Open defecation solves the (lower) child mortality puzzle among Indian Muslims
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Open defecation solves the (lower) child mortality puzzle among Indian Muslims 05 Jun 2014 11:35 #8882

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Dear SuSanA Forum users,

This post could fit in different categories. But it is certainly part of Hygiene, Health and Schools.

We want to encourage a discussion about a new study that has been conducted in India. The topic is open defecation and its relation to child mortality and development:
Open defecation solves the child mortality puzzle among Indian Muslims - The Asian enigma

Here is the link to the article:
arstechnica.com/science/2014/06/open-def...g-indian-muslims/#p3

"We show that the entire gap between Muslim and Hindu child mortality can be accounted for by a particular kind of sanitation externality," wrote Spears and Michael Geruso, professor of economics at the University of Texas at Austin, in their working paper (attached, open access document).

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Behavioral Change seems to be the underlying challenge here. What do you think? Any knowledge or experiences to share?
What is the lesson to learn for international and local organisations in programme design?

I found this interesting CNN video on this issue, published in September 2012



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Last Edit: 08 Nov 2014 22:44 by muench.

Re: Open defecation solves the child mortality puzzle among Indian Muslims 05 Jun 2014 12:53 #8883

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Ahh, this is very interesting as it seems to confirm a suspicion I had a while ago based on toilet coverage maps: forum.susana.org/forum/categories/39-any...-toilet-map-of-india

Given that the majority of open defecation is being done in India this is quite significant for the global debate on OD.

Edit: I wonder if that might not be an effect of religion per se, but rather that of the caste system?
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Last Edit: 05 Jun 2014 13:04 by JKMakowka.

Re: Open defecation solves the child mortality puzzle among Indian Muslims 08 Jun 2014 12:04 #8899

  • F H Mughal
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Some thoughts on child mortality puzzle among Muslims….

Islam has given great importance to cleanliness. Muslims are required to keep themselves clean at all times. We say prayers 5 times a day. Before saying prayers, we perform ablution – cleaning hands, mouth, nose, arms, feet and a wet hand over the head. We are also required to wear clean cloth. We have some religious codes while using toilet (en.wikipedia.org/wiki/Islamic_toilet_etiquette). Muslims say prayers while entering and leaving toilets. Muslims are forbidden from urinating into stagnant water; and defecating near water sources, by the roadside and in the shade. Sanitary engineers know the implication of defecating in the shade.

On the water side (not quite related to this discussion, but is important as sanitation goes hand in hand with sanitation) too, Islam has given out great importance. In Holy Quran, the Arabic word for water has been mentioned 63 times (signifying importance). There are verses in Holy Quran which says: "We (Allah) made from water every living thing;" and, "And Allah has sent down the water from the sky and therewith gives life to the earth after its death." This signifies life-giving properties of water.

Muslim women are required to breastfeed their new born child. Holy Quran says: "The mothers shall give suck to their children for two whole years, for those who wish the suckling to be completed..." Breastfeeding has been referred to in the Dean Spears’s papers. Breastfeeding is a significant aspect in child’s survival.

While Dean Spears and his colleagues have a valid point of community and neighborhood hygiene (clean environment helps child survival as opposed to dirty environment), there is a little known Muslim-related aspect, which may not have been noticed by Dean and his colleagues. When the delivery time is around the corner, the Muslim women and their family members pray to Allah (God) ardently for the child’s survival, and for the well-being of the to-be-born child. This is in the shape of offering obligatory prayers (other than the mandatory 5 times prayers), giving food or money to needy people and, extensive recitation of Holy Quran. After the child is safely born, thanksgivings prayers are offered on a large scale. Muslim believes that if the prayers are accepted by Allah, no harm will be done to the child and, the child will survive all odds. In other words, the child’s survival is assured.

All said and done, Dean Spears needs to be commended for his useful research that he has done. This is, probably, the first of its kind in South Asia. I sent personal email to Dean, sometime back, for doing similar research in Pakistan. Dean, probably, is too much busy at his Delhi office.

Thank you, Dean, for your good work.

