Sustainable Sanitation

Editors note on our Health & Development series:

The correlation between access to first-rate healthcare and least developed countries is striking.  That correlation is more than superficial.  Causality runs in both directions: poor health leads to poverty by constraining the ability to work while simultaneously requiring expensive treatment.  But poverty limits access to expensive care and therefore leads to poor health.  All of this is exacerbated in countries without strong healthcare institutions.  As a result, fighting poverty is as much about providing healthcare opportunities as it is about providing economic opportunities.  Our ongoing series on Health & Development this year will focus on how the world is dealing with these interactions.


Here is a puzzle, based on an article written by Angus Deaton and Jean Dreze (2009): For quite a while now, the Indian economy has been growing rapidly – 4% per year from 1980-2005, measured in per-person gross domestic product (GDP). Recently, it’s been growing even faster – at a clip of 5.4% per year from 2000-2005. Household incomes, consumption, and spending have followed suit, leaving many other developing countries in the dust. Moreover, such gains have been relatively equal across the socioeconomic spectrum; rich and poor alike have become better off. And yet there is one area of well-being in which India continually lags behind most other nations: nutrition. Malnourishment among Indian children remains among the highest in the world and, recently, has not been falling, in spite of the auspicious economic trends. Data on ‘weight relative to age’, which is one common metric of malnutrition, say that 47% of children born in India between 1996 and 2005 were undernourished. A side-by-side comparison of 1996 and 2005 shows that malnourishment did not really improve at all over that 10-year period. This begs the question: How is it that child nutrition in India has not improved at a rate anywhere near that of economic growth?

One answer that is receiving increasing amounts of attention in academia, policy circles, and popular media alike is that sanitation – the treatment of domestic and industrial waste – is the wrench in India’s plans for comprehensive development. The New York Times ran a piece in July that highlights this idea: “Poor sanitation in India may afflict well-fed children with malnutrition”. Child malnutrition was, as recently as two years ago, chalked up as a problem of food supply – Unicef, The World Bank, and the World Health Organization all said as much in a joint report. Of late, however, sanitation has entered the equation. The hypothesis is that, in the presence of harmful pathogens, children’s bodies use scarce energy and nutritional resources to fight infection, at the cost of mental and physical development. In turn, this tradeoff results in stunting (low height relative to age), wasting (low weight relative to height), and classification as ‘underweight’ (low weight relative to age).

The New York Times article cited above uses a cross-country, graphical comparison of stunting and open defecation (going to the bathroom in the open) to provide suggestive evidence of the link between sanitation and nutrition. That graph is reproduced below and reveals that India has both extensive stunting and extensive use of open defecation.

times article

While the visual of India’s place in the international spectrum here is stunning, the graph above depicts just one piece of the nutrition-sanitation relationship. Moreover, it is merely suggestive; it does not prove that open defecation is the cause of malnutrition in India. We don’t know that yet.

What we do know is that sanitation in India is inadequate. Take the matter of sewage, which is a huge concern in a country with rapid population growth, rapid urbanization, and some of the densest cities on Earth. India’s Central Pollution Control Board reports on its website that the total sewage load among cities of greater than 50,000 people is 29,129 million liters per day (MLD). Meanwhile, the installed sewage treatment capacity in these same cities is 6,190 MLD. That is a shortfall of 78.7%! Worse yet, that gap is rising – expansions in treatment capacity lag behind the speedy growth in consumption (and thus waste) described earlier.

Open defecation, too, is a major problem, as the graph above suggests. According to Diane Coffey – a researcher studying the phenomenon of open defecation in India – over half of all Indians defecate in the open, while only 1% of Chinese, 4% of Bangladeshis, and 25% of sub-Saharan Africans do the same. This staggering number may be partially explained by a lack of latrines in (especially rural) India, but it is also a result of cultural beliefs about the cleanliness of different defecation practices. Latrines are viewed as ritually impure by many, whereas going to the bathroom in the open air is often viewed as healthier than the alternative.

Another thing we know is that government intervention to address shortfalls in sewage treatment infrastructure and latrine usage have not, thus far, been particularly successful. Indian federal policy has prioritized “the interception, diversion, and treatment of sewage” since as far back as 1986, first along the Ganga River (the country’s largest and holiest) and later along rivers all across the country. But just-published research by economists Michael Greenstone and Rema Hanna suggests that this policy is not associated with any significant improvements in water quality.

Federal policy has also attempted to address India’s propensity for open-defecation: Its Total Sanitation Campaign (TSC), initiated in 1999, has a mission of eliminating the practice of open defecation by 2017. The TSC has aimed to do so through not just building infrastructure (such as latrines themselves) but also changing attitudes towards latrine usage. Researchers, however, have come to conflicting conclusions about the TSC’s success. On the one hand, analysis by economist Dean Spears has attributed significant reductions in infant mortality and significant increases in children’s height to the TSC. On the other, recently-published work by a team of researchers (Patil et al.) describes only very modest impacts of the TSC on latrine construction and open-defecation and no noticeable impacts on child health or growth.

The collective understanding of the relationship between sanitation and health remains incomplete. The hypothesis that sanitation is the binding constraint on India’s poor health outcomes has yet to be proven correct. But if there is one takeaway from the established facts, it is this: Sanitation in India pales in comparison to other countries, and producing sustainable improvements is no simple task. The persistence of cultural beliefs on the one hand, and the ever-changing urban landscape of India on the other, mean that government cannot solve sanitation problems simply by building more.

Image credit by Cididity Hat via Wikimedia Commons.

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