Poverty, Malnutrition and Mortality in South Asia : A Review of Issues and Options

K. Navaneetham and Sunny Jose, “Poverty, Malnutrition and Mortality in South Asia: A
Review of Issues and Options”, CICRED Seminar on Mortality as Both a Determinant and
a Consequence of Poverty and Hunger, Thiruvananthapuram, India, February 23-25, 2005,
pp. 1-21

Draft paper before publication.



Poverty, Malnutrition and Mortality in South Asia: A Review of
Issues and Options
K. Navaneetham and Sunny Jose
Centre for Development Studies, Trivandrum

---

A. Introduction
The contemporary world, in which we live, continues to register substantial progress in
economic growth, abundance in production of food grains, and profound breakthrough in
medical technology and knowledge on diseases and healthcare. These are no mean
achievements and there are reasons to further them, as they play important role in both
reducing poverty and hunger and improving the health and nutrition substantially. Despite
these progresses and achievement, a number of regressive aspects also continue to plague
many parts of the world and blight the lives of men and women in various ways. For
instance, economic progress coincides with widespread poverty and hunger in various
regions and countries within regions. Similarly, advancements in medical technology and
improved knowledge of diseases and healthcare go well along with lack of awareness on
elementary aspects of hygiene and preventive measures and non-availability of primary
healthcare facilities. Due to these and other such factors, the contemporary world also has
widespread, chronic malnutrition and premature mortality of children and adults.
Why do poverty and hunger tend to coexist with substantial economic progress and
abundance in production of food grains? Why do chronic malnutrition and premature
mortality of children prevail despite the availability of, and access to, ways and means to
address them? These are important questions, which no one can afford to ignore. There are
no simple answers exist, we believe, for these questions. Rather than addressing these
issues explicitly, what we attempt to do here is to examine their association and
development consequences. Broadly, we tend to examine the association as well as the
interaction between poverty and mortality. Specifically, we try to understand and identify
how do poverty is interrelated with malnutrition and mortality of children and the
mechanisms through which they operate. South Asia will be our locus of discussion, as
despite a reasonably better record in economic growth and alleviation of poverty it tends
to suffer from pervasive malnutrition and mortality of children.
The paper is organised as follows. The second part of the paper discusses the associations
and interaction between poverty and mortality and their causal connections. To do so, a
brief and selected review of literature is also attempted. The experience of South Asia is
discussed in the third part. Attempts will also be made, wherever possible, to highlight the

2

---

experience of India or states within India. The final part will sum up the arguments and
suggest possible areas for further research.
B. Selected review of issues
One of the recent works, which analysed the issues that are relevant to the theme of the
present attempt, is by Osmani and Bhargava (1998). In all the indicators of malnutrition,
South Asia turns out to be worst off among all the regions in the developing world,
including Sub-Saharan Africa. What is so special that explains this phenomenon? It
emerges from their cross sectional analysis that child nutrition is positively influenced by
urbanisation; female literacy; access to healthcare, safe water, and sanitation. The
incidence of low birth weight has a negative impact on child nutrition. In fact, the
excessively high incidence of stunting in South Asia is explained almost entirely by the
exceptionally high levels of low birth weight observed in this region.
What lies behind the incidence of higher level of low birth weight in South Asia? A cross-
country regression on incidence of low birth weight was carried out to shed light on this
question. Even after controlling the effects of income, food, non-food inputs, urbanisation,
education, and age at marriage, there remains an unexplained excess of low birth weight in
South Asia. The low birth weight essentially reflects the quality of maternal nutrition,
because women who experience greater nutritional stress during pregnancy tend to bear
more low birth weight babies. Why do women in South Asia tend to have lower health and
nutrition? Are there any factors that are specific to the region that disadvantage women
and affect adversely their health and nutrition?
Osmani and Bhargava (1998) argues that there is something in the culture of this region
that leads to the excessive neglect of maternal nutrition, in addition to what can be
explained by the usual determinants of health and nutrition. This excessive neglect of
maternal nutrition ultimately accounts for excessive child undernutrition in South Asia. In
other words, a particularly pernicious kind of intergenerational transmission mechanism
seems to be operating there: the neglect of maternal nutrition causes high incidence of low
birth weight, which in turn causes poor child nutrition. The excessive stress suffered by
South Asian women in their reproductive life has profound implications for the overall
nutritional status in this region. Given the socio-cultural norms prevalent in this region,
maternal health and nutrition is likely to be influenced by the strength of female agency.

