Open Defecation in India- Solution Through Indian Squatting or Western Sitting Type Toilets?

07-06/10

For me the Western side of the globe has always been a bundle of contradictions. When we use an internationally accepted system of measurement in kilograms and litres most of them still use archaic systems like pounds and gallons. If we use the left side of the road they use the right side. While we use our hands to eat our food they use a whole lot of things spoon, fork, knives etc. And finally when it comes to defecation they sit and we squat.

Having got used to the Indian Squatting Type toilets all my life, I had a tough time switching over to the Western Toilet for some time after an accident. The most irritating part was placing my thighs on the seat and then came the fear of splashing water. Indian houses traditionally had only the squatting type toilets. These days houses are built with both these facilities and in some cases only Western toilets are built. This blog post is about the defects of the Western Sitting type toilets.

Though we had a Western toilet in our house we had seldom used it. In 2008, I met with an accident and had a nasty ligament tear on my right leg and was confined to bed rest for a couple of months. There was no other go other than using the Western facility at home. Since then I have been using it with the hope that I would soon be able to squat with my right leg flexing completely and start using the Indian toilet again. It was in 2008 that I realised that the Western type resulted in more stress and strain in defecating compared to the Indian type. I wanted to ascertain this fact and googled.

With my newfound interest in sanitation and finding a solution to India’s Open Defecation problem, this research, I thought, was timely. When we are planning a massive campaign to dissuade people from the archaic practice of open defecation, it is imperative to look at the best position to defecate and the ergonomics of the postures for defecation before deciding on the type of toilets.

Humans defecate in various positions. The main defecation postures are:

*Squatting Posture: Traditionally followed in most Asian and Indian toilets. In this position the angle between the body and the thighs is between 22 and 23 degrees.

*Sitting Posture: Modern Western toilets provide a facility to sit on the toilet. In this position the angle between the body and the thighs is 90 degrees.
*Sitting Posture on a lower seat: A posture in between the sitting and the squatting postures. In this position the angle between the body and the thighs is 60 degrees.

Apart from this angle formed between the body and the thighs while seated, the ano-rectal angle, the angle formed at the junction of the rectum and the anus is also an important factor in the ergonomics of the posture. “The anorectal angle (ARA), the angle formed by the junction of the rectum with the anus, is an important consideration in defecation posture studies. ARA is "one of the most important contributions to anal continence"; its normal value at rest is 90 degrees.” (ALTOMARE Donato F.; RINALDI Marcella; VEGLIA Antonella; GUGLIELMI Altomarino; SALLUSTIO Pier Luca; TRIPOLI Gaetano - in International journal of Colorectal Disease, 2001, vol. 16, number 1, pp. 51-54 .)

Lots of literature is available in the net which go to say that the Western Squatting Type Toilet is an ‘ergonomic nightmare’. The Western Toilet creates a strain on the user compared to the Squatting Type toilets. A study on the comparison of the straining in the three positions shows that the Squatting Type posture is the best for defecation: -

“The aim of the study was to compare the straining forces applied when sitting or squatting during defecation. Twenty-eight apparently healthy volunteers (ages 17–66 years) with normal bowel function were asked to use a digital timer to record the net time needed for sensation of satisfactory emptying while defecating in three alternative positions: sitting on a standard-sized toilet seat (41–42 cm high), sitting on a lower toilet seat (31–32 cm high), and squatting. They were also asked to note their subjective impression of the intensity of the defecation effort. Six consecutive bowel movements were recorded in each position. Both the time needed for sensation of satisfactory bowel emptying and the degree of subjectively assessed straining in the squatting position were reduced sharply in all volunteers compared with both sitting positions. In conclusion, the present study confirmed that sensation of satisfactory bowel emptying in sitting defecation posture necessitates excessive expulsive effort compared to the squatting posture.” -Dov Sikirov-Comparison of Straining during Defecation in Three Positions: Results and Implications for Human Health- Digestive Diseases and Sciences- Vol: 48- No: 7- July 2003.

The best material on matters pertaining to ergonomics of squatting posture for defecation, the physiological benefits of squatting and the defects of the Western Sitting type toilets is “Health Benefits of the Natural Squatting Position” http://www.naturesplatform.com/health_benefits.html . It is a very good reading material and is a must for people interested in the subject of sanitation. It has completely demystified the notions about all the three type of defecation postures.

Since the above material is a very lengthy one I am placing an excerpt and I suggest that you go to the above URL to get the complete information.

