Reposted from the 1/14 Huffington Post.

A story on the high incidence of malnutrition among children in India reminded us of a curious phenomenon that for years had puzzled development and health professionals. Despite India’s growing economic power and successive governments who paid serious attention to increasing food supply, children in that country remained smaller than those in less well-off countries in sub-Saharan Africa.

It took years of research and large-scale case studies – some of which were published by UNICEF, USAID and WHO in Improving Nutrition Outcomes with Better Water, Sanitation and Hygiene - to pin it down. There is a very widespread lack of adequate and diverse food intake among young children, which needs to be addressed, in both India and poor countries in sub-Saharan Africa. However, in India there is an additional and unexpected villain in the piece: a lack of toilets.

Open defecation has been a problem for a very long time in India. So common was the practice that almost 100 years ago Mahatma Gandhi urged his compatriots to stop it. It remains widespread to this day, practiced by 44% of the population in 2015. This runs to 569 million people, the highest number of people practicing open defecation of any country in the world. In part it is due to a lack of facilities, but not entirely. Significant numbers of Indians with toilets at home still defecate in the open.

What does open defecation in India have to do with the size of its children?

There is open defecation in sub-Saharan Africa. Of the 700 million people in the region who do not have proper toilets around 230 million defecate in the open. What is different in India is the pervasiveness and the concentration of the practice.

In India, a child is surrounded by feces. It is where babies crawl; where children play; where they eat; in the water they drink and bathe. It gets into their mouths; they ingest it from their own unwashed hands as well as those of their care-givers. And when it gets inside it does some very dirty work.

Feces carry bacteria that in young children especially can lead to multiple episodes of diarrhea every year. Not only do these episodes prevent the retention of nutrients from food, we now know that they permanently alter the absorptive capacity of a child’s guts, by lessening the number of the villi on intestinal walls which are meant to trap nutrients.

Feces can also carry intestinal parasites – like hookworm, which causes anemia in pregnant women, leading to malnourished, underweight babies. These parasites rob infected children of even more nutrients.

What is the result? A stunted child.

Stunting means children are not growing as they should, they are short and small for their age, and they can have permanent cognitive damage. That has implications on a country’s economy. Stunted children grow up to be weaker and more susceptible to illness, bringing an extra burden to the public purse. They do less well in school, so they earn less as adults. The ramifications are far reaching.

In India 4 out of 10 children under 5 years old are stunted. And around the world, 159 million children are stunted.

India might have numerically the biggest problem, but unless the world wakes up and does something about sanitation, the problem could grow.

In sub-Saharan Africa the number of people who defecate in the open is growing. Countries in the region have been scrambling to keep up with a population which has very nearly doubled between 1990 and 2015. The urban population, in fact has almost tripled, and services have not kept pace.

We do know that when political will, outside intervention, and – crucially – community involvement combine, excellent results are possible.

During the prolonged Sahel drought, Mali used UNICEF’s community led approach to end open defecation in communities with high malnutrition rates. They saw vastly improved health and nutrition in children.

In conflict-affected Democratic Republic of the Congo, displaced communities were given both extra nutrition and help with improving water, sanitation and hygiene. Waterborne diseases fell dramatically in children under 5, and some 90 per cent of malnourished children returned to normal weight during a 12-month period.

It is 2016. We know what to do and we know how to do it. India’s children, and all children around the world, deserve a chance to grow tall and strong and live healthy and productive lives.

A total of 165 million children worldwide are considered stunted, which is associated with increased risk of death prior to age 5 years and cognitive disability. Stunting has, in part, been attributed to the presence of environmental enteropathy. Environmental enteropathy is a poorly understood condition leading to chronic intestinal inflammation. It has been postulated that small intestine bacterial overgrowth contributes to the pathogenesis of environmental enteropathy as overgrowth has been associated with intestinal inflammation and micronutrient malabsorption when it develops in other clinical contexts.

