Saturday, August 16, 2014

Oh! Shit!

OH! SHIT![1]

By Ajit Chaudhuri

Toilets are more important than Temples” J. Ramesh in 2012, N. Modi in 2013

One of the myths we grow up with is that Indian Muslims are dirty – they bathe less, they have unclean personal habits, and their habitations are unsanitary compared with other communities in India. Don’t deny it – many of us think it, not just those with Hindu right wing leanings. Even I remember, back in 1986 when I shared a barsati with two friends, one of us Muslim and all three non-religious, his younger brother visited for a day en route to some other destination and decided against having a bath. Two of us smirked, and the third furiously hauled his befuddled brother off into the bathroom.

It was therefore a pleasure to read an econometric paper whose findings contradict this common assumption. Now, I normally give academic papers that use structural equation modelling and multivariate analyses a wide berth, but there was something compelling about this one; the simplicity with which it was written, the sheer force of what it was saying, and the policy implications emanating from its findings. This note attempts to describe the paper ‘Sanitation and Health Externalities: Resolving the Muslim Mortality Paradox’[2].

Indian Muslims are poorer, less educated, and more backward on average than Hindus, which should contribute to them having higher child mortality rates (I will use Ms and Hs to abbreviate for the two communities respectively, and CMR is the number of children dying before their fifth birthday per 1,000 live births). And yet, the CMR for M children is 18 percent lower than for H children across socio-economic categories, a robust and consistent pattern that has been evident since the 1960s. It means, in effect, that an additional 1.7 M children per hundred survive up to age 5. This phenomenon is well documented, does not reconcile with the literature on the importance of income and education in explaining mortality differences, and has therefore been termed ‘the puzzle of the Muslim Child Mortality advantage’.

The paper uses data from three rounds of the National Health and Family Survey (1992/93, 1998/99, and 2005/06), studies mortality rates from birth history information of 310,000 children, and shows that differences in defecation practices between Ms and Hs account for the entire CMR gap.

This is because human shit is particularly dirty – it contains pathogens (bacteria and parasites, such as worms), and open defecation (I will use OD for this one) introduces these pathogens into the environment, into feet, hands, mouths and the water supply, leading to acute and chronic illnesses.

Ms are 40 percent more likely than Hs to use pit latrines or toilets, which serve to safely dispose of excreta. The reason for this is difficult to trace! It could be because of institutional features of the respective religions – the Hadith forbids OD (‘Guard against three things that produce cursing: relieving oneself in watering places, in the middle of the road, and in the shade’[3], something that any modern epidemiologist would parrot), whereas H tradition views excreta as something to be kept away from home (‘Far from his dwelling let him remove his urine and excreta’ – The Law of Manu, chapter 4, verse 151). It could also be that different sanitary practises evolved between the largely segregated H and M communities for purely secular reasons. Either way, H households are more likely to have electricity than to use a toilet, even better off H households, with assets such as motorcycles, opt for OD, and toilets constructed or paid for by the government for Hs tend to remain unused or be re-purposed. The prominence of OD among Hs is not due to affordability.

More importantly, Ms are more likely to have M neighbours who do the same. The defecation practise of a neighbourhood as a whole is far more important than that of a particular household in accounting for mortality rates, to the extent that moving from a locality where everyone ODs to one where no one does is associated with a larger difference in CMR than moving from the bottom to the top twenty percent of the population in terms of wealth. And it is defecation practise that explains the difference in CMR, not idiosyncratic religious or cultural differences between Hs and Ms; Hs living in mainly M villages have lower CMRs than Hs living among other Hs; in places where Ms and Hs have similar OD rates, they also have similar CMRs; and the M advantage reverses in the rare places where Hs have less OD rates than Ms.

The persistence of OD among Hs has been of concern for some time. MK Gandhi famously observed in 1925 that ‘sanitation is more important than independence’, and cultural scholars have associated it with the caste system, where the link between human waste and ‘polluted’ castes reinforces norms that make sanitation problems ignored even by upper caste Hs. Policy makers have recognized the problem, and there are a multitude of government schemes that encourage the building and use of toilets. Thinking politicians from both ends of the political spectrum, as can be seen from the title quote, have also joined in despite the issue not being a vote-catcher.

I hope they succeed! And yet, I remember with fondness my own defecation habits in the villages I worked in in western Rajasthan in the early 1990s, in each of which I had my designated spot and time, where the long trek with a lota[4] in hand would enable the building of pressure (or ‘vatavaran nirman’, as we called it), and where we joked about situations when a crow came and tipped the lota over (my favourite – when it happened to a person twice in a row, he washed up before defecating the third time). I also remember my time in the harsh Changthang (eastern Ladakh) winters of 1997 and 1998, when the job had to be done in -30c temperatures every morning, where the task of minimising the exposed surface area without impeding the free fall of matter was arduous, and where discussions on the most important invention of all time unanimously settled on toilet paper. Coming generations of rural extension workers will miss the opportunities that OD provides for building relationships from one of the few things in which we are all on an equal plane.

[1] Borrowed from the sign on the toilet door at the students’ accommodation ‘Citadel’ in VV Nagar, Gujarat.
[2] By Michael Geruso and Dean Spears, March 2014, available on the Internet.
[3] Mishkat-al-Masabih (a Muslim sacred text), page 76.
[4] The local term for a metal urn that is used to carry water for washing up in the aftermath.


Ajit Chaudhuri said...

