If there is one thing you will read today, let it be this interview of Bezwada Wilson by Vidya Subrahmaniam of The Hindu Center in The Wire. Bezwada Wilson and Vidya Subrahmaniam discuss some of rice’s sanitation research, but more importantly, Bezwada Wilson describes the changes he would have liked to see before, or along with the government’s ‘cleaning frenzy’ and ‘toilet construction spree’, as well as the non-implementation of the ‘Prohibition Of Employment As Manual Scavengers And Their Rehabilitation Act, 2013’.
Diane and I were at the Annual Meeting of the Population Association of America 2017 in Chicago this week. Diane presented her paper, co-authored with Ashwini Deshpande, Jeff Hammer and Dean, “Local social inequality, economic inequality, and disparities in child height in India”. I don’t have a photo of Diane presenting, but I did take one in which she was on the panel with other presenters.
Mike Geruso, member of rice’s board, was the presenter yesterday at Penn’s Business Economics and Public Policy seminar series. He presented his research on “Upcoding: Evidence from Medicare on Squishy Risk Adjustment”, co-authored with Timothy Layton. I have read Mike’s papers, but never heard him speak. The talk was a reminder for me of the extreme relevance Mike’s research, and how clear he is in his writing, presentation, figures and tables. Do check out his working paper here. I am posting the abstract below.
Upcoding — manipulation of patient diagnoses in order to game payment systems — has gained significant attention following the introduction of risk adjustment into US insurance markets. We provide new evidence that enrollees in private Medicare plans generate 6% to 16% higher diagnosis-based risk scores than they would generate under fee-for-service Medicare, where diagnoses do not affect payments. Our estimates imply upcoding generates billions of dollars in excess public spending annually and significant consumer choice distortions. We show that coding intensity increases with vertical integration, reflecting a principal-agent problem faced by insurers, who desire more intense coding from the physicians with whom they contract.
This week, Dean came to Penn’s Population Studies Center present his & Mike Geruso’s “Neighourhood Sanitation and Infant Mortality” paper. I don’t have a photo of Dean presenting, but I did click a photo of him, in the PSC lab, doing two things he likes: drinking (a lot of) Diet Coke and working on Stata.
We are very happy to report to you that there are additions to the r.i.c.e. family.
First of all, Kritika joined us as ha research fellow. Kritika has completed a Masters in Economics from the Delhi School of Economics. Her paper on Public Health Facilities in Rural North India, with Reetika, came out recently in the EPW.
Both Payal and Aarav are very healthy.
Just two days ago, award winning journalist Sreenivasan Jain and Manas Roshan of NDTV did a story on the Swachh Bharat Mission as part of their investigative show, Truth Versus Hype. You can watch the show here. The show was quite remarkable. For the first time on national television, someone said that they do not like government toilets because they thought that their pits were too small (3:34 minutes into the show). They also said that the pits, according to them, would fill up in a month or two. As those who have followed r.i.c.e. research on perceptions of toilets in rural India know, this is just not true. The Indian government actually builds nice toilets (if there is no corruption, that is) which meet WHO requirements for pit size, and these pits would last a family of 5 more than 5 years. The world over, people use these pit latrines, saving themselves and others from disease and death. As the culture and sanitation paper shows, rural Indians think that these pits are too small for their use because they are anxious that they will have to empty the pits once they fill up. Feces are considered ritually polluting, and dealing with feces is considered to be the job of the lowest castes. Many people in rural India consider manually emptying a pit latrine to be extremely degrading. In order to avoid this issue altogether, rural households aspire to build latrine pits that are big enough to last a generation. Rural Indians prefer not to use government latrines, because these pits require periodic emptying. The show was also remarkable in that it was able to cut through the hype around the Swachh Bharat Mission and show the truth that in reality, Swachh Bharat Mission is more or less similar to the UPA’s Nirmal Bharat Abhiyan. It may even be worse, because it cuts spending for IEC (information, education, communication) activities, from 15% of the program’s total expenditure to just 8% of the program’s expenditure. One part that we have some reservations about is the show’s portrayal of a success story in Bikaner, Rajasthan. We would really love to see a success story, but our experience in Rajasthan shows that in success story districts such as Churu and Bikaner, people build latrines with very large pits, requiring a substantial financial investment from families. What is also alarming is the use of patriarchy, as shown in the show, to promote toilets in rural Rajasthan. Rural Rajasthan, especially the desert parts of Rajasthan can be extremely patriarchal, where women are supposed to remain in the house and practice ghoonghat, covering the head and face with a veil. Indeed, evidence from the India Human Development Survey 2004-05 corroborates this: in Rajasthan, 94% of women said that they practice ghoonghat or purdah, the highest in India. The proportion of women practicing ghoonghat in Rajasthan is much higher than the all India practice: 55% of women in India said that they practice ghoonghat (Table A.10.5a). Despite this, or perhaps because of this, the state government of Rajasthan actively promotes the construction of toilets using women’s ghoonghat as a tool: In a patriarchal rural society, messages like these are often counterproductive – they sanction regressive social practices that involve the subordination of women, and they also harm the usage of toilets by men. Toilets become something that women use, not men. These messages also reinforce the notion that women should remain within the ghoonghat and within the chaar-diwari (four walls) of the house. Surely, it would be possible to promote the use of toilets and promote health in India without the use and promotion of regressive social practices?
