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Magnitude of sanitation problem at national and global levels

Sanitation includes water supply, safe disposal of human waste, waste water and solid waste management, control of vectors of diseases, domestic and personal hygiene, food, sanitation, housing etc. The US National Sanitation Foundation defines sanitation thus: “It is the quality of living expressed in clean homes, clean farms, clean neighbourhoods and clean ommunity. Being a way of life, it must come from people, nourished as it is by knowledge and it grows as obligation and ideal in human relations”. Accordingly, environmental sanitation is viewed as “the control of all those factors in man’s physical environment which exercise a deleterious effect on his physical development, health and survival” (WHO, 1992). Environmental sanitation is vital for protecting the environment, improving health, alleviating poverty, enhancing quality of life and raising productivity – all of which are essential for sustainable development. Sanitation is not only keeping clean but protecting those sources of the environment which support and promote sustainable development. The development programmes, howsoever innovative they may be, are not likely to yield desired results unless the environmental sanitation is improved and protected.

At The Global Level

Highlighting the absence of rudimentary sanitation facilities in half the world, a UNICEF report (1997) has pointed out that about 2.2 million children die annually of diseases caused by unhygienic conditions. The report has underlined that the problem is most acute in rural areas where only 18 per cent of the people worldwide have access to a toilet. In urban areas of developing countries, 40% of the world’s population lack basic sanitation facilities now. And even there, according to reports, Uganda, for example, claims adequate sanitation in about 80 per cent of households, but the figure shrinks to just three per cent if pit latrines are excluded. Considering that the cost of providing adequate toilets or latrines ranges from five to 60 dollars, the UN agency estimates that the problem can be solved in ten years if an amount equal to 10 per cent of a year's global military spending is set aside for toilet construction programmes. But as WHO's rural health chief Dennis Warner notes, sanitation is not a priority issue and governments either do not have a political commitment or do not like to provide services to 'squatters'. They only hope the problem will just go away, but it doesn't; and lack of funds only aggravates it further.

The global coverage of population with access to excreta disposal facilities has increased from 55% (2.9 billion people served) in 1990 to 60% (3.6 billion) in 2000. Still a total of 2.4 billion people in the world were without access to improved sanitation at the beginning of the year 2000. In India, the % coverage increased from 21 to 31 during the same period. Although there is an appreciable gain in the access to sanitation facilities by the population in absolute numbers, the percentage coverage appears to be modest due to high population growth.

The health implications for this state of affairs are appalling. Globally 10 millions children under age of five die every year; of which 1.5 million children perish from diarrhoeal deseas each year. The majority are children under the age of five in developing countries. Improved hygiene and sanitation help reduce sickness from diarrhoea considerably. Intestinal worms infect about 10% of the population of developing countries that can be controlled through better sanitation, hygiene and water supply. As per the WHO report globally 200 million people are infected with schistosomiasis, out of which 20 million suffer seriously. Basic sanitation facilities reduce the disease by up to 77%. Sanitation facilities help check transmission of many faecal – oral diseases by preventing contamination of water and soil through human excreta. Epidemiological evidence suggests that sanitation is at least as effective in preventing diseases as improved water supply.

Adequate supply of safe water and sanitation is vital for sustainable development and for improving the quality of life no less than alleviating poverty. Sustainable development is the result of a political order in which a society is so structured that it learns fast from its mistakes in the use of its natural resources and rapidly rectifies its human-nature relationships in accordance with the knowledge it has gained. Sustainability thus demands the creation of a political order in which, firstly, control of natural resources rests, to the maximum extent possible, with local communities which are dependent on those resources; and, secondly, decision-making within the community is as participatory, open and democratic as possible. The bedrock of sustainable development is composed of freedom and democracy.

Studies carried out in India and abroad indicate that human excreta is the cause of many enteric diseases: cholera, dysentery, typhoid, paratyphoid, infectious hepatitis, hookworm, diarrhoea, etc. Over 50 infections can be transferred from a diseased person to a healthy one by various direct or indirect routes from human excreta and it causes nearly 80 per cent of the sickness. Therefore, appropriate human waste management should be the primary objective of improved sanitation to build a healthy nation and provide a cleaner environment.

