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Where India Goes

Problems with Open Defecation

  • Burden on disabled and the old

  • Open defecation -> fecal germs ->

    • diarrhea
    • potential longer term = environmental enteric dysfunction -> flattening of folds of intestine. so lower absorption of nutrients.
    • parasites --- roundworm, hookworm etc.
      • '1 study in Bihar' --> 70% children had at least one parasite infection.
    • diarrhea, parasites etc. -> can cause anemia - 70% of young children anemic in 2005
  • Infant Mortality

    • Descriptive facts
      • Under 5 mortality, based on Family Health Survey = 74 per 100k
        • mortality rate of hindu babies 14 per 100k greater than muslim babies
        • 66% of avg. Hindu baby's neighbors defecate in open compared to 45% of Muslim baby's
    • Use above to est. impact of open defecation ---> 100k--200k under 5 per year die because of open defecation
  • Height

    • Descriptive facts
      • avg. Indian man = 164 cm tall. (2005 National Family Health Survey)
        • avg. Japanese man 172 cm
      • avg. 5 year old girl in India 2/3 cm shorter than in sub-Saharan Africa
        • at 5, 2/3cm mean missing 38 days of growth
      • avg. Indian children adopted in Sweden grew as tall as avg. Swedish children --- lemm proos. children adopted earlier in life grew taller than those adopted later in life.
      • avg. European 11cm in 1980 than mid-19th. Tim Hatton finds cause = disease env. as proxied by infant mortality. Income, ed., healthcare all less imp.
    • causal-lite: avg. Indian in WB shorter than in Bangladesh when you adjust for income and wealth
  • IQ, Mental Ability

    • Descriptive facts
      • Correlation b/w height and ability to read words or more much greater in India than US
      • Fraction of Indian kids reading words or better at ages 8, 9, and 10 and 11 a good 10--20 points lower
    • Causal
      • Lamba and Dean exploit variation in Total Sanitation Campaign (TSC). Exposure to TSC increased fraction of rural 6 year olds who could recognize letters by .3%.
  • Less food

    • Average cal. intake in India declining since 1980s. Data from National Sample Survey. In 1983, avg. rural person ate 2240 cal. In 2005, it was 2047. By Deaton and Dreze. Jo and Dean estimate 25% of decline due to less disease load.
    • Saving ~ 50 cal/per day. $3/4 per year per person in cheapest calories. Or 10--20% of public distribution of food budget.
  • What doesn't kill you, makes you poorer

    • cost of medicine etc. etc. + more food + lower iq
  • Less Taxes

    • Nicholas Lawson estimates Rs 25k/per family to switch to latrines --- gov. still comes out ahead.
  • Increases Inequality

    • Richest 20% -- 16% neighbors defecate in open
    • Poorest 20% --- 86% neighbors ...
  • Potential overprescription of antibiotics

    • one way to decrease that is to simply decrease disease load
    • jishnu das and hammer have data that show doctors in delhi overprescribe antibiotics
      • sometimes to meet consumer demand
      • currie, lin, and meng found same in china

Rate of Open Defecation


* 53% of Indian households had no toilet + didn't use public toilet. 
* 13% of urban households lack a latrine, 70% of rural hh.
    - from the 2011 census
* Rate of decline in open defecation between 2001 and 2011 --- 1% per year
- during the same time, GNP grew at 8% per year
- Indians account for 60% of people defecating in open
- b/w 2001 and 2011, rural hh w/ latrine increased by 9%. But due to pop. growth, total hh w/o latrines increased by 8M.


* 13% of world population defecates in open
* 25% of people in sub-saharan africa defecate in open
* 12% of people in S. Asia except India defecate in open
    - UNICEF and WHO 2015 Joint Monitoring Report
* In Bangladesh, 67% of hh in 1994 used latrine. In 2014, it was 95%
    - Demographic and Health Surveys
* 92% of countries poorer (GDP/ppp) than India (46 out of 50) have lower open defecation rates
* 19 of 21 countries with higher fraction of people living on less than $1.25/day have lower open defecation rates

Potential Causes

  • Hedonistic

    • Pleasant to defecate in open
    • Latrine in the house smells
    • Plenty of women also like to defecate outside
      • short break from hh
  • Ritual purity

    • building a latrine in house will make it 'dirty'. 'Temple is in the house.' etc.
    • people don't even want a free latrine from gov. sometimes
    • sanitation work seen as polluting
  • Caste

    • Cleaning feces is the job of Dalits
    • Some allegedly throw trash on ground because cleaning trash is job of dalits (Teltumbde)
    • As their is conspicuous consumption, there is also conspicuous purity. To cue that you are higher, you observe stricter purity rituals. Om Prakash Valmiki mentioned that Dalits don't want to raise pigs (lucrative) as pigs are polluting etc.
  • Information

    • Villagers not aware of consequences of open defecation
    • People don't know:
      • how quickly pits fill: WHO estimates 1.5 cubic meter honeycomb style pit latrine used daily by family of 6 will fill up in 5 years.
      • letting full pit alone for 6 months makes it pretty safe
  • Consequences:

    • Because of misinformation about how quickly pit fills, disgust about emptying pit, etc. --- for most rural Indians, minimum acceptable latrine ~ Rs. 20--25k. For them, min. acceptable = build superstructure, v. large pit (3 cubic meters)
      • median size of privately constructed latrine pit = 7 cubic meters or 5x larger than WHO recommendation (1.5 cubic meters)
    • Extremely hard to find someone who will empty the pit. Someone paid Rs. 5500 for 2.5 hrs of work using someone from city as no one willing to do the work.
  • Poverty

