Earlier this month, Scroll published this article calling for more support for women to help them successfully breastfeed their babies. This support includes not only compensation and time off of work, but also assistance in order to get adequate nutrition in pregnancy and after child birth.
It is very exciting to see r.i.c.e.’s research on maternal nutrition and India’s maternity entitlements program mentioned in the article, referred to as commonly known fact. For example, the article says that “Forty-two percent of Indian women are underweight during pregnancy,” a finding from Diane’s 2015 paper, Prepregnancy body mass and weight gain during pregnancy in India and sub-Saharan Africa. And in explaining the cash assistance benefit for pregnant women required by the NFSA, it states that “The cash can help them buy nutritional support through pregnancy and lactation.” This is a recommendation that Diane and Payal made in their 2016 article, Underweight and Pregnant: Designing Universal Maternity Entitlements to Improve Health, which suggests improvements in the structure of the NFSA’s maternity entitlement to address poor maternal nutrition.
The Scroll article also highlights how the 2016/17 national expansion of the maternity entitlements program actually promises less to pregnant women by adding on new restrictions. It is good to see this important issue getting coverage – there is no doubt that more conversation is needed to push for universal access to services that support mothers in taking care of themselves and their children in the critical months during pregnancy and after birth.
Payal’s op-ed on women’s work was published in the Indian Express today. She uses SARI data to explore social disapproval of women working outside the home, and how patriarchal attitudes contribute to India’s low female labor participation rate.
Data reported in the article are presented in the graph below (which could not be printed in the article). See the piece here.
Hat tip to r.i.c.e. board member Avinash Kishore for noticing this article in the Hindustan Times: “In Telangana’s Karimnagar, police deploy drone to stop open defecation.”
Two quotations from the article:
“Ironically, almost all the houses in these colonies have toilets. ‘Yet, people were habituated to come out early in the morning for open defecation, despite the hectic campaign about Swachh Bharat in the last two years. So, we thought we could shame them by exposing them through drone camera,’ the commissioner said.”
“The police want to continue the drone surveillance on the banks of the lake after checking the open defecation. ‘We are now focusing on pig-rearers who bring their animals to the reservoir bank and make the waters dirty,’ the police commissioner added.”
You can read the whole review at this link. Here is a quotation:
“Researchers Diane Coffey and Dean Spears have written a book that is important, timely, and easy to read. It argues that caste is the biggest stumbling block to overcoming open defecation. Drawing heavily on field studies and data analysis, the authors contend that the power of the state over open defecation is limited because it not only lacks the human resources needed for behavioural change but also because the social forces against it are strong.”
If you are in Delhi on Oct 25th, please mark your calendars for a book discussion of Where India Goes with IIT Delhi’s Ambedkar Study Circle at 2:30pm in LH 308. Dean and I are really looking forward to it!
This blog post was written by Sapna Gopal and was originally published at India Climate Dialogue:
If India reduced its air pollution to comply with the air quality standard of the World Health Organisation (WHO), Indians could live about four years longer on average, according to a study published on September 11 in the Proceedings of the National Academy of Sciences (PNAS) journal. If the country reduced pollution to comply with its national standards (lower than the WHO), its people could live more than one year longer on average, the study said.
“These results greatly strengthen the case that long-term exposure to particulate air pollution causes substantial reductions in life expectancy. They indicate that particulates are the greatest current environmental risk to human health, with the impact on life expectancy in many parts of the world similar to the effects of every man, woman and child smoking cigarettes for several decades,” co-author Michael Greenstone, director of Energy Policy Institute at University of Chicago (EPIC), told indiaclimatedialogue.net. “The histories of the United States, parts of Europe, Japan and a handful of other countries teach us that air pollution can be reduced, but it requires robust policy and enforcement.”
The study found that a Chinese policy is causing people in northern China to live 3.1 years less than people in the south due to air pollution concentrations that are 46% higher. These findings mean that every additional 10 microgrammes per cubic metre of particulate matter pollution (PM10) reduces life expectancy by 0.6 years. The elevated mortality is entirely due to an increase in cardio-respiratory deaths, indicating that air pollution is the cause of reduced life expectancies in northern China.
Air Quality-Life Index
The results from this paper can be used to quantify the number of years that air pollution reduces lifespan around the globe. Greenstone and his colleagues at EPIC used the finding that an additional 10 microgrammes per cubic metre of PM10 reduces life expectancy by 0.6 years to develop a new pollution index, which has been named the Air Quality-Life Index (AQLI).
