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Weighing an InfantHow can it be possible, in 2009, that almost half of all Indian children under three years old are underweight or severely underweight, and that child malnutrition accounts for more than one-fifth of the total burden of disease in that country? Something like three-quarters of all preschool children in India have iron-deficiency anemia, which impairs learning, and more than half have at least mild vitamin A deficiency. Given India's place as one of the fastest growing economies in the world, the persistently high levels of malnutrition among children -- close to double that of sub Saharan Africa -- have to be cause for alarm and puzzlement. And the extraordinary vulnerability of Indian children, as manifested in these figures, holds in it a warning for what might happen as economic growth slows. Any claims of progress in child health have to be tempered by these sobering facts. A feature in yesterday's New York Times focuses on the problem and describes it well, but leaves the questions -- why and what can be done? -- for others to answer.

Who those "others" are in the field of nutrition is not at all clear, in India or elsewhere. Nutrition has long been a subject area that has fallen between the stools: related to health, yes, but never at the heart of what Ministries of Health consider their main mission. Moreover, a health-centric response to under-nutrition -- which often boils down to providing medical care for severely malnourished children, promoting breastfeeding among new mothers, and distributing vitamin A capsules -- usually fails to address the household food consumption patterns that are shaped by everything from women's access to income to the way food is produced and distributed. It is everyone's job, and no one's.

The responsibility and accountability problem is reproduced at the international level. A set of international institutions and bilateral agencies have traditionally focused some of their activities on nutrition, amidst many other, more prominent programs. UNICEF, the World Food Programme, the World Bank, USAID and CIDA are among the organizations that have made contributions in the field, but it's well recognized that international nutrition is severely under-resourced, and has for years suffered from internecine squabbles and coordination problems. As the Lancet stated a year ago, "Leadership is absent, resources are too few, capacity is fragile, and emergency response systems are fragmentary." (Also see the Lancet article, Effective international action against under-nutrition: why has it proven so difficult and what can be done to accelerate progress?) As the expert community has now started to come to a technical consensus about the menu of interventions that are needed to address child under-nutrition in high-burden countries (see What works? Interventions for maternal and child under-nutrition and survival) and the importance of addressing under-nutrition before age 2, the leadership and governance gap is looking more and more like the binding constraint to progress.

Fostering leadership at the national and international levels is no mean feat, but tackling this huge and potentially growing problem demands it. When the food price crisis hit the headlines last year we heard some welcome messages from World Bank President Robert Zoellick and the Government of Japan (at least as hosts of the G-8). The Government of the UK has prepared an action plan and Irish Aid has convened a Hunger Task Force. But none of what international institutions or OECD donors have done has yet added up to anything resembling the focused attention and commitment that we've seen for childhood immunization, let alone for HIV/AIDS.

Perhaps there's another way. Maybe, just maybe, one or two of the members of the G-20 -- Brazil's President Lula and India's Prime Minister Singh? -- could state strongly that they understand the urgency of the problem, are committed toward progress in their own countries, and call upon international agencies to work intensively with high-burden countries on development and implementation of national action plans to address child malnutrition. There is an opportunity for countries whose citizens' lives hang in the balance, and those who have the role of representing the developing world, to take the lead.