The long and short of open defecation

 www.thehindu.com   November 19th, 2013

You can learn a lot from measuring children’s height. How tall a child has grown by the time she is a few years old is one of the most important indicators of her well-being. This is not because height is important in itself, but because height reflects a child’s early-life health, absorbed nutrition, and experience of disease.

Because health problems that prevent children from growing tall also prevent them from growing into healthy, productive, smart adults, height predicts adult mortality, economic outcomes, and cognitive achievement. The first few years of life have critical life-long consequences. Physical or cognitive development that does not happen in these first years is unlikely to be made up later.

So it is entirely appropriate that news reports in India frequently mention child stunting or malnutrition. Indian children are among the shortest in the world. Such widespread stunting is both an emergency for human welfare and a puzzle. Why are Indian children so short? Stunting is often considered an indicator of “malnutrition,” which sometimes suggests that the problem is that children don’t have enough food. Although it is surely a tragedy that so many people in India are hungry, and it is certainly the case that many families follow poor infant feeding practices, food appears to be unable to explain away the puzzle of Indian stunting.

‘Asian enigma’

One difficult fact to explain is that children in India are shorter, on average, than children in Africa, even though people are poorer, on average, in Africa. This surprising fact has been called the “Asian enigma.” The enigma is not resolved by genetic differences between the Indian population and others. Babies adopted very early in life from India into developing countries grow much taller. Indeed, history is full of examples of populations that were deemed genetically short but eventually grew as tall as any other when the environment improved.

So, what input into child health and growth is especially poor in India? One answer that I explore in a recent research paper is widespread open defecation, without using a toilet or latrine. Faeces contain germs that, when released into the environment, make their way onto children’s fingers and feet, into their food and water, and wherever flies take them. Exposure to these germs not only gives children diarrhoea, but over the long term, also can cause changes in the tissues of their intestines that prevent the absorption and use of nutrients in food, even when the child does not seem sick.

More than half of all people in the world who defecate in the open live in India. According to the 2011 Indian census, 53 per cent of households do not use any kind of toilet or latrine. This essentially matches the 55 per cent found by the National Family Health Survey in 2005. Open defecation is not so common elsewhere. The list of African countries with lower percentage rates of open defecation than India includes Angola, Burundi, Cameroon, Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Liberia, Malawi, Rwanda, Senegal, Sierra Leone, South Africa, Tanzania, Uganda, Zambia, and more. In 2008, only 32 per cent of Nigerians defecated in the open; in 2005, only 30 per cent of people in Zimbabwe did. No country measured in the last 10 years has a higher rate of open defecation than Bihar. Twelve per cent of all people worldwide who openly defecate live in Uttar Pradesh.

So, can high rates of open defecation in India statistically account for high rates of stunting? Yes, according to data from the highly-regarded Demographic and Health Surveys, an international effort to collect comparable health data in poor and middle-income countries. International differences in open defecation can statistically account for over half of the variation across countries in child height. Indeed, once open defecation is taken into consideration, Indian stunting is not exceptional at all: Indian children are just about exactly as short as would be expected given sanitation here and the international trend. In contrast, although it is only one example, open defecation is much less common in China, where children are much taller than in India.

Further analysis in the paper suggests that the association between child height and open defecation is not merely due to some other coincidental factor. GDP or differences in food availability, governance, female literacy, breastfeeding, immunisation, or other forms of infrastructure such as availability of water or electrification do not account for it. Because changes over time within countries have an effect on height similar to the effect of differences across countries, it is safe to conclude that the effect is not a coincidental reflection of fixed genetic or cultural differences. I do not have space here to report all of the details of the study, nor to properly acknowledge the many other scholars whose work I draw upon; I hope interested readers will download the full paper at http://goo.gl/PFy43.

Double threat

Of course, poor sanitation is not the only threat to Indian children’s health, nor the only cause of stunting. Sadly, height reflects many dimensions of inequality within India: caste, birth order, women’s status. But evidence suggests that socially privileged and disadvantaged children alike are shorter than they would be in the absence of open defecation.