F H Mughal
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Karachi, Pakistan

Re: Open defecation solves the child mortality puzzle among Indian Muslims 09 Jun 2014 01:31 #8901

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Dear All,

I must apologize for this really long message but felt it necessary to give detailed explanation because (a) the results of the study could become the object of inflammatory discussion while people within and outside India would do a lot to have Hindu-Muslim unity and (b) considering that there is possibility of applying the study results to policy for population around the globe, a serious discussion is called for.

Before I give my views, I would just like to state that: (a) I am an Indian and an upper-caste Hindu (stating my demographic info for clarification - because each of these variables are mentioned in the study and there might be questions in readers' minds about my antecedents ) and (b) like millions of other Hindus, I always hope for Hindu-Muslim unity and feel happy that Mr. Nawaz Sharif, the Prime Minister of Pakistan, was invited to Mr. Narendra Modi's swearing-in ceremony as the Prime Minister of India. Therefore, I hope my thoughts with respect to the study will be seen in that light.

Please find below the key points (details in attached file). I have also attached copy of the study with text highlighted so that it is easier to find the relevant text.

(a) Applying results of the study for policy advocacy:

The authors have stated: "Finally, our study is important in highlighting the potential nature of the problem. Establishing that open defecation is largely an externality, rather than a consequence of own household behavior, is an important starting point for justifying any policy intervention on economic efficiency grounds and for properly designing such interventions."

This has already been established and also forms part of India's Nirmal Bharat: Rural Sanitation and Hygiene Policy 2012-2022. The policy document states this (in Box 3, please see page 37 of the policy document):

"Why target collective behavior change to end open defecation?

A Rapid Assessment undertaken in Himachal Pradesh in 2005 revealed that in villages with ~30 per cent household toilet use, the incidence of diarrhea was reported as being around 40 per cent. Even in villages with 95 per cent household toilets, still reported around 25 per cent diarrheal incidence. Only open defecation free villages with 100 per cent usage have reported significant drop in diarrhea to less than 10%. In effect, even if a few individual households switch to using toilets, the overall risk of bacteriological contamination and incidence of disease continues to be high." (emphasis as per text.) The source is 'formative research by WSP - Knowledge Links for IEC Manual in Himachal Pradesh, 2005'.

Note #1: Therefore, (i) the importance of the externality has already been recognized in the Nirmal Bharat Rural Sanitation Policy document for 2012-2022, (ii) the present study adds strength of empirical evidence for strengthening policy advocacy for eradicating open defecation, from an evidence-informed policy (EVIP) perspective, by demonstrating the significance on a nationally representative population surveyed in the NFHS vis-a-vis only Himachal Pradesh (HP), one state with 0.57% of total Indian population as per 2011 Census) in the previous study.

However, the present study compares neonatal, infant and child mortality rates (pg 11 of the study) (which could be due to various reasons as for instance, pneumonia at 18% of all under-5 deaths globally is a bigger child-killer compared to diarrhea at 11% of under-5 deaths) while only diarrhea-related deaths might have been a stronger indicator (even after including linkages for diarrhea causing reduced nutrient intake resulting in lesser immunity and similar risk pathways). In comparison, the earlier HP study compares diarrheal incidence (which probably is a better indicator compared to even diarrea-caused mortality as it would include cases where the child was treated and did not die).

In the Himachal Pradesh study, open defecation villages (with 29% toilet use) had 38% of households (HH) reporting diarrheal incidence, almost ODF (95% toilet use) had 26% HH reporting diarrheal incidence and only 100% ODF (100% toilet use) had 7% HH reporting diarrheal incidence. The present study has found that "village-level average open defecation has an effect about twice as large as own latrine use on child survival" (pg 4).

Note # 2: Further, are there special schemes or focus on Muslims because of constitutional provisions that result in higher number of toilets being built? I am not sure about this at all and would prefer to have experts answer this question. The Working Group Report on WATSAN for the XII Five Year Plan recommended that financial provisions for minority communities be contemplated and strengthening online monitoring in this regard (though this was to be started with the 93 notified Minority districts initially). Did the authors control for differences in focus on sanitation provision in predominantly Muslim neighbourhoods, either directly because of constitutional provisions or indirectly because of specific administrative focus?

(b) Diarrhea mortality not linked to handwashing?

