A very recent paper (published 2 March 2016), published in the International Journal of Epidemiology, as highlighted in the Sanitation Updates, is attention-grabbing, and has a rather novel title: I get height with a little help from my friends: herd protection from sanitation on child growth in rural Ecuador.

Initially, I got a bit struck up with the term “herd protection,” – I thought it has something to do with animal herding. However, reading the paper made it clear.

This is the key message from the paper (abstract): “improved sanitation in one household may provide community-wide benefits if it reduces contamination in the shared environment. Sanitation at the household level is an important predictor of child growth, but less is known about the effect of sanitation coverage in the community.”

If there is improvement in sanitation in a house, people have tendency to link the benefits of improved sanitation within that particular household – benefits include stunting benefits. Generally, people do not vision benefits in the wider community.

The researchers took repeated anthropometric measurements on 1314 children under 5 years of age in 24 rural Ecuadorian villages, during the period 2008-2013. They investigated the association between sanitation coverage in surrounding households and child growth.

The researchers - from the Department of Epidemiology, University of Michigan; Center for Human Growth and Development, University of Michigan; Centro de Biomedicina-Carrera de Medicina, Universidad Central del Ecuador; and Department of Anthropology, Trinity College, Hartford, USA – found that the sanitation coverage in the surrounding households was strongly associated with child height, as those with 100% coverage in their surroundings had a 67% lower prevalence of stunting compared with those with 0% coverage.

Children from households with improved sanitation had a lower prevalence of stunting. When analyzing height as a continuous outcome, the protective effect of sanitation coverage is manifested primarily among girls during the second year of life, the time at which growth faltering is most likely to occur.

The study has important implications that received less attention in the past. The conclusions says it all:

“Study highlights that a household’s sanitation practices can provide herd protection to the overall community. Studies which fail to account for the positive externalities that sanitation provides will underestimate the overall protective effect.”

The paper is available at: ije.oxfordjournals.org/content/early/201...dyv368.full.pdf+html


F H Mughal

An informative post of Sanjay Wijesekera, Chief of Water, Sanitation and Hygiene, and Associate Director of Programmes at UNICEF, appeared in The Huffington Post on 14 Jan 2016 (www.huffingtonpost.com/sanjay-wijesekera...small_b_8980648.html)

Sanjay attributes stunting mainly due to poor sanitation – a lack of toilets, as he calls it.

“Open defecation has been a problem for a very long time in India. So common was the practice that almost 100 years ago Mahatma Gandhi urged his compatriots to stop it. It remains widespread to this day, practiced by 44% of the population in 2015. This runs to 569 million people, the highest number of people practicing open defecation of any country in the world. In part it is due to a lack of facilities, but not entirely. Significant numbers of Indians with toilets at home still defecate in the open."

Some of the points in the post are:

• There is open defecation in sub-Saharan Africa. Of the 700 million people in the region who do not have proper toilets around 230 million defecate in the open. What is different in India is the pervasiveness and the concentration of the practice.

• In India, a child is surrounded by feces. It is where babies crawl; where children play; where they eat; in the water they drink and bathe. It gets into their mouths; they ingest it from their own unwashed hands as well as those of their care-givers. And when it gets inside it does some very dirty work.

• Feces carry bacteria that in young children especially can lead to multiple episodes of diarrhea every year. Not only do these episodes prevent the retention of nutrients from food, we now know that they permanently alter the absorptive capacity of a child's guts, by lessening the number of the villi on intestinal walls which are meant to trap nutrients.

• Feces can also carry intestinal parasites - like hookworm, which causes anemia in pregnant women, leading to malnourished, underweight babies. These parasites rob infected children of even more nutrients.

• Stunting means children are not growing as they should, they are short and small for their age, and they can have permanent cognitive damage. That has implications on a country's economy. Stunted children grow up to be weaker and more susceptible to illness, bringing an extra burden to the public purse. They do less well in school, so they earn less as adults. The ramifications are far reaching.

• In India 4 out of 10 children under 5 years old are stunted. And around the world, 159 million children are stunted.


F H Mughal

According to an open-access, BMJ paper: Household sanitation and personal hygiene practices are associated with child stunting in rural India: a cross-sectional analysis of surveys - Jee Hyun Rah, Aidan A Cronin, Bhupendra Badgaiyan, Victor M Aguayo, Suzanne Coates, Sarah Ahmed – available at: bmjopen.bmj.com/content/5/2/e005180.full:

Improved conditions of sanitation and hygiene practices are associated with reduced prevalence of stunting in rural India. Policies and programming aiming to address child stunting should encompass WASH interventions, thus shifting the emphasis from nutrition-specific to nutrition-sensitive programming. Future randomised trials are warranted to validate the causal association (conclusions)

A nice catch phrase, the authors, all from UNICEF (India, Nepal and Jakarta), recommend shifting emphasis from nutrition-specific to nutrition-sensitive programming.

