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BEYOND ACCESS TO IMPROVED
WATER SUPPLY AND SANITATION:
IMPACTS ON AND OF WOMEN AND CHILDREN



by



Mary Elmendorf, Ph.D.
Consulting Anthropologist


Presented at the
U.S. Agency For International Development
J eSeminar: The Im act of Interventions
in Water Supply and Sanitation in Developing Countries
P.A.H.O. March 25-26, 1980
Washington, D.C.


Home:
535 Blvd. of Presidents
Sarasota, FLA 53577
813.-388-1184


Office:
1514 17th Street, N.W.
Washington, D.C. 20036
202-483-5890








Draft 3/80


BEYOND ACCESS TO IMPROVED
WATER SUPPLY AND SANITATION:
IMPACTS ON AND OF WOMEN AND CHILDREN


Introduction and Background

In attempts to meet the 1990 target for providing

all peoples with safe drinking water*/ and improved

sanitation, and "health for all by the year 2,000,"**/

increased emphasis must be given to the interdependence

of these laudable goals for enhancing the quality of

life. Because a disproportionate number of the poor
up
is made by of women and children, a concerted attempt

must be made to assess the social impact of interven-

tions in water supply and sanitation on this group. The

major thrust of this paper, therefore, will be to:

(1) examine the impact of improved water supply and

sanitation programs on the lives of women and children

and (2) highlight those ways in which women can be the

key agents in assuring that such projects will have a

more significant impact on all the target population.


*/ UN Conference on Water in Mar del Plata, Argentina
1979.

**/ WHO/UNICEF Primary Health Conference at Alma Ata,
Russia, 1978.







- 2 -


It has been stated that: "If the drinking water

of the world could be cleaned up overnight it would, by

some estimates, cut the infant mortality worldwide by

50 percent." (Bourne: 1980) Not everyone is in agree-

ment with this statement, 'however. Feachem, in his

excellent book on rural water supply programs in

Lesotho, states: ". . our conclusions are that no

measurable reduction in water-related disease has re-

sulted so far from village water supplies. It is

possible that benefits might result were other health

measures to be implemented together with water supply

improvements." (Feachem et al: 1978)

At the recent annual PAHO Conference, the Ministers

of Health from Latin America pledged their full support

for the Water Decade, reviewed the past accomplishments

of their Ministries, and presented a revealing chart which

showed a close correlation (in most of the 23 countries

listed) between the percentage of the population served

by potable water and the incidence of death among children

under four years of age from gastro-intestinal and other

diarrheal diseases.*/ There are, however, some startling


*/ World Health Organization, 1979 (PAHO:12).













Figure 2. Percentage of the population served by potable water and deaths from enteritis
and other diarrheal diseases per 100,000 children aged 1-4 years, by country, 1977 or latest
year.
porcentaje servido defunciones por 100,i


0

Barbados
Bahamas;
Trinidad y Tabago-
Suriname
Panama
Jamaica
Venezuela
Costa Rica
Chile-
Uruguay
Nicaragua
Argentina
Belice
Colombia
Cuba
Mex co
Rep. Dominicana
El Salvador
Ecuador
Perui
Honduras
Guatemala
Paraguay


50 100
.1~ I
-. 1


- ..........
' "" :


000(b)


(1-4 ainos de edad)
0 200 400 600 800
|t-------


(a)
alrededor de 1977.


alrededor de 1976.


Source: World Health Organization. 1979


*- I *=






* I I !







___ __----




-4 -


exceptions which need further analysis to determine why

some countries with the same percentage of people served

by potable water show a much higher infant mortality

rate. For Guatemala and Honduras, the 1976 data in-

dicate that although both countries have an equal per-

centage of the population served by potable water, the

infant mortality rate for children in Guatemala was

nearly 800 per 100,000 whereas in Honduras the death

rate was approximately 200 per 100,000. Paraguay,

with the same infant mortality rate as Honduras, had

less than one-third the amount of water available. -en

the-other-hand, Cuba, with such a small percentage

served, has one of the lowest infant mortality rates

from enteritis and other diarrheal diseases of all the

countries, even those that have greater access to water.-

To what extent can these substantial differences

be attributed to a well-functioning primary health care

program or responsible community participation? To

what extent were women involved? As we now plan, we

need to know more about the reasons for the variation





C'k///Z( /I /3 Z/A//^/4&d /&e ^e; 0U^





a







5 -


in impacts in both the successful and unsuccessful pro-

grams., */ And yet as McJunkin pointed out so succineetly

"the tortured, contrived estimates of
y,.Monetary benefits for health improve-
ments, reduction in the toil of house-
wives, increased gardening, etc., piling
assumption upon assumption, to a pre-
conceived answer . is a bureaucratic
extravagance, a useless diversion of funds
and manpower at the expense of the
beneficiaries." (McJunkin 1979:53-54)