Indeed, the situation is even worse for Indian children than the simple percentage rate of open defecation suggests. Living near neighbours who defecate outside is more threatening than living in the same country as people who openly defecate but live far away. This means that height is even more strongly associated with the density of open defecation: the average number of people per square kilometer who do not use latrines. Thus, stunting among Indian children is no surprise: they face a double threat of widespread open defecation and high population density.

The importance of population density demonstrates a simple fact: Open defecation is everybody’s problem. It is the quintessential “public bad” with negative spillover effects even on households that do not practice it. Even the richest 2.5 per cent of children — all in urban households with educated mothers and indoor toilets — are shorter, on average, than healthy norms recommend. They do not openly defecate, but some of their neighbors do. These privileged children are almost exactly as short as children in other countries who are exposed to a similar amount of nearby open defecation.

If open defecation indeed causes stunting in India, then sanitation reflects an emergency not only for health, but also for the economy. After all, stunted children grow into less productive adults. 

It is time for communities, leaders, and organizations throughout India to make eliminating open defecation a top priority. This means much more than merely building latrines; it means achieving widespread latrine use. Latrines only make people healthier if they are used for defecation. They do not if they are used to store tools or grain, or provide homes for the family goats, or are taken apart for their building materials. Any response to open defecation must take seriously the thousands of publicly funded latrines that sit unused (at least as toilets) in rural India. Perhaps surprisingly, giving people latrines is not enough.

Ending a behavior as widespread as open defecation is an immense task. To its considerable credit, the Indian government has committed itself to the work, and has been increasing funding for sanitation. Such a big job will depend on the collaboration of many people, and the solutions that work in different places may prove complex. The assistant responsible for rural sanitation at your local Block Development Office may well have one of the most important jobs in India. Any progress he makes could be a step towards taller children — who become healthier adults and a more productive workforce. (Dean Spears is an economics PhD candidate at Princeton University and visiting researcher at the Delhi School of Economics.)

India does need toilets more than temples

www.indiasanitationportal.org    October 5, 2013

India’s Prime Minister Narendra Modi had stirred up the toilets and sanitation issue while he was a candidate for the post with his “toilets before temples” remark. There was seemingly nothing wrong in what Modi said, but it irked the then Union rural development minister Jairam Ramesh no end and started a political row. Ramesh said enlightenment has dawned on Modi rather late in the day because when he (Ramesh) had said the same thing he was opposed by Mr. Modi’s political party. The war of words between the Congress party then in office, and the newly elected BJP party is not new.  But what has been missed in all this din is the ground reality—almost 70 per cent of rural India still defecates in open.

Concern over poor sanitation in India is nothing new. Mahatma Gandhi once said sanitation is more important than Independence. But more than 65 years after Independence, only 31 per cent of rural Indian households have toilets (see table). Census 2011 data shows that nearly 70 per cent of rural households defecate in the open in the absence of toilet facility. Data from the 65th round of survey by the National Sample Survey Office (NSSO) varies very little from Census data of 2011.

But another report, Indian Rural Development Report 2012-13, released by the Union Ministry of Rural Development (MoRD) presents a sharply divergent picture. The report claims 73 per cent rural households have access to toilets.

Sanitation has been work in slow progress. The 2008-09 NSS data shows nearly 49 per cent households had no latrine facility, and the rural urban divide was considerable: nearly 65 per cent of rural households had no latrine facility whereas only 11 per cent of urban households did not have any latrine (see table).

The NSSO surveys revealed that households in lower MPCE (monthly per capita expenditure) quintile (one-fifth) classes are more likely to be without a latrine facility than the households in higher quintile classes. In rural areas, about 85 per cent of the households in the bottom quintile class had no latrine facility against nearly 42 per cent of the households in the top quintile class. In urban areas, nearly one-third of the households in the bottom quintile class and less than one per cent of the households in the top quintile class had no latrine facility. In rural areas, low MPCE households mostly have no toilet facility (see table).

Surveys also show that acceptability of toilets is lower in the traditionally deprived social groups with low MPCE, like Scheduled Tribes, Scheduled Castes and Other Backward Classes.

