It is well known that access to clean water and proper sanitation facilities play a key role in maintaining public health. In this interview Pragya Akhilesh tells us how the absence of proper toilets has exacerbated India’s health crisis amidst the Covid-19 pandemic.

Q) Is it true that toilets have become hotbeds for disease spread in the pandemic?

A) The lockdown has had its own problems with decreasing toilet usage. In 2020, there has been a massive decline in actual toilet usage in rural India. This is mainly because toilets are in poor shape, roofs are falling, doors are breaking or soggy and there is an acute shortage of water supply. The outcome of this is that toilets have become hotbeds for disease spread. The sanitation workers are cleaning these toilets without the accessibility of any kind of protection gear. The government’s silence on toilet maintenance is shocking as the ‘value of service’ is declining and because of that all the pressure falls on the sanitation workers. All through the lockdown the sanitation workers have continued this work but they have not been given their due like health care professionals in India.

Q) You have been recording 10 lakh toilets in India and have found 46,000 new dry latrines in active use just in the lockdown. Can you tell us about it?

A) Despite the Prohibition of Employment as Manual Scavengers and their Rehabilitation (PEMSR) Act, 2013, the implementation in the informal settlements in the rural areas of India is completely fractured therefore ‘dry latrines’ are one of the biggest crises in 2021 India. These toilets damage the health of the sanitation workers and the communities severely. In the India-Bangladesh border areas, we found a series of many ‘hanging toilets.’ The unmanaged effluents mix with nearby water bodies even polluting the drinking water! Because these areas are remote, there is no accessible sanitation coverage. Lockdown has also resulted in communities building ‘dry latrines’ by digging small pits in nearby compounds, because women do not feel comfortable sending their children to far-away toilets.

Q) The government and institutions are spending so much on the Swachh Bharat Abhiyan. Then why is there still the prevalence of these types of toilets?

A) In India we are only focusing on building toilets. There is less focus on eradication of the previously constructed dry latrines. There is a vast difference between the database of the urban and rural sanitation coverage in India. The hanging toilets and the dry latrines found in the semi-urban and rural areas have continued to exist also because we have not been able to reach them. The sanitary toilets built under the Swachh Bharat Abhiyan (SBA) have their own unique problems. In this way both, insanitary and newly constructed sanitary toilets, have become burdens for India’s sanitation workers. There is no focus on the fact that 80 per cent of the sanitation workers are not even reaching the age of retirement. Even within sanitary toilets they are forced to manually scavenge excreta because of non-availability of continued water supply.

Q) Why is there a non-availability of continued water supply in spite of increasing water coverage in the last decade?

A) In rural areas, even in the households which have improved water coverage like the availability of piped water supply, long power cuts hinder toilet usage. If there are 6 to 8-hour power cuts then how will the tanks get filled enough for every flush. People therefore leave the toilets without flushing them. Even the pour flush technique can only be accessed if there is an availability of unimproved water supply nearby. This again puts focus on the proximity of the water supply for single toilet usage from mobile containers. So, if the built-in water supply cannot be used then the procedure becomes very complex even after the efforts to integrate water services with sanitation services in every toilet.

Q) Can dirty toilets be also the reason why people prefer to defecate in the open?

A) Many women still chose to defecate in the open even in big cities like Delhi and Mumbai. For example, people defecate on banks of Yamuna early in the morning in Delhi. This is also because the amount of water in the containment is not directly proportional to the number actually using it. So, if you are going to use the toilet after 9 A.M there is no water left anymore. So, community toilet building is completely different to household toilet building. The water usage and tank capacity have to be kept in mind, otherwise people will continue to defecate in the open. Another important aspect is toilets without continued water supply become hotbeds for disease spread. The government has no understanding of the current state of the toilets they have probably built 5 years ago. While sanitation workers continue to get sick, forced to clean these toilets, hundreds of these toilets are in poor shape and almost abandoned.

*The interview was conducted by the Co-ordinator, Sulabh Sewa Campaign, Mumbai.

