Stunting in India: The sanitation connect
India has the highest number of stunted children worldwide. Not just toilet numbers, but poor toilet use and hygiene behaviour too need urgent redressal at the policy level to reduce stunting.
Rally on nutrition awareness by Jeebika Suraksha Manch, Odisha (Source: Amir Khan)

On Children’s Day on November 14 this year, two organisations in Odisha--Shramajeebee Sangathan (SJS), Malkangiri and Jeebika Suraksha Mancha, Kandhamal--organised a massive padayatra (street walk) in villages as an awareness drive and to mobilise communities to curb malnutrition deaths among children below five years of age in the region.

“My 5-year-old son Sibant died last year due to recurrent diarrhoea. We spent more than Rs 50,000 on private medical services and ran pillar to post to save him but whenever we brought him home from the hospital, his health deteriorated within a few days. Finally, he died. Doctors said that the reason for my son’s death was contaminated water and malnutrition,” says 38-year-old Lunjari Mallik of Padapadar village of Kandhamal district. 

“In the Kandhamal district alone, 3,000 infants died in the last five years from malnutrition. The situation is worse in Malkangiri which ranks among India’s top 15 districts where one-third of the child population under five years of age suffers from wasting, stunting and low weight, mainly from under-nutrition,” says Amir Khan, a researcher and human rights activist working with Atmashakti trust in Odisha.
In fact, according to a recent WaterAid report (2016), India, with 39 percent of its children stunted, features on the list of top 10 countries with the most number of stunted children [1]; this is, despite the impressive economic growth rate of the country in comparison to other South Asian countries on the list such as Pakistan and Bangladesh.

Among the states in India, Uttar Pradesh, Bihar, Jharkhand, and Meghalaya show the highest prevalence of stunting with more than 40 percent of children afflicted by it while Odisha has 38.2 percent of its children affected by stunting [2].

What is stunting?

Stunting is a serious form of malnutrition or chronic undernutrition during the most critical periods of growth and development of children. It is characterised by low height for age and is caused mainly due to insufficient nutritional intake often triggered by recurrent infections such as diarrhoea [3].

Stunting can have serious consequences and can lead to long-lasting harmful effects such as diminished mental ability and learning capacity and poor performance at school. This results in poor earnings in adulthood; they are also at increased risks of nutrition-related chronic diseases, such as diabetes, hypertension, and obesity [4].

What are the causes of stunting?

Although nutritional status of the mother before and during pregnancy and chronic hunger among children during their growing years are primary determinants of stunting in children, environmental factors such as lack of availability of clean water, poor sanitation and hygiene practices also play a part because they could lead to infections such as diarrhoea [4].

As high as a quarter of the cases of stunting are linked to chronic diarrhoea among children in the first two years of life [4]. India registers the third highest proportion of child deaths caused by diarrhoea in South Asia [5] and diarrhoeal diseases are the most prevalent of all waterborne diseases in the country [6].

Water, sanitation and stunting

Household water, sanitation and hygiene (WASH) practices play a huge role in stunting in India. Though India appears to fare better than other countries with high stunting rates in the coverage of safe water [1], according to a Water Aid (2016) report, this coverage is exaggerated as the census (2011) considers supply from hand pumps and tube wells as safe notwithstanding the fact that most of these sources are found to be carriers of water-borne diseases [7].

Although the coverage of safe drinking water has increased according to government figures, only 43.5 percent of this is tap water of which only 32 percent is treated according to the Census 2011 figures. According to Census 2011, 22 percent rural households have to travel long distances to get water as compared to 9.4 percent in urban areas [9]. Poor quality and availability of water can have a significant impact on sanitation and hygiene behaviour in populations affecting handwashing practices and toilet use.

India is the worst performer in terms of sanitation coverage as compared to other countries with almost half of the households in the country not having access to toilets. India has the highest number of people practising open defecation in the world at 49.8 percent [9]. In sanitation, India lags behind South Asian countries like Bangladesh and Pakistan which are not as progressed as India economically [1].

The link between poor sanitation and stunting

A number of studies have found the connection between poor sanitation and stunting among children in India. A multicountry study by Danaei et al (2016) of 137 developing countries found that poor sanitation is one of the important factors affecting stunting among children in South Asia, second only to poor nutrition and care in the foetal stage [10].

A study by Spears et al (2013) that looked at the prevalence of stunting in 112 districts of India found that open defecation is an important factor influencing stunting among children in different districts preceding factors such as maternal education, calorie intake, socio-economic status, etc [11].

A recent study by Rah et al (2015) found that improved conditions of sanitation and hygiene such as access to toilets and hygiene behaviour such as handwashing practices after defecation led to the reduction in the prevalence of stunting among children in India [12].

Dr Angeline Jeyakumar, a faculty at the School of Health Sciences, University of Pune who has conducted research on community nutrition in urban and rural areas of Maharashtra emphasises the role of poor drinking water quality, poor handwashing practices among mothers, poor sanitation leading to open defecation practices in increasing the risk of frequent infections and poor growth among children in low-income settings.

Dr Angeline adds, “Open defecation, poor garbage and sewage disposal mechanisms result in unhygienic surroundings. Infants and young children can ingest large quantities of faecal bacteria through their contaminated hands or toys while playing in the surroundings. This can lead to intestinal infections which could result in a dip in the growth.”

In a study by Ghosh A et al  (2014) comparing stunting in West Bengal in India to that of the neighbouring country Bangladesh which is similar to West Bengal in population as well as in socio-cultural factors, it was found that though India is doing better economically, it has more cases of stunting than Bangladesh. This is mainly due to poor sanitation practices and higher open defecation rates as well as a lack of adequate maternal nutrition in the country [13].

Looking beyond toilet numbers to deal with stunting

India has identified sanitation as one of its important priorities in recent years. The Swacch Bharat Mission that focuses on toilet construction, however, has achieved limited success. Though the Swachh Bharat (Gramin) website reports an increase in the total percentage of household toilets constructed--from 42.02 percent in 2014 to 56.85 percent as on November 15, 2016--questions still remain about their acceptance and continued usage [14], emphasising on the need to consider a range of infrastructural, technological and user factors while ensuring toilet use.

Dr Yogesh Jain, a paediatrician and researcher from Jan Swasthya Sahayog, Chattisgarh says, “Although sanitation is an important concern, the narrow view of looking at sanitation and stunting at the policy level (sic) and the focus on toilet building as the solution without addressing broader issues of poverty and food provision for which the state has a responsibility, will not solve the issue".

Dr Jain adds, “The state should first ensure adequate and diversified food for all. Also, putting all the responsibility on people’s behaviour for poor sanitation will not help unless broader poverty and infrastructure-related issues like access to water, poor sewage disposal mechanisms, availability of user-friendly and appropriate technologies are dealt with while addressing poor sanitation outcomes in the country”.

Although improving sanitation is an important concern that needs to be addressed while looking at issues related to stunting, emphasis needs to be not on increasing the number of toilets, but on redressal of factors leading to poor toilet use and hygiene behaviour among people. At the same time, issues related to poverty, lack of food and hunger affecting children also need urgent redressal at the policy level.

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