This is a statement following a workshop on ‘Hunger and Health: An Interdisciplinary Dialogue’ attended by a cross-section of India’s nutritional scientists, health professionals, public health specialists, economists, agriculturists and grass root activists.   

Chronic and widespread hunger resulting in misery, disease and death, is entirely avoidable in a country like India with overflowing food stocks. The causes of such hunger have to been seen in the context of the production, distribution and price of food and the purchasing power of the rural and urban poor. The issue has implications for the health and well-being of our people, especially poor people, whose labour drives our economic growth.  

A balanced diet in adequate quantity is central to the health, growth, and development of human beings.  Poverty, which impacts on the availability of food, is currently the biggest determinant of ill health in India and is intimately linked to several major public health problems, the most important being tuberculosis. India’s most prevalent and persistent public health problem, across ages, today is undernutrition. According to the UNICEF, every third malnourished child in the world lives in India and the average nutritional level of our children is worse than that seen in Sub-Saharan Africa. It is clear that this level of undernutrition contributes to a very high burden of communicable and non-communicable diseases, with high rates of morbidity, and premature and avoidable death in children and adults. Undernutrition is a cause as well as an effect of poverty: it affects cognitive development and work capacity, itself, a result of  widely prevalent anemia. Undernutrition also extracts severe   economic and social costs by contributing to illnesses.  An estimated 300,000 children, for instance, are forced to  drop out of school every year in India, because of an illness like tuberculosis in the family.  

Disturbing Trends in Nutrition in India  

A review of the national trends in nutrition over the past four decades is a sad commentary on our increasingly iniquitous model of development:  we find levels of undernutrition have remained the same in large sections of our population. In our most disadvantaged classes, that is, dalits and  adivasis, who together comprise 25 % our population, weight at birth and mean weights and heights at any age thereafter have not improved at all in the last 40 years. In rural areas, more than 40% of all adult women of all sections(nearly 50% of the poor)have a Body Mass Index (BMI, a measure of weight that takes height into consideration) below 18.5[2]. In a healthy society according to the World Health Organisation this figure should be less than 5%. This points to a critical situation indicating chronic starvation. In India we have exchanged the occurrence of famine with an enduring occurrence of chronic hunger. In fact, hunger, manifesting as undernutrition, is so pervasive amongst the rural and underprivileged sections of our population that it appears to be ‘normal’ in the eyes of health professionals, administrators and policy planners. This is possibly one of the reasons why undernutrition has never been accorded its rightful importance in the enumeration, analysis and management of illnesses in our country, and a deafening silence surrounds all these issues.  

Extent of Disease Caused by and/or Aggravated by Hunger in India  

It has been recognised by the scientific community for the past four decades - non-medical people have always known this to be true- that undernutrition predisposes to diverse illnesses. Undernutrition also causes many diseases to occur in a more severe form. Many of these illnesses, in their turn, perpetuate undernutrition, constituting a vicious cycle that often ends in death. Globally, undernutrition contributes to 55% of the deaths seen in children due to common illnesses. In India, the percentage of childhood deaths that can be attributed to undernutrition is 69%, which is the highest for any country in the world. There is evidence that hunger or undernutrition contributes significantly to adult deaths too. Despite these facts being well known, we are disturbed to find undernutrition being completely ignored in the planning and implementation of control efforts against major diseases of public health importance.  

A case at point is tuberculosis (TB). TB is the single largest killer disease in India, leading to the premature, avoidable and therefore unacceptable, death of nearly half a million people every year. Infection with the tuberculosis bacillus, Mycobacterium tuberculosis, is widespread in India, with 40% of the population harbouring the bacilli inside their body in small numbers. However, 90% of these people never suffer from tuberculosis since the immune system is generally capable of keeping the bacteria under check and the infection therefore remains latent throughout their lifetime. Only about 10% of infected people ever develop the disease when their immune system is weakened by different factors, of which, undernutrition is the commonest.  