The AQLI translates particulate pollution concentrations into the impact on lifespan. It provides a reliable measure of the potential gain in life expectancy communities could see if their pollution concentrations are brought into compliance with WHO, national or some other standard. Unlike much of the research linking air pollution and human health consequences, the AQLI is based on the consequences of sustained exposure to air pollution and plausibly isolates the impact from other factors that could affect health. It serves as an important complement to the frequently used Air Quality Index (AQI), which is a complicated function of air pollution concentrations and does not map directly to health.
The new index allows users to better understand the impact of air pollution on their lives by calculating how much longer they would live if the pollution in the air they breathe were brought into compliance with national or WHO standards. “The AQLI uses critical data and information gathered from our China research and applies it to every country, allowing billions of people around the world who are exposed to high air pollution levels to estimate how much longer they would live if they breathed cleaner air,” Greenstone explained.
Air pollution and climate change
Air pollution and climate change are closely related, according to the Institute for Advanced Sustainability Studies. “The main sources of CO2 emissions — the extraction and burning of fossil fuels — are not only key drivers of climate change, but also major sources of air pollutants, it said.
Currently, an estimated 4.5 billion people around the world are exposed to particulate pollution levels that are at least twice what the WHO considers safe. India is one of the most polluted countries in the world and air pollution is a major threat to health.
“Some of the greatest gains would be seen in the country’s largest cities, such as Delhi. There, people could live six years longer if the country met its national standards, and nine years longer if the country met WHO standards,” the EPIC study said. “The people of Kolkata and Mumbai could live roughly 3.5 years longer if the country met WHO standards.”
In too many instances, the current policy imposes significant costs on industries without receiving sufficient pollution and health benefits. There are great opportunities for India to pursue regulatory policies that reduce air pollution, extend lives and decrease the regulatory burden on industries. Whether the WHO standard or a less stringent one is right for India is a difficult political decision that involves trade-offs between growth and, as the paper demonstrates, longer lives, Greenstone told indiaclimatedialogue.net.
“Naturally, India is searching for the best way to balance the dual and, at times, conflicting goal of economic growth and a clean environment,” he said. “The study highlights that improvements in air pollution offer concrete benefits in terms of longer lives and the least costly way to gain these health improvements is to pursue market based regulatory approaches, like cap-and-trade for particulates, that is built upon a foundation of reliable monitoring of industries.”
Renewable energy can help
Renewables too can help in India although electric cars are probably unlikely to add much at this point because the Indian grid relies so heavily on coal. The best bet is to devise market-based regulations that target particulate air pollution emissions, added Greenstone.
India is already taking action to reduce pollution. In fact, EPIC-India is currently working with the central government and several state pollution control boards to implement India’s first emissions trading programme for particulate pollution. This will be the world’s first trading programme specifically for particulate pollution. “However, the programme is still in its pilot phase,” said Greenstone. “For it to be successful, it is critical for regulators to insist that industries install reliable and robust monitoring devices.”
Reduce coal dependency
In India, districts that got a coal plant between 2005 and 2012 saw a worsening of respiratory health, reveals a study published in April this year in the Journal of Environmental Economics and Management. Titled Health externalities of India’s expansion of coal plants: Evidence from a national panel of 40,000 households, authored by Aashish Gupta of Population Studies Centre (PSC) of the University of Pennsylvania and Dean Spears of University of Texas. The study says this pattern is specific to respiratory health and coal plants, which suggest that coal-fired plants are causing the bad effects.
“One reason that some economists do not give too much importance to climate change is that its damages will be in the future, but these costs to the health and well-being of the Indian population and workforce are happening now. That means that reducing India’s reliance on coal would not only be an important step towards reducing greenhouse gas emissions, it would also have substantial health co-benefits today,” Spears told indiaclimatedialogue.net. “These health co-benefits are especially important for India, where air pollution is uniquely terrible, and where many people’s houses do not have the sort of walls, doors and windows that keep air pollution out. This is true in rural places and urban places, and means even buying an expensive air filter is not enough to guarantee healthy air.”
Such evidence has led some writers, such as philosopher Dale Jamieson, to conclude that no more coal plants should be built. Deciding whether this is true depends on how much the total benefit of a new coal plant (the value-for-money of the electricity relative to the next best source of electricity) compares with the total social cost, meaning both the future climate cost and the costs to many people’s health and productivity today.
