Monday, November 3, 2014

Total Sanitation Campaign in India Fails

The Total Sanitation Campaign (which has been renamed the Nirmal Bharat Abhiyan) is a program in India to provide subsidies for the construction of household toilets for those at and near the poverty level to prevent diarrhea, soil-transmitted helminth infection, and child malnutrition and stunting of growth. The programs has been in operation since the turn of the century, but has failed to improve childhood health and the stunting of growth.

The World Health Organization (WHO) estimates that 2.5 billion people have no access to toilets or latrines. More than 70% of these people live in rural areas, as do more than 90% of the 1.1 billion who practice open defecation (when people defecate outside onto the open ground, and in full view of other people). India represents a particular challenge, accounting for roughly a third of the world's population without improved sanitation and two-thirds of the population practicing open defecation.

The WHO states that poor sanitation is associated with various infectious diseases, including diarrhea, soil-transmitted helminth infection, trachoma, and schistosomiasis. Diarrhea alone causes an estimated 1.4 million deaths annually, including 19% of all deaths of children younger than 5 years in low-income households. Furthermore, evidence has linked poor sanitation with stunting, and impaired cognitive development which may be caused by environmental enteropathy, a poorly understood subclinical condition caused by constant fecal-oral contamination and resulting in blunting of intestinal villi and intestinal inflammation. Simply put living surrounded by poop is bad for your child’s health.

Although historical improvements in urban sanitation are widely believed to be the most important health advancement of the 20th century, the of the health effect of household toilets/latrines in low-income rural settings is not strong. From May 2010 until December 2013 the Bill and Melinda Gates Foundation funded a study to assess the effectiveness of installing rural household latrines in India under the Total Sanitation Campaign in preventing diarrhea, soil-transmitted helminth infection, and child malnutrition. The study attempted to investigate the effect of the installing latrines as actually delivered by the foundation and its local partners working in India within the Total Sanitation Campaign.

The researchers performed a controlled study in 100 rural villages in the coastal district of Odisha (formerly Orissa) India. The villages were chosen from a list of 358 villages that were not previously covered by the Total Sanitation Campaign. Villages were eligible if less than 10% of households had latrines; had improved water supply; and if no other water, sanitation, or hygiene (WASH) intervention program was planned during the study period. Fifty of the villages were placed in intervention group with the local foundation offering the Total Sanitation Program and 50 villages served as the control group. There were 4586 households (24 969 individuals) in intervention villages and 4894 households (25 982 individuals) in control villages.

During the study period the Total Sanitation Campaign intervention increased mean village latrine coverage from 9% of households to 63%, compared with an increase from 8% to 12% in control villages. Health surveillance data were obtained from 1437 households with children younger than 5 years in the intervention group (1919 children younger than 5 years), and from 1465 households (1916 children younger than 5 years) in the control group. The key indicators tracked were the prevalence of reported 7-days of diarrhea in children younger than 5 years, the hand and household water bacterial count, and the level of worm infestation in children’s feces and the prevalence of flies. Their findings showed no evidence that the Total Sanitation Campaign program in rural Odisha reduced exposure to fecal contamination or prevented diarrhea, soil-transmitted helminth infection, or child malnutrition. The program was found to be a failure and had no impact on health. These findings are consistent with another study performed in India within the Total Sanitation Campaign in the Indian state of Madhya Pradesh, but in contrast to results found with improved sanitation and hygiene in other world programs.

from Lancet
The study findings cast doubt on the health effect of the Total Sanitation Campaign (now under the name Nirmal Bharat Abhiyan) that focus only increasing latrine construction but do not end open defecation or address other sanitation issues that might reduce other possible sources of exposure fecal contamination. Although latrine coverage increased substantially in the study villages to levels targeted by the Total Sanitation Campaign, many households did not build latrines and others were not functional at follow-up. Even householders with access to latrines did not always use them. Open defecation remained widely practiced  by men and children in homes with latrines. India needs to address the underlying cultural acceptance of open defecation, before they can make any progress in improving childhood health and the eliminating the widespread stunting of growth in Indian children. Latrine use was nearly five times higher for women than for men or children. However, the study results show that the health benefits generally associated with sanitation cannot be assumed simply by construction of latrines.
from Lancet
Thomas Clasen, Sophie Boisson, Parimita Routray, Belen Torondel, Melissa Bell, Oliver Cumming, Jeroen Ensink, Matthew Freeman, Marion Jenkins, Mitsunori Odagiri, Subhajyoti Ray, Antara Sinha, Mrutyunjay Suar, Wolf-Peter Schmidt; Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial. The Lancet Global Health, Volume 2, Issue 11, Pages e645 - e653, November 2014.

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