India Lags Sub-Saharan Africa in Public Hygiene

[Riaz Haq]

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":



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India and Pakistan Contrasted

[Riaz Haq]

Hindus are less likely to use a toilet than Muslims in India
MICHAEL GERUSO and DEAN SPEARS 27 March, 2018

https://theprint.in/governance/hindus-are-less-likely-to-use-a-toil...

Data reveals 25% of Hindus who own toilets don’t use them, only 10% of Muslims do the same.

Far from his dwelling let him remove urine and excreta –The Laws of Manu (a Hindu sacred text), Chapter 4 verse 151

More than half of the Indian population, over 600 million people, defecate in the open, without the use of a latrine or toilet. The prevalence of open defecation (hereafter OD) is particularly high among India’s Hindu majority. Data from the most recent wave of the National Family Health Survey (NFHS) of India show that as of 2005, 68% of Hindu households defecate in the open—e.g., in fields, near streets, or behind bushes. In comparison, only 43% of the relatively poorer Muslim households do so.

To investigate these patterns in more detail, we turn briefly to the Sanitation Quality, Use, Access, & Trends survey, which was collected by one of this study’s authors in rural northern India in 2013 and 2014. Unlike our main analysis dataset, the NFHS, this survey was specifically designed to elicit preferences over latrine use. We use it here to provide a clearer context and understanding of the stark demand differences we exploit below.

The roots of these behavioural differences are difficult to trace and are beyond the scope of this paper. Sanitation practices may have evolved differently across Muslim and Hindu communities for purely secular reasons, and could have been privately or socially optimal given the context under which they arose. Even specific religious instruction with respect to sanitation and hygiene that we observe today may have been established long ago— codifying then-existing norms, rather than establishing those norms. Regardless of the historical path, we show here that religion is a highly predictive marker for group differences.

While we take no position on whether religion causes OD per se, it is common for Indians to discuss waste disposal choices with reference to religious purity. Row 4 of Table 1 shows that a substantial fraction of both Hindu and Muslim respondents self-report that a religious leader has told them explicitly where to defecate. The last two rows of Table 1 show that Hindus are more likely than Muslims to respond that OD away from the home is pure, while using a latrine near the home is not pure. All Hindu-Muslim differences in the table are statistically significant at the 5% level.

The possibility that open defecation would ever be chosen if a working toilet or latrine were available may be surprising to many readers, but these patterns, and indeed the Hindu-Muslim behaviour difference itself, are well known to many residents of rural India.

Moreover, this behaviour has long been recognized and documented publicly: Cultural scholars attribute the modern persistence of OD among Hindus in India to the persistence of the Hindu caste system, with its ritual avoidance of excreta. Recently, Hindu politicians across the political spectrum have publicly recognized this pattern. And nearly a century ago, Gandhi campaigned to change Indian behaviour with respect to excreta disposal, famously declaring, “Sanitation is more important than independence.”

[Riaz Haq]

Open Defecation in India: A Major Health Hazard and Hurdle in Infection Control
Paurush Ambesh1 and Sushil Prakash Ambeshcorresponding author2
Author information ► Article notes ► Copyright and License information ► Disclaimer
Sir,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5020240/

“Cleanliness is next to Godliness”, a proverbial adage that traces its inception to ancient Indian times, is the epitome of irony in the current Indian health situation. The lost Indus Valley Civilization, with modern cities like Harappa and Mohenjodaro, was once the gold standard of sanitation infrastructure. Its extensive and efficient sewage system was not only an exemplary gem, but also a gift of knowledge to entire mankind. However history resides in books and has little relevance to the current situation.

Though over the last 50 years, the general health of Indians has improved and the life expectancy has increased, myriad health and sanitation problems still stare one in the face. The biggest one, open defecation, is the mother of all infection and morbidity. The WHO declared the year 2008 as International Year of Sanitation. It was here that the term ‘Open Defecation’ was widely publicized. Community Led Total Sanitation (CLTS) programs helped spread the term all around the globe.

