**Potential trigger warning.
Public health is a wonderful field
full of motivated and energetic people with a real drive to do good in the
world. There is ostensibly something elegantly uncontroversial about many of
the goals of global health: you’re preventing people from dying from
preventable or curable diseases. You’re saving lives. While other programs are
sticky with politics and controversy, health programs keep people alive, and
that is good.
This is the
kind of narrative that has attracted many people (myself included) to the field
of public health. In this whole mess of a
world, we can at least we can do this—get children a headstart in life by
encouraging their mothers to breastfeed, give people clean water, immunize
people against diseases. But this kind of thinking has resulted in a tendency
to have a end-oriented perspective: the
ends justify the means. Preventing children from dying is important and
good, and this is an end that justifies its methods.
This is the
sort of thinking that led to some of the brutalities of the smallpox vaccine
campaign: lies and manipulations of government officials, doors kicked down in
the middle of the night, children held down and forcibly vaccinated. The harsh
memories from those days lingers on in these places, and it hinders current
vaccination work and collaboration. Yes, we eliminated smallpox, and that is
incredible—but what was the cost?
Community-Led Total Sanitation
(CLTS), as I’ve previously
, is an approach started by Kumal Kar in Bangladesh
. It triggers disgust in
a community at open defecation, then and mobilizes community shame in order to
motivate individuals to build their own latrines. This approach is ubiquitous
around the world, but most particularly in South Asia
Amina Mahbub, an anthropologically-trained health practitioner and researcher,
wrote a chapter in the book Shit
Matters: the potential of community-led total sanitation.
Mahbub’s chapter discusses how CLTS approaches affect
women and children in Bangladeshi communities. While she points out that CLTS
does not do a good job helping the extremely poor, her review is a mostly positive perspective of the approach.
going to go into a line-by-line critique of the whole chapter or discuss the
approach overall (I’ve done the latter previously), but this sentence just
stopped me short:
“VDC (local government)
members…further stated that no bichar
(arbitration) would be held if young women and adolescent girls were raped
whilst defecating outside” (47).
Let me repeat that: If someone is raped while trying to find a place to defecate, the village counsel
is going to ignore it. They are going to ignore
rape. Because a young women or girl, who is looking for a place to defecate
outside because she probably can’t afford a toilet in her house, deserves to be raped.
I believe in sanitation. I believe
in its importance to change lives for the better and its importance in ensuring
health. But I do not think there is any justification for measures that rely on
the degradation of women. These are older, powerful, male villagers who said
this. They are seated in places of privilege. With the government and NGOs
looking at them to decrease open defecation, they are strongly motivated to
decrease OD in order to maintain or increase their prestige. When they say they
will not arbitrate rape cases, they are telling young women that their bodies,
their rights, do not matter as much as their status. They are telling men that it's open season on any young woman you see after dark, because you can always
say they were out defecating.
The next sentence is, “Therefore
the extreme poor were compelled to install toilets.” How sad, really. Instead
of wanting to install toilets, instead of being worked with to improve their
sanitation situation, they are threatened—the threat of the awfulness of rape
or by the loss of honor that would come with having a female in
the household raped.
Most approaches—this one
included—are multipronged, so it’s difficult to point out what particular aspect
of any approach was effective. So I cannot argue with this approach on an
effectiveness level; we cannot say, Well,
at least it’s effective or This
wasn’t even effective.
effectiveness isn’t the point. While yes, open defecation put the whole
community at risk, does that really excuse these kinds of threats against
individuals? Furthermore, what do you think people will remember next time a
development group wants their cooperation?
The struggle for better health for all (which
is really what we’re in this for) is a long, long struggle. Impatience leads to
collateral damage. ‘Ends justifies the means’ behavior leads to other problems
in other areas down the line. In trying to save people, let’s not make their