Improving Sanitation Indicators Can Lead To Better Nutrition Outcomes

Sanitation and health are closely interlinked. An unhealthy and unsanitary environment leads to frequent diarrhoea or other diseases associated with unclean water, which in turn leads to a loss of appetite, with nutrients not being absorbed properly, and chronic anaemia. The World Health Organization estimates that as much as 50 per cent cases of children affected by undernutrition are associated with poor water, sanitation and hygiene (WASH) practices.

 The role that good sanitary practices play in creating better nourished communities is a logical corollary and studies have shown that proper sanitation, hygiene and safe drinking water have many positive effects on health and nutrition.

 The historical linkage between sanitation and nutrition can be reviewed through three closely interrelated occurrences – diarrhoeal diseases, environmental enteropathy and nematode infections. Each leads to the other and the final result is most often death.

 In a low income country like India, large parts of the population – rural or urban – still live under primitive conditions with little or no access to proper sanitation and water. Diarrhoeal diseases mainly occur as a result of faecal matter lying out in the open and not being disposed off in a correct and timely manner. This is still a common sight in most Indian villages and a large number of city slums where the only form of sanitation available is common use toilets, which are either too few or unusable and hence the need to defecate in the open.

 Compounding this is the fact that mothers who are the primary care givers often due to a lack of water may end up wiping their hands with paper or rub them with mud instead of cleaning them with water and soap post cleaning the child, thus increasing the possibilities of the household becoming contaminated with pathogen-ridden human faeces. These pathogens transmitted through the faecal-oral route cause diarrhoeal diseases. 

 Repeated infection with diarrhoeal diseases contributes to chronic malnutrition by inhibiting intestinal absorption of nutrients and is strongly correlated with stunting. Undernutrition in turn increases the susceptibility to infectious diseases, such as diarrhoea, thus perpetuating a somewhat vicious circle. Chronic diarrhoea leads to Environmental Enteropathy (EE), which is the subclinical condition of the small intestines resulting from the ingestion of faecal bacteria, and which increases gut permeability and malabsorption of nutrients, leading to stunting.

 For infants, particularly those under six months of age, diarrhoea can cause permanent damage to intestinal development, reducing a child's ability to absorb nutrients. The World Health Organization has declared that approximately 50% of malnutrition cases occur on account of repeated diarrhoea or intestinal worm infections, which occur as a direct result of inadequate water, sanitation and hygiene.

 As per research, subclinical infections from environmental enteropathy as a result of malnutrition lowered resistance to infection and caused death due to diarrhoea and other infections.

 The third direct pathway between poor sanitation and bad nutritional outcomes concerns Soil-transmitted Helminth (STH) infections, such as Hookworm, Ascaris Lumbricoides and Trichuris Trichiura. These infections result in the malabsorption of nutrients and growth retardation. The majority of worm-related infections are transmitted via contact with or consumption of soil contaminated with human faeces containing worm eggs. Improved sanitation, by reducing the presence of faeces in an individual’s environment, can assist in curbing transmission of STH infections.

 Studies have found that access to sanitation is associated with decreased likelihood of infection with any STH, and specifically with Ascaris Lumbricoides and Trichuris Trichiura (Strunz et al., 2014), while other studies have found that availability and use of latrines reduces the risk of STH infection by roughly 50 per cent (Ziegelbauer et al., 2012).

 In summary and based on several research indicators, child health and nutritional indicators can be significantly influenced by a sanitation programme such as Swachh Bharat Mission (SBM). Its main objective is to secure an Open Defecation Free environment, where there is no faecal contamination of the surface water and surface soil. It can be achieved not only through access to toilets and their usage, but also through safe disposal of the faecal waste.

 Cross sectoral collaboration by establishing common platforms for knowledge sharing, including nutritional targets in WASH goals and vice vera and establishing joint indicators to monitor progress are among the most basic but transparent ways to ensure sustainable solutions.

 The work currently being undertaken under SBM2 where the main objectives of the programme are building sustainable solid and liquid waste management systems both in rural and urban India are the first steps towards creating a healthy environment for future generations. This programme can be easily enhanced to include the cross linkages with nutritional goals so as to ensure the future health of civilisation as well.

 (Natasha Patel is  CEO, India Sanitation Coalition, FICCI. She focuses on bringing together investors, grantees and intermediaries, including the government agencies, to enhance private sector funding in water, sanitation and hygiene (WASH) initiatives.)