Related:

Safai Karamchari Andolan campaigns against dry latrines
Govt aims to eliminate manual scavenging by August 2021 

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D P L Simon/Shutterstock.com

For people to invest in sanitation, they need to access the kinds of toilets and services that they want to use. One of the benefits of safe sanitation – and one that motivates many to invest in it – is better physical well-being. But messages about preventing disease are often insufficient to change behaviours.
One approach that combines behavioural change with improved access to sanitation products and services is sanitation marketing programmes, defined as:
 

The application of the best social and commercial marketing practices to change behaviour and to scale up the demand and supply for improved sanitation, particularly among the poor.

Toolkits and guides to develop and implement sanitation marketing have been published recently, as have region- and country-specific manuals produced by NGOs and government agencies. There is a growing community working in this area, evidenced by reports and discussions of projects across the globe.

An unsafe toilet next to an informal settlement in Fiji. Author’s own, Author provided
 

Reviewing past outcomes

In most such programmes, an external support agency conducts market research and then assists local entrepreneurs in developing a market in which to sell products and services. These might be toilet slabs and superstructures, pay-per-use toilets or pit emptying for latrine owners. The programmes normally include advertising campaigns to encourage uptake of safe sanitation.

This may seem like a sensible approach, but we and our colleagues suspected that some of these programmes use practices that adversely affect some people. In a new paper, we review 33 sanitation marketing programmes to understand what practices are used and the outcomes reported. Four of the 33 programmes reviewed reported the following adverse effects:
 

• The death or injury of someone falling into a badly constructed latrine pit;
• Social unrest where entrepreneurs were viewed as being subsidised and not passing on the benefits;
• Negative impacts on social cohesion due to conspicuous consumption, where customers are encouraged to purchase items so as to enhance their social status;
• The shock, shame and disgust of intended beneficiaries when practices criticised their personal sanitation behaviours.

We were particularly interested in conspicuous consumption and the criticism of personal sanitation behaviours, because these were common in the 33 cases we reviewed. Sixteen included practices which promoted conspicuous consumption and ten included practices which criticised individuals who did not use a safe toilet.

Use of status and shame

Conspicuous consumption occurs when improving status is emphasised in promoting products and services. In this case, that means attempting to convince potential buyers that investing in sanitation will enhance their standing compared to those around them. This is achieved, for example, through promoting toilets as a status symbol, and invoking peer pressure to increase sales. The idea of “Keeping up with the Joneses”, a worldwide phenomenon whereby people purchase goods and services so as to socially and financially keep up with, or outdo, their neighbours, is very much at work here.

Some sanitation marketing programmes set out to make people feel disgusted by their sanitation behaviour to encourage them to invest in the product or service on offer. One example in Indonesia portrayed a character who defecates in the open, Lik Telek (“Uncle Shit”), as a threat to his community. One of the programme’s posters portrayed Lik Telek being driven out of his village for not investing in sanitation, reading:
 

My village is clean and healthy. No stench, no flies, and no more Lik Telek. The whole village is more dignified.

Although many of the programmes we looked at which employed such tactics evaluated their impact in terms of whether toilets were purchased or used, few evaluated their impacts on well-being. But personal dignity is a human right that can be or is eroded by these practices. Reduced dignity is associated with poor physical and psychosocial well-being in the form of depression, social anxiety and alienation.

A banner in a Nepali village promoting safe sanitation, as open defecation is ‘only for cows’. Author’s own
 

Adverse effects

Safe sanitation protects and improves physical well-being for those who acquire and use it, and for those around them. One person using a toilet reduces the amount of excreta entering the environment, with benefits community-wide for those who use toilets and those who do not. It has been argued that temporary loss of dignity leading to the adoption of behaviours that are beneficial to both the individual and community is tolerable.

This argument is only sound so long as the remedy – safe sanitation – is universally achievable. But there are often disadvantaged people who are unable to invest in safe sanitation (for financial reasons, perhaps, or because they are physically unable to contribute to construction). Many sanitation marketing programmes do not provide subsidies or other pro-poor strategies which may assist because such practices are considered to “distort the market”. Individuals who do not acquire safe sanitation are particularly susceptible to reduced well-being, and they will be unable to remedy this.

