Swachh Bharat

Interview: The surprising links between casteism, open defecation and high infant mortality in India

Economists Dean Spears and Diane Coffey reveal insights that many administrators would never openly admit to.

Why are children in India shorter than children from other countries, even those poorer than India? It was the urge to solve some of India’s development puzzles like this one that drew American scholars Dean Spears and Diane Coffey to India in 2009.

The couple co-founded the Research Institute for Compassionate Economics or RICE in 2011 and settled in Sitapur, a rural district in central Uttar Pradesh, four years ago. With a population of 4.5 million people, the district is the size of Sierra Leone and Liberia and has a similar infant mortality rate.

“Sierra Leone and Liberia have a health ministry, education ministry, a Unicef mission; Sitapur has none of that. So it made a lot of sense to go somewhere like that and add value,” Spears said in an earlier interview.

Spears and Coffey have a masters in public administration and completed their PhDs at the Princeton University. Spears specialised in economics and public affairs and Coffey in demography. The two met and fell in love when Spears was a teaching assistant in a statistics class where Coffey was a student. They got married in 2011.

Their research in India has established links between open defecation and high infant mortality in rural India. It has also exposed the caste prejudices that encourage open defecation. A surprising fact showed up in their study – many people in rural areas, especially in North India, choose to defecate in the open even if they have a toilet at home. Many reasoned that it was a more “pleasant, comfortable and convenient” option.

Their new book, Where India Goes: Abandoned Toilets, Stunted Development, and the Costs of Caste throws up many such insights that sanitation experts and administrators would never openly admit to. Excerpts of an interview with Spears and Coffey:

At least one person in 40% of rural households with latrines in Bihar, Uttar Pradesh, Haryana, Madhya Pradesh and Rajasthan defecates in the open, according to the SQUAT survey. Why do Indians hate to use latrines?
Spears: There are a few things that play into [the habit] – people like to wake up early in the morning and be in the field and it is considered manly. Some young women are kept in the house all the time, like a young daughter-in-law isn’t allowed to go outside. The biggest reason is casteism and people worrying about what will happen if the latrine pit gets filled up.

All around the world people use the simple pit latrine and when it gets filled, somebody has to empty it and either the family does it themselves or they hire someone to do it. It is unpleasant but it is not an enormously big deal. In India, it is an enormously big deal because it is associated with being a Dalit. The Dalits don’t want to be doing it either and they are looking at forward to a better future when they will be no longer oppressed.

Lot of families with latrines think that if they use them, it will pollute their home and they will never be able to empty them. To avoid all this, it is easier is to defecate in the open. It is going to be a hard problem to solve because it is rooted in these old and strongly held issues of social inequality.

Source: R.I.C.E
Source: R.I.C.E

You talk of the connection between infant mortality rate and sanitation in your book. Could this be the reason India’s IMR is falling at a slower rate than in poorer countries like Bangladesh?
Spears: If you live next to neighbours who defecate in the open, there are germs on the ground, lot of the people don’t wear shoes, they get their fingers on it [germs], their moms get their fingers on it and then there are flies on it and they get on the food and the entire environment is where is lot of faeces and there is lot of opportunity to get on germs.

One interesting thing is that it is not about your own household’s open defecation but your neighbour’s. People who live close to people who open defecate are more likely to die. In Bangladesh where open defecation is as less as 1%, the infant mortality rate is much lower than India even though it is much poorer than India. It is not the only reason but it is one of the important reasons.

Source: R.I.C.E.
Source: R.I.C.E.

Can you tell us how sanitation factors ensure that Muslim children have better chances of surviving in India than Hindu children?
Spears: There was a puzzle in health economics literature that within India, Muslim babies are more likely to survive infancy than Hindu babies. It is a puzzle because richer populations are healthier on average and on average, Muslim populations are poorer than Hindu populations in India.

It is not really about being a Muslim or Hindu baby at all because there is the same advantage of living next to Muslim neighbour. We were looking at what is so different about neighbourhoods where Hindu and Muslim live. We found that Muslim neighbourhood are less likely to have piped waters, less likely to have other state services than Hindu neighbourhoods. But, on average, there is less open defecation in Muslim neighbourhoods because they are more likely to have and use latrines than Hindu households.

Of course, (this is not the case) in all states but on an average, children living with more Muslim neighbours are going to have healthier environments than people living with Hindu neighbours.

For a long time, it was assumed that Indian women do not want to defecate in the open. Your book breaks that myth. Can you elaborate?
Coffey: This is complicated. For women whose families do not want them to defecate during daylight or who insist that they always be accompanied when they defecate in the open, it can be very helpful to have a latrine. Also, some women who grew up using latrines may marry into households that don’t have them and they may feel uncomfortable defecating in the open. But our research suggests that in many parts of India, such women are in the minority.

Many women are opposed to using affordable latrines with small pits, just like men. Also, open defecation is normal for women just like it is normal for men, so it is often not seen as the shameful or uncomfortable practice that city people assume it is. Finally, for some women, open defecation provides a welcome, socially-acceptable opportunity to get out of the house and walk around a bit. Such opportunities can be few and far between, especially for young women whose movements are often carefully monitored by their in-laws or husbands.

How has open defecation impacted the health of Indian women?
Coffey: Research by Dean Spears and Josephine Duh shows that women who are more exposed to open defecation are thinner, on average, than women who live in villages and neighbourhoods where more people use latrines. And underweight is an important health problem in India. It makes both men and women less productive. When pregnant women are underweight, babies are often born too small and are less likely to survive infancy. Further, my research with Dean Spears and Michael Geruso on the effect of open defecation on children’s hemoglobin levels in Nepal suggests that open defecation likely contributes to high rates of anemia among men, women, and children in India, as well.

