It’s time to become comfortable talking about an uncomfortable topic: human waste. I don’t mean trash; I mean excreta. A little more than one billion people worldwide defecate in the open – not using a toilet or latrine – but 60 per cent of them live in India. That means over 600 million people, and a majority of the Indian population.
One reason to become comfortable talking about it is that there is now persuasive evidence that widespread open defecation in India comes at tremendous human and economic costs. This is because even in rural India, population density is often high enough for children to have many opportunities to encounter other people’s faeces. As a result, open defecation causes diseases that kill children and stunt growth. Worldwide, diarrheal disease causes around two million child deaths each year. Open defecation also hurts those children who survive. Stunting is not merely a measure of “nutrition”; it reflects both sides of an early-life balance of food and energy lost to disease.
It is no coincidence that India suffers from profound rates of child stunting, when compared internationally, while also accounting for over half of the world’s open defecation. Indian children are shorter, on average, than those in many African countries — who are poorer, on average. Yet, this is not the puzzle it initially appears: sanitation in India is much worse.
Open defecation also costs India economic productivity. The same early-life conditions that promote bodies growing tall help brains to grow smart. Taller people are paid more, on average, because taller people have higher cognitive ability, on average. We all have different genetic cognitive and height potentials, and good early-life health helps us reach those potentials, whatever they are.
So, open defecation is a health issue, but it is also a critical economic issue. And it is a public policy priority.
Luckily, there is another reason to get comfortable talking about defecation: evidence is accumulating to suggest that something can be done. It has long been known that simple pit latrines are a safe way to dispose of excreta. The difficult step is getting people to use them. It has until recently been an open question whether any public programme could ever accomplish that.
For a little more than 10 years, the Indian government has been pursuing a Total Sanitation Campaign, sometimes called the TSC. The TSC has subsidised the construction of latrines throughout rural India. But latrine construction does not save lives, nor does it help children grow. That requires latrine use.
The TSC recognised this concern and incorporated a Nirmal Gram Puraskar, or NGP. The NGP offers villages and their leaders an ex-post monetary reward if the village becomes open defecation free. This is a policy an economist will love: it incentivises the outcome that we actually care about — ending open defecation. It would shift the focus away from subsides for contractors. It would ensure that money is spent in the places where something is being achieved. Above all, it gives local leaders with social or political power a tangible incentive to make sanitation happen.
I have been using data representative of rural India to study the effects of the TSC on children. The results are encouraging: on average, the TSC has had beneficial initial results that stand up to statistical scrutiny. As a result of the TSC, infant mortality is a little lower, children are growing a little taller, and six-year-olds are slightly better able to recognise letters and numbers. Moreover, open defecation is so profoundly bad for children’s health that the TSC has been able to prevent an average infant death quite inexpensively, on average – compared with other rigorously studied policy options – despite uneven implementation.
Yet, much remains to be done. The TSC is becoming the Nirmal Bharat Abhiyan (NBA), with an increased investment of government funds. Everybody involved deserves applause for this commitment to ending open defecation. However, it is critical that the government strengthen what can succeed, and avoid the risks faced by any programme that is given the blessings and curses of a lot of money.
Admirably, attention to data has long been central to the TSC. Now there is an opportunity for two further investments. First, the NBA can ensure a strong ex-post incentive, so that all open defecation free villages – and only open defecation free villages – win the prize. An incentive that is not accurately awarded is no incentive at all. Second, the NBA can dedicate resources to ongoing collection of quality-monitoring data, so that people whose job is to report information have an interest only in accurate, useful numbers.
The NBA faces a challenging – but critical – task. If the NBA uses these opportunities to protect the government’s investment in rural sanitation, then we can hope for healthier children, fewer infant deaths and a more productive workforce.
The writer is in the economics department of Princeton University