Shaming and Sanitation in Indonesia: A Return to Colonial Public Health Practices?

Shaming and Sanitation in Indonesia: A Returnto Colonial Public Health Practices?

Susan Engel and Anggun Susilo

ABSTRACT

Adequate sanitation is vital to human health, yet progress on the MillenniumDevelopment Goal for sanitation has been slow and the target is likely tobe missed by one billion people. Indonesia has the third highest number ofpeople of any country in the world without access to sanitation and, likemost developing countries, it is devoting insufficient resources to the issue.In rural areas, rather than providing additional funding, the government —with support of the World Bank — has promoted the Community-Led TotalSanitation (CLTS) approach, which uses social mobilization to encouragepeople to construct their own latrines. In Indonesia as elsewhere, CLTSinvolves more than just education and encouragement; it uses social shamingand punishments. The authors argue that this is not only an inadequateapproach but one which echoes coercive, race-based colonial public healthpractices. This article thus integrates extant historiography on Indonesiancolonial medicine with contemporary scholarly literature and field researchon CLTS using case studies of a 1920s hookworm-eradication programmefunded by the Rockefeller Foundation, and the current World Bank Waterand Sanitation Programme, both in Java.

INTRODUCTION

Improving sanitation is an important goal: some 2.4 billion people across theglobe lack access to improved sanitation. This increases their vulnerabilityto disease because human waste transmits bacteria, viruses and parasitesthat harm human health (WaterAid, n.d.). The health impacts on children areparticularly serious as diarrhoea is the second biggest killer of children un-der five worldwide. For girls and women, lack of sanitation impacts schoolattendance, especially during menstruation; it also impacts safety, as womenoften wait for the cover of darkness to defecate in the open. Poor sanitation

We would like to thank M. Ilham Sofyana for sharing his insights and analysis during our field-work. Two anonymous referees provided thorough and constructive comments that significantlyimproved the final version of this article; a big thanks for their input. Thanks also to Ian Rosier forhis editorial and fieldwork support. Finally, we wish to acknowledge the villagers who sacrificedtheir time for the interviews.

Development and Change 45(1): 157–178. DOI: 10.1111/dech.12075C© 2014 International Institute of Social Studies.Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and350 Main St., Malden, MA 02148, USA

158 Susan Engel and Anggun Susilo

impacts productivity, longevity and health care costs for the whole commu-nity. Untreated or poorly treated sewage is also a major source of water andenvironmental contamination.

Against this background, we set out to study a sanitation project in EastJava, Indonesia, with a particular focus on the district of Trenggalek. Ourinitial concern was issues of decentralization and participation in the post-reform context; however, we quickly became concerned about the use ofshaming techniques to promote improved sanitation and to end open defe-cation. Programmes to promote sanitation have been in place since colonialtimes. The technique of inducing shame and embarrassment amongst thecommunity about open defecation that is now popular evolved from socialmobilization approaches to community development labelled Community-Led Total Sanitation (CLTS). CLTS was developed in 1999 in Bangladeshby Kamal Kar, working with local and international non-governmental or-ganizations (NGOs) (Harvey, 2011: 96).1 CLTS is now a widespread andcommonly used approach in rural and peri-urban sanitation and is promotedas a way to aid achievement of the Millennium Development Goal (MDG)on sanitation, on which progress has been slow. The technique was origi-nally promoted by NGOs and some developing country governments haveadopted it, but its rapid spread is predominantly due to the support of majordonors, in particular the World Bank. CLTS is the key technique in thesanitation component of the multi-donor funded and World Bank-led Waterand Sanitation Programme (WSP), which operates in twenty-five countries(see WSP, 2011).

CLTS is a supposedly participatory process with two main stages. In thefirst stage, communities are taken through a ‘walk of shame’ to identifyand raise consciousness regarding the extent of faecal matter in the village;they then participate in a defecation mapping exercise, which is supported bytechnical data in the form of core faecal counts. The second stage is householdlatrine construction, backed by technical advice and further action with thoseunable or unwilling to construct latrines, but with no financial support fromthe state. While some proponents posit that the triggering process is notsupposed to ‘shame, insult or embarrass the community in any way’ (Harvey,2011: 100) and others note that it is about collective consciousness-raising ofthe severe impacts of open defecation (Kar and Pasteur, 2005), the reality isthat in a range of countries using the technique, it involves systems of ‘fines,taunting or social sanctions to punish those who continue to defecate in theopen’ (Pattanayak et al., 2009: 581, emphasis added). Viewing the project onthe ground, we were quite surprised by the CLTS approach and its inclusion

1. CLTS was pioneered in the small community of Rajshahi, Bangladesh, by Kamal Kar, whowas working with a local NGO, the Village Education Resource Centre, with support fromWater Aid (Kar and Pasteur, 2005: 1). The approach was then adopted by other NGOsbefore becoming mainstream among bilateral and multilateral donors such as the WorldBank.

Shaming and Sanitation in Indonesia 159

under the umbrella of participatory development and even more surprisedto find that there have, as yet, been few studies critical of the approach. Thesupportive studies and evaluations we found were produced or funded bydonors promoting the technique.

The support for shaming is based on its supposed effectiveness in achiev-ing latrine construction, which was also a key argument for the often coer-cive approaches used in colonial public health programmes in Indonesia andelsewhere. This article does not aim to fully evaluate the effectiveness or oth-erwise of shaming versus other techniques for promoting sanitation; rather itseeks to integrate the extant historiography of Indonesian colonial medicinewith contemporary scholarly literature and our own field research on CLTS,using case studies of a Rockefeller Foundation funded hygiene and sanitationprogramme in the 1920s, and the WSP programme in East Java in the 2000s.This enables us to highlight new insights about the outcomes of CLTS asa hybrid approach that links colonial and modern governmentality but, inits modern form, involves not just the state but also sub- and supra-nationalorganizations of various kinds. Foucault’s idea of government as the ‘con-duct of conduct’ incorporating ‘governing the self’ and ‘governing the other’(Foucault, 1991: 87; Lemke, 2002) is a useful way of highlighting some of theconnections between the WSP and Rockefeller programmes. Both of theseprojects are about educating desires, habits, aspirations and beliefs; they area form of government through (constructed) community (Li, 2007). Theyboth involve what Li (ibid.) calls ‘rendering technical’, which highlights theprocess by which a particular ‘problem’ is identified, its boundaries set, le-gitimate information is collected and appropriate techniques for addressingthe ‘problem’ are crafted. Both programmes also highlight the continuitiesof governmentality with older coercive regimes which are linked, in theRockefeller case, to colonial racial stereotyping and, in the WSP case, toclass stratification. The result is a form of governmentality that does notengage with local practices in their cultural, ecological, social, political andeconomic dimensions (Jewitt, 2011). When villagers resist donor sanitationprogrammes, this is understood as a continuation of ‘filthy’ traditional prac-tices and not engaged with as an ethico-political (Mukhopadhyay, 2006)and/or socio-economic response. The content and nature of the programmeare never questioned. Thus, in looking at WSP in the context of historicalinterventions in sanitation in Indonesia and elsewhere, we shed new light onmodern sanitation regimes for rural areas and their claims of participatorydevelopment.

