Progress is still slow and political will still patchy, but there are signs that a new approach to fighting malnutrition is just beginning to reap dividends.
Efforts to improve rural health and education have combined with an expansion of a child welfare program that employs nearly 2 million village health workers to focus on maternal and infant health and nutrition. A rural jobs plan has helped raise wages in the countryside and new programs are educating adolescent girls, nearly half of whom will marry before age 18, about feeding and hygiene.
There are indications it could be starting to pay off. An independent survey of malnutrition in 100 of India's least-developed districts released in January showed the first signs of progress, with the proportion of underweight children falling to 42 percent, a drop of 11 percentage points.
Even more dramatic are preliminary data from the western state of Maharashtra released last month, showing a decline in the number of children who were stunted, to 22.8 percent from 39 percent in 2006, thanks to a government program aimed at the needs of infants and mothers.
"We are confident that there is a good story in the making," said Victor Aguayo, head of UNICEF's India nutrition program. "There is excitement that what can happen, is happening."
Maharashtra is home to India's financial capital, Mumbai, and is the country's economic powerhouse. Still, malnutrition rates did not begin falling significantly until the state government started showing the political will to tackle the problem head-on.
Nationally, the wake-up call came in 2007 with the realization that a decade-and-a-half of buoyant economic growth had scarcely dented child malnutrition rates, which remained higher than the average in sub-Saharan Africa. Nearly half of Indian children under age 5 were stunted and underweight for their age, a government survey released that year showed, permanently impairing their mental and physical development.
But in a country where many middle-class Indians find the subject of malnutrition rather boring, it took the idea that India was underperforming — not just compared with Africa but also with neighbors like Bangladesh — to embarrass the government into action. In 2007, Prime Minister Manmohan Singh called it a "national shame" and a failed strategy began to be reevaluated.
"India as a nation had been overemphasizing economic growth in the hope it would somehow solve the problem," Aguayo said. But growth has not been equitably distributed, and experts argue that the health sector has been neglected.
"Malnutrition," Aguayo said, "has been undermining India's ambitions to be the nation it wants to become."
Despite the progress, India has a long way to go. In a poor tribal district of Banswara in the western state of Rajasthan, the mismatch between India's aspirations and its current problems, between its self-image and the grueling reality of millions of its citizens' lives, is striking.
On the outside of one family's simple home, between paintings of Hindu gods, were two pictures. One was a drawing of a woman cradling her baby, entitled "Mother's Love." The other was a photo of a pudgy white-skinned baby, wearing only a woolly hat.
But beneath the posters, a filthy and thin Indian baby named Jitendra sat listlessly on the verandah, dirt caking his cheeks, flies gathering around his eyes, mouth and snotty nose.
Three months ago, when Jitendra was 15 months old, health workers caught up with him and he weighed in at just 12.1 pounds — less than two-thirds the minimum global standard for his age. The workers have since been visiting regularly and giving the family supplementary food and he has put on roughly two pounds. But he remains severely malnourished.
Jitendra was not born underweight, but after repeated illnesses he started falling behind.
"He has been sick for a long time," said his slight 18-year-old mother, Sundari Dhindor. "Where is the money? How do you expect me to feed him? He is still on my breast milk."
The family's situation is just one illustration of what nutritionists call a perfect storm of factors driving India's malnutrition crisis. Many children are born to teenage, anemic, malnourished mothers; feeding practices are poor; and the environment they live in, a crowded country where 600 million people have no access to toilets, is rife with fecal matter.
Health programs were largely missing infants in the first two years of their lives, when malnutrition usually sets in and causes permanent mental and physical damage, Aguayo said.
Fewer than half of Indian children start nursing within their first 24 hours, receiving water rather than the early, antibody-rich breast milk that helps protect against infections, and most spend their first few years subsisting on protein- and vitamin-poor diets of just rice or bread. The fact that economic growth has still not trickled down to the poorest communities and the low status of Indian women are also major factors.
In Banswara, village health workers blame rampant malnutrition on the prevalence of child marriages. Sundari, Jitendra's mother, got married at the age of 13 to a man she describes as a "good for nothing drunkard." She said she spends most of her day cooking, washing, cleaning and fetching firewood or water for her in-laws, or trying to earn money as a day laborer in local fields.
Even now, India's progress in fighting malnutrition fails to impress many experts.
Save the Children and World Vision recently ranked India alongside the Democratic Republic of Congo and Yemen at the bottom of a global Nutrition Barometer for its commitment and performance.
While the nation frets constantly about whether economic growth and the stock market are up or down, the government has not collected data on child malnutrition since 2004 — something Purnima Menon of the International Food Policy Research Institute calls "mind-boggling."
Last month, India's president and a leading Bollywood actor launched a national publicity campaign to combat malnutrition. The government has also promised a huge rise in health-care spending during the next five years.
Nevertheless, experts say the government still lacks a coherent plan to overcome the shortcomings of the child health program, which depends on village health workers who are overburdened and poorly educated, trained and paid.
Spending comes easily to the government, critics say, but setting up mechanisms to monitor performance and raise accountability seems far less instinctive. Meanwhile, the Ministry of Women and Child Development remains a junior cabinet post, a department where few civil servants want to work, said A.K. Shiva Kumar, an independent adviser to the government on development.
"The problem of malnutrition is not visible or in your face," he said. "The political attraction of working on nutrition is very low. It doesn't really sell."