It is a matter of national concern as India has the most number of people practicing open defecation in the world, around 600 million [1], and is followed by Indonesia, Pakistan, Nigeria and Ethiopia. Still these countries come nowhere close to the staggering number contributed by India.

Most of it occurs in villages with a prevalence of 65% [2]. In urban settings the prevalence is close to 16%. The problem has thick deep roots with a multi-factorial origin. Unavailability of proper toilets or toilets with dimly lit, broken or clogged latrines is common. However, the biggest problem is the mindset of people in both rural and urban settings. Children grow watching parents and grandparents practice open defecation. Most farmers believe that waking up early and defecating in the field, not only adds natural fertilizer to the soil, but also rejuvenates the bowel and the mind.

Open defecation is a major cause of fatal diarrhea. Everyday about 2000 children aged less than five succumb to diarrhea and every 40 seconds a life is lost [3]. It is depressing that all this needless suffering is actually preventable. In densely populated countries like India, the health impact is magnified many fold [4]. There is evidence to suggest that water sanitation and hygiene practices are associated with child linear growth [5]. Children have a tendency to put common things in their mouth. In rural settings where open defecation is prevalent, large amounts of fecal pathogens via human and animal feces, are ingested by children. This creates a massive reservoir of bacteria, parasites and viruses that keep spreading gastrointestinal infection. An eventual result is growth stunting and malnutrition.

Though the health challenges seem to compound with time, the health budget allocation by the Government of India is getting smaller every year. This year also it is quite meager, only about 1% of the Gross Domestic Product. This may put financial constraints on dealing with sanitation linked diseases.

[Riaz Haq]

Connection between open defecation and rape in India: 

An incident in Badaun district, where two teenage sisters who ventured out to defecate due to lack of a private toilet, were raped and murdered, stimulated the masses into anger and dissent. Investigating authorities admitted that 95% of all rapes in India occur when girls go out alone in secluded places, to urinate or defecate. Delinquent men have been known to cluster at such locations, awaiting helpless victims. Similar situation exists in many African countries like Kenya, Zimbabwe and Somalia. Thus, a direct correlation between crime and open defecation seems to exist.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5020240/

[Riaz Haq]

Open defecation leads to sexual #violence and #rape in #India.There is a rapid and alarming increase in violence against #women in India. #ViolenceAgainstWomen #crime #OpenDefecation #toilets #sanitation

https://www.livelaw.in/open-defecation-and-violence-against-women-s...

There is a rapid and alarming increase in violence against women in India. The National Crime Records Bureau has reported 3,09,546 cases on of rapes in 2013, but these statistics do not highlight the varied circumstances in which these offences were committed, including the lack of sanitation facilities and the practice of open defecation. In order to fill this gap, our judicial decisions involve the offence of the rape as defined under Section 376 of the Indian Penal Code (IPC), 1860. However, in the research, only those cases are considered where the offence was committed when the victim went for, was engaged in or was returning from answering the call of nature or relieving herself. This section reproduce...

[Riaz Haq]

#India won't get ODF (Open Defecation Free) status by February 2019: CSE....the rush to achieve targets has led to false claims. 
#sanitation #toilets #hygiene #rape #Modi #BJP http://www.ecoti.in/zJBrLY via @economictimes

1,00,000 tonne of excreta every day produced by 720 million people using 144 million household toilets -- just to give a sense of scale, more than 5,200 trucks would be needed every day to transport this amount of excreta! 

The CSE has based this estimate on the standard calculation that on an average, an individual produces 128 gram of excreta every day. 

[Riaz Haq]

What is superbug NDM-1’s India connection?
After a 70-year-old American woman died of the superbug NDM-1 (New Delhi Metallo-beta-lactamase-1) in November last year, health officials recently revealed that her infection was resistant to all the available antibiotics, raising major concerns in the health community.

https://www.hindustantimes.com/health-and-fitness/what-is-superbug-...