Government efforts so far

In 1986, the first national effort to improve sanitation coverage was launched in the form of Central Rural Sanitation Programme. But it failed to achieve its objective in 1990s. In 1999, MoRD initiated the Total Sanitation Campaign (TSC) that aimed to eradicate open defecation by 2017 by providing basic sanitation facilities.

In 2003, the Nirmal Gram Puraskar was introduced under TSC to reward local village, block, and district level governments that achieved full sanitation coverage for housholds and schools. In 2012, TSC was renamed Nirmal Bharat Abhiyan (NBA) with aim to accelerate rural sanitation coverage so that 50 per cent of gram panchayats attain Nirmal Gram status by 2017 and Nirmal Bharat (clean India) by 2022.

Given the progress made in sanitation, a clean India does indeed seem to be a highly ambitious aim. Read More (Source: Jitendra, DownToEarth.org)

Modi's New Slogan: "Pehle Shauchalaya, Phir Devalaya" (Toilets First, Temples Later)

www.indiasanitationportal.org   

New Delhi, Oct. 3, 2013: Build toilets first and temples later -- that’s the message Bharatiya Janata Party’s prime ministerial candidate Narendra Modi gave the youth at a function organised in New Delhi on Wednesday.

Modi said he dared to say so even though his image as a Hindutva leader did not allow him. "I am known to be a Hindutva leader. My image does not permit me to say so, but I dare to say. My real thought is -- Pehle shauchalaya, phir devalaya (toilets first, temples later)," he said.

The Gujarat Chief Minister's comment could well stoke a controversy from within his party and sister organisations, which are keen to rake up the "temple issue" again ahead of next general elections.

A similar comment on toilets from (the then) Union Rural Development Minister Jairam Ramesh that the country needs more toilets than temples had stirred a row with a large number of  women. organisations and NGOs protesting against the remark.

Touting the slogan of development that could take the country on the path of speedy progress, Modi said lakhs of rupees were spent on temples in villages, but there were no toilets there.

Invoking Mahatma Gandhi's thoughts, he lamented that it was ironic that women in the country had to go in the open for easing themselves in the absence of toilets.

Modi said it was the quality of a real leader to have the strength to handle all problems and lead the way forward. He said that for good governance and speedy progress, it was necessary for planners to focus on outlay, outcome and social audit. (Source: PTI)

Modi's New Slogan: "Pehle Shauchalaya, Phir Devalaya" (Toilets First, Temples Later)

By Jitendra, DownToEarth.org.  Oct 3, 2013

New Delhi, Oct. 3, 2013: Build toilets first and temples later -- that’s the message Bharatiya Janata Party’s prime ministerial candidate Narendra Modi gave the youth at a function organised in New Delhi on Wednesday.

Modi said he dared to say so even though his image as a Hindutva leader did not allow him.

"I am known to be a Hindutva leader. My image does not permit me to say so, but I dare to say. My real thought is -- Pehle shauchalaya, phir devalaya (toilets first, temples later)," he said.

The Gujarat Chief Minister's comment could well stoke a controversy from within his party and sister organisations, which are keen to rake up the "temple issue" again ahead of next general elections.

A similar comment on toilets from Union Rural Development Minister Jairam Ramesh that the country needs more toilets than temples had stirred a row with a large number of women organisations and NGOs protesting against the remark.

Touting the slogan of development that could take the country on the path of speedy progress, Modi said lakhs of rupees were spent on temples in villages, but there were no toilets there.

Invoking Mahatma Gandhi's thoughts, he lamented that it was ironic that women in the country had to go in the open for easing themselves in the absence of toilets.

Modi said it was the quality of a real leader to have the strength to handle all problems and lead the way forward.

He said that for good governance and speedy progress, it was necessary for planners to focus on outlay, outcome and social audit. (Source: PTI)

Background:

The 2008-09 NSS data shows nearly 49 per cent households had no latrine facility, and the rural urban divide was considerable: nearly 65 per cent of rural households had no latrine facility whereas only 11 per cent of urban households did not have any latrine (see table).