“This is a quantitative economic question. Finding a credible estimate of the total social cost of a new coal plant for Indians present and future should be a top priority for policy-relevant economics research in India,” said Spears. “Given the falling costs of renewables, the health costs may not need to be enormous for Jamieson to be correct.”
Indoors polluted too
Air pollution may have killed around 600,000 Indians in 2012, according to WHO. With coal production in India set to double by 2020, the situation appears slated to get worse. In India, 49% of cooking is still done with firewood; 8.9% use cow dung cakes; 1.5% coal, lignite or charcoal; 2.9% kerosene; 28.6% liquefied petroleum gas (LPG); 0.1% electricity; 0.4% biogas; and 0.5% other means.
About 80% of rural households rely on biomass fuel, making India the country with the largest population lacking access to cleaner fuel for cooking. The result is the worst indoor air pollution situation in the world. “There are many reasons to suspect that the current government solution of providing LPG stoves to poor households may not take us very far,” Gupta told indiaclimatedialogue.net.
“The health toll in India is staggering. Diarrhea kills over 117,000 children under age five each year. Millions more struggle on with chronically infected intestines that don’t absorb nutrients and medicines well. The misery cycles on: Underweight women give birth to underweight babies, who are more vulnerable to infections, more likely to be stunted, and less able to benefit from vaccines. In 2016, 39 percent of Indian children under age five were stunted.
The Swachh Bharat mission offers each household about $190 to construct a pit latrine—far more than other developing nations spend. In Jawda, however, nobody uses the latrines. ‘It’s for washing clothes or bathing,’ says a woman in a pink-and-black sari, resting on a rope-strung cot in the shade. ‘We have a lot of open space. Why shouldn’t we use that?’ Grassy fields dotted with wildflowers surround her village.”
Read the full article by Elizabeth Royte: “Nearly a Billion People Still Defecate Outdoors. Here’s Why.” The article, and the photography by Andrea Bruce, are outstanding. You’ll read that r.i.c.e.’s Nikhil takes us on a tour of a Madhya Pradesh village, and Sangita provides statistics on child height.
Also, the printed book is now available for same-day delivery in India:
r.i.c.e. is delighted to announce Harper Collins’ publication in July of Dean and Diane’s new book Where India Goes: Abandoned Toilets, Stunted Development, and the Costs of Caste!
Book launch: Come for snacks and discussion at 7:20 pm, Friday 14 July at the Juniper Room of the India Habitat Centre in Delhi.
Pre-order for kindle: The book is available for pre-order for delivery to your kindle on July 10th! Links:
AIIS Joseph Elder Prize: We are honored that Where India Goes has received the 2017 Joseph Elder book prize in the Indian social sciences. Read the prize announcement here!
Foreword by Angus Deaton: r.i.c.e. is grateful to Nobel laureate economist Angus Deaton for his foreword to Where India Goes.
We are very excited to share that Dainik Bhaskar – the most widely-read Hindi newspaper in India – published an article written by Nikhil! And soon after, Satyagrah @Scroll.in published another article! We are on a roll in the Hindi media.
Both articles highlight two separate pit-emptying drives, one carried out by the Secretary of the Ministry of Drinking Water and Sanitation, and another by Bollywood actor Akshay Kumar in the presence of Minister of the Ministry. The articles call for the Prime Minister, the government and people to take-up the great idea of pit emptying.
Close to one fourth of Indians speak Hindi, hence having these articles in Hindi newspapers helps spread our research findings to a bigger audience.
Congrats to Dean and Diane for winning the Joseph W. Elder Prize from the American Institute of Indian Studies for their soon-to-be-published book Where India Goes: Abandoned Toilets, Stunted Development, and the Costs of Caste. The prize is named after Professor Joseph W. Elder, a sociologist at the University of Washington, Madison who has studied and written extensively on India, and South Asia more broadly.
In regards to the book, the prize announcement notes that:
“The members of the AIIS Publication Committee noted the book’s dramatic ethnographic case studies and well-documented statistical arguments as being of great potential value to both policy makers and general readers unaware of the magnitude and public health implications of the lack of toilets and the practice of open defecation in much of South Asia.”
See the full prize announcement here.
Payal, Dean, and Diane’s article, “Can collective strategies motivate behavior change to reduce open defecation in rural India?” was recently honored with the Jeroen Ensink Memorial Prize from Waterlines Journal. See the announcement and full paper here.
