Honoured Middle

The gut is at the heart of health, and access to good sanitation alone can prevent serious disease and innumerable deaths in low-income countries. In today’s fast-paced world, we are constantly bombarded with new diet fads, including the increasingly popular gluten-free diet. However, one crucial area that is often overlooked is gut health. The gut microbiome, which consists of trillions of microorganisms in the digestive tract, plays a vital role in maintaining good health. It is increasingly evident from the literature that the gut microbiome is an essential component of overall health.

Hippocrates, the father of modern medicine, alluded to the idea that “all disease begins in the gut”. Ayurveda and Chinese traditional medicine also emphasise the critical role of maintaining good gut health in protecting the heart. Japan has an interesting analogy for the gut, referring to it as the “honoured middle” (onaka) and the “centre of spiritual and physical strength” (hara), with the soul residing in the gut.

The topic of gut health is often discussed but rarely measured due to the lack of clear boundaries and characteristics defining gut wellness. Diagnostic efforts primarily focus on identifying pathological conditions. However, preventive medicine still has room for improvement when addressing subjective complaints and objective parameters.

Good gut health needs a clear definition; knowledge and research focus on therapy, not prevention. The human gut consists of good microorganisms and bad microorganisms. The balance in the micro-flora determines the gut’s health and is determined from the time a baby is conceived in the mother’s womb, as per an article, The Role of Microbiota in Infant Health: From Early Life to Adulthood, published in research publishers Frontiers.

We often hear people talking about how dietary habits affect gut health, but very few discuss how the composition of gastrointestinal tract microflora is established. It begins with the conception of the baby. It continues throughout the antenatal period until the baby is delivered, which ultimately determines its overall health from infancy to adulthood. Environmental factors and food habits also significantly affect how the gastrointestinal tract functions. Good gut health is directly proportional to an individual’s immunity. Although gut health is affected by various factors, including sanitation, there is no comprehensive approach, and each factor is dealt with separately.

Proper sanitation can eliminate the changes of spread of pathogens from the excreta of an infected person. There are 50 known pathogens, including bacterial, viral, protozoan and helminth, in the human faeces. Most of the faeces-associated infections occur through the gastrointestinal tract. These infections can spread through direct or indirect contact with contaminated hands, drinking water, soil, utensils, food and flies. This is illustrated best as an F-diagram, first propounded in 1958 by Wagner and Lanoix. The F-diagram shows how pathogens in faeces can be transmitted through many different routes to humans, including fluids (drinking water), food, flies, fields (crops and soil), floors, fingers and floods (and surface water generally). Poor hygiene practices, lack of adequate sanitation and unsafe or limited water supplies can contribute to a significant impact on gut health, including the spread of preventable diseases such as cholera, diarrhoea or typhoid.

According to the World Health Organization (WHO), poor sanitation is linked to the transmission of enteric diseases such as cholera, dysentery, diarrhoea, typhoid and intestinal worm infections. These diseases can cause inflammation in the gut and lead to digestive problems.

According to a recent WHO report, unsafe drinking water, poor sanitation and unhygienic practices are responsible for a significant disease burden, especially in low- and middle-income countries (LMICs). The report highlights that in 2019, 70% of the population in LMICs lacked access to basic sanitation facilities. Adherence to safe water, sanitation and hygiene (WASH) practices could have prevented at least 1.4 million deaths and 74 million disability-adjusted life years (DALYs) from diseases like diarrhoea, acute respiratory infections, soil-transmitted helminths and undernutrition. Unsafe sanitation facilities alone contributed to 38% of diarrhoeal disease deaths in LMICs, accounting for 564,000 deaths and 30 million DALYs in 2019. Diarrhoea is a leading cause of child mortality, responsible for 9% of all deaths.

Diarrhoea is the third leading cause of childhood mortality in India and is responsible for 13% of all deaths annually in children under five years of age, according to a paper, Diarrheal diseases among children in India by S. Lakshminarayanan and R. Jayalakshmy, published by the National Library of Medicine.

The Swachh Bharat Mission was initiated under the leadership of the Prime Minister Narendra Modi on October 2, 2014, to commemorate Mahatma Gandhi, who strongly advocated sanitation and believed it was more important than achieving political independence. For five years, from 2014 to October 2019, India made significant progress in preventing 300,000 deaths and 14 million DALYs attributed to diarrhoea and protein-energy malnutrition through this mission.

A financial and economic impact analysis of the Swachh Bharat Mission in 2018 performed by UNICEF underscored the key gains achieved per household per year from the initiative since 2014. These include: $124 in medical costs, $382 as value of time saved, $273 as value of saved lives and $294 as property value due to presence of a toilet, according to a UNICEF report.

Despite all the progressive efforts made in sanitation, India still accounts for one-third of all global diarrheal cases. This shows that we have a long way to go in achieving open defecation and proper utilisation of clean toilets.

In conclusion, it is essential to maintain a healthy gut microbiome for overall health and well-being. We can achieve this goal by promoting good hygiene practices, ensuring access to clean water, proper waste disposal and having access to adequate sanitation facilities.

Dr Chris Merin Varghese is Lead-Public Health & One Health, Reckitt.