For Third World, Water Is Still a Deadly Drink

Children like the Bhagwani boys scamper about barefoot on the narrow muddy paths that wind through the labyrinth of a slum here, squatting and relieving themselves as the need arises, as casual about the filth as the bedraggled rats that nose about in the raw sewage trickling beside the paths.

Parents, like Usha Bhagwani, a rail-thin 28-year-old housemaid, point out their children and fret about how to spend their rupees. Should they buy good food so that the children will get stronger? Or should they buy shoes so that the children will not get hookworms? Or should they send their sons and daughters to school? Or should they buy kerosene to boil the water?

There is not enough money for all of those needs, so parents must choose. It was to save money, as well as to save time, that Mrs. Bhagwani was serving unboiled water the other day to her 5- and 7-year-old boys in her one-room hovel. Her bony face and sharp eyes softened as she watched them take the white plastic cup and gulp the deadly drink.

The water has already killed two of her children, a 15-month-old, Santosh, a boy who died two years ago, and Sheetal, a frail 7-month-old girl who died just a few months ago. But everyone in the slum drinks the water, usually without boiling, and water seems so natural and nurturing that Mrs. Bhagwani does not understand the menace it contains.

''I try to boil the water,'' Mrs. Bhagwani said pleasantly. ''But the boys sometimes insist on drinking right away because they're thirsty.''

Then, she said, there is the cost. To boil water consistently would cost about $4 a month in kerosene, almost a third of Mrs. Bhagwani's earnings. She could afford that, but then there would be less money for food.

The water comes from a pipe that runs into the slum where the Bhagwanis live, in the city of Thane, near Bombay. The pipes are cracked and run in a ditch that is filled with sewage. Even if the water was properly treated at its origins, health workers say, sewage seeps into the water to produce one of the most deadly ailments in the world today: diarrhea. Diarrhea kills some 3.1 million people annually, almost all of them children.

The larger issue is that the most fundamental health challenge in the world at the end of the 20th century may be the same as it apparently was four millenniums ago: sanitation. To families like Mrs. Bhagwani's, perhaps nothing would make more difference than clean water and a toilet.

All in all, human wastes may be more menacing than nuclear wastes, for feces kill far more people than radioactive substances. A huge range of diseases and parasites infect people by the fecal-oral route, transmitted from one person's waste by food or water or poor hygiene into the mouth of a neighbor. Some of those ailments are fatal, while others weaken people and entire nations.

The Carrier

Illnesses Delivered By Filthy Water

The burden of poor water and sanitation was evident in the frown on Sok Kheng's face as she sat in a hammock on the porch of her wooden hut beside a meandering dirt trail in the southwestern part of Cambodia. Mrs. Sok Kheng, a 36-year-old farm wife with a round face and hair tied back in a pony tail, was supporting her 2-year-old son, Thouch, who is physically and mentally retarded.

''He still can't walk, and he can't even sit on his own,'' Mrs. Sok Kheng said. ''He isn't talking at all, either.''

Thouch will probably not recover. In November his mother took him to a doctor, who said the boy was severely malnourished, apparently because of worms or chronic diarrhea.

The culprit is probably the drinking water, which Mrs. Sok Kheng gets from a pond 50 feet from her house. The villagers bathe in the pond, and cattle use it as well. Moreover, since there is no toilet the water is probably contaminated with human waste.

The doctor recommended giving Thouch cow's milk to supplement his diet, and so the family scrounged to buy a can of milk -- at 85 cents a can, more than twice what the boy's father earns for a day's work. A neighbor felt sorry for the child and gave them a few cans as well.

But the family has no concept of hygiene, and so the milk might do more harm than good. Because the milk is so precious, Mrs. Sok Kheng makes each can last as long as possible, even though she has no refrigerator to keep it cool in tropical temperatures.

''We put just a little bit of milk in a bottle and then add a lot of warm water,'' Mrs. Sok Kheng said. ''One can lasts us five days.''

Soon it was time to feed Thouch, and Mrs. Sok Kheng's eldest child, a 14-year-old boy, poured a bit of milk and a lot of pond water into an unsterilized bottle. With their unwashed hands, Mrs. Sok Kheng and each of her three older children felt the bottle and the nipple to see if the temperature was right. Then they handed it to Thouch.

Mrs. Sok Kheng is in many ways representative of those living in the third world. Some 2.9 billion people -- 66 percent of the population in the third world -- have no access to a toilet, not even a decent pit latrine. The vast majority simply use a bush or a quiet piece of ground, and for them toilet paper is an unimaginable luxury. Most rely on leaves or a splash of water, and afterward few have the means and training to wash their hands thoroughly with soap and water.

Even if Mrs. Sok Kheng were to take her children to the district hospital, conditions would be no better. In midafternoon, the Phnom Srough District Hospital a couple of dozen miles away was nearly deserted -- except for a few pigs rooting around the yard.

