Re: Law on infant foods inhibits the marketing of complementary foods for infants, furthering undernutrition in India
The response dated December 16, 2012 focuses not on technical issues, but on corruption that in India is a larger epidemic than malnutrition, and the failure of the system. But the logic is certainly intriguing - the administration is corrupt, the IAS is corrupt, and therefore as a retired IAS officer, I must be corrupt. Systemic breakdown in many sectors is a fact, but adding to what the good doctor has to say – the breakdown is because of a joint partnership of all stakeholders of governance, including health professionals. And the BMJ is hardly the forum to discuss this. Yet, I must place on record my strong objection to the completely unfounded and presumptive comments, verging on to defamatory, such as, ‘having a vested agenda’, milking cows, providing benefits to patrons. The comments are unbecoming of a health professional, enough to warrant legal action, which however may just be a waste of time, money and energy.
The response of Dec 17 - ‘Lack of Transparency in the Malnutrition Business” begins by casting aspersions against me for concealing my association with the BNF as Advisor. This association has been in the public domain since I became their Advisor in 2009, and I do not see it as a competing interest until I was told that a potential competing interest must also be viewed as one. Fair enough. The letter then targets Britannia Industries, (with whom I have no connection), respected Organizations like Global Alliance for Improved Nutrition, (GAIN) and Scaling up Nutrition, (SUN) that is headed by UN Secretary General’s Special Representative, casting aspersions against their motives.
Coming to the technical content of the responses dated December 17, the complex and heterogeneous causes are clearly stated at the beginning of the article, but this particular piece focuses on lack of access to low cost complementary foods for infants from poor families after 6 months, as against the access available in privileged families. The issue raised is very simple and direct, and is contained in the last paragraph of the article – Let the WHO 2001 guidelines on complementary feeding be made into a code for providing access, and setting standards and regulations. The objective is to provide access to inexpensive complementary foods for the poorest families in the market, as per accepted standards and regulations, whether produced by private, public, cooperative, or the home industry sector, just as there is access for privileged children. A reading of Page 75 of the Lancet January 2008, Maternal and Child Undernutrition -4 could provide further insights.
I would also like the responders to note the inequity that I see in the poorest rural areas. Mothers of severely malnourished children are spending their entire week’s salary to buy Horlicks, because nothing cheaper is available in the market. In fact, there is open discussion that producers of expensive complementary foods have found their best ally in the present law and its promoters, because their expensive complementary foods enjoy a monopoly in the market to which the poor must also turn out of necessity.
I would also like to point out what ‘culture specific’ diets mean for the poor. Anyone who sees the reality of the poorest families in rural India knows that they are governed by only one culture, and that is the culture of poverty, getting worse with rising food prices and inflation. I have made specific enquiries about the daily diet of the poorest families. In certain areas, it is millet (ragi) and horse gram in the morning, and the same in the evening. No fruit, vegetables or milk. In another area it is jowar roti, (sorghum bread) onion, and green chilly in the morning, and the same, perhaps with watery lentils, in the evening. I really have no idea how the daily diet of the ‘family foods’ described above can be converted to ‘culture specific infant feeding’ that is recommended. Or from where the ingredients for the recommended porridge and well mashed foods will arrive for infants of the poorest families, who have neither safe drinking water, nor electricity nor assured fuel? And who will do what counselling? A woman who works as a construction labourer in Bangalore has a severely malnourished child who is always hungry because she cannot take time off to prepare food for the child, or else she will forego wages. Do we have anything to offer her except words or failed programmes?
Every journal and research study states that one of the main causes of child undernutrition is delayed/inadequate/ inappropriate or lack of complementary feeding after 6 months. Of course, in certain food secure house-holds, it is not given on account of superstition, lack of information. But the poorest 30% of the population are food insecure, cash starved and lack information. And we must use every method to reach out to them, from government, civil society and the market. It would be good to know how children’s underweight dropped from 53% to 42% in 100 focus districts, so that we can replicate the strategies, particularly regarding complementary feeding. Of course, undernutrition and micronutrient deficiency is not a problem of the poor alone. But there is no doubt that families that suffer from poverty, and nutrition and information deficit are the most vulnerable.
The definition of the ‘highest wealth index’ used by the NFHS 3 is not related to payment of wealth tax, but is based on certain baseline criteria described in Page 43 of the report. The criteria could apply to the low middle class and above. But even with this modest wealth index, 6 out of 10 children in the poorest households were underweight as against 2 out of 10 in the highest wealth percentiles as defined by the NFHS.
The author has stated a point of view. Let it be countered or debated through scientific and technical argument, not through making unsubstantiated allegation or shooting the messenger. I can only close by suggesting that we should shed our prejudices and dogmas, pool our resources of experience and knowledge, dialogue constructively and scientifically in a spirit of cooperation not opposition, and do something tangible to engineer transformational change in the nutritional status of our children. And most importantly, we should consult with poor communities and ask them what they would like, instead of deciding for them.
Competing interests: Advisor, BNF