National

On Thursday, a woman and her children were found dead after being sequestered in a menstruation hut in Nepal. The death came on the heels of a protest on Jan. 1 in India, where thousands of women created a human wall that stretched 385 miles from the north of Kerala state to its capital in support of equal rights and against gender discrimination.

The big picture: Notions of ritual purity are at the heart of Hindu practices that ban women from entering kitchens or temples when they are menstruating. Public health professionals and women’s rights advocates have campaigned against ostracizing women for a long time, but the events in both Nepal and India have brought the discussion into mainstream media again.

Background: The Nepalese government has banned the practice of sequestering menstruating women, but the ban has never been strictly enforced. A similar practice was challenged in the Supreme Court in India last month, leading to a decision that allowed all women to enter Sabarimala temple in Kerala.

Nepali girls sent away from their homes miss school during these periods of confinement, are often not fed adequately, may not be allowed to bathe and can become sick, as such huts are often poorly built and insulated. 

Close to a quarter of all adolescent girls drop out of school in India, partly as a result of their inability to manage menstruation.

What’s new: In a recent decision by India's Supreme Court, judges commented on the equal rights of men and women to pray at the temple but also maintained that menstruation did not make a woman “impure.” The Kerala government allowed two women to enter the temple under police protection, but that decision led to violent protests that forced the state government to enforce a shutdown to prevent further violence. 

What to watch: The right-leaning Bharatiya Janata Party threw its weight behind the protestors, prompting public intellectuals to argue that the Court was being undermined by political parties and setting a dangerous precedent for democratic governance and the rule of law. Some have also expressed a concern that that the ruling may become a flashpoint for more violence at Sabarimala, especially around the upcoming national elections in spring 2019.

Tanvi Nagpal is the director of the International Development Program at Johns Hopkins School of Advanced International Studies.

Women are challenging menstruation taboos in India and Nepal

India's Supreme Court recently ruled that it doesn't make a woman “impure."

Women take oath as they gather to participate in the 620 km-long 'Women's Wall' against communalism and gender discrimination

Women gather to participate in the 385-mile-long "Women's Wall" against gender discrimination, in Kerala, India, on Jan. 1, 2019. Photo: Vivek R Nair/Hindustan Times via Getty Images

World

Women's rights

Expert Voices

On Thursday, a <a class="gtmContentClick" data-vars-link-text="woman and her children" data-vars-click-url="https://www.bbc.com/news/world-asia-46823289" data-vars-content-id="43048014-b2cd-42c7-a067-73993cdb1d36" data-vars-headline="Women are challenging menstruation taboos in India and Nepal" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.bbc.com/news/world-asia-46823289" target="_blank">woman and her children</a> were found dead after being sequestered in a menstruation hut in Nepal. The death came on the heels of a protest on Jan. 1 in India, where thousands of women created a <a class="gtmContentClick" data-vars-link-text="human wall" data-vars-click-url="https://www.irishtimes.com/news/world/europe/temple-ban-on-menstruating-women-protested-in-kerala-1.3746164" data-vars-content-id="43048014-b2cd-42c7-a067-73993cdb1d36" data-vars-headline="Women are challenging menstruation taboos in India and Nepal" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.irishtimes.com/news/world/europe/temple-ban-on-menstruating-women-protested-in-kerala-1.3746164" target="_blank">human wall</a> that stretched <a class="gtmContentClick" data-vars-link-text="385 miles" data-vars-click-url="https://www.nytimes.com/2019/01/08/opinion/india-women-sabarimala-temple.html" data-vars-content-id="43048014-b2cd-42c7-a067-73993cdb1d36" data-vars-headline="Women are challenging menstruation taboos in India and Nepal" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.nytimes.com/2019/01/08/opinion/india-women-sabarimala-temple.html" target="_blank">385 miles</a> from the north of Kerala state to its capital in support of equal rights and against gender discrimination.The big picture: Notions of <a class="gtmContentClick" data-vars-link-text="ritual purity" data-vars-click-url="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408698/" data-vars-content-id="43048014-b2cd-42c7-a067-73993cdb1d36" data-vars-headline="Women are challenging menstruation taboos in India and Nepal" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408698/" target="_blank">ritual purity</a> are at the heart of Hindu practices that ban women from entering kitchens or temples when they are menstruating. Public health professionals and women’s rights advocates have campaigned against ostracizing women for a long time, but the events in both Nepal and India have brought the discussion into mainstream media again.

