India Lags Sub-Saharan Africa in Public Hygiene

India's rivers have been turned into open sewers by 638 million Indians without access to toilets, according to rural development minister Jairam Ramesh. He was reacting a UNICEF report that says Indians make up 58% of the world population which still practices open defection, and the sense of public hygiene in India is the worst in South Asia and the world.

India(638m) is followed by Indonesia (58m), China (50m), Ethiopia (49m), Pakistan (48m), Nigeria (33m) and Sudan (17m). In terms of percentage of each country's population resorting to the unhygienic practice, Ethiopia tops the list with 60%, followed by India 54%, Nepal 50%, Pakistan 28%, Indonesia 26%, and China 4%.

18 percent of urban India still defecates in open while the percentage of rural India is as high as 69 percent of the population. It is the key reason why India carries among the highest infectious disease burdens in the world.

The number of open defecators in rural India alone is more than twice those in the whole of sub-Saharan Africa, according to a report by DFID, the UK's Department for International Development.

The World Bank has estimated that open defecation costs India $54 billion per year or $48 per head. This is more than the Government of India’s entire budget for health.

The UNICEF report says that with only four more years to go until 2015, a major leap in efforts and investments in sanitation is needed to reach the targets of Millennium Development Goals.

After the embarrassing headlines, it appears that Minister Ramesh is ready to step up the efforts to improve sanitation. He is quoted by Times of India as saying that "we are going to focus now on `nirmal gram abhiyan' -- today 25,000 nirmal grams are a tiny fraction of 6 lakh villages. These nirmal grams are in Maharashtra and Haryana. Maharashtra is a success of social movements while Haryana an example of determined state government action."

Here's a video clip of Indian environment minister Jairam Ramesh saying "if there was a Nobel Prize for dirt and filth, India would win it hands down":

Related Links:

Haq's Musings

Fixing Sanitation Crisis in India

Food, Clothing and Shelter in India and Pakistan

Heavy Disease Burdens in South Asia

Peepli Live Destroys Indian Myths

India After 63 Years of Independence

Poverty Across India 2011

India and Pakistan Contrasted

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Comment by Riaz Haq on July 7, 2012 at 11:02pm

Here's a Wall Street Journal article by Aatish Taseer on Aamir Khan's new TV show:

On Indian TV, there has never been anything quite like "Truth Alone Prevails." Since its debut in May, the weekly show has reached more than 470 million viewers with its inquiries into issues like pesticides in food, domestic violence and the abortion of female fetuses. Within moments of airing, each episode trends at No. 1 on Twitter in India. Ten million people have sent text messages, emails and comments to the show's website to share their questions, opinions and fears.

In two Indian states, the show has prompted governments to bolster the enforcement of existing laws, and a few weeks ago the show's host was called to testify before a parliamentary committee after an episode on medical malpractice. The scale of the response has made "Satyamev Jayate" (as the show is called in Hindi) more like a people's movement than a television show.

More astonishing is the fact that this social and political phenomenon is the work of Aamir Khan, a superstar of India's giant film industry. At 47, Mr. Khan combines something of the glamour and social concern of George Clooney and Brad Pitt. Like many Bollywood actors, he made his name dancing around trees and singing in the rain, but over the years he has turned to more serious things. Three years ago he had a great success with "3 Idiots," a comedy about the mind-numbing state of Indian education. Now, having turned down offers to do the game shows that many actors of his standing have taken up, he has created something startling and altogether new in India.
What emerges from their stories is a creeping horror, a vision of modern India that is stark and deeply unsettling: the family whose mother's life is snatched away, they say, in a botched and unauthorized organ transplant; the 12-year-old girl who accuses a 55-year-old family friend of sexual abuse; the call-center worker who tells of the forced abortion of her female fetuses—six times in eight years—at the hands of her husband's family. Mr. Khan's style is wry and laid back, but occasionally the stories are too much for him, and his eyes well with tears...
What gives "Truth Alone Prevails" its optimism is the voice of India's new middle class, which is increasingly politically and socially aware, though still unsure of itself and its newfound wealth and security. If the old India of my childhood—which was a far bleaker place—is to be superseded, it will depend on this new class's ability to understand and defend the freedoms that have enriched it. Mr. Khan's achievement has been to use his celebrity to show Indians, with rare clarity and grittiness, how far the country has come, and how far it has yet to go.

