In a tragic incident on October 5, four sanitation workers died allegedly after inhaling toxic gasses while working in a 10-foot-deep underground sewer in Faridabad, Haryana. They had no safety gear on. Despite repeated guidelines issued by the government, there have been several fatal accidents involving sanitation workers, especially desludging workers.

According to a July 2022 statement by the Centre in the Parliament, 347 workers died while cleaning septic tanks and sewers in India from 2017 to 2002. A majority of these deaths happened in Uttar Pradesh, Tamil Nadu, Delhi and Haryana. Most workers put their lives at risk for a meagre sum of about Rs 400.

While there are several categories of sanitation workers along the value chain and everyone is prone to different kinds of danger, it is the desludging operators (DSO) that are most at risk as they are directly exposed to highly toxic gasses. They are at the risk of exposure to chemical or biological toxins by indirect contact with faecal sludge and inhalation of harmful gasses.

Even if they follow safety protocols, the nature of their job involves risk factors like extreme weather conditions, bad roads, poorly constructed sewers and tricky soil. Apart from this, they also face other hazards like poisonous snakes and insect bites at their job sites.

The injuries caused, especially by toxic gasses can prove fatal if immediate first aid is not given. Experts say that it is crucial for sanitation workers to have knowledge about occupational first aid and have access to adequate safety measures like Personal Protective Equipment in order to reduce the risks of fatality.

In states like Tamil Nadu, due to the high volume of accidents, several measures are being taken to prioritise safe sanitation. The Tamil Nadu Urban Sanitation Programme (TNUSSP) as part of this mission, engages with different stakeholders in the sanitation value chain to ensure safe, sustainable, and inclusive sanitation services.

One of their key roles is capacity building of different categories of sanitation workers and ensuring that their health and safety is not compromised. In order to do this, they conducted a Needs Assessment Study to understand the current desludging practices, the safety and health concerns of desludging operators.

Desludging is the process of clearing the faecal sludge from septic tanks. The DSOs are involved right from the safe collection to the transportation and disposal of the faecal sludge. The desludging activity is largely mechanised, with operators using large trucks to empty, transport, and dispose of faecal sludge.

The truck is usually fitted with a storage tank and a vacuum pump. Although the process is mechanised, desludging workers often enter into the septic tanks to clear blockages and hence come in contact with faecal sludge. Not only is it a physically laborious job with risks of cuts and bruises, but the toxic gases can also cause skin ailments and other health issues.

So it is vital for the stakeholders, including desludging operators and staff to have a basic knowledge of first aid to ensure that a life is kept out of danger till medical help arrives. In order to do this, a training manual has been prepared for trainers to create awareness and spread knowledge about first aid measures to desludging workers in the event of an injury or accident.

Karuppaiyah Raju, a de-sludging operator in Tamil Nadu, who had some first-aid training recalled an incident he witnessed and explained to The Citizen why training is so important.

"It was in 2021. I was working in a house with an eight-foot-deep septic tank. It was heavily clogged with black sludge. I had training before, but I still didn't take it seriously. I didn't try to find out whether there are poisonous gases. As the sludge was too thick, one of my men, 23-year-old Karthick (name changed for anonymity) got into the pit to try to clear it.

"We usually use a suction hose to drain the sludge. These suction hoses use very high pressure. So the pressure needs to be adjusted based on the thickness of the sludge. If there is no sludge, the hose goes in very fast. He was trying to clear the sludge, but was accidently pulled in due to the force of the suction.

"I could hear him breathing heavily and he was asking for help. I immediately understood that he was inhaling poisonous gasses. So I advised the others not to go near as it could be fatal to them as well. We could hear his breathing getting heavier.

"I was in shock, I couldn't react. Just in time, someone near us found a ladder and dropped it inside the septic tank. I had a rope too. So we used it to pull him out. When he came out, his body was cold. So we poured several buckets of water on him till his body temperature came back to normal.

"We then rushed him to the hospital. He was treated there for a few days. There were repeated tests done to ensure all his levels were normal and he was discharged. He managed to survive. It was a miracle, but that day, I realised the importance of safety measures and first aid training. After that, we've been very careful. We don't let anyone get into septic tanks."