The award was established in memory of Jeroen Ensink, an engineer, researcher, and teacher who dedicated his life and work to using research in the WASH sector to improve lives. We are indeed humbled that the committee felt that our paper contributed in some way to his life’s work, and to the larger work of water and sanitation in the developing world.
r.i.c.e. has recently launched the Social Attitudes Research in India (SARI) phone survey to track social attitudes over time and experiences of discrimination on the basis of gender, caste, and religion in India. We study discrimination and social exclusion because they play an important role in determining human development outcomes. The Social Attitudes Research in India survey (SARI) is a tool that we hope will both raise awareness and influence policy.
The World Food Program is hosting a webinar addressing questions such as how to engage women when conducting surveys via mobile phone, biases that emerge from low female participation in surveys, and using mobile data collection methods to collect information on women’s experiences. Join Sangita as she speaks about r.i.c.e.’s experiences in collecting data from women through mobile phones in India.
On Monday, December 12 at 9am EST/7:30pm IST, you can join the webinar here.
Check out a new book chapter authored by Aashish, Diane, and Dean, called “Purity, pollution, and untouchability: challenges affecting the adoption, use, and sustainability of sanitation programmes in rural India” in the book “Sustainable Sanitation for all: Experiences, challenges and innovations“, published by Practical Action and edited by Petra Bongartz, Naomi Vernon and John Fox.
Angus Deaton’s Nobel lecture is Tuesday. You can watch it online here, at the Nobel prize website.
The lecture is at 1:30 pm Central European Time. To make life easier on everyone in r.i.c.e., that’s:
- 6:00 pm here in India,
- 7:30 am for board members John and Louis in the U.S. east, and everyone in Princeton,
- 6:30 am for Mike in Texas,
- 4:30 am for Josephine in California, and, of course,
- 1:30 pm for Nicholas in France.
Today, Diane’s article on maternal undernutrition and maternity entitlements came out in India in Transition, as well as the Hindu Businessline. Here is the text of the article from Hindu Businessline:
Healthy mothers give birth to healthy children who grow up to be productive adults. By contrast, women who begin pregnancy too thin and do not gain enough weight during pregnancy are far more likely to have low birth-weight babies.
In India, low birth-weight is the leading cause of neonatal mortality, or death in the first month of life. Neonatal mortality accounts for about 70 per cent of infant deaths in India — and is far higher than would be predicted by India’s GDP. India’s high neonatal mortality rates is a symptom of widespread maternal malnutrition.
How does India fare on important indicators of maternal nutrition, such as pre-pregnancy body mass and weight gain during pregnancy? My recent research finds that 42.2 per cent of Indian women are underweight at the beginning of pregnancy. This means they have a body mass index (BMI) score of less than 18.5, which is the Food and Agriculture Organization’s cut-off for chronic energy deficiency. This is an extremely high rate of underweight among pregnant women, even relative to poorer, less developed regions of the world; only about 16 per cent of women in sub-Saharan Africa are underweight at the beginning of pregnancy.
Not only are Indian women too thin when they begin pregnancy, they do not gain enough weight during pregnancy to compensate for low pre-pregnancy body mass. Women in India gain only about 7 kg, on average, during pregnancy. This is far too low to produce a healthy baby; it’s only about half of what the US Institute of Medicine recommends for women in the US. Unfortunately, this topic has been studied very little by Indian researchers and the government; no national guidelines for weight gain during pregnancy are available.
Poor maternal nutrition has serious consequences for the health and human capital of the Indian population. It leads to low birth-weight, and is likely an important reason why Indians are among the shortest people in the world. The fact that Indian children and adults are so short is a sign that they are not achieving their cognitive potential. Researchers now understand that the same early-life health processes that stunt child height also affect the development of their brains. Children who are stunted are less likely to be able to read, and grow up to earn lower wages than taller people. Thus, maternal nutrition, low birth-weight, and stunting are not only health issues, they are also economic issues.
Patriarchy and malnourishment
Why are pregnant women in India so poorly nourished? One important reason is because, as young women living in a patriarchal society, they have very low status in their households. While over 40 per cent of young women who get pregnant are underweight, a smaller fraction of middle-aged men — about 25 per cent — are underweight. If food and work were shared equally between family members within households, we would expect to see similar fractions underweight for these different demographic groups. Instead, many prior studies confirm that young, newly-married women are often treated poorly by their own family members and are expected to be self-sacrificing, do hard work, and eat little.
Although there is important regional variation in women’s health, and in a number of measures of gender inequality in India, with the south outperforming the north, improvements in women’s status would likely result in better child outcomes everywhere. My recent research, with Reetika Khera and Dean Spears, on joint households in rural India, provides further confirmation of the importance of intra-household status for nutrition.