It is important to understand both the constraints and

motivations in order to promote activities and programs

that will have positive impacts.

Before looking specifically at some of the other

impacts on women, I want to review this world-wide

tragedy of infant death caused by diarrhea and dehydra-

tion. Recognizing that the value of children is a

universal one and that infant mortality takes a serious

toll on the psychological and physical well-being of

mothers, there is no way to separate the incidence of

water and sanitation-related morbidity and mortality from

the overall social impact, particularly on women.

Aware of this serious health problem resulting in

high infant mortality, the United States Agency for In-

ternational Development hasAlaunched a five-year Mass
7/\









- 6 -


Media and Health Practice Project aimed at rural mothers

and other child-rearing family members. An integral

part of this mass media campaign is the use of face to

face intervention in promoting the adoption of practices

that will help to treat and t acute infant diarrhea.

Midwives will serve as one vital link in the development

communication process, reinforcing project messages

relevant to environmental sanitation, personal hygiene,

continued breastfeeding and oral rehydration.


Sanitation and Behavior

But here once again we are offering primarily

curative -- not preventative -- solutions. To a great

extent, diarrheal diseases are related to a lack of

adequate sanitation or safe water. And yet, as far as

I know, there has been no attempt to investigate the

integration of other Health sector programs such as

rehydration, nutrition, and population with the planning

for increase investment in water supply and sanitation --

and particularly with the need for scatalogical data

in order to understand attitudes toward human excreta

and diarrheal infection.








7 -


The perception that children's A res is "harmless"

(PRAI, 1968) can be a continuing link in chains of

reinfection whether the faeces is thrown on a nearby

garbage heap or baby diapers are washed with dishes in

an urban home with a newly installed standpi These X

practices should be understood and analysis of them in-

cluded in the preparation of audiovisual messages. In

the Yucatan, no diapers are used, but mothers are so

attuned to their children's needs that they merely hold

them away from them usually over the dirt floor of the

hut or just outside to urinate or defecate.R\ MetheLn,

as tey begin to understand the dangers of even infant

faeces -- not necessarily the "germ theory," but the

cause/effect relationship^will change their behavior.

- For instance, Chan Kom, the May village where I

have lived off and on for the last ten years, has had

piped water since 1974. In 1976, when the water system

was inoperable for the first time, the women started

complaining that their children were suffering from

diarrheal illnesses. They clearly saw the relationship

between the lack of clean water and the increased

incidence of illnessA~ d I ia/ Ci Al







- 8 -


Mothers are the socializers, the teachers of their

children in personal hygiene and sanitation practices.

- Where are the toddlers to ge? In many villages where

latrines have been installed they have not been used

because: (1) the distance from the house makes trips

during the day infrequent and at night impossible and

(2) the size of the hol and the dark pit below frightens

mothers and children. Dire tales of children falling infr-

>^ the pit abound.

What can be done? Do latrines have to continue to

be so far from the homes when there is no well to pollute?

Do privies have to emit such an unpleasant odor that they

cannot be nearer to or attached to the home? Sanitary

engineers say there are ways to make aesthetically pleasing

- as well as healthy safe latrines. Rather than continue

to spend millions of dollars on malodorous, unattractive,

inconvenient latrines as we enter the Water Decade, let

us focus on the accelerated interventions in water and

sanitation characterized by more appropriate technologies.

Another point to think about is the relationship

of water availability to the latrine. The faecal-oral

reinfection route is well known, but there has been very







- 9 -


little designing of facilities to help break this vicious

circle. How can water for hand-washing be made easily

available to the latrine? How might people be successfully

motivated to adopt hygienic practices such as handwashing?

