While appreciating the efforts made through the article “Culture versus Coercion: Other Side of Nirmal Gram Yojana” (EPW, 25 October 2008) to bring the issue of sanitation into the public discourse, this comment offers some clarifications on the alleged shortcomings of the programmes. It also builds a strong case for focusing more attention on achieving total sanitation in our country.

Views expressed are strictly personal. They do not reflect those of my employer in any fashion.

Benny George (ddws_consme@nic.in) is with the Department of Drinking Water Supply, New Delhi.

Economic & Political Weekly

I

Nirmal Gram Puraskar

Nirmal Gram Puraskar (NGP) was launched by the government of India in June 2003 to incentivise sanitation coverage in rural areas. NGP is awarded under the Total Sanitation Campaign (TSC) and not the other way round. M&P make a factually wrong statement that “the campaign (TSC) is funded under the Nirmal Gram Yojana” (p 25). States, panchayati raj institutions (PRIs), at village, block and district levels, non-governmental organisations (NGOs) and individuals are eligible to apply for the award. To win the NGP, states and PRIs should have universal sanitation c overage and maintain an open defecationfree e nvironment, apart from ensuring environmental cleanliness.

In the first year (2005), 40 gram panchayats (GPs) and two blocks had won the NGP, in 2006, 760 GPs and nine blocks made the cut, and in 2007 there was a

vol xliv no 8

Sanitation and the Tribal Question

M&P observe that the tribal people of B astar have been going to river banks for defecation. They are of the opinion that the concept of modern sanitation is alien to tribal culture and they should be left alone (p 26). Legislative interventions were required to fight some of the customs such as sati of the “civilised” societies and the agenda is still unfinished as we grapple with casteism, gender discrimination, etc. To substantiate their view, the authors cite a couple of anthropological studies as well. Even as I appreciate the divergent viewpoints, I believe that there is nothing sacrosanct about the views of a few anthropologists. It appears that viewing the sanitation issue of tribal people through the prism of “civilising” them is what is causing repugnance.

To set the record straight, it may be stated that TSC is implemented to achieve the f avourable public health outcomes that go with total sanitation. It is not conceived with a “holier than thou” mindset and it regards the faeces of non-tribal people as infectious as that of tribal people. Incorporating the wisdom accrued through implementing not-so-successful sanitation programmes over decades, TSC has community participation as its core strategy.1 That the strategy of community mobilisation under TSC is effectively employed in Bastar district is highlighted in the article itself. M&P observe that

the state authorities engaged several agencies to drive home the message. These are panchayats, NGOs, schools, anganwadi workers, health professionals like doctors, ANMs, mitanin, SHGs…They used counselling, cajoling, community oath taking, coercion and even threats for achieving targets. The young children had been brainwashed and blackmailed to force their parents to use the new toilets…The government personnel, who otherwise rarely visit the villages, had suddenly become active and they were working personally supervising the task (p 26).

DISCUSSION

If true, the aforementioned state of a ffairs, barring the alleged elements of c oercion and force, points to the strong p olitical and administrative will in ensuring community participation in implementing a development programme of the government of India. If only we could achieve that kind of participation in the implementation of other programmes, our country would be a much better place to live in. Maybe it is time we thought about such an award in health sector!

The importance of having proper sanitation facilities for a healthy living cannot be overemphasised. Public sanitation was voted the greatest medical breakthrough since 1840 in a poll carried out by the B ritish Medical Journal in January 2007. The architect of modern India, Jawaharlal Nehru, once said that “the day every one of us gets a toilet to use, I shall know that our country has reached the pinnacle of progress”.

Howard (2002) observes that many diseases are caused by food, water and hands that are contaminated by disease-causing organisms or “pathogens” that come from faeces. The diseases caused by these p athogens are called faecal-oral diseases b ecause faecal material is ingested. These diseases, which include dysentery, cholera, giardiasis, typhoid and intestinal worm infections, are responsible for much sickness and many deaths each year. Many of these illnesses and deaths occur unnecessarily, since the faecal-oral routes of d isease transmission are among the most easily blocked.

As per the findings of the World Health Organisation (WHO 2004), 1.8 million people die every year from diarrhoeal disea ses (including cholera). Of these, 90% are children under five, mostly in developing countries. Other important findings of the study are: (1) improved sanitation reduces diarrhoea morbidity by 32%; (2) hygiene interventions including hygiene education and promotion of hand washing can lead to a reduction of diarrhoeal cases by up to 45%; and (3) 133 million people suffer from high intensity intestinal helminths infections, which often lead to severe consequences such as cognitive impairment, massive dysentery or anaemia.

UN Water (2008) observes that diarrhoeal diseases are the second most c ommon cause of death in children under five, and of these deaths, 88% were caused by lack of sanitation, poor hygiene practices and contaminated drinking w ater. The United Nations Children’s Fund has estimated in 2007 that daily 1,000 child deaths occur in India which are a ttributable to diarrhoea alone.

Intestinal worms (helminths) which e nter feet from faecal matter lying around on the ground, or in filthy or “unimproved” toilet facilities, are less life-threatening than diarrhoeal disease, but seriously u ndermine children’s health. There are around 133 million annual cases worldwide of a scaris (roundworm), trichuris (whipworm) and hookworm infestation. A typical a scaris load diverts around one-third of the food a child consumes, and malnutrition is at the root of 50% of childhood illness.

Hookworm is a frequent cause of anaemia. Trichuris leads to chronic colitis in toddlers, a condition which often persists for so long that mothers may think it normal and fail to seek medical help. Children in poor environments often carry 1,000 parasitic worms in their bodies at a time. When at school, such children may be l istless, sleepy and unable to concentrate.

