By Aakash Mehrotra
Chandan reaches out for his mother’s breasts, as she rests him on her knees. Famished, the 8-month-old cries of hunger. Malnourished, he has no strength. His mother’s breasts have gone dry. His hair is golden brown, dry and patchy. His eyes are sunk and still, and his legs are as weak as twigs. His protruding belly is evident. Ironically, his mother supplements breast milk with eggs, fruits and rice water. But, the extra food just doesn’t help.
Even after populist schemes have pumped large amounts of money to solve malnutrition, far in the hinterlands, infants let out a dry, incessant cry from their mother’s lap. In a sense, the schemes stand synonymous to ‘lean and mean’.
The anganwadis are witness to the chilling silence of these children, who come to the centre, eat their food, never demand more and lie down waiting for their mothers. This is a weak, silent, diarrheal and malnourished generation; brazenly staring at us. They are not hungry. They are malnourished.
Much of what we read on malnutrition focuses on food security and the related issues of availability, access and affordability. It is not the lack of empathy that makes malnutrition an unsolvable issue. It is the complexity of the problem itself. Malnutrition is not just a question of health and equity. There are some finer linings to it, which remain unappreciated. The problems do not exist in silos, and so, neither do their solutions. Instead, answers must be found in the broader framework of wider thoughts and practices. The solutions lie within the larger settings of systems and structures. While the broad concepts do loosely include social and cultural themes, the issues of micronutrients’ absorption and safe sanitation, are frequently overlooked or under-emphasized.
The Defecation Crisis
India is reeling under an unfavourable crisis, with regards to the number of people practising open defecation. Of the 1.1 billion people worldwide, who defecate openly, nearly 60 percent live in India. More than half of the population of India adds to this global statistic. These numbers are corroborated by the 2011 census. It found that 53.1 percent of all Indian households and 69.3 percent of rural households do not use any kind of toilet or latrine. In fact, open defecation is more common in India than in most of the poorest sub-Saharan countries.
Interestingly, up to 30 percent of all malnutrition problems can be tackled by just improving environmental health. Diarrhoea, by far, claims the most number of lives of children up to 5 years of age. Approximately 860,000 of these malnutrition-related deaths of under-fives are induced by unsafe water, sanitation, and hygiene. A study of two-year-olds showed that the probability of stunting increases by 2.5%, per episode of diarrhoea. Further, 25% of all stunting could be attributed to having five or more episodes of diarrhoea. This provides substantial evidence to answer the infamous ‘Asian enigma’ of short heights.
Still, this is just the tip of the iceberg. There are deeper questions we need to dig into and answer, to understand the complexity of malnutrition. Dunn Nutrition Laboratory has been undertaking research with Gambian children for the last two decades.They recorded a big drop in diarrheal rates in these 20 years, without any major change in stunting. They recognize that understanding malnutrition involves far more than just adequate diet and diarrhoea. There are variables that are still hidden and unflagged. The two maps—one of malnutrition and the other of lack of sanitation—overlap. A profound appreciation of this intersection opens up deeper questions.
The lack of basic toilet infrastructure and the practice of open defecation in India are leading to a problem of ‘Environmental Enteropathy’. In simple words, it refers to intestinal diseases caused by poor environmental conditions. It specifically refers to infections through faecal contamination. The issue of environmental enteropathy has gained importance in the last two decades. It was brought to the fora when the American soldiers, stationed in Vietnam and as Peace corps in Pakistan, developed intestinal disorders. Interestingly, the effect was completely reversed when they changed their base station to the USA. The tropical enteropathy was then attributed to environmental conditions.
While Environmental Enteropathy is reversible in adults, it is found to have a life-lasting impact on children. Shockingly, about 60 percent of children in India suffer from some form of environmental enteropathy. To quote the medical definition, “EE is a persistent subclinical condition in which infections damage and reduce the absorptive capacity of the gut and, at the same time, make it permeable so that nutrient energy has to be continuously diverted to make antibodies to fight the infection.”
Thus, securing food to the malnourished would fail to eradicate the deficiency, if the body suffers from some form of enteropathy.
