On January 30th 2020, the World Health Organisation (WHO) declared the present COVID-19 (earlier known as 2019-nCoV) pandemic as ‘Public Health Emergency of International Concern (PHEIC)’. As of September 17th 2020, COVID-19 infected 29.91 million people, and claimed more than 0.94 million lives worldwide. The most affected by these emergencies are people living in the developing and least-developed countries where health infrastructure is in a dismal situation, resulting in people losing their lives and livelihoods with no sustained support from the government.
India is ranked 2nd among the worst affected countries in the world in terms of confirmed cases (more than 5.12 million) and 3rd in deaths (83,198) caused by coronavirus. More alarmingly since August 6th, highest number of daily confirmed cases are reported in India. On August 30th a record for the biggest (79,461 new positive cases) single-day rise in cases were reported and experts cautioned that India is becoming the new epicentre. Further, due to reverse (urban-rural) migration, concentration of COVID-19 is increasing significantly in migrant receiving poor districts.
The current COVID-19 pandemic has increased appreciation for hygiene globally. To date, no vaccine or cure is available, and the most effective ways, as suggested by WHO, to prevent the spread of infection of COVID-19 are safe and clean water, proper and frequent handwashing, sanitation, hygiene (WASH), and maintaining physical distancing.
Long way to WASH
The lack of access to basic water, sanitation and hygiene (WASH) facilities are one of the critical examples of the lethal effects of inequality being exposed by the pandemic. Approximately 2.2 billion and 4.2 billion people around the world do not have safely managed drinking water and sanitation services and 3 billion lack basic handwashing facilities. In context of India availability and access to WASH services are captured in the latest available nationally representative data, i.e., National Family Health Survey, 2015-16 (NFHS-4). Findings show that like health infrastructure, India’s scorecard on availability of WASH facilities is also not up to the mark. Migrant receiving states Bihar, Uttar pradesh, West Bengal etc. has already high population density and poor health infrastructure. Reverse migration increased the pressure on existing WASH facilities available in household or community.
In Indian social structure, caste and religion have always been an intrinsic part of social hierarchy. The caste system influences economic and socials status. Dumont (1980) in his book “Homo hierarchicus: The caste system and its implications” mentioned that in India, historically, scheduled tribes (STs) and Scheduled castes (SCs) are the poorest and at the bottom on the ladder of the social hierarchy while privileged-castes are at the top. Marginalization on the socio-economic front in the society increases their vulnerability. There are three conventional and developmental divides (rural-urban, poor-rich, and by the social group) in terms of access to these facilities.
The problems of accessing quality water is worrisome in India. As per our estimation from (NFHS-4) data, in the urban area, 81.65 % of households have water availability in their own dwelling, while only of 58.05 % households in the rural area. In the rural area, 51 % of households rely on boreholes or tubewell for water, and more than 70 % don’t perform any treatment to water before drinking. Overall, in the poorest wealth quantile, 56 % of households bring water from outside the dwelling, and only 8 % households in richest wealth-quintile go outside for the water Similarly, the following percentage of households have water in their own dwelling, 77 % privileged-caste, 40 % scheduled tribes (STs) and 59 % and scheduled castes (SCs). This implies that a large swaths of population in India is dependent on the community tubewells or taps where maintaining physical distance is difficult given a shared source of water. Notably, this is a dual edged sword situation for underprivileged sections of the society because on the one hand if they use more water for handwashing and maintain hygiene they may face household water insecurity, on the other hand if they don’t wash hands frequently there is higher risk of infection.
Apart from primary routes (respiratory droplets and close person-to-person contact) of transmission evidence on spread of COVID-19 through fecally mediated route is accumulating but more studies are required. Public health researchers raised the concern that when shared sanitation facilities are used by an infected person it could be a sources of transmission via both airborne and contact exposures to SARS-CoV-2 exposure, especially in the absence of adequate water and soap for hygiene purposes.
