This might be the greatest development puzzle of all: Why growing prosperity over the past decades has failed to put an end to open defecation in India? Roughly half the Indian population continues to defecate in the open. Contrast this with China, where only one per cent of the population defecates in the open. Or with Bangladesh, a country whose per capita income is only half of India's but only five per cent defecate in the open.
While Prime Minister Narendra Modi's call to prioritise building of toilets over temples last year was a welcome shift in political thinking, simply building toilets might not be enough to end open defecation. What is needed, some observers say, is a national movement, perhaps with Modi leading from the front, to change people's minds and attitudes.
A lack of access to toilets is not the primary issue. The government has built toilets that often exceed international standards, spending Rs 12,000 on one pit latrine on an average, while neighbouring Bangladesh spends only Rs 2,000. Yet, government latrines are less likely to be used than private ones, says a new paper, titled Culture and the health transition: Understanding sanitation behaviour in rural north India.
Infrastructure not an issue
Even in households with working latrines, individuals continue to defecate in the open. Latrine use, the authors note, is largely limited to the elderly, disabled and the weak. Households often use the structures for purposes such as storing their tools or housing cattle. This implies that building toilets alone is not going to solve the problem of open defecation.
Culture: The culprit
Why do people prefer to defecate in the open? The authors discount the usual suspects - income, poverty, education, access to water and governance - and see the culprits as a curious combination of a culture of purity and pollution that teaches people it is bad to accumulate faeces near home, coupled with false beliefs about how long it will take for the pit to fill and, thus, the problem of emptying (typically a pit latrine of 60 cubic feet takes five years to fill if regularly used by a household of four) and misconceptions about manual scavenging.
Some economists such as Vivek Dehejia, associate professor of economics at Carleton University in Ottawa, are sceptical about claims of culture influencing defecation habits. An earlier paper by one of the authors, Dean Spears, executive director at Rice Institute in Delhi, was criticised for drawing a link between open defecation and culture and religion. The new paper draws on a new survey by the authors to explore the link between open defecation and culture in greater detail.
Others concur with the central premise of the paper. Santosh Mehrotra, professor at Jawaharlal Nehru University, says, "Poor people have the money to build toilets. But if they have a certain belief pattern that has been there for centuries, having a toilet will not be of any help."
Nothing captures the problem more vividly than Mehrotra's own observation of rich farmers in Punjab, who have constructed "good" toilets at homes, piling into a car in the morning and going to the fields to defecate, reaffirming the problem is largely unrelated to the economic status of households.
Population density worsens the issue
The problem is compounded by the fact that open defecation is disastrous when practiced by groups living in close vicinity. With parts of rural India such as Bihar more densely populated than places such as New Jersey, the most densely populated state in the US, the problem worsens.
The effect of open defecation, especially in close quarters, on child outcomes is large. Spears says, "All the evidence points to not only there being an effect but being quantitatively big enough, that the difference between open defecation densities in Indian and sub-Saharan Africa, could account for the difference in average child height."
But Biraj Patnaik, principal advisor to the food commissioner appointed by the Supreme Court, cautions against making assumptions that reducing open defecation will automatically result in corresponding gains in reduction in stunting or malnutrition. He argues that "Bangladesh is a case in point. Open defecation rates are only three per cent in Bangladesh but close to 41 per cent of children (2011) in Bangladesh are stunted. In India, though close to half the population defecates in the open, the stunting rate is close to that of Bangladesh."
Spears defends his position by saying, "If we could expose Indian kids to the African distribution of open defecation we would get rid of about seven per cent of kids in India from being too short. Now, seven per cent is a lot. But it's not saying that open defecation is the only thing that matters."
What needs to be done
The main contribution of the paper is that it shifts the terrain of the debate by arguing that simply building toilets, as the PM's Swachh Bharat programme seems to largely focus on, is not likely to end open defecation. What is needed, as Spears argues, is to also work on changing behavior and attitudes.
Mehrotra says, "The cultural barrier can be broken but it requires a change in government thinking. The focus of the Swachh Bharat Abhiyan has to be on a certain kind of ICE (information, communication and education). You have to make them realise that by defecating in the open, diseases spread." Additionally, finding a way of telling people that pits don't fill in a few months and a credible way of assuring them that the government will empty the pits in a few years, so that they don't worry about it, is also likely to help.
But Patnaik cautions against an over-reliance on influencing cultural practices. "It would be dangerous to just fetishise cultural practices and privilege these over creation of infrastructure. Both are not mutually exclusive, and India needs toilets as much as it needs to address the behaviour and attitude issues around sanitation."