Carlos Morales & Jameson HollisSAR HS 430

4-9-16

InterventionProblem: Issues of sanitation in parts of India inhibit efforts to effectively address maternal and infant mortality. Our interventions seek to address determinants that lead to negative maternal and child health outcomes and also the negative effects of unsanitary behaviors on the affected population, like diarrheal disease which, in 2015, was the third leading cause of death in children in India.i

Problem Context: India is the second most populated nation in the world. As of March 2, 2016, India had a population of 1,236,344,631 people.ii India’s population is only increasing,

growing bigger day after day. That population is scattered throughout all of India, as evidenced by the fact that the six major indigenous ethnic groups of India find home in various parts of the country.iii The massive population of the nation also has its wealth gaps. In late 2014, the richest

10 percent of all people in India held 75 percent of all wealth; the richest 1% of that 10% held nearly half of that.iv In 2011, approximately 259,500,000 people in India were living off of just

$1.90 daily.v In 2014 alone, approximately 62 million children had their growth stunted (inhibited);vi 50 percent of malnutrition in India pertains to diarrheal and intestinal worm

infections that come from dirty water, and bad sanitation and hygiene.vii Part of that 50 percent is the 162 million children who suffer from malnutrition because of poor sanitation.viii Infectious diarrhea is a nasty disease, as it kills 4.6 million children less than five years of age annually.ix

Part of that comes from the fact that people in India lack access to toilets; in lieu of using restrooms and toilets, people there publically defecate to remove excrement from their system. Research shows that there is a link between massive amounts of public defecation and the nearly 50 percent of children under five years of age who suffer from growth stunting problems in the country.x Children there who have been exposed to public defecation and dirty water supplies can “…ingest bacteria, viruses, fungi, or parasites that cause intestinal infection,”xi which can ultimately lead to the growth stunting. To prevent public defecation from occurring to avoid such problems, there have been programs whose goal has been to increase the number of toilets for villagers to use; one such program occurred between 2001 and 2011. It ultimately reduced the number of households without toilets by seven percent.xii The problem with these programs is India’s population growth rate; it grew from 2015 to 2016 grew by 17,206,607 people; by 2017, the total population is expected to become 17,436,659 people.xiii While proportionally the population percent increase is growing smaller, each year, more and more people are being born there.

The same efforts previously mentioned to increase the number of toilets in households between 2001 and 2011 ultimately did nothing because of how fast India’s population is growing.xiv One study conducted by The Lancet actually verified this; economic growth does nothing in preventing early childhood growth stunting for middle-income and low-income countries (India was one of the low-income countries researched in this investigation) because of how rapidly their nation-wide population is growing.xv Greater food distribution from governmentally based programs has also failed to reduce how problematic improper hygiene and sanitation are in India’s malnourishment problems.xvi Public defecation is even more of a problem because of the lack of waste management systems within the nation. Even in modern

cities in India today, there are no sewage systems to properly manage wastes that come from practices like public defecation.xvii Even cities that have sewage systems still are in massive need of repair, as they are currently severely malfunctioning.xviii Delhi and Mumbai have 40 percent of all of India’s sewage management programs, but still generate 20 percent of the whole country’s sewage.xix The sewage treatment plants do nothing to actually remove the contaminants in water to purify it for human consumption.xx In addition, The Lancet found that 41.5% of urban houses and 60% of rural houses in New Delhi and Uttar Pradesh, different cities in India, had contaminated water supplies.xxi As long as there is a lack of a proper sewage to handle materials like human feces, water will become contaminated, and people of all ages will continue drinking it. Because of the fact that the immune system is initially weak when developing while children are young, the kids will be more drastically affected by contaminants that find their way into the water.

Women in India are also in need of toilets to not have to publically defecate. Worse, they are also only allowed to relieve themselves at certain times of day; according to Indian tradition, women must either defecate before sunrise or wait until nightfall.xxii The fact that sometimes women have to wait for darkness to come is a problem. Snakes are more likely to bite women at nighttime, and sexual predators are more likely to take advantage of vulnerable, isolated women under darkness’ veil.xxiii In Uttar Pradesh, two teenage girls were raped and murdered while attempting to relieve themselves at nighttime.xxiv In 2013, in Bihar, India, 400 women would have avoided rape if there had simply been access to a toilet in their home.xxv Aside from issues pertaining to safety because of cultural practices, sanitation among women in India is not good. One-estimate states 65 percent of all women in the country practice open defecation; another estimate claims that, in 2014, approximately 300 million women and girls practice open defecation in the nation.xxvi One report found that the main to motivators for women to have household toilets are primarily for safety reasons and convenience; a mere one percent of all women asked about why they would want a personal toilet said it would be to maintain proper hygiene and sanitation practices.xxvii

