Globally, diseases associated with poor water and sanitation, have considerable public health significance.

In 2003, it was estimated that 54 million disability-adjusted lifeyears (DALYs) or 4% of the global DALYs and 1.73 million deaths per year were attributable to unsafe water supply and sanitation, including lack of hygiene (Hutton, et al, 2006). The percentage of people worldwide who have access to an improved water supply has risen from 78% in 1990 to 83% in 2004 (Global Water Supply and Sanitation Assessment Report 2002). At the current rate of progress, the MDG (Millenium Development Goals) water supply target is close to being met at global level, with a global target of 89% in the year 2015. Though the official statistics show improvements, the ground reality speaks a different story (Hutton, et al, 2006) Cross-national regressions suggest an inverted U-shaped relationship between per capita income and the dimensions of degradation that are presently the most worrisome in India - drinking water, sanitation, indoor pollution, and even water and air-pollution (Shafik and Bandyopadhyay 1992). Most of the urban poor in Delhi live in slums which lack access to basic facilities particularly water and sanitation. There are more than 1000 slum clusters in Delhi (Municipal Corporation of Delhi, 2009). As per the MCD Rules, the urban poor are not entitled to water supply and sanitation facilities from the government. In most of urban India, intermittent supply is a persistent problem. The urban poor too suffer from a particular lack of access to drinking water with only a third or so having safe access. Thus, the poor resort to polluted surface sources for meeting their water requirements (Rao, 1995). There are consequent effects on people's health and survival chances, which then feedback on the production system. These effects may be expected to be particularly severe given the widespread poverty and the low level of fulfillment of basic needs like food, water, sanitation, housing and health-services. A quick overview of disease incidence in the State of Delhi will substantiate this:
1. From 2007 to 2009, Delhi has seen an increase in dengue cases by about 2 times (from 548 cases to 1153 cases) 2. In the year 2009, Delhi saw 47 reported deaths due to Enteritic fever and 107 reported deaths due to Acute Diarrhoea and Dysentery (ADD). 3. In 2008, Delhi saw 117766 cases of ADD reported out of which 86 deaths were reported. 4. During the period 2001-2008, Delhi has consistently seen about 1000 reported cases of cholera.

5. Delhi has seen a consistent decline in Malaria incidence though there was a sudden peak in the year 2005-06. 6. In the years 2007-2008, out of the total cases of pneumonia reported, about 61% were males. The number of cases reported each year was about 31,000. (Source: www.indiastat.com; Ministry of Health and Family Welfare, Govt. of India)

Environmental Risks: There are many ways by which pathogens can infect individuals and affect their health through water, sanitation and hygiene. They include: (i) Water-borne diseases (e.g. cholera, typhoid); (ii) Water-washed diseases (e.g. trachoma); (iii) Water-based diseases (e.g. schistosomiasis); (iv) Water-related vector-borne diseases (e.g. malaria, filariasis and dengue); (v) Water-dispersed infections (e.g. legionellosis), (vi) Chemical contamination of water (e.g. arsenic, fluoride). Water and sanitation related illnesses such as cholera, dysentery and gastroenteritis account for about 60 per cent of all urban deaths (Sivaramakrishnan, 1993) and, presumably, a similarly high proportion of total morbidity. With about 25% of Global Burden of Disease attributed to environmental risk factors, 40% falls on children below the age of 5 years (WHO 2002b). Human waste handling practices in urban Bangladesh were evaluated for their contribution to childhood diarrhea and a specific educational program to improve waste handling was developed and evaluated. Modest reductions in diarrheal disease were achieved. A survey of diarrhoea in Delhi showed the highest incidence rates (11.9 episodes per child per year) in urban slums with the worst sanitary conditions. (Hrudey et al., 1988) Conversely, studies have shown that improved access to clean water and improved sanitary habits contribute substantially to a reduction in the incidence of various diseases among children. Studies have also shown that while disease may be transmitted by drinking water containing pathogens, faecal-oral disease transmission may also be reduced or interrupted with increased access to water coupled with domestic hygiene. Poor or absent sanitation may increase faecaloral transmission by contaminating water sources, contaminating hands or food, or increasing potential transmission by flies. (Ezzati, et al, 2005)

