It Takes Guts!

‘Gut Ecology’ is the name of a book brought out by the St. Marks Academic Institute which is dedicated to ‘advancing scientific knowledge of colorectal disorders’. I think the book, which features topics like ‘The gut microflora: traditional and molecular identification techniques’, and ‘The ‘unculturables’’ deserves to be a bestseller. Not that I would understand the contents, but I have to admire the dedication and scientific spirit it takes to spend a lifetime researching and writing on such topics! Guts indeed!

But what exactly would the book be about? Let’s break it down. Ecology is the study of organisms and how they interact with the environment around them. An ecologist studies the relationship between living things and their habitats. ‘Gut’ is commonly used to refer to the stomach, entrails, parts or the whole of the digestive tract. So a ‘gut ecologist’ would study the insides of our digestive tract to understand the micro-organisms (collectively referred to as gut microbiota) that live there, and how they interact in our digestive system.

For very long, the presence and role of micro-organisms in our body was not known. It was in the 1670s and ‘80s when Antoine van Leeuwenhoek started using his newly developed handcrafted microscopes that scientists started studying them. Leeuwenhoek described and illustrated five different kinds of bacteria present in his own mouth and that of others, in a letter he wrote to the Royal Society of London in 1683. He later also compared his own oral and faecal microbiota, and proved that there are differences in micro-organisms in body sites. (See why I say it takes guts to be in this field!)

Gut bacteria
Gut bacteria

Now we know that the human gastrointestinal tract—from mouth to anus– is divided into sections, and each provides a different environment and different kinds of micro-organisms thrive in each section. In all, about 100 trillion micro-organisms (most of them bacteria, but also viruses, fungi, and protozoa) exist in the human gastrointestinal tract. In fact, the colon contains the highest microbial density recorded in any habitat on Earth, representing between 300 and 1000 different species. There are actually about as many bacterial cells in our bodies as there are human cells, and they contribute over a kilogram to our weight! So Stewart Brand, the American writer, environmentalist and editor of the highly influential Whole Earth Catalogue was right when he said, ‘If you don’t like bacteria, you’re on the wrong planet.’

These organisms are such an integral part of the functioning of the human body that they are sometimes called ‘the forgotten organ’.

A foetus has no bacteria at all in the system. Through the process of birth, it picks up a good number, and then in the first few years of its life, the child picks up a huge number of different bacteria from its environment. Fascinatingly, like fingerprints, a person’s gut microbiota composition is unique to each individual.

These micro-organisms influence our energy metabolism and many other areas of human health, from immunity and the progress of diseases, to appetite, to nutrition uptake, and even personality! They therefore greatly influence our health, well-being, weight etc.

External factors influence the composition of these micro-biota but by changing our diet or fasting can change the composition of these life-forms in our systems, in a matter of days or weeks, and this is why it is important to pay attention to what we eat. This is also the reason why medical science is increasing focus on  prebiotics and probiotics. If like me, you are confused about the two terms, here are simple definitions:

* Probiotics are foods or supplements that contain live microorganisms intended to maintain or improve the “good” bacteria (normal microflora) in the body.

* Prebiotics are foods (typically high-fiber foods) that act as food for human microflora. Prebiotics are used with the intention of improving the balance of these microorganisms.

Kudos to the scientists who work so hard to help us understand our bodies and their functioning, ready to spend their lives poring over microscopes to figure out how we can live healthier and better!

–Meena

The Conviction to Refuse an Honour

The Ramon Magsaysay Award is undoubtedly a high honour and prestige. Instituted in 1957 (with the first awards given in 1958), it is called the Noble Peace Prize of Asia. It ‘celebrates greatness of spirit and transformative leadership in Asia.’ It has till date, been conferred on 300 individuals and organizations  ‘whose selfless service has offered their societies, Asia, and the world successful solutions to some of the most challenging problems of human development.’ The awardees are selected by the Ramon Magsaysay Foundation trustees who call for nominations from a pool of international confidential nominators. The nominations go through a rigorous process of evaluation by the trustees.  

