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)

Menstruation is concomitant with womanhood. Nevertheless, in my adolescence, I was taught to deal with this as a taboo subject. But, that was a while ago. What is the situation now? How does the modern adolescent girl, in this age, deal with this inevitable body function? Has the silence around ‘those five days’ been broken? It was with these thoughts that I embarked upon a study to explore what adolescent girls in small towns think of menstruation, and how to deal with it.

Recently, I happened to chat with a bunch of 12-14- year old girls about menstruation, and what they thought about it. The girls were shy and uncomfortable in the beginning. Gradually, they began to open up and what followed was a very engrossing discussion. Every single girl in the group had something to say from her own personal experience. While many of the stories sounded similar, a few were rather unusual.

When I was growing up, despite the silence and the taboo, my mother had taken care to introduce the concept of menstruation to me. When I attained menarche, I was mentally prepared to handle it. Contrary to what I had experienced, most of the girls I spoke to practically had no information about menstruation from their mothers. On the other hand, many of them had been told that they had to inform an aunt or an elderly woman in the neighbourhood at the onset of their first period. It was a popular belief that informing the mother or the grandmother would bring bad luck to the girl for her entire life. The girls also said that during the course of their first period they were made to sit on a wooden plank in a secluded area of the house for a period of 7 to 10 days. Some of them were also made to remain there for as long as two weeks. Once the period of seclusion was over, some families celebrated the occasion with a grand ceremony to which neighbours and relatives were invited.

However, once this celebration was over, the girls were not expected to speak about their periods openly even with their own mothers. Their monthly cycle was to be ‘suffered’ in silence, because of which girls got the basic information from their peers, who were as ill-informed as themselves. This had resulted in a variety of misconceptions around menstruation and menstrual hygiene.

The girls also reported that several restrictions were imposed on them during their monthly menstrual cycle. They were prohibited from attending any religious festivals, going to the temple, prevented from entering the kitchen or hanging out with their friends and family members. Some of them were even prevented from eating certain kinds of foods.

“During my periods, my family behaves like I have got a contagious disease. I am not even allowed to touch anyone else,” said one girl, while some others reported that they had to refrain from eating some kinds of foods. Anything sweet was forbidden because it was popularly believed that eating sweets would result in increased blood flow, which would be detrimental to the health of the girl.

Attending school during the menstrual cycle continued to be a nightmare, with problems being faced at every stage from travelling to school to concentrating in the classroom to changing sanitary pads. “Taking a sanitary pad out of my bag, carrying it discreetly to the toilet and safely disposing of the used pad, is not at all easy,” said one girl. Her story reminded me of my school days.

While government schools have made a small attempt to make girls comfortable during their monthly cycle by offering them six packets of free sanitary napkins each month, the girls were not comfortable using them. “These pads are not very absorbent,” they said, adding that most of them took the packets and gave them to their mothers, who used them along with the usual cloth. The girls, on the other hand, preferred to use branded sanitary pads, which they got from the local pharmacy.

Home remedies were still the most popular form of treatment to deal with problems and discomfort associated with menstruation. Most of the girls said that they had never thought of consulting a physician for any period-related discomfort like stomach aches or cramps. Coconut oil, turmeric powder, fenugreek seeds, castor oil etc., continued to be the sought-after remedies during those five days. Superstitious beliefs continued to thrive around everything related to menstruation, some of them even leading to unintended good. “My grandmother says if I don’t dispose of the used napkin properly I will get Naga Dosha,” said one girl to my amusement. At least proper disposal was being taken care of, I thought.

As the discussion came to a close, I realised that taboos and irrational fear continued to abound around everything related to menstruation. It is very important that girls are not only educated about menstruation and menstrual hygiene but also to be given lessons that would trigger a positive perception about their monthly period, thereby boosting their self-esteem. Parents, especially mothers, had to be brought into the ambit of discussion and talking about menstruation and menstrual management had to be encouraged.

Once the ignition is switched off, we watch in amazement at Kumar’s metamorphosis. He is no longer the chatty person who was sitting beside us behind the wheel. He jumps down from the driver’s cabin, reaches the septic tank and breaks open the sealed manhole with a crowbar. In an equally well-coordinated move, Muthu pulls down the extension hose from the top of the truck, connects it to the valve embedded on the tanker, and pushes the other end into the septic tank. Thanks to the vacuum suction technology, the vacuum tank is filled with 5000 litres of septage in a few minutes. Throughout the entire process, Kumar has kept a careful watch on the volume gauge mounted on the tanker.

While this entire exercise is taking place, Suresh and I introduce ourselves to the staff of the poultry farm. After some initial hesitation, some of the workers began speaking to us. We get to know that close to 90 workers work and live on the poultry farm. They share common sanitary facilities, which are spread around the farm, and on an average around 15 lorry loads of septage was being generated by the farm every month. Our jaws drop on hearing this number. “Where do they take so much septage? What is the disposal mechanism,” was the question on our minds. We keep a straight face and ask Kumar where the nearest dumping location was. “Oh, I have an arrangement with the nearby farmland,’’ he says confidently. “We will go there in a while,” he adds.

Surely enough, half an hour later we are at a large coconut grove. With the farmer’s wife supervising the unloading, Kumar and Muthu empty the entire tanker into the groove. We take the opportunity to speak to the farmer’s wife. She tells us that her farm receives around 20 loads of septage every couple of months. “It is not only from the poultry farm, we have an arrangement with a couple of other places for regular supply of septage,” she says with a smile. Her husband who had joined her tells us that the septage is very important during dry spells when the farm faces acute water scarcity.

Soon it is time for lunch. The owners of the farm invite Suresh and me to join them for lunch. Kumar and Muthu have brought their lunch along with them. They go to a nearby tap and begin washing up. I watch as Muthu fumbles around in the driver’s cabin and pulls out a used detergent soap wrapped in a newspaper, which he and Kumar use to clean their hands and feet. The sight is a kind of relief for us, as we had observed the two carry the hosepipe from one septic tank to another on their shoulder, wiping the spillage with their bare hands!

Once lunch is done, the work continues. Kumar and Muthu take turns building mud bunds around the coconut trees, with their bare hands, to prevent spillage and overflow. The farm owners’ small children continued to play in the vicinity. One toddler keeps coming to Kumar and Muthu and the duo keep embracing him, carrying him, playing with him throughout the time they are working.

It is late in the evening, when the work is done. It is time to head home. On our way back, we find out that both Kumar and Muthu had dropped out of school and taken up this profession. Kumar earns close to Rs 17,000/- per month, while Muthu earns Rs 12,000/- .
As we near Coimbatore, we stop at a roadside teashop. “Take that smelly truck away,” someone shouts from inside. We look at Kumar. He has a defiant look on his face, but his voice trembles as he says, “There is no point in getting into a brawl. This is our profession and we are proud of it.

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.

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.