Dr Arun Gupta, Paediatrician and Asian Regional Coordinator of International Baby Food Action Network (IBFAN), explains why it makes economic, political and development sense to make infant nutrition a central strategy to handling India’s nutritional challenges
When all is done and dusted, the Modi government’s claims to success will be judged against India’s darkest distended underbelly, its millions of malnourished children. And, the key for the government lies in its ability to replace ad hoc actions with coordinated ones and focus on infant nutrition which will largely set the tone and tenure to the drive for ending child malnutrition.
Need for focus on infant nutrition
India has more malnourished children, than any other country. The National Family Health Survey-3 (2005) found that 42.5 per cent of children under five years old were underweight and the newly released Rapid Survey on Children (RSOC) done by UNICEF and Government of India finds it coming down to little less than 30 per cent. That’s good news. But it’s bad news as well, as India stands higher than Africa as the underweight children in Africa are at 21 per cent. Let’s take the BRICS route, we stand lowest in nutrition performance!
Why focus on infancy?
It is well known, that optimal infant and young child feeding practices are crucial to prevent the child malnutrition; both under and over. Breastfeeding is ‘food’, ‘health’, and ‘care’ has it all and provides food and nutrition security to infants and young children that has been largely ignored in fight for child malnutrition.
At the same time in India 1.2 million children die under the age of five. This means one lakh young children die every month. Among the 1.2 million under five deaths, more than 70 per cent occur during first year, and over 60 per cent deaths are due to preventable causes. According to latest analysis, 15 per cent of these are due to pneumonia and 12 per cent due to diarrhoea. Newborn infections are another major killer too. Early breastfeeding within one hour, and exclusive breastfeeding for the first six months, good complementary feeding after six months and continued breastfeeding for two years or beyond is what WHO recommends to achieve optimal health and nutrition of children. Breastfeeding, other than providing optimum nutrition inputs during infancy and early childhood, has been shown to be number one intervention for these three major killers.
Fact Sheet on breast feeding
- Children who are optimally breastfed as infants have a 3-7 IQ point advantage
- Breastfeeding also protects children from obesity and found to reduce NCDs like diabetes, cancers, hypertension and cardiovascular disease
- Early breastfeeding within one hour, and exclusive breastfeeding for the first six months, good complementary feeding after six months and continued breastfeeding for two years or beyond is what WHO recommends
Brain develops rapidly during the initial two years, almost 80-90 per cent of it. Children who are optimally breastfed as infants have a three to seven IQ point advantage, thus implying potential educational attainment and future capabilities, productivity and earnings.
That’s why focus on infancy is critical. Not that children are vulnerable. Breastfeeding also protects children from obesity and found to reduce non-communicable diseases like diabetes, cancers, hypertension and cardiovascular disease.
Makes economic and development sense
Most recent study from Brazil reveals a major economic developmental advantage that breastfed human beings have higher earning ability at 30 years related to their IQ. Raising breastfeeding rates amounts to saving huge amount of public expenditure on diarrhoea, family planning and other illnesses. By lowering the incidence of diarrhea it could save $7.2 billion, and another $5 billion through providing protection in family panning. At the household level the cost of artificially feeding a three-month-old infant was calculated to be 43 per cent of the minimum wage of a skilled urban worker in 1999.
Policy support
India enacted a law in 1992 and 2003, the Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003. In spite of the law, baby food companies continue to aggressively promote their products, that needs to be checked to protect breastfeeding.
The 2015 report titled ‘Arrested Development’ on the findings of the fourth assessment of done by the World Breastfeeding Trends Initiative (WBTi), shows many gaps in all policy and programmes related to optimal infant feeding. Some areas that need most attention are national coordination and plan of action with budgets, Baby Friendly Hospital Initiative, Maternity Protection, implementation of the IMS Act, and infant feeding during emergencies/ disasters.
Government of India claims that 80 per cent deliveries take place in health facilities, but we have only 40 per cent women initiating breastfeeding within one hour, exclusive breastfeeding nosedives to nearly 20 per cent by the time child is six months. Only about half of kids receive adequate complementary feeding and 20 per cent kids get diverse foods during six to 24-month period. This exposes kids to serious under nutrition.
In past two decades, it has not changed much. Reason is simple; we don’t invest in the interventions required to rise breastfeeding and complementary feeding rates. While one sector intervention can increase early breastfeeding within an hour, exclusive breastfeeding requires multi sector interventions.
Need to invest
It is important for governments and international agencies to invest more than what the industry does to expand its markets in order to prevent premature weaning from breastfeeding, and to address the on-going harm of current suboptimal infant feeding practices. Breastmilk and breastfeeding is economically valuable, but it is not ‘free’ and needs investment in interventions to boost it. Interventions that need investment include Baby Friendly Hospital Initiative, monitoring and implementation of the law to protect breastfeeding, training of health workers, maternity protection etc. All these need money.
Lessons can be learnt from Brazil. The evidence and the current situation make a compelling case for investment in interventions to increase optimal feeding practices. Optimal infant and young child feeding, especially breastfeeding avoids waste of a valuable food resource, and strengthens a nation’s human capital. Formula feeding on the other hand increases mortality and morbidity, placing extra demands on economic resources.
What action?
Currently attention to this issue is peripheral as compared to its impact and value. Breastfeeding is a great equaliser in providing universal healthcare. Actions that may help set in motion nutrition agenda include a national plan of action on infant and young child feeding with specific budgets. Creating a separate budget line for breastfeeding will be useful. It should be done as a priority in both relevant ministries reflected at state level also.
PM Modi should lead a national programme for nutrition of women and children on the lines of ‘Beti Bachao, Beti Padhao’ keeping infant nutrition as a central strategy. Under the aegis of the ‘PM’s Council on India’s Nutrition Challenges’ this could be a driving force.
Last but not the least, a National Nutrition Authority may be established under the PM’s Council that would lead coordinated action on nutrition and support the states technically with its group of experts/mentors. It could become a fulcrum for a coordinated response and report to the PM’s Council, thereby reducing prevailing institutional weakness to address the problem. India does not have such an institution. On the contrary, the entire task is left to the Ministry of Women and Child Development. And, this Ministry has a very weak nutrition section in the form of a Food and Nutrition Board to deal with this. There is little coordination between the Ministry of Health and the Ministry for Women and Child Development (the nodal ministry for nutrition), let alone with other ministries such as Agriculture, Food Supplies, Labour, Trade, and Finance. There is total lack of coordination at the level of policy and plan development.
This can strengthen governance and help change the nutrition scenario for short and long term, and as well as rapidly reduce infant mortality. These actions would help the ruling government to achieve what was said in its manifesto, and help boost its political image; which matters more in current times. There is a pressing need to put an end to ad-hocism by giving power to such a Council to lead the policy discussions and then oversee implementation of the solutions.
Improving governance will go a long way and sustain action. Gains are too big to ignore. Can the Indian government demonstrate this leadership and will?
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