A slum on the banks of the Cooum in Chennai. Public health risks are greater in urban than in rural areas because of the cramped conditions of the slums where the poor live without basic sanitation facilities.
"I WAS always first in the class. I am very much interested in studies. I want to become a lawyer. But my mother stopped me from going to school after Class V as the middle school I was attending, 5 km from my house, had no toilet. Can someone help me?"
Eleven-year-old Susheela's anguish is shared by a large number of girls in India who drop out of school for what sounds like an absurd reason: want of a toilet in school. "Sanitation is closely linked to female literacy in India," says a United Nations Children's Fund (UNICEF) study. According to V. Balakrishnan, convener of the Tamil Nadu Primary Schools Improvement Campaign, the lack of proper toilet facilities in schools has a definite and significant bearing on the drop-out rate of girls, particularly around the time they reach Class VIII. In 2000, barely 10 per cent of Tamil Nadu's 40,000 government schools had usable toilets; the figure is much lower for the country as a whole.
By the World Health Organisation's (WHO) definition, sanitation is safe management of human excreta and includes the provision of latrines and the promotion of personal hygiene. Environmental sanitation is a broader term, encompassing excreta disposal, solid waste management, waste water disposal, vector control, and drainage. Personal hygiene includes practices such as washing hands with soap after defecation and before contact with food, and in a broader sense, extends to the collection, storage and handling of safe water. Studies show that the promotion of personal hygiene can reduce diarrhoeal disease by over 35 per cent, while the use of latrines can reduce it by over 40 per cent. Yet, over 70 per cent of the people in India - 90 per cent in the rural areas - have no access to a toilet or safe water supply.
In India, over 700 million people defecate in the open - along roadsides, on farmland, in municipal parks and so on. According to the Water Supply and Sanitation Collaborative Council, a single gram of faeces can contain 10 million viruses, one million bacteria, a thousand parasite cysts and a hundred eggs of worms. No wonder, water contaminated with faecal matter causes diarrhoea (with proper sanitation, the risk level can drop by 40 per cent); malnutrition, anaemia or retarded growth (60 per cent); blindness (25 per cent); schistosomiasis (77 per cent); and cholera (72 per cent).
The Mumbai-based SNDT University, in a study on women's health in Tamil Nadu, found that there are virtually no toilets in the rural areas. Of the 1,017 women interviewed, only five had toilets at home; the others used fields and open spaces for defecation.
The absence of toilets is devastating for women. It severely affects their dignity, health, safety and sense of privacy, and indirectly their literacy and productivity. To defecate women and girls have to wait until dark, which exposes them to harassment and even sexual assault.
According to a study called "Talking Toilet" by Toilet Talk, a Mumbai-based magazine brought out by the National Slum Dwellers Federation, Mahila Milan and the Society for the Promotion of Area Resource Centres, the millions of women and children who defecate along railway tracks, on footpaths, on empty plots, between buildings, over drainage nullahs and in makeshift privies of sticks and gunny sacks are shouted at, molested, exposed to indignities, insulted and beaten. "For most," says the report, "where to relieve themselves is not a choice at all, as they have no option."
Women are forced to endure punishing restraints. Many suffer from gastroenteritis almost all the time. For many women without access to toilets, the only solution is to ensure that their need to use one is reduced as far as possible. So, most do not even drink water when thirsty or eat when hungry. This affects their health and often leads to bouts of illnesses.
A number of gynaecological factors make women urinate more frequently than men. They also take a longer time to relieve themselves owing to anatomical and sartorial factors. Yet, the facilities they have are fewer and inadequate. With the rapid disappearance of the green cover, women have lost privacy and with it their sense of dignity.
According to Water Aid, a United Kingdom-based organisation that focusses on water, sanitation and hygiene promotion in developing countries, India faces the "silent emergency of sanitation neglect". Lack of sanitation and hygiene is the primary cause of almost all infectious diseases. Over half of all polio cases in the world are reported in India when this crippling disease has virtually been wiped out in the developed countries. Over 500,000 children die every year owing to diarrhoea though it has a very simple cure. Jaundice and viral, gastro-enteric and cholera outbreaks are almost an annual feature in many villages. Over 180 million mandays - equivalent to Rs.12 billion - are lost every year because of sanitation-related diseases. At the root of most public health problems is poor sanitation and hygiene.
Though sanitation and hygiene are hot topics at United Nations conferences since the 1980s, they are most often ignored or given low priority in developing countries. Governments seem to stop with setting targets. For example, the U.N. set 2025 as the interim target year for universal access to sanitation, which was agreed to by all governments from developing countries. According to this criterion, by 2000, 75 per cent of the urban population should have had access to sanitation. But the Human Development Report 2000 shows that hardly 30 per cent of India's population enjoy this luxury. Despite attempts by Central and State governments to improve water and sanitation coverage, the facility is available to only 14 per cent of the rural population and 35 per cent of the urban population. And in many cases, the facilities are not usable.
