Better toilets may not mean better health

timesofindia.indiatimes.com October 10th, 2014

LONDON: The world's biggest sanitation programme, being run in India, will reduce the shameful practise of open defecation in the country but may not improve the country's abysmal health indicators, according to a study by an international group of scientists.

The study comes at a time when Prime Minister Narendra Modi has launched the Swachh Bharat Abhiyan with great fanfare.

Once covered toilets were made for families, the researchers looked at whether practising hygienic sanitation improved their health.

To everyone's surprise, the researchers found no evidence that the intervention protected against diarrhoea in children younger than 5 years: 7-day prevalence of reported diarrhoea was 8.8% in the intervention group (data from 1,919 children) and 9.1% in the control group (1,916 children).
Defecating in a toilet with water did not reduce the prevalence of parasitic worms that are transmitted via soil and can cause reduced physical growth and impaired cognitive function in children.

There was also no impact on child weight or height — measures of nutritional status.
Lead author of the study professor Thomas Clasen from Emory University, Atlanta and the London School of Hygiene and Tropical Medicine in the UK said, "Many householders do not always use the latrines. This, combined with continued exposure from poor hygiene, contaminated water, and unsafe disposal of child faeces, may explain the lack of a health impact".

More Indians have a cell phone than a covered toilet.

Around 626 million people in the country don't have access to a close toilet and consequently practice open defecation. The sanitation intervention delivered under the terms of the Government of India's Total Sanitation Campaign — the world's largest sanitation initiative — provided almost 25,000 individuals in rural India with access to a latrine.  (NDMC staff cleaning eco-friendly toilet near Valmiki colony.)

However, a study to be published in the British Medical Journal Lancet on Friday, involving 100 rural villages, shows that it did not reduce exposure to faecal pathogens or decrease the occurrence of diarrhoea, parasitic worm infections or child malnutrition.

This cluster randomised trial involved 9,480 households in 100 rural villages in Odisha with a child younger than four years or a pregnant woman.

Households in 50 villages were randomly assigned to receive the sanitation intervention in early 2011; control villages received the intervention after a 14-month surveillance period.
The intervention increased the average proportion of households in a village with a latrine from 9% to 63%, compared to an increase of 8% to 12% in control villages.

Worldwide, around 2.5 million people lack access to basic sanitation facilities such as a latrine, a third of who live in India. Two-thirds of the 1.1 billion people who practise open defecation and a quarter of the 1.5 million who die every year from diarrhoeal diseases caused by poor hygiene and sanitation also live in India.

Trying to explain why the intervention did not help bring down India's abysmally high diorrhea rates, the researchers suggest a number of possible explanations including insufficient coverage and inconsistent use of latrines, or that a lack of handwashing with soap or animal faeces could also be contributing to the disease burden.

Dr Stephen Luby, research deputy director at the Centre for Innovation in Global Health, Stanford University, said, "This rigorous assessment is important, because it provides the best evidence so far for the uncomfortable conclusion that well -funded, professionally delivered sanitation programmes, even when they reach coverage levels that are quite commendable for large scale interventions, do not necessarily improve health".

In 1990, households without any sanitation facility in India stood at 76%. To meet its Millenium Development Goals, India was required to reduce the proportion of households having no access to improved sanitation to 38% by 2015. The government had earlier estimated that India may reduce the proportion of households without any sanitation to about 43% by 2015 missing the target by about 5 percentage points. By 2015, India is likely to reduce the rural proportion of no sanitation to 58.8% (against target of 46.6%) and urban proportion of no sanitation to 11.6% (against target of 12.1%).

The UN had recently said that the number of people forced to resort to open defecation remains a widespread health hazard and a global scandal. "In 11 countries, a majority of the population still practices open defecation. Even in countries with rapidly growing economies, large numbers of people still must resort to this practice — 626 million in India, 14 million in China and 7 million in Brazil," a UN MDG report said recently.