Everything you need to know about Helminths – Well, almost everything

It had been such a warm day in Chennai and like everyone else I was also looking at the clear skies wondering how much hotter it could get. As I was thirsty and hungry, I went to a nearby street vendor selling some fruits which he had cut and laid out on display. Just as I was making my decision on what to buy, I overheard a conversation from other buyers who were talking about some kind of ‘worms’ that causes serious ‘illness’ in people. Being the curious type, I went ahead and joined in the conversation, while I continued to gulp down the pieces of mangoes which the vendor had wrapped in the previous day’s newspaper.

Here is the gist of the conversation from the alleged ‘worm expert’.

It turns out the worms the person was talking about are called Helminths. So what are Helminths? And how do they make people fall ill? Well, Helminths are basically worms that are widely present in areas which plagued by poor sanitation and where open defecation is widely practised. The Helminth worms are usually tape worm (Taenia solium), hook worm (Anclostoma duodenale and Necator americanus), round worm (Ascaris lumbricoides), whip worm (Trichuris trichiura) etc., I realised that the Helminths eggs and larvae are the agents that cause infection, and are usually discharged into the environment via faeces. The ‘Worm expert’ told me that the viable eggs will be infective when it develops as a larva and gets attached to a suitable host such as humans.

But, “Why is it important to know about Helminths?” I wanted to know. “Because it causes various kinds of illnesses in human beings,” he said, adding that these illnesses are commonly known as Helminthiases. Helminths are transmitted mainly through water and soil through the oral – faecal transmission pathway (popularly referred as the F-diagram). “Synergy between WASH and nutrition” – It’s complicated The worms are widely present in faeces, sewage, sludge and fecal sludge and crops. Consuming infected water or food, physical contact when handling infected soil and water, or even walking barefoot on contaminated soil, can lead to one getting infected. Wow! who would have thought of that, right?

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Relative sizes of Helminth eggs.                                                                             Source: http://ogimed.blogspot.in/2013/06/relative-sizes-of-helminth-eggs.html (dated Aug 4, 2017)

The worm expert told me, that worms come in sizes varying from 1 mm to several metres in length. The eggs range from 20 to 80 microns’ size, which means they cannot be seen by the naked eye. Interestingly, the eggs are also sticky in nature, and can stick to vessels, furniture, cash, food, water, door handles, stair cases rails, fingers and nails etc., thereby escalating the risk of infection without people even realising it.

The situation is so alarming that the World Health Organisation in 2015 called Helminthiases a major health concern. Helminths infections in human beings affect the nutritional status by causing poor absorption of nutrients, loss of appetite, bowel obstruction and increased blood loss. Long term and heavy infections can cause abdominal pain, diarrhoea, blood and protein loss, and slow down the physical and cognitive growth. Heavy infections with whipworm and roundworm can even impair growth in children. Hookworm infections are a major cause of anaemia in pregnant women and children.

Wow, not only had I learnt something about these ‘dangerous worms’ that makes people sick, but thanks to my newly established camaraderie with the ‘Worm expert’, I went on to ask him more questions:  How do we ensure that Helminths are eliminated from our surroundings? There are various ways, he said. But the most important one is to make sure that all those materials which consists of Helminths are treated before being released into the environment. In that way, we can minimise the risk of infection, if not completely eliminate it.

I realised that we have reached the end of our intense conversation. But there was one more question to which I needed an answer. How do we reduce the incidence of Helminths -related infections in our day-to-day activities, I wanted to know? “Well, the obvious yet often overlooked practice of hand washing, is one of the most effective ways to beat the infection cycle. In addition to that, thorough washing of vegetables and fruits before consumption should be compulsorily followed,” the worm-expert said. I thought of the delicious mangoes that I had just gulped down. I had not bothered to find out if the fruit had been washed properly, and how long ago it had been cut.

I thanked the worm-expert profusely for answering all my questions and bade him goodbye. As I left, he said: “Don’t underestimate the power of what you can’t see or smell.” I was strangely intrigued. So I decided to find out more. And what I found out included a wealth of information on the universe of microbial pathogens and their implication on public health, and how the very act of defecating in the open can lead to Helminth infection and what can be done to keep ourselves safe.
But more of that in the next part, where we will talk about Helminths infection and its very obvious relationship to open defecation.

For further reference

https://www.unicef.org/media/files/IntegratingWASHandNut_WHO_UNICEF_USAID_Nov2015.pdf (accessed on April 24, 2017)

http://atm.eisai.co.jp/english/ntd/helminthiasis.html (accessed on April 25, 2017)

B.E. Jimenez-Cisneros and C. Maya-Rendon (2007) “Helminths and Sanitation”, Communicating Current Research and Educational Topics and Trends in Applied Microbiology

Suneethi

 

 

 

Suneethi Sundar
Specialist, TNUSSP

A loo that is usable too!

In the winter of 1999, when I was a post graduate student of social work in Mumbai, we were taken to a remote village in Banaskantha District, Gujarat. The objective of this visit was to understand the rural way of life, their customs and practices, the formal and informal institutions at work and so on. As young 20 somethings, we all were very excited about the trip but for one aspect. There were no toilets!! We were all told that we would have to use the open fields just like all the other women in the village did. At some point or the other in our growing up years, we would have definitely relieved ourselves in public; either while travelling by bus, or while visiting our native village or sometimes even within the city while going from point A to point B where public conveniences were either absent or open defecation (OD) was better than using these toilets.

