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.

How Green is Your Lawn- The Use of Pesticides

From the beginning of recorded time humans have utilized pesticides to protect their crops and food stores. Humans tried many substances as pesticides; toxic chemicals were tried in the 1600’s. Arsenic, mercury and lead were applied to crops to kill pests; the fact that these substances also killed larger animals including humans resulted in their abandonment for use as pesticides. One of the results of chemical development during World War II was the widespread manufacture and use of pesticides after the war. With the use of pesticides and herbicides to control unwanted pests came dramatic changes in agriculture and the agricultural business model and increasing crop yields in excess of 10%. Pesticides including herbicides and insecticides are used to control harmful and annoying organisms. They can be used to protect from diseases carried by mosquitoes or parasites. Herbicides can be used to kill invasive weeds in gardens, parks and public spaces, to clear roadside weeds, trees and brush. They are also used to prevent algae from taking over ponds and pools. Pesticides are used to control termites and mould that can damage buildings and homes. Pesticides are used in grocery stores and food storage facilities to prevent mice and insects that infest food such as grain. Much of our very clean and sanitary American life is the result of pesticide use. Each use of a pesticide carries some associated risk and controlled and limited use of these pesticides is believed to reduce the risks to a level deemed acceptable by the US EPA.

DDT became the most widely used pesticide in the world in the 1950’s. It’s potential to do harm was not fully recognized until, the 1960’s when it was identified as the cause of diminished populations of eagles, hawks, gulls and other birds. DDT use was banned. The recent reemergence of support by the World Health Organization for the use of DDT to prevent malaria is an example of the questions raised by pesticide use. The WHO argued that used sparingly DDT was the most effective method to control the spread of malaria and that saving human lives from malaria was more important than potential impact to lesser species. DDT’s potential as an endocrine disruptor was not full appreciated at that time and it has recently been implicated in increased incidence of breast cancer in women exposed before or at puberty in the California study. The wide spread use of herbicides and their potential presence in water resource was also ignored. The fate and transport model for understanding chemicals added to the environment has not always been fully appreciated. However, by the 1980’s alachlor, atrazine, cyanazine and metolachlor (all common corn and soybean herbicides) were being detected in surface water and near surface groundwater. The US EPA began to restrict use of these herbicides, too, and they were phased out over the next decade.

A new generation of herbicides was developed during the phase out period encouraged by the US EPA. The newer herbicides were applied at much lower levels, broke down more quickly in the environment and were less toxic to animals. Applying ounces of herbicides per acre that broke down in days rather than pounds of chemicals that persisted for weeks or months was a victory to the US EPA. These new herbicides were based on sulfonylurea an imidazolinone. The lower concentrations of the new herbicides and their breakdown products rendered them virtually invisible in water. We could not detect them and assumed they were not present. Now it seems that the degradation products of these new herbicides are far more persistent in the environment that originally believed or hoped.

Recent studies have documented endocrine disruption in a wide variety of marine gastropods, frogs, and fish associated with exposure to low levels of non specific endocrine disrupting chemicals of unknown sources. The current state of analysis only allowed the documentation of EDC presence. EDCs are a structurally diverse group that includes natural and synthetic estrogens, alkyl phenols surfactants, phthalates, bisphenol A, brominated flame retardants and some pesticides. Studies in recent years have documented a wide occurrence of endocrine disrupting compounds (EDCs) throughout aquatic ecosystems. This could indicate non-point sources of contamination from run off or an additive effect, which may have serious implications for US water quality. Suspect EDCs are used in large quantities by consumers and industry. Domestic and industrial wastewater and agricultural run-off are believed to be the major sources of EDCs today. The impacts of trace concentrations of EDC on wildlife do beg the question about the potential effects on humans. Drinking water is not tested for minute quantities of endocrine disrupting chemicals; we simply do not have the knowledge of what to look for nor the technical ability to identify all the trace contaminants of that nature.

In April of 2009 the US EPA issued the Final List of Initial Pesticide Active Ingredients and Pesticide Inert Ingredients to be Screened Under the Federal Food, Drug, and Cosmetic Act as potential endocrine disruptors. Pesticide runoff is a large contributor of known pollutants to the watershed. Maybe we should be re-examining the risks associated with what is now known as conventional agricultural practices, and embrace (at the very least) the best management practices for controlling environmental release of agricultural chemicals and waste. Several Provinces in Canada are in the process of banning the use of herbicides for ornamental lawn use.