Dean posted yesterday about Diane’s new paper in the PNAS, which showed that maternal nutrition in India was much worse than previously thought. As the abstract of the paper says,
42.2% of Indian women are underweight when they begin pregnancy compared with 16.5% of African women. In both regions, women gain little weight during pregnancy, but because of prepregnancy deficits, Indian women end pregnancy weighing less than African women do at the beginning.
Apart from the New York Times, The Hindu and the Business Standard, the article was also covered by The Economic Times, NDTV, Deccan Chronicle and LiveMint. We imagine that more newspapers will follow through. We usually post news articles covering rice research in the news section, but since there are so many of them for this paper, we will just be posting the articles that have the most information on the news tab. Do share this important paper with your friends and colleagues.
Our Associate Director Sangita Vyas was a panelist on DelhiDemand’s show on Sanitation and waste in Delhi. You can see the show here. In the show, Sangita referred to Dean’s work on sanitation and health, and on Jeff Hammer’s work in Delhi slums, which shows that people who have flood water enter their houses are more likely to get sick from water-borne diseases.
With gut bacteria, the chances of that happening may increase when you take antibiotics, because bacteria, like every species, evolve to survive. “The NDM-1 gene has found its way to over 40 species of different bacteria, which is unprecedented in antibiotic resistance,” said Walsh.
Given the appalling state of sanitation in India, it is not surprising that the majority of adult Indians carry highly resistant bacteria in their gut. Walsh said his team, in 2013, found that 90% of adults in south Pakistan carried a gene that made common bacteria that live in the intestines of healthy people resistant to potent antibiotics.
“We believe the same statistics apply to northern and urban India,” Walsh said. “In contrast, only 10% of adults in the Queens area of New York carry bacteria bearing the same gene.”
All these adult Indians could contribute to the evolution of superbugs, if they were to abuse antibiotics. It appears Indians are doing just that. The country is not yet a hotbed of super-resistant pathogens, but if NDM-1 transfers to highly pathogenic bacteria, it could happen very soon.
At India’s largest public hospital, the All India Institute of Medical Sciences in New Delhi, doctors are already experiencing the era of antibiotic resistance. They will tell you how bacteria causing pneumonia in intensive care unit patients are much less responsive to antibiotics today than they were a decade ago.
Another article, in the New York Times, was specifically about the threats to new born infants from anti-biotic resistance. It quoted r.i.c.e. research on sanitation and anti-biotic resistance.
Bacteria spread easily in India, experts say, because half of Indians defecate outdoors, and much of the sewage generated by those who do use toilets is untreated. As a result, Indians have among the highest rates of bacterial infections in the world and collectively take more antibiotics, which are sold over the counter here, than any other nationality. A recent study found that Indian children living in places where people are less likely to use a toilet tend to get diarrhea and be given antibiotics more often than those in places with more toilet use. On Oct. 2, the Indian government began a campaign to clean the country and build toilets, with Prime Minister Narendra Modi publicly sweeping a Delhi neighborhood. But the task is monumental.
