How would babies vote?

Different places in India are voting in national elections on different days. Diane and I wrote these thoughts about the election together.

Today, India is preparing for an election which will shape the lives of more people than any election ever has before. Hundreds of millions of people will vote. Of course, the two of us personally will not vote in this election. We are privileged to be guests here in India, as visiting economics researchers.

But we are not the only ones who will not be voting. Millions of Indians will not be able to vote in this election. Indeed they will live their whole lives, and die, never having been able to vote even once. These lifelong disenfranchised citizens live in every state and every district of India – perhaps you have even met some of them.

Who are these millions of excluded Indians? They are children and babies who will die in their first few years, or days, or minutes of life. It is well known that even as India has been experiencing exceptional average economic growth, the population suffers from surprisingly poor early life health.

Thousands of babies will die between today and the day the ballots are counted. We will never know how these babies would have someday voted. But when you decide how you will vote, you can keep these babies in mind. What policies would they be voting for? How could your vote help keep more of them alive?

These are complicated questions, and we do not pretend that there is any one right answer. The only certainties are that the problem is profound and its scale is vast. So many die, and so many suffer, that even a small improvements the problems that contribute to infant mortality—such as poor sanitation, maternal malnutrition and indoor air pollution—would mean many lives would be saved between this election and the next.

In India, between 4 and 5 percent of babies die before their first birthday, compared with much less than 1 percent in Europe or North America. However, this figure averages over all of India, a diverse country where one-sixth of all humans live. Some Indian babies are born into enclaves as glamorous as any address worldwide; yet, hundreds of millions of people live and die in districts as large, as poor, and as unhealthy, and sometimes even unhealthier, than many sub-Saharan African countries.

For instance, the state of Uttar Pradesh has a higher infant mortality rate than the developing countries of sub-Saharan Africa. Additionally, many Indian districts match or exceed African countries in both population and infant mortality. If Indian districts were countries, 5 of the world’s worst 10 countries for infant mortality and 13 of the worst 20 would be Indian districts. Tens of millions of Indians are living in big places with infant mortality as bad as anywhere on earth.

Millions of preventable child deaths are bad enough. However, the tragedy is compounded by the fact that early-life health has lasting economic consequences for those who survive. Medical scientists and economists are accumulating research that shows that the disease and nutritional environment to which children are exposed before birth and in infancy shapes their physical and cognitive development. Put simply, healthy babies are more likely to reach their full potentials. An economy where babies are developing to their potential is an economy which will one day have healthier and more productive workers. So, early-life health matters for everyone.

What sort of changes could keep more babies alive and growing healthily? The answers are simultaneously easy and vastly challenging. Make a healthier disease environment, with better sanitation and less infection. Make pregnancy a healthier time for mothers and babies, with plenty of good nutrition and less indoor air pollution, and follow it with exclusive breastfeeding for six months, and the timely introduction of complementary food. Take on the grand challenge of placing the problems of early-life health front and center on the national stage.

Although we will never learn it, each of the disenfranchised babies is entitled to her own views on how to achieve these goals. You are entitled to yours, too. To be clear: if there is one right answer, we don’t know it. But, as India reflects on which directions to take next, we are certain that this is one of the most important questions to be asking.
Between this election and the next, millions of Indian children will die unnecessarily. Many, many more will be sent into life irreversibly limited by early life disease and deprivation. They will not have the opportunity to vote next month for better early life health in India. But you will.

Wealth & Children’s Health in India in EPW

My article with Aparajita Chattopadhyay and Rajan Gupt just came out in Economic and Political Weekly — check it out!

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Wise words, part II

I wanted to share Jeff Hammer’s blog post on the World Bank blog about the role of development economists in policy making.

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More wise words from Jeff Hammer can be found on a previous blog post on the Indian health care system.

Sagar the horrible

In fact, Sagar, Madhya Pradesh – where I have been watching the surveyors ask about toilets – is not any more horrible than the other districts where we have done the survey, but I could not resist the pun.