This study confirms the finding that overgrowth occurs at high rates in the developing world. This is the first study to show that overgrowth is associated with intestinal inflammation and linear growth delay in this setting and is the first to examine why children with no known gastrointestinal dysfunction develop overgrowth from the developing world environment.

This abstract of this article (http://mbio.asm.org/content/7/1/e02102-15.full) is as follows:

Recent studies suggest small intestine bacterial overgrowth (SIBO) is common among developing world children. SIBO’s pathogenesis and effect in the developing world are unclear. Our objective was to determine the prevalence of SIBO in Bangladeshi children and its association with malnutrition. Secondary objectives included determination of SIBO’s association with sanitation, diarrheal disease, and environmental enteropathy.

We performed a cross-sectional analysis of 90 Bangladeshi 2-year-olds monitored since birth from an impoverished neighborhood. SIBO was diagnosed via glucose hydrogen breath testing, with a cutoff of a 12-ppm increase over baseline used for SIBO positivity. Multivariable logistic regression was performed to investigate SIBO predictors. Differences in concomitant inflammation and permeability between SIBO-positive and -negative children were compared with multiple comparison adjustment. A total of 16.7% (15/90) of the children had SIBO.

The strongest predictors of SIBO were decreased length-for-age Z score since birth (odds ratio [OR], 0.13; 95% confidence interval [CI], 0.03 to 0.60) and an open sewer outside the home (OR, 4.78; 95% CI, 1.06 to 21.62). Recent or frequent diarrheal disease did not predict SIBO. The markers of intestinal inflammation fecal Reg 1β (116.8 versus 65.6 µg/ml; P = 0.02) and fecal calprotectin (1,834.6 versus 766.7 µg/g; P = 0.004) were elevated in SIBO-positive children. Measures of intestinal permeability and systemic inflammation did not differ between the groups.

These findings suggest linear growth faltering and poor sanitation are associated with SIBO independently of recent or frequent diarrheal disease. SIBO is associated with intestinal inflammation but not increased permeability or systemic inflammation.

A growing body of evidence indicates that access to safe drinking-water, sanitation, and hygiene (WASH) services has an important positive impact on nutrition. Achieving the six Global Nutrition Targets 2025, as well as global goals for WASH and health, will require greater investments in nutrition and WASH. It will also require maximizing impact through smart and sustainable integrated actions.

This document (http://apps.who.int/iris/bitstream/10665/193991/1/9789241565103_eng.pdf?ua=1), jointly prepared by WHO, UNICEF and USAID, summarizes the current evidence on the benefits of WASH for improving nutrition outcomes. It describes how WASH interventions can be integrated into national nutrition policies and programmes to add value.

It will also serve as a valuable tool to help countries implement the policy options on WASH recommended in the Framework for Action adopted by the 2nd International Conference on Nutrition (ICN2), Rome, November 2014.

From Ideas for Development, January 7, 2016

http://ideas4development.org/en/sanitation-and-nutrition-should-we-link-them-together-in-our-development-actions-4/

The links between the lack of sanitation and hygiene and nutritional status are increasingly well documented.Yet in the field, few development actors include nutrition in their water and sanitation operations. Why do they fail to take it into account? What are the barriers? Would building stronger links between sanitation and nutrition significantly reduce malnutrition? Is there not the risk that wanting to address all topics in the same development action would lead to none of them being addressed?

The debate was coordinated Emmanuelle Bastide, journalist at RFI. The speakers were Joséphine Ouédraogo, Ministry of Agriculture, water Resources, Sanitation and Food Security, Burkina Faso (in visioconference) ; Cassilde Brenière, Head of AFD’s Water and Sanitation Division at AF ; Jean Lapègue,Technical Advisor for Water, Sanitation and Hygiene at the Scientific and Technical Department of Action Against Hunger (ACF) France; Frédéric Naulet Head of Drinking Water and Sanitation Programs at GRET.

Please find below the Conference synthesis

While one person in three does not have access to basic sanitation facilities, the question of sanitation is “a public health issue that is not properly addressed” (Emmanuelle Bastide). Yet sanitation is critical for preventing undernutrition “a deadly disease which causes 45% of deaths in children under 5” (Jean Lapègue). However, the capacity to interconnect the two issues comes up against the specificities of each sector.

