India’s diarrhoea problem that no one wants you to know about

Diarrhoea, that slightly embarrassing infection we avoid talking about when we suffer from it! We often consider diarrhoea as something not very serious, yet in India, it has become the second biggest killer of children under the age of five. Around the world, more than 500,000 children under five lose their lives annually due to severe dehydration caused by diarrhoea. And even though statistics report a downward trend in deaths due to diarrhoea in India, India still accounts for 20% of this global number.

Historically it has been open defecation that has been the primary vector in the spread of diarrhoea. Ironically, however, in areas where public toilets have been constructed, it is the toilets themselves that are making the situation worse, especially in urban slum areas. Effluent pipes are often clogged due to heavy usage of the toilets. Raw, untreated sewage often oozes into the ground – and stays there. In cities like Mumbai, the situation grows worse as monsoon approaches with heavy rains flooding slum-dwellers’ homes with sewage. In many places, the toilets are not free to use, so children continue to relieve themselves openly in the drains that run along the central path.

Despite being the seventh largest country in the world, India does not have a comprehensive waste treatment system. Most Indian rivers, lakes and large water bodies are therefore open sewers. On the one hand, our country is singing songs about the success of Swachh Bharat Abhiyan, while on the other, there is no significant reduction in child deaths at the hands of diarrhoea. The government is on a spree of building toilets around the country while continually ignoring their proper management. As a result, there are clogged toilets everywhere, oozing sewage out onto the roads and even near living areas. In my post, India’s Sanitation Bomb, I have described the decrepit conditions of most of the toilets built around our country and the reasons behind them. These are the same reasons why diarrhoea has become a monster in our country. Just building more toilets won’t be enough to save India’s children.

The primary reasons behind diarrhoea are poor access to clean water, sanitation and malnutrition. Slum areas in major cities of India are growing exponentially. These are localities which lack proper sanitary facilities. Clogged toilets and filthy water running openly into living areas are perceived as accessories of life by people living here because they have become used to it over generations. Considering the conditions of the toilets themselves, people prefer to defecate openly near railway tracks and streams. A lot of areas have community toilets which are closed at night, leaving residents no option but to defecate in the open. This results in the accumulation of a massive amount of human faecal matter in the surrounding areas. The human excreta lies on the roads, at the mercies of climate. As a result, people living in these neighbourhoods are directly exposed to germs, increasing the occurrence of diarrhoea. Equally importantly, excess human faecal matter in the septic tanks at community toilets has rendered numerous toilets useless and turned them into perfect breeding grounds for E. coli (responsible for diarrhoea) and maggots!

And children are the most vulnerable. The economic status of the poor in India does not afford them the luxury of well-balanced diets. As a result, most children are underdeveloped. In India, around 72 percent infants and 44 percent children below five are underweight. When these children are in proximity with open faecal matter, they get infected from germs breeding on them. Constantly occurring infections due to this exposure cause malnutrition-like situations, as their bodies take energy and nutrients away from growth and brain development to prioritise fighting the infections.

According to one international study, one in five children under age two suffer from severe diarrhoea every year that increases the risk to their lives 8.5 fold and results in stunted growth over a two-month follow-up period. Among all the different types of diarrhoeal infections, an infection caused by rotavirus is common in infants. Every year, 98,000 toddlers lose their lives due to rotavirus infection. The severity of rotavirus infection is so high that even if a child is somehow cured of the infection, rapid dehydration and metabolic disturbances leave the child malnourished because of a damaged gut.

Further damage is caused by drinking water. Improperly managed sewage often gets into the drinking water supply. Wastewater from filthy toilets seeps into the ground, carrying millions of deadly viruses and bacteria along with it. Together, they contaminate the groundwater. A large chunk of Indian population still uses groundwater for drinking and cooking. Their fate is sealed when they take even a sip of the water with pathogens swimming in it. According to World Bank estimates, 21 percent of communicable diseases in India are water related. For most Indian children, malnutrition and septic bacterial infection are the results of drinking water contaminated by human or animal excreta.

Hundreds of toilets are being built every minute in India. We have modern immunisation programmes to prevent infection and thousands of people working to improve sanitary status in India. However, India is still finding it hard to control the child mortality rate due to diarrhoea. Meanwhile, our neighbouring country, Bangladesh, despite having half our GDP, has managed to lower child-mortality levels to negligible rates.

