The South Asian Enigma
A disproportionately high percentage of children in India suffer from malnourishment relative to India’s per-capita income levels and poverty rates, a phenomenon dubbed by researchers the South Asian enigma.
A recent survey found a marked improvement in the proportion of stunted (too short for age) Indian children, from 48 per cent in 2006-07 to 39 per cent in 2013-14.
However, many Indian states continue to exhibit significantly higher rates of chronically undernourished children than sub-Saharan African countries with analogous multidimensional poverty levels.
For example, 47.3 per cent of children younger than five are stunted in the Indian state of Jharkand while only 29 per cent in the comparable country of Angola; another divergent pair is Uttar Pradesh in northern India with 50.6 per cent of stunted children compared to Senegal with 19 per cent.
The undernourishment-sanitation link and open defecation
High malnourishment rates have been traditionally associated with food shortages and famines. But there is a growing recognition that factors beyond the lack of food or its quality contribute to the large proportion of Indian children that suffer from undernourishment. It has been increasingly acknowledged that poor sanitation plays a role here.
One of India’s key sanitation problems is open defecation. According to Indian census of 2011, fewer than 50 per cent of Indian households have access to a toilet, whether a private or a public one. In rural areas, where the majority of Indians still live, this percentage is even higher, at 69.
Moreover, even in households with working toilets, many members choose to defecate outside.
A survey of five northern India states – Bihar, Uttar Pradesh, Rajasthan, Madhya Pradesh, and Haryana – found that more than 25 per cent of men with access to a toilet regularly defecate in the open. They do so because they regard it as convenient, comfortable, or even pleasurable.
However, researchers have concluded that the differences in rates of open defecation between Indian districts account for 35 to 55 per cent of differences between stunting rates among children, solidifying the sanitation-undernourishment link.
A Total Sanitation Campaign (TSC) aimed at the eradication of open defecation through construction of toilets was launched in India in 1999, by then-Prime Minister Atal B. Vajpayee.
An audit from 2014 concluded that the campaign was largely unsuccessful, due to large-scale diversions, wastages, and irregularities in the use of funds as well as the failure to instil behavioural change among toilet participants.
The current Prime Minister Narendra Modi scrapped the TSC in 2014 and introduced an even more ambitious scheme, the Clean India (Swachh Bharat) campaign, which aims to eliminate open defecation in India by October 2, 2019 – 150th birth anniversary of Mahatma Gandhi.
As of December 2016, the campaign built 30 million toilets. It has also actively attempted to improve people’s attitudes towards using toilets, through awareness-raising, shaming, mascot deployment, and fines.
Will it help?
Is this drive to make India defecation-free likely to reduce malnourishment rates among India’s children?
Yes, particularly in areas where the practice is eradicated en masse.
Majority Muslim neighbourhoods in India experience on average 40 per cent lower rates of open defecation than majority Hindu areas and as a result, Muslim Indian children are significantly less undernourished than Hindu Indian children even though they are on average much poorer.
Quasi-experimental impact evaluations of interventions that combined building toilets with locally delivered sanitation education also showed a significant improvement in household food security.
At the same time, it would be dangerous to assume that resolving the open defecation problem in India will fully settle the undernourishment issue.
The latrines commonly built by the Clean India campaign in rural areas are not connected to a sewage system. The water used in them thus flows untreated into the ground, where it may contaminate the wells used by villagers to draw drinking water.
The resultant effect on their children’s undernourishment is thus unlikely to be positive – they may receive the faecal pathogens just via a different transmission route.
Lack of dietary diversity is another important factor driving Indian children’s undernourishment rates. This is compounded by gender issues.
Research indicates that particularly in adolescence, Indian boys receive more high-protein and nutritious foods than girls.
Consequently undernourished girls are more likely to give birth to malnourished children once they become mothers.
Thus, behavioural change in more than just open defecation is needed to do away with the South Asian enigma in India.
Dr Ivica Petrikova is a Lecturer in International Relations and Development at Royal Holloway, University of London. In this blog, she has drawn on her research recently published with Professor David Hudson in Development in Practice and in her book, Global Food Security and Development Aid.