Open defecation linked to stunting in Indian children

By Kundan Pandey     Down to Earth, Sep 23, 2013

Research finds 10 per cent increase in open defecation associated with a 0.7 per cent increase in stunting in 112 districts

Poor sanitation gives arise to a number of health problems, but now research shows that it is linked to stunted growth as well. A research published last week in journal PloS One has concluded that lack of sanitation is a potential contributor to stunting in the country.  

The study was carried out by Dean Spears from the Centre for Development Economics 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 researchers found that a 10 per cent increase in open defecation was associated with a 0.7 per cent increase in both stunting and severe stunting. 

 The researchers used recently published data on levels of stunting in 112 districts of India to explore the relationship between open defecation and stunting within the population in these districts. They used information from the 2011 HUNGaMA (hunger and malnutrition) survey  for stunting data and 2011 Indian Census for the same districts was referred to for other indicators like open defecation. The HUNGaMA survey is the most recent large-scale data on malnutrition which evaluated 109,093 children under five years of age in 73,670 households. 

The researchers carried out a statistical analysis after adjusting potential confounding factors such as socio-economic status, maternal education and calorie availability. They found that stunting figure of the districts where people defecate in the open is higher. In general, children in these districts were found unhealthy. “Over half of the children are stunted, and almost a third of children are severely stunted. The early-life disease environment is poor: over 70 per cent of households defecate in the open and 71 out of every 1,000 babies born alive die before they are one year old. Two-thirds of all adults, and slightly more than half of females, are reported as literate in the Census,” the research findings state.

Population density's compounding effect

The finding calls for immediate attention of and follow up by policy makers in India. Open defecation is a pressing problem because it is much more common in India than in many poor African countries. UNICEF and the WHO estimate that in 2010, 25 per cent of people in sub-Saharan Africa defecated in the open. Recent health surveys in the largest three sub-Saharan countries show that 31.1 per cent households in Nigeria, 38.3 households in Ethiopia, and 12. 1 per cent households in the Democratic Republic of the Congo defecate in the open. Consider the comparative data for India. The Planning Commission report on Evaluation Study on Total Sanitation Campaign, 2013, suggests that around 72.63 per cent of rural India still defecates in the open. 

What's more worrying for India is that density of population in the country is very high which has the potential to compound the problem. 

Spears has written on the subject in a research paper prepared for Public Health Foundation of India (PHFI) on February 15 this year. “If open defecation is indeed keeping children from growing to their genetic potentials–rather than merely being coincidentally correlated with height–we would expect open defecation to be more important for health outcomes where children are more likely to encounter whatever fecal germs are introduced into the environment. This means that population density should matter: living near neighbours who defecate in the open is more threatening than living in the same country as people who defecate in the open far away.”

He goes on to say that Indian children face the double threat of widespread open defecation and high population density, and that  stunting among Indian children is no surprise.  He stresses on proper efforts to motivate people to not only construct latrines but use them as well. 

However, motivation and awareness have not received sufficient attention in the planning of the government. The Planning Commission evaluation report of Total Sanitation Campaign report  points out that the practice of open defecation was supposed to be stopped with all individual households being given access to the toilets by 2012; toilet facilities to all schools and anganwadi centres were to be provided by  2009 and Community Sanitary Complex/Women Sanitary Complex were to be provided in case of lack of space or financial constraints. Government of India gives Nirmal Gram Puraskar to push the sanitation campaign. But there is no significant progress as 72 per cent people  in rural India still defecate in the open.

Forget Food Bill, India Needs Sanitation

By Atish Patel, blogs.wsj.com   July 10th, 2013

Children ate food near a road in Hyderabad, October 3, 2011. Photo by: Noah Seelam/Agence France-Presse/Getty Images

India is poised to launch one of the biggest food subsidy programs ever attempted, but some experts say it will fail unless major steps are taken to improve sanitation.

“In the absence of focus on sanitation, what we have is taxpayer-funded diarrhea and little else,” Pavan Srinath, policy research manager at the Takshashila Institution, a think-tank, said of the program that the government says will cost about $20 billion a year.

The government approved the National Food Security Law last week. As Parliament is in recess, the law is classed as an ordinance, or temporary legislation, until Parliament reconvenes and votes on it at the end of the month or early August. The passing of the law is expected to be a formality.

Under the program, the government will sell very cheap rice, wheat and other grains to around 800 million poor Indians, or around 70% of the population.

In addition to the critics who say the program is misdirected and a bid by the ruling Congress party-led government to win votes, health experts say the subsidies overlook the problem of poor sanitation.

A lack of access to toilets means that hundreds of millions of people defecate in the open in India.  As a result, children are exposed to bacterial infections and parasites that can damage the small intestine and reduce or stop its capacity to absorb nutrients needed for growth and development, no matter how much food is consumed.

