Dr. Mohammad Akram
Convener RC 12 (Population, Health and Society), ISS
Associate Professor of Sociology
Department of Sociology, AMU, Aligarh

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Dr. Mohammad Akram, Sanitation, Health and Development Defecit in India|http://www.youtube.com/watch?v=if3DXz6o_BM

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Illnesses caused by germs and worms in feces, wastes and pollutants are constant source of discomfort for millions of people. Poor sanitation is something that not only affects the health of the people of the country, but also affects the economic and social development of the nation. India is still lagging far behind many countries in the field of sanitation. Most cities and towns in India are characterized by over-crowding, congestion, inadequate water supply and inadequate facilities of disposal of human excreta, wastewater and solid wastes. Fifty five percent of India’s population (nearly 600 million people) has no access to toilets.

Sanitation in personal and public life is the joint responsibility of individual, community and state. Sanitation is the first step towards achieving the goal of public health. But public health system is very weak in India and sanitation could hardly attract the attention of government policy makers till the last decade of the past century. Experience suggests that India’s late entry into ensuring total sanitation and a limited sectoral approach for it has not yielded desired results. This paper tries to locate the structuration of insanitation in the deficit cultured development trajectory of India. It also examines the formation of the habitus and the social world which promote inadequate sanitation rather than sanitation in public life.

Sanitation can no longer be seen as a ‘segment’ or ‘isolated’ component of rural/urban development ministries. Sanitation is a ‘public good’ and needs to be seen as an integral component of the health structure and the ‘Basic Health Goods’. The development goals need to imbibe the sanitation standards. India’s development trajectory has several deficiencies. There are visible ‘sanitation deficits’ in policy formulation, implementation and technology appropriation. Insanitation in India is largely the consequence of development deficits. Bureaucratic targetism, medicalism, povertism and dehealthism are some of the factors which promote sanitation deficits in India. ‘Sociology of health and sanitation’ can help in understanding the larger phenomenon in Indian context. It will also help in understanding the typical Indian behaviour (or practice) of open defecation.

Sanitation

Sanitation generally refers to principles, practices, provisions, or services related to cleanliness and hygiene in personal and public life for the protection and promotion of human health and well being and breaking the cycle of disease or illness. It is also related to the principles and practices relating to the collection, treatment, removal or disposal of human excreta, household waste water and other pollutants. The World Health Organization states that: Sanitation generally refers to the provision of facilities and services for the safe disposal of human urine and feces. Inadequate sanitation is a major cause of disease world-wide and improving sanitation is known to have a significant beneficial impact on health both in households and across communities. The word ‘sanitation’ also refers to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal. According to Mmom and Mmom (2011) environmental sanitation comprises disposal and treatment of human excreta, solid waste and waste water, control of disease vectors, and provision of washing facilities for personal and domestic hygiene. It aims at improving the quality of life of the individuals and contributing to social development.

Sanitation and Development

There can be several answers to the question, ‘why sanitation is very important in personal as well as public life?’ A study conducted by World Bank’s ‘South Asia Water and Sanitation Unit’ estimated that India loses Rs 240 billion annually due to lack of proper sanitation facilities. The multilateral body said that premature deaths, treatment for the sick and loss of productivity and revenue from tourism were the main factors behind the significant economic loss. Poor sanitation is something that not only affects the health of the people of the country, but also affects the development of the nation. In fact, women are most affected by the hazards of lack of proper sanitation. For instance, in India majority of the girls drop out of school because of lack of toilets. Only 22% of them manage to even complete class 10. On economic grounds, according to the Indian Ministry of Health and Family Welfare, more than Rs 12 billion is spent every year on poor sanitation and its resultant illnesses.