Cholera has returned in the aftermath of the deadly Cyclone Idai that devastated large swaths of southern Africa on March 15.

Why it matters: Catastrophic events have the potential to reverse health, education and income gains in countries like Mozambique and Malawi, which are among the poorest in the world. Approximately half the population in both countries live below the official poverty lines, and many lack access to safe water and toilets.

Background: If untreated, cholera can be fatal. When clinics and hospitals have been destroyed following natural disasters and people are living in close proximity to each other, early detection and treatment are challenging but critical.

What's happening: 1.8 million are need of urgent assistance, with 128,000 living in shelters at 154 sites across Mozambique, Malawi and Zimbabwe. At least 750 people are estimated to have been killed, but that number continues to climb as bodies are discovered.

Mozambique was already dealing with floods that had displaced 60,000 people — pushing many into crowded shelters — when the cyclone hit, destroying homes, clinics and schools in its path.

In Beira, Mozambique's fourth largest city, the primary water treatment facility was severely damaged by the storm. At least 1,052 people have been infected by cholera, and one person has reportedly died from the disease. 

Other diseases such as typhoid may also break out. Standing water is a breeding ground for mosquitoes, which transmit malaria.

Where it stands: The WHO has requested $13 million for medical supplies and disaster response in areas cut off by flooding. It has shipped 900,000 doses of cholera vaccine to Mozambique, and a vaccination campaign is set to begin in Beira on April 3.

USAID has sent a disaster assessment response team and committed $7.3 million to the region.

NGOs such as Save the Children and MSF are also actively engaged in fundraising and support, with the latter operating a hospital to treat cholera patients in Mozambique.

The bottom line: Though the international donor community has begun responding to the crisis, the specter of cholera death raises further alarm. And with such wide devastation, rebuilding will be a long process.

Mounting cholera cases add to post-cyclone challenges in Mozambique

More than 1,000 infections have been reported.

Children in a medical treatment tent in Beira, Mozambique.

A medical treatment tent in Beira, Mozambique. Photo: Yasuyoshi Chiba/AFP/Getty Images

Cyclone Idai

Cholera <a class="gtmContentClick" data-vars-link-text="has returned" data-vars-click-url="https://www.apnews.com/a02e54de4434422191e8251d26c3ab91" data-vars-content-id="e5682bd7-4a8f-4cda-849c-7be08910d674" data-vars-headline="Mounting cholera cases add to post-cyclone challenges in Mozambique" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.apnews.com/a02e54de4434422191e8251d26c3ab91" target="_blank">has returned</a> in the aftermath of the deadly Cyclone Idai that devastated large swaths of southern Africa on March 15.Why it matters: Catastrophic events have the potential to reverse health, education and income gains in countries like <a class="gtmContentClick" data-vars-link-text="Mozambique" data-vars-click-url="https://data.worldbank.org/country/mozambique" data-vars-content-id="e5682bd7-4a8f-4cda-849c-7be08910d674" data-vars-headline="Mounting cholera cases add to post-cyclone challenges in Mozambique" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://data.worldbank.org/country/mozambique" target="_blank">Mozambique</a> and <a class="gtmContentClick" data-vars-link-text="Malawi" data-vars-click-url="https://data.worldbank.org/country/malawi" data-vars-content-id="e5682bd7-4a8f-4cda-849c-7be08910d674" data-vars-headline="Mounting cholera cases add to post-cyclone challenges in Mozambique" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://data.worldbank.org/country/malawi" target="_blank">Malawi</a>, which are among the poorest in the world. Approximately half the population in both countries live below the official poverty lines, and many lack access to safe water and toilets.

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

Progress in reducing malnutrition has been slow and uneven, according to the newly released 2018 Global Nutrition Report. Although donors exceeded the $19.6 billion commitment they made in 2013, disbursing $21.8 billion two years ahead of schedule, the report also found that official development assistance is still too low.

The big picture: Malnutrition imposes high socioeconomic costs, the majority of which are borne by children, young adults, and women. While the quality of data on both problems and solutions has improved, more investment is needed in programs specific to nutrition, especially in the most challenged countries.

Background: Malnutrition, which includes undernutrition and obesity, is responsible for more ill health than any other cause.

