Global health inequality and the diffusion of 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 recognized, little is known about the early evolution and drivers of unequal access to sanitary services.

Some scholars claim that political inequality has hindered public health investment, as local elites favoured low taxation and expenditures. Other scholars argue, instead, that elites encouraged public health investments, whenever their interests aligned with those of the population-at-large. This NWO Veni project is motivated by the observation that the focus on public finance misses two key elements of the globalization of sanitary infrastructures: 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 how disparate local political contexts resulted in an almost simultaneous worldwide adoption of sanitary infrastructures in the 1850s–1880s, followed by 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.