What is the cost India is paying for this high incidence of open defecation?
Spears: It is hard to put a number on but one thing that we do is we look at a small part of it. If children are healthy when they are babies then they grow up stronger and taller, they are able to concentrate at school and learn more and they have higher achievement. Our whole workplace would be healthier if they were exposed to a healthier environment, including sanitation, as children.

We can see that in wage data. If we look at a survey like India Human Development Survey and how much workers in India make, we find that adults are paid more and are more productive if they are born in a better disease environment. Their families get to consume more and they pay more taxes and government gets more revenue.

So what we do is that if you can cause a household to stop defecating in the open, just one household, there would be money in the future but it will be an equivalent of increasing the revenue of India by Rs 20,000 per household. That’s just looking at government’s revenue, but then the family gets to eat more, there is more productivity and they will be healthier and they will be more likely to survive.

Source: R.I.C.E.
Source: R.I.C.E.

India’s high open defecation rates have less to do with poverty, literacy or governance. Your analysis is contrary to what most policy makers and sanitation experts believe. How did they react to it?
Spears: It is not like it came out in one moment, we had research papers in 2013, 2014 and we have been talking to lot of people over the years. When we talk to people in international development organisations, they often seem very surprised, especially if they are not from India or they maybe think it is offensive when we talk about it.

When we talk to a state or district government, they are not surprised. They may have not spoken about it but when we say it is about caste and untouchability, people from the state and district government who go out in the field and are in touch with village life are not surprised at all.

We were talking about the state-level secretary in rural government and we were giving him our presentation, he said: “Oh wow, I didn’t know this specifically that I could say it but I suspected it and now that you have said it, it just made things clear to me.”

Governments are good at building latrines.You had different political parties across the decades and rural sanitation has always been about building latrines. (But) this sort of issue which is about long-standing social attitude – and when open defecation is common and it is something people believe in – then it is hard for the government to do something about it.

Gandhi spoke about this but in your view, why are beliefs related to sanitation and caste still strong when things around are changing?
Spears: In rural India, caste, caste system and untouchability are still important. If you see survey data on untouchability, lot of people say that they still practice untouchability and ghoongat (the veil used by married Hindu women). Many say that they would favour laws that will make it illegal for a high-caste person to marry low caste or Hindu (to marry a) Muslim.

As long as many people in India still believe in these things, when they think about latrine they (will) think about caste.

Are there any strategies at all to stop open defecation?
Coffey: In the last chapter of the book, we have outlined some strategies that we think are worthy of experimentation. One is to challenge people’s beliefs about latrine pits by teaching people how pit latrines work: how long it takes them to fill; and to make clear that emptying decomposed latrines is not the same thing as manual scavenging.

Another is to experiment with ways of accommodating beliefs about latrine pits – perhaps more of the government’s subsidy could be spent on the pit alone and less on the superstructure. We also think that, in a diffuse but nonetheless important way, it would be useful for the government to address the manual scavenging that still exists and to raise awareness about links between casteism and poor sanitation.

Is there a gradual change in our sanitation policy are we looking at behaviour change and creating a demand for the toilet first?
Spears: It is certainly something that policy documents talk about. Policy makers know that what matters is hundreds of block offices across dozen of rural districts actually organising something that changes the way people think about casteism. It is easy to sit in the office in a capital and write down on a paper ‘behaviour change’ what is hard is to actually find a way to change people’s mind about inequality.

Has there been community-led total sanitation intervention in India?
Spears: There is not a lot of CLTS [community-led total sanitation] in India and I even think there is an important debate about how much it has contributed in other countries. For example we have a graph about it in our book about CLTS in Bangladesh.

CLTS was invented in 2000 and people talk about how it was an important part of what happened in Bangladesh. But open defecation in Bangladesh in 1991 was much less than what it is in India today. It was already going down in Bangladesh and if you look at open defecation before and after CLTS, it is going down at the same rate. That doesn’t definitely prove that CLTS doesn’t work but we need to think about it carefully.

In CLTS, people are supposed to come together as a community against open defecation. In most places, community means local area, my town or my village but in India, it means religion or caste.

The whole idea of CLTS is to get the whole village to cooperate but people in villages in India unfortunately don’t co-operate, especially ones where open defecation is common. Exactly the places where casteism is important, those are the places where open defecation is common and those are the places where there is a lot of conflict among castes.

What happens in a scenario where everyone gets and actually uses a latrine?
Spears: Imagine if Swacch Bharat Mission was successful and magically everyone is using the latrines. In a few years, they are going to fill up and who is going to empty them? It is going to set back progress in social liberalism because, one way of the other, Dalits will be the people who have to empty the latrine pits. I don’t think there is a solution to the problem and I think it is problem that we should all be thinking about.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Relying on the power of habits to solve India’s mammoth sanitation problem

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

At its simplest, the benefits of WASH can be availed through three simple habits that safeguard against disease - washing hands before eating, drinking clean water and using a clean toilet. Handwashing and use of toilets are some of the most important behavioural interventions that keep diarrhoeal diseases from spreading, while clean drinking water is essential to prevent water-borne diseases and adverse health effects of toxic contaminants. In India, Hindustan Unilever Limited launched the Swachh Aadat Swachh Bharat initiative, a WASH behaviour change programme, to complement the Swachh Bharat Abhiyan. Through its on-ground behaviour change model, SASB seeks to promote the three basic WASH habits to create long-lasting personal hygiene compliance among the populations it serves.

This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.


SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.