Awardees include Vinobha Bhave, the Dalai Lama, Mother Teresa, Verghese Kurian, Tribhuvandas Patel, The Peace Corps in Asia, Jayaprakash Narayan, Muhammad Yunus….the list of luminaries is distinguished indeed!

KK Shailaja
KK Shailaja

This year, Kerala’s former health minister KK Shailaja (called Shailaja Teacher) was one of those selected. This was in recognition of her stellar performance as health minister of Kerala, especially the management of Covid-19 in Kerala. She was one of the first people world-wide to recognize the potential seriousness of the virus, and ensured that her state was ready to combat it.

When she got the news of her award, Shailaja informed her party, the CPI(M). They deliberated on this and asked her to refuse it. Being a loyal party worker, she politely wrote to the Ramon Magsaysay Foundation refusing the award, saying that the battle against Covid was a collective effort, and that she was not individually responsible for it, and thus could not accept the award.

Controversy has raged since then. Was it jealousy on the part of some of her senior colleagues that she was getting such a high-profile recognition? It has been perceived for some time now that some of the party leaders in Kerala fear her success and her being highlighted on the international stage, and that is why she was refused a second term as Minister. Was it misogyny? That some people will do anything to bring down a successful women?

Well, maybe a bit of both.

But there is more to it. In fact, deep ideological reasons.

The Ramon Magsaysay Award was instituted in memory of Ramon Magsaysay, former President of the Philippines, and his commitment to integrity in governance, courageous service to the people, and pragmatic idealism within a democratic society.And indeed Ramon Magsaysay did live by these ideals. He did a lot for the people of his country, cleaned up the administration and made government responsive. He created the Presidential Complaints and Action Committee, a body which heard grievances of the public and recommended remedial actions.  He established the National Resettlement and Rehabilitation Administration (NARRA) which redistributed thousands of acres of lands to the landless. He set up the Agricultural Credit and Cooperative Financing Administration (ACCFA) to make available rural loans to small farmers and share tenants loans at low interest rates.He played a significant role in regional affairs too. Magsaysay’s presidency was considered one of the cleanest and most corruption-free in Philippine history.

So he was a tall leader, no doubt. But the explanation for Shailaja’s refusal of an award names after him goes a little further back in time. In early August 1950, using his own experiences in guerrilla warfare during World War II he was the strategist behind then-President Quirino’s plan to fight the Communist guerrillas. He led this attack when he was named Secretary of National Defence in September 1950. All his life, he opposed communism not only in speeches and forums, but also on the ground through military action.  All through his years in power, he was a close friend, ally and supporter of the United States whose foremost enemy was communism.  All his life, Magsaysay was a vocal spokesman against communists. 

So that is one part of it.

Coming to the award itself. The Ramon Magsaysay award was instituted through an endowment from the Rockefellers Brothers Fund. The Rockefellers were staunchly anti-communist. For instance, as Assistant Secretary of State, Nelson Rockefeller played a big role in the establishment of NATO, its stance against the Soviet Union, and the resolution of NATO members to defeat communism and its spread. The Rockefellers also had a big hand in the shaping of the UN and its stance against communisim.

So the people who instituted the award as well as the man whom it commemorates were dead against communism.

To me, it makes sense why Ms. Shailaja, a life-long member of the Communist Party of India (Marxist), with a deep committment to the communist ideology, refused the award. I am now a bigger fan than ever!

KK Sahilaja has a host of awards and recongitions from across the world, and awards probably do not matter to her.

But I hope that she will be able to play a bigger part in the management of public affairs not only in her state but the country too. We would be the poorer if she cannot!

–Meena

Elizabeth Garrett Anderson: Path-breaking Victorian

This past week I was reading about the grand Platinum Jubilee celebrations to mark 70 years on the throne of Queen Elizabeth II of the United Kingdom. This is the longest reign of a monarch of Great Britain; the closest being the rule of Queen Victoria who reigned for 64 years—a period called the Victorian Era.

