Co-author:Sophie Durrans, Research Uptake Officer at London School of Hygiene & Tropical Medicine
A child who is stunted early in life – who fails to grow as tall as expected for their age – often has reduced physical and mental development. Water supply, sanitation, and hygiene (WASH) influences a child's growth in multiple ways. Evidence across low and middle-income countries demonstrates that higher open defecation rates are associated with stunting and higher overall incidence of poverty.
Two years ago, I visited a village in Rudaki, a hilly district located to the south of Dushanbe, Tajikistan. It lies about forty kilometres from the capital, but it feels like a thousand kilometres away. On our drive up a hill, we saw women carrying buckets of water from a nearby spring. Moving further up, we saw children bathing and animals drinking from the same river. Once in the village, it was clear that life is largely shaped by water scarcity—the backyards were filled with pots and buckets, fuel and stoves for boiling water, and pit latrines that were no longer used because of lack of water. Although we could spot remnants of a once-functional water supply network, people living there had not had access to piped water for at least two decades. Without it, they were only able to practice the most basic forms of sanitation and hygiene.
The conditions we witnessed in Rudaki were harsh, but not rare. Located on the western tip of the Himalayas, Tajikistan is a country blessed with large fresh water resources in its lakes, rivers, and glaciers. Yet, access to safe drinking water and sanitation connected to a functioning sewer system is lacking, particularly for rural residents and the poor. Much of the existing infrastructure was built during the Soviet era and has not been upgraded for decades. Tajikistan is one of the few countries outside Africa that did not meet the Millennium Development Goal on drinking water and basic sanitation. Because poor water and sanitation conditions, together with poor nutrition and care, are key determinants of childhood stunting, Tajikistan’s childhood stunting rates remain high. Recent estimates indicate that in Tajikistan more than one in five children under the age of five are stunted and will not reach their full potential as adults.
In a new report, Glass Half Full: Poverty Diagnostic of Water Supply, Sanitation and Hygiene (WASH) Conditions in Tajikistan, we document the realities of Tajikistan’s WASH-deprived population. Our analysis builds on one of the largest data collection efforts of its kind – including national surveys of households and schools, water quality tests, ethnographic work, and case studies of existing WASH projects. It also includes poverty mapping and analysis of other secondary data, including a UNICEF nutrition survey that shared a subsample with our WASH survey.
Have you ever wondered how your life chances are affected by where you were born? Odds of being born at all are already miraculously small, but only one in ten of us is born into the relative security of a high-income country. What if you are born in Niger or in the Democratic Republic of the Congo (DRC)? Before you could even walk or talk, your challenges would be daunting. That's because, despite progress, deaths of children under five years old are more than twenty times higher than in the EU and nearly ten times higher than in China.
Even if you survived, you would confront another major risk to your development: malnutrition. In Niger and DRC, almost one out of every two children is stunted. Stunting has significant and long-lasting negative effects on early childhood development, impeding physiological and mental development, and making small children more vulnerable to disease. Starting off in life stunted is akin to starting a marathon with a broken ankle.
While child mortality rates have plummeted worldwide, nearly one-third of all children under 5 in developing countries are stunted. Children who are stunted (having low height-for-age) suffer from a long-term failure to grow, reflecting the cumulative effects of chronic deficits in food intake, poor care practices, and illness. The early years of life, especially the first 1,000 days, are critical; if a child’s growth is stunted during this period, the effects are irreversible and have lifelong and intergenerational consequences on their future human capital and potential to succeed.
For the water and sanitation community the year 2009 marked a turning point in our understanding of the role that Water, Sanitation and Hygiene (WASH) has on child stunting. A provocative Lancet article (Humphrey 2009) put forth the hypothesis that a key cause of child stunting is asymptomatic gut infection caused by ingestion of fecal bacteria. Small children living in poor sanitary environments are especially at risk, through frequent mouthing of fingers and objects during exploratory play, playing in areas contaminated with human and animal feces and ingesting contaminated food and water (Ngure et al. 2013). Researchers now estimate that up to 43 percent of stunting may be due to these gut infections, known as environmental enteric dysfunction (EED) (Guerrant et al. 2013).
Just last week estimates were released suggesting that poor sanitation is the second leading cause of child stunting worldwide (Danaei et al. 2016). In a key departure from previous work, the researchers defined risk as the sanitation level of a community, rather than an individual. This is consistent with mounting evidence showing that a community’s coverage of sanitation is more important than any one household’s (Andres et al. 2013). Across different studies, data sets and outcomes the evidence consistently shows that a threshold of around 60–70 percent household usage within a community is needed before the health and nutrition benefits of sanitation begin to accrue. Studies that have focused on an individual’s toilet use as a predictor, rather than a community’s use, may have vastly underestimated the impacts (Hunter and Prüss-Ustün 2016).
As we advance our understanding of the ways in which a poor sanitary environment impacts growth in small children, we can better design water and sanitation interventions to target these pathways. While there is a role for multi-sectoral interventions, which can simultaneously target the underlying determinants of child undernutrition, such as food security, access to health services, and childcare practices — there are ways that the water sector can adapt its own approaches so that they are more nutrition-sensitive, and more impactful on nutrition. Here are four key actions:
Alassane Sow, World Bank Country Manager for Cambodia, and Rana Flowers, UNICEF Representative to Cambodia, wrote an op-ed for The Phnom Penh Post. Read the op-ed below, courtesy of The Phnom Penh Post.
Did you know that in communities where a high proportion of people defecate outdoors, children are on average shorter than children living in communities where most people use toilets?