Khalifa Farajat, now 25, is not the only one among his peers who has been suffering from a chronic kidney disease since school days. Back then, he avoided using the school’s “filthy” toilets. Anas al Rawashdeh, 22 year old, also suffers from Dysuria because he used to hold his urine in until he returned home. Farajat and Rawashdeh were not aware of the severe health risks they were exposing themselves to. Both were diagnosed with chronic pyelonephritis; a urinary tract infection that reaches the kidney’s pelvis. According to experts, high concentrations of urine toxins in the body for long periods of time may cause bacterial infections in the pelvis and marrow of the kidney. Physicians warn that badly maintained school toilets affect, not only children’s health but also their ability to concentrate, and hence their academic standing. Malak Odwan contracted Hepatitis A (HAV) in April when school toilets were not properly functioning. She was the fourth student to fall ill within a one-month period. Odwan, 9, is a third-grader at Sleihi School in the Balqaa governorate, home to 280 other students.Her mother sadly notes that the hygienic environment provided by Malak’s family at home did not protect her from becoming infected at school.Lina Atiyyat, an eight grader at the Petra co-ed school in Amman, also became infected with HAV. None of her other family members were infected by the virus. Her mother explains that preventive measures were taken to keep them safe.Furthermore, another virus spread among students at the Petra School within a time span of one month. Students Acil Khalaf, Mays Zaki, Louay Labib, and Baraa and Bayan Aboul Hoummous contracted chickenpox. Assistant School Director Hind al Kurdi explains that “the virus spread among them because they shared the same environment.”Al Kurdi, as well as the school health teacher Sawsan Mohammad Soleiman, stated the infection was spread due to the limited number of toilets. Only three people are employed to clean an entire school which has 18 toilets used by 1,459 boys and girls in the elementary and intermediate levels.
10 to 14 HAV cases per week according to the Department of Infectious Diseases at the Ministry of Health, 11,356 cases of chickenpox (varicella) were reported among school children in 2008. In addition, 464 cases of HAV and 13 cases of Hepatitis B (HBV). Between the beginning of 2009 and mid-May, 298 cases of HAV were reported, in addition to dozens of dysuria and kidney infections. About 10 to 14 new cases of HAV have been reported weekly, most of them among school children less than 15 years old.In April 2008, the Health Department in Amman reported six cases of HAV among school children who attended the Manshiyat Hasban School. The first symptoms appeared in two brothers and their cousin.
In September 2008, four cases of HAV were diagnosed among students at Hasni Freiz School in the Balqaa governorate.Recently, more than 300 cases of chickenpox were registered among young students between April and May at Karama School in Southern Shouna district– approximately 30 km from Amman.
Most cases registered were among first-grade elementary students. According to the Department of Infectious Diseases, the advice doctors gave was that all children should stay at home in order to stop the disease from spreading any further. Interviews with school officials, as well as field visits to approximately 150 public schools for boys and girls in various regions of the Kingdom, revealed that the main causes of these outbreaks were the lack of cleanliness and the limited number of toilets. Officials and students also complained that toilets are not maintained or repaired. An official report of the Department of School Health notes that 1,677 out of the 3,000 or so public schools in Jordan suffer from the lack of adequate facilities such as ventilated classrooms, hygienic sanitation, and safe water supply. The 2007 Global School-based Student Health Survey (GSHS) conducted among Jordanian students aged between 13 and 15, showed that 1 in every 3 students did not have access to safe drinking water at school. It also demonstrated that 2 in 3 students used non-hygienic toilets.
Exchange of accusations
A Ministry of Health (MoH) official, who prefers to remain anonymous, emphasized that the School Health Department regularly carries out health checks on students attending public schools and examines water deposits and sanitation. The department prepares the School Environment Report that is reviewed by the Ministry of Education (MoE) officials, who then decide what measures to take.
This MoH official is very critical of the MoE because it deploys modest efforts to remedy the problems reported by MoH..
Mohammad al Akour, Director of Public Education at the MoE refutes these accusations, stressing that the ministry takes every report seriously and coordinates, when necessary, with the relevant departments.
