Addressing Nutrition’s Backend through Sanitation & Hygiene

A low-income family living in rural India sits down to a nutritious home-cooked meal. The mother attended nutrition courses led by her local Angawadi worker during pregnancy and so understands the importance of proper nutrition, both for herself as well as her children.  Each of her three children were breastfed, and she buys fortified products when she can. She includes lots of fruits and vegetables in her family’s diet. Unfortunately, however, her children have diarrhea often and are regularly sick. Despite her best efforts they remain malnourished. Though she has done everything right, raising children in a country where more than 600 million people defecate in the open, spreading pathogens and contaminating food and water, diarrhea is a common occurrence.

Diarrhea, Nutrition’s Worst Enemy

India stands out globally for “the prevalence of diarrhea as a killer of infants.” Chronic diarrhea is closely related to “poor sanitation, malnutrition, and lack of access to basic healthcare services.” According to UNICEF, diarrhea kills 13% of the children under 5 that die each year in India, and this
devastating figure pales in comparison to the number of children it leaves malnourished. Initiatives in fortification and food treatment, education courses and prenatal nutrition interventions, and even India’s Mid-day Meal Scheme promise a solution, but nutrition is about so much more than proper food. It’s about clean water, toilets, hand washing, and access to proper healthcare. Without addressing the hygiene and sanitation ecosystem, which serve as nutrition’s backend, even the most impressive nutrition interventions will be merely palliative.

The Government of India has taken on a key role in addressing the country’s sanitation challenge with their Total Sanitation Campaign, a program offering subsidies for the construction of private home toilets. The campaign, however, has failed to achieve the health impact it hoped. Many of the toilets constructed with subsidies aren’t used; their owners continuing to defecate in open fields. As this seemingly illogical outcome demonstrates, toilet use, or lack there of, depends on more than access. Successful behavior change initiatives must normalize positive behavior if they are to impact health indicators like malnutrition and infant mortality.

Making Toilets a Source of Pride for Indian Grooms

The “No toilet no bride” campaign was launched in 2008 by the Minister of Rural Development, Mr. Jairam Ramesh. With its catchy slogan “No loo, no I do,” the campaign re-contextualized the

toilet within the dialogue on Indian marriage—already rife with associations and expectations. Having a “loo” became a source of pride, a badge of honor much like a respectable family or a steady job. Through print advertisement and catchy radio jingles, the campaign encouraged families to refuse their daughters’ marriage unless the prospective groom could furnish the couple’s future home with a toilet, saving her the shame and danger of having to relieve herself in the open. The campaign has demonstrated real success in regions like Haryana, where 1.4 million toilets have been constructed since the campaign’s launch. Though this is not categorically a nutrition success, and as we’ve seen, toilet construction does not always lead to use, efforts to curb open defecation are a good first step in combating malnutrition…from its root.

Another noteworthy initiative that is changing the image of sanitation in India is Eram Scientific Solutions. Their electronically enabled, automated, self-cleaning public toilets look more like futuristic space pods than the dark, dirty public toilets so often found in Indian cities. Eram’s attractive and dignified toilet solution positions itself as an aspirational product, encouraging healthy toilet use and decreasing the spread of disease.

A Helping Hand in the Fight Against Malnutrition

The numerous health benefits of improved sanitation are difficult to dispute, but building sanitation infrastructure can be expensive. Hand washing with soap, on the other hand is one of the most cost effective ways to prevent the spread of the disease. Employed properly it can have an immense impact on health and nutrition. Like other behavior change initiatives, though, hand washing programs must involve education and awareness building, as well as “provide practical support for change.”

Though it has received some criticism for it’s focus on the former at the expense of practical support, Unilever Lifebuoy’s “Help a Child Reach 5” is a great example of a large corporate organization using media to create an emotional dialogue around health and hygiene.

The program’s 2013 pilot project in Thesgorra, a village in Madhya Pradesh claiming the highest incidence of diarrhea in the country, proved a success. Following Lifebuoy’s intervention in the region, the incidence of diarrheal infections decreased “from 36% to 5% aided by significant adoption of hand washing among mothers and children at key occasions during the day.” Though the success of this effort alone cannot ensure proper nutrition, decreasing diarrheal infections supports a sound backend from which sustained nutrition interventions can be built.

As the nutrition ecosystem illustrates, innovation does not always come in the neatest, newest, shiniest package; it is not always a sleek, jaw-dropping product. Innovation is sometimes connecting the seemingly unconnected and apparently uninteresting pieces of a puzzle to support an ecosystem of impact. In the fight against malnutrition, hygiene and sanitation are the behind-the-scenes innovation that deserve some recognition.

 About the Author: Research & Project Manager at Innovation Alchemy, Hannah Rosenfeld explores the intersection of design and social impact & supports entrepreneurs in thoughtfully crafting products and services to transform under served communities.

• "Help a Child Reach 5"
• "No Loo No I Do"
• "No toilet No Bride"
• Diarrhea
• Eram Scientific Solutions
• Fortification
• Hannah Rosenfeld
• Haryana
• Healthcare
• Hygiene
• india
• Innovation Alchemy
• Jairam Ramesh
• Lifebuoy
• Micronutrient
• Mid-Day Meal Scheme
• Minister of Rural Development
• New
• Nutrition
• Open Defecation
• Parvathi Menon
• Sanitation
• Total Sanitation Campaign
• UNICEF
• Unilever