The NSSO surveys revealed that households in lower MPCE (monthly per capita expenditure) quintile (one-fifth) classes are more likely to be without a latrine facility than the households in higher quintile classes. In rural areas, about 85 per cent of the households in the bottom quintile class had no latrine facility against nearly 42 per cent of the households in the top quintile class. In urban areas, nearly one-third of the households in the bottom quintile class and less than one per cent of the households in the top quintile class had no latrine facility. In rural areas, low MPCE households mostly have no toilet facility (see table).

urveys also show that acceptability of toilets is lower in the traditionally deprived social groups with low MPCE, like Scheduled Tribes, Scheduled Castes and Other Backward Classes.

Government interventions so far

In 1986, the first national effort to improve sanitation coverage was launched in the form of Central Rural Sanitation Programme. But it failed to achieve its objective in 1990s. In 1999, MoRD initiated the Total Sanitation Campaign (TSC) that aimed to eradicate open defecation by 2017 by providing basic sanitation facilities.

In 2003, the Nirmal Gram Puraskar was introduced under TSC to reward local village, block, and district level governments that achieved full sanitation coverage for housholds and schools. In 2012, TSC was renamed Nirmal Bharat Abhiyan (NBA) with aim to accelerate rural sanitation coverage so that 50 per cent of gram panchayats attain Nirmal Gram status by 2017 and Nirmal Bharat (clean India) by 2022. 

Given the progress made in sanitation, a clean India does indeed seem to be a highly ambitious aim.(Source: Jitendra, DownToEarth.org)

Open defecation linked to stunting in Indian children

By Kundan Pandey     Down to Earth, Sep 23, 2013

Research finds 10 per cent increase in open defecation associated with a 0.7 per cent increase in stunting in 112 districts

Poor sanitation gives arise to a number of health problems, but now research shows that it is linked to stunted growth as well. A research published last week in journal PloS One has concluded that lack of sanitation is a potential contributor to stunting in the country.  

The study was carried out by Dean Spears from the Centre for Development Economics at the Delhi School of Economics along with Arabinda Ghosh, an Indian Administrative Service official, and Oliver Cumming of the London School of Hygiene and Tropical Medicine. The researchers found that a 10 per cent increase in open defecation was associated with a 0.7 per cent increase in both stunting and severe stunting. 

 The researchers used recently published data on levels of stunting in 112 districts of India to explore the relationship between open defecation and stunting within the population in these districts. They used information from the 2011 HUNGaMA (hunger and malnutrition) survey  for stunting data and 2011 Indian Census for the same districts was referred to for other indicators like open defecation. The HUNGaMA survey is the most recent large-scale data on malnutrition which evaluated 109,093 children under five years of age in 73,670 households. 

The researchers carried out a statistical analysis after adjusting potential confounding factors such as socio-economic status, maternal education and calorie availability. They found that stunting figure of the districts where people defecate in the open is higher. In general, children in these districts were found unhealthy. “Over half of the children are stunted, and almost a third of children are severely stunted. The early-life disease environment is poor: over 70 per cent of households defecate in the open and 71 out of every 1,000 babies born alive die before they are one year old. Two-thirds of all adults, and slightly more than half of females, are reported as literate in the Census,” the research findings state.

Population density's compounding effect

The finding calls for immediate attention of and follow up by policy makers in India. Open defecation is a pressing problem because it is much more common in India than in many poor African countries. UNICEF and the WHO estimate that in 2010, 25 per cent of people in sub-Saharan Africa defecated in the open. Recent health surveys in the largest three sub-Saharan countries show that 31.1 per cent households in Nigeria, 38.3 households in Ethiopia, and 12. 1 per cent households in the Democratic Republic of the Congo defecate in the open. Consider the comparative data for India. The Planning Commission report on Evaluation Study on Total Sanitation Campaign, 2013, suggests that around 72.63 per cent of rural India still defecates in the open. 

What's more worrying for India is that density of population in the country is very high which has the potential to compound the problem. 

Spears has written on the subject in a research paper prepared for Public Health Foundation of India (PHFI) on February 15 this year. “If open defecation is indeed keeping children from growing to their genetic potentials–rather than merely being coincidentally correlated with height–we would expect open defecation to be more important for health outcomes where children are more likely to encounter whatever fecal germs are introduced into the environment. This means that population density should matter: living near neighbours who defecate in the open is more threatening than living in the same country as people who defecate in the open far away.”

