Ramanan Laxminarayan says undernutrition impairs brain development, contributing to delayed school enrolment, poor school performance, and lower learning outcomes Image Credit:

Despite enjoying better economic advantages and greater access to nourishing food, why are children across India more malnourished and consequently shorter than those of their poorer counterparts in Sub Saharan Africa? Genetic differences do not provide any conclusive answer, assert economists. Instead, this puzzling phenomenon, referred to as the Asian enigma, indicates that impressive economic growth and reduced poverty have not translated into improved nutrition for children in the South Asian region.

Stunting, or a child’s low height for age, is often caused by chronic malnutrition, and the primary cause of malnourishment was thought to be lack of access to highly nutritious foods and insufficient food intake. However, consumption of adequate nutrient-rich food has not been able to fully explain the missing pieces of this puzzle. A new study published last year now suggests that it is poor sanitation, and particularly open defecation, that is causing stunted growth among Indian children.

Authored by Dean Spears, an economics PhD candidate at Princeton University and visiting researcher at the Delhi School of Economics, along with Arabinda Ghosh, an Indian Administrative Service official, and Oliver Cumming of the London School of Hygiene and Tropical Medicine, the results of the study also state that the proportion of malnourished children in India is nearly double that in the Sub Saharan region.

According to a World Health Organisation (WHO)/United Nations Children’s Fund (UNICEF)/World Bank joint monitoring report of 2012, of the 1.1 billion people who practice open defecation, India accounts for nearly 600 million. Comparing India and China, the two countries with populations of more than a billion each, WHO statistics suggest that while in China 1 out of every 100 people defecates in the open, the comparative ratio in India is the highest in the world — 1 in every 2 people.

That stunting takes a toll on human health is a validated fact but, according to Prof Ramanan Laxminarayan, vice president for research and policy at the Public Health Foundation for India (PHFI), there are many underlying causes of stunting and “the contribution of open defecation per se, to stunting is still unclear. Open defecation is one manifestation of the problem of lack of sanitation. There are families with toilets that are not maintained or used. Moreover, having a toilet without adequate treatment of sewage does not solve the sanitation problem.”

India loses each day, on average, 1,000 children below the age of five due to diarrhoea, hepatitis-causing pathogens and other sanitation-related diseases, says the UNICEF.

As 44 per cent of mothers dispose of their children’s faeces in the open, the risk of microbial contamination of water escalates, causing frequent diarrhoea episodes. This makes children more vulnerable to malnutrition, stunting, and infections such as pneumonia.

“Worldwide, under-nutrition is responsible for one-third of child deaths, directly or through diseases made more severe because of it,” says Prof Laxminarayan. “Even mildly underweight children have nearly double the risk of death of well-nourished children, including deaths from such treatable diseases as diarrhoea, malaria, and acute respiratory infections.”

The risk of death is also double among low birth-weight infants (less than 2.5 kilograms) when compared to normal birth-weight infants. What is worth noting is that these children are also at higher risk of non-communicable diseases in adulthood. “There is increasing evidence that low birth weight and early-life under-nutrition increases the risk of chronic diseases such as diabetes and heart disease,” he adds.

Stunting poses the largest loss of human potential, continues Prof Laxminarayan, explaining: “Undernutrition impairs brain development and cognitive abilities, contributing to delayed school enrolment, higher drop-out rates, poor school performance, and lower learning outcomes. This is because, on average, undernourished children attain fewer years of schooling and also learn lesser per year in school relative to their healthier counterparts. Stunting therefore limits both educational and economic performance.”

The low nutritional levels of a country tend to have a great impact on its rate of economic growth and in India, sanitation and hygiene-related issues are trimming its GDP growth considerably and preventing the nation from reaching full potential. A 2006 World Bank report estimates that the result is a reduced productivity of the workforce causing India to lose 6.4 per cent of its GDP annually.

According to Prof Laxminarayan, “Studies show that stunting deficits in adults lead to an estimated loss of about a fifth of adult annual income. In a country like India where almost 61 million children under the age of five are stunted as of 2005-06, this estimated loss in adult productivity has significant implications for overall economic growth and development of the country as well.”

This does not augur well for a nation that is home to one in every three malnourished children in the world.

