Valuing Toilets

As the World Toilet Day site says: ‘Life without a toilet is dirty, dangerous and undignified. Public health depends on toilets. Toilets also drive improvements in gender equality, education, economics and the environment. There will be no sustainable future without toilets.’

3.6 billion people across the world still lack access to safe sanitation.

World Toilet Day is observed on 19 Nov every year as a way to remind ourselves of this situation. This year, the theme as declared by the UN is Valuing Toilets. World Toilet Day is an occasion to remind ourselves of a goal the world is committed to, viz, Sustainable Development Goal  6, which is about Clean Water and Sanitation. Specifically under this Goal, the sub-goals related to sanitation are:

6.1 By 2030, achieve universal and equitable access to safe and affordable drinking water for all

6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations

6.A By 2030, expand international cooperation and capacity-building support to developing countries in water- and sanitation-related activities and programmes, including water harvesting, desalination, water efficiency, wastewater treatment, recycling and reuse technologies

6.B Support and strengthen the participation of local communities in improving water and sanitation management

India has made some progress, but there is still a long way to go. Creating infrastructure is the easier part. Bringing about behaviour change to get people to use toilets; to ensure water supply; to ensure maintenance and functionality—these are the bigger challenges that we still have to tackle.

This is where innovations are needed. And are happening. A very interesting publication ‘ 10 Innovative Approaches To Improve The Urban Wa-S-H Sector In India’ brought out by the  USAID and the National Institute of Urban Affairs documents some of these. Here are some of the most interesting:

Creation Of A Urine Bank and Collection by A Special Vehicle and Its Utilization as Fertilizer: Society for Community Organization and People’s Education (SCOPE), a Trichy based NGO, has tried this experiment in Musiri, Tamilnadu. Basically, they separated urine and faeces at the household/institution level through the use of ECOSAN toilets. About 400 litres of urine, which is good fertilizer, were collected with the help of a special van, suitably treated, diluted and put into use in agriculture. The application increased yields and was found to be cost-effective.

Waterless Urinals to Conserve Fresh Water, Save Energy and Reduce Maintenance Costs: This IIT-Delhi incubated innovation is for urinals in public spaces. It avoids the use of water for flushing. This is a considerable amount of water saved, for each flush uses from 4 to as much as 15 litres of water. The odour control mechanism like the sealant liquid, membrane trap and biological blocks are used to substitute for flushing.

I have personally had some experience of this innovation, having installed it in one of the public toilets we built and maintained in Hyderabad, and it worked pretty well.

Vandal Proof, Easy to Maintain and Durable Toilets: Anyone, like me, who has experience of managing public toilets, knows that vandalism, breakage, and irresponsible usage of the facilities are an inevitable and unpleasant part of a difficult job. This is one reason why the recurring costs of running such toilets is high. GARV toilets, an innovation tried in Faridabad, use stainless steel for the superstructure of the toilet pan and wash basin, rather than the less durable china clay or porcelain. This not only increases the life of various utilities in, but also reduces maintenance cost and water needed for cleaning. This innovation was apparently born out of the desire of a manufacturer who wanted to use the steel lying around in his factory. If you think through it, it is the approach used by the Indian Railways for maybe over a century now, and if it can work in our trains, it can work anywhere!


The publication is over five years old, and the innovations discussed go back even a decade. Some, like waterless urinals, have found wide application. Hopefully, the others have been also diffused far and wide, picked up and improved further.

The need to scale up and innovate in the sanitation sector is urgent. There is no better way to put it than to sum it up than in Gandhiji’s words: ‘A lavatory must be as clean as a drawing-room ‘.

–Meena

Smiling is Infectious

Among the many “pick-me-up” messages that are circulating these days is a poem that exalts the magical power of a smile. The poem is attributed to Spike Milligan, a British comic poet, actor, playwright and author. The son of a British military officer, Spike Milligan was born in Ahmednagar and spent his growing up years in India, and this is reflected in several of his poems.

I have always enjoyed his tongue-in-cheek poems, but I had not seen this one before.

