It has now been two years since my wife and I moved to the Netherlands from India for our temporary sojourn here. I am frequently asked how I like living in the Netherlands. Since this is normally small talk, my response tends to be polite and perfunctory. I usually cite wonderful public transport, excellent museums, bicycles everywhere, an absence of hierarchy and of hills, and a utilitarian attitude towards food, if not drink. I am less prone to stress the physical challenges encountered by a shorty like myself. These include the need to use step stools everywhere in the house to reach the top shelves of kitchen cupboards and closets, and coat racks in trains that are so high that I sometimes need to stand on the seat to retrieve my articles.
I was generally aware that the Dutch around me, men and women, seemed tall and healthy (though often with cigarettes between their fingers), but I had not reflected deeply on this matter until this past January. The epiphany occurred when I attended a conference on maternal and child health in Oxford organised under the sponsorship of the Emerging Markets Symposium, an activity of Green Templeton College at the University of Oxford.
Each year the symposium takes an in-depth look at an area of structural policy of particular interest to the economic development and well-being of emerging markets - a diverse group of economies, ranging from India and the Philippines at the lower end of real per capita GDP to Organisation for Economic Co-operation and Development (OECD) members such as Mexico and Poland. These countries are increasingly neglected by the official development community, which is now more focused on assisting the poorest countries - even though more poor people now live in middle-income countries than in poor countries. I have been a member of the steering committee of the symposium since its inception in the middle of the last decade.
The theme of this year's symposium was maternal and child health. The focus was on the enormous long-term pay-off to national productivity and equity that are available through specific, affordable interventions in prenatal attention to the mother and thereafter to the infant at the neonatal stage and in the first thousand days after birth. Given Oxford's global eminence in medicine and public health, there was a commendable emphasis on presenting the most recent research findings in this area. (Relevant material can be found at http://ems.gtc.ox.ac.uk/maternal-and-child/maternalpressmedia.html.)
Perhaps the most interesting, ambitious and striking research that was presented was an international research effort called the "Intergrowth-21st Project", or the "International Fetal and Newborn Growth Consortium for the 21st Century", to give it its full name. This has been supported by the Bill & Melinda Gates Foundation and has been centred in Oxford for the last six years (http://www.intergrowth21.org.uk/). The primary purpose of the project is to "develop new 'prescriptive' standards describing normal foetal growth, preterm growth and newborn nutritional status in eight geographically diverse populations, and to relate these standards to neonatal health risk".
To implement this apparently straightforward goal turns out to be a monumental task, since it involves equalising the nutritional and health status of all mothers participating. This is needed to capture any residual differences in foetal development that might be associated with genetic or racial type. Accordingly, prenatal progress from conception to birth was monitored at eight clinical centres around the world. At each of these centres, exactly the same monitoring and measurement tools were used. The findings of this multi-year effort are now emerging and were presented at the conference in advance of their official release. Crucially, the findings indicate that there is no systematic difference in foetal development by ethnic or racial type. To put it more formally, variations within populations exceeded variations across populations.
This brings us back to the tall Dutch, and thereby to India. It is indeed the case that the Dutch are the nation with the greatest average height in Europe. As would be consistent with the Intergrowth findings (but confirmed by other, prior research), this is not primarily because of differences in genetic stock - but is rather attributable to systematic, multi-generational investment in female empowerment and maternal health. Healthy mothers produce healthy babies, and healthy babies are less susceptible to chronic diseases (such as obesity and diabetes) as well as being more capable of realising their full cognitive capabilities.
Yet this is not the whole story. For in addition to their record height, the Dutch also lead Unicef's rankings across the rich countries as being the most child-friendly. Accounting for this outcome is more difficult, but according to sociologists and social psychologists, it seems embedded in the value system of Dutch society. The Dutch are not unique in this regard, but it seems that the Dutch do the job even better than their Scandinavian peers. It is worth reflecting on the magnitude of the achievement. A small nation on a river delta (the Rhine) subject to many of the same natural perils as, say, Bangladesh, has propelled itself to being one of the wealthiest members of the European Union with enviable social indicators, largely through success in social organisation.
What are the implications of all this for India? First, if Intergrowth becomes widely accepted, we will no longer be able to use the excuse that low average birth weight, or subsequent stunting, is the result of genetic predisposition. Second, while concentration on prenatal and neo-natal health can yield extremely high social return, it cannot substitute for babies who have already come into the world with low birth weight. Third, it is not valid to argue that these problems can only be resolved as we get richer. The opposite is more likely to be the case.
None of this is to deny the long-standing efforts of the Indian government through schemes such as the Integrated Child Development Services (ICDS) to address issues of prenatal care, food supplementation and early childhood monitoring. But, for me, the deeper issue raised by Dutch success is how far such official efforts can succeed in the absence of supportive social attitudes and the political will they engender. The fundamental challenge is to change social perceptions and norms. That is an effort that has to involve society as a whole, as the example of the Dutch confirms.
These views are personal