At The National Level

The severity of the problem in India could be judged from the fact that hardly 33% population has sanitation facility available. In rural area percentage coverage is only 22%, however it is 59% in urban areas. (WHO/UNICEF Sanitation Assessment Report 2004). In recent years there is continuous progress in the sector, however a lot is required to meet the Millennium Development Goal on sanitation. Majority of the people defecate in the open. Open defecation defiles ecology, fouls water resources and causes stink in inhabitated areas. Of the estimated 2 million children who die from diarrhoeal diseases each year in developing countries, almost 600,000 die from sanitationrelated ailments alone. This disease is endemic throughout the world. Refugee populations and children suffering from malnutrition are among the worst affected. During 1994, dysentery was the leading cause of death in the Rwandan refugee camps in Burundi, Tanzania, and Zaire in Africa. Elsewhere in Asia, 11 countries were hit by waterrelated epidemics in 1994. There are four clinically important species of Shigellae (dysentery) but most life-threatening diseases are caused by just two species – S. dysenteriae and S. flexneri – and by 5 serotypes. S. sonnei is the leading cause of endemic disease in industrialised countries. In 1993, it was responsible for over 90 per cent of cases of dysentery reported in the USA. And, all of them were caused in unclean areas.

Vibrio cholerae – one of the oldest scourges known to man – causes about 5.5 million cases of cholera every year and about 120,000 deaths, and over a fifth of those deaths occur among children under five and a quarter in children aged 5 to 14. Most cholera deaths occur in Africa and Asia. Without treatment (rehydration therapy and antibiotics) it is one of the most dangerous infectious diseases – leading to fatality rates as high as 40 per cent. The disease is associated with poverty, poor sanitation, lack of hygiene and unsafe drinking water. It is spread by contaminated water or food and by person-to-person contact.

In 1991, there were more cases of cholera and more countries were affected by this disease than in any other year on record. Both Latin America and Africa were hit by virulent epidemics. The first outbreak occurred in Peru and spread rapidly throughout South and Central America – sparing only seven countries. More than 4,000 people died. In the same year, a major epidemic swept across Africa, killing 14,000 people in over 20 countries. In India and Bangladesh the emergence of a new strain of V. cholerae was reported in 1992 following an initial outbreak in Chennai and followed by another among fishermen on remote islands in the Bay of Bengal. The new strain spread rapidly to China, Malaysia, Myanmar, Nepal and Pakistan involving thousands of deaths – mainly among adults. This was reported by the World Health Organisation in 1996.

Cost of Poor Sanitation

The sustainability of water and sanitation services depends on many factors, including financial viability. The economics is complex and we are still learning about them throughout the world, through both successes and failures. The most important economic point is that failure to meet basic water requirements generates major social costs, both economic and financial. In 1970, water-related diseases cost an estimated $125 billion per year in direct medical costs and lost work time for sick people plus the (unquantified) social costs of lost education, family disruption and shortened life expectancy. A major water-related disease outbreak could cost far more in medical care and lost productivity than the universal provision of safe water and sanitation . It is also known that poor people often pay far more

for informal, poor-quality services than the wealthy do for piped water systems with heavily subsidised tariffs. And the poor often pay doubly by suffering losses from preventable water-related diseases. This imbalance is economically unacceptable and morally wrong. (Source: Water Supply & Sanitation Consultative Council)

In recent years there have been hot debates on how to finance water and sanitation services. Many governments had previously provided these basic services, bearing both the capital and operating costs and charging little or nothing from the users. This has generally proved to be unsuccessful.

It has also been found that people are prepared to pay for a service. Even the poorest urban residents are often willing to pay water vendors four to five times more than the typical price of municipally supplied water. This takes a large proportion of their income. In the case of a regular service, experience shows that recovering full operating costs and part of the capital costs from poor people is possible in many cases. To maintain equity, water supply agencies can link tariffs to the wealth of the users, so that rich people cross-subsidise poor people. As a general rule, users are more willing to pay if the operation and maintenance is managed at the local level and if the agency communicates well with them and involves them in the decision-making. Good agencies also discuss the levels of service and tariffs with the users and communities before the service starts.