Thorsten Kiefer, founder & CEO of WASH United, has an article in Forbes, called “Why Innovative Campaigning Is Critical To Fixing Sanitation In India”. There is a paragraph that I particularly like:
Kevin Shane, a colleague from Indian innovation consultancyQuicksand who leads a sanitation innovation project in Bhubaneswar/Orissa, recently told me about a project visit with a delegation from Yale university. Standing outside his house, a community leader directed his American guests to a lush, green field, where he proudly declared: “this is my toilet. I bet your president Obama doesn’t have a toilet as beautiful as mine.”
Consultants at Dalberg also have an article on the NextBillion website. They have a conclusion we agree with:
Success in curbing open defecation can only be achieved by generating demand for toilets through a consistent focus on behavior change. Infrastructure-focused programs are by themselves inadequate in solving the problem of open defecation. The Indian government needs to remember this lesson as it embarks on an ambitious path to provide a toilet to every household.
Without saying much, I’ll post the full interview here. Its available online on the Business Standard website here.
Rural India is a dismal outlier when it comes to open defecation and that’s a major reason for its stunted, unhealthy children, the Princeton economist tells Kanika Datta
It never occurs to Dean Spears that an invitation to Lunch with BS might be an opportunity to indulge in even the mildest of hedonism. Since the meal is on Business Standard, many of our guests understandably choose upscale restaurants. Spears’ first suggestion for our meeting was the canteen at Delhi School of Economics where his wife, Diane Coffey, co-founder of Research Institute for Compassionate Economics (Rice), was making a presentation.
Too noisy, I say, so he innocently suggests we could carry the food into the visitors’ room, a solution I reject out of hand. His next choice is a shade more ritzy: Evergreen Restaurant in Green Park, famous in the area for its vegetarian snacks and sweets.
Rice is a three-year-old policy and advocacy group focusing on child and maternal health in India and it’s already making an impact. It was founded with funding from the Gates Foundation and, recently, the National Institutes of Health, an agency of the US department of health and Spears, an economist from Princeton, is widely considered its moving spirit.
Both he and the institute have been attracting notice for highlighting the strong link between widespread open defecation in rural India, high infant mortality and the stunted growth of children, factors that ultimately impact a country’s economic productivity. These are issues that go right to the heart of Prime Minister Narendra Modi’s Swachh Bharat Abhiyan campaign launched with such fanfare on October 2 last year.
In June, Rice came out with The SQUAT Report, an extensive survey in rural India of Sanitation, Quality, Use, Access and Trends, to spell out the full form, that proved depressingly revelatory. Among other things, it revealed that uniquely in India open defecation isn’t just a result of poor access to sanitary infrastructure but also a behaviourial choice. Most rural Indians, the report said, can afford a toilet but preferred not to have one. Even more incredibly, those who did own toilets often preferred to defecate in the open. In fact, the report highlighted, India was one of the significantly worst performers in terms of sanitation compared with even significantly poorer countries such as Nepal and Bangladesh.
When we do meet, I discover Spears is just 31 years old, roughly in the same age cohort as those Indians the media and businesses are wont to describe as “aspirational”. Rail thin and yet to shed his college grad aura, it is clear that Spears’ only aspiration is for his mission. But he is no jholawala in any sense of the term. He and his organisation rely on painstaking, unfashionable data collection and hard statistics to present a distinctly unlovely picture of an insanitary, unhealthy rural India.
We’re on the first floor of Evergreen. Spears is a frequent visitor and he quickly orders in fluent if accented Hindi — rajma, butter naan and Diet Pepsi. To save time I do the same. “ Chawal ya naan?” Spears asks me. Chawal, my Bengali genes automatically respond.
Why should two young Americans, with access to the best that life can offer at home, choose the dubious comforts of India in general and Sitapur, a rural district in Uttar Pradesh, in particular to live? It was a joint decision with Diane, he explains. “We’re economic demographers and both of us wanted to do work as useful as possible. India is the best place for that for a lot of reasons.”
First, he says, there is an enormous number of poor but also – and this sounded encouraging to me – “an environment where one hopes the evidence of research and better understanding can help one do something about it. The number of people who live in India is almost the same as the number of people who live in sub-Saharan Africa and Latin America put together,” he continues. “What is less known is that the fraction of people who live on a $1.25 a day, the extreme poor, is almost the same in India as those two regions put together — and so is the infant mortality rate.”
