharan Africa based faulty WHO criteria

By Rajiv Shah 
Amidst raging controversy around whether Gujarat’s child malnutrition levels have actually gone down, with the Gujarat government vehemently denying a recent Comptroller and Auditor General (CAG) report that every third child in the state suffers from malnutrition, a recent research paper by one of the senior-most economists, Prof Arvind Panagariya of the Columbia University, has sharply contested the criterion of comparing India’s child malnutrition levels with those of Sub-Saharan African countries, which have much lower per capita incomes and poorer health indicators.
Saying that the comparison is based on “the artefact of a faulty methodology that the World Health Organization (WHO) has pushed and the United Nations has supported”, he adds, “If appropriate corrections are applied, in all likelihood, India will be found to be ahead of Sub-Saharan Africa in child malnutrition, just as in other vital health indicators.” His research paper, "Does India Really Suffer Worse Child Malnutrition than Sub-Saharan Africa" was published in Economic and Political Weekly, a periodical that publishes well-researched articles.
Pointing how international media has sought to highlight this with reputed periodicals like “The Economist” (September 23, 2010) stating that “nearly half of India’s small children are malnourished: one of the highest rates of underweight children in the world, higher than most countries in sub-Saharan Africa”, Panagariya is worried that the Government of India has bought the argument. “In January 2011, even India’s otherwise measured Prime Minister Manmohan Singh went on to lament, ‘The problem of malnutrition is a matter of national shame’, while releasing the much publicized Hunger and Malnutrition (HUNGaMA) Report”.
Panagariya, who belongs to what is called the neo-liberal school of economists, argues, “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 geographical factors. Though medical literature recognises the importance of these factors, the WHO totally ignores them when recommending globally uniform height and weight cut-off points against which children are compared to determine whether they suffer from stunting (low height for age) or underweight (low weight for age) problems.”
Proposing the need to correct the “current globally uniform height- and weight-based measures of child malnutrition”, Panagariya says, health experts and economists should come together “to devise a better methodology of measurement”. He underlines, this is especially necessary as “indicators such as life expectancy, infant and child mortality rates, and maternal mortality ratio, India does not suffer worse child malnutrition than Sub-Saharan Africa.” Given wrong methodology, the issues that should be asked are: “Should more be spent on combating child malnutrition or on improving elementary education? Or on providing guaranteed employment or on alleviating adult hunger?”

Under-5 child mortality rate per 1000 births: Sub-Saharan Africa, India

Wondering why micronutrient deficiency resulting from inadequate levels of iron, folate, iodine, and various vitamins, including A, B6, D, and E, in the body are not considered, Panagariya says, “These deficiencies lead to anaemia, goitre, bone deformities, and night blindness. Given these many dimensions involved in identifying malnutrition, only a thorough medical check-up can properly determine whether a child is malnourished or not. But few globally comparable large-scale surveys rely on extensive medical check-ups to measure malnutrition in children”.
Comparing a set of commonly-used health indices for the child and the mother in India to those in Chad and the Central African Republic, two of the poorest countries in the world, Panagariya says, “Chad has just 48 years of life expectancy against India’s 65 years; an infant mortality rate (IMR) of 124 against India’s 50; an under-fi ve mortality rate of 209 relative to India’s 66; and a maternal mortality ratio (MMR) of 1,200 compared to India’s 230. Yet, Chad has disproportionately fewer stunted and underweight children than India. The comparison with the Central African Republic is equally stark.”
Further comparing Kerala with two other countries from Sub-Saharan Africa, Senegal and Mauritania, Panagariya states, he has chosen Kerala of the 28 states in India, “as it brings out the absurdity of the current child malnutrition indicators as sharply as possible.” He says, “The conventional vital health statistics in Kerala are the highest among all Indian states and rival those observed in China. Among the largest 17 Indian states, it ranks fourth in terms of per capita income. In terms of per capita income, Senegal and Mauritania are among the better-off countries in Sub-Saharan Africa but both lag behind India and Kerala with the gap being especially large with respect to the latter”.
However, says Panagariya, “Senegal, which has 4.25 times the infant mortality rate of Kerala, almost six times Kerala’s underfive mortality, and 4.3 times Kerala’s maternal mortality ratio, has lower rates of stunting and underweight children. Children in Senegal, better nourished as per malnutrition estimates, die at rates many times those in Kerala. A comparison with Mauritania yields the same picture. A higher incidence of child malnutrition in Kerala than Senegal and Mauritania is even more puzzling given its significantly higher female literacy rate.”
He adds, “The state has had a long history of educating its women and its female literacy rate at 92% in 2011 is among the highest in the developing world. In addition, women have traditionally enjoyed high social status in Kerala with many communities following the matrilineal tradition. In contrast, at 29%, Senegal has one of the lowest female literacy rates in the world. Mauritania does better at 51%, but it also lags far behind Kerala.”
Making a comparison Sub-Saharan Africa with India, Panagariya says, “The life expectancy at birth in India at 65 exceeds those in all but two of the 33 Sub-Saharan African countries (at 66 years, Eritrea edges out India, while at 65 Madagascar ties with it). The infant mortality rate per 1,000 live births in India at 50 is lower than those in all but three of the 33 Sub-Saharan African countries (Eritrea, Madagascar, and Ghana have infant mortality rates of 39, 40, and 47, respectively). The under-five mortality rate per 1,000 live births in India at 66 is lower than those in all but two of the 33 Sub-Saharan African countries (Eritrea and Madagascar have under-fi ve mortality rates of 55 and 58, respectively).”
Panagariya further says, “The stillbirth rate per 1,000 births at 22 in India is lower than those in all but five of the 33 Sub-Saharan African countries (Eritrea, Madagascar, Zimbabwe, Kenya, and Ghana have stillbirth rates of 21, 21, 20, 22 and 22, respectively). But this pattern collapses when it comes to child malnutrition.”
He adds, “The proportion of children under five years of age classified as stunted (low height for age) at 47.9% is higher in India than all but six of the poorer Sub-Saharan African countries (Burundi, Malawi, Ethiopia, Niger, Madagascar, and Rwanda have stunting rates of 63.1%, 53.2%, 50.7%, 54.8%, 49.2% and 51.7%, respectively). The proportion of children under five years of age classified as underweight at 43.5% is higher in India than every one of the 33 poorer Sub-Saharan African countries.”