The World Bank has termed the malnutrition as ‘India’s silent emergency’ and ‘among India’s greatest human development challenges’. Although India has witnessed high economic growth in the last three decades, malnutrition in children under five years of age in the country continues to be among the highest in the world. Nearly half of all India’s children—approximately 60 million—are underweight, about 45% are stunted (too short for their age), 21% are wasted (too thin for their height, indicating acute malnutrition), 75% are anaemic, and 57% are Vitamin A deficient.
Rates of malnutrition among India’s children are almost five times more than in neighbouring China, and twice those in Sub-Saharan Africa—even though India enjoys vastly higher income levels and food security than Sub-Saharan Africa. Such findings are perplexing, some economists even call the phenomenon the ‘South Asian Enigma’, and suggest that India’s problem of child malnutrition may have to do with factors other than the availability of food.
So, what are these other factors contributing to the problem?
One prominent explanation, termed as the ‘intergenerational cycle of malnutrition’, connects the disproportionately high levels of undernutrition in India with the status of women in Indian society. Frederika Meijer, former United Nations Population Fund’s country representative for India and Bhutan, summed up the explanation as follows, “Undernourished girls become undernourished mothers who give birth to the next generation of undernourished children”.
This theory has emerged out of compelling evidence from a body of research in the area.
India has one of the highest burdens of malnourished adult women among developing countries. To add to that, new mothers in India are too often adolescents, an appalling 75% of whom are anaemic, and most put on less weight during pregnancy than they should—5 kilograms on average compared to the worldwide average of close to 10kgs.
Another exceedingly alarming statistic is that the under-five mortality rate for girls is higher than that of boys in India. This trend starkly differs from the rest of the world, where the girl child enjoys clear survival advantages. For example, in Bangladesh, the sex mortality ratio is 86.4 female per 100 male deaths. Globally, this ratio stands at 92.5 female per 100 male deaths, and in the UN’s Least Developed Countries, girls tend to fare even better, averaging 88.3 female per 100 male deaths. This raises the concern that there may be conditions (environmental and inherited) prevalent in India that prevent girls from showing the expected rates of survival.
Researchers have identified one important cause for this anomaly: that gender bias against girl children is working to reduce their access to nutrition, and thereby leading to higher mortality rates. The preference for male children in Indian parents has been linked with an increased likelihood of stunting in their girl children and concerningly, Indian girls experience about one-half month shorter breastfeeding duration than boys on an average. Girls in India are also found to be less likely to have received breast milk and fresh milk as a source of protein compared to boys.
Unfortunately, this nutritional disparity does not seem limited to early childhood years of girls.
A study conducted by researchers from Oxford University found that by the age of 15, a gender gap appears in the variety of food consumed, with boys having a significant advantage. The results show a gap even when the researchers controlled for other factors such as the onset of puberty, time spent working or at school, or dietary behaviours such as number of meals.
In addition, domestic abuse and violence is rampant in India, with data from the National Family and Health Survey (NFHS) indicating that over 30% of Indian women have been physically, sexually, or emotionally abused by their husbands at some points in their lives. A woman’s experience of abuse and acceptance of domestic violence is known to have a significant negative impact on her nutritional status.
Another problem is that of poor access to sanitation facilities. The absence of sanitation facilities in most rural homes compels women to relieve themselves in the open where they risk being seen by others and in some cases, even assaulted. Therefore many women in rural India prefer to go at odd hours of the morning, walk long distances to reach the outskirts of villages where they are less likely to come across people, and to go in the company of other women and not alone. This limits how frequently women find a chance to relieve themselves in the day. In one qualitative study conducted in Odisha in 2017, an attempt was made to understand women’s concerns about sanitation. The most disheartening finding was that a significant number of women reported limiting their intake of food and water as a coping mechanism. Responses like this were common:
“I do not eat at night out of the fear that I will have the pressure to defecate…Recently I had been admitted in the hospital as I reduced eating. The doctor was angry…he said that if you do not eat at night you will die.”
Also worth examining when discussing malnutrition in India is the manner in which distribution of resources (including food resources) takes place within the household. Right to Food in India, a 2003 paper of the Centre for Economic and Social Studies, states that, “Particularly among the rural poor, food distribution in households is not based on need. The breadwinner gets sufficient food, the children get the next share, and women take the remains.”
S Mahendra Dev and Alakh Sharma—economists who have investigated malnutrition trends in India for many years, write in a 2010 Oxfam publication, “Low birth weight is the single largest predictor of undernutrition. The problem could be empowerment. Women in South Asia tend to have lower status and less decision-making power than women in sub-Saharan Africa.”
Drawing from the work of Dr. Amartya Sen, one approach to understanding the perpetuation of gender inequalities with respect to access to food and other resources (such as healthcare) is the cooperative conflicts theory. According to this theory, when two parties are engaged in a cooperative conflict (which is defined as a conflict of interest in which mutual cooperation is the most desirable outcome for all parties involved), the party with the worse breakdown position (the position that party is left at in case cooperation fails) will receive the shorter end of the stick. Dr. Sen applies this ‘bargain problem’ to the way in which resources are distributed within the household, thus attributing women’s relatively disadvantageous access to household resources to their inferior breakdown positions, which in the case of the household refers to the failure of the household unit with one or both parties walking away.
In a country where the failure of marriage often amounts to a woman losing a substantial portion of income, social security and social standing, it is no surprise that women are deprived of household resources—sometimes at the cost of their physical health. The benefits of adopting this view is that it identifies a theoretical link between women’s socio-economic position and their health, and points that an improvement in women’s breakdown position can lead to better health outcomes for them.
Such findings and theories take on new urgency in the time of coronavirus. While the ongoing crisis is directly affecting food security in the country, the above-mentioned studies indicate that the brunt of this will be borne by women and girls. Other causes of concern include that the pandemic is decreasing women’s ability to escape situations of domestic abuse and is further restricting their access to healthcare and sanitation facilities. The present situation is likely to take an unprecedented toll on our health in the long term, one that is larger and more insidious than the pandemic itself, disproportionately affecting those most vulnerable among us—women, young children, and the poor.
There exists a need to reconceptualise malnutrition as more than just a physical health problem or simply an inevitable consequence of poverty, but a socio-culturally rooted phenomenon. Interventions in the area might better achieve desired ends by doing more than targeting the availability of nutritious foods and by working towards broader goals such as promoting female labor force participation, female literacy (which leads to greater employment opportunities for women), and gender sensitivity in communities. Moreover, the role of social scientists in furthering our understanding about the socio-cultural dimensions of the issue and in bringing about the desirable attitudinal, behavioural and social change is important and should be enhanced.
Saumya is pursuing her Master’s degree in Lifespan Counselling Psychology from St Xavier’s College, Mumbai. Within the field of psychology, her deepest interest lies in understanding how social contexts impact health and well-being. You can find her on Facebook.
Featured Image Source: Feminism In India