Yesterday, I accompanied an interview with a daughter-in-law in a Hindu brahmin household, situated among all the other pale blue brahmin households, near the large, tall temple in the middle of the village.  Indeed, it is election season in India, and many of the houses nearby had stenciled paintings advertising one of the political parties that has long been associated with Hinduism-inspired policies.

In comparison with her village, this woman’s family was relatively well off (her father in law had an unspecified government job), and she made sure to let us know.  It struck me that the interview was a fun (rare) opportunity for her to flaunt her education.  When we asked how good the public schools are in her village, she made a show of not knowing: after all, her children go to private schools!  When we showed the “life satisfaction” ladder and asked how her life was going, she practically bellowed that this was the best of all possible lives for her.  When we asked “what is your religion,” she immediately answered “Brahmin!”

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So, it is little surprise that her household has a latrine, although you have to walk out the back door and a little ways away to get to it.  I saw the same thing in another brahmin house in the next village over that afternoon: a huge latrine-building about 30 meters out the back door, with two pits, each 10 feet deep.  Our daughter-in-law interviewee twice explained that not only does everyone in their household use the latrine, but these days “everyone” has and uses latrines!  Unfortunately, she probably does not get out and about much, due to social restrictions on young women, so it is interesting to reflect on how she learned this.  Of course, there are many people in her village that do not use latrines.  Another surveyor, randomly assigned to go in a different direction, interviewed two “Other Backwards Caste” households on the edge of the village, neither of which had latrines.  A third interviewed a large household around the corner that, somehow, had two latrines – but only the 95-year old grandmother ever used one!

The daughter-in-law knew very well that using latrines is healthier.  She found open defecation disgusting, but not so very disgusting: it would be much worse to have a dirty dog in her kitchen, or for a dirty person to go into a temple.  (She gave no indication whatsoever of minding the cow in her kitchen.)

But when we started asking about religious purity, her answers took a different turn.  I’m highlighting this in a blog post because it turns out to be a pattern that we see all the time.  We ask these four questions:

  • Is it religiously pure, not pure, or does it make no difference to use a latrine far from your house?
  • Is it religiously pure, not pure, or does it make no difference to defecate in the open far from your house?
  • Is it religiously pure, not pure, or does it make no difference to use a latrine near your house?
  • Is it religiously pure, not pure, or does it make no difference to defecate in the open near your house?

The brahmin daughter-in-law gave a very common pattern of answers: pure, pure, not pure, not pure.  In other words, what matters for religious purity is not whether you defecate in the open or use a latrine, but whether you do it far from or close to your house.  This may be why her family’s latrine was some distance out the back door.

As long as people use them – a big “if” – I don’t see any reason why it would matter for health outcomes if latrines are right next to people’s houses or a little distance away.  However, although the ones that I saw two weeks ago in Tamil Nadu did not have latrines, my understanding is that the simple houses that the government sometimes provides for poor people are supposed to have latrines built right in.  It may be no wonder that people don’t agitate when their latrine money is stolen if it has to be pollutingly attached onto the house.  Similarly, a government message I sometimes see painted on walls suggests: “don’t let your daughters or daughters-in-law go outside: build a latrine right in your house!”  Could this be a counterproductive message?

update: Diane tells me that IAY houses are not, in fact, officially supposed to have the latrines attached, or at least not required to.  April fools!

Economic growth does not cause child growth… so what does?

A recent article about child height in the Lancet has been getting wide attention, even at macroeconomist Paul Krugman’s blog.  As Sebastian Vollmer and coauthors conclude, in their paper titled “Association between economic growth and early childhood undernutrition: evidence from 121 Demographic and Health Surveys from 36 low-income and middle-income countries,“ “a quantitatively very small to null association was seen between increases in per-head GDP and reductions in early childhood undernutrition, emphasising the need for direct health investments to improve the nutritional status of children in low-income and middle-income countries.”

