Sanitation (from the Latin sanitas, meaning health) refers to the maintenance and delivery of clean, hygienic conditions that help prevent disease through services such as drinking water supply, garbage collection, and safe disposal of human waste. Sanitation is the focal point of public health policy, but in the experience of local communities much more than health is at stake in “sanitation.”
World Health Organization (WHO) reports show that in 2004, 5.3 billion people (83% of the world population) had access to clean water sources (in 1990 that percentage was 78). Of the 1.1 billion people without access to clean drinking water, 84 percent live in rural areas. The situation is particularly critical in sub-Saharan Africa, where 44 percent of the population remains without clean drinking water, and in Eastern and Southern Asia.
Similar statistics apply to the coverage of “basic sanitation” (improved toilet facilities). According to the same 2004 WHO report, only 59 percent of the world population had access to a hygienic toilet in 2004. It is again sub-Saharan Africa (38 percent) and Eastern Asia (45 percent) that have the highest populations without basic sanitation.
Unsanitary conditions are the main cause of ill health and premature death in poor societies. WHO statistics of 2004 report that 1.8 million people die every year from diarrheal diseases (including cholera), 90 percent of whom are children under five. Eighty-eight percent of diarrheal disease is attributed to poor sanitation. Malaria, another sanitation related disease, kills 1.3 million people each year; again, 90 percent of these deaths are children under five. Other diseases that originate in poor sanitary conditions include schistosomiasis (a parasitic infection), intestinal helminthes (ascariasis, trichuriasis, hookworm), and hepatitis-A. Although the health consequences of sanitation are overwhelming, people often have reasons to pursue—or refuse—better sanitation.
EVOLUTIONIST VIEWS: SURVIVAL INSTINCT
Social scientists have developed various theories to interpret or explain human concern about avoiding dirt and promoting hygiene. Evolutionist thinkers believe that there is medical wisdom in the human fear of dirty things. Dirty objects and activities pose a danger, so it is wise to avoid them. Disgust of dirt is a survival strategy (usually a non-conscious one). A 2001 study by Valerie Curtis and Adam Biran list five disgust elicitors derived from research in India, Burkina Faso, The Netherlands, Britain, and an international airport. The five elicitors are: (1) body excretions and body parts; (2) certain animals; (3) decay and spoiled food; (4) certain categories of “other people;” and (5) violations of morality. Bodily excretions were mentioned most frequently as causing disgust and among them, feces topped the list, but vomit, sweat, spittle, blood, pus, and sexual fluids were also regarded with aversion. Animals that were mentioned most often included pigs, dogs, rats, snakes, worms, cockroaches, maggots, lice, and flies. People that were found disgusting were those with signs of sickness, dirt, or deformity, and strangers with whom one was forced to come into close contact, for example in crowded places. People who behaved immorally also evoked aversion.
Curtis and Biran’s hypothesis is that humans have evolved behavioral defenses against disease and that “disgust is one of the mechanisms crafted by natural selection to keep our distance from contagion” (Curtis and Biran 2001, p. 22). The researchers found support for their hypothesis by checking the routes of transmission for a selection of common infectious diseases. In all of them, one or more elicitors of disgust were mentioned as playing an important role in transmission. Feces were named as the source of more than twenty infectious diseases. Breath, saliva, lice, rats, and sexual organs were also important sources or transmitters of infection. All of these score high for human disgust.
William Ian Miller’s 1997 study of disgust is difficult to place in any disciplinary tradition. His own expertise mainly lies in literature and history but his study also draws on psychologists, moral philosophers, and political and social theorists. Trying to decipher the origin and working of emotion, Miller derives most inspiration from psychology.
The disgust Miller discusses applies to many phenomena and activities, such as defecation, sex, food, and drink. He distinguishes two types of disgust. The first, which is clearly Freudian, prevents the activation of unconscious desire. It defends against pollution, denies access to objects and acts that would block the psychic development of the human person. The evolutionist perspective of disgust as a survival instinct returns here at the level of the human psyche. The second type of disgust is “disgust of surfeit,” it punishes after having indulged in a “disgusting” activity. The two types complement each other. In the aversion of things perceived as dangerous because of their power “to contaminate, infect, or pollute by proximity, contact, or ingestion” it is first of all the unconscious reaction to psychic dangers that is at work (Miller 1997, p. 2).
Most authors writing on hygiene and sanitation from a sociological point of view refer to Norbert Elias’s study on the civilization process. Elias studied etiquette books, letters, and other documents in France and England from the eleventh century onward and describes how the authors of those guides for proper conduct gradually became more particular about body functions, body parts, and body products.
He talks about a general process of civilization, which implies a “privatization” or “intimization” of human behavior. More and more, public activities became shameful and were confined to the private world. The human body was a focal point. The body itself had to be well covered and activities such as sex, sleep, urination, and defecation became embarrassing when carried out in front of other people. Modern hygiene facilities are regarded as expressions of the civilizing process.
