A study published by the Oxford Clinical Research Unit Nepal in 2008 mentioned that Kathmandu was considered the enteric fever capital of the world. By the time I arrived in Kathmandu in October 2014, I am told the number of infected cases have decreased significantly this year.

It is worth mentioning that precisely because of Dr. Abhilasha's studies on the presence of Salmonella Typhi and Salmonella Paratyphi A in water sources around Patan, including those collected from the hiti that sparked this project. There is substantial effort in studying illnesses caused by poor sanitation and contaminated water, but not enough is known about the complex relationship people have with the hiti, which aside from providing water has many other religious and social functions. 

So what is enteric fever? 

After some research for my own understanding, the following is a breakdown of the sickness in layman terms. 

Enteric fever, or typhoid, is a bacteria infection that can spread to other organs. It can be critical if not treated, particularly in children and young adults. It is caused by Salmonella enterica and its subdivisions Paratyphi A, B, and C. In Nepal S typhi and Paratyphi A are mainly responsible for outbreaks. 

'Bacilli of typhoid fever from a culture' Photo from the Wellcome Library, London. CC By 4.0

'Bacilli of typhoid fever from a culture' Photo from the Wellcome Library, London. CC By 4.0

Typhoid spread when people ingest food or water contaminated by feces of an infected person. This happens when the infected person serve food or water without washing their hands after defecation, or when insects and house flies spread the bacteria in places with poor sanitation and open sewers by landing on waste material and then on food or drinks. The disease also spread quickly when water sources for consumption are contaminated by sewage or waste water. Below is a fantastic illustration from 1939 showing water in a well become contaminated from the Wikipedia page for typhoid fever.

'An illustration showing various ways that a water well (center) may become infected by typhoid fever bacteria' 1939. Illustration from the Vore Sygdome; Bind II, side 116. PD

'An illustration showing various ways that a water well (center) may become infected by typhoid fever bacteria' 1939. Illustration from the Vore Sygdome; Bind II, side 116. PD

Typhoid outbreaks mostly occur in poor areas with low sanitation. Because it only spreads from human to human, it can be prevented by improving sanitation and hygiene. The simple act of washing our hands after using the bathroom can help prevent infection.

In the case of Nepal, the influx in rural people moving into the city in recent years created overcrowded unhygienic living conditions and water shortage. Rural people also lack resistance to bacteria present in the valley and are more susceptible to getting ill. The religious function of the hiti as well as old habits also make the act of drinking straight from the spouts very common and accepted. In the case when water from these hiti are badly contaminated, a large number of people, consequently, become ill. 

Mangaa Hiti, built around 570 AD, at the Patan Durbar Square on Mangal Bazaar

Mangaa Hiti, built around 570 AD, at the Patan Durbar Square on Mangal Bazaar




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