Undernutrition's blind spot: a review of fecally transmitted infections in India

With relevance to India and more widely, this review article examines links between fecally transmitted infections (FTIs) and undernutrition, presents a new framework for understanding the relative nutritional significance of FTIs, and draws practical implications for professionalism, professionals and research. In India, despite many efforts and programmes to get more and better food into children, stunting has been obstinately resistant, India remaining with about one-third of the undernourished children in the world. Recent research has found strong correlations between open defecation and stunting. This paper reviews published and emerging evidence to explore these correlations through a focus on FTIs. The nutritional significance of FTIs, and so of water, sanitation and hygiene, has been a professional ‘blind spot’. Among FTIs, the visibility, measurability, relative manageability, and lethal potential of diarrhoeas have diverted attention from more continuous and often subclinical conditions of many other FTIs including environmental enteropathy, other intestinal infections, and parasites. Diarrhoeas are only the visible tip of the FTI iceberg. Access to sanitation in India is sharply skewed against the poor. India's proportion of the world's open defecation has risen to 60%. Safe sanitation and hygienic behaviour have become more vital than ever for reducing stunting more effectively.