The seminar will examine the widely neglected and underestimated adverse nutritional impact of lack of safe water, sanitation and hygiene (WASH). It makes apparent how governments struggling to feed their citizens can make a substantial contribution to food and nutrition security by making WASH investments. Reducing faecal infections through sanitation and hygienic behaviour is a major means for reducing the undernutrition of children, enhancing the wellbeing of children, women and men, and achieving the MDGs. Approaches for scaling-up WASH like Conditional Cash Transfers (CCT) as well as approaches to improve food and nutrition security through productive sanitation will be presented using regional case studies. Together with the participants the potentials and challenges of these approaches will be discussed in rotating discussion groups facilitated by distinguished sector experts. The goal is to get an in-depth understanding of this neglected link and to provide constructive impulses for promising ways forward to strengthen this nexus at scale and push towards fulfilment of the human right to water and sanitation. This seminar was part of World Water Week, 2012.

2. WASH &
Undernutrition
Oliver Cumming
London School of Hygiene and Tropical Medicine
SHARE Consortium

3. Key points
1. Background
2. Evidence
3. Disparities/equity
4. Implications for policy

4. Undernutrition
Prevalence of stunting (> 2 SD HAZ)
Source: Black et al. 2008

5. Undernutrition
It is estimated that undernutrition causes 2.2 million deaths and
21% of global disease burden for children younger than 5 years
(Black et al 2008)1
30% of children in low-income countries <5 years are chronically
undernourished (UNICEF 2008)2
As diarrhoea causes undernutrition, it also reduces a child’s
resistance to subsequent infections creating a vicious circle
(Brown et al. 2003)
Further evidence suggests that sustained exposure to excreta-
related pathogens – including helminths referred to above – in
early life limits cognitive development and lowers immunity
(Prüss-Üstün & Corvalán 2006)

6. Growth faltering
Mean height for age z-scores by age by region
Source: Victora et al 2010

7. WASH
• Review of 42 studies for food programmes in
Africa found the best result was 0.7 z-score
• Average growth deficit for Africa (& Asia) 2.0
• So, the best programmes only achieved 33%
normalisation
• Environmental influences may explain some of
this

8. Systematic Review
1. To evaluate the strength of
evidence on the
effectiveness of water,
sanitation and hygiene
interventions in improving
child nutritional status
2. To identify current
research gaps
Source: Dangour et al 2011
(Cochrane online)

9. Hypothesis
• Evidence that WASH interventions positively impact prevalence of
childhood disease3 4 5
• Diseases such as diarrhoea, tropical enteropathy and nematode
infections have negative effects on nutritional status in children6 7 8 9
• WASH interventions could be associated with improved measures
of nutritional status in children.
• Indirect pathways could also contribute:
– time taken to collect water
– the purchase of water
– chemical contamination of water

10. Low water quantity
Water source far from home
Inadequate storage
capacity
Poor water quality
Unprotected water source
Less time for
food preparation
and meal
supervision
Water pricing
High amount spent on water
DiarrhoeaTropical EnteropathyNematode infection
Contaminated material ingested
Faecal contamination of home
Poor nutritional status
Poor hand-washing
post-defecation
Unimproved sanitation
Less money
for food
Low
quantity and
quality
Conceptual framework

11. Three key pathways
1.Repeated bouts of diarrhoea
2. Intestinal worm infection
(hookworm, ascaris)
3. Environmental enteropathy***

12. Methods
• Primary outcomes:
– weight-for-height (wasting)
– weight-for-age (underweight)
– height-for-age (stunting)
• Secondary outcomes:
– all other child anthropometric measures
– biochemical measures of micronutrient status (including EE)
• 6 databases searched using a keyword search and MeSH terms

13. Method
• Study design: intervention with control arm
• Participants: children < 18 years old from both low and high income
countries.
• Intervention types included are those aimed at:
1. improving access to facilities which ensure the hygienic separation of
human excreta from human contact
2. promotion of hand-washing with soap
3. introducing a new/improved water supply and/or improved
distribution
4. improving the microbiological quality of drinking water

14. Preliminary Results
Few high quality interventions studies <10
Most studies included ranked as poor quality by Cochrane
One randomised controlled trial:
Du Preez (2011)
Water treatment median 0.8 cm gain for u5 stunting (0.7 - 1.6 cm; P-
0.031)
A number of important protocols identified:
• Clasen et al – Orissa, India (Z-scores)
• Luby et al – Bangladesh (Z-scores, MUAC, EE markers )
• Humphrey et al – Zimbabwe ((Z-scores, MUAC, EE ) *from birth/factorial*

15. Disparities
Sanitation progress 1995-2008 by wealth quintile
Source: UNICEF 2011

16. All toilets are equal?
• 2.5 billion people without toilet
• Every toilet built (used!) is progress
• But, need to get toilets to the most at risk
• Sanitation risks is not distributed evenly in populations
• RR of fatal diarrhoea higher for u5 with under-nutrition
• Nutrition is a high determinant of sanitation health risk

17. So what?

18. “If preventable, why
not prevented?”
(1891)

19. Key messages
1. New research but WASH a cause of undernutrition
2. Undernutrition increases risk of infection & death
3. Need food, healthcare access, and WASH
4. Different exposures may mean different interventions
5. Investment case: revalue ‘costs and consequences’
6. Policy coherence – WASH, nutrition, NTD…
7. Another reason to consider disparities/equity/non-
discrimination!

20. Concluding footnote
Edwin Chadwick (1847)
Sanitary reform to improve nutrition
of urban poor
Mills-Reinicke (McNutt 1901)
“The surprising fact that the
reduction in child mortality
accompanying improvements in
water supply was greater than
what could be accounted for by
the fall in mortality caused by
enteric, waterborne diseases.”

21. Thank you
www.SHAREresearch.org
oliver.cumming@lshtm.ac.uk