Pics for blog
Photo Courtesy: Nitin Kumar Gupta/NavShrishti NGO

However, in our early twenties, defecating in the open seemed quite an uncomfortable task to do especially when you had to choose between early morning or late night. During the course of those ten days, while some of us got adjusted to the open toilets, few others had severe gastrointestinal problems on our return back to Mumbai. Of course there were a fair share of humorous incidents such as the one where after an “evening visit” to the anointed spot, as we were collecting the “lotas” to leave, we suddenly saw a huge black thing move right next to us. To our utter alarm, we realized we had been blissfully unaware of the camel sitting right next to us while we defecated under the star-lit sky!

Our experience with inadequate toilets didn’t quite end in the village. As we waited in Ahmedabad for our train to Mumbai, we were forced to use the toilets in a movie hall which repulsed us to the core.   Badly maintained, with no running water, poor electricity and broken doors, it made us want to run back to the open fields in the villages. When I look back at this episode in light of the recent attention to sanitation and OD, I am able to relate to all the reasons people gave for not cultivating the toilet-using habit. Despite having built toilets, poor maintenance, lack of water and hygiene were the main reasons which made several women in the villages to prefer open fields to toilets, risking their safety, privacy and convenience.

So, why is that though there are several schemes and programmes for toilet construction, OD is still a major concern in India? The answer, I believe, lies in the usability of the toilets constructed. By usability, I don’t mean only the cleanliness and maintenance of the facility. Usability comprises of several other factors: availability of the toilet, followed by the distance to the facility, accessibility i.e is there sufficient lighting, are there ramps for the disabled and senior citizens, are the toilet pans appropriate for different age groups such as children? Is there privacy and safety for adolescent girls, and so on. The sanitation infrastructure in India lacks the human life-cycle thinking. The recognition that different people have different sanitation requirements at different stages in their life which affects the way they use toilets is neglected in toilet design and construction. Although a handful of organisations working at the grassroots have incorporated some aspects of this life-cycle thinking by making smaller pans for children, open dwarf-walled cubicles where children can see their mothers or defecate under the mothers’ supervision and so on, these modifications in design are exceptions and not the norm.

With rampant construction of toilets under the SBM and attention to behavior change where people are encouraged to use toilets, it might be worthwhile to conduct rapid assessments of the different needs of toilet users in order to reorient the current toilet designs. With several players getting involved in sanitation construction and campaigns targeting behavior change, we need to mainstream studies on usability to bring about a shift in the guidelines on toilet specifications. For our multi-crore schemes to be effective and reach the target audience, it is time to pause and pay attention to the needs of the end user. Achieving universal access to sanitation is a good thing, but let us ensure people can use it too.

Harini Pic for website

Sriharini Narayanan
Senior Specialist, TNUSSP

The Curious Case of Mr Muthusamy

The Millennium Development Goals, which were launched with much fanfare in the beginning of the millennium, were meant to be reached by the end of 2015.  Even a cursory glance at the report card will show that India’s performance has been far from satisfactory. Interestingly, just before the MDG time frame came to an end, the Government of India lunched the Swachh Bharat Mission in 2014 aimed at making the country Open Defecation Free by 2019. While this programme has gained immense momentum in the last few years and continues to do so, it is important to note that the agenda has not gone beyond building toilets.
Just as in the case of many low and middle income countries, onsite sanitation systems are predominant in India. Toilets need containment structures such as septic tanks and twin pits that are scientifically constructed. Moreover, these containment structures need to be desludged regularly and the sludge has to be treated before being disposed. While an emerging market has made way for private operators to desludge the septic tanks and twin pits for a price, the story does not end there.
Have you ever wondered where the septage from the septic tank and twin pits is dumped ? More often than not, this septage is disposed of into water bodies or in open grounds thereby polluting the environment. Another convenient option is farm land, thanks to the popular perception that septage has high nutrient value and is beneficial to crops. Moreover, the water content in the septage also compensates for the increasing water shortage.
Recently, my colleagues and I went to a nearby town panchayat to interact with farmers who use raw septage as manure, and to understand the rationale behind this practice. Though it was a hot summer day, the cool breeze from the farms around made our expedition rather pleasant. The whole area was lush green, covered with a variety of crops. There was a strong aroma of fresh milk from the dairy nearby. Brushing aside the nostalgia that I felt for my hometown, I began my work by talking to the farmers who were working in their farms. “What are the crops you grow? How do you deal with the increasing water shortage? Has climate change impacted productivity,” we wanted to know. The farmers were very vocal in their responses and we hurriedly wrote down everything they were saying.
It was then that I saw Mr Muthusamy. He looked somewhere about 50 years old. He had a tired look about him. He was either exhausted from working in the fields or was just unwell. He, however, was eager to talk to us, and we made our way to where he was lying down on his rope cot. Mr Muthusamy began talking to us about the good old days when farming was easy, climate more predictable and water was plenty.  He said that though his borewell had enough water even to this day, he just like the other farmers had begun applying raw septage to his fields to save water. “But, we have stopped that practice in the last couple of years,” he said.
This naturally aroused our curiosity. We wanted to know the reason why Mr Muthusamy, unlike others, had suddenly stopped using readily available raw septage. “It smells a lot,” he said. “We cannot work on the land for at least three to four days after applying septage.”  This reply did not satisfy us. There was nothing new about the stench. So why had Mr Muthusamy stopped using raw septage in his farm?
A bit of prodding brought out the answer. “Using raw septage has led to the proliferation of visha poondu,” he said. “This plant is hindering the growth of crops and has led to decreasing yield.”  “Can you show us some visha poondu?,” we asked him. We wanted to know what this plant looked like. An half-hour’s walk into the field revealed that visha poondu was nothing but the parthenium weed.
parthenium_hysterophorus86“When there were a few plants around, we used to remove them manually, but now there seems to be an infestation of the weed. We are scared because people seem to be falling ill with different kinds of allergies,” he said.
Parthenium, (Parthenium hysterophorus) is a noxious invasive species, which is considered to be one of the worst weeds currently known. This is a weed of global significance responsible for severe human and animal health issues, such as dermatitis, asthma and bronchitis, and agricultural losses besides creating a great problem for biodiversity (Holm et al., 1997).
Mr Muthusamy was now in a talkative mood. “We have other issues too,” he said. “Whenever we work in the fields where septage has been freshly applied, we end up getting skin infections on our feet. As farmers, we consider our crops to be auspicious and we don’t wear footwear when we are in our fields. So each time we go to a field where raw septage has been freshly applied, a few of us end up with skin allergies,” he explained.
After a long conversation with Mr Muthusamy, we turned to leave.
As we were leaving, his wife, who was listening to the entire conversation quietly, asked us. “Can you do something about the septage? Add some chemicals to it, so that it becomes safe for us to use it?”
It looked like the importance of treatment had reached Muthusamy’s farm.