We start by examining colonial hygiene and public health practices inIndonesia, highlighting a number of interesting continuities between colo-nial developmental regimes and current aid practices. Next we evaluatethe WSP sanitation project in East Java and in Trenggalek in the lightof both colonial health practices and post-World War II sanitation prac-tices by donors. We conclude with an analysis of WSP as participatorydevelopment.


SHAMING AND COLONIAL SANITATION PRACTICES IN INDONESIA

Sanitation was one of the earliest arenas of colonial public health activityin the Dutch East Indies thanks to the appointment of sanitary inspectors.Intervention grew with the expansion of Dutch control over the peninsulaand the introduction of the so-called Ethical Policy in 1901, which increasedthe focus on ‘native’ welfare (Boomgaard, 1993; Furnivall, 1967: 362–3;Mesters, 1991, 1996). This change coincided with the major breakthroughsin medical science that marked the start of modern medicine, which in turnprovoked significant changes in colonial health practices (Anderson, 2006;Comaroff and Comaroff, 1997; Hattori, 2004; Latour, 1988). A substantialhookworm-eradication programme funded by the Rockefeller Foundationcommenced in 1924 and focused more on preventative public health thanon treatment — in other words on hygiene and sanitation improvements tostop the spread of hookworm. The focus on preventative public health pro-grammes was seen as an affordable way of providing modern scientific healthknowledge to the masses, in contrast to expensive biomedical interventionswhich reached only a few. The programme encouraged a move away fromthe traditional Dutch approach of legislating for latrine construction, backed-up by fines, towards an approach that focused on hygiene practices utilizingsocial mobilization and education techniques; despite its racial overtones,it was very much a programme of conducting conduct (Amrith, 2006: 30).There is a parallel here to the change that occurred in development practicein the 1990s, whereby the sanitation sector changed from focusing on theprovision of hardware to focusing on participation and social mobilizationin order to encourage individuals and communities to construct and maintaintheir own sanitation facilities. We return to this change later in the article.

The use of both coercive and educative techniques in public health wasnot, of course, unique to the Dutch East Indies. The nineteenth centurysaw the management of bodily functions become an increasing focus ofEurope’s growing civilizing mission and, by the early twentieth century,racialized medicine was a tool of Empire (Amrith, 2006; Anderson, 2006;Boomgaard, 1993; Hattori, 2004; Latour, 1988).2 Writing about SouthernAfrica, Comaroff and Comaroff (1997) highlighted the deep interactionand conflict around healing and hygiene involving missionaries, colonialauthorities and local populations, which resulted in increasing policing ofdomestic life. In Africa and elsewhere, these interventions produced various

2. The civilizing mission in colonies was, in many ways, a continuation of the moral crusadeof the Victorian era regarding the conditions of the urban poor, which also prompted oftencoercive public health interventions (Black and Fawcett, 2008: 21–22). As Latour explains,the expansion of public health measures was also a contested process in Europe. It onlybecame dominant (or rather hegemonic in the Gramscian sense) after Louis Pasteur’s ideasbecame mainstream amongst physicians, which took some forty years (Latour, 1988: 136–40). However, once it had obtained this dominance, hygiene equally turned to ‘policing andcoercion’ (ibid.: 140).


forms of resistance that can be seen as ‘emblematic of the broader culturalconfrontation at work in the colonial encounter’ (ibid.: 337). These conflictsremain in play in the post-colonial context, as we shall see with WSP.

The Rockefeller Foundation programme, with its focus on education, hadmore impact than Dutch programmes in changing sanitary practices. Theprogramme in Indonesia, as in much of Southeast Asia, originated from theactivities of the American Dr Victor Heiser, who was initially Director forthe East on the International Health Board.3 Heiser met resistance in In-donesia, as Dutch officials did not think that the education and propagandaapproaches used by Rockefeller would work in the Dutch East Indies. Theyeven argued that these programmes might disrupt the authentic customs andtraditions of Java’s villages (Gouda, 2009).4

The programme in Indonesia was run by another American, Dr JohnLee Hydrick, who was tasked with applying the Foundation’s successfulUS hookworm-prevention model in Java between 1924 and 1939 (Hull,2008: 140; Hydrick, 1942). Hydrick established a demonstration projectin Bantam, an area in the west of Java, using the Foundation’s education-based model, while the government’s Public Health Service set up anotherusing the traditional authoritarian Dutch approach, in this case involvingprovision of worm medication and ‘mandatory enforcement of regulationsto build latrines’ (Hull, 2008: 142). This competition was driven by thecolonial administration’s desire to have Rockefeller funding without havingits staff and programmes. Nevertheless, a comparison of the two approachesin early 1926 showed that, while the Dutch programme had resulted in theconstruction of some 150,000 latrines, few if any were in use; the Rockefellerprogramme produced fewer latrines but they were in use and the populationseemed enthusiastic about the programme (Hull, 2008). Subsequent researchhas questioned this enthusiasm, a topic we return to a little later (Stein,

3. The International Health Board (originally Commission) was established in 1913 witha grant from the Rockefeller Foundation. It was inspired by the work of the RockefellerSanitary Commission for Eradication of Hookworm Disease and worked with it (RockefellerFoundation, 2011). The hookworm programme worked initially with African-Americancommunities in the southern US before turning its sights globally, to Egypt, the northof Australia, the Philippines and elsewhere (Anderson, 2006). The Philippines was theRockefeller Foundation’s ‘test bed for many of its international health projects, whether inracial development (as in hookworm prevention) or ecological intervention (as in malariacontrol)’ (ibid.: 217).

