'Where India Goes' Gives a First-Hand Analysis of India's Poor Early-Life Health and Stunting

Where India Goes is essential reading not only for policy-makers and development professionals, but for anyone interested in the paradoxes of development in the early 21st century.

An ‘open-defecation-free’ India in 2019 is a chimera. Decades will pass before that goal is achieved. In the meantime, millions of babies in India will die due to poor sanitation. Millions more will, through their lives, bear the stamp of impaired physical and cognitive development caused by the toilet practices of their neighbours.

This is the brutal prognosis of Diane Coffey and Dean Spears in their timely and out-spoken book. Having set up their home in a village in Sitapur district of Uttar Pradesh “where we could learn first-hand about the poor early-life health and the process of stunting that affect so many children in India”, Where India Goes reflects their lived experience and presents extensive research and analysis conducted through the Research Institute For Compassionate Economics (rice), an institute they established.

Diane Coffey and Dean Spears
Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste
Harper Collins, 2017

The figures are not unknown: The vast majority (70%, as per the 2011 census) of rural households in India defecate in the open. Out of every thousand babies born 43 die before their first birthdays – more than in any of our South Asian neighbours (other than Pakistan); India’s infant mortality rate is a fifth higher than countries with corresponding GDP per capita and three times more than in China or Brazil; the proportion of undernourished children below 5 is much higher than the average for Sub-Saharan African countries.

Children in Bangladesh, where latrine-use is virtually universal, are comparatively taller than children of similar income groups in West Bengal. The Muslim paradox is telling: Muslim households in India are on average poorer than Hindu households, but their babies are more likely to survive childhood – because Muslims are more prone to using toilets.

Multiple studies, using a variety of methodologies, have established the correlation between child health and exposure to faecal germs. Endemic illnesses and under-nourishment afflict children in communities where open defecation is customary – even if their own households eschew the practice – decreasing their productivity and earning capacity as adults.

Referring to this as “one of the greatest human development challenges of our times”, Coffey and Spears argue that speeding the decline of open defecation offers a one-off opportunity to accomplish a quantum improvement in the quality of life and to add value to the pool of human capital.

The problem is unique to India. The prevalence of open defecation here is not explained by under-development or poverty; nor is it a matter of education levels or governance, access to latrines, availability of water or quality of available toilets. Rural Indians are not ‘forced’ to defecate in the open; they do so by choice.

“Poor sanitation persists in rural India”, the authors contend, “because of unique social forces – in particular, caste”.

In villagers’ minds, open defecation is a far superior choice to storing faeces in a government-provided latrine pit that would need to be emptied by hand, an activity which invokes a generations-old struggle between people who are still too often thought of as ‘Untouchables’ and those who still too often exploit, exclude and humiliate them.

Ironically, from the initial programme for rural sanitation in 1986, through various clones, up to the Swachh Bharat Mission of today, the emphasis has always been on latrine construction.

Diane Coffey

Diane Coffey. Credit: RICE institute website

With ‘beneficiary’ households not committed to using them, it is not surprising that a majority of the toilets reportedly constructed through the years exist only on paper, providing a source of rampant corruption. It is estimated that only one in five of the toilets said to have been constructed since 2001 was in place in 2011. In a village that Coffey and Spears studied, latrines were found to have been provided by the government sans underground pit, toilet pan, outlet pipe, door and roof. But the ‘beneficiaries’ were not complaining: they used the incomplete structures for a variety of domestic purposes, and continued blithely to defecate in the open.

The fear of pollution associated with a toilet and, especially, a storage pit on the household premises, is only exceeded by the horror of having to empty the pit when it fills. Social mobility makes Dalits aspire to similar social norms and, hence, equally averse to household toilets.

As it is near impossible today to find willing people for the job, the problem of emptying storage pits – which are mistakenly believed to fill up in a matter of months rather than years – is a major impediment to toilet use. The authors pose a hypothetical question: will the economic demand created by a successful latrine-building programme bring a resurgence of something similar to manual scavenging, rolling back what progress has been achieved towards social equality?

Dean Spears

Dean Spears. Credit: RICE institute website

Clearly, behaviour change lies at the heart of the challenge of open defecation in India. For a start, policy-makers should acknowledge the socio-cultural dimensions of the issue and set aside their aversion to talking about caste and untouchability.

The Swachh Bharat mission adopts an essentially technocratic approach, allocating a miniscule portion of its resources to behaviour change. The community-based strategy it proposes will work only to the extent the community buys into the challenge of modifying societal rules of purity and pollution.

“Above all, embrace the problem”, Coffey and Spears advocate. “Both the government and international development should be vocal about the causes of widespread open defecation in India. Struggling against untouchability is working towards the end of open defecation in India, and vice versa.”

Where India Goes is essential reading not only for policy-makers and development professionals, but for anyone interested in the paradoxes of development in the early 21st century. Presenting rigorous quantitative analysis for a lay person’s understanding alongside qualitative insights based on personal interactions, the book is an engaging and rewarding read.

As Angus Deaton, the Nobel laureate, puts it in his foreword:

It is one of the great achievements of this book that it works on so many levels, untangling the intellectual puzzles with the verve of a good mystery, telling us the stories of people who are suffering, how they live their lives, why they think and behave as they do and what sort of interventions might help or hurt them.

Govindan Nair is a retired civil servant who lives in Chennai after more than three decades in Uttar Pradesh, Delhi and overseas.