Undernutrition is the primary cause of around 45% of deaths among children under five, with 20 million underweight newborns every year.

Obesity affects 39% of adults, or 2.01 billion people, contributing to an estimated 4 million deaths every year.

These problems often coexist — India has the largest number of undernourished children but also more than a million overweight children — but also vary by cause. Africans are the most likely to face multiple forms of malnutrition: stunting (low height for age) in children, anemia among young women, and obesity in adult women.

What’s new: A combination of interventions including exclusive breastfeeding and improvements in maternal health and newborn care have led to a decline in stunting among children everywhere except in Africa. Anemia, however, has been rising slowly. Most worrisome is a rise in obesity among people of all ages and income groups, who are eating diets too rich in refined grains and sugar and too poor in fruits, vegetables and whole grains.

What’s needed: In 2017, the World Bank estimated that donors, governments and the private sector would need to spend $70 billion to meet four of the World Health Assembly's six nutrition targets.

Interventions such as improving nutrition for breastfeeding mothers, food staple fortification, improving newborn feeding practices, and better child nutrition could prevent 65 million stunting cases and 265 million anemia cases, significantly reduce wasting (low weight for age), and increase the number of children being breastfed, with every dollar invested yielding a return between $4 and $35.

What to watch: Reasons for cautious optimism include fortified foods that deliver micronutrients, better use and collection of data collection by governments, and new programs that involve young adults.

Global nutrition has improved, but targeted investments still needed

Malnutrition is responsible for more ill health than any other cause.

India, Bihar, Bodhgaya, A family eating vegetarian street food in Bodh. 

A family eating vegetarian street food in Bodh, India. Photo: Eye Ubiquitous/UIG via Getty Images

Nutrition

Science

Progress in reducing malnutrition has been slow and uneven, according to the newly released <a class="gtmContentClick" data-vars-link-text="2018 Global Nutrition Report" data-vars-click-url="https://globalnutritionreport.org/reports/global-nutrition-report-2018/" data-vars-content-id="f0b23214-8b90-415c-a0bc-ca66d8704082" data-vars-headline="Global nutrition has improved, but targeted investments still needed" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://globalnutritionreport.org/reports/global-nutrition-report-2018/" target="_blank">2018 Global Nutrition Report</a>. Although <a class="gtmContentClick" data-vars-link-text="donors" data-vars-click-url="http://www.action.org/uploads/documents/NutritionScorecard_2016_11x17_FINAL_web_3.pdf" data-vars-content-id="f0b23214-8b90-415c-a0bc-ca66d8704082" data-vars-headline="Global nutrition has improved, but targeted investments still needed" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="http://www.action.org/uploads/documents/NutritionScorecard_2016_11x17_FINAL_web_3.pdf" target="_blank">donors</a> exceeded the $19.6 billion commitment <a class="gtmContentClick" data-vars-link-text="they made in 2013" data-vars-click-url="https://nutritionforgrowth.org/nutrition-growth/" data-vars-content-id="f0b23214-8b90-415c-a0bc-ca66d8704082" data-vars-headline="Global nutrition has improved, but targeted investments still needed" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://nutritionforgrowth.org/nutrition-growth/" target="_blank">they made in 2013</a>, disbursing $21.8 billion two years ahead of schedule, the report also found that official development assistance is still too low.The big picture: Malnutrition imposes <a class="gtmContentClick" data-vars-link-text="high socioeconomic costs" data-vars-click-url="https://glopan.org/sites/default/files/pictures/CostOfMalnutrition.pdf" data-vars-content-id="f0b23214-8b90-415c-a0bc-ca66d8704082" data-vars-headline="Global nutrition has improved, but targeted investments still needed" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://glopan.org/sites/default/files/pictures/CostOfMalnutrition.pdf" target="_blank">high socioeconomic costs</a>, the majority of which are borne by children, young adults, and women. While the quality of data on both problems and solutions has improved, more investment is needed in <a class="gtmContentClick" data-vars-link-text="programs specific to nutrition" data-vars-click-url="https://www.karger.com/Article/PDF/452392" data-vars-content-id="f0b23214-8b90-415c-a0bc-ca66d8704082" data-vars-headline="Global nutrition has improved, but targeted investments still needed" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.karger.com/Article/PDF/452392" target="_blank">programs specific to nutrition</a>, especially in the most challenged countries.