Comment by Riaz Haq on June 21, 2013 at 9:02am

Here's a Reuters' blog post on lack of hygiene in India:

My Indian friends and I joke around a lot about me as the typical white American guy visiting India. Cows! Con men! Colors! Most people I’ve met in India have restricted their reactions to my westerner-in-the-east experiences to gentle teasing. When I stuck a picture of a man urinating in public on my Facebook page, calling it one more picture of what you see everywhere you go in India, people weren’t as patient. What was I doing? Insulting the nation? Focusing on the ugly because it’s what all the westerners do when they visit India? Why does India provoke such visceral reactions in visitors?

Public urination, public defecation, dirt, garbage, filth, the poor living on the street — talking about these things, even acknowledging that they’re in front of your face, risks making your hosts unhappy, and possibly angry. It’s the third rail of India, and the voltage can be lethal. That’s why I was surprised when B.S. Raghavan decided to touch it with all 10 fingers.

Raghavan’s column in The Hindu Business Line newspaper begins with this headline: Are Indians by nature unhygienic?

Consider these excerpts:

From time to time, in their unguarded moments, highly placed persons in advanced industrial countries have burst out against Indians for being filthy and dirty in their ways of life. A majority of visitors to India from those countries complain of “Delhi belly” within a few hours of arrival, and some fall seriously ill.

There is no point in getting infuriated or defensive about this. The general lack of cleanliness and hygiene hits the eye wherever one goes in India — hotels, hospitals, households, work places, railway trains, airplanes and, yes, temples. Indians think nothing of spitting whenever they like and wherever they choose, and living in surroundings which they themselves make unliveable by their dirty habits. …

Open defecation has become so rooted in India that even when toilet facilities are provided, the spaces round temple complexes, temple tanks, beaches, parks, pavements, and indeed, any open area are covered with faecal matter. …

Even as Indians, we are forced to recoil with horror at the infinite tolerance of fellow Indians to pile-ups of garbage, overflowing sewage, open drains and generally foul-smelling environs.

There’s plenty more that you can read in that story, but I’ll direct you to the article. I’ll also ask you some questions:

Some people say you shouldn’t point out these problems, and that every country has problems. Do you agree with this statement? Why?
Does anyone disagree with Raghavan’s descriptions of these sights and smells?
Is this even a problem? Or should people get used to it?
Should visitors, especially ones from countries where people are generally wealthier, say nothing, and pretend that they don’t see unpleasant things?
As for me, I can say this: I got used to it, but I would be lying if I said I didn’t notice it. Indians notice it too. Otherwise, people wouldn’t suggest public shaming campaigns against people urinating in public, they wouldn’t threaten fines for doing it, and they wouldn’t respond with relief to plans to finally make sure that toilets on India’s trains don’t open directly onto the tracks. Of course, these are people in India. It’s a family, taking care of business the family way.

As for me, the message usually seems to be: “If you don’t love it, leave it.” It would be nice if there were some other answer. Acknowledging problems, even ones that are almost impossible to solve, makes them easier to confront.

Comment by Riaz Haq on June 21, 2013 at 4:28pm

Here's a Pulitzer winning piece on the dangers of India's medical tourism for the unsuspecting foreigners:

