Health challenges of basic sanitation and hygiene

By Shanika SRIYANANDA

This story is not a rosy one. It's about the one billion South Asians clamouring for toilets. Though sanitation is not an attractive topic, it means a lot to these people as it has a bearing on their 'dignity' and 'cleanliness'.Out of this number, about 700 million men, women and children do not have toilets and have to adopt a undignified modes to relieve themselves in remote rural villages and the poor in informal urban localities in metropolitan cities.

They are exposed to severe health risks, violence and add to environmental pollution.

A majority of schools do not have decent toilets and hand washing facilities for children hence, a chance to change their hygiene in the next generation is missed out.Economically better performing regions during the global economic slowdown is facing health challenges of basic sanitation and hygiene.

This is a problem which the developed world faced and resolved in the early 18th century as a fundamental human development. This neglect in the way of human development may be consequential for future economic development potential.

The economic, social and environmental consequences of this situation are globally known. The World Bank estimates that the consequences of inadequate sanitation cost India approximately USD 53.8 billion - 6.4 percent of GDP - every year and Bangladesh BDT 295.5 billion (US$4.2 billion)-6.3 percent of GDP.In India alone every day, more than 1,000 children under the age of five die from diarrhoea caused by dirty water, lack of toilets and poor hygiene, placing India in the top spot in world diarrhoea rankings.

Pakistan and Bangladesh, two other South Asian nations, follow close behind.They aspire for dignity, privacy and freedom from a life of shame and embarrassment.

They want functional toilets, waste water disposal systems, and adequate and regular arrangements for disposal of solid waste.All countries in South Asia are signatories to the right to water and sanitation; however, almost half the region's population is without improved sanitation andmore than seven hundred million people defecate in the open every day.

The report - South Asian people's perspective on sanitation - released ahead of the SAARC Summit held in The Maldives have highlighted people's view through interviews conducted in South Asian countries, focus group discussions held with underprivileged communities and social groups across Bangladesh, India, Nepal, Pakistan and Sri Lanka.All countries in South Asia are signatories to the right to water and sanitation; however, almost half the region's population is without improved sanitation andmore than seven hundred million people defecate in the open every day.

The report, which prepared together with the Freshwater Action Network South Asia (FANSA) and the Water Supply and Sanitation Collaborative Council (WSSCC) quoted people who believe that sanitation programs and projects have failed because of a lack of involvement and commitment from both communities and external agencies and the consequent lapses in technology, planning, implementation, supervision, support and, above all, accountability.

For making services sustainable and programmes successful, the quality of construction work should be improved, minimising vested interest group to benefit, controlling corruption and establishing an effective operation and maintenance system."Why is this pathetic condition socially and politically accepted in the region, which otherwise inspires the world in many areas? Put another way, how this very basic developmental challenge has been addressed by developed countries? The factors we found are public sector investment and greater political commitment at higher level which transformed the societies.

There is political commitment to change but not at the required levels, with new policies and investment for public services but these are not adequate. The region also faces the inherent problem of exclusion.

The biggest, and often overlooked, problems of exclusion and inequality deny millions of poor and marginalised people of their basic rights", Mustafa Talpur, Regional Advocacy Manager-WaterAid South Asia said at a function held in Colombo to release the report in Colombo.

He said sanitation had never been on the agenda of SAARC in 16 summits over the span of 25 years and the Millennium Development Goal target for sanitation to be achieved by 2015 rests with countries in South Asia and it had demonstrated that it can make things happen with political will."If South Asia makes progress on sanitation, then the world will make progress.

The overarching message emerged from peoples' voices across the region is that their political leadership must take a collective resolve in the region to promote right to sanitation and dignified lives, work to provide them and their children a disease-free and healthy environment.

How this aspiration could be translated into a reality when this region faces political hostilities, struggling to share a common regional development vision. Can the issue of sanitation be a common factor in this unfriendly political environment?", he said.Mustafa said it was high time for SAARC political leadership to come up with clear and ambitious targets, timeline and cash for sanitation and the SAARC leadership needs to recognise that sanitation is the building block of a dignified society in South Asia.

" They must recognize sanitation crisis in the region as diarrhoea is the biggest child killer in the region.

There is a greater challenge of inequity in resource distribution and service provision. SAARC can encourage such moves by national governments.

They need to work out a regional mechanism for implementation, coordination, research and knowledge sharing and steering the plan through the existing SAARC secretariat and strengthening South Asian Conference on Sanitation process", he pointed out.FANSA's Ramisetty Muraili said the report clearly indicates that people want to live a life of dignity and health, but are frustrated by lack of effective support and failure of poorly planned and implemented projects, whereas some communities are reluctant to adopt safe hygiene practices because of sociological and cultural barriers and extreme poverty."Moreover, the collective voice of the people also associates sanitation with notions of happiness, pride, safety, health and education.

The study appeals to policy-makers to revamp institutional mechanisms that invite community participation in sanitation projects.Above all, the study calls for greater accountability and transparency measures and a focus on human-centred development, targeting the below-poverty communities in India and the hardcore-poor of Bangladesh and Nepal.