Indicators of Environmental Risk: To ensure that interventions are designed appropriately, a reliable and consistent analysis of exposure to environmental risks, their technological and behavioural determinants is necessary, especially in resource poor settings. The indicators can be divided into four categories: (a) access and infrastructure, (b) technology, (c) behaviour, and (d) agents and vectors. (Ezzati, et al, 2005) Access and infrastructure indicators permit assessing the feasibility and cost for increased coverage of technological interventions, which rely on delivery infrastructure. If technology availability is the main determinant of risk exposure, policies that encourage research and development of more effective or less costly technologies are needed. The inclusion of behaviour as a category of indicators acknowledges the critical interface between technology and behaviour in determining not only whether a technological intervention is used but also how it is used. Finally, agents and vectors are not directly modifiable by policies, but are important indicators of hazard, and of success of technological and behavioural interventions (Ezzati, et al, 2005). Sample Study: A study in Mumbai brings out the risks due to environmental factors. Firstly, it presents primary data on the present situation of living environment and health condition in four urban poor settlements in Mumbai. It is aimed to demonstrate a collective profile on several categories of urban poor in Mumbai. Mean family size of households is five in all settlements. The three major occupations among main wage earners are: (i) providing labour (free labour or regular workers in construction/factory) - 41 %; (ii) service (clerical or technical job in public or private offices) 24 %; and, (iii) business - 26 %. Water consumption and quality: Almost all households in slum and pavements rely on the municipal water supply for all purposes from drinking and bathing to kitchen and laundry. Water tap connections in slums are generally given to a group of households to be shared in common; the set criterion is five households per tap connection. In slums, none of the households use any kind of pathogen killing or filtration mechanism. The living environment of urban poor could be basically characterized by nearly 70% households living in flimsy shacks and temporary dwellings, 2 m2 housings pace per person, 28 LPCD consumption of water, 1.5% households having access to sewer and only half of the people having access to toilets. Similarly, health status were shown as nearly 11% people sick at

any point of time; and TB and asthma patients numbering as many as 18 and 11 per thousand population respectively. The annual cases of water-related disease such as diarrhoea, typhoid and malaria is estimated at about 614, 68, 126 cases per thousand of population respectively. Secondly, this study attempts in linking socio-economy and environmental factors to the health consequences of the people. This fact has been substantiated by data that income, literacy, sanitation and personal hygiene (in terms of water consumption rate) have had impact on the morbidity of the people. Matrices of Pearson's correlation coefficients and multiple correlation coefficients were determined from the obtained data to identify the possible relationship between socio-economic and environmental conditions in each community. The entire result is presented diagrammatically. Multiple correlation data ascertains the combined impact of two or more variables on the state of affairs in urban poor.

Based on the results, it is revealed that overall, at any moment about 30 per cent households have at least one person sick, or 4-8 per cent of slum population is suffering from any kind of short duration illness. Similarly, further 20 per cent households have either at least one patient, or 3-6

per cent population, of chronic diseases at any point of time (Table 4). Among short duration disease, more than one-fourth of sick-ness is accounted for by water-related diseases. Regarding chronic diseases, whereas most of the diseases show a higher prevalence rate, tuberculosis and asthma in particular appear the most severe. (Karn et al, 2003) Study conducted by us: Madanpur Khadar, a slum in Delhi, is divided into 8 colonies. We surveyed 3 colonies and a sample of 50 households was taken. Important characteristics of the survey area are: Average income ranged between Rs.4000-5000/household, no municipal supply water, bore-wells are the only source of water with hand-pumps in front of every house, drainage runs alongside the house and is open, all residents buy water for drinking purpose only from a local filtration unit at Rs.10/can as the bore-well water was found to have a bad odour and a brackish color, area not covered by MCD and thus lacks waste disposal and sanitation facilities, all residents are aware of the poor sanitation conditions but lack financial resources to take up any step, and lastly, the closest government medical facility is AIIMS or Safdurjung Hospital which are about 20 Kms away (there are Private Hospitals in the vicinity). Since all households mainly use only groundwater for most activities, they are affected by the contaminated groundwater. The two main sources of pollutants/contaminants of groundwater are point sources and distributed sources. Point source pollutants or contaminants come from zones or areas of known and definable boundaries that are easily amenable to mathematical analysis and modeling. Distributed sources of pollutants/contaminants are those in which the pollutants or contaminants are spread through a large area of hydrologic environment and in which they extend over the entire source area (Egboka et al, 1989). A survey of 50 households saw the following results: (i) Most (about 98%) of the women are housewives, (ii) Out of the 250 residents covered, only 57 are working individuals and all are males with most working as casual labor and as taxi or auto-drivers, (iii) Disease incidences in the last 6 months included Enteritic Fever, Dengue, Chronic Cough, Typhoid, Asthma, Diarrhoea, and Malaria, (iv) Enteritic Fever and Dengue have had the highest incidences followed by Diarrhoea and Typhoid, (v) Based on data of disease incidence in the last 6 months, it was found that at any given point of time, 30% of the population is sick which is very high, (vi) The sick population is mainly consisted of earning male members and children, (vii) Most of those affected were in the age-group of 5-12 years or 35-50 years, (viii) Each household made

