The history of global health has been marked with a dramatic turnaround starting from around the mid to late 19th century. This period witnessed an unprecedented decline in death rate and a steady increase in the life expectancy of populations across Western Europe and North America. Conventional wisdom for a long time held that the improvement in public health indicators came through because of rising incomes and consequently, rising nutritional levels. However, a number of scholars now agree that the real reason for the rapid advance in the conditions of human life in this period was made possible by the ‘sanitation movement’ that provided – particularly in the growing urban centres of industrialising Europe – sewers and clean drinking water to the population. The state played a very important role in the provisioning of these ‘public goods’ as the markets typically failed to deliver, say for instance universal vaccination or urban sewage systems, owing to what is known as market failures in neoclassical economics. Gradually, the long, arduous and killing phase of infectious diseases got over by the middle of the 20th century along with the new ‘therapeutic revolution’. Thus, improvements in basic health, nutrition and well being indicators are possible and have been achieved despite low economic growth, for instance in Kerala.
The Indian enigma
The South Asian region registers the highest rates of child malnutrition in the world despite the fact that the per capita income and GDP growth rate of this region is better than many other poor countries, including sub-Saharan Africa. Some scholars in the mid-1990s termed this peculiar problem as the ‘Asian Enigma’. For instance, India’s sustained level of growth since the 1980s and unprecedented economic growth rates in the last decade do not seem to have impacted the high levels of child malnutrition in the country. However, the same period saw Bangladesh and Nepal catch up with and leave India far behind in key indicators, such as life expectancy and child survival. Several scholars have identified two key factors responsible for child malnutrition in South Asia, specifically India –
First, the status of women and their participation in the decisions related to their bodies, economic resources, and social and public services, which have been instrumental in transforming the landscape of Bangladesh, at least as far as child nutrition is concerned,
Secondly, sanitation which includes provision of safe and clean drinking water and, in the case of India, the practice of open defecation.
The National Family Health Survey (NFHS)-4 (2015-16) suggests that about 52% of all Indian households defecate in the open. The share for rural India was much higher at 63%. The proportion of women between the age group 20-24 years who were married before they attained the age of 18 years was about 27%. The share of women between the age group of 15-49 years who were anaemic decreased from 55.3% to 53% between NFHS-3 (2005-06) and NFHS-4 (2015-16), a decline of less than two percentage points over a decade. The reduction in key child malnutrition indicators over a decade spanning from NFHS-3, pertaining to 2005-06 and NFHS-4 (2015-16) has also been very slow.
Take for instance, the reduction in the proportion of children under five years who were stunted (low height for age):
The figure came down from 48% in the year 2005-06 to about 38% in 2015-16.
The share of children who were wasted (low weight for height), in fact, increased from 19.8% to 21% in the given time period.
The same is true for the proportion of children who were severely wasted which rose from 6.4% to 7.5% between NFHS-3 and NFHS-4.
The decline in the share of children under five years who were underweight has been very slow, from 42.5% to 35.7%.
Diane Coffey and Dean Spears’ recent book, Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste, is a path breaking and brilliant addition to the literature on child malnutrition and development policy in India. In their long journey of following cases of child malnutrition and mortality, they zeroed down on a simple, commonly known but rarely acknowledged fact in policy and academic circles, and that was the link between open defecation and the spread of harmful germs that lead to higher levels of child malnutrition. The government of India and other multilateral international agencies even today swear by the myth that it is poverty which is at the root of open defecation. Coffey and Spears do not reject that poverty is a part of the problem, but they insist that social inequalities play a bigger role in explaining why a majority of rural Indian families continued to defecate in the open.
Also read: ‘Where India Goes’ Gives a First-Hand Analysis of India’s Poor Early-Life Health and Stunting
The persistence of open defecation
The book is divided into three parts: causes, consequences and responses.
In the first part, the authors deconstruct certain myths associated with open defecation, purveyed by government and development professionals uncritically, the first and foremost of which is that poverty is the cause of open defecation. India not only has higher levels of open defecation than countries with similar national per capita GDP but also in comparison with countries with similar national poverty rates. Secondly, India is also seen to have higher levels of open defecation than countries with similar water access and adult literacy rates. The other explanation of governance failure also does not hold much water if we compare India with other countries with obviously worse systems of governance. Even in the Indian states which are supposed to be governed well, such as Gujarat and Tamil Nadu, the authors point out, the rates of open defecation among rural households, according to the 2011 census, is 67 and 76.8% respectively.
