Nearly 170 years ago in the Vienna General Hospital, the Hungarian physician Ignaz Semmelweis discovered that infection rates and deaths among new mothers could be drastically cut if healthcare providers simply washed their hands with chlorinated lime solution. Around the same time in London (1848), John Snow, one of the fathers of modern epidemiology, drew attention to contaminated water and poor waste management behind a deadly cholera outbreak.
That safe water, sanitation and hygiene (WASH) prevent diseases is not unknown, yet it receives underwhelming attention. India ranks among countries with the highest rates of diseases and death among mothers and children. Economist Dean Spears advocates a strong link between open defecation and stunting among Indian children. Poor sanitation and open defecation transmit pathogens through contaminated fluids and food, flies and fields. The resulting diarrhoea and environmental enteropathy prevent intestines from absorbing vital nutrients and hinder growth. With more than half of India's population defecating in the open, it's not surprising that 61.7 million Indian children under the age of five are stunted.
Inadequate sanitation, poorly maintained latrines, poor hygiene practices contribute to the spread of Japanese elephantiasis, helminth (worm) infections, and trachoma, undermining their treatment as well.
Inadequate sanitation, poorly maintained latrines, poor hygiene practices contribute to the spread of Japanese elephantiasis, helminth (worm) infections, and trachoma, undermining their treatment as well. Malaria and dengue spread rapidly when water is stored improperly, or sources are contaminated, providing breeding grounds for vectors.
Another health crisis that needs urgent, unfailing attention to alleviate it is the increased vulnerability of women who lack access to safe WASH facilities. Research in Odisha found that open defecation puts pregnant women at risk for pre-term birth and that poor menstrual hygiene increases risk of urogenital infections. Girls and women face many problems, including loss of time, the risk of sexual harassment and animal attacks when defecating in the open, walking far to access a toilet, or when using unsafe toilets.
The presence and quality of WASH in healthcare facilities must be considered in light of hospital-acquired infections. Studies peg prevalence of hospital-acquired infections in India at 9-80%. Particularly important are handwashing and hygiene practices by healthcare providers, and cleanliness of hospital facilities in patient care and clinical settings. Puerperal sepsis, the second leading cause of death among new mothers in India, is associated with poor hygiene practices during delivery.
The WHO and UNICEF 2015 report on the status of WASH in healthcare facilities highlights that 72% of health facilities in India have water and 59% have sanitation facilities. But, this discounts their usage and quality. Health facility assessments by WaterAid India in Karnataka, Odisha, Madhya Pradesh, and Telangana (2014-15) reiterate that the presence of WASH infrastructure in health facilities does not necessarily ensure adequate quality and quantity of water, sanitation and handwashing conveniences. Particularly alarming are the mixed levels of awareness and inadequate hygiene, infection control and prevention practices among healthcare staff.
[T]he presence of WASH infrastructure in health facilities does not necessarily ensure adequate quality and quantity of water, sanitation and handwashing conveniences.
Integrating WASH into healthcare
The role of WASH in preventing disease and in supplementing curative services cannot be overlooked much longer. The Swachh Bharat Mission (SBM) strives to achieve universal sanitation coverage, and is a window of opportunity to improve health through WASH. The 2015 Swachhta/KAYA KALP Guidelines embody a direct effort to adopt WASH in healthcare, with immense potential to fill a critical, but largely ignored infrastructure gap in health services.
In addition to WASH infrastructure, health promotion and disease prevention efforts in communities, health and nutrition centres and in schools must incorporate WASH to spread awareness of its impact on the health of mothers and children, and on infectious and vector-borne diseases, prompting and sustaining hygiene behaviours (such as latrine use, hand and personal hygiene, menstrual hygiene etc), and generating demand for safe WASH services. India's progress towards Sustainable Development Goal 3--to ensure healthy lives and promote well-being for all by 2030--can be accelerated by assimilating WASH into health interventions and services in a comprehensive and resolute manner.
The next time we are tempted to take WASH lightly, let's just remind ourselves of these figures:
178 maternal deaths per 100,000 live births (2012). Sepsis is the second-leading cause.
61.7 million Indian children under the age of five are stunted
13% of childhood deaths under the age of five due to diarrhoea, killing 300,000 children annually.
99913 Dengue cases with 220 deaths in 2015 - worst Dengue outbreak till date.
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