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Sanitation and Sewage Disposal in India

By : Prof. M. S. Khuroo         Dated : 12/31/2015

Sanitation and Sewage Disposal In India
The ultimate among so many practices which shall impact economy; stabilize healthcare; give dignity, respect and safety to women and improve children health statistics.
During my MBBS course, we mocked at our proactive Professor of Community Medicine who often uttered “Shauchalaya banoay; Desh ko pau” (make latrines; Discover India). On Oct 2, 2013 Indian public was confronted by a controversial statement which read as: “I am known to be a Hindutva leader. My image does not permit to say so, but I dare to say. My real thought is- Pehle Shauchalaya, phir devalaya (toilets first, temple later) - Narendra Modi”. The then Gujrat Chief Minister said so even after BJP and the sister organizations were keen to rake up the “temple issue” during and after the general elections. Around the same time the then Congress Union Rural Development Minister Jairam Ramesh, a staunch ideological and political opponent, dared to utter that India needed more toilets than temples, in spite of the wrath he faced from women organizations and NGOs. Concern over poor sanitation and sewage disposal in India is nothing new. Mahatma Gandhi once said sanitation is more important than Independence! Of late on October 2, 2014, “Clean India Campaign” was launched to fulfil Mahatma Gandhi’s vision of clean India and many public figures were invited to join this national mission. An estimated US$ 10 billion will be spent on the Mission over the next five years. Targets identified include cleaning the environment, construction of pubic and school latrines and implementing hygienic practices like hand hygiene to name a few. By 2019, around 1.2 billion residents shall have access to toilets. You may wonder why there is so much rhetoric about sanitation and sewage disposal. This article shall critically analyze this ultimate practice in relation to national economy, healthcare, women dignity and safety and children health statistics. Sanitation means safe collection, storage, treatment and disposal/re-use/recycling of human excreta (feces and urine), solid wastes (trash or rubbish), household wastewater (sullage), storm water, sewage effluents, industrial waste products and hazardous wastes (hospital waste, chemical or radioactive and other dangerous substances). The term “improved sanitation”   means to hygienically separate human excreta and other wastes from human contact and hence reduces health risks to humans.  Inadequate sanitation is thus the lack of improved facilities (toilets, conveyance, and treatment systems), and hygienic practices (for example, hand washing, proper water handling, personal hygiene, and so on) that exposes people to human excreta and thus to disease-causing fecal-oral pathogens through different transmission pathways. Fundamental in sanitation is the safe way of treating and disposal of the infected and toxic effluent, which can be done in many ways (outside the scope of this article).   In this regard it is hearting to know that Bill & Melinda Gates Foundation has been working in China and India  to enable universal access to sustainable sanitation services by supporting the development of radically new sanitation technologies as well as markets for new sanitation products and services. It must be stressed here that building a facility (latrine) and letting untreated effluent flow through open drains in to waterways or environment is dangerous. One gram of feces can contain: 10,000,000 viruses, 1,000,000 bacteria, 1,000 parasite cysts and 100 parasite eggs. The untreated infected effluent pollutes water sources/supplies and lead to water borne diseases. Also untreated sewage in environment and soil can lead to spread of infectious diseases through food, person-to-person contact and vectors. Thus crucial in implementing improved sanitation is building and availability of clean latrines as well as safe disposal of sewage.
The current sanitary situation remains grim in developing countries. WHO-UNICEF recently released the report, titled Progress on sanitation and drinking-water 2013 update  and warned that at the current rate of progress, the 2015 Millennium Development Goal (MDG) target of halving the proportion of people without sanitation compared to 1990 will be missed by 8 per cent or half a billion people. Around 2.4 billion people, one third of the World population, will remain without access to improved sanitation by 2015.  That is at a time when more people have mobile phones on Earth than a toilet. Globally, an estimated 1.8 billion drink fouled water that’s fecally contaminated. The situation in India shall continue to remain a matter of great concern. Over 300 million Indians still defecate in the open. India accounts for about 60 percent of Earth’s residents without toilets, highest in the world, with human excrement that goes into a field polluting groundwater, crops and waterways, causing illnesses such as diarrhea and cholera. An estimated 1.1 million liters (290,000 gallons) of human excrement enters the Ganges River every minute, the revered waterway that many Governments have promised to purify. In contrast, adjacent three countries namely Pakistan, Burma and Bangladesh have done better. Pakistan showed an annual decline rate of 3.9 percent, lowering its open defecation figures from 52 per cent in 1990 to 29 per cent in 2011. Nepal too has lowered its open defecation figures from 84 per cent of the population in 1990 to 43 per cent in 2011. This amounts to an annual decline rate of 3.2 per cent.   Bangladesh, with 32 per cent of total population practicing open defecation in 1990, has shown remarkable annual decline of 9.9 per cent to a figure of 4 per cent in 2011.  Great progress has been made in eastern Asia, where sanitation coverage has increased from 27 per cent in 1990 to 67 per cent in 2011. This amounts to more than 626 million people gaining access to improved sanitation facilities over a 21-year period.
