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Sanitation and hygiene are the two important components of public health. India’s abysmal standards of sanitation are responsible for our poor developmental outcomes. There is an adverse impact of poor sanitation and hygiene on various aspects including environment, economics, education and gender. So, promotion of sanitation and hygiene has multidimensional outcomes and we need a multidisciplinary approach to achieve those goals. India has a population of almost 1.2 billion people and about more than half of this population (55%) has no access to toilets and defecate in open Most of these numbers are made up by people who live in urban slums and rural areas.

 Over 50 million people in urban India defecate in the open every day. Slum dwellers in major metropolitan cities, reside along railway tracks and have no access to toilets or a running supply of water. It is clear that, high density followed by highly congested living conditions in urban areas escalates problems like poor sewerage systems resulting to unhygienic conditions. 4,861 out of 5,161 cities across the country do not have even a partial sewerage network and eighty per cent of India’s surface water pollution is on account of sewage alone. Waste water treatment facilities in India are inadequate with very fewer sewage treatment plants. A report suggests that only 30% of India’s water is treated. The rest of the water makes its way into streams and rivers inducing water pollution. According to the country’s tenth 5 year plan, 75% of India’s surface water resources are polluted and 80% of this is due to sewage alone.

Problems related to sanitation in rural India are quite different, and they can mainly attribute to socio cultural reasons. For example, in the “Laws of Manu”, a Hindu text some 2,000 years old encourages defecation in the open, far from home, to avoid ritual impurity. Caste division is another factor, as by tradition it was only the lowliest in society, “untouchables” (now Dalits), who cleared human waste. Many people, notably in the Hindu dominated Gangetic plains, today still show a preference for going in the open—even if they have latrines at home.

Always there exists a direct correlation between better public health measures, improved health technology with rise in living standards and life expectancy. Noble laureate Angus Deaton explained this correlation excellently by narrating the story of “escape from poverty and death” in his important new book The Great Escape. During the mid19th century cholera epidemic in London, it was widely believed that cholera was caused by a blood disorder. John Snow, a physician, collected data on 1854 cholera deaths in London and put it on a map to find that cholera epidemic was more severe in areas with contaminated water supply, debunking the myth that cholera was caused by blood disorder. This led to a significant reduction in child mortality not only in Britain but also across the world in the 20th century.

India’s sanitation crisis is a key reason for India’s severe child malnutrition burden: rates of child malnutrition are higher in India than even in Sub-Saharan Africa. Research suggests that an unhygienic environment combined with high population density creates a perfect storm for diseases to thrive, and malnutrition to flourish in India and having severe impact on human health.  The water pollution aids the transmission of oral-fecal diseases like diarrhea, typhoid and other intestinal infections such as round worm and hook worm. Diarrhea alone accounts for over 535,000 deaths in children under 5 years of age. Several malnutrition cases in children due to contaminated water causing infectious diseases, rob them of their ability to absorb nutrients. Polluted water is also breeding grounds for mosquitoes. Mosquitoes, carriers of diseases like Malaria and Dengue fever are responsible for another 300,000 deaths in our country annually.

In addition to health issues, the health-related economic impacts of inadequate sanitation, in India amounts to Rs. 2.44 trillion (US$53.8 billion) a Year this was the equivalent of 6.4 percent of India’s GDP in 2006. This means a per person annual impact of Rs. 2,180 (US$48). The economic repercussions are also evident in other areas like fisheries and tourism which are also hit by water related problems. The use of untreated sewage water for irrigation and the contamination of water bodies and contiguous areas is fast emerging as a health and environmental hazard in several countries, including India

Public safety of women is one under appreciated problem, as young women have to leave their rural homes after dark. In May, two teenage girls in Uttar Pradesh visiting a field used as a communal toilet were raped, murdered and strung up from a tree. That case won notoriety for its extreme barbarity, but similar attacks are distressingly common. 66 per cent of the women in Delhi slums are verbally abused, 46 per cent are stalked and more than 30 per cent are physically assaulted while accessing toilets.

Present NDA government’s initiative of Swachh Bharat mainly aimed at ending open defecation by 2019. That will be 150 years since the birth of Mohandas Gandhi, who said good sanitation was more important than independence. But there is need to think beyond Swachh Bharat, rather than making flamboyant advertisements without any significant outcomes. While there is emphatic and unqualified evidence that better sanitation leads to better health, there is very slim evidence that large subsidies are alone responsible for reduction in open defecation. The answer to the sanitation puzzle in India could well be a combination of subsidies and social mobilization. Achieving better sanitation is not an easy task, as there are behavioural aspects that prevent people from adopting improved sanitation. Deaton argues in The Great Escape that “diffusion of ideas and their practical implementation take time because they often require people to change the way they live.

Social pressure is an important determinant of success in improving sanitary outcomes. Social shaming through information, education and communication can also be effective. There is a need for collective action and community participation. NO toilet and NO bride campaign campaign started by Haryana government is a good initiative

Swachh Bharat should include promoting sanitation facilities in public hospitals and to encourage research in areas like eradicating open defecation and improving sanitation. It should also include proper rehabilitation schemes and skill development programs for manual scavengers, which will reducing the caste prejudices present in the society. Smart cities initiative aimed at developing 100 smart cities in the country within in 5 years. Smart cities should be slum free and should have efficient drinking water facility with effective sewerage network. The urban sanitation policy of 2008 should be reviewed on the lines of present smart city project. There is a need for integration of smart cities project with swachh project to make the cities livable.

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