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Why toilets matter

Open defecation in urban India is declining very slowly, with over 5 million people in Indian cities still defecating outside. Could this be because the urban middle class monopolises the existing basic services like water supply and sanitation and therefore does not impel change, asks Kalpana Sharma

At the recent G8 meeting in Japan, world leaders discussed oil prices and climate change. They did not, however, address what is being called a “development emergency” in some countries -- the chronic absence of improved sanitation among large sections of the population, particularly in poor communities, that is contributing to the spread of disease.

Even as countries like India boast of a consistently high rate of economic growth, they cannot hide the abject failure to tackle the consistently low rate of growth in access to improved sanitation.

Year after year, while the number of those getting access to safe water climbs, the equivalent figures for sanitation remain stubbornly low. This is a constant reminder of the failure of many governments to evaluate the importance of improved sanitation and to put enough political will and investment into bridging this deficit.

One of the more unsavoury facts that the government in India would most certainly not want advertised is the fact that one out of every two people in the world who are forced to defecate out in the open is an Indian.

According to a recent report of the Joint Monitoring Project on Drinking Water and Sanitation of Unicef and the World Health Organisation, 18% of the world’s population, or 1.2 billion people, still have no access to sanitation and are compelled to defecate out in the open. Of these, an astounding 665 million live in India.

What is even more depressing is that the rate at which this situation is changing, in India, is slow. Overall, the rate of open defecation has declined from 73% in 1990 to 58% in 2006. However, while in rural India the rate of open defecation has declined from 89% in 1990 to 74% in 2006, in urban India it has gone down by only 10% in 16 years, from 28% in 1990 to 18% in 2006. This means that even today, over 5 million people in Indian cities defecate out in the open. If evidence of this were needed, one has only to take an early morning suburban train in Mumbai to witness the spectacle of people using the open spaces around railway tracks as a vast open-air toilet.

This is the extreme end of the spectrum. What sanitation is available by way of toilets is also generally far from satisfactory. Shared toilets, or community toilets, are generally poorly maintained, leading to contamination of soil and water sources. The problem is exacerbated in urban areas as the settlements where the urban poor live are tightly packed, with few open spaces. In such conditions, open defecation and leaking toilets greatly enhance the danger of contamination and the spread of waterborne diseases.

The link between sanitation and health hardly needs to be emphasised. Yet, although progress has been made in the realm of supplying drinking water, for some reason provision of adequate sanitation continues to lag behind in India. As of now, India is not on target to meet the Millennium Development Goal of providing 46% of its population ply with adequate sanitation by 2015.

The international charity Water Aid put together data on this issue for the recent G8 meeting and emphasised yet again the need to renew commitment and investment in sanitation. According to its report, 40% of the world’s population lacks access to improved sanitation and this, in turn, kills more children than malaria, HIV/AIDS and measles put together.

Water Aid also suggests that as many as 910,000 child deaths from diarrhoea could be avoided each year through the provision of improved sanitation. An estimated 85% of the 1.6 million deaths due to diarrhoea each year can be linked to poor sanitation and unsafe drinking water, it says. Also, the underlying cause of the 5 million child deaths each year is chronic malnutrition. Recurring bouts of diarrhoea in children already malnourished means that nutritional supplements have no impact on their chances of survival, as their weakened digestive systems simply cannot absorb them.

The key input to enhancing child survival is not necessarily more and better food or medical interventions but conditions of living that ensure that children do not get ill. There is simply no shortcut to providing sanitary living conditions and an adequate supply of potable water. Such interventions do not provide instant results that are demonstrable. But they are a long-term investment that pays enormous health dividends for all, poor and rich.

The cost of poor sanitation and unsafe water is borne disproportionately by the poor living in urban or rural areas. However, sometimes the health status of urban poor communities is worse than their counterparts in rural areas.

‘Our cities, our health, our future’, a report to the WHO commission on Social Determinants of Health (the final report is due to be released worldwide in August this year) by the Knowledge Network on Urban Settings, illustrates this point with data from Kenya. The infant mortality rate (IMR) in Kenya is 74 per 1,000 live births -- 76 in rural areas and 57 in urban areas excluding Nairobi. But in the country’s capital city, while the IMR in high-income areas in likely to be under 10, in the slums of Kibera and Embakasi it is 106 and 164 respectively. In Nairobi as a whole, it is 39. This clearly shows that the health status of the urban poor, living in wretched conditions, is much worse than the status of those in rural areas who also live in poverty.

In India too, the data shows that the health status of the urban poor is either the same or worse than that of people in rural areas. For instance, the percentage of underweight children in the urban poor population is 47.1%, compared to 45.6% in the rural population, and stunting is seen in 54.2% of urban poor children, compared to 50.7% of rural children (according to NFHS-3 data). Apart from children, women in poor urban communities are almost as badly off as their rural sisters, with 58.8% of women between the ages of 15-49 years being anaemic, compared to 57.4% of rural women. NFHS-3 data also reveals that there is little difference in the figures for the number of children with diarrhoea in urban poor communities and those in rural communities. This data merely underlines the reality that while urban areas as a whole might have better medical facilities and piped water and sewerage, these facilities do not extend to the urban poor.

