|Hunger: Old torments and new blunders|
It is so old a story,/ Yet somehow always new," so said Heinrich Heine, the German poet, essayist and political activist, in Lyrisches Intermezzo. That early nineteenth century frustration of Heine (Intermezzo was published in 1823 — he went into voluntary exile in revolutionary Paris seven years later) cannot but recur in our thoughts as we observe the continued barbarity of old problems with new and added dimensions, in the distressing world in which we live. Nowhere, perhaps, is this as exasperating as in the terrible continuation of massive hunger and undernourishment in India.
It is not that nothing has been achieved in India over the half-century or more since independence in 1947. Positive things have certainly happened. First, the rapid elimination of famines in India with independence is an achievement of great importance (the last sizeable famine occurred in 1943 — four years before independence), and this is certainly an accomplishment that contrasts with the failure of many other developing countries to prevent famine. And yet this creditable record in famine prevention has not been matched by a similar success in eliminating the pervasive presence of endemic hunger that blights the lives of hundreds of millions of people in this country.
Second, the stagnating agriculture that so characterised — and plagued — pre-independence India has been firmly replaced by a massive expansion of the production possibilities in Indian agriculture, through innovative departures. The technological limits have been widely expanded. What holds up Indian food consumption today is not any operational inability to produce more food, but a far-reaching failure to bring entitlement to food within the reach of the more deprived sections of the population. Indeed, as M.S. Swaminathan has pointed out, "We have reached a stage in our agricultural evolution when our production will increase only if we can improve consumption."
First enemy: Smugness and ignorance
How can things be changed? The first thing to get rid of is the astonishing smugness about India’s food record and the widespread ignorance that supports it. India has not, we must recognise unambiguously, done well in tackling the pervasive presence of persistent hunger. Not only are there persistent recurrences of severe hunger in particular regions (the fact that they don’t grow into full-fledged famines does not arrest their local brutality), but there is also a gigantic prevalence of endemic hunger across much of India. Indeed, India does much worse in this respect than even Sub-Saharan Africa. Calculations of general undernourishment — what is sometimes called "protein-energy malnutrition" — is nearly twice as high in India as in Sub-Saharan Africa. It is astonishing that despite the intermittent occurrence of famine in Africa, it too manages to ensure a much higher level of regular nourishment than does India. About half of all Indian children are, it appears, chronically undernourished, and more than half of all adult women suffer from anaemia. In maternal undernourishment as well as the incidence of underweight babies, and also in the frequency of cardiovascular diseases in later life (to which adults are particularly prone if nutritionally deprived in the womb), India’s record is among the very worst in the world.
A striking feature of the persistence of this dreadful situation is not only that it continues to exist, but that the serious public attention it gets, when it gets any at all, is so badly divided. Indeed, it is amazing to hear persistent repetition of the false belief that India has managed the challenge of hunger very well since independence. This is based on a profound confusion between famine prevention, which is a simple achievement, and the avoidance of endemic undernourishment and hunger, which is a much more complex task. India has done worse than nearly every country in the world in the latter respect. There are, of course, many different ways of shooting oneself in the foot, but smugness based on ignorance is among the most effective.
Poverty, healthcare and education
This takes us to the next question. Once we get rid of the smugness, what should we do? The old barriers to good nutrition do, of course, remain, and we have to recognise that they have not lost their bite. People have to go hungry if they do not have the means to buy enough food. Hunger is primarily a problem of general poverty, and thus overall economic growth and its distributional pattern cannot but be important in solving the hunger problem. It is particularly important to pay attention to employment opportunities, other ways of acquiring economic means, and also food prices, which influence people’s ability to buy food, and thus affect the food entitlements they effectively enjoy.
Further, since undernourishment is not only a cause of ill health but can also result from it, attention has to be paid to healthcare in general and to the prevention of endemic diseases that prevent absorption of nutrients in particular. There is also plenty of evidence to indicate that lack of basic education too contributes to undernourishment, partly because knowledge and communication are important, but also because the ability to secure jobs and incomes is influenced by the level of education.
Maternal undernourishment and its far-reaching penalties
So low incomes, relatively higher prices, bad healthcare and neglect of basic education can all be influential in causing and sustaining the extraordinary level of undernutrition in India. Yet, as Siddiq Osmani has shown, even after taking note of low levels of these variables, "one would have expected a much higher level of nutritional achievement than what actually obtains" in India in particular, and in South Asia in general.
So something else must be brought in. Osmani suggests — plausibly enough — the lasting influence of maternal undernourishment, working its way via underweight babies (India and South Asia lead the world in this field), who grow into children and adults more prone to illnesses of various kinds. This is in line with findings that have been identified by others, such as Ramalingaswami and his colleagues. Recent medical research has brought out the long-run effects of foetal deprivation, reflected in low birth weight, which appear to cause immunological deficiencies and other health vulnerabilities. The health and nutritional adversity related to maternal undernutrition and low birth weight children is almost certainly a significant factor in explaining the terrible nutritional state of India.
Since maternal undernourishment is causally linked with gender bias against women in general in India, it appears that the penalty India pays by being unfair to women hits all Indians, boys as well as girls, and men as well as women. Even though there is ambiguous empirical evidence regarding the relative nutritional backwardness of girls vis-à-vis boys (as Svedberg discusses in his paper in this number), there is no dearth of definitive evidence of the neglect of pregnant women. For example, the proportion of pregnant women who suffer from anaemia — three quarters of all — is astoundingly higher in India than in the rest of the world. The long-run effects of underweight births not only worsen the chances of good health and nutrition of children — both boys and girls — but also immensely increase the incidence of cardiovascular diseases late in life. Interestingly, since men are, in general, more susceptible to cardiovascular diseases, it also turns out that the adverse impact of the neglect of the nutrition of pregnant women is, in this respect, even greater for men than for women. What is sown in the form of unfairness to women is reaped as illfare of men, in addition to the suffering of women themselves.
The analysis so far has identified particular problems that have to be tackled if India is to overcome the massive prevalence of persistent hunger from which it suffers in many different ways. The areas of action include economic opportunities (such as growth of income and its distributional pattern), social facilities (such as basic healthcare and education), and the countering of special deprivations of women (such as maternal undernourishment). These are old problems that have not yet been overcome, unlike other fields in which success has been achieved, such as famine prevention and technological expansion of production opportunities. What, then, are the new problems?
Amartya Sen is Master, Trinity College, Cambridge, UK. His work on hunger, poverty,
social choice and entitlements earned him the Nobel Prize for Economics in 1998