Reference:

  1. Holm, J. Doll, E. Holm, J. V. Pancho, and J. P. Herberger, World Weeds: Natural Histories and Distribution, John Wiley & Sons, New York, NY, USA, 1997.

Vini

Vinitha Murukesan
Environment and Sanitation Analyst, TNUSSP

Laws are good, implementation not so much

As a child back in the village, I had always cherished the sight of clear water running below bridges. But moving to the city, the car windows are always drawn up and the car zooms across bridges in a bid to avoid the stench emanating from the river. This begs the question, why are we in urban India so deprived of a clean environment?

We live in an age where adequate importance is being given to toilets. However, what happens after one uses the toilet? Where does it all go? Ideally the toilets are either connected to the underground sewer (off-site sanitation system) or a pit latrines or septic tanks (on-site sanitation system) from which the waste is taken to the sewage/septage treatment plants. Does this really happen?

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Urban India with a whopping population of 377 million sends out only 30% of the sewage/sepatge from its toilets to the treatment plants. An analysis by Indiaspend says that the remaining three-fourths of the sewage/septage is illegally dumped into our lakes, rivers and seas polluting our water bodies.  So why is this rampant pollution of our environment being ignored? Is it the lack of legal instruments and monitoring mechanisms to control the pollution, or is it the poor implementation of existing laws?

To start with, let us look at the laws which are in place for safe containment, collection and transportation of fecal sludge.

  1. Tamil Nadu District Municipalities Act, 1920 (applies to the 124 Municipalities and 528 Town Panchayats in the state)
  2. 12 Municipal Corporation Acts enacted for the 12 Municipal Corporations in the State.
  3. Tamil Nadu Public Health Act, 1939.
  4. Various bye-laws at the State and Urban Local Body level.

The TN District Municipalities Act, 1920 and 12 Municipal Corporation Acts has rules and bye-laws in place for construction, operation and maintenance of toilets, sewer systems and septic tanks. The Tamil Nadu Public Health Act, 1939, is a significant Act which exercises rules for prevention of sewage/septage from containment systems or insanitary toilets to be let out into open spaces or water bodies, prohibits practices of open defecation, and further issues directions for closure of unfit containment systems/insanitary toilets violating the laws.  With respect to Toilets and On-site systems, there are Acts which enforce safe regulation. In any case, despite existence these legal instruments a deeper question arises with respect to implementation of these laws.

The enforcement of many of these rules do not hold good at the field-level due to practical difficulties involved in identifying insanitary toilets and retrofitting them. The minimal fines starting from Rs. 30 to be imposed for violation of laws are seldom put into practice. In terms of collection/desludging, the CPHEEO Manual on Sewerage and Treatment, 2013 advises regular de-sludging of septic tanks. The Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013 recommends the usage of mechanical devices and safety gears for deslugding.

A further look at the transport and emptying of fecal sludge component denotes neglect with respect to legal structures. Although the Act says that only authorised vehicles/carts with adequate covers and licenses are allowed to collect fecal sludge from households; regulatory practices for checking on their safe disposal seem to be absent. Particularly, there is an absence of any designated monitoring authority to prevent disposal of fecal sludge into the water bodies/open lands. As a result of these gaps there is a rise in the unregulated private sector operating under unsatisfactory conditions causing harm to the environment and public health.

While there are gaps existing in the current legal instruments which need to be plugged, the bigger issue, however, is the poor implementation mechanisms. These can be attributed to fragmented laws, lack of awareness on the negative impacts of improper sanitation and inadequate number of existing sanitary personnel solely dedicated to implementing sanitary works.