Here’s all you need to know about the superbug, the infection it causes, where it’s found and its effects:

NDM-1 (New Delhi Metallo-beta-lactamase-1) is an enzyme that makes bacteria resistant to a wide range of powerful antibiotics, including the carbapenem class of antibiotics that are used to treat multidrug-resistant infections.

The gene for NDM-1 encodes beta-lactamase enzymes called carbapenemases, which makes bacteria resistant to antibiotics, including carbapenem, which is used to treat other superbugs such as methicillin-resistant Staphyloccus aureus (MRSA).

Bacteria that produce carbapenemases are popularly referred to as superbugs because they are difficult to treat and result in the infection spreading easily within the body, especially in people who are ill or recuperating from an illness or a surgery.

People die of septic shock after the infection enters the bloodstream and reached the heart, lungs, kidneys, bones or joints to cause multi-organ failure.

The enzyme that makes bacteria drug resistant got New Delhi in its name because it was first detected in 2008 in Swedish patient of Indian origin who had travelled to India.

NDM-1 has been detected in bacteria in the UK, US, India, Pakistan, Croatia, Canada and Japan.

The first death was recorded in Belgium, where a man who was treated in a hospital in Pakistan died in August 2010.


The most common bacteria that make this enzyme are E. Coli and K. pneumoniae, but the NDM-1 gene can spread to other bacterial strains.

[Riaz Haq]

NDM-1 in India: Drug Resistance, Political Resistance

https://www.wired.com/2011/10/ndm1-india-politics/


It's been more than a year since the "Indian superbug" NDM-1 – not actually a bacterium, but a gene that directs production of an enzyme – hit the news. The enzyme, whose acronym is short for New Delhi metallo-beta-lactamase-1, disables almost all antibiotics directed against it, leaving the bacteria in which the gene appears vulnerable to only two imperfect and sometimes toxic drugs.

The enzyme and its gene, blaNDM-1, were first identified in 2008 in people who had traveled in India or sought medical care in South Asia. Hence its name: Many beta-lactamases, enzymes that denature the very large class of everyday antibiotics known as beta-lactams, are named for countries and cities where they were first identified. Since its identification, NDM-1 has been discovered in patients in more than a dozen countries and has also been found to be widely harboured outside hospitals in India, and in surface waters and sewage there.

The unveiling of NDM-1 clearly caused embarrassment for India, and media and lawmakers there struck back, throwing around intemperate language and claiming the naming of the enzyme was a plot to derail the subcontinent's medical-tourism industry — even though the Indian doctors hadattempted to raise the alarm earlierand had been ignored.

So it seemed like a promising signal of openness when an international conference on antibiotic resistance opened in New Delhi a week ago. But in its wake, just what is going on in India – and whether its government is willing to face up to what might be an international crisis – is less clear than ever.

------------------

If India is moving to contain NDM-1, it is doing so barely in time. Dr. Timothy Walsh, who first isolated the gene and enzyme in a resident of Sweden who had been hospitalized in India, told the Times of India:

We estimate that the carriage rate of NDM-1 in India is between 100 and 200 million, which means that NDM-1 has become a very serious public health issue... With globalization, NDM-1 will continue to spread unchecked around the world and once established in higher enough numbers in a particular country, will further disseminate.

We are desperate to help in any way we can to initiate studies to realize the full impact of NDM-1 on Indian society... I cannot say whether the Indian government is finally taking the issue seriously – only they can answer that charge. However, what is clear is that we have lost a year fighting amongst ourselves when our energies and resources should have been focused elsewhere – on NDM-1.

[Riaz Haq]

The growing peril of drug-resistant superbugs

Many in India face a similar fate – they get admitted to hospitals with seemingly treatable illnesses, only to contract HAIs caused by superbugs.

https://www.hindustantimes.com/india-news/the-growing-peril-of-drug...