Sanitation and Disease

Illnesses caused by germs and worms in feces, wastes and pollutants are constant source of discomfort for millions of people and animals. These illnesses can cause many years of sickness and can lead to other health problems such as dehydration, anaemia, and malnutrition. Severe sanitation-related illnesses like cholera can spread rapidly, bringing sudden death to many people. Children have a high risk of illness from poor sanitation. While adults may live with diarrheal diseases and worms, children die from these illnesses. More than 300 million episodes of acute diarrhoea occur every year in India in children below 5 years of age. Of the 9.2 million cases of TB that occur in the world every year, nearly 1.9 million are in India accounting for one-fifth of the global TB cases. More than 1.5 million persons are infected with malaria every year. Diseases like dengue and chikungunya have emerged in different parts of India and a population of over 300 million is at risk of getting acute encephalitis syndrome/Japanese encephalitis. One-third of global cases infected with filaria live in India. Nearly half of leprosy cases detected in the world in 2008 were contributed by India (MOHFW 2010: 14).

Sanitation Infrastructure

India has a population of almost 1.2 billion people. Fifty five percent of this population (nearly 600 million people) has no access to toilets. Most of these numbers are made up by people who live in urban slums and rural areas. A large populace in the rural areas still defecates in the open. Slum dwellers in major metropolitan cities, reside along railway tracks and have no access to toilets or a running supply of water. India is still lagging far behind many countries in the field of sanitation. According to Harshal T. Pandve (2008), most cities and towns in India are characterized by over-crowding, congestion, inadequate water supply and inadequate facilities of disposal of human excreta, wastewater and solid wastes. No major city in India is known to have a continuous water supply and an estimated 72% of Indians still lack access to improved sanitation facilities. Besides this, the 63 percent of urban population in India is without proper sanitation. Besides these, the waste disposal and sewage treatment plants are missing in most of the cities. Most of the wastes are disposed in rivers, canals or outskirts of the cities. The 11th five year plan envisages 100% coverage of urban water, urban sewerage, and rural sanitation by 2012. Although investment in water supply and sanitation has seen a jump in the 11th plan over the 10th plan, the targets do not take into account both the quality of water being provided, or the sustainability of systems being put in place (Kumar, Kar, and Jain 2011).

Whose Responsibility?

Sanitation in personal and public life is a joint responsibility of individual, community and the state. Some experts believe health problems caused by poor sanitation can be prevented only if people change their personal habits, or “behaviours,” about staying clean (Conant, 2005). When behaviour does not change, people are blamed for their own poor health. But this idea often leads to failure because it does not take into consideration the structural barriers or the development gaps that people face in their daily lives, such as poverty or lack of access to clean water. Others consider lack of infrastructure as the main problem. Many other experts look for technical solutions, such as modern toilets that flush water. Technical solutions are often suggested without understanding the habitus or the social worlds of the people. Sometimes they go unnoticed and often they create more problems than they solve. The diseases caused by poor hygiene and sanitation will not be prevented if people are blamed or victimised for their own poor health, or if only technical solutions are promoted without mitigating the development deficits. Hence, sanitation needs to be seen as an integral component of the public health programmes and individuals, communities and the state agencies are treated as equally important agencies in achieving total sanitation.

Sanitation and Public Health

Sanitation is first step towards achieving the goal of public health for all. Most histories of public health begin with a discussion of what is known as the ‘sanitation phase’ in the mid –nineteenth century, a period characterised by concentration on environmental issues such as housing, working conditions, the supply of clean water and the safe disposal of waste. Further, the motivating force of this public health movement is thought to be a concern with economic efficiency and better social cohesion between the working poor and other sectors of society. There has also been a significant investment in many countries in creating infrastructures and services to protect health and to prevent ill health. In most industrialising countries over the last 150 years, public health regulations and health and safety legislation have been enacted to provide safeguards for the industrial workforce, to control pollution levels in rivers, and to ensure proper sewerage and drainage. In nineteenth century England, sanitary reformers and radical politicians argued, on economic grounds, for ill health prevention through public policy interventions. The sanitation phase of the public health movement emphasised environmental change. This sanitation phase led to a considerable and measurable reduction in infectious diseases-especially diphtheria, tuberculosis and cholera (Sarah Earle 2007:11-12).

