Monsoons Near, Nepal Focuses on Sanitation to Stem Illness After Quake[ courtesy: The New York Times]

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Saili, 25, from Selang, said that her 2-year-old son died in the earthquake and that her home was destroyed. She and her two surviving children are now living in a shelter with four other families. Credit Gardiner Harris/The New York Times.

PAUWATHOK, Nepal — After years of intense effort, officials here in rural Sindhupalchok district had persuaded almost all of the nearly 61,000 households to each build a toilet. Then the earthquake struck, destroying most houses — and the very toilets that could have helped stave off the diseases that can run rampant after natural disasters.

Now, instead of celebrating a public health triumph, residents are holding services for their dead and digging through the rubble to find more bodies. And relief workers are pouring into the district, hoping to salvage the remarkable progress in improving hygiene made here in recent years.

“There will be outbreaks of cholera and other diseases,” said Antti Rautavaara, chief of water, sanitation and hygiene for Unicef in Nepal. “It is a battle we cannot win. We can only try to minimize the pain and death.”

Two weeks have passed since a magnitude 7.8 earthquake devastated large swaths of this mountainous country, killing more than 7,900 people and injuring more than 17,000. Nepal’s government and charitable organizations are racing to beat monsoon season, which begins in about six weeks, to get tents and food to as many as 800,000 Nepalis whose homes are uninhabitable. But they say an equally urgent task is to provide clean water and toilets before the rains make the poor sanitary environment in these devastated areas far worse by carrying contamination into water supplies and making direct contact with fecal bacteria almost inevitable.

Small outbreaks of diarrhea have been reported across Nepal since the earthquake, and although such outbreaks are routine here, they have raised worries that the quake’s aftermath is at least partly to blame. But getting residents to consider building more toilets amid the devastation has not been easy.

About every fourth house in Chautara, among the district’s largest villages, is rubble. Most of those still standing are leaning precariously or have slid down the hill. The road through town is a narrow pathway choked with the red dust of pulverized bricks.

A sign still standing at one end of town declares, “To Defecate In Open Areas Is To Commit A Crime.” But in interviews, many residents said the destruction had forced them to return to that now-criminalized practice.

Chameli Giri, 45, is one. Standing on a pile of rubble and wood that was once her house in the nearby village of Pauwathok, an eye-watering stench from the family’s crushed goats rising around her, Ms. Giri made it clear that her worries were more immediate. She and her seven children were all living in a jury-rigged lean-to next to the family’s surviving livestock; the night before, she had heard a tiger. She feared thieves.

For the moment, she said gesturing toward the hillside, the family would have to make do with the outdoors.

“What else can we do?” she said.

More than 80 charities and government agencies have poured into Nepal since the quake to work on its well-documented water and sanitation problems. Nepal’s water ministry has held routine meetings with them in its biggest conference room, which is still not large enough to accommodate the scores of people who show up in T-shirts and vests emblazoned with the bright-colored logos of their organizations.

They are coming to a country that was already among the world’s most unsanitary, with a 2011 government survey finding that 45 percent of Nepalis did not use toilets, one reason 82 percent of drinking water supplies are contaminated with fecal bacteria. A study found that about 11 percent of Nepali children have diarrhea at any given moment, which contributes to the stunting that affects more than a third of the nation’s children, according to government figures.

“The risk is that an already bad situation gets much worse,” said Mr. Rautavaara of Unicef. “But at the same time, this is a massive opportunity for the sanitation movement.”

Before the earthquake, Unicef had intended to spend $25 million over four years aiding the government in its sanitation efforts. Now, the United Nations intends to dole out $63 million in water and sanitation grants for work that must be completed within three months, if international donations meet hopes.

Some of the money will be spent on providing and constructing temporary pit latrines — each a hole in the ground with a small booth above it. Stacks of the materials for the latrines have been appearing in district headquarters across Nepal, courtesy of aid organizations like Oxfam. The government’s goal is to quickly build one such latrine for every 50 male residents and another for every 30 females.

While the aid is considered necessary, it has raised at least some fears that handouts will backfire. Many Nepalis have shown over the years that they prefer using open fields to using smelly pit latrines. In fact, giving away or having the government construct toilets has been a singularly unsuccessful strategy in much of South Asia, where people often turn government toilets into storage rooms or simply abandon them altogether.

So Nepal began a series of initiatives to persuade and sometimes shame residents into spending their own money to build toilets, figuring the expenditure would give the people more of an investment in the modern convenience. Most areas lack running water, and the toilets are usually outhouses with pour-flush systems. The strategy was especially successful in the country’s hilly and mountainous districts — precisely the ones most affected by the earthquake.

Arun Simkhad, the district water and sanitation chief, said the area had been tantalizingly close to having all its residents use toilets when the quake undid the progress. “We only had about 300 households out of 60,600 in the district that still didn’t have toilets,” said Mr. Simkhad, sitting in a thatch pagoda outside his destroyed district office. He has not given up, though.

“People are going to rebuild their homes,” Mr. Simkhad said. “And when they do, we are asking them to build a toilet as well.”

Sanitation experts said they were uncertain whether Sindhupalchok’s residents, with jobs now scarce, would be able to afford to rebuild toilets without financial or construction assistance. And while some worried that would lead people not to value the toilets, others suggest that will no longer be a problem.

“They’ve already built toilets once. I’m sure the habits are ingrained now,” said Payden, a regional water and sanitation adviser for the World Health Organization who, like many South Asians, uses only one name. “So I don’t think they’ll abandon facilities built by external donors or governments.”

But getting residents to even discuss toilets has been difficult in recent days, she said. “If you’re not bringing tents or food, people in these hard-hit areas can get angry and even aggressive,” Ms. Payden said. “Some water and sanitation assessors have had to leave villages.”

In interviews, many residents of Sindhupalchok also said that getting a toilet was the least of their worries.

Saili, 25, of Selang, said that her 2-year-old son had died and that she had been buried up to her waist when her home, like every other in her village, collapsed. Now, she and her two surviving children live in a makeshift shelter of branches along with four other families.

“We really need a tent and some food,” she said. “A toilet? I don’t know. Not really.”

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