快四歲的Vishal是西印度馬哈拉施特拉邦州一位農場工人的兒子，他的體重應該有16公斤，但是他的瘦弱的幼稚園女老師卻可以輕而易舉的把Vishal從地上抱起來。為了秤重，女老師將Vishal那瘦骨如柴的腿穿進了磅秤布袋的洞裡，而測出來的體重剛好超過10公斤，也就是一歲健康嬰兒的體重。

女老師點了點頭，將無精打采的Vishal放回地上，讓他坐在拼圖玩具前。女老師鎮定的態度在印度並不稀奇，因為印度將近有一半的孩童都是營養不良，也是全球兒童體重過輕比例最高的國家，其比例甚至比非洲撒哈拉以南地區的國家還高。全球五歲以下的營養不良兒童有一億五千萬，其中印度就佔了三分之ㄧ以上。

瘦小孩童在這裡是令人鬱悶，卻又習以為常的光景，但Vishal的村莊還不算特別貧窮，因為村莊離印度經濟核心的孟買只有120公里遠，大部份的村民可以到那裡的工廠或農場找工作。即使如此，在Vishal所待的破舊托兒所，又稱anganwadi(庭院)的國營托兒所裡，半數以上的孩童依舊是營養不良，有幾個甚至還是慢性的營養不良。Sunanda是資歷25年的老師，每個月都要替小孩秤重她表示，營養不良的情況一直都是如此，從來就沒有變過。

令人吃驚的是，印度這種快速成長的國家，不但無法降低營養不良的問題，還讓此問題盛行。自1991年以來，印度的GDP值幾乎成長了一倍，但是營養不良的問題卻只減少了幾個百分點，而且孩童的差別待遇也逐漸地成長：五歲以下的鄉村兒童、低種姓兒童和女童有營養不良的機率會比起都市兒童、高種姓兒童和男童的機率還要高。看來印度無法達成其千禧年發展目標的重要目標之ㄧ，無法在2015年達成營養不良數量減半的目標。

營養不良是印度的重擔，因為營養不良是孩童過半的死因，也大約佔了病例的四分之ㄧ。營養不良的孩子通常都懶於開發身體和精神上潛力，在學校的表現未達自己的水準，導致印度生產力受到衝擊。世界銀行認為因營養不良所導致的肢體障礙會降低低收入亞洲國家百分之三的GDP，既然如此，印度為何沒有採取行動呢？

其中的原因有很多，最主要的原因是貧窮父母無法買到足夠的糧食，但這不是唯一的因素。貧困和鄉村家庭缺乏乾淨的水源和環境，父母也不常帶小孩去給醫生看病。此外，營養不足會降低免疫系統，增加罹患傳染病的風險，而疾病本身也會消耗孩童身體裡的營養。兩歲的Tara住在西拉賈斯坦邦州的錢登村裡，她的母親一邊抱著瘸腳的孩子，一邊陳述Tara一年前曾因腸胃炎而住院，但出院後就因頻繁的腹瀉而無法增加體重， 目前體重只有 七公斤 。

令人吃驚的是，即使是較為富有的家族，營養不良的比例也是相當的高。根據印度政府資料顯示，最富有的五分之ㄧ人口中，有三分之一的孩子有營養不良的問題。這是因為不良餵養的方法所導致的結果，大部分的孩子在出生後的半年裡都沒有喝到母乳，這個理由佔了因食物短缺而營養不良的極大部分。改善此情況的良機就是教育父母如何養育孩子，這方法遠比保障生活在貧困線之下的四億一千萬印度人的糧食還來的快速。

在解決兒童營養不良和貧困線人口問題上，印度政府無疑是失敗的。印度政府花費大量資金，設計了向窮人提供食物援助的大眾分配系統(PDS)和一億兩千萬學童的營養午餐方針，但是這兩項減少營養不良的計畫都因低效率和貪污而受到限制。而政府最主要的解救方針，綜合兒童發展服務(ICDS)則因不同的理由而宣告失敗。

1975年開始的ICDS是世界上最大的幼兒計畫，其構想是每一千人可以分配到一間托兒所、一位老師和一位助理，而且每間中心要提供懷孕婦女和學齡前兒童的營養保健。托兒所也提供學齡前兒童看護和教育，並且幫每位孩童保管許多記錄資料，如體重紀錄和財務報表。這些過量的負責項目導致托兒所員工只關注於熟人身上，小孩兩歲以上的母親會侵占中心提供的免費兒童看護和餐點。這些要讓每位孩童每天都能攝取500大卡的餐點是有益的，但是無法代替幼兒父母所需要的營養指導。除此之外，這種重視年長孩童的方針相對的犧牲了懷孕婦女和兩歲以下孩童受益的機會。