Coincidentally the same week I read two accounts about women in the Victorian Era, and could not help but wonder how much things have changed. The first was fiction–a ‘murder mystery’ which featured some women who attempted to defy the existing norms,  and the other was the true story of a woman who was a pathbreaker in changing how the role and status of women was perceived in that era. 

The reign of Queen Victoria was an extended period of peace, prosperity, progress, and essential social reforms for Britain; however, it was also characterized by widespread poverty, injustice, and social discrimination. There was a very strictly defined ‘class system’ that determined every aspect of social life.

There was also a very strong perception (and application) of gender roles. A woman’s place was clearly considered to be in the home, and domesticity and motherhood were considered by society at large to be a sufficient emotional fulfilment for females. Even the upper class women who were educated to some degree by private tutors were not encouraged to use their minds in any way that would distract them from their assigned roles. A telling paragraph in the novel: “Did you read it in a newspaper?” “Oh no” she lied immediately. She had not yet forgotten that ladies of good society would not do such a thing. Reading the newspaper overheated the blood; it as considered bad for health to excite the mind so much, not to mention, bad for the morals.

The rights which the women enjoyed were similar to those which were enjoyed by young children whereby they were not allowed to vote, sue or even own property. But these rights were to be questioned, and changes demanded by a group of women who pioneered the suffrage movement. Among these was Elizabeth Garrett Anderson, who broke many glass ceilings in her day.

Elizabeth Garrett was born on 9 June 1836 in Whitechapel, London, to Newson Garrett and his wife Louisa; the second of twelve children. Her father was originally a pawn broker who went on to become a successful businessman. The family moved to Aldeburgh in Suffolk when Elizabeth was very young. As a child, Elizabeth got her basic education from her mother and a governess. When she was 13 she was sent to a private boarding school near London where she was taught languages and literature, but not sciences and math. Unusual for the time, her parents encouraged their daughters to travel and pursue their ambitions. After completing school Elizabeth, although engaged in domestic duties, continued to study Latin and arithmetic, and read widely. It was accepted that she would marry and live the life of a lady.

When she was 22, a group of women started a magazine for women, English Woman’s Journal. Among these women was one Emily Davies, who became a dear friend. She invited Elizabeth to hear a lecture given by Elizabeth Blackwell, the first American woman physician. Elizabeth was so inspired by her namesake and her lecture that she decided that she wanted to become a doctor. A female studying medicine was unheard of at that time. But her father was supportive. She was denied admission in any medical school, so she enrolled as a nursing student at Middlesex Hospital and attended classes intended for male doctors. She also employed a tutor to study anatomy and physiology. But after complaints from the other students she was barred from the hospital; however Elizabeth continued to study on her own. She was determined to secure a qualifying diploma that could entitle her to put her name on the Medical Register. Unless a person’s name was listed on the Medical Register, that person could not legally practice medicine in England.

Elizabeth found a loophole: she registered to pursue a degree of Licentiate of the Society of Apothecaries which did not specifically forbid women from taking their examinations. In 1865 she passed their exams and gained a certificate which enabled her to practise as a doctor. This was a shocking step; the Society subsequently changed its rules to prevent other women entering the profession this way. However Elizabeth obtained her licence to practise medicine in 1869; the first woman in Britain qualified to do so.

Even though she now had a licence, Elizabeth still could not get a medical post in any hospital. With her father’s financial backing, in 1866 she opened her own practice in London. A little later, towards her goal to establish a hospital for women staffed by women, Elizabeth set up St. Mary’s Dispensary for Women and Children. Initially people were reluctant to consult a female physician, but an outbreak of cholera saw patients teeming to her clinic.

