MALNUTRITION is the underlying cause of half of under-five child deaths. So even though the proximate cause of children dying may be measles, diarrhoea, diphtheria, jaundice or malaria, the real reason is that they are so weakened by malnutrition that their small bodies are unable to withstand infection. Half of Uttar Pradesh’s children (52%) were malnourished when the last National Family Health Survey (1998), the second, took place; half of them (47%) are still malnourished according to the latest NFHS (2005-6), the third. Considering that India’s children on average are more likely to be undernourished than an African child, and UP’s children are still doing worse than a typical Indian child, it is clear that UP’s children are doing far worse than a typical African child.

There is only some good news that the latest survey provides us for UP. First, the infant mortality rate (deaths of less than one year olds per 1000 live births) has fallen from 89 in 1998 to 73 – which is still way above the national average and worse than the national average nine years ago (67.6). It is the high child malnutrition rates that are reflected in the persistently high infant mortality. In fact, UP continues to be caught in a vicious cycle of high fertility and high child mortality: when parents are uncertain that their children will survive, there is a tendency to over-compensate by having more children than they desire. The result is that even though the contraceptive prevalence rate (CPR) in UP has gone up between NFHS 2 and NFHS 3 from 27% to 44%, total fertility has remained stuck at 3.8 children per woman of reproductive age.

In fact, the contraceptive prevalence by any means, modern or traditional, of 44% is still not only under half for UP women of reproductive age but lower than even the CPRs national average in 1998 (48%). So if there was need for evidence of UP’s backwardness and its lack of progress over the last decade relative to the rest of the country, one need look no further.

 

The current state of affairs is a telling commentary on the political leadership of UP for the last 16 years, which has apparently been a great champion of both backward castes, dalits and Muslims. Yet, as we have argued elsewhere,¹ the dalits and backward castes of UP continue to suffer from among the worst health, education and nutrition indicators of any social group in the country, and (except in elementary education) UP has not converged with the rest of the country because it is these deprived social groups who are not making progress in their social indicators.

Let us look at the life cycle of a human being in UP. What is the likelihood that a child conceived by a mother in UP will have access to institutional delivery, supervised by a trained nurse, let alone a doctor? In 1998 only 15% of births were institutional, in 2005-6 it was 22%. In other words, in eight years, UP made practically no progress in this regard. In India 34% of births were so supervised a good nine years ago – so in this respect UP still remains far behind the rest of India of nine years ago.

 

Malnutrition sets in early in life, and is, inter alia, partly the result of poor caring practices. Once born, it is recommended by WHO norms that the infant should be breast-fed within one hour; only seven per cent of UP’s children are still so fed. The WHO norms also recommend that all infants should be exclusively breast-fed, and not given any other source of water or food for five months. Only half of UP’s children are exclusively breast-fed. The norm is that from six months on, infants should be given semi-solid or mushy food (as well as breast milk); only half of UP’s children were so fed.

In all these respects, it is possible for behavioural change to be brought about by health workers and ICDS workers providing counselling and advice, but with a non-functional public health system and a corruption-prone ICDS, no such messages were reaching the majority of UP’s population or the messages were being ineffectively delivered (since there is no change in behaviour in the past nine years). Not surprisingly, the nutritional outcomes of children are what we noted above.

Note that malnutrition that sets in the first three years of life is irreversible and life-long, so the state’s appalling public health system is directly responsible for the wasted lives of millions of UP’s children. If 55% of UP’s under-three year olds were stunted in 1998, 46% are still stunted; 11% were wasted then, and 13% are still wasted; and 47% are still underweight.

Within two years of birth children should be fully immunized (against polio, BCG, measles and DPT) if they are to survive and live a healthy life, avoiding disease in the first precious 36 months that their bodies and minds are growing fast. But only 22% of UP’s children are still fully immunized according to the independent National Family Health Survey 3 (2005-06), barely two percentage points higher than nine years ago – making them vulnerable to frequent morbidity and poorer absorption of food and nutrients. The cruel irony is that the government has been boasting near complete immunization of children, as in UP the number of fully immunized children that was being reported by the state government is almost 100 per cent, in 2001-02.

 

It is perfectly possible for UP to use central government resources, not its own, to remedy many of these problems, but even those are used poorly. The Integrated Child Development Scheme, a centrally sponsored scheme, in existence since 1975 – aimed at providing supplementary nutrition to 3-6 year olds as well as pregnant women. The Supreme Court has been instructing the state governments to end the use of contractors to supply rations to these children. Contractor-raj has traditionally been the source of corruption on a grand scale of the order of large-scale larceny in the supply of food for little, innocent children in whose name the larceny is committed.

The Supreme Court appointed N.C. Saxena as a Commissioner to monitor the progress of ICDS, who reported the following: ‘A very large number of anganwadi centres were being run in the house of some rich farmer. This discouraged children of lower castes to attend the centre. Hence the UP government took a bold decision to shift them to primary schools. On balance it is a very good decision, at least until the centre has its own building, but the present policy of shifting anganwadi centres to schools has its problems too. First, the schools are sometimes far away from the habitation, which makes young children walk quite a distance. Second, schools are closed during summer. Third, often two to three anganwadi centres get attached to the same school, which creates problems of space. And last, while school children regularly get hot cooked midday meals, supplementary nutrition programme for the pre-schoolers is most irregular, and confined to just a single dish, day in and day out, and that too of poor and often inedible quality.’