Manoj Ghamandayan, 21, has little memory of the month he was hospitalised and nearly died.

It started out as a fever in the first week of October 2019. Then he began to have trouble breathing. Soon, Ghamandayan, an undergraduate Arts student from Haryana’s Jhajjar district, was admitted to Sunflag Global Hospital in Rohtak. He was diagnosed with dengue, a viral infection spread by the Aedes mosquito and scrub typhus, a bacterial infection. To help him recover, the hospital hooked him to multiple devices: a mechanical ventilator to aid breathing, a catheter for draining urine, and a central line to pump medicines into his body.

But Ghamandayan got sicker. During his two-week stay at the hospital, he caught three healthcare-associated infections (HAIs) or infections that patients catch at hospital. Invasive devices like ventilators, central lines and catheters pose the risk of HAIs because they breach the body’s protective barriers.

For example, a ventilator’s breathing tube could easily transfer bacteria from a nurse’s hands to the patient’s lungs, triggering pneumonia.

Ghamandayan came down with two bacterial infections, Escherichia coli and Acinetobacter baumanii, and a fungal species called Candida.

These pathogens were superbugs — i.e, resistant to multiple antimicrobial drugs — which make them hard to treat. His family moved him to New Delhi’s Sir Gangaram Hospital, where his doctor, Atul Gogia, deployed two last-line antibiotics called colistin and meropenem —both expensive, with toxic side effects. Yet these drugs are the only hope for patients when all else fails.

Ghamandayan eventually got better and was discharged nearly a month after he was first hospitalised. In all, he had spent Rs 6 lakh on his treatment.

Many in India face a similar fate – they get admitted to hospitals with seemingly treatable illnesses, only to contract HAIs caused by superbugs.

Few Indian hospitals track their HAI rates, which is why it is hard to get a countrywide picture of this problem.

But several stand-alone studies show that India has higher rates compared to richer countries like the US. For example, a study by the International Nosocomial Infection Control Consortium, which surveyed data from 40 hospitals in 20 cities in India, between 2004 and 2013, found that for every 1,000 days that patients were hooked to ventilators in Indian cardiac Intensive Care Units, there were around 11 times as many pneumonia cases as in American hospitals. “The rates of infections in Indian hospitals are just unacceptably high,” says Ramanan Laxminarayan, a public-health expert at Washington DC’s Center for Disease Dynamics, Economics & Policy (CDDEP).

But that’s just part of the problem. Many of the bugs that cause these infections have learnt to tolerate powerful antimicrobial drugs. Unpublished 2019 data from a 20-hospital surveillance network run by the Indian Council for Medical Research (ICMR) shows that key hospital bugs, like Acinetobacter baumanii and Klebsiella pneumoniae, have grown widely drug-resistant.

Patients infected with any of these bugs often have to be treated with last line drugs, which are both expensive and toxic. Many of them succumb: A 2018 study, carried out in 10 Fortis Group hospitals found that patients with multidrug resistant infections were almost thrice as likely to die as those with susceptible ones.

While there are no India-wide estimates of how many people die due to antimicrobial resistance, Laxminarayanan pointed out that a bulk of the deaths take place in hospitals. “So, if I were to prioritise measures to tackle drug resistance, infection control in hospitals would be number one.” To be sure, HAIs have always been a risk to hospitalised patients globally. But increasing antimicrobial resistance is throwing a new spanner in the works; it is turning previously curable maladies into death sentences. The problem is that infection-control is not easy. It requires hospitals to aggressively push a range of best practices, including frequent hand washing, and caution while setting up devices like ventilators and catheters. Not enough hospitals check these boxes.

