COMMENTARY
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Caste, Religion and Malnutrition Linkages
Nidhi Sadana Sabharwal
The poor are not uniformly disadvantaged. Across most health indicators, the situation of the scheduled castes, scheduled tribes and Muslims is significantly worse than that of others. While nutritional status is closely linked with levels of income, education and public health services, the social belonging of persons also acts as an additional aggravating factor for nutritional inequity.
The author would like to thank Sukhadeo Thorat for comments on this article.
Nidhi Sadana Sabharwal (nidhi@dalitstudies. org.in) is with the Indian Institute of Dalit Studies, New Delhi.
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groups such as the scheduled castes (SCs), scheduled tribes (STs) and Muslims. In this context, we develop an understanding of the possible reasons for a relatively high malnutrition level in general and among the SCs, STs and Muslims in particular. We first present the inter-group disparities in
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malnutrition and then provide reasons for the particularly high malnutrition among certain social and religious groups.
Inter-group Disparities
The inter-group disparities in the nutritional level in rural areas are examined using the National Family Health Survey (NFHS) for 2005-06. Indicators of malnutrition include percentage of the underweight children, a body mass index (BMI) below 18.5 kg/m2 and anaemia.
The percentage of underweight children at the aggregate level was about 45.6. However, the nutritional problem is particularly serious for children, women and men belonging to the SCs, STs, and OBCs. Table 1 (p 17) shows that underweight rates are approximately 50% and anaemia 10-20% higher in the SC/ST children compared with the rest. A BMI of less than 18.5 kg/m2 which indicates chronic energy deficiency is particularly serious for the Sc/St and
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COMMENTARY
affects the nutritional status of children.
CMR (Weight for Age) BMI <18.5 Hindu Muslim Christian Sikh Others
<Med-2SD The likelihood of children of illiterate
SC 25.6 50.6 44.7 51.3 57.6 30.6 33.5 43.4
ST 38.3 56.1 48.4 56.9 36.5 44.1 NA NA
OBC 18.7 45.7 39.7 45.6 46.7 27.3 19.6 NA
Others 13.3 36.3 35.8 33.7 43.5 27.7 18.8 NA
Average 21.0 45.6 40.5 46.3 44.0 37.0 24.6 44.5
mothers being malnourished is twice that of children of mothers with secondary or higher education (odds ratio of illiterate mothers to those having higher education
Source: Computed from National Family Health Survey-3 (2005-06) data file, NA- indicates sample size less than 50 so not = 1/0.463 = 2.16). considered. CMR: Child Mortality Rate.
Access to health services is the third OBC women. As Table 1 shows, while na-underweight children as a measure of mal-crucial factor affecting nutrition. The imtionally the chronic energy deficiency rate nutrition, and income (wealth index – proxy pact of a poor standard of living and eduis about 40.5% for all women, women for income), education of the mother, access cation level could be overcome to a great from the SC and ST groups have an 8% and to antenatal care (indicator for access to extent, particularly by the poor individu13% higher incidence respectively of under-health services), social and religious belong-als through better access to affordable nutrition than those from the “others”. ing, occupation of the father, gender, place public health services. Data indicates that
A woman’s nutritional deficiencies have of residence, and supplementary nutrition mothers who have better access to health important implications for her health as it as determinants of child nutrition (Table 2). services, such as antenatal care, have lower
reflects in the health status of her children. Table 2: Logistic Regression Results of Factors Affecting odds of having malnourished children, Child Malnutrition
Data indicates disparity in child mortality and the likelihood that they will have mal-
Explanatory Variables Exp(B)
rates between the SCs, STs, OBCs and others nourished children is 0.67 times that of
Wealth index Poorest 1.000
in rural areas in 2005-06. Child mortality mothers who do not receive such services.