One would agree, when the authors say that improved sanitation and hygiene practices (I would add safe drinking water, as well) are associated with reduced cases of stunting.

F H Mughal

Ms. Geeta Rao Gupta, Deputy Executive Director, UNICEF, recently visited Pakistan. According to the news (Dawn, 9 March 2015, www.dawn.com), she said that there are 41 million people who do not have access to a toilet in Pakistan and as a result they are defecating in the open. Open defecation has significant health and nutritional consequences, Ms. Geeta Rao Gupta said.

She further said: “Open defecation is a major contributor to stunting and that’s why we’ve got to do all we can to stop it.” Pakistan is the third largest country when it comes to people going to the bathroom in the open, behind India and Indonesia. The problem can spread disease and lead to intestinal infections, which can contribute to stunting in young children, she said. Stunting means children don’t grow as tall as they would otherwise, and it can also affect a child’s brain development. Stunted children are more at risk of disease, don’t do as well in school and stunted mothers can also give birth to stunted children.

UNICEF is working with the Pakistani government to improve sanitation by doing things like encouraging people to wash their hands more often. They’re also working with communities to help them build toilets so they don’t have to use the bathroom in a field or elsewhere. Building more toilets is also vital for empowering women and girls and keeping them in school, Ms Gupta said. If women have to walk long distances to find a private place to relieve themselves, they are more vulnerable and exposed to attack. They’re also less likely to go to school if there are no toilets. “Having toilets is a big advantage to girls,” she said.

F H Mughal

Dear Alexandra,

Thank you for your inputs. Could you kindly send details of that sanitation conference?

Thanks,

F H Mughal

Dear F H Mughal,

thanks for sharing this very interesting report.

Here in Zambia 45 % of the children are stunnted according to the Living Conditions Monitoring Survey of the Government. A lack of food is usually not the cause, but rather malnutrition and diarrheal disease (and enteropaty?) mostly caused by poor sanitation.

I read the other threat on stunnting and tropical enteropaty with great interest as well.

Im looking for input to an conference on sanitation in Southern Africa. In case someone can recommend more experts (and especially one that speaks well) regarding the relation of stunnting and sanitation I would appreciate.

Many thanks,
Alexandra
This email address is being protected from spambots. You need JavaScript enabled to view it.

According to a recent World Bank report (How Much International Variation in Child Height Can Sanitation Explain? Dean Spears; Policy Research Working Paper 6351, February 2013), poor sanitation (open defecation), which is exceptionally widespread in India, can account for much or all of the excess stunting in India.

This is not only a startling finding, but, frankly, a finding that was least expected. This has major implications - one that should be an eye-opener for the decision-makers in developing countries.

In the context of sanitation, there are some already well-established facts and view-points. Guy Hutton has said that poor sanitation and water supply result in economic losses estimated at US$260 billion annually in developing countries, or 1.5% of their GDP. The benefits from meeting the water supply and sanitation (WSS) MDG targets combined equal over US$60 billion annually and combined WSS interventions have a US$4.3 return for every dollar invested.

Poor sanitation impacts wide-ranging sectors like women and child health, poverty, school education (girls’ drop-out at school is due to the non-availability of separate toilets for girls), diseases (principally, diarrhea, which kills thousands of children every day in developing countries), environment, wealth, equity, dignity, and the list goes on and on. In case of Sindh, Pakistan, a major impact of poor sanitation is on the welfare and safety of girls and women. Having no access to sanitation at homes renders women and girls most vulnerable to their personal security, when they move out at the dead of night to seek private locations.

Perhaps, referring to the Dean Spears’ findings, the Vice President of Sustainable Development at the World Bank, Rachel Kyte has said that poor sanitation is a major cause of diarrheal disease and there is increasing evidence of its link to childhood stunting, which deprives the poorest and most vulnerable from opportunities for a better life.

In Pakistan, the average height of male adults is, more or less, same as that of male adults in India. Open defecation is also common here in Pakistan. It would be interesting and helpful if the resourced persons from India, representing a range of sectors, give their views on the impact of poor sanitation on the height of children.

F H Mughal


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Note by moderator (EvM): Thank you. And here is the link:
econ.worldbank.org/external/default/main...58349_20130205082533

This sentence from the summary is remarkable:
Open defecation, which is exceptionally widespread in India, can account for much or all of the excess stunting in India.