‘India Can’t Arrest Child Stunting If It Can’t Fight Poverty’

Carlos Monteiro, professor of nutrition and public health at the University of Sao Paulo, Brazil, played active roles in the campaigns against both malnutrition and obesity. Monteiro spoke to IndiaSpend about tackling malnutrition and the lessons India can learn from Brazil

New Delhi: In the 1970s, undernutrition was a common problem in the urban slums and poorer regions of Sao Paulo in southeastern Brazil. Brazilian health crusader Carlos Monteiro, who was practising medicine in these pockets then, recalls the large number of stunted children he dealt with.

Brazil was then known as one of the most unequal societies in the world. The richest 20% of its population held 56% of its wealth.

Brazil then started bold initiatives like Bolsa Familia Program where a small amount is transferred to poor families every month to keep children in schools and ensure health checks. A decade later, extreme poverty halved from 9.7% to 4.3%. The programme has now reached a quarter of the country’s population.

Propelled by the expansion and improvement in public institutions such as primary schools and health centres, Brazil made strides in reducing malnutrition. Stunting in children, which stood at 37% in 1974, fell to 7% by 2006. The decline was even steeper between 1996 and 2006 when stunting fell by more than 50%.

But by then Brazil was facing another challenge--rising obesity. As incomes rose and access to packaged foods grew, obesity among adults rose from 5.4% in 1974 to 21% in 2006.

The Brazilian government has been moving against multinational food corporations who sell and market “ultra-processed foods”, as Monteiro describes processed foods high in sugar, salt and fat. These are often ready-to-eat, cheap foods.

Monteiro played active roles in the campaigns against both malnutrition and obesity. A professor of nutrition and public health at the University of Sao Paulo he has published more than 100 journals on nutritional and food intakes and their impact on populations. In 2014, he helped Brazilian government frame its national nutritional guidelines, appreciated for its focus on food sustainability and traditional cuisine.

Monteiro is a member of the Nutrition Guidance Expert Advisory Group of the World Health Organization (WHO) and the scientific advisory committee of the International Obesity Task Force. In 2010, he received the Pan American Health Organization (PAHO) Abraham Horwitz Award for excellence in leadership in inter-American health.

In New Delhi for a conference on “Critical Public Health Consequences of the Double Burden of Malnutrition and the Changing Food Environment in South and South-East Asia”, Monteiro spoke to IndiaSpend about tackling malnutrition and the lessons India can learn from Brazil. Here are the excerpts:

In your presentation, you said that child stunting is not an intractable condition. Brazil could reduce stunting from 37% in 1974 to 7% in 2006. In India, 38.4% of children under age five are currently stunted. What is the most important measure India needs to take to reduce stunting?

Well, Brazil is not a poor country but a middle-income country. So the wealth of the country is a little better distributed and that can resolve most of the stunting. With better income distribution, cash transfer income programme and with other programmes for the better distribution of public resources--extending education, primary schools and primary health care, water supply and sanitation--it was possible to reduce child stunting. So, I'll say that it in India if you had a better income distribution achieved with pro-poor public policy and if you do at the same time extensive coverage of essential basic services, you can get the same results.

You maintain that economic growth alone cannot lead to a reduction in child stunting. Can you explain?

In India, the economic growth [GDP growth] is 5% per year and we cannot dream of having this in Brazil. When child stunting in the poorest region of Brazil declined from 32% to 6% in just ten years, the economic growth or the GDP was 1.4% per year--it was very modest. But due to the income transfer from the rich to the poor, the reduction in poverty was achieved.

But in India the government is getting into public-private partnership (PPP) in health, giving hospitals to private players to run. Also, health services are getting more expensive in the public sector. What will be the long-run impact of these developments?

The cash transfer programme was a state programme and the expansion of services--water supply, education etc--was handled by the public sector and really not by a (public-private) partnership. Of course, the private sector participated--building new schools, water supply systems, health centres. They can profit in the process but they cannot lead in the process. A market economy is not efficient in dealing with problems like child stunting.

The private sector works differently--they value profits so they do whatever increases profits. Capitalism works with a different logic and the state, not the market, has the responsibility to resolve problems like child stunting.

When did the campaign against stunting become high on the Brazilian government's agenda? Was it the one policy that changed everything?

Actually, it was not child stunting that the government was interested in. The target of the changes was poverty, lack of access to services. The cash transfer programme started in the mid-1990s and the first budget for this programme came from old supplementary feeding programme.

So in the earlier policy targeting child undernutrition, each family received a food basket and priority was accorded to families with stunted children and women etc. We then started income transfers to the women in the families. In the beginning, money was given to women with children younger than six years and then to women with children younger than 14 years and then 18 years. So, there was a focus on children but through women, and the transfer was conditional, based on certain requirements--like the women had to send children to school and take them for vaccinations.

So, the main target was to bring people out of extreme poverty. This started progressively in the mid-1990s when food baskets for families with children under six was replaced by cash transfer. The money went to each municipality and the families were registered in the municipal level and the mayor of each municipality had the option to keep the food basket or go for cash transfer and 99% of them opted for cash transfer.

Why is cash transfer a better idea than food rations?

