Studies show a link between open defecation and stunted development, but merely building toilets may not be the answer
More people have mobile phones than access to toilets, the UN reminded us last week as the general assembly designated 19 November official UN world toilet day.
Six billion of the world’s population of 7 billion have mobile phones. However, only 4.5 billion have access to toilets – meaning that 2.5 billion, mostly in rural areas, do not have proper sanitation. In addition, 1.1 billion people defecate in the open. Sanitation does not get its due. So, the assembly urged member states to encourage behavioural change and implement policies that increase access to sanitation, along with a call to end open defecation, which it deems extremely harmful to public health.
The UN says countries where open defecation is most widely practised have the highest numbers of deaths of under-fives, high levels of undernutrition and poverty, and large wealth disparities. Stunting, or low height for age, affects 165 million children worldwide, has negative long-term impacts on physical and mental development, and reduces productivity in adulthood. Undernutrition causes 3.1 million deaths annually – nearly half (45%) of deaths in children under five.
Recent studies suggest a strong link between open defecation and undernutrition in India, which, despite strong economic growth, has high rates of stunting. The latest reliable estimates (pdf) show that 48% of Indian children under five are stunted. On average, children in India are shorter than their sub-Saharan African counterparts, even though Indians are richer on average.
Dean Spears, from the Delhi School of Economics, argues that the height of children has a correlation with their, and their neighbours’, access to toilets, and that open defecation accounts for much stunting in India. As 53% of India’s population defecates in the open, children are widely exposed to infections transmitted by faeces, such asenvironmental enteropathy, a condition resulting from the ingestion of bacteria, which results in reduced ability to absorb nutrients.
For Robert Chambers, at the Institute of Development Studies, and Gregor von Medeazza, a sanitation expert with Unicef, hygiene is a blind spot for many concerned with child undernutrition.
“Journal articles and books repeatedly focus on quantity and quality of food, feeding programmes, and issues of governance and rights,” they wrote in Economic and Political Weekly last month.
“Few if any references are made to insanitary practices and open defecation.”
That may be changing. A report on Thursday from the London School of Hygiene and Tropical Medicine and WaterAid found evidence of small but significant improvements in the growth of under-fives who have access to clean water and soap.
Researchers identified 14 studies conducted in low- and middle-income countries (Bangladesh, Cambodia, Chile, Ethiopia, Guatemala, Kenya, Nepal, Nigeria, Pakistan and South Africa) that provided data on the effect of sanitation programmes on the physical growth of 9,469 children.
The data suggests that interventions to improve household water quality and provide soap resulted in an average 0.5cm height growth in children under the age of five. The authors say access to clean water and soap is likely to have led to the increase in height because of the reduction in microbiological and parasitic infections.
“We typically think that providing clean water, sanitation and hygiene is an effective way to reduce the incidence and associated deaths from diseases such as diarrhoea – which remains the third biggest killer of under fives worldwide,” says Dr Alan Dangour, lead author, from the London School of Hygiene and Tropical Medicine.
“For the first time our analysis suggests that better access to these services may also have a small, but important impact on the growth of young children. While there are some important shortcomings in the available evidence base, we estimate that clean drinking water and effective hand washing could reduce the prevalence of stunting in children under the age of five by up to 15%.”
The question is how to improve sanitation. Merely building toilets is not necessarily the answer as more often than not they fall into disuse and disrepair. Community-led total sanitation (CLTS) concentrates on behaviour rather than facilities. Pioneered by Kamal Kar, a development consultant from India, with Village Education Resource Centre, a partner of WaterAid Bangladesh, CLTS seeks to mobilise the community through shock and disgust.
“The moment of ignition comes when people realise they’re eating each other’s shit,” says Chambers, a proponent of CLTS, who asserts that the approach has an influence out of all proportion to the money spent on it.
But CLTS takes time and is unlikely to find favour with donors in search of quick results or who prefer more technological approaches. CLTS has run into opposition from sceptics in senior government positions, along with those involved in large subsidy programmes and those who think CLTS can degenerate into coercion.
Whatever the merits or drawback of CLTS, there is a growing acceptance of the link between sanitation and nutrition.
“Until now, we have not had a demonstration of the direct nutrition impact of Wash interventions on nutrition,” says Dr Francesco Branca, director of nutrition for health and development at the World Health Organisation. “This review shows that a multi-pronged approach is the way to go – bringing together actions to improve food quality and safety as well as feeding and care of children, with others to prevent and treat infections and improve the home environment – to address the scourge of chronic malnutrition.”