It was during this period that Elizabeth was also getting engaged with the issue of women’s rights. Her younger sister Millicent Fawcett was active in this growing movement; the two sisters with a group of like-minded women set up a discussion group that strongly influenced the battle for women’s education and empowerment.

Although Elizabeth had already obtained many ‘firsts’ she was still determined to achieve her original dream of a formal degree in medicine. So she taught herself French and successfully earned her MD degree from the University of Paris in 1870. The British Medical Register refused to recognize her qualification.

In 1870 Elizabeth became Visiting Medical Officer for the East London Hospital for Children. In 1872 Elizabeth transformed the St Mary’s Dispensary for Women and Children into the New Hospital for Women in London. The hospital specialised in women’s health and all of the staff were women. It was renamed the Elizabeth Garrett Anderson Hospital in 1918 and continued to appoint only female staff until the 1980s. Elizabeth also co-founded the London School of Medicine for Women, the first place in Britain specifically intended to train women as doctors.

In 1871 Elizabeth married a businessman James Anderson, in a  wedding ceremony in which she did not take a ‘vow of obedience’;  she continued with her pioneering work even as she ran her own household and brought up her three children. 

Elizabeth’s determination paved the way for other women.  In 1876 an act was passed permitting women to enter the medical professions and the Medical Register. Today over 48 per cent of licenced doctors in UK are women.

Elizabeth continued to lecture at the London School of Medicine for Women for 23 years, and from 1883 she was also the School’s Dean. She was Senior Physician of the New Hospital of Women for 24 years and in 1896–97 she was President of the East Anglian branch of the British Medical Association. She also found time to write on medical topics, including a textbook for students.

In 1902, Elizabeth retired from her medical career and moved to the town of Aldeburgh in Suffolk. In 1908, at the age of 72, she became the Mayor of Aldeburgh; she was the first female mayor in England. In her final years, Elizabeth was a prominent member of the women’s movement and campaigned for equal rights for women. Elizabeth Garrett Anderson died in Aldeburgh on 17 December 1917 at the age of 81, just two months before the Representation of People Act extended the right to vote to women over 30.

Elizabeth Garrett Anderson, with quiet determination and persistence, opened many doors, and paved the path that women take for granted today. 

–Mamata

Doctor Without Borders: Jonathan Kaplan

Last week I wrote about a young doctor who chose to use his medical training to serve people in war situations. This was Dr Kotnis who worked with passion and dedication on the war front in China, almost a century ago. Every generation and every period of history has examples of such professionals who voluntarily choose to serve in some of the most difficult and dangerous situations.

Doctors without Borders

I recently read a fascinating account by such a doctor in our own times. This is Dr Jonathan Kaplan who began his medical career, as do all doctors, after long and intensive years of study. Dr Kaplan graduated from medical school in South Africa and spent the next ten years acquiring specialist qualifications and training as a general surgeon, and super-specialization in vascular surgery in hospitals in the UK and USA. This equipped him to move on to become a “consultant” with a comfortable and prosperous practice. In his own words:

Master of Surgery. The title had a ring of Zen about it, as though I was now a sage of some martial art, a mystic bladesman. I had trodden the path of professional dedication, served the necessary years at the required levels of experience and responsibility, paid all my dues to date. A consultant post—the reward for all this industry—lay ahead, with attendant success and security. But I found myself beset by an odd emptiness…

This sense of emptiness led Jonathan to choose otherwise. He became a “medical vagabond” as he describes himself. He spent many years as a volunteer surgeon in some of the world’s most dangerous war zones in the 1990s. He attended to the casualties of apartheid in Cape Town; worked on the front line treating Kurdish fighters during the uprising at the end of the Gulf War, and in a part of Burma’s Shan state under attack by the Burmese army; in Mozambique during the civil war, and in Eritrea at the time of the Ethiopian offensive in 2000.