In the beginning, I hesitated. I was the advisor to the ministry of health at that time. I thought at least when we give food, we know they will use it. But I was wrong. Money transfer had several consequences.

First, it gave more power to women. They had an income and could decide how to use it. They spent the money in local shops and so it is an incentive to the local economy in a way. Some women bought sewing machines so they could earn. In a way, if you inject even little money in very poor areas it makes a lot of difference.

So overall it is much better to give money instead of food. You give power, autonomy, you stimulate local economy and in any case, evaluation has shown that giving money was much better. Then there was an acceleration in the reduction in child stunting.

Then you noticed a rise in obesity in Brazil. In India, can we can afford to wait till we deal with stunting to start working on obesity?

It is a much more difficult situation here. The level of undernutrition in Brazil was much lower than in India.

So we could arrest stunting in a short time. Of course, undernutrition still exists but we can handle it and it’s not a public health emergency [in Brazil].

In India, particularly in urban areas, there are problems not just of obesity and diabetes but several NCDs [non-communicable diseases]. So you can’t wait till you solve the problem of undernutrition [to start working on obesity].

But, you have to fight poverty to fight child stunting and if you say you can't fight poverty, you can forget about arresting child stunting. There is no magic pill, stunting is caused due to poverty--by lack of food, sanitation and everything.

This lack of everything is due to the fact that people don't have money and purchasing power. But when you start handling the problem of child stunting through improving economic condition of people, you expose the people to the problem of obesity and NCDs. Because essentially NCDs are a consequence of consumption, of wrong consumption while obesity is a consequence of wrong type of food.

In any case, if you are very poor, you are protected from obesity but then you start getting access to food products. These transnational corporations are using their power to push their products--reducing prices, dumping, producing bad stuff. So, you cannot wait--because the same actions that can reduce child stunting will necessarily produce the condition for obesity.

How did Brazil regulate the big food corporations?

The basic cause of obesity is that people are replacing their traditional diets--far from perfect but still superior--with ultra-processed foods. So we need to decrease the capacity of these transnational corporations to sell their products.

The way you can do it is by increasing taxes because ultra-processed foods are very low quality and that allows them to reduce prices. It is the same thing with tobacco. The real cost of tobacco is very small because it comes from nature and you don’t require too much technology [to produce or process it]. So there are countries that tax it at 300% the cost price. This is the weapon we have to make them less accessible and affordable.

Second, these very powerful companies hire very talented marketing people and they can afford ads on TV, internet and cell phones, (they can) afford to hire actors [to promote]. So you need to regulate them the same way you regulate tobacco.

It is impossible to ask companies to not manufacture ultra-processed foods or forbid them from producing it. But you must have policies that make these products less attractive and affordable--by regulating them, imposing taxes and thirdly, by labelling them. Consumers have the right to know what is there in the products. When people know what they are eating, these products will be less attractive for them.

Fourth, is food procurement policy. In Brazil, a lot of food is bought by the state for school programmes and hospitals. This makes the state powerful. If you have rules that make people buy real and minimally processed foods and promote healthy foods as well, you are interfering in the market and making these products more affordable [to public].

So which of these strategies did Brazil finally adopt?

Food procurement processes, including for a national school programme where 50 million meals are distributed a day. In the past, there was demand for ultra-processed foods [from schools], now the demand is for minimally processed foods. Not just schools but also hospitals, prisons, every public institution that provides food supports good food and that is very important.

In the last (parliament) session, there was a discussion in the congress about taxing ultra-processed foods but the companies’ lobby is very strong so nothing changed. The minister of health in Brazil said that they favoured tax.

In terms of marketing, there were several attempts [to control the big food chains] but the transnational companies are very strong. There was recently one study that showed that a large proportion of congressmen and women [members of the parliament] were funded by food and alcohol companies. So we need pressure from the civil society because politicians have to listen to their donors and funders but they also listen to the people because they elected them. So this is something that we are doing.

We are close to changing the nutritional labelling [regulation] and we are expecting good news soon.

How do we implement stricter food labelling norms in a country like India with a large illiterate population?

The Chilean model is interesting because it requires warnings like in tobacco: there is a stop sign where you put words like high in sugar, sodium or energy [calories].

In Brazil, we are proposing a black triangle, a sign of something bad. Like cigarettes, we can extrapolate labelling to ultra-processed foods.

In our urban slums, women work and tell their children to eat biscuits or chips because they have no access to healthier alternatives. How do you educate mothers and the public about the dangers of ultra-processed foods?

Child stunting is the problem of the first two years of life when they need enough energy to grow quickly. We were able to reduce child stunting in Brazil--even when (demand and supply of) ultra-processed foods were increasing--because mothers tend to protect children. There was an increase in breast feeding.

But after two years of age, the problem is obesity, diabetes and the metabolic syndrome. The main advice is to avoid ultra-processed food, to stick to traditional dietary patterns and to diversify the diet with different food groups--which is important for NCDs. You can't just have rice and potatoes, you need to have vegetables and fruits and pulses. This is the advice (we gave the people).

(Yadavar is a principal correspondent with IndiaSpend.)

We welcome feedback. Please write to respond@health-check.in. We reserve the right to edit responses for language and grammar.