Midday meals for schoolchildren in India: More good than harm

On July 16th at least 23 children in the Indian state of Bihar died after eating a midday meal that was provided for free by their school. Nearly as many are in critical condition in a local hospital. Tests have revealed that adulterated cooking oil, perhaps containing pesticides, is likely to blame. A government inquiry has determined that the principal of the school, who is in hiding, must be held responsible for the bad ingredients or unsafe methods used in preparing these meals.

This event is horrific, without a doubt. Yet its damage could be even worse, if it raises too many doubts about the value of a largely successful programme. The midday-meal scheme, which began on a small scale decades earlier, received the support of India’s Supreme Court in 2001. Since then most Indian states have adopted it, offering free meals to children in state-run or state-assisted schools. More than 120m children, including many who would otherwise go hungry, receive these meals every school day.

According to a recent analysis by Farzana Afridi of Syracuse University and the Delhi School of Economics, at a cost of three cents per child per school day, the scheme “reduced the daily protein deficiency of a primary-school student by 100%, the calorie deficiency by almost 30% and the daily iron deficiency by nearly 10%.” Ms Afridi also found that, after controlling for all other factors, the meals scheme has boosted the school attendance of girls by 12%. Abhijeet Singh of Oxford University found that, in some parts of India where children were born during a drought, the health of those who had been brought into the meals scheme before the age of six was compensated for earlier nutritional deficits.

What the disaster in Bihar has done, at the very least, is to highlight some of the pitfalls of the scheme. As with any programme of this size in a country rife with corruption, the meals scheme is riddled with problems. The corruptible state is not alone in funding the programme; it is joined by private companies and NGOs. Corruption exists not just among state entities but among the supporting agencies too, as was demonstrated in 2006 when a Delhi NGO was caught dipping into rice that was meant for midday meals. In the states of Bihar and Uttar Pradesh, where the levels of malnutrition are among the highest in the country, it was found that only three-fourths of the food meant for children reached them. Food is often stolen by the administrators’ faking their students’ attendance. Beyond that, reports of adulteration—not only with shoddy or unsafe foodstuffs, but including finding worms, lizards and snakes—are common.

Next month, the Indian government will be voting on a food security bill which aims to provide food to 60% of the entire population, by means of a public distribution system. This one school’s tragedy comes at an especially crucial moment, when officials ought to be forced to inspect the leaky pipeline of distribution. At the same time it will be important to bear in mind: This scheme has done a lot more good than harm.

First published on economist.com.

Image credit: GlobalPartnership for Education

Tobacco in India

State governments in India are cracking down on chewing-tobacco products. What were once a royal delight have since become a “health menace”. On October 2nd Himachal Pradesh became the 15th state in India to ban gutka, a form of chewing tobacco made with crushed betel nuts. More than half of all states have done likewise and many others, including Karnataka, Andhra Pradesh and Tamil Nadu, are planning to follow suit.

More Indians chew tobacco than smoke it, 26% compared to 14%. Gutka, in particular, is prevalent among children who get addicted thanks to easy access and dirt-cheap prices (1 rupee or 2 cents per sachet). This means India suffers from one of the highest rates of oral cancer in the world, as much as twice the global average. Of the annual 5.6m cancer deaths in India, a third can be blamed on tobacco use.

The central government stands accused of inaction, even though the Supreme Court issued several warnings. Non-governmental organisations had been lobbying for a ban for quite some time. Finally in August 2011 the Food Safety and Standard Authority, aware of the health ministry’s indecisive stand on the matter, issued regulations under which no foodstuff, including gutka, may contain tobacco. The central government’s orders followed in March and the states’ bans followed.

But the tobacco industry is not taking it lightly. Many have dragged the states to court. They claim that gutka falls under the 2003 Cigarettes and Other Tobacco Products act, and cannot, therefore, be classified as foodstuff.