Smiling is infectious

You catch it like the flu

When someone smiled at me today

I started smiling too

I walked around the corner

and someone saw me grin

When he smiled I realised I

I’d passed it onto to him.

I thought about the smile

And then realised its worth

A single smile like mine

Can travel across the earth.

So if you feel a smile begin

Don’t leave it undetected

Let’s start an epidemic quick

And get the world infected.

When I read this I thought that it was a bit ironic, and somewhat contra indicatory in these times when all our smiles are tucked away behind our masks.

So here are some alternate lines for the times, that I have penned.

Thanks to Spike Milligan (an old favourite) for the inspiration!

.

Sneezing is Infectious

Sneezing is infectious and coughing is contagious too,

It can spread the virus that is way wickeder than the flu.

When someone simply smiled at me today, even behind their mask,

I drew back in terror and turned my face; “Such rudeness?” let them ask!

I walked around the corner, and there before my eyes

I came upon an unmasked group of goodly size.

I had to other way but to pass them by, but I was filled with tension

What was floating through the air, and spreading the infection?  

I thought about the virus and how deadly it can be

And realised how fast it spreads and offers itself for free.

A conversation, a slogan, or a song can spread it far and wide

Crossing every boundary, and respecting no identity nor side.

So if you feel a sneeze begin don’t leave it undetected

Isolate, test, and quarantine; always stay protected.

Wash your hands like Lady Macbeth, and mask up like the Lone Ranger

Let’s restrain and refrain, so that we can live to smile again without danger.

Who would ever have imagined that there would come a day when we would not encourage people to “Be Positive” and instead wish that they “Stay Negative”!

Stay safe. Keep smiling–behind that mask!

–Mamata

Toilet Travails

Last week we marked World Toilet Day. Continuing on the theme, I thought I would share some experiences of constructing and running urban public pay-and-use toilets. Never a dull moment in this game, I assure you. But the stories about operations I shall keep for another occasion. Here I would like to share some feedback from a survey we did of women in Hyderabad, as part of our planning exercise before we took up construction of toilets when the city decided, for the first time, to open up this activity in Public Private Partnership mode. The survey is over a decade old. But sadly, most of the challenges we found still probably stand.

Here are some of the findings from a survey of close to 400 women:

  • About a fourth of the respondents were not even aware that there are Pay-and-Use toilet facilities for women.
  • About half the respondents reported that they wait till they reach home even if they feel the need to use a toilet when they are out. 
  • Women in higher economic strata, non-working women and students use these facilities significantly less than women from lower economic strata and working women.
  • 64.2% of those respondents who used public convenience had a bad experience. The reported major reasons for the  ‘bad experience’ were:
ReasonPercentage
1. Unhygienic Conditions92.5
2. Insufficient water availability69.2
3. Bad smell62.8
4. Caretaker being male57
5. Joint infrastructure (both male and female facilities in one building, with a partition)53
6. Feeling of insecurity36.4

The respondents also made several valuable suggestions:

  • About 53% women suggested that there should be exclusive toilets for women.
  • Around 57% women opined that the caretaker of the public toilet should be properly trained and should be gentle, and he/she should be educated and middle-aged.
  • Respondents also expressed that the following facilities are needed by women in  public toilets; dustbins for disposable things; small shelves for women carrying things; mug and bucket provision; mirror; good lighting and alternative lighting arrangement in case of power fails.
  • Indian and western toilets both to be provided for convenience of various types of users.
  • Security is paramount.
  • Proper maintenance, cleaning at regular intervals and supervision.
  • In some cases, men are using the space around the toilets as the toilets! This not only leads to bad smell but also a feeling of embarrassment on the part of women who want to enter.
  • In many toilets, there is no proper indication for “gents” and “ladies”, which creates problem for women in using public toilets.

Public toilets are definitely more prevalent today than a decade ago. And the maintenance is not as bad as it was. But I think some of the survey findings and recommendations are still very relevant to those concerned about public sanitation, and about making the most basic of facilities accessible to one half of humanity!