Besides the blood, sweat and tears of the battlefield, the adventurous Jonathan Kaplan was always looking for new challenges. In his own words Working as a doctor in war zones was voluntary and unpaid. My hospital career looked increasingly uncertain—my curriculum vitae was a curious patchwork of jobs that shocked the sensibilities of staid consultants—and I was considering a full-time post in accident and emergency medicine where I hoped a varied resume might be less provocative to the interview committees.

But that was not to be. A variety of chance offers led to interesting stints where Dr Kaplan saw different sides to the realities of illness and emergency care. Among these was being an air ambulance doctor, and a resident doctor on a cruise liner. He also became deeply engaged in an investigation on the impacts of mercury poisoning in a part of Brazil.  

For most of his life Jonathan Kaplan worked tirelessly, and with minimal resources, amidst the most challenging conditions and heart-rending human tragedy, using every skill at his disposal to treat the wounded, and save lives. At the same time he also meticulously documented the politics, struggles, and universal human dilemmas. These have been published in a book titled The Dressing Station.

The book is a fascinating read, that vividly describes some of the most tragic and devastating impacts of war on human beings, alongside some highly technical details of surgery, and the contradictions of war-zone realities. But Jonathan is much more than a reporter. He also shares his angst and his internal struggles to maintain his humanity even under the most inhuman circumstances. He wonders about human life, and the role that doctors have to play in the human drama between birth and death. That is what makes his writing both eye-opening, as well as thought-provoking, not just for medical practitioners, but for every one of us who are on the other side of the ‘consulting table’.

As he shares: I have practised medicine in diverse fields: as a hospital surgeon, a flying doctor, a ship’s medical officer. I have operated on wounded straight off the battlefield, treated people with rich stains of tropical disease raging in their bloodstreams, and tried to help those affected by occupational illness from industrial toxins or work place stress. I have run research programmes funded by corporate finance—that met the needs of the shareholders before they benefitted any patients—and I’ve cared for children wasted by diseases of famine and war. Like most doctors I have seen my craft used and abused; been part of its successes and witnessed its failings. It is by the means of this unforgiving arena that we struggle to define ourselves.

He further ponders on his work and on life: No clinician can give an objective account of that work: the intersection between doctor and patient is mutual and intimate, and in the end comes down to something between us that is a fragile thing, as fragile as life. All we can do is the best we can in the war against death and against despair, including our own. For at its extreme the practice of medicine is a succession of front line, and each victory is only a temporary respite.

Dr Kaplan continues to take periodic assignments as a volunteer surgeon in conflict zones amidst UK hospital surgery, film-making, academic teaching, and working as a photographer, and as an advisor on medical TV dramas. He has also proposed, investigated, researched, produced and directed documentaries on health, development and environmental issues for several TV channels.

I picked up The Dressing Station by chance, not having earlier heard of Jonathan Kaplan. It was a gripping read. I look forward to reading his second book Contact Wounds.

–Mamata

Celebrating Pulses

They are an intrinsic part of every Indian’s meal. They are eaten as a staple or as a snack; they are part of something sweet and something savoury; they come in many forms, colours and flavours. They are pulses–the most sustainable, affordable, and versatile food items since time immemorial.

While we do not consciously think about them, we are making decisions regarding their use every day, for every meal—soak or saute, grind or roast, pressure cook or slow simmer, what spices go best with each one, and what accompaniments will make it a perfect meal?

Every Indian kitchen has a variety of pulses that go under the umbrella term of “dal”. Technically, pulses, also known as legumes, are the edible seeds of leguminous plants cultivated for food. Dried beans, lentils and peas are the most commonly known and consumed types of pulses.

Interestingly pulses do not include crops that are harvested green (e.g. green peas, green beans)—these are classified as vegetable crops. Also excluded are those crops used mainly for oil extraction (e.g. soybean and groundnuts), and leguminous crops that are used exclusively for sowing purposes (e.g. seeds of clover and alfalfa).