The present infrastructure in India, however, doesn’t present a possibility to turn the coin in favour of better sanitation. The country lags far behind its targets. The unplugged sanitation problem takes a heavy toll through faecal infections. The fact that 200 million, of the 700 million children worldwide suffering from hookworms – a gut parasite, are from India is shocking. Duncan Mora et al., in their paper ‘Sanitation and Health’, state that one gram of fresh faeces from an infected person can contain around 106 viral pathogens, 106–108 bacterial pathogens and 100–104 helminth eggs. This is enough to make a child sick and prone to enteropathy. Furthermore, the fact that exposure to faecal infections is a daily routine for children in rural set-ups and urban slums is a huge cause for worry.
Sanitation—The Hidden Answer?
Not having safe sanitation is invidiously leading up to one of the world’s deadliest crisis. Today, more than a third of the world’s children are infected with intestinal nematodes. A cluster randomised study, that was taken up in slums of Lucknow, demonstrates that five 6-monthly rounds of single-dose anthelmintic treatment, for malnourished children between 1 and 5, results in substantial weight gain. Similar studies done in Africa buttress this hypothesis. Deworming drugs are almost irresistibly affordable. A dose of benzimidazoles costs only Rs. 1, while Rs. 10 is needed to buy an average dose of praziquantel. Deworming has immense economic benefits which would even be difficult to measure.
Dr Shally Awasthi’s (Head of paediatrics, KGMC Lucknow – http://indianpediatrics.net/jan2000/orig1.htm) study shows that a six-monthly deworming exercise was able to substantially reduce stunting. Additionally, dewormed children showed a 35% increase in weight, that amounts to a gain of nearly 1 kg. The study also put forth the fact that deworming can reduce child mortality by up to 10%. Dr Abhijeet Banerjee (Professor of Economics at the Massachusetts Institute of Technology) had conducted similar randomised controlled studies to link deworming with the cognitive behaviour of pre-school children.
Both, the present and past Prime Ministers, have termed malnutrition as the country’s ‘biggest shame’. As it turns out, proper sanitation might actually be the answer to finally eradicating malnutrition.
Traditionally, sanitation has been eyed as a logistics issue – a domain of engineers. Yet, sanitation underpins all development efforts and is a domain well traversed by health professionals and engineers. The World Bank ranks hygiene promotion as the most cost-effective public health intervention.
The Next Step Forward
Our pace in ensuring sanitation has been slow. However, some acceleration can be seen after the war bugle was sounded by Narendra Modi. Over the last 20 years, various governments have spent $1,500,000 million to over 700 million people in 1.5 million rural habitations. They achieved sanitation coverage in 31 percent of the rural households. Puff! Sounds enormous. But, less than 11 percent of Gram Panchayats were able to receive the ‘Nirmal Gram Puraskar’ status for their villages. As a result, the ‘money going down the drain’ theory was confirmed. Ministry reports show that, since 2014, there has been an 11% increase in toilet construction and over 65,000 villages (10% of total villages) have declared themselves ‘open defecation free’. Despite these numbers, there are still roadblocks. While Sikkim achieved the 100% ‘open defecation free’ status in 2012, Bihar lags way behind with only 25% coverage.
With the assistance of the World Bank, the Ministry is developing a dedicated National Program for Rural Water Supply and Sanitation for Lagging States (RWSSP-LS). The program, with a budget outlay of US$ 1 billion, is aimed at bringing about reforms in institutional aspects, infrastructure setup, social and environmental aspects, implementation arrangements, financing and capacity building requirements. It’s high time that efficiency is brought about in the program outlays to solve the sanitation issue. New ways need to be devised to capture all the faecal routed infections, just below the anus, in a safe box and flush them away.
Dietary nutrition is, in fact, a very small part of a long chain. Yet, it gets the most attention. The solution lies in the broader story of putting the unknowns together.
India needs to frame a change story by integrating the issues of sanitation, deworming, access, equity and the values that challenge the status quo.
It is pertinent that the policy initiatives of health and sanitation are designed to complement each other. This needs to be taken as ‘food’ for thought, followed by quick action, to ensure that sanitation is the ‘last taboo’.
Aakash Mehrotra is a management consultant working in the field of financial technology, focusing on using technology to extend financial services to rural and low income households. He is also a travel blogger.