Nutrition, water and sanitation: Interdependent issues

“The link between the health environment and nutritional symptoms” stems from “a vicious circle that needs to be broken”. Indeed, “undernutrition destroys the immunity of the person” who suffers from it and then becomes “susceptible to all infections, and especially water-borne infections”. Yet the lack of hygiene and access to drinking water creates a breeding ground for the emergence of diseases – diarrhea, intestinal worms, environmental enteropathy – which maintain the undernutrition: “A person who is suffering from diarrheal infections will lose their appetite, become dehydrated and suffer from catabolism (meaning that nutrients pass directly into the stools).” (Jean Lapègue)

All the field observations confirm the vicious circle: in Burkina Faso, “it is estimated that 50% of malnutrition is related to infections, poor hygiene conditions or unsafe water and the absence of sanitation.” (Joséphine Ouedraogo) In a region in South Kivu in DRC, AFD has seen that there is “a clear and even temporal link between the number of cases of cholera in the city and the deficiencies in water supply.” (Cassilde Brenière)

Promote the multisectoral approach: An effective solution…

The identification of these causalities has led to a paradigm shift in the perception of undernutrition: while for a long time the only response to this phenomenon was to supply food aid, “today, there is a trend that is conducive to increasing the role of the water-sanitation sector in preventing undernutrition”. Indeed, at Action against Hunger, “34% of projects work on water, sanitation and nutrition in an integrated way” (Jean Lapègue). For example, the association develops comprehensive strategies, such as WaSH-in-nut, where a “water, sanitation and hygiene” component is systematically coordinated with all the programs to combat undernutrition.

In Burkina Faso, the pilot phase of a WaSH-in-nut action program has just been launched: to treat “children under 5 suffering from acute malnutrition, pregnant women and breastfeeding women”, “we have distributed WaSH kits to families, built latrine in homes, raised awareness on handwashing”. The results are satisfactory: “The operations for access to water-sanitation-hygiene have an impact of almost 45% on reducing malnutrition.” (Joséphine Ouedraogo)

…but which comes up against structural specificities

“The planning of sanitation and nutrition needs to be linked and coordinated in both the field and in institutions” (Cassilde Brenière), like what is being established in Burkina Faso: “With the Ministries of Health, Social Action and Education, we are trying to develop a common strategy for operations in order to improve the fight against malnutrition” (Joséphine Ouedraogo). But this approach is still insufficiently widespread: GRET notes that “there are very few exchanges between the public authorities responsible for national strategies and policies”, as is the case with NGOs and financial partners, who “also [work] a lot in silos.”

What are the reasons for this segmentation? The two sectors do not involve the same type of economic circuit: access to water and the sanitation activity involve “market-based relations between service providers and the beneficiary users”, whereas nutrition falls within a different sphere that does not require so much heavy infrastructure. The two sectors also work with different actors: sanitation involves working “with municipalities and the technical services of local governments [….] and nutrition “more with healthcare institutions than with municipalities.” (Frédéric Naulet)

Furthermore, there is not total consensus on the degree to which water, sanitation and nutrition issues should be integrated. AFD advocates for a case-by-case approach, depending on the projects: “Otherwise there is a risk of blurring the lines, which partly prevents a scaling-up” (Cassilde Brenière). For GRET, integrated programs are relevant: “which is especially the case in territories that suffer from a combination of handicaps (extreme poverty, high nutritional prevalence, isolation”. However, in these areas where institutions are often weak, “it is extremely difficult to guarantee the permanence of sanitation services and sustainability of hygiene and nutrition awareness-raising programs”. GRET therefore advocates for “cross-fertilization”, which involves “identifying in each sector […] the common issues and innovations that can benefit one another/” (Frédéric Naulet)