–Meena

‘Down in the Dumps’ Day

No, let me hasten to clarify that there is no such Day. But there is indeed a World Toilet Day which is observed on 19th November every year, and ‘celebrates toilets and raises awareness of the 4.2 billion people living without access to safely managed sanitation’. The Day is about taking action to tackle the global sanitation crisis and achieve Sustainable Development Goal 6: Water and Sanitation for all by 2030.

Well, if we were to ‘celebrate toilets’ as urged in the mission, I would advocate for  a lovely little book called ‘Toilets of the World’ by Morna Gregory and Sian James, and published by Merrell Publishers.

The book begins with a very brief History of Toilets which is followed by a continent-wise round-up of interesting toilets. The beautiful colour plates are themselves an education of how creative photographers can make art out of not conventionally photogenic items!

Here are some interesting nuggets of information from the book.

  • The oldest known flush toilet is that of the palace of Knossos on the island of Crete, dating back to 1700 BC.
  • Solid waste generated by astronauts in space is compressed into round, flat discs and brought back to earth. NASA’s toilet engineers refer to them as ‘people patties’.
  • Toilets on board ships are referred to as ‘heads’.

And here are some toilets mentioned in the book which caught my attention for their ‘extreme’ qualities:

Public Toilet, Ephesus, Turkey. About 200 AD.

Keith Siding Road, Crandon Wisconcin: Someone as part of their garden decorations has put up an outhouse with the sign ‘Up North Rest Stop’. The door of the facility is open, and on the toilet sits a life-like lady in full view of the road, using the facilities!

Incahuasi Island, Bolivia: In the middle of 12000 sq. km. salt desert is a toilet carved from the trunk of dried cactus, with the needles removed to allow for comfortable seating.

30-Gold Store, Kowloon: This gold washroom put up in his shop by a Hong Kong jeweler is down in the Guinness Book of Records as the most expensive washroom. Fixtures, sinks, toilet brushes, toilet paper holders, all are made of gold.

Ancient Roman City, Ephesus, Turkey: Built around 200 AD, these communal pay-and-use marble latrines were for men only, and were a place for social gatherings and where many business deals were struck. Slaves used to come in early to literally warm the seats so that their masters did not feel the chill of the marble on their bottoms. There are many other yucky details, which I will refrain from sharing. (The picture is from an unforgettable family trip there.)

For more interesting information on toilets, the place to visit would of course be the unique Sulabh International Museum of Toilets at  New Delhi, which, to quote the museum website ‘has a rare collection of facts, pictures and objects detailing the historic evolution of toilets from 2500 BC to date. It provides a chronological account of developments relating to technology, toilet related social customs, toilet etiquettes, prevailing sanitary conditions and legislative efforts of different times. It has an extensive display of privies, chamber pots, toilet furniture, bidets and water closets in use from 1145 AD to the modern times. It also has a rare collection of beautiful poems related to toilet, their usage.’

In India, where close to half the population does not have a toilet at home, and where no ‘nudge’ or carrot or stick or government slogan seems to work towards reducing open defecation, every day has to be Toilet Day, and every person a Toilet Warrior!

Let’s get Vocal for Local Toilets!

–Meena

PS: I had borrowed this book from a dear friend David Foster and hope to meet him soon to return it.

PPS: Photo credit: Ashok Seshan

Mamitu and Emaye: Women Warriors

This year the term ‘frontline warriors’ has become deeply embedded in the vocabulary around the world.  As we show our respect and appreciation for these tenacious, dedicated health workers, here is a much older story of two remarkable women who saved and changed the lives of thousands of others. The story spans over 60 years, and starts from two different places.

It begins in 1959 when a young doctor couple in Australia, Reginald and Catherine Hamlin, saw an ad in The Lancet looking for gynaecologists in Ethiopia.  With the zeal to do something useful, the idealistic couple flew across the oceans and continents to land in a tiny airport in Addis Ababa. They had plans to stay for 3 years, but they never went back.