“Seven Advantages of Squatting

1) Makes elimination faster, easier and more complete. This helps prevent "fecal stagnation," a prime factor in colon cancer, appendicitis and inflammatory bowel disease.
2) Protects the nerves that control the prostate, bladder and uterus from becoming stretched and damaged.
3) Securely seals the ileocecal valve, between the colon and the small intestine. In the conventional sitting position, this valve is unsupported and often leaks during evacuation, contaminating the small intestine.
4) Relaxes the puborectalis muscle which normally chokes the rectum in order to maintain continence.
5) Uses the thighs to support the colon and prevent straining. Chronic straining on the toilet can cause hernias, diverticulosis, and pelvic organ prolapse.
6) A highly effective, non-invasive treatment for hemorrhoids, as shown by published clinical research.
7) For pregnant women, squatting avoids pressure on the uterus when using the toilet. Daily squatting helps prepare one for a more natural delivery.” (Courtesy: Health Benefits of the Natural Squatting Position)

I also liked the conclusion part of the above write up:

“For 150 years, the people of the Western World have been the unwitting subjects of an experiment. By an accident of Fate, they were forced to adopt sitting toilets, while the other two-thirds of the world (the "control group") continued to use the natural squatting position.
The results of this experiment have been clear and unequivocal. The experimental group has suffered dramatically higher rates of intestinal and urological disorders. The following diseases are almost exclusively confined to the Western World: appendicitis, colon cancer, prostate disorders, diverticulosis, bladder incontinence, hemorrhoids, and inflammatory bowel disease.
But the results have been misinterpreted by researchers who were unaware that the experiment was even taking place. Western doctors have tried to blame these diseases on the "highly refined" western diet. Their attempts have consistently failed to show that diet is a significant factor. Conventional medical websites all tell the same story:
This is a disease of the Western World. We don't know what causes it, or why the developing world seems so strangely immune.

Medical researchers have been working diligently to solve these deadly mysteries, but they have made little progress. Due to their habit of studying diseases in isolation, they failed to notice a remarkable coincidence: Many different bowel, bladder and pelvic diseases – previously rare or unknown – suddenly became commonplace in the last half of the 19th century.
This simple observation would have alerted them to the presence of a common underlying factor. It would have prompted the obvious question: What suddenly changed in the daily habits of the population?

The obvious answer: They abandoned the squatting posture for bodily functions (including childbirth.) For each disease, the anatomical relevance of this change has been explained above. The relevance is confirmed by the absence of these disorders among squatting populations.
In conclusion, the porcelain throne has caused enormous amounts of needless suffering, and the annual waste of billions of dollars in health-care costs. Clearly, the time has come to reacquaint Western Man with his natural habits – and put this unfortunate experiment to an end.” (Courtesy: Health Benefits of the Natural Squatting Position) .

As per the latest statistics available, 54% of the Indian population do not have the luxury of defecating in a toilet and adopt open defecation. That works to a whopping 11,59,93,178 toilets. There are many efforts by various interested parties to assist the population to construct their own toilets. Any effort in this direction should take into consideration the above facts and all the focus should be in providing ONLY Squatting Type Toilets.

This write up is part of the Kuckoos Campaign- a campaign against open defecation in India- a crusade to dissuade the last person squatting in the open before the first Indian lands on the Moon. Welcome to the Campaign. Endorse your support by following the Blog. Just become a Kuckoos follower.

P.Uday Shankar

Open Defecation in Urban India- Government Ranks Cities Based on Sanitation Levels

6-06/10

The Urban Sanitation Wing of the Ministry of Urban Development, Government of India has published a list of 423 cities and towns in India as per a Sanitation Ranking adopted by the Government. Keeping in mind the MDG Goals and the need to hasten up the process of abolishing open defecation, the Ministry needs to be commended for the initiative to rank Indian cities on the basis of various indicators.

Open defecation continues to be a menace in the towns and cities too, apart from the villages where it is still rampant. Having travelled across India I have always compared towns and cities based on their level of sanitation and cleanliness. A city as old as Varanasi was always bound to have a lower scale on my estimation compared to planned cities like Pondicherry or Chandigarh. How long are we going to tolerate this apathy on matters related to sanitation when it comes to old cities? When are these cities going to learn from other old cities which have made strides in sanitation? I had recently been to Nagpur and the first thing that appealed me was the effort taken by the Corporation to cleanse the city. When asked how this has happened, the locals remember a Commissioner from Andhra Pradesh who was responsible for the sweeping changes in Nagpur.

My thoughts went back to my own home town, Coimbatore, when years back it took one Municipal Commissioner to make an everlasting change in the city. As a school going boy I had always remembered buildings belonging to the Municipality as places where people urinate anytime or defecate in the dark. It was one person who made a change by painting all Municipal buildings grey and white. Compound walls of Municipal buildings were painted and strips of road-side gardens cropped up everywhere. I still remember the name of the person who did this as much as the citizens of Coimbatore- Mr Niranjan Mardi. His two pronged strategy did pay dividends. He not only painted the buildings and gave them a place of pride among the citizens but also gave a serious look ‘inside’. He successfully thwarted the red tapism which was a virtual rot in the system then. This I can say with all impunity because my mother who retired as a teacher in the Municipality during that time had her retirement papers moved fast enough to get her benefits, which otherwise would have been buried ‘deliberately’ under files.