However, in India, things are quite different. Public health system is very weak and sanitation could hardly attract the attention of government policy makers till the last decade of the last century. Initiative taken by agencies like Sulabh International brought huge impact but such initiative could hardly get translated into government mission for several limitations and structural handicaps. The Government of India launched the Total Sanitation Campaign (TSC) in 1999 with the goal of achieving universal rural sanitation coverage by 2012. The responsibility for delivering on programme goals rested with local governments (Panchayati Raj Institutions — PRIs) with significant involvement of communities. The state and central governments had a facilitating role that took the form of framing enabling policies, providing financial and capacity-building support, and monitoring progress. To give a fillip to the TSC, the government introduced an innovative incentive programme known as Nirmal Gram Puraskar (NGP) in 2003. The NGP offers a cash prize to motivate Gram Panchayats (GPs) to achieve total sanitation. In addition, the NGP is an attractive incentive as winners are felicitated by the President of India at the national level and by high-ranking dignitaries at the state level. The TSC has recently completed a decade of implementation (1999-2009) and the NGP has completed five years of operation (2005-10). Since its launch, the programme framework of the TSC and NGP has been based on a common national guideline whereas implementation has been decentralised to the state and district levels.

An assessment of the TSC is carried out by the ‘Department of Drinking Water and Sanitation’, Ministry of Rural Development, Government of India after completion of one decade of the TSC and a report is published. The report (A Decade of the Total Sanitation Campaign: Rapid Assessment of Processes and Outcomes, Vol. 1: Main Report) finds that the TSC has achieved significant success over the last one decade. The sanitation coverage has increased significantly from 21 percent in 2001 (Census, 2001) to more than 65 percent. The number of Gram Panchayats which have won the Nirmal Gram Puraskar for achieving total sanitation has also increased to more than 22,000. The report finds that there is an undeniable upward trend in scaling up rural sanitation coverage. But the national performance aggregates conceal significant disparities among states and districts when it comes to the achievement of TSC goals. It also acknowledges that open defecation is a traditional behaviour in India and in most of the states, changing this practice is the biggest challenge. It is also important to note here that the ‘Rural Development Department’, Government of India had initiated India’s first national programme on rural sanitation, the ‘Central Rural Sanitation Programme’ (CRSP) in 1986. The CRSP interpreted sanitation as construction of household toilets, and focused on the promotion of a single technology model (double pit pour-flush toilets) through hardware subsidies to generate demand. However, according to the report, the key issue of motivating behaviour change to end open defecation and to use toilets was not addressed, contributing to the programme’s failure. The government launched National Urban Sanitation Policy in 2008 and identified 100% sanitation as a goal during the 11th Five Year Plan. The ultimate objective is that all urban dwellers will have access to and be able to use safe and hygienic sanitation facilities and arrangements so that no one defecates in the open. The overall goal of this policy is to transform urban India into community-driven, totally sanitized, healthy and liveable cities and towns.

Experience suggests that India’s late entry into ensuring total sanitation and a limited sectoral approach for it has not yielded desired results. The disparity among states in outcomes is a cause of great concern. To improve sanitation in a lasting way, the issues related to defecation, waste disposal, water, environment and health must be seen from a comprehensive and sustainable solution perspective. When communities use hygiene and sanitation methods that fit their real needs, abilities, and expectation, they will adopt sanitation practices and enjoy better health. It is, therefore, very important to understand the structural handicaps and the development trajectory responsible for inadequate and poor sanitation conditions prevailing in India. Sanitation can no longer be seen as a ‘segment’ or ‘isolated’ component. Sanitation needs to be seen as an integral component of health structure and development agenda. ‘Sociology of health and sanitation’ can help in understanding the larger phenomenon in Indian context. It will also help in understanding the typical Indian behaviour (or practice) of open defecation.