Access to water and sanitation services is closely related to each nation’s economy. The economic gaps between different countries have widened over the last twenty years. Many of the least developed countries have been caught in a downward economic spiral. In such situations, governments find it hard to sustain basic social programmes, including water and sanitation.

This situation is most apparent in sub-Saharan Africa. In Asia, the Middle East, North Africa, Latin America and the Caribbean, the situation is generally better (other than in the growing cities of South Asia). In industrialised countries service levels are generally high, though the dissolution of the USSR has caused large parts of Central Asia to slip back in quality of service. Small islands have particular water problems.

India has an unenviable record of high incidence of several infectious (and non-infectious) diseases. The 1993 World Development Report, Investing in Health, ranks India next only to Sub-Saharan African countries (all countries south of the Sahara, excluding Mauritius, and Seychelles) and some countries in the Middle East, in the number of people afflicted with infectious diseases. In Sub- Saharan Africa, infectious diseases account for 71 per cent of all diseases. The corresponding percentages are 50.5 per cent, 25.3 per cent, 8.6 per cent and 9.7 per cent for India, China, the former socialist economies of Europe and the more developed countries, respectively.

Sanitation Data

More people have gained access to safe drinking water since 1980 than ever before. Many countries have doubled its provision during that time. In 20 countries, including some of the world’s most populous countries, more than 80 per cent of people now have access to safe water. Taking the world as a whole, provision of new water services is outpacing population growth. The number of people with adequate sanitation is far lower than that with safe water, and the provision of sanitation is not keeping up with global population growth. And yet there are also positive aspects of sanitation; for example, a large number of people have gained improved sanitation during the 1990s. New designs and low-cost technologies have significantly expanded the options available to both peri-urban and rural communities. Water and sanitation-related diseases are increasing. Nearly 250 million cases are reported every year, with between 3 and 10 million deaths. Diarrhoeal diseases leave millions of children underweight, mentally and physically handicapped, and vulnerable to other diseases. Poor hygiene and sanitation is largely responsible for the following:

• 200 million people with schistosomiasis
• 16-17 million people with typhoid
• 1500 million people with intestinal worms
• 2 million infants and children dying each year.

Ways To Do It

In industrialized countries, the goal “to provide all citizens capable of receiving piped water supplies and connecting up to sewerage systems with high quality and reliable services at affordable prices” could become a reality in most cases within a reasonable time. This goal should be supported by an awareness among the public of the importance of these services and what they as individuals can contribute; their trust in the service providers and the value for money they receive; as also proper pricing to recover costs of provision.

• From the customers’ perspective, different models for citizen participation, in line with the history and culture of the area concerned, can help assure stakeholder participation. Consumers should have full access to information on the performance of service providers and on water quality.
• Important constraints include a non-holistic approach to environmental management, regulations unsuited to local problems, and access to finance for renovation. Accordingly, some important future actions include: raising the profile of water and sanitation services, tackling pollution at the source, improved efficiency in providing services, national and regional frameworks for local actions, encouragement of technological innovation, and improvement of access to finance.
• Effective water management plays an important role. This should reflect the environmental, cultural and historical dimensions of water. In the short term, the quality of water and environment sanitation should improve so that water used for human consumption does not need sophisticated treatment. Water resources being a common good, they should fall under the responsibilities of communities in a river basin. Avoidance of pollution should have priority over pipe solutions; the “polluter pays” principle should be applied to all users. Water quality monitoring programmes should be increasingly developed.
• Assisting non-industrialized countries must be a major contribution, rendered in the form of information, training and advice; the employment of local human resources; and, more generally, the keeping up of financial aid flows, coupled with debt relief.