CULTURAL SYMBOLICS AND RELATIONAL CONCERNS
The symbolic anthropologist Mary Douglas, in her classic Purity and Danger, turns away from evolutionist and “medical materialist” (a term used by American psychologist and philosopher William James, meaning reducing ritual to its supposed positive medical effect) explanations of hygiene and presents dirt as “matter out of place,” a definition that became famous for its beautiful simplicity and provocation. Shoes on the table (Douglas’s example) are dirty; under the table they are clean. Saliva safely caught in a handkerchief is hygienic, but when it falls in a plate it turns disgusting. Her claim that absolute dirt does not exist opened new windows in the study of hygiene as a cultural phenomenon. Dirt is defined by its context. It is disorder and carries an invitation or rather an obligation to restore order: “Ideas about separating, purifying, demarcating and punishing transgressions have as their main function to impose system on an inherently untidy experience” (Douglas 1970, p. 15). Hygiene, in short, is a basic cultural act: it distinguishes dirt from what is clean and thus, creates cultural order. Enculturation of small children starts with teaching them what is clean and what is not clean. Hygiene is the essence of culture. What is dirty is of less importance. Crucial is that dirt exists. Without the concept of dirt people could not formulate the norms and values of culture.
What makes an object abject and threatening? Douglas suggested: its out-of-place condition. Others claimed it depends on the matter itself. Too little attention has, however, been given to the identity of the person who is directly associated with something dirty, to the social life of the dirty matter. The answer to the question “whose?” determines the experience of disgust much more than has been suggested by Douglas and other authors who wrote about the cultural meaning of dirt. By adding a sociological dimension to dirt, Douglas’s theory of matter out of place becomes more true to life and effective as an interpretative tool.
The humanist Erasmus’s dictum that one’s own shit has a pleasant smell (Suus cinque crepitus bene olet) is a humorous exaggeration, but it is not exaggerating to say that people usually are not disturbed by the smell (and sight) of their own feces. Objects, substances, and acts become dirtier as the person behind them is less close or less liked. Animals that produce dirt are also placed in categories of less and more disturbing. Animals that are “part of the family” are experienced as cleaner than those who belong to another family. And so on. Acts and gestures from a loved person that are cherished as dear and intimate (bodily contact, sex) turn into horrifying violence when another person performs them. Good or bad, clean or dirty, in this case, depends entirely on the actor. The “matter” remains the same. The urge for “hygienic action” also depends a great deal on such relational concerns. Washing hands after toilet use or before eating, for example, is as much a social as a healthful act.
Hygiene, in the medical sense, is a core value in modern societies. Objects, activities, and people are judged by their medical qualities. Food, houses, streets, markets, working places, holiday camps, public transport, and visitors should be clean and not pose a danger to health. Dirty things and people are rejected and rejected things and people are called dirty.
Anthropologists and historians argue, however, that people do not always make that explicit link between Page 323 | Top of Articlehealth and dirt. After studying the hygienic ideas and practices by mothers in Burkina Faso, Curtis concluded that their cleanliness and dirt avoidance were primarily a matter of “etiquette and social acceptability rather than to avoid illness” (Curtis 1998, p. 110). In a 2005 study, conducted in Bénin, Jenkins and Curtis observed that modern toilets were popular because they were seen as a sign of social prestige and success.
Michel Foucault argues that in the modern state, medicine is a major instrument of control by societal and political institutions. His concept of “Bio-power” suggests that the state can reward or punish its citizens by providing or withholding health. Sanitation, preventive heath care, implies the imposition of a regime. Sanitary policy legitimizes the state’s interference in households and private lives of people and thus helps to establish more effective disciplinary power. Bio-power—and sanitation in particular—constitutes the link between macro and micro (Foucault 1990; Gastaldo 1997).
Sanitation policies have been most successful when they also appealed to other values in people’s lives, such as social decency, respect, comfort, and religion. Cultural ignorance and lack of respect for local knowledge and practices of hygiene are major problems in sanitation projects by both foreign organizations and local governments in low-income societies. Tiokou Ndonko’s 1993 anthropological study in Cameroon for example, analyzed cultural and religious resistance against the government’s sanitation policy. Hygiene, seemingly a purely medical concern, lies at the heart of culture and is both a means of political control and resistance.
Curtis, Valerie. 1998. The Dangers of Dirt: Household, Hygiene and Health. PhD diss., Agricultural University Wageningen.
Curtis, Valerie, and Adam Biran. 2001. Dirt, Disgust and Disease: Is Hygiene in Our Genes? Perspectives in Biology and Medicine 44 (1): 17–31.
Douglas, Mary.  1970. Purity and Danger. An Analysis of Concepts of Pollution and Taboo. Harmondsworth, U.K.: Penguin.
Elias, Norbert.  1982. The Civilizing Process. New York: Pantheon.
Foucault, Michel. 1990. The History of Sexuality, vol. 1: An Introduction. London: Penguin.
Gastaldo, Denise. 1997. Is Health Education Good for You? Rethinking Health Education through the Doncept of Biopower. In Foucault: Health and Medicine, ed. Alan Petersen and Robin Bunton, 113–133. London: Routledge.
Goudsblom, Johan. 1986. Public Health and the Civilizing Process. Milbank Quarterly 64 (2): 161–188.
Jenkins, Marion W., and Val Curtis. 2005. Achieving the “Good Life”: Why Some People Want Latrines in Rural Benin. Social Science and Medicine 61 (1): 2446–2459.
Miller, Ian. 1997. The Anatomy of Disgust. Cambridge, MA: Harvard University Press.
Ndonko, Flavier Tiokou. 1993. Répresentations Culturelles des Excrements. Münster, Germany: Lit Verlag.
World Health Organization. 2004. Water, Sanitation and Health. http://www.who.int/water_sanitation_health/publications/facts2004/en .
World Health Organization. 2005. Meeting the MDG Drinking Water and Sanitation Target. The Urban and Rural Challenge of the Decade. Geneva: World Health Organization.
Sjaak van der Geest