Stunted kids

More toilets needed to get taller children?

That’s the main message coming out of recent public health research.

But first let me explain some of the terms involved here. The medical definition of “stunting” is cold and detached: low height for age. A child’s height is measured and compared to statistics showing the normal range of weights depending on different ages.

The Filipino word, “bansot,” sounds worse, and children are teased and taunted by school bullies with it.

Yet, a third of Filipino children below the age of five are stunted, with many adverse consequences for life, from being bullied in school to low-height women having greater difficulties when theyíre delivering children.

Psychologists talk of “short man syndrome,” where shorter people try to compensate for their height by being more assertive, even aggressive (Napoleon Bonaparte being the prime example). Note that it seems to be specific for men, with women not being under as great a pressure to be tall.

Filipino parents are well aware of the consequences of being stunted, and there are all kinds of folk “solutions” that have been invoked, from mandatory afternoon naps to circumcision at puberty to those vitamins with so-called growth supplements. My pediatrician-friends are not convinced that these work, but mothers will buy the supplements anyway, worried that their children might blame them later on if they’re short.

Genetics determines height to a large extent, but not stunting. Stunting occurs during the first three years of life, and child health experts have traditionally blamed this on poor maternal nutrition (during pregnancy) and poor child nutrition.

WASH

Early this month, experts from throughout the world gathered for a Unicef conference in New Delhi to discuss recent findings on stunting, with much focus on how poor “WASH” (water, sanitation and hygiene) contributes to stunting.

I was not at the conference but I was able to download presentations from a site, stopstunting.org. (I wish more conference organizers can do this—that is, upload papers and PowerPoint presentations on the Internet so more people can access the information and knowledge coming out of the meetings.)

Reading the reports and journal articles cited in the presentations, I was reminded of how even basic medical knowledge has to be constantly reexamined.

In the past, the absence of toilets and poor sanitation were blamed mainly for parasitic infections (bulate in Filipino or, sometimes tongue-in-cheek, “boarders”), which were in turn linked to anemia.

Public health workers also recognized that poor sanitation led to bacterial infections and diarrhea, which used to be a main killer of children.

Research is now showing that poor WASH is connected to stunting, with rather complicated mechanisms.

An advisory is in order: If youíre reading this over a meal, I advise you to save the column to read after the meal.

Back to WASH. What happens is that with poor sanitation, a child is exposed to bacteria in feces, which causes frequent diarrhea. These bouts with diarrhea damage the gastrointestinal tract and leads to a condition called environmental enteric dysfunction (EED), also sometimes called tropical enteropathy and environmental enteropathy.

When a person has EED, the microbes that enter the gastrointestinal tract will pass into the bloodstream, which sets off the body’s immune system. That’s good in the sense that the body fights back, but if the infections are chronic, then the immune system becomes problematic because it actually switches off one of the growth hormones, which results in stunting.

When a child has EED caused by lack of sanitation, even the best of nutrition may not be enough to prevent the stunting, not just because the nutrients are lost to parasites and to diarrhea but also because the growth hormone is switched off.

Researchers are finding that even if a child is growing up in a home with a toilet and good sanitation, if he or she is exposed to the bacteria from feces from a neighboring community without toilets, he or she will also be stunted.

Even more disturbing are some research suggesting that a pregnant woman who develops EED from an unsanitary environment may also be at greater risk for a miscarriage.

Sh-t and ladders

Preventing EED requires an entire package of interventions. Toilets are not going to be very useful without access to water. This is not just for flushing the toilets but for washing hands. I like the “tippy taps” that have been designed, where plastic containers are mounted on a bar and tipped to pour out water. The tippy taps are strategically located right outside the toilets.

Other interventions include designs for clean play spaces, and even a game called “Sh-t and Ladders,” taking off from Snakes and Ladders, to educate people on the need for hand-washing, safe water supplies and toilets.

We should give more attention to these findings. For example, the Department of Social Welfare and Development might want to consider integrating financial assistance for toilets and safe water supply into its CCT (conditional cash transfer) program. Schools will have to reinforce messages about water and sanitation, and reach out as well to parents and inform them that those growth supplements are a waste of money.

The battle to convince Filipinos to use toilets is decades-old, and although we’ve made progress, there are still many households, usually among the urban poor, that resort to “flying saucers”—human waste wrapped in old newspapers and dispatched, by air, here there and everywhere.

Besides reviving old health messages about using slippers, we need to look into our whole “toilet culture.” I often wonder if our tabo system (using a water ladle instead of toilet paper to clean after toilet duty) and buhos (using a water bucket for flushing) might actually be contributing to exposure to fecal material.

I am not saying toilet paper is cleaner; in fact, not washing the hands after using “tissue” can be even worse in terms of spreading germs. That’s why you need piped-in water, or the tippy-taps I described earlier.

Tangkad sagad (full height)? Let’s bridge the WASH gap first.

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E-mail: mtan@inquirer.com.ph