Stinking Cities And Fecund People

Large and festering city slums, where the lumpen and sexually productive people live in varying states of deprivation, are the victims of our age. Millions of people are migrating to cities at a rate which by the year 2010 may be more than the combined population of the UK, Germany and France. With the expansion of cities, at this pace, scope for open defecation in cities has shrunken. No wonder, people are seen easing themselves along roads, railway tracks and in parks – a humiliating sight. The sewerage networks are far too inadequate and expensive to carry waste and sullage into rivers. Consequently, more bucket latrines have come up in unauthorised colonies with the number of scavengers growing. Loss in working days due to sanitation related diseases work out to be millions every year. According to the World Health Organisation (1992), every year about eight million new cases of tuberculosis are added globally, with India alone contributing 1.2 million. 5 per cent of our population carry the hepatitis B virus which causes jaundice, a potentially fatal disease if left untreated, and annually about 2.11 per cent of people are infected with malaria. Approximately, the same number of births occur in China and India, but the death rate among children is three times higher in India. Praynay Gupte (Time, May 25, 1998) says that India loses 10 billion dollar (half the total currency reserve in RBI) in productivity each year through workers' illness caused by deteriorating physical conditions.

Sanitation involves waste disposal systems, water supply, sewerage networks and preserving ecology. And, on all these counts, India is very deficient. Our cities and towns are among the dirtiest in the world. Stinking garbage heaps, large number of people defecating in the open or urinating on the walls even in the so-called posh areas, degraded land and destroyed forests – all these indicate bad health of the people living in a decaying society. The increased application of technology has created wealth centers, touching off migration of people far beyond the capacity of cities and towns to support them. These people live in slums and around dirty places. The scope of sanitation may vary and the emphasis may shift with the need of communities, but in developing countries, safe disposal of faeces is very vital for improving health and environment.

India is faced with the formidable task of handling 900 million litres of urine and 135 million kg of faecal matter per day with a totally inadequate system of collection and disposal. In most of the urban areas even on the streets where sewers have been laid, houses have not been connected in spite of municipal laws making such connections compulsory. Thus, insanitation continues. In the rural areas, 102 million households have no toilet facilities at all.

Strangely enough enteric diseases are not often spotted timely, and the damage they cause is not being recognised adequately even today. The Press ignores stories on water supply and sanitation, because they don’t make hot news and their reading is dull and soporific. No wonder, sanitation is never high on the agenda of the developing countries where it has been singled out as the most potent source of poverty, bad health, low productivity and much else besides. In truth, water and sanitation put together should be studied along with land, labour and capital while making plans for national growth. Water and sanitation are not only health problems, but are areas where investment is woefully inadequate. There are still more than half a million scavengers in the country who physically clean and carry human excreta manually, working on 7.6 million service latrines. These old statistics, however, do not fully reflect the magnitude of the problem. A large number of houseless people living in slums or on pavements have been counted out of the census. The entire rural population in India, which is more than the population of Europe and Africa put together, have no organised toilet facilities worth the name.

Three-fourths of India's Population Without Toilets

The Planning Commission Task Force has estimated the total number of dry latrines at 76.4 lakh, of which 54 lakh are in the urban areas and 22.4 lakh in the rural areas. At the time of 1991 Census, it was found that the percentage of households, having toilet facility, was only 23.70 per cent. In other words, more than 76 per cent of the people (or about three-fourths of the total population in the country) had no toilet facility. In the urban areas, the percentage of households having toilet facilities in 1991 was 63.85 per cent as compared to 58.15 per cent in the 1981 census. More than one-third of the urban households in most States and Union Territories did not have toilet facilities while more than half of the urban households in 177 districts did not have toilets. The percentage of households having toilet facilities in the rural areas at the time of 1991 Census was only 9.48 per cent. It is evident from the above that the problem of sanitation has been tackled to an extent in the urban areas, but it is still grave in the rural areas.

The Sixth Five-Year Plan (1980-85) stated that “so far little attention has been given to the problem of rural sanitation except some pilot projects in some states. It is estimated that almost 98 per cent of the rural households did not have latrines.” It further stated that keeping in view the present position of rural sanitation and the limitations of budgetary resources, sanitation facilities could be provided to only 25 per cent of the rural population by the end of the decade. It was also visualized that much more could, however, be done in the area through selfhelp schemes organised by the village community. It was recognised that extension efforts will need to be made on a large scale to assist the village organisations in the adoption and use of suggested simple low-cost designs of water seal latrines. The Plan document also noticed that the UN Resolution on the International Drinking Water Supply and Sanitation Decade called for basic sanitation facilities being made available to all citizens by 1990. The government recognized that this objective could be attained only through a large scale mobilisation of voluntary effort at the village level.