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So, it turns out that GDP growth does not make children taller, on average.  This is actually somewhat old news: Angus Deaton showed in 2007 that GDP levels are not correlated with height.  At last summer’s child height conference at the Delhi School of Economics, Aparajita Chattopadhyay presented a paper, which is now forthcoming in EPW, showing that economic growth in Indian states is not correlated with children’s height.

So, if economic growth does not cause child growth, what does?  Good early life health and net nutrition – including moms getting good things to eat during pregnancy and breastfeeding and a healthy epidemiological environment free from disease and poor sanitation.  Money does not appear to be the most important constraint on either of these here in India.

The Lancet article was published along with a comment by Abhijeet Singh, who made this point, and cited some of r.i.c.e.’s work on sanitation and child height along the way: “Public health and nutritional interventions can have an important role in reducing child undernutrition.  Spears documents a clear gradient between sanitation and child undernutrition, large enough to statistically explain excess stunting in India compared with sub-Saharan African countries; in another recent study, my co-authors and I also document that the Indian Midday Meals programme in schools leads to catch-up growth to compensate for drought-related nutritional deprivation in early childhood.  Although economic growth alone might not accomplish an end to child undernutrition, proven interventions targeted at nutrition might.”

Baby care II: Down under

I have spent most of the past three days in airports or airplanes going to or coming from Australia.  Even in a 26 hour visit, there was enough time for me to be deeply impressed.  In particular, this is the highest possible implementation of classy:

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But perhaps more importantly, with all that time in airports, I was able to revisit my recent post on “Baby Care” in the Delhi airport.  Australia takes a different, but similarly explicit, approach:

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update: I’m heading back to the airport (where else?) to catch up with the surveyors in sunny Sagar, Madhya Pradesh, but I realized that in my sleepiness I forgot the punch line,

ahem:

So, can Indian men become as manly as the Aussies?

 

 

Reflections on a first visit to India

Editor’s Note: Nicholas Lawson is a Postdoctoral Fellow at the Aix-Marseille School of Economics, and is the newest member of the r.i.c.e. extended family.  Nicholas is a labour economist who has been studying the effect of early life health and disease on adult wages, and recently visited us in India to collaborate and present his work.  Look for more blog posts from Nicholas to come!

 

When I arrived in India a few weeks ago for the first time – in fact, my first time in any developing country – my first impression was astonishment at contrasts on a level that one simply doesn’t see in Europe or North America.  Delhi is a bewildering mixture of poverty and plenty, with wealthy colonies and cramped poor neighbourhoods, mansions next to fields of trash, and chaotic and noisy streets above the quiet, clean, elegant Metro.

And I imagine that, for many tourists to India, that is extent of the poverty and inequality that they see in India; they stay in nice hotels, visit the many tourist attractions – temples, markets, palaces – and marvel at the unique culture and enticing (and cheap) food.  And then they go home, and tell their friends what a fascinating place India is.

Of course, they’re right about that; but the India that most people see is just a small fraction of the whole.  In central and south Delhi, or in tourist towns like Udaipur, it’s easy to see one side of India, the side that is growing fast and becoming a prosperous economic power, “India Shining” as one election slogan of the past decade puts it.  But Jean Drèze and Amartya Sen called India “islands of California in a sea of sub-Saharan Africa,” and accompanied by the incomparable Dean Spears, I had the opportunity to see just a bit of that sub-Saharan sea.  The results were eye-opening and disturbing.

In several days spent visiting villages in Rajasthan and Uttar Pradesh, I saw schools with no books and hospitals without soap, where rampant absenteeism makes it hard to predict if the teachers and doctors will even show up to work.

I saw villages without latrines, without any basic sanitation infrastructure, where “going to the toilet” means squatting down in a field; villages where the common cooking fuel is dung collected by young wives; and these villages might be considered lucky, as they at least seemed to be connected to electricity, unlike hundreds of millions of people in rural India.

I saw so many women whose first and only reaction to seeing us was to cover their face and turn away, women who are physically underdeveloped and whose children are stunted, signs of the village patriarchy that makes a woman subordinate to her husband and other males, and makes it shameful to interact with men who are not her husband.