In Matlab region of Bangladesh, for example, the mortality rate due to diarrhoea has dropped by 90 percent since the 1990s. This remarkable decline is proof of how Bangladesh has successfully managed the war against diarrhoea. While we are still building toilets all over the country, Bangladesh managed to eliminate the open defecation practice from most of the country. It started in 2006 when a sanitation programme run by BRAC, a ubiquitous charity in Bangladesh, helped more than five million households in building outhouse toilets, made of affordable material like tin or palm fronds which conceal simple pit latrines with toilets on the top. Soon after, Bangladeshis realised the importance of having toilets in their homes to prevent many diseases and started aggressively taking part in building toilets in their homes. In many villages where BRAC was operating, two-thirds of latrines were built not by the government or NGOs but by ordinary people. The WHO has reported that zero percent Bangladeshi households defecate openly these days. India needs a revolution like this.

The Indian government is investing a tremendous amount of money to improve the sanitary situation of the country. They are building personal and public toilets in urban as well as rural areas. Yet, most of the country continues to lack access to clean, hygienic toilets. Improved sanitation does not mean abundance of tumbledown, badly maintained toilets; it refers to every household having their toilet, connected to a sewer system or septic tank.

In 2015, the Indian government adopted an Integrated Action Plan for Prevention and Control of Pneumonia and Diarrhoea (IAPPD) to beat the child-eating monster of diarrhoea. IAPPD aims not just to reduce the mortality rate from various water-borne infections but also to educate people about the importance of personal hygiene. The primary goal of IAPPD is to provide safe drinking water and improved sanitary conditions to people living in high-risk areas like slums. Under IAPPD, the government runs various vaccination programmes, where vaccination of rotavirus and pneumococcal infection are made available at affordable rates.

IAPPD also aims to educate people about the importance of personal hygiene. Government bodies and NGOs educate people on hygiene, including creating awareness about simple habits like washing hands. Multiple studies around the world have proved the importance of washing hands in the prevention of many contagious diseases.

Another important factor of the IAPPD programme is the introduction of Oral Rehydration Solution (ORS), a mixture of clean drinking water with salt and sugar. When an infected baby is fed with ORS, the sugar and salt content fulfil water and electrolyte loss caused by diarrhoea. According to WHO, zinc supplements from ORS decrease the duration of diarrhoea by 25 percent and also reduce the stool volume by 30 percent.

The government propagated the use of ORS on various platforms, and as a result, the proportion of children infected with diarrhoea who received ORS packets has increased from 26 percent to 51 percent. With the efforts of government and many NGOs, India has successfully reduced child death rate by 52 percent. However, their efforts could not reduce the occurrence of diarrhoea, as it remains high at the rate of 9.2 percent. WHO reports that despite all the efforts being made to reduce mortality rate, diarrhoea is still among the leading causes of death in Indian children below age five, killing nearly 321 children every day in 2015.

India is one of the most aggressively developing countries in the world. Our government has realised the importance of sanitation in maintaining a healthy and disease-free environment and therefore, putting enormous efforts to achieve it. However, their efforts will always be incomplete without active participation from the public. In Bangladesh, people themselves acted to rid their country of the filthy practice of open defecation while in India, 40 percent of our people still choose to relieve themselves openly. The two main reasons behind this awful state are public mentality and poor maintenance of the public toilet systems.

Efforts are needed from all directions to improve the state of affairs. After building toilets, it is also the government’s responsibility to check and maintain them. Many toilets are closed due to unavailability of water and poor maintenance. A significant amount of investment must go to the maintenance of toilets rather than just building them. If the toilets are clean, more people will use them rather than defecating openly. Maintenance of toilets will also include building proper sewerage lines so that the untreated sewage will not go directly into water bodies. This will prevent water contamination and ultimately restrict water-borne diseases.

And while we’ve had campaigns on personal hygiene for ages, it has still not permeated through to people. We need to find a way to make people understand the importance of personal hygiene and also the severity of diarrhoeal infections. Many people still think diarrhoea is a common infection that can be cured with simple home remedies. And while that might be partly true, when it comes to young children, diarrhoeal infections require more drastic interventions. People also need to learn about the importance of a proper diet and its role in maintaining health throughout life.

Of late, our government has realised the importance of education in preventing diarrhoeal infections and is designing programs for immunisation and treatment and promoting them via different channels. Many NGOs are educating people about the importance of breastfeeding practices to strengthen the innate immunity of new-born child. The Indian government is also encouraging women for institutional birth to avoid early exposure of infants to many germs. However, their efforts will be successful only when people join them to win the war against diarrhoea.

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