Stunted India Needs To Grow Up

From Ayurvedic remedies to nutritional drinks that “keep them shooting up”, there are any number of products available that claim to add magical extra inches to your child’s height. Open any parenting magazine and there almost always is an article offering tips to boost your child’s height.

Height does have something to do with genetics, but also, with nutrition and hygiene. So when one looks at data that shows that India is the fifth most stunted nation in the world, there is serious cause for concern. Indian children are among the shortest in the world – children born here are on average shorter than those born in the poorest African countries.

Globally, an estimated 25% of children under the age of five are stunted, which means they are shorter than normal for their age. But in India, nearly 40% of such children across all income groups are stunted — a subject that was also the focus of research by this year’s Nobel winner for economics, Angus Deaton.

In his 2009 paper ‘Food and Nutrition in India: Fact and Interpretations’, co-authored with development economist Jean Dreze, Deaton documented how malnutrition is linked not just to lack of calories but also to a lack of variety in diet, poor maternal health and inadequate sanitation.

Stunting is more than simply a matter of appearance. It’s a marker for a range of developmental problems, says Dr. Armida Fernandez, former dean of Mumbai’s Lokmanya Tilak Hospital, one of the city’s largest public health facilities, and founder of the NGO SNEHA (Society for Nutrition, Education and Health Action), which works closely among women and children in slum communities.

“When you are short there are many things that are affected”, says Dr. Fernandez. “The immediate risk is associated with wasting, where the weight to height ratio is very low. The other risks are that the brain is not fully developed and the child is vulnerable to developing hypertension, heart disease and diabetes”.

Stunting also has an economic impact as it affects productivity. Various studies have linked childhood stunting with poor IQ and school performance.

The 2014 Global Nutrition Report places India in a group of 38 nations that includes least developed countries like Sudan, Somalia and Ethiopia. While we have been able to reduce the incidence of stunting, children in India continue to rank among countries with far lower GDP. Why does stunting remain so widespread, affecting even well fed children and decades of investment in programmes targeting child malnutrition?

Recent studies suggest that one of the potential causes for persistent malnutrition may be poor hygiene and inadequate sanitation. The problem is no longer so much the lack of food, but rather a lack of toilets. A recent trial by Stanford University among some communities in the Republic of Mali, West Africa, has established how increasing access to, and promoting use of, toilets has helped improve child growth. The study says that children who were less than a year old when the programme was launched showed the maximum gain in height and weight.

However, getting people to use toilets and observe basic hygiene is just one part of the problem, say experts. There is a need to effect a larger change in gender attitudes to address the problem of chronic malnutrition.

“There are many, many factors responsible for stunting –beyond just the lack of toilets”, says Dr. Fernandez. “It also has a lot to do with the state of the mother’s health and well-being – what she is fed, her general health and the violence she is exposed to’’.

Dr. Aparna Hegde, founder of Mumbai-based NGO ARMMAN (Advancing Reduction in Mortality and Morbidity of Mothers, Children and Neonates), concurs. ARMMAN works towards improving the wellbeing of pregnant mothers and newborns.

“Malnutrition in pregnant women leads to poor pre-pregnancy body-mass index (BMI) and inadequate weight gain during pregnancy, along with severe micronutrient deficiency. These heighten the risk of intrauterine growth retardation and low birth weight, which affects the physical and intellectual development of the child’’.

According to NFHS-3 figures, over 36% women between the ages 15 – 49 years had a BMI less than 18.5. Even in Mumbai, more than 70% of pregnant women are anemic, says Dr. Hegde. “We have to realize that years of poor nutrition cannot be wiped out in one shot”.

It took about a century for the Dutch to go from being among the shortest in the world, to among the tallest, thanks to nutrition and good hygiene. We have much less time if we are to indeed reap the demographic dividend of 1.2 billion productive Indians.

This article was published in the Business Standard under the headline Why are Indian Children stunted?

Lack of contraceptive choices a leading cause for young mothers’ deaths

By the time she was 17 Meena had lost two children. One was a stillbirth, the other she miscarried.