NDM-1 bacteria are propagating most lushly in India. The NDM-1 gene circulates in a family of bacteria called “Gram-negative” (after the Gram test used to identify them) whose unique cell envelopes make them both more toxic and harder to treat than “Gram-positive” bacteria. Many Gram-negative bacteria colonise the human gut and thrive in places with poor sanitation, where gut bacteria can pass from host to host through food and water contaminated with faecal matter. Basic sanitation remains rudimentary in many places in India. Only 65% of Delhi’s sewage is adequately treated and 20% of the population live in overcrowded slums highly exposed to contaminated water and food (9). Uncollected trash and teeming crowds abound just outside Medanta’s gates. Hawkers sell freshly squeezed fruit juice and vegetables from carts and, in a dusty lot next to the hospital, men sit on overturned buckets, eating rice and curry. A narrow stream emerges from near the hospital gates; its weedy banks are lined with trash. In a nearby slum, barefoot children play in narrow alleyways lined by open gutters carrying waste water and excrement.
In April 2011 researchers found NDM-1 bacteria in samples of Delhi’s drinking water and in puddles around the city. University of Cardiff microbiologist Tim Walsh suspects that between 100 million and 200 million Indians now carry NDM-1 bacteria in their guts. NDM-1 bacteria flourish at tropical temperatures, so the warm weather and floods of the monsoon season expose even more people.
Better healthcare for the poor, improved hospital hygiene and more judicious use of antibiotics could help contain NDM-1. But the politics of national pride may make such measures impossible. Indian medical authorities and politicians have both denied the public health relevance of NDM-1, and accused scientists working on the issue of a “conspiracy to hurt Indian medical tourism”, as The Indian Express put it. After initial reports on the bacteria appeared, Indian government authorities sent threatening letters to Indian researchers who had collaborated with British scientists on NDM-1 studies, according to the UK’s Channel 4 News (10). Walsh, who led many of the studies, said that his Indian collaborators were pressured to disavow their research and he became persona non grata in India: “I’m the devil incarnate and eat babies for breakfast according to the Indian government. It’s a witch hunt.”
The Indian government first complained that the bacteria gene was named after their capital city. Then, as the controversy grew, it convened an advisory committee on antibiotic resistance, and floated an ambitious proposal to ban the sale of antibiotics without a physician’s prescription, and restrict the use of last-resort intravenous antibiotics to tertiary hospitals. But after pharmacists went on strike in August 2011, the proposal was withdrawn (11). “The committee was a knee-jerk response,” said Ramanan Laxminarayan, of the Public Health Foundation of India. Wattal, Laxminarayan and others agree that the proposed restrictions would have affected a wide range of drugs besides antibiotics, and would have impeded access to life-saving antibiotics for the rural poor. In fact, the policy had little chance of being enforced: health policy is implemented at state level in India, not federal level.

Comment by Riaz Haq on June 22, 2013 at 7:54am

Here's a Bloomberg story on a tourist's experience with Indian medical system:

Lill-Karin Skaret, a 67-year-old grandmother from Namsos, Norway, was traveling to a lakeside vacation villa near India’s port city of Kochi in March 2010 when her car collided with a truck. She was rushed to the Amrita Institute of Medical Sciences, her right leg broken and her artificial hip so damaged that replacing it required 12 hours of surgery.
Three weeks later and walking with the aid of crutches, Skaret was relieved to be home. Then her doctor gave her upsetting news. Mutant germs that most antibiotics can’t kill had entered her bladder, probably from a contaminated hospital catheter in India. She risked a life-threatening infection if the bacteria invaded her bloodstream -- a waiting game over which she had limited control, Bloomberg Markets magazine reports in its June issue.

“I got a call from my doctor who told me they found this bug in me and I had to take precautions,” Skaret remembers. “I was very afraid.”
Skaret was lucky. Eventually, her body rid itself of the bacteria, and she escaped harm from a new type of superbug that scientists warn is spreading faster, further and in more alarming ways than any they’ve encountered. Researchers say the epicenter is India, where drugs created to fight disease have taken a perverse turn by making many ailments harder to treat.
India’s $12.4 billion pharmaceutical industry manufactures almost a third of the world’s antibiotics, and people use them so liberally that relatively benign and beneficial bacteria are becoming drug immune in a pool of resistance that thwarts even high-powered antibiotics, the so-called remedies of last resort.
Medical Tourism
Poor hygiene has spread resistant germs into India’s drains, sewers and drinking water, putting millions at risk of drug-defying infections. Antibiotic residues from drug manufacturing, livestock treatment and medical waste have entered water and sanitation systems, exacerbating the problem.
As the superbacteria take up residence in hospitals, they’re compromising patient care and tarnishing India’s image as a medical tourism destination.
“There isn’t anything you could take with you traveling that would be useful against these superbugs,” says Robert Moellering Jr., a professor of medical research at Harvard Medical School in Boston.