Economic impacts of inadequate sanitation in India are enormous.  The data have been worked out by Water and Sanitation Program’s (WSP’s) Global Economics of Sanitation Initiative (ESI). The findings are based on 2006 figures but a similar magnitude of losses is likely in later years. The methodology adopted by the study included disaggregating the economic impacts of inadequate sanitation into health-related impacts (premature deaths, costs of treating diseases; productive time lost due to people falling ill, and time lost by caregivers who look after them), domestic water-related impacts, access time impacts, and tourism impacts. The study estimates that the total economic impacts of inadequate sanitation in India amounts to a whooping Rs. 2.44 trillion (US$53.8 billion) a year which is equivalent of 6.4 percent of India’s GDP in 2006. This means a per person annual impact of Rs. 2,180 (US$48). More than Rs. 1.3 trillion (US$29 billion) was lost due to premature mortality, the single-largest sub-category.   
Heath related impact of inadequate sanitation are no less than a tsunami.  An estimated 801,000 children younger than 5 years of age perish from diarrhea each year, mostly in developing countries. This amounts to 11% of the 7.6 million deaths of children under the age of five and means that about 2,200 children are dying every day as a result of diarrheal diseases. Unsafe drinking water, inadequate availability of water for hygiene, and lack of access to sanitation together contribute to about 88% of deaths from diarrheal diseases. Worldwide, millions of people are infected with cholera, typhoid, dysentery and hepatitis.  These diseases are most often found in places with unsafe drinking water, poor sanitation, and insufficient hygiene practices.  Worldwide, soil-transmitted helminths (ascariasis, Guinea Worm Disease, and Schistosomiasis) infect more than one billion people due to a lack of adequate sanitation. Trachoma is the world’s leading cause of preventable blindness and results from poor hygiene and sanitation. Approximately 41 million people suffer from active trachoma and nearly 10 million people are visually impaired or irreversibly blind as a result of trachoma. Trachoma infection can be prevented through increased facial cleanliness with soap and clean water, and improved sanitation. Apart from infections, inadequate sanitation can lead to exposure to heavy metals, toxic organic and inorganic substances, causes hematological diseases (blue baby syndrome), liver disorders (hepatitis, cirrhosis and liver cancer) and skin diseases to name a few. 
Water, sanitation and hygiene has the potential to prevent at least 9.1% of the global disease burden and 6.3% of all deaths. Improved water sources reduce diarrhea morbidity by 21%; improved sanitation reduces diarrhea morbidity by 37.5%; and the simple act of washing hands at critical times can reduce the number of diarrhea cases by as much as 35%. Improvement of drinking-water quality, such as point-of-use disinfection, would lead to a 45% reduction of diarrhea episodes. Achieving the MDG for sanitation would result in US$66 billion gained through time, productivity, averted illness and death. It is estimated that a 10 year increase in average life expectancy at birth translates in to a rise of 0.3-0.4% in economic growth per year. The impact of clean water technologies on public health in the U.S. is estimated to have had a rate of return of 23 to 1 for investments in water filtration and chlorination during the first half of the 20th century. Water and sanitation interventions are cost effective across all world regions. These interventions were demonstrated to produce economic benefits ranging from US$ 5 to US$ 46 per US$ 1 invested. 