about 5 visits on an average to the doctor in a month, (ix) Monthly expenditure on health was about Rs.1000, (x) Most people were aware that environmental conditions were a cause for diseases. According to the Economic Survey of Delhi 2007-08, it was found that groundwater samples tested in the area were found to have a high fluoride content of 6.67mg/L. Solutions: In the context of the study undertaken in Madanpur khadar, Delhi, possible ways ahead are: (i) Coverage under the main water supply of the MCD, (ii) Covered drainage, (iii) Since there exists willingness to pay for sanitation facilities, the local bodies should consider the provision of the same, (iv) Setting up of a common filtration unit on existing fallow land. Institutional innovations for development of infrastructure should be considered by the local bodies as these will save costs for them while simultaneously increase coverage. Some of them are: (i) New system of maintaining municipal budgets and devolution of state funds based on performance; (ii) Assigning of planning responsibilities to local bodies: Given their difficult financial situation, local bodies can go in for consultation services with stakeholders with the help of financial institutions acting as intermediaries and providing them with informal help; (iii) Management contracts for services to be provided by private agencies and NGOs; (iv) Arrangements for raising resources from capital market and financial institutions: Efforts should be made to develop the capital market so that a few local-level agencies that are more efficient can mobilise resources by issuing Structured Debt Obligations and other credit instruments. (Kundu, 2001) Discussion and Conclusion: Water Supply and Sanitation are important social sector projects but the right kind of intervention can be determined by a detailed Cost-Benefit Analysis of all available options. Cost-benefit analysis presents the benefits which accrue to different beneficiaries, thus implying who may be willing to contribute to intervention financing. There is a need in India to take up such analysis of social sector projects so as to understand the relationship between the various factors. Improved water supply involves better physical access to water sources as well as protection of those sources. Improved sanitation involves better access and safer disposal of human excreta covering septic tank, simple pit latrine, and ventilated improved pit latrine.

On the cost side, the costs are very tangible, requiring financial input upfront for the interventions to be put in place. On the benefit side, however, the majority of the benefits are not highly tangible, in that the benefits do not bring immediate money in the hand. An important drawback of such analysis is that it does not provide information on who is able to pay. The ability to pay is very important and not just the willingness to pay. In summary, the benefits can be divided into the following: (1) Health sector benefit due to avoided illness, (2) Patient expenses avoided due to avoided illness, (3) Deaths avoided, (4) Time savings due to access to water and sanitation, (5) Productive work days gained of those with avoided illness (at least 15 years old), (6) Days of school attendance gained of those with avoided illness (5-15 years old), (7) Baby days gained of those with avoided illness (0-4 years old). (Hutton, 2006) However, the main beneficiaries do not always understand the full benefits as many of them accrue over a longer period of time. In conclusion, depending on the income and asset base of the target population , there should be a variety of financing mechanisms for meeting the costs of water and sanitation improvements, the availability of credit, the economic benefits perceived by the various stakeholders, the budget freedom of government ministries, and the presence of private sector and NGOs to promote and finance water supply and sanitation improvements. (Hutton, 2006)