4. Other factors were undoubtedly Dutch concern about growing US influence in the regionafter their take-over of the Philippines in 1901 (Gouda, 2009) and specific rivalry betweenRockefeller’s Standard Oil Co. and the Dutch petroleum industry (Hull, 2008: 141; Mesters,1996: 56–7). The US were pioneers in providing colonial public health programmes andspent significant sums on the effort, in contrast to the Netherlands East Indies where colo-nial welfare was self-funded and always came a clear second to Dutch financial interests(Zainu’ddin, 1968: 156). The US did, however, also adopt a range of quite coercive tech-niques including in the sanitation campaign, where the Rockefeller Foundation was also akey player; for details see Anderson (2006). The US public health programme in Guam wasperhaps even more authoritarian as it was run by the US military; see Hattori (2004).


2006). As a consequence, a new Public Health Education Unit was set up,with a Hygiene Propaganda Unit using mass media and education to promotepreventative health techniques, with funding coming from the RockefellerFoundation, the colonial administration and local governments.

It is interesting to note that Hydrick’s enthusiasm for educative techniqueswas not a social or moral issue but a question of efficiency. His 1942booklet on the programme provided a mix of arguments to support education,starting with the analysis that attempts ‘to carry out hygienic measures bybeginning with the use of force gives rise to active and passive resistancewhich always accompany the enforcement of any law which is not supportedby public opinion’ (Hydrick, 1942: 18, emphasis in original). Hydrick arguedthat education may require ‘great patience and devotion’ but it producespermanent results, with the proviso that, once overall public opinion supportsthe new system, laws and regulations may be needed for the remaining few‘reactionary individuals’ (ibid.). His support for education was limited torural areas where distances meant that enforcement would require too manypersonnel; in urban areas Hydrick saw that ‘it is often necessary to use force’(ibid.: 19, emphasis in original). Indeed, he had ‘no objection whatever tothe use of coercion if its use could secure permanent results’ (ibid.: 19–20,emphasis in original).

The programme itself saw health workers (mantri) recruited to conduct theeducation component. They were initially all male and had to be literate, nottoo young or old and have a good speaking voice. They received intensivefield training prior to commencing their duties, which began with a focuson hygiene and hookworm but were expanded over time (Hull, 2008: 146;Hydrick, 1942: 66–8). There was also a mass media component that producedpopular silent films for the annual fairs in towns. While Hydrick (1942: 35)was not convinced of the films’ efficacy in changing hygiene habits, Stein’s(2006) deconstruction of them, showing how they assumed their audience tobe scientifically and cinematically illiterate, is the more important issue forthis analysis. Thus, for example, the process of magnification of hookwormlarvae was thought too complex for villagers to understand so several filmsspent much time elaborating on the idea of magnification (Stein, 2006: 27–8).Furthermore, while not all of the hookworm films were overly moralizing,most used quite explicit and ‘disgusting’ images of villagers holding pansof worm expelled from their bodies. As Stein (ibid.: 27) concludes, thisimage: ‘signifies the truth of the diseased Javanese body and aimed to turnaudience disgust inward, toward the wormy self’. Thus, there were in this, asin most of the Rockefeller health efforts, strong racist overtones (Anderson,2006).

Hydrick (1942: 73) prioritized cost and education over construction stan-dards of the latrines themselves: ‘[t]he latrine should cost very little ornothing, but if possible it should be durable, convenient and sanitary’. Tothis end, although hinting at improvement at a later stage, the programmeallowed that initially a latrine needed be little more than:


[a hole] covered with a strong bamboo frame which is in turn covered with a bamboo mat toshut out the light. The small hole in the center is kept closed by a piece of wood or wovenbamboo which serves as a cover. This type costs the village man nothing . . . Later after hehas learned to use a latrine, he is willing to spend something for better materials . . .

It is more important that the people learn to use a latrine and thereby stop the general pollutionof soil and water. Also the people must first learn to use a latrine and to keep it sanitary.After this habit has been thoroughly implanted, then the question of improvement of typeand material can be taken up. (Hydrick, 1942: 73, 75)

Despite some claims of success for the Public Health Education Unit (Hull,2008: 146) and the low cost focus, Stein (2006: 38) found that many peo-ple in Hydrick’s demonstration area did not build latrines and that localsremembered the project as being for the wealthy. Even local materials cameat a cost and it took up to a week’s labour to construct the latrines — aprocess which had to be repeated every few years. This involved signifi-cant costs, especially in the 1930s when Java was deeply impacted by boththe Great Depression and local economic crises and many villagers werefocused on little more than survival. Nevertheless, Hydrick was stronglyopposed to latrine construction or subsidization by colonial authorities ordonors — another debate which rages to this day. The WSP sides stronglywith Hydrick here; indeed WSP could have borrowed verbatim Hydrick’s(1942: 74) comment that ‘[e]xperience has already shown that the people arewilling to build latrines if they can be shown how this can be done withoutgreat costs’.5

By 1932, the Dutch had come to accept that there was a need for a broaderrange of health services which were continually accessible by locals, anda decentralized approach to delivery was thought appropriate (Hull, 2008;Mesters, 1996). Such interventions were seen as a counter to the growingunrest in Indonesia, although the depression of the 1930s meant that therewas little funding for programmes (Amrith, 2006: 30). So Hydrick was giventhe job of developing health units, the basis of the system of health clinicsthat continued into the Soeharto era (Stein, 2006: 20).