What are the usual behavior patterns? Can there be more

dialogue with the women with respect to where they wash

-- clothes/dishes/hand schildren/themselves? Behavioral

mapping, as well as participant observation, are needed

as we work together on designing culturally acceptable

solutions. If water development projects are to have

a successful impact, considerable attention must be

paid to socioeconomic variables7 L'kf /.

As more water is made available from pumps or

standpipes, there will be a need for appropriate vessels

and patterns of use/reuse of water to enhance the health

aspects. We cannot expect women to bring their stones

from the river to their back yards to wash. If water is

being used for laundry and bathing, can it be reused in

an aqua-privy? Do we only think of bathroom planning

for urban areas?

In various remote villages, bathing areas have been

set aside. In some instances ,a stone inset in the








- 10 -


dirt floor of a Yucatec-Maya hut. In Guatemala and

Chiapas, a temascal, the water-efficient sweat bath, is

usually used. Small huts for bathing were also noted

in Honduras and Nicaragua.

-Ga hese existing patterns be incorporated in a
Spp) O-AFid iiA) Alff'i W
privy program Can -there h "dream latrines" in rural /'Af dcatOa

$^4gZ (Rodriguez Pineo and Elmendorf: 1977) If there

cannot be dream latrines, there can at least be recognition

of the need to understand present attitudes, beliefs, and

health knowledge to motivate behavioral change in

latrine usage and hand-washing following the introduc-

tion of new technology.

In Guatemala, as an incentive to promoting personal

hygiene, a simple package containing a wash basin, soap

dish, pails, and shelf to attach to the latrines, was

given as a reward to each household following inspec-

tion of their new privy. (UNC/AID 1978) For such a kit,

I would also add a mirror and soap. vea

With respect to the introduction of excess. disposal

facilities, limited attention has been given to matters

of pride and aesthetics. A case study of water supply

and excreta disposal revealed that Colombian families








- 11 -


preferred brightly colored cement stools and slabs

over drab gray facilities. (Rodriquez) When asked about

latrine preferences and practices in the Yucatan, women also

cited their preference for an 'aesthetically attractive

latrine with a shiny porcelain seat or a brightly painted

cement floor or stool. ('Elmendorf and McGarry: 1978)

The low impact of past programs on women and

children is primarily attributable to nonuse and misuse.

In thinking through the whole cycle of water supply and

waste disposal it is important to go beyond the number

of water pails carried by the women or the number of

latrines built, to a consideration of the overall impact

once the technology is in place.

In Bangladesh, a study of 120 villages showed

usage of the latrine by only 12.8 percent of the children,

while adult usage (mostly women) was 59.9 percent.

(Skoda et al: 1977) A similar study of 525 latrines in

India also revealed that many more women used the

latrines than men, while the children's faeces were

thrown on garbage heaps. (PRAI: 1968) This behavior

ties in with the widespread belief that children's excreta

is harmless. (PRAI: 1968) It is also interesting to








- 12 -


note that adopters of latrines in Gorakhpur, India,

appreciated the privacy and convenience more than a

decrease in disease (PRAI: 1969) This was noted in most

of the World Bank Studies (Elmendorf and Buckles: 1977

and 1978) A commonly held belief in Honduras, that women

should not use the same latrine as men lest they become

pregnant, limits the use of even household latrines to

female members of the family. (Eoff: 1980) In Tanzania

it was noted that the excreta of fathers and daughters

should not be mixed. (Hall: 1978)

In some areas, women and children use the same

latrines, but in many places the children defecate just

outside since they are afraid of falling through the

large opening. In our case studies concerning water

supply and waste disposal in Latin America, we found

that this fear was widespread. In fact, in Nicaragua

several women in the urban barrios of Managua who had

just installed flush toilets had kept their older,

stepped latrine with two openings -- the smaller, lower

one for children. These UNICEF model latrines were

being maintained as training devices for children. A

similar model was well accepted in Yugoslavia.







