MLN2238 In June Pakistan s military operation

In June 2014, Pakistan\'s military operation against the Taliban in North Waziristan district of FATA, resulted in the displacement of an estimated 1 million people. The mass MLN2238 of previously unvaccinated people from North Waziristan resulted in an increased transmission of polio within Pakistan, which is quite evident from the fact that as of Nov 29, 2014, 186 cases of polio have been reported since June 2014, taking the total number of cases in 2014 to 268. Despite the large increase in number of polio cases, the hope that polio can be eradicated in Pakistan is still present. This migration has created an opportunity to vaccinate people who previously were left unvaccinated due to the ban imposed by the Taliban. Vaccination centres were set up along check points out of North Waziristan, and more than 700 000 people out of the 1 million people displaced were vaccinated. Furthermore, vaccination campaigns have been undertaken in districts where the migrants have settled. So far in 2014, 11·8 million individuals have been vaccinated throughout Pakistan, compared with 8·5 million in 2013 alone. Although the 2014 deadline to interrupt wild polio virus transmission is unlikely to be achieved, these developments give us hope for a decline in polio cases in the coming year 2015. In a country that is going through political turmoil, a lot more effort by all political stakeholders is required to make eradication a possibility.
This letter relates to the Article by Thomas Clasen and colleagues on the effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in India (November, 2014, p e645). We don\'t deny the usefulness of this study or its results. Rather it reaffirms something we know from field experience. Toilets are one part of the complex solution to the problem of diarrhoea and malnutrition. The history of work on sanitation has informed us that toilets alone are not the answer, and our sanitation programmes have inadequately addressed this gap. We write this letter having learned through a recent community-based qualitative study that access to toilets have important effects beyond sanitation, and these effects should be considered by public health experts and policy makers when assessing programmes. Women (adolescents, married women, mothers, and senior citizens) from rural areas in Karnataka, India, reported that their main concerns about the poor access to toilets were related to being subjected to teasing, sexual harassment, suspicion, and violence, and consequently to feelings of humiliation, insecurity, distress, and even suicidal thoughts. These findings become more important in the light of the recently launched National Mental Health Policy in India. Awareness about toilets is increasing through media exposure and health promotion, and now women from some rural areas in India are demanding for toilets through innovative campaigns (“build toilets or go without food”). Women, who are considered as the primary educators within the family, are expressing their need for toilets. It is now up to the programme implementers and evaluators to see leaf veins as a legitimate reason for supporting construction of toilets, and modify and evaluate the sanitation programme accordingly. Reduction of diarrhoea and malnutrition are larger goals, which will be realised with concomitant efforts at addressing water supply, education, access to food, and other determinants.
The study by Clasen and colleagues does not have enough evidence for the effectiveness of the sanitation programme, but denotes the clear message that the health benefits might not be assumed only by construction of latrines. We doctors, having grown up in villages of Odisha, are aware of the practice of many people using latrines initially and then moving to a nearby pond to clean their anal orifice with their hand. These practices lead to contaminate water, hands, and soil. Poor adherence to toilet use at home can also be attributed to the traditional habit of defecating in the open air while visiting field crops. Many children aged 6–18 months defecate on the floor and then take their contaminated fingers to their mouth.