Even houses with toilet access still have problems. One study found 40% of houses with properly functioning toilets still have at least one person in them who still openly defecates.xxviii Individuals who still do so claim that publicly defecating is “…pleasurable, comfortable, and convenient.”xxix There needs to be some means of making using toilets more appealing for persons than publicly defecating. There also needs to come to light some means of educating people the importance of practicing proper hygiene and sanitation, if more good women and children (even India as a whole here) outcomes are to occur. There also needs to be some means of incentivizing individuals into not publicly defecating when they have the knowledge of and access to facilities to prevent the diseases that can result from unhygienic and unsanitary practices. For the record, lacking toilets is not a new problem. Gandhi, during his time in guiding India to being the independent nation it is today, had this to say with respect to toilets in the city known as Rajkot: “[They are] dark and stinking and reeking with filth and worms.”xxx Toilets, even if present, are not managed in such a way that they are good for frequent use among India’s masses. Gandhi also found that untouchables, the lowest persons in India with respect to the Hindu based caste system, had no access to toilets;xxxi there are currently more than 100 million untouchables in India.xxxii

Intervention: This intervention program seeks to provide changes in Goa, India in the hopes of changing sanitation infrastructure from a grassroots level. Ultimately, we believe that infrastructural intervention would be a more comprehensive solution to the sanitation problem.

Program Context: This intervention seeks to develop modern infrastructural approaches to improve sanitation outcomes and to lessen the burden of dysentery, cholera, and other similar diarrheal diseases. The same dilemma exists in Afghanistan where there is such a high burden of sanitation related diseases. Fortunately, intervention policies have been implemented and have proven to generate positive externalities. The Afghan Ministry of Health and Ministry of Rural Rehabilitation and Development is joining forces with UNICEF and other partners to launch a new nationwide campaign to tackle water-related disease in Afghanistan.xxxiii This joint effort with UNICEF has helped to provide a more cohesive integrated campaign, ensuring maximum effectiveness in its design. The campaign launched in 2004 and combined numerous initiatives such as “hygiene education, health promotion and the physical safeguarding of the water supply.”xxxiv Afghanistan has proven to have similar maternal and child health statistics in India. UNICEF estimates that up to half of the deaths of all children under the age of five are related to diarrheal disease, caused by inadequate sanitation, lack of clean drinking water and poor hygiene practices.xxxv Population density also proves to be a challenge. The concentration of people in one setting who have been accustomed to unsanitary practices compromises the integrity of ground water and sanitary systems. The significant increase in urban populations brought about by high numbers of returnees in the last two years has placed particular strain on the water and sanitation systems in Afghanistan's major cities, with households increasingly using contaminated ground-water from shallow wells for drinking and food preparation. xxxvi The campaign has specifically targeted school and community hygiene education starting by the “chlorination of shallow wells and the social marketing of safe water and sanitation systems. xxxvii These integrations are however not merely enough to ensure positive results. Physical improvements are essential beginning with adequate food preparation, hand washing, and other sanitary requirements. The integrated outreach approach has proven some success. As a follow-up to the 2008 International Year of Sanitation, UNICEF has initiated clean village projects promoting sustainable behavior changes on key hygiene practices among families. To date, 1,000 schools with a total of about 320,000 students in total benefit directly from this intervention. xxxviii

In Bolivia, sanitary interventions were underway to improve health statistics. A mixed-method (qualitative-quantitative) study was conducted in 14 rural intervention and control communities throughout Bolivia in November 2008, six years after the completion of interventions designed to improve knowledge and practices related to maternal and child health, nutrition, community water systems, and household water and sanitation facilities. xxxix This study accessed the long term effects of sanitation intervention programs in the community, a crucial element in the fight to foster sustainable community wide sanitary practices. Researchers found “Six years post-project, participants remained committed to sustaining the practices promoted in the interventions. The average rating for the functional condition of community water systems was 42% higher than the average rating in control communities” xl and those who received integrated intervention programs that included development and health system renewal did significantly better than communities that only received assistance in one focus area. Ultimately, the interventions proved to be beneficial long term. Infrastructure such as sanitation facilities were maintained and modernized. This study also utilized community wide participation to

optimize intervention efficiency. Community wide intervention effectively maximized more frequent use of sanitary practices by women and children.

