The World Health Organization’s (WHO) guidelines for protection against COVID-19 are simple and basic. They advise people to wash their hands frequently with soap and water, practice social distancing, and stay home if one happens to be in an affected area or has been exposed to the virus in any way. They also advise home quarantine for people who are in or have recently visited (in the past 14 days) COVID-19 affected areas to avoid the spread of the disease (World Health Organisation nd).

Even as healthcare systems in developed countries, like the United States (US), the United Kingdom (UK), and Italy, have not been able to contain the rapidly rising number of cases, following such advice is crucial to pre-empt the spread of the virus, especially in low- and middle-income countries where healthcare systems are even less developed. But, in reality, in a densely populated country like ours, how practical it is to adhere to these guidelines?

Using the latest National Sample Survey Office (NSSO) data on housing and sanitation (76th round, 2018)[1], we make an assessment of the availability of basic housing and related amenities, such as sanitation facilities, which are minimum requirements for following WHO guidelines effectively. We consider per capita availability of rooms, access to water, and bathing and toilet facilities as prerequisites for compliance with the social distancing norms, and to maintain hygiene.

Cheek-by-jowl Living Spaces

Examining the housing infrastructure in India reveals that almost a third of the rural population and half of the urban population in India live in houses where the per capita space available is less than a single room, which effectively means that isolating a person with the risk of infection is extremely difficult. This implies that home quarantine/self-isolation measures would be difficult to implement among 60% of the population in the event of spread of infection (Table 1).

Table 1: Per Capita Availability of Rooms (%)

Rural Urban Total Less than a room 66.08 45.16 59.6 Just a room 14.71 17.1 15.45 More than one room 19.21 37.74 24.95 Total 100 100 100

Water Woes

The availability of running water in houses is a necessity to ensure frequent handwashing with soap. The NSSO data reveals that 40% of urban households and 75% of rural households in India do not have access to tap water in the house or within their residential premises (Table 2).

Table 2: Source of Water (%)

Drinking Water Domestic Needs

Source Rural Urban Total Rural Urban Total Bottled water 3.4 10.3 5.5 0.1 0.4 0.2 Piped water into houses 11.5 43.7 21.4 13.9 49.6 24.8 Piped water to yard/plot 9.8 14.1 11.1 9.8 10.8 10.1 Piped water from neighbour 0.8 1.0 0.8 0.8 0.9 0.8 Public tap/standpipe 9.1 7.1 8.5 7.4 5.4 6.8 Tube well 10.8 10.3 10.7 11.5 17.2 13.2 Hand pump 45.3 8.0 33.9 41.4 7.9 31.2 Well: Protected 2.9 1.6 2.5 2.7 2.4 2.6 Well: Unprotected 4.3 2.5 3.7 4.5 2.8 4.0 Tanker truck: Public 0.1 0.8 0.3 0.1 0.5 0.5 Tanker truck: Private 0.4 0.5 0.4 0.5 0.5 0.5 Spring: Protected 0.3 0.1 0.2 0.2 0.0 0.2 Spring: Unprotected 0.3 0.0 0.2 0.4 0.0 0.3 Rainwater Collection 0.3 0.1 0.2 0.1 0.0 0.1 Surface water: Tank/Pond 0.4 0.1 0.3 4.9 1.0 3.7 Other surface water (river, dam, stream, canal, lake, etc. 0.2 0.1 0.2 0.3 0.1 0.2 Others (cart with small tank or drum, etc.) 0.2 0.1 0.2 0.3 0.1 0.2 Total 100 100 100 100 100 100

It means that households fetch water from public taps, wells, or other communal water sources. This implies that while maintaining hand hygiene itself is difficult in these circumstances, there is a higher risk of contamination of water and also the spread of infections during public health crises.

Additionally, it has been found that the average time required to fetch water from community sources is close to an hour everyday implying that social distancing is difficult to follow for a large proportion of households. As is the practice in many developing countries, the burden of fetching water is predominantly on women (73%) exposing them to greater health risks (Table 3).

Table 3: Access to Drinking Water (%)

Rural Urban Total (a) Access to drinking water Within dwelling 30 59 39 Outside dwelling but within the premises 31 22 28 Outside premises Less than 0.2 km 28.6 13.7 24.0 0.2 km to 0.5 km 8.0 3.2 6.5 0.5 km to 1.0 km 2.1 1.2 1.8 1.0 km to 1.5 km 0.4 0.4 0.4 1.5 km or more 0.5 0.5 0.5 Total 100 100 100 (b) Average time (in minutes) required to fetch water in a day from outside premises 48.5 40.0 47.0 (c) Who fetches water? Male members 20.8 33.8 23.0 Female members 77.5 56.6 73.9 Hired labour 0.6 4.7 1.3 Others 1.1 4.9 1.8 Total 100 100 100

Poor Sanitation Facilities

Next, we examine access to exclusive washrooms and latrines required to maintain hygiene to avoid coming into contact with viral discharges of infected persons (Table 4). Among the rural households, 45% have no access to exclusive washrooms, and 39% have no access to exclusive latrines, of these 5% each use public facilities.

In urban areas, while the percentage of people without access to washrooms and latrines is lower at 9% and 4% respectively, a higher proportion of households use common/public washrooms and latrines (11% and 13.5% respectively).

Overall, about 8% of the Indian population uses public sanitation facilities and a quarter of the population has no access to any sanitation facility, making it difficult to follow good hygiene.

Table 4: Access to Bathrooms and Latrines (%)

Bathrooms Latrines

Rural Urban Total Rural Urban Total For the exclusive use of household 51.5 79.7 60.2 65.0 82.2 70.2 For common use of households in a building 4.8 10.7 6.6 5.7 10.6 7.2 Public/community use without payment 0.1 0.2 0.1 0.2 1.5 0.6 Public/community use with payment 0 0 0 0 1.2 0.4 No bathroom 43.5 9.3 33.0 28.7 4.1 21.1 Others 0.2 0.1 0.2 0.5 0.4 0.4 Total 100 100 100 100 100 100

Prevalence of Proper Handwashing Practices

Finally, we examine handwashing practices among Indians, before meals and after defecation to understand how strongly embedded is the idea of washing hands with soap and water (Table 5). We find that while 75% of the population wash their hands using soap and water after defecation, only 34% do so before having a meal. The majority of the population (62%) use only water to wash hands before meals. This shows that the most crucial practice to curtail infections through handwashing with soap several times a day is a habit that the majority of Indians are yet to cultivate.

Table 5: ​Handwashing Practices (%)

Rural urban Total (a) Handwashing regularly before meals With water and soap detergent 25.0 55.3 34.3 With water and ash mud/sand etc. 3.6 1.4 2.9 With water only 70.1 42.7 61.7 Do not wash 1.3 0.6 1.1 Total 100 100 100 (b) Handwashing regularly after defecation With water and soap detergent 68.4 89.2 74.7 With water and ash mud/sand etc. 18.1 2.1 13.2 With water only 13.5 8.7 12.0 Do not wash 0.1 0.0 0.1 Total 100 100 100

Our analyses demonstrate that maintaining social distancing, following hygiene, and complying with self-isolation guidelines is extremely difficult for a majority of the population due to existing housing and sanitation facilities. Even if information regarding preventive measures is disseminated to reach the entire population, the lack of basic amenities renders the less-privileged sections of the Indian society defenceless against COVID-19.