UNICEF: Without toilets, childhood is even riskier due to malnutrition

Fatuma Nuior, 16, and her cousin Audi Arab, 12, stand by her latrine next to her house in Ber'aano Woreda in Somali region of Ethiopia 12 February 2014. The village is the first village declared ODF (Open Defecation Free) and All but one household has a latrine. While flags fly over each latrine. In Somali Region water supply coverage is estimated at 59.7%, lower than the national average of 68.5%. The need for water supply normally increases in the dry season, especially at the time of drought such as in recent years. However, the technical and organizational capacity of the Somali Regional State Water Resources Development Bureau (SRWDB) the government agency responsible for water supply and facilities management in the region to satisfy the water supply need is not adequate to cope with the situation. Donor agencies and NGOs are making efforts to ameliorate the situation by constructing and repairing water supply facilities across the region, supplying water by water trucks during chronic shortages, but the supply is still significantly below the demand.
Fatuma Nuior, 16, and her cousin Audi Arab, 12, stand by her latrine next to her house in Ber’aano Woreda in Somali region of Ethiopia ©UNICEF Ethiopia/2015/Ose

NEW YORK, 19 November 2015 – Lack of access to toilets is endangering millions of the world’s poorest children, UNICEF said today, pointing to emerging evidence of links between inadequate sanitation and malnutrition.

Some 2.4 billion people globally do not have toilets and 946 million – roughly 1 in 8 of the world’s population – defecate in the open. Meanwhile, an estimated 159 million children under 5 years old are stunted (short for their age) and another 50 million are wasted (low weight for age).

A report issued today, Improving Nutrition Outcomes with Better Water, Sanitation and Hygiene, from UNICEF, USAID and the World Health Organization, for the first time brings together years of research and case studies which demonstrate the link between sanitation and malnutrition. More importantly, it provides guidance for action.  

Lack of sanitation, and particularly open defecation, contributes to the incidence of diarrhoea and to the spread of intestinal parasites, which in turn cause malnutrition.

“We need to bring concrete and innovative solutions to the problem of where people go to the toilet, otherwise we are failing millions of our poorest and most vulnerable children,” said Sanjay Wijesekera, head of UNICEF’s global water, sanitation and hygiene programmes. “The proven link with malnutrition is one more thread that reinforces how interconnected our responses to sanitation have to be if we are to succeed.” 

Diarrhoea accounts for 9 per cent of the deaths of children under 5 years old each year and is essentially a faecal-oral disease, where germs are ingested due to contact with infected faeces. Where rates of toilet use are low, rates of diarrhoea tend to be high. 

Children under 5 years old suffer 1.7 billion cases of diarrhoea per year. Those in low income countries are hit hardest, with an average of three episodes per year. The highest frequency is in children under 2 years old, who are weakest and most vulnerable. Multiple episodes of diarrhoea permanently alter their gut, and prevent the absorption of essential nutrients, putting them at risk of stunting and even death.  

Some 300,000 children under 5 years old die per year – over 800 every day – from diarrhoeal diseases linked to inadequate water, sanitation and hygiene. The poorest children in sub-Saharan Africa and South Asia are particularly at risk.

Intestinal parasites such as roundworm, whipworm and hookworm, are transmitted through contaminated soil in areas where open defecation is practiced. Hookworm is a major cause of anaemia in pregnant women, leading to malnourished, underweight babies. 

Some countries have made significant progress in addressing both access to sanitation and the nutritional status of their children. Many have successfully used UNICEF’s Community Led Total Sanitation approach, in which the affected populations themselves devise local solutions to the problem of open defecation. 

  • Pakistan met the 2015 Millennium Development Goal to halve the proportion of people who in 1990 did not have access to improved sanitation. Using CLTS, entire communities abandoned the practice of open defecation, leading to improved health and nutrition indicators among their children.
  • Ethiopia mobilized community workers and achieved the largest decrease globally in the proportion of the population who defecate in the open. Despite population growth, the practice reduced from 92 per cent (44 million people) in 1990 to 29 per cent (28 million people) in 2015.
  • In Mali the CLTS approach was also used in communities with high malnutrition rates, exacerbated by drought in the Sahel region. Improved access and use of latrines ensued, and improved health and nutrition in children.
  • During the emergency linked to conflict in the Democratic Republic of the Congo, integrated nutrition and WASH interventions were used for displaced communities. Children under 5 years old saw significantly reduced undernutrition and waterborne diseases. Around 60 per cent of the population constructed latrines and some 90 per cent of malnourished children returned to normal weight during a 12-month period.

“There are no excuses not to act on access to toilets, even in the poorest communities, or during emergencies,” said Wijesekera. “On the other hand, there are millions of reasons – each one a child who is stunted or wasted, or worse, who sickens and dies – to treat this with the urgency it deserves.”

Why did the toilet paper roll down the hill? To get to the bottom.

Why did the toilet paper roll down the hill? To get to the bottom.