Therefore, it is necessary that the Central government and Tamil Nadu State government which are now in the process of seriously implementing the National Policy on Fecal Sludge Management and Operative Guidelines for Septage Management for Urban and Rural local bodies in Tamil Nadu, 2014 respectively, should work towards creating awareness among all stakeholders which will go a long way in the implementation of these policies/guidelines.

References:

Tamil Nadu District Municipalities Act. 1920. “Tamil Nadu District Municipalities Act.” Tamil Nadu: Government of Tamil Nadu.

Public Health Act. 1939. “Tamil Nadu Public Health Act.” Tamil Nadu: Government of Tamil Nadu.

https://thewire.in/20320/70-of-urban-indias-sewage-is-untreated/

Sri

 
Srinithi Sudhakar
Senior Associate, TNUSSP

 

Bladder Woes: Bridging the sanitation gap along the highways

As I was mentally getting prepared for an almost 12-hour journey from Delhi to Shimla, my thoughts were fixed on one crucial thing, to get through the journey without having to use any of the public toilets on the way. The highways do not have any specific public toilet structures and by public toilets, I refer to those available in hotels or restaurants situated on the highway. I am not ashamed to confess that I suffer from toilet anxiety or toilet phobia particularly at the thought of using public toilets. The fear of having to use an unhygienic and a reeking toilet compels me to consciously hold the urge to urinate, no matter how bumpy the ride is. Though it may sound anomalous, it is a fact that many women silently endure this inescapable dilemma while traveling. This pernicious tendency to procrastinate the urge to pee not only increases one’s likelihood of developing urinary tract infections (UTIs) but also intensifies the anxiety level. This then leads us to an important question, why is there a vacuity in sanitation amenities between urban set ups?

 

Toilet 11The answer is rather direct – sanitation along state and national highways has not received adequate attention within the WASH sector or policy in India. In the context of urban sanitation, which in recent years has received concerted attention among policy-makers and practitioners in India, the provision of toilets along National or State Highways is a missing component. The vision of the National Sanitation Policy 2008 by the Ministry of Urban Development, Government of India clearly states that, “All Indian cities and towns become totally sanitized, healthy and livable and ensure and sustain good public health and environmental outcomes for all their citizens with a special focus on hygienic and affordable sanitation facilities for the urban poor and women” (NUSP, 2008 www.moud.gov.in). Providing sanitation related amenities along State or National Highways certainly does not come under its purview and this gap has been filled to some extent by other Government departments and agencies like the Ministry of Road Transport and Highways and the National Highway Authority of India (NHAI).

The Ministry of Road Transport and Highways has dove-tailed the sanitation component into their broader sector guidelines and in 2013, issued a set of guidelines/norms for access permission to fuel stations, private properties, rest area complexes and such other facilities along National Highways. The rest areas will have to provide a variety of amenities to road users including free access to toilets 24/7.  Further, in 2016, NHAI announced that, in line with the Prime Minister’s Swachch Bharat Mission, processes are in place to upgrade toilets in petrol pumps along the National Highway. The petroleum companies were also given a basic design to conform to and renovate. Further, proposals were called for setting up wayside amenities along National Highways across India using Public Private Partnership (PPP) (www.nhai.org) . These initiatives are commendable and definitely provides some amount of solace to the existing problem. However, it does not cater to all kinds of road users especially those who travel by public or private tourist buses that operate on their own terms and makes pit stops in stipulated motels/restaurants. So, what can be the solution to this cohort?

The most viable opportunity is to target motels and restaurants that dot all along the State and National Highways. These rest points offer to the tourists or travellers an opportunity to replenish and relieve themselves. Nevertheless, the toilets offered by these establishments are often dirty and insufficient with just one toilet for a busload of people. By identifying and mapping the existing motels or restaurants amenity-wise, the State or Urban Local Government can include them under the broader umbrella of a Sanitation Mission. This can include orientation and training of motel or restaurant owners on the need to provide and regularly maintain hygienic toilets. In order to motivate them to ensure a standard, the toilets in the establishments can be given a five-star ranking based on the level of cleanliness and usability of the toilet. The toilet star ranking can be then exhibited outside the establishment for visibility. In addition, the tourist logistic companies can also be roped in to educate them on ensuring that tourists are given a fair opportunity to use clean toilets. In doing so, they should be encouraged to choose motels or restaurants that have a toilet star ranking that is four or five.

Access to a clean and a safe toilet is a right for all and the responsibility to ensure accessibility rests predominantly with the National and State Governments. By re-defining urban spaces within the existing National Sanitation Policy, these oblivion toilets will serve its purpose to anxious travellers like me.

 

Reeba11

 

 

Reeba Devaraj
Senior Specialist, TNUSSP

Linking Information Technology to Fecal Sludge Management

Fecal Sludge Management (FSM) is a management system that safely collects, transports, and treats fecal sludge (also called septage) from pit latrines, septic tanks or other onsite sanitation facilities (OSSF). One of the key components of fecal sludge management is the safe transportation of fecal sludge from the onsite sanitation facility to the point of treatment. There is no doubt that safe disposal of fecal sludge is the primary objective of any FSM project, and the fecal sludge transporters play a key role in this process.