Poorer .856*
rates are over 15% for SC/ST children than
Middle .681*for the “other” children. The OBCs are Richer .538*Caste and Religion worse off in comparison to the “others”, Richest .342* Certain social, ethnic and religious groups Education of mother No education 1.000
though better off than the SC/ST. are disproportionately affected by child
Primary 0.828*
Similar differences are observed for malnutrition. The logistic regression indi
Secondary 0.799*
social groups by their religious background rectly captured the influence of caste,
Higher 0.463*
(Table 1). Children from the Christian and ethnic and religious background on the
Mother’s ANC No antenatal care 1.000 Sikh groups have relatively better nutritional Taken antenatal care .669* incidence of malnutrition. It estimated the
status than those from Hindu and Muslim groups. Among social groups, the SC Muslims have the highest proportion of underweight children followed by ST and SC Hindus. In fact, the situation of children from the SC Muslims is the worst amongst all social groups. Close to 58% of the SC Muslim children were malnourished as com pared to the average for that group. Similarly, women from the ST Hindus and SC Muslims have the highest incidence of malnutrition (51% and 45% respectively, as compared to the average in those groups). Women from these social groups are worseoff than their male counterparts. Like all women, these women too suffer from low nutritional levels as compared to men but the SC, ST and Muslim women suffered most compared with the other women. This heightened deprivation can be attributed to the social and religious belonging.
Factors Common to All
Using logistic regression analysis for rural areas in 2005-06 we try to capture the key factors affecting child malnutrition in rural areas. We have taken the proportion of
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| Social group | Others | 1.000 |
| SC | 1.350* | |
| ST | 1.418* | |
| OBC | 1.218* | |
| Religious groups | Others | 1.000 |
| Hindu | 1.092 | |
| Muslims | 1.065 |
*: Significant at 1% level, Exp (B) is the odds ratio. Source: Computed from NFHS-3, Unit-Level Data.
Taking each of these factors separately it emerged from the logistic regression analysis that children from wealthier households have a lower incidence of malnutrition than the others. When all other factors, including the social group, are held constant, the likelihood of the poorest children being malnourished is about three times that of children from the highest wealth quintile (odds ratio of children from poorest households to those from the richest = 1/0.342 = 2.9). The gap in nutritional status between the poorest and the richest quintiles is very wide for men as well as women. As one moves along the wealth index ladder from the poorest to the richest, the proportion of under-nutrition women and men reduces indicating that income does matter for a better nutrition level.
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likelihood of children from these groups being malnourished as compared to the rest, when the wealth index, education, access to health services and other factors are held constant. In other words, it captures the malnutrition level for identical persons in terms of their wealth, education, access to health services and other factors.
The logistic regression exercise indicates that the likelihood of SC and ST children being malnourished is about 1.4 times that of children from the “other” category. The same results for Muslim children indicate that although their nutrition levels are lower than other religious groups, the difference is not statistically significant. For women and men, we ran a logistic regression controlling for limited variables, namely, educational level, wealth and occupation. For SC women, the likelihood of being malnourished is 1.1 times that of “other” women after controlling for wealth, occupation and level of education. For the ST women, the likelihood of being malnourished is 1.2 times that of women from the “other” category. The logistic regression further indicates that the likelihood of the
COMMENTARY
Access to Essential Health Services SC ST OBC Others
Percentage of children vaccinated 39.7 31.3 40.7 53.8
times that of the rest of the religious cate-in accessing the sources of
% distribution of children 0-59 months covered
gories. The likelihood of SC and ST men income, education and public
by AWC by frequency of weighing 78.1 64.2 83.3 82.7
being malnourished is 1.1 times and that Place of delivery at home (in %) 67.1 82.3 62.5 49.0 health service, besides these
of Muslim men is 1.5 times that of the oth-Assistance during delivery (in %) common measures, they
ers after controlling for wealth, occupation and level of education. It is clear that Muslim women seem to have a higher likelihood of being malnourished, followed by the women from the STs and SCs, in that order.