Specific handicaps in the sanitation sector

Finally, it should be noted that certain issues remain specific to the sanitation sector. The first is financing: “Very few sanitation projects are submitted to donors” since priority was for a long time given to access to water (Frédéric Naulet). Indeed, “if we look at total development assistance in the water-sanitation-hygiene sector, 75% is allocated to water, 24% to sanitation and 1% to hygiene” (Jean Lapègue). There is a pressing need to come up with sustainable financing solutions for sanitation if we want to scale up: “It will not be possible to provide 2.5 billion people with access [to basic sanitation facilities] with small-scale integrated projects in villages.” (Cassilde Brénière)

The other main challenge is to involve communities. Issues such as latrines and hygiene are still taboo: for the time being, sanitation “is not subject to a strong enough demand from communities”. There is a “need to change behavior” (Joséphine Ouedraogo). At the same time as developing infrastructure, actions need to be conducted to raise public awareness, especially because the most basic actions can have very significant effects: for example, the researcher Lorna Fewtrell has shown that to reduce morbidity and mortality, especially from diarrhea, “the first action to take is handwashing with soap”. However, due to the lack of resources, “priority needs to be given to effective and inexpensive actions.” (Jean Lapègue)

Issued early in 2016, the World Bank study provides a systematic review of the evidence on the relationship between water and sanitation and nutrition in Bangladesh. The report is intended to accomplish two things: first, to synthesize the results/evidence evolving on the pathway of WASH and undernutrition for use by practitioners working in the nutrition and water and sanitation sectors to stimulate technical discussions and effective collaboration among stakeholders. Second, the report can serve as an advocacy tool, to assist policy makers in formulating a multisectoral approach to tackling the undernutrition problem.

A link to the report can be found here:  https://openknowledge.worldbank.org/bitstream/handle/10986/22800/9781464806988.pdf?sequence=1&isAllowed=y

This first in the series of learning briefs, “WASH and Nutrition,” documents WASHplus’ WASH and nutrition integration programming efforts to stimulate the discussion and improve the evidence base as well as share experiences and approaches to integrating the two sectors at the global and country level.  WASHplus has been stimulating the discussion and improving the evidence base around integrating WASH into nutrition programming and sharing experiences and approaches to integrating the two sectors at both the country and global levels.

The brief can be found here: http://www.washplus.org/sites/default/files/wash_nutrition-brief2015.pdf

The brief  discusses several examples of nutrition integration with WASH. For example, a two-year WASHplus program in Mali was designed as an integrated WASH and nutrition program from the start. Lessons learned from this pilot are generating dialogue and interest in integrated programming at the regional and national levels.

In Bangladesh, WASHplus has been working at the national level to integrate key WASH indicators into nutrition activities and monitoring, to both build the evidence base linking WASH and nutrition programming and increase the frequency of integrated programming.

In Uganda, WASHplus worked through other USAID partners, primarily the FANTA, SPRING, and Community Connector projects, to integrate WASH components into nutrition and food security programs. WASHplus developed a modular WASH-nutrition training and offered both stand-alone and integrated sessions and promoted small, doable actions.

The brief discusses ongoing challenges, such as that WASH is often considered after the initial design of nutrition projects, so projects improvise by identifying strategic opportunities as they arise and incorporating one or two WASH components into an established nutrition program, often without the accompanying indicators appropriate to those interventions. Without these indicators, it is difficult to quantify and justify the inclusion of WASH components. Other difficulties include that the integration of WASH into nutrition programs is one-sided: it takes place more often than nutrition being integrated into WASH programs. There can also be “message overload” if the scope and number of behavioral objectives are targeted.

The hope is that results from the integrated programming in Bangladesh, Mali, and Uganda will be validated and replicated in other countries to further build the evidence base and promote nutrition-WASH integrated programs.

Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries. Maternal and Child Nutrition, Nov 2015. Authors: Mduduzi N.N. Mbuya and Jean H. Humphrey.

Water, Sanitation, Hygiene, and Nutrition in Bangladesh” Can Building Toilets Affect Children’s Growth? 2015.

• Full text

Authors: Iffat Mahmud and Nkosinathi Mbuya. World Bank.

