Reviews

Malnutrition, Policy
and Action
The Double Burden of Malnutrition
in Asia: Causes, Consequences and
Solutions by Stuart Gillespie and
Lawrence J Haddad;
Sage Publications, New Delhi, 2003;
pp 225+xi, Rs 280.
NEERAJ HATEKAR

his book addresses the long-felt need

for a comprehensive review of the
literature on malnutrition in Asia, while
also situating it in the wider world context.
It provides an excellent overview of the
problem, and at the same time gives details
that will be particularly helpful to field
practitioners trying to grapple with the
problem. The double burden of malnutrition is concerned with the simultaneous occurrence of under- and overnutrition that is increasingly being observed in Asia. This, the authors demonstrate, is due to the rapid acceleration of
the nutrition transition among populations
that faced severe under-nutrition just a
few decades ago. There is a growing body
of literature, centred around the so-called
Barker hypothesis, which asserts that
poor nutrition during foetal and infant
development (measured by low birth
weight and stunting), when combined with
positive energy balance in later periods of
life, are risk factors for overweight people.
The first chapter discusses the evidence
on various forms of malnutrition in Asia.
Asia has a higher prevalence of low-birth
weight malnutrition than any other region
in the world. Low birth weight (weight
less than 2,500 g at birth) is perhaps the
most important causal factor behind the
extraordinary prevalence of stunting in
childhood. Low birth weight is also
strongly correlated with maternal malnutrition; about 60 per cent of the women
in south Asia and 40 per cent in south-east
Asia are below 45 kg in weight. The other
important causes include the prevalence
of endemic malaria and maternal infections that can cause appetite loss, higher

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nutrient losses, abnormal placental blood

flow or structure, and foetal infections.
The other significant form of malnutrition
is early childhood growth failure. Southcentral Asia has a high degree of growth
stunting (the second highest in the world
at 44 per cent in 2000), while that in Asia
is also remarkably high (33 per cent).
Though the incidence has been declining
steadily the world over, south-east Asia
will still have 16 million stunted children
in 2005. Among Asian countries, India
has an alarmingly high incidence of stunting (at 51.8 per cent, it is only slightly
below those observed in Bangladesh and
Bhutan). The percentage of underweight
children is also rather high in India, and
at 53.4 per cent, is second only to
Bangladesh in Asia. All this points to
malnutrition among children being a serious public policy issue. Unfortunately,
it still has not got the attention that it
deserves from policy-makers and academics. States like Maharashtra have a relatively higher incidence of malnutrition,
running across the rural-urban divide.
However, malnutrition in the state has
somehow been perceived as a tribal
problem. The tendency is to blame it on
the superstitions and ignorance among
tribals. The data in this book should come
as an eye-opener, specially to the media,
that malnutrition is not specifically tribal,
nor has it much to do with supposedly
inferior cultural practices. The first chapter also discusses evidence on micronutrient deficiencies.
The rest of the book is about solutions
to the problem. The second chapter concerns direct nutrition action. There is clear
evidence that though economic growth is
a necessary condition for reducing malnutrition, it is not sufficient. Poverty reduction does not automatically translate
into better nutrition. The second chapter
discusses common nutrition interventions
like promotion of breast-feeding, growth
monitoring and promotion, communications for behavioural change, supplementary feeding and micronutrient supplementation. Many of these are community

actions. The authors emphasise that the

care aspect, especially developing the
capacity for care at the community level,
is a critical part of any community-based
direct nutrition intervention. This chapter
also discusses the efficacy (potential of a
nutrition intervention determined under
highly supervised conditions) as well as
efficiency (the real world impact) of
nutritional interventions targeting interuterine growth retardation, stunting and
the major micronutrient deficiencies. It
provides invaluable material for NGOs
and government organisations working
with malnourished children. The chapter
points to the paucity of rigorous evaluation of community-based nutrition interventions that plausibly demonstrate the
net effects clearly attributable to the
programme. This is all the more true
because most of the large-scale
programmes are multi-component. The
chapter also discusses issues of programme
design and lists several possible preventive and promotional interventions, making it useful to practitioners in the field.
The optimal interventions are, to a very
large extent, context-specific. This
emphasises the need for flexibility on the
part of organisations that are implementing programmes over wide areas and in
varying contexts. Greater decentralisation
of the programme should be an important
priority. The chapter lists factors that
have been significant in the success of
community-based nutrition programmes
in Asia. Finally, it discusses issues of
sustainability of nutrition-intervention
programmes. The authors emphasise that
sustainability will ultimately be measured
by the ability of the programme to
strengthen the community-based nutrition
intervention process. Finally, it is the
sustainability of the process, and not the
programme, that is going to matter.
Leading on from the second chapter, the
third discusses issues related to developing community capacity for nutrition
action. The authors essentially adopt the
UNDP definition of capacity: the ability
of individuals, organisation, institutions
and societies to develop capabilities to
perform functions, solve problems, and
set and achieve objectives. The recognition of the importance of capacity has
implications for the role of outside agencies working with local organisations. The
authors discuss ways in which capacities

