Building toilets holds the key to reducing India's malnutrition burden
Commenting on the Indian elections in his satire show, British humorist John Oliverremarked, “(Narendra) Modi has managed to inspire people with his populist platform including a pledge to put a toilet in every home. That’s a bold move, coming out as pro-toilet."
Oliver’s wisecrack may have deliberately exaggerated Narendra Modi’s pitch on toilets but the focus on sanitation has been one welcome change in the 2014 election campaign. In a public rally, Modi had exhorted, “pehle shauchalay, phir devalay" (first toilets, then temples). Jairam Ramesh promptly accused Modi of stealing his lines. Irrespective of who gets the credit, that senior politicians took toilets seriously is a remarkable development. After a cabinet reshuffle in 2011, Congressman Gurudas Kamat had refused to take charge of the ministry of water and sanitation, considering the ministry to be beneath him.
The importance of sanitation can be gauged by looking at the manifestos of the two major parties over time. While sanitation was conspicuous by its absence in the manifestoes of major parties in 2009, this time has been different. Both the Bharatiya Janata Party (BJP) and Congress promise to make India open-defecation free in their 2014 manifestoes.
The increasing recognition of sanitation as a major challenge for the country follows a growing body of evidence that shows how India’s abysmal standards of sanitation is responsible for our poor developmental outcomes. About half of Indian households defecate in the open according to the latest census data and open defecation has remained one of the major causes of child malnutrition.
A recent report by the World Health Organization (WHO) puts the returns to building a toilet in India at about ₹ 5 per spent.
Narrating the story of “escape from poverty and death" in his important new book The Great Escape, the celebrated Princeton University economist Angus Deaton shows how better public health measures and improved health technology led to a rise in living standard as well as life expectancy all over the world. During the mid-19th century cholera epidemic in London, it was widely believed that cholera was caused by a blood disorder. John Snow, a physician, collected data on 1854 cholera deaths in London and put it on a map to find that cholera epidemic was more severe in areas with contaminated water supply, debunking the myth that cholera was caused by blood disorder. This led to a significant reduction in child mortality not only in Britain but also across the world in the 20th century.
Recent research has established the causal relationship between open defecation and poor health outcomes. An entire session called ‘Toilet Papers’ was devoted to research on the impact of sanitation on child health in the last conclave of the American Economic Association. There is concrete evidence now that moving away from open defecation has led to a reduction in child mortality globally. Building toilets also accounts for increases in children’s height under different settings, research shows.
There is of course a Palaeolithic-era argument that genes, not factors like sanitation and maternal health, are responsible for difference in children’s height across countries. The Columbia University economist Arvind Panagariya advocated such a view in a 2013 Economic and Political Weekly (EPW) article arguing that Indian children are shorter than sub-Saharan African children because of genetic differences. Panagariya argued that WHO’s horrible methodology is to be blamed for conventional wisdom about malnutrition being higher among children in India than those in sub-Saharan Africa. Researchers from different disciplines-- economics, paediatrics, and nutrition—took a dim view of this rather astonishing claim. Princeton University economist Dean Spears refuted it first in Mint explaining that sanitation is the key predictor of the difference between children’s height across countries. This was followed by the publication of a collection of six papers in EPW by, among others, Deaton and Spears, who pointed out how Panagariya had ignored the role of disease and ill-health, often caused by poor sanitation, in stunting growth.
Research by Spears and two of his colleagues, Arabinda Ghosh and Aashish Gupta, shows that for a given level of economic status, children in Bangladesh are taller than those in West Bengal because of lower level of open defecation in Bangladesh. Similarly, Cambodia experienced a rapid decline in open defecation in the last 10 years; this alone accounts for much of the rise in the height of children, Spears et al argue in another study. Spears, Ghosh and Oliver Cummings in an analysis of data for hundred poor districts in India show that “ten percent increase in open defecation was associated with a 0.7 percentage points increase in stunting and severe stunting."
Is there any evidence that there are long term benefits of improved sanitation? In a remarkable study on the impact of sanitation projects in US Indian reservations, Tara Watson, economist at the Williams College, Massachusetts found that this intervention alone accounted for about 40% improvement in native American mortality rates vis-a-vis the rates for Whites between 1968 and 1998.
In 1999, India launched a sanitation program which is now known as the Total Sanitation Campaign (TSC). Increased participation in this programme has led to a reduction in child mortality and an increase in children’s height, on an average. In a recent study, Spears and Lamba found that children who reside in districts with greater intensity of toilets built under TSC are more likely to recognize alphabets and numbers at the age of six.
Achieving better sanitation is not an easy task for there are behavioural aspects that prevent people from adopting improved sanitation. Deaton argues in The Great Escape that “diffusion of ideas and their practical implementation take time because they often require people to change the way they live."
While subsidies may help in incentivizing the take-up of toilets, these incentives are sometimes just not enough and a nudge is required. Social pressure has played a very important role in whatever success TSC had in building more toilets. A randomized experiment by Subhrendu Pattanayak of the Sanford Institute of Public Policy and Nicholas School of the Environment, Duke University and others in 40 villages in Odisha on TSC makes the case for social pressure as an important determinant of success in improving sanitary outcomes. Social shaming through information, education and communication (IEC) approach contributed to about two-third of the toilets constructed and the rest one-third by subsidies, the study showed.
Complementing what Pattanayak et al found, Yaniv Stopnitzky, an economist at University of San Francisco noted that subsidies had made very little impact on adoption of toilets through the large subsidy programme. Much of this failure, critics argue, is due to lack of collective action and community participation .
In another research paper, Stopnitzky showed that the “No Toilet, No Bride" scheme in Haryana led to greater male investment in toilets after exposure to the programme.
In a provocative new paper, economists Michael Geruso and Spears find that Muslims are taller than Hindus and have lower rates of child mortality solely because of the differing sanitation practices in the two communities. While 67% poor Hindus defecate in the open, only 42% poor Muslims do so, they report, using data from the last National Family Health Survey. Their estimates also suggest that relatively wealthy Hindus invest more on assets like motorcycle and choose open defecation. They also argue that not only is using toilet important, it also matters if neighbours also use toilets.
Research has shown why toilets are important and how policymakers should address the issue of open defecation. While there is emphatic and unqualified evidence that better sanitation leads to better health, there is very slim evidence that large subsidies are alone responsible for reduction in open defecation. The answer to the sanitation puzzle in India could well be a combination of subsidies and social mobilization. Given that collective action matters so much in the provision of better sanitation facilities, politics, as always, has a very important role to play.
Sumit Mishra is a research scholar at the Indira Gandhi Institute of Development Research
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