Sanitation and Health

1. Demography India
Vol. 37, No. 1 (2008), pp. 79-94
Rajeshwari*
Sanitation Situation and Disease Pattern in Haryana:
A Spatial Analysis
* Department of Geography, Kurukshetra University, Kurukshetra. Email: rajeshwari.singh@rediffmail.com
Introduction
SANITATION is a broad term that includes disposal of human waste, wastewater, solid
waste, domestic and personal hygiene etc. The lack of sanitation has a detrimental effect
on health status and negates developmental efforts. It has become a yardstick of socio-
cultural and economic development of a nation. Lack of sanitation and hygiene is the primary
cause of almost all infectious diseases. There is a direct relationship between availability of
water, sanitation, health services, nutrition and human well-being. The burden of disease
linked to water and sanitation conditions is enormous. According to of global total (UNDP,
2006: 45), human excreta alone cause many infectious and parasitic diseases such as cholera,
dysentery, typhoid, paratyphoid, infectious hepatitis, hookworm, diarrhoea, polio, etc.
(www. Sulabhenvis.in:1). It is estimated that one gram of faecal contains about 1 crore
virus, 10 lakh bacteria, 1000 parasite cyst and 100 parasitic eggs and with 65 per cent of
rural India defecating in the open, the daily faecal load is estimated to be about 2 lakh
metric tones (www.undp.org:homepage).According to Health Information Statistics of India,
about 25 per cent of deaths in the country are attributed to infectious diseases (HII, 1998-
2000). Over half of all polio cases in the world are reported in India whereas this crippling
disease has virtually been wiped out in the developed countries. India alone accounts for
about one-fourth deaths out of 25 lakh deaths in the world every year due to diarrhoea
(http://www.who.int). Jaundice, viral hepatitis, gastro-enteritis and cholera outbreaks is
almost an annual feature in many villages. High levels of malnutrition (national average
being 41 per cent) are also attributed to poor sanitation. Water borne diseases and intestinal

2. 80 Rajeshwari
worms lead to loss of nutrition as these parasites consume nutrients and aggravate
undernutrition from the already insufficient diets of the rural people and consequently result
in deficiency diseases like night blindness, poor growth, vitamin deficiencies, low immunity
etc. and retard child’s physical development. Not only this, certain maternal health conditions
are also the manifestations of the cycle of infectious diseases. Further, various kinds of skin
diseases are also attributed to lack of water, sanitation and hygiene. At the root of most
public health problems is poor sanitation and hygiene. Studies have shown that sanitation
alone can reduce the incidence of infectious diseases by up to 80 per cent by inhibiting
disease generation and interrupting disease transmission (WHO, 1998: 6).
Access to sanitation is also critical to social and economic progress. It should also be
noted that over a billion people in the world do not have access to safe water and over 2
billion lack adequate sanitation. Out of this, about 636 million reside in India alone. The
lack of toilet facilities and open defecation at such a large scale in the rural areas contaminates
the soil and water bodies with pathogens (GOI, 2002: 39). This is a key causative factor
behind the high prevalence of soil and water borne diseases in rural India. Therefore, proper
sanitation is important not only from the general health point of view but it has a vital role
to play in our individual and social life too. Sanitation is one of the determinants of quality
of life and human development index. Further, its availability can be linked to women
empowerment as they are more adversely affected by the lack of sanitation facilities in
terms of their dignity and privacy.
It is generally believed that the provision and coverage of water, sanitation and hygiene
increases with increase in income. It is guided by the argument that these services have to
be financed out of household budget. However, the global snapshot reveals that in many
countries, wealth and provision of water and sanitation has not much correspondence. For
example, Phillipines, as compared to Sri Lanka and India in comparison to Bangladesh
have much higher income, yet their citizens have lower access to sanitation coverage (UNDP,
2006: 36). In case of India also, one finds that sanitation, hygiene and sewerage facilities
(generally associated with the poor economy, low purchasing power, low levels of literacy
and other such social indicators) are poor in many economically developed states such as
Maharashtra and Haryana (35 per cent each) Gujarat and Tamil Nadu (45 per cent each). On
the other hand, the states of Kerala andAssam have 80 to 84 per cent of households provided
with sanitation (toilets) facilities (Census, 2001). Further, what is more disturbing is the
fact that in economically developed states, the gap between provision of water and sanitation
is quite high. Sanitation provision basically lags far behind access to water. These gaps
matter not just because access to sanitation is intrinsically important, but also because the
benefits of improved access to water and to sanitation are mutually reinforcing. In this
context, Haryana has been taken as the study area. The state has exhibited above average
performance in all sectors which is reflected in its high per capita income as compared to
national average (Govt. of Haryana, 2006: 6). Not only this, the state also has the distinction
of having all kinds of physical infrastructure i.e. roads (length and coverage), connectivity
of villages with pucca road, public transport, villages supplied with electricity, postal network,
potable drinking water supply, schools, health centres and likewise. With this pattern of

