The first two years are forever

The first two years are forever This is a saying from Unicef (the United Nation’s Children’s Fund). It refers to the fact that health and nutrition during the first two years of a child’s life are crucial to a child’s development, and irrevocably affect a person’s life chances. The early development of children before they are born, and the subsequent two years of their life will determine not only their physical attributes but their cognitive ability, which will have far-ranging consequences throughout their life. One way to measure this is through height. The height of a child is a good indicator of what happened in utero and during the first two year’s of the child’s life. And in India, around one in five children are already stunted at birth.

Earlier this week, during a session on “making evidence count in the WASH (water, sanitation and hygiene) sector”, speakers discussed why this was the case, with a particular focus on the role of sanitation. Poor access to sanitation is linked to a range of diseases, including in particular diarrhoeal diseases but also other illnesses such as nematode infections. In India, diarrhoea accounts for 13% of all under five deaths. There is a close link here to malnutrition. Children who suffer from malnutrition are more susceptible to diarrhoeal diseases, and those who suffer from diarrhoeal diseases then become malnourished. This then affects not only their height, but their overall development.

However, as several speakers have highlighted, it is difficult to say whether sanitation alone is the key factor in determining height, and therefore the best area to target for development. In India, the government has allocated large sums for sanitation, although as other sessions have highlighted, it is not enough to build toilets if there is no water for cleaning them, or no demand from people to use them. New approaches therefore focus on engaging more closely with communities. The evidence for the link between sanitation and hygiene is therefore important in deciding whether scarce resources should be used for scaling up sanitation or not.

One of the difficulties with measuring the impact of sanitation is that illnesses such as diarrhoeal diseases are also closely tied to water and hygiene, and as discussed above, malnutrition. It is difficult to isolate which factor alone is most significant. Another difficulty is that a lack of sanitation may not pose such a significant health risk in areas which are sparsely populated. This is because people are much less likely in such areas to come into contact with the bacteria. However, in areas such as India, where half of the population still have no access to a toilet, and many areas are densely populated, it seems that the risks are much higher. Finally, there is still a lack of rigorous research. Whilst the studies that the speakers in this session discussed therefore indicated a strong link between WASH and height (and therefore child development), they stressed the need for further research.

Similarly, today, in a session convened by WaterAid, speakers discussed the importance of evidence in the context of water security. In particular, they discussed the potential of community monitoring of water resources for improving the sustainability of WASH interventions. Simple, low cost techniques, such as rainfall meters and water level gauges inserted in hand pumps, could be used to generate data about the water flows in the local area. This information could then be used by local communities to create rules and regulations to manage supplies during periods of stress. For example, limits might be set on the amount of water each household can use during the dry season, or activities which require large amounts of water may be restricted during those times. Such information could also be used to identify the most viable sources of water for water supply schemes. In discussions afterwards, speakers discussed whether this was perhaps an additional burden on communities. In order to mitigate the effects on communities, suggestions included harnessing existing institutions such as farmers groups, running competitions in schools to incentivise them to collect the data, and ensuring that communities which participate in such schemes can see the benefits in terms of installing concrete improved water supply schemes in such areas, using the data that they have generated. In this way, community monitoring can enhance rather than undermine existing schemes.

Photography: G Plasmati; Asmara District, Eritrea.