SHEOHAR
DISTRICT, India — He wore thick black eyeliner to ward off the evil eye, but
Vivek, a tiny 1-year-old living in a village of mud huts and diminutive people,
had nonetheless fallen victim to India’s great scourge of malnutrition.
His
parents seemed to be doing all the right things. His mother still breast-fed
him. His family had six goats, access to fresh buffalo milk and a hut filled
with hundreds of pounds of wheat and potatoes. The economy of
the state where he lives has for years grown faster than almost any other. His
mother said she fed him as much as he would eat and took him four times to
doctors, who diagnosed malnutrition. Just before Vivek was born in this green
landscape of small plots and grazing water buffalo near the Nepali border, the
family even got electricity.
So why
was Vivek malnourished?
It is a
question being asked about children across India, where a long economic boom
has done little to reduce the vast number of children who are malnourished and
stunted, leaving them with mental and physical deficits that will haunt them
their entire lives. Now, an emerging body of scientific studies suggest that
Vivek and many of the 162 million other children under the age
of 5 in the world who are malnourished are suffering less a lack of food than
poor sanitation.
Like almost everyone else in their village, Vivek and his family
have no toilet, and the district where they live has the highest concentration
of people who defecate outdoors. As a result, children are exposed to a
bacterial brew that often sickens them, leaving them unable to attain a healthy
body weight no matter how much food they eat.
“These
children’s bodies divert energy and nutrients away from growth and brain
development to prioritize infection-fighting survival,” said Jean Humphrey, a
professor of human nutrition at Johns Hopkins Bloomberg School of Public
Health. “When this happens during the first two years of life, children become
stunted. What’s particularly disturbing is that the lost height and
intelligence are permanent.”
Two
years ago, Unicef, the World Health Organization and the World Bank released a major report on child
malnutrition that
focused entirely on a lack of food. Sanitation was not mentioned. Now, Unicef
officials and those from other major charitable organizations said in
interviews that they believe that poor sanitation may cause more than half of
the world’s stunting problems.
“Our
realization about the connection between stunting and sanitation is just
emerging,” said Sue Coates, chief of water, sanitation and hygiene at Unicef
India. “At this point, it is still just an hypothesis, but it is an incredibly
exciting and important one because of its potential impact.”
This
research has quietly swept through many of the world’s nutrition and donor
organizations in part because it resolves a great mystery: Why are Indian
children so much more malnourished than their poorer counterparts in
sub-Saharan Africa?
A child raised in India is far more likely to
be malnourished than one from the Democratic Republic of Congo, Zimbabwe or
Somalia, the planet’s
poorest countries. Stunting affects 65 million Indian children under the age of
5, including a third of children from the country’s richest families.
This disconnect between wealth and malnutrition is so striking
that economists have concluded that economic growth does almost nothing to reduce malnutrition.
Half
of India’s population, or at least 620 million people, defecate outdoors. And
while this share has declined slightly in the past decade, an analysis of census data shows that rapid population growth has
meant that most Indians are being exposed to more human waste than ever before.
In
Sheohar, for instance, a toilet-building program between 2001 and 2011
decreased the share of households without toilets to 80 percent from 87
percent, but population growth meant that exposure to human waste rose by half.
“The
difference in average height between Indian and African children can be explained entirely by differing concentrations of open
defecation,” said Dean Spears, an economist at the Delhi School of Economics.
“There are far more people defecating outside in India more closely to one
another’s children and homes than there are in Africa or anywhere else in the
world.”
Not only does stunting contribute to the deaths of a million children under the age of 5 each year, but
those who survive suffer cognitive deficits and are poorer and sicker than
children not affected by stunting. They also may face increased risks for adult
illnesses like diabetes, heart attacks and strokes.
“India’s
stunting problem represents the largest loss of human potential in any country
in history, and it affects 20 times more people in India alone than H.I.V./AIDS
does around the world,” said Ramanan Laxminarayan,
vice president for research and policy at the Public Health Foundation of
India.
India
is an increasingly risky place to raise children. The country’s sanitation and air quality are
among the worst in the world. Parasitic diseases and infections like
tuberculosis, often linked with poor sanitation, are most common in India. More
than one in four newborn
deaths occur in India.
Open
defecation has long been an issue in India. Some ancient Hindu textsadvised
people to relieve themselves far from home, a practice that Gandhi sought to
curb.
“The
cause of many of our diseases is the condition of our lavatories and our bad
habit of disposing of excreta anywhere and everywhere,” Gandhi
wrotein 1925.
Other
developing countries have made huge strides in improving sanitation. Just 1 percent of
Chinese and 3 percent of Bangladeshis relieve themselves outside compared with
half of Indians. Attitudes may be just as important as access to toilets.