The government visualised that the effort during the period 1980-1985 was only towards a modest beginning by undertaking pilot projects which would help know the community attitudes in the rural areas to types of latrines to be provided and the nature of sanitation facilities needed. In regard to the urban sanitation situation, at the beginning of 1980- 85 the government recognised that urban sewerage and sanitation was also unsatisfactory. Of the 3119 towns, only 198 had the sewerage facilities 20 years ago. Even in respect of towns with population exceeding 100,000 only 46 per cent had arrangements for sewerage and sewage treatment. The overall population coverage was only about 20 per cent. It was recognised that the pressing need for providing adequate sewerage facilities in the larger cities, especially in the high-density areas populated by the low-income groups, must continue to receive priority. It was also intended to evolve low-cost techniques for urban sanitation. It was, thus, obvious that 20 years ago India did not have the resources to go for expensive sanitation solutions like sewerage. In 1970 the Sulabh had introduced the cost-effective technology which fitted the bill; it was affordable and culturally acceptable. The atmosphere was thus conducive to promote the Sulabh technology.

State-wise Analysis

There was an appreciable increase in the availability of toilet facility in the urban areas as recorded in the 1991 census when compared with 1981. In terms of percentage, the increase was registered in Mizoram (59.92), Lakshadweep (38.03), Sikkim (24.54), Meghalaya (15.54), Kerala (13.52), Dadra & Nagar Haveli (12.31), Andhra Pradesh (10.53), Arunachal Pradesh (10.49), Goa (9.31), Nagaland (9.03), Karnataka (9.24), Punjab and Pondicherry (8.48 each), Orissa (7.39), Manipur (7.07), Tamil Nadu (6.20), Haryana (6.18), Rajasthan (5.79), Gujarat (5.60), Andamans (5.18), Maharashtra (5.08), Himachal Pradesh (4.86), Uttar Pradesh (4.48) and Bihar (3.59). The other States/Union territories which recorded only marginal increase were Chandigarh (1.24), West Bengal (1.01), Tripura (0.65) and Madhya Pradesh (0.27). It is rather surprising that the metropolitan city of Delhi registered a decrease in the availability of toilet facility from 68.02 per cent in 1981 to 66.64 per cent in 1991. This may be presumably due to the constant migration of people to Delhi from other areas since the last decade.

Comparative study

The toilet facility was available in varying degrees to the urban households in different States and Union Territories. The lowest percentage of 49.27 was found in Orissa and the highest percentage of 96.32 in Tripura. If the States/Union Territories are arranged in ascending order, according to the percentage of availability of toilet facilities based on 1991 Census, the eight North-eastern States of Arunachal Pradesh, Assam, Meghalaya, Mizoram, Manipur, Nagaland, Sikkim and Tripura top the list (more then 81 per cent), followed by West Bengal (78.75), Punjab (73.23), Kerala (72.66), Delhi (66.64), Uttar Pradesh (66.54), Karnataka (62.52), Gujarat (65.71), Maharashtra (64.45), Haryana (64.25), Rajasthan (62.27), Himachal Pradesh (59.98), Tamil Nadu (57.47), Bihar (56.54), Goa (55.82), Andhra Pradesh (54.60), Madhya Pradesh (53.00), and Orissa (49.27). Among the Union Territories Chandigarh (79.77) tops the list followed by Andamans (65.72), Dadra & Nagar Haveli (65.14), Lakshadweep (64.65), Pondicherry (50.02), and Daman & Diu (45.75).

A Toiletless World

More than 1.3 billion people in the world today live in extreme poverty. Nearly 1.1 billion lack access to clean water. 2.6 billion live without basic sanitation. In 1999, 11 million children under the age of five would die of preventable diseases. For children who live past five, more than 250 million would work instead of going to school. (Source: James D. Wolfensohn, World Bank President – June 1999). Of the 4.4 billion people living in the developing countries, almost three-fifths have no basic sanitation facilities, one-third have no safe drinking 40 water, a quarter lack adequate housing, one-fifth have no healthcare facilities, and one-fifth of children drop out of schools. An estimated 2.7 million deaths occur each year from air pollution alone. Although the global consumption of goods and services has expanded at an unprecedented pace in the twentieth century, (with the public and private consumption expenditures reaching $24 trillion in 1998, six times the figure for 1995), civic facilities have declined relative to population. This was revealed in the Human Development Report 1998.

