Published on The Water Blog

Better together: Toilets and nutrition

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​Studies show children grow taller and perform better
on cognitive tests in communities where residents have
access to improved sanitation and do not defecate
in the open.  Photo credit: World Bank
Toilets have a significant effect on children’s health and nutrition ; access to toilets can help children reach their full physical and mental potential. The inverse, however, is also true and the absence of a toilet can have profound implications. Consider the life of a child who lives in a village with poor sanitation. They go outside; they play in the same field where people defecate; they put their fingers in their mouths. They might not be aware of what contaminants are on their fingers.
Considering such things is not the job of a young child but it is important for his/her family, village, governments and the development community. We have a growing body of knowledge of the multi-generational and cyclical effects of what happens when a child’s environment is contaminated with feces. The UN estimates that 2.4 billion people still lack access to improved sanitation facilities, nearly 1 billion of which practice open defecation.

This year the theme of World Toilet Day focuses on making explicit the link between toilets and nutrition. Malnutrition is a multifaceted problem that involves more than availability and affordability of food. According to the World Health Organization (WHO), roughly 58 percent of diarrhea is associated with poor water, sanitation and hygiene. 
Children who suffer from repeated bouts of diarrhea have permanent changes in the structure of their intestines which causes trouble absorbing nutrients, leading to stunting, a form of chronic malnutrition. When pathogens in the environment, especially fecal pathogens, constantly assault the gut, the infections, which may remain as sub-clinical infections and hence not evident, damage the gut lining and deprive it of its ability to absorb nutrients, leading to malnutrition. The small intestine becomes more porous, and disease-causing pathogens enter the bloodstream more easily, activating an immune response and diverting energy from human growth.
Access to food, health service and a healthy environment, and good caring practices are considered essential for good nutrition outcomes. But no one of these three essential elements (food, health or care), is sufficient in and of itself. For example, an abundance of food may do little to nourish communities that are in constant contact with fecal germs, where water and excreta-related diseases are spread as a result of inadequate sanitation, water supply and hygiene practices. Malnutrition can be widespread even in regions with plentiful supplies of affordable food because this food is not well absorbed by the body [1].
Stunting may not matter as much if the consequences were restricted to children’s height alone. But it is also associated with severe and permanent cognitive deficits, impaired vaccine responses, future predisposition to obesity and chronic diseases, and perpetuating the intergenerational transmission of poverty [2].
Perhaps even more concerning is that stunting and the poverty induced by open defecation persist across generations.  Stunted women are more likely to give birth to stunted children, poor maternal nutrition and exposure to infectious diseases have impacts even before a child is born, setting children on a trajectory of slower growth over the lifetime  [3] and conditioning a child for worse health outcomes and lower economic productivity later in life  [4].
The development community’s narrow focus on diarrhea may have largely underestimated the health impacts that improved water, sanitation and hygiene (WASH) can have on children and on future human capital in countries. The importance of these linkages has gained momentum in recent years to leverage investment projects across the health, nutrition and WASH sectors. This new approach will help ensure that in addition to the other determinants of nutrition - such as nutrient availability and care practices – the WASH constraints are being addressed. The World Bank Group is currently integrating WASH, nutrition and health in at least 13 projects across India, Pakistan, Lao PDR, Cambodia, Vietnam, Ethiopia, Mozambique, Uganda, Zambia, and Haiti for a total of around US$440 million in investments. As the evidence continues to build around this synergy, the demand for integration keeps growing along with the need to strengthen the mechanisms for tracking these investments.

The World Bank Group’s health and water teams are working jointly on a US$31 million grant to support implementation of nutrition-sensitive sanitation investments in Pakistan and has enabled a successful pilot of the approach to go to scale in Sindh and Punjab provinces. The project is training grassroots health mobilizers to conduct follow-up visits with households to promote sanitation and monitor village progress towards Open Defecation Free status.  The project emphasizes a critical element of sanitation projects: the individual and community  [5] level behavior change that is essential for improving health and nutrition outcomes and reaping the rewards of infrastructure investment.

​If we are to reach our goals of boosting shared prosperity and ending extreme poverty, we must work closely with our partners and clients to structure our work for better health outcomes. By working closely across what were long considered silos, we can make the link between toilets and nutrition explicit and help children grow taller with toilets. 
[1] Bhutta et al. 2008, 2013.
[2] Guerrant 2013.
[3] Victora C.G., de Onis M., Hallal P.C., Blössner M., Shrimpton R. 2010. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics.
[4] Barker 1990.
[5] “Sanitation and Externalities: Evidence from Early Childhood Health in Rural India,” Luis A. Andres, Bertha Briceno, Claire Chase and Juan A. Echenique, World Bank Policy Research Working Paper 6737, January, 2014.
​Andres et al. 2014, Gunther and Fink 2010.


Meera Shekar

Global Lead, Nutrition

Richard Damania

Chief Economist, Sustainable Development Practice Group

Martin Gambrill

Lead Water and Sanitation Specialist

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