Early this month, a paper in the journal Nature drew a heartening and widely reported conclusion about India’s Swachh Bharat Mission, the sanitation programme launched 10 years ago. It said that the mission “may have contributed to averting approximately 60,000–70,000 infant deaths annually”.
Prime Minister Narendra Modi, who launched the mission in 2014, tweeted that he was “happy to see research highlighting the impact of efforts like the Swachh Bharat Mission. Access to proper toilets plays a crucial role in reducing infant and child mortality. Clean, safe sanitation has become a game-changer for public health. And, I am glad India has taken the lead in this.”
The authors studied data from 35 States and Union Territories and 640 districts over 10 years (2011–20), including infant mortality rates and under-five mortality rates per thousand live births. “Toilet access and child mortality have a historically robust inverse association in India,” the paper said. Under the Swachh Bharat Mission, over 100 million toilets have been constructed across the country in a bid to end open defecation. And studies show that open defecation can be correlated to diarrhoea and other diseases among children.
Declining toilet use?
What the Nature paper does not address, however, is a crucial question: while it refers to the number of toilets constructed and access to them, it does not account for the percentage of toilets that are utilised. The absence of this data puts a question mark on the link to infant mortality in the research paper. Other health initiatives, too, could have contributed to the decreased deaths.
In September last year, the World Bank released a critical paper on the Swachh Bharat Mission that reported a declining trend in toilet use in rural India from 2018-19 onwards, especially among Scheduled Caste and Scheduled Tribe communities. In December, the World Bank mysteriously recalled this paper citing “technical and procedural issues”.
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Frontline spoke to three social scientists and economists about the Nature paper’s conclusion. Their responses treat the study with caution.
A Swachh Bharat Mission toilet in Somayampalayam village, Coimbatore, which lacks water supply, is used to store household articles, on September 26, 2019. | Photo Credit: The Hindu
“Merely providing access to sanitation facilities does not ensure their effective usage, said Nikhil Srivastav, founder, Research and Action for Health in India (RAAHI). “The decision to use a latrine is personal, with significant intra-household variation.” During his field visits for a new-born care programme, he said that they “frequently encounter latrines in rural Uttar Pradesh that are not used for defecation: instead, some are used for washing dishes, others to store cowdung cakes, and many more seem dilapidated,” he said.
“The primary challenge that these twin pit latrines face is the lack of demand for them. People, if they aspire for latrines, aspire for those that may cost four times more than twin pit latrines. They want someone else to empty them when they get filled. This is due to the long history of caste and untouchability in the country, highlighting a gap between access and utilisation.”
Using infant mortality to assess the impact of sanitation programmes such as the Swachh Bharat Mission might not be the most appropriate approach, Srivastav said. “Infant mortality, defined as death within the first year of life, includes neonatal mortality (death within the first 29 days). Neonatal deaths are primarily caused by factors such as asphyxia, low birth weight, prematurity, neonatal sepsis, congenital malformations, and other pathological challenges, which are often unrelated to infection from faecal exposure. A closer analysis of the National Family Health Survey (NFHS) 2019-21 data reveals that about 70 per cent of infant deaths occur in the neonatal period. Therefore, using post-neonatal mortality as the dependent variable would provide a more accurate assessment of the impact of sanitation on mortality rates,” he added.
According to Srivastav, while the Swachh Bharat Mission has likely contributed to improving the disease environment, attributing all reductions in infant mortality to the Mission does not fully recognise the tireless efforts of healthcare workers striving to reduce neonatal, infant, and child mortality.
Not so rosy
Jean Drèze, the noted development economist, said: “With the Swachh Bharat Mission, there was substantial improvement [in the reduction of open defecation], but nothing like what the government claims. Indeed, the government declared India open-defecation free in 2019, but the fifth National Family Health Survey, for 2019-21, reveals that about 20 per cent of households were still practising open defecation at that time, and this is still one of the highest rates in the world (in Bangladesh, the corresponding figure is around 1 per cent).”
Drèze added, however, that “the situation today is nevertheless better than it used to be, both in terms of toilet availability and utilisation. There would be nothing surprising if this contributed to lower infant mortality rates, as the study suggests. Quantifying this contribution, however, is quite difficult, and the estimates are best treated as indicative.” Dreze added: “From a quick smell test, they [the Nature paper estimates] seem a little rosy to me.”
In a working paper posted in August this year in the Social Science Research Network, Sangita Vyas, a development economist and assistant professor in economics at CUNY Hunter College, New York, finds an association between reduced open defecation and increases in child height between 2015-16 and 2019-21; but the trend “is weaker in our [India] data compared to other countries and earlier periods in India”. This pattern, her paper says, “could be partly explained by increases in misreporting due to widespread coercive implementation of the [Swachh Bharat Mission], or increased open defecation among individuals living in households with latrines, among other possibilities.”
These “coercive tactics” likely “discouraged” respondents from telling surveyors that they defecate in the open for fear that they may be punished in some way, Vyas told Frontline. “Analysing the data in various ways, under-reporting of open defecation appears to have increased because of the Mission. Using a simple model of measurement error, I’m able to back out an estimate of true open defecation after the Swachh Bharat Mission and I estimate it to be about half of rural households. If this is true, it would mean that the Mission brought about a much less substantial reduction in open defecation than the NFHS data seem to suggest.”
Workers curing cement pipes used to create septic tanks for toilets constructed under the Swachh Bharat Mission, on the outskirts of Hyderabad on May 22, 2018. | Photo Credit: NAGARA GOPAL
She explained that “many rural Indians prefer to defecate in the open because of beliefs, values, and norms about purity, pollution, caste, and untouchability that cause people to reject affordable latrines”.
The Nature paper’s co-author Parvati Singh, assistant professor at the College of Public Health Division of Epidemiology, Ohio State University, replying to Frontline’s question on whether the scope of the paper pertains to toilets constructed and not toilets utilised, replied in the affirmative: “Yes, the scope of the paper is toilet availability (pre-existing and newly constructed toilets).”
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Singh agreed that access to toilets alone will be insufficient to improve child health outcomes in the absence of access to improved sources of water, including piped water. The “improvement in the quality of piped water [in addition to increase in access] remains crucial for improving public health outcomes. We also need to be cognisant about contamination of water sources with faecal matter as increased toilet usage without proper waste management may worsen water quality that, in turn, may adversely impact health gains from toilet use alone.”
Singh pointed to some socio-economic challenges to the Swachh Mission. “Discrimination based on caste, religion, class, and gender invariably hurts public health efforts. We need social changes to overcome widespread discrimination, particularly in the Indian context, given a deep-rooted cultural connotation of inferiority ascribed to groups who have traditionally been associated with waste disposal. Personally, it is heartbreaking to see our fellow citizens being treated this way for no reason other than sociocultural perceptions, and this needs to end. All people deserve respect, and hygiene and sanitation should [in my opinion] be regarded as noble, rather than ‘unholy’ practices,” said Singh.
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