Poor sanitation and lack of clean water threatens maternal health in rural...

Poor sanitation and lack of clean water threatens maternal health in rural Kashmir

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Zareena Begum has visited the sub-centre in her area for a regular check-up. But, the centre is closed so she requests the locals to let her know once the staff comes.
Zareena Begum has visited the sub-centre in her area for a regular check-up. But, the centre is closed so she requests the locals to let her know once the staff comes. Photograph by Aliya Bashir

Kanyari, Bandipora — At a nearby river bank, Zareena Begum, 30, is struggling to fill some clean water in a corrugated aluminum bucket. In her background, two school-going kids are roving a shikara to reach to their school. The boat is the only means of transport to this forgotten piece of land and it carries everything: daily essentials, ill to hospitals and children to school.

As she leans to refill the bucket with clearer water, Zareena yells at the kids and asks them not to throw biscuit wafers into the water. But, they mock at her and run away.

The wafers are a new, glossy addition to an-already floating debris in the river.

Zareena’s utensil then takes one last dip and out comes a bucket full of water, the color of mud.

And that’s what her family is going to drink for survival.

Tucked behind many makeshift sheds in Kanyari village of north Kashmir’s Bandipora district sits a small wooden shack, covered with cheap blue color tin sheets and a dented roof.

It is Zareena’s home. She lives with her husband Ghulam Mohammad Khosa, 35, a fisherman.

Inside the small shed, there are two partitions, one acting as kitchen and another as bed room. On one wall made of wooden planks are studded iron nails on which clothes are hung; besides a storage trunk, a mattress is stacked on top of a blanket.

The cramped conditions at Zareena’s home doesn’t upset her that much as she is overjoyed with her six months baby bump, as she has become pregnant after three years of marriage.

Recently when she missed her monthly menstrual cycle, she was spotted by a female neighbor and taken to a sub health centre, few minutes away from her home. The sub centre was closed and she rushed to a nearby private lab for a urine examination, after rowing a boat herself and then walking around three kilometers by foot.

“I get a lot of stomach aches,” she says with desperation. “The water is very dirty as it makes me sick. But, I have no other choice.”

Kanyari was hit by massive flooding in September 2014. The local population suffered badly due to the lack of basic facilities since the flood water submerged the main road to the households, cutting them entirely from the rest of the neighborhood. Kanyari is originally an island – from north it is surrounded by Wular Lake and on its south half a dozen water channels flow which submerge it from all sides during the rise of the waters.

The slum infrastructure in this hamlet has not remained sufficient due to the failure of the government policy to resettle the poor who are mostly associated with the fishing trade near the banks of river Jhelum. The government considers them as “illegal” settlements.

“We blocked the main road many times to protest for our rights,” Zareena says. “But, a poor is always considered a burden. No one listens to our pleas.”

Anemia, low birth-weight and malnutrition are some of the reasons for poor health among women in rural areas who are often averse to discussing sanitation and other pregnancy health issues. These women mostly look after their household chores and help men in their family agricultural activity which is considered an additional household duty. They usually don’t get any separate share for their contribution in the businesses and have to mainly depend on men for their financial needs. However, during the past many years the trend is slowly changing among the new generation.

Saleema Jan, a local woman in Kanyari village collects water outside her home to prepare lunch for her kids. She says that her hands aches whenever she washes her hands in the water but expresses her helplessness with no other option.
Saleema Jan, a local woman in Kanyari village collects water outside her home to prepare lunch for her kids. She says that her hands aches whenever she washes her hands in the water but expresses her helplessness with no other option. Photograph by Aliya Bashir

“We don’t have any cleanliness here at all,” Zareena says. “Even if we try our best as individuals to keep the environment around us clean, but everyone defecates, drinks and washes in the same water.”

In absence of any toilets, Zareena either defecates in the open or sometimes uses a dilapidated wooden toilet of a neighbor outside her house. The waste from the toilet directly goes into the water despite the river being the only source of drinking water for the villagers. However, to lessen the hazard, people in the area boil the water to make it drinkable.

That too, however, has not been of any help.

“I don’t feel safe there,” Zareena says. “The pot is mostly full as there are no water taps to clean it. One has to collect water first and then use it. The open air is easier behind the dense forests.”