Hydrick left the East Indies in mid-1939. He had a long career with theInternational Health Board in a range of former or current colonies which,as Anderson (2006: 229–33) has shown, played a critical part in a complexcirculation of health staff across the Pacific and Western Hemisphere duringthe 1920s and 1930s. This is important because both the programmes studiedhere need to be situated within a framework emphasizing the international

5. Hydrick’s views on the funding of medicine and hygiene were a small advance on thecommon colonial position, namely that medical care is an individual responsibility otherthan in the case of epidemics and emergencies and that government’s role should be limitedto basic infrastructure provisions (Abeyasekere, 1986: 2–3). This minimal view of thegovernment’s role in health returned with the neoliberal revolution in the 1980s and, alongwith the neoliberal view of utilities, influenced donor ideas about how sanitation programmesshould run.


and transnational circulation of governmental technologies in health. Withregard to the Rockefeller programme, Amrith (2006: 32) notes: ‘Throughthe League of Nations, the Rockefeller Foundation and other transnationalnetworks, the local techniques of Hydrick and his counterparts across theregion began to coalesce into a set of ideas and prescriptions gaining ethicalforce, as a body of knowledge and practice: “international public health”’.Amrith further emphasizes how the creation of international health organi-zations bolstered the governmentalism of colonial and post-colonial healthprogrammes (ibid.: 11).6

Hydrick and the Rockefeller Foundation did not succeed in fully changingthe Dutch approach to colonial sanitation and health practices (Mesters,1996: 60–61). As late as 1945, Dr P. Perverelli, former director of the DutchEast Indies Public Health Service, claimed that modern medicine ‘shouldsimply be imposed, either through courteous coercion (printah haloes) ormore forceful measures’ (cited in Gouda, 2009: 2–3). The Dutch responsesto malaria, the plague and smallpox all showed that coercive techniquesremained central. The smallpox programme’s coercive techniques promptedlocals to flee to the mountains and the Plague Service in the twentieth centurywas renowned for spleen punctures (which went against Muslim beliefsabout not violating the body after death), costly compulsory rat-proofingprogrammes for houses and even burning down whole villages which weretouched by plague (Abeyasekere, 1986: 10; Boomgaard, 1993: 87).7

A complex overall picture thus emerges. As Stein (2006: 39) concluded,the hygiene projects represent a move away from the most dominant colo-nial health and village control practices. They were an early step beyond theminimalistic colonial health model of ‘preventing epidemics and ensuringthe productivity of labour’ (Amrith, 2006: 2), although hookworm treatmentwas strongly motivated by labour productivity concerns (Anderson, 2006;Hattori, 2004). The Public Health Service established by Hydrick and theDutch colonial authorities used education as well as some coercion andexpanded the state’s regulation of colonial subjects. In other words, the pro-grammes embody a shift towards rule though governmentality that occurredin the late colonial period, although there was ‘a degree of intrusivenessunforeseen even by Foucault and others in their theorizations of state inter-vention and surveillance’ (Hattori, 2004: 180). Furthermore, the racializedovertones of earlier public health interventions remained.

6. Although as Amrith (ibid.) argues, colonial and post-colonial health were as much charac-terized by absence, ineffectiveness and failures, and there is a tension between this viewand one which emphasizes governmentality.

7. The Dutch colonial health budget remained dominated by a small curative and technicalprogramme (Abeyasekere, 1986: 4–5). After independence, the relative funding of curativeover preventative services continued, although the Dutch system of rural polyclinics wasdramatically expanded into a network of Primary Health Care Centres.


THE WORLD BANK WATER AND SANITATION PROGRAMME

Despite the work of the Rockefeller Foundation and others in encouraging apublic health focus in hygiene and health care, in the three decades follow-ing World War II the focus of sanitation projects in developing countrieswas largely on hardware and engineering. Indeed, donors in general did notfocus much on sanitation: it was, and remains, the poor relation to watersupply (Black and Fawcett, 2008: 40; WaterAid, 2011).8 The big reductionsin mortality in this period were not due to success with diseases related tostandards of living (Amrith, 2006: 184). By the mid-1960s, ‘“non-specific”diarrhoeal diseases were the biggest killers in Asia and Africa’ and ‘[t]hese“non-specific” infections proved much less amenable to control with tech-nological “magic bullets”’ (ibid.).

The focus on hardware in sanitation started to change in the late 1970s,which was when the Water and Sanitation Programme was established. Itstarted in 1978 with a focus on testing low-cost technologies and modelsfor providing safe water and sanitation to the poor. This followed the 1977UN Conference on Water, after which the World Bank downgraded itssupport for sites and services interventions, seeing in the newly discoveredresourcefulness of urban slum dwellers a reason to withdraw direct financialsupport and provide assistance only for technology and models (Black andFawcett, 2008: 41–2). Rural inhabitants were not regarded as resourceful; thelimited number of rural projects were focused mostly on latrine constructionbut inadequate attention to education resulted in many latrines remainingunused (ibid.: 41–2, 77).

In the 1990s, the World Bank’s new approach to sanitation was reinforcedby the replacement of ‘supply-side thinking’ with a focus on local communi-ties accessing ‘water and sanitation services according to their own demands’(see WSP, 2011). In other words, the neoliberal revolution and the associatedstructural adjustment approaches that the Bank applied to public utilities inthe 1980s furthered the hostility to state provision of sanitation and waterservices (Amenga-Etego and Grusky, 2005; Engel, 2010; Yi-chong, 2005).At the grassroots level, this was presented as a shift to demand-responsiveapproaches which encouraged the poor to ‘take responsibility’ for their owndevelopment — and, of course, to pay for it. WSP now offers a combinationof self-help water and sanitation programmes and evaluation and researchto expand knowledge.9 It also continues to promote expanded private sector

8. Judging by our own research, and internet searches for the term ‘sanitation’ in a cross-section of journals (including Development and Change), this also seems to be true withinacademia.

9. In addition to the World Bank’s lead role in WSP, it is a significant player in the sectorthrough its lending programme. Its International Development Association lending arm isthe second largest provider of official development assistance (ODA) to sanitation afterJapan (WaterAid, 2011: 29). The International Bank for Reconstruction and Developmentarm of the Bank is also a significant lender in the sector.


participation in these sectors, which was another key battleground of the1990s.