    • poor explanation because:
      • building basic toilets not expensive
    • poorer people elsewhere have much lower rates of open defecation. In 2006, in Bangladesh, 52% of hh had dirt floors and no electricity. In India, it was 21% of hh. But open defecation rates among such hh = 28% in Bangladesh, 84% in India
    • In 2014, 75% Bangladeshis used pit latrines. Cheap to build ~ Rs 3k
    • You can also dig a hole and cover later. Ala camping in the West.
    • takes issue with framing open defecation as issue of 'access' and not also perhaps choice.
  • Access to Water

    • poor explanation because:
      • can easily build toilets w/o water seals.
    • 90% of rural Indians have access to 'an improved water source'. Sub-saharan Africa --- 49%. Open def. rates in rural sub-saharan = 35%.
    • many latrines in rural Africa do not have water seals. Easy to do so in India also.
    • In 2011, ~ 50% of rural Indian hh w/ water on premise did not own a latrine
  • Education

    • poor explanation
    • 23 of 28 countries w/ lower literacy rates have lower rates of open defecation
    • rural hh where someone has a BS or more --- 32% defecate in open. 51% of rural hh where highest educated adult passed secondary school defecate in open.
  • Governance

    • 39 of 47 countries where it is harder to do business have lower open def. rates
    • Somewhat better gov. states like Gujarat and TN have rates = 67% and ~ 77%. UP = ~ 78% and Bihar ~ 82%. Sikkim ~ 15.9%, Mizoram ~ 15%, Manipur ~ 14%
    • Corruption: But Ministry said 46% increase in coverage due to total sanitation campaign.
  • Access to Latrine

    • original discovery by authors
    • In hh with latrines, 40% hh have at least 1 person who defecates outside. SQUAT survey.

Solutions For Increasing Welfare

  • Breastfeeding matters more for Hindu babies than Muslim babies as disease load greater

  • SBM

    • Promised to reduce to 0 in 5 years
    • Needs 12x acceleration. Nothing like this ever achieved anywhere.
    • Amounts to building 67k/per day over 5 years. 84k seconds in a day.
    • Subsidizes latrine by 12k. Needs 30k crores per year ignoring admin costs. Allocation for rural portion of SBM in 2014 = 2850 crores. In 2015 = 8915 crores.
    • 3% of budget dedicated to changing behavior
    • (Survey of rural pop.) In only 1 out of 10 districts across 5 states were 15% of respondents aware of any type of sanitation promoter. Median = 3%.
    • Survey in 2016 --- telephone survey of UP + Delhi:
      • 62% in Delhi said they had heard
      • 63% in urban UP
      • 45% in rural UP
      • When asked what is SBM, only 5% of people in Delhi, 6% in urban IP, 4% in rural UP mentioned anything about toilets. Of 700 women interviewed, not a single one w/o education beyond secondary school mentioned toilet/latrines.
  • Other idiotic things

    • India gov. has stopped doing Demographic and Health Surveys. Last in 2005--06. Bangladesh has done 3 since.
    • BS website that maintains record of number of toilets for which funds have been spent --- nothing to do w/ reality on ground
  • Community Led Total Sanitation

    • Shame people who shit outside. Touted as a success in Bangladesh. When you look at agg. time series, it doesn't look like it did much.
  • Target rich hh --- as they can build large latrines

  • Measure open defecation honestly via surveys + make realistic plans

  • Talk about culture, choices and caste

    • don't take open defecation as 'clearest indication of extreme poverty' (UN)
    • don't deny decision making power of poor people
    • culture matters in same ways as alcoholism is a serious issue in Russia, son pref. in S. Asia etc. So don't shy away from it.
    • Hoff and Gauri --- 80% of poor people in Jakarta, Nairobi, Lima think that whatever happens to them in future depends on them. WB experts predicted only 20% of respondents will say so.
    • poor not always 'forced to do' stuff.
  • teach people that latrine pits take a long time to fill up etc.

  • teach people about twin pit latrines

  • consider large latrine subsidy

  • offer methods/services to empty pits

India Facts

  • From 2010--2015, avg. country spent 17% of GDP on gov. (weird way of putting it). India ~ 11%.

    • 18M public employees in India. 5.7M in the UK.
  • In 2005, India had higher fraction of underweight women than any country in Demographic and Health surveys than Eritrea

  • Diane estimates in 2005, 40% of Indian women began pregnancy underweight

  • Women in Bangladesh more likely than women in India to be able to read and have jobs

  • Caste

    • In some places in Maharashtra, Dalits required to wear black threads so that non-Dalits could avoid contact
    • 20% urban respondents report having at least 1 fam. member who practices untouchability
      • later on in book says 16% of urban respondents who are brahmin or forward caste admitted someone in their family did so.
      • 2012 India Human Dev. Survey. See Thorat and Joshi.
    • Book rec. --- Joothan by Om Prakash Valmiki
  • In 2015, 1 in 5 births happen in India

  • Indian children shorter than children in sub-Saharan Africa (1996)

Infant Mortality

* In 2012, 43 out of 1000 babies born died before 1
* In 2012, 150 out of 194 countries had infant mortality rate lower than India. Higher than Bangladesh, Kenya, Rwanda.
* Infant mortality in India is 20% greater than what GDP/per capita predicts
* Under 5 mortality, based on Family Health Survey = 74 per 100k
    - mortality rate of hindu babies 14 per 100k greater than muslim babies
* Some regions within India with much higher infant mortality. For instance, in Sitapur, in 2010-2011, mortality at 82/1,000
* In 1953, mortality < 1 ~ 280/1000
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