In March, a study titled The State of Nutrition Among Children in Parliamentary Constituencies of India provided constituency-wise data for child malnutrition across all the 543 Lok Sabha seats. This is the first such study for India, which has the highest prevalence of child malnutrition in the world.

The study found that some of the constituencies represented by high-profile MPs were among the most neglected when it came to child malnutrition. For instance, Prime Minister Narendra Modi’s constituency Varanasi was ranked 250 (543 being the best and 1 being the worst).

When it came to anaemia, a child malnutrition indicator along with stunting, low weight for age and wasting, Congress president Rahul Gandhi’s Amethi fared worse at 161. The most damning finding was in Pilibhit, the constituency of Union Minister for Women and Child Development Maneka Gandhi, which was ranked among the bottom 14 when it came to anaemic children in India.

SV Subramanian, who led the study, is a professor of population health and geography at Harvard University. He is also an editorial consultant to The Lancet and an international advisory board member for Lancet Global Health, the open access online journal from Lancet.

He discussed his study and the larger problem of the high prevalence of child malnutrition in India with journalist Rohit Inani.

The interview has been edited and condensed for clarity.

Presently, the government releases state and district-wise health data in India. If the government were to officially release the same data constituency-wise, would it make our parliamentarians more accountable?
Absolutely. Making these data routinely available at the constituency level would keep any Member of Parliament or minister in charge on their feet in terms of where they stand. So unlike at the district level, which is a faceless and nameless entity, the constituents can approach the main representative whom they can connect with, and who represents the will of the people. And it will put more pressure on the parliamentarians [to deliver].

Last year, an ASSOCHAM-EY report found that India has about 50% of the malnourished children in the world, the highest in the world, with close to 40% of children in India being undernourished. Apart from a lack of non-nutritious, non-balanced food, the report also put the onus on social inequity.
Of course, one of the biggest contributors to malnutrition in India is the socio-economic status [of the affected]. And apart from access to sanitation etc, poor diet is a big issue. So there is a very direct consumption angle here related to one’s socio-economic status.

And even if you take the malnutrition rate overall, it’s almost three-fourths amongst the poor. So there is a social story here, but I think the bigger story is the economic one. For instance, we don’t find any gender difference in malnutrition rate between boys and girls. None at all. Even though caste [discrimination] is [also] an important issue affecting child malnutrition, I think economic deprivation whether at the household or village level [plays a larger role].”

SV Subramanian, professor of population health and geography at Harvard University. (Photo credit: Harvard TH Chan School of Public Health).

How does a child become malnourished over a period of time?
It is [due to] multiple factors but certainly dietary intake and composition is among the most important intervenable factor. Infection or more precisely treating infection in a timely manner is also critical, which in turn is related to poor access to water (quantity and quality) as well as sanitation. Of course, the most potent instrument is poverty alleviation and income generation. However, even with that, one may wish to focus on access to nutritious food as opposed to increasing empty calories.

In the last decade, India clocked impressive economic growth and according to a recent United Nations Development Programme report, it also lifted 271 million people out of multi-dimensional poverty between 2005-’06 and 2015-’16. Yet, it made insignificant progress toward eradicating child malnutrition. What, according to you, explains this?
The evidence of macroeconomic growth to population level changes is very mixed and, at best, weak on the unique goal of economic growth leading to reduction in child malnutrition. But at the micro level, there is strong evidence that if you correlate malnutrition rates with household wealth, there is a very strong relationship. So if macroeconomic growth is translated into money, the mechanism through which it will work from income to malnutrition is food because India is still very calorie deficient.

So I think the first route through poverty alleviation [that] helps with malnutrition is the ability to purchase food. So, even if you have access to food but the child is consistently falling sick and you don’t have immediate access to healthcare, then it’s still messed up. You are not immune to public infrastructure deprivation.

But I think in the last 10 years, things are improving in the right direction in India. I don’t think the issue of child malnutrition has been raised to such a high profile as it has been in this government. Now whether it translates into real action, that we have to see by how much independent assessment and data collection is done on the ground. But rhetoric matters because one can always ask the government: “Hey, you are talking about it, [but] what are you doing about it?”

Does economic growth drastically reduce child malnutrition in developing economies? Is there any statistical evidence?
Evidence is mixed. But we also know malnutrition is highly patterned [on] the household’s economic status. I take your point that simply a change in economic growth or a change in India’s income between 2005-’15 did not significantly reduce child malnutrition and stunting. The correlation is very weak. Growth benefited a certain section of the population. We also need to take into account how much of this growth tricked down in terms of access to public infrastructure. And this is where I think some of the parliamentary constituency data might be more helpful because in some poorer districts, people don’t care about the [quality of] airports. So this is one question where we thought that presenting statistics at the political level brings that sharper focus: Whose will is getting represented in these broad policies?

The larger question is that if we put more money into your pocket, would it lead to a reduction in the risk of undernutrition of your child? Yes, there is no question about it.

Children eat their midday meal at an anganwadi in Ramanagara district in Karnataka. (Photo credit: Nayantara Narayanan).

How would this widespread prevalence of child malnutrition affect India’s much trumpeted demographic dividend?
This is an important point. India keeps talking about its demographic dividend but it is based on sheer numbers that there are a lot of young people, which matters [because] this is what is going to feed into the basic human capital. So if children, who would be India’s future youth, are not having an early childhood that is fulfilling in a cognitive sense, then the demographic dividend would be a drag because you will have a population that won’t have the skill set to participate in an economy that is evolving rapidly. And they would end up with low-wage, low-skill jobs.

The Congress recently announced its much debated NYAY scheme: a minimum income of Rs 6,000 per person per household for 20% of India’s poor, if voted to power. If increased household incomes decrease the risk of child malnutrition, do you think a guaranteed basic income for the poorest would reduce child malnutrition over a period of time?
Yes, a basic income would go a long way if it gives the [poorest of the poor] a way to buy food. I think there is a lot of merit in guaranteeing an income to the poor from a human development and human rights perspective. Given the consistently strong associations between child malnutrition and household economic well being, policies aimed at guaranteeing income for poorest of the poor are very desirable. Of course efforts should be seen as complementing efforts to also provide quality and nutritious food items through subsidised schemes and mechanisms such as the PDS [public distribution system]..

Over the last few decades, India has taken great efforts to reduce child malnutrition. Yet, it made a modest dent in reducing malnutrition rates even when we achieved food grain security at the national level. We still have pockets of deep poverty where there exists chronic food insecurity and hidden hunger. If today we have the largest number of malnourished children in the world, is it owing to an inefficient state?
Yes, it could be said. But remember that this is where data comes handy. Until at least the 2000s, it was not even being discussed. And the first survey when we came to know what is the malnourishment of children here goes back to 1992. Before that we had zero information. We thought everything is okay; there is poverty for sure, but we didn’t know the details of this poverty. So it was all framed around poverty in the ’80s if you recall Indira Gandhi’s “garibi hatao” [slogan]. It was without any details or nuances. 1992 was the first time public data became available.

Finally it was in 2005, I think, when the government finally woke up and took this issue seriously. So to put your question in perspective, yes, the government was ineffective as far as thinking proactively about data. Even today, India doesn’t count every single child death; it all comes from estimates. So this is the bigger story that even after 75 years of independence we can’t count how many kids have died.

Here I agree with you: it is a damning story that the Indian state has failed its children, but I’d also say that part of it was sheer ignorance in a sense that if you don’t know the magnitude of the problem then there is nothing to talk about. On the other hand, once data started coming [in the early 2000s] and if you take the last 10-15 years, we are heading in the right direction.