In fact, urbanisation should lead to better health for all. That is the lesson drawn not just from richer countries like Japan, Sweden and the Netherlands but also countries like Sri Lanka, Malaysia, Singapore and South Korea. Here, healthy urban living conditions that include provision of housing, water and sanitation have changed the health statistics quite dramatically.

Susan E Chaplin, who did her doctoral thesis on ‘Cities, Services and the State: The Politics of Sanitation in India’ from La Trobe University, Australia, draws a comparison between sanitation in post-Industrial Revolution England and Indian cities, in an essay in the journal Environment and Urbanisation (April, 1999). She looks at the policies pursued in mid-19th century England and now in India, and brings out several useful points.

Sanitary reform in Britain really took off only in the 19th century when the spectre of disease haunted the entire population, rich and poor. Conditions in industrial cities like Liverpool and Manchester were not very different from those that prevail in the slums of Kolkata or Mumbai today. Chaplin quotes Friedrich Engles on these English cities. He wrote that they had “...streets (that) are generally unpaved, rough, dirty, filled with vegetable and animal refuse, without sewers or gutters but supplied with foul, stagnant pools instead”.

The pattern of urbanisation in the two countries has also been similar, with the advent of work and industrialisation drawing in the poor from villages. But in England, Chaplin writes, three factors contributed to sanitary reform. “These were the campaigns by medical practitioners along with reform of local government, advances in science and engineering, and the presence of a ‘threat from below’, in terms of diseases and organised labour.”

Chaplin argues that in India the urban middle class has not been interested in bringing about any change in conditions because it has successfully monopolised the existing basic services like water supply and sanitation. The British built sewers only in areas they inhabited; the native towns were left to manage with the scavenger system that, shockingly, persists in some of the smaller towns. The better-off Indians today live in areas that have benefited from the colonial sewerage systems, while the poor mostly live in unserviced plots.

Furthermore, science and medicine have reduced the possibility of the spread of disease ‘from below’. And the rich really do not need to fear any revolution ‘from below’, as did the rich in England, because the urban poor are mostly unorganised. As a result the urban middle class, and one might add the policymakers, can continue to be indifferent to the conditions of the poor. Combine this with an ineffective local government and you have the situation we see in most Indian cities today.

In England too, the rich were initially not interested in reform that would benefit all classes. The single factor that altered this situation was the prospect of their getting cholera. An epidemic in the 19th century established the link between sanitation and health as nothing else could have done.

Also, the militancy of the working classes prompted the rich to accept that providing them with basic services was a wiser proposition than risking the disruption that would inevitably follow an attempt to overthrow the hold of the ruling classes.

Between 1880 and 1891, urban authorities in many cities in Britain provided sewerage and clean water supply under the Sanitation Act of 1866. This step benefited all citizens, not just the rich.

In India, the provision of improved sanitation, especially for the urban poor population that is estimated to grow at an annual rate of 5-7%, requires similar action and political will. Already, one-third of the country’s population lives in cities and towns. Of this, anywhere between a quarter and a half live in slums and informal housing with inadequate provision of water and sanitation. Health parameters of the urban poor are uniformly worse than those in formal housing, for the obvious reason that, besides poverty, overcrowding and unsanitary conditions expose this population to ill health. Compounding the situation is inadequate and affordable healthcare.

Health data in India has shown that the poor turn to private healthcare wherever the public health system is inadequate. In urban areas, the absence of adequate public health outposts in slums and the presence of private practitioners guarantee that people turn to the latter rather than seek free healthcare from the public system. The pressure on the budgets of people living on the margins is enormous and often unbearable. For instance, a 2003 study of 850 households in Dhaka, Bangladesh, found that increased expenditure on healthcare due to illness had forced many families to take loans, sell assets and even resort to begging to meet the costs of ill health. This pattern is evident in most developing countries with large populations of urban poor, including India.

“Lack of investment in sanitation reveals a blind spot in development policy: a failure to recognise sanitation’s integral role in reducing poverty,” the Water Aid report rightly points out.

In these times of political turmoil, such issues are not high on India’s priority list. Nor is the media interested in highlighting them. Yet, economic growth cannot be sustained if almost half the country’s population lacks access to something as basic as sanitation. Boasts of being an economic power -- or even a nuclear weapons state -- seem quite hollow against this ugly reality.

(Kalpana Sharma is a journalist and writer based in Mumbai. She is the author of Rediscovering Dharavi: Stories from Asia’s Largest Slum)

InfoChange News & Features, July 2008