Among the many gynaecological and obstetrics cases that they treated, the most common and most horrendous was a childbearing injury known as obstetric fistula. The condition is caused when prolonged labour opens a hole in the birth canal, leaving many women incontinent. For Ethiopian women, the injury often led to their being rejected by their husbands and ostracized by their communities.

When the Drs. Hamlin arrived in Ethiopia, there was little or no treatment available for such patients anywhere in the country, causing of thousands of women to barely survive, with life-threatening and life-changing injuries. Poring through medical books, journals and drawings of operations by other experts, the young doctors developed innovative surgical techniques to repair the damage.

One day in 1963, a 16 year-old girl was brought to them from a distant village, carried for twelve hours through mountainous terrain, on a primitive stretcher made from eucalyptus branches, and then on a bus to Addis Ababa. She had been in labour for four days, and her baby had died. She was in excruciating pain, and close to dying.

Her name was Mamitu Gashe. She was illiterate and terrified. She had never left her village, nor seen white people before; in her delirium she thought that they were angels. The agony, and the trust of the girl immediately touched the hearts of the doctors. Her injuries were the worst they had handled. It took months of repairs and treatment to heal her ravaged body. By then the innocence and indomitable spirit of Mamitu had created a special bond between the patient and her saviours.

As she gradually started her road to recovery, the young girl did not know how to show her gratitude to her doctors. Even while she was still in hospital, she started helping with chores like sweeping and changing sheets. Then as she regained her strength and confidence, Mamitu started to greet and comfort new patients, remembering her own terror when she first came. She refused to go back to her husband and village, and declared that she would stay and help the doctors. They in turn treated her like a daughter. She started calling them Emaye (mother) and Abaye father).

Over the next ten years Mamitu worked shoulder to shoulder with the Hamlins, helping out in the operating theatre, and then assisting in their operations; initially sewing up at the end of the surgery but progressing to learn all the steps in an operation. She learned to operate on fistulas by placing her hands over the surgeon’s and tracing her intricate incisions as she worked to save the women. In 1987, at the age of 40, Mamitu began operating on her own. She still could not read nor write, or speak English, but she had the gift of dextrous fingers, and just the right touch. Under the training and guidance of the Hamlins, Mamitu went on to be recognised as one of the finest fistula surgeons in the world. In 1989 she won the Gold Medal for surgery from the Royal College of Surgeons in London.

Emaye Catherine and Mamitu Source:https://hamlin.org.au/

In 1993 Reginald passed away, but Catherine continued with her life’s mission, with Mamitu by her side. In 1995 they built another new hospital, one of a series that had started with their first in 1975–Addis Ababa Fistula Hospital. Today an estimated 60,000 women have been treated, and cured, by the Hamlins’ hospital and clinics. 

Mamitu and her Emaye were inseparable companions for 57 years. In the later years, Mamitu became the caregiver of the one who once gave her a new life and purpose. The two were finally separated in March 2020, when Catherine Hamlin, passed away, aged 96. Seven months later, the still-grieving Mamitu has recently returned to the operating theatre. Now 74 years old Mamitu carries on her parents’ legacy, and continues to be a formidable frontline warrior.

–Mamata

Wash ‘Em Clean

One of our favourite childhood books was a delightfully illustrated Russian book called Wash ‘Em Clean. It was a funny poem about a little boy who would not wash and bathe, and how he was converted to cleanliness.

Instilling the habit of proper hand hygiene has been one of the great challenges through the ages.

On 15 October, in 2008, over 120 million children in more than 70 countries around the world washed their hands with soap. This marked the first Global Handwashing Day, founded by the Global Handwashing Partnership as a way to raise awareness about the importance of washing hands. Since then, this day is celebrated annually to reiterate the simplicity and value of clean hands. The theme for this year is Hand Hygiene For All.

Ironically, in just over a decade since then, a single Handwashing Day is not enough. Handwashing is making daily headlines across the world as, possibly, the most effective protection from Covid 19.