In fecal sludge transportation, different stakeholders are involved in the successful transfer of sludge from containment to the treatment facility. These stakeholders include households, service providers, sanitary workers, septage truck owners and officers from the Urban Local Body (ULB). However, it is commonly seen that these different stakeholders do not work in a co-ordinated fashion when it comes to transporting fecal sludge from households to a treatment facility.  It is in this case that technology can come to the rescue.

At present, the existing system is not fully equipped for holding, retrieving and maintaining information on sanitation facilities including service provision. For example, no authorised body in the ULB has complete information on Households (HHs) sanitation facility, fecal sludge containment and fecal sludge flow. This lack of information and communication will, in the long run, account for badly managed sanitation systems. In this scenario, it would be interesting if fecal sludge transportation followed a system like Uber or Ola cabs using an application.

Let us examine this idea a little more closely. What do the residents want from any service? 1. Reliability, 2. Efficiency 3. Cost effectiveness. All these three are available in the Uber and Ola Apps. These transport services are using mobile web-based GIS technology to provide real-time information about the vehicle, vehicle number, contact number and approximate cost (based on travel distance, total travel time and base fare). Once the service is complete, the customer is asked to rate the service for efficiency.

While this system can be easily adopted by the ULBs to reach customer locations as well as keep track of the septage trucks, the ULBs are wary about its misuse because once the mobile has been turned off or the app has been uninstalled, it is difficult to track the vehicle. However, if we keep in mind that the core aim is to provide customers with better services, and not just prevent illegal dumping of fecal sludge, these small lapses can be set right.

FSM projects in countries like Senegal have established the world’s first innovative call centre system to enable the customer to receive the best and most economical service for desludging. This system operates on request-based desludging not schedule-based desludging. The clients send their request for desludging to the call center, and the call center contacts the operators near the said client’s location for quotations. The call center, then sends the lowest quotation to the client based on which the client asks the call center to send a particular desluding vehicle. Once the desludging is completed, the call centre calls the client to check for customer satisfaction.  This system works well, but requires transparency at all levels to be sustainable in the long run.

APP_Truck1

APP_Truck2

The integration of GPS, GIS, GPRS and the mobile-based web application for Urban Local Body, service providers and residents will improve the quality of service, are easy to monitor and ensure safe environment. GPS will provide the current position, GIS will provide route directions and how to get there (simple algorithm for path finding using different aspects shortest path, regulated path and travel time), while GPRS will provide real time data, through the mobile towers.

If the FSM project needs to be successful, it should follow the improved service orientation approach not just monitoring approach. If the sludge transport system has to run successfully for long periods, the process has to be transparent, and it should benefit both clients, as well as the service providers. Towards this end, all stakeholders have to sit together and discuss the possibility of an improved service-oriented approach to create a better environment for everyone to live in, and this approach should be facilitated by the Urban Local Bodies.

NavamaniPhoto

Navamani Ramasamy
Specialist, TNUSSP

Is your child’s shit affecting your health?

It was September 2008. It took me almost two-and-a-half hours to reach G-plot, one of the remotest islands among the deltoid labyrinth of Sundarbans. My colleague – a native to G-plot was waiting to receive me at the jetty. We got on a van fitted with a motorcycle engine, popularly known as Vano in this part of the world. Assaulting our eardrums with more than 85 decibels and leaving behind a deep dark trail of fume, the Vano set out for Satyadaspur, one of our intervention villages in G-plot.  Reaching the destination, we immediately jumped into action and rushed to meet the beneficiaries who had built their household toilets under the Total Sanitation Campaign Programme.

We reached a house located near the centre of the village. Stepping into the yard, I noticed a small child defecating on the other side of the premises near a bush. We knocked on the door and a lady in her mid-twenties came out. My colleague introduced me and told her the purpose of our visit. The lady welcomed us indoors, offered us a glass of water with sugar candy and started answering my questions. I was curious to know whether all members of her family were using the toilet. She answered in the affirmative. I pointed to the toddler and asked if he was using the toilet. With a chuckle she replied that the toddler could not sit on toilet. There was a danger of his falling down and injuring himself. The lady then took a mug of water and got busy cleaning the child. Once she had finished washing the child, she wiped her hand with her saree and continued talking to us. The shit was lying unattended.

“Don’t you use soap after going to the toilet?” I could not resist asking. “Of course we do. In fact, after using the toilet the women bathe in the village pond and only then get into the kitchen.”  Seeing me staring at the child who had just finished defecating in the open, she said. “Öh, him? He is not even three, his stool is not harmful at all.”

June 2014 – Odisha: While entering a large slum called Bapuji Nagar Railway Basti right in the heart of Bhubaneswar, a familiar sight of a small child defecating on a newspaper caught my eye. After some time, an aged woman, probably the child’s grandmother picked up the shit, wrapped it in the newspaper and threw it on the nearby railway tracks.

Unlike in the earlier case, none of the families in Bapuji Nagar Railway Basti had their own toilets. Adults used the railway track in the wee hours of the morning or late at night. Since it was not safe for children to use the tracks, an alternative arrangement was made using the toilet.

February 2017 – Tamil Nadu: We arrived at a small town to do an assessment of a community toilet. The toilet block was full of faeces indicating a high prevalence of open defecation.  A little probing showed that while adults from the neighbouring slums were using the community toilet, children were using the toilet premises itself.