REFERENCES

Egboka B. C. E, Nwankwor G. I, Orajaka I. P, Ejiofor A.O, 1989, Principles and Problems of Environmental Pollution of Groundwater Resources with Case Examples from Developing Countries, Environmental Health Perspectives, Vol. 83 (Nov., 1989), pp. 39-68 Ezzati M, Utzinger J, C Sandy, Cohen A J, Singer B H, 2005, Environmental Risks in the Developing World: Exposure Indicators for Evaluating Interventions, Programmes, and Policies Journal of Epidemiology and Community Health (1979-), Vol. 59, No. 1 (Jan., 2005),pp. 15-22 Hrudey S E, Hrudey E J, 1988, Health Effects Associated with Wastewater Treatment, Disposal and Reuse Journal Water Pollution Control Federation), Vol. 60, No. 6, 1988: Literature Review(Jun., 1988), pp. 858-864 Hutton G, Haller L, Bartram J, 2006, Economic and health effects of increasing coverage of low cost household drinking-water supply and sanitation interventions to countries off-track to meet MDG target 10, Background document to the "Human Development Report 2006" Karn S K, Shikura S, Harada H, 2003, Living Environment and Health of Urban Poor: A Study in Mumbai, Economic and Political Weekly, Vol. 38, No. 34 (Aug. 23-29, 2003), pp. 3575-3577+3579-3586 Kundu A, 2001, Institutional Innovations for Urban Infrastructural Development: The Indian Scenario, Development in Practice, Vol. 11, No. 2/3 (May, 2001), pp. 174-189 Panwar T S , et al, State of Environment Report for Delhi, 2010, Department of Environment and Forests, Government of NCT of Delhi, 2010 Rao .J.M, 1995, Whither India's Environment?, Economic and Political Weekly, Vol. 30, No. 13 (Apr. 1, 1995), pp. 677-686 Suk W. A, Ruchirawat K. M, Balakrishnan K, Berger M, Carpenter D, Damstra T, Garbino J P, Koh D, Landrigan P J, Makalinao I, Sly P D, Xu Y, Zheng B S, 2003, Environmental Threats to Children's Health in Southeast Asia and the Western Pacific, Environmental Health Perspectives, Vol. 111, No. 10 (Aug., 2003), pp. 1340-1347 Data Source: www.indiastat.com; Ministry of Health and Family Welfare, Govt. of India

HEALTH AND ENVIRONMENT TERM PAPER

Health Impacts of Poor Water Supply and Sanitation Facilities On Urban Poor

ADITY A RAMJI RITIKA SEHJPAL

MSc Economics QUESTIONNAIRE (Used in the Survey at Madanpur Khadar, Delhi)

FAMILY DETAILS NAME RELHEAD OCCPN AGE SEX

PAST 1 MONTH DISEASE INCIDENCE (ANY 3) MEMAFFECT DISEASE ED SYMPTOMS TREATME NT

LAST 6 MONTHS DISEASE INCIDENCE (ANY 3) MEMAFFECT DISEASE ED SYMPTOMS TREATME NT

EXPENDITUR E ON HEALTH FOR MEDSPUR DISEASE EXPMED EXPDOC

DISEASES ATTRIBUTED TO ENVTL FACTORS ENVTLCAUS DISEASE E PREVENT

LOCAL SOURCE OF WATER CONTAMINA TION DRAINAGE OPEN CLOSED WATER SUPPLY PIPING BELOW SURFACE ABOVE SURFACE TIME

MORNING EVENING SOURCE OF WATER HANDPUMP TUBEWELL MAIN LINE

EXISTENCE OF WASTE TREATMENT FACILITY CETP SANITATION PIT OTHERS (PLEASE SPECIFY)

VARIABLES DEFINED

1. NAME Name of Person 2. RELHEAD Relationship to Head of Household 3. OCCPN Occupation of the Person 4. AGE Age of the Person 5. SEX Male/Female 6. DISEASE Name of the disease suffered/suffering from 7. MEMAFFECTED Member of Family Affected by the disease in question 8. SYMPTOMS Symptoms observed during period of illness 9. TREATMENT Whether disease was treated or not AND whether treated at Pvt or Govt Facility 10.MEDSPUR Medicines Purchased

11.FOR DISEASE Disease for whose treatment the particular medicines were purchased 12.EXPMED Expenditure on that Medicine 13.EXPDOC Expenditure on Doctoral Visits 14.ENVTLCAUSE Whether the disease is attributed to environmental conditions 15.PREVENT If ENVTLCAUSE=1, then what steps are taken to prevent the occurrence of disease?