Huge number of toilets urgently needed in quake-hit north

An acute lack of latrines in quake-affected areas of northern Pakistan, where millions of survivors live under dire sanitary conditions, will undermine health and could lead to serious disease outbreaks unless immediate action is taken, aid workers warn. "We go in the open air," 12-year-old Rafit giggled, obviously embarrassed by the question, as his cousin Umcad, laughed out loud. "We don't use the toilets over there - it's too far," he complained, referring to the basic amenities on offer at the Dawa tented camp in Muzaffarabad, capital of Pakistan-administered Kashmir and home to over 1,000 quake victims. In fact, both boys concede going outside was simply an easier option. "It's a problem for ladies, but not for us," they bragged. But for aid workers, health officials and UN agencies on the ground, the problem is huge. "We need to build about 200,000 toilets," Andrew MacLeod, head of the UN Emergency Coordination Centre, told IRIN in the Pakistani capital, Islamabad. "We have to aim for something like that - but that goal is a long way off," Larry Robertson, project officer and chief of water and environmental sanitation for the United Nations Children's Fund (UNICEF), said in Muzaffarabad. Whatever the exact figure, it's clear the challenge in building these latrines is daunting. With an estimated 4 million people defecating in the open and 1,500 mt of faeces being produced every day, communities were at high risk of an outbreak of communicable disease, UNICEF has warned.

For Rafit and Umcad, relieving oneself outdoors is easier

According to the World Health Organization (WHO), a whole range of communicable diseases exist that are associated with poor sanitation. A large proportion of morbidity and mortality cases related to poor sanitation were spread faecally and orally - particularly diarrhoeal diseases, including cholera, typhoid and dysentery. "All of these are major killers in populations with poor sanitation," Dr John Watson, a WHO medical officer for communicable diseases, said in Muzaffarabad, adding these were priority diseases for the world health body as they were epidemic-prone. "They can become very big problems, very fast, especially in a population that is particularly vulnerable following a complete disruption of water and sanitation in many areas," Watson said, emphasising the need to keep people separate from excrement. But with the vast majority of toilets and latrines throughout the 30,000 sq km area devastated by the 8 October quake, it's clear a great deal of work is needed. UNICEF is currently working to install latrines at a number of camps established in populated areas like Muzaffarabad, working with the UK-based NGO Islamic Relief and Irish-based NGO Concern, as well as coordinating with Oxfam and MSF Holland. "We would like to do more, but at the moment we don't have the resources," Robertson said. "The money resources are probably there, but we haven't been able to mobilise the squatting slabs we need, as well as our implementing partners," he explained, noting they were not yet geared up to installing such a large number of latrines. Meanwhile, conditions at camps in the vicinity continue to deteriorate as more and more people arrive from remote mountain areas in need of assistance. "The camps are filthy," one aid worker complained, noting many women would not venture far from the camp areas to relieve themselves citing protection and cultural issues. "We're concerned about any outbreaks of communicable diseases due to the open defecation that is happening now. It would be great if people would bury it afterwards, but that's simply not happening," Robertson said, emphasising the need to accelerate their efforts. UNICEF hopes to install one latrine for every three families, giving the families themselves the responsibility of maintaining it. "There's no other way around it. In the beginning we were just putting in toilets, but now our strategy is to give two or three families ownership," he said.

Women rarely venture far from the camp to relieve themselves

Indeed, many newly installed toilets in the Muzaffarabad area inspected by IRIN showed little or no evidence of maintenance at all. Although to date UNICEF, its partners and other organisations have installed over 600 toilets in the Muzaffarabad area at various camps and health centres, that number remains a small fraction of what actually is needed. "It's not enough by any means," Robertson repeated. "We need to have had these latrines in yesterday. We're keeping our fingers crossed that there are no outbreaks, but there's no guarantee." Time, however, is quickly running out, with reports of acute diarrhoea cases already appearing. On Wednesday, the United Nations reported serious outbreaks of acute watery diarrhoea in Muzaffarabad and other devastated areas, underscoring the need to scale up efforts to provide safe water and sanitation in the self-settled camps. "Although the laboratory diagnosis is not yet confirmed, these cases of acute watery diarrhoea should be taken extremely seriously. Prompt treatment by rehydration is essential and we should continue to monitor the situation," Dr Khalif Bile, WHO country representative for Pakistan, said. According to Wednesday's UN statement, diarrhoeal diseases were caused by bacteria getting into the potable water supply system, much of which had been damaged or destroyed in the quake-affected area. With the establishment of spontaneous camps by homeless quake survivors, people are living in crowded conditions, with an unsafe water supply and poor sanitation facilities. With insufficient latrines being dug, there is no provision for those affected by acute watery diarrhoea to use separate latrines. This results in further contamination of the drinking water supply, the statement read.