The study, in controlling for the possibility of confounding factors, found that there were no significant differences in mortality rates based on handwashing, systematic differences in unobservable ways, assets, parental education, urban residence or state fixed effects but only to open defecation (OD) rate in the living environment. I am not sure, what is the implication of finding no observable differences due to handwashing compared to difference in child mortality? The study does not mention this analysis directly, though.

In this context, (i) a 2009 Cochrane Review (a systematic review which is considered the highest quality evidence in evidence informed policy) found that that interventions promoting hand washing can reduce diarrhea by one-third while (ii) the findings of the present study are based on IMR which includes all causes of death and not diarrhea alone and it is not based on diarrheal incidence.

Therefore, unless we can demonstrate that handwashing does not result in significant reduction in diarrheal incidence in case of high OD environment, handwashing will continue to be the most cost-effective and easier solution to implement.

(c) Toilets paid for by the government remains unused or repurposed

The study quotes another article, “toilets constructed or paid for by the government often remains unused or repurposed by Hindus” - this paints a starkly different picture compared to the fact only 10% do not want to use a toilet and only 2% repurposed the toilet – close to 2/3rds (41% + 22%) had poor unfinished installation or no superstructure as per a CMS 2010 Study cited in the Working Group Report on WATSAN for the XII Five Year Plan of the Government of India.

(d) A possible explanation:

The fact is that 67% of Hindus practice open defecation compared to 42% of Muslims. This could probably be due to differences in decisionmakers’ in households (predominantly men in both cases) about household spending priorities as a choice between their cultural attitudes towards women and their own preference regarding toilet use rather than a strict compliance with a religious scripture.

(e) Would we want to use the statistics in a sanitation campaign?

Would we really want to use religion as the basis for stepping up the sanitation campaign? Because messages as well as intent can be lost in translation / communication process. Also, identifying a community to create a sense of shame might not be the right approach. This is very much like telling a child, “look at him, he is so much better than you are; why cannot you be more like him?”. All experts on child psychology agree that this is an incorrect approach to take. Looking at a difference from the perspective of identifying vulnerabilities is very different from shaming someone.

And, I am not writing this because I am a Hindu. It is simply that it is incorrect and we really do not want a flurry of counter-shaming based on some other grounds. As an Indian, I want peace in my country and, in this case, I am more than justified in expecting it. From the perspective of global policy also, I would still not want to use the statistic – delving into the details is acceptable from a truth finding perspective – but using it in public communication strategy is not acceptable. Essentially, we would have been breaching an individual’s right to dignity (their sense of self-worth) if we implemented a strategy that has an unavoidable element of humiliation built into it. There have already been instances of using humiliation to coerce people into accepting indoor sanitation and these have been soundly protested against by different actors / stakeholders.

Dear Mughal,
You have a commendable knowledge of the scriptures! So, I should perhaps ask you this question: there is a set of ten sentences that Muslims have to state, the first one being 'La ilah il Allah Mohammed rasul Allah' (I think it means 'there is one God but Allah and Mohammed is his prophet'). I have been trying to find those ten lines but do not know what keyword to use to search for it on Google. When I read your post, I was reminded of it and thought I would ask you.

To everyone: These are just my first thoughts and I backed it up with some stats / content I could quickly pull out from having read about sanitation in India. None of what I have written is intended to hurt the sentiments of any community, Hindu or Muslim. Hope it will be considered in the same spirit.

Thanks and regards,

Sowmya

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Last Edit: 09 Jun 2014 01:42 by Sowmya. Reason: a word repeated twice.
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Re: Open defecation solves the child mortality puzzle among Indian Muslims 09 Jun 2014 13:05 #8906

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Dear Sowmya,

I'm not quite sure which 10 lines are you referring to, but since you have mentioned the "first kalma," and you have used the words: "Muslims have to state," you are referring to the "6 kalmas" that we have in Islam. These are:

First Kalma: Laa ilaaha illal Lahoo Mohammadur Rasool Ullah
Translation: There is none worthy of worship except Allah. Muhammad is Messenger of Allah - (you have already mentioned this)

Second Kalma: Ashahado An Laa ilaaha illal Laho Wahtha Ho La Shareekala Hoo Wa Ash Hado Anna Mohammadan Abdo Hoo Wa Rasoolohoo
Translation: I testify that there is no partner for Him. And I testify that certainly Muhammad is His worshipper and His Messenger.