Has that joke left you flushed with amusement? Or was it a flash in the pan? Do you feel you got a bum deal from a supposedly serious editorial? Puns and humour abound whenever toilets or poop come into the conversation, and that’s understandable: over the last couple of hundred years the natural, inevitable act of defecation has been locked out of polite society, to be talked about only with humour or embarrassment. As India’s Rural Development Minister Jairam Ramesh recently said that “when we talk about sanitation we can only giggle.”

But that is about to change, because today is the first ever UN-endorsed World Toilet Day.

A latrine stands alone in the expanded area of Kobe refugee camp in Dolo Ado refugee camp
A latrine stands alone in the expanded area of Kobe refugee camp in Dolo Ado refugee camp © UNICEF Ethiopia/2012/Ose

That may make you laugh too. After all, there are UN days for Africa Industrialization, Philosophy and Television, and that’s just in November. But behind the humour of toilets and pooping, there are some deadly serious facts and figures that make it obvious why 100 countries – from Afghanistan to Viet Nam – came together earlier this year to pass the resolution that enshrined an official UN World Toilet Day for the first time in history. Here is one figure: 10 million viruses. That’s the number that can be found in only one gram of human faeces. Here is another: 2.5 billion. That’s how many people around the world still have no decent sanitation. One billion of them must do something called “open defecation”, or pooping in the open, in fields, on roadsides, on railway tracks. Every day, nearly two billion tons of human faeces, with a dizzying number of potential viruses, bacteria and worm eggs, are lying around our planet ready to be trodden on, touched or ingested in water and food. The consequences are easy enough to calculate: Diarrhoea, caused by that contaminated food, water and environment, is still the second deadliest killer of children in the world, killing 1,600 children every day. Only pneumonia and respiratory infections are more deadly (by the way, World Pneumonia Day is in November too). Women and girls get a particularly raw deal, having to find somewhere safe to defecate in darkness for modesty’s sake, putting them at risk of rape and animal attacks (linked to another UN day in November focussing on violence against women). That children are dying from something as seemingly trivial as diarrhoea, or girls are getting raped because they have to find somewhere to do their toilet business: neither of those facts should make you giggle (International Children’s Day is also in November).

Yet the attention and funding given to sanitation and diarrhoea – which is easily preventable with adequate sanitation, safe water and good hygiene – have for decades been dwarfed by that given to other causes and challenges such as HIV/AIDS. When the Millennium Development Goals – a set of targets to reduce poverty and better maternal health and education amongst other things – were signed in 2000, sanitation wasn’t even mentioned. (It was added in the 2002 Johannesburg summit.)

Kanu Fanta, 30, mother of 6, washes her hands at a latrine at her house
Kanu Fanta, 30, mother of 6, washes her hands at a latrine at her house in Amari Yewebesh Kebele of Amhara Region in Ethiopia © UNICEF Ethiopia/2013/Ose

Luckily, there is much more to celebrate now than ten years ago. Since 1990, 1.9 billion people have gained access to improved sanitation (although population growth means the number without scarcely changed). Even so, on average, 26,000 Africans gained access to sanitation every day, and there are 244 million fewer people defecating in the open worldwide. Also, we’re doing our sums better. The World Bank’s Water and Sanitation Program has launched an Economics of Sanitation Initiative that is producing figures to dazzle any treasury minister, calculating that a country can lose 1.5% of its GPD to costs incurred by poor sanitation (economic loss, hospital costs. Kenya loses $324 million a year in this way. India is $54 billion out of pocket (that’s the entire GDP of Croatia). But we can look at those figures from another angle: if we can figure out how to install adequate sanitation for 2.5 billion people, we can save $260 billion a year. Investing $1 in installing sanitation can save up to $5 in economic losses avoided. No matter how you do your sums, that’s a bargain.

Other cheering connections are being made between sanitation and other fields and departments. After research showing that sometimes up to a quarter of schoolgirls drop out of school permanently because of the simple lack of a toilet (usually when they begin menstruating), WASH – water and sanitation and hygiene – in Schools initiatives have multiplied. Experts in malnutrition now understand that sanitation plays a vital role in both the problem and the solution. Improving sanitation can reduce stunting and improve nutrition, the economy and development.

So do laugh by all means. All these new connections and understandings are causes for jubilation, and World Toilet Day is a wonderful way to celebrate them. It’s also a new spotlight on a public health crisis that has been hidden by shame for far too long. If jokes work at getting people to turn their attention to sanitation, let’s keep telling them.

Michel Jarraud, Chair of UN-Water, and Secretary-General of the United Nations World Meteorological Organization (WMO)

Hon. Anna Kajumulo Tibaijuka, Minister of Lands, Housing and Human Settlements Developments, United Republic of Tanzania, and Chair of the UN-hosted Water Supply and Sanitation Collaborative Council (WSSCC)

HRH Prince El Hassan bin Talal, Chair of UNSGAB, the United Nations Secretary-General’s Advisory Board on Water & Sanitation