Globally, it is Nutritionally Acquired, and not HIV Acquired Immune-Deficiency, that is the leading cause of a weakened immune system. Fortunately, unlike HIV infection, undernutrition is completely preventable and correctable. Therefore, improved nutritional status could greatly reduce the chance of these large numbers (400 million) of infected people ever developing the disease. The improvement in nutrition would simultaneously protect people, especially children, from many other infectious diseases. It is urgently necessary, in light of these facts, to improve the access of our population to food, which is the most versatile vaccine already known to mankind. In the developed world, the prevalence of many infectious diseases and the rates of death there from declined with improvements in nutrition and living standards, much before modern drugs or vaccines were discovered[3]. While acknowledging the historical role of some vaccines in reducing suffering and death, we express strong reservations about the current obsession with vaccines of all kinds, micronutrient supplements and other purely technical solutions for health at the cost of, and as a substitute to basic public health measures in the form of nutrition, safe drinking water and sanitation.  

Apart from communicable diseases, we note that rural India has a significant and unmet load of non-communicable diseases such as hypertension, diabetes, and coronary artery disease, apart from cancer and respiratory illnesses, which has been acknowledged by bodies like the ICMR, in their recent documents[4] . We have discussed new evidence[5],[6]  that links maternal and foetal malnutrition and the weight at birth to a higher lifetime risk of non-communicable diseases such as hypertension, diabetes and coronary artery disease.  We feel that the ongoing epidemic of chronic hunger and malnutrition in our country, coupled with the psychological stress of living in deprivation, has enormous implications for the emerging epidemic of non-communicable diseases. Improving the level of nutrition would therefore improve health across generations, leading even to a lower prevalence of non-communicable diseases in the poor.  

Illnesses occur more frequently in the poor and the undernourished and lead to a vicious cycle of greater poverty and more illnesses through the loss of wages, disability and death. The rising cost of illnesses to the poor is leading to widespread indebtedness, liquidation of meagre assets including land and permanent descent into poverty. Studies in two major states in India have shown healthcare costs to be the second commonest cause of destitution in rural areas. Our surveys show that an increasing number of people are not accessing any healthcare at all for purely economic reasons. To prevent a worsening of the situation, it is essential for the government to address the social and economic determinants of ill health, to strengthen the public health system in the rural areas and to regulate the cost of drugs and services provided by the private sector. 

Alarming Decline in Food Grain Availability:  Worsening of Hunger in the Presence of Surplus Food Stocks  

The workshop also dealt with the problems of agriculture, food availability and its results on the nutritional status of the people. We are extremely concerned about the serious decline in the average annual per capita availability   of food grains since the early 1990s. This trend worsened from 1999 with the average dropping from 177 kg to 154 kg, wiping off whatever meagre gains in food availability had been achieved since Independence. This steep fall has entailed a sharp increase in the number of people in hunger, particularly in rural areas. We should remember that 154 kilograms is an average for the entire country and the amount available to the rural poor is actually even lower. In contrast, it is sobering to realise that the average food grain absorption/availability is over 850 kg in USA, 650 kg in Europe and 325 kg in China. Given this background of decreasing food grain availability, we are concerned by the promotion of micronutrients in health and disease as a substitute for availability of wholesome nutrition.  

The forces unleashed in India by the neo-liberal economic reforms package have led to an alarming decline in public investment in agriculture and have precipitated large-scale agrarian distress, the most acute manifestations of which are farmer suicides across the country and the chronic manifestations are of mass migration to the urban centres. Its impact on the health of the people is apparent and the already serious health situation seems to be poised at the brink of a crisis. There has been a stark decline in the food purchasing power of rural people over the last decade that has been responsible for the large surpluses of food stocks accumulating all over the country. The public distribution system (PDS) for food is the only source of food grains for large sections of the people, which, in view of the crisis in nutrition, needs to be retained in the public domain and strengthened with an increase in entitlements without bar. We think it will be catastrophic if the PDS is privatised, food prices are increased and entitlements reduced, as is being envisaged. We strongly oppose measures to subvert the PDS and dismantle the food supplementation programmes as is being done in certain states. However, at the same time, we seek to protect indigenous food and crop biodiversity and promote traditional agricultural practices that are sustainable in nature. 