Self-help approaches have been particularly appealing in the troublingand expensive area of sanitation where a lack of funds, management skills,maintenance capacity and water supply have all meant that the water-bornesewage disposal and treatment model prevalent in the industrialized worldis rarely viable in urban settings and is regarded as irrelevant in rural ones(Black and Fawcett, 2008: 7). The change in thinking about sanitation did seethe re-emergence of useful insights about the importance of education andmobilization that were known to the Rockefeller Foundation and Hydricksixty years earlier. That is to say that when latrine construction is imposedby coercion or decree, it usually fails; people must want and value latrinesfor them to be used and maintained. Equally, sanitation projects need todo more than just provide education according to a donor programme; theyalso need to understand and engage with local practices impacting sanitationand local practices regarding excrement disposal. In other words, thosebehind the projects need to study what works in creating and maintainingdemand for sanitation in an area and what types of sanitation a communityprefers, otherwise sanitation systems tend not to be used (Black and Fawcett,2008; Jewitt, 2011). Furthermore, WSP’s strong focus on community-led andcontrolled projects does not fit with historical experience regarding broadaccess, which shows that without government intervention, services haveonly been provided in wealthier locales.10 The issue of access by the poorestis only now attracting greater attention in CLTS processes (Fawazi andJones, 2010; WaterAid, 2011), no doubt because WSP’s key focus has beenon discouraging subsidies for latrine construction in any context.

Sanitation and Shaming: WSP in Indonesia

The sanitation situation in Indonesia overall is poor: it has the third highestnumber of people of any country in the world without access to sanitation,over 109 million people in 2010 (WaterAid, 2011: 17). This is despite slowimprovements in the past couple of decades: in 2008, 67 per cent of urbandwellers and 36 per cent of rural dwellers used improved sanitation facilities,up from 58 and 22 per cent in 1990 (WHO/UNICEF, 2010: 11–12).11 In ruralareas, 30 to 40 per cent of the population still engage in open defecation. This

10. Successful systems have always involved both public and private components (Black andFawcett, 2008: 51). The private sector has generally been central to ensuring the supply ofappealing items at affordable prices in locations that people can access, and has played arole in maintenance and repair of systems. Governments play a central long-term role ininvestment in ‘public health institutions, governance and regulation, marketing, technology,R&D, and other underpinning components of a new sanitary order’ (ibid.: 193–5).

11. However, only 2 per cent of urban dwellers’ sanitation systems connect to piped sewers andthese are non-existent outside urban areas.


situation reflects the general lack of focus on public health care during theSoeharto years, which resulted in poor health outcomes by regional standardsdespite achievements in economic growth and poverty reduction (Achmad,1999). Soeharto’s interest in health only extended as far as family planning.In the context of paternalistic central government priorities, which continuedthe late-colonial tendency towards demobilization of village politics, andthe ‘weak grass-roots demand for political participation and social services’,public health languished (ibid.: 1).

The process of decentralization that commenced in 2001 saw district gov-ernments given responsibility for water supply and sanitation. This has notyet resulted in notable improvements in access or service quality, which hasbeen generally attributed to lack of resources and capacity in district gov-ernments. Indonesia has seen some growth in donor activity in the sanitationor water sector: between 2002 and 2009 official development assistancedisbursements to the water supply and sanitation sector grew from a paltryUS$ 30 million to US$ 155 million per annum, the largest donor being theWorld Bank’s IDA, followed at some distance by Japan and the Netherlands(OECD, 2011). The World Bank’s direct lending for rural water supply andsanitation sector work has mostly been through its Water and Sanitationfor Low-Income Communities (WSLIC) programme as well as technicalsupport through the WSP.12 The WSP started promoting the CLTS processas early as 2001 and was instrumental in its spread to Indonesia in 2004(Buhl-Nielsen et al., 2009; Kar and Pasteur, 2005: 6–7). Indonesia was alsoone of three participants in the WSP’s Global Scaling Up Rural Sanitationprogramme launched in 2006 (Cameron and Shah, 2010: v).13 The projectfocused on twenty-nine Kabupaten (regencies or cities) in East Java, withthe aim of ending open defecation using the CLTS process. Approximately40 per cent of households across densely populated East Java still practiseopen defecation.14

We studied the WSP in East Java generally and specifically in KabupatenTrenggalek. For East Java overall, we analysed WSP documents and reportsfrom independent evaluations, and interviewed regional officials. One ofour key informants was a researcher working for the Jawa Pos Instituteof Pro-Autonomy (JPIP), a local foundation of East Java’s largest media

12. The third stage of the WSLIC was renamed PAMSIMAS for its Indonesia title — ProgramPenyediaan Air Minum dan Sanitasi Berbasis Masyarakat (Community-based DrinkingWater and Sanitation Provision Programme). The World Bank also offered support tothe water supply and sanitation sector through its large rural community developmentprogrammes (KDP and PNPM), where villages can select from a menu of infrastructure andsocial sector improvements. However, communities have only used 5 per cent of funds forimproving sanitation facilities (Buhl-Nielsen et al., 2009: 5).

13. The other countries are India and Tanzania. In Indonesia, this project is known as SanitasiTotal dan Permasaran Sanitasi (SToPs).

14. The remainder have access to either a septic tank (36 per cent), various forms of pit latrines(16.3 per cent) or a piped sewer system (around 7 per cent) (Cameron and Shah, 2010: 26).


network that has been tasked with monitoring the implementation of WSP.In Trenggalek, we undertook an initial series of interviews in 2010 withdifferent stakeholders including heads of the villages (Kepala Desa), localgovernment officials and local WSP facilitators. In this round, we conductedformal interviews with nine people; the interviews with village residentswere conducted in the presence of local government officials. In 2012, weundertook further interviews with seven households, without governmentofficials present. We do not claim that this is a comprehensive view of theWSP in East Java; however, the qualitative focus provides valuable insightinto a range of key sanitation issues.

For the East Java programme overall, the facilitators are trained by WSPfor participatory analysis of existing community sanitation practices and howthey could be improved. Most WSP funds are spent on technical assistance,including regular training and workshops, mostly for facilitators but alsofor government officials. No district may receive more than IDR 40 million(approximately US$ 4,500) per year of WSP funds; local governments alsocontribute towards project costs (JPIP, 2009: 15). To support the programme,facilitators are recruited and trained by WSP Jakarta to work in the nationaloffice (Jakarta based) and in local offices (district based). Staff in the nationaloffice in Jakarta are paid by WSP, whereas local facilitators are paid by thelocal government.15 This strong link to local government is an interestingdivergence from the standard CLTS model in which facilitators are engagedby NGOs.