These facts, he says, get overlooked mainly because international development experts are used to seeing India as one country. So Sitapur has a population of 4.5 million people, which means it’s basically the size of a country even though it’s just one of India’s 600-odd districts. Also, “the population of Sitapur is almost the same as Sierra Leone and Liberia and, strikingly, the infant mortality rate of Sitapur is almost the exact same as the infant mortality rate of those two countries. Now, those two countries are some of the biggest human development basket cases on earth. Sitapur would be too if it were a country. 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,” he concludes.
The food arrives in record time. The spicy rajma reminds me of boarding school where it was dished out regularly for being cheap and nutritious. I covetously eye a crisp naan dripping with butter and Spears generously asks me to help myself, which I do with alacrity while he spoons a tiny portion of rice on to his plate.
I am most admiring of his command of Hindi since despite nearly 18 years in the capital my grasp of the language remains inept. “Oh, itâs not all that good,” he demurs, “Dinah mujhse hoshiar hai,” [Dinah is better than I am]. He explains that his wife’s name becomes Dinah in Hindi since, pronounced slightly differently, diane
is the Hindi word for “witch” (which roughly corresponds to dynee
in Bengali, I think).
“Now tell me about yourself, so that I can get in a couple of bites,” he says. This recitation is embarrassingly short so he manages a few mouthfuls before the talk inevitably turns to Swachh Bharat. He’s worried that it is going to be too much like a giant construction programme like the United Progressive Alliance’s Bharat Nirman Yojana.
“Building a bunch of cement buildings is the easy part. The hard part is that it fundamentally matters what people do. The latrine is an asset that households have; open defecation is a behavioural pattern. What we want to do is to get more people to use latrines. But the last time I checked, the budget for Information, Education and Communication had decreased
from 15 to 8 per cent. That’s moving us in the wrong direction.”
Still, he’s happy that the government has been talking about a latrine-use monitoring survey. “And when the prime minister says he hopes to eliminate open defecation by 2019, I am delighted and hope that we can come together and succeed.”
What also worries him is how far the campaign stays on track. He whips out a tablet from his backpack to display a picture he’s taken of a hoarding in Defence Colony with a verse that ran “Clean up the clutter/Shun the litter…” and so on. “I’m very much afraid Swachh Bharat will be diverted from a life-saving campaign on sanitation to cleaning up the litter in markets of the urban rich,” he says.
Isn’t one impediment to greater latrine-use water shortage? “That’s a myth,” he shoots back. “Sub-Saharan Africa has much lower access to water than India but also much lower rates of open defecation. India is a global exception — 60 per cent of people who defecate in the open in the world live in India. Every year, that number goes up. When we asked people, nobody talks about water.” Nor, he adds, did it have anything to do with education – plenty of people in rural India have high school degrees and still defecate in the open.
I suggest women must be the biggest advocates of latrine use because of the safety and privacy. True, Spears says, but the issue is more complex. “If you have a latrine, young women are a lot more likely to use it than men are. Yet, a majority of women in their twenties in households with a government-built latrine defecate in the open. Then, we ask women who do use latrines what will happen when you get older and become the saas
? Many of them say, ‘then I’ll go back to defecating in the open’! I must say I don’t claim to perfectly understand this,” he laughs.
It was the puzzle about height that got him interested in research about sanitation. “Economists care a lot about height because average population-level height is an important monitor of human development. The best evidence: European populations got taller not when the food environment got better but when the disease environment improved and infant mortality fell. And the average height of a population is basically about the health and nutrition of its babies in the first two years of their life.”
Surely south-east Asia and China are counterfactuals? He surprises me by saying the average Chinese baby is much taller than the average Indian baby. Height, he explains, is measured by something called a Z-score, where zero is average and a negative number is bad. In China, the average number is (-) 0.75; in India, it is (-) 2. And in China, open defecation may be 3 to 4 per cent.
We’ve polished off the rajma and eschew dessert in favour of tea (for me, to counter the soporific effects of the rice). Spears settles for the caffeine fix in his 600 ml bottle of Pepsi. Meanwhile, the bill is placed, as Spears notes, in front of him – “have you noticed, they always expect the man to pay?” I’m too busy noticing the amount, which at Rs 433 has got to be the cheapest lunch Business Standard has ever hosted.