Meena was 13 when she got married, a common practice in Marathwada, Maharashtra. Here nearly 60 per cent of girls get married before they are 18. Across India, 47.3 per cent of women between 20-24 years are married before 18.

Many of them come under pressure to give birth within a year of marriage. Those who want to delay having children don’t know how to as there is little awareness of, or access to, contraceptive methods.

At 21% India reports among the highest unmet needs for contraception in the world. Unmet need was also a key target under MDG 5 that the country has been unable to meet. This is despite the fact that India was the first country to have a government supported family planning programme. Countries like Bangladesh and Malawi have fared much better in comparison.

A high unmet need for contraception translates into a high number of unintended pregnancies and has tremendous health implications. The risk of maternal and neo-natal mortality is five times higher among girls who conceive before 20 They are more vulnerable to experiencing spontaneous abortions, infections and anemia.

Various studies show that the unmet need is highest among 15-19 year olds from less educated and poorer homes. Clearly there is a desperate need to provide information on, and access to, a variety of contraceptive methods.

However, for decades, the mainstay of India’s family planning programme has been female sterilization. UN data shows that over 37 per cent of women in India between 15 and 49 years use sterilization as a method of contraception, compared to 3.1% who use a pill and 5.2% who rely on condoms.

“Female sterilization is like a gunshot intervention”, says Dr Ashok Dyalchand, Director, Institute of Health Management, Pachod. “There is no follow up required. Contrast that to contraceptives where you have to ensure that they are available and monitor their use. It’s a month on month, year or year effort so both policymakers and providers have preferred to promote female sterilization, often coercively.”

Since fertility levels in women peak at 25 years, the focus should instead be on creating awareness and supplying contraceptives to delay the first conception. and for spacing.

“Girls are married at 15 and are get at 16”, says Dyalchand. “They don’t know whom to ask and what to choose because there is a total lack of communication. The government needs to focus on behaviour change communication and the easy, regular availability of contraceptives, which is currently lacking. We also need to understand unmet need from the couples’ perspective”.

An IHMP-led, community-based intervention for married adolescent girls across five districts of Marathwada between 2003-2009 saw a 300 per cent increase in the use of contraceptive methods.

Clearly there is a need felt for contraceptives. “A large proportion of very young woman have expressed the desire for it so we have to start defining unmet need from the clients’ perspective, not that of providers”, says Dyalchand

Another outstanding example is Prachar, Promoting Change in Reproductive Behavior of Adolescents, a Pathfinder International program implemented in Bihar.

Unmet need for contraception in Bihar is 31 per cent among women between 15 to 19 years and 33 per cent among those between 20 to 24 years.

“We realized that there was lack of awareness regarding contraceptive options among married adolescent girls and newly married couples”, says Mahesh Srinivas, Director of Programs, Pathfinder International. “And young married girls find it hard to communicate frankly with their husbands about such issues”.

To promote behaviour change, PRACHAR held events for newly wed couples where they would celebrate their marriage and emphasize the benefits of delaying having children. Along with the advice, oral contraceptive pills and condoms were provided as well.

Counselors also spoke to young married men and women individually in their homes, and workshops were held for unmarried adolescents.

“A big challenge was the availability of men”, says Srinivas. “These areas witness high migration so people would not be available for long periods. We also realized that there was a large unmet need among men. Many of them didn’t want their wives becoming pregnant soon after marriage or they wanted a gap between the births of their children. Men do want to get involved but don’t know how”.

Over it’s 12-year intervention, PRACHAR reached out to nearly 960 villages in Bihar. The program was successful in delaying the marriages of both girls and boys and led to an increase in contraceptive demand and use among married women under 25.

Although India’s total fertility rate is down to 2.5, and the country is approaching replacement-level fertility, this has not translated into saving maternal and infant lives. India accounts for 17 per cent of the world’s maternal deaths. Meeting the unmet need for contraception will help save many.

This article was published in the Indian Express

Can urban India push the car free momentum?