These three instances from different parts of the country indicate a widespread perception about children’s faeces not being harmful.  According to the NFHS 3 (2005-2006) data, stools of around 79 percent children in India are disposed of unsafely. Two subsequent studies in rural Odisha and West Bengal show that the prevalence is around 81 percent (Majorin et al, 2014) and 72 percent (Preeti PS et al, 2016), respectively.  The commonly held belief that faeces of infants and young children is not harmful is untrue. There is evidence that children’s faeces could be more harmful than that of adults due to higher prevalence of diarrhoea, Hepatitis A, Rotavirus and E Coli in children (Feachem R G et al, 1983).

Often impact of poor sanitation and hygiene is measured by the effect it has on children, either in terms of infant mortality or morbidity due to diarrhoeal diseases, loss of intellectual capacity due to stunting or worm infestation. However, most sanitation and hygiene interventions target adults. According to JMP[1] 2015,  globally 68% population have access to improved toilets[2].  These estimates are based on the households’ primary sanitation facility and may have overlooked the disposal practices of faeces of young children. In many cases children might have access to improved toilets, but are not able to use it because of their age, stage of their physical development or just because of safety concerns of their caregiver.

In 2015, the Water and Sanitation Programme of World Bank released a research brief on management of child faeces. In this paper, the methods of disposal of children’s faeces from 26 locations across Africa, East Asia and Pacific, Latin America and South Asia were presented (see charts).  The key findings from the research showed that faeces of children under the age of three was less likely to be safely disposed of than that of the adult population, across the three study sites.  Not surprisingly, there was a higher rate of unsafe disposal of child faeces in populations practicing open defecation. Households with access to improved toilets have also reported exhibiting unsafe disposal traits when it comes to child faeces. This clearly shows that the belief that child faeces is less harmful is equally prevalent in many parts of the globe.

Chart

Poor management of child faeces can result in substantial health impacts on children, including a higher prevalence of diarrheal disease, intestinal worms, enteropathy, malnutrition, and death. A series of empirical studies across different countries (Baltazar J. C., et al, 1989; Curtis, Valerie, et al. 2011, Aulia, H. et al, 1994; Mihrete, T.,2014; Bawankule R, 2017) have proved the strong association between unsafe disposal of child’s faeces and clinically diagnosed diarrhoea among young children.  Based on the findings of several studies, The Child Health Epidemiology Reference Group (CHERG) has concluded that safe stool disposal has protection effect.

Despite such empirical evidence, sanitation for children has been a neglected area of research, policy and programme. There are significant knowledge gaps in this domain, and it is evident that we are trying to estimate the magnitude of the problem by referring to pretty outdated data. Nevertheless, to reach the proposed Sustainable Development Goal of universal coverage or end of Open Defecation by 2030, we must ensure that children’s faeces is disposed of safely. The World Bank report is undoubtedly indicating that India is far behind its neighbouring countries like Pakistan, Afghanistan and many countries from Africa, East Asia and Pacific in terms of safe disposal.

However, we are already witnessing an increased international acknowledgement of the importance of monitoring the practice. The Joint Monitoring Programme on Sanitation has recommended that the “percentage of children under five whose stools are hygienically disposed of” as a sub-indicator under the eliminating open defecation target.  Our own Swachh Bharat Mission also has laid “effective disposal of child faeces” as an essential indicator for obtaining an Open Defecation Free certificate.

References:

  1. International Institute for Population Sciences. National Family Health Survey (NFHS-3), 2005-06: India; 2007. Available from: http://dhsprogram.com/pubs/pdf/FRIND3/ FRIND3-Vol1andVol2.pdf.
  2. Ministry of Urban Development (India). Guidelines for Swachh Bharat Mission (Gramin); 2014 [cited 2016 Sep 26]. Available from: http://phed.bih.nic.in/Docs/Guidelines-Swachh-BharatAbhiyan.pdf.
  3. Majorin, F., Freeman, M. C., Barnard, S., Routry, P., Boisson, S., & Clasen, T. (2014). Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study. PLOS One, 9(2). doi:10.1371/journal.pone.0089551
  4. Unsafe Disposal of Child Faeces: A Community-based Study in a Rural Block in West Bengal, India. (2016, September 8). Journal of Preventive Medicine and Public Health, 323-328. doi:https://doi.org/10.3961/jpmph.16.020
  5. Feachem, R. G., Bardley, D. J., Garelick, H., & Mara, D. D. (1983). Sanitation and Disease Health Aspects of Excreta and Wastewater Management. John Wiley & Sons.
  6. Baltazar J. C., and F. S. Solon. 1989. “Disposal of Faeces of Children under Two Years Old and Diarrhoea Incidence: A Case-Control Study.” International Journal of Epidemiology 18(4 Suppl 2):S16–S19
  7. Curtis, Valerie, et al. 2011. “Hygiene: New Hopes, New Horizons.” The Lancet Infectious Diseases 11(4):312–321; Curtis, Valerie, et al. 1995. “Potties, Pits and Pipes: Explaining Hygiene Behaviour in Burkina Faso.” Social Science & Medicine 41(3):383–393
  8. Aulia, H., S. C. Surapaty, E. Bahar, et al. 1994. “Personal and Domestic Hygiene and Its Relationship to the Incidence of Diarrhea in South Sumatera.” Journal of Diarrheal Diseases Research 12(1):42–48.
  9. Mihrete, T., G. Alemie, and A. Teferra. 2014. “Determinants of Childhood Diarrhea among Underfive Children in Benishangul Gumuz Regional State, North West Ethiopia.” BMC Pediatrics 14:102. http://www.biomedcentral.com/1471-2431/14/102
  10. Bawankule, R., Singh, A., Kumar, K., & Pedgaonkar, S. (2017). Disposal of children’s stools and its association with childhood diarrhea in India. Biomed Central Public Health, 3. doi: 10.1186/s12889-016-3948-2
  11. UNICEF and WHO, WASH Targets and Indicators Post-2015: Recommendations from International Consultations. Comprehensive Recommendations – Updated April 2014. 2014. 5
  12. Government of India MoUD. Swachh Bharat Mission; 2015. Available at http://www.swachhbharaturban.in/sbm/home/#/SBM. Accessed 21 May 2015.