NDTV’s award winning journalist, Sreenivasan Jain, on his much acclaimed programme Truth versus Hype, discussed the truth and the hype of the Swachh Bharat Abhiyan. You can see the video here.
Nikhil took Sreenivasan Jain around villages of Uttar Pradesh, India’s most populous state, and talked on the show about his experiences of fieldwork on sanitation programmes as well.
Payal was also a part of the show.
The programme is fairly important. For the first time, on national television, points that r.i.c.e. has continues to made in articles and op-eds can be seen. People might not believe the SQUAT survey, but people would have a tough time ignoring villagers from Madhya Pradesh, Rajasthan and Uttar Pradesh talking about their toilets and why they don’t like using them.
The Narendra Modi Government has announced that Swacch Bharat Mission (SBM) has to be a mass movement to make India open defecation free in five years. By spending Rs 1.34 lakh crore ($22 billion) to build about 110 million toilets across the country, “the pet project of the Prime Minister will be executed on a war footing with the involvement of every gram panchayat, panchayat samiti and zila parishad in the country, besides roping in large sections of rural population and school teachers and students in this endeavor.”
While it is commendable that the Government has set high ambitions, it is worth exploring how they plan to reach the goal. Unfortunately, plans for SBM don’t look very different from the erstwhile Nirmal Bharat Abhiyan (NBA). The priority is still on construction, perhaps even more so than before, and so does not appear to be as significant a break from the past as hoped.
One important change in the new SBM is its increased budget. 110 million is the number of rural households that have no toilet facilities. So, much of the enlarged budget will go towards building a new toilet for every rural household in India without one. This may seem like a good idea to those who argue that having a latrine is a prerequisite to using one but we at Research Institute for Compassionate Economics (r.i.c.e.)would argue that there’s something that needs to happen even before that. We recently conducted the Sanitation Quality, Use, Access, and Trends (SQUAT) Survey in over 3,000 households in rural north India to explore people’s sanitation attitudes and practices.
We found that many people in households with working latrines choose to defecate in the open anyway. To reach these people, we need to create a desire in them to actually have and use a toilet even before they physically get or make one. Access to toilets alone will not solve the problem of open defecation when many people simply prefer to defecate in the open. Is the Government really prepared to waste resources?
Not only are more toilets to be built but at Rs 12,000 each, they cost Rs 2,000 more than each toilet built under NBA. As a simple exercise, we calculated that if the Government hired one dedicated behavior change staff member for 700,000 villages, five staff members in each of the 6,000 block offices and one staff member in each of the 600 districts, for five years, it would cost less than one-fifth of what it would cost to build a Rs 12,000 toilet for every household without one in rural India. Not only does it make practical sense to focus on changing people’s minds, it also makes financial sense.
Rather than motivating people to want and use their latrines, SBM is actually worse than NBA in terms of behavior change because the information, education, and communication (IEC) allocation has declined from 15% to just 8% of the budget. While it may be true that this is a larger monetary amount than previously allocated (because the SBM’s entire budget is much larger than that of the NBA), the reduction is symbolic in terms of the importance given to changing people’s minds and sanitation practices versus construction. The language of the new policy indicates that “behaviour change and usage of toilets shall be given top priority to ensure increased demand,” but given budgetary allocations, this seems even less possible now than it was under the NBA.
It is useful to reflect on how much money has actually been allocated, only for the construction of new toilets in rural India. Per year, the projected construction allocation under just the rural part of the SBM is more than 9 times the 2013-14 NBA expenditure and close to three-fourths of 2013-14 employment guarantee programme (NREGA) expenditure. These numbers are enormous. And still, the question remains whether the Government will actually be able to spend whatever money ultimately gets allocated.
Of the cumulative funds allocated to NBA and its predecessor, Total Sanitation Campaign (TSC), till date, the Government has been able to spend only 84% for household construction and 45% for IEC. Without hiring more ground staff to increase what the Government has the capacity to spend, it is unlikely that SBM will be able to make faster progress than previous sanitation efforts.
For now, it appears that construction will yet again trump behavior change in SBM. Since the full set of guidelines for SBM is yet to be released, there is still an opportunity for the Government to change course, ensure that funds allocated to behavior change are actually spent and make sure that only toilets that are constructed are those that will be used.