''There's normally a doctor here only in the mornings, from 7 A.M. to 11 A.M.,'' said Lee Lina, a young pharmacist who was rummaging through supplies. He said the hospital had no electricity, no running water, no food and almost no medicine.

There is an outhouse, but it is so decrepit and overgrown that patients and doctors just use the bushes nearby.

''We don't have a place to wash hands,'' Mr. Lee Lina said dolefully.

Does the local doctor wash his hands?

''Well,'' Mr. Lee Lina began awkwardly, and then he paused in embarrassment. ''Well, it's hard to tell.''

In some respects, sanitation in poor countries has worsened in the last few years. World Health Organization statistics show that in the first half of the 1990's the proportion of people in the third world with access to a toilet actually fell, from 36 percent to 34 percent.

But over all, sanitation conditions and water supplies have improved noticeably in the last few decades, and child death rates have fallen sharply. Packets of oral rehydration salts, popularized by Unicef and now widely available in rural areas of the third world, save the lives of countless children with diarrhea; improved water and the rehydration packets may together save the lives of more than a million children a year.

In particular, most countries are registering great progress in supplying potable water. In the first half of the 1990's, the proportion of people in the third world with access to safe drinking water rose from 61 percent to 75 percent.

''When you look at the last century, the greatest advance was not antibiotics,'' said Dr. Graham Ogle, an Australian with long experience as a physician in Papua New Guinea. ''It was sanitation and the provision of clean water.''

Dr. Ogle, who has just started running a hospital in Phnom Penh, the Cambodian capital, noted that dirty water causes diarrheal illnesses like gastroenteritis that are not normally life-threatening but that cumulatively wear a patient out.

''It's a vicious cycle,'' he said. ''If you've got a kid who's a little bit malnourished, then he gets gastroenteritis, and he's more malnourished, and his immunity drops. Then he can get pneumonia or tuberculosis, and while you or I might shrug it off, here a kid can die of it.''

Children are also weakened by worms, a common result of poor sanitation. Up to 60 percent of humanity has some kind of worms crawling in their bellies or under their skin. Sometimes these grow so numerous that they entirely block the intestines and cause death, but mostly they are simply painful, distracting and debilitating.

''You eat only so much food, and worms get some of that,'' Dr. Ogle said. ''You get a bellyache, so you don't feel like going to school or going to work. And worms give you anemia, so you feel lethargic and are less likely to develop your skills and grow. And in young children, anemia affects cognitive development, and that's permanent. It can shift down the learning ability of your entire population.''

The Conditions

Sanitation's Bane: Huge Urban Slums

The biggest slum in the world may be Dharavi, a vast shantytown in Bombay, where hundreds of thousands of people live in hovels connected by tiny meandering alleys. Sewage runs in the paths along with the rats.

''We give the kids sandals, but they don't wear them,'' grumbled Jaya Pardesi, a 25-year-old mother in Dharavi. Her three small children were running around barefoot on a dirt pathway that they and all the other children also use as a toilet, and her 3-year-old daughter was sucking her filthy finger.

These urban slums present a sanitation nightmare. The challenge is increasing, because urbanization is a trend everywhere in the third world, from Brazil to Zambia. Villagers trek to cities and set up shacks on any bit of deserted ground, in places where there is no water and no toilet.

On the Bassac River just outside Phnom Penh is one of the most wretched slums in the world, a putrid slope of mud and excrement that is home to tens of thousands of people packed in rickety shacks on the bank of the river.

There are latrines of a sort, for entrepreneurs have set up little platforms over the water. These are open toilets where men and women squat behind half-barrels, a determined nonchalance substituting for privacy, as the toilet owners make money by raising fish on the sewage in fenced-off waters below the toilet platform.

The fish may not sound appetizing, but the worst problem is that the slow river is used by the slum not only as its toilet, but also as its source of drinking water.

Preung Sriy, a round-faced 27-year-old mother of three, uses buckets of river water for washing vegetables, for bathing her children and for drinking. She says she normally boils the water before drinking it, but her 8-year-old son died a few years ago after a bad case of diarrhea and her three other children also regularly get diarrhea.

Mrs. Preung Sriy says she went to school for a total of six months, and she is too lethargic -- or anemic -- to put any emphasis on hygiene. Soap is not such a problem, for it is relatively inexpensive; the greater challenge is a recognition of the importance of hand-washing, and clean water to go with the soap. In Mrs. Preung Sriy's case, the only water available for washing hands is the black liquid taken from between the toilets in the river.

''I sometimes wash my hands before making food, and my kids sometimes wash their hands before eating and sometimes don't,'' she said. ''My husband and I use the toilet over the river, and the kids just go down below the house. My kids are lazy -- they don't wash their hands afterward.''

