Children in India are exceptionally short, with their stunted growth historically attributed to malnutrition. However, new evidence is suggesting that food, or lack of it, is not the cause. Noticing that Indian children were smaller than their counterparts in sub-Saharan Africa — who are, on average, poorer and hence less well fed — researchers have been coming to the conclusion that diseases stemming from poor sanitation are more to blame than diet.
More than half of India’s population — over 600 million people — do not use a toilet because sanitation is inaccessible or unaffordable. At the same time 61.7 million Indian children are stunted, the highest prevalence in the world.
The atrocious hygiene that results from widespread lack of sanitation is made worse by the density of the population. With large numbers of people openly defecating, fecal-oral-transmitted infections are common, leading to diarrhea, with such diseases draining growing children of vital nutrients. Growing up in environments teeming with fecal pathogens has a permanently debilitating effect, experts say. Over time, a large buildup of fecal germs in the body can also manifest as severe intestinal diseases.
Last month, a group of economists, epidemiologists, pediatricians and nutritionists gathered at a conference in New Delhi to push for recognition of poor sanitation as the cause of child stunting in India. “It was striking that each of them [the participants] had something to say about sanitation being important for child health,” Sangita Vyas, of the Research Institute for Compassionate Economics, which co-organized the meeting, told TIME. Such claims emerge at a time when the results of a massive government survey into the availability of sanitation have become available and converged with long-standing epidemiological literature.
Rural Indians remain hard to convince that this is a health epidemic, researchers say, because stunting creeps through communities, affects “everybody on average” and there are “no real dramatic cases,” Dean Spears, Princeton University economist who is currently at the Delhi School of Economics, tells TIME. “The sorts of dramatic tragedies that persuade people [to change] don’t happen.”
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A few years ago, a government sanitation program was implemented in half of 60 villages in Ahmednagar, in the western Indian state of Maharashtra. After the program, Spears and fellow economist Jeff Hammer later found that on average the height of children in the experimental group had increased by about 1 cm, relative to those in the 30 villages where the program had not been introduced.
“Widespread child stunting in India is a human-development emergency,” Spears says. “It matters for everybody.”