It finds that daughters-in-law married to the younger brother in a joint household are thinner than daughters-in-law married to the older brother due to the fact that women married to the older brother have higher intra-household status than women married to the younger brother. This research shows an effect of social status on maternal health in a way that is unlikely to be confounded by other factors. It also finds that poor nutrition in pregnancy is one way in which the low social status of women can affect the health of the next generation.
The fact that poor maternal nutrition is related to social hierarchy and the low social status of young women in Indian households makes it a very difficult issue for the government to address. Changing how husbands treat their wives, how mothers-in-law treat their daughters-in-law, and whether women stand up for their own and their infants’ health will not happen overnight. However, the costs of taking a business-as-usual approach to poor nutrition in pregnancy are simply too high to ignore.
Measuring maternal health
An important first step in addressing poor maternal health is to measure it. India has not had a National Family Health Survey (NFHS) for 10 years. Thankfully, a new NFHS is being carried out right now, but in order for these surveys to be more useful, they must be implemented regularly. Bangladesh, for instance, carries out a similar health survey every three years. In addition to conducting a regular NHFS, India should implement a continuous national monitoring system to track a representative sample of women throughout pregnancy and delivery. Such systems are in place in other countries, and cost very little. With a continuous monitoring system in place, the government could more easily experiment with new maternal health programmes, such as maternity entitlements, and see how birth outcomes respond.
Under the National Food Security Act, pregnant women are entitled to receive ₹6,000 in maternity benefits. Unfortunately, it has been more than two years since the NFSA was passed, and maternity entitlements have not yet been implemented. This is a missed opportunity to begin addressing India’s abysmal maternal nutrition. Although it is not likely that maternity entitlements could reduce the prevalence of pre-pregnancy underweight, a well-designed maternity entitlements programme might help improve weight gain during pregnancy.
The government should experiment with pairing education about the importance of weight gain during pregnancy, and put pressure on families to take better care of pregnant women, with a lump-sum, unconditional cash transfer to women as early in pregnancy as beneficiaries can be identified (when it could still potentially be spent on more nutritious food for the pregnant woman).
Such a design would make the programme relatively easy to implement, and might signal the importance of greater weight gain during pregnancy to beneficiaries and their families.
If you would like to attend the conference, you must register by here by 25th Sept.
Last year, the Government of India launched the Swachch Bharat Mission, aimed at eliminating open defecation by 2019. How can the widespread adoption of latrine use be accomplished?
To this end, the Indian Institute for Dalit Studies and the research institute for compassionate economics are organizing a half-day Conference on Purity, Untouchability, and Open Defecation: Starting a Conversation for a Swachch Bharat, hosted at Jawaharlal Nehru University. The goal of the conference is to explore the connections between these issues and deepen a dialogue between organizations working in these fields.
The conference will have the following presentations of original research:
- Dirty, disastrous and desolate: engaging with conservancy workers to understand caste and work inter-sectionalities, Dr. Sanghmitra Acharya, Director of IIDS and Professor at JNU;
- The continuing practice of untouchability in India: patterns and mitigating influences and implications for open defecation, Dr. Amit Thorat, Associate Fellow at NCAER;
- Purity, pollution, and open defecation: evidence from new qualitative and quantitative data, Ms. Sangita Vyas, Managing Director for Sanitation at r.i.c.e.
A policy panel will conclude the conference, on which Dr. SK Thorat (Chairman of the Indian Council of Social Science), Mr. Bezwada Wilson (founder of the Safai Karamchari Andolan), Mr. Sujoy Mojumdar (Water, Sanitation, and Hygiene Specialist at UNICEF), and Mr. Avinash Kumar (Director Policy and Program at Wateraid), among others, will be participating.
We look forward to your participation in this event. Others from your organization are also welcome to attend. All participants must register here by 25th Sept.
Date: 29th Sept, 2015
Time: 9:00 am to 2:00pm
Place: Convention Centre, JNU
Yep. Its at the India Habitat Center, on Sunday. Here is the link for the event. When the video is available on the internet, we will link it here.
Please go to livemint and see Nikhil and Aashish’s op-ed on the struggles being faced by the new Swachh Bharat Mission. They compile a lot of data from the website of the Swachh Bharat Mission to present the case that the mission is not any different from the Swachh Bharat Mission, and in some ways, may even be worse. It reduced spending on behavior change spending, for certain.