In 2014, the government of India launched the “Swachh Bharat Mission” or clean India mission, which is considered as India’s most massive sanitation and cleanliness program. In October 2019 the government declared India open defecation free (ODF), but a recent study by Gupta et. al, (2020) using rural sanitation survey 2018 data (collected during August-December 2018) of four (Utter Pradesh, Bihar, Madhaya Pradesh and Rajasthan) north Indian states concluded that 44 % of the rural population above the age of two defecate in the open.
Huge rural-urban and socio-economic disparities also prevail in access to sanitation facilities. We estimated that 51 % of households don’t have improved sanitation facilities (NFHS-4). Further break-down shows an alarming picture. A large swath (63 %) of the rural population doesn’t have improved sanitation facilities compared to 29 % of the urban population. In the privileged-caste, 65 % of households have improved sanitation facilities, whereas less than half of this is accessible to the STs and SCs (i.e., only 26 % and 37 % respectively). The poor-rich gap is very significant, only 6 % of poorest households have improved sanitation facilities as compared to 93 % households in the richest wealth quintile (NFHS-4). Lack of improved sanitation facilities and use of shared facilities in densely populated poor area increased the vulnerability of exposure to COVID-19.
Hand hygiene is vital in lowering the transmission of highly infectious coronavirus. But for India, handwashing like other WASH services seems more aspirational than actionable due to significant rural-urban, poor-rich, and social divide. Unfortunately, promoting handwashing was not included as an objective in the “Swachh Bharat Mission” 2014 by the government. The NFHS-4 data reveals that 80 % of households in urban and only 49 % in rural areas have both water and soap at the place of handwashing. This gap remained persistent by social status and increased when it comes to economic status. 75 % of privileged caste households have access to handwashing facilities, whereas only 51 % of SCs and 38 % of STs households have the same. Again, wealth quintile used as a proxy for standard of living is one of the most critical barriers to handwashing, because less than 25 % of households in the lowest wealth quintile and 93 % household in the richest wealth quantile have access to handwashing facilities (NFHS-4).
To fight the pandemic with a dismal health system coupled with unaffordable long-term lockdown, and lack of WASH facilities seems very challenging. It is impossible to establish a robust health infrastructure overnight, and in a long-term lockdown, hunger may claim more lives than COVID-19.
The anticipated inability of many households to follow WHO and UNICEF guidelines during the COVID-19 pandemic reveals that major investments in both water infrastructure and water governance are critically needed to manage and provision the WASH services.
Though it is not high time to cheer but people are more aware about public health utility of handwashing and sanitation. Scaling up awareness programs among people on public health utilities of WASH strategies are upmost needed through the virtual platform. The government should promote this by providing ‘hardware’ (availability and access to handwashing station and soap, etc.) and using ‘software’ (mass-media, community meeting, and face to face engagement) strategies. Noteworthy, in February, 2020, the Government of India has launched the phase-II of ‘Swachh Bharat Mission (Grameen) [SMB (G)]’ which will be implemented during 2020-21 to 2024-25. The SBM (G)-II will be known as ‘ODF plus’ that include maintaining village ODF and solid and Liquid Waste Management (SLWM). Recognising the importance of community-level sanitation facilities further emphasise is given to the construction of Community Managed Sanitary Complex (CMSC) at village level aiming no one is left behind.
Finally, COVID-19 is a lesson for future health uncertainties, and the government should strengthen the health infrastructure and access to safe and clean water and sanitation facilities, by ensuring adequate budget allocation for health and improving physical infrastructure. Economic impoverishment caused by COVID-19 will have an adverse knock-on effect on utilisation of WASH services because due to limited resources poor people will give priority to spent money on food over soap or water, where it has to be paid for. For better and equitable access to WASH services, an integrated approach by water, sanitation, and the health department is indispensable.
About the authors
Mukesh Kumar is a Research Fellow in Economics (Ph.D) at the Department of Humanities and Social Sciences at the Indian Institute of Technology, Roorkee.
Pratap Chandra Mohanty teaches Economics at the Department of Humanities and Social Sciences (Economics) Indian Institute of Technology, Roorkee.