Agriculture and the Threat to our Food Security, Diversity and Soil Health  

The system of food production promoted from the mid-1960s has created serious anomalies in the diversity, production, distribution and availability of food grains in our country and had a deleterious impact on the nutritional status of rural people. Side by side, alternative models of food production and distribution that are decentralised, community-controlled, low-cost, and based on the preservation of biodiversity and soil health have been ignored and marginalised. The ‘green revolution’ model promoted agricultural methods that were dependent on high external inputs and were limited to a few crop species. It also concentrated production in limited geographic areas and concentrated state resources to these areas. The production and marketing of pulses, coarse grains, millets and related were affected, thus degrading the farming systems and knowledge of farmers and adivasis on the one hand and the quality of the diet on the other with the decreased availability of pulses and millets. Erosion of food biodiversity, degradation of soil health, and pollution of the food chain with pesticide residues have been the other problems associated with this model. A reversal of this situation is needed through the promotion of diversified food production in dry land and rain-fed areas with state support to increase wage employment and regenerate wastelands with an increase in biodiversity.  

We express our concern at the propagation by transnational corporations and their Indian counterparts, of untested technologies and their unregulated use, under the rubric of biotechnology, with an attendant grave threat to food security and sovereignty.  On the other hand, the potential of organic farming has now been tested and proven in many ways all over the country, one of the most prominent examples being the Madagascar system of rice production or the System of Rice Intensification.  

Poverty and the Question of the Poverty Line
 
We have deliberated on the question of poverty and its measurement by the government. The official claim by the Government of India of the number of people below the poverty line (BPL) having gone down flies in the face of the reality of falling food grain consumption and widespread prevalence of starvation-level body weights. On closer inspection, we also find that the method used for estimating the number of persons BPL is based on assumptions that are completely unscientific and irrational, if not deliberately misleading.  

Direct inspection of NSS data of the calorie intake corresponding to the quantities of foods consumed by persons in the various per capita expenditure groups, reveals a totally different picture:  by 1999-2000, seven-tenths of the rural population was below the norm of 2400 calories per day (the norm originally adopted in all poverty studies); about one-tenth had an intake around the norm;  and only one-fifth had an intake above the norm. This means that at least seven-tenths of the rural population was in poverty in 1999-2000. About two-fifths of the urban population was below the lower urban norm of 2100 calories.  

These are disturbing implications –  both in terms of the extent of immiserisation of people of India as well as the complicity of policy makers, and scholars, in denying harsh realities.  

(It was estimated in 1973-74, to purchase the minimum monthly equivalent   2400 calories per diem in rural areas and 2100 in urban areas, one would need a poverty level  income  of Rs.49.10 for rural and Rs 56.60 for urban areas. In order to estimate the poverty for later years, it was assumed that the quantities people consumed, and thus  the pattern of consumer expenditure, remained unchanged from 1973-74. Thus a price index was applied to the old poverty line to update it. Thus the indirectly estimated official poverty line of Rs.328 per month(Rs 11 / day)  in 1999-2000 corresponds to less than 1900 calories per diem.   The direct estimate gives a poverty line at Rs.567 per month (Rs 19 per day), over 60% higher than the official one. This means far more people are below the poverty line,  that is far more people than the official estimates would have us believe, are consuming less that the required levels of calorie intake.)  

Indeed, because of lower calorie consumption over the years, a large segment of the rural masses in India have been reduced to the nutritional status of sub-Saharan Africa.  On the basis of the NSS data on calorie intake for 1999-2000, one finds that about 40 % of the rural population was at the low absorption level of the sub-Saharan average. By 2001, there has been a disastrous slide-back to the low level of 151 kg per head food absorption in rural areas, a level not seen for fifty years. And preliminary data further indicates that by 2005-06, the situation has only worsened.  

We question the practice of calculating minimum wages on the basis of cereals alone, something that has kept the rural poor chronically undernourished in terms of access to other vital ingredients of a balanced diet.  

Right to Food Campaign  

Decreasing food consumption in the country is central to our concerns. We would like to look at this issue holistically within a framework of not just the right to food but also of food security and food sovereignty.  

We endorse the efforts of the Right to Food Campaign in mainstreaming the discourse on the right to food in India and we are committed to finding ways of working more closely with the campaign in bringing chronic hunger and its underlying causes back to the domain of public attention. We note that it is as important to delineate the relationship of widespread and chronic hunger with long-term morbidity and mortality as to focus on acute starvation-related deaths.  

