A fact of life in India for centuries, this practice has major health implications. The author explains what these are and looks back at a major national campaign to build toilets across the country. The apparent success of the campaign fails to conceal the underestimation of its impact on the caste system.
Whether apocryphal or not, Gandhi’s statement that “sanitation is more important than independence” is well known to sanitation specialists who have turned their attention to India. For a long time, the country held the dubious distinction of being the place where open defecation (OD) was the most practised. The consequences of this practice on public health, on undernutrition and more generally on the subcontinent’s economy have been widely studied and described. For want of proper sanitation, the Indian population is exposed to a whole range of diseases, generating health care costs and sick days, all contributing to a loss of around 2% of the country’s gross domestic product.
Yet it appeared nothing could change the behaviour of millions of Indians who, every morning, carry out the most basic of bodily functions along railway lines, in slum gutters or in paddy fields bordering villages. This situation did not fit well with the vision of a “clean” India projected by the nationalist Modi when he took office. To put an end to this, between 2014 and 2019 the government launched the Swachh Bharat Mission, a large-scale campaign to build toilets which seems to have achieved its objective: thousands of latrines sprang up in every state of the Indian union. But does this mean OD has disappeared? Monitoring toilet use is always difficult – you cannot install an observer all day outside each toilet to measure its usage. Nevertheless, if the apparent success of the mission is true, OD should gradually be wiped out and its positive impacts on health and malnutrition begin to be observable in the next few years. The aim of this article is to analyse the development of the campaign, how the government deliberately focused on the financial aspect at the expense of the involvement of civil society and prioritised an economic model based on subsidising supply rather than creating demand, a model whose long-term effectiveness is questionable.
The link between OD and undernutrition
Poor sanitation is above all a public health problem. Any remediation solution (sewers and water treatment works, pit latrines in the ground, septic tanks, eco-friendly toilets) has two functions: to contain the sewage and to treat it to make it safer. Without access to a toilet, an individual has no choice but to practise OD or another method which fails to meet these two criteria (such as defecating into a stream or into a bag and throwing it away). Pathogens can then find their way into the environment and contaminate a new host. The illnesses transmitted in this way are mainly those causing diarrhoea, but there is a lesser-known link between lack of sanitation and undernutrition. This is particularly the case in areas of high population density, to the point where chronic undernutrition is sometimes described as a communicable disease.
In the period from 2016 to 2018, corresponding to the ramping up of the Swachh Bharat campaign, the prevalence of acute undernutrition in India stood at 17% and that of stunted growth (chronic undernutrition) at 34%.According to the Comprehensive National Nutrition Survey 2016 – 2018, Ministry of Health and Family Welfare, Government of India, 2019, … Continue reading In an article published in 2013, the economist Dean Spears reflects on average size within populations, taking this variable as an indicator of undernutrition. He notes that “puzzlingly, however, differences in average height across developing countries are not well explained by differences in wealth. In particular, children in India are shorter, on average, than children in Africa who are poorer, on average, a paradox called the ‘Asian enigma’, which has received much attention from economists. Could toilets help children grow tall, while disease externalities from poor sanitation keep children from reaching their height potentials?”Dean Spears, “The nutritional value of toilets: How much international variation in child height can sanitation explain?”, World Bank policy research working paper, June 2013.
The article, backed by statistics, shows a link between malnutrition, poor access to sanitation and population density in India. This link is based on three types of disease: diarrhoea, intestinal worm infestation and environmental enteropathy that reduces the absorption of nutriments during digestion. A good way of measuring the success of the campaign will thus be to follow the curves of malnutrition and waterborne diseases in the coming years.
The campaign, its rollout and organization
“Clean up the country” is a classic theme of the national populist movements which have sprung up lately in many places. More often than not this is simply metaphorical, but in the case of India, the expression “Clean India” (Swachh Bharat Abhiyan or “Clean India Mission”, the official title of the campaign) should be understood in its original sense as well as figuratively. The current Indian Prime Minister Narendra Modi was elected for an initial term in 2014, at the head of the National Democratic Alliance formed by the Bharatiya Janata Party (BJP), a right-wing nationalist political party. Once elected, Modi implemented reforms aimed at fostering Hindu traditions, from setting up a Ministry of Ayurvedic Medicine and Yoga to promoting Hindu cultural heritage at the expense of Muslim or Moghul traditions. This is tantamount to calling into question the secular nature of the Indian union and marginalising part of the population. However, according to political scientist Isabelle Saint Mézard: “Modi considerably broadened the base of the BJP – traditionally formed from the urban middle classes in northern and western India – by attracting people from more humble social strata with his promise of development for all.”Isabelle Saint-Mézard, « L’Inde de Modi : un “développement pour tous” écorné », Politique étrangère, vol. 83, n° 2, juin 2018, p. 79-88. Reconciling “Hindu pride” and development for all seems a difficult task, so conflicting are the two concepts in an India of so many minorities, whether religious, linguistic or ethnic. A unifying, universal theme needed to be found, one which would also convey an image of purity and cleanliness: sanitation was the ideal theme to reconcile these political objectives. To achieve this, it was absolutely essential for the campaign to meet three criteria: to be a quantifiable, measurable success, hence the toilet building; to be underpinned by the personal commitment of the prime minister and flawless communication; to reflect Hindu nationalism and so achieve its objective without outside help such as funding or aid from international non-governmental organisations (NGOs).