3

---

Therefore, female education and female labour force participation is crucial for improving
maternal nutrition and hence child nutrition in South Asia.
The analysis and findings of Osmani and Bhargava (1998) not only sheds light on various
issues raised by Ramalingaswamy, Jonsson and Rohde (1996), but also seems to reinforce
their arguments. The analysis of plausible determinants of higher levels of child
undernutrition in South Asia by Ramalingaswamy, Jonsson and Rohde (1996) reveals that
poverty and food production are almost same for both the region. In fact, South Asia tends
to fare slightly better in these aspects. Socio-economic inequality, which may potentially
influence the nutrition of children through various ways, does not appear to be
significantly worse in South Asia than in Africa. Nor is malnutrition in South Asia a result
of predominantly vegetarian diet. Also, the child malnutrition does not seem to arise nor
can be related to governmental inaction. Similarly, theories about the inappropriateness of
international growth standards for Asian countries do not seem to explain the problem
fully. If these potential factors are ruled out, then, what is the possible reason for such
higher levels of child malnutrition?
Herein, the authors seem to converge with the findings of Osmani and Bhargava. It seems
that one third of all babies in India are born with low birth weight, whereas in Bangladesh,
the proportion is even one half. In Sub-Saharan Africa, on the contrary, the proportion is
about one sixth. Low birth weight indicates that the infant was malnourished in the womb
and/or that the mother was malnourished during her own infancy, childhood, adolescence
and pregnancy. The proportion of babies born with low birth weight, therefore, reflects the
condition of women, and particularly their health and nutrition, not only during pregnancy
but also over the whole of their childhood and young lives. They argue that girls and
women in South Asia are less well cared for than in sub Saharan Africa. Women in both
regions, indeed in all regions, may be subordinated, but the demands made in patriarchal
South Asian societies on the time and energies of women are visibly more excessive and
unfair than in other regions of the world.
The lack of freedom for women in South Asia limits opportunities for interaction even
between women themselves. It therefore restricts transmission of new knowledge about
health matters and child care, damages the self-esteem of women, and induces a kind of
crushed dependency on the husband. Thus, the poor care that is afforded to girls and
women by their husbands and by elders is the first major reason for levels of child

4

---

malnutrition that are markedly higher in South Asia than anywhere else in the world. The
issue of malnutrition should be moved, they argue, from the agenda of welfare to the
agenda of rights. It is the right of the child to have adequate care, and to grow to the
mental and physical potential with which he or she was born. The right of women-
including her right to education, to dignity and respect, to time, to rest, to adequate food
and health care, to resources and to special care in pregnancy and childbirth are a priority
both in and of themselves and as a fundamental part of any permanent solution to the
particular problem of child malnutrition.
But this gives rise to yet another enigma or paradox. If hygiene is markedly worse, and if
child malnutrition is excessively high as well as so strongly associated with child deaths,
then why are child survival rates considerably low in South Asia than in Sub-Saharan
Africa? They argue that South Asia has better access to modern healthcare, and especially
to life saving antibiotics. Also, there are larger number of private medical practitioners in
South Asia than Sub-Saharan Africa, who possibly save more lives, but they do relatively
little for nutrition.
An interesting work that examines the mechanism that transmits the malnutrition and their
impacts is Scrimshaw (1996). Nutrition and other factors during pregnancy and infancy
influence not only the health of the fetus and the infant, but also that of the individual
throughout life. Iron deficiency in the mother during pregnancy increases maternal
mortality, prenatal and peri-natal infant loss. Moreover, if the mother is iron deficient, her
child is born with poor iron reserves and is at greater risk of morbidity and mortality
during infancy. Iron deficiency in the child also inhibits growth, impairs immunity, and
increases childhood morbidity from infectious disease. One of the most recent finding,
referred to as Barkar hypothesis, is that poor nutrition during fetal development and
infancy influences the occurrence of chronic diseases in adulthood.
Fetal growth restriction due to maternal malnutrition and other adverse environmental
factors leads to a small-for-gestation baby. Low weight for duration of gestation not only
predicts poorer health in early childhood but also more problems of chronic degenerative
diseases in adults as they age. In underprivileged children, the synergism of malnutrition
and infection commonly impairs growth and development and may lead to both physical
and mental stunting. Throughout life, the quality of the diet influences the occurrence of
both acute and chronic diseases including hypertension, heart disease, type II diabetes and