I saw district government offices where, amidst typewriters and enormous piles of paper, much of the work seemed to be done by private contractors whose job it is to invent numbers about the painfully slow progress in infrastructure improvement.

In the end, I found the experience rather overwhelming and confusing.  I could only find one question to ask: why does it have to be this way?  Why do “we” in the West – people like myself and our governments – do so little to help our fellow human beings in places like these villages?  It is widely known that people in the West, particularly the US, vastly overestimate the amount given in foreign aid: a poll at  http://www.interaction.org/document/american-public-overestimates-us-foreign-aid indicates that the median American believes that 25% of the federal budget goes to foreign aid, a number that they would like reduced to 10%, even as the real amount is an order of magnitude smaller at just 1%.  In other words, we think we are doing so much – and we might even be okay with that – but in reality we are doing nothing to help.

I’m not even talking about “handouts” of the sort that sometimes cause populist displeasure; I’m not talking about people who aren’t working as hard as “us” in the West, or about giving them food or clothing or lump sums of cash (not that that would necessarily be a bad thing).  I am talking about public investment in human development, and while money can’t do everything, it can do a lot: we could put toilets in every village, and fund extensive public information programs to teach people about the benefits of using them.  We could invest in technology and incentives to reduce absenteeism, and finance books in schools and sanitation in hospitals.  We could build better roads, water supply, and other basic infrastructure.  We can’t solve every problem; as indicated by my comments about private contractors inventing numbers, India still faces large administrative capacity constraints which often prevent even good policies from having their desired impact, with resources often failing to make it from the government to the intended recipients.  But we can solve a few of them, and we can give our fellow human beings a better chance to reach their full potential.

We owe it to our fellow human beings to do this, because we can; because by giving up so little, we can  provide opportunities to live a more fulfilling life to so many.  Not to mention that, in my opinion, we in the West have taken advantage of developing countries to a considerable extent, from the domination and resource theft of colonialism to the “structural adjustment” and unfair trade regimes of today.  We have a choice, and not doing anything to help ordinary people in developing countries, indeed pretending our fellow human beings don’t exist, is a deliberate choice no matter how easy it might feel to ignore them.

So why do we make that choice?  Thinking about my own experiences, I think it comes down to seeing these villages, seeing these lives in person, recognizing that these are people just as much as I am, with just as many rights and as great a moral weight in humanity’s social welfare function.  I knew all of these things before, as I’m sure we all do, and morally whether we can see people shouldn’t make a difference to the way we think about them, as long as we know they exist.  But it does; for whatever reason, it alters the way that we think about such issues.  I don’t know yet where we go from here, how to make a difference, but I know that there is much to be done, and I hope that in my role as an economist I can play some small role in doing it.

Baby Care: Men’s not allowed

Sitting at the Delhi airport at 5:30 am, I noticed a pair of signs.  The first was the official, plastic government-sponsored sign for the family restroom: “Baby Care,” illustrated with a diaper.  The second, printed on what we used to call computer paper, read “MEN’S NOT ALLOWED.”

At r.i.c.e., we’re too often forced to reflect that too many women and men agree: babies are women’s problem, especially low-ranking young women. Men need not — and sometimes may not — get involved.  (In a slightly related story, our housekeeper burst into laughing aloud when I, a man, joined Diane to personally give her, who washes my floor, a Holi present earlier this week.)

Of course, one of the things the Baby Care room is for is breast feeding.  I have no desire to enter the politics of public breast feeding here, but note that in gender-segregated India, one can understand how this second sign came about.  But if you have a baby, sometimes you have to change a diaper.  The nearby men’s room has 16 urinals, 8 sinks, 4 toilets, a line for the 4 toilets, and nowhere to change a diaper.  The assumption that no man would be responsible for a baby is physically built into the shiny, modern airport.  (This has come up at the airport before, when a guard explained to me that the reason women are allowed to bring a bag into the arrivals hall but men are not is that women might need to take care of a baby).