Unicef says there are 61.7 million stunted children in India, more than anywhere else in the world. The government estimates that around 20% of children under five are wasted, or too thin for their height and 43% are underweight for their age.

In a recent paper in Economic and Political Weekly, Robert Chambers from the University of Sussex in the U.K. and Gregor von Medeazza from Unicef India said the link between sanitation and under-nutrition has been largely overlooked, describing it as a “blind spot.”

Last month, Rural Development Minister Jairam Ramesh was quoted in the media as saying: “I don’t see the same degree of political enthusiasm on sanitation. I think we neglect this at peril… When we talk about sanitation, we can only giggle.”

Gagandeep Kang, professor in the Department of Gastrointestinal Sciences at Christian Medical College in Vellore, is involved in an international study funded by the Bill and Melinda Gates Foundation to look at how pathogens damage children’s guts, leading to malnutrition.

“You can’t argue sanitation alone is going to lead to people not being malnourished. Nor is food alone going to lead to every single child growing fine. It has to be a combination of both of those,” she said.

According to research by Dean Spears, a visiting economist at the Delhi School of Economics, there is less stunting of children in Indian districts with toilets. Improved sanitation meant infant mortality decreased by four per 1,000 and children’s height increased, he said.

The World Health Organization says diarrhea is a leading cause of malnutrition in children under five. More than 800,000 children in that age bracket die every year from diarrhea globally, according to Unicef. A quarter of these deaths happen in India.

A survey from 2011 found that nearly 80% of Indian children with diarrhea did not wash their hands with soap after visiting the toilet.

The challenge the government faces is finding a way to get more Indians to use toilets, which some have said is a culture problem. “The biggest thing about sanitation is individual behavior,” Mr. Srinath said.

“It’s an individual choice. Most people in India don’t want to spend money to build a toilet,” he added.(Atish Patel is a multimedia journalist based in Delhi. You can follow him on Twitter @atishpatel.)

Over 300 million Indians still defecate in the open: WHO-UNICEF report

By Kundan Pandey,   Down to Earth,   May 15, 2013, 

Bangladesh, Nepal and Pakistan do much better in improving access to sanitation

One-third of the world’s population, about 2.4 billion people, will remain without access to improved sanitation in 2015, according to a report recently published  jointly by the World Health Organisation (WHO) and the United Nations International Children’s Education Fund (UNICEF). The report says that three south Asian countries, including Bangladesh, Pakistan and Nepal have shown significant improvement in the past 20 years. In India, however, more than the quarter of the population still practices open defecation.

The report, titled Progress on sanitation and drinking-water 2013 update, warns that at the current rate of progress, the 2015 Millennium Development Goal (MDG) target of halving the proportion of people without sanitation compared to 1990 will be missed by 8 per cent – or half a billion people. The report, which is based on data collected in 2011 with updated information, was published on May 13.

East Asia tops among good performers

While three countries of South Asia – Pakistan, Bangladesh and Nepal – have been deemed good performers, India has less than 50 per cent of its people using improved sanitation (see figure 1).

Bangladesh, with 32 per cent of total population practising open defecation in 1990, has shown an annual decline of 9.9 per cent to a figure of 4 per cent in 2011 (see table). Pakistan showed an annual decline rate of 3.9 per cent, lowering its open defecation figures from 52 per cent to 29 per cent. Nepal too has lowered its open defecation figures from 84 per cent of the population in 1990 to 43 per cent in 2011. This amounts to an annual decline rate of 3.2 per cent.

According to a region-wide assessment, eastern Asia has performed better than any other region in the world. The report says, “Greatest progress has been made in eastern Asia, where sanitation cove-

-rage has increased from 27 per cent in 1990 to 67 per cent in 2011. This amounts to more than 626 million people gaining access to improved sanitation facilities over a 21-year period.” (see figure 2)

Sanitation for progress

“There is an urgent need to ensure all the necessary pieces are in place – political commitment, funding, leadership – so the world can accelerate progress and reach the Millennium Development Goal sanitation target,” says Maria Neira, WHO Director for Public Health and Environment. “The world can turn around and transform the lives of millions who still do not have access to basic sanitation. The rewards would be immense for health, ending poverty at its source, and well-being,” she adds.

The report echoes the urgent call to action by United Nations deputy secretary-general Jan Eliasson for the world community to combine efforts and end open defecation by 2025. With less than three years to go to reach the MDG deadline, WHO and UNICEF have called for a final push to meet the sanitation target.

"This is an emergency no less horrifying than a massive earthquake or tsunami," says Sanjay Wijesekera, global head of UNICEF's Water, Sanitation and Hygiene (WASH) programme. “Every day hundreds of children are dying; every day thousands of parents mourn their sons and daughters. We can and must act in the face of this colossal daily human tragedy.”