The authors and their team then decided to conduct their own Sanitation Quality, Use, Access and Trends (SQUAT) surveys in Haryana, Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. The data collected presents an uncanny truth that anyone familiar with rural India is probably aware of: over 40% of households in the sample that possessed a latrine had at least one member who chose to defecate in the open. Why did rural Indians find it easier to defecate in the open compared to a latrine? The answer, according to the authors, lies in how Indians perceive ritual and physical cleanliness or “a world view in which open defecation is clean and latrines are dirty”. In the larger scheme of the Hindu caste system and its associated ideas of purity and pollution, a number of objects, situations and individuals/groups are considered pure/clean or impure/unclean. One of these things is human faeces. This is amply clear in the Muslim mortality paradox that the authors try to figure out in the second part of the book. Muslims are less likely to defecate in the open than the Hindus in rural India. And unsurprisingly, infant mortality among Muslims is lesser than the Hindus. This is despite the fact that Muslims, on an average, are poorer and less educated than the Hindus. The point is simple: any neighbourhood with a lesser degree of open defecation, keeping everything else constant, will have lower child mortality rates than a neighbourhood with higher share of people defecating in the open.
Poor people world over construct and use simple and inexpensive pit latrines but poor Indians refuse to do so even when they can afford the cost. This is because after the pits get full of faeces, somebody needs to clean it manually. This work is considered ritually impure and hence, the preserve of a certain group of people, namely the Dalits. With the rise in Dalit consciousness and change in power equations across rural areas, the cleaning up of pit latrines is getting expensive. The end result is the more convenient option of open defecation which is ritually pure, rather than cleaning the pit occasionally which is ritually polluting and affects one’s caste status and pride. The rural households which can afford latrines in terms of money either defecate in the open or build relatively more expensive latrines where the pits are bigger and bigger. This is to bypass cleaning of the pit manually.
Consequences of poor sanitation
Poor standards of public and private sanitation lead to the spread of germs and diseases, many of which are life threatening for children. In the foreword to the book, Nobel laureate Angus Deaton says that Indian women will probably take 250 years to catch up with British women in terms of their height even if we assume that the latter will grow no taller than what they are today. This is not simply a nutritional or height disadvantage but is closely linked with the ability of Indian children to grow healthier and learn better and when they grow, earn better.
The economic consequences of poor sanitation are multifaceted and extreme. The environment of open defecation which leads to diseases traps poor populations into intergenerational deprivation from good health, education and wages. This might be an interesting assertion to the new Indian middle class that claims that caste is dead and ‘merit’ must rule. Objectively speaking, the caste system in India influences the life chances of all the poor persons in the country. Through its impact on public sanitation, it affects everyone.
What has been the government’s response to the crisis of sanitation in rural India? Predictable, to say the least. Governments have made policies to construct latrines or subsidise the construction of latrines for poor people. The new NDA government even dedicated itself to completely eliminating open defecation by providing a latrine to every household which doesn’t have one today (12.3 crore households to be precise) by October 2, 2019. However, the Swachh Bharat Abhiyan does not budge an inch from earlier schemes and their presumption that construction of latrines will take care of open defecation in rural India.
The authors’ recommendations in this regard are threefold. One, the government and/or civil society need to find out how many Indians defecate in the open and where. The datasets that we have are actually about the construction of latrines which perform more of an accounting purpose for a scheme like Swachh Bharat. Two, the authors want the governments and development agencies to speak about culture and how it affects development policies and more specifically, caste and casteism. Finally, the authors want a policy solution that is based on the two earlier suggestions so as to combat open defecation, and the havoc it causes to children and adults alike, decisively.
Why is the Indian state silent?
This book is one of the bravest attempts to comprehend and unravel the Achilles’ heel of development policy in a country like India and that is caste and its associated manifestations – the real reason behind some of the longstanding policy issues in India, which the state and international development agencies often collude to deny. The book might inspire research on themes such as gender and its role in explaining child malnutrition in India – another uniquely Indian enigma. While we have secondary data on subjects like age at marriage, decisions regarding pregnancy and domestic violence, etc., a book like this one that combines the best of secondary and primary research along with quantitative and qualitative methodologies is the need of the hour.
I have only one minor quibble against the book and that is its silence on why the state in India does not possess the willingness to take the issue of open defecation or such severe levels of child malnutrition head on. The Indian state is a messy and complex enterprise which, the authors assert, is also relatively small in terms of its expenditure and capacity to effect change in society. Society in a way triumphs the state in India. However, that is an inadequate diagnosis of the Indian state. One reason why I think this question is important is because if the state has not done it till now, why would it formulate policies that will tackle sanitation in the coming future? Here, I think the question of the nature and the character of the state becomes imperative.
The state in India continues to derive its power from the alliance of rural landlords and urban businesses. The caste character of the state is feudal and upper caste and it highlights the lack of conviction among state agencies and civil society in bringing modernity to the Indian village. This affects the everyday discourses around and the commonplace conceptualisation of education and health in determining lifestyles and community habits. As far as the economic argument for productivity and growth is concerned, it is clear that the desire for social control of the working people in India is much deeper than the perceived benefit that can be derived from their enhanced economic roles in the process of production. The need of the hour is to wage a double war of social reforms and political power, for one is incomplete without the other.
Awanish Kumar is a lecturer and researcher based in Mumbai.