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The problem is far worse than Delhi Belly

Common illnesses have devastating consequences for public health and nutrition, reports Ami Dalal

india Updated: Mar 17, 2006 12:50 IST

India may be notorious for its brain drain, but it exhibits strangely magnetic qualities that do just the opposite for germs. Upon arrival, all viruses, bacteria, amoebas and parasites have made themselves at home in my intestines. Last week, after a paneer tikka roll at Khan Market, I woke up the next day with full-blown vertigo, nausea, and stomach cramps. After sleeping for more than twelve hours a day for six days, I emerged five pounds lighter and with an ungovernable craving for strawberry-crème cake, cheese fries, and my mother.

I doubt that any visitor to India has escaped without warming the toilet bowl for at least a week, and some return despite repeated bouts of the stomach flu. I had thought I was immune to all germs after a three-week tryst with unwashed vegetables last July attuned me to sunrise appointments with the toilet and a loss of muscle mass that left me at the same weight as when I was at fourteen. I was undefeated for the next eight months until mint chutney and raw onions at the best kebab stall in Delhi wrestled me back into the tiled ring.

Friends have traveled through India for months, suffering from intestinal upset the entire time. They take a cocktail of antibiotics, but relapse again almost immediately. Some travelers leave India so weakened that their doctors at home administer a battery of tests to rule out anemia or more serious illnesses. Even seasoned combatants of stomach parasites are not immune. My aunt traveled to Delhi from Mumbai for a few days and left with a stomach virus that survived for weeks. Her husband contracted hepatitis E from roadside snacks, and it was months before he was able to eat solid food. But, horror stories aside, the problem is far worse than a few veteran anecdotes about India's amoebic tenants.

The World Health Organization estimates that four million children under the age of five die each year from diarrhea, predominantly from developing countries. India accounts for more child deaths due to unsafe drinking water than any other country. Approximately 1.5 million children die every year in India due to diarrhea and other diseases related to poor water quality. One-fifth of the population of rural India does not have access to safe drinking water.

Most of India's water sources are contaminated by sewage and agricultural runoff. The World Bank estimates that 21% of communicable diseases in India are related to unsafe water. Diarrhea alone causes more than 1600 deaths each day. The ability to practice safe hygiene is severely compromised because of poor waste disposal facilities. Latrine usage is extremely low in rural areas, and only 14% of the rural population has access to a latrine.

A recent World Bank report estimates that nearly half of the children in India are undernourished. "Poor nutrition is implicated in more than half of all child deaths worldwide," said Jean Louis Sarbib, the World Bank's senior vice president for human development.

"It is intimately linked with poor health and environmental factors, and yet policymakers, politicians and economists often fail to recognize these connections," said Sarbib, adding that 60 percent of children who die of diseases like diarrhea and malaria may have survived had they not been malnourished.

World Bank experts say that contrary to popular perceptions, malnutrition is not simply a result of having too little food. Children who have plenty to eat are still underweight or stunted because of misguided infant feeding, care practices, poor sanitation, and access to health care.

The World Bank report said under-nutrition was most damaging during pregnancy and in the first two years of life, after which problems with brain development, intelligence and productivity were largely irreversible. It urged governments with limited resources to focus attention on this "conception-to-24-months" period.

"There is actually a very small window of opportunity to improve nutrition, between pregnancy and two years of age," said Meera Shekar, a senior nutrition specialist at the World Bank and lead author of the World Bank report. "The damage that happens during this period is irreparable." The report said nearly one-third of children under five in the developing world remain underweight or stunted.

The prevalence of malnutrition in heavily populated countries such as India, Bangladesh, Afghanistan and Pakistan, at 38 percent to 51 percent, is twice the 26 percent rate in sub-Saharan Africa. Improving nutrition could add 2 to 3 percent per year to developing nations' gross domestic product, the report said, because children would be less likely to drop out of school, and would boost their future income potential.

Christina Mathews, a volunteer in rural Rajasthan with the non-profit Bhagavatula Charitable Trust (BCT), emphasizes the importance of infant nutrition. "Breastfeeding can have far reaching effects on malnutrition, infectious diseases, and affects a child's immunity and ability to thrive in these challenging conditions," says Mathews. Surveys show that almost 60% of women in nearby villages practice pre-lacteal feeding, defined as giving another substance to a newborn prior to breastfeeding.

Traditionally, a homemade mixture of sugar and wheat called janam ghutti is fed to the baby to teach the child how to suck. "Because the sucking reflex is strongest in babies in the initial hours after birth," says Mathews, "when a child is given another substance to suck before the mother's breasts, it may have problems accepting the mother's nipple." Mothers have to find different ways to feed the baby, compromising the infant's health.

Sometimes buffalo or goat milk is fed to babies in addition to mother's milk. Because this milk is too thick to swallow easily, it is diluted with water. Often this is rain water that has been sitting in a water collection tank for several months, says Mathews, and many infants die of chronic diarrhea.

Even if infants are provided with proper nutrition during the critical 24-month period, contaminated drinking water and unhygienic living conditions still expose them to debilitating diseases like diarrhea. Nourishment is flushed out along with diarrhea, pointing to the need not only for a monumental investment in the country's health care but also in its water and waste disposal systems. However, with the United Nations reporting that private investment in water services is declining and government resources to overhaul the water sector are limited, the growing health and infrastructure crisis in India is far from being addressed.

First Published: Mar 17, 2006 12:50 IST