Tackling India’s pervasive open defecation problem could be a significant part of the answer to saving millions of children from stunting
By Meena Bhandari
GUNA, Madhya Pradesh India – 21 November 2013 – Forty-five-year-old grandmother Surti Patalya is blazing a small but powerful trail through the cornfields of the central Indian State of Madhya Pradesh. Her head draped in a blue and white chequered chiffon sari is barely visible over the tall crops as she glides her way deeper into the growth with a small entourage.
Surti and her fellow village ‘natural leaders’ in the hamlet of Hilanga, Guna District are heading for the latest family they have persuaded to construct a kutcha (temporary) toilet. This one is at the back edge of the field, in what looks like an idyllic setting with soft rolling hills.
“A toilet is a question of not eating each other’s business! And importantly women get their “izat” – their respect back,” Sruti says.
Despite being rich in natural resources Madhya Pradesh it is poverty that meets the eye. The State has some 50 million people defecating in the open every day (around 70 per cent of its 72 million people) and the State will not meet global Millennium Goal Targets for sanitation until 2105. Something has to change.
Madhya Pradesh is also home to some of the most undernourished children in India with 58 per cent of under three’s suffering from malnutrition (compared with 45 per cent nationally). 50 per cent of children under-five also suffer from stunting, an indicator of long-term persistent malnutrition, associated with a child’s low height relative to its age. Stunting is also associated with an under-developed brain and low IQ.
The effects of stunting are said to result in a 10 per cent decrease in future income over the lifetime of stunted adults – with tragic implications for child survival, growth and development, seriously impeding India’s development. The implications for stunted mothersgiving birth to stunted children are very real.
The Missing Link
Economists have long debated the ‘Asian Enigma’ of why Indians are more stunted - shorter in height - compared to relatively poorer children in Sub Saharan Africa for example. Now, new research has shown a correlation between long-term under-nutrition with its resultant stunted children in India, and the lack of access to toilets and hygiene. Provide children with the right nutrition at the right time, and ensure an environment free of excreta, and there will be no Asian Enigma.
“The height of Indians is not simply about genetics or down to poverty – there is a strong correlation to the poor sanitation environment many live in. India’s lack of sanitation with its high population density, stunts its children through both the loss of food, and the reduced absorption of nutrients,” says Dean Spears, of the Delhi School for Economics.
Emerging evidence contends that open defecation explains 54 per cent of international variation in child height; in contrast, GDP only explains 29 per cent. [Spears-height-and-sanitation-2-12-13.pdf]
“When environments change - when Indian’s migrate overseas for example, they on average become taller. The comparison with Bangladesh is also evident where the country has reduced its open defecation - and its people have become taller,” Spears adds. There is also evidence to show open defecation can have an impact on the efficacy of oral vaccines such as polio, with serious policy implications for India.
As much as 50 per cent of malnutrition is caused not by a lack of food or poor diets, but due to poor water, poor sanitation facilities and unhygienic practices – like not washing hands properly with soap. 2.5 billion-cases of diarrhoea in children under-five are recorded worldwide every year, and in India diarrhoea caused an estimated 136 000 child deaths in 2012 alone. Moreover, many people do not recognise diarrhoea as a problem; because it is so recurrent it is thought to be normal, and they do not seek help. These numbers are therefore likely to be under reported.
Beyond diarrhoea and the subsequent loss of nutrients increasingly open defecation has bearing on repeated faecally-transmitted infections (FTIs) that damage the gut. These FTIs deplete the absorption of vitalnutrients that also cause chronic under-nutrition and stunting. Diarrhoea - the most visible and measured of these FTIs - is thought to be just the tip of the iceberg of illnesses.
Statistics for the numerous other FTIs are limited and are likely to be causing untold damage because they are invisible.
Governments and the development community have long missed what is being called a ‘blind spot’ in nutrition by not better connecting the dots to stunting in India and the widespread practice of open defecation. This has serious implications for how India should be tackling open defecation – by better combining nutrition and health, to sanitation interventions. Hyperkink:../EPW-Chambers-vonMedeazza-Sanitation_and_Stunting_in_India.pdf
Increase the number of toilets?
A common approach to solve the conundrum of open defecation is to increase the supply of toilets. While constructing more toilets might seem to be the answer to reduce open defecation, people must first be convinced that they want to use a toilet.
“Government officials in India like targets and numbers, and India’s army of engineers like constructing hardware. But, we know that unless people demand toilets themselves they will go un-used. It’s like the hare and the tortoise – challenging and then changing community behaviour is the slowest solution – but it’s ultimately the winner,” says Mr Sandeep Yadev, District Collector of Guna who has been working with UNICEF to see community driven approaches to create open defecation free villages in Madhya Pradesh.
Agencies like UNICEF say this contagion effect - using village level natural leaders like Sruti to persuade their neighbours and relatives is key. All of the other 34 families in Sruti’s tiny hamlet of Hirapur, on the outskirts of Hilanga Village have constructed toilets – most of them have converted theirs to more pukka (permanent) structures.
Jitra Patalya, a slender man with sunken cheeks and large moustache who owns the kutcha toilet describes how he and his family of ten used to defecate every morning in the stream. “I had to build one, if I didn’t I would have been left behind eating my own families poo, and with my children eating mine,” he says.
“People have practiced open defecation for generations and it’s hard to persuade them there is anything wrong with it. No one wants to be lectured into having a toilet – it doesn’t work. What works better, however, is taking communities on a journey to realising the links between their own unhygienic behaviour like open defecation and how this leads to people, especially children, falling sick. Ultimately it is a matter a bringing about collective behaviour change,” says Gregor von Medeazza, UNICEF’s Water and Sanitation Hygiene (WASH) specialist in Madhya Pradesh.
Under the Government of India programmes, Nirmal Bharat Abhiyan (Total Sanitation Campaign), and the Mahatma Gandhi NREGA (National Rural Employment Guarantee Act), the State Government of Madhya Pradesh launched the Maryada Campaign (translating as Dignity) to make its rural villages Open Defecation Free (ODF). These ODF model villages will be provided with piped water in the first phase and like Hirapur in Hilanga will create a social movement for sanitation.
The campaign is designed not as a toilet construction campaign, but as a social movement and behaviour change campaign – with information education and behaviour change communications at its heart.
The state government is beginning to train and pay 80,000 plus sanitation frontline workers drawn from community based natural leaders to create an army of ‘Swachhata Doots’ - a village level task force of “Cleanliness Messengers.”
“Adding to this community based legion the growing evidence of open defecation’s link to India’s stunted children, is incredibly powerful – to bring together government flagship programmes to accelerate the elimination of open defecation,” von Medeazza adds. While changing behaviour is one key strategy, water and sanitation, hygiene programmes also have to be better connected to improving the nutritional health of young girls and future mothers if India is going to tackle its insidious stunting problem.