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November 6, 2004

could be limited, as well as a variety of

capacity development strategies. The authors focus on community, government
and institutional capacity. They point out
that capacity for nutrition intervention has
declined in India, and suggest broad
measures to rebuild it. Unfortunately, most
government interventions in India are still
top-to-bottom, with very little capacity
creation at the community level. They are
also too thinly spread to be able to significantly build capacity. Recently, in the wake
of media coverage of malnutrition-related
deaths in Maharashtra, the state government decided to extend the Melghat pattern,
essentially centred around care of pregnant
mothers, to other areas. However, this
initiative too might be in danger of not
being able to adapt to changing contexts.
What needs to be done is to give affected
communities a much greater say in the
formulation and implementation as well as
monitoring of the programmes. For this,
local awareness of the issues involved must
also be raised significantly. Gillespie and
Haddads book will be extremely relevant
to policy-makers in this regard.
The fourth chapter is concerned with
indirect nutrition relevant actions. The
authors point out that womens education,
food availability, health, and environment
are important factors in determining the
nutritional status of a given population.
They then discuss the various food policy
instruments and in particular the impact
of the WTO regime on food security. The
authors argue that, since poorer countries
tend to have a comparative advantage in
labour-intensive fruits and vegetables,
crops that are also high in micronutrients,
access to developed country markets if it
comes about might benefit the poorer
countries. The supply response is likely to
be large, and might also generate incomes
in non-farm sectors. Also, the efficiency of
domestic production might go up, thereby
lowering the cost to home-country consumers. However, all this depends on the
hypothetical equitable access to developed
country markets which, the authors claim,
is by no means certain. Food safety measures could act as non-tariff barriers to
trade. The SPS agreement is intended to
ensure that food safety rules are not used
as non-tariff barriers, but there is an escape
clause for members seeking to apply stricter
conditions in the name of scientific justification. This many times simply reflects
normative judgments.
An important way in which agriculture
affects nutrition (apart from its well known
effects) is through the time allocation of
persons, particularly women, engaged in
Economic and Political Weekly

agriculture. Another way in which agriculture affects nutrition is through its impact
on food prices. If productivity gains are
significantly centred around staples, and
foods are relatively less market-tradable,
the price of micronutrient-rich non-staples
might actually increase. The authors also
draw attention to the possibilities of food
fortification. Once fortification technologies are evolved, they need to be adopted
by industry. This involves many actors: the
food technology community, the commercial food distribution industry, public and
private social marketers, and the public
sector regulatory framework. It is necessary
to get all the stakeholders collaborating as
closely as possible. Income-generating
interventions are also necessary. These can
include microfinance interventions, human
investment programmes, welfare programmes like food for work, and food price
stabilisation and food subsidy programmes.
These have to be judged in terms of their
cost effectiveness relative to their reach.
The chapter also discusses the possibility
of improving the status of women, mainly
through legislative changes, and the need
to create gender-sensitive project designs.
Improving water, sanitation and health
services as well as access to these services
is also considered by the authors to be an
important indirect nutritionally relevant
action. This chapter is important from a
policy point of view. However, it is not
easy to understand why the authors call
such interventions indirect. They have a
very strong synergy with direct nutritional
interventions. Direct interventions would
not succeed without these equally important
interventions. It might help if one looked
at the whole problem in the context of
unfavourable energy balances; they might
come about as much from insufficient
intakes (which itself implies poor food
security) as well as illnesses and infections, both of which could result from lack
of access to basic resources. It is important
to emphasise this because organisations
working on the problem often tend to overemphasise the direct nutritional intervention at the cost of the so-called indirect
ones. Government organisations especially
work independently of each other.
Programmes like the integrated tribal
development programmes especially need
to keep these synergies in mind.
Nutrition interventions are highly context-dependent. Some of these contextual
changes are enabling, others could be
disabling. The fifth chapter discusses the
relationships between economic growth,
poverty reduction, democratisation, globalisation, urbanisation and decentralisation,

