Millennium Post

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One missing piece of the malnutrition puzzle is social inequality. For example, girl children are more likely to be malnourished than boys, and low-caste children than upper-caste children. But the most important aspect is sanitation. Most children in rural areas and urban slums are constantly exposed to germs from their neighbours’ faeces. This makes them vulnerable to the kinds of chronic intestinal diseases that prevent bodies from making good use of nutrients in food, and they become malnourished.

According to the Planning Commission’s evaluation report of the Total Sanitation Campaign, close to 72 per cent people in the country’s rural areas still defecate in the open. Every day, an estimated 1,00,000 tonnes of human excreta are left unguarded along river and stream banks, in open fields, on road sides and farms to contaminate water sources. According to Unicef, each gram of human excreta contains 10 million viruses, one million bacteria, 1,000 parasite cysts and 100 parasite eggs. Given the high population density in the country, this is sufficient to trigger widespread diseases. Children are more susceptible to such diseases.

A visit to Dholpur district of Rajasthan shows how government efforts to provide health and nutritional care to children through ICDS and anganwadi centres have failed due to lack of sanitation. Dholpur is one of India’s highly malnourished districts. Close to 80 per cent of people here defecate in the open. In Sakhwara village of Dholpur, an open drain, carrying human faeces, passes right through the village.

Children and expectant mothers cross the drain on foot to reach the anganwadi. ‘Diarrhoea and pneumonia have always been part of our lives,’ says Bhanmati Pitaka, an elderly woman of the village. ‘Every monsoon at least five to six children suffer from the diseases in the village.’ She claims that the village always had thin children.

Lack of sanitation and clean drinking water are the reasons why high levels of malnutrition persists in India despite improvement in food availability, says Joe Mediath of Gram Vikash, a non-profit that works on sanitation in India and Africa.

A few recent reports also provide evidence that lack of sanitation could be the key reason for high malnutrition.

A research paper published in a science journal in September this year concludes that lack of sanitation is a potential contributor to stunting in India. The study was done by Dean Spears of 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 analysed recently published data on the levels of malnutrition and open defecation in 112 rural districts. They found that 10 per cent increase in open defecation resulted in 0.7 per cent increase in both stunting and severe stunting. ‘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 turn one,’ states the report. The researchers point out another missing piece of the malnutrition puzzle: two-thirds of all adults are literate in this region. In 1999 when the Centre launched Total Sanitation Campaign, its aim was to eradicate the practice of open defecation by 2017. Under the campaign, the government had to provide toilet facilities to schools and anganwadi centres by 2009 and to rural households by 2012. But the Planning Commission report states that the campaign is yet to achieve the targets. Today, India lags behind sub-Saharan Africa in terms of sanitation practices. About 56 per cent people defecate in the open across the country, including rural and urban areas. In sub-Saharan Africa, only 25 per cent the people defecated in the open in 2010, according to the Unicef and WHO. 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 Congo defecate in the open. ‘This difference in sanitation practices between India and African countries explains the difference in malnutrition rate,’ says Joe.

Even in India, good sanitation practices have helped curb malnutrition. Ahmednagar district of Maharashtra is one such example. In 2004 the government successfully implemented the Total Sanitation Campaign in half of the 60 villages in the district. Following this, open defecation stopped in these villages. A few years later, Spears and his fellow economist Jeff Hammer, who were monitoring the health of an experimental group in these villages, found that the average height of children had increased by about one centimetre compared to that of children in nearby 30 villages where the campaign was not introduced.

The latest survey by the National Nutrition Monitoring Bureau (NNMB), which conducts surveys in rural and tribal areas to find out nutritional status of people, also brings out this aspect. NNMB found that malnutrition level among children reduced over a period of time despite less intake of food. ‘The improvement in nutritional status could be due to non-nutritional factors, such as improved accessibility to health care facilities, sanitation and protected water supply,’ the report notes.

The government should take note of such findings while implementing its anti-malnutrition programme.

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