5

---

some of the most series forms of cancer. It thus appears from the above discussion that
though a number of factors influence child malnutrition, the most important factor seems
to be the low birth weight, which in turn is influenced by the maternal nutrition. Lack of
maternal nutrition arises from a number of factors, including lower agency of women.
Freedom from premature mortality ? a capability central to human life ? refers to right
to survival. Mortality of children, therefore, implies the curtailment, to some extent even
denial, of denial of human right to live. Further, being alive is valuable not only in its own
right, but also central to achieve any other functioning (Sen 1998). In certain regions of
the world and many countries within regions, children die in far great number during their
infancy. The number is excessively large for female children in most of the South Asian
countries. Studies suggest that infant or child mortality is an outcome of a complex web of
interrelated factors. A number of factors, such as infection and incidence of diseases, lack
of immunisation and appropriate care, malnutrition, and so on, contribute both
individually and cumulatively to the mortality of children (Scrimshaw 1996; Osmani
1997; Martorell 1999).
It has been argued that five childhood conditions, namely diarrhoea, respiratory infections,
malaria, measles and peri-natal conditions, are responsible for 21 percent of all deaths in
low-income and middle-income countries (Bloom and Canning 2001, p. 56). Expectedly,
the contribution of these childhood conditions on the mortality of children would be
substantially high. What forces the children from poor countries to get exposed
excessively to these infections is an important issue, which calls for a detailed but separate
investigation. Given the focus of the present paper, we do not attempt to address this issue
here. Nevertheless, an important interconnected aspect is worthy of discussion here. A
crucial mediating factor that not only puts the children vulnerable to frequent infections,
ill-health and obviously their death is malnutrition in general and protein energy
malnutrition in particular.
Malnutrition seems to deteriorate the life chances of children in synergy with infections.
Because, malnutrition is not only a consequence of infections, but also renders the
children vulnerable to ? in that sense, a cause of ? infections. For instance,
malnourished children have reduced resistance to infections because of lower humoral and
cell-mediated immunity. The result is that they have more frequent and severe infections,
particularly diarrhoeal and respiratory diseases. Additionally, infections, even when they

6

---

are mild or sub-clinical, can worsen nutrition of children by a variety of ways. These
include ? but by no means limited to ? reduced appetite, metabolic nutrient losses in
urine, internal diversion of nutrients, and frequent reduced absorption of nutrients
(Scrimshaw 1996). Thus, it appears from the above that adequate nutrition is
quintessential to prevent infections as also for an early cure. Since nutrition emerges as an
essential ingredient for better health and hence lengthy life, it is important to examine the
factors that lead to malnutrition.
It has been argued that ‘malnutrition is associated with a cluster of related, often
coexistent, factors that together constitute what may be termed the poverty syndrome. The
major attributes of it are: 1) income levels that are inadequate to meet basic needs of food,
clothing and shelter; 2) diets that are quantitatively and qualitatively deficient; 3) poor
environment, poor access to safe water, and poor sanitation; 4) poor access to healthcare;
and 5) large family size and high levels of illiteracy, especially female illiteracy’ (Gopalan
1992, p. 18, emphasis added). It is important to state here that these determinants relate to
malnutrition in general, rather than to children’s malnutrition. A number of other factors
tend to complement these general factors in causing the malnutrition of children. Before
discussing these specific complementary factors, it is important to acknowledge that the
poverty syndrome referred to above is also applicable for, and hence an important role in,
determining the nutritional status of children.
Maternal malnutrition seems to have a lasting effect on the nutritional status of children.
For instance, maternal malnutrition, such as lower body mass index and iron-deficiency
anaemia especially during pregnancy, can potentially result in intra-uterine growth
retardation for the foetus, and can possibly lead to high prevalence of low birth weight.
Low birth weight, in turn, may lead to both a high rate of child undernutrition, as well as
to higher prevalence of adult ailments, both directly and indirectly through child
undernutrition (Scrimshaw 1996; Martorell 1999; Osmani and Sen 2003). Viewed in this
sense, child malnutrition is both an outcome and the transmission of maternal
malnutrition. Malnourished children not only begets lower nutritional and health status
from their birth but also transfer, through their greater propensity to infections and ill-
health, malnutrition into next generation. Thus, besides poverty, maternal malnutrition
plays an important role on the nutritional status of children.

7

---

The pathways of child malnutrition and the role played by maternal malnutrition are
depicted in the following diagrams (appended herewith). The first diagram, which is the
framework developed by the UNICEF (Jonsson 1997), disaggregates the causes of child
malnutrition into three, such as basic causes, underlying causes and intermediate causes.
The basic causes are lack of resources, including material, economic, social and cultural
resources. These lack of resources are converted into various deficiencies such as
inadequate access to food, care for children and women and insufficient health facilities or
services and unhealthy environment. These underlying factors put children into vulnerable
situation by leading to inadequate dietary intake and infections to disease, which
obviously results in the malnutrition of children.
The first diagram presumes, arguably, that child malnutrition is primarily an outcome of
lack of resources (viewed in a broader sense), and hence lays more emphasis on the lack
of resources. The second diagram, which tends to differ from the first in some important
ways, seems to bring in additional dimensions than resource shortfall. In fact, the second
diagram not only portrays the transmission mechanism discussed above, but also clearly
begins with the maternal malnutrition. It depicts that malnourished mothers give birth to
low birth weight babies. Low birth weight babies, in turn, not only become malnourished
but also transmit their malnutrition to adulthood and possibly to later life (a detailed
account of malnutrition across life cycle is presented in the Appendix Table). Viewed in
that sense, this approach tends to capture the transmission mechanism with the source of
origin and also seems to offer a competing framework for analysing child malnutrition.
C. South Asian experience
Table one presents information on the incidence of poverty, defined in terms of people
living below $1 a day per person, in South Asia. To get a comparative picture, incidence
of poverty, both in terms of number of people and percentage, in other regions is also
given. It appears from the table that substantially large number of poor people, as high as
522 million in 1998, live in South Asia. However, incidence of poverty is relatively
higher, in terms of percentage of people living below poverty, in Sub-Saharan Africa (46
percent) than South Asia (40 percent) in 1998. The same pattern holds good for the year
1990 as well. Given the higher incidence of poverty in Sub-Saharan Africa than South
Asia, we would expect relatively higher levels of infant and child mortality in the former
than the latter, as poverty is known to be one of the potential factors causing the infant and