[Riaz Haq]

As outbreaks of the coronavirus spread throughout the world, people are reminded over and again to limit physical contact, wash hands and avoid touching their face. The recent Netflix docuseries “Pandemic: How to Prevent an Outbreak” illustrates how the Islamic ritual washing, known as “wudu,” may help spread a good hygiene message.

https://theconversation.com/what-islamic-hygienic-practices-can-tea...

The series focuses on Syra Madad, a Muslim public health specialist in a New York hospital, who takes a break to say her prayers at the Islamic Center of New York University. Before entering the prayer room, Madad stops to perform wudu, and washes her mouth and face as well as her feet.

Islamic law requires Muslims to ritually purify their body before praying. As a scholar of Islamic studies who researches ritual practices among Muslims, I have found that these practices contain both spiritual and physical benefits.

Ritual purity
The Prophet Muhammad left detailed guidance for Muslims on how to live their lives, including how to pray, fast and stay ritually pure. This guidance is available in collections called the Hadith.

According to Islamic law, there are minor and major impurities. Minor impurities involve urinating, defecating and sleeping, among other practices. A person of Muslim faith is supposed to perform a ritual washing of their bodies before praying to get rid of these minor impurities.

Wudu is to be performed, as was done by the Prophet Muhammad, in a specific order before praying, which takes place five times a day. Before each prayer, Muslims are expected to wash themselves in a certain order – first hands, then mouth, nose, face, hair and ears, and finally their ankles and feet.

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Muslim institutions have begun to recommend that people make sure to wash their hands for 20 seconds with soap before doing wudu. Emphasizing that wudu alone cannot prevent the virus from spreading, other Islamic institutions recommend that mosques supply extra soap and hand sanitizer near the washing area.

They have issued rulings to cancel Friday prayers, urged Muslims to wash their hands with soap regularly, refrain from touching their face and practice social distancing.

While people have cleared local store shelves of hand sanitizers, wipes, cleaning supplies, gloves and masks, basic hygiene practices remain the best way to prevent the spread of the coronavirus and other viruses.

At this time, Islamic practices that emphasize purity of body could help reiterate the importance of hygienic practices along with the use of soap or hand sanitizer, to reduce one’s vulnerability to the virus.

[Riaz Haq]

Ten newborn babies have died in a fire at a #hospital in #India's #Maharashtra state. The fire was caused by a short circuit in the SNCU (Sick Newborn Care Unit). #MedicalTourism #Health #Modi https://www.cnn.com/2021/01/09/india/india-hospital-fire-babies-int...

Ten newborn babies died in a hospital fire in the western Indian state of Maharashtra on Friday, according to the country's state-run broadcaster Doordarshan.

The fire broke out in a local hospital's Sick Newborn Care Unit (SNCU) in Maharashtra's Bhandara district, Doordarshan said in a tweet on its verified Twitter account. Firefighters rescued seven other babies from the unit.
The fire was caused by a short circuit in the SNCU, said CNN affiliate CNN-News18, citing Maharashtra Health Minister Rajesh Tope.
"The investigations are going on," Tope said, adding that $6,813 (5 lakh Indian rupees) would be paid in compensation to each of the families affected. The state will also bear funeral and counseling costs.
"Whosoever is guilty in this will not be spared at all," Tope said. "It should be ensured that such type of incidences do not occur henceforth."
Indian Prime Minister Narendra Modi mourned the incident on Saturday morning. "Heart-wrenching tragedy in Bhandara, Maharashtra, where we have lost precious young lives. My thoughts are with all the bereaved families. I hope the injured recover as early as possible," he wrote on Twitter

The office of Indian President Ram Nath Kovind also tweeted in Hindi, "I am deeply saddened by the untimely death of infants in a fire accident in Bhandara, Maharashtra. My heartfelt condolences to the families who lost their children in this heartbreaking event."
Home Minister Amit Shah said in a tweet that he was "pained beyond words" by the "irreparable loss."
The country's Health and Family Welfare Minister, Harsh Vardhan, said he was in touch with Tope about the incident.