- 13 -


Even in the U.S. as recently as 1972, Belcher

reported that although many families built toilets in

their homes, many people, especially men, continued to

use the old privies or the fields:

one man . said that he just did not
feel comfortable responding to nature in
the home. To him, this was an act that
could not be satisfactorily carried on
within the confines of a house because it
was something that was rated as unclean
and he felt compelled to get away from
living quarters to carry out such functions.
(Belcher: 1972, p. 4)

The occurrence of regular patterns for excreta disposal

in the field have been reported in many countries (Kochar

et al: 1976; Kochar: 1977) As we noted in our Latin

American case studies, defecation habits in the field

may point to informal uses of excreta for productive

purposes:

Reuse of human excreta in Latin American is
an understood technology and is practiced
traditionally in a less advanced and systematic
form than in Asia. Re-use is informal --
often not verbalized because of the taboo
nature of the subject -- and it takes place
primarily in the individual households. De-
fecation in cornfields or on coffee plants is
considered to have a fertilizing function.
Similarly, fruit trees are purposely planted
over old, filled latrine pits. In some areas,
human excreta deposited near the house is con-
sumed by pigs as an aid to maintaining sani-
tation. This last practice is sometimes for-
malized when penned pigs are released







- 14 -


periodically to clean areas designated for
depositing human waste. (Elmendorf and
Buckles: 1978)

Perhaps these various findings indicate a need to

include latrines in the field-- similar to our portable

johns -- but designed as demonstrations for the intro-

duction of latrines with fertilizer re-use capacity. Such

a program might also be used in the fields where

schistosomiasis is a problem, such as in Egypt. (Sanbach:

1975) If we are looking at the impact on women and

children, greater care should be taken in designing

segregated facilities which would solve not only the

problem of decreased use in the home, but alsoA )in-

adequate facilities in the field for men.

It is, however, significant to mention the obser-

vation made in a recent World Bank study of the socio-

cultural aspects of water supply and excreta disposal.

(Elmendorf and Buckles: 1977 and 1978) Findings indicated

the practice of latrine even in urban slum ar )

among relatives or intimate friends who had previously

established a relationship through daily interactions

in their work. (Nieves and Farrell: 1978)

The design of the facility for excreta disposal

may not be in accordance with the local motoric patterns,







- 15 -


of which latrines not adapted to a squatting position

are the best known examples (Foster: 1952; Rogers and

Shoemaker: 1971). The opposite may also occur. In a

case study in Yucatan, r -we it n- m nA longer (

acceptable for the majority of the population who kkew

about flush toilets through their work in the tourist
7rhes. people
industry and other outside contacts, and therefore wanted

a stool-type rather than a squat plate. (Elmendorf and

McGarry: 1978) In Quatemala seats were preferred also;

as a place to rest, and to prevent falling in. (Buckles:

1978)

Socio-cultural variations among villages and

sexes in the same country, as well as those of different

continents and climates, are to be expected. However,

amazing similarities with respect to fears and constraints

appear in cross-cultural studies. For purposes of

effective project design, more detailed information con-

cerning these constraints is needed.

In the Moslem world, cleaning after defecation is

performed using bare hands and water as opposed to cloth,

leaves, or paper. (Simpson: 1979) Women here, as in

many parts of the world, wait to relieve themselves after

dusk or in the dark of early morning for reasons of female







- 16 -


modesty and dignity. In Yucatan and Guatemala, where

women wear wide skirts, many urinate standing in market

areas since no private facilities are available.


Impact of Children on Intervention
in Water Supply and Sanitation


Because cultural inhibitions can and do provoke

the misuse and underuse of safe water supply and waste

disposal systems, it is critical that adequate health

education and community participation efforts involving

women become integral components of planning strategies

for eradicating this problem. Third World women,

the traditional drawers and carriers of water, can play

a significant role in promoting community acceptance of

improved water supply and sanitation programs. During

the 1977 United Nations Water Conference in Mar del

Plata, 30 non-governmental organizations recommended

that developing countries give serious consideration in

their national plans to the following five points:

(a) include strategies to develop human resources
at the community level to meet local needs;

(b) ensure equal access for women to training
with regard to the maintenance, management
and technology of water sources and
supplies;






- 17 -


(c) ensure that women be included in any
educational programs on the use of water
and its protection from contamination;

(d) ensure the participation of women in local
councils arid planning boards responsible
for making decisions on community water
supply;

(e) recognize the increasingly effective role
that AOsen, NGOs and other women's organi-
zatic8 an play in the-'ducation of public
opinion for needed c )


("Special Situation of.Women in Regard to Water"
Statement prepared by the
Non-Governmental Organizations Committee on
UNICEF for the Preparatory Committee,
United Nations Water Conference
3 7 January 1977 mimeo)


In 1975 the World Plan of Action adopted at the

International Women's Year Conference in Mexico City

had stressed that "improved easily accessible safe water

supplies (including wells, dams, catchments, piping, etc.)

sewage disposal and other sanitation measures should

be provided both to improve health conditions of

families and to reduce the burden of carrying water

which falls mainly on women and children."