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Niladri Chakraborti
Senior Specialist, TNUSSP

[1] Joint Monitoring Program by WHO/UNICF

[2] The JMP standardized definition for an improved sanitation facility is one that hygienically separates human excreta from human contact.

Thoughts on the Masons’ Training

Who built the Taj Mahal? Yes, that’s right. The masons built it.”

With this opening remark, the Masons’ Training Programme held at Coimbatore was kicked off.

I had the opportunity to join in on the Masons’ Training initiative conducted as a part of Capacity Building initiative in both Trichy and Coimbatore.

Now for a brief introduction to the training programme: the audience belonged to an age group ranging between those in their teens to those in their 60s. The average experience ranged from 20 to 30 years.  About 35 attendees were present in each of the venues and the training programme was coordinated by IIHS, CDD and Gramalaya in Trichy and, IIHS, CDD and Keystone foundation in Coimbatore.

Why was a training programme needed for the masons? It has been found that in most households septic tanks are mere holding tanks built without any proper lining. And these are not desludged regularly which has led to groundwater contamination. The training programme was arranged to create awareness among the masons on the sanitation value chain and provide them with information on how to construct septic tanks and twin pits according to the Indian Standard Guidelines.

What did the masons learn? Though most masons seemed to know the dimensions of the septic tank to be constructed (for an average household of five people), particulars about twin pit construction and information about gas formation in septic tanks were new to them. The masons were also unaware of important details like the necessity and placement of vent pipes. This knowledge was imparted during the training.

DSC_4934What we can learn from the masons? There were masons with over 30 years of experience sitting very patiently listening to the training programme with great modesty and respect for the instructors. Many were brilliant organisers in addition to being builders. In Trichy we conducted a session where a septic tank and twin pit was actually built. The manner in which the masons cooperated with each other was notable. Most of them had no experience of working together yet they managed to divide the work amongst themselves efficiently and execute it. In another instance, during the Coimbatore training programme, the masons were given a task in which they had to make a bio-toilet model from hardboard cutouts. Bio-toilets are to be placed above the ground level with steps leading to the door. In the model that they were asked to build the door of the toilet opening outside. One of the masons pointed that if there are to be steps leading upwards to the door, the door has to open on the inside. The masons were aware of these small but important details in construction, which if ignored would lead to difficulties at a later date.

What I learnt from the training? Educated personnel, such as professional engineers, are ignorant of technical terms in native/regional languages, which are crucial in communicating with those on the ground especially if we are attempting to change their habits. I learned many of the commonly used engineering terms in the regional language during the training programme, including words for treatment, technology, advanced technology, septic tank, soak pit, twin pit, single pit etc. This was of considerable benefit and motivated me to find out the translations or the words used by masons in my native language as well.

Another lesson I learnt was one of wisdom that is acquired from experience. So for instance, it is one thing to know that if plastering is to be done, then the ratio of cement to sand is 1:6, (being a civil engineer I know this) then again the amount of water to be added is something I will require some time and effort to get right. But for the masons all of this comes naturally – without any effort at calculation. It is my belief that civil engineering students should spend at least a day with the masons to understand the difference between “textbook knowledge” and one gained through experience.

Was the mason’s training helpful to the masons? Though they were aware of the basics, many masons were deficient in their grasp of crucial details to be kept in mind during the construction of a septic tank or twin pit- regarding vent pipes, gas formation etc. Filling these gaps in their existing knowledge helped the masons a great deal. And when we see proper onsite sanitation systems being built in the households of Trichy and Coimbatore in the coming years, we will get a definitive answer on how useful the training was.

Vimala

 

 

 

Vimala PP
Junior Specialist, 
TNUSSP

“Synergy between WASH and nutrition” – It’s complicated

Sounds like a status message in Facebook. But that should pretty much sum up the relationship between WASH strategies and nutrition outcomes. Obviously, when there is unsafe water, pitiable and inadequate sanitation conditions with woeful hygiene practices, it will inadvertently lead to public health implications. This is especially critical, when we talk about the imminent health hazards, in overtly crowded and densely populated spaces filled with undernourished urban poor population with low economic background.

The reason and outcome of poverty itself are mutually exclusive for undernourishment in the urban poor populations. In addition to that, undernourished people with poor health are obviously more prone and vulnerable to WASH related infections, such as fecally transmitted infections including but not limited to diarrhea, environmental enteropathy, nematode infections and other intestinal infections.