WSSCC's Archana Patkar said, "SAARC needs to recognise the sanitation crisis in the region and challenge the inequity in the provision and distribution of resources. Governments need to engage pro-actively in matters related to water, sanitation and hygiene." She added, "The regional mechanisms for implementation, coordination, research and knowledge-sharing through the existing SAARC Secretariat is needed to strengthen the process of the South Asian Conference on Sanitation", she said.

The report states that the level of understanding of sanitation and hygiene, and its articulation, was influenced to an extent by both the educational attainment of respondents and interventions in the area. Interventions made communities more educated and aware, and in turn people in these communities described sanitation as 'hygienic toilets', 'closed drainage' and 'rubbish-free settlements'. For such communities, it also meant regular maintenance of the facilities and sustained availability of services. Similarly, it was observed, especially in India and Sri Lanka, that the higher the educational status of community leaders and respondents, the better knowledge they possessed and the better they could articulate their understanding of sanitation.

However, at the same time even the illiterate respondents had a basic understanding of sanitation and hygiene. Mina Begum of Aadibasi Sundarpara of Shyamnagar, Satkhira, Bangladesh, is illiterate and belongs to a minority group.

To her, sanitation means a hygienic latrine, safe drinking water, washing hands with soap, and disposing of children's faeces in the latrine. "Sanitation is essential for life. It is an important part of our religion too. Cleanliness helps a person get a better education and higher position in society. Hand-washing with soap after defecation is very important for maintaining hygiene. Food hygiene prevents disease and keeps children healthy." she said.There was also a difference between women's perspective of sanitation and men's. For women it especially meant keeping themselves, their houses and their childrenclean.

Women from some rural communities in states like Tamil Nadu said that a clean house gave them immense 'happiness' and 'pride'."Sanitation is the basis for happiness and satisfaction. It urges me to get up early and remains as the first thought for the day to keep my home and surrounding clean. As the day starts with cleaning,the whole day then becomes very active and happy" Punitha, Chinnaviai, urban panchayat in the district of Kanyakumari in Tamil Nadu, India said.It is a matter of dignity despite the gender.

Understanding of sanitation was closely related to open defecation and the need for toilets, especially in crowded urban settlements. Whether recalling exposure to a sanitation intervention or not, almost all women and most male respondents reported feeling acutely embarrassed in front of neighbours as well as outsiders in the absence of a private toilet.

Privacy and dignity are especially important to women.

"There is a need for separate toilets for each house because people without toilets are cornered by others and face difficulties entertaining guests", that was the view of Gayani Mendis, from Galle, Sri Lanka.The safety of men, women and children was often found to be compromised by poor sanitation.

Open fields - especially in the night or during the rainy season -or railway tracks were described as unsafe and instances of people losing their limbs, or even their lives, and of women being molested were frequently reported,"Everyone in the village goes to the nearby fields for defecation.

According to 50-year-old Veerkala, 50, Kota Dewara, Uttar Pradesh, India it was 'dirty, troublesome, time consuming and dangerous as well, especially for women and physically challenged people. It is very common for pigs to attack us from behind when we are squatting in the field.

We are forced to take someone along when going out to the fields".Goma Chaudhari, community leader in Bhiratnagar Municipality, Nepal said some people, especially children, still defecate in the open, and while almost all households have toilets, the drainage is open and sewage poorly managed. "People know about health and hygiene in general, but they lack the attitude.

For example, they know the importance of hand-washing but do not act upon it. I guess only 40 percent of people in the village are active regarding their cleanliness."Many people across all the countries believed that keeping one's body and environment clean, leading a healthy life and protecting oneself from diseaseconstitute sanitation and hygiene.

Those who had a clear understanding of hygiene perceived that living in an unhygienic environment led to all kinds of diseases.

They said that following simple hygiene practices, like washing hands before meals or cooking food, keeping the drinking water covered and so on, would eliminate many of the diseases. They were clear that it would therefore also contribute towards reducing poverty,H. A Chandana, from the Uva province, Sri Lanka, who was quoted in the report, said: "It is government responsibility that it should expand people's right to them. I do not know much about non government organisations; if they help people we deserve that.

I believe if people collectively struggle for the solution of problems, they can achieve any goal. Considering the United Nations' standards, it is the duty of the Sri Lankan Government to ensure access to water and sanitation.""For Sughran Bibi, a housewife of Jungle Barali, district Vehari, Punjab, Pakistan it her and her family dignity to have a toilet. "In the absence of sanitation facilities, people feel degraded,especially when guests arrive.

Many people have migrated from this place just because of poor sanitation."Is sanitation is a 'right'? Although notions of sanitation as a 'right' were not always clear in many countries, most people, whom were interviewed, thought that it was important and it meant that the government was responsible to provide adequate facilities and services to the people.The disposal of used cloths and sanitary napkins is a huge issue across South Asia.

In most countries they are thrown into nearby ditches or places where other waste is thrown.

In Sri Lanka schools reported that as toilets lacked proper bins or disposal systems, soiled napkins were strewn around toilets, dissuading other children from using them.According to the report, projects have been successful where there has been a high level of community involvement from the planning to the implementation stage. Community leaders in Nepal for instance suggested that projects need to first sensitise communities to construct public and private toilets, and engage local people to monitor and maintain the initiatives.

They believe that unless people take ownership of what they receive, success is not possible. Most community leaders believe that support for infrastructure alone is not sufficient to make sanitation initiatives successful.