How long are we going to depend on such one person miracles to happen in our cities? It is high time we brought in a sea change in the system. What prevents all employees of a Municipality or a Corporation to behave like a Niranjan Mardi? The rot has become systemic and it is in the DNA. It is like the residual effect of pesticides, traces of which can be found in human blood.

Despite all the rot, hats off to all those young Commissioners who are striving to make a dent in their cities by improving the level of sanitation. This method of grading cities will surely help in moving up the scale to reach the top. This sense of competition has to be infused in the minds of all stakeholders and the foremost is the common man. The message of this competition has to reach the common man so that he also strives to keep his/her city clean. This was my intention of placing this news on my Blog.

Descriptions of the methodology adopted by the Ministry- All indicators have been allotted marks and the overall assessment is on a scale from 0 to 100:
“1. Ouput-related - 50*

A. No open defecation sub-total- 16

i. Access and use of toilets by urban poor and other un-served households (including slums) - individual and community sanitation facilities- 4
ii. Access and use of toilets for floating and institutional populations - adequate public sanitation facilities- 4
iii. No open defecation visible- 4
iv. Eliminate Manual Scavenging and provide personnel protection equipment to sanitary workers- 4

B. Proportion of total human excreta generation that is safely collected (6 points for 100%) - 6

C. Proportion of total black waste water generation that is treated and safely disposed off (6 points for 100%) - 6

D. Proportion of total grey waste water generation that is treated and safely disposed off (3 points for 100%) - 3

E. Proportion of treated water that is recycled and reused for non-potable applications - 3

F. Proportion of total storm-water and drainage that is efficiently and safely managed (3 points for 100%) - 3

G. Proportion of total solid waste generation that is regularly collected (4 points for 100%) - 4

H. Proportion of total solid waste generation that is treated and safely disposed off (4 points for 100%) - 4

I. City wastes cause no adverse impacts on surrounding areas outside city limits (5 points for 100%) - 5

2. Process-related** 30

A. M&E systems are in place to track incidences of open defecation - 4

B. All sewerage systems in the city are working properly and there is no ex-filtration (Not applicable for cities without sewerage systems) - 5

C. Septage/sludge is regularly cleaned, safely transported and disposed after treatment, from on-site systems in the city (MAXIMUM 10 marks for cities without sewerage systems) - 5

D. Underground and Surface drainage systems are functioning and are well-maintained - 4

E. Solid waste management (collection and treatment) systems are efficient (and are in conformity with the MSW Rules, 2003) - 5

F. There is clear institutional responsibility assigned; and there are documented operational systems in practice for b)/c) to e) above - 4

G. Sanctions for deviance on part of polluters and institutions is clearly laid out and followed in practice - 3

3. Outcome-related 20

A. Improved quality of drinking water in city compared to baseline 7

B. Improved water quality in water bodies in and around city compared to baseline - 7

C. Reduction in water-borne disease incidence amongst city population compared to baseline - 6

* The marks for the above indicators will be revised every two to three years. Over time, indicators about
more stringent conditions e.g. no-urination, or spitting in open/public spaces, etc. will be introduced as
indicators. The weights accorded to each category and specific indicators will also be revised

** In this context, bigger cities may consider instituting good practice systems that comply with ISO (International
Standards Organization) and/or BIS (Bureau of Indian Standards) process systems.

Based on the above ratings a colour coding has been given by the Ministry:

1. Red Cities on the brink of public health and environmental “emergency” and needing immediate remedial action - less than 33

2. Black Needing considerable improvements - 34-66

3. Blue Recovering but still diseased – 67-90

4. Green Healthy and Clean city – 91 – 100

■ On the basis of plans prepared and implemented, cities will be able to measure the results of their actions, and be able to clearly chart out their improvements over time compared to their baseline situation.

■ On achievement of remarkable results, i.e. coming into the Green category (Healthy and Clean City), cities will typically become eligible for the national award. Other cities showing remarkable incremental performance or selective achievements may also be given special or honorary awards. Cities in different size-classes may also be considered for category-wise awards.

■ Based on results of the Rating survey and selection of awardees, cities will be invited to participate in a National Urban Sanitation Award ceremony.”

You may note from the list of cities that none of the cities have qualified themselves for the ‘ Green Healthy and Clean City category of 91 to 100 marks. The city on the top of the list Chandigarh is still at a low 73.48 and has a long way to make it to the Green slot. I was surprised to find my home town Coimbatore down at 92nd place and Nagpur at 239th place.

In case you are interested to know where your city/town in India is placed you may refer the following site:
Source:
National Urban Sanitation Supply-Ministry of Urban Development

The entire list of ranked 423 cities/towns is available here: Ranking of 423 cities in India

P.Uday Shankar