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There is an active, nasty cycle of WASH related infections and undernutrition. For instance, an under nourished person who is recently infected by diarrhea due to poor WASH practices, will have lower stamina and strength left in his/her body, as their capacity to absorb nutrients will have reduced on their way to recovery. So in the context of the urban poor, the nutrients absorption rate or the capacity of the undernourished person to take advantage of the nutrient / calories intake is significantly reduced. With poor immunity, under nutrition and lack of access to good healthcare, they will be more susceptible to subsequent infections, and the cycle continues, adding to their cup of woes.

The impact of poor sanitation practices and the resulting diarrheal infections, on under nourished children is much worse. It has been proven to cause growth stunting (low height-for-age), wasting (low weight-for-height), and underweight (low weight-for-age), and even child deaths. The micronutrients deficiency (in terms of Vitamin A, B12, Riboflavin, Folic acid, Iron and Zinc) that is evident among children and also women, exacerbates their vulnerability to WASH related infections. I don’t want to sound like an emissary of Doomsday. But the other associated fallouts that dampen the functioning of the system besides malnutrition, stunting in children, premature deaths, are wasted time and loss of productivity.

So in order to achieve a universal and sustainable outcome, it is imperative that we start to think on the lines of linking and establishing synergies between WASH plans and policies with nutrition strategies. We need to work towards demonstrating and bringing in WASH interventions by coalescing with nutrition programmes.

The key priorities would be to reduce the high malnutrition rate, to address the micronutrient deficiency, improve quality, coverage and access to water, sanitation and hygiene services and practice, adopting nutrition sensitive sanitation and holistic WASH related interventions, to improve the overall health of the populations and well, the betterment of humanity. Pretty lofty and ambitious one might say. Easier said than done, right! But in this so called post-truth and self-awareness era, as the popular saying goes, to making it count, if we do our bit to instill a systematic progressive change in our midst then we just might make a positive difference in the world.

References used:

http://riceinstitute.org/wordpress/wp-content/uploads/downloads/2013/04/rice-sanitation-stunting-brief.pdf (accessed on Mar 28, 2017)

http://thousanddays.org/wp-content/uploads/The-Impact-of-Poor-Sanitation-on-Nutrition-1.pdf (accessed on Mar 28, 2017)

https://www.unicef.org/media/files/IntegratingWASHandNut_WHO_UNICEF_USAID_Nov2015.pdf (accessed on Mar 28, 2017)
 Suneethi

Suneethi Sundar
Specialist, TNUSSP

Will building toilets end Open Defecation?

Will building toilets solve the problem of Open Defecation? – Fecelore – Stories on Sanitation

Sanitation is the name given to the process, facilities and services employed towards the safe disposal of human waste – which includes feces and urine. Human waste unless properly disposed of, is not just really gross but also tends to be a major cause for several water-borne diseases like cholera, diarrhoea, gastro-enteritis and typhoid. According to the World Health Organisation, improving sanitation can have a hugely significant beneficial impact on the health of individuals and families.

Inadequate sanitation also has serious economic implications. The health impact of poor sanitation results in pronounced economic losses which come from direct medical costs of treating sanitation-related illnesses, and indirect costs due to reduced or lost productivity as a result of ill health. Infact, inadequate sanitation is said to have caused India considerable economic losses, equivalent to 6.4 per cent of India’s GDP in 2006, or Rs.2.4 Lakh Crore.

According to the UN report card, close to 946 million people in the world have little or no access to sanitation and continue to practise open defecation. According to 2011 census, 53.1% (63.6% in 2001) of the households in India do not have a toilet, with the percentage being as high as 69.3% (78.1% in 2001) in rural areas and 18.6% (26.3% in 2001) in urban areas. However, providing toilets alone cannot solve the problem of unsafe sanitation.

Addressing the sanitation problem is not just about eliminating open defecation by providing toilets, but also of ensuring safe disposal of the fecal waste without it being exfiltrated into the environment. Attention should be paid to the social and behavioral aspect of the community while formulating solutions for access to safe sanitation.

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Looking beyond toilets

Will building toilets solve the problem of Open Defecation? – Fecelore – Stories on Sanitation

A close look at the ground realities will show us where the problem actually lies. For instance, it has been observed that toilets are being provided by the government and ULBs to end open defecation, but access to toilets continues to be a problem. A casual walk around any city or town would show us people urinating in public spaces because they do not have access to toilets. Providing toilets at random locations has not helped in solving the problem of open defecation or urination.

A news article in the Indian Express titled ‘It’s No Joke – State of the World’s Toilets’ by Water Aid said: “If all 774 million people in India waiting for household toilets were made to stand in a line, the queue would stretch from Earth to the moon and beyond. However, in places where toilets do exist, scant attention has been paid to the needs of women, children and people with disability. Access to clean and working toilet is a key to preventing open defecation, and beginning the journey towards safe sanitation.

Providing user-friendly and clean toilets in parks, bus stations, markets, petrol pumps, small restaurants and places of tourist interests should be made mandatory. If we continue providing toilets without looking into their access, maintenance and usability, it is unlikely that we will witness a real change as far as open defecation and open urination is concerned. Toilets with no water or unsafe toilets are only structures which will play little or no role in the long journey towards safe sanitation.

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