3. Sanitation Situation and Disease Pattern in Haryana: A Spatial Analysis 81
development, there should have been better sanitation conditions and smooth epidemiological
transition in the state. But the sanitation condition in the state is not found satisfactory and
it has a direct bearing on the disease pattern.
Objectives
Following are the objectives of the present paper.
1. It presents a spatial pattern in the provision and availability of sanitary facilities in
rural and urban areas taking district as a unit.
2. It outlines the disease pattern and existing spatial variations in it.
3. It seeks to relate the various infectious and parasitic diseases (water and sanitation
borne) to sanitation situation in the state.
Data Base and Methodology
Present paper is based on the secondary sources of data. The data on sanitation has
been taken from the Tables on houses, household amenities and assets, series 7, Directorate
of Census Operations, Haryana, for the year 2001. Similarly, the data on various diseases in
Haryana have been obtained from the Directorate of Health Services, Haryana, Chandigarh.
This relates to the year 2003. The disease pattern is based on the data of total (indoor and
outdoor) patients treated for various diseases in government hospitals of respective districts.
The classification of diseases is based on 9th International classification of diseases. In the
present paper disease pattern of Haryana has been presented by two ways. First, total patients
treated for various diseases based on 9th International classification of diseases, classified
into 18 categories such as: infectious and parasitic diseases, neoplasm, diseases of nutritional
deficiency, diseases of blood and blood forming organs, mental disorders, diseases of
circulatory system, diseases of nervous system and sense organs etc. (details presented in
Table 3).
Further, for the purpose of seeing the sanitation effect, a detailed classification of
infectious and parasitic diseases has been taken into consideration. For this analysis, water
borne and human excreta borne diseases have been separated. Though many such diseases
are a combination of scarcity of water and lack of sanitation and hygiene due to low
availability of water, yet an attempt has been made to classify water-washed, water borne,
human excreta borne and other tropical diseases. The classification adopted for the purpose
is given in Table 1.
In the present study, a district-wise pattern of infectious and parasitic diseases has
been presented and within this broad category, the pattern of a combination of human excreta
borne and water contaminated diseases has been analysed. The diseases of skin and
subcutaneous tissues are also discussed as these are considered to be strictly water-washed,
i.e. spread in absence of proper hygiene. The researcher would like to highlight that while
the data collection methodology of the state regarding disease scenario has improved, still

4. 82 Rajeshwari
it suffers from few problems. The disease pattern in the state is basically calculated as
percentage of treated patients from total treated patients (suffering from all diseases) in the
respective districts. Hence, the data may be an undercount as it takes into account only
those people who reported for treatment in public hospitals only. Yet, this gives a broad
regional pattern of diseases in the state. Further, simple statistical methods like percentages
have been used to analyze the data.
I
National Policy on Sanitation
The Environmental Hygiene Committee (1948-49) appointed by the Union Government
was the first agency of its type charged with an overall assessment of the country wide
problems in the entire field of Environmental Hygiene. The Committee recommended a
comprehensive plan to provide safe water supply and adequate sanitation services for 90
per cent of the population within a period of 40 years. In 1954, when the first national water
supply programme was launched as part of Government’s health plan, sanitation was
mentioned as a part of the section on water supply.
Sanitation in fact was never perceived as a priority especially in rural areas. Nor was
it seen as a development programme—more often related to lower levels in the priority
ladder and left unmonitored. It was only in 1980, the UN declared the decade 1981-90 as
the International Drinking Water Supply and Sanitation Decade and goals were set for
adequate sanitation facilities for all. This effort crystallized into India’s first nationwide
programme for sanitation, the Central Rural Sanitation Programme (CRSP) in 1986 in the
Ministry of Rural Development. But during this decade also, the coverage with regard to
TABLE 1 : CLASSIFICATION OF INFECTIOUS AND PARASITIC DISEASES
Category Diseases Major Cause of transmission
Intestinal infections Cholera, typhoid, para typhoid, Faecal-oral (Human excreta
ameobiasis, gastroenteritis, and other borne)
related intestinal diseases
Viral diseases Polio, measles, entric fever, encephellities, Human excreta and water-
viral hepatitis, chickenpox, trachoma, contamination borne
Dengu and others
Other bacterial diseases Diptheria, whooping cough, tetanus, Tropical and childhood
meningococcal infection, septicaemia, diseases
leprosy
Veneral Disease Syphilis, Gonococal infection, others Lack of sanitation
Tuberculosis Tuberculosis of various types
Malaria Various types of malaria, Leishmaniasis Water-based (insect vector)
Other Infectious diseases Mycosis, Filariasis, Nicatoriasis, late effects Water and Sanitation borne
of polymyelitis and other infections and
parasitic diseases
Source: Adapted from Feachem-Bradley, 1983, Classification of diseases.