Sadly, whether they are allowed or not, many of the modern suit-wearing men sitting with me now in the airport agree that early-life health and human capital formation is not their job.  In too many places, the only advocate for next generation’s workforce is — literally — not allowed to show her face.

 

For rice research on women’s social status and child height, see: http://riceinstitute.org/wordpress/research/?did=14

“What’s the use?”: CLTS blog post by Nicholas Lawson

In the coming days we will introduce a new blogger and member of the rice extended family: Nicholas Lawson of the Aix-Marseille School of Economics.  Today, you should read his new post on the CLTS blog at IDS: “What’s the use? A tale of two latrines,” online here: http://www.communityledtotalsanitation.org/blog/whats-use-tale-two-latrines

His story, once again, highlights the challenges of low demand for latrine use in rural Hindi heartland north India.

Building Latrines, or Encouraging Their Use?

Today we have a blog post by Nidhi Khurana, our wonderful SQUAT survey team leader. She has been traveling around with our SQUAT team for the past 3.5 months, and she is finally sharing some of her experiences with you all today! We will hopefully have many more of these before the survey ends.

“We have got 450 latrines built for our villagers. 650 more applications have been received and we seek to provide them soon to everyone.”

Last month, I visited a village with the SQUAT team in Tonk, Rajasthan, that had started its own local sanitation campaign. The figures mentioned above are the number of latrines that were given to the beneficiaries in this village, impressive given what the NBA and IAY normally cover in a year.

As usual, after sending all the surveyors in their assigned directions, I went to talk to the Sarpanch. I reached the Sarpanch’s house and asked for him/er. Somebody escorted me to the back courtyard without asking my purpose for meeting the Sarpanch. Thinking this was a normal Gram Panchayat meeting, I took a seat and started listening to the conversation. At first, I was a little baffled because they were speaking in English! This was quite strange for a GP meeting. Then, a lady who was so well-dressed I thought she could be a TV reporter started introducing her colleagues to the others at the meeting. This lady turned out to be the Sarpanch. And she was introducing her team to some visitors from a large international NGO. This wasn’t a normal GP meeting at all!

And then everyone’s eyes reached me as if they expected me to introduce myself. I began to speak and told them that I am from Delhi University, here with 4 other people, hoping to get permission to conduct interviews with a few households. Without much trouble, the Sarpanch gave me permission after I gave everything to her in writing. I completed all the formalities and went out.

On my way back I saw many latrines outside people’s houses. All of these latrines looked the same, and all of them had the Sarpanch’s name written on them. I found Rajkumar, one of our surveyors, and sat down to accompany him while he did his interview. The household had one of these latrines, but when we asked about the household’s defecation practices, the respondent said that everybody goes out in the fields, including his younger sister and the old dadi. For the next two interviews I sat through, we got the same response. Nobody seemed to be using these latrines, even though they looked decent and had everything that a normal latrine would have!

I also managed to interview the Secretary of the NGO which was instrumental in getting these latrines built. The man told me that they are relying on CSR funds for the latrine construction and the Sarpanch was helping them a lot in fetching these sponsors. I quite liked the approach that the Sarpanch was using but I also wondered if it was a sustainable way of making an open defecation free country, or village to say the least. An English speaking Sarpanch can easily attract the corporates. But the question is how many Sarpanch’s in India can do that?

The Sarpanch surely had a potential to change the face of her village. In fact, the village did look better and cleaner than many other villages, convincingly a Nirmal Gram in the making. However, I hardly found any incentive that was promoting the use of the latrines that were being built. None of the respondents in that village said that they had seen an advertisement or street play on latrines. The latrines with the Sarpanch’s name written on them seemed more like a superficial exhibition of her power and influence.

The Sarpanch needs to realize that a culture which has been practicing open defecation for so long cannot embrace latrines without having a need for them. Emotional motivators can be very effective. Information and Education Campaign (IEC) and Behavoiral Change Communication (BCC) techniques can spur action but subsidies without an associated motivational campaign is indeed good for nothing.

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