The Strategies

Approaches Aimed At Cleaner Living

However grim conditions sometimes seem to be today, the progress of the last few decades is striking. The record in a variety of countries is also important because it suggests that while there is no single magic bullet available, there are a myriad of approaches that help control sanitation-related diseases.

Many development economists now emphasize the importance of operating bank-like institutions that offer credit to poor people in third-world cities and villages, so they can start small businesses and generate some cash. The idea is that with a bit of money, people will be able to help themselves by building covered wells, buying mosquito nets and visiting doctors when necessary.

Likewise, there is no doubt that one way for governments to save lives is to supply water to poor areas -- not just clean water, but lots of it, even if it means charging for water to pay for the service. One of the most persistent reasons for poor hygiene is simply that there is almost no water to wash with in many parts of Africa, India and China. Hand-washing after defecation can seem like a luxury when the water must be lugged from a creek two hours away.

India has cut diarrhea-related deaths by providing many villages with covered wells, often with chlorinated water. Bolivia managed to cut diarrhea among children by showing poor people how to disinfect water and then keep it at home in narrow-necked jugs with covers.

While they have done poorly over all in improving the lives of their people, Communist governments in some countries have done very well in promoting community health projects that emphasize sanitation, water supply, immunization and basic health care. Cuba has achieved a life expectancy -- an average of 76 years -- that is about the same as that of the United States. And in Shanghai, China's largest city, there are no India-style slums and a newborn baby can also expect to live 76 years, two years longer than a baby born in New York City.

China achieved its progress in part through coercive steps, like barring peasant families from moving to the cities and forcing peasants to work on community health projects. But Cuba and China, along with many capitalist countries, have also achieved public-health gains by promoting basic education.

''Everything runs into everything else,'' said John Chaloner, who has spent most of the last two decades in Africa and is now the Tanzania representative for Plan International, the child sponsorship organization known in America as Childreach. ''Sanitation runs into health. And health runs into income levels.''

''But I would argue that education is perhaps the most important,'' Mr. Chaloner continued. ''If you educate a girl in basic literacy and health, then when she becomes a mother, she is going to be able to better care for her children.''

Education is important in part because sending girls to school is one of the best ways of reducing the number of children they will have -- and improving the health of the children that they do have. Beyond that, people with schooling tend to understand better the dangers that they cannot see, like germs, and consequently tend to allocate their limited savings in a different way.

Saidi Simba, a congenial 54-year-old Tanzanian farmer who never went to a day of school, underscores how uneducated parents inadvertently cost the lives of those they love the most. Mr. Simba, a lean man with an oval face, faint mustache and warm smile, has had 20 children by his two wives. Six of the children have died.

Mr. Simba lives on a winding dirt street in a shantytown in Dar es Salaam, the Tanzanian capital. The shanties are built on marshy ground, so sewage often floods or leaches into the wells, and most families know enough to use well water only for washing.

Not Mr. Simba. Teen-age boys sell drinking water on the streets for 30 cents for a huge jug, but he refuses to spend most of his earnings on water when it is available free from a well. He could boil the water, but then he would have to pay large sums for kerosene or firewood.

While Mr. Simba is poor, at bottom it is a question of priorities and education: Mr. Simba did once spend $5 on a watch, and a few dollars more on an old ring. When his children do get sick, he is willing to spend what to him is a fortune to save them. But, again because of his lack of education, the money is wasted.

The most recent child in the family to fall seriously ill was Tatu, Mr. Simba's 18-month-old daughter, who in September began to come down with severe diarrhea and fever. Mr. Simba took her to the local traditional healer and without question handed over the huge sum of $20, along with a chicken, and $8 worth of cloth used for the magic.

The healer put Tatu under the bed and had her mother squat on top of it and urinate, drenching the child. Then the healer burned elephant dung and had the child breathe the fumes.

''Usually it helps,'' Mr. Simba said dejectedly. But not this time, for Tatu died. Mr. Simba aches at the loss of a sixth child, yet he continues to offer his family the same water.

''We don't like to drink water from the wells,'' Mr. Simba said soberly. ''But if we don't have any other water, we'll drink it.''

Groups That Help Those Who Fall Ill

Readers have asked how to help victims of malaria, diarrhea and other illnesses common in areas with poor sanitation and hygiene. Many organizations are active in combating these problems, including these:

Africare, 440 R Street N.W., Washington, D.C. 20001.

CARE, 151 Ellis Street, Atlanta, Ga. 30335.

Childreach, 155 Plan Way, Warwick, R.I. 02886.

Interaction (an umbrella organization for about 150 groups working around the world), 1717 Massachusetts Avenue N.W., Washington, D.C. 20036.

International Rescue Committee, 122 East 42d Street, New York, N.Y. 10017.

Save the Children, 54 Wilton Road, Westport, Conn. 06880.

World Vision, 919 West Huntington Drive, Monrovia, Calif. 91016.