India’s Deadly Diarrhea Problem

Noah Seelam/Agence France-Presse/Getty Images

A woman held her daughter who is undergoing treatment for diarrhea in Hyderabad, May 10, 2009.  

For many people, a case of diarrhea means a visit to the doctor, a course of medication or eating bland food for a few days. Yet diarrhea is still the second biggest killer of children globally, with more than 800,000 under-fives dying every year according to Unicef. A quarter of these deaths occur in India. Hundreds of thousands more children in the country are hospitalized and permanently stunted from the disease.

Two new studies were published Tuesday: one highlights the major viruses, parasites and bacteria that lead to the most severe types of diarrhea, while the other details promising results of an affordable Indian vaccine trial for the most important cause of childhood diarrhea.

In the largest international study ever conducted on diarrhea death, published in the Lancet today, the Global Enterics Multi-Center Study found that the top cause of moderate to severe diarrhea in India is rotavirus. In a world where cholera, typhoid and dysentery are well known as common diseases acquired through the gut, the greatest killer of them all doesn’t have name recognition amongst parents or policymakers.

The World Health Organization estimates that rotavirus leads to the death of 450,000 children worldwide every year. India is the worst affected, with an estimated 98,000 deaths a year. Even if children don’t die, the diarrheal illness due to rotavirus can be severe, resulting in rapid dehydration, metabolic disturbances and possible long-term consequences of malnutrition and a damaged gut.

Although most diarrheal diseases can be managed without a specific drug by making sure that hydration is maintained, rotavirus also causes vomiting, which results in additional fluid loss and makes it difficult to treat a child except by giving intravenous fluids.

The GEMS study looked at seven countries in Africa and Asia. Many children with the most severe diarrhea had a rotavirus infection. Facilities where very young children can be safely and effectively treated are severely limited and if parents cannot reach them in time, their children die. Even if they can get to the right place, managing illness in young children is not easy or cheap. And this is without counting the costs to parents having to travel to reach health care, pay for medicines and lose time at work, which cumulatively can push families into poverty.

So what can be done?

The results of the final part of a 25-year effort project to develop an indigenous vaccine against rotavirus were presented in New Delhi Tuesday. The vaccine, based on an Indian strain and developed and tested here, was found to be safe and effective in preventing rotavirus disease, according to the study supported by the Department of Biotechnology and Bharat Biotech.

At the projected price of $1 per dose, this vaccine is at least 60% cheaper per dose than other available rotavirus vaccines procured by Unicef for GAVI supported countries.

Critics might ask why there is a focus on a vaccine when we know that safer water and food prevents disease. Unfortunately, although a cleaner environment delays rotavirus infection, it doesn’t prevent it. Many children even in the most high-income countries get infected and sick with rotavirus; it just happens at a later age and children do not die, because they are older. They also have fewer underlying problems such as malnutrition and they can access healthcare more easily.

In the U.S., for example, all children are recommended rotavirus vaccines, even though none die of rotavirus disease and immunization costs $200 a child. Still, according to the New England Journal of Medicine, the U.S. healthcare system is estimated to have saved $270 million because of the number of hospital admissions the vaccines have prevented.

Preventing and treating diarrhea cannot be done through one vaccine alone. Available vaccines aren’t perfect and public health systems don’t reach every child. Water and sanitation must be improved, oral rehydration solutions need to be made more widely available, and zinc should be distributed to children with acute diarrhea. 

There is much to do, but that includes giving serious and urgent consideration to addressing rotavirus. Every year, we count the number of children’s lives we lose to preventable disease in developing countries. It is not up to the children to protect themselves; it is up to us to stop neglecting them.

Dr. Gagandeep Kang is a professor in the Department of Gastrointestinal Sciences at Christian Medical College in Vellore

Bangalore's 'night soil' collectors

By Habib Beary, news.bbc.co.uk

Removing raw sewage by hand

It may be India's high-tech capital, but the practise of humans using their bare hands to clean toilet pits continues in Bangalore to this day. In the dead of the night, when the city of six million goes to sleep, groups of jobless low-caste Hindus, known as Dalits, eke out a living by removing human excrement from pits in the poorer neighbourhoods of the city.

The failure of the civic authorities to provide a proper sewage system has forced the residents in these localities to build these pits, a common feature particularly in rural India. But that such a system exists in Bangalore attracts sharp criticism from those who care for human values and dignity, as the city is often called the Silicon Valley of India due to the presence of global and Indian software companies.

Caste values

"There is a long tradition of misusing Dalits for this dirty work. It just shows there is no human value for Dalits" says Babu Mathew, a human rights activist and professor at India's premier National Law School based in Bangalore. "By law it is abolished but in reality night soil allied activity is practised even today" said Mathew, blaming it on the insensitivity of politicians and bureaucracy.

Worker clears sewage at night

Ashok Salappa, a member of the government-run Safai Karmachari (sweepers) Monitoring Committee, estimates the number of Dalits employed in cleaning toilet pits in Bangalore to be between 10,000 to 15,000. "I feel ashamed that it is still happening even after 53 years of Independence" said Salappa, who calls those who undertake such a job as "dalits among dalits". "They are treated the worst in society," said Salappa.

K Ravi, a member of the local welfare association at Venkateshapura, one of the localities where manual excrement removing exists, described the situation as "pathetic." "The government is doing nothing here. It is barely six kilometres from the state secreteriat - but look at the mess here."