The Central Bureau of Health Intelligence (CBHI) estimated that during 1998-99 poor sanitation and related disease b urden r esulted in an annual loss of 180 million man-days and an economic loss of Rs 1,200 crore in India. Mehrotra (2008) contends that without clean water and sanitary means of excreta disposal, there is little possibility of a dramatic improvement in health outcomes. He goes on to observe that 92% of hospitalisation cases in rural Uttar Pradesh were on account of infectious and parasitic diseases, especially for diarrhoea and gastroenteritis. Time and again, empirical studies have brought out that hospitalisation is one of the most important reasons for indebtedness and abject poverty in rural areas.

Impact of sanitation is not limited to health alone. Investments in education are undermined by inadequate sanitation at home and at school. Significant progress has been made in extending primary education but sick children do not attend school. Inadequate sanitation in schools reduces girls’ attendance and is a s ignificant barrier to the achievement of the Millennium Development Goals target to remove gender disparity in primary e ducation. The Education for All Report for 2008 highlights the disproportionate effect that poor sanitation has on girl students’ enrolment and attendance and calls on governments to address gender disparities by building schools with proper sanitation. A failure to a ddress sanitation in schools, including facilities for menstrual hygiene management, w idens the gulf b etween the opportunities a fforded to girls and boys through e ducation (ibid). (More facts and figures are presented in Mehrotra 2006; Planning Commission of India 2002 and UNDP 2006.)

Chhattisgarh is often described as a rich state inhabited by poor people. The state is characterised by widespread malnutrition and child deaths. NFHS-3 data featured in the following table indicate that the levels of child malnutrition are unacceptably high in the state. As per the data released by the CBHI, infant mortality rate in Chhattisgarh was 61 in 2006 against the national average of 57.2 Given the close linkages between sanitation, h ygiene, w ater-borne diseases and child mortality and morbidity, one of the easiest and most cost-effective methods for remedying the situation may be redoubling the efforts towards providing basic sanitation facilities in the state and educating the people about the importance of safe handling of human excreta and maintaining environmental cleanliness.

february 21, 2009 vol xliv no 8

EPW

Economic & Political Weekly

DISCUSSION

Even as the government of India makes efforts towards enhancing sanitation c overage, it does not lose sight of a critical issue – sustainability. The government is conscious of the reality that mere construction of toilets does not serve the purpose and makes all-out efforts to get people to use it. It is acknowledged at the highest level that 20% of the toilets built in the country are not used for various reasons.4

Community participation and awareness generation are at the core of the strategy adopted to ensure sustainability of sanitation. TSC places greater thrust on information, education and communication for bringing about behaviour change, community participation, etc, to create demand and motivate people to use, maintain and upgrade existing facilities, so that sanitation and hygiene become an integral part of rural life and thereby sustainable. Funds are earmarked for R&D to develop technology options for building toilets suitable for different hydro-geological conditions and address the issues of a ffordability and aesthetics. Alternative delivery mechanisms (rural sanitary marts and production centres) are established to meet the demands of the people related to their sanitation facilities. Attempts are made to ensure greater participation of women for improved sanitation and h ygiene behaviour and focus on the sanitation needs of young girls and women. Also, provision of sanitation facilities is being positioned as an avenue for income generation for women. Finally, convergence with other programmes such as N ational Rural Health Mission, Sarva Shiksha Abhiyan and Integrated Child D evelopment Services is being effectively used to achieve synergies, thereby ensuring greater sustainability.

Conclusions

Sanitation programmes in India have come a long way from its subsidy-driven and construction-oriented days. It is nobody’s argument that everything is hunkydory about them. However, proper sanitation facilities are indispensable for living the way we have been living and it is i mperative that no exception is made to ensure that the hard-won benefits are not frittered away. At the same time, there is a need to make a constant effort to improve the performance of the programmes by making it more responsive to the local needs and aspirations.

Notes

1 A perusal of TSC Guidelines may help appreciate the programme better. It is available at http:// www.ddws.gov.in/popups/TSC%20Guideline%20 Oct07.pdf.

2 http://www.cbhidghs.nic.in/writereaddata/linki mages/Demographic%20Indicators133750362.pdf, accessed on 4 December 2008.

3 http://ddws.nic.in/TSC/crsp/main.htm, accessed on 16 December 2008.

4 http://pmindia.nic.in/lspeech.asp?id=756, accessed on 25 November 2008.

References

Howard, Guy (2002): Healthy Villages – A Guide for Communities and Community Health Workers ( Geneva: WHO).

Kumar, A K Shiva (2007): “Why Are Levels of Child Malnutrition Not Improving?”, Economic & P olitical Weekly, Vol 42, No 15.

Mehrotra, Santosh (2006): “Child Malnutrition and Gender Discrimination in South Asia”, Economic & Political Weekly, Vol 41, No 10.

– (2008): “Public Health System in UP: What Can Be Done?”, Economic & Political Weekly, Vol 43, No 15.

Planning Commission of India (2002): India: Assessment 2002 – Water Supply and Sanitation, New Delhi.

UNDP (2006): Human Development Report: Beyond Scarcity: Power, Poverty and the Global Water C risis, New York.

UN Water (2008): Tackling a Global Crisis: International Year of Sanitation 2008. Water Aid (2008): Tackling the Silent Killer – The Case for Sanitation, London. WHO (2004): Water, Sanitation and Hygiene Links to Health – Facts and Figures, Geneva.

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