Even extra food can’t help malnourished children in unsanitary surroundings

Aameena Mohammed provides plenty of food for 20-month-old daughter Daslim Banu, supplementing breast milk with eggs, soup and rice. But the extra food doesn’t help. Daslim still weighs only as much as a healthy infant half her age.
Mohammed’s home, in one of the poorest districts of the south Indian city of Vellore, is among the 65 percent of India’s homes without running water and safe sewage disposal. Feces and urine collect next to the doorway in an open drain — the source of odor permeating the tin-roofed shack and of the microbes likely retarding the toddler’s growth.
Scientists increasingly suspect that constant exposure to bacteria, virus and parasite-laden fecal contaminants may be frustrating attempts to end malnutrition. The best diet-based measures to fight chronic hunger in the developing world are being negated by a failure to meet basic human needs: Clean water and sanitation.
The problem exists not just in India. A quarter of children in developing countries are underweight, and malnutrition is the root cause of the deaths of more than 2 million children annually, according to the United Nations Children’s Fund in New York.
“You really can’t address stunting unless you clean up the sanitary environment,” said Clarissa Brocklehurst, Unicef’s former chief of water, sanitation and hygiene, who worked in India from 1999 to 2001. “It doesn’t matter how much extra food you try to stick into kids or how much dietary supplements you give them, it will all just go through them.”
Daslim, wearing a red and green dress that hangs limply from her bony shoulders, has suffered at least five bouts of debilitating diarrhea in the past 10 months and was hospitalized for three days with a high fever in September. In November, she weighed 7 kilograms (15 pounds) — about two-thirds the normal weight of a girl her age.
A decade of economic growth averaging almost 8 percent a year has doubled the size of India’s middle class and produced more billionaires than Britain. That same time period has made the situation worsen for children: Nearly half of those under 5 years remain stunted.
About 200,000 children under 4 die in India annually because of diarrheal diseases caused by dirty water and lack of proper sanitation, according to a study published in April in the Lancet medical journal. Waterborne diseases also hamper productivity, depriving India of 73 million working days each year, the nonprofit group WaterAid said in a 2008 report.
India has distributed nutrient-fortified supplements and meals to children. The UN has called for a broader approach that includes providing safe drinking water and toilets.
Daslim is one of more than 200 children in Vellore enrolled in an international study examining how pathogens damage children’s digestive tracts. Previous studies have shown that a gut constantly assaulted by infections is less adept at absorbing nutrients for growth and development.
Researchers involved in the latest study, funded by the Bill & Melinda Gates Foundation, hypothesize that children in unclean environments ingest germs continually: The children may not show symptoms because of the defensive response by their intestinal tracts, but the germs may block key nutrients from being absorbed through the intestinal wall.
Each month, researchers test the children’s urine and stool specimens for signs of infection and carbohydrate absorption, and check the results against their weight and height records.
“The gut is supposed to absorb, secrete and act as a barrier, and all of these functions can be affected in people who are exposed to a lot of pathogens all the time,” said Gagandeep Kang, professor of gastrointestinal sciences at Vellore’s Christian Medical College, who is leading the study in India. “You may be getting what is considered an adequate diet, but if you don’t absorb it, it doesn’t help.”
In Daslim’s case, Kang suspects her growth is being impeded by environmental enteropathy, a condition in which the nutrient- absorbing, fingerlike projections lining the small intestine are transformed into broad, leaflike flaps in response to constant exposure to pathogens.
“We think it’s because their gut gets damaged because they are repeatedly infected with organisms that damage the intestinal lining,” said Kang, who has been studying gastrointestinal diseases for the past 25 years. “We are trying to investigate whether that damage is what stops children from being able to use the nutrients they get in the food.”