Rural India is a dismal outlier when it comes to open defecation and that's a major reason for its stunted, unhealthy children, the Princeton economist tells Kanika Datta It never occurs to Dean Spears that an invitation to Lunch with BS might be an opportunity to indulge in even the mildest of hedonism. Since the meal is on Business Standard, many of our guests understandably choose upscale restaurants. Spears' first suggestion for our meeting was the canteen at Delhi School of Economics where his wife, Diane Coffey, co-founder of Research Institute for Compassionate Economics (Rice), was making a presentation. Too noisy, I say, so he innocently suggests we could carry the food into the visitors' room, a solution I reject out of hand. His next choice is a shade more ritzy: Evergreen Restaurant in Green Park, famous in the area for its vegetarian snacks and sweets. Rice is a three-year-old policy and advocacy group focusing on child and maternal health in India and it's already making an impact. It was founded with funding from the Gates Foundation and, recently, the National Institutes of Health, an agency of the US department of health and Spears, an economist from Princeton, is widely considered its moving spirit. Both he and the institute have been attracting notice for highlighting the strong link between widespread open defecation in rural India, high infant mortality and the stunted growth of children, factors that ultimately impact a country's economic productivity. These are issues that go right to the heart of Prime Minister Narendra Modi's Swachh Bharat Abhiyan campaign launched with such fanfare on October 2 last year. In June, Rice came out with The SQUAT Report, an extensive survey in rural India of Sanitation, Quality, Use, Access and Trends, to spell out the full form, that proved depressingly revelatory. Among other things, it revealed that uniquely in India open defecation isn't just a result of poor access to sanitary infrastructure but also a behaviourial choice. Most rural Indians, the report said, can afford a toilet but preferred not to have one. Even more incredibly, those who did own toilets often preferred to defecate in the open. In fact, the report highlighted, India was one of the significantly worst performers in terms of sanitation compared with even significantly poorer countries such as Nepal and Bangladesh. When we do meet, I discover Spears is just 31 years old, roughly in the same age cohort as those Indians the media and businesses are wont to describe as "aspirational". Rail thin and yet to shed his college grad aura, it is clear that Spears' only aspiration is for his mission. But he is no jholawala in any sense of the term. He and his organisation rely on painstaking, unfashionable data collection and hard statistics to present a distinctly unlovely picture of an insanitary, unhealthy rural India. Dean Spears
We're on the first floor of Evergreen. Spears is a frequent visitor and he quickly orders in fluent if accented Hindi -- rajma, butter naan and Diet Pepsi. To save time I do the same. " Chawal ya naan?" Spears asks me. Chawal, my Bengali genes automatically respond. Why should two young Americans, with access to the best that life can offer at home, choose the dubious comforts of India in general and Sitapur, a rural district in Uttar Pradesh, in particular to live? It was a joint decision with Diane, he explains. "We're economic demographers and both of us wanted to do work as useful as possible. India is the best place for that for a lot of reasons." First, he says, there is an enormous number of poor but also - and this sounded encouraging to me - "an environment where one hopes the evidence of research and better understanding can help one do something about it. The number of people who live in India is almost the same as the number of people who live in sub-Saharan Africa and Latin America put together," he continues. "What is less known is that the fraction of people who live on a $1.25 a day, the extreme poor, is almost the same in India as those two regions put together -- and so is the infant mortality rate." These facts, he says, get overlooked mainly because international development experts are used to seeing India as one country. So Sitapur has a population of 4.5 million people, which means it's basically the size of a country even though it's just one of India's 600-odd districts. Also, "the population of Sitapur is almost the same as Sierra Leone and Liberia and, strikingly, the infant mortality rate of Sitapur is almost the exact same as the infant mortality rate of those two countries. Now, those two countries are some of the biggest human development basket cases on earth. Sitapur would be too if it were a country. Sierra Leone and Liberia have a health ministry, education ministry, a Unicef mission; Sitapur has none of that. So it made a lot of sense to go somewhere like that and add value," he concludes. The food arrives in record time.
The spicy rajma reminds me of boarding school where it was dished out regularly for being cheap and nutritious. I covetously eye a crisp naan dripping with butter and Spears generously asks me to help myself, which I do with alacrity while he spoons a tiny portion of rice on to his plate. I am most admiring of his command of Hindi since despite nearly 18 years in the capital my grasp of the language remains inept. "Oh, itâs not all that good," he demurs, "Dinah mujhse hoshiar hai," [Dinah is better than I am]. He explains that his wife's name becomes Dinah in Hindi since, pronounced slightly differently, diane
is the Hindi word for "witch" (which roughly corresponds to dynee
in Bengali, I think). "Now tell me about yourself, so that I can get in a couple of bites," he says. This recitation is embarrassingly short so he manages a few mouthfuls before the talk inevitably turns to Swachh Bharat. He's worried that it is going to be too much like a giant construction programme like the United Progressive Alliance's Bharat Nirman Yojana. "Building a bunch of cement buildings is the easy part. The hard part is that it fundamentally matters what people do. The latrine is an asset that households have; open defecation is a behavioural pattern. What we want to do is to get more people to use latrines. But the last time I checked, the budget for Information, Education and Communication had decreased
from 15 to 8 per cent. That's moving us in the wrong direction." Still, he's happy that the government has been talking about a latrine-use monitoring survey. "And when the prime minister says he hopes to eliminate open defecation by 2019, I am delighted and hope that we can come together and succeed." What also worries him is how far the campaign stays on track. He whips out a tablet from his backpack to display a picture he's taken of a hoarding in Defence Colony with a verse that ran "Clean up the clutter/Shun the litter..." and so on. "I'm very much afraid Swachh Bharat will be diverted from a life-saving campaign on sanitation to cleaning up the litter in markets of the urban rich," he says. Isn't one impediment to greater latrine-use water shortage? "That's a myth," he shoots back. "Sub-Saharan Africa has much lower access to water than India but also much lower rates of open defecation. India is a global exception -- 60 per cent of people who defecate in the open in the world live in India. Every year, that number goes up. When we asked people, nobody talks about water." Nor, he adds, did it have anything to do with education - plenty of people in rural India have high school degrees and still defecate in the open. I suggest women must be the biggest advocates of latrine use because of the safety and privacy. True, Spears says, but the issue is more complex. "If you have a latrine, young women are a lot more likely to use it than men are. Yet, a majority of women in their twenties in households with a government-built latrine defecate in the open. Then, we ask women who do use latrines what will happen when you get older and become the saas
? Many of them say, 'then I'll go back to defecating in the open'! I must say I don't claim to perfectly understand this," he laughs. It was the puzzle about height that got him interested in research about sanitation. "Economists care a lot about height because average population-level height is an important monitor of human development. The best evidence: European populations got taller not when the food environment got better but when the disease environment improved and infant mortality fell. And the average height of a population is basically about the health and nutrition of its babies in the first two years of their life." Surely south-east Asia and China are counterfactuals? He surprises me by saying the average Chinese baby is much taller than the average Indian baby. Height, he explains, is measured by something called a Z-score, where zero is average and a negative number is bad. In China, the average number is (-) 0.75; in India, it is (-) 2. And in China, open defecation may be 3 to 4 per cent. We've polished off the rajma and eschew dessert in favour of tea (for me, to counter the soporific effects of the rice). Spears settles for the caffeine fix in his 600 ml bottle of Pepsi. Meanwhile, the bill is placed, as Spears notes, in front of him - "have you noticed, they always expect the man to pay?" I'm too busy noticing the amount, which at Rs 433 has got to be the cheapest lunch Business Standard has ever hosted.