Dear Sir,

It was a nice and informative 2 pager. I liked the way you put forth the argument substantiated with evidences from hard economic data. Although I support the use of toilets but I have some ambiguity regarding the validity of this argument.

As a kid when I used to visit my maternal grandparents, my grand father would ask me to apply oil on my feet before going out for defecation. I could not understand the reason and his answer never satisfied my query. But almost 10 years down the line when I joined as a veterinary officer I came across a tribal priest (disari). I heard him advising the same. He gave me an answer which I guess could be compared to the scientific explanations. He told me that the oil can prevent harmful organisms entering into our body. As you know the most common parasites entering our body are hook worms and ring worms. These
worms enter our body through the pores in our feet. When we apply oil we are able to block these pores and hence prevent the entry of these worms.

My grandfather as well as this disari was against the use of toilet in villages. They argued fecal matter contains a lot of bacteria, virus and other
microorganism. If you keep them within a pit you provide the necessary breeding environment for replication. But in the open field under the sun many of these get destroyed. Moreover, they argued toilets in villages are the places where you find high concentration of these organisms where as open defecation helps to prevent concentration of these organisms. Another thing both of them used to advocate is practice of taking bath after defecating. The logic was to get rid of all impurity.

I am not sure if these arguments can be validated scientifically. Some of them seem correct . And that is why I could never get rid of this ambiguity regarding the use of toilets. While working as a veterinarian I used to visit different villages and hamlets. One of my observations which I could relate ( but with a caution; i need more sturdy scientific methodology to validate these claims) to the issue you have raised. Hamlets or villages where high morbidity or mortality was a major concern were the ones with worst hygiene practices. People in these villages were neither bothered about the personal hygiene nor worried
about the environmental hygiene. In many places they had toilets but with a hygiene standard enough to expose them to the lethal microorganisms mentioned by you.

What I want to say is that toilet is not the appropriate solution when people rarely bother about their personal hygiene. Rather this so called panacea can prove as a boomerang in the absence of proper sanitary practices. Second thing the traditional practices have evolved over a period of time. They can not be denied or rejected out rightly without looking into the missing link in these practices. The practice in different parts of the India/world evolves according to the
environmental condition. Similar is the case with sanitary and hygiene practices. Modification in case of the tradition happens due to resource constraints. A better understanding of these tacit knowledge and the resource poorness can help us find the causal relationship between the child mortality, morbidity, sanitary practices and the use of toilet.


Dr. Nilamadhab Mohanty

Ajit Chaudhuri said...

Like so many of your two pagers- this one is both an eye opener and a hoot.

But with an extra twist to the lota: bringing back my own western-rajasthan-behind-the-videshi-babool days.

Praneeta Kapur

Ajit Chaudhuri said...

Hi Ajit,

Thanks for sending Sanitation M and H......Interesting Hs and Ms sanitation practices probing...

Just to let you know that Samerth has constructed 1222 sanitation units in Nakhtrana for H and M both. H- 90% and M- 10%....Each of the unit is being used appropriately. In fact,am going to write a case study as a learning document for presenting to the state government . We are leveraging NBA funds too for the individuals to offset the labor that they have put in. For Samerth the funds comes from an individual donor from Boston who is originally from Nakhtrana- Kutch.

Gazala Paul

Ajit Chaudhuri said...

Dear Ajit,

Thank you for sharing the 2 pager. As always pleasure to read your 2 pager.

I don’t know about other multivariate analyses but I write this with authority ( I have attained mastery over structural equation modeling now!!!) that SEM doesn’t give results the way you want it. It is the most robust method to carry out econometric analysis.

Ateeque Sheikh

Ajit Chaudhuri said...

Dear Ajit,

One clarification re. the relative figures of CMR of M & H categories that is referred to in the 2-pager, does H include Scheduled Tribes as well?

Liby Johnson

Ajit Chaudhuri said...

Good one, well written and interesting observation. ​Yes we all are at equal plane!!
Keep it up.
Pravin Mahajan

Ajit Chaudhuri said...

As always, it was a pleasure to read you, and how timely it is for you to write on the topic that the PM dwelled on at length in his I-Day speech. Do give some pointers on the solution as well some time soon, and don't forget to forward it to the powers that be, hope their good sense prevails too.

Kuheli Sen

Ajit Chaudhuri said...

Excellent paper. Can't say enough on the relevance of this issue!! Just yesterday i saw news on some channel where they said that a 'mind boggling' 65% (of Indians) have no access to toilets. This is also one of the issues that i repeatedly talk about in the workshops with the kids at the NGO School.

Vibha Chhabra

Ajit Chaudhuri said...

Good to read this. Just to add that a few recent surveys in Bihar and Jharkhand have also proved that acceptance of building of toilets and using them is much higher in Muslims.

Ranjan Verma

Ajit Chaudhuri said...
This comment has been removed by the author.
Ajit Chaudhuri said...

Dear Mr. Chaudhuri,

I enjoyed reading the note, which is very timely too. It was funny when I tried to explain there is less IMR among Ms than Hs due to better sanitation, a colleague started in a defensive tone, "..that may be because all the sanitation drives have focused on M areas" and just mumbled something similar to your first paragraph to tell me why :)

I shared your note with many of my development walla n growth walla friends n colleagues. Some of them wrote back thanking for sharing it.

Some of us has years of nostalgic memories of OD. As urban women we hated OD n OB then but now they feature in many of our gappa sessions.

I would look for the main study that you have referred to. If you have an e-copy, please share.

Thanks and regards,

Nayana Chowdhury