The report focuses on consumption of goods and services and looks at how the global consumption boom has resulted in historic gains in human development. India, which was ranked 138 in 1998, has slipped one rank to 139, just behind Pakistan, among 174 countries. However, India among has a more equitable distribution of resources as it has adopted “fairly pro-poor policies”.

20% people consume 86% of world's resources

The report adds that 20 per cent people consume 86 percent of world’s resources. The gross inequalities in consumption have excluded over one billion people who fail to meet even their basic consumption requirements, including sanitation. The wealthiest one-fifth of the world’s people consume 45 per cent of meat and fish, 58 per cent of the total energy. They have 74 per cent of the telephone lines; use 84 per cent of all paper and own 87 per cent of the world’s vehicles. The poorest fifth, on the other hand, consume less than 5 per cent of meat and fish, 4 per cent of total energy; they have 1.5 per cent telephone lines, use merely 1.1 per cent of paper and own less than 1 per cent of the world’s automobiles. Though the poorest one-fifth are responsible for barely three per cent of carbon dioxide emissions, they are the most vulnerable to the rising sea levels associated with global warming as they live in the low-lying regions. The wealthiest one-fifth consume 53 per cent of the fossil fuels, accounting for a far larger share of carbon dioxide emissions. And, global warming.

With one metre rise in the sea level, Bangladesh would lose 17 per cent of its land area and Egypt 12 per cent. Much of the land of small island-nations, such as Maldives, would also disappear beneath waves. These and many other countries will disappear in water because the rich people consume more resources than can be fully met by nature without damage to its ecological structure, including damage to the ozone layer which will produce floods and high water.

The report places India at 128 in gender-related development index (GDI), a life expectancy at birth of 63.3 for females and 61 for males; an adult literacy rate of 37.7 per cent for females and 65.5 per cent for males; combined first-second-third level gross enrolment ratio of 46.5 per cent for females and 60.1 per cent for males; percentage of shared income being 25.4 per cent for females and 74.6 per cent for males and a GDI value of 0.424. The top ten countries in order are Canada, France, Norway, USA, Iceland, Finland, The Netherlands, Japan, New Zealand and Sweden. China is ranked 106. A child born in the industrial world consumes and pollutes more in his or her lifetime than do 30-50 children in poor countries. The report also mentions the health status of the poor countries to highlight the fact that insanitation causes more damage to society than most people seem to realise. (Source: UNDP report 1998)

China’s Latrine Revolution In Henan Province

A ‘latrine revolution’ in China’s Henan Province has been an outstanding example of political commitment and strong local leadership. One of the most densely populated parts of the country, Henan launched its campaign in 1989 with full support of the provincial governor. By 1995, out of every ten most advanced latrine coverage counties in China, nine were in Henan province. Latrines were started in 1987 only in a few villages in Yucheng country because of the efforts of a “Mister Latrine”, the physician Dr Song Lexin. Going from village to village on his bicycle, he would discuss the benefits of his latrine with the villagers. After he experimented with a demonstration latrine with the villagers, they gradually saw that the manure from this latrine made their apples grow larger and sweeter. Conviction that the latrines had made their villages richer was evident even eight years after the ‘revolution’ began. Most of the latrines were still found to be kept very clean, thanks to the efforts of the village women. In most cases, the communities themselves paid 90 per cent of the total cost of their improved latrines. Efforts were underway to develop a revolving fund and other credit options to help spread latrine improvement to poorer villages in the province. (IRC Water Newsletter, Dec. 1995)

