OPEN AIR DEFECATION

Of   TOILETS   and   TALLNESS 

Dr. T. Rama Prasad

         The cricket icon, Sachin Tendulkar was named (Nov. 28, 2013) the regional brand ambassador for South Asia by the UNICEF to promote its Total Sanitation Campaign in India, Pakistan, Sri Lanka, Bangladesh and Nepal.  Actress Vidya Balan stresses on the need to have toilet in every household through UNICEF sanitation advertisement.  It is sad to note that 36 per cent of the world population do not have access to proper toilets and that 1600 children die every day due to diarrhoea.  In South Asia, in 2011, 2.3 million children under the age of five years died and 70 million children (39 per cent of all children), under the age of five years are stunted.

SHAME

People openly defecating in public places, on the roadside, along the railway track and in the fields around homes is an ubiquitous part of the Indian scenery.  My writings in The Hindu of Jan 17, 2011 & Jan. 31, 2011 point to the rampant and hazardous practice of open air defecation, urination and spitting in public places in India.  Come to think of it, in India, a majority of the population – 63.8 crore – has no access to ‘flush toilets’.  This accounts for a 58 per cent of the world population who defecate in the open, crowning India the dubious distinction of being the global capital of open defecation.  Nearly seven decades after Independence, in January 2016, a 17-year-old girl student committed suicide unable to bear the shame of open defecation.  Forget about the shame (both for the girl and the nation), the resultant health hazard costs the nation Rs.2.4 trillion (about 6.4 per cent of  the GDP) and lakhs of lives annually !  (http://www.newindianexpress.com/editorials/Nalgonda-Suicide-Should-be-Eye-opener/2016/01/29/article3249693.ece)

A recent survey indicates that India is one of the dirtiest and least liveable countries in the world.  In the liveability index of 150 cities in the world our cities are all listed below 130.  Health and sanitation are the chief criteria in this survey. Go to  http://www.newindianexpress.com/magazine/Punes-Toilet-Hero/2014/04/06/article2147721.ece#.U0mm8vmSxxM  to read about Swapnil Chaturvedi who gave up lucrative software jobs in US to provide toilet facilities to the urban poor in the slums of Pune, using ICT, behavioural sciences, analytics and design.  He is the ‘Chief Toilet Cleaner’ at Samagra Sanitation.

SHORT  STATURE

           A startling finding of recent research is that open defecation results in short statured individuals !  And it also produces unhealthy, shorter living, less intelligent and less productive population.  Another shocking revelation is that even the children from affluent families who never practised open defecation but lived in the neighbourhood of people practising open defecation suffer from the same disadvantages, including the short stature !  This may sound curious, unconvincing, ridiculous and incomprehensible as we all think that height is mostly determined by genetic, nutritional and racial factors.  How open defecation affects the height of the population ?  Why the children who use ‘flush toilets’ also do not grow up to their genetic or racial maximum ?

           “Faeces contain germs that, when released into the environment, make their way onto children’s fingers and feet, into their food and water, and wherever flies take them.  Exposure to these germs not only gives children (even children who do not practice open defecation but live in the neighbourhood of those practising it) diarrhoea, but over the long term, also can cause changes in the tissues of their intestines that prevent the absorption and use of nutrients in food, even when the child does not seem sick.”  This is the explanation.

          Don’t think that you are safe because you live in a home with good sanitary facilities    (this applies to many diseases in our country;  for example, tuberculosis spreads through air, and an aristocrat may have a private aeroplane but cannot have private air to breath !).  Open defecation is not just some “third person singular number” any more as this affects the height, health and productivity of the population in the country as a whole.  Taller children become healthier adults and a more productive workforce.  I don’t have space here to mention details of the concerned scientific studies; I hope interested readers will download the evidence at http://www.thehindu.com/opinion/lead/the-long-and-short-of-open-defecation/article4505664.ece and /^{http://goo.gl/}PFy43 ^.

AHIMSA

Now let us have a peep into preference for open defecation.  While ‘Swachh Bharat  Abhiyan’ aims to construct 12 crore toilets in rural India by 2019 to make India free of open defecation,  some  invoked ‘ahimsa’ to defend open defecation. They appealed against a ban on open defecation because their “Munis” consider it as a religious ritual and as flushing in the sanitary toilets will kill microorganisms in the faeces and as killing any living organism is considered as a sin. It is reported that they are planning to launch peaceful protests and seek legal protection to their religious practice of open defecation. Incredible India ! (http://www.newindianexpress.com/nation/Hurdle-to-Swachh-Bharat-Goal-as-Jains-Invoke-Ahimsa-to-Defend-Open-Defecation/2015/09/27/article3049784.ece

          World Toilet Day was celebrated on November 19, 2015 and India was abuzz with ‘Swachh Bharat’ slogans.  If the focus is only to meet toilet construction targets rather than changing hygiene behaviour of people, the ‘Swachh Bharat Abhiyan’ activity will also end up like the previous experiments such as ‘Nirmal Bharat Abhiyan’ and ‘Total Sanitation Campaign’.  People’s hygiene behaviour is such that open defecation is much ‘cleaner’ than using toilets at home.  That is the reason why many toilets previously constructed free of cost were being used for storing fodder and grains.  It is imperative that primacy should be given to change the hygiene behaviour.