Sociology of Health and Sanitation

Health is the basic human right of all the human beings. Health contributes to a person’s basic capability to function. Denial of health is not only denial of ‘good life-chance’, but also denial of fairness and justice (Sen 2006). The Universal Declaration of Human Rights stated in Article 25: ‘Everyone has the right to a standard of living adequate for the health and wellbeing of himself and his family….’(United Nations 1948). The Preamble to the World Health Organisation (WHO) constitution affirms that it is one of the fundamental rights of every human being to enjoy the highest attainable standards of health. Article 21 of the Constitution of India also identifies health as an integral aspect of human life (Desai 2007). Further, Article 47 (Part IV: directive principles of state policy) says: The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavour to bring about prohibition of the consumption except for medicinal purposes of intoxicating drinks and of drugs which are injurious to health. However, the spirit of the constitution hardly gets reflected in the health policies and programmes in India.

The concepts of health, disease and treatment are related to the social structures of communities. Every culture, irrespective of its simplicity or complexity, has its own system of beliefs and practices concerning health and disease and evolves its own system of treatment to combat disease (Akram 2007). Definitions and conceptualisation of health may vary systemically among various social groups and it is likely that different accounts of health are drawn according to social circumstances (Nettleton 2006). The biomedical approach which dominated the medical thought till the end of nineteenth century and based on the ‘germ theory of disease’ views health as an ‘absence of diseases’. This approach almost ignores the role of environmental, psychological and other socio-cultural factors in defining health. The ecological approach views health as a dynamic equilibrium between man and his environment. For them, disease is maladjustment of the human organism to environment. The psychological approach states that health is not only related to the body but also to the mind and especially to the attitude of the individual. The socio-cultural approach considers health as a product of the social and community structure (Advani and Akram 2007). A holistic definition of health has been given by the World Health Organisation (WHO) which states that health is a state of complete physical, mental and social well-being, and not merely an absence of disease or infirmity.

Sociologists show how diseases could be differently understood, treated and experienced by demonstrating how disease is produced out of social organisation rather than nature, biology, or individual lifestyle choices only (White 2002). A functional definition of health implies the ability of a person to participate in normal social roles. This may be contrasted with an experiential definition which takes sense of self into account (Kelman 1975). The Marxists see the role of economy and class structure in the causation, production, distribution and treatment of disease. Medicine in a capitalist society reflects the characteristics of capitalism: it is profit-oriented, blame the victim, and reproduce the class structure in terms of the people who become doctors. Foucault, too, highlights the social role of medical knowledge in controlling populations, and like Parsons emphasises the diffused nature of power relationships in modern society. Foucault also sees the professions, especially the helping professions, playing a key role in inducing individuals to comply with ‘normal’ social roles. For him, modern societies are systems of organised surveillance with the catch being that individuals conduct the surveillance on themselves, having internalised ‘professional’ models of what is appropriate behavior (White 2002). McKenzie, Pinger & Kotecki (2002) have defined health as a dynamic state or condition that is multidimensional in nature and results from person’s adaptations to his/her environment. It is a resource for living and exists in varying degrees (for a detailed discussion see Akram 2012).

India had its first National Health Policy (NHP) in 1983 and before it only vertical health programmes like National Malaria Control Programme (NMCP), National Leprosy Eradication Programme, National Tuberculosis Control Programme, National Cancer Control Programme, etc. existed, which were meant to address specific diseases. The first National Health Policy came in the aftermath of the Alma Ata declaration of 1978 and specified the target of health for all by 2000 as its specific goal. However, health was not seen in a holistic perspective and the focus always remained on clinical treatment of ‘diseases’. The Primary Health centres (PHCs) and sub-centres could never attract the attention that they deserved in many parts of the country even after the comprehensive recommendations made by the Alma Ata Declaration. The second National Health Policy (2002) came in the aftermath of Millennium Development Goals (MDGs). It incorporated many of the health related goals and objectives suggested by the MDGs. The National Rural Health Mission (NRHM) was launched in 2005 to ensure participation of the local self-government institutions at village and panchayat level in a meaningful way. Although the NRHM claimed to make an architectural correction in the health policies and plans, it again grossly missed the recommendations of the Alma Ata declaration for taking a comprehensive approach on health and primary care.

