Think sanitation, not food security

Not only does the Food Security Bill show  poor economic reasoning and flawed policy design, it is also treating the wrong problem.

The proposed National Food Security Bill is not just poor medicine for the problems of hunger and malnutrition that it aims to address. It is also a wrong diagnosis of the disease, where the self-appointed doctors fail to read the symptoms correctly. Malnutrition is a condition where certain basic nutrients are lacking in the human body, leading to poor health and physical development. The mistake has been in assuming that this is because people do not have enough food to eat. Nutrition is not just about what people eat – but about how well the body is able to utilise it. Could it be, that people are losing their health, not because of the lack of food but because of recurring bouts of dysentery, diarrhoea and an infection from a host of parasites? Could the problem here be a lack of sanitation and not food insecurity? Could the problem have been fundamentally misdiagnosed?

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First, let us look at the symptoms – chronic hunger and malnutrition. Numbers on both are debated in India. There are widespread claims of a fifth of Indian population suffering from chronic hunger which are not backed up by good data. 99 percent of rural households and 99.4 percent of urban households reported that they had two square meals a day throughout the year, as per a 2009-10 National Sample Survey Organisation report. While this recall survey may miss out on capturing sporadic instances of people going hungry, it makes a robust case against widespread chronic hunger. Apart from this, measured calorie consumption has been declining because of a host of reasons including changing dietary habits and a reduction in physical labour work. Interpreting a decline in measured calorie consumption as evidence for chronic hunger is fallacious.

The second symptom, malnutrition, cannot be measured effectively through oral or recall surveys. Researchers use child height (stunting), height-to-weight ratios (wasting), upper arm circumferences and other bodily measurements to determine if someone has received sufficient nutrition or not. By and large, these proxies are more reliable for growing children than they are for adults. The assumption here is that if children are born to healthy mothers anywhere in the world, they will reach a certain height range if they receive adequate nutrition through their childhood. Thus, it is children of height well below the acceptable height who are classified as stunted, and hence malnourished. It is by these measures that 43 percent of India’s children are classified as malnourished.

When posed with a symptom, doctors perform a differential diagnosis. The question to ask is: what causes this malnutrition? Is it because of a lack of food intake (or availability), or because of unclean drinking water and open defecation? The latter is particularly hard to measure, because people are affected not only if they defecate in the open – but also if their neighbours do so. New research from Dean Spears of Princeton University shows that open defecation (and a lack of basic sanitation) explains a majority of variation in child height across all countries in the world – as opposed to food availability, income, literacy or any other reason. Spears provides evidence that consistently shows the high negative impact of open defecation on child height and malnutrition, across countries, within India and when controlled for factors like GDP.

While stunting and wasting are widely accepted as robust measures of malnutrition, economists Arvind Panagariya and Jagdish Bhagwati disagree – stating that it is wrong to assume the same healthy range of heights for people of all ethnicities and genetic make-ups. They contrast sub-Saharan African countries with India: the former have lower malnutrition rates than India, but have much higher Infant Mortality rates. Since the latter are much harder numbers less open to dispute, and have largely the same causal reasons, Panagariya and Bhagwati argue that the Indian malnutrition numbers cannot possibly be true. What Dean Spears finds is that if one looks at granular data within India or sub-Saharan Africa, habitations with open defecation have both higher infant mortality and higher rates of stunting. While India does much better than sub-Saharan Africa on almost all development indicators, the one that it remains far behind on is sanitation. This hidden factor is ably demonstrated as explaining this long-standing enigma between India and Africa.

While the National Food Security Bill proponents have been looking at nutrition as a ‘gross’ problem which requires more input in the form of cheaper food, the reality is that it is largely a ‘net’ problem. Far too much nutrition is lost to recurring diarrhoea, dysentery, persistent worm infestations and chronic environmental enteropathy linked to open defecation and a lack of sanitation. People in 69 percent of rural Indian households continue to defecate in the open. While most of the urban population uses toilets, little human waste gets collected and treated properly.

It is ludicrous that sanitation has not been made a priority in development policies addressing malnutrition. While the official government of India position has always been that malnutrition is ‘complex, multidimensional and inter-generational’, the interventions have largely been about targeted and non-targeted nutritional interventions, subsidized healthcare, and with token mention of clean drinking water supply and sanitation. This is like giving dysentery patients subsidized food and medicine, and asking them to eat more, and stopping the medical advice there. In the absence of focus on sanitation, what we have is taxpayer-funded diarrhea and little else.

The High Powered Executive Committee report on urban infrastructure and services in 2012 estimated that India would need to invest approximately 5.6 lakh crore rupees over the next twenty years on urban water and sanitation infrastructure. While this may sound like an incredibly high number – it is the same as just three to five years of total estimated expenditure for the food subsidies, depending on whose cost estimates you believe. The challenge in rural sanitation is even more basic – motivating people to build and use toilets, and help those who do not have the means to.

Not only does the Food Security Bill show poor economic reasoning, and flawed policy design, it is also treating the wrong problem. What national policies need to focus on are rural and urban sanitation along with the provision of clean drinking water. Not on quaint notions of food security.

Photo: Overseas Development Institute