The death certificate for 3-year-old Rashid Ahmed hides more than it reveals.
It lists his name, misspells his mother’s and says he died of malaria. What it doesn’t say is how little he weighed when he was brought to hospital with the disease in New Delhi one August night, how his ribs jutted from his chest, or how helpless his doctor, 28-year-old Gyvi Gaurav, was in trying to save him.
June 14 (Bloomberg) — Gyvi Gaurav, a doctor at St. Stephen’s Hospital in New Delhi, talks about the case of a 3 year-old patient that died of malnutrition, which left him unable to fight off a case of malaria. In the 2005 National Family Health Survey, when India last measured its children for signs of hunger, it found 46 percent, or 31 million, weighed too little for their ages. That’s almost an entire Canada of malnourished under-three-year-olds. (Source: Bloomberg)
Clothes are hung out in a small alley in the Dharavi slum area of Mumbai, India. Photographer: Dhiraj Singh/Bloomberg
Children hold bowls of sprouts outside their home in the Dharavi slum area of Mumbai, India. Photographer: Dhiraj Singh/Bloomberg
Shabana Khan makes bread for her husband and four children at their rented home in the Dharavi slum area of Mumbai, India. Photographer: Dhiraj Singh/Bloomberg
A roadside vegetable vendor arranges brinjal in the Dharavi slum area of Mumbai, India. Photographer: Dhiraj Singh/Bloomberg
“It was hunger that killed him,” said Gaurav, who worked the night of August 15 at St. Stephen’s Hospital and was on watch when the toddler died. “He was so weak, so malnourished, that he would have died the first time he ever got really sick – – from malaria, diarrhea, anything.”
For Rashid’s mother, Nazia, the three-decade road from her birth to the death of her son ran alongside a slow collapse in India’s elemental struggle to feed its people. More than three- quarters of the 1.2 billion population eat less than minimum targets set by the government, up from about two-thirds, or 472 million people, in 1983. India’s failure to feed its people came as the economy accelerated, with gross domestic product per capita almost doubling in the past decade.
“I cry every night,” Nazia said on May 15, speaking through sobs after being told her child may have lived had he eaten better. “For my wasted life, for my dead child, for the hunger in my stomach. What could I give him? I had nothing, nothing to sell.”
Calories V. Nutrition
While nutritionists and economists debate the importance of targets defined solely in calories, other data shows gains in nourishment also stalled. In the 2005 National Family Health Survey, when India last weighed, measured and counted its children for signs of hunger, it found 46 percent — 31 million — weighed too little for their ages, almost an entire Canada of malnourished under-three-year-olds. In 1999, that number was 47 percent.
Some indicators worsened: 79 percent of children had anemia, against 74 percent in 1999; 19 percent were wasted — weighed too little for their height — up from 16 percent. Anemia prevents the absorption of nutrients; as do the diarrhea and other diseases caused by poor hygiene and sanitation.
In sheer numbers, 4 out of 10 malnourished children in the world are Indian, more than in all of Africa. War-torn Sudan and famine-struck Eritrea had smaller percentages of malnourished children, at about 32 percent, according to the Washington-based International Food Policy Research Institute.
India’s hungry children are likely to have lower cognitive skills, grow up to be weakened workers, suffer from chronic illnesses and die prematurely, according to the United Nations Children’s Fund. Hunger stalks them into adulthood too: 21 percent of all Indians are undernourished, according to Ifpri, up from 20 percent a decade ago. All of which costs the country about $68 billion a year, or almost 4 percent of GDP, according to Veena S. Rao, who heads nutrition initiatives for the government of Karnataka, the Indian state that encompasses the city of Bangalore.
“The problem of malnutrition is a national shame,” Prime Minister Manmohan Singh said in January, in one of about 50 public speeches where he has mentioned the subject. “Despite impressive growth in our gross domestic product, the level of under-nutrition in the country is unacceptably high.”