We welcome the interventions of the Supreme Court in creating entitlements for addressing the problem of chronic hunger. We also welcome the initiatives of the Government in this regard, in particular the National Rural Employment Guarantee Act (NREGA), which could potentially transform rural livelihoods as well as the universalisation of the ICDS and the Mid-Day Meal Schemes. We fervently hope that State Governments will not dilute the provisions of the NREGA and instead promulgate more progressive legislation to ensure that the spirit of the employment guarantee is fostered.  

At the same time, we are deeply concerned over the systematic attempts to reduce the entitlements of the poor as was done recently by the Government in reducing food grain quotas. We stand committed to a PDS that is universalised and addresses food sovereignty concerns. We urge the government to create entitlements for the availability of pulses, indigenously produced oils as well as locally available millets. We are also concerned by the continued and large-scale diversions of food grains meant for the poor and the continuing export of food grains despite the existence of starvation in large parts of the country.  

To conclude………
 
We urge the government to consider these serious issues as an integral part of the developmental plan for the equitable and sustainable economic growth of our nation. We should never forget that a nation of undernourished, anaemic and diseased children and adults with one of the lowest per capita food consumption in the world cannot become a strong economic power. There is a need to focus on sustainable agriculture in our economy. There is a need to focus on nutrition as a critical determinant of the health of our people. There is a need to consider our abysmal nutritional and public health indicators while drawing up the developmental balance sheet of our nation, alongside the economic indicators that apparently shine so bright. If we continue to choose to ignore these issues, it will only be at our collective peril.  