Quoting the most recent data from UNICEF, Prof Laxminarayan highlights that 39 per cent of Indian children under the age of five are stunted, that is too short for their age; and 15 per cent are wasted or have abnormally low weight for their height. “The decline in these indicators has been slow despite rapid economic growth over the last two decades and India still lags behind Bangladesh and some countries in Sub-Saharan Africa that are poorer and less developed in comparison,” he states.

There is growing evidence that environmental threats to early life health have long-term consequences on physical growth and cognitive development in adults. As Prof Laxminarayan explains, “Medical and epidemiological studies have shown that poor sanitation can be linked to poor health and early life cognitive development through a disorder known as environmental enteropathy (EE). This is an intestinal disorder caused by continued faecal exposure which reduces the small intestine’s ability to absorb nutrients, even without necessarily manifesting as diarrhoea.”

He adds: “Recent studies evaluating the Indian government’s rural sanitation programme called the Total Sanitation Campaign (TSC) have found that early life exposure to improved sanitation through TSC has reduced infant mortality and improved children’s height and has additionally caused an increase in cognitive achievement among 6-year-olds.”

Acknowledging that lack of sanitation is one of the important contributing factors of stunting, he argues that as there are several other underlying causes for it, “there is no single bullet” to overcoming this public issue in India. Tackling stunting, according to Prof Laxminarayan, “requires a multi-sectoral approach that includes strengthening direct nutrition-specific interventions that improve exclusive breastfeeding and encourage complementary feeding of young children. Focus should also be given to nutrition-sensitive actions that improve women’s education, food security, access to health services and maternal education.”

India’s high population density poses an additional challenge for sanitation policy towards issues such as open defecation because faecal germs are more easily transmitted in areas of high density. More people in India are exposed to human waste than ever before as open defecation severely impacts everyone who is exposed to it — even households that do not observe this practice.

“Children living in more populous areas are more likely to be exposed to other people’s faecal germs, thus increasing the costs of open defecation for health and human capital,” he says. “For instance, 25 per cent of under-5 children in the wealthiest income quintile in India are stunted so malnutrition goes well beyond food security and calorie consumption.”

With his “toilets first, temples later” pre-election agenda and the launch of Swachh Bharat Abhiyan or Clean India Campaign on October 2 this year, Indian Prime Minister Narendra Modi has made sanitation in the country a public issue. While it may seem that the woeful sanitation issues across the nation are finally getting the traction they deserve, there is no denying that the challenge of implementation is going to be humongous. Incidentally, the investment on improving sanitation in India has until now been at least 60 times lower than its annual spend on food programmes.

Calling the practice of open defecation a “blot on the society”, Modi said the goal would be to eliminate this unhealthy practice by 2019, the year that marks the 150th birth anniversary of Mahatma Gandhi, India’s foremost freedom struggle icon.

Declaring that sanitation is more important than political independence, Gandhi, a staunch hygiene and cleanliness enthusiast, wrote in the “Navajivan” weekly in 1925: “The cause of many of our diseases is the condition of our lavatories and our bad habit of disposing of excreta anywhere and everywhere.”

Making cleanliness and sanitation a national priority, the Government of India has now promised a toilet in each household in both rural and urban areas by 2019. But will the construction of toilets alone solve India’s sanitation problem?

Building new toilets is not enough, opines Prof Laxminarayan. “More bang for the buck would be around promoting toilet use, upkeep and maintenance, and hygiene practices. In general we have a blind spot for sanitation and the revealed preference for open defecation even by those who own a fully functional toilet is indicative of that.”

While he feels that the target of a clean India by 2019 is not easy to achieve, he is confident that it is certainly a step towards improving the sanitation situation in India.

“Merely building toilets is not a panacea to India’s manifold health problems,” he reiterates. “We know that toilet access is not the same as toilet use. There has to be massive efforts around behaviour change and communication regarding toilet use and other hygiene practices around hand washing, waste management, disposal of children’s stools, menstrual hygiene and so on. While meeting toilet construction targets may be an easier goal to push and achieve through monetary incentives, government subsidies, and the recent social responsibility initiatives by corporates, changing people’s behaviour and mindsets around sanitation poses a bigger challenge for policymakers.”

Sangeetha Swaroop is a writer based in Dubai.