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1/ Why do many WASH interventions have limited effects on child stunting? Our historical data suggest something surprising: Sanitation infrastructure alone often wasn’t enough, even in the past. New BMJ Global Health paper 👇 doi.org/10.1136/bmjg...

2/ Poor water, sanitation and hygiene (WASH) are widely seen as drivers of child stunting. Repeated exposure to faecal pathogens → diarrhoeal disease → impaired nutrient absorption → slower growth. So improving sanitation should reduce stunting. But the evidence is mixed.

4/ Take 19th-century England. Cities invested massively in sanitation and clean water. The results were dramatic: • cholera epidemics were eliminated • under-5 typhoid mortality fell by ~88% Yet child stunting remained above 40% in the 1890s.

5/ Why? Because building sanitation infrastructure doesn’t necessarily reduce children’s exposure to all faecal pathogens. Exposure pathways also depend on: • hygiene behaviour • infant feeding practices • environmental contamination (e.g. horse manure)

6/ In Britain, diarrhoeal disease remained widespread and only declined decades after the introduction of clean water and sanitation. Declining diarrhoeal disease caused by: • improved hygiene behaviour • safer infant feeding • environmental changes (fewer horses in cities)