Some IDR 20–25 million was allocated in 2008 for sanitation trainingin East Java. The training was held in Surabaya (the capital of East JavaProvince) and hundreds of participants attended. Participants learnt tech-niques for working with communities and providing training on sanitationissues. They were also taught technical skills for constructing a toilet. Of thethirty-seven districts in East Java, twenty-nine have implemented the WSP.Staff from Badan Pemberdayaan Masyarakat (the Department of People’sEmpowerment) in Kabupaten Trenggalek, who were interviewed in June2010, indicated that regions were selected based on the following criteria:(a) the location is far from a river or canal; (b) there is high participationby villagers (civil society); (c) the village is not classified as poor; and (d)there are active and/or participative stakeholders. Asked why the villagescould not be poor, the response from staff was that these were the guidelinesthey were given. This is a powerful statement of the lack of poverty focusin WSP.

There are strong parallels between WSP’s facilitation and Rockefeller’seducation process. In both cases, the aims and objectives of the educa-tion/facilitation process were determined from the outset by donors, basedon experience in other countries, not by local communities; both show the

15. Specifically through the Anggaran Pendapatan dan Belanja Daerah (APBD).


logic of governmentality in how they identify what and who represents theproblem, and how they respond, using a staged response of special tech-niques and specially developed promotional and educative materials. Bothprogrammes target communities and households as the site of their interven-tion, although the Rockefeller programme had a stronger focus on house-holds than WSP. Indeed, the Rockefeller programme demonstrated greaterconcern about the dignity of households, working with them one-on-one toensure privacy and open discussion (Hydrick, 1942: 30–31).

Trenggalek

Kabupaten Trenggalek is located in the southern part of East Java Province;due to a large mountain range, it is a relatively isolated area, yet like mostof Java it is quite densely populated. Trenggalek district has been a leaderin sanitation: in 2008, it had the second highest budget for sanitation ofany district in East Java and made a commitment to being free of opendefecation by 2010 (JPIP, 2009: 15, 25).16 In addition to examining theoverall WSP process in Trenggalek, we undertook interviews in two villages,Rejowinangun in Kecamatan (sub-district) Trenggalek and Panggungsari inKecamatan Durenan, in order to develop a deeper understanding of howWSP has impacted residents. The villages were recommended by staff fromthe Department of Health as the villages in Trenggalek that had most quicklyachieved Open Defecation Free (ODF) status. In both cases, many of theyounger villagers have gone to larger towns or overseas (Malaysia and HongKong) for work. A key reason that WSP was implemented in both villages isbecause many households were still using the canal and river for defecationand waste disposal, thus the criteria of being far from a river seems to havebeen reversed here.

The WSP/CLTS facilitators in both Rejowinangun and Panggungsari weregovernment officials from the local health centres — in Indonesian, Pusat Ke-sehatan Masyarakat but generally known by the abbreviation PUSKESMAS.This is a major departure from the original CLTS model, where the facil-itator is generally an outsider and the process of looking at village ‘filthand dirt’ though an outsider’s eyes is regarded as a key factor in initiatingchange (Kar, 2003: 27). As per the model, WSP encouraged the construc-tion of individual latrines and shared public toilets, which can be traditional,semi-permanent or permanent. The type of toilet to be constructed dependson the capacity of the families using it to pay for its construction. The poorare encouraged to form a group of three or four families to erect one sharedtraditional public toilet, which is accessible to all of them. Semi-permanentand permanent public toilets are shared amongst low- and middle-income

16. Kabupaten Trenggalek came seventh out of twenty-nine districts in JPIP’s 2009 award forbest practices in sanitation in East Java.


families. A shared traditional pit latrine can cost as little as IDR 25,000although our studies found that most cost IDR 200,000. A semi-permanentlatrine costs around IDR 500,000 while a permanent indoor pour–flush toiletcosts around IDR 1,000,000 per unit.17 In theory, WSP in Indonesia providesno subsidies for toilet construction yet in practice we found both rewardsand provision of pit rings and covers from the village head. Nevertheless,the outlays required from households were quite large, given that 32.5 percent of the Indonesian population live below the (quite low) national povertyline of US$ 21 per month and a further 40 per cent live just above it (WorldBank, 2010).

Indeed, there is growing evidence that WSP is not accessing the poor-est (Fawazi and Jones, 2010) and that subsidies have beneficial impacts inparticular circumstances and are being supported by some governments, forexample India (Black and Fawcett, 2008; McFarlane, 2008; Pattanayak et al.,2009).18 In our second round of interviews, which were in Rejowinangun,six of the seven households we interviewed had constructed latrines; onehousehold could not afford the additional cash outlay required for construc-tion despite having received a concrete pit liner and cover from the villagechief. Two other households also received concrete pit liners, despite theCLTS opposition to subsidies and support for using local materials for con-struction. For five of the six households where latrines were constructed, thecosts ranged between IDR 200,000 and one million depending on the typeof latrine constructed; there was also a loss of between three days and twoweeks of income due to time spent in labour and supervision of latrine con-struction. All of the households noted that this was a drain on their income.The World Bank is reporting the outcomes of WSP to the Joint MonitoringProgram on progress towards the MDG for sanitation, but without consider-ing the impact that the cost of progress in sanitation may have on the capacityof the poor to meet other MDGs (Mukherjee et al., 2010: 1).

Both villages supposedly followed the standard CLTS process. To fosterimprovements in sanitary standards, this includes a triggering method in-volving approaches and informal talks with stakeholders prior to the projectbeing formally triggered. Local facilitators (called cadres) were responsiblefor organizing triggering, the first stage of which involved cadres dissem-inating information on health and sanitation to villagers both door-to-doorand through public meetings (musyawarah desa).19 The meetings took vil-lagers through the standard CLTS process of a walk of shame and defecation

17. This converts to approximately US$ 2.75 for a traditional pit latrine and between US$ 50and US$ 100 for more permanent and pleasant sanitation facilities.

