Swachh Bharat only possible when health is a priority
Despite advances in health, we find that certain preventable diseases are endemic to our country. Neglected tropical diseases (NTDs), a group of bacterial and parasitic diseases, affect one in six people around the world. While these diseases are not fatal, they are known to cause disability, anaemia and malnourishment; undermining the human capital that we seek to capitalise for future growth.
This aspect of public health bears significant importance especially with regard to the Swachh Bharat Mission (SBM) anniversary that we are commemorating today. The ambitious initiative of Prime Minister Modi has rightly articulated objectives that we Indians must aspire to achieve as public health goals.
Though many of the shortcomings such as open defecation and poor hygiene can be (and are) a function of circumstance for many, manual scavenging and abysmal solid waste management are a result of discrimination and unscientific management respectively.
It is in this context that one will find that eradicating NTDs are inextricably linked to the objectives of the SBM. NTDs refer to a set of bacterial and parasitic diseases, such as lymphatic filariasis (commonly known as elephantiasis or hathipaon) and soil-transmitted helminths.
NTDs are spread by insects like mosquitos and flies, or through contact with contaminated water or soil. They affect the "bottom billion" or the world's poorest people - the same people who lack access to clean water or improved sanitation and hygiene infrastructure like toilets. Some estimates suggest that over 600 million people are at risk of contracting one or more NTDs in India.
Shortcomings
Unfortunately, our awareness of this issue is strikingly low. Perhaps the reason why the NTDs have not captured the public imagination the way other health crises have is because they are often not fatal. However, this relatively low mortality rate masks the many grim consequences of being afflicted by the NTDs.
For example, lymphatic filariasis (LF) causes severe swelling of the limbs that keeps people from leading normal lives - or, in some cases, undertaking a job that might be the only means to support their families. Likewise, soil-transmitted helminths can sap the energy and health of children, and keep them from regularly attending school. Thus, the NTDs cause disability, contribute to malnutrition and perpetuate poverty among those affected by them.
Fortunately, India has invested significant time, technical capacity and financial resources to eliminate and control NTDs. The serious nature of the effects of NTDs helps to explain why the government has adopted mass medication programmes aimed at controlling NTDs in the vulnerable parts of the country. In 2012, the National Vector Borne Disease Control Programme provided anti-NTDs medication to over 400 million people. Similarly, the National Deworming Day initiative saw 89 million children receive deworming medication in 2015.
While the scale of these interventions is no doubt impressive, we must not fail to notice that all of these efforts have focussed on medication rather than preventing the presence of these diseases in people's bodies in the first place. That is a troubling realisation, because it is a well-known fact that ensuring access to better-quality water, sanitation and hygiene is a key way to prevent the parasitic worm eggs that cause these diseases from infecting humans in the first place.
Medication
Proper water management also prevents the breeding of mosquitoes, who serve as carriers of LF. These are the reasons why the World Health Organisation has called for water, sanitation and hygiene efforts to be undertaken in areas affected by the NTDs, rather than exclusively focus on post-infection medication.
This is where the SBM comes in. As a mission to improve sanitation and hygiene in India, it should be evident from the beginning that a Swachh Bharat or Clean India will also be one where NTDs are less likely to be found. The complementary nature of what needs to be done to fight NTDs and what the SBM seeks to achieve becomes even clearer when one realises that the latter's stated objectives include creating awareness about the links between sanitation and public health, and promoting the adoption of healthy sanitation practices.
Yet, goals on paper often differ from priorities in the field, and this one-year mark is a good time for us to take stock of how the SBM can better contribute towards a NTDs-free India. While the focus of the programme so far has been on building infrastructure (especially toilets and solid waste management units), there needs to be more explicit focus put into achieving the public health objectives.
Incorporating measures to provide better water, sanitation and hygiene into SBM - and these even include elementary steps such as ensuring that water does not remain stagnant - will go a long way in protecting our citizens from NTDs. And crucially, as the term NTD itself suggests, vigorous awareness efforts are required to dispel the public ignorance around these diseases.
As highlighted earlier, our commitment towards SBM and efforts towards controlling and eliminating the NTDs are complementary. Falling NTDs rates will provide a good indication of the success of the SBM. The eradication of the NTDs should be seen as low-hanging fruits whose success will help set the national agenda on public health and sanitation.
Sanitation
However, one pressing concern that limits our progress is the people's inertia in ensuring cleanliness and hygiene in their communities.
One reason for this is the perception that cleanliness is not something that tangibly benefits you. A stronger focus on the link between cleanliness and health can help change this perception, get more people on board, and improve the SBM's chances of success. Indeed one of the objectives of the SBM is to effect behavioural change regarding healthy sanitation practices.
We are not far from the success with regard to NTDs (2015 was the target for LF eradication). Similar to the story of the successful eradication of polio from India, the same effort and strategy must be implemented for preventable diseases such as NTDs. These positive outcomes will have spill over effects to other public health programmes, and consequently growth outcomes of India's human capital.