Flushing away disease: A one health perspective on sanitation, pathogen transmission, and rural health in China

Improved sanitation is a cornerstone public health intervention, fundamentally integrating human, animal, and environmental health. China's Toilet Revolution marked a nationwide initiative to upgrade rural sanitation, yet evidence on its integrated health effects remains scare. Drawing on provincial panel data and China Health and Nutrition Survey (CHNS), this study applies two-way fixed effect and staggered Difference-in Differences (DID) from a one health perspective to assess the reform's impacts. Our results indicate that the expansion of sanitary toilets significantly disrupted environmental pathogen transmission, reducing the incidence of fecal-oral diseases such as bacillary dysentery and infectious diarrhea. The reform also lowered risks of zoonotic infections-including brucellosis, echinococcosis, and leptospirosis-by interrupting pathogen cycles between humans, animals, and the environment. At the household level, this reform generated substantial health benefits. Specifically, the probability of illness fell by 6.7 % in the past four weeks, and healthcare expenditure declined by 17.7 %. However, these benefits were not distributed equitably, with men and higher-income households benefiting more than women and lower-income groups. Collectively, this study demonstrates that while rural sanitation upgrades are a powerful one health intervention, their health benefits are maximized and sustained only through equitable and cross-sectoral collaboration.