18. Studying an urban sanitation project in India using a similar participatory process, McFarlane(2008: 102) notes that the ‘focus on cost recovery from the poor means that sanitation isoften provided not according to those who need it most, but according to how many can paya contribution’.

19. In Rejowinangun, as in other areas in Indonesia, religion has been used in promotingcleanliness, thus reciting the Koran was also a tool for disseminating information.


mapping, which are aimed at triggering subsequent latrine construction. Thefirst three months were considered the hardest period in triggering, but after afurther five months, officials claimed that 97 per cent of the total populationin the villages had access to at least a public toilet.20 However, in our firstround of interviews, the Kepala Desa (village head) in Panggungsari statedthat villagers were not intensively engaged during the early phases of theCLTS; rather the importance of this project was taken for granted by theKecamatan. He said that many villagers did not even know that their villagewas being used as a trial for the CLTS process. The situation was similar inRejowinangun, where, in our second round of interviews, we found that oneof the two hamlets in the village had not fully participated in WSP; of theseven households we spoke to, two had never heard of WSP and a furtherthree said they had heard of the programme but had not been involved in theparticipatory and socialization components.

According to the Kepala Desa in Panggungsari, despite the supposedlyparticipatory approach of the CLTS, the villagers did not want a sanitationproject and would have preferred an adequate irrigation system for theirfarmland and a programme for replanting an area of cleared forest locatednear their farmland.21 A further indication of the lack of community partic-ipation comes from the JPIP public survey across East Java in 2009, whichshowed that 58.7 per cent of respondents thought that the key factor in thesuccess of sanitation improvement programmes was the level of commit-ment of the district head, whereas community participation was seen as keyby only 6.6 per cent. The authors of the report note that: ‘This is an ironicfinding as sanitation improvement programs have been claimed to involvemore community roles’ (JPIP, 2009: 13).

Yet, there is little doubt that government support is vital in achievingongoing improvements in sanitation and the lack of commitment has beennoted as a key reason for Indonesia’s poor progress. There was a dramaticchange in the commitment to WSP in Trenggalek after the election of a newBupati (Mayor) in 2011. WSP is not his priority — rather, he has a strongfocus on waste management — so by late 2011 the project was no longeractive. In 2011, sanitation cadres were still assisting people with latrineconstruction but enthusiasm for achieving ODF status had declined. A veryactive WSP cadre, whom we interviewed in October 2011, had been toldthat he would be transferred to another post in a different department by theend of that year. He noted that there were no cadres to replace him.

20. CLTS also promotes strong public displays of commitment. In Rejowinangun this took theform of villagers sticking pamphlets on the sides of their toilet walls stating: ‘we commit tonot using the river for waste anymore’ (Kami tidak akan buang air lagi di sungai).

21. The deforestation occurred in 2001, when a group of people from another area came andcut the trees for logging. The logging caused a large area of land to become infertile. Thevillages linked the soil infertility and deforestation to water shortages, but the exact causalityis unknown.


According to this WSP cadre, one of the reasons for the enthusiasm for theproject in Trenggalek was that the previous Bupati had promised a rewardof IDR 5 million (US$ 555) per village for ODF certification. The cadre feltthat this stimulated people to construct a toilet even though the price wasnot always within their means, partly because of community pressure to getthe reward and partly because it was felt that the reward would be used torepay the debt. The promise of a reward and the use of shaming techniquesboth make it difficult to judge the motivations of villagers in such instances.The ‘reward’ and the provision of concrete pit liners and covers in someplaces in Trenggalek can be viewed as a local way of getting around WSP’shostility to subsidies.22

The CLTS model used in Trenggalek, as elsewhere in Indonesia, reliesstrongly on techniques involving shame, enforcement, responsibility andsanctions. Each villager has to take responsibility for analysing the extentof open defecation, for financially and morally solving the problem andfor reporting to local and district government — in a participatory manner,of course (Mukherjee et al., 2010: 2). In some communities, those house-holds with unimproved sanitation are marked with a sticker, ‘which servesboth as an embarrassing and persuasive force encouraging owners to up-grade to improved facilities as soon as possible’ (ibid.: 9).23 In two villageselsewhere in East Java, regulations providing sanctions for open defecatorswere instituted: the sanctions involved fines, and offenders sweeping villageoffices. One village used village funds to take and post pictures of opendefecators. These fines and public humiliation were reported by the JPIPas ‘distinguished institutionalisation’ (JPIP, 2009: 12)! The JPIP awards forbest practices in sanitation were supported by WSP (Mukherjee et al., 2010:17).

The WSP has also produced its own social marketing material starringa figure called Lik Telek, which translates roughly as Uncle Faeces (WorldBank, 2008). Lik Telek is poor, physically deformed, dirty and ‘disgusting’;he is quite similar to a character called Kromo in one of the films producedby the Rockefeller programme in Indonesia (Stein, 2006) although, interest-ingly, Kromo is not as much of a caricature as Lik Telek. Kromo’s nameis a colonial Malay word for ‘common people’ and he is disfigured butnot as dirty or perverted as Lik Telek, who in one image is presented as apeeping tom. Indeed, as Stein (ibid.: 24) points out, the film about Kromois designed more to elicit ‘empathy and identification from the audience’

22. A number of CLTS supporters have expressed concern about the negative impacts ofoffering inappropriate (or indeed any) incentives to achieve ODF status (Harvey, 2011;Kar and Pasteur, 2005: 4). The experience in Trenggalek indicates that it does change theprocess; this was also the case in Noy and Kelly’s (2009) study of East Timor where the‘reward’ for achieved ODF status was transition to a water supply programme.

23. Moreover, to be certified as ODF, whole teams visit specified households. Their guidelinesfor verifying villages as ODF state that there must be: ‘sanctions, rules or other safeguardsimposed by the community to prevent open defecation’ (Mukherjee et al., 2010: 22).


than to encourage moralizing, although other films produced by the unitdid adopt a more moralizing tone, highlighting the underlying belief in thediseased Javanese body. One of our informants from the 2012 interviews inRejowinangun shared that he had been identified as a Lik Telek. He said itwas ‘very embarrassing’ to be Lik Telek and that the village head and othergovernment staff had ‘encouraged’ him to construct a latrine by teasing himand his family because of their use of the canal. He said the ‘Village Headand his staff teased me like this: “you have a gorgeous wife, if you are notmaking a proper toilet, we may see your wife”’. The ‘encouragement’ didnot seem to consider his poor household circumstances at the time, althoughhe was given a concrete pit liner by the village head for his latrine.