November 6, 2004

and the process of nutritional improvement. As far as economic growth and

poverty reduction are concerned, they are
necessary though not sufficient conditions for nutritional improvement. The
authors point out that countries that experience economic growth as well as reduction in inequalities have a good environment for nutritional improvements. Direct
nutrition interventions will still be necessary for countries that are increasing their
per capita output at 2.5 per cent per year.
However, this section does not emphasise
enough the importance of economic
growth. Sustained economic growth is
certainly not a sufficient condition, but it
is very much a necessary condition. Growth
does improve access to resources, even
when it is not completely equitable. For
example, in post-reforms India, sustained
growth has ensured poverty reduction,
even when the growth process has been
spatially and socio-economically skewed.
Social groups like scheduled tribes who
have not experienced the benefits of
poverty reduction have not done so specifically because the growth process has
failed to include them.
While discussing the relationship between globalisation and nutrition, the
chapter overstresses the experience of the
Asian crisis of 1997. The data show increases in poverty for countries that experienced the crisis. Much of the poverty
impact occurred through labour markets.
Indonesia experienced a decline in diet
diversity, loss of weight among adults and
allocation of fewer resources to education.
However, the results on child undernutrition and micronutrients are rather contradictory. The authors argue for a monitoring mechanism that would work with
sufficient accuracy and reliability under
rapidly changing shock situations so as to
guide timely action. They also argue for
flexible safety nets which would go taut
during a crisis. The authors also discuss
globalisation of trade and information
flows. The impact of globalisation of trade
will critically depend on the access to
developed-country markets for developing
country exports. Demands for higher safety
standards could be significant non-tariff
barriers for developing country exports.
Globalisation of information can bring
several benefits, if the authenticity of the
information can be maintained. Good
information, especially in a democratic
set-up, can help significantly in combating
malnutrition. Democratic institutions are
vital in translating the demands for better
nutrition into policies. Legislation, especially regarding fortified foods, is an

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important aspect of the same process. The

benefits of decentralisation cannot be
overemphasised because of the highly
context-dependent nature of the problem.
The benefits of decentralisation will be
greater to the extent that local capacities
are scaled up. Malnutrition is generally
perceived as a rural, and more specifically,
a tribal problem. The section on urbanisation shows that urban malnutrition is as
prevalent as rural; most urban data mix
rich and middle class populations with the
urban poor and hence the incidence seems
to be lower. Indeed, for the urban poor
access to clean drinking water, sanitation,
adequate food and jobs is often more
precarious than for the rural poor. The
chapter closes with a discussion of ageing
and the HIV/AIDS epidemic. Ageing might
impose costs as well as generate opportunities. As ageing increase, the dependency ratios will increase and social security provisioning might become more
expensive. At the same time, ageing may
provide child-care services at home, and
improve the ability of the poor to maintain
small garden plots.
The next chapter concerns financing of
nutritional interventions. Nutrition clearly
has an intergenerational externality. Also,
several nutritional inputs are merit goods,
if not outright public goods. Another
rationale for public intervention derives
from the human rights perspective. Elected
governments are duty-bound with respect
to many human rights, including the right
to adequate nutrition, and are directly
accountable to the populations that they
serve. However, the problem is specifically the translation of the hypothetical
accountability into electoral pressure. This
is clearly a missing element in the link.
Gillespie and Haddad are often intrigued
by why some governments spend more on
nutrition than others, but do not really
explore the political processes that will be
required if the need is to be translated into
a political demand. Malnutrition is certainly a critical problem in India. About
50 per cent of Indias children are malnourished. This should imply that adequate
nutritional interventions should be high on
the political agenda of the government as
well as other political parties, simply
because there are votes at stake. However,
this is far from true in India. One of the
factors could be poor awareness of the
problem. This would require a database,
which does not exist as of now on a panIndia basis. The causal mechanisms need
to be clearly understood and placed on
a public platform. The media has a large
role to play in this direction. However, as

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of now, the media has certainly failed in

this. It has projected the problem as a
tribal problem, laying the blame on tribal
superstition and ignorance. That malnutrition is not specific to tribals, but is a
much more wide ranging problem affecting a vast majority, has to be projected as
a political demand. As long as this does
not happen, expenditure on nutrition
will not be substantial enough to raise
this problem. For example, in 1999,
Maharashtra spent only Rs 11 per malnourished child. However, the issue of
financing will raise its head once the extent
is recognised politically. When that happens, the tools discussed in this chapter
will come in handy. They are standard
tools of benefit-cost analysis. It also discusses some external funding sources as
well as food aid.
The final chapter discusses the way
forward. It basically puts together the
analyses of the previous six chapters in
order to consider the construction of
typologies to help prioritise actions at the

direct and indirect levels. This chapter

presents a stylised agenda for action research in terms of the questions to be
addressed and possible solutions.
In all, this book is an extremely useful
tool kit for policy-makers and NGOs
working in the field of malnutrition. It
provides technocratic answers to the
issues involved. If one were to look for
a shortcoming, it can only be that the book
does not discuss the political economy
aspects of nutritional security. Several
interventions also require the local population as well as outside agencies to take
political activist stances. For instance,
the attitude of civil society organisations
as well as NGOs working in Mumbai
slums towards schemes, like forcible
demolitions and slum redevelopment,
indeed have a bearing on the nutrition
problem. In addition to advocacy, political
mobilisation can be a critical variable.
Without such mobilisation, nutritional
demands will not come on to the public
agenda. EPW

Economic and Political Weekly

November 6, 2004