Al Akour explained that the maintenance of hygienic conditions is the responsibility of students’, parents, the MoE and MoH. However, the role of the MoE, should be limited to promoting awareness among students in order to encourage them to practice hygienic habits and prevent contamination. He adds that 4,500 copies of a hygiene manual have been distributed for this purpose.
Al Akour admitted that some infectious diseases are spread among students inside schools, but stressed that all cases are referred to the Health Center for Treatment.
Health and educational supervisors reported health incidents at schools, and when an infectious disease is diagnosed, the school principal informs the MoE, al Akour explained.
“An infectious disease can easily spread among students especially those under 15 years old,” he stated, “because they are not aware of preventive measures.”
He confirmed that at least two toilet cleaners are appointed for every school, but when one of them is absent for emergency reasons, hygienic conditions become critical.Only 8,594 toilet cleaners are appointed to serve 5,324 schools with a total enrollment of 1.200,000 students, according to an official at the MoE. This means that there is one toilet cleaner per 1,396 students.The officials admitted that the situation is not satisfactory in some schools. He also stated that “girls’ toilets are cleaner than boys’ toilets.”However, MoE’s officials maintain that “sanitation facilities at schools are adequate.”Mansour al Abbadi, the director of school buildings at the MoE, pointed out that there are no “bad” sanitation facilities at any school in the kingdom. He stated that all units are adequate — despite the fact that some of them were built more than 50 years ago.Seven million JD allocated to maintain 600 schools
Al Abbadi stated that his department spent 7 million JD ($10.5 million) in 2008 to carry out maintenance at about 600 schools. In 2009, the MoE allocated 5 million JD for maintenance work at 120 schools. This work includes repairing faulty toilets.
About 2,000 schools, attended by approximately 100,000 students, received maintenance between the years 2006 and 2008.
Abbadi also explained that his department allocates one toilet for every 40 students in the new plans for school buildings.
Water taps vandalized
Maintenance work is executed according to a priority list that takes into consideration the schools’ most urgent needs. Schools’ requests are examined by a committee that defines those needs as well as the costs.
An official at Birin Secondary School for boys stated that since 2003, he has filed six requests for maintenance work that date back to 1986. Each time, the relevant authorities come back with the reply: “maintenance work is executed according to a priority scheme that is governed by financial resources.”
The school budget that amounts to 2,000 JD is used to buy stationery, and to pay for emergency maintenance work, in addition to covering laboratory needs and other activities.
Around 420 students use one sanitary unit in a school that has six toilets. Two attendants are responsible for keeping the whole school clean– including the toilets.
Abbadi believed that drinking water fountains are separated from hand cleaning taps in all public schools. But the ministry had to build protective metal boxes around the fountains so that pupils did not break the water taps or steal them.
The official explains that 25% of public schools are located in rented buildings that do not ensure an adequate educational environment. No maintenance work was undertaken in the sanitation facilities at these schools until last year. Work was continually being postponed as the ministry had plans to terminate the lease agreement.
The domino effect
Osama Nabil Shalabaya, a seventh-grade student at Hettine secondary school in Amman, follows his parents’ advice to not to use the school’s toilets for fear of contracting an infection. Zayed Kassem, also stated that he prefers “holding it in rather than using crowded toilets”.
The school’s 1,180 students have to share 12 toilets during a 20 minute break period.
Adham, a fifth-grade student, says that the school’s facilities lack basic hygiene. Adham says that his physician gave him three weeks of sick leave after he fell ill with symptoms including high fever, loss of appetite and the “yellowing” of his eyelids.
He maintains that none of his five brothers became ill, despite sharing the same bedroom.
Abdel Salam al Toubassi, the Hettine secondary school principal, says that the school toilets are well maintained and systematically cleaned– an attendant is in charge of cleaning them at the end of every school day.
He explains that drinking water taps are placed outside the toilets to prevent the spread of infections among students.
A field visit to the school, however, revealed that even soap was not available in the toilets, and that drinking cups were not provided near the drinking fountains.
The situation was no any better at the School of Applied Studies in Amman. There, students use unclean toilets, and only three out of nine washbasins are working.
Students complained to this journalist about the lack of hoses or water jugs for personal cleaning after using the toilets.
The school principal Faraj Tambizi says that the school bought new jugs at the beginning of the academic year, but they were all stolen.