Niladri Chakraborthy from the Indian Institute of Human Settlements, which was instrumental in conducting the study said, "sanitation workers are the people who keep our city clean. In selected cities, we have worked closely with different categories of sanitation workers. We know some people come and take the waste and keep our cities clean.

"But we don't realise the hardships and risks they face. There is a huge awareness about the need for sanitation across the globe, but not enough attention is given to those who undertake the sanitation work.

"Some take solid waste, some clean septic tanks, some clean sewage lines, some clean railway tracks. Across the value chain on sanitation, all sanitation workers are in some way or the other dealing with some kind of waste. Not all of them have the same exposure to risk.

"But waste is a hazard. On top of that, many people are not trained sanitation workers. They just learn from their ancestors. A major chunk is from the informal sector. So one, it is a hazardous environment and add to that, there is inadequate training. There needs to be more effort to ensure their safety.

"Desludging workers are people who deal with emptying septic tanks. It's mostly mechanised emptying. Occupational safety in the sanitation space is an evolving area. I think there are three sections in the constitution that deal with occupational safety, 16 laws and two acts.

"One bill came in 2018 and is passed now. But if you look at it closely, it mostly deals with road safety, safety of construction workers, etc. No where it is mentioned that sanitation work is hazardous. But in our close interaction and association with sanitation workers, we've realised that they work in the most hazardous environments.

The manual scavenging act touches upon the risks involved, but there is no mention about the risks involved with mechanised sanitation work When desludging operators try to empty the tank, there is a risk of getting injured because of the positioning of the septic tanks.

"In India, septic tanks are not constructed in such a way that it is easily accessible. Further, they deal with raw septage and other toxic gasses. The general trend is just give them PPE and everything will be solved.

"But in our Needs assessment study for this community, we found that while PPE is important, there was a bigger need to have first aid training for the workers. Everyone knows first aid, but it is important to have a systemic manual for occupation specific first aid," he added.

Karuppaiyah added that the workers often get calls from houses saying there is a bad smell coming from the septic tank, "we're asked if we can come immediately. A lot of times, these septic tanks are not constructed properly and it's very hard to access them. Even when we just try to open it, we can slip and fall into it. Sometimes, it's left untouched for years and there are risks of poisonous snakes."

He added, "the training has really made a difference. Most of the sanitation workers don't know what toxic gasses are and how harmful it can be. In places like Tuticorin, many sanitation workers clean sewers in factories and they're unaware of the highly toxic gasses present. As soon as you open the septic tank, the gasses can harm you. During the training, we were taught how to use gas monitors, what sort of injuries can be caused, etc."

He added, "all sanitation workers need to have safety training. Our job is such that anything can happen anytime. There needs to be more awareness about safety measures. During monsoon, all the drains get clogged. It will be almost impossible to clear. Inside the septic tanks, we can't even see if there are rocks or snakes or anything else. It is always a risk."

Dr G Chandramouli, a general surgeon at the Rajiv Gandhi Government General Hospital said, "there are several occupational hazards depending on which sector you work in. But in this sector, what is unique is that it is a situation where without first aid, it is almost impossible for the victim to survive.

"That's the nature of the hazard. According to statistics, a majority of the accidents in the sanitation sectors are due to inhalation of poisonous gasses and not falls or snake bites. The workers need to be aware of the toxic gasses. Some gases like hydrogen sulfide can be traced easily because of the smell, but others like methane are very difficult to trace.

"Gasses like methane are also very heavy and can easily and very quickly displace the oxygen in your body. If the oxygen levels go below 21 per cent, it will lead to asphyxiation. Sanitation workers will often think there are no poisonous gasses because gasses like methane are odorless. But it is extremely dangerous."

He added, "If you look at history, Hitler used poisonous gasses to kill people because it is one of the most dangerous substances. Within four minutes, the physiology of your body will begin to change. So if you cross that limit, no matter which hospital you go to, one can't survive. One needs to also understand the symptoms of asphyxiation.

"You need to know which hospitals are nearby. You need to wear a PPE kit. In hospitals, the first treatment is to give oxygen. For those who are working in remote areas, the ambulance will take time to reach. It would be helpful if the government can bring about a law that trucks should carry an oxygen cylinder so that it can be used for emergencies. It's not very expensive."