Third Kalma: Subhanallahe Wal Hamdulillahe Wa Laa ilaha illal Laho Wallahooakbar. Wala Haola Wala Quwwata illa billahil AliYil Azeem
Translation: Glory is for Allah. And all praises for Allah. And there is none worthy of worship except Allah. And Allah is the Greatest. And there is no power and no strength except from Allah, the Most High, the Most Great

Four Kalima: Laa ilaha illal Lahoo Wahdahoo Laa Shareekalahoo Lahul Mulko Walahul Hamdo Yuhee Wa Yumeeto Wa Hoa Haiy Yul La Yamooto Abadan Abada Zul Jalal Lay Wal Ikraam Beyadihil Khair. Wa hoa Ala Kulli Shai In Qadeer
Translation: There is none worthy of worship except Allah. He is only One. There is no partners for Him. For Him is the Kingdom. And for Him is the Praise. He gives life and accuses death. And He is Alive. He will not die, never, ever. Possessor of Majesty and Reverence. In His hand is the goodness. And He is the goodness. And He is on everything powerful

Fifth Kalma: Astaghfirullah Rabbi Min Kullay Zambin Aznabtuho Amadan Ao Khat An Sirran Ao Alaniatan Wa Atoobo ilaihe Minaz Zambil Lazee Aalamo Wa Minaz Zambil Lazee La Aalamo innaka Anta Allamul Ghuyoobi Wa Sattaarul Oyobi Wa Ghaffaruz Zunoobi Wala Haola Wala Quwwata illa billahil AliYil Azeem
Translation: I seek forgiveness from Allah, my Lord, from every sin I committed knowingly or unknowingly, secretly or openly, and I turn towards Him from the sin that I know and from the sin that I do not know. Certainly You, You are the knower of the hidden things and the Concealer of the mistakes and the Forgiver of the sins. And there is no power and no strength except from Allah, the Most High, the Most Great

Six Kalma: Allah Humma inni Aaoozubika Min An Oshrika Beka Shai Aown Wa Anaa Aalamo Behi Wasthaghfiruka Lima La A'lamu Behi Tubtu Anho Wa Tabarrato Minal Kufri Washshirki Wal Kizbi Wal Jheebati Wal Bidaati Wan Nameemati Wal Fawahishi Wal Bohtani Wal Maasi Kulliha Wa Aslamtoo Wa Aamantoo Wa Aqoolo Laa ilaaha illal Lahoo Mohammadur Rasool Ullah
Translation: O Allah! Certainly I seek protection with You from, that I associate partner with You anything and I know it. And I seek forgiveness from You for that I do not know it. I repended from it and I made myself free from disbelief and polytheism and the falsehood and the back-biting and the innovation and the tell-tales and the bad deeds and the blame and the disobedience, all of them. And I submit and I say there is none worthy of worship except Allah, Muhammad is the Messenger of Allah

There are five essentials (pillars) of Islam. The five pillars of Islam are the framework of the Muslim life. They are: the testimony of faith (the first kalma, you have referred to); five times prayers, daily; giving zakat (support of the needy); fasting during the month of Ramazan (this month is now 20 days away from today); and the pilgrimage to Makkah once in a lifetime for those who are able.

Regards,

F H Mughal
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Karachi, Pakistan
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Re: Open defecation solves the (lower) child mortality puzzle among Indian Muslims 09 Jun 2014 17:35 #8908

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While I agree with Sowmya that this shouldn't be used to blame certain religious groups, it is still an important discussion for sanitation experts.

On the one hand we have a global campaign to stop open defecation and probably millions of dollars spent on various related programmes, but on the other hand there is very little reflection and research on the topic. It seems to me the entire discourse is way too much about the moral high-ground of being disgusted by the practise (and the negative health effects in very broad & simplifying strokes).

It makes for example pretty much no sense to advocate for a 100% open-defecation free world, as there are areas (e.g. sparsely populated drylands) and livelihood styles (e.g. nomadic pastoralism) where is simply doesn't make a significant difference to abolish the practise (and unhygienic shared toilets might make matters worse).

