Contextualizing India’s Sanitation Crisis

A dysfunctional, but still used, toilet block in Bhubaneswar, India.

I was invited to speak once again to students at my alma mater St. Bonaventure University about my current job here in India, and the experience of living and working abroad in general. I did this last year as well, and detailed a bit of the experience in a previous post, and, due to some technical difficulties, ending up winging the speech, speaking off-the-cuff for its duration rather than taking them through the presentation I’d put together. It went reasonably well in spite of this, and I absolutely loved the experience, but thought it’d be best to spend a little more time structuring my thoughts “offline” so as to not be so tech-dependent.

As I’ve written several times in the past, I’m working on an urban slum sanitation initiative called Project Sammaan, acting in the dual role of project manager and communications lead. The project’s aim is to experiment at scale with community sanitation facilities featuring various “hardware” and “software” interventions in India’s urban slums in an effort to increase adoption rates of such facilities and, in turn, reduce instances of open-defecation; “hardware” meaning brick-and-mortar, physical adjustments and amenities (e.g., menstrual waste incinerators, architectural designs allowing for natural light and ventilation, universal access toilet stalls, clothes-washing stations, etc.), and “software” meaning improvements to business and operating models. The initiative is set to launch with over 100 facilities, and the effectiveness of the systems will be quantified with years-long end-user research, and learnings will be shared in an open-source toolkit with the intention of expanding the project throughout India and beyond, if proven successful.

In order to properly frame the need for such a project, one needs to have a sense for the scale of the issue, both in India and throughout the world. As such, here are some facts and figures to consider:

– Globally, 780 million people live without clean drinking water, and 2.5 billion lack access to adequate and safe sanitation (UN Water)

– One child dies every 20-seconds from diarrhea related to inadequate sanitation; 1.5 million+ each year (UNICEF)

– Diarrhea kills more children than malaria, AIDS, and measles combined (UNICEF/WHO)

– Globally, 162 million children under 5 are malnourished due to poor sanitation (UNICEF, WHO, and World Bank joint report)

– 443 million school days are lost each year due to water-related illness (UNDP)

– 1/2 of all schools in developing countries have inadequate sanitation facilities; 2/3 lack gender-segregated toilets (UNICEF)

– Women and girls spend 97 million hours per year looking for a place to go to the bathroom (e.g., fields, railroad tracks), which is more time than the entire world spends watching YouTube each year. (WaterAid)

– More than 280 million children under five live in households without access to improved sanitation facilities (UN)

– Out of the world’s estimated 7 billion people, 6 billion have access to mobile phones while only 4.5 billion people have access to working toilets. (UN)

– Twelve countries (India, Indonesia, Pakistan, Ethiopia, Nigeria, Sudan, Nepal, China, Niger, Burkina Faso, Mozambique, Cambodia) account for 75% of the world’s people forced to open-defecate due to a lack of adequate sanitation facilities. India is far-and-away the worst, with ~10x the amount of people than #2 Indonesia, and nearly 2.5x the other 11 countries combined. (WHO)

And this last point is a perfect segue into looking at India specifically, as no other country even comes close to the scale of the sanitation crisis here:

– India’s share of open-defecators is not just a function of population and associated economies of scale. Compare it to world’s most populous country China: India has nearly 60% of its population open-defecating, whereas China “only” has 1%. (WHO)

– Diseases related to inadequate sanitation cause growth stunting in 45 out of every 100 children in India (UNICEF)

– India loses over 6% of its annual GDP ($50+ billion dollars) due to lost labor related to inadequate sanitation (World Bank’s Water and Sanitation Programme, “Economic Impact of Inadequate Sanitation in India”).

– Every minute, 1.1 million liters (300,000 gallons) of raw sewage is dumped in the Ganges river (UN World Water Development Report)

– Only 13% of India’s sewage is treated (The Economist)

– 21% of communicable diseases in India are related to unsafe water (World Bank)

– There are around 340,000 manual scavengers in India (BBC)

– In addition to the threat of assault and harassment, not being able to access toilets has a series of health implications for women and girls from urinary tract to kidney infections, not to mention the stress of not being able to access a bathroom during monthly menstrual cycles (Huffington Post)

And on, and on, unfortunately. It is so significant a problem that it touches nearly all social problems here, from violence against women and dropout rates amongst schoolgirls, to children’s malnourishment and government corruption. And there are as many contributing factors bolstering it as there are aspects of life touched by it.

When I first accepted the job, I had the preconceived notion that the root of the problem was simply the lack of toilets. While this is certainly the case to a large extent, especially when one reads that a group of activists found over 37 million toilets featured in the official government census to be ‘missing’, it puts too fine a point on too large an issue that affects far too many people. However, if you’re into the whole brevity thing, the sanitation crisis in India can be boiled down to three extremely hyper-generalized scenarios affecting people’s daily sanitation needs: 1. No toilets 2. Toilets are present, but not functional

3. Functional toilets are present, but people don’t use them

The simple lack of facilities is the proverbial “low hanging fruit” and, regrettably, is the easiest to quickly remedy in order to achieve a tangible expression of mobilization to address the problem; being able to say one has built ‘X’ number of toilets allows for a quick quantification of action, but is misleading: if one builds 1,000 toilets that sit unused, does it really matter? This is the thinking behind the “wait and see” apprehension that many greeted India’s new Prime Minister Narendra Modi’s proclaimed advocacy for toilet construction at a massive scale in an effort to meet the promise of eradicating open defecation by Gandhi’s 150th birthday in 2019. A chief concern amongst practitioners and those involved in the sanitation sector involves the operations and maintenance of facilities, and not just their construction, which leads us to point #2.