Gurgaon marks its third Car-Free Tuesday this week, an event that many hope signals the beginnings of India’s cyclovias. Cyclovia, bike path in Spanish, is an event that originated in Bogota, Colombia in 1974. Every week a designated major thoroughfare within a municipality is closed temporarily to create an open, car-free environment.

The idea is to turn the street into a space for people to bike, skateboard, run or walk at their leisure without the interference of motorized vehicles.

Sounds like a bit of a stretch given how automobile-centric Indian cities are.

According to the Clean Air Initiaive for Asian Cities, a 2011 study our cities account for 13% of the pedestrian fatality share at the national level, with metros like New Delhi, Bengaluru and Kolkata reporting greater than 40%.

In Bengaluru, every two days, three pedestrians are killed on roads. Annually over 10,000 are hospitalized. The elderly and school children are most often the victims.

Conditions that are far from ideal for cyclovias.

Not so believes Sarika Panda Bhatt, co-founder of Raahgiri Day, a movement that promotes car-free and pollution-free streets.

Raahgiri Day, which is inspired by cyclovias, is helping the Gurgaon administration drive the car free initiative.

“What we are going through today was the state of affairs in many Latin American countries”, says Bhatt. “There were no cycle tracks and public transport was poor. Cyclovias helped build momentum and people began demanding that cities be oriented away from cars. So we have to focus on mobilizing people”.

Today cyclovias are popular in many countries like Australia, the US and Canada. The movement is especially strong in Latin America, where over 350 cities open up their streets every week.

There are several compelling arguments for promoting such an initiative across India. Improving pedestrian infrastructure is just one. At 5% per annum the vehicle population is growing rapidly and motor vehicles are a major source of air pollution. From cardiovascular diseases to cancer, the health impact of vehicular emissions is well documented.

In this context, the response to Gurgaon’s car-free Tuesdays is encouraging. In the second week of the initiative, six schools joined in. “Children who go to school by private cars took school buses instead which means we saw nearly 40,000 cars less on the streets”, says Bhatt.

Apart from public demand, support from city authorities and corporates played a big part in helping to drive cyclovias across Latin America where cities are home to large slum populations. L

Like in India, cities like Buenos Aires and Rio de Janeiro were built to transport people on automobiles and bus and there was little room for pedestrians or cyclists.

The popularity of cyclovias compelled authorities to adopt innovative ideas that would enable city streets to become inclusive spaces. Different lanes for cars, buses, cyclists and walkers have been created and modes of transport modified according to the location of the street.

In Gurgaon, apart from the police and local administration, NASSCOM and infrastructure giant DLF Ltd are playing a vital role in driving the car free movement

“We want to upgrade the infrastructure to encourage cyclists and walkers”, says Rohit Shukla, Director, Estates, DLF Ltd. “So we re upgrading roads leading to the toll plaza by building cycling tracks, foot overbridges and pedestrian walkways.”

It is this change of attitude that experts are most encouraged by.

“If we had started such a movement three years ago, it would never have gotten this kind of attention”, says Prashanth Bachu, who launched Raahgiri Day in Hyderabad in January this year.

Bachu is a transport planner with EMBARQ India, an organization that collaborates with government authorities, corporates and civil society to reduce pollution, improve public health, and create safe and accessible public spaces.

“We have been observing Thursdays as car free days in the hi-tech city area,” says Bachu. At first the response was lackluster. That changed when people saw the space that opened up to cycle and walk. Gradually the local police and corporates got involved. 1444366202-2014

“The congestion was so bad that the travel speed in these areas had gone down to four kilometres per hour”, says Bachu. “We have been able to reduce fuel consumption by 18,000 litres every Thursday and there is potential to reduce it further by 70,000 litres”.

For that to happen there needs to be a larger policy level change.

“The administration has to impose certain restrictions like heavier parking fines but these have to come from those at the higher levels”, says Bachu who has raised a a vision document highlighting steps what some of these steps could be.

“Incentives like replacing car loans with bicycle loans for employees and offering them transport passes will make a big difference”, believes Madhav Pai, Director, EMBARQ India. “The harder change will be to redesign roads and beefing up public transport. The important thing is that we have started taking baby steps”.