Zareena has done one ultrasound scan at Sub-District Hospital Sopore for the free of cost. The district hospital Bandipora is too far for her – 35 kilometers – while as Mother and Child Health Centre at Sopore in Baramulla district, which many of the expectant mothers in her area visit, is just seven kilometers.

“I always feel nausea, even after boiling the water,” she says. “I don’t feel like eating anything. My entire body aches with pain and irritation whenever I take a bath.”

Zareena also complains of frequent urinary tract infection. She has grown used to holding her bladder and bowel till she gets a chance to urinate somewhere safely.

“I can’t even eat properly,” she says. “The doctor always advises me to keep my body hydrated as my body is often dehydrated. But, we try to avoid drinking this dirty water as much as possible.”

Zareena’s neighbor, Kulsooma Shafi, 28, is also six months pregnant with her third child. She also complains of frequent cough and fever due to the consumption of muddy water.

Kulsooma had a severe abdominal pain last week. Her husband took the loan of 1000 rupees from a neighbor and took her to the MCH Sopore where the doctors advised blood test, ultrasound scan and a urine test.

“I was writhing in pain. I had no patience to wait in long queues and wait for my turn or delay the treatment,” she says. The doctor suggested her to take tests at a private laboratory and also prescribed some medicines.

Kulsooma found it unaffordable to carry out the prescription of the doctor completely. So, she only did a urine test and purchased few medicines.

“My husband purchased one medicine for Rs 250,” she says. “We went in sumo and had to pay around Rs 300 for the fare and also purchased some iron and calcium supplements.”

Kulsooma’s hemoglobin is 8.5 grams and she has visited the MCH Sopore at least six times in the past six months.

“I have spent around Rs 10,000 on my pregnancy in these months,” she says. “I haven’t been well due to frequent worm infection, diarrhea and stomach aches.”

Kulsooma says that her doctor always enquires about her health. “We over-boil the vegetables and at the end there are no nutrients left. Water is also stinky and there is usually no appetite left for food after drinking water,” she says.

Her two sons and husband, who is also a fisherman, are also not keeping good health due to lack of safe water source and poor sanitation.

Her elder son, who studies in first grade, misses most of his classes due to skin allergy and frequent cough as he plays hide and seek in rubble and dirty water outside his home in tattered slippers.

A girl barely six hides herself behind a tree pulls down her shalwar and urinates quickly, leaves the place and washes her hands in the river.

Saleema Jan, a local woman in Kanyari village collects water outside her home to prepare lunch for her kids. She says that her hands aches whenever she washes her hands in the water but expresses her helplessness with no other option.
Saleema Jan, a local woman in Kanyari village collects water outside her home to prepare lunch for her kids. She says that her hands aches whenever she washes her hands in the water but expresses her helplessness with no other option. Photograph by Aliya Bashir

The families like that of Zareena and Kulsooma mostly suffer from the sewage-borne infections and water-borne diseases, as they either run into the trees to defecate openly or in the makeshift toilets, putting all the human excreta into their only source of water – the river Jhelum.

“I will go for permanent birth control after my delivery,” Kulsooma says, with a mixture of sadness and confidence. “We can’t put our lives at risk in this contaminated atmosphere.”

Afroz Ahmad Danthoo, a community health worker in the area, says that the exposure to unsafe water and poor sanitation complicates the health of pregnant women with adverse pregnancy outcomes and affect the well-being of their children.

“We have unsafe water, unimproved sanitation as well as poor waste management system in the area which increases the risk of infection,” he says.

A vast majority of expecting women in the area is anemic who often complain of stomach aches, urinary tract infection, low birth weight, delayed growth among children, vomiting and preterm birth, Danthoo says. These problems, he says, are some of the common outcomes that he has noticed frequently in last five years of his service.

The distance to the Bandipora district hospital is not the only problem, Danthoo says. “But, what adds to the miseries of the people is less transport facility due to bad roads,” he says. “It is convenient for women to visit Sopore hospital than their own district hospital which doesn’t even have a basic blood bank facility.”

According to the Baseline Survey 2012 of the Union Ministry of Drinking Water & Sanitation, “Jammu and Kashmir is among the worst states with poor sanitation with more than 54 per cent of more than 1.2 million households without toilets and the 2014-15 target for household latrines falling short by 86 per cent.”