(Payal Hathi is a researcher and associate director at the research institute for compassionate economics)
Written by Aashish Gupta on October 18th, 2014
Sanitation has dominated the r.i.c.e blog for sometime, but this paper on violence against women has been pending for an equally long time too. I finally revised it, and its online now. The paper, which estimates the proportion of cases of violence against women which are actually reported to the police, is available here. I am pasting below the abstract of the paper.
Using data from the National Crime Records Bureau and the National Family Health Surveys, this article estimates, conservatively, the under-reporting of violence against women in India. I calculate under-reporting of sexual and physical violence, both for violence committed by “men other than survivor’s husband” and violence committed by husbands. In 2005, only about six of every hundred incidents of sexual violence committed by “men other than the survivor’s husband” are estimated to be reported to the police. Most incidents of sexual violence, however, were committed by husbands of the survivors: the number of women who experienced sexual violence by husbands was forty times the number of women who experienced sexual violence by non-intimate perpetrators. Less than 1% of the incidents of sexual violence by husbands were reported to the police. Similarly, only about 1% of the incidents of physical violence by other men, and 2% of the incidents of physical violence by husbands were reported. These striking findings shed further light on the presence of endemic violence against women in India, and reveal the extent of the obstacles confronted by women in reporting violence.
The working paper will benefit from your comments, so if you have any, please feel free to write to me at [email protected] Your comments will help me revise the paper. If you like the paper, do share it. I have written it with the hope that it would be of use to the feminist movement in India. Thanks.
The other thing that will change, the government says, is an emphasis on behavioural change. Over the last year, a series of research studies have shown that not everyone who gets a toilet uses it — 40 per cent of the households with access to toilets had at least one family member not using it, economists from RICE found in a five-State study.
The government says this will change. “Building toilets and effecting behaviour change — these are the two prongs of the strategy,” Sandhya Singh, Joint Director of the SBA (Rural), said. Yet, as RICE economist Payal Hathi points out, funding for the information, education and communication segment of the scheme has fallen from 15 per cent to 8 per cent as a proportion of total funds spent.
“With the SBA, this new government has the opportunity to do things differently and put India on a better trajectory … the government will need to increase its capacity to carry out the important work of changing people’s attitudes about latrine use, and make clear that the use of latrines is more important than simply constructing them,” Ms. Hathi said.
This is what he has to say!
Had he a head for anything other than the trivial, Modi would not have been looking for film stars (and comprador Congressmen) as “brand ambassadors”, but summoning the hard working authors of the SQUAT survey to learn what has gone right and how much has gone wrong with the sanitation programmes we already have and what we need to do to get the strategy right. SQUAT, incidentally, stands for Sanitation Quality, Use, Access and Trends. The survey has been undertaken by New Delhi’s Research Institute for Compassionate Economics, and the two young authors, Aashish Gupta and Payal Hathi, have summarised their findings in an article published the day after the launch in The Indian Express.
You can read the full article here.
Here are some quotes from the article:
The answer though, sanitation experts say, doesn’t lie only in building more bathrooms. First, people need to learn to love using the latrine.
“Many people regard open defecation as part of a wholesome, healthy, virtuous life,” a recent study conducted in Bihar, Haryana, Madhya Pradesh, Rajasthan and Uttar Pradesh found. Researchers at the New Delhi-based Research Institute for Compassionate Economics added that the practice is “not widely recognized among rural north Indians as a threat to health.”
Those five northern Indian states account for 45% of the country’s households without a toilet, according to data from the 2011 census. But even in homes where toilets were installed, many people still prefer to go outside.
The RICE study found that out of 3,235 rural homes fitted with a working toilet, over 40% had at least one member of the household who opted to defecate in the open. When asked why, almost 75% said they did so because it was pleasurable, comfortable and convenient.
Sangita Vyas, one of the authors of the RICE study, said this is partly because of the red tape involved in getting education campaigns approved. She worries it will be the same for Mr. Modi’s new mission.
When the money is spent, it’s not all being put to good use: Researchers point out that the government has failed to inform people about the adverse health effects of open defecation as it has done in campaigns to reduce tobacco and alcohol consumption.
Read the article here.