Abstract
In the first decades of the 21st century, hunger and malnutrition figure among the most burning issues in many countries, particularly those of the global South. Meanwhile, analyses by international bodies demonstrate that the Earth’s resources are sufficient enough to sustain an even significantly larger number of people than there are today (over 7 billion). Considering these facts, every endeavor aimed at highlighting the underlying causes and suggesting solutions to the question of how to feed the starving populations of various parts of the world should be welcomed.
Nira Ramachandran’s Persisting Undernutrition in India: Causes, Consequences and Possible Solutions focuses on a country where undernutrition is a major public health challenge, because, as we learn in the first chapters of the book, over one-third of Indian adults have chronic protein energy malnutrition (as expressed in body mass indices below the norm), and far higher proportions of children (as many as 43%) are stunted, wasted, or underweight for age. As the second largest country in the world, India is home to the largest number of undernourished children globally and has the highest child undernutrition levels in South Asia.
The starting point of the book is the observation that however divergent assessments of undernutrition levels provided by various sources may be, India remains one of the so-called developing countries where reduction in hunger and undernutrition levels has not kept pace with economic growth. Moreover, even in cases where income rises (which many developing countries have experienced over the past two decades), the population’s nutritional status does not necessarily improve correspondingly. India’s undernutrition levels place the country ahead of many other Asian countries (e.g., China, Thailand, and Bhutan), as well as sub-Saharan Africa, which, in the public imagination, is the home of the malnourished child.
The first objective of the book is to reevaluate the existing nutrition situation in India, which the author does, first, by providing a comprehensive overview of various studies assessing the extent and causes of the problem. Second, a detailed analysis of statistical data follows, illustrating trends in calorie consumption and in food expenditure, as well changes in dietary patterns across the Indian states, in both the rural and urban areas. The problem is, therefore, dealt with in a comprehensive manner, with a focus on diverse statistical data, social groups, and regions. The states are ranked on a composite index of nutrition outcomes developed by the author and based on the percentage of underweight women, men, and children in each state. Most issues relating to undernutrition and discussed in the book are dealt with in a similar way: the core analysis consists of a simple presentation of relevant statistics in different geographical locations.
Having highlighted the status quo, Ramachandran moves on to analyze the various factors that come into play in the discussion on what is responsible for perpetuating undernutrition in India, particularly poverty and gender discrimination with the resultant poor status of women (extending to differential treatment of children depending on their sex, with expensive and preferred foods being unequally distributed in favor of boys). While doing this, the author provides a critical review of existing evidence, which contradicts some commonly held beliefs, e.g., that undernutrition is more prevalent among women than men (whereas in some Indian states the opposite is true), or that strategies aimed at eradicating poverty lead simultaneously to improved nutrition, because, as it turns out, disproportionately high levels of child undernutrition exist across all income quintiles in both urban and rural areas (p. 92).
Seeking to pinpoint possible causes of extremely high levels of undernutrition in India, the author examines various correlates of undernutrition among both adults and children in different parts of the country. Throughout the book, the argument is made against the school of thought that attributes undernutrition solely to a lack of access to sufficient calories (food insecurity) and which underlies many official programs addressing the problem. The author demonstrates that good nutrition is not a direct result of access to sufficient food, but stems from ‘a complex interaction of conditions prevailing in a number of intersecting, yet independent sectors, i.e. food, agriculture, sanitation, water supply, health and education’ (p. 70). In other words, providing food to the needy will not solve the problem of undernutrition if lack of knowledge of proper diet, poor caring practices, and poor sanitation prevail.
The book has a practical orientation as it seeks, in the author’s own words, ‘to identify shortcomings in existing schemes [aimed at eradicating undernutrition] and suggest strategies to fast-track improvement’ (p. v). A large part of it is, therefore, devoted to a detailed presentation and assessment of governmental responses to undernutrition: nutrition policy framework and key interventions. The author demonstrates that the interventions in place do not bring about expected results and identifies possible causes of the poor outcomes thereof. While discussing strategies aimed at reducing undernutrition, Ramachandran argues for a universal coverage of nutrition programs (as opposed to the ones with focus only on children). The argument is based on the premise that adults are primarily responsible for the economic support of the rest of society. Malnutrition among this age group leads to impaired cognitive capacity, as well as generating additional costs of poor health and susceptibility to disease (indirect impact on poverty), whereas poor productivity leads to low wages (direct impact on poverty; p. 71). In support of her thesis, the author provides detailed estimates of the economic costs of underweight in adults for different Indian states (and also in selected other Asian countries).
For the most part, the analysis in Ramachandran’s Persisting Undernutrition in India is firmly anchored in extensive statistical data, highlighting various aspects of the problems discussed and constituting one of the book’s biggest assets. Frequent references are made to existing scholarly studies, as well as publications by relevant international bodies (e.g., the Food and Agricultural Organization [FAO]), although some sources would benefit from a more critical approach. For example, an overview at the end of the book of the situation in China (used as an example of a successful breakthrough from poor to excellent nutrition levels) is based solely on official documents and ignores factors other than government policy in reducing malnutrition, whereas facts such as the Great Famine under Mao Zedong are not mentioned.
Among the book’s shortcomings is the fact that it becomes rather disjointed in the final chapters and occasionally some paragraphs are repeated (probably because they had previously been published elsewhere in a different form). Analysis moves beyond India to include some other Asian countries where undernutrition has a slightly different face; instead of complementing the picture of undernutrition in the country under study, this part blurs some of the previous arguments (e.g., the recommended target group of nutrition programs: should the prevailing focus on children and women be retained or should interventions be extended to include men?). Extensive use of abbreviations (not only for various agencies and their programs, but also medical conditions and other technical terms) makes it occasionally a difficult read.
In some places the analysis lacks depth. The author provides a lot of quantitative data but the analytical tools seem insufficient at best, and sometimes the use thereof raises doubts as to their adequacy and the value of the conclusions they lead to. This is the case with one of the few statistical measures employed throughout the book, namely Pearson’s r, which the author seems to overuse, sometimes failing to provide the purpose thereof, as well as convincing interpretations (e.g., relationship between per capita calorie consumption and household expenditure on food; p. 37). Finally, the book seems overly detailed in some places (e.g., when the author lists types and amount of food distributed as part of various government programs), and too general where more detail would be required (e.g., the impact of climate change on India’s nutrition situation).
Although the book would benefit from a more sophisticated analysis of quantitative data, as well as the use of qualitative studies to complement it, the empirical evidence provided illustrates the gravity and extent of the problem of undernutrition in India. Diagnosis of the situation, as well as the solutions proposed, calling for a more community- and family-oriented approach, is amply justified in light of the data and arguments provided by the author. Overall, Persisting Undernutrition in India, being a fact-based, thorough assessment of the causes and consequences, as well as possible solutions, to the problem in this country, may serve as a practical guide to policy makers and a valuable introduction to more in-depth scholarly studies.