PAKISTAN: Malnourishment has become too big an issue to be ignored in Pakistan
Publicly disseminated last September, the National Nutrition Survey reports mass deprivation from adequate nutrition. Along comes another dire news from Save the Children -- over 90 percent of infants receive unacceptable diets that threaten both physical and mental development (A Life Free From Hunger, 2012). A recent (draft) report by UNICEF is grim: unacceptably large numbers of children die before their first birthday; widespread malnutrition is a core reason for an even more wrenching tragedy of remaining children unable to survive beyond 5 years (Situation Analysis of Children, 2012).
It is a tragedy when a majority of families are unable to overcome acute nutritional deprivation despite multiple earners, including children and juveniles confronting hazards in violation of their rights.
Two-thirds or more districts were hit badly after unexpected floods and severe rains. Hence the matter could rest as a temporary phenomenon, though warranting serious concern at the inadequate access to private and public assets, amidst warnings of more floods during the decade.
Given cruelly high levels of (officially acknowledged) malnourishment in recent decades, there should be more to say about the probability of permanent and pervasive malnourishment for significantly large numbers, perhaps even a majority, of citizens across the country.
Growing slowly over the decade, (real) national income per capita still exceeds Rs 30,000 per annum in recent years (Economic Survey). This seems more than enough to ensure adequate nutrition for every child, woman and man in the country. So why then is malnourishment observed?
Is domestic production the problem? Food grain harvests have generally been below that required for adequate calorie intake fully through cereals (around 200 kg per capita); similarly domestic output of pulses has remained substantially less than protein requirements met entirely through pulses. But: there are food imports and people do consume other foods that provide these nutrients. And we can certainly wonder why the state does not achieve food sovereignty for its citizens.
More than half of female citizens have been socially condemned to remaining illiterate, which is surely a contributing factor to mass malnourishment of not one but several generations. Isn’t lack of health education a failure of an Islamic state acknowledging the right to life?
Official data remains missing, but it is widely held that at least in poor households there is significant gender inequality in consumption over much of South Asia. Since females fare badly, this is a cause of mass malnourishment for a very large section of the population, and extends to even male infants of malnourished mothers.
Should the state have no responsibility to offset social discrimination? Surely the health of our children extends beyond parental responsibility. What evidence is present from diets in Pakistan -- unaffordable, or mostly misallocation of food expenditure to taste rather than nutrition?
There are two reasons to begin with calorie intake: one, that official poverty lines are based upon calorie standards; two, that calorie intake appears to be the first priority for biological and economic reasons (such as relative prices of other nutrients; work needs energy).
Do official income and expenditure surveys support the likelihood of mass malnourishment? If there is mass undernourishment (of calories) then most members of these families remain deprived of other nutrients (protein, vitamins and minerals) corresponding to their needs (e.g. pregnant and lactating mothers and their infant children; arduous labour; old persons).
The official, conservative, daily calorie requirement (2350 per adult or 1880 per capita) yields nearly Rs 900 per adult as the official minimum monthly expenditure in 2004-5. Adjusted for general inflation, this threshold would rise to around Rs 1400 per capita in 2010-11. Since food prices are critical to nutrition, the minimum expenditure would then jump to Rs 1600 per capita.
The official Household Integrated Economic Survey 2010-11 reports mean consumption expenditure at over Rs 3000 per capita (close to the national income per capita). Since a skewed distribution is very likely, median consumption is probably much lower i.e. half the population may well be unable to afford minimally adequate calorie intake without cutting back on minimal non-food expenditure.
This drastic implication is confirmed by consumption expenditure in the bottom three quintiles. Hence, at least one-third and perhaps as much one-half of the population was deprived from minimum required expenditure. If citizens cannot afford even the cheapest nutrient, then it is no wonder that women and children in particular suffer from mass deficiency in other nutrients!
Across the country, food expenditure implies a possible daily intake of 1900-2300 calories per capita, depending upon how liberally we approximate calories from food. Using a (conservative) official calorie standard (1900 per capita), mean food consumption appears to provide adequate calories. If the consumption distribution is skewed in favour of high consumption (median larger than mean), then less than one-half of the population would have inadequate calorie intake.
In view of our opposite conclusion on the basis of income, i.e. affordability, two checks can be made. One is to disaggregate consumption by low and high incomes; the other is to differentiate between rural and urban families.