How much has happened since 1975? since 1977?

What is going to happen before 1990? Before the year

2000? Jane Stein noted in 1977 in her informative report

entitled: Water: Life or Death, that planners had begun









18-


tQcwomen in Adevelopment schemes. As an adjunct to

an agricultural development project in Bolivia, a program

was underway to train young women 17 25 years of age

to administer immunization shots, provide information on

good nutrition for children, and lecture on the proper

maintenance of water andi sanitation facilities. (Stein:

1977) A number of these young women now are in complete

charge of repair and maintenance of the facilities, not

just to keep them clean.

Such examples however are still rare. successful

pilot projects such as the ones in Mexico in 1958 where

women/village worker played key roles in community

participation in multi-sectiasti programs with water

supply and sanitation components are easily replicable

but have not become the model. Usually t'ey last through
at-NOSht f0^4"4
one administration a dwindle as private agencies change

focus. (Elmendorf 1977)

Training programs such as these bode well in terms

of ensuring that fSP inhabitants will benefit from

development projects. Moreover, the utilization of


* Women supervisors and planners were also relevant to
the success of these projects. Poston: 1962








- 19 -


indigenous resources for diffusing information will enable

many developing countries to realize their self-reliance

objective. With respect to community water supply and

waste disposal facilities, it is important to recognize

that the target population may accept facilities with-

out altering their hygienic behavior. For this reasonqb

planners stress the relevance of creating educational

programs which focus upon the intendedd as well as

"perceived" benefits if development efforts are to

exceed the mere adoption of the innovation. (WHO: 1979)

Understanding the needs for better sanitary

habits is not a simple process, particularly in the

area of human defecation -- a taboo subject in many

cultures, with overtones of magic, witchcraft, or just

Victorian prudishness in others. One key concept

central to diffusion of appropriate technology in

sanitation is understanding the way taboo subjects are

communicated. Taboo subjects are perceived as extremely

private and personal in nature because they deal with

proscribed behavior. As we know, and as the literature

confirms, taboo communication occurs between individuals

who are highly similar in certain characteristics such








- 20 -


as social status, education, beliefs, and often sex.

This limiting factor is a barrier to widespread and

rapid diffusion of taboo messages/information which,

in turn, "perpetuates the taboo status of the topic."

(Rogers et al, 1971) )

Another recognized characteristic of taboo communi-

cation is that it usually occurs in interlocking, closed

networks rather than open radical networks so the flow

of messages is restricted.

The implications of these facts for effective

- programs in the field of improving/changing behavior

patterns or technologies related to human defecation

and personal hygiene are obvious: The decision-makers/

leaders in the communities and in the agencies are

usually men, and they communicate with other men and

not with the women. Until women are involved and under-

stand the importance of good sanitation we can expect

limited acceptance. Once the women understand, they

can play key roles in household decisions relating to

changing behavioral patterns and to socializing

children in similar behavior and attitudes in areas

such as personal hygiene and sanitation.








- 21 -


As we enter the Mid-Decade Conference of Women

in Development and the Decade of Water and Sanitation

within the context of health for all, we have the

opportunity the challenge, really to combine our

development strategies. Intersectoral, multidisciplinary

planning should involve women at all levels, from the

village household to the policy-making level.

When .- 1il the etoric about including women in

development become a reality, Women are the key to the

realization of our goals of water and health for all.

But even with the help of women these goals can 9ot be

achieved unless w- go beynd- aeeess.


Beyond Access

As soon as there is a demonstrable relationship- K

not necessarily the germ theory -- between childhood -

deaths caused by diarreheal diseases and use of improved

water supply and sanitation, the mothers will become

the caretakers of these resources/facilities.

Some say that people won't change their un-

hygienic personal habits because of custom, religion,

education, economics, or laziness cJ.:








- 22 -


No one wants to be sick or die . .
Regardless of history or culture, people
learn to protect themselves when given
the opportunity and understanding.
"Abel Wolman's Charter" World Health,
Jan. 1977: 17 I

Neither the peasants nor the scientists seem to

be able to prove that interventions in water supply and

sanitation (WS/S) bring about better health. The problems

in our programs today are not primarily in the engineering

aspects but, in the

ways they are introduced COdiL L

missing links in the effective use of them.

