Neglecting Children & economic gains?

NEW DELHI — Small, sick, listless children have long been India's scourge — "a national shame," in the words of its prime minister, Manmohan Singh. But even after a decade of galloping economic growth, child malnutrition rates are worse here than in many sub-Saharan African countries, and they stand out as a paradox in a proud democracy.

China, that other Asian economic powerhouse, sharply reduced child malnutrition, and now just 7 percent of its children under 5 are underweight, a critical gauge of malnutrition. In India, by contrast, despite robust growth and good government intentions, the comparable number is 42.5 percent. Malnutrition makes children more prone to illness and stunts physical and intellectual growth for a lifetime.

There are no simple explanations. Economists and public health experts say stubborn malnutrition rates point to a central failing in this democracy of the poor. Amartya Sen, the Nobel prize-winning economist, lamented that hunger was not enough of a political priority here. India's public expenditure on health remains low, and in some places, financing for child nutrition programs remains unspent.

Yet several democracies have all but eradicated hunger. And ignoring the needs of the poor altogether does spell political peril in India, helping to topple parties in the last elections.

Others point to the efficiency of an authoritarian state like China. India's sluggish and sometimes corrupt bureaucracy has only haltingly put in place relatively simple solutions — iodizing salt, for instance, or making sure all children are immunized against preventable diseases — to say nothing of its progress on the harder tasks, like changing what and how parents feed their children.

But as China itself has grown more prosperous, it has had its own struggles with health care, as the government safety net has shredded with its adoption of a more market-driven economy.

While India runs the largest child feeding program in the world, experts agree it is inadequately designed, and has made barely a dent in the ranks of sick children in the past 10 years.

The $1.3 billion Integrated Child Development Services program, India's primary effort to combat malnutrition, finances a network of soup kitchens in urban slums and villages.

But most experts agree that providing adequate nutrition to pregnant women and children under 2 years old is crucial — and the Indian program has not homed in on them adequately. Nor has it succeeded in sufficiently changing child feeding and hygiene practices. Many women here remain in ill health and are ill fed; they are prone to giving birth to low-weight babies and tend not to be aware of how best to feed them.

A tour of Jahangirpuri, a slum in this richest of Indian cities, put the challenge on stark display. Shortly after daybreak, in a rented room along a narrow alley, an all-female crew prepared giant vats of savory rice and lentil porridge.

Purnima Menon, a public health researcher with the International Food Policy Research Institute, was relieved to see it was not just starch; there were even flecks of carrots thrown in. The porridge was loaded onto bicycle carts and ferried to nurseries that vet and help at-risk children and their mothers throughout the neighborhood.

So far, so good. Except that at one nursery — known in Hindi as an anganwadi — the teacher was a no-show. At another, there were no children; instead, a few adults sauntered up with their lunch pails. At a third, the nursery worker, Brij Bala, said that 13 children and 13 lactating mothers had already come to claim their servings, and that now she would have to fill the bowls of whoever came along, neighborhood aunties and all. "They say, 'Give us some more,' so we have to," Ms. Bala confessed. "Otherwise, they will curse us."

None of the centers had a working scale to weigh children and to identify the vulnerable ones, a crucial part of the nutrition program.

Most important from Ms. Menon's point of view, the nurseries were largely missing the needs of those most at risk: children under 2, for whom the feeding centers offered a dry ration of flour and ground lentils, containing none of the micronutrients a vulnerable infant needs.

In a memorandum prepared in February, the Ministry of Women and Child Development acknowledged that while the program had yielded some gains in the past 30 years, "its impact on physical growth and development has been rather slow." The report recommended fortifying food with micronutrients and educating parents on how to better feed their babies.

A World Food Program report last month noted that India remained home to more than a fourth of the world's hungry, 230 million people in all. It also found anemia to be on the rise among rural women of childbearing age in eight states across India. Indian women are often the last to eat in their homes and often unlikely to eat well or rest during pregnancy. Ms. Menon's institute, based in Washington, recently ranked India below two dozen sub-Saharan countries on its Global Hunger Index.

Childhood anemia, a barometer of poor nutrition in a lactating mother's breast milk, is three times higher in India than in China, according to a 2007 research paper from the institute.

The latest Global Hunger Index described hunger in Madhya Pradesh, a destitute state in central India, as "extremely alarming," ranking the state somewhere between Chad and Ethiopia.

More surprising, though, it found that "serious" rates of hunger persisted across Indian states that had posted enviable rates of economic growth in recent years, including Maharashtra and Gujarat.

Here in the capital, which has the highest per-capita income in the country, 42.2 percent of children under 5 are stunted, or too short for their age, and 26 percent are underweight. A few blocks from the Indian Parliament, tiny, ill-fed children turn somersaults for spare change at traffic signals.

Back in Jahangirpuri, a dead rat lay in the courtyard in front of Ms. Bala's nursery. The narrow lanes were lined with scum from the drains. Malaria and respiratory illness, which can be crippling for weak, undernourished children, were rampant. Neighborhood shops carried small bags of potato chips and soda, evidence that its residents were far from destitute.

In another alley, Ms. Menon met a young mother named Jannu, a migrant from the northern town of Lucknow. Jannu said she found it difficult to produce enough milk for the baby in her arms, around 6 months old. His green, watery waste dripped down his mother's arms. He often has diarrhea, Jannu said, casually rinsing her arm with a tumbler of water.

Ms. Menon could not help but notice how small Jannu was, like so many of Jahangirpuri's mothers. At 5 feet 2 inches tall, Ms. Menon towered over them. Children who were roughly the same age as her own daughter were easily a foot shorter. Stunted children are so prevalent here, she observed, it makes malnutrition invisible.

"I see a system failing," Ms. Menon said. "It is doing something, but it is not solving the problem."

Ruth Fremson/The New York Times

Malnutrition in India is worse than in many African nations, stunting the growth of children like this girl in Shivpuri, photographed in November 2008.