A revisit to the Alma Ata Declaration (1978) is very relevant here. The declaration states that primary healthcare includes at least: (i) education concerning prevailing health problems and the methods of preventing and controlling them; (ii) promotion of food supply and proper nutrition; (iii) an adequate supply of safe water and basic sanitation; (iv) maternal and child health care, including family planning; (v) immunisation against the major infectious disease; (vi) prevention and control of locally endemic disease; (vii) appropriate treatment of common disease and injuries; and, (viii) provision of essential drugs. However, India’s policy makers could never include the first three elements, as suggested by the declaration, into India’s health policies, plans and programmes. India’s health policies are dominated by the bio-medical “germ theory” and mainly prescribe clinical treatment oriented curative care. The broad based preventive and promotive health care (except immunisation against select diseases) could never find their place in the core health policies and programmes. Food, nutrition, potable water and sanitation could never become component of health policy in India.

Out of the eight primary elements necessary for primary health care, as suggested by Alma Ata declaration, the author considers unadulterated nutritious food, safe drinking water and sanitation as the ‘Basic Health Goods (BHGs)’. BHGs are basic in the sense that they are indispensable for human life and life is impossible without them. ‘Health for all’ is just an illusion without the comprehensive and sustainable availability of the BHGs to all individuals in any society and more particularly in developing societies like India (Akram 2012). Most of the states in India have a lackadaisical approach towards making universal availability of primary health care and especially the BHGs. The mechanism and practice of denying primary health care and especially the BHGs to the population or a part of it or even gradual withdrawal from it is denial of health chance and can conveniently be termed as ‘dehealthism’ or at least ‘ahealthism’. Any group, community or state practicing dehealthism or ahealthism can’t achieve the goal of health for all, no matter how much medicalisation it is promoting.

Thus, health policies and programmes in India don’t treat the BHGs and especially sanitation as a component of health or health care. The Total Sanitation Campaign, as discussed earlier, did make some efforts in ensuring sanitation but in the absence of proper budget, infrastructure and strategies, sanitation practices are yet to find their popularisation among the masses in India. A recent policy initiative of government of India in the form of ‘Universal Health Coverage’ has also missed the importance of sanitation, potable water and nutrition as component of health coverage. It gives the impression that health policies and plans in India are witnessing ‘over-medicalisation’ and the BHGs are becoming victim of ‘medical neglecting’. ‘Medicalisation of health’, ‘privatisation of health care’, and ‘pharmaceuticisation of health behaviour’ are the dominant trends of Indian health scenario.

Universal availability and accessibility of ‘public health facility’ is the first step towards developing a modern health system in any society. But such facilities are poorly funded in India. And further, such facilities are poorly designed and even more poorly implemented (through bureaucratic targetism). The under achievements of various development plans and programmes and the wastage and pilferage of the resources are ‘bureaucratically managed’ by blaming the people for their cultural poverty and illiteracy (povertism). On the other hand, the poorly designed public health institutions are further degraded by ‘medical absenteeism’. The absenteeism of the medical professionals from their duties is explained as people’s traditionalism and lack of preference for institutional care. Medical managers and vested interests are playing dominant role in redesigning the public domains of ‘health care’ and ‘health coverage’ as ‘medical care’ and ‘medical coverage’. The cumulative and compounding negative consequences of ‘medical neglecting’, targetism, povertism, absenteeism and ‘over’ medicalism are manifested in continuous perpetuation of prevalence of communicable disease in India. The mechanisms and processes together create a development deficit in the health structure of India.

Further, labelling ‘open defecation’ as an ‘unchangeable traditional behaviour or practice’ of rural or poor people is also a part of the larger mechanism of blaming people for inadequate institution building, improper policy making, inefficient programme implementing, unprofessional and ad hoc target making, and diverting all the issues through capitalising povertism. Cleanliness and hygiene is a natural and human choice, universally. Given a choice and the power to decide, people always prefer sanitation and good environment. No illiterate or poor person will ever prefer a dirty piece of cloth over a clean piece while purchasing it by paying the same amount. But when offered a lower price for the dirty cloth, he/she can purchase it for saving his/her hard earned money. The choice for the dirty cloth, in the second situation, is reflecting the development deficit and not a cultural deficit. Just like it, the choice of open defecation is an indication of development deficit and not a cultural deficit. The statement ‘women demand mobile phones, not toilets’ reflects an improper understanding of development and cultural deficits.