Pulses have formed an essential part of diets in many parts of the world for thousands of years and thus humans have cultivated this ancient food crop for centuries. Scientific studies of archaeological remains have suggested that people from modern-day Turkey grew chickpeas and lentils in 7000-8000 B.C. Evidence of lentil production has also been discovered from Egyptian pyramids, and dry peas were found in a Swiss village—dating back to the Stone Age. Experts have hypothesized that chickpeas production started to spread from the ancient Mediterranean region between Morocco in the west and the Himalayas in the east before 3000 BC. There are even mentions of certain pulses in the Vedas, which are widely believed to be at least 4000 years old.

From the Yajurveda onwards, Sanskrit literature has mention of the three Ms—mudga (green gram or mung), masura (pink gram or masoor) and masha (black gram or urad). The Buddha is said to have endorsed all three Ms for regular use. The three pulses continue to be widely used in all parts of India in different dishes and forms. It is believed that when Iranian scholar Abu Rayhan al-Biruni came to India 1,000 years ago, he discovered the daily meal of the average Indian, the porridge-like khichdi, a mixture of rice and lentils. Traditionally, the definition of a balanced meal in most parts of India always consisted of pulses, along with cereals, vegetables, fruits, and milk products.

Pulses are indeed what we call “superfoods”. The tiny seeds are loaded with nutrients, fibre, vitamins, and minerals. They are gluten-free and have high protein content, making them an ideal source of protein particularly in regions where meat and dairy are not culturally or economically accessible. Pulses are low in fat and rich in soluble fibre, which can lower cholesterol and help in the control of blood sugar. They are a great source of vitamins and minerals such as iron, zinc and magnesium.

Pulses are a rich source of fermentable fibre, which feeds intestinal bacteria and promotes the assimilation of nutrients, thus facilitating proper immune system functioning. Because of these qualities they are recommended by health organizations for the management of non-communicable diseases like diabetes and heart conditions. Pulses have also been shown to help combat obesity.

Pulses are important not just for human consumption, but also for the farmers who cultivate these. They are an important crop because they can both sell them and consume them, which helps farming families maintain food security. They provide economic stability as compared with perishable crops as they can be dried and stored for a long time.

 Pulses are farmer-friendly as well as friends of the environment. The nitrogen-fixing properties of pulses improve soil fertility, which increases and extends the productivity of the farmland. Using pulses for intercropping and cover crops can promote field biodiversity and improve soil microbiome, while keeping harmful pests and diseases at bay.

Pulses are highly drought and frost-resistant, which makes them suitable for a wide range of climatic conditions and environments. Pulses are also known to be climate-smart, which means they can easily adapt themselves to weather fluctuations. They have a low water footprint. As compared to others, pulses only require one-tenth of the amount of water to grow and therefore can be easily grown in semi-arid conditions.

Pulse crops have a lower carbon footprint than most foods because they require a small amount of fertilizer to grow, and they help to naturally introduce nitrogen in the soil. One of the advantages of biological nitrogen fixation is that it provides a natural slow-release form of crop nitrogen supply that matches crop needs. By reducing dependence on synthetic fertilizers which release greenhouse gases during both their manufacture and use, pulses contribute to climate change mitigation.

While pulses have always been integral to our daily diets, they are usually not seen from these other perspectives. Recognising their multi-dimensional value the United Nations proclaimed 2016 as the International Year of Pulses (IYP). The celebration of the year, led by the Food and Agriculture Organization of the United Nations (FAO), was aimed to increase the public awareness of the nutritional and environmental benefits of pulses as part of sustainable food production.

In December 2018, the United Nations General Assembly designated February 10th to be marked as World Pulses Day every year, to recognise, and remind of, the important link of pulses to the United Nations’ 2030 Agenda for Sustainable Development.

Today, as the world celebrates World Pulses Day, let’s take a look at our own meals and list the numerous forms of pulses on our menu for the day. And as we relish our dal baati-churma, sambar-idli, rajma-chaaval, cholar dal-luchi, or even the simple khichdi, let’s put our hands together for the pulses!

–Mamata

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