In Kenya, a clustered randomized study was conducted to assess the impact of school water, sanitation, and hygiene interventions on the health of younger siblings of pupils. These interventions were spearheaded under the WASH program to reduce rates of diarrhea-related outcomes among school-aged children. Researchers conducted, “a cluster-randomized trial among 185 schools in Kenya from 2007 to 2009. We assigned schools to 1 of 2 study groups according to water availability. Multilevel logistic regression models, adjusted for baseline measures, assessed differences between intervention and control arms in 1-week period prevalence of diarrhea and 2-week period prevalence of clinic visits among children younger than 5 years with at least 1 sibling attending a program school.” xli The results are a positive indication of the efficient results these sanitation programs deliver. Among water-scarce schools, comprehensive WASH improvements were associated with decreased odds of diarrhea (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.27, 0.73) and visiting a clinic (OR = 0.36; 95% CI = 0.19, 0.68), relative to control schools. xlii Ultimately, WASH interventions can reduce the burden of diarrheal related diseases.

Program Population: Implementing a program to help sanitation to ensure better health outcomes for both women and children in Goa, India will by no means be an easy task. As previously stated, this intervention will attempt to make a difference initially in Goa, India; if successful, this intervention will continue to expand to other cities throughout India. The reason why this intervention will first take place in Goa is because of how Goa is the smallest state in all of India. Goa has a population of approximately 1.5 million people;xliii however, the intervention will not need to focus on all 1.5 million of these people in the state. Data recently collected shows that only 5.09% of all of the people who call Goa their home are impoverished.xliv Also given that women comprise about half of the total population in the state,xlv and children aged between zero and nine years of age make 14.21% of Goa’s total population,xlvi, the intervention will only need to focus on approximately 19% of Goa’s complete population, or about 285,000 people. These 285,000 people will become the women and children on whom we will test our intervention in our attempt to improve sanitation.

Methods: One means of dealing with infectious disease, should it have already occurred, is oral rehydration therapy (ORT). ORT involves replacing bodily fluids lost because of communicable disease like infectious diarrhea. Infectious diarrhea, as previously stated in the problem context, is a terrible disease that claims the life of millions of children annually;xlvii infectious diarrhea kills by purging essential salts and fluids from the body needed for metabolic processes. ORT works to replace those lost fluids and decrease the amount of times individuals afflicted with the disease need to poop.xlviii In reducing the number of times persons afflicted need to poop, the fluids added to the body have time to allow the body to recover what they have lost so the body can ultimately make a recovery from the disease. One potential problem with administering ORT to individuals may include language barriers that impede individuals in Goa from understanding what ORT is, or why it is important for them to take should they acquire infectious diarrhea. One intervention that used ORT in Guatemala found that having workers speak Spanish in a non-condescending manner allowed for a greater ability to distribute the ORT to individuals afflicted by infectious diarrhea. As such, one solution that would allow for

ultimately a better outcome is to hire workers who are familiar with languages common to Goa,xlix which include the primarily spoken Konkani, which is Goa’s official language, and Marathi.l Other languages secondarily spoken around Goa include Kannad and Urdu.li Another important matter with ORT (and all methods for this intervention in general) is to debunk any myths associated with ORT; one study that implemented ORT in Ethiopia found that parents who thought teething in infants caused infectious diarrhea were statistically significantly less likely to use ORT than parents who did not thinking infant teething caused infectious diarrhea.lii

Local individuals are going to be an invaluable asset to ensuring the intervention works. If locals fail to understand the purpose of an intervention, or if an intervention is pitched to them in a way that makes absolutely no sense to them, then the intervention will ultimately fail. One study looked into why fishermen were using bed nets as fishnets.liii The study found that bed nets intended for malaria accounted for up to 83.8% of the total amount of nets used on beaches to catch fish.liv When asked why they were using the bed nets as fish nets, fishermen typically responded with how the nets dried the fish faster, and because various NGOs were just handing them out to anyone who wanted them, at no charge;lv the fishermen did not view the nets as means of preventing malaria, but rather, a means of making their living easier at no extra cost to them. Bed nets also were not used for their proper purpose because, initially, people just viewed them as a means of simply ruining their night’s sleep; sleeping underneath bed nets, while providing great protection from malaria containing mosquitoes, tends to result also in “protection” from a night’s cool breeze, which results in sleeping in a hotter environment, which can potentially ruin a good night’s sleep.lvi People who live around malaria also just view it as part of the cultural norm; initial efforts to use bed nets failed because locals just perceived malaria, no matter how dangerous of a disease it is, to just be a normal part of life. In believing this deadly disease to just be part of the daily grind, they did not use the bed nets they were given because they would rather simply have a good night’s sleep than prevent themselves from becoming infected.lvii Local aid and understanding will be essential in getting people to follow through with sanitation procedures so that way people will both initially follow them and encourage others to follow through with them too.