5. Sanitation Situation and Disease Pattern in Haryana: A Spatial Analysis 83
urban sanitation (through sewerage and other excreta disposal methods) and for rural
population was extremely low. However, the target set were 80 per cent for urban population
and 25 per cent for rural population by the year 1990. The position of coverage for urban
and rural sanitation was 25.04 per cent (40.03 million population) and .5 per cent (2.8
million) respectively. Since then, sanitation situation has been covered by a variety of surveys
like Census, National Sample Survey Organization (NSSO), and National Family Health
Survey (NFHS) etc. The figures continue to be alarmingly low. A temporal view in the
availability of toilet facilities in rural and urban India has been presented in Table 2.
TABLE 2 : PER CENT HOUSEHOLDS WITH NO TOILETS FACILITY IN RURALAND
URBAN INDIA : 1988-1998
Rural Urban
1988 (44th round) 89.0 31.8
1993 (49th round) 85.8 30.6
1998 (54th round) 82.5 25.5
Source: NSSO estimates of 44th, 49th and 54th rounds: NSSO (376, 429, 449).
The Central Rural Sanitation Programme (CRSP) was restructured in 1999 and Total
Sanitation Campaign (TSC) was introduced. The TSC was being initiated under the sector
reform process to promote greater user involvement, lower subsidies, to facilitate NGOs
role, and promotion of technologies. The 9th Five Year Plan emphasized the need for
undertaking all possible measures for rapid expansion and improvement of sanitation facilities
in urban and rural areas. The sanitation coverage in terms of individual household toilets
during the 9th Five Year Plan period (1997-2001) was 16 to 20 per cent of total rural
households. Census 2001 data shows that about 22 per cent rural households use toilets.
Increasingly it is being realized that development is not only economic growth, rather
it is the creation of enabling environment and enhancement of quality of life. It is this
realization at international level that in Johannesburg Conference in 2002, challenging
Millennium Development Goals (MDGs) and targets were set. India accepted the MDG
targets and has since then evolved its policies to achieve them. India through its 10th Five
Year Plan endorsed the ambitious growth target of providing rural sanitation to half of its
population by 2015 with 8 per cent growth per year. In June 2003, GOI initiated an incentive
based scheme for fully sanitized and open-defecation-free Gram Panchayats, Blocks and
Districts, called the Nirmal Gram Puruskar to encourage and improve sanitation conditions
in rural areas through Total Sanitation Campaign.
II
Spatial Pattern of Sanitation in Haryana
The data of 2001 Census reveals that about 44 per cent household in Haryana were
having toilet facilities. If we take rural-urban break up, one finds that even in urban areas,