China with a population of 1,134 million and nearly comparable incomes (in 1990) has achieved a marked improvement in the health and sanitation status of its people during the past 15 years, especially with reference to infectious diseases. In any given year, an average Indian loses at least four times more healthy days due to infectious and sanitation-related diseases than does an average Chinese. This is not due to lower expenditure on healthcare but lack of concern for health and sanitation. Indeed, India spends more funds per person ($ 21 per year) on healthcare than China ($ 11 per year) only to be behind it in the race. (Source: Microbes and Disease by M.S. Mahajan)

However, the significant difference lies in the fact that China has spent a considerable amount in the public sector on specific public health measures, rather than on setting up hospitals and other facilities for treatment of diseases as is done in India. Public health programmes, which have a direct bearing on promoting a healthy environment, include provision of clean and adequate quantities of water, sanitation, sewerage and solid-waste collection and disposal. Direct investment in the development of these programmes leads to removal of reservoirs of pathogens and, in turn, to reduction in the incidence of infectious diseases. And, in making a healthy and growing society.

How Sanitation Reduces Poverty

Mr. Deepak Vohra, an IFS officer, has worked out a computer model to say that the Human Poverty Index (HPI) is based on deprivation in three essential areas of human life – life expectancy, knowledge (literacy) and standard of living. Interestingly, per capita Gross Domestic Product (GDP) income is not taken into account directly while computing HPI, on the assumption that achieving a respectable level of human development does not always require an enormous income. The deprivation in the living standard includes non-availability of two essential services directly related to sanitation – safe drinking water and health.

In the 1999 Human Development Report (published by the United Nations Development Programme), India’s position was 59 among 124 developing countries. The percentage of population without access to sanitation is 71 per cent. If this percentage were reduced to half (50 per cent of the population), the consequent increase in access to safe water and health services would take India to the first 25 countries in the Human Poverty Index. In other words, India could be among the top 25 developing nations in terms of the quality of life of its people if the sanitation facilities are provided to half of its population. And, this is least expensive to do in comparison with increasing literacy, life expectancy, and raising the living standard of people.

Sanitation Based Growth

There is, however, a different method to work out the Human Development Index (HDI) which is based on three indicators – life expectancy at birth, education and real GDP per capita assessed in terms of purchasing power parity (PPP). In the 1999 Human 42 Development Report, India’s rank is 132 out of 174 countries. (In 1998 HDI, India ranking was 139) Since equal weightage is given to all three indicators, any improvement even in one can significantly upgrade a country’s rank. According to an accepted model, a 20 percentage point increase in the number of people with access to sanitation facilities would enhance life expectancy by 4-5 years from 62.6 years at present. This, in turn, would push India’s HDI ranking several notches up, probably within the first 75 against 132 now. In sum, if the sanitation status is improved, India's ranking would enormously improve both in HPI and HDI ratings and, to that extent, poverty will be reduced.

“Sulabh has shown that it can be done by placing sanitation, healthcare and safe drinking water in the centre of the national consciousness. If Indians adopt the Sulabh model, the quality of life will improve considerably which the world will watch in admiration and amazement,” says Mr. Vohra.

However, poverty is defined differently by different agencies. The World Bank has defined the povertyline as those living on $1(US) per day and the number of such Indians rose to 340 million by the end of 1997 against 300 million at the end of the previous decade. More than 30 per cent of the world’s 1.2 billion poor live in India, indicating the enormousness of the poverty problem. In terms of per capita income, India ranks 124 out of 157 nations listed in the 1998 World Bank Atlas. On the basis of purchasing power parity (PPP) India may be the fifth largest economy in the world after the US, Germany, China and Japan, but in per capita PPP rankings, as stated earlier, India is down at 126.

The World Bank adds that there has been no reduction in rural poverty in India with the absolute number of rural poor rising from 224 million in the early '90s to 340 million by the end of 1997. There is a virtual stagnation in the number of urban poor at 73 million. This finding confirms the belief that the economic reforms initiated in 1991 have failed to alleviate poverty (measured by HDI standard) which has expanded despite a per capita annual growth of 1.9 per cent between 1991-95 and anticipated 3.7 per cent growth during 1997-2000 against the required 1.3 per cent growth necessary for reducing poverty by 50 per cent by the year 2015.