The three-storey school provides 15 toilets for 980 students and employs three people for general cleaning. During the field visit, one of those attendants “was on sick leave,” according to Tambizi.
Furthermore, he explains that the maintenance and repair works are carried out once a year, at the start of the academic year.
Maysoun Talhouni , the principal of Arwa Bent al Hareth School for girls in Amman, says that the school employs only one person for general and toilet cleaning. The 252 students use eight toilets with two bathrooms, situated in two buildings, separated by a public street.
Talhouni says that, at the beginning of the academic year, she filed a request to the department of education for toilet maintenance and is still waiting for that work to be carried out.
Yahia Abdallah, a tenth grade student at Khansa Secondary School is very critical of the officials of the MoE who, he says, do not show any concern regarding the students’ needs for clean toilets and drinking cups.
His colleagues Nayef and Haytham Zawahira refuse to use the school toilets for fear of contracting a disease. They point out that some students use the same taps for drinking and cleaning their hands after using toilets.
Raad Ahmad Abdel Hafez , a tenth grade student at Om Roummana Secondary school, holds the school’s management responsible for the inadequate sanitation facilities. He says that “some students pee in deserted rooms adjacent to the school because they don’t want to use the school toilets.”
Mahmoud Khalayla, whose son Younes attends the same school, stated his worry regarding his son’s kidneys because the son waits until he arrives home to pee.
Girls are more vulnerable than boys
Doctor Nour el Dine Alawena, a senior consultant nephrologist, maintains that holding urine in for several hours affects the bladder and when repeated frequently, could affect the ureters and the kidneys since their functions may be affected. In acute cases, this could lead to kidney failure.
Holding urine in “increases the risk of getting microbial urinary tract infections, especially in girls,” he explained.
He stated that physicians are treating a large number of similar cases in boys between 9 and 18 years old.
On the other hand, panic spread among the parents of students attending Beit Ras School for boys in Irbid, after two cases of HAV were reported at the school. The same scenario occurred in the Mafraq governorate when a girl became infected with HAV at Hamama al Ammoush mixed school. The girl and her two sisters were infected with the virus. The center for disease control in the health department in al Mafraq governorate said that water samples were taken from the girls’ home, but tests revealed no water contamination.
Doctor Sultan Abdallah, the head of the disease control center in the Department of contagious diseases, stated that the HAV and Chickenpox vaccines are not included in the National Vaccine Program, due to the fact that the cost of one dose of HAV vaccine is around 20 JD.
Chickenpox is a highly contagious viral disease that is usually mild in children and is characterized by general weakness and a rash. Affected children suffer from a high fever, joint pain and sometimes difficulty in swallowing. Chickenpox rashes are often the first sign of the disease. The rash begins in crops and then develops into blisters that potentially burst to open sores which may leave scars if scratched.
Varicella is an airborne pathogen transmitted from one person to another through direct contact and respiratory droplets. The virus enters the human body through the respiratory tract and conjunctiva, stated Dr. Abdallah.
Contagious diseases such as HAV, Chickenpox and Mumps were detected among school students. Cases of Typhoid fever were also detected according to Dr. Abdallah, who stated that infections are spread among children because of non-hygienic sanitary facilities, and contaminated food and drinking water.
HAV is one of the main causes of acute liver disease, Dr. Abdallah warned, explained that HAV cases should be immediately reported to the health authorities. He also emphasized the need to have disease control centers pay visits to some of the reported sick students, and to examine those student’s environmental and hygienic conditions at home.
However, Dr. Abdallah stated that home visits revealed satisfactory hygiene conditions.
HAV virus spreads from person to person, by drinking contaminated water or eating contaminated food that was handled by persons who touched contaminated waste and did not wash their hands properly. For these reasons, filthy toilets could be a source of pathogens and diseases, Dr. Abdallah warned.
He stressed that in order to prevent contagious diseases, clean running water, and jugs or hoses should be provided at schools for students to clean themselves after using the toilets.
In the absence of serious measures by the government to provide safe drinking water and proper sanitation at schools, more generations of students will suffer from microbes and viruses.
This investigation was sponsored by Arab Reporters for Investigative Journalism (ARIJ) under the supervision of coach Saad Hattar.