Constructing and maintaining tens of millions of toilets in India would cost
untold billions, a price many voters see no need to pay — arecent survey found that many people
prefer going to the bathroom outside.
Few
rural households build the sort of inexpensive latrines that have all but
eliminated outdoor waste in neighboring Bangladesh.
Photo
Clothes washers work near a sewage
pipe in the Ganges in Varanasi, India, where no city has a comprehensive treatment
system.CreditDaniel Berehulak for The New York Times
One analysis found that government spending on toilets pays for itself in increased tax receipts from greater productivity, but the math works only if every member of a family who gets a toilet uses it.
“We need a cultural revolution in this country
to completely change people’s attitudes toward sanitation and hygiene,” said
Jairam Ramesh, an economist and former sanitation minister.
India’s
government has for decades tried to resolve the country’s stubborn malnutrition
problems by distributing vast stores of subsidized food. But more and better
food has largely failed to reverse early stunting, studies have repeatedly
shown.
India
now spends about $26 billion annually on food and jobs programs, and less than
$400 million on improving sanitation — a ratio of more than 60 to 1.
“We need to reverse that ratio entirely,” Dr. Laxminarayan said.
Lack of food is still an important contributor to malnutrition
for some children, and some researchers say the field’s sudden embrace of
sanitation has been overdone. “In South Asia, a more important factor driving
stunting is diet quality,” said Zulfiqar A. Bhutta, a
director of the Center for Global Child Health at the Hospital for Sick
Children in Toronto.
Studies
are underway in Bangladesh, Kenya and Zimbabwe to assess the share of stunting
attributable to poor sanitation. “Is it 50 percent? Ninety percent? That’s a
question worth answering,” said Dr. Stephen Luby, a professor of medicine at
Stanford University who is overseeing a trial in Bangladesh that is expected to
report its results in 2016. “In the meantime, I think we can all agree that
it’s not a good idea to raise children surrounded by poop.”
Better
sanitation in the West during the 19th and early 20th centuries led to huge
improvements in health long before the advent of vaccines and antibiotics, and
researchers have long known that childhood environments play a crucial role in
child death and adult height.
The present research on gut diseases in children has focused on
a condition resulting from repeated bacterial infections that flatten
intestinal linings, reducing by a third the
ability to absorb nutrients. A recent study of starving children found that they
lacked the crucial gut bacteria needed to digest food.
In
a little-discussed but surprising finding, Muslim children in India
are 17 percent more likely to survive infancy than Hindus, even though Muslims
are generally poorer and less educated. This enormous difference in infant
mortality is explained by the fact that Muslims are far more likely to use
latrines and live next to others also using latrines, a recent analysis found.
So
widespread housing discrimination that confines many Muslims to separate slums
may protect their children from increased exposure to the higher levels of
waste in Hindu communities and, as a result, save thousands of Indian Muslim
babies from death each year.
Just
building more toilets, however, may not be enough to save India’s children.
Phool
Mati lives in a neighborhood in Varanasi with 12 public toilets, but her
1-year-old grandson, Sandeep, is nonetheless severely malnourished. His mother
tries to feed him lentils, milk and other foods as often as she can, but
Sandeep is rarely hungry because he is so often sick, Ms. Mati said.
“We all use the bathroom,” she said.
The
effluent pipe that served the bathroom building is often clogged. Raw sewage
seeps into an adjoining Hindu temple, and, during the monsoon season, it
flooded the neighborhood’s homes. The matron of the toilet facility charges two
rupees for each use, so most children relieve themselves directly into open
drains that run along a central walkway.
No Indian city has a comprehensive waste treatment
system, and most Indian rivers are open sewers as a result. But Varanasi,
India’s oldest and holiest city, is so awash in human waste that its decrepit
condition became a national issue in recent elections. The city’s sewage plants
can handle only about 20 percent of the sewage generated in the city, said
Ramesh Chopra of Ganga Seva Abhiyanam, a trust for cleaning the river. The rest
sloshes into the Ganges or fetid ponds and pits.
Millions of
pilgrims bathe in the Ganges along Varanasi’s ancient riverfront, but a stream
of human waste — nearly 75 million liters per day — flows directly into the
river just above the bathing ghats, steps leading down to the river. Many
people wash or brush their teeth beside smaller sewage outlets.
Much of the city’s drinking water comes
from the river, and half of Indian
households drink from
contaminated supplies.
“India’s problems are bigger than just
open defecation and a lack of toilets,” Dr. Laxminarayan said.
Source: The Newyork Times
http://www.nytimes.com/2014/07/15/world/asia/poor-sanitation-in-india-may-afflict-well-fed-children-with-malnutrition.html?_r=0