Peter Harvey, the Chief of Water, Sanitation and Hygiene Education(WASHE) for UNICEF, has claimed that while the shock factor is part ofCLTS, the triggering process done by external facilitators should not ‘shame,insult or embarrass the community in anyway’ (Harvey, 2011: 100). YetCLTS is clearly a very intrusive process involving facilitators from outsidethe village inspecting individual households and shaming predominantlypoor individuals and households for their circumstances and local practices.The process has, since its inception in Bangladesh, involved a policingand punishment component.24 In both WSP and the Rockefeller project,such interventions take place within a village realm that is seemingly freeof differences — there are no class, ethnicity, gender or age distinctions.Thus, the possibility that the projects will adversely impact any particulargroup is not considered; indeed, with WSP the implicit assumption is thatthe participatory CLTS process will reconcile these sometimes antagonisticinterests (Carroll, 2010: 4; Zerah, 2009). Our research indicates that it isprimarily the poor who are the ‘targets’ of this intervention and that theyare, in effect, punished for their poverty and local practices.

Sustained latrine use is meant to be a strength of WSP, as it was forthe Rockefeller programme. However, evidence for this is slim. For WSP,despite claims of its efficacy, there are still very limited data available onoutcomes for latrine use across the globe.25 One study in Timor Leste foundthat regular latrine usage may have been only 50 per cent one year after the

24. Kar explains that in Bangladesh:

The communities also developed innovative community policing and sanctioning method-ologies. They undertook collective action, started night patrols to catch offenders that stillused open spaces, undertook early morning raids on defecation spots and used the villagewatchmen to catch and identify offenders. This policing procedure in itself became a com-munity project and fines were imposed on the offenders while financial rewards were offeredto the identifier and the witness. Money from the fines supported the WATSAN committees.Even children participated in the project by following offenders and then sticking little nameflags on the ‘offence’ so that passers-by could identify the guilty party. (Kar, 2003: 40)

25. A study by CLTS founder Kar, together with Shafi, found most latrines in Bangladesh werein use and being maintained (cited in Kar and Pasteur, 2005: 3).


programme (Noy and Kelly, 2009), and a study of CLTS in Indonesia foundonly 12 per cent of 547 participating villages had achieved ODF status(Buhl-Nielsen et al., 2009). Our interviews in 2012 in seven householdsshowed that one latrine was already full and the household had returned toopen defecation, while another latrine was close to being full. The familywas willing to have the pit emptied; however they did not have sufficientfunds to do this and were not sure when they would. Further, one of thelatrines that was designed to be used by three households was only beingused by the one household we spoke to, as the latrine was on their property.They said that the other households do not use the latrine because they areconcerned about disturbing the household whose land it is on and that, ifall the households used the pit, it would get full too quickly and requireemptying. The effectiveness of CLTS in providing long-term sustainablesanitation solutions thus seems questionable and certainly requires furtherresearch.

CONCLUSION: SHAMING AS NOT-SO-PARTICIPATORY DEVELOPMENT

In this article, we have shown that WSP involves a process of governmen-tality that is reminiscent of colonial government programmes: sanitationpractices not conforming to (newly discovered) Western standards are con-demned as filthy and backward. The result is that sanitation programmesdo not engage with local practices in their cultural, social, political andeconomic dimensions. A better appreciation of pre-existing local sanitationpractices as well as related spatial, economic, cultural and psychologicalfactors is more likely to produce inclusive, holistic local sanitation systemsthat do not rely for their success on humiliating people.26

In Indonesia, there has been no analysis of the deeper cultural and socialnorms around sanitation and very little about the political, spatial and eco-nomic dimensions. These are important aspects if participatory developmentschemes in sanitation are to work and to move beyond derogatory, sham-ing approaches. The CLTS/WSP programme combines ideas from grass-roots empowerment and neoliberal self-help doctrine. However, the use ofshaming and taunting both disqualifies it as an empowerment approach andis likely to undermine its effectiveness in promoting long-term behaviourchange. Even if shaming were shown to be effective, the morality of pun-ishing the poor for their circumstances requires deeper consideration.

Moreover, in the hands of big donors, CLTS has become another one-size-fits-all approach to a development ‘problem’ intended to be scaled up and

26. As McFarlane (2008: 97) notes, ‘[a]ttention to the power relations within communities,and a more detailed understanding of people’s sanitation needs and desires, is important ifsanitation delivery is to be participatory in practice’. See also Jewitt (2011); Mukhopadhyay(2006).


applied across the globe. It was, in other words, quickly ‘rendered technical’by big donors despite the concerns of its founder, Kar.27 The WSP is anotherexample of the World Bank’s instrumentalist use of participatory rhetoricto support development programmes that are fundamentally in line with theneoliberal approach of making the poor responsible for their own develop-ment (Cammack, 2003; Engel, 2010; Kapoor, 2005; Li, 2007). Within WSP,the concept of communities determining their own standards does not meanthat they can determine the participatory process, community priorities orredistributive mechanisms; rather it means they can select from a menu oflatrine designs and police their neighbours’ sanitation habits. This is whatpasses for empowerment for Indonesian households in the post-WashingtonConsensus era.

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Susan Engel researches political economy, development theory and prac-tices, aid and Southeast Asian development. She published The World Bankand the Post-Washington Consensus in Vietnam and Indonesia: Inheritanceof Loss in 2010. She can be contacted at: Faculty of Law, Humanities andthe Arts, University of Wollongong, Northfields Ave, NSW 2522, Australia(e-mail: [email protected]).

Anggun Susilo is a Lecturer in the Faculty of Social and Political Science,University of Brawijaya, Indonesia (e-mail: [email protected]). He is pur-suing his Doctoral degree at the Institute of Social Studies (ISS), The Hague,The Netherlands. His research interests are community-driven developmentand neoliberal reforms under the post-Washington Consensus.

Shaming and Sanitation in Indonesia: A Return to Colonial Public Health Practices?

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