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

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 and Assam 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

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

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.

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 RURAL AND

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,

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).

Sanitation Situation and Disease Pattern in Haryana: A Spatial Analysis 85

Fig. 1. Availability of Drainage Facility 2001

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.