Pulitzer Center Update

The Link Between Sanitation and Malnutrition

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Life in Bwondha, Uganda, revolves around the contaminated waters of Lake Victoria. In Bwondha, the prevalence of schistosomiasis, spread by parasites that inhabit contaminated water, is 80 percent. Image by Samuel Loewenberg. Uganda, 2014.

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A church camp dumps its waste in the forested mountains. Close by is what appears to be an open-air male toilet. Image by Diksha Bali. Ghana, 2013.

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Dealing with thirst at school is one thing; lack of access to restrooms is another. School bathrooms are so bad they scare many students away. Image by Tecee Boley/Graphic by FrontPage Africa. Liberia, 2013.

“Many of the 162 million other children under the age of 5 in the world who are malnourished are suffering less [from] a lack of food than [from] poor sanitation,” reports Gardiner Harris, public health reporter for The New York Times. Globally, but in developing countries in particular, children continue to die from illnesses preventable by straightforward measures like building proper sewage systems, discouraging outdoor defecation, and promoting hand washing.

The link between health and hygiene is well understood, yet the fundamental importance of sanitation in fighting malnutrition was a recent discovery. According to Johns Hopkins Bloomberg School of Public Health professor Jean Humphrey, the stunting these children experience is not simply due to a lack of food. The constant ambush of germs and bacteria from their environment forces “these children’s bodies [to] divert energy and nutrients away from growth and brain development to prioritize infection-fighting survival,” Humphrey told The New York Times. The ability of children who have repeated bacterial infections in their digestive tracts to absorb nutrients is reduced by one-third.

Harris’s article highlights the sanitation and malnutrition crisis in India, but as Pulitzer Center reporting finds, the problem is global. The UN’s Food and Agriculture Organization estimates that by 2025, two-thirds of the world's population could be living in “severe water stress conditions," leaving billions more children vulnerable to stunting, as well as cholera, diarrhea, skin disease, trachoma, parasitic diseases like schistosomiasis, and malaria, among others.

Fecal contamination of Lake Victoria, a major water supply and center of life and culture in East Africa, is the focus of Pulitzer Center grantee Samuel Loewenberg’s project “Uganda Tries to Clean Up.” In Bwondha, a lakeside village, the prevalence of schistosomiasis is 80 percent. Alan Fenwick, a professor of tropical parasitology at Imperial College, London, says the disease will only disappear once “everyone has access to clean water and sanitation.” With Kampala’s drinking water contamination level at nearly 100 percent, there seems to be no light at the end of the tunnel.

Loewenberg writes that “both the health and water ministries say they recognize the problem, but each blames the other. The result is that not much gets done.”

Too few government resources are being allocated to this issue, but one student is hoping to make a difference in spite of bureaucratic obstacles. In Liberia, Pulitzer Center grantee Tecee Boley followed Sarta S. Bawoh, an 18-year-old running for vice president of G.W. Gibson High School in Monrovia. Bawoh insists that the biggest problem currently facing students is lack of clean water and sanitation.

As Boley reports, children are unable to attend school due to illness and the high price of clean drinking water, and girls who have started menstruating have the additional obstacle of having no private toilets. According to the World Health Organization (WHO), as many as 18 percent of deaths in Liberia are the product of sanitation problems and lack of access to clean water. Despite the rising death toll, “(water and sanitation) is not being taught in school,” says Z. Abraham Gardour, the principal of G.W. Gibson High School.

In the absence of school organized programs, some local leaders and health workers are turning to community churches and mosques to help spread the word. Student fellow Diksha Bali’s Pulitzer Center project on waste management in Ghana addressed the role of religious organizations in the sanitation crisis. Samuel Yabani, a university student in Ghana, says that while there have been special sermons and educational programs for his congregation at New Apostolic Church, they have never addressed the topic of waste management.

This lack of education on the importance of personal hygiene is an unfortunate reality in many of the developing countries where poor sanitation, and therefore illness and malnutrition, is widespread. In Bangladesh, over 50,000 children under five die each year from diarrhea-related diseases like typhoid and cholera. Many of those deaths are preventable by the simple act of washing one’s hands. As Pulitzer Center contributing editor Kem Knapp Sawyer reported in her coverage of the Global Forum on Sanitation and Hygiene in 2011, hygiene education programs are one of the simplest and most important measures a country can take to protect its youth.

But lack of education is not the only problem. The Republic of Mali has hand washing campaigns underway, yet only 4.9% of boys and 5.3% of girls wash their hands after using the latrine. Misinformation and false beliefs within these populations are also to blame: Many women believe that excessive cleanliness can cause infertility, and some traditions hold that those who wash their hands regularly will never be rich.

Currently, 783 million people do not have clean water and 2.5 billion lack proper sanitation. This complex problem will require a combination of education, public funding, and cultural shifts. Sanitation and access to clean water have been linked to improved health, increased access to education, longer life expectancies, a better quality of life, and now, an answer to malnutrition.