Sanitation in schools in India is a matter of concern. Poor sanitation, water scarcity, inferior water quality and inappropriate hygiene behaviour are detrimental to the health of school-aged children, who spend long hours in schools.   Disease spreads quickly in cramped spaces with limited ventilation, where hand-washing facilities or soap are not available, and where toilets are in disrepair. Too often, schools are places where children become ill. An estimated 1.9 billion school days could be gained if the MDG Goals related to safe water supply and sanitation are achieved and the incidence of diarrheal illness is reduced. One way of achieving this is by providing schools with safe drinking water, improved sanitation facilities and hygiene education that encourages the development of healthy behaviour for life. This strategic approach is known as Water, Sanitation and Hygiene Education (WASH) in Schools. The strategy helps fulfil children’s rights to health, education and participation, and has been widely recognized for its significant contributions to achieving the MDGs, particularly those related to providing access to primary education, reducing child mortality, improving water and sanitation, and promoting gender equality. WASH in Schools not only promotes hygiene and increases access to quality education but also supports national and local interventions to establish equitable, sustainable access to safe water and basic sanitation services in schools.
Hospitals and health units have special requirements for sanitation as they deal with patients who are infected with diseases like cholera, typhoid, hepatitis etc. This can cause nosocomial infections as well as expose other inpatients to risk of infections. Toilets for such patients need to be separated from staff and other patient’s toilets. Additional efforts to sanitize such toilets are needed. Excreta and sullage should be treated in hospital owned plants and there needs to be special arrangements for disposal of radioactive hospital waste. Hospital must own incinerators to process infected materials like syringes, needles, drips, or infected bedding and other infected wastes.  
Health is not the only reason why people want improved sanitation and access to latrines. Privacy, dignity, respect, cleanliness and safety may be additional reasons.  First latrines allow privacy to every person men and women as the act has to be completed with significant exposure to body parts. It adds dignity and respect to women. Comfort is another reason and for this reason latrines need to be close to house to avoid seasonal adversities. Cleanliness is another factor as defecation in open can be an exercise which can soil clothing and make the area of use dirty. However in India safety to young girls and women is by far the most important reason. Open defecation especially late in the night can expose women to sexual assaults. Of late India has seen rapes in women by unscrupulous elements especially when they use open fields and secluded areas late at night for defecation. This has become the most impending reason to have latrines within the residential areas. Around a third of Indian women are at a risk to rape or sexual assault, a danger that gained worldwide attention in May 2014 when two girls from a village in Uttar Pradesh were raped and hanged from a mango tree after they went outdoors to defecate.  
There is an urgent need to ensure all the necessary pieces are in place – political commitment, funding, and leadership – so the world can accelerate progress and reach MDG 2015 sanitation target. The world can turn around and transform the lives of millions who still do not have access to basic sanitation. The rewards would be immense for health, ending poverty at its source, and well-being. There is urgent call to action by United Nations for the world community to combine efforts and end open defecation by 2025. This is an emergency no less horrifying than a massive earthquake or tsunami. Every day hundreds of children are dying; every day thousands of parents mourn their sons and daughters. We can and must act in the face of this colossal daily human tragedy.  
Prof. Mohammad Sultan Khuroo is former Director, Professor and Head Gastroenterology and Chairman Medicine Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, J&K India; Former Consultant and Head Gastroenterology & Hepatology and Liver Transplantation, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia 
SANITATION HIGHLIGHTS
Sanitation means building and availability of clean latrines as well as safe disposal of sewage. Letting untreated effluent flow through open drains in to waterways or environment is dangerous.
2015 Millennium Development Goal (MDG) target of halving the proportion of people without sanitation compared to 1990 will be missed by 8 per cent or half a billion people. Around 2.4 billion people, one third of the World population, will remain without access to improved sanitation by 2015.  
Over 300 million Indians still defecate in the open. India accounts for about 60 percent of Earth’s residents without toilets, highest in the world. That is at a time when more people have mobile phones on Earth than a toilet.
Economic impacts of inadequate sanitation in India amounts to whooping Rs. 2.44 trillion (US$53.8 billion) a year which is equivalent of 6.4 percent of India’s GDP.
An estimated 801,000 children less than 5 years die from diarrhea each year in developing countries. 2,200 children are dying every day as a result of diarrheal diseases.
Water, sanitation and hygiene has the potential to prevent at least 9.1% of the global disease burden and 6.3% of all deaths.
Around a third of Indian women are at a risk to rape or sexual assault, as a result of open defecation especially during late hours. 
An estimated 1.9 billion school days could be gained if the MDG Goals related to safe water supply and sanitation are achieved and the incidence of diarrheal illness is reduced.