Than there is this horrific figure of 1 billion people still practising open-defecation, but what are the actual details of it? Without being a real expert on the topic, I am quite sure if one subtracts all the cases where the practise makes perfectly sense (see above), a small percentage of people totally socially and economically excluded that exist in every country (even rich & developed ones, see homeless people), and emergency cases (displaced persons and economic refugees in slums), one will be pretty much left with that out-of-the-ordinary high percentage of people on the Indian subcontinent (Muslims, Hindus what ever). Thus it makes perfectly sense to closely scrutinising what is really going on there and what the driving forces might be.

Having lived both in a predominately Muslim (Pakistan) and Hindu (Nepal) country of the subcontinent, and going by their various deeply culturally and religiously engrained hygiene practises (for Muslims see Mughal's response above, for Hindus I would say mostly food hygiene), my unscientific guess it that it really can't be blamed on (or explained by) the religious practises themselves. I much rather suspect that it is a social dynamic of the caste-system, since (as Sowmya has already mentioned) it is very much an issue of community and not personal hygiene.
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Last Edit: 09 Jun 2014 19:57 by muench.

Re: Open defecation solves the (lower) child mortality puzzle among Indian Muslims 10 Jun 2014 20:15 #8921

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At least the so-called "mysterious child mortality puzzle" is not being blamed on malnutrition which is often confused with malabsorption syndrome caused by poor sanitation.

Re: Open defecation solves the (lower) child mortality puzzle among Indian Muslims 04 Jul 2014 09:20 #9228

  • sebastian
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Hello Forum Users,

Thank you for your statements and the respectful way of communication. Drawing the lines along religious differences cannot be the only reason for the big differences within the country.

The following publication points in the same direction. Open defecation vs. toilet use is assessed in spatial models and can therefore add another piece for the "puzzle". I found it by chance and immediately thought about this thread. It is a publication from 'Social Science Research Network' Working Paper Series by a PhD Candidate at UCLA.

From the study:
Tests of local spatial autocorrelation also reveal that poor sanitation is clustered in districts that have high under-five mortality rates (and vice versa); the location of these clusters appears to reflect broader cultural differences within India that are not captured by state-level analyses.


I'd be interested in how this study compares to the previous one for you.



Abstract: Inadequate toilet use directly contributes to high rates of morbidity and mortality in India. Despite a strong research focus on sanitation solutions, understanding of the determinants of toilet use in India is remarkably poor. This paper uses spatial analysis techniques to explain variation in sanitation use at the district scale. A test of global spatial autocorrelation confirms that sanitation use is strongly clustered geographically, and spatial clustering remains robust after controlling for socioeconomic explanations. In addition to providing an empirical model of toilet use, this paper suggests that variation in regional adoption of use must be incorporated into future national program design.
Keywords: Toilet Use, India, Spatial Analysis, Total Sanitation Campaign
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Re: Open defecation solves the (lower) child mortality puzzle among Indian Muslims 15 Jul 2014 08:05 #9352

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Also an interesting paper, although it seems a bit strange how their entire argument is carefully "santitized" to simply state a geospatial correlation.

The location they have identified is what some people refer to as the "hindu belt" however, where up to 95% percent of the population is of that religion.

Also interesting is this recent article in the NYT:
www.nytimes.com/2014/07/15/world/asia/po...ml?_r=1&referrer
And especially the graphic it includes that shows just how much of an outlier India is globally when it come to open defecation:


sanitation_india_globalstunting_NYT.png
Krischan Makowka
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Last Edit: 15 Jul 2014 08:15 by JKMakowka.
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Re: Open defecation solves the (lower) child mortality puzzle among Indian Muslims 16 Jul 2014 21:06 #9375

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Dear Kris,

I didn't fully understand your sentence here: ?
a bit strange how their entire argument is carefully "santitized" to simply state a geospatial correlation.


Are you saying the authors glossed over the data so that they only mention results for certain regions of India without trying to figure out the specific characteristics of these regions that might cause that effect? (as Sowmya has pointed out above, it could be tricky to do so, with unpleasent, and perhaps even dangerous, side effects for the national politics)

About the New York Times article (which has been all over Twitter, everyone seems to tweet about it!):

That graph that you have copied here is remarkable. I have never before seen open defecation expressed in this "density" unit, i.e. "number of people who defecate outdoors per square kilometre". This is what makes India stand out like this: so much open defecation plus a country that is very densely populated (according to Wikipedia: Density 378.8/km2 (31st most densely populated country in the world)). All the other figures from WHO and UNICEF quote only the % of people in a given population practicing open defecation. Here, India doesn't stand out as much. But when it's expressed as per square kilometre, then India does stand out!