We have recognized the first point -- the importance

of community participation -- but until the faecal/oral

route of infection is broken we can not expect much

improvement in health.

And village mothers will not know how to break

this vicious circle until they have some important bits

of equipment -- primarily soap and a hand basin, adequate

carrying and storage containers, along with convienty-a y

located, unsmelly, safe latrines. A M $. e /4WIAJOA' /A

At the present time we cannot say that all in-

terventions in water supply and sanitation -"EIRM-bring









- 23 -


-`improved health. Recent research points out that these is

a certain level of socio-economic development necessary

before our present programs in WS/S correlate with better

-- health. (Shuval AO. 1979) To accept these findings

as a reason not to make We/S available to the marginal

people -- the poorest ofithe poor, is unthinkable. In-

stead it should give us cause to reexamine our past

approaches. Along with the introduction of improved

community facilities there should be provision for new

appropriate household equipment to maximize effective

- use.Osd a0#4,O P{LC/d /YNVLA c.

If there is only one pail and no money to buy-

another of course it will be used for everything. If

there is no top for the pail, a covering with leaves is

a poor substitute. To use a dipper or cup is much

easier than trying to lift a heavy pail or jug.

Making available -- at inexpensive, subsidized

prices or even as rewards in recognition of labor and/or- Y

S time contributedinexpensive ancillary kitchen, laundry

and bathroom equipment, and soap will make it possible

for the villages to take advantage of the improved







- 24 -


interventions in water and sanitation.*/ Audio-visual

messages and health education should relate specifically

to the effective use of the new equipment -- both comm-

unity and household -- so that they can be used efficiently

with pride and pleasure resulting in better health

and productivity.


Summary

In summary, development planners and implementors

must be cognizant of the fact that there is as much to

- learn as there is to impart) Tf development schemes

for improved water supply and sanitation are to go

beyond increased access. jt is important that they in-

clude action plans and techniques for reducing the waste

of human energy in developing nations.

Women and children continue to expend inordinate

amounts of time and energy on arduous tasks that can

be alleviated by the acceptance and continued use of

appropriate village technology. Concerted efforts to

ease their burdens would provide released time and re-

newed energy for. adult education and training of children,,.


*/ In several countries brightly-colored, lightweight
plastic water jugs and tubs have had ready acceptance.







- 25 -


Increased emphasis needs to be placed on training

opportunities which enable women, the ultimate primary

care workers, to serve as interpersonal contacts in

persuading people to accept and continue using innova-

tions for improved basic living conditions.

Not onlyarrier us be understood, but accept-

able incentives for change must be identified and con-

sidered. Foster suggests that:

people will change traditional behavior, i.e.
innovate (1) if they perceive personal,
economic, social, psychological, health, or
other advantages in so doing; (2) if they
perceive change as a realistic
possibility for them; (3) if the economic
costs are within their capabilities; or
(4) if the social costs do not outweigh
the perceived advantage. (Foster 1962)

Together we can explore new and more appropriate

techniques, both hardware and software, to help the

poorest of the poor, the marginal people, meet their

basic needs -- including water, sanitation and health.

There is much fugitive data concerning problems and

situations in social analyses of programs, in ethno-

graphic studies and in anecdotal material which needs

to be gathered, shared, and made a part of program de-

signs. a4C A. 41r '4nn L 441








- 26 -


More research to obtain relevant socio-cultural

data to identify these problems and constraints should

be conducted. There is a dearth of information on the

roles of women in this field., More specific research

is needed to find existing data as well as to have case

studies in various regions with different technologies

- to evaluate impact. (. .. Much of this re-

search can and should be an integral part of development

strategies, particularly if a problem-solving dialogue

approach is used. If we really believe that community

participation is the key to more effective use and main-

tenance of technological innovationsVthen women, as'the

primary users, must be involved both in the selection

and implementation of programs and as behavioral change

agents within the homes.










Bibliography


Belcher, J. C.; and Vazquey-Calcerrada, P.B. "Cross-
Cultural Aspects of Sanitation Norms." Presented at
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