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The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement

  • Cumming, Oliver1
  • Arnold, Benjamin F.2
  • Ban, Radu3
  • Clasen, Thomas4
  • Esteves Mills, Joanna1
  • Freeman, Matthew C.4
  • Gordon, Bruce5
  • Guiteras, Raymond6
  • Howard, Guy7
  • Hunter, Paul R.8
  • Johnston, Richard B.5
  • Pickering, Amy J.9
  • Prendergast, Andrew J.10
  • Prüss-Ustün, Annette5
  • Rosenboom, Jan Willem3
  • Spears, Dean11
  • Sundberg, Shelly3
  • Wolf, Jennyfer5
  • Null, Clair12
  • Luby, Stephen P.13
  • And 2 more
  • 1 London School of Hygiene and Tropical Medicine, Department of Disease Control, Faculty of Infectious Tropical Disease, London, UK , London (United Kingdom)
  • 2 University of California, Division of Epidemiology and Biostatistics, School of Public Health, Berkeley, CA, USA , Berkeley (United States)
  • 3 Bill and Melinda Gates Foundation, Seattle, WA, USA , Seattle (United States)
  • 4 Emory University, Department of Environmental Health, Rollins School of Public Health, NE Atlanta, GA, USA , NE Atlanta (United States)
  • 5 World Health Organization, Department of Public Health, Geneva, Switzerland , Geneva (Switzerland)
  • 6 North Carolina State University, Department of Agricultural and Resource Economics, Raleigh, NC, USA , Raleigh (United States)
  • 7 University of Bristol, Department of Civil Engineering, Queens Building, Bristol, UK , Bristol (United Kingdom)
  • 8 University of East Anglia, The Norwich Medical School, Norwich, UK , Norwich (United Kingdom)
  • 9 Tufts University, Department of Civil and Environmental Engineering, Medford, MA, USA , Medford (United States)
  • 10 Blizard Institute, Queen Mary University of London, London, UK , London (United Kingdom)
  • 11 The University of Texas at Austin, Department of Economics, Austin, TX, USA , Austin (United States)
  • 12 Mathematica Policy Research, Center for International Policy Research and Evaluation, Washington, DC, USA , Washington (United States)
  • 13 Stanford University, Department of Infectious Diseases and Geographic Medicine, Stanford, CA, USA , Stanford (United States)
  • 14 Johns Hopkins University, Department of International Health, Bloomberg School of Public Health, Baltimore, MD, USA , Baltimore (United States)
Published Article
BMC Medicine
BioMed Central
Publication Date
Aug 28, 2019
DOI: 10.1186/s12916-019-1410-x
Springer Nature


BackgroundThree large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations’ Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners.Main bodyHere we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health.ConclusionThese results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that – in any context – a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.

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