Open defecation due to lack of access to sanitation poses a hazard to public health. Exposure to human excreta or its contamination of drinking water sources, causes a host of illnesses such as cholera, dysentery,  typhoid, polio and infections with E coli and tapeworm. Such exposure can even cause epidemics.

Ronnie Screwvala’s Big Plan for Rural India

By Arti Megha Bahree     http://blogs.wsj.com/indiarealtime/2013/04/03/ronnie-screwvalas-big-plan-for-rural-india/ Apr 3, 2013

Swades Foundation  Ronnie Screwvala.

On a recent day, about 120 men sat on chairs in rows in a community hall in Matunga, a Mumbai suburb. All migrants, they had left their villages in the districts of Ratnagiri and Raigad in western Maharahstra in search of jobs as there weren’t any at home. Most of them were now working in Mumbai in a myriad of jobs including waiting tables and in the mailrooms of companies to running their own small businesses.

The men had gathered to attend a meeting organized by the Swades Foundation, a nonprofit organization that has been set up Walt Disney Co. India’s Managing Director Ronnie Screwvala, and which is run by his wife Zarina Mehta, the managing trustee of the nonprofit.

Swades, the men were told, was undertaking various initiatives in their or neighboring villages to help get access to water and sanitation, healthcare and education. Swades hopes that if these basic facilities are available in these villages, these migrants could be lured back to their villages to set up businesses locally or take up agriculture.

This is key to Mr. Screwvala’s plan to boost the economy of rural India.“If India is looking to become one of the top three economies globally, can we actually achieve that without the 600 million people who live in rural India,” said Mr. Screwvala, who co-founded UTV Software Communications Ltd. and sold it to Walt Disney last year. “Rural India lives in a different time warp and will continue to do so…. Unless we fix rural India, we can’t be a rocking economy.”

Mr. Screwvala’s plan is to provide, by December 2017, one million people with access to clean water and sanitation, education, healthcare services and better agricultural practices in the roughly 1,800 villages in the districts of Ratnagiri and Raigad in rural Maharashtra.

The plan requires about $120 million, half of which will be funded by him and his family, and the rest through donors, he says. Mr. Screwvala is one of a handful of Indians who are starting to open up their wallets for philanthropic causes. In 2011 Microsoft Corp. founder Bill Gates and Berkshire Hathaway Inc.’s Chief Executive Warren Buffett met with Indian business leaders in New Delhi to encourage them to join them in their effort to donate their wealth to charity. So far tycoon Azim Premji, the founder and chairman of Wipro Ltd, is the only one in India who has signed up to their Giving Pledge initiative. But philanthropy is a growing trend. In its annual India Philanthropy Report last year, consulting firm Bain & Co. Inc. found that India’s rich increased their contributions from 2.3% of household income in 2010 to 3.1% in 2011. Bain says its research has found that these philanthropists would likely increase their donations in the years ahead.

Thousands of villagers across the country move to big cities every year because there aren’t any proper health and education facilities in their villages, limited means of earning a living, no easy access to clean drinking water or sanitation.

The pattern followed by these villagers is the same as that of immigrants the world over—it’s usually the working age men who first go to the land of opportunity and once they find jobs, they start bringing over family members one at a time.

The trend is widely prevalent in the villages that Swades is currently working in. It’s common for many villages to have old people or wives and little children as their only residents as most of the men are in the cities of Mumbai and Pune, working mostly in a myriad of low skilled jobs, often living in pitiful conditions on their meager salaries.

Mr. Screwvala says most of the villagers would not leave if they lead comfortable lives and had opportunities for economic growth in their own backyards.

But instead of only handing out cash to lay a pipe to bring water to a village or build toilets in homes, Swades also works with different government agencies that often already have funds to address the needs and problems of the villagers but may not be aware of what is required.

Swades believes that once these basic requirements are met, then villagers can focus on building a local economy whether by setting up small businesses or by adopting smarter agricultural practices that would give them higher yields.

Mr. Screwvala says he came up with this focused plan after several years of philanthropy in Maharashtra. He set up his nonprofit foundation in 1990 and named it the Society to Heal, Aid, Restore, Educate. It started out by training mentally challenged young adults to recycle old newspapers and cloth pieces and convert them into items for like photo frames, pen stands, gift bags.

In the last decade it expanded into doing rainwater harvesting, building toilets in homes and training farmers how to plant a second crop to enhance their incomes. It changed its name to Swades last summer when it came up with this plan.

Swades is taking this message to the villages it works in as well as to the migrants in Mumbai through monthly town hall-style meetings that it hosts.

It’s not clear if Mr. Screwvala will succeed. So far a handful of migrants have gone back to their villages and taken up farming. For most, the bright lights of Mumbai are still a better option.  (Follow  Megha at India Real Time on Twitter @mbahree and @IndiaRealTime.)