List of Signatories  

            1.    Prof. Utsa Patnaik (Centre for Economic Studies and Planning, Jawaharlal Nehru University, New Delhi)

            2.    Prof. Imrana Qadeer (Centre for Social Medicine and Community Health, JNU, New Delhi)

            3.    Dr. Veena Shatrugna (Deputy Director, National Institute of Nutrition, Hyderabad)

            4.    Dr. Sultan Ismail (Vice-Principal, New College, Chennai and Director, Ecology Research Foundation

            5.    Dr. Yogesh Jain (Paediatrician, Village Health Programme, Jan Swasthya Sahyog, Bilaspur)

            6.    Dr. B. R. Chatterjee (Founder President, Jan Swasthya Sahyog, Bilaspur)

            7.    Mr. Jacob Nellithanam (Consultant  Organic Farming, Jan Swasthya Sahyog, Bilaspur)

            8.    Dr. Binayak Sen (President, Chhattisgarh State PUCL)

            9.    Mr. Dunu Roy (Hazards Centre, New Delhi)

            10.          Dr. Anurag Bhargava (Physician, Jan Swasthya Sahyog, Bilaspur)

            11.          Dr. Raman Kataria (Surgeon, Jan Swasthya Sahyog, Bilaspur)

            12.          Dr. Biswaroop Chatterjee (Microbiologist, Jan Swasthya Sahyog, Bilaspur)

            13.          Dr. T. Sundararaman (Director, State Health Resource Centre, Raipur)

            14.          Dr. Ilina Sen (Rupantar, Raipur)

            15.          Ms. Lalitha (Anveshi, Hyderabad)

            16.          Dr. P.K. Sarkar (Foundation for Health Action, Kolkata)

            17.          Dr. N. P. Chaubey (Secretary, Indian Academy of Social Sciences, Allahabad)

            18.          Mr. S.Srinivasan (Managing Trustee, LOCOST, Vadodara)

            19.          Ms. Renu Khanna (SAHAJ, Vadodara)

            20.          Dr. Saibal Jana (Physician, Shaheed Hospital, Dalli Rajhara, Chhattisgarh)

            21.          Mr. Biraj Patnaik (Principal Adviser to the Commissioners of the Supreme Court (Writ 196/ 2001).

            22.          Ms. Sudha Bharadwaj (Advocate, Chhattisgarh High Court and Secretary, Mahila Mukti Morcha)

            23.          Mr. Anant Johuri (Sarvadaliya Kisan Sangh, Anuppur, Madhya Pradesh)

            24.          Dr. Madhuri Chatterjee (Physician, Jan Swasthya Sahyog, Bilaspur)

            25.          Dr. Anju Kataria (Paediatrician, Jan Swasthya Sahyog, Bilaspur)

            26.          Dr. Rachana Jain (Gynaecologist, Jan Swasthya Sahyog, Bilaspur)

            27.          Dr. Madhavi Bhargava (Surgeon, Jan Swasthya Sahyog, Bilaspur)

            28.          Dr. Yogendra Parihar (Advisor, Jan Swasthya Sahyog, Bilaspur)

            29.          Dr. Sister Aquinas (Holy Cross, Mysore, Karnataka)

            30.          Mr. Ranjan Ghosh (Jan Chetna Manch, Chandankiari, District Bokaro, Jharkhand)

            31.          Ms. Lindsay Barnes (Jan Chetna Manch, Chandankiari, District Bokaro, Jharkhand)

            32.          Sr. Elizabeth (Secretary, Raigarh Ambikapur Health Association, Pathalgaon, Chhattisgarh)

            33.          Dr. Sarla Kataria (Retired Professor of Economics, Lady Shri Ram College, Delhi University)

            34.          Ms. Rajashri Dasgupta (Freelance journalist, Kolkata)

            35.          Mr. Rehmat (Manthan Vichar Manch, Badwani, Madhya Pradesh)

            36.          Mr. V.R. Raman (Co-ordinator, State Health Resource Centre, Raipur)

            37.          Mr. Amulya Nidhi (CRY, and Shilpi, Indore, Madhya Pradesh)

            38.          Dr. Ashish Gupta (Shilpi, Indore, Madhya Pradesh)

            39.          Mr. Sameer Garg (Koriya Initiative, Chhattisgarh)

            40.          Ms. Sulakshana Nandi (Koriya Initiative, Chhattisgarh)

            41.          Ms. Asha Shukla (Journalist, Nav Bharat, Raipur)

            42.          Dr. Surabhi Sharma (Ayurvedic Physician, Jan Swasthya Sahyog, Bilaspur)

            43.          Mr. Mahesh Sharma (Co-ordinator, Organic Farming, Jan Swasthya Sahyog, Bilaspur)

            44.          Mr. Praful Chandel (Co-ordinator, Village Health Programme, Jan Swasthya Sahyog, Bilaspur)

            45.          Ms. Santoshi Viswakarma (Co-ordinator, Village Health Program, Jan Swasthya Sahyog, Bilaspur)

            46.          Mr. Suresh Sahu (Rupantar, Raipur)

            47.          Gangaram Paikara (Right to food Campaign, Chhattisgarh) and other friends from the Right to food campaign, Chhattisgarh

            48.          Dr. Arun Gupta (Fellow, Community Health Cell, Bangalore)

            49.          Mr. Shivnath Yadav (Dharohar, Kondagaon, Bastar)

            50.          Mr. Shailesh Bambore (Chhattisgarh Kisan Sangh, Dalli Rajhara)

            51.          Mr. Gajanan Singh (Jan Jagriti, Chhattisgarh)

            52.          Ms. Durga Jha (Dalit Study Circle, Raipur)  

[1] Organized by Jan Swasthya Sahyog at village and P.O. Ganiyari –495 112, Bilaspur, Chhattisgarh, on February 10-11, 2006.

[2] National Family Health Survey-2, 1998-99. International Institute  for Population Sciences, Mumbai.

[3] Ref “ Rethinking Public Health: Food,Hunger,Mortality Decline In South Asian History” by Sheila Zubrigg ( Public Health and Poverty of Reforms: The South Asian Predicament. Qadeer I, Sen K, Nayar KR, eds. Sage Publications2001 pp 174-197),  where it is seen that in UK mean annual deathrate of TB declined from 4000 deaths per million to blow 500 from 1838 to 1950 before discovery of TB medicines…..same for measles ,whooping cough etc.

[4] Assessment of Burden of Non-communicable Diseases. ICMR.2004.

[5] Barker DJP, Eriksson JG, Forsen T, Osmond C. Fetal origins of Adult disease. Strength of association and biological basis. Int J Epidemiol 2002; 31:1235-1239.  

 

[6] Harding JE.. The nutritional basis of the fetal origins of adult disease. Int J Epidemiol. 2001;30:15-23.