Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste Diane Coffey and Dean Spears HarperCollins ₹250

09 September 2017 19:10 IST

Linking the poor growth of Indian children to sanitation with a large section of households still without a toilet

“It is hard to think of anything more important than how we treat our children…What happens to children ricochets through their lives, and many of society’s ills could be addressed if we were to take more care of the youngest among us,” writes the Nobel Prize-winning economist Angus Deaton in his foreword to this important book by Diane Coffey and Dean Spears.

And yet, millions of children in India are shorter than they ought to be for their age. They are stunted. Child stunting due to malnutrition is greater in India than in poorer regions in sub-Saharan Africa. It bears repeating, because we don’t talk about this enough: a devastating combination of poor nutrition, frequent infections, and lack of early psychosocial stimulation leads to stunted growth in children. Stunting impairs not only children’s physical development but also their learning. Taller children are less likely to miss school than shorter children of the same age. They are also more likely to read earlier and learn better.

Further, as Seema Jayachandran and Rohini Pande have shown, height differences among children in India are associated with son preference and especially favouritism towards eldest sons. (Deaton mentions in his foreword to the book by Coffey and Spears that by one estimate, at the current rate of progress, it could take 250 years for Indian women to catch up in height with British women.)

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The domino effect

The effects of childhood stunting remain into adulthood. Stunted children earn less as adults than their non-stunted peers. Most critically, if not addressed in the early years, the effects of stunting are largely irreversible.

The extent of stunting among young children in India is one of the parameters in the National Family Health Survey (NFHS). NFHS-4, conducted in 2015-16, has come after a gap of 10 years; NFHS-3 was in 2005-6. As per NFHS-4, 38.4% of young children in India are stunted. This is a reduction from 48% in 2005-6: that is, about 1% reduction every year in the decade in between.

The reduction of 10% is welcome. Nevertheless, that still leaves two out of every five young children in India growing up stunted.

We can and should do better. A common fallacy in earlier decades was that nutrition was the only factor in preventing stunting. For some time now, there has been a recognition that a comprehensive approach is required, including sanitation to prevent diarrhoeal diseases and to keep faecal germs separate from places where young children grow, play and learn.

And yet, as Coffey and Spears point out, India’s sanitation programme comes up against the challenge of behaviour change in a society divided by caste. According to the 2011 Census, over half of India’s households had no toilet; the majority of these in rural India. Despite India’s economic progress, the rate of decline in open defecation has been very slow. Common assumptions are that this intractable problem is due to poverty, low literacy levels, weak governance, or the lack of water. But as Coffey and Spears point out, India has more open defecation than other countries with similar poverty and literacy rates, and similarly rated governance; and rural India has more open defecation than other countries with similar access to improved water. There is more stunting in West Bengal than in Bangladesh among children from families at the same level of poverty.

Heartbreaking accounts

Underpinning this analysis of the problem of open defecation are the deeply moving and humanely told stories of real people: from the heartbreaking account of the last day in the life of little Naina, Ramila’s one-month-old baby daughter in Uttar Pradesh — the drops of Pepsi, the sleepy infant, the mother patting the baby to sleep — to that of the elderly and ailing Govind, in Haryana, whose eyes well up with tears at the indignity of not being able to control his bowels during illness, so that he had to squat in a metal pan and his wife or son or daughter-in-law would have to throw his faeces out in the fields.

This is a deeply researched and thoughtfully written book about open defecation, the role of caste, and the challenges of implementing policy interventions at this scale. Beyond these questions, it also reflects on the difficult road of development beyond conference platitudes and technocratic solutions. It points to the need for better exchanges between policymakers, development professionals and researchers if we are to reflect and act on some of the important questions of our times: Can economic development ever be sufficient without a focus on human development as well? Are there better ways to spur development among less served sections of the world’s population? With all the constraints, how can we do better for our poorer populations? Now more than ever, in the context of climate change and drought, combating malnutrition requires a comprehensive life cycle approach. In a country with high rates of child marriage, undernourishment and early pregnancy, several interventions are needed together, including a strong focus on adolescent girls, their health and nutrition, as well as their retention in high school and beyond, along with social change communication to delay the age of marriage.

It is also essential to adopt a ‘first 1000 days approach’ to the young child’s development, one that includes quality antenatal and postnatal care and nutrition of mothers and children during this critical period.

Newer approaches to existing interventions are also needed: for example regular height measurement of children from birth, and technology-aided individual growth monitoring of young children for height, weight, gender differentials in stunting, wasting, growth faltering, immunization rates and developmental milestones. It is time for a strong push to break the intergenerational cycle of malnutrition.

For all this, local involvement is needed to ensure community ownership. We have seen that panchayats, parents, and even alumni of anganwadis already support their early childhood centres: often gifting uniforms to children, RO water filters, play equipment, even dropping off vegetables and fruits into the basket that hangs outside every anganwadi. Given ownership of information about their children’s growth and development, local communities will surely partner with frontline workers to monitor and ensure better outcomes for the children.

Finally, along with the push for better nutrition and sanitation, we must begin training frontline workers to counsel young parents on effective early parenting skills and psychosocial stimulation of young children.

The last two decades were the years of unprecedented growth of schooling in India. This should be the decade of early childhood development and the end of stunting. We must do better for our children.

Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste; Diane Coffey and Dean Spears, HarperCollins, ₹250.