The economic cost of this neglect is enormous. According to a World Bank Report, the annual cost (health expenditure and productivity loss) is put at $ 9.7 billion - over 4 per cent of India's gross domestic product (GDP) in the mid-1990s. Yet, sanitation receives very little official attention and resources.
A survey on public toilet facilities in 151 Mumbai settlements by Toilet Talk showed that over 1,480 persons used one toilet seat though the target set by the municipality was one seat for 50 people. While the Mumbai municipality had built 3,433 seats, 80 per cent of them were in disrepair and the rest were in various degrees of disuse.
Kenneth J. Cooper of The Washington Post Foreign Service, who studied "human waste and India's war on diseases", terms the situation "ironical". "While cities of an early civilisation in the Indus River Valley had sophisticated sewer systems and among the oldest known toilets in the world - brick models that date back 4,500 years - today over two-thirds of Indians do not have access to toilets," he says.
If it is not an aberration of history, it is not of law either. For the British introduced the first sanitation Bill in India in 1878, which made the construction of toilets compulsory even in huts in Calcutta (now Kolkata), then the capital of India. The Bill also proposed the construction of public toilets. The Interstate Migrant Workmen (Regulation of Employment and Condition of Service) Act, 1979, mandates toilet and washing facilities at all workplaces, including construction sites. The Sanitation Act that made dry latrine and its manual cleaning a punishable offence came in 1993. But this law remains only on paper. Even today about six lakh scavengers lift night soil from over 72 lakh dry latrines in 2,587 towns.
While the Ministry of Health recognises the importance of discharging sewage water, no more than 250 of the country's 4,000 cities and towns have proper sewerage systems, and fewer still have treatment plants. The bulk of municipal sewage is let out untreated into rivers, lakes or the sea. Though two-thirds of city-dwellers have bathrooms at home and the majority of the middle-class practise good hygiene, public health risks are greater in the urban than in the rural areas because of the cramped conditions of the slums where the poor - for example, over 40 per cent in general and nearly half of Mumbai's 13 million residents - live without toilet or sewer connection.
A study by the Exnora International civic movement in Chennai shows that one main reason for the unsanitary conditions in the city is that over 267 million litres per day (mld) of sewerage is discharged into the city's waterways; this happens mainly because the sewage pumping stations and treatment plants are not functioning properly.
According to experts, sewerage-connected toilets remain out of the reach of the majority of Indians primarily because the sewerage system needs not only sufficient quantity of running water, but also a regular supply of water for waste disposal. The cost of constructing and maintaining the sewerage system is also enormous. According to some estimates, nearly $500 billion is needed to provide all of India's population with a conventional water supply and sewerage system (at the rate of $150 a unit). The challenge is to propagate and ensure the installation of toilets that are affordable and easy to maintain.
In the 1980s, the Union government initiated the Central Rural Sanitation Programme to encourage the development of safe sanitation in village communities. It promoted one design - the twin-pits, pour-flush latrine with a brick superstructure, which costs Rs.2,500. The programme failed because the government gave a subsidy of Rs.2,000 for every latrine, making the project unsustainable - over $6 billion was needed to provide subsidy to every rural household. The project was scrapped, but it did raise the coverage of sanitation facility to 14 per cent in the 1990s from almost zero in the 1970s. But a recent government study shows that hardly 3 per cent of the latrines built by the project were used; most were converted into storerooms while others were damaged because of poor construction.
It is not as if total sanitation coverage cannot be achieved. The internationally acclaimed Sulabh Sanitation Movement, which has constructed and maintained about a million public toilet-cum-bath complexes since its start in the mid-1970s, has shown that it is possible to build accessible, affordable, self-sustaining and eco-friendly sanitation facilities. Sulabh International has also built 62 human excreta-based biogas plants, which are successfully run in several parts of the world.
In 1996, Water Aid India started its sanitation programme in 1,750 villages in Tamil Nadu. The main features of the programme were varying options for the construction of latrines depending on the water supply situation and the geology of the place, and raising people's awareness and participation in constructing and maintaining latrines. By 2000, all the villages where the programme was implemented had 100 per cent sanitation coverage, sustained primarily by local participation.
According to the WHO, given the technology used by the Government of India and the current rates of construction and population growth, it would take 200 years for every Indian to have access to a toilet. But Sulabh International has shown that toilets can be built for various economic categories of people at reasonable costs - much lower than the cost incurred by the government.
Says Dr. Bindeshwar Pathak, founder of Sulabh International: "Some organisations such as ours have shown that affordable and sustainable toilets can be constructed. Considering that providing basic sanitation facility helps tremendously on the economic, health and female literacy fronts, we should stop depending on the government and start providing for 100 per cent sanitation coverage ourselves. It is possible. It is only a question of how much importance we give sanitation."
Technology options for providing the sanitation facility are plenty. There are organisations willing to help. The best practices and successful models are available. The enormous gains of sanitation coverage are also well demonstrated. What is needed is official will.
(Letters to the Editor should carry the full postal address)
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