In March 2015, the WHO and UNICEF found that among 66,000 health facilities from “low- and middle-income countries,” more than a third did not contain soap for hand washing, and a fifth of that 66,000 lacked toilets.lviii One important means of this intervention will be bringing toilets and soap to the people of Goa to ensure they stop infectious disease from even having a chance of occurring, a means of primary prevention. Currently, access to sanitation via means such as a toilet or latrine is lacking in about a quarter of India.lix By adding toilets and latrines to even just a quarter of Goa, because of our previously established fact that women and children in Goa make only 19% of the total population,lx lxi the intervention will already have supplied more than enough toilets and latrines for all of the women and children in the state to use. One study found before it started attempting to implement toilets around India that some areas already had toilets.

However, even when there are toilets available, the toilets themselves typically are in horrible condition; the intervention coordinators noted public toilets “…are often in serious disrepair within three months of being constructed, leaving people with little or no alternative but to [publically defecate.]”lxii The coordinators also found a topic already discussed in this intervention. Women suffer the most from their inability to access safe toilets.lxiii Women can

suffer from gastrointestinal problems from having to wait either until early dawn or late dusk to relieve themselves because of cultural practices,lxiv but also can find that wildlife and sexual predators can harm them as well when they attempt to go to the bathroom during these relatively light-absent hours.lxv lxvi Ultimately, we seek to curb the rate of sexual assault by adding protective personnel to defecation sites. These protective entities will be in the form of law enforcement (police officers) stationed at select known defecation sites in Goa. To figure out how many officers to place around these defecation sites, this intervention’s coordinators compared Goa to the US state Maryland. Maryland is a state in the U.S. with a similar area per square miles as Goa. In Maryland, there are approximately five officers per 1,000 local residents.lxvii We propose to put 100 additional law enforcement personnel in Goa to act as escorts for women to and from these defecation sites, and to protect them as they relieve themselves. There will be 20 different stations and five enforcement officers at each station. Some possible sites may include those in Panaji, Goa’s capital and Vasco da Gama, Goa’s largest city.

In addition, we propose an implementation of heavy fines. This legislative initiative is key to tackling the sanitary burden of public defecation. Fines paid in lieu of public defecation will be allocated towards all legislations concerning sanitary initiatives in Goa. This money will be used to fund law enforcement salaries, toilets, sanitation station implementation, and infrastructural adjustments. The fine will provide incentive means to curb the influx of diarrheal related sickness. In 2015, at a bus stand in the city of Panaji, “people urinate and defecate at the bus stand despite [two sanitation officials] in the premises. Dry and wet wastes from shops are dumped around the [bus stops], and heaps of paper and plastic are burnt every day causing air pollution.”lxviii Participants who choose to publically defecate will be ticketed. Ultimately, these measures will prove to curb the incidence of illegal defecation and the expansion of disease in the region.

In the mid-1960s, the people of Mumbai fought for a better sewage system, and ultimately got approximately $200,000,000 in US dollars in order to be able to construct it.lxix The problem with this loan was that, because of how Mumbai’s population at the time (again, mid-1960s) was approximately 4,854,000 people,lxx which is more than triple of what Goa is currently today. Concurrently in Mumbai (also known as Bombay at the time) at the time was the problem that most of the population did not in sanitary conditions; more than half of Mumbai’s citizens at the time lived in slums, which ultimately led to a greater emphasis on improving toilets there.lxxi If this intervention uses the logic that the reason then that public toilets were emphasized much more in Mumbai was because of poverty, then because only 5.09% of Goa’s residents are considered impoverished,lxxii then there can be a much greater emphasis on implementing a better sewage system and less of a need to implement public toilets in the region.

Budget: Included here is a budget of all materials this program will need to have a real chance of being effective and making a difference in preventing poor sanitation from causing more death and disease spread. Please note that each dollar translates to 66.55 Indian Rupees. The total cost for this whole program should ultimately come to between $7,269,754 and $7,349,151.20 USD.

