A few years ago I posted a blog titled ‘Nutrition Puzzles’. Today, the puzzles seem a bit nearer to resolution. And the answer may be shit.
The earlier blog was prompted by the huge and massively expensive nutrition survey that was sponsored by a range of international aid donors. It showed to everyone’s surprise that, despite the crisis, nutrition indicators across Zimbabwe, including in rural areas, were not as disastrous as expected. Indeed, they were better than most neighbouring countries, including South Africa.
Why was this? I suggested a number of reasons. First, the availability of food was higher than many had assumed – and this was due to underreporting, and especially the production that was occurring in the new resettlements. This line of argument was reinforced in the discussion about the mismatch between ZimVac assessments of food insecurity and realities on the ground, commented on in another blog.
Second, and perhaps most intriguingly, it could also be due to the level of sanitation in Zimbabwe, reducing the effect of diarrhoea, but also crucially many other often subclinical and continuously debilitating faecally-transmitted infections, including environmental enteropathy, other intestinal infections and parasites. In a 2009 article in the Lancet, Jean Humphrey, working in Zimbabwe, argues that a combination of poor sanitation and poor nutrition can have major effects, resulting in effects on growth, even though nutritional intake remains high. The massive investment in toilet building – dating from the colonial period – has meant that protected toilet coverage is large in Zimbabwe, including in rural areas. The famed ‘Blair toilet’ -nothing to do with Tony, but the product of Zimbabwe’s Blair Institute from the 1970s (and the work of Peter Morgan) has had a major impact, providing cheap, sanitary toilet options across the country, reducing open defecation to a minimum.
Shit makes a big difference to nutrition, as work by the Community Led Total Sanitation (CLTS) initiative and others is showing. As Robert Chambers puts it “shit stunts”. CLTS is a global movement pioneered by Kamal Kar to encourage community-led behaviour change around sanitation. It has facilitated major unsubsidised investments in toilet building, and changed behaviours around shitting outside on a massive scale across particularly Asia and Africa.
Asia in particular is an enigma. Despite the Green Revolution, growing incomes and better metrics on all sorts of counts, nutritional deprivation is widespread. This, Chambers and colleagues argue, may well be due, in significant part, to poor sanitation. The puzzle for southern Africa is different. Zimbabwe may be an enigma in its own region but in reverse: it has higher nutrition indicators than perhaps would be expected. But the explanation may be the same: shit (or the lack of it) counts. Zimbabwe’s sanitation revolution has happened over many decades. Maybe the impacts on nutritional status are being seen in its seemingly anomalous comparative statistics.
The CLTS research, published as an IDS Working Paper by Robert Chambers and Gregor von Medeazza, argues that nutritional indicators have to be understood as a combination of food intake and health status. 5 As must be addressed – the traditional indicators of food availability and access. But also three other less understood As: absorption, antibodies and allopathogens. Clearly genetics matter too, and often confound some of these data (including I suspect in Zimbabwe, given the anomalies in height to weight ratios in different parts of the country). But taking only ‘environmental’ influences for now, the focus on food intake (quantity and quality – and so availability and access) may miss a big part of the story. If nutritional uptake by the body – and so how tall, fat/thin, and healthy you are – is significantly affected by environmental enteropathy, as well as micro-parasites and pathogens, then forgetting this dimension is a big mistake.
The paper has a striking graph from India correlating the percentage of households practising open defecation in different Indian States (both urban and rural) and stunting (below 2 SD).
This focus on food availability and access, rather than a more holistic assessment of food, environmental health, sanitation and nutrition is almost universal. Take the Global Nutrition Report, a new initiative from IFPRI, and involving my home institution IDS too. This compiles reams of statistics on every country, inevitably of varying quality (they seem to draw from the joint UNICEF, World Bank and WHO database, and so Zimstat data, for Zimbabwe). The report presents the data in a series of graphs and tables, but does not offer an integrative analysis.
A comparison across countries though is instructive – although it may be influenced by uneven data. For example, if we compare Zimbabwe with its now economically successful neighbour Zambia, nutritional indicators are better for Zimbabwe. For example, stunting of under 5s is 29-36% for the data shown in Zimbabwe (from 1994-2012), while in Zambia it ranges from 46-58%. And this despite Zimbabwe’s lower GDP growth rates, an ailing economy and assumed food insecurity rife across the country.
As before, both explanations may be required: there’s more food than we thought, and there’s less shit. But as with the wider commentary about nutrition, the Global Nutrition country reports don’t make the link and stick to an aggregate picture. The bigger puzzle lurks within and across these data. Work on shit and nutrition suggests an important hypothesis though, but despite the obvious policy implications this has largely been ignored. Maybe Zimbabwe is more like Kerala, and Zambia more like West Bengal (see graph above)? According to the data presented in the Global Nutrition country reports, 43% of people have unimproved facilities or openly defecate in Zambia, while this figure is 33% in Zimbabwe.
I heard recently that new work on nutrition in the new resettlement areas of Zimbabwe is being proposed as an extension of the earlier ZHRDS survey carried out from the 1980s. This is excellent news, and will fill an important gap to our knowledge of the impact of land reform, exploring a dimension that our team hasn’t been able to tackle. Earlier work on old resettlement areas showed intriguingly that, despite improved indicators of production, income, asset ownership and the rest, resettlement households often had poor nutrition indicators compared to their communal area counterparts. The research put this down to higher household sizes and the need to share food and income among more people. This is certainly a plausible explanation – and one that we have discussed for new resettlement households. But perhaps there was another reason – a lack of toilets and poor sanitation.
In our work in Masvingo and Mvurwi we have looked at toilet building since settlement. Certainly in the early years as people carved out homesteads and villages toilets were few and far between, but the numbers have grown rapidly (completely unsubsidised by government, donors or NGOS, and often using the classic Blair design). 83% and 63% of households in the A1 sites in Mvurwi and Masvingo had built a toilet by 2014 and 2012 respectively in our sample. Because these facilities are often shared in villages, basically everyone has access to a toilet. Resettlement households definitely value toilets. Toilet building has been a key part of the investments in new resettlements. Based on estimates of the cost of building (materials, not labour), we worked out that households in our sample had spent on average the equivalent of around US$150 since settlement on toilet building.
The impetus of CLTS programmes is not it seems needed to build them, and people have recognised the importance of sanitation over many, many decades of exposure to various programmes. I have no idea whether this cultural and social history of toilets has affected attitudes to shit in different ways to other countries in the region, but it’s an interesting question worthy of some comparative research, along the lines of the India study mentioned earlier.
As new work on nutrition in new resettlements is undertaken I hope the ‘shit factor’ is added into the hypotheses and research design. Working this out and establishing the evidence base may have major implications for policy – not only in Zimbabwe, but also the region. If addressing poor nutrition is a goal for sustainable development – as it should be – then building more toilets may be as important as growing more food.