There are no magic bullets after all.
That’s the saddest conclusion that comes out of a five-year-study of 1 million children in 8,338 government-supported childcare centres in villages across Uttar Pradesh.
The study led by the King George Medical University, Lucknow and the University of Oxford in UK was looking at two simple solutions public health officials had come up with to combat child mortality and growth.
Solution 1: Mass administration of vitamin A. The hope was that would reduce childhood mortality by 20 to 30 percent.
Solution 2: Mass administration of the deworming tablet aldendazole every six months to all young children. The hope here was that it would eliminate intestinal worms and help children gain weight faster.
Now the results are out in the medical journal Lancet. “I think these long-awaited results cast doubts on the benefits of what have been promoted as magic bullets,” said paediatrician Harsh Pal Sangh Sachdev to The Telegraph.
The mortality reduction was only 4 percent. The weight gain difference after two years between those who got the deworming tablet and those who did not was 0.04 kg.
Obviously, these results are not what the government was looking for. Government policy dictates all children between six months and five years get vitamin A through government health centres. Deworming campaigns are underway in several states. Is that why they were not published in a journal for 5 years? The Telegraph says the findings were first published by the newspaper in April 2008. But until a journal like Lancet publishes them they don't have policy impact.
Whatever the truth may be, this is dispiriting news from a policy perspective.
And it comes at a time when there is more bad news for Indian children. Indian children are among the shortest in the world. The culprit is not just malnutrition or genetics. Indian children are shorter than Chinese. And they are shorter on average than countries in Africa which are poorer. The problem, writes researcher Dan Spears in The Hindu, might be those worms. Specifically the problem of open defecation.
This is not just an eyesore that caused V. S. Naipaul to recoil in horror. Open defecation is actually a factor in stunting our growth.
Fecal germs, Spears explains, can make their way into children’s food and water, carried by their fingers and feet. Even when children are not carrying them, flies are. We all know you can get diarrhoea because of it. But long-term exposure means even when the child seems fine, her intestinal tissues cannot absorb nutrients in food the way they are supposed to.
The statistics are dismal when it comes to toilets. 53 percent of Indian households 'usually' do not use a latrine or toilet according to the 2011 census. Of the 1.1 billion people who defecate in the open, 60 percent live in India. Nitish Kumar’s Bihar is already 'special' in this category. “No country measured in the last 10 years has a higher rate of defecation than Bihar,” writes Spears. Countries like Angola, Democratic Republic of Congo, Ethiopia all clock in with lower rates of public defecation than India.
What does that mean? In his full study available on the website of The Rice Institute, Spears writes, “controlling for GDP, the difference between Nigeria's 26 percent open defecation rate and India's 55 percent is associated with an increase in child height approximately equivalent to quadrupling GDP per capita.”
The problem with trying to improve public sanitation in India is that public toilets, even when they do exist are so filthy, ill-maintained and safety hazards for women, that people are forced to use the great outdoors. 54 percent of urban slum dwellers have no access to any toilet. That’s where the class problem kicks in writes Kalpana Sharma for InfochangeIndia.org.
Those with money have secure housing and therefore do not need to worry about public toilets. They can walk with confidence into hotels or shopping malls when they are out, and otherwise have toilets in their homes. For the poor living in informal housing without individual toilets, public toilets are a necessity. If, on top of that, they have to pay each time they use it, the burden becomes heavy.
The real solution has always been secure housing. Then the public toilets will be used for what they were meant for – the person on the go who suddenly needs to use one, not the daily use of all the families crammed into the local slum. But for most of us, this is the classic not-in-my-backyard problem where we are only disgusted when we step out of our houses in the morning to find someone has taken their morning dump just outside our house. We sidestep the problem, literally.
But Spears writes in his report that we cannot just flush the problem away as something unfortunate, but not affecting us. What makes the issue especially for India, is the population density. Height is strongly associated with the density of open defecation. So our children face a double whammy. And that’s not just the kids in the slum who don’t have a toilet at home.
Here’s the bad news for all of us:
Children who live in urban homes with flush toilets that they do not share with other households; whose mothers are literate and have been to secondary school; and whose families have electricity, a radio, a refrigerator, and a motorcycle or car. Even these relatively rich children are shorter than healthy norms; this is expected, because 7 percent of the households living near even these rich children defecate openly.
In short, your child might have a toilet. But he might live around households who don’t. And that could affect his height in ways that those chirpy ads for Complan and Horlicks cannot do anything about.
Toilets for all will not be magic bullet just as the Vitamin A pills and deworming tablets were not. But Spears is making clear that in our densely populated country, we cannot think the problem does not affect us.
World Toilet Day falls on November 19th. That also happens to be the late Prime Minister Indira Gandhi’s birth anniversary. Our Congress politicians are too busy garlanding statues and taking out effusive full-page ads to deal with matters like sanitation on that day. But perhaps an enterprising politician will combine the two and take up an issue which, as it turns out, is literally about the country’s growth.
Please read Dan Spears' complete article about sanitation and height here.
Please read G.S. Mudur on the Vitamin A and deworming study here.