In the March 1998 report on South Asia, the world renowned Pak growth economist who was the first to launch the UNDP Human Developments Reports, the late Mehbub-ul-Haq, had pointed out that "India has 135 million people who have no access to basic health facilities; 226 million lack access to safe drinking water; half of India's adult population is illiterate, 70 per cent lack basic sanitation facilities, 40 per cent of the people survive in absolute poverty." One-third of the absolute poor in the world live in India which has also the distinction of having the largest illiterate population in the world. The July 1998 report from the Tata Energy Research Institute (TERI) confirms this to say: "Nearly half the country's population does not have access to drinking water; about 90 per cent of the water supply is polluted with only 10 per cent of sewage treatment plants in working order. Sanitation is the dominant issue which is not adequately addressed." This indicates that until we step up our efforts, only affluence will rise without any corresponding reduction in poverty – all because of sanitation.

Microbes Control

Our present record in the area of public hygiene and control of infectious diseases is poor, even in Asia. The incidence of these diseases is four times higher in India as compared to China, despite our higher per capita expenditure on health. They lead to considerable loss of life and working time, resulting in low economic activities and poor quality of life. The current situation urgently demands that people be made aware of microbes and the role they play in causing diseases so that the right measures to control infectious diseases are taken. One has then to devise strategies to limit the breeding grounds of microbes, take steps to avoid their spread, instill good hygienic habits in the masses and also provide facilities such as those which are part of the Sulabh Movement. Sensitizing the masses about the close connection between microbes and diseases by providing proper information and understanding is another important task in this fight against infectious diseases.

The scientific basis of the connection between lack of sanitation and infectious diseases was provided by Louis Pasteur, Robert Koch, Elie Metchnikoff and other 'microbe hunters' who established that these diseases are caused by micro-organisms, viz. bacteria, fungi and viruses. Antoni van Leeuvenhoek was the first person to work on microbes by peering through microscopes of his own making. The work of these and several other scientists resulted in mankind's biggest advance in fighting diseases. Ronald Ross's work on malaria carried out at Calcutta and that of Valdemaar Haffkine on plague at Bombay are some other exciting episodes in the same pursuit of tracking deadly microbes.

The work of these and several other scientists led to the development of three concepts which play an important role in the control of infectious diseases. These are: (a) infectious diseases are caused when we come in contact with pathogens; (b) these pathogens are present in several environmental reservoirs, which include drinking water, food, garbage heaps, sewage and human excreta; and (c) one can protect oneself from these diseases by avoiding contact with the pathogenic micro-organisms. The most effective way to do this is to eliminate the environmental reservoirs of these microbes; the second best alternative is to keep ourselves away from these reservoirs. As the links between microbes and diseases became clear, people understood the reasons why simple measures, especially involving personal and public hygiene, protected them from infectious diseases. Advances in immunology (vaccination) and antibiotics soon followed, and the global health situation improved still further.

Dr. Feachem's Report

Studies conducted by Dr. Feachem of the London School of Health and Tropical Medicine indicated the relative importance of alternative preventive strategies concerning water supply, sanitation and health education. The studies gave a rough guide to the relative importance of the preventive measures considered; excreta disposal 25, excreta treatment 15, personal and domestic cleanliness 18, water quality 11, water availability 18, drainage and sullage disposal 6 and food hygiene 17. The studies concluded that the health impact of supplying clean water alone is limited. However, carefully designed programmes which combine water quality with good sanitation and hygiene education have the potential to make enormous differences in the quality of life. A similar study conducted by the All India Institute of Hygiene and Public Health, Calcutta (1944-1953) in its Rural Health Centre at Singur revealed that the number of morbidity and mortality cases due to gastro-enteric diseases and helminthic infection were lowest in the villages where both hand-pumps or tubewells for safe water and pourflush toilets were provided. The next in order were villages where such toilet facilities had been made available, although those villages had no safe water. Still next were those with only hand-pumps or tube-wells but no toilet facilities; and lastly were those villages with neither facility.

The obvious fact is that the future of the country largely depends on sanitation which is the most important thing, next to population control. We have to accept this fact in order to raise production and create a clean and civilised society which India has always been.