WASH: a basic human right and essential intervention for child health and development
Authors: Fiona Russell, Peter Azzopardi
Journal: The Lancet Global Health (2019)

In their cluster-randomised trial, Jean Humphrey and colleagues (January, 2019)1Humphrey JH Mbuya MNN Ntozini R et al.Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial.Lancet Glob Health. 2019; 7: e132-e147Summary Full Text Full Text PDF PubMed Scopus (223) Google Scholar report that water, sanitation, and hygiene (WASH) interventions in combination with improved infant and young child feeding (IYCF) is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. The accompanying Comment2Maleta K Manary M WASH alone cannot prevent childhood linear growth faltering.Lancet Glob Health. 2019; 7: e16-e17Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar concludes that the “absence of a growth or clinical morbidity response in SHINE does not mean that WASH is totally unimportant as development agencies and agents strive to achieve the Sustainable Development Goals, but it should cause such agencies and agents to carefully reconsider their approaches”. We are concerned that this concluding statement could jeopardise essential ongoing investments in WASH. We argue that WASH remains a crucial intervention for child health and development and is central to sustainable development for three key reasons. First, access to WASH is a fundamental human right.3UNResolution adopted by the General Assembly on 28 July 2010. 64/292. The human right to water and sanitation.http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/64/292Date accessed: December 19, 2018Google Scholar Governments have committed to achieving universal access to WASH through the Sustainable Development Goals. Second, we are interested in measuring and addressing childhood stunting because it is an indicator of childhood health and development; the benefits of investing in WASH should not be assessed on the basis of improving stunting outcomes alone. WASH prevents the two syndromes that are common causes of childhood deaths globally—diarrhoea and acute lower respiratory infection.4WHOUNICEFEnding preventable child deaths from pneumonia and diarrhoea by 2025: the integrated global action plan for pneumonia and diarrhoea. World Health Organization, Geneva2013Google Scholar WASH prevents trachoma and helminth infections in children.5Stocks ME Ogden S Haddad D et al.Effect of water, sanitation, and hygiene on the prevention of trachoma: a systematic review and meta-analysis.PLoS Med. 2014; 11: e1001605Crossref PubMed Scopus (141) Google Scholar, 6Freeman MC Clasen T Brooker SJ et al.The impact of a school-based hygiene, water quality and sanitation intervention on soil-transmitted helminth reinfection: a cluster-randomized trial.Am J Trop Med Hyg. 2013; 89: 875-883Crossref PubMed Scopus (93) Google Scholar The intervention also prevents impetigo,7Luby SP Agboatwalla M Feikin DR et al.Effect of handwashing on child health: a randomised controlled trial.Lancet. 2005; 366: 225-233Summary Full Text Full Text PDF PubMed Scopus (495) Google Scholar and plays an important role in preventing or slowing disease outbreaks.8Aiello AE Coulborn RM Perez V et al.Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis.Am J Pub Health. 2008; 98: 1372-1381Crossref PubMed Scopus (444) Google Scholar Infectious diseases have a negative effect on growth and nutrition, and children with poor nutrition have excess mortality from such diseases; arguably an even greater need exists for targeted investments in WASH to address poor growth and nutrition. Third, although this study did not show short-term effects of WASH on stunting and nutrition, there is likely to be a substantial intergenerational contribution to stunting.9Patton G Olsson CA Skirbekk V et al.Adolescence and the next generation.Nature. 2018; 554: 458-466Crossref PubMed Scopus (180) Google Scholar WASH is a determinant of educational outcome in girls,10Lloyd CB Young J New lessons: the power of educating adolescent girls. A girls count report on adolescent girls.https://www.popcouncil.org/uploads/pdfs/2009PGY_NewLessons.pdfDate: 2009Date accessed: December 19, 2018Google Scholar with maternal education a strong predictor of child health outcomes, including stunting and nutrition.11Bicego GT Boerma T Maternal education and child survival: a comparative study of survey data from 12 countries.Soc Sci Med. 1993; 36: 1207-1227Crossref PubMed Scopus (228) Google Scholar In settings with restricted access to clean water, the burden of water collection is typically placed on girls,12Graham JP Hirai M Kim S-S An analysis of water collection labour among women and children in 24 sub-Saharan African countries.PLoS One. 2016; 11: e0155981Crossref PubMed Scopus (103) Google Scholar with predictable negative effects on education. Access to improved sanitation facilities, which are single sex and usable, is also essential for menstrual hygiene management and enables school attendance for pubertal girls.13UNICEFWHODrinking water, sanitation and hygiene in schools: global baseline report 2018. UNICEF, New York2018Google Scholar Investments in WASH assure a fundamental human right. WASH interventions are essential for assuring child health and development, and are also likely to have an impact on childhood stunting and nutrition, but perhaps through pathways not investigated in this study. We declare no competing interests. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trialHousehold-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. Full-Text PDF Open Access