As school reopens after a break, Arjun is rather upset for still being in the first bench. “Why am I so short?” he asks, “Others in the class who are younger than me are taller. They sit behind me.”

What Arjun does not realise, perhaps, is that he is among the many short children who, by 2022, will comprise almost 31.4% of the under-fives in the country. But why are so many kids so short? Is it just genetics?

Not really. Arjun is stunted rather than short. His physical stature is a key indicator of child malnutrition, indicating that a boy could be shorter than his age and his height is more than two standards below the World Health Organization (WHO) Child Growth Standards median. The following video gives a more detailed explanation of stunting as a phenomenon.

One in four urban under-fives in India is stunted, according to a survey conducted in 10 of the country’s most populous cities. The most severely stunted children, 11.7%, are found in Delhi.

There is some partially redeeming news, though. A recent report by the UN World Food Programme, in collaboration with the Ministry of Statistics and Programme Implementation, says that in the decade between 2006 to 2016, stunting has reduced quite rapidly in the country — by 10%, which works out to 1% every year. However, while stunting dropped in India from 48% in 2006 to 38.7% in 2016, there are still almost 48 million stunted children under five, which works out to be the highest in any country in the world today. By 2022, one in three under-fives will still remain stunted according to the report, with population of such children still being 31.4%, far higher than targetted.

“Stunting is a very real problem in the country, although we have been taking up a number of ways to fight the issue,” said Arundhati Muralidharan, Manager – Policy (WASH in Health & Nutrition, WASH in Schools) at WaterAid India. “The reduction by 1% per annum is a low figure.” Hence, the phenomenon of stunting in India continues, placing us on top of the list of countries with similar issues, even though India’s GDP is higher than the others in the list. So

Although this report is relatively recent, there are no surprises here. Last year, the Global Nutrition Report, 2018, revealed that three countries comprised almost half (47.2%) of all stunted children in the world, and India topped the list there too, with 46.6 million stunted kids. The gulf between India and Nigeria, with 13.9 million stunted children, the second largest number in the world, is huge. Pakistan stood third with 10.7 million.

Very much an urban issue

But are these concerns really relevant to those who live in the cities?

While the overall urban incidence of stunting is less than rural India, some of the bigger cities show really high rates. The National Family Health Survey data analysis reveals that more than a quarter of children below five are stunted in the major state capitals, except in Kochi and Hyderabad. The surveyors questioned residents of Mumbai, Delhi, Bengaluru, Hyderabad, Ahmedabad, Chennai, Kochi, Kolkata, Surat, Pune and Jaipur.

Interestingly, it found that Bhopal has higher rates of child stunting than the rural Indian average. Stunting levels in Patna, Jaipur and Bhopal are worse than in Nigeria. Delhi and Nigeria show almost the same levels.

Over a quarter of children are also categorised as “wasted”, which means that they have low weight for their height, in the populous states of Mumbai, Bengaluru, Lucknow and Ahmedabad.

HUNGaMA report

A more comprehensive picture is given by an earlier study — the Urban HUNGaMA (hunger and malnutrition) Survey 2014, which took a bigger sample size (than the National Family Health Survey data analysis)  of 11,955 households in 10 cities, interviewed 12,286 mothers and measured 14,616 children aged between 0-59 months.

Though the survey was conducted in 2014, it was released only on February 7 2018, by Naandi Foundation, a Hyderabad-based non-profit organisation.

In our fast growing cities,  the study hit upon troubling facts: 22.3 percent of urban children under five were stunted, 21.4 percent were underweight and 13.9 percent were wasted in the ten most populous cities of India, ie Mumbai, Delhi, Bengaluru, Hyderabad, Ahmedabad, Chennai, Kolkata, Surat, Pune and Jaipur, which account for 5.3% of India’s population and 4.1% of child population under the age of six.

The report found that Kolkata, at 25%, had the highest proportion of under-fives with low birth weight of below 2.5 kg. The prevalence of stunting ranged from 14.8% in Chennai to 30.6% in Delhi and was more among children whose mothers had just five years or less of education.

However, none of these “average” figures from cities may paint the complete picture,  given the sharp inequality in cities. For example, figures in themselves, do not underline the fact that residents of slums and resettlement colonies in cities are particularly vulnerable to inadequate nutrition and hygiene. Or that, social safety nets, especially for new migrants, remain weak.

