The concepts of FTIs and the 5 As reframe more inclusively how undernutrition is perceived, described and analysed. We hope this reframing will contribute, however modestly, to a cleaner, healthier and happier world in which all children and adults are well-nourished and can grow and live to their full potential.
It is increasingly suggested that much of the ‘Asian Enigma’ – referring to the high levels of undernutrition despite growing economies – can be explained by open defecation (OD) combined with population density. However, the insight that ‘shit stunts’ remains a widespread blind spot. Its persistence can partly be explained by institutional, psychological and professional factors. Reductionist focus on diarrhoeas – which are serious, dramatic, visible and measurable – has led to the relative neglect of many other, often sub-clinical and continuously debilitating faecally-transmitted infections (FTIs), including environmental enteropathy, other intestinal infections, and parasites.
This paper explores how OD and FTIs, poverty and undernutrition reinforce each other, looking at India as an example. Globally, it accounts for about 60 per cent of OD, around a third of all undernourished children, and a third of those living in poverty. While other countries make rapid progress towards becoming open defecation free (ODF), India remains obstinately stuck, making undernutrition in India one of the great human challenges of the twenty-first century.
Through numerous ways, including OD and FTIs, lack of sanitation leads to losses estimated at between 1 per cent and 7 per cent of gross domestic product (GDP) in various countries.
To reframe undernutrition for a better balance of understanding and interventions, the paper proposes two inclusive concepts: FTIs and the ‘5 As’. The first two As – availability and access – are oral, about food intake, while the last three As – absorption, antibodies and allopathogens – are novel categories, anal and internal, about FTIs and what happens inside the body. These concepts have implications for research, professional teaching and training, and policy and practice.