不幸的是，這些無法受益的族群才是政府團隊需要關注的對象，因為大部分的生長遲緩都是發生在兩歲以下的孩童身上，而且這是無法復原的症狀，很多孩童在懷孕時期就已經有生長遲緩情形，而且印度有30%的孩童出生時就體重過輕。在生育年齡的印度女性有半數以上患有貧血症，需要靠強化營養來改善症狀，患有貧血症的健康嬰兒可在半年內，藉由純母乳餵養來改善症狀。但是印度鄉村的女性通常在生產當天就回到農地工作，嬰兒的食物都是用牛奶和水來替代，導致嬰兒受到感染。當嬰兒六個月大，開始實用固體食物後，受到感染的風險會大幅提升。

ICDS中心的品質和範圍會隨著州的不同而改變，最貧窮的州擁有最高的營養不良率，同時也有最少間中心。不過這種遍布國家的方案跟其他印度大眾服務一樣有著同樣的問題，要提供給托兒所的食物被建商順手牽羊，轉交給當地的女性。經由複雜的交易系統後，即使是Maharashtra這種盡力提升ICDS服務的地方，也需要等上四個月才有現金購買食物。Vishal所待的中心每天提供兩餐，內容是一盤帶有幾塊核果的爆米花和一份綠豆芽，很顯然無法提供500大卡的熱量。Vandana Krishna是印度婦幼發展部的州秘書，她認為資金缺口應透過鄉村委員會或當地政府，設立特殊貸款給托兒所，但這也需要更多的錢來解決。

即使如此，政府還是打算嘗試任何能有效改善兒童營養不良的方法，唯獨一種方法受到了印度政府的抵制，那就是改善PDS所發放的食物的營養價值。這種方法既便宜又有效，還可以減少貧血症狀、提升國民的營養。不過許多專家認為印度只有專心照料懷孕婦女和幼兒後，或在托兒所追加家訪員工，才有可能對營養不良的情勢產生影響。聯合國兒童基金會印度營養企劃執行長Victor Aguayo說：「不重視母親和三歲以下幼兒已經讓印度錯過了它的大好機會，它已經沒有能力在多等下去了。」

VISHAL, the son of a farm labourer in the west Indian state of Maharashtra, is almost four. He should weigh around 16kg (35lb). But scooping him up from the floor costs his nursery teacher, a frail woman in a faded sari, little effort. She slips Vishal’s scrawny legs through two holes cut in the corners of a cloth sack, which she hooks to a weighing scale. The needle stops at just over 10kg—what a healthily plump one-year-old should weigh.

The teacher nods and puts Vishal back on the floor, where he sits listlessly before a jigsaw puzzle. That his teacher does not look perturbed is unsurprising. Nearly half of India’s small children are malnourished: one of the highest rates of underweight children in the world, higher than most countries in sub-Saharan Africa. More than one-third of the world’s 150m malnourished under-fives live in India.

That makes the sight of small, skinny children depressingly routine. Vishal’s rural village is not especially impoverished; 120km (75 miles) from Mumbai, India’s financial centre, it offers factory-work as well as the farm labour most country people do. But the battered register in Vishal’s nursery, a government-run centre known as an anganwadi (literally, courtyard), shows that close to half the children are malnourished, a handful chronically so. “It’s always been this way,” says Sunanda, the anganwadi teacher, who has weighed the children in her care every month for 25 years. “Nothing has changed.”

Almost as shocking as the prevalence of malnutrition in India is the country’s failure to reduce it much, despite rapid growth. Since 1991 GDP has more than doubled, while malnutrition has decreased by only a few percentage points. Meanwhile, the chasm between lucky and unlucky Indian children is growing: under fives in rural areas are more likely to be underweight than urban children, low-caste children than higher-caste children, girls rather than boys. And the disparities are growing. India seems certain to miss one of its key Millennium Development Goals: halving malnutrition by 2015.

Malnutrition places a heavy burden on India. It is linked to half of all child deaths and nearly a quarter of cases of disease. Malnourished children tend not to reach their potential, physically or mentally, and they do worse at school than they otherwise would. This has a direct impact on productivity: the World Bank reckons that in low-income Asian countries physical impairments caused by malnutrition knock 3% off GDP. Why, then, has India done so little to reduce it?