India has collected reliable and consistent national data on nutrition since 1972, soon after setting minimum daily intakes of about 2,100 calories a day for city residents, who are assumed to be less physically active. The level for rural- dwellers was pegged at 2,400 calories on the basis that tilling fields, harvesting crops and drawing water require greater exertion.
Only in 1999-2000 did the average urban Indian meet the target — and that may have been due to a counting error, according to the National Sample Survey Office, a branch of the statistics ministry. Rural Indians never have, and have seen their intake slide to 2,020 calories in 2010, from a high of 2,266 calories in 1973, according to Bloomberg calculations based on data from the office.
A National Nutrition Monitoring Bureau study in nine states that make up the majority of India’s malnourished population showed a steeper decline, with average rural calorie counts falling to about 1,900 in 2005 from 2,340 in 1979. Daily protein intake dropped to 49 grams (1.5 ounces) from 63 grams.
The global average is 77 grams, according to the UN’s Food and Agricultural Organization. The worldwide average daily caloric intake is about 2,800 calories a day.
Neither the diets of Nazia nor her two surviving children meet the averages.
A hard life outside Nagpur city in central India, where her husband died of tuberculosis and a failing cotton crop meant work dried up in the fields, was followed by a hard life in a New Delhi slum. After arriving in the Indian capital 10 years ago, Nazia begged on the streets before landing work as a day laborer on construction sites. Her third son, Rashid, was fathered by a different man.
At 5 feet and 3 inches (1.6 meters), Nazia weighs 43 kilograms (95 pounds). Her hands, rough and torn from years of lifting bricks and balancing them on a small turban over her head, move feverishly as she rolls wheat dough into a type of unleavened bread called rotis for dinner on a recent weeknight.
Sitting on the floor in their 7-foot by 8-foot home, she and her sons, Aslam, 12, and Akbar, 14, eat a hurried dinner, a bare lamp providing the only light. The brick-built room, topped with a patchwork corrugated metal roof in a small, illegal shanty-town between the Old Delhi railway station and the tourist spots of the Jama Masjid and the Red Fort, smells of old sweat and fresh sewage.
Three rotis each, a gruel of potatoes and curry powder, an onion and a chili make up a typical dinner. Once a week in summer, they share two mangoes, with Nazia sucking on the flesh left around the seed after the boys eat most of the fruit. Lunch is the same, which the boys serve themselves cold from a small steel container, and breakfast is tea and two slices of coarse white bread. It all adds up to a daily consumption of 1,500 calories to 1,600 calories of mostly carbohydrates.
That places the family in the poorest quarter of Indians in terms of nutrition, with the group averaging 1,624 calories a day, according to Bloomberg calculations based on National Sample Survey data. The poorest 10th on average consume 1,485 calories — a little more than a McDonald’s Big Mac with large Coke and large fries.
Calories are a blunt tool for understanding malnourishment, according to Angus Deaton, a Princeton economist who has studied India closely. While gains against malnourishment largely stalled between 1999 and 2005, two earlier surveys showed dropping calorie counts even as nourishment indicators improved, he said.
That suggests “the real focus should be on improving health, not just improving calorie counts,” Deaton said in a May 21 interview.
Indian lifestyles have changed since the early 1970’s, he said. More people in rural areas own bicycles, saving energy moving around and transporting things. Farm machinery is more widespread, cutting down on tilling and planting by hand. Ailments like malaria and diarrhea are less common as the supply of potable water improved.
“If you’re doing less manual labor, if your children are falling sick less often, then you need fewer calories,” Deaton said. “This is a natural progression of the Indian diet. Focusing just on calories is misleading.”
‘Republic of Hunger’
Not everyone agrees. Utsa Patnaik, a professor at New Delhi-based Jawaharlal Nehru University and author of “The Republic of Hunger,” said that the decline in calorie consumption is the result of a shortage of food availability, and a capitalist economy that hasn’t spread the benefits of India’s economic boom equitably.