Interestingly this was the very message that was sought to be promoted as far back as 1847 by Dr. Ignaz Semmelweis, a German-Hungarian physician and scientist. Armed with a doctorate from the University of Vienna and a Master’s degree in midwifery, Semmelweis joined as Director of the maternity clinic at the Vienna General Hospital in Austria.  At that time a mysterious infection known as ‘childbed fever’ was leading to high mortality rates in new mothers in maternity wards across Europe. Semmelweis was determined to understand what caused this rampant infection, and he began to closely observe the practices of the doctors on duty.

Until the late 1800s surgeons did not scrub up before and after surgery, or even wash their hands between patients; causing infections to be transferred from one patient to another. In fact, even after dissecting corpses, doctors and medical students went straight to the maternity wards to examine women who had recently delivered, without first washing their hands. Semmelwies deduced that it was the doctors who were transmitting infections to the patients. In maternity wards these infections led to the new mothers dying from puerperal fever or ‘childbed’ fever as it was called.

This was in the era before antibiotics (and before the recognition that germs are the agents of infectious disease).

Dr Semmelweis immediately instituted a strict regimen wherein all medical staff had to wash their hands between patient examinations. This seemingly simple step was the most difficult to implement. His peers were very sceptical, some were openly hostile; how could he dare to claim that the doctors were killing their patients? His own staff rose against him. He was labelled a madman because of his fanatic insistence on hand washing.

But the results of his ‘lunacy’ spoke for themselves–before hand washing was instituted in May 1847, his clinic’s mortality rate was 18.3%. By July, the rate had dropped to 1.2%, and it was zero the next year. But despite the clear link between cause and effect, most doctors did not change their practices.

Instead, in the face of opposition from a large part of the medical fraternity, the doctor  was dismissed from his post, and he moved to Budapest. At the age of 47 he was committed to a mental asylum, and died there only 14 days later.

Semmelweis never published an explanation of the logic behind his theory.  His experiments with hygienic practices were only validated some years later when Louis Pasteur expanded on the germ theory of disease. This was taken further by Joseph Lister a British surgeon. Based on his observations as a surgeon, Lister also deduced that a high number of post-operative deaths, which were attributed to ‘ward fever,’ were caused not by the surgery but by infections spread by germs from unwashed bed linen and surgical instruments, as well as lack of hand hygiene among doctors. Lister saw this as the cause, as well as the solution, to the problem. He started using carbolic acid to wash hands and to sterilize instruments, as well as to dress wounds. He experimented successfully with these techniques, and, unlike Semmelweis, went on to publish everything he discovered in a medical journal The Lancet in 1867. He became known as the father of antiseptic surgery.

That was a hundred and fifty years ago; but how much have things changed even now?

Here are some shocking facts.

Most patients and their families believe that a hospital is the safest place in terms of hygiene. But the Centers for Disease Control (CDCs) in America estimate that 1 in 25 patients pick up an infection while hospitalized. In 2011 there were more than 700,000 health care-related infections at intensive-care hospitals, and about 10 per cent of the infected patients died during their hospitalization. One of the major contributors to the spread was low hand-washing compliance among the attending doctors and nurses.

The well-known author and surgeon Dr Atul Gawande wrote an eye-opening essay in 2004. Titled On Washing Hands the essay endorsed that hand washing non-compliance was a major factor in spread of infection. But it also explained why this seemingly simple measure is, in practice, very complicated due to the sheer volume of interactions between a medical caregiver and a patient. For example, in a regular 12 hour shift a nurse would have up to 100 occasions on which hand washing is required. Given the tremendous pressure of time and patients, he accepts that the kind of hand washing that would be effective would mean that one-third of the medical staff’s time would be spent on washing.  While this is not realistic, he urges that even a small increase in compliance would mean saving at least a few more lives that are lost to infection.  

From Semmelweis to Gawande, the crusaders for hand washing have been spreading the message for almost 200 years. In this year of the Corona, never before has hand washing been more critical and more imperative. Handwashing is not just for doctors. Every one of us can save lives—especially our own, by becoming fanatical about hand washing.

Let’s put our hands together to applaud the super power of soap and water.

–Mamata