              On reaching 2019,  we have the following following pleasant news that a miraculous change  for good is taking place in the scenario. 

That is the long and the short of open defecation

“Doctor, you cured me of my tuberculosis fifty years ago.  But why are you now saying that you can’t be certain of curing my son,” asked Gokul, the parent of a tuberculosis (TB) patient.  I didn’t give a long lecture to answer that question.  I advised him to go to a  government hospital where he would get appropriate treatment and five hundred rupees a month for several months.  He shook his head disapprovingly and insisted to have treatment privately.  Trust deficit ?  Monetary incentives are given under the TB control programme, even to private doctors.

Why couldn’t I give a positive assurance of a cure to Gokul’s son ?   When his dad was treated, the TB bacilli were vulnerable to attack by the drugs.  With inadequate and irregular treatment over the decades, the bacilli gained resistance to the drugs and so the drugs may not act well. And so, the doctors are a bit guarded in pronouncing prognosis now.

DRUG RESISTANT TUBERCULOSIS

In those good old days, words like ‘multi-drug-resistant tuberculosis (MDR-TB)’,  ‘extensively-drug-resistant tuberculosis (XDR-TB)’ and virtually incurable ‘totally-drug-resistant tuberculosis (TDR-TB)’ were not in our parlance.  And, 40 years ago,  I wrote in the columns of The Hindu (Apr. 28, 1977) that " … development of drug resistance, which is a result of inadequate and irregular treatment mostly, has far-reaching implications and if unchecked would make tuberculosis totally unmanageable by the present methods in course of time, whatever be the means. Irregular and inadequate treatment keeps the patient often alive, suffering and infective to disseminate drug-resistant organisms into the environment …"    

Now, with my experience of half-a-century in this field, I find that there is less guarantee of a cure now than a few decades ago, notwithstanding the availability of more drugs, due to drug resistance. There were tools, but we didn’t use them properly.  And so, we landed in the medical quagmire.  And now it seems that TB has become insurmountable and invincible, notwithstanding the introduction of new regimens which include molecules like Bedaquiline, Linezolid and Pretomanid.  TB is killing more people than ever before in history  --  1,000 people everyday in India at present !  This chronic mortality doesn’t go into news whereas one case of coronavirus grabs the headlines.  According to the latest ‘2019 Global Tuberculosis Report’ of the WHO, India has the maximum number of TB cases and drug resistant TB cases in the world.  Officials may say that there is a declining trend, but Dr. Paula I Fujiwara, Scientific Director of the International Union Against Tuberculosis and Lung Diseases said: “Let’s be honest – TB is still not falling fast enough in India, progress is still too slow to meet the targets … and if we don’t end TB in India, we can’t hope to end it globally.”

TB  Hatao

          If one goes through the 'India TB Report 2018 : Annual Status Report',  one gains the impression that there is a committed  political will and a strong programming strategy in place to reach the goal of ending TB in India by 2025,  in line with the 'National Health Policy, 2017'.   Everyone concerned should work hard honestly to see that this new initiative would not end as a "TB Hatao" slogan !

          And to have a critical insight into the conundrum of tuberculosis control in India, read my ‘scribbling’ at:  http://drtramaprasad.blogspot.com/2017/03/tuberculosis-in-india.html .

RITUALISTIC EXHORTATIONS

        It is the celebration day on the World TB Day (March 24) but we mourn for the thousand deaths every day. The annual rituals of conducting rallies, delivering sermons and hosting seminars go on mechanically.  Statistics rolled out in India must be taken with a pinch of salt as the infrastructure is plagued by lack of well-structured and genuine reporting systems.  In the midst of all the brouhaha, one may have to leave the platform with a sense of déjà vu.  All the theatrical activity dissipates quickly, much like the fizzling out of the effervescence from a soda bottle.  Hackneyed gestures and lackadaisical efforts are commonplace.   One who follows up these acts would visualise a great scenario of farcical dimensions.  The grand pronouncements and the rhetoric may never meet the reality.  Why all this hoo-ha ... singing the same chorus in a different style ?

TB is made a 'notifiable disease' for better follow up and management.  In addition, pan-India engagement with private sector to close the enormous gaps across the patient-care-cascade in private medical care is initiated through NSP, WJCF, CHAI, CHRI, FIND India, GFATM, CTD, WHO, JEET, etc. to eliminate TB during 2017 - 25.

         We should hope and wish that this strategy would eliminate TB from India by 2025.  The proof of the success may be seen in 2025.   'The proof of the pudding is in the eating'.   Let's review in 2025 against a backdrop of ‘$ 5 trillion economy’ !   And let’s wish Gokul’s son a speedy recovery.

Dr. T. Rama Prasad,  ‘PAY WHAT YOU CAN’  Clinic, Perundurai.

Former Medial Superintendent (Special),  R.T. Sanatorium and Perundurai Medical College & Research Centre, Perundurai.  E-mail: drtramaprasad@gmail.com

                                                                               

THIS  IS  AN  ABRIDGED  TEXT  OF  MY    SCRIBBLING.      CLICK  HERE  TO  SEE  THE  FULL  TEXT.   --  T. Rama Prasad