Divya Ravindranath

Malnutrition (whether undernutrition or overnutrition) is a widespread global phenomenon. It is estimated that more than one third of child deaths and 11% of disease burden worldwide can be attributed to malnutrition. Apart from contributing to child mortality, malnutrition also impedes physical and cognitive development. It impacts children’s overall health, affecting educational performance and economic opportunities later in life.

India is home to about one-third of the world’s malnourished children; at an all India level, 46% of children under the age of three and 40% of children under five years of age are underweight. This makes the prevalence of underweight children in India among the highest in the world, more than that of Sub-Saharan Africa – a point that has received immense national attention.

Hitherto, malnutrition was considered to be a distinctively rural problem based on the assumption that people in the urban areas are better off on all health indicators than their rural counterparts. Malnutrition was also seen to be closely associated with the failures of the agricultural production system, which made it a rural issue. The UNHABITAT report debunks this myth. It asks researchers to step outside the rural-urban rhetoric, by providing a compelling case for studying urban malnutrition. It points out that in many parts of the world the prevalence of malnutrition is as high in urban slum pockets as it is in rural areas. In other words, the report shows that nutrition estimates that are consolidated for city-wide populations fail to present intra-urban differentials. The assumption of urban health advantage simply disguises enormous disparities. In reality, the urban poor are incapacitated by poverty which reduces their ability to benefit from better proximity to resources and services.

It is estimated that 25% of the urban population in India lives under the national poverty line. The poor are generally located on the fringes of the city and are affected by a host of factors that have long and lasting implications on their nutritional status. Several factors are involved.

Income insecurity: A majority of the urban poor tend to be unskilled and employ a variety of strategies to earn their living. Incomes are highly unstable and people are susceptible to spells of underemployment. Under such circumstances, households are compelled to place restrictions on the expenditure or consumption of food. This along with inflation in prices of food items has a direct bearing on the food security, dietary diversity and the nutritional status of poor households, especially children who require a steady supply of nutritious food in their early years for better growth and development. Income insecurity also limits expenditure on health, affecting children who require constant care and examination due to poor nutrition.

Food insecurity: The problem of food insecurity in urban areas is distinctly different from that in rural areas, because the former are usually located at a distance from the food production systems. Research points out that urban households almost completely rely on local markets and are most likely to buy more than 90% of their food. This may seem advantageous because a market provides more choices to the consumer than an agricultural land that can grow only a limited number of crops. However for the urban poor, proximity to a market place doesn’t necessarily guarantee increased dietary diversity or better food intake. The ‘cost of calories’, as literature notes, is higher in urban areas than in rural areas, especially in the case of staple food items – rice, wheat, local fruits and vegetables.

Living conditions: Child malnutrition, morbidity and mortality have been directly linked to poor water and sanitation facilities. In the absence of government water connections or easily extractable groundwater resources, poor households are forced to depend on private players. Poorer households tend to spend more money than non-poor households to access water in urban areas where water is a highly contested resource. The quality of water received by slums is also highly questionable, and the risk of water and food contamination, diarrheal disease, and malnutrition is higher among children when a household does not have access to clean potable water. Similarly, sanitation remains a big issue in urban slum areas. Children are generally encouraged to defecate in the open either because there is no toilet facility, or there are safety concerns because of the distance to the toilet block or the high density of usage which disables them from using the facility. Exposure to feces and interaction with water makes children vulnerable to diseases like cholera, jaundice, malaria and other water borne diseases. This is a common trigger for the cyclic relationship between malnutrition, infections and diseases. Contamination causes diarrhea and intestinal diseases, and malnutrition weakens the body’s ability to fight these problems making them more susceptible. These diseases in turn impair nutrient absorption and lead to nutrient losses.

Children also have to deal with air, water and soil pollution as slum pockets tend to be located in temporary wastelands – swampy lands, near dumping grounds or semi-industrialized zones. Children are in constant contact with leached water sources or other domestic and industrial contaminants even when they play in their neighborhoods. Respiratory disorders are also rampant due to indoor air pollution caused by the use of wood fuel. Malnourished children are at more risk in such cases due to low immunity. Apart from these, low maternal education, low maternal health, breastfeeding practices, inadequacy of complementary feeding or lack of dietary diversity are considered to be among the other major causes of malnutrition.

The scale and extent of urban child malnutrition has reached dangerous proportions in India. The Government of India, researchers, practitioners and communities have to work together to resolve large systemic problems – urban housing, water, sanitation, poverty etc. But simultaneously immediate concerns of food and nutritional insecurity must also be addressed to pull children out of life-long crises that are triggered by malnutrition.