Rema Nagarajan  | TOI

Malnutrition kills more Indians than any specific disease. That’s hardly surprising since a weakened body is more prone to infections and responds less to medicine or treatment than a well-fed, healthy one.

Widespread malnutrition has been termed a national shame and a top priority. Yet, the debate in governments is mostly about whether or not to give packaged food and whether deficiencies of vitamins and minerals should be addressed by fortifying food or by distributing micronutrient powders. It is rarely about the chronic hunger of millions despite the country’s much-touted economic growth. This focus is pushed by the food industry eyeing the huge ‘bottom of the pyramid’ market, where people are too poor to be meaningful consumers unless governments buy on their behalf.

It would be laughable, if it was not so tragic, that governments talk about supplements and packaged food when people are eating too little nutritious food, as household consumption expenditure data shows. A shocking 80% of rural people and 70% of urban folks don’t get the stipulated 2,400 kcal per day, leave alone sufficient vegetables, fruits, eggs, milk products, fish and meat. There is, of course, no food scarcity, unlike in places affected by civil war or natural calamities. Recall the yearly boast of bumper harvests.

Governments eagerly grab at ‘technical fixes’ like new vaccines or programmes for non-communicable diseases (NCDs). Both are needed, but why the reluctance to engage with the more complex problem of ensuring people can get nutritious food? Could it be because the technical fixes have powerful backers – vaccine manufacturers for expanded immunisation programmes, hospitals and drug makers for more government funds to treat NCDs among those who can’t afford the rapidly escalating cost of private healthcare?

Besides poverty alleviation measures, government efforts include interventions like the public distribution system. Increasingly, these are targeted narrowly at the ‘poor’, officially just 24% of the population, ignoring the fact that the malnourished are more numerous – according to the 2015-16 National Family Health Survey-4, barely 10% of children below two years have an adequate diet, nearly 40% of those under five are stunted and over 35% underweight. Clearly, many more than the officially poor urgently need such interventions.

Successive governments have failed to effectively implement the two largest programmes for addressing malnutrition, the Integrated Child Development Scheme (ICDS) to provide nutritional diets to infants, pregnant and nursing mothers, and the Midday Meal Scheme to provide 13 crore schoolchildren hot cooked meals. These are underfunded and depend on millions of contractual workers, mostly women.

The government pays them meagre ‘honorarium’ and ‘incentives’ less than the minimum wages. The 8.3 lakh Accredited Social Health Activists (ASHAs) who drive the National Health Mission are also contractual workers. The indifference to preventive healthcare shows in the fact that it merits just 20% of the health budget despite overwhelming evidence that it is far cheaper than treating diseases.

Governments invest vast sums on treating NCDs but overlook the link between them and under-nutrition. Nutritional deprivation causing low birthweight pre-disposes individuals to type-2 diabetes, which in turn could cause chronic kidney disease, cardiovascular diseases and other complications. As children continue to be born premature or underweight, the burden keeps growing.

Under-nutrition also kills lakhs of babies every year. Low birthweight or premature birth accounts for 55% of neonatal deaths or about a quarter of all deaths below five years. Underfed mothers, under-age motherhood and poor ante-natal care are the major causes for underweight or premature babies.

Under-nutrition is estimated to contribute to more than half the TB cases in India, affecting the poor disproportionately. It also makes drug toxicity, relapse and death in TB patients more likely. India had 28 lakh new cases of active TB and almost five lakh deaths in 2015. Yet, the vaccine that could cut TB in India by half – food – gets scant attention.

The relative neglect of malnutrition reflects a broader shift from preventive to curative healthcare. At Independence, the health ministry dealt with housing too, reflecting a view of public health that included people’s living conditions. It has shrunk to become dominated by medical care. We need to recognise afresh that our health indices will remain poor as long as millions remain hungry or underfed, leaving them vulnerable to diseases.