Her research shows that per-capita availability of rice, wheat and other food-grains in India has fallen from 177 kilograms in the early 1990s to 153 kilos in 2004 — about what it was in 1934. Much of the deterioration in food security has come after Singh began opening India’s economy to free-market competition.
“Forty years of efforts to raise how much food-grains Indians are able to eat has been destroyed by a mere dozen years of economic reform,” Patnaik said.
Riddled With Graft
The government has expanded subsidy programs, spending about $11 billion in 2011 — about 5 percent of the central government’s $231 billion budget — to buy and distribute food at below-market prices to people officially designated as poor.
More than 30 investigations by the National Human Rights Commission, the Supreme Court and anti-corruption agencies such as the Central Bureau of Investigation have concluded that the public distribution is riddled with graft. As much as 40 percent of food purchased for the poor doesn’t reach them, according to the UN’s Standing Committee on Nutrition.
“Subsidies don’t reach the poor. Trickle-down doesn’t reach the poor. Nothing reaches the poor,” said Yogendra Alagh, an economist in Gujarat state who first proposed in 1972 the calorie guidelines that still govern food policy in India. “In the past two or three decades, we’ve regressed backwards into a country that can’t even guarantee a poor, pregnant woman a glass of milk so the next generation isn’t born stunted.”
At the same time, the number of rich is swelling. Households with more than $1 million in assets jumped 21 percent in the past year alone, a May 31 Boston Consulting Group report shows.
Efforts to improve sanitation are struggling to keep pace with a growing population and the spread of urban slums.
More than half of India’s population defecate daily in fields, bushes, beaches and other open spaces, according to a 2012 report by the World Health Organization and Unicef. Diarrhea among children younger than 5 years accounts for more than 47 percent of the total health-related economic impact of contaminated water and untreated fecal matter, according to a 2010 report by the World Bank’s Water and Sanitation Program.
Nazia’s family must pay to use a communal toilet. The queues are often so long, the stench so overpowering, that the boys defecate in an open sewer not far from the slum.
Every third night Nazia cooks dal, a curry of lentils common across north India, their calorie intake increases slightly, and the boys get some protein. On Fridays, after visiting a nearby mosque to pray, she makes a curry of eggs. Once a year, to mark the end of the month of day-time fasting called Ramadan, she buys some mutton.
“You should see how happy they are that day,” she said. “They talk about it for weeks before, and weeks after.”
Nazia recalls when she first moved to Delhi she thought, if nothing else, she and her children would be eating more, if not better. Instead, recounting the meals she was able to pull together — with spinach from a small plot of land behind her hut, carrots when they were in season, coarse brown rice and yoghurt from the milk of a family goat, Nazia realizes that for her family the escape to Delhi has been a nutritional disaster.
A detailed description of her meals in the country yields an intake of about 1,800 calories a day, and far more nutrients — calcium, vitamin A and protein — than her diet in Delhi.
“If you had told me in the village that I wouldn’t get to eat any yoghurt in the city, I would have called you a liar,” she said, during one of eight interviews at the family’s home.
Instead, her move to New Delhi made her among the country’s biggest losers in terms of calories. The greatest drop in consumption, on average, is for village dwellers who migrated to the cities in the past 30 years. They’ve seen their intake fall to about 2,000 calories a day from about 2,200 calories in a village in the 1980s, National Sample Survey Office data show.
At the same time, Nazia’s income has doubled. She remembers living on 20 to 30 rupees (40-50 cents) a day in the village, where she didn’t have to pay rent. It’s a common trajectory, as traced out by the nutrition data: Indians like Nazia have seen measurable increases in income, with real GDP per capita almost doubling to 48,734 rupees ($873) a year in the past decade. And like Nazia, on average, they now consume fewer calories and less nourishing food.
These meals eat up almost a third of the 80 cents a day Nazia earns from her work at a construction site near the Old Delhi railway station. Nazia said she is too weak to labor more than four hours at a stretch. Because her children are young, they work only around the house, sometimes helping neighbors with chores in exchange for handfuls of uncooked rice.