There are many reasons. Most fundamentally, poor parents find it hard to buy enough food; but that is by no means the only factor. Impoverished and rural families are also less likely to go to a doctor when their children fall sick, which they do a lot, thanks to dirty water and poor hygiene. Inadequate nutrition lowers the immune system, increasing the risk of infectious disease; illness, in turn, depletes a child’s nutritional stocks. Tara, a two-year-old in Chandan, a village in the northern state of Rajasthan, has yet to bounce back from a bout of gastroenteritis that put her in hospital a year ago. Since then, any weight gain has been offset by frequent bouts of diarrhoea, says her mother, Maya Devi, as she holds her limp child on her lap. Tara weighs a pitiful seven kilos.

Even the children of wealthier families suffer surprisingly high rates of malnutrition. Government data show that a third of children from the wealthiest fifth of India’s population are malnourished. This is because poor feeding practices—foremost among them a failure exclusively to breastfeed in the first six months—play as big a role in India’s malnutrition rates as food shortages. Here lies an opportunity: educating parents about how to feed their children should be more quickly achieved than ensuring that the 410m Indians who live below the UN’s estimated poverty line of $1.25 a day have enough to eat.

The government, however, has largely failed in both areas. Two big, expensive schemes designed to reduce malnutrition—a public distribution system (PDS) that provides subsidised food to the poor and a vast midday-meal scheme, to which 120m schoolchildren are signed up—are hampered by inefficiency and corruption. But the government’s main effort to tackle child malnutrition, the Integrated Childhood Development Service (ICDS), has failed for rather different reasons.

The ICDS, launched in 1975, is the world’s biggest early-childhood scheme. It provides, in theory, an anganwadi centre with one teacher and an assistant for every 1,000 people. Each centre is responsible for providing nutritional care to pregnant women and all children up to six, the age at which Indian children start school. Anganwadi centres also provide daily pre-school child care and education, as well as keeping a dozen-odd registers recording everything from children’s weights to financial accounts. Overburdened by this long list of responsibilities, anganwadi workers have tended to focus on the group they see every day: children over the age of two whose mothers take advantage of free child care and daily meals offered by the centres. While these meals—supposedly providing each child with an extra 500 calories a day—are certainly beneficial, they do not replace the nutritional guidance the parents of young children need. More seriously, this emphasis on older children means that the under-twos and pregnant women barely get a turn.

Unfortunately, this is precisely the group the government should be targeting. Most growth retardation occurs by the age of two and is irreversible. Often, it starts during pregnancy. More than half the women of childbearing age in India are anaemic—a condition that can be much improved by fortifying food—and 30% of Indian children are born underweight. In healthy infants, this could be corrected with six months of exclusive breastfeeding. But especially in rural India, where women often go back to the fields mere days after giving birth, babies’ diets are often supplemented with cow’s milk and water, which exposes them to infection.

That risk increases after six months, with the introduction of solid food. The quality and reach of ICDS centres varies from state to state: the most impoverished states, with the highest rates of malnutrition, also have the lowest numbers of centres. But countrywide the scheme suffers from the usual ailments of public services in India. Recently the production of daily meals served at anganwadi centres was taken out of the hands of pilfering contractors and given to groups of local women. A complicated system of payments, however, means that even in a state like Maharashtra, which has done more than most to improve ICDS services, centres must wait four months for cash to buy pay food bills. The two meals served at Vishal’s anganwadi—a plate of puffed rice dotted with a few nuts and a serving of sprouted moong dal—seem unlikely to give him 500 calories. Vandana Krishna, the state’s secretary of Women and Child Development, says the funding gap could be solved by giving village panchayats, or local governments, a special fund to make loans to anganwadis. But this would need a lot of money.

So too would any significant improvement in the government’s efforts to fight child malnutrition—with one exception. Fortifying the food handed out by the PDS would be an economical and effective way to lower rates of anaemia and increase nutrition. So far, India has resisted that idea. But most experts agree that the country will make a serious dent in child malnutrition only when it focuses on pregnant women and the very young, perhaps by providing an additional worker in each anganwadi centre to make home visits. “India has missed its big window of opportunity by not giving priority to mothers and the under-threes,” says Victor Aguayo, chief of Unicef’s nutrition programme in India. “It cannot afford to do so any longer.”