Modus operandi

As and when the pits get clogged, the call goes out for these wretched workers, who are desperate for even the dirtiest of jobs. "We normally do this work in a group of five. The wages are shared" said 25-year-old Mariappa, explaining the modus operandi. After swigs of strong alcohol to ward off the stench, one member of the group gets into the pit and empties it with buckets or cans and the refuse is taken away by others away from the vicinity. "We have to get drunk to do this job. Nobody likes it but we do it for a livelihood."

At the end of the night, they stagger back home with earnings of between 300 and 500 Rupees (about $6 to $10). "It is not enough. We barely manage to make a living" says Mariappa. "But for the liquor and its intoxicating effect, it is impossible to get anywhere close to the pit," said Ashok Salappa, who has been campaigning for replacing manual clearance with suction machines. Civic authorities have finally taken note and plan to buy two machines. The work is seen as an extension of the night soil system, banned by the state government in 1973.

Low-caste Hindus were forced to carry human excreta on their head, a practise that was opposed by Mahatama Gandhi, championing the cause of the underprivileged in the country during the freedom struggle. The National Human Rights Commission in Delhi has written to the then Prime Minister A B Vajpayee to end what it called the degrading practice across the country. "It is a matter of national shame that despite over half a century of our independence, the inhuman practice of manual scavenging continues," said Commission Chairman J S Verma. It is a problem India should get on and flush out much faster.  (Adam Roberts : Delhi bureau chief, The Economist)

Waste Management: Meet a few families that have made this their catch phrase.

Did you know that in Chennai, 68 per cent of the city’s total solid waste is generated by households? Did you know that one person produces 200 kg of solid waste per year? *

There is little point in keeping our homes sparkling clean when most of us step out into streets piled high with garbage. What can we do to reduce the amount of bio-degradable waste that leaves our home and goes into streets and landfills? Zero waste homes are fast becoming the norm. They not only make your home clean and eco-friendly, they also keep your streets and city clean. And you can get there simply by composting waste.

Composting sounds messy but it’s just the practice of converting organic waste into manure. If you can do it easily and simply at home or in your workspace, why not? You don’t need lots of space or a dedicated compost yard. A small green patch, a balcony or just about any unused space in an office or apartment block can do the trick.

The Bangalore-based Daily Dump has been offering a range of home composting products since 2006. Poonam Bir Kasturi, the founder, explains why everyone must take it up at home, “It makes you proud to keep waste off the streets. It is sensitive to natural cycles and tolerant of different life forms. It builds a sense of joy that you can actually make a change to the mess around, and moves you from being a consumer to a change agent.”

Segregation is the first step in composting. Says Poonam, “Without segregation, composting cannot happen.” A family can start immediately but in an apartment block, it takes time to get a consensus. You need a group to follow it through and the space and budget to invest in bins. “The capital cost per family in both individual homes and apartment blocks is approximately the same. The recurring cost for individual homes is higher, whereas communities can achieve economies of scale,” explains Poonam.

Navneeth Raghavan, Chennai’s very own Daily Dump clone, began her compost journey after she met Poonam in Bangalore. “I was very impressed with what she did. I found a potter, made some pots, and trained myself to compost. Now, my entire family is involved in it and they see the benefits of composting.” Poonam and Navneeth use three-layered terracotta pots called khambas for composting.

What Navneeth started on a small scale in 2008 today benefits 3,500 families. “We make our pots locally. I live on the fourth floor of an apartment and leave my khamba on the balcony. There is no stink during decomposition and we have a solution to keep away flies.” Navneeth gives away plastics and tins to the recyclers and the rest goes into the khamba.

Preethi Sukumaran and Sruti Harihara Subramanian are just two of the many who have followed the Daily Dump example. “After we began composting, I saw a remarkable reduction in the amount of garbage going out of home. We have started to critically examine everything that comes into the house to see if it can be recycled or composted.” Preethi even carries her own containers and oil cans to grocery stores. “If we can’t avoid packaged groceries, the covers are washed, dried and put into the recycling bin.”

Preethi has a separate bin in the kitchen for plastic and paper to be given away to the recycler. Her family has replaced plastic water bottles with stainless steel ones and the plastic water storage can with a copper pot. They save the rinse water from hand-washed clothes to mop floors and clean toilets. Water used to wash vegetables or rice is recycled for plants. In fact, Preethi and her husband make sustainable alternatives like organic and eco-friendly detergents.

Sruti began composting to sustain her terrace garden and she too uses the khamba. “It’s easy,” she says, “Throw all your organic waste into it. You get microbes and additives to mix in. Just follow the instructions.” Sruti, who runs Ashvita Bistro in Alwarpet, uses a khamba there as well, apart from retailing the compost sets. “Do you know about 60 per cent of waste from any home is organic waste,” she asks.

Singapore-based blogger Bhavani Prakash has written an e-book called 50 Ways to Make Your Home Eco-Friendly. “I compost vegetable and fruit peels in my apartment. I started by using empty flower pots and soil for my method. Start with a thin layer of soil, then peels, then a layer of browns (cardboard, dry leaves, paper) and another layer of soil. This prevents flies and smells. There has to be a judicious mix of wet and dry waste. Once that’s done, moisture, heat and air will do the trick. Stir, if it starts to smell and in a few days it will be alright.” It’s better to start with a flower pot, she says, since you use things you already have at home; old pots, unused soil, paper. Clearly, cleanliness too begins right at home.