How Is Modi's Swachh Bharat Dealing With the Public Health Crisis of Open Defecation?

The Swachh Bharat Mission (Gramin) has become a single-minded toilet-building exercise, with little focus on behaviour change.

This is the first part of a series of reported stories on open defecation in Uttar Pradesh.

Lucknow: In 2014, when Narendra Modi announced the Swachh Bharat Mission (SBM) during his Independence Day address, one billion people in the world defecated in the open. More than 600 million of them lived in India, a majority of them in rural areas. According to the Census 2011, more than 67% of rural Indians defecated in the open, as against 13% of urban dwellers.

Open defecation has significant adverse public health outcomes. Writing in the Economic and Political Weekly, social scientists Diane Coffey and Dean Spears, who have for years studied the causes and consequences of poor sanitation in India, explain how open defecation leads to the spread of germs. “Open defecation releases faecal germs into the environment where they can contaminate children’s water and food, reach their hands and feet, and be spread by flies.”

The contaminated food or water can then cause diseases like diarrhoea – which is the leading cause of malnutrition and the second major cause of death among children –, worm infestations, chronic enteric inflammation, typhoid, jaundice and cholera, all of which are preventable causes of illness and death.

Every day, nearly 1,500 children under five years of age die owing to diarrhoea across the world. The United Nations (UN) estimates that in India more than 110,000 children under the age of five die due to diarrhoea each year, that is 20% of the deaths in the world. In their seminal book on the state of sanitation in India, Where India Goes, Coffey and Spears estimate that “perhaps over 200,000 and almost certainly over 100,000 children under 5 die each year who would otherwise survive if there were no open defecation in India”.

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Incidents of diarrhoea and other diseases linked to open defecation can also have long-term impacts such as malnutrition and stunting – where the height of a child is significantly lower than the standards for her age. Research has shown that stunting, which is a consequence of poor nutrition, also occurs among children who are well fed. Owing to repeated bouts of diseases such as diarrhoea, energy that would otherwise be utilised for growth is diverted towards fighting the infection. The diseases also reduce the capacity of the intestines to absorb nutrients from food.

As per the National Family Health Survey (NFHS)-4 (2015-16), 38% of children under the age of five in India were stunted. In states with high incidence of open defecation, the percentage of stunted children was higher. In Uttar Pradesh, where 70% of rural households defecated in the open, 46% of children under the age of five suffered stunted growth. In Bihar, 73% of rural households defecated in the open, and 48% of children under five were stunted. On the other hand, in Kerala where only 1% of households defecated in the open, 19% of children were stunted.

Poor sanitation also has adverse economic impacts owing to increased costs of healthcare, sometimes necessitating borrowing from money lenders, and reduced productivity. Children with compromised physical growth develop, on an average, with poor cognitive abilities which leads to poor educational performances, lower wages and lost productivity.

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According to a 2015 study on the costs of poor sanitation authored jointly by the LIXIL Group Corporation, Water Aid and Oxford Economics, poor sanitation cost the world $222 billion in 2015. India accounted for almost half of that cost at $106 billion, or 5.2% of the country’s GDP.

Given the enormity of the problem, the SBM has focused significantly on eliminating open defecation. Narendra Modi himself has spoken about the problem several times including during his first speech from the Red Fort on August 15, 2014, when he said, “Has it ever pained us that our mothers and sisters have to defecate in open? The poor womenfolk of the village wait for the night; until darkness descends, they can’t go out to defecate. What bodily torture they must be feeling, how many diseases that act might engender. Can’t we just make arrangements for toilets for the dignity of our mothers and sisters?”

As over 90% of households who defecate in the open in India are rural households, the SBM’s rural version, SMB (Gramin), is critical for eliminating open defecation. The objective under the SBM (Gramin) is to eliminate open defecation by October 2019. The strategy adopted is to “ensure that sanitary toilets are constructed, which ensure safe confinement and disposal of faeces” while also focusing on behaviour change with the aim of leading to “demand generation for sanitary facilities”. In its vision documents, the SBM (Gramin) recognises that open defecation cannot be eliminated “without all the households and individuals conforming to the desired behaviour of toilet use every day and every time”.

In practice, however, the focus has been single-minded on building toilets, which has led the SBM (Gramin) to become a toilet-building exercise with little focus on behaviour change. More than 90% of the money spent under SBM (Gramin) is on the construction of toilets. On the SBM’s (Gramin) website, the achievement most prominently highlighted is the number of toilets built. It claims that 95% of households in the country now have individual toilets, as against 38% on October 2, 2014 when the mission was launched. Modi has himself, from time to time, used the building of a certain number of toilets to claim the success of the SBM.

In 2014, Diane Coffey, Aashish Gupta, Payal Hathi, Nidhi Khurana, Nikhil Srivastav, Sangita Vyas and Dean Spears published the results of a survey in the Economic and Political Weekly. They found that a large proportion of rural Indians in the five north Indian states surveyed would continue to defecate in the open even if they had access to a toilet.

“Latrine construction is not enough to substantially reduce open defecation in the northern plains states, where it is concentrated,” the authors wrote. The study predicted that more than half of the people in the states surveyed would continue to defecate in the open even if the government built a toilet for every household that does not have one without working on behaviour change.

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Another study by the Institute of Development Studies, Water Aid and Praxis published in October 2017 found open defecation prevalent in several villages in UP, Madhya Pradesh and Rajasthan that had been declared ODF. In several villages that had also been verified as ODF, the toilet coverage was well below 100%. Toilet coverage in parts of Shamli that, according to the government had 100% toilet coverage, was as low as 16%. In parts of Pali in Rajasthan which had also been verified as ODF, the toilet coverage was only 16% and the usage was just 1%.

Focus on Uttar Pradesh

Uttar Pradesh is India’s most populous state containing 16% of its population. Only four countries, including India, house more people than UP’s 200 million. Of this population, 77% live in rural areas. And 70% of UP’s rural population, or 108 million people, defecate in the open according to NFHS 4. That is slightly less than 112 million, the total population of India’s second most populous state, Maharashtra, and more than the total populations of Madhya Pradesh and Chhattisgarh put together.

The UP government set itself an ambitious deadline of October 2, 2018 to eliminate open defecation. As on October 2 2017, a little over 15,000 of its 98,000 villages had been declared ODF. Now, on October 1, 2018, 81,000 of its villages have been declared ODF, implying that 66,000 villages have been declared ODF in the last one year.

The toilet coverage in the state is now 99.65%, according to government figures. More than eight million toilets have been built in the six months since April 2018, implying that 45,000 toilets have been built every day, or a toilet every tw0 seconds.

In the latter half of September, The Wire visited 18 randomly chosen villages in five districts of UP to understand the reality of the government’s claims and how the process of eliminating open defecation is working on the ground. Some of the districts – in western UP – that we visited had been declared ODF in October 2017. The others – in central UP – are inching towards ODF status, according to government figures.

Over the course of the next few days, we will publish stories based on our interactions with intended beneficiaries, village heads and government officials at various levels, most of whom chose to remain anonymous.