Necessity for Integrated Programs to Contain Water Borne Diseases, Particularly in Monsoon
Clean and safe drinking water, sanitation and hygiene forms the crucial link in many health related conditions; for example, it is a vital component that perpetuates the vicious cycle of infectious diseases (for example, diarrheal diseases like cholera, typhoid, etc.) followed by malnutrition in children or dehydration and death in severe cases. To that end, it becomes a critical policy intervention to provide adequate WaSH services to disrupt such detrimental chains of events from getting eternalized in the community. To achieve this, the government needs to ensure safe and adequate WaSH services to all. For this a number of programs have been executed.
Despite significant and substantial investments (around Rs. 173,950 crores since the first five year plan, according to the Outcome Budget (2015-2016) of the Ministry of Drinking Water and Sanitation) in the rural water supply sector, the problem of availability of water, and safety and potability of water, when available, continues to plague parts of the nation. Water quality is affected by both point and non-point sources of pollution. These include sewage discharge, discharge from industries, run-off from agricultural fields and urban run-off.
The issues around water quality become particularly intense around the monsoons as the rains often contribute to breaching of the sanitation barrier, especially in vulnerable areas or sites with poor sanitation and hygiene infrastructures.
Programs for the Prevention, Control and Treatment of Water Borne Diseases
Despite sustained interest and investment in the water and sanitation sectors, there have remained major gaps in coverage, to address which the eleventh and twelfth five year plans proposed radical changes. The major issues in focus in the eleventh five-year plan were:
- Sustainability in water availability
- Improvement of poor water quality
- Decentralised management by PRIs
- Addressing equity in regards to gender, weaker sections of the society, economically weaker sections, and school children
In the twelfth five-year plan, the ministry focused on the following:
- Provision of piped water supply in the rural areas
- Reduce the burden of fetching water on women and children
- Increase the service level of water from 40 lpcd to 55 lpcd of drinking water in the rural areas
- Aspire for universal coverage and access to adequate potable water through piped supply
- Reduce the negative impact of non-potable drinking water on health
To achieve these, a number of programs have been instituted. They include:
- The National Rural Drinking Water Program overseen by the Ministry of Drinking Water and Sanitation
- National Rural Health Mission which addresses the total sanitation campaign and functions under the Ministry of Health and Family Welfare
- Rajiv Gandhi National Drinking Water Mission, overseen by the Ministry of Drinking Water and Sanitation, is a technology mission to ensure accelerated coverage of safe drinking water in India.
- National Program for Prevention and Control of Fluorosis
- Swachh Bharat Mission to increase awareness and activities at the community level to ensure sanitation and hygiene, including establishment of open defecation free areas.
- Integrated Disease Surveillance Program for the surveillance of outbreaks of diarrheal diseases and mounting an adequate set of mitigation activities in response.
- IEC Activities towards water, sanitation and hygiene and other related issues under the Ministry of Health and Family Welfare
Details at a more granular level are available in the documentations associated with each of the mentioned programs.
Monsoon Related Activities
The set of activities outlined within the frameworks of the programs intended to prevent and control the diarrheal diseases are carried out throughout the year, although there is increased focus on their execution during monsoon seasons. However, formal program evaluation data on how these programs fare in monsoons and whether they can adequately meet the local needs are not available in the public domain. Further, it is not clear if there is a re-evaluation of the activities and resources that need to be deployed in terms of local requirements (e.g. increasing focus on provision of safe drinking water in drought affected areas) in a pre-emptive fashion.
There are technological analytics available which can advise the deployment of adequate resources in response to the local requirements, based on predictive modeling, especially in areas that are prone to droughts or floods and thus need closer attention. It is not clear whether such analytical tools are employed in the deployment of pre-emptive resources for addressing and mitigating potential challenges of the emergence of or threats of outbreaks of water borne diseases.
The government is in the process of developing a National Action Plan on Climate Change and its impact on Human Health, part of which is an adaptation and mitigation strategy for combatting water borne diseases. It is essential to ensure multidisciplinary inputs for developing the plan and devising a cross-sectoral plan of action to address potential threats of water borne diseases arising from monsoons or anthropogenic climate change.
Solid Waste Management
Waste management is a major issue across urban, peri-urban and rural ecosystems. While the challenges are different in the different areas, the impact on health outcomes is undeniable. Sixty-two million tons of waste is generated annually in the country at present, out of which 5.6 million tons is plastic waste, 0.17 million tons is biomedical waste, hazardous waste generation is 7.90 million tons per annum and 15 lakh ton is e-waste. The per capita waste generation in Indian cities ranges from 200 grams to 600 grams per day. Forty-three million tons of waste is collected, 11.9 million tons is treated and 31 million tons is dumped in landfill sites, which means that only about 75-80% of the municipal waste gets collected and only 22-28 % of this waste is processed and treated.
In rural areas, open defecation is a cultural norm and despite the success of the Swachh Bharat Abhiyan in construction of toilets, only three states have achieved complete open defecation free status till now (Sikkim, Himachal Pradesh and Kerala). However, sanitation coverage has increased from 42% in October 2013 to 60% at present.
Meanwhile, in peri-urban and urban areas, the main challenge is dealing with the rapidly increasing amount of waste being generated by the rapidly growing population. The lack of an Integrated Solid Waste Management system is also contributory to dealing with the mixed wastes, which are usually generated in cities. It is expected that with improving ODF status and municipal waste management solid waste control would become less of a threat to health.
Steps have been taken to ensure that there is scaling up of waste management infrastructure in keeping with the increasing load. Solid Waste Management Rules have been recently updated in 2016 and in a strong move, they have extended the mandate beyond municipal areas to cover urban agglomerations, census towns, notified industrial townships, areas under the control of Indian Railways, airports, airbase, port and harbor, defense establishments, special economic zones, State and Central government organizations, places of pilgrims, religious & historical importance. Extensive details of the legislation are available on the Press Information Bureau site and the related links.
Preventive Strategies in Monsoons (Chlorination)
There is a large randomized controlled trial, which states that boiling, disinfecting and filtering water in the home does not provide significant protection from diarrhea because of low compliance and modest improvement in water quality through domestic interventions. However, in areas where there is inadequate supply of safe drinking water, it is essential to introduce chlorination and other disinfection strategies. Further, it is not clearly known whether there is a need to improve coverage of such preventive measures in monsoon months, and if there is, by what magnitude, to ensure the protection of health of the population.
Although these preventive activities are integrated within the mandate of the various safe water supply initiatives, there needs to be in place thorough monitoring and evaluation of the efforts to ensure higher coverage and adequate improvement in quality. The adoption of customized purification strategies for improvement of water quality through multiple modalities, including boiling, chlorination at supply and consumption points, and safe storage also needs to be evaluated. The IEC activities undertaken by the MoHFW contain messages to this end, including provision of chlorine tablets and knowledge on how to use them.