6. 84 Rajeshwari
about one-fifth of the households do not have sanitation facilities (Table 3). Meaning thereby
that our towns and cities are not clean and a large population is still defecating in open. It
also refers to ill health for the people living on the fringe. It may be obtained from Table 3
that within urban areas, not even single district of Haryana has the distinction of 100 per
cent toilet facility. Inter-district disparities can also be seen. It is Sirsa district where 88 per
cent of its urban households have got toilet facility. In Mahendragarh and Kaithal districts,
TABLE 3 : DISTRICT-WISE AVAILABILITY OF FACILITY IN URBAN HARYANA: 2001
Per cent Households with Toilet and Drainage Facility
Districts Toilets Per cent Rural-urban Gap Drainage Per cent Rural-urban Gap
Jind 76.84 62.33 85.51 2.14
Yamuna Nagar 86.28 61.43 90.27 16.26
Jhajjar 78.82 60.12 88.93 11.66
Rohtak 83.98 58.68 88.59 4.85
Gurgaon 84.35 56.86 89.02 35.04
Sonipat 81.59 55.4 91.28 –1.07
Panipat 84.11 54.46 88.90 –0.52
Karnal 83.95 54.03 94.72 8.05
Faridabad 77.19 53.87 84.60 7.42
Panchkula 82.26 53.26 91.18 17.3
Rewari 78.27 53.1 90.55 34.4
Ambala 82.23 51.7 93.45 8.52
Kurukshetra 83.34 51.36 90.67 12.36
Hisar 81.41 49.79 89.30 18.53
Bhiwani 74.49 48.42 85.45 26.99
M. Garh 65.53 47.34 87.02 37.16
Kaithal 67.01 44.0 86.11 3.17
Fatehabad 83.49 42.29 88.34 32.32
Sirsa 88.17 18.33 85.24 39.55
Haryana 80.17 52.0 88.40 16.70
Source: Census of India (2001), Tables on houses, Household amenities and Assets, Series 7, Directorate of
Census Operations, Haryana
35 to 33 per cent of urban households do not have any toilet facility. One can imagine the
enormous pollution effect of lack of sanitation in the cities and towns of these districts,
more so in the context of increasing density of population, higher population growth and
squeezing open spaces. It is generally said that sanitation and sewage is the conscience of
cities. In case of Haryana, the total sanitation still seems to be a challenge. The table also
presents the provision of drainage in urban areas and gap between rural and urban areas.
Drainage and waste-management are interrelated aspects of sanitation. The flow of sullage
water over streets in villages is common sight all over India. In case of Haryana, however
one finds that in urban areas, the drainage facilities are better, yet inter district disparities
are there. A full picture may be obtained from Fig. 1 (Availability of Drainage Facility).

7. Sanitation Situation and Disease Pattern in Haryana: A Spatial Analysis 85
Fig. 1. Availability of Drainage Facility 2001

8. 86 Rajeshwari
Rural areas in Haryana continue to lag behind many states in terms of provision of
drainage facilities, access to sanitation and safe drinking water supply. The picture for
sanitation is an eye opener and it shows that only 28.7 per cent of its rural households have
constructed toilets. This might be due to multiplicity of factors, such as : low awareness of
potential health benefits of better hygiene, perception of the costs of its construction being
unaffordable and sheer convenience, availability of open space or cultural factors.
There are wide inter-district variations and the pattern presents a very interesting picture
(Fig. 2, Availability of Toilet Facility). Located in the extreme western part of the state with
5.28 per cent population, it is Sirsa district which has the distinction of having about 75 per
cent of its total and about 70 per cent of its rural households having toilet facilities. Further,
the rural urban gap in the provision of toilet facility in Sirsa is also lowest in the state. It
must be noted that in terms of total literacy and women literacy, the district stands well
below the state average. The reasons for better sanitation in the district may be attributed to
purely cultural factors. Again, its adjoining district Fatehabad is the second ranking district
in the availability of toilet facility in its rural households. Though the gap between the two
districts is large, in Fatehabad, only 48 per cent households have access to sanitation facility.
Surprisingly, this is also one of the least urbanized districts, with highest proportion of SC
population, and with low levels of female literacy. Paradoxically, in terms of district level
development index as calculated by taking 18 parameters of household amenities, the district
of Fatehabad and Sirsa rank among the least developed ones.
As evident from Fig. 2 and Table 4, the worst situation in terms of rural sanitation can
be seen in the district of Jind where about 86 per cent of its rural households are not having
toilet facility, followed by the districts of Mahendragrah (75 per cent in urban areas and 82
per cent in rural areas) Jhajjar and Kaithal (82 per cent rural and 70 per cent total ). Figure
shows that the problem of sanitation is not confined to rural areas only.
TABLE 4 : SANITATION FACILITY IN HARYANA: 2001
Per cent households Name of Districts (Total) Name of districts (Rural)
with toilet facilities
> 65 Sirsa Sirsa
55 to 65 Faridabad, Panchkula —
45 to 55 Fatehabad, Ambala, Yamunanagar, Fatehabad
Kurukshetra, Panipat, Hisar
35 to 45 Karnal, Sonipat, Bhiwani, Rohtak, —
Gurgaon
25 to 35 Kaithal, Jind, Jhajjar, Rewari Bhiwani, Hisar, Kurukshetra, Ambala,
Karnal, Panipat, Sonipat, Gurgaon,
Rohtak
Less than 25 Mahendragarh Kaithal, Mahendragarh, Faridabad,
Rewari, Jind, Yamunanagar, Jhajjar
Source: Census of India (2001, 7: 3-11), Table on houses, household amenities and assets, DCO, Haryana,
Chandigarh.