Children's malnutrition linked to poor sanitation

He wore thick black eyeliner to ward off the evil eye, but Vivek, a tiny 1-year-old living in a village of mud huts and diminutive people, had nonetheless fallen victim to India’s great scourge of malnutrition.

His parents seemed to be doing all the right things. His mother still breast-fed him. His family had six goats, access to fresh buffalo milk and a hut filled with hundreds of pounds of wheat and potatoes.

The economy of the state where he lives has for years grown faster than almost any other.

His mother said she fed him as much as he would eat and took him four times to doctors, who diagnosed malnutrition.

Just before Vivek was born in this green landscape of small plots and grazing water buffalo near the Nepali border, the family even got electricity.

It is a question being asked about children across India, where a long economic boom has done little to reduce the vast number of children who are malnourished and stunted, leaving them with mental and physical deficits that will haunt them their entire lives.

Now, an emerging body of scientific studies suggest that Vivek and many of the 162 million children under the age of 5 in the world who are malnourished are suffering less a lack of food than poor sanitation.

New research on malnutrition, which leads to childhood stunting, suggests that a root cause may be an abundance of human waste polluting soil and water, rather than a scarcity of food.

Like almost everyone else in their village, Vivek’s family have no toilet, and the district where they live has the highest concentration of people who defecate outdoors.

As a result, children are exposed to a bacterial brew that often sickens them, leaving them unable to attain a healthy body weight .

“These children’s bodies divert energy and nutrients away from growth and brain development to prioritize infection-fighting survival,” said Jean Humphrey, a professor of human nutrition at Johns Hopkins Bloomberg School of Public Health.

“When this happens during the first two years of life, children become stunted. What’s particularly disturbing is that the lost height and intelligence are permanent.”

Two years ago, Unicef, the World Health Organization and the World Bank released a major report on child malnutrition that focused entirely on a lack of food.

Sanitation was not mentioned. Now, Unicef officials and those from other major charitable organizations said in interviews that they believe that poor sanitation may cause more than half of the world’s stunting problem.

“Our realization about the connection between stunting and sanitation is just emerging,” said Sue Coates, chief of water, sanitation and hygiene at Unicef India.

“At this point, it is still just an hypothesis, but it is an incredibly exciting and important one because of its potential impact.”

This research has quietly swept through many of the world’s nutrition and donor organizations in part because it resolves a great mystery: Why are Indian children so much more malnourished than their poorer counterparts in sub-Saharan Africa?

A child raised in India is far more likely to be malnourished than one from the Democratic Republic of Congo, Zimbabwe or Somalia, the planet’s poorest countries.

Stunting afflicts 65 million Indian children under the age of 5.

This disconnect between wealth and malnutrition is so striking that economists have concluded that economic growth does almost nothing to lessen malnutrition.

Half of India’s population, or at least 620 million people, expels waste outside. And while this share has declined slightly in the past decade, an analysis of census data shows that rapid population growth has meant that most Indians are being exposed to more human waste than ever before.

In Sheohar, for instance, a toilet-building programme between 2001 and 2011 decreased the share of households without toilets to 80 per cent from 87 per cent, but population growth meant that exposure to human waste rose by half.

“The difference in average height between Indian and African children can be explained entirely by differing concentrations of open defecation,” said Dean Spears, an economist at the Delhi School of Economics. “There are far more people defecating outside in India more closely to one another’s children and homes than there are in Africa or anywhere else in the world.”

Not only does stunting contribute to the deaths of a million children under the age of 5 each year, but those who survive suffer cognitive deficits and are poorer and sicker than children not affected by stunting.

They also may face increased risks for adult illnesses like diabetes, heart attacks and strokes.

Loss of human potential

“India’s stunting problem represents the largest loss of human potential in any country in history, and it affects 20 times more people in India alone than HIV/AIDS does around the world,” said Ramanan Laxminarayan, vice president for research and policy at the Public Health Foundation of India.

India is an increasingly risky place to raise children.

The country’s sanitation and air quality are among the worst in the world. Parasitic diseases and infections like tuberculosis, often linked with poor sanitation, are most common in India. More than one in four newborn deaths occur in India.

Human waste surrounds parks and lines roads and train tracks. Women in rural areas wait until dark to relieve themselves outside, leaving them vulnerable to rape.

In the darkness, some say they sometimes set down young children in others’ waste or step in it themselves.Open defecation has long been an issue in India.

Some ancient Hindu texts advised people to relieve themselves far from home, a practice that Mahatma Gandhi sought to curb.

“The cause of many of our diseases is the condition of our lavatories and our bad habit of disposing of excreta anywhere and everywhere,” Gandhi wrote in 1925.

Other developing countries have made huge strides in improving sanitation. Just 1 percent of Chinese and 3 percent of Bangladeshis relieve themselves outside compared with half of Indians.

Attitudes may be just as important as access to toilets. Constructing and maintaining millions of toilets in India would cost untold billions, a price many voters see no need to pay — a recent survey found that many people prefer going to the bathroom outside.

India’s government has for decades tried to resolve the country’s stubborn malnutrition problems by distributing vast stores of subsidized food.

But more and better food has largely failed to reverse early stunting, studies have repeatedly shown. India now spends about $26 billion annually on food and jobs programmes, and less than $400 million on improving sanitation — a ratio of more than 60 to 1. “We need to reverse that ratio entirely,” Dr. Laxminarayan said.

Better sanitation in the West during the 19th and early 20th centuries led to huge improvements in health long before the advent of vaccines and antibiotics, and researchers have long known that childhood environments play a crucial role in child death and adult height.