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Malnutrition, illness, and societies
Asok Mitra
Centre for Regional Development, Jawaharlal Nehru University,
New Delhi, India
Barely three decades ago the great killers in India were malaria and contagious diseases, alternating with severe regional droughts and famines that compounded malnutrition with a spiralling effect. Even now the major killers are diarrhoea, food- and water-borne infections, and respiratory diseases, again compounded by malnutrition and chronic low intake of food. Permanent damage is reflected in: low height and weight for age, reduced immunocompetence, low vitality and economic productivity because of chronic morbidity, impaired homoeostasis, and high mortality rates among young people and women in their reproductive years.
In 1935-1936 J.A. Sinton of the Malaria Survey of India attempted to estimate "what malaria costs India, nationally, socially, and economically." He estimated that about 100 million people suffered from malaria annually, resulting in a minimum of one million deaths. By any crude accounting, financial losses to individuals and families alone were a minimum of £80 million. The social losses were destruction or disintegration of families, the emergence of large numbers of orphaned households bereft of principal earners, erosion of community life, and grievous physical and emotional trauma to bereaved parents and relations, leading to loss of zest for any enterprise. The national losses were (a) morbidity caused directly and indirectly, bringing serious problems in sanitation and preventive and curative health-delivery services; (b) low and fluctuating life expectancy; (c) depopulation and consequent reversion to waste and large, unproductive tracts of crop-bearing land; (d) marked decline in industries and services; (3) deterioration in infrastructure; (f) interruptions and even premature termination of education and learning of technical and professional skills; (9) interruptions in the growth of productive capital assets, technological skills, and economic enterprises at micro and macro levels; (h) deterioration in quality of life among backward communities and regions; (i) widening of disparities and inequalities at all levels; and (j) further impoverishment and debilitation of large segments of a population subsisting at the nutritional margin and below.
Periodic famines and droughts increased the damage over large areas of the country, where chronic malaria, epidemics, disease, and malnutrition were already annual scourges.
These calamities struck with varying degrees of severity at different social and economic classes, compounded by the effect they had on the demographic structure of the population in each stratum. The highest morbidity and mortality naturally struck hardest at those sections of the population with low economic and biological staying power: agricultural labourers, households with one- to two-hectare parcels of land owned or cultivated on a crop-sharing basis, small producers, retailers, and persons engaged in a whole range of personal and other services. Higher incidences of mortality and morbidity among these classes periodically carried off larger proportions of economically productive populations than from the more viable groups, often with permanent impairment of productivity. Biological replenishment among these segments was also affected by infecundity and sterility, heavily impaired homoeostasis and immunocompetence, and, of course, higher morbidity and mortality. These calamities facilitated the continuing transfer of assets from the lower to the higher economic groups, mostly through debt settlements, usufructuary mortgages, and outright sale of movable as well as immovable assets, running concerns, and capital assets. Estimates of transfer of assets by acquisition and amalgamation from the lower to higher income groups were attempted in reports by government commissions on successive famines from 1876 to the last major one in 1945, including the Bengal famine of 1943.
The statistics are often fearsome and explain some of the striking inequalities that accumulated exponentially and were handed down historically. These inequalities were and still are compounded by mortality and morbidity caused by periodic epidemics and disease. Periodic land revenue settlement reports from districts, beginning with the Great Revenue Survey in the middle of the last century on down to our time, afford estimates of similar transfers of assets between economic and social classes as a consequence of these pestilences. A root cause of these problems was differential malnutrition between economic and social communities, engendering wide variations in staying power over time. The 1951 Census Reports for the state as a whole and for several of the 14 districts in West Bengal include some economic and demographic accounts of this process between 1881 and 1951. These accounts are quite mind-boggling.
My object here is to underline the fact that the accentuation of economic and social inequalities, not to speak of regional disparities and disabilities, is not merely the product of economic or socially and politically discriminating processes set in motion in underdeveloped countries in the colonial period and continuing beyond it. It is also the product of differential demographic consequences of malnutrition and inadequate food intakes during recurrent infections and frequent famines over decades. This twin process has worked like a double helix, an aspect yet to be appreciated properly by social and economic historians. Little systematic attention has been paid to changes in the social and economic structure of colonial societies brought about by changes in the respective demographic structures of their broad economic and social classes as a result of differential mortality and morbidity because of what, in the ultimate analysis, boils down to malnutrition. The Japanese shogun Ieyasu Tokugawa had a very expressive phrase to fit this historic process: "Lest they live, lest they die. Feed them just enough so they can survive and work for us. Deny them with judicious forethought so they cannot grow over-mighty and rise against us."
It is this dialectic that has diminished the prospects of agricultural production and distribution and fostered low income and regional inequalities in production and distribution of goods and services. It has also complicated problems of distributive justice, quality of life, communication and delivery systems, and questions of who benefits from state welfare and why. The incubus of malnutrition therefore carries very specific implications for economic and social planning for development toward increased production and more equitable distribution of wealth.
To unwind a long historical process is not easy, particularly when it is deeply embedded in the interstices of social and economic structures to the point of providing a kind of cement to these structures. Recent nutrition programmes in a way militate against these entrenched structures, which is why they are resisted or subverted in various ways. The bulk of nutrition programmes launched in the past two decades, whether nationally or with bilateral or multilateral aid, either turn a blind eye to this reality or invest in bounty programmes that serve as a salve to bad conscience. Most societies, irrespective of whether they are developed or developing, have a positive economic and political stake in maldistribution leading to differential mortality, morbidity, and productive efficiency. While nutrition programmes can be made to serve as an attractive populist plank for retaining political hold, the perpetuation of malnutrition itself can serve as a level for the preservation of inequality, maldistribution of assets, and social and economic opportunism.
Unless this is appreciated in its proper perspective and determined steps are taken through economic and social structural adjustments to combat it, while simultaneously stressing nutrition and other social welfare programmes, nutrition programmes per se will be repeatedly frustrated. They will be reduced to well-meaning and naive programmes leaving no lasting benefits.
"The problem of malnutrition is closely linked with that of poverty, large family size, unemployment, illiteracy, and lack of environmental sanitation and hygiene and safe drinking water. Intervention programmes will achieve limited results if this problem is addressed only to individuals in the households, like children, mothers, and the aged. "
- The Indian Sixth Five-Year Plan, 1980-1985