During the design and implementation phases of sanitation marketing programmes, external support agencies need to understand sanitation marketing’s potential to reduce well-being. If practices that erode dignity are used, then such agencies must consider how the programme will eventually restore it.

During the design and implementation phases of sanitation marketing programmes, external support agencies need to understand sanitation marketing’s potential to reduce well-being. If practices that erode dignity are used, then such agencies must consider how the programme will eventually restore it.

Dani J Barrington, Lecturer in Water, Sanitation and Health, University of Leeds and Jamie Bartram, Director of the Water Institute, University of North Carolina – Chapel Hill

This article was originally published on The Conversation. Read the original article.

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Uttar Pradesh (UP), Bihar, Madhya Pradesh (MP), Assam and Chhattisgarh had India’s highest under-five mortality, higher stunting (low height-for-age) rates and higher prevalence of diarrhoea due to lack of “improved sanitation”–usually a house with its own latrine connected to a sewer or septic tank–according to the National Family Health Survey 2015-16 (NFHS-4).
 
Unsafe water, poor hygiene practices and inadequate sanitation are not only the causes of the continued high incidence of diarrhoeal diseases but a significant contributing factor in under-five mortality caused by pneumonia, neonatal disorders and undernutrition, according to this 2016 report by the United Nations Children’s Fund.
 
Poor sanitation makes unhealthy children prone to water-borne diseases such as diarrhoea, jaundice and cholera, as IndiaSpend reported on January 6, 2016.
 
Improved sanitation, as we said, refers to a household with its own toilet, connected to a piped sewer system or flush to septic tank, flush to pit latrine, ventilated improved pit/biogas latrine, pit latrine with slab, twin pit/composting toilet, which is not shared with any other household.
 

Source: National Family Health Surveys 2005-06 and 2015-16
Under-five mortality rate: deaths of children under the age of five per 1,000 live births
 
India’s under-five mortality rate–deaths of children under the age of five per 1,000 live births–declined from 74 in 2005-06 to 50 in 2015-16. Over the same time period, households with have improved sanitation have gone up from 29.1% to 48.4%.
 
Bihar has the the lowest percentage (25%) of households with improved sanitation, and the state recorded an under-five mortality rate of 58 deaths per 1,000 live births in 2015-16.
 
One of the leading causes of under-five mortality is diarrhoeal diseases, mostly caused due to lack of sanitation, according to this 2015 study by Public Health Foundation of India, a Delhi-based think tank.
 
Bihar is followed by Chhattisgarh, with only 32.7% of households reporting use of improved sanitation facilities.
 
Uttar Pradesh has the highest under-five mortality (78 deaths per 1,000 live births) and only 35% households reported use of improved sanitation facilities.
 
Only 44% rural households in UP reported toilet coverage till October 2016 under the Swachh Bharat Abhiyan (Gramin), a central government programme to make India open defecation-free by October 2, 2019.
 
As many as 77% rural households practice open defecation (as against the national average of 55%), IndiaSpend reported on October 1, 2016.
 

 
Diarrhoeal diseases are the third largest cause of deaths among children under the age of five in India, according to this 2015 study by Indira Gandhi Medical College and Research Institute, Puducherry.
 
UP, with the highest under-five mortality rate of 78, also reported the highest prevalence (15%) of children suffering from diarrhoea prior to the survey.
 

Diarrhoeal diseases are also responsible for stunting in children (low height-for-age), according to this 2015 study by The institute of Fiscal Studies, a UK-based think tank.
 
“Growth failure (stunting), often associated with poor nutrition, is correlated, likely in a causal way, with lower educational and labour market attainments,” the study said.
 
(Salve is an analyst with IndiaSpend.)

Courtesy: India Spend
 

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It has taken the workers a decade to get relief from an exploitative contract system followed by the Mumbai Municipal Corporation. 

For ten years the battle wore on in the Courts until the Bombay High Court gave a verdict in the worker’s favour. Two thousand seven hundred workers were not only made permanent but they were awarded backwages from 2007. A victory indeed.

