Photo:  Suryan and Dang

sanitation

‘A Solution That Can Help Shrink Inequality’

Anoop Jain, an assistant professor of environmental health, researches the far-ranging benefits of shared high-quality toilet facilities serving impoverished communities in India

In 2010, Anoop Jain and two colleagues launched Sanitation and Health Rights in India, a non-governmental organization dedicated to improving sanitation and access to clean water in some of the country’s densest and more impoverished areas.

In the ensuing years, the organization has grown into a robust team of 70 people ensuring the smooth operation of shared community toilet facilities that offer some of India’s most vulnerable citizens safe, dignified places to defecate.

The shared facilities are in communities where households often don’t have the space, money, or resources to have their own private toilet, Jain says. SHRI currently operates 18 facilities across two Indian states that serve nearly 8,000 people per day, and plan to scale up to hundreds more facilities. After more than a decade working with myriad governmental and local stakeholders, “We finally feel like we’ve got a really good pilot under our belt, and we really know what we’re doing,” Jain says.

SHRI’s shared facilities are a sanitation hub for small communities, providing free sanitary toilets that are connected to waste biodigesters that generate and trap methane. The gas is collected and used to power small electric generators to pump and filter drinking water to a high standard, which is then sold to villagers for less than a penny per liter. The nominal charge covers the staffing and operation of the facilities, making most self-sustaining.

Over the past 10 years, the Indian government embarked on a massive public works project to eliminate open defecation by providing low-cost or free toilets to households, improvements to solid waste management and infrastructure in cities and villages, and by subsidizing the construction of more than 600,000 toilet facilities across the country. The ambitious Clean India Mission has achieved mixed results but the government’s commitment to ending open defecation resulted in an opportunity for Jain and colleagues to switch their focus from building similar facilities to researching best practices for improving existing facilities.

“Oftentimes these facilities are not kept in good condition,” Jain says. “They’re not clean, they’re not safe to use.” SHRI is currently working on memoranda of understanding (MOU) with several Indian states to adopt some of their facilities and deploy SHRI’s operating and monitoring systems to ensure the cleanliness of the shared facilities. “We’ve built out a whole data dashboard that anyone in the world can see to check the quality and use indicators on a daily basis of any of these facilities.”

While improving sanitation in critically underserved areas, SHRI’s community toilets have also generated new research opportunities that directly relate to Jain’s academic work at SPH. His previous research centered on the social determinants of toilet access for households in rural or peri-urban settlements, but Jain has broadened the scope of examination and plans a rigorous evaluation of various cleaning practices on actual measured cleanliness of the facilities. He is currently coordinating with the Centers for Disease Control on a pilot study.  

“The concern with these shared toilets—and we saw this during Covid—is that shared facilities often spread disease,” Jain says. “We want to make sure that our cleaning practices are leaving no visible evidence of dirtiness or grime, and at a microbiological level, the door handles, the taps, the switches and everything, are relatively pathogen free.”

Jain is also collaborating with peers in India and at SPH on ways to use SHRI as a platform for novel translational research into the significance of sanitation on multiple aspects of health. The connections between sanitation and infectious disease are well documented, but Jain says there is emerging evidence of the importance of sanitation for positive mental health outcomes as well. “Especially when you don’t have access to a toilet, with women and girls walking long distances, there’s fear, shame, the lack of dignity,” Jain says. India’s rising numbers of elderly is an understudied population, says Jain, who has collaborated with Department of Epidemiology Chair Maria Glymour on a grant to examine the impact of sanitation on the mental health of older Indians who don’t have toilets in their home.

“The percentage of people above the age of 60 is going to be a huge share of the total population by 2050,” Jain says. “When you think about depression and other sorts of psychosocial mental health outcomes, which are no less debilitating whether you’re 65 or 25, it’s important for us to understand and reemphasize the importance of sanitation as it pertains to not only kids and younger adults, but certainly as it pertains to the health and wellbeing of older adults as well.”

SHRI is also well positioned for future involvement in broader disease surveillance efforts in rural and peri-urban settlements where no sewer network or wastewater treatment plants exist. The community toilets usually store waste in sewage tanks that enable efficient sample collection or periodic monitoring. “We want to design a system and network of doing this routine surveillance because it’s important to be able to track the emergence of infectious diseases in these kinds of underserved communities,” Jain says.

But each of those promising opportunities is accompanied by its own new set of challenges that reveal the difficulty of working within complex social and government structures. For example, many of the millions of toilet facilities the government claimed to have built during the Clean India Mission boom have already fallen into disrepair.

The shifting landscape has prompted a change in the way that Jain and colleagues think of their role, moving from an organization trying to improve health one community at a time to one trying to strengthen systems. “The government cares deeply about ensuring that people have access to toilets, and shared toilets for communities where household toilets are impossible,” Jain said. “We are trying to strengthen that system by saying, okay, the infrastructure is there. Now let’s make sure the quality is also there so that everyone gets the high-quality services that they deserve.”

Jain says the Indian government has been a welcoming partner in local sanitation efforts, but the goal of eliminating open defecation is still a puzzle subject to larger societal and economic factors out of SHRI’s control.

“There are so many root causes of open defecation but largest among them is extreme poverty. People can’t afford to build a toilet, and as a function of extreme poverty, they don’t have enough space to build a toilet, “Jain says. “And as another function of extreme poverty, they live in communities where there is no sewer network. So even if they were to build a toilet, there’s no waste management provision. It’s going to take a lot of systematic structural change, which we hope for, but in the time being, we see high-quality shared toilets as a solution that can help shrink inequality.”