 

Given this current state of ICDS on the ground, it is hardly surprising that the enrolment of poorest children in ICDS in UP is as low as reported in Table 1 in a World Bank survey on the ICDS in various states. It is the poorest children who need the ICDS programme most, and they are the ones that are most excluded, and much more so in UP than in other states.

The Integrated Child Development Scheme that is supposed to reach out to 0-6 year olds countrywide, actually reaches only a quarter of India’s child population. Moreover, its programmatic content is not geared towards the 0-3 year-olds, who are most vulnerable, and which is the window in the child’s life when the in utero malnutrition could be corrected. The Supreme Court of India has in a judgment on 13 December 2006 required the Chief Secretary of UP (and of 12 other states) to appear and explain to the Supreme Court why they have repeatedly flouted court instructions to universalize the scheme over the last five years that such instructions have been issued.

Undernourished and unhealthy children grow up to be adults who have a lower capacity for productive labour and thus are more likely to earn a lower income. It is the lifelong effects on not only the current generation but the next generation these adults give birth to that should be of concern. As many as 34% of adult UP females between the ages of 15 and 49 have a body mass index that is below the normal (i.e. who still suffer from malnutrition). Almost the same number of men suffered from the same problem in 2005-06. Small women give birth to small babies, so the problem of low birth weight is endemic in UP – and low birth weight is an indicator of in utero malnutrition. Tragically, this problem of low body mass index has shown no signs of diminishing in UP over the nine years since the last survey.

The problem of low birth weight is more likely to occur among children whose mothers suffer from anaemia. A full half of all 15-49 years old UP women, including pregnant women, suffer from anaemia – a proportion that has shown no change whatsoever in the nine years since the last survey. Anaemic mothers are more likely to have anaemic children, and 85% of under-threes in UP suffered from anaemia in 2005-06.

 

With 30.5 million children in the age group 0-6 age group, UP has the largest child population in the country. The sex ratio in the state has been decreasing as compared to the All India sex ratio. From 927 in 1991 the child sex ratio declined to 916 in 2001. The states in the country most affected by the problem of male-preference sex-selective abortion are the relatively richer states of Punjab, Haryana, Delhi, but richer western UP belongs to the same belt. These are all contiguous and relatively prosperous agrarian regions where the spread of private clinics to facilitate sex-selective abortion has contributed to the worsening of an overall adverse sex ratio in the population.

 

While the child sex ratio is an important enough indicator of the systematic discrimination against the girl child, the sex ratio in the entire population is a key indicator of serious societal problems at large, especially gender discrimination over the life cycle of an infant girl, the girl child, the adolescent girl and the woman. Since, for biological reasons, women in all societies live longer than men, the natural expectation is that the share of women in the population will be larger than 50%. It is well known, however, that the sex ratio in India is well below that: it was 930 females to every 1000 males in 1971, and it was still 933 in 2001. Even in China, the other major nation in the world which has a seriously adverse sex ratio, the national average sex ratio in the population is still 967; there is no Chinese province where the sex ratio is below 930 – but there are at least six major states of India with a sex ratio of less than 930. The three Indian states with the worst sex ratio are UP (901), Punjab (876) and Haryana (861). In Punjab and Haryana the problem, as we noted above, is primarily that of sex-selective abortions. In UP it is not just a problem of sex-selective abortion.

The southern states of India systematically have a higher sex ratio than the BIMARU states. Even a poor state like Orissa, which is counted with the Bimaru states in all other respects, has a sex ratio of 972. All the other southern states have reasonably respectable sex ratios in the total population: Andhra Pradesh 978, Kerala 1058, Karnataka 965 and Tamil Nadu 987. UP, on the other hand, has the worst sex ratio even among the Bimaru states. Even Bihar’s sex ratio is 924, and Rajasthan with 921 and Madhya Pradesh 937 are still doing better than UP.

This is clear evidence that in the Bimaru states, and especially in UP, the problem of an adverse sex ratio is not merely a reflection of sex selective abortions. Rather, it is evidence of systematic discrimination against women over the life cycle, which is far worse than that found in any other state of India.

 

As we have argued above, the worst child malnutrition rates in the country are closely linked to the worst gender discrimination in the country, this is evidence of the signal failure of successive governments of UP. Future governments may well wish to give these issues some more consideration than they have been given so far.

Of the eight years that have elapsed since the last NFHS, for five of these years the current government has been in power. Hence some responsibility for the lack of progress may have to be borne by the current government even though the problems have historical roots. This is perhaps one reason why the Chief Secretary of the UP government (together with Chief Secretaries of 12 other states) has been summoned by the Supreme Court (in its judgment of 13 December 2006) to depose before it, as to why actions have not been taken to respond to the court’s instructions regarding child malnutrition and the ICDS programme.

 

Footnote:

1. S. Mehrotra, ‘Caste and Well-being in Uttar Pradesh: why UP is not like Tamil Nadu’, Economic and Political Weekly, 7 October 2006.