Ranked by income, the bottom one-fifth of country population would be at high risk of calorie deficiency. At somewhat lower risk would be the next one-fifth population. The remaining sixty percent of population in higher income households is unlikely to have many with calorie inadequacy. It does appear that poorer households adjust diets when unable to afford the standard diet.
However, if one accepts that low incomes imply physically more exerting work and higher morbidity than the average, then a significantly higher daily calorie threshold at well over 2000 per capita does imply mass calorie deficiency. The Asian Floor Wage Campaign, for example, insists upon 3000 daily calories per adult even for urban areas in contrast to 2150 as the Pakistan standard (similar to other low standards in South Asia for official denial of failure).
A rural-urban study indicates rural families to be at higher risk. As found for the country, disaggregating incomes or having more reasonable thresholds does suggest the likelihood of mass calorie deficiency. Surprisingly, in the very locations that food is grown, undernourishment is more pervasive. Or perhaps this should be expected given the highly inequitable access to crop land – even including tenancy, but not ignoring the massive illegal occupation of public land by large landowners.
Malnourishment is not simply calorie deficiency; protein, vitamins and minerals are also crucial to a decent diet. This note only extends to protein intake.
Ignoring the fact that proteins get converted to calories when the latter are inadequate, the average daily consumption suggests less than 60 grams per capita, but this is well over an official threshold of 65 g per adult. As with calorie intake, does average protein consumption hide lower intakes among much of the population?
And so it is: in the first quintile of incomes, average protein consumption is lower than even a conservative threshold. Many in the next quintile are also likely to be undernourished. It should be a matter of much concern that even among rural households -- supposedly with better access to nutrition -- the poorest report inadequate protein intake. Yet again, we find that state subsidized modern agriculture fails to be fair to the rural poor.
To conclude: prevalent, and entrenched, substantial inequality -- not of assets alone but also of returns to labour -- has led to immense and continuing inequity in incomes across Pakistan. This imperils adequate nourishment of not just adults but also of children, threatening both physical and mental distortions among many if not most citizens.
We all know that a very large part of labour depends upon wages in standard employment. But so-called self employment is also the employment status for many suppliers of services but with irregular incomes. Scarcity of full time work and absence of decent wages have to be a major reason for nutritional impoverishment. Official Labour Force Surveys illustrate extreme labour exploitation: not many more than half of adults seek jobs.
The wage distribution among employees -- representing a fourth of the active labour force -- reveals extremely difficult survival for these families. Mean monthly wages were just about the minimum wage (Rs 7,000) but below the household poverty line (of over Rs 10,000 for a family of 6-7 persons). Data indicates that more than one third of employees may have been given wages less than half the poverty line.
Of the lucky or desperate earners, a substantial number find work for less than 35 hours a week; and many more have to work excessively (beyond 48 hours a week). Either labour (including self-employed) was underemployed, reducing earnings; or it was overworked, increasing nutritional needs.
State failure hits badly the majority of citizens, as overworked and underpaid labour. Ignoring policy exclusion of agricultural labour, and general non-enforcement, the legal minimum wage has arbitrarily failed to keep pace with double-digit inflation in food prices. Furthermore, even an inflation-adjusted minimum wage remains much lower than an inflation-adjusted poverty line, let alone a living wage. The wage deficit is even more enormous for a state committed to seriously equitable growth e.g. through enforcing minimum wages tied to national economic growth.
It is urgent to rethink the folly of abandoning universal food subsidy as ‘inefficient’ targeting despite its almost divine status in Washington.
There is much wisdom in aiming towards a universal employment guarantee as a citizen right, overcoming obvious deficiencies in the Indian scheme. This would be much more dignified than cash transfers, especially to the desperately deprived.
Yet again we must note that a development model based on extreme inequality and mass deprivation cannot build a fair society. At over $ 1200 per capita, annual national income per capita is well above that required to eliminate nutritional deprivation through domestic agriculture. There is no shortage of farmland for adequate provision of calories and protein through cereals, pulses and milk. Furthermore, billions in worker remittances enable more than sufficient foreign exchange for meeting domestic shortfalls.
About the author: Aly Ercelan is an economist and works for the labour movement through PILER and PFF. He can be reached at email@example.com