Is building toilets improving health in India?
New evidence has raised troubling questions about India’s 25-year strategy of pushing people to use toilets as a way to improve health.
In a paper published on Friday morning in the medical journal Lancet , >researchers led by Thomas Clasen of the U.S.-based Emory University found that increased toilet coverage did not lead to any significant improvements in the occurrence of child diarrhoea, prevalence of parasitic worm infections, child stunting or child mortality. For their study, Dr. Clasen and his team looked at 50 villages in Odisha’s Puri district between May 2010 and December 2013, where the then Total Sanitation Campaign to build toilets was in effect, and 50 otherwise similar villages where the campaign had not yet started.
One key possible explanation for the absence of a health impact, the researchers said, could be the patchy implementation of the scheme, and uneven rates of use of toilets — at the end of the study period, just 63 per cent of households in the villages where the scheme ran had any toilet, and two-thirds of this group reported a family member using the toilet. Usage was substantially lower among men than among women.
If everyone with a toilet were to use it, would India then see the positive health impacts of its sanitation scheme?
Dr. Clasen told The Hindu that his research could not conclusively answer that question, given that the study compared all households, whether compliant or not, in the 50 ‘treatment’ villages with the 50 ‘control’ villages.
However, a troubling finding was that even villages with higher toilet coverage, and households that had some family members using the toilet did not see any difference in health.
Is India’s sanitation programme, dating back to 1986 and heavily-focused on building toilets, then wrong-headed? “We have not seen this new study, but behaviour change will be an important part of the Swachh Bharat Mission,” said a senior official in the Mission who did not want to be named.
“India should be proud of the efforts that have been made to improve sanitation and eliminate open defecation. It is an exceptionally large challenge and the new government should be applauded for the commitment it is making,” Dr. Clasen said. He recommended two changes, however. “First, it must target latrine use, not latrine coverage,” he said. Secondly, the sanitation programme should be combined with other environmental health schemes, including safe drinking water and hand-washing, that will limit other forms of exposure.
Other studies, like the one by economists Jeffrey Hammer and Dean Spears in rural Maharashtra, showed an increase in child height following the implementation of the TSC. “It [Dr. Clasen’s] is an important study because it shows that even a very careful effort to improve sanitation might not actually reduce open defecation, because sanitation behaviour is very hard to change,” Dr. Spears told The Hindu .
