Sunday, July 21, 2013
Measuring Malnutrition
My op-ed, defending Arvind Panagariya's EPW paper on malnutrition (link) appeared in Mint last week. I am also reproducing the full text here.
A recent article by economist Arvind Panagariya of Columbia University, titled Does India Really Suffer from Worse Child Malnutrition than Sub-Saharan Africa, in the Economic and Political Weekly (18 May) has led to a lively debate on child malnutrition.
Panagariya’s thesis is that World Health Organization (WHO) sanctioned, one-size-fits-all approach to measuring child malnutrition is based on assumptions unsupported by evidence. It assumes that identical nourishment leads to identical average heights and weights in different populations, regardless of differences in race, culture, geography and physical environments between them. In other words, the WHO approach is premised on the assumption that given proper nutrition, on average, a five-year-old Keralite girl reared in Kerala will soon attain the same height and weight as a five-year-old Dutch girl reared in Holland. Panagariya argues that this is a false premise and leads to overestimation of stunted (low height for age) children in India relative to, say, sub-Saharan Africa.
Several commentators have criticized the politically sensitive argument by Panagariya, including in this newspaper. Here is a sample of criticisms offered:
• Panagariya says that Indian children are simply genetically short and, therefore, their heights are nothing to worry about.
• Malnutrition in India is less bad than we think, but so what?
• Malnutrition can be explained by factors such as the social status of women, rather than genetics.
• Diseases such as HIV/AIDS explain the differences between India and sub-Saharan Africa when it comes to non-nutritional health indicators.
I am puzzled by some of these criticisms. Even a casual reader of the Panagariya paper will notice that he is not advocating that we quit worrying about stunting among children. Here is what Panagariya explicitly says: “It is important to point out at the outset that it is not my intention to downplay the seriousness of the child malnutrition problem in India. Just like vital health statistics such as life expectancy, infant and child mortality rates, and maternal mortality ratio, which need continued improvement, child malnutrition must be brought down and eliminated.” He goes on to state that his beef instead is with the use of the globally uniform height and weight standards regardless of race, culture, geography and environment.
Regarding the second point, a proper count of the malnourished population does matter. In a country with 1.2 billion people, whether malnutrition strikes 50% children or 30% is a huge difference. India is still a poor country and it must allocate scarce resources judiciously across many social and economic ills it needs to combat and, therefore, diagnosing a problem correctly is critical.
The third point made by critics both misrepresents what Panagariya has argued and obfuscates his central point. Panagariya explicitly allows for improvements in height and weight through improved diet, reduced incidence of disease, female education and other factors that can be humanly controlled. Indeed, he goes a step further and cites evidence of progress India has made in raising average heights and weights of Indian children since the late 1970s. His contention instead is that these factors fall short of explaining the large incidence of stunting and underweight implied by WHO standards. He questions critics who reject genetics as a possible explanation as to why Kerala exhibits greater incidence of stunting than countries such as Senegal and Mauritania despite being light years ahead of the latter on every other human development metric.
More importantly, the critics have been unable to explain the persistent height difference of 12.5 centimetre (cm) between a Japanese male and a Dutch one (the two countries that have both been rich and free of malnourishment for decades), or a 9.5cm difference between a Portuguese male and a Dutch male. For that matter, the critics haven’t explained the persistent height difference between children of Moroccan extraction born in Holland and native-born Dutch children of 6cm among men and 7.9cm among women. As for social status of women, can we seriously make the case that women in Mauritania have a higher social status than women in Kerala?
Regarding the last criticism, we must note that Senegal, for instance, has a HIV/AIDS incidence of less than 1%. Therefore, HIV/AIDS cannot explain why Senegal does so much worse than Kerala on every human development indicator except for malnutrition.
Combating malnutrition is very important, so I read with interest Dean Spears’ article (Coming up short in India, Mint, 5 July) suggesting that the lack of toilets and open defecation explain much of the gap in stunting between India and sub-Saharan Africa. But here again Kerala has near universal coverage of toilets and minuscule open defecation and yet it shows a greater incidence of stunting than Senegal and Mauritania. Could it be there is something more to malnutrition than open defecation?
Just like the exclusive focus of the national food security Bill on carbohydrates, the focus of malnutrition measures on height and weight is excessively narrow. Malnutrition is a multi-dimensional problem, involving both protein energy malnutrition and micronutrient deficiency and can only be diagnosed with a proper medical examination. Given the importance of combating malnutrition, a reassessment of the current metric, and development of a new national or regional metric is called for.
Reuben Abraham is the executive director of the Centre for Emerging Markets Solutions at the Indian School of Business, and a non-resident scholar at New York University.