Indian Prime Minister Narendra Modi’s national campaign, Swachh Bharat Abhiyan, was started in 2014 to build individual and community toilets and solid waste management in consideration with local cultural practices and sensibilities. The campaign puts emphasis on behavioral change intervention to strengthen its implementation for the elimination of open defecation, conversion of unsanitary toilets to pour flush toilets and eradication of manual scavenging.

Like Kanyari, another village, Banyari, in Bandipora district, almost 15 kilometers far from it, has also agonized villagers especially pregnant women and children. Few years ago, there was an outbreak of cholera in the village due to the contaminated water sources and lack of proper sanitation.

“Due to the lack of proper healthcare facility, we have to travel longer distances for even a simple treatment,” says Gulshan Shiekh, 50, auxiliary nurse midwife (ANM) in the area. “It gets quite difficult for pregnant women as they are mostly poor and cannot walk during illness.”

Gulshan remembers the incident when she was rowing a boat during a heavy rainfall. Her niece died in her seventh month of pregnancy along with her baby due to severe fever on way as she couldn’t reach the hospital on time.

“Many women in the area have died in the past from preventable causes relating to pregnancy and childbirth,” Gulshan says. “The contaminated water, poor sanitation and hygiene make their immune system weak and they are quite vulnerable to infections.”

Things are slowly changing due to National Health Mission, encouraging women for institutional deliveries, she says.

“We cannot do much in construction of toilets or ensuring drinking safe water but we try to educate expecting mothers in monitoring their pregnancies,” she says.” “At least now women don’t die in absence of information that they ought to know before they give birth.”

However, she admits, the lack of resources and unavailability of doctors in the primary health centres, sub-centres and other district-level institutions are still lagging behind to help pregnant women with at least transport facility.

“The most important facility that a patient in a rural area wants is to reach hospitals to give birth, instead of being stranded in their villages,” Gulshan says. “But, there is a long way to go.”

She says no one has ever visited the village to test the water. But, many women were advised by the ASHAs and ANMs to buy the chlorine tablets during the floods which helped many women fight infection.

A local girl washes her utensils in the muddy water of Kanyari with her sister. The village doesn’t have any tap facility and have to manually collect the water from the source.
A local girl washes her utensils in the muddy water of Kanyari with her sister. The village doesn’t have any tap facility and have to manually collect the water from the source. Photograph by Aliya Bashir

Access to clean water and sanitation is also one of the Sustainable Development Goals of the United National Sustainable Development to ensure that diseases associated with poor water, sanitation and hygiene are not overlooked. But, the entire Kashmir region is battling with this problem, especially rural population due to poverty and negligence by government to create sustainable policies and infrastructure along with manpower to fight the problem.

In an article published on India Spend titled, “96% of J&K Swachh-Bharat Money Unspent,” it has been reported that “J&K, a state of 12.5 million people, did not use about 96% of the money granted by Delhi for the sanitation programme for 2014-15, using Rs 4.66 crore of Rs 121.52 crore.”

The article further cites the figures that the state has failed to implement National Rural Drinking Water Programme, with Rs 310.15 crore unspent in 2014-2015 and more than 60 per cent of the target unmet. “The lack of toilets and safe drinking water leads to outbreak of diseases, especially among pregnant rural women,” the report suggests.

According to USAID, investing in water, sanitation, and hygiene for maternal and newborn health (WASH) is one of the most effective and efficient choices that one can make for global nutrition, child health, education, and empowerment of women.

Dr. Nisar-ul-Hassan, former president of Doctors Association Kashmir (DAK) who has been working in different areas of rural Kashmir on various free health awareness programs, says that people in villages mostly depend on nearby streams and ponds for water. These ponds and streams, he says, are a breeding ground for the bacteria.

“Pregnant ladies and children are most susceptible to diseases due to unsafe water and poor sanitation,” he says. “It not only complicates the pregnancy but also affects children with diarrhea, infections, malnutrition, and stunted growth and can even cause death.”

He says that untreated sewage is channelized into water bodies without any filtration treatment which contaminates the water.

In 2015, DAK issued a press statement citing that, “Around 70% of the population in Kashmir is infected with H pylori which cause most of the gastro duodenal diseases due to consumption of contaminated water.”

“The government needs to take serious measures both in hospital as well at community level through implementation of various programs and schemes to control infection and poor sanitation,” Dr. Hassan says. “As an individual, one should take utmost possible care not to provide conducive conditions for resistant deadly microorganisms to emerge, spread and persist.”