India is susceptible because it has many sick people to begin with. The country accounts for more than a quarter of the world’s pneumonia cases. It has the most tuberculosis patients globally and Asia’s highest incidence of cholera.
Most of India’s 5,000-plus drugmakers produce low-cost generic antibiotics, letting users and doctors switch around to find ones that work. While that’s happening, the germs the antibiotics are targeting accumulate genes for evading each drug. That enables the bugs to survive and proliferate whenever they encounter an antibiotic they’ve already adapted to.
India’s inadequate sanitation increases the scope of antibacterial resistance. More than half of the nation’s 1.2 billion residents defecate in the open, and 23 percent of city dwellers have no toilets, according to a 2012 report by the WHO and Unicef.
Uncovered sewers and overflowing drains in even such modern cities as New Delhi spread resistant germs through feces, tainting food and water and covering surfaces in what Dartmouth Medical School researcher Elmer Pfefferkorn describes as a fecal veneer..

Comment by Riaz Haq on September 9, 2013 at 9:37am

Here's a Time magazine story of a finding that Indian children's exceptionally short heights are attributable to poor sanitation in India, not malnutrition:

Children in India are exceptionally short, with their stunted growth historically attributed to malnutrition. However, new evidence is suggesting that food, or lack of it, is not the cause. Noticing that Indian children were smaller than their counterparts in Sub-Saharan Africa — who are, on average, poorer and hence less well fed — researchers have been coming to the conclusion that diseases stemming from poor sanitation are more to blame than diet.

More than half of India’s population — over 600 million people — do not use a toilet because sanitation is inaccessible or unaffordable. At the same time 61.7 million Indian children are stunted, the highest prevalence in the world.

The atrocious hygiene that results from widespread lack of sanitation is made worse by the density of the population. With large numbers of people openly defecating, fecal-oral-transmitted infections are common, leading to diarrhea, with such diseases draining growing children of vital nutrients. Growing up in environments teeming with fecal pathogens has a permanently debilitating effect, experts say. Overtime, a large build-up of fecal germs in the body can also manifest as severe intestinal diseases.

Last month, a group of economists, epidemiologists, pediatricians and nutritionists gathered at a conference in New Delhi to push for recognition of poor sanitation as the cause of child stunting in India. “It was striking that each of them [participants] had something to say about sanitation being important for child health,” Sangita Vyas, of the Research Institute for Compassionate Economics, which coorganized the meeting, told TIME. Such claims emerge at a time when the results of a massive government survey into the availability of sanitation have become available and converged with long-standing epidemiological literature.

Rural Indians remain hard to convince that this is a health epidemic, researchers say, because stunting creeps through communities, affects “everybody on average” and there are “no real dramatic cases,” Princeton University economist Dean Spears, who is currently at the Delhi School of Economics, told TIME. “The sorts of dramatic tragedies that persuade people [to change] don’t happen,” he says.

(MORE: Are Toilets a Feminist Issue? Why the Burden of Bad Sanitation Falls on Women)

A few years ago, a government sanitation program was implemented in half of 60 villages in Ahmednagar, Maharashtra, Western India. After the program, Spears and fellow economist Jeff Hammer found on average, that the height of children in the experimental group had increased by about one centimeter, relative to those in the 30 villages where the program had not been introduced.

“Widespread child-stunting in India is a human development emergency,” Spears says. “It matters for everybody.”

Comment by Riaz Haq on September 9, 2013 at 4:41pm

Here's a NY Times report on salmonella contamination of Indian spices exported to US:

...The United States Food and Drug Administration will soon release a comprehensive analysis that pinpoints imported spices, found in just about every kitchen in the Western world, as a surprisingly potent source of salmonella poisoning.

In a study of more than 20,000 food shipments, the food agency found that nearly 7 percent of spice lots were contaminated with salmonella, twice the average of all other imported foods. Some 15 percent of coriander and 12 percent of oregano and basil shipments were contaminated, with high contamination levels also found in sesame seeds, curry powder and cumin. Four percent of black pepper shipments were contaminated.

