Why are so many Indian children stunted?

Why are so many Indian children short for their age, or stunted? Cognisant of the country’s nutrition problem, especially among children, the Government has made concerted efforts to get food to children and their families through various initiatives. India has undoubtedly made progress with regard to child undernutrition with stunting rates dropping from 48 per cent in 2006 to 38.7 per cent in 2015. Yet India continues to be home to a staggering 48 million stunted children under age 5 — the highest in the world.

To understand this, experts have turned to investigating the role of the underlying drivers of nutrition — factors outside of the traditional, direct causes of undernutrition that affect whether food reaches those it should and whether nutrients are being absorbed. One such underlying driver is access to safe water and toilets, handwashing facilities, and hygiene behaviour. Safe water, sanitation and hygiene (WASH) have been identified as playing a key role in catalysing further reductions in undernutrition, contributing to improvements in children’s growth and development. So how exactly can improvements in the WASH situation contribute to improved nutritional status of India’s children?

Tackling undernutrition Stunting, where children are short for their age, results from severe and persistent undernutrition. While the lack of nutritious food significantly contributes to undernutrition, the World Health Organization estimates that half of all undernutrition is associated with diarrhoea and infections resulting from unsafe water and sanitation, and unhealthy hygiene behaviours. Repeated diarrhoea in the first two years of life directly contributes to a quarter of all cases of stunting, with WASH responsible for a majority 88 percentage of all diarrhoea cases. WASH contributes to diarrhoea through several key routes. First, when people lack access to adequate sanitation, they often defecate in the open, polluting water sources used for drinking, cooking, and washing purposes. When people don’t have access to safe drinking water or resources to make water safe, they end up consuming contaminated water. And lastly, when people do not have awareness about the importance of hygiene or access to adequate hygiene facilities such as water and soap, they may not wash their hands at critical times like after defecation and before they eat, which leads to germs entering their bodies and their children’s bodies when they prepare and eat food.

Children who drink unclean water contaminated by faecal matter, or are unable to wash their hands after defecating and before eating are vulnerable to diarrhoea, intestinal worm and other infections. What is particularly harmful about these conditions is that they prevent a child’s intestines from absorbing nutrients, preventing physical and cognitive growth. Research suggests that children can become stunted if they experience five or more cases of diarrhoea before their second birthday. Stunting is irreversible after age two, and its effects are long-lasting in terms of educational performance, health, and future potential.

Critical issues According to a landmark article in The Lancet in 2013, direct nutrition interventions, while essential, can reduce stunting only by 20 per cent in the worst-affected countries. If we are to reduce the remaining 80 per cent of stunting, nutrition-sensitive interventions that tackle the underlying drivers such as WASH, among others, are critical. This is particularly salient in the case of India where 76 million people do not have access to safe water, and 774 million live without adequate sanitation. Tackling WASH for nutrition can also contribute to mitigating the economic impacts of malnutrition, estimated to be 11 per cent of GDP in Asia and Africa annually.

For India to continue to make significant strides to reach the Sustainable Development Goal target to end all forms of malnutrition by 2030, the Government must continue with its direct nutrition interventions such as promoting breastfeeding, iron and vitamin supplementation, and food fortification. But in addition to these, the Government must support efforts to improve WASH by investing in safe water, hygiene facilities and activities that engender hygienic and healthy behaviour. A multi-sectoral approach is critical. This can be done by the nutrition sector integrating WASH components into their ongoing platforms and programmes such as ICDS, and by the WASH sector keeping in mind nutrition outcomes affected by water, sanitation and hygiene and ensuring that these messages are incorporated when speaking about the benefits of WASH.

The writer is Manager-Policy (WASH in Schools, Health & Nutrition) at WaterAid India