That did not signal the end of the ordeal, however. The Mumbai Mahanagar Palika, a cash rich city corporation,  reviled for its inefficiency and corruption, appealed the order in the Supreme Court. After 10 years of litigation to demand permanent jobs, a Supreme Court order on April 7 signaled a triumph for 2,700 sanitation workers in Mumbai. The workers, who were forced to work on short-term contracts for the past 10 to 20 years, are now not only entitled to permanent jobs with the Mumbai municipal corporation, but will also receive two years payment as arrears. The SC reduced the back wages to just two years.

Over 93-94 per cent of India’s workforce is in the unorganised sector; getting permanent employment here with the civic authority means that the workers will now also be able to claim the right to take weekly offs, medical leave and other leave without a salary cut.

Kachra Vahtuk Shramik Sangh, a union of sanitation workers in Maharashtra, had first filed a case in the industrial tribunal of Mumbai, in 2007, on behalf of the 2,700 workers. The tribunal took seven years to rule in favour of the workers, granting permanent employment to the sanitation workers in October 2014. The Mumbai municipal corporation, however, immediately challenged the tribunal order in the Bombay High Court, which also ruled in favour of the contract workers in December 2016.The corporation appealed once more, but on Friday, the Supreme Court dismissed the petition.

“This is a double victory – not just for these 2,700 workers but for contract workers in general,” said Milind Ranade, general secretary of the Kachra Vahtuk Shramik Sangh. “At a time when the country’s labour laws are under threat and when employers have the right to sack contract workers for joining a union, this judgement will boost the morale of those working under contracts.”

An exploitative system
Mumbai’s civic body employs more than 35,000 sanitation workers who sweep streets, clean sewers, collect garbage and transport it to dumping grounds. The majority of these workers, however, are not permanent employees of the corporation. They are hired through a complex network of contractors and sub-contractors, many of whom claim to be non-profit entities.

According to the union, it is routine for contractors to deny labourers timely wages, protective masks and gloves, paid leave and medical expenses for injuries sustained at work. The poor work conditions take a severe toll on the health and life expectancy of workers. In 2015, a study by the Mumbai civic body found that 1,386 sanitation workers had died in just six years. Devious means and manipulations are employed by contractors to keep workers tied to this exploitative contract system.

The Industrial Disputes Act of 1947 allows all contract workers the right to demand a permanent position if they have worked continuously in a particular job for 240 days, because by law, contract work cannot be perennial in nature. To skirt this law, contractors often hire workers on short contracts of 210 days, after which they are made to sign new contracts.

Meanwhile, the Contract Labour Act of 1970, which specifically provides labour rights to contract workers, is applicable only to establishments that employ more than 20 workmen. But the Mumbai civic corporation has been outsourcing its sanitation work to more than 200 different small contractors, who hire less than 20 people in order to be exempt from the Contract Labour Act.

Unions like the Kachra Vahtuk Shramik Sangh have been hesitant to demand a complete abolishment of the contract system out of fear that thousands of workers could lose their jobs. Instead, the union has been approaching the labour court with a series of petitions, seeking permanent jobs for different batches of workers.

The Mumbai industrial tribunal, however, has noted the illegalities in the contract system with respect to sanitation work. In its 2014 judgement, while granting permanent jobs to the 2,700 workers, the tribunal noted that sanitation work in a city is squarely the responsibility of the municipal corporation, and cannot be outsourced through contractors. It further noted: “This tribunal has turned down the entire contract system by holding it as sham and bogus.”

When the municipal corporation appealed this order, the High Court not only upheld the tribunal’s judgement but also pointed out that the appeal reflected the lengths to which the corporation had gone to “deprive the benefits of permanency” to the sanitation workers.

The corporation took the case further nonetheless, only to be ordered by the Supreme Court to grant permanent employment to the 2,700 contract workers. The apex court also ordered the corporation to provide employment to relatives of sanitation workers who died during the pendency of the long litigation.

Finally, the corporation has been ordered to pay the workers the additional wages they would have received had they been granted permanent jobs after the tribunal’s judgement in 2014. “This amounts to around Rs 2.5 lakh per worker for the past two years,” said Ranade.
 
 

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