Each year, 1.2 million people in the United States become sick from salmonella, one of the most common causes of food-borne illness. More than 23,000 are hospitalized and 450 die. Symptoms include diarrhea, fever and abdominal cramps that begin 12 to 36 hours after infection and can last three to five days. Death can result when infection spreads from the intestines to the bloodstream and affects vital organs. Infants and older people are most at risk.

Mexico and India had the highest share of contaminated spices. About 14 percent of the samples from Mexico contained salmonella, the study found, a result Mexican officials disputed.

India’s exports were the second-most contaminated, at approximately 9 percent, but India ships nearly four times the amount of spices to the United States that Mexico does, so its contamination problems are particularly worrisome, officials said. Nearly one-quarter of the spices, oils and food colorings used in the United States comes from India.

The findings, the result of a three-year study that F.D.A. officials have on occasion discussed publicly and recently published in the journal Food Microbiology, form an important part of the spice analysis that will be made public “soon,” agency officials said.

“Salmonella is a widespread problem with respect to imported spices,” Michael Taylor, deputy F.D.A. commissioner for food, said in an interview. “We have decided that spices are one of the significant issues we need to be addressing right now.”

Westerners are particularly vulnerable to contaminated spices because pepper and other spices are added at the table, so bacterial hitchhikers are consumed live and unharmed. Bacteria do not survive high temperatures, so contaminated spices present fewer problems when added during cooking, as is typical in the cuisine of India and most other Asian countries.
Salmonella can survive indefinitely on dried spices, and killing the bacterium on the craggy surface of dried peppercorns without ruining their taste is especially challenging.

Government officials in India emphasized in interviews that spices slated for export are often treated to kill any bacteria. Such treatments include steam-heating, irradiation or ethylene oxide gas. But F.D.A. inspectors have found high levels of salmonella contamination in shipments said to have received such treatments, documents show. Much of the contaminated pepper in the 2010 outbreak had been treated with steam and ethylene oxide and had been certified as tested and safe, officials said.

At another spice farm, in the village of Chemmanar, Bipin Sebastian is in the midst of a four-year transition to organic farming in hope of earning a premium price for his pepper, cloves, cardamom, turmeric and coffee. Mr. Sebastian says he has used government subsidies to buy tarps, netting and a machine thresher.

“We used to put our pepper directly on the ground,” Mr. Sebastian said. “Now, we put down tarps and netting over it to protect it from the birds. And I’ve been getting a higher price. It’s been great.”

Comment by Riaz Haq on September 18, 2013 at 9:57pm

India accounted for three of every five new leprosy cases worldwide last year, or 134,752 of the 232,857 cases reported globally, the Geneva-based WHO said in an Aug. 30 report. New cases have increased annually from an historic low of 126,800 in 2010, yet remain well below the 560,000 recorded as recently as 2000, thanks to the effectiveness of multidrug therapy.

Comment by Riaz Haq on October 2, 2013 at 10:23am

Here's a <a href="">Dawn newspaper</a> story on India's rent-a-womb industry:

<i>Commercial surrogacy in India has become a profiteering business with an annual earning of $1 billion.

Most pregnant mothers are kept in Shelter Homes during their days of confinement; critics have dubbed these homes as “baby factories”.

Why do women take such a step?

An 18-year-old surrogate mother Vasanti, said, “In India, relationships and family are very highly valued. One can do anything for one’s children. I have become a surrogate mother so that I can provide my children with all the very best in life, which I have only dreamed of.”

Vasanti is at present pregnant; but the child protected in her womb is not her own, instead it belongs to a Japanese couple. Vasanti shall be paid $8000 for her troubles.

Such a huge amount is like a dream to Vasanti, who can now build a new home and also educate her kids, who are seven and five years of age. With regards to the impending payment, Vasanti declared that she was extremely happy with the arrangement.

The “baby production” process

The procedure for injecting her womb with the embryo of the Japanese couple was undertaken in the Akanksha IVF Centre in Anand town of the Gujrat state. She has been moved to a nearby temporary shelter home provided by the centre, where she will continue to live for nine months.