The campaign’s success is based on two pillars: media coverage and grants. Its logo represents Gandhi’s round spectacles – a reference to the independence leader’s famous quotation – and is found everywhere on posters, in newspapers, at cultural events and sporting competitions, even on banknotes. Its rollout is also very simple: every Indian family can register with the campaign office in their local community. Once registered, they receive documentation on latrine construction and the various possible options. They can then carry out the work themselves or use a builder. Once the work is completed, they just have to send proof (a photo, invoice, work handover certificate, etc.) to the campaign office in order to be reimbursed with a lump sum, ranging (according to the State) from 10,000 to 12,000 rupees (approximately 120 to 150 euros). The whole procedure can also be carried out online. The Ministry of Drinking Water and Sanitation, the regulatory authority, keeps up-to-date accounts of the number of toilets built state by state. Sixty percent of the funding comes from central government and 40% from the State. Finally, it is important to note that the budget earmarked for information and communication only represents 8% of the total campaign budget. Until now, NGOs had focused more on activities designed to shift behaviours which, rolled out over the long term and passed down to children, were intended to ensure the success of sanitation campaigns.
In 2019-2020, the Indian government announced that all the campaign’s targets had been met. The figures are impressive: more than 40 million toilets built in four years, meaning access to sanitation soared from under 40% in 2014 to nearly 100% in 2020. This success was “formalised” the following year when the annual report from the Joint Monitoring Programme (JMP) run by the United Nations (UN)WHO/UNICEF, the Joint Monitoring Programme JMP measures how far sustainable development objectives have been met, https://washdata.org noted a reduction of nearly 50% in the number of people in the world practising OD: improved sanitation in India means that this previously struggling indicator has considerably improved worldwide. Nevertheless, it should be noted that the JMP figures are less optimistic than those issued by the government: the latter only measure the presence or absence of toilets while the UN establishes a “ladder of services”. Thus a poorly contained or shared latrine or one with an outlet into a watercourse will be categorised as “unimproved” or “limited” sanitation by the JMP. The Indian government on the other hand will count it as a toilet even if it is not safely managed on a health or environmental level.
Based on what is still an undeniable success, in 2021 the government launched the second phase of the mission, aimed at ensuring the continuity of the remediation solutions and extending them to solid waste, greywater and industrial pollution.
A tentative assessment of the results
The Indian government had the courage to tackle a hitherto insurmountable problem. The campaign was implemented without outside funding and without intervention from NGOs or the United Nations Children’s Fund (Unicef), even though they are on the front line in these areas. Usually, in other regions, the methods used to bring an end to OD can be divided into two categories. There are those targeting increased provision: expanding latrine construction, if necessary via grants. The others aim to create demand by encouraging people to use toilets. In the first category (to which Swachh Bharat belongs), we find the so-called “mass latrine coverage” campaigns which took place in the 1990s in countries as diverse as Burma (organised by the military regime) and Haiti and included various African countries. These campaigns supported by Unicef and other NGOs consisted of building toilets and then briefly explaining the benefits of their use. They were not particularly successful: if more often than not users did not modify their behaviour, this is because they did not appropriate the toilets as their own, regarding them as something coming from outside their communities.
This approach was re-examined in the years from 2005 to 2010 with the appearance of CLTS (Community-led Total Sanitation)Kamal Kar et Robert Chamber, Manuel de l’Assainissement Total Piloté par la Communauté, Institute of Development Studies et Plan International (UK), mars 2008, … Continue reading that caused a paradigm shift: no subsidies were granted, and it was up to the user or the community to bear the costs of installing toilets. Rather than focusing on provision, efforts were made to create demand, through activities aimed at raising user awareness of OD as a cause of disease. Building toilets and using them is shown as the best way of eradicating these diseases, while being viable from an economic point of view (construction costs are largely offset by lower health care spending). The idea is to change behaviour and make a financial investment, entailing a twofold effort by the user. The toilets constructed in this way are not generally built to last, for reasons of economy or because of the limitations imposed by self-building (bamboo structures, wooden foundation slabs, etc.). But demand has been created and users can see the benefits of a sanitation system. Then it just remains to guarantee a supply of higher quality and more sustainable solutions – a network of builders trained in the construction of septic tanks; ceramic or concrete covering slabs; PVC drainage pipe coils – from NGOs or more generally the private sector, from small businesses to social enterprises manufacturing sanitaryware.
The subsidised approach chosen by Modi is fast, large-scale and spectacular in the progress it has achieved, but it struggles to change behaviour since cultural resistance is a huge factor, defecation practices having being learned from childhood. The demand-based approach is more complicated to implement but more effective in the long term since it combines behavioural change and economic realism.
Addressing a conference, the Indian activist Sangita Vyas shared her personal reflections on the “surprising truth behind the reasons for open defecation in India”.Sangita Vyas, video “The surprising truth of open defecation in India”, https://www.youtube.com/watch?v=V35Vw29tay0 She outlined two main points:
- the practice of OD in India is essentially a cultural habit, based neither on any economic constraints nor even on ignorance of the consequences of the practice;
- this practice is also underpinned by the caste system, the emptying and upkeep of latrines being assigned to the low “untouchables” castes: when a higher caste family finally makes the decision to install toilets, they will often be reluctant to clean them and above all empty them when full, this work being seen as impure. This dimension of social stratification was not taken into account by the campaign either: it is to be expected that the latrines dug, even if they were used, would not be emptied and therefore would not be sustainable.
There is still much to do to achieve an OD-free India. Despite undeniable progress, there is no justification for stating that the country has rid itself of the scourge of OD. One thing is certain: the government alone, notwithstanding its resources, will not be able to accomplish the mission without the massive mobilisation of civil society, NGOs and the country’s many activists.
Translated from the French by Fay Guerry