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More thoughts on evidence... and a good example

Blog Post2 min read

A few days ago, Sangita asked an important question: What makes us think that not knowing the effect of x on y is what is holding back better policies? Do policy-makers even care? Is there any realistic mechanism whereby they learn what a complex body of research concludes? And isn't it all politics and personalities anyway?

Perhaps the perfectly optimal plan for Utter Pradesh is not immediately obvious. But who needs the perfectly optimal plan? Surely the UP powers that be know enough to start trying, say, five or six really great investments in human development if they really wanted to! So what is evidence for?

These are all big questions that require a lot of thought. But perhaps we need to be a little more humble. No, the confidence interval on my regression coefficient might not change the world. But the reason that we can all think of five or six places for UP to start (birth weight, sanitation, disease, breastfeeding, healthy school lunches, school for that matter...) is the accumulation of generations of evidence. Not very long ago, humans did not know where diarrhea comes from.

Two types of research could be very useful, even without estimating the causal effect of anything on anything else. One is research that helps us understand what is important, what is a big deal. There are some policy-makers out there who care, and simply are not aware of how much maternal malnutrition, or infant mortality, or open defecation there is in rural north India. Another strategy for evidence is to accumulate simple facts that challenge the things "everybody knows" that are not true.

Along these lines, one good example is a recent simple, cross-sectional survey about sanitation behaviors, beliefs, and attitudes in Orissa by Sharmani Barnard and coauthors. They offer some simple evidence that sanitation behavior change in rural India is going to be especially hard. We at r.i.c.e. were particularly delighted to see that their results are quite consistent with what we are finding in other states. In particular, they show that:

  • "The most common reason reported for not using a latrine was that people prefer open defecation."
  • Among those with a latrine, only 61% of households and 47% of individuals use them (and 37% of people always defecate in the open!)
  • 34 % did not say there are health benefits of latrines (or, they report that 66% said there were benefits).

These simple facts -- now being found again and again in different contexts -- amount to a challenge to the sanitation policy community in India to rethink whether models that worked elsewhere will work here. Of course, the Orissa paper is only actually a good example of my response to Sangita if it indeed helps promote changes in policy and practice. What can we do to help that happen?


r.i.c.e. is a non-profit research organization focused on health and well-being in India. Our core focus is on children in rural north India. Our research studies health care at the start of life, sanitation, air pollution, maternal health, social inequality, and other dimensions of population-level social wellbeing.

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