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.

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)

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.

What 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.

So, you have finished using the toilet. And, have flushed it down. But seriously, where does it all go?

When you ask this question, the answers you get will range from septic tanks to pits to the underground sewerage systems etc. But, is that the whole story? Now that is the difficult question, which begs a real hard look at the ground reality.

Let’s travel some years back in history. It is a well-known fact that ancient India had a fine network of storm water drains, which acted both as groundwater recharge systems, as well as flood control devices. In cities like Chennai, the network of storm water drains led to ponds (kulams) which acted as natural flood control devices. Thanks to unbridled ‘development’ and growth of unplanned settlements both these ‘kulams’ and the storm water drains are polluted and choked.

How have things come to this state? One of the major contributors of pollution in storm water drains (SWDs) are the people themselves. This happens in three ways: Many of the households, which have no containment structures attached to their toilets, connect the toilets to the storm water drains. Sometimes, even households, which have containment structures, connect the outlets the storm water drains. Thirdly, it is not unusual to see that the grey water from the kitchen and bathroom being connected to the storm water drain directly.

A study conducted by Tamil Nadu Urban Sanitation Support Programme (TNUSSP) on the state of the storm water drains showed that this kind of pollution was not only common in small towns but also in mega cities. When asked why toilets and containment structures were connected to storm water drains, most of the residents said that they used the storm water drains as an easy option because it was the “common practice in the area.” Some of them also mentioned the “lack of other options” as one of the reasons.

Letting grey water from the kitchen and bathroom into the open or closed drains is a very common practice all over the country. This is also because many of the people believe that storm water drains are meant to carry the grey water. It comes as a surprise to many people when they learn that storm water drains are meant only to carry storm water and urban runoff (surface runoff of rainwater) to the natural water bodies. However, in reality, the storm water drains end up carrying all the wastewater from the cities (and towns) to the natural water bodies resulting in the grand scale pollution of the water bodies and leading to a colossal public health hazard.

How does dumping of solid waste affect drains?
Dumping of solid waste in the drains is another huge problem that affects the functioning of the drain itself. The drains are designed based on certain set of criteria like the amount of rainfall in the area, natural slope and type of soil etc., which helps to estimates the amount of storm water that will get collected in a particular area. Dumping of solid waste and wastewater into the drains affect their functioning, resulting in improper flow, siltation and stagnation of water which further leads to a whole range of problems like bad odour and serving as a breeding ground for diseases like malaria, dengue, etc.

Where does it end up?
The final destination for the wastewater, which is carried by the drains are the natural water bodies such as streams, rivers, canals etc. A research into how these waterbodies have transformed over a period of time into gutters carrying dirty water will help us understand how we are killing them slowly. Not very long ago, people used to stop to look down bridges to enjoy the scenic beauty of clean, flowing water. Today, they cover their noses and try to get away as soon as possible.

To understand this problem better, the TNUSSP team conducted catchment level assessment of drains in selected locations. Watch this space for further insights into the study.

For Further Reference:

(http://www.downtoearth.org.in/news/what-drains-mean-to-cities-44069, 2014)

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.

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.

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.

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.