He goes on to say that Indian children face the double threat of widespread open defecation and high population density, and that  stunting among Indian children is no surprise.  He stresses on proper efforts to motivate people to not only construct latrines but use them as well. 

However, motivation and awareness have not received sufficient attention in the planning of the government. The Planning Commission evaluation report of Total Sanitation Campaign report  points out that the practice of open defecation was supposed to be stopped with all individual households being given access to the toilets by 2012; toilet facilities to all schools and anganwadi centres were to be provided by  2009 and Community Sanitary Complex/Women Sanitary Complex were to be provided in case of lack of space or financial constraints. Government of India gives Nirmal Gram Puraskar to push the sanitation campaign. But there is no significant progress as 72 per cent people  in rural India still defecate in the open.

Forget Food Bill, India Needs Sanitation

By Atish Patel, blogs.wsj.com   July 10th, 2013

Children ate food near a road in Hyderabad, October 3, 2011. Photo by: Noah Seelam/Agence France-Presse/Getty Images

India is poised to launch one of the biggest food subsidy programs ever attempted, but some experts say it will fail unless major steps are taken to improve sanitation.

“In the absence of focus on sanitation, what we have is taxpayer-funded diarrhea and little else,” Pavan Srinath, policy research manager at the Takshashila Institution, a think-tank, said of the program that the government says will cost about $20 billion a year.

The government approved the National Food Security Law last week. As Parliament is in recess, the law is classed as an ordinance, or temporary legislation, until Parliament reconvenes and votes on it at the end of the month or early August. The passing of the law is expected to be a formality.

Under the program, the government will sell very cheap rice, wheat and other grains to around 800 million poor Indians, or around 70% of the population.

In addition to the critics who say the program is misdirected and a bid by the ruling Congress party-led government to win votes, health experts say the subsidies overlook the problem of poor sanitation.

A lack of access to toilets means that hundreds of millions of people defecate in the open in India.  As a result, children are exposed to bacterial infections and parasites that can damage the small intestine and reduce or stop its capacity to absorb nutrients needed for growth and development, no matter how much food is consumed.

Unicef says there are 61.7 million stunted children in India, more than anywhere else in the world. The government estimates that around 20% of children under five are wasted, or too thin for their height and 43% are underweight for their age.

In a recent paper in Economic and Political Weekly, Robert Chambers from the University of Sussex in the U.K. and Gregor von Medeazza from Unicef India said the link between sanitation and under-nutrition has been largely overlooked, describing it as a “blind spot.”

Last month, Rural Development Minister Jairam Ramesh was quoted in the media as saying: “I don’t see the same degree of political enthusiasm on sanitation. I think we neglect this at peril… When we talk about sanitation, we can only giggle.”

Gagandeep Kang, professor in the Department of Gastrointestinal Sciences at Christian Medical College in Vellore, is involved in an international study funded by the Bill and Melinda Gates Foundation to look at how pathogens damage children’s guts, leading to malnutrition.

“You can’t argue sanitation alone is going to lead to people not being malnourished. Nor is food alone going to lead to every single child growing fine. It has to be a combination of both of those,” she said.

According to research by Dean Spears, a visiting economist at the Delhi School of Economics, there is less stunting of children in Indian districts with toilets. Improved sanitation meant infant mortality decreased by four per 1,000 and children’s height increased, he said.

The World Health Organization says diarrhea is a leading cause of malnutrition in children under five. More than 800,000 children in that age bracket die every year from diarrhea globally, according to Unicef. A quarter of these deaths happen in India.

A survey from 2011 found that nearly 80% of Indian children with diarrhea did not wash their hands with soap after visiting the toilet.

The challenge the government faces is finding a way to get more Indians to use toilets, which some have said is a culture problem. “The biggest thing about sanitation is individual behavior,” Mr. Srinath said.

“It’s an individual choice. Most people in India don’t want to spend money to build a toilet,” he added.(Atish Patel is a multimedia journalist based in Delhi. You can follow him on Twitter @atishpatel.)