As developing countries continue to improve plumbing and provide toilets, many have left sanitation workers suffering from weak legal protections, poverty and social stigma, according to a recent joint report from the World Bank, WHO, ILO and WaterAid.

Why it matters: The workers who connect and clean toilets and sewers are on the front lines of a major global health campaign. According to UN Water, 4.2 billion people live without safely managed sanitation and 673 million use no toilet at all, a situation that compounds poor hygiene in causing 432,000 diarrhea deaths every year.

How it works: Access to a toilet is only the first step to improving sanitation.

Many subsequent services — such as emptying pits and treating wastewater or fecal sludge — are missing in developing countries, where most households rely on a septic pit or tank, often emptied manually by sanitation workers.

In some areas, these laborers also clean city sewers, often without proper equipment or protective gear. In India, 50 workers died in the first half of 2019 from drowning, asphyxiation and other serious accidents during this work.

What’s next: Some countries are making strides to identify and protect sanitation workers by helping them organize, buy equipment and charge set fees for their services.

South Africa passed a series of laws to protect workers formally employed by the government and private sector. Employers are responsible for minimizing safety risks, providing training and offering health benefits.

Bangladesh has created worker registries, acknowledged workers in the private formal market and provided state employees union membership, housing and and health insurance.

Yes, but: In India, an estimated 182,505 families still perform manual scavenging. The National Commission for Sanitation Workers, set up by an Act of Parliament, recently issued a report encouraging the government to help eradicate the practice.

Many states have not yet complied with a 2014 Supreme Court Order to identify all sanitation workers who had died on the job and to compensate their families.

The bottom line: Even amid tremendous progress — such as India's installation of more than 110 million toilets — grave risks remain to the workers who ensure that sanitation infrastructure is maintained and services are delivered.

Sanitation workers often neglected as countries expand access to toilets

They are left at risk on the front lines of a major global health campaign.

a public toilet on side of the street with two men standing in front

A public toilet in Chennai, India. Photo: Arun Sankar/AFP via Getty Images

Public health

As developing countries continue to improve plumbing and provide toilets, many have left sanitation workers suffering from weak legal protections, poverty and social stigma, according to a recent <a class="gtmContentClick" data-vars-link-text="joint report" data-vars-click-url="https://www.who.int/water_sanitation_health/publications/health-safety-dignity-of-sanitation-workers.pdf?ua=1" data-vars-content-id="f6351764-0474-4261-9074-14f92db76d1f" data-vars-headline="Sanitation workers often neglected as countries expand access to toilets" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.who.int/water_sanitation_health/publications/health-safety-dignity-of-sanitation-workers.pdf?ua=1" target="_blank">joint report</a> from the World Bank, WHO, ILO and WaterAid.Why it matters: The workers who connect and clean toilets and sewers are on the front lines of a major global health campaign. According to <a class="gtmContentClick" data-vars-link-text="UN Water" data-vars-click-url="https://www.unwater.org/world-toilet-day-2019-leaving-no-one-behind/" data-vars-content-id="f6351764-0474-4261-9074-14f92db76d1f" data-vars-headline="Sanitation workers often neglected as countries expand access to toilets" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.unwater.org/world-toilet-day-2019-leaving-no-one-behind/" target="_blank">UN Water</a>, 4.2 billion people live without safely managed sanitation and 673 million use no toilet at all, a situation that compounds poor hygiene in causing <a class="gtmContentClick" data-vars-link-text="432,000 diarrhea deaths" data-vars-click-url="https://www.who.int/en/news-room/fact-sheets/detail/sanitation" data-vars-content-id="f6351764-0474-4261-9074-14f92db76d1f" data-vars-headline="Sanitation workers often neglected as countries expand access to toilets" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.who.int/en/news-room/fact-sheets/detail/sanitation" target="_blank">432,000 diarrhea deaths</a> every year.

A dangerous combination of hot and dry weather, poor water management and rising demand is leaving cities such as Chennai, India, and Harare, Zimbabwe, without water for days on end.

The big picture: The pressures on municipal water supplies are likely to worsen with the effects of climate change. Cape Town, South Africa, narrowly averted its "Day Zero" last year, but cities in 17 other countries classified as high stress could soon face their own water crises.