The reasons behind the decline in urban calories are unclear.
One theory argues that much of the increased income from moving to cities is spent on expenses forced upon slum-dwellers. Their children fall sick more often from dirty water; they must pay for transportation to work sites; they must pay rent rather than live in huts they built themselves.
“These are the costs of participating in the urban economy,” said Madhura Swaminathan, an economist at Kolkata’s Indian Statistical Institute. “Your increased income is canceled out by increased expenditure. In the end, you have even less left for food.”
That’s what happened to Mohamed Hafiz Khan, 40, and his family of five. In 1992, they moved to Mumbai, joining the economic refugees who flock to the city at a rate of one person every eight minutes. Most end up in slums, like the one where Khan lives with his wife Shabana and their four children.
Khan, who works as a tailor, spends almost $90 out of the $150 he makes each month on food and kerosene for the family’s stove. In 1992, he paid $6.40 a month from his $38 wage for their 12-foot by 8-foot home in the Dharavi slum. This year, rent is $36 a month. His children fall sick almost twice a month, and the doctor’s fees add up. Their diet deteriorated as the price of kerosene in the slum’s black market soared.
While Singh’s government subsidizes the fuel, the Khans said corrupt local officials are siphoning off their allotment, forcing them to buy on the black market. Benchmark Asian prices of Kerosene in Singapore have risen fivefold in the past decade.
The four children used to drink Complan or Horlicks, enriched supplements their mother would mix with milk. They no longer do. The Khans used to eat rice, which used up more kerosene to cook. They no longer do. They used to eat as many rotis as they wanted to. Now they share 12 because they can’t afford the kerosene needed to roast them. They eat fruit maybe once every two weeks. The few vegetables the local market provides are withered and old.
Across India, the percentage of daily calorie needs being met by fruit and vegetables dropped between 1993 and 2010, according to the National Sample Survey Office. Rural families get 1.8 percent of their energy from those foods, from 2 percent in 1993, the data show. For city-dwellers, the share fell to 2.6 percent to 3.3 percent.
In the weeks before he died, Rashid tasted his first ice cream. Older brother Akbar was given one by a foreign tourist at the railway station, and he ran back home before it could melt so he could share it with Rashid.
“It was the sweetest thing I’ve ever had,” said Akbar, describing how he and Rashid licked the inside of the cardboard container, and then saved it as a reminder.
Both Rashid’s brothers survived malaria, common in Delhi’s slums during the monsoons, when rain water pools in potholes and open sewers for the Anopheles mosquito to breed. Rashid was weaker. Aslam, in an old picture taken for an identity card when he was three, appears to have rounded cheeks, and his arms were thicker than Rashid’s, his mother said. That may have been the result of two years when he lived with his grandparents in the village. When Akbar was 3, his father had been alive, and food was not that scarce.
Staff at St. Stephen’s Hospital weighed Rashid when his mother brought him in, shivering from eight hours of malaria- induced fevers. He weighed 12 kilos and his arms were “thin as sticks,” said Gaurav, the doctor.
Malnourishment had left his immune system too weak to fight the parasitic disease. He struggled with the richer hospital food and wasn’t able to properly absorb the chloroquine he was given for the malaria. A saline drip helped his condition a little, said Gaurav, who said he recalled the night so vividly because Rashid was the first child to die under his care. Gaurav gave the listless toddler medicines to lower his temperature, while mother Nazia tried to cool his skin with dampened rags.
To boost Rashid’s energy, Gaurav tried a trick that had worked with other children in his care: he gave an orderly the equivalent of 50 cents to buy ice cream.
“He ate three in three hours,” said Nazia.
On August 16, at about 3 a.m., Rashid died in his sleep.
In the refrigerator under the night shift nurse’s desk, surrounded by fresh syringes and medicines, a fourth cup of vanilla ice cream sat uneaten.