What I was wondering in the NYT article: they talk about India as a whole but surely also with the stunting there must be huge differences in the different states of India. I guess one would have to dig into the cited sources to see that. But a "stunting map" overlain with a "open defecation per km2" map for inside of India could be quite revealing.

I do get the feeling (or is it just wishful thinking?) that India will start to tackle their sanitation problems more seriously now as the evidence is simply mounting and it is - maybe - getting too embarrassing for the Indian government as well (?). Or maybe I don't know enough about Indian politics yet.

Greetings,
Elisabeth
Dr. Elisabeth von Muench
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Last Edit: 16 Jul 2014 21:09 by muench.

Re: Open defecation solves the (lower) child mortality puzzle among Indian Muslims 17 Jul 2014 11:55 #9377

  • F H Mughal
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Dear Elisabeth,

According to the news in ProPoor Newsletter of 17 July 2014, Indian government will provide toilets to every houe by 2019. See below for details:

Indian government gets robust about sanitation
OneWorld South Asia
Jul 16, 2014

Giving high priority to sanitation, the Indian government said that we intend to provide toilets to every house by 2019.

New Delhi: With an objective to provide sanitation to every household by 2019, the 150th birth anniversary of Mahatma Gandhi, the Indian Finance Minister Arun Jaitley announced Rs 4,260 crore for Nirmal Bharat Abhiyan which includes Rs 426 crore for northeast regions and Sikkim.

The Budget-2014 also allocates Rs 11,000 crore for National Rural Drinking Water Programme and the rural water supply sector including Rs 1,100 for northeast regions and Sikkim.

In an order to improve inland waterways transport, the government announced a project titled ‘Jal Marg Vikas’ (National Waterways-I) on river Ganga. It will cover a distance of 1,620 kms from Allahabad to Haldia. It will also enable commercial navigation of at least 1,500 tonne vessels. With an estimated period of six years to get it completed, the Budget allocates Rs 4,200 crore.

‘Namami Gange’, an integrated Ganga development project has also been allocated Rs 2037 crore. The government has also announced ‘Neeranchal’, a watershed development programme, with an estimated outlay of Rs 2,142.

It also announced to introduce metro-rails in Lucknow and Ahmedabad through public-private partnership.

In an effort to improve water availability throughout the year, the government again opened the ambitious project on interlinking rivers.

Let us hope, sanitation scenario improves in India in foreseeable future!

Regards,

F H Mughal
F H Mughal (Mr.)
Karachi, Pakistan

Re: Open defecation solves the (lower) child mortality puzzle among Indian Muslims 17 Jul 2014 15:16 #9381

  • JKMakowka
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muench wrote:
Dear Kris,

I didn't fully understand your sentence here: ?
a bit strange how their entire argument is carefully "santitized" to simply state a geospatial correlation.


Are you saying the authors glossed over the data so that they only mention results for certain regions of India without trying to figure out the specific characteristics of these regions that might cause that effect? (as Sowmya has pointed out above, it could be tricky to do so, with unpleasent, and perhaps even dangerous, side effects for the national politics)


Pretty much, but the entire argument is left somewhat hanging because of that. They are so careful not to state a obvious correlation that the paper becomes very abstract and a bit hard to follow.


Concerning the NYT's graphic: I think the OD/square km measure makes a certain sense and should probably be used more often. I also don't think the overall population density in India is distorting this, as the neighbouring countries are similar densely populated (or even much more e.g. Bangladesh! see also: en.wikipedia.org/wiki/List_of_sovereign_...y_population_density) and still do not fall out of the normal range like India does.
The graphic does fail in correlating child stunting to OD in India though, as many countries with a much lower OD/area rate show similar levels of child stunting.
Krischan Makowka
“You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete” - Buckminster Fuller
Last Edit: 17 Jul 2014 15:25 by JKMakowka.
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