Infant mortality rate in India may not be as high as WHO estimates, study shows
India has often been portrayed in foreign movies as an impoverished country. While this portrayal could offend many of us, data points to some truth to the "impoverished" adjective. With a population of 1.3 billion, we are the second-most populous country. India's Global Hunger Index (GHI) is 102 and malnutrition is rampant-14.5% of the population is undernourished and 51.4% women in the reproductive years are anaemic. About four out of ten kids are stunted, with their height far less for their weight, and one in five are wasted, with very low weight compared to their height. Although there is no consensus about these statistics providing the entire picture, the country still has a massive problem with hunger and poverty.
Studies conducted by the World Health Organization (WHO) nearly fifteen years ago reported a mortality rate of 10- 20% in children with severe acute malnutrition (SAM). The WHO made several guidelines to curb this rate, one of which was providing ready-to-use therapeutic food to affected children. However, few recent studies conducted in India refute these mortality rates as they include hospitalised children in the data. The mortality rates in India are calculated based on mortality rates in African nations, where diseases like AIDS are prevalent, and hence do not paint an accurate picture.
"Our children have a much thinner build and shorter stature, and it is not fair to compare them to African children," says Dr Harshpal Singh Sachdev from Sitaram Bhartia Institute of Science and Research, New Delhi. Indian children have a "thin fat phenotype", where they have fat reserves from the womb that they carry into young adulthood. This fat helps them store energy in the face of nutritional deprivation and is not an indicator of mortality risk.
In a recent study, Dr Sachdev and an international team of researchers have shown that India's mortality rate due to severe acute malnutrition is a fraction of the WHO estimates. This study, published in the journal PLOS Medicine, reports that the case mortality of children in the impoverished states of Jharkhand and Orissa is in the range of 1.2% as opposed to WHO's 10-20%.
The researchers collected data with the help of Anganwadi workers. Anganwadis are part of the rural healthcare initiative by the Indian government partaken in 1975 as a part of Integrated Child Development Services (ICDS). The data thus collected included information about nearly 120,000 children and pregnant women who were in their final months of pregnancy.
The WHO's approach to using ready-to-use therapeutic food, which is high in calories, vitamins and minerals, may not be the right solution for a country like India, argues the study. Although such foods are nutritionally rich and do not need refrigeration, they may be better for hospitalised children, say the researchers. Instead, they call on the government to focus more on a holistic approach towards prevention and proper nutrition to bring down the rate of mortality in malnourished children. It can include preventing diseases with adequate immunisation, sanitation, and providing nutritious food.
Another factor of ready-to-use therapeutic food is its widespread use and the cost.
"The commercial aspects of such foods is another reason which has caused an unnecessary panic amongst mass media and people to believe that expensive therapeutic food is the only way out of malnutrition," says Dr Sachdev.
According to WHO the cost of a kilogram of ready-to-use therapeutic food is about USD 3 and every HIV-negative child suffering from SAM requires around 10-15kg over 6-8 weeks, bringing the price to $45 per child.
Is this 'fall' in mortality rates still a reason to rejoice?
"While it's one of the first studies of its kind and debunks the old numbers from the WHO, it is also worth remembering that any research, and thus intervention of this kind, might create a bias amongst people who are being monitored and doctor the data obtained when compared to people who are not being monitored every three months," opines Dr Zulfiqar Bhutta. He is the Co-Director of Research at the Centre for Global Child Health in the Hospital for Sick Children in Toronto, Canada, and was not a part of this study.
While the findings of the current study give us hope, what could be done to address malnutrition in the country? While Anganwadi is a noble initiative to provide nutrition in remote corners of the country, it's not enough to combat our tricky relationship with hunger. India is still a country where there is rampant marginalisation based on class, caste and gender. It might be interesting to see if mortality due to malnutrition differs in kids from marginalised and tribal communities. We may have the right policies in place, but more can be done with regards to implementing said policies.
As Dr Bhutta sadly pointed out, "If India can send a spaceship to Mars, we certainly can do more for our hungry children."
This article has been run past the researchers, whose work is covered, to ensure accuracy.