This report provides a systematic review of the evidence to date, both published and grey literature, on the relationship between water and sanitation and nutrition. 

We also examine the potential impact of improved water, sanitation, and hygiene (WASH) on undernutrition. This is the first report that undertakes a thorough review and discussion of WASH and nutrition in Bangladesh.

The report is meant to serve two purposes. First, it synthesizes the results/evidence evolving on the pathway of WASH and undernutrition for use by practitioners working in the nutrition and water and sanitation sectors to stimulate technical discussions and effective collaboration among stakeholders.

Second, this report serves as an advocacy tool, primarily for policy makers, to assist them in formulating a multisectoral approach to tackling the undernutrition problem.

Notes from the SuSanA WASH & Nutrition Working Group

(The notes below are from Claire Gaillardou/ACF of the SuSana Working Group on WASH & Nutrition meeting at World Water Week in August 2015)

Dear members/followers of WG 12,

I would like firstly to thank you for your participation during the side event ACF-GWN on WWW.

The WIN topic has been strongly pushed in Stockholm this year. There is a significant improvement in the involvement of nutrition sector in this transversal topic.

ACF-GWN session on how to operationalize WASH in Nut was organised to have first an institutional, research and operational update on current practices, and then three working groups (institutional, operations and research) listing recommendations. Recommendations (9 in total) have then been compiled and validated: please see doc attached.

Some important remarks:

• The 1000 days window for intervention is critical for proper WASH interventions (domestic hygiene, child feces management, waste management) – Oliver Cumming, London School of Hygiene and Tropical Medicine
• Germany Government strategy is supporting the “one world no hunger” initiative, which includes multi-sectoral approach in 11 countries to prevent under nutrition – Ms. Hieronymus, Head of Division: Special Unit “One World No Hunger”, German Federal Ministry for Economic Cooperation and Development and Mr. Francois Marre, Heads of Department BMZ
• Burkina Faso Minister of agriculture, water resources, sanitation and food security, insisted on the actions accompanying the strategies (food hygiene, CLTS, hand washing, improve water quality, improve coverage, the issue of surveillance and early identification of undernourished people) – Francois Lompo
• ACF spoke of seasonality, ORS/Zinc, SAM targeting, NCA, challenge in measuring diarrhea, and impact of WASH projects on prevention, relapse and treatment – Claire Gaillardou

The main conclusions from the working groups appear in this presentation.
Research group:

• Quantify the impact of what works and where and what interventions are cost effective
• How to measure nutrition and WASH more consistently (bio indicators markers, etc.)
• Explore enabling factors that ensures best impact for an intervention
• Share key studies results – better dissemination of the key research findings

Institutional group:

• Funding the gaps
• Global policies, appeals and budgets for integrated projects
• Ensure Nutrition sector involves more WASH and vice versa
• Consider funding the two ways integration, especially Nut in WASH (food hygiene and food conservation, hand washing with soap before eating)
• Use existing platforms such as SUN to scale up WASH in Nutrition policy approach

Operational group:

• BC strategies Ensuring that WASH and nutrition projects include a Behaviour Change strategy
• Capacity of delivering service, focus on engage and training of health practitioners
• Value chain to support financial sustainability (PPP, innovative social marketing etc.)
• Meal approach

Please, do not hesitate to amend this document.

The presentations of the working group are below:

• Bonn WASH Nutrition Forum 2015: Political Dialogue Forum & Thematic Conference
• WASH and Nutrition Integration and Small Doable Actions – Ron Clemmer, FHI 360 and USAID/WASHplus
• Research on the benefits of a household WASH package to Community Management of Acute Malnutrition (CMAM) program in Chad - Jovana Dodos, ACF International
• WASH in Nutrition Overview – Jean Lapegue, ACF International

Finally, an online WASH in Nutrition mapping form is actually in progress and will be uploaded to SuSana WG 12 forum soon.

Regards,

Claire GAILLARDOU

ACF- WASH -DRM Advisor for Burkina Faso, Cameroon, Ivory Coast, Central African Republic and Chad