8

---

child mortality. Table two presents information on the levels of infant and child mortality
across regions.
Table 1: Incidence of poverty (less than $1 a day) across region

1990 1998
Regions
Millions Percent Millions Percent
South Asia
495.1
44.0
522
40.0
Sub-Saharan
Africa
242.3 47.7 290.9 46.3
East Asia and Pacific
452.4
27.6
278.3
15.3
Latin America and the Caribbean
73.8
16.8
78.2
15.6
Source: World Bank, 2001, p. 23
Table two suggests that mortality levels, both infant and child mortality, are relatively
higher in Sub-Saharan Africa than South Asia. The differences are substantially large in
both infant and child mortality. On the face of it, the larger pattern emerging from the
table ? relatively higher levels of mortality of children in Sub-Saharan Africa than South
Asia? seems to go in line with the pattern emerging from the previous table. For
instance, not only is the incidence of poverty relatively lower in South Asia, but also
levels of infant and child mortality are relatively lower. Equally, higher incidence of
poverty in Sub-Saharan Africa tends to go with relatively higher mortality of children.



Table 2: Mortality of children across regions (1998)
South Sub-Saharan East Asia and

Asia
Africa
Pacific
Infant Mortality
69.8
91.7
43.4
Under Five Mortality 101.6
166.3
71.2
Source: Klasen 2004
As discussed in the previous section, one of the important factors that would significantly
influence the health and potentially increase the probability of mortality of children is the
extent of their malnutrition. Let us examine, therefore, whether South Asia tends to have
lower levels of child malnutrition when compared to Sub-Saharan Africa, as both
incidence of poverty and mortality of children are lower in the former region than the
latter? Table three gives information regarding the incidence of malnutrition of children

9

---

across regions. Three anthropometrical indicators that are used commonly to indicate the
nutritional status of children, such as wasting, stunting and underweight, are given in table
three. These three indicators refer respectively to weight for height, height for age and
weight for age. If an anthropometrical indicator, for instance, height for age, is below 2 or
3 Standard deviation from the norm, it is considered as the incidence of moderate and
severe stunting respectively.
It appears from table three that incidence of child malnutrition is relatively higher in South
Asia than Sub-Saharan Africa. It seems that in all the three indicators considered here,
South Asia fares far poorer than other two regions. The difference, in percentage points, is
noticeably large. For instance, severe underweight in South Asia is 25.7 percent, which is
around 12 percentage points higher than the incidence of Sub-Saharan Africa. Similarly,
incidence of severe underweight in South Asia (17.5 percent) is more than double the
incidence in Sub-Saharan Africa (7.4 percent).
Table 3: Malnutrition of children (under 5) across regions (%)
South Sub-Saharan
East Asia and
Anthropometrical Indicators
Asia
Africa
Pacific
Moderate and Severe Wasting
15.5
8.7
7.7
Severe Stunting
25.7
13.9
12.6
Moderate and Severe Stunting
44.8
32.8
32.9
Severe Underweight
17.5
7.4
5.5
Moderate and Severe Underweight
46.5
25.7
26.3
Source: World Health Organisation (1998) and UNICEF (various years),
cited in Klasen 2004, p. 28, Table 1.

We have seen that incidence of poverty is relatively lower in South Asia when compared
to Sub-Saharan Africa. However, relatively lower incidence of poverty goes together with
relatively higher incidence of undernutrition in South Asia than Sub-Saharan Africa.
These contrasting patterns not only tend to go against our expectation, but also seem to
raise a number of important questions. Why, for instance, despite lower incidence of
poverty malnutrition levels are higher in South Asia? Further, why irrespective of higher
levels of malnutrition, mortality levels of children are lower in South Asia? It would
seem, then, that besides poverty certain factors are also at work in causing child
malnutrition. As mentioned already, infections, especially incidence of diarrhoea and
acute respiratory infection, not only influence the nutritional status of the children but also

10

---