Budget

Items

Specifics

Quantity/Tools

Needed

Total Cost (US

Dollars)

Total Cost

(Indian

Rupee (INR))

Additional

Notes

Programs WASH Inspectio

n Tests 2000 10,000 665494.54

Soap Dispense

rs10,000 20,000 1330989.

08

Liquid Soap -

Each kilo 1000 USD

30 330,000

1996483.625

Each Kilogram Should Cost

$1,000 USD

Waterholes 1000 10,000 665494.5

63

Toilets 10,000 50,000 3327472.7

Boreholes 6 60,000 3992967.

25

ORT

Each small

packet of salts

costs ~$1 USD

285,000 $285,000

18966593.25

Sanitary

Defecation

Sites

Cubic Yards

592.592 Yards

Between

1,689.60 and

3,119.60

Between 112441.9

5 and 207607.6

6

Each cubic yard

should cost

between $84.48

and $155.98

USD

Labor 5 Workers A Site

Between

27,939.40 and 66,956.

60

Between 1859351.

70 and 4455924.

90

Each site's labor

should cost

between $1,396.97

and $3,347.83

USDDebris

Disposal Costs

Tools to Remove

Disposable Materials

Between

18,900 and

Between 1257784.

60 and 1390883.

Each site's

disposal costs

20,900 50

should be between $945.00

and $1,045.00

USD

Excavation

Equipment

Demolition, Loading, & Excavation Equipment

Between 3,225

and 4,575

Between 214621.9

8 and 304463.7

3

Each site’s

excavation costs

should be between $161.25

and $228.75

USD

Sewage System

10 Throughout Goa

Installation

Between

$15,000 and

$50,000

Between 9982417.

50 and 3327472

55

Each installation should

cost between $15,000

and $50,000

Maintenance & Septic

Tanks

300,000

19,964,835.00

Funding for this

will come from

World Health

Organization

Signs to State How

Public Defecat

ion's Illegal

Should Look

like Stop Signs

1,000 511 34,006.77

Advertising

Materials

Handwashing

Cards10,000 $1,000 66549.45

4

Personnel

Police Officers

Escort to And from And

Protect Women

at Defecation Sites,

Patrol Streets to Ensure

100 $5,626,000

374407205.7

Annual Salary

should be $56,250 USD per officer

No Public

Defecation,

Fining Public

Defecators,

Ability to Speak

Local Language(s) to

Effectively

Communicate with

Locals

Appendix: Included are sample materials that this program will use during its implementation throughout Goa.

This card will be placed at all authorized defecation sites. The card promotes hand washing with soap in Hindi. The card is legible appealing to populations that are illiterate in the rural areas of Goa.lxxiii

This card will be placed in front of every wash station. It is a reminder to wash hands before doing daily duties.lxxiv

This diagram simplifies how to administer Oral Rehydration Salts to make and ORS solution. This is key to administer in the midst of a diarrheal epidemic.lxxv