Situations in which there is a dysfunctional toilet present are deadly both literally (i.e., community members are exposed to viruses and bacteria from the untreated excrement) and figuratively (i.e., the mental association with toilets as disgusting places to be avoided). I’ve had the good fortune to spend a lot of time over the past nearly three years visiting slum communities throughout India and have seen first-hand just how bad dysfunctional community toilet facilities can be. The smell alone is enough to take your breath away, and the sights are none the better. Above and beyond the significant challenges of ensuring uninterrupted access to water and electrical supply to keep the facilities operational, you have the sociocultural taboos around handling waste that on the one hand severely limits the interest in taking up a job whose responsibility is to clean a toilet facility and, on the other hand, leads to prejudice against anyone that does take the position. Work around human waste is seen as something those in the lower strata of the caste system take up, largely leading to them being considered “untouchable”. Above and beyond these considerations, there exists a very disjointed, if nonexistent, system for end-users to report issues relating to operations and maintenance of sanitation facilities, and, correspondingly, to have any redressal for such issues. It’s easier to find someone to build a brand new toilet than it is a plumber to fix a dysfunctional one.

The last scenario, functional toilets left unused, is a much more slippery slope than the previous two in terms of defining the prevailing motivating factors that push people to choose defecating in open spaces such as fields and railway tracks over toilet facilities. Recently there was some controversy when western media outlets like The Economist and The New York Times drew connections between ancient Hindu texts and the prevalence of open-defecation in India. In conversations with community members, I’ve heard reasons ranging from the deplorable conditions of facilities to the simple fact that it’s what their forefathers did. Irrespective of rationale, the practice is so inculcated, and worse yet, accepted, that shifting people’s habits isn’t merely a function of adding infrastructure; there needs to be a drastic reimagining of the entire ecosystem that provides clean, functional, and hygienic facilities designed around the needs and habits of end-users while also instilling a sense of appreciation for the positive health benefits that come from using these facilities.

Project Sammaan will attempt to be the counterpoint to all of these challenges, or as many of them as possible in any event. The facilities have been designed to incorporate local materials, feature layouts that account for sanitation habits and corresponding user-flows, provide natural light and ventilation, include new amenities not normally found in such community sanitation facilities such as menstrual waste incinerators, and other aesthetic improvements. Additionally, the sewage management systems will provide a greater level of on-site treatment than the existing septic systems, helping to ensure the discharge has no ill-effects on the communities housing them. Beyond this, efforts are being made to not only build capacity within the local government bodies to maintain the facilities, thereby ensuring long-term sustainability, but also to create a direct line from end-user to these management bodies so that any issue affecting usage is addressed as quickly and effectively as possible. There is also a massive community engagement effort to educate community members on the importance of healthy sanitation and hygiene habits to ensure their buy-in. Finally, a dedicated team of empirical researchers will spend years studying the communities to quantify the impact of the facilities.

The Sammaan facilities will service approximately 65,000 people in two cities in eastern India. While that certainly sounds like a considerable amount, that represents 0.0001% of the people forced to open-defecate on a daily basis here in India. Our project, though significant in its scope and potential, is a very small drop in a very huge bucket.

Also, in the three years we’ve been working on the project, we have yet to even begin construction on a single facility due to pervasive apathy and recalcitrance to act by government partners working on the initiative. This is perhaps the most distressing of all components of the sanitation crisis here: there is no sense of urgency being shown by those in a position to do the most in terms of exacting change. I’ve been a part of enough off-the-record conversations with representatives at all local and state levels of government to say with conviction that a majority of people simply do not care that more than half the people in this country lack basic and adequate sanitation. I’ve even been asked point blank, and in all honesty, to explain why someone should care about providing toilets to people in slums. If there is no direct, tangible benefit to the individual, then there’s no point in continuing the conversation. Perhaps it is the simple fact that those in power have access to toilets; there is no personal connection to the issue, and there’s a fundamental lack of empathy that prevents even a basic consideration of such.

Trying to wrap one’s mind around the numbers associated with the sanitation crisis is a challenge in and of itself. It’s like trying to count the stars in the sky: at some point you just give up and rest assured knowing there’s a whole lot. But giving up on solving what is arguably the world’s most pressing concern is just not an option. Every day, due to inadequate sanitation, children die, women are raped, and a younger generation is further conditioned to be resigned to their fate and accept open-defecation as part and parcel of their life experience; and all of this could be avoided.

This is essentially the message I’ll attempt to convey when I speak to the students at St. Bonaventure, but it still feels shallow, incomplete, and insufficient. I suppose that in and of itself is a commentary on the complexity of the issue. Hell, far more informed and intelligent people than I have dedicated their life’s work to solving the world’s sanitation problem. Hundreds of millions of dollars are pumped into “developing” countries the world over in an effort to stem the flood, to throw a lifeline to the 1 in 3 people around the world that lack a proper toilet and supporting infrastructure. Our grandchildren’s grandchildren will likely find themselves working on this issue long after our efforts are forgotten.

I guess one can always lean on cliches such as “fight the good fight” and “it’s not over til it’s over” to elucidate motivations behind taking up such a Sisyphean endeavor, but that just feels cheap. I can say that the people I’ve met working in this sector are some of the most positive, optimistic, and committed individuals I’ve met, particularly in a professional capacity. Perhaps it is a delusion we all share, but there does seem to be solace in the effort; that, win or lose, at least we’ve tried, and no one can take that away.

Thankfully I have a few more weeks to sort this out.

Originally published at on September 11, 2014.

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