How Prof Panagariya got it wrong
Veena S Rao | November 24, 2011
Professor Arvind Panagariya wrote an article titled “The Child Malnutrition Myth,” in Times of India on October 1, 2011 (see link: http://articles.timesofindia.indiatimes.com/2011-10-01/edit-page/30230007_1_underweight-children-maternal-mortality-mortality-rate) in which he expressed in strong language extreme doubt and scepticism regarding the reliability of child malnutrition data in India, even suggesting that it was nonsensical. Many of us social workers and professionals working in this area were rather disturbed regarding the damage and misinformation that such an article, based on completely wrong premises and comparisons, could cause, especially when written by an eminent economist of Columbia University. Hence, this riposte.
Panagariya rests his arguments on the fact that since life expectancy at birth, infant and maternal mortality indicators and per capita income in India are better than most sub-Saharan African (SSA) countries it is puzzling that the incidence of underweight and stunting among children should be higher in India. Panagariya obviously believes that better infant and maternal mortality rates and life expectancy at birth automatically translate into better weight and height for children.
Before going into the merit of Panagariya’s argument, I would like to remind him that the abnormally high infant and maternal mortality rates in SSA are substantially related to high prevalence of HIV/AIDS, conflict situations that result in lack of essential health care for women and children, and sometimes famine and food scarcity. Poverty being a common factor with SSA, causes for high infant and maternal mortality in India are not only symptomatic, but also deep-rooted and structural, most importantly, in the low status of the girl child and women throughout the life cycle, in family and society, negatively impacting upon food consumption, even during pregnancy. (A typical Indian mother gains around 5 KGs weight during pregnancy as compared to an African mother who gains 10 KGs).
This leads to low-birth weight babies (30% in India and much higher than SSA) who constitute about 35% of neonatal mortality, with at least 65% of all infant mortality being caused by malnutrition related factors. Surviving LBW infants will most likely add to the stunted/underweight pool. Hence, India’s IMR and MMR are much more related to maternal malnutrition, low birth weight, gender discrimination than SSA, poverty and quality of health care being equal. The weight gained by women during pregnancy, the birth-weight of an infant, and the BMI of an adolescent girl, give a snapshot of the status of women in society, all for which SSA fares much higher than India.
Over the passage of time, with social attitudes remaining unchanged, even with improved economic conditions, malnutrition (that includes underweight and stunting) has become inter-generational, linking underweight and malnourished adolescent girls to similar status mothers and LBW babies. The Indian adolescent girl is the most underweight in the world. India’s health and nutrition transition in the last four decades, indicates that even with gradually declining infant mortality rates, underweight and stunting figures have remained more or less static in the last decade.
This is understandable – because as infant and child mortality reduces because of nutritional/ health interventions, underweight/stunting can actually increase, because vulnerable (LBW) infants or wasted babies may not die, but will grow to be severely stunted/ underweight children; children belonging to the severely stunted/ underweight category climb higher into the moderate category with proper interventions, improved diets and health care. Hence, it is entirely possible that SSA countries can have better child nutritional status than India, even though their mortality rates and life expectancy at birth are worse than ours.
Panagariya also raises questions regarding the rationale and methodology of the WHO standards derived from WHO Multi Centre Growth Reference Study (MGRS) for determining the parameters of stunting and underweight and generating the percentile and z-score curves for length/height-for-age, weight-for-age, weight-for-length, weight for-height and BMI-for-age. The MGRS Design combined a longitudinal study from birth to 24 months with a cross-sectional study of children aged 18 to 71 months. Feeding practices and growth information on the transition from supine length to standing height were important components of the longitudinal design. It covered 8,440 children from India, Brazil, Ghana, Norway, Oman and the US, so as to represent a diversity of ethnic backgrounds. The decision to include populations from the major world regions was supported by solid evidence showing that the growth patterns of well –nourished, healthy preschool children across the world are very similar, which was validated by the MGRS, that showed a striking similarity among the six sites, with only about 3% of variability in length.
The report states that “the remarkable similarity in growth during early childhood across human populations is consistent with genomic comparisons among diverse continental groups reporting a high degree of inter-population homogeneity. Nevertheless, the MGRS sample has considerable built-in ethnic or genetic variability in addition to cultural variation in how children are nurtured, which further strengthens the standards' universal applicability.”
The sample criteria for the MGRS were: birth weights, education of parents, maternal age, mother and father’s height, alcohol consumption by mother, family income, piped water, flush toilet, refrigerator, gas/electric cooker, telephone and car. The parameters were: breastfeeding, complementary feeding, calories and micronutrient content of complementary feeding, feeding during illness, hygiene and food handling, immunization, motor development. The study concluded that even in this affluent group of children, 2.3 % had a standard deviation of -2 for underweight. This is not an arbitrary figure, but the result of a six-year longitudinal and cross-sectional study conducted by experts, Indian and international, rigorously reviewed by WHO and UNICEF at several levels and then universally adopted. Details of methodology, study design and finalization of the operational tools are available in the public domain.
Panagariya raises doubts regarding this figure. He quotes a GoI report (without naming it) that draws from a highly restricted sample of elite children’ from NFHS 3, (children whose mothers and fathers have secondary or higher education, who live in households with electricity, a refrigerator, a TV and an automobile or truck, who did not have diarrhoea or a cough or fever in the two weeks preceding the survey, who were exclusively breastfed if they were less than five months old, and who received complementary foods if they were at least five months old. I presume he refers to ‘Nutrition in India’, 2009, published by the Ministry of Health and Family Welfare. Assuming so, the argument is that this study that also culled out the elite children from the NFHS concluded that 15% of children were stunted. Prof Panagariya is at a loss to reconcile these two findings.
The parameters and methodology of the MGRS, in addition to the household assets, included quantity, quality and timing of nutritional intake and feeding practices in wellness and sickness, hygiene, motor development and anthropometric measurements during the 60-month period. These were not part of the GoI 2009 study that merely culled out one time data from the NFHS ‘elitist children’ (based mostly on household assets) and analyzed the same. The GoI report also clearly states, “If the analysis had included additional variables that would permit elite children to be better defined, it is likely that the cumulative distribution would have moved even closer to the cumulative normal distribution.”
Hence comparing the nutritional status of elite children as defined by the report of 2009 and the determination of WHO growth standards may not be quite appropriate. I earnestly request Prof Panagariya to kindly go through the detailed reports of NFHS 3 and the WHO Multi Centre Growth Reference Study, in addition to the executive summaries. I’m sure with his vast academic experience and knowledge, he will be able to see that the two are not necessarily contradictory. I also take this opportunity to request him to lend his moral and intellectual support to combat malnutrition in India.
Rao is a retired IAS officer and presently advisor to the Karnataka Nutrition Mission. She informs us that this article has been reviewed by Dr Brahmam, National Institute of Nutrition, Hyderabad; Dr C S Pandav, Professor & Head, Centre for Community Medicine, AIMS, New Delhi, and Dr R Shankar, Regional Manager, Global Alliance for Improved Nutrition, New Delhi.
We contacted Prof Panagariya, through email, to respond to the criticism. He assured us that he hoped to write, “in due course”, a follow-up piece responding to the criticisms of his original article.
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