Sources from The United Nations Children’s Fund (UNICEF), who work on nutrition and health among the underprivileged in the country, say that although there has been a drop in malnutrition, it has been slow. “We have reasons to believe that improvements due to our work related to nutrition do not benefit the urban slum pockets, because these lack facilities and do not have well-organised health set-ups, as the rural areas do.  For instance, Mumbai municipalities have put in a lot of effort to improve people’s well being in slum areas, but the problem is too overwhelming.” According to him, resolution of such challenges and issues have not kept pace with the rate at which urbanisation has occurred.

Getting to the roots

Interestingly, the report is clear that poverty is not the only or even the primary cause, though it did indicate that children in richer families are less malnourished than those in the lower economic class. A surprising finding was that there seemed to be little difference between boy and girl children overall. In fact, boys were found to be a little more malnourished than girls.

There was more malnutrition among children of women with little or no schooling. Stunting among children of mothers with five or less years of schooling was 35.3% while it was 16.7% among children whose mothers had finished at least Class 10.

Stunting automatically leads to poor cognitive and academic results in later childhood and adolescence. It also results in weak educational and economic outcomes at the individual, household and community levels. But why does this phenomenon remain so widespread in cities, affecting even well-fed children, and after decades of investment in programmes targeting child malnutrition?

Reason 1: Poor nutrition

“The primary reason is lack of enough nutrition for adolescents, pregnant and lactating women,” said Arundhati Muralidharan of WaterAid. “Is there good food going into girls’ bodies? Are children receiving adequate nutrition? That is key. We have to ensure that nutrients are retained and build up the body.”

Chronic malnutrition in the first 1,000 days of a child’s life, from early pregnancy to two years, causes stunting, according to Save the children. NFHS data analysis also concludes that poor infant and young child feeding practices, the poor status of women and prevalence of household poverty in cities are the main reasons.

In an IndiaSpend analysis of NFHS-4 in May 2017, it was clear that urban children affected during the weaning period, or during the move from breast milk to family foods, or ‘complementary feeding’, were in a more vulnerable position, with only one in 10 Indian children getting “adequately fed”.

Children of unschooled mothers, with less awareness of the kinds of food that help to build up healthy bodies, naturally suffered from greater malnutrition.

Reason 2: Unsafe hygienic practices

Lack of hygienic practices, open defecation, unsafe water and bad sanitation are important reasons for stunting, even though they are not primary reasons, said Muralidharan. “Lack of washing and toilets may be contributing factors, but they are not the main ones. Food leaching out of the girls’ bodies due to poor sanitation and non-hygienic practices are secondary,” she added.

Improved sanitation helps to reduce malnutrition, but the World Health Organization estimates that this is related mostly to diarrhoea and poor hygiene — especially lack of access to safe water, toilets, handwashing facilities, nutritious food. Water, sanitation and hygiene (WASH) can reduce almost 88% of diarrhoeal cases, she said.

An article in The Lancet, in 2013, makes it clear that direct nutritional intervention is very important and can reduce stunting by 20 per cent in the worst-affected countries, but in order to further reduce the remaining 80 per cent incidences of stunting, it is important to handle secondary interventions that address WASH gaps.

Measures by the government

Over the past two decades, the battle against malnutrition has been multi-pronged — including mid-day meals at schools, anganwadis offering rations to pregnant and lactating women and the public distribution system for those below the poverty line. The National Food Security Act (NFSA), 2013 attempted to reach food to all through targetted schemes. Last year, the government took the Poshan Abhiyaan programme forward, declaring September to be ‘nutrition month’.

Some steps such as promoting breastfeeding, iron and vitamin supplements fortifying food have been taken, said Muralidharan. However, she added that the government should invest more in safe water, hygienic facilities and activities. A multi-sectoral approach is critical due to the number of issues involved, such as maternal nutrition, gender disparities, anaemia and exclusive breast-feeding.

Have things improved due to Swachcha Bharat? “I don’t think connections are that simple. It’s more than just a well-designed toilet,” she said. It has to do with awareness. Are the people aware, and do they follow the rules or not? “For instance, what is the use of having a well-designed toilet if people don’t wash their hands after defecation, or before eating?” she said. Multi-sectoral approaches alone can lead to holistic results.