Friday, Sep 30, 2022

To tackle nutrition challenges, we must also address sanitation issues

B Sesikeran writes: According to the World Health Organisation, 50 per cent of all malnutrition can be traced to diarrhoea and intestinal worm infections, caused by poor water, sanitation and hygiene.

In simple terms, environmental enteropathy is a disorder of the intestine which prevents the proper absorption of nutrients, rendering them effectively useless.

In the 75th year of Independence, India has a lot to rejoice about and a lot to reflect on. We have overcome two crushing Covid-19 waves. However, more than four lakh people have died from the disease. Thousands of children have been orphaned and thousands more are suffering from a lack of basic facilities. Of all the problems confronting the youth, nutritional insecurity is the worst, holding the power to cripple the future of an entire generation. A recent UNICEF report stated that nearly 12 lakh children could die in low-income countries in the next six months due to a decrease in routine health services and an increase in wasting. Nearly three lakh such children would be from India — nearly as much as the countrywide death toll from Covid-19. If this challenge has to be mitigated, India must use the pandemic as an opportunity to come up with long-term multi-stakeholder solutions to the problem of nutrition in the country.

The National Family Health Survey (NFHS 5) indicates that since the onset of the pandemic, acute undernourishment in children below the age of five has worsened, with one in every three children below the age of five suffering from chronic malnourishment. According to the latest data, 37.9 per cent of children under five are stunted, and 20.8 per cent are wasted — a form of malnutrition in which children are too thin for their height. This is much higher than in other developing countries where, on average, 25 per cent of children suffer from stunting and 8.9 per cent are wasted. Inadequate dietary intake is the most direct cause of undernutrition. This, however, is the most obvious cause of the problem. Several other factors also affect nutritional outcomes, such as contaminated drinking water, poor sanitation, and unhygienic living conditions.

According to the World Health Organisation, 50 per cent of all mal- and under-nutrition can be traced to diarrhoea and intestinal worm infections, which are a direct result of poor water, sanitation and hygiene. Nutrition and water, sanitation, and hygiene (WASH) are intricately linked, and changes in one tend, directly or indirectly, to affect the other. The global nutrition community has long emphasised this interdependence, suggesting that greater attention to, and investments in, WASH are a sure-shot way of bolstering the country’s nutritional status. In India’s case, in particular, with its population of more than a billion people, both WASH and nutrition must be addressed together through a lens of holistic, sustainable community engagement to enable long-term impact.

The realisation that most cases of malnutrition cannot be explained by poor diet led researchers to re-examine other possible sources of the problem, including the longstanding suspicion that unsanitary living environments lead to chronic gut injury. One of the first instances of the link between WASH and nutrition appeared in the Convention on the Rights of the Child in 1989, which urges states to ensure “adequate nutritious foods and clean drinking water” to combat disease and malnutrition. In 2015, Jean H. Humphrey from the Johns Hopkins Bloomberg School of Public Health highlighted that poor hygiene and sanitation in developing countries leads to a sub-clinical condition called “environmental enteropathy” in children, which causes nutritional malabsorption and is the source of a variety of problems, including diarrhoea, retarded growth and stunting.

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In simple terms, environmental enteropathy is a disorder of the intestine which prevents the proper absorption of nutrients, rendering them effectively useless. Since the disorder was intricately connected to the poor environmental conditions its victims lived in, it came to be called “environmental enteropathy”. Diarrhoeal diseases, intestinal parasite infections and environmental enteropathy together impact the normal growth and cognitive development of children, leading to anaemia, stunting, and wasting. Childhood diarrhoea is a major public health problem in low- and middle-income countries, leading to high mortality in children under five. According to NFHS 4, approximately 9 per cent of children under five years of age in India experience diarrhoeal disease.

Safe drinking water, proper sanitation and hygiene can significantly reduce diarrhoeal and nutritional deaths. On the one hand, poor WASH facilities exacerbate the effects of malnutrition. But, on the other hand, pre-existing micronutrient deficiencies exacerbate children’s vulnerability to WASH-related infections and diseases. WHO has estimated that access to proper water, hygiene and sanitation can prevent the deaths of at least 8,60,000 children a year caused by undernutrition. It’s evident that there is a direct, and irrefutable, correlation between sanitation and nutrition, and the sooner we acknowledge it, the faster we can work towards fixing it.

With the onset of Covid-19, proper hygiene and sanitation measures have assumed even greater importance. A simultaneous approach to nutrition and WASH will not only aid India’s fight against malnutrition, bolster Covid resilience amongst the most vulnerable sections of society but also safeguard against monsoon-related health challenges. This will require a coordinated, multisectoral approach among the health, water, sanitation, and hygiene bodies, not to mention strong community engagement. An integrated approach to nutrition and WASH at the individual, household, and community levels along with Covid management will serve to tackle the problem of mal- and under-nutrition from the ground up, building awareness and accelerating implementation of clean and safe living strategies.


At the end of the day, all sides are working towards a common goal: A safe and healthy population and the hope that the 75th year of Independence becomes a watershed moment in India’s journey.

This column first appeared in the print edition on September 6, 2021 under the title ‘The nutrition-hygiene link’. The writer is former director, ICMR- National Institute of Nutrition

First published on: 06-09-2021 at 03:01:15 am
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