The bans are a crucial step forward, for the public-health campaigners. But challenges lie ahead. For instance, enforcement remains difficult—without a nation-wide ban, many users can get their fix from a neighbouring state quite easily. A recent report in the Lancet, a British medical journal, found that, on average, poor countries spend only $1 on tobacco control for every $9,000 they earn in tobacco taxes. According to the World Health Organisation many poor families spend up to 10% of their income on tobacco, leaving that much less to spend on education and health care. Any country’s health-care costs far outweigh the tax income raised through tobacco. A study by America’s Centres for Disease Control and Prevention showed that in 2011 American taxpayers paid $96 billion in health-care costs due to disease caused by smoking, while earning back only $20 billion in tobacco taxes. As their own health-care costs rise, Indian states could do worse than ensuring that the gutka ban stays and is enforced.

Also published on economist.com.

Image credit: Wikimedia Commons

Oral cancer in India: Chewed out

Many poor Indians addicted to nicotine are likely to indulge their habit by chewing gutka. In 2010 a survey by the National Cancer Registry Programme (NCRP) found that one in three inhabitants of the state of Madhya Pradesh aged 15 and older—or some 15m people—use the stuff, a preparation of crushed betel nut, tobacco and an acacia extract called catechu. Even more worryingly, a report in 2008 estimated that 5m Indian children were addicted. It is not uncommon for tykes as young as eight to be users. Gutka is also popular among women, in part because smoking among the fairer sex remains frowned upon in much of India. Add cheapness—1 rupee, or 2 cents, buys a sachet, whereas a cigarette costs at least twice as much—and it is little wonder that two-thirds of Indian tobacco users get their fix in chewable form.

As a result, however, India has one of the highest rates of oral cancer in the world. More than 80,000 new cases are reported every year across the country. The NCRP study reported 35,000 cases of oral cancer in Madhya Pradesh alone, equivalent to four times the national average of around 13 cases per 100,000 people—and almost eight times the world’s. The state’s government has now taken a drastic step. On April 1st it introduced a complete ban on the sale of all chewing-tobacco products.

Bhavna Mukopadhyay, who heads the Voluntary Health Association of India (VHAI), an advocacy, has praised the move. Speaking after it was announced in March, she called for a country-wide gutka ban under the rules introduced in August 2011 by India’s Food Safety and Standard Authority. These followed a ruling by the Supreme Court in February that year, banning the use of plastic in gutka sachets and calling the gutka habit a menace to public health. Because it could not ban the sale of gutka without the government’s backing, the court chose to make the manufacturers’ life difficult by prohibiting the use of plastic in packaging. This forces producers to package it in paper instead, making transportation of large quantities trickier.

However, the VHAI has found that many were brazenly flouting the ruling. Others have simply decamped to towns in Nepal and continue to use plastic sachets which are then smuggled into India. There are also troubling reports that some gutka contains waste from perfumeries and tanneries as flavouring, making it even more noxious. The government lacks the labs needed to ascertain adulteration of this kind, Ms Mukhopadhyay laments. It may also be reluctant to enforce its own rules, wary of antagonising a $10 billion industry.

According to a recent paper in the Lancet, 5.6m Indians die of cancer each year. Many live in the countryside; most never seek medical attention. Tobacco, the paper’s authors write, is responsible for a third of those deaths. Getting Indians to spit it out might save millions of lives.

Also published at economist.com.


  1. Most cancer patients in India die without medical attention: studyDown to Earth, March 29, 2012
  2. Madhya Pradesh bans gutkha and other chewing tobacco productsDown to Earth, April 3, 2012
  3. SC bans plastic gutka sachets from March 1Times of India, December 8, 2010
  4. Global Adult Tobacco Survey: IndiaWorld Health Organization, October 19, 2010
  5. Gutka still sold in plastic sachetsThe Hindu, March 13, 2011
  6. 2011 Census Data: Madhya PradeshGovernment of India

 Image credit: The Economist