Thus in the case of the SCs, STs and Muslims even after controlling for factors such as income, educational level, access to health services, etc, the malnutrition rates turn out to be high indicating that there are constraints that are associated with their social and religious belongings. Because of lack of data we could not include such constraints in the regression equation. However, some field-based studies indicate groupspecific factors for high malnutrition levels. These group-specific factors generally relate to the discrimination that these communities face in accessing income earning assets, education and government schemes providing services like food and health. There is some evidence for the sc. The sc faced discrimination in accessing food from the public distribution system (PDS). The sc children also faced discrimination in accessing food (mid-day meal) in schools and anganwadi centres, which adversely affects their food intake and thereby their nutritional levels (Thorat and Lee 2010; Jan Sahas 2009). Sangamitra’s study (2010) provides evidence of the discriminatory access of SC women and children to primary health services leading to lower utilisation of the health services. Indeed, the NFHS data for 2005-06 reveals that SC mothers and children have relatively poorer access to public health services than others. For example, the immunisation rates for SC children are about 20% lower than the others (Table 3). Access to health services at the time of delivery is also lower for the SC mothers compared to the others. Thus, discrimination resulting in limited access appears to be an additional pervasive factor contributing to the higher rates of malnutrition among the SC compared with others. The issue of discrimination-induced malnutrition has been neglected in the literature which in fact needs more research.
overcome the constraints im-
Postnatal check-up: less than four hrs (in %) 23.7 16.3 26.4 34.5
posed by processes of social
Source: Computed from National Family Health Survey-3 (2005-06) data file.
In sum, malnutrition is a direct outcome of not only income levels, education and public health services, but also the indirect one of the discriminatory access to income opportunities, health and food security-related services from mid-day meal, the Integrated Child Development Scheme (icds), the PDS and others. This indicates that the income level, education and access to health services are important factors to reduce malnutrition for all, including the SCs, STs and Muslims. But in the case of the SCs, STs and Muslims additionally, safeguards against discriminatory access to education, health services, food security schemes and livelihood opportunities are necessary.
Policy Implications
These results have policy implications which are dual in nature. They call for measures common to all poor (including poor from the social and religious groups), and supplementary measures for the SC, ST and the Muslims to provide safeguards against discrimination. Among measures which are common to all (including the social and religious groups) are increasing incomes of the poor through improved access to assets and earnings which is essential for better diet and access to healthcare. Similarly, there is a need to improve the education level and access to the public health services and food security. Increasing the enrolment levels of girls and retaining them in school is critical at least until the secondary education stage. Expanding the functional health services to the rural and poorly served urban areas is necessary for improving access of the poor to health. At the same time, programmes to create awareness of nutrition, and healthcare are necessary to inform critical feeding and caring behaviours at the family level and to promote use of health services.
exclusion and discrimination in accessing earning, education, public health services and food security. This will require measures to provide safeguards against discrimination and measures to promote equal and non-discriminatory access. These measures may include: establishing ICDS – anganwadi centres, health facilities and “fair-price food shops” in underserved SC, ST and Muslim habitations, monitoring and using data disaggregated by social group at all levels to identify underserved communities/groups. Recruitment of ICDS anganwadi workers (AWW) and auxiliary nurse midwives (ANM) from the SC, ST and Muslim communities is equally necessary to improve the coverage of these groups. Thus, increasing their education levels will be an important measure. The AWW and ANM training courses must emphasise the adverse effects of caste, ethnic and religious discrimination on access to public health and food security schemes. Conducting national public awareness campaigns against discriminatory practices and ensuring that organisations delivering public/social services do undertake such campaigns should constitute a part of these measures.
References
IIPS (1996): “National Family Health Survey-1992/93”, International Institute for Population Sciences, Mumbai.
IIPS and ORC Macro (2000 and 2007): “National Family Health Survey-India (NFHS-2 and 3), India 1998-99”, International Institute for Population Sciences, Mumbai.
Jan Sahas Social Development Society (2009): “Exclusion and Inclusion of Dalit Community in Education and Health: A Report”, Dewas, Madhya Pradesh.
Sangamitra, Acharya (2010): “Public Health Care Services and Caste Discrimination: A Case of Dalit Children” in Thorat Sukhadeo and Newman Katherine (ed.), Blocked by Caste-Economic Discrimination and Social Exclusion in Modern India (New Delhi: OUP).
Thorat, Sukhadeo and Joel Lee (2010): “Caste Discrimination and Government Food Security Programme” in Thorat Sukhadeo and Newman Katherine (ed.), Blocked by Caste-Economic Discrimination and Social Exclusion in Modern India
(New Delhi: OUP).
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