This home houses a 100 other surrogate mothers just like Vasanti. All of these women are under the supervision of gynecologist, Doctor Nayana Patel.

Each room in the shelter home is allocated to 10 surrogate mothers, who are provided with food and vitamins. They are also instructed to rest regularly; Vasanti however does not rest that often.

“I keep roaming around here and there at night because I can’t sleep. As the child in my womb grows, I am beginning to get bored. I want to go home as soon as possible, back to my husband and children.”

According to the rules and regulations of the shelter home, pregnant surrogate mothers are prohibited from indulging in sexual acts. These women are also very explicitly told that in case of any complexities, the doctors, the parents who have donated the embryo(s) and the hospital will not be liable to pay for any damages.

If a surrogate mother carries twin embryos until the time of delivery she is paid $10,000 but if she suffers a miscarriage during the first three months, then she is only paid $600 for her troubles....</i>

Comment by Riaz Haq on April 18, 2014 at 7:59pm

@UNICEFIndia Is Inviting #India to a Poo Party #IndiaElections #Sanitation #hygiene #Toilettes … via @vicenews

Comment by Riaz Haq on July 15, 2014 at 11:29pm

NY Times: India's malnutrition and stunting due to poor sanitation.

SHEOHAR DISTRICT, India — He wore thick black eyeliner to ward off the evil eye, but Vivek, a tiny 1-year-old living in a village of mud huts and diminutive people, had nonetheless fallen victim to India’s great scourge of malnutrition.

His parents seemed to be doing all the right things. His mother still breast-fed him. His family had six goats, access to fresh buffalo milk and a hut filled with hundreds of pounds of wheat and potatoes. The economy of the state where he lives has for years grown faster than almost any other. His mother said she fed him as much as he would eat and took him four times to doctors, who diagnosed malnutrition. Just before Vivek was born in this green landscape of small plots and grazing water buffalo near the Nepali border, the family even got electricity.

So why was Vivek malnourished?

It is a question being asked about children across India, where a long economic boom has done little to reduce the vast number of children who are malnourished and stunted, leaving them with mental and physical deficits that will haunt them their entire lives. Now, an emerging body of scientific studies suggest that Vivek and many of the 162 million other children under the age of 5 in the world who are malnourished are suffering less a lack of food than poor sanitation.

Two years ago, Unicef, the World Health Organization and the World Bank released a major report on child malnutrition that focused entirely on a lack of food. Sanitation was not mentioned. Now, Unicef officials and those from other major charitable organizations said in interviews that they believe that poor sanitation may cause more than half of the world’s stunting problems.

“Our realization about the connection between stunting and sanitation is just emerging,” said Sue Coates, chief of water, sanitation and hygiene at Unicef India. “At this point, it is still just an hypothesis, but it is an incredibly exciting and important one because of its potential impact.”

This research has quietly swept through many of the world’s nutrition and donor organizations in part because it resolves a great mystery: Why are Indian children so much more malnourished than their poorer counterparts in sub-Saharan Africa?

A child raised in India is far more likely to be malnourished than one from the Democratic Republic of Congo, Zimbabwe or Somalia, the planet’s poorest countries. Stunting affects 65 million Indian children under the age of 5, including a third of children from the country’s richest families.....
No Indian city has a comprehensive waste treatment system, and most Indian rivers are open sewers as a result. But Varanasi, India’s oldest and holiest city, is so awash in human waste that its decrepit condition became a national issue in recent elections. The city’s sewage plants can handle only about 20 percent of the sewage generated in the city, said Ramesh Chopra of Ganga Seva Abhiyanam, a trust for cleaning the river. The rest sloshes into the Ganges or fetid ponds and pits.

Millions of pilgrims bathe in the Ganges along Varanasi’s ancient riverfront, but a stream of human waste — nearly 75 million liters per day — flows directly into the river just above the bathing ghats, steps leading down to the river. Many people wash or brush their teeth beside smaller sewage outlets.

Much of the city’s drinking water comes from the river, and half of Indian households drink from contaminated supplies.

“India’s problems are bigger than just open defecation and a lack of toilets,” Dr. Laxminarayan said.


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