Overuse and drought have dried up the 4 reservoirs serving the 9 million residents of Chennai, India's 6th largest city, and the annual monsoon barely eased the shortage. Since mid-July, a daily train has delivered 2.5 million liters of water from a dam 125 miles away, yet many taps have still gone dry.

The 2 million people of Harare, Zimbabwe’s capital, turn to shallow wells and ditches to supplement the water piped in once a week. Of the city's 4 reservoirs, 2 are dry and the other 2 are so polluted by raw sewage and industrial waste that their water must be heavily treated before piping. A shortage of chemicals has led to a decommissioning of 1 water-treatment plant and inadequate supply from another, as well as an uptick in waterborne diseases.

Between the lines: Weather alone is not to blame.

Chennai's natural rainwater collection systems and aquifers have been completely neglected. Deep-well drilling by industry and agriculture has gone unregulated, and the government's recent attempts to encourage rainwater harvesting have met with limited success.

In Harare, decades of underfunding have led to crumbling infrastructure, leaky pipes and widespread water theft.

India's government warned in 2018 that 21 Indian cities would run out of groundwater by 2020, placing almost 100 million citizens at risk unless urgent steps were taken to protect and replenish aquifers.

Despite the threat of an impending drought, Zimbabwe's protracted political crisis and economic contraction have thwarted major investments in public goods. A good monsoon, together with greater water savings, could avert day zero in the near term, but they are no substitute for long-term planning and investment in water resources and demand management.

The bottom line: Without significant investments in plugging leaky pipes, improving agricultural efficiency, harvesting rainwater and mandating conservation, 45 cities — home to 450 million people — could see their taps dry up by 2030.  

Dry taps in India and Zimbabwe signal looming urban water crises

45 cities — home to 450 million people — could face similar shortfalls by 2030.

bicyclist transporting colored water cans

A cycle cart of water cans in Chennai, India. Photo: Atul Loke/Getty Images

Water

Cities

A dangerous combination of hot and dry weather, poor water management and rising demand is leaving cities such as Chennai, India, and Harare, Zimbabwe, without water for days on end.The big picture: The pressures on municipal water supplies are likely to worsen with the effects of climate change. Cape Town, South Africa, narrowly averted its <a class="gtmContentClick" data-vars-link-text="&quot;Day Zero&quot;" data-vars-click-url="https://qz.com/africa/1272589/how-cape-town-delayed-its-water-disaster-at-least-until-2019/" data-vars-content-id="fb32e29f-4450-4944-bb99-abc536b1557d" data-vars-headline="Dry taps in India and Zimbabwe signal looming urban water crises" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://qz.com/africa/1272589/how-cape-town-delayed-its-water-disaster-at-least-until-2019/" target="_blank">&quot;Day Zero&quot;</a> last year, but <a class="gtmContentClick" data-vars-link-text="cities in 17 other countries" data-vars-click-url="https://www.wri.org/blog/2019/08/17-countries-home-one-quarter-world-population-face-extremely-high-water-stress" data-vars-content-id="fb32e29f-4450-4944-bb99-abc536b1557d" data-vars-headline="Dry taps in India and Zimbabwe signal looming urban water crises" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.wri.org/blog/2019/08/17-countries-home-one-quarter-world-population-face-extremely-high-water-stress" target="_blank">cities in 17 other countries</a> classified as <a class="gtmContentClick" data-vars-link-text="high stress" data-vars-click-url="https://www.nytimes.com/interactive/2019/08/06/climate/world-water-stress.html" data-vars-content-id="fb32e29f-4450-4944-bb99-abc536b1557d" data-vars-headline="Dry taps in India and Zimbabwe signal looming urban water crises" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.nytimes.com/interactive/2019/08/06/climate/world-water-stress.html" target="_blank">high stress</a> could soon face their own water crises.

Ominous forecasts about the impact of climate change serve as the backdrop for the world — led by U.S. lawmakers and companies — to debate big action on the problem, which could upend energy systems and our way of life.

Tanvi Nagpal

Stories

Sanitation workers often neglected as countries expand access to toilets

Dry taps in India and Zimbabwe signal looming urban water crises

Mounting cholera cases add to post-cyclone challenges in Mozambique

Women are challenging menstruation taboos in India and Nepal

Global nutrition has improved, but targeted investments still needed