Sanitation, in India, is yet to become an integral part of development paradigm. Most of the industries in India run without having any standard mechanism of waste disposal. No city in India can claim to have a state of the art sewage treatment plant. No river in India has pure water. This is a reflection of policy deficit and implementation deficit in India. Indian rail is one of the largest systems of modern transportation. Passengers, travelling in all the classes in Indian rails, unite the rural and urban India by expelling and spreading the feces in the railway tracks. This is development deficit. The drainage system in most of urban India is inadequate. A good rain in any city and everything that we put under the carpet is coming out. Sanitation, in India, never received the attention that it deserves. The local self governments in most of the cities in India are unable to deliver the sanitation rights of citizens of India. No government office in India can claim to have a 24×7 clean premise or even toilets. One may get an impression that Indians don’t value sanitation in personal or public life. That is not true. The problem lies elsewhere. The problem lies with Indian elites and rich. It may sound strange, but true. Let us examine.

Indian rails were neither designed by rural poor people nor used by them, at least initially. But India continued with the technology deficit trains. The industries are neither owned by poor nor controlled/administered by the illiterate. But the infrastructure deficit is approved by all. It needs to be realised that the organs, symbols and vehicles of development and modernity often promote insanitation in public life because of ignored or neglected deficits. Just as development cannot be achieved through continuous financial deficits or budgetary deficits; development cannot be achieved even through continuous or perpetual development deficits. The developed world is developed because it keeps identifying and rectifying such deficits. The deficits cannot be improved without identifying those who are responsible for the acts. Very often, the development models are set in urban spaces; the rural spaces gradually adopts. If rural India can learn to operate ATMs, mobiles, smart cards, it can also learn to sanitise its behaviour. The deficits need to be removed by the elite and the urbanites first because they structure the development goals. This is perhaps difficult, because the elites and urbanites have learnt to ‘manage’ and ‘pass the buck’. Often, we talk about ‘corporate social responsibility’. We also talk about government’s responsibility. We seldom talk about ‘individual’s social responsibility’ or ‘intellectual’s social responsibility’. Sanitation is a social apace: it needs engagement not only between citizen and the state, it also needs engagement between the individual occupying government/private positions and the citizen he or she, himself or herself is. We need to come above the deficit model we all are habituated in working with. We need to fill up the deficits.

The problem of open defecation is not denied here. The health problem created by it is also undeniable. But what is denied here is that, the problem is related to only rural or urban poor class. The problem is equally related to the elite and the governing class. In India, the citizens, in general, are yet to take up the citizenship roles as duties. The citizens are more or less influenced by the habitus and the social world (terms used by Bourdieu) which are structured by multitude of factors and the government agencies are the most important among them. The habitus is yet to adopt the sanitation goals because of the sanitation deficits of the government, elite or urban middle class agents/agencies. Sanitation needs a conscious decision making. The citizens are yet to become the conscious agents in the field of sanitation and health. The state organs are yet to become the agencies. India needs the active presence of many more conscious agencies like civil society groups, who can fill up the various deficits. The habitus both produces and is produced by the social world. Sanitation needs to be a part of the social world. From a broader perspective, health and health care needs to become parts of the social world. From a holistic perspective, active citizenship needs to be an integral part of the social world. This social world is not confined to rural or urban, elite or masses, rich or poor, or even literate or illiterate. The habitus is a structuring structure as well as, a structured structure. It is also the dialectic of the internalisation of the externality and the externalisation of the internality (Bourdieu 1977, 1989). A practice is not just traditional or modern; a practice is something that is structured within the social space of interfaces between the habitus and the social world. If development is a part of the habitus and social world, development deficit is also a part of the duo. The sanitation deficit can be mitigated only through mitigating the policy deficits, technology deficits, implementation deficits and the overall development deficits. So, one can conclude from the perspective of sociology of health and sanitation: insanitation in India is structured by development deficits and not by cultural deficits.

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