Global health inequality and sanitation since 1850

Contaminated water and inadequate waste disposal are major causes of disease, morbidity and early death. In 2016, 2.2 billion people were lacking in-house tap water and toilets, making them highly vulnerable to waterborne illnesses. Although the long-term roots of public health inequalities have long been recognised, little is known about the early evolution and drivers of unequal access to sanitary services. The aim of this project is to understand the historical determinants of public health infrastructures by analysing how the local concentration of political power influenced the initial adoption and subsequent diffusion of modern clean water and sewerage systems in major cities worldwide since 1850. A better understanding of the drivers of public health investments is vital for achieving Goal 6 of the Sustainable Development Goals: universal access to sanitary infrastructures; and comprehending the historical origins of global health inequality dating back to the late 19th-century.

Project description

This project provides a new perspective to understand how the concentration of political power results in sanitary investments by arguing that the traditional focus on public finance misses two key elements of the global sanitary revolution: initial adoption (i.e. the year waterworks/sewerage start functioning) and subsequent diffusion (i.e. network expansion across neighbourhoods). This distinction is crucial because the late-19th-century adoption of waterworks did not systematically differ between cities in Europe and North America – with arguably better political and fiscal conditions– and cities in the ‘global South’, but the timing and intensity of within-city diffusion differed greatly. Thus, the relevant question is not how elites influenced public finance, but rather, how disparate local political contexts resulted in an almost simultaneous worldwide adoption of sanitary infrastructures in the 1850s–1880s, and then gave rise to highly different paths of network diffusion.

This project uses new archival sources and a mixed-methods approach to investigate how local political contexts shaped the global spread of waterworks and sewerage. My hypothesis is that elites in large unhealthy cities promoted the adoption of sanitary infrastructures, but hindered the network diffusion on varying economic, social or ideological grounds. I test this hypothesis through a comparative analysis of sanitary adoption in major cities worldwide since 1850, and by conducting an in-depth case-study of the local political economy of sanitary diffusion in four big cities.

Results

Three patterns are key to understand the diffusion of waterworks and sewerage systems worldwide since 1850. First, major cities throughout the world built these infrastructures at a (roughly) similar time between ca. 1850s and 1890s. Second, there were large differences in their timing both within and between countries before ca. 1880; afterwards only municipalities in some (industrialised) countries converged with frontrunners. And third, the within-city diffusion of pipes and sewers was even more unequal between countries than the initial construction of waterworks and sewerage.

What were the health consequences of the new water and sanitation technologies? Evidence from a large number of countries points at positive effects, although somewhat lower than initially thought: estimates from comparable studies indicate that infant mortality declined between ca. 10 and 30 percent following their construction.

What explains the adoption patterns of water and sanitation technologies since ca. 1850? This project points at some concrete processes that shaped local political power and decision making that ultimately brought about sanitary investments. For instance, broad democratisation was not a necessary condition for cities to invest in water and sanitation projects everywhere. The extension of franchise in England did not invariably result in greater public health spending; the highly-unequal political environment of German cities did not prevent them from becoming world leaders in sanitary services; and American elites used their ability to discriminate against their black counterparts to construct expensive waterworks from which they were excluded.

In such contexts, it was in the interest of elites to support their provision, be it to promote their industrial business requiring clean water and a healthy labour force or to lower their construction by limited within-city coverage. In addition, these elites may have demanded clean water and more efficient waste disposal if they felt that their lives were at stake. The development of a culture of hygiene during the 19^th century, ultimately underpinned by scientific medical advances, first spread among the elite and ultimately increased the perceived value of expensive public health investments. This issue was particularly salient during deadly epidemics, such as cholera, that were associated with filth and deprivation. The quantitative importance of this mechanism, however, is unclear and further research is needed to assess its importance in various contexts. In this regard, the literature would greatly benefit from non-Western experiences where epidemic outbreaks did not recede during the late 19^th century.