i (2015). Lakshminarayanan, S., & Jayalakshmy, R. Diarrheal Diseases among Children in India: Current Scenario And Future Perspectives. Journal of Natural Sciences, Biology and Medicine, 6. 10.4103/0976-9668.149073ii (2016). Most Populated Countries in The World. Maps of World. Retrieved from http://www.mapsofworld.com/world-top-ten/world-top-ten-most-populated-countries-map.html iii (2012). Indian Ethnicity. Historical Boys’ Clothing. Retrieved from http://histclo.com/country/other/india/eth/india-eth.htmliv (2014). India’s Staggering Wealth Gap in Five Charts. The Hindu. Retrieved from http://www.thehindu.com/data/indias-staggering-wealth-gap-in-five-charts/article6672115.ecev (2016). India Poverty & Equity. The World Bank. http://povertydata.worldbank.org/poverty/country/INDvi (2014). Worley, H. Water, Sanitation, Hygiene, and Malnutrition in India. Population Reference Bureau. Retrieved from http://www.prb.org/Publications/Articles/2014/india-sanitation-malnutrition.aspx vii Worley, H. Water, Sanitation, Hygiene, and Malnutrition in India. Population Reference Bureau.viii (2014). Harris, G. Poor Sanitation in India May Afflict Well-Fed Children with Malnutrition. The New York Times. Retrieved from http://www.nytimes.com/2014/07/15/world/asia/poor-sanitation-in-india-may-afflict-well-fed-children-with-malnutrition.html?_r=1 ix (2009). Hall-Clifford, R.A. Oral Rehydration Therapy in Highland Guatemala: Long-Term Impacts of Public Health Intervention on The Self. Proquest Dissertations Publishing. 42. Retrieved from http://search.proquest.com.ezproxy.bu.edu/docview/304843688?accountid=9676 x Harris, G. Poor Sanitation in India May Afflict Well-Fed Children with Malnutrition. xi Worley, H. Water, Sanitation, Hygiene, and Malnutrition in India. Population Reference Bureau.xii Harris, G. Poor Sanitation in India May Afflict Well-Fed Children with Malnutrition.xiii (2016). India Population. Country Meters. Retrieved from http://countrymeters.info/en/India xiv Harris, G. Poor Sanitation in India May Afflict Well-Fed Children with Malnutrition.xv (2014). Vollmer, S. et al. Association between Economic Growth And Early Childhood Undernutrition: Evidence from 121 Demographic And Health Surveys from 36 Low-income And Middle-income Countries. The Lancet, 2, 232. Retrieved from http://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(14)70025-7.pdf xvi Harris, G. Poor Sanitation in India May Afflict Well-Fed Children with Malnutrition.xvii (2013). Twelfth Five Year Plan (2012 – 2017). Faster, More Inclusive and Sustainable Growth. 163. Retrieved from http://planningcommission.gov.in/plans/planrel/12thplan/pdf/12fyp_vol1.pdf xviii Twelfth Five Year Plan (2012 – 2017). Faster, More Inclusive and Sustainable Growth. 164.xix Twelfth Five Year Plan (2012 – 2017). Faster, More Inclusive and Sustainable Growth. 164.xx Twelfth Five Year Plan (2012 – 2017). Faster, More Inclusive and Sustainable Growth. 165.xxi (2014). MDG 7c for Safe Drinking Water in India: An Illusive Achievement. The Lancet, 383, 1379. Retrieved from http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(14)60673-5.pdfxxii (2014). Snakebites, Diarrhoea And Violence: Why India’s Rural Women Need Toilets. The Guardian. Retrieved from http://www.theguardian.com/global-development/poverty-matters/2014/nov/19/snakebites-diarrhoea-violence-india-rural-women-toilets xxiii Snakebites, Diarrhoea And Violence: Why India’s Rural Women Need Toilets. The Guardian.xxiv (2014). Biswas, S. Why India’s Sanitation Crisis Kills Women. British Broadcasting Corporation. Retrieved from http://www.bbc.com/news/world-asia-india-27635363 xxv (2013). Tewary, A. & Bihar, P. India Bihar Rapes ‘Caused by Lack of Toilets.’ British Broadcasting Corporation. Retrieved from http://www.bbc.com/news/world-asia-india-22460871 xxvi Biswas, S. Why India’s Sanitation Crisis Kills Women. British Broadcasting Corporation.xxvii Tewary, A. & Bihar, P. India Bihar Rapes ‘Caused by Lack of Toilets.’ British Broadcasting Corporation.xxviii (2014). Anand, A. Lack of Toilets Puts India’s Health And Rural Women’s Safety at Risk. Lack of Toilets Puts India’s Health And Rural Women’s Safety at Risk. Retrieved from http://www.theguardian.com/global-development/2014/aug/28/toilets-india-health-rural-women-safetyxxix Anand, A. Lack of Toilets Puts India’s Health And Rural Women’s Safety at Risk. Lack of Toilets Puts India’s Health And Rural Women’s Safety at Risk.xxx (2012). Biswas, S. Is India’s Lack of Toilets A Cultural Problem? British Broadcasting Corporation. Retrieved from http://www.bbc.com/news/world-asia-india-17377895 xxxi Biswas, S. Is India’s Lack of Toilets A Cultural Problem? British Broadcasting Corporation.xxxii India’s Untouchables. Cultural Survival. Retrieved from https://www.culturalsurvival.org/ourpublications/csq/article/indias-untouchables xxxiii New campaign to tackle water-, sanitation-related disease in Afghanistan. British Broadcasting Corporation monitoring South Asia. Retrieved from http://search.proquest.com.ezproxy.bu.edu/docview/459848824/fulltext/

F6FD2D8918F84550PQ/1?accountid=9676xxxiv New campaign to tackle water-, sanitation-related disease in Afghanistan. British Broadcasting Corporation monitoring South Asia.

xxxv New campaign to tackle water-, sanitation-related disease in Afghanistan. British Broadcasting Corporation monitoring South Asia.

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