Public Health Should Focus More On Sanitation Than Sanitisation

By: Mathew George

Sanitation is one of the most important ideas that resonates throughout the history of public health and is continuing even now and is denoted as the sanitary movement, which is considered the genesis of public health.

The classic work by Edwin Chadwick in 1842 on the sanitary conditions of the labouring population of Great Britain led to the first Public Health Act of 1848. The sanitary conditions of the working population were important for Chadwick because he believed that their hygiene behaviours are an outcome of their available sanitary conditions.

Sanitation is a process of ensuring a sustainable and healthy environment for people in any given locality. This is accomplished by erecting barriers to prevent transmission of disease-causing agents or by promoting hygiene behaviours among people for the same. Thus, the relationship between sanitation and hygiene is so intertwined that in most of the literature these two are considered inseparable.

Sociologically speaking, sanitation is the context or condition that determines whether people can follow hygiene behaviours effortlessly. The reason why water and soap are considered as a prerequisite for handwashing behaviours and toilets with running water, a prerequisite for reducing open defecation, all emerges from this basic acknowledgement of the close linkages between sanitation and hygiene behaviours.

Sanitation and hygiene efforts in public health emerge from the environmental health movement and focus more on the need to ensure adequate waste disposal and sewage management system for human excreta and other effluents.

Few of the statistics will reveal the divide between the rich and the poor in access to sanitation facilities. Almost 85% of urban Indians had access to toilets a decade ago which for rural areas was only 35%. This has improved substantially in recent years, especially in rural areas where 64% have access to toilets as per NFHS 5, thanks to Swachh Bharat Abhiyaan and its policy for building toilets.

But the most crucial challenge is whether these toilets are connected to an open drain or a septic tank, which needs periodic servicing. Only 30% of urban and only a meagre 2% of rural households have their toilets connected to underground sewerage or into some form of a treatment plant. The challenges of creating a proper sewage disposal mechanism for the management of human excreta and other liquid wastes need a large-scale infrastructure supported with an institutional mechanism and unfortunately most of the current technology is highly water intensive as well. A more practical and contextual approach for sanitation could be of the ecological sanitation movement, also known as EcoScan, that links sanitation with agricultural needs. Human wastes are seen more as a resource and nutrients required for agriculture and are to be locally processed and recycled.

Is Sanitation a health concern or an aesthetic one?

There has been a transition in the purpose of sanitation across societies and it appears that the health-related purpose at times gets subsumed in aesthetic purposes. It might appear normal to have an aesthetic intent toward any form of sanitation measures, as an unintended goal but at times this can be detrimental as well.

For instance, waste management focuses on reducing, reusing and recycling, wherein the waste at the end needs to be converted into something as a resource that no longer raises a threat to human inhabitation.

On the contrary, when the aesthetic purpose dominates, it is the ‘waste site’ that is manipulated. Appearance and looks of a certain locality gain significance rather than what is done to the ‘wastes’ per se. The emergence of dumping grounds and the shifting of wastes from one location to another are all with an aesthetic purpose and not for addressing health concerns.

For aesthetic purposes, it is only shifting the burden and the movement is always from the richer sites to that of the poor. The biggest question that arises here is of sustainability of waste management as shifting of burden is neither reducing nor recycling the waste, thus failing to address the problem at its core.

The programme on preventing open defecation practices by constructing toilets without a proper drainage system or treatment plants is only shifting the burden for a shorter period. Those well-performing states in India that are having almost 100% utilisation of toilets are struggling to address this latter challenge. This domination of aesthetics over health concerns in waste management also emerges from the purity notion that ‘cleanliness is near to godliness’, an idea propagated by religious institutions about sacred places.

Sanitation, Capability and Public good

From a public health perspective, the need for sanitation as an ideal condition for human existence owes to Amartya Sen’s capability approach where he articulates the responsibility of societies to ensure every human being to live to their maximum potential to remain healthy. There is an inherent capability of human beings to remain healthy. It is the society and its context that assure every human being to enact this potential to its fullest to become a just society.

Ensuring sanitation facilities is an important responsibility of every developed society to help achieve maximum potential for its citizens. The dominance of aesthetic orientation in sanitation has also transformed the idea of hygiene behaviours as more individualistic in orientation and is expected to accomplish through the consumption of more and more market commodities.

Historically, hygiene behaviours were misconstrued as ‘individual’ behaviour by the behavioural sciences and have led to victim blaming-- a problem of individualistic approach to all forms of human behaviours devoid of social context. Hygiene behaviours are an outcome of the sanitation facilities available in any society and ensuring sanitation is the responsibility of the state and local governments, its violation is acknowledged as a violation of the right to life and is treated as a failure to improve the standard of living towards building a healthy society.

Individualism and the aesthetic purpose of sanitation are shifting the discourse from sanitation to sanitisation, putting the onus back on the individual. This is further fueled by the elite hygiene practices that existed among the better off earlier, which is acquiring a lot of legitimacy among the masses. Hand sanitisers, which were used mostly by the rich and the better off and masks which were used mostly among the immunocompromised and those working in dusty environments, got normalised as an ideal ‘public health’ tool to protect oneself during Covid-19. There is a tendency to practise disinfection and protection of individual spaces, be it the workplace, office spaces and homes. More than the pieces of evidence that are driving this trend, there is an inherent shift in translating a state-level responsibility to ensure sanitation that can ensure the hygiene behaviours of its citizen to that of individual responsibility by adopting sanitisation measures.

What happens in the process is that ensuring sanitation, which is a public good to be ensured by the state to its citizen as a right is eventually transformed into a private good whose access is determined by the purchasing power by bringing in the idea of sanitisation of individual spaces.

Another shift in the dimension is that sanitation was intended to prevent a potential threat to humankind and is getting substituted by the idea of sanitisation which is to keep your individual spaces clean and disinfectant, irrespective of the threat involved, a move towards purity and healthism. Public health should go back to its original focus on sanitation as a public good to be ensured for any society and not to get carried away by sanitisation move towards healthism at an individual level as health ultimately is a public good and can only be a societal goal to be achieved for all.

(Mathew George is Professor at the Department of Public Health and Community Medicine, Central University of Kerala)

Disclaimer: Views expressed in this article are personal