The New York Times recently featured a story in which NYT South Asia correspondent, Gardiner Harris conflates India's serious problem of open defecation with Hinduism. Hindu American Foundation co-founder and member of its Board of Directors, Aseem R. Shukla, MD, offers the following response and analysis as a guest on this blog. Dr. Shukla is a pediatric urologist in Philadelphia and works extensively in India teaching at several of India's largest public hospitals and providing medical aid to refugee camps.
The New York Times ran a story on the crisis in India of open defecation on the front pages of its online portal on July 13, 2014. The issue tackled is critical -- that according to some studies, up to half of the Indian population lacks access to functioning toilets and continues to relieve itself outdoors. This, the story reported, may be causing chronic gastrointestinal disease that causes children to suffer stunted growth despite access to adequate nutrition. It's yet another paradox in the India Rising story -- launching Mars orbiters and ranking second in the world for mobile phone users on the one hand and lagging embarrassingly behind in dealing with a most basic bodily necessity on the other.
But Gardiner Harris, the South Asia correspondent for the Times, authored the story, and as is his wont, he provoked. So was Harris' story on Indian stooling habits an important story? No doubt. A tragic story? Indeed. Outrageous? Absolutely. But check out these passages in the story:
Open defecation has long been an issue in India. Some ancient Hindu texts advised people to relieve themselves far from home, a practice that Gandhi sought to curb.
And then this gem:
In a little-discussed but surprising finding, Muslim children in India are 17 percent more likely to survive infancy than Hindus, even though Muslims are generally poorer and less educated. This enormous difference in infant mortality is explained by the fact that Muslims are far more likely to use latrines and live next to others also using latrines, a recent analysis found.
So widespread housing discrimination that confines many Muslims to separate slums may protect their children from increased exposure to the higher levels of waste in Hindu communities and, as a result, save thousands of Indian Muslim babies from death each year.
The web is littered by various rejoinders to Harris over his depictions of Hindus as societal antagonists accused of riots and persecuting India's minorities, and his choice epithets in covering the current Indian prime minister elected by overwhelming margins have led to extended meetings in editorial offices of the New York Times.
This round, Harris managed to post an important public health story with just enough bias, just enough entirely misguided references to Hinduism, and a dollop of statistical misinterpretation, that of over 400 comments amassed on the website in two days. There were many such enlightened comments as:
Clive Deverall AM., Hon D.Litt.
Perth, Australia 3 days ago
Very hard to reach a solution when some, mostly Hindus, prefer to defecate in the open, often when toilets are available. How can a 'public health policy' be imposed when so many are unwilling to alter their daily 'habits'. What is happening now will impoverish India, a country so rich in resources and intellect but no society can sustain itself against biological harm to very young children; especially when it is invisible.
California 2 days ago
What you say is probably true, but I have no desire to visit India because of the poverty, ignorance and filth which exist there. The caste system seems still to exist, a horror which was brought about by the Hindu religion. No thanks.
Let me start by acknowledging that Gardiner Harris' basic hypothesis about sanitation in India is certainly plausible. Open defecation is most definitely a risk factor for various enteric pathogens, and as a physician I wouldn't be surprised if it is a major contributor to infant mortality and stunting. Moreover, the paper to which Mr. Harris links approvingly is based on datasets that strive to be representative. But in his zeal to connect Hindu beliefs to stunted growth, Harris makes too many assumptions that lead him badly astray, eventually making statements that border on outright racism.
Correlation, not Causation
First of all, the paper in question, the authors seek to "prove" that Hindus suffer higher infant and child mortality rates than the Muslim population in India due to higher rates of outdoor defecation. Co-written by a recent PhD graduate, Dean Spears, the paper does not appear to be peer reviewed. This doesn't mean it is wrong, but it certainly means that it should be taken with a heavy load of salt, especially such audacious statements like:
This paper offers a simple solution to the puzzle in the form of an important sanitation externality
or
...we solve the Muslim mortality puzzle ...
Keep in mind this entire paper is based on a cross sectional survey. Cross sectional survey data can never prove any association, as correlation is not causation. My colleague at the Hindu American Foundation, Raman Khanna, MD, a physician and clinical researcher in San Francisco, CA, recently deconstructed Harris' coverage as well as many of the findings of the research he cites. Dr. Khanna has remarked that there is a possibility that observed differences are due to selection bias (those with stunting being more likely to respond to a survey and also to be Hindu due to differences in literacy for example), measurement bias, and to confounding.
He also observed that, "Beyond this, there is clear noise in the dataset. India is massively an outlier when it comes to open defecation, but as noted in one of the studies Harris cites, large districts with the same rate of open defecation can have rates of stunting that vary as much as 40%. I very much want to believe that this cross sectional survey proves that the tragedies of child mortality and stunting in India had one clear and ameliorable root cause. But it would be irresponsible to draw such a sweeping conclusion on the basis of a cross sectional survey, particularly because open defecation is itself such a complex problem."
Statisticians know that a multivariate regression that Spears employed is a reasonable statistical tool, however, the tool does not give itself to bold, even haughty, conclusions as "solving" a major epidemiological question that is confounded by a plurality of different variables that can account for differences in mortality in a community. Harris should have known better, especially as a former health reporter, than to corroborate this startling conclusion with the imprimatur of the Times.
Hindus and their Texts
For someone who writes about India on a regular basis, Harris is awfully comfortable with tone-deaf statements like:
So widespread housing discrimination that confines many Muslims to separate slums may protect their children from increased exposure to the higher levels of waste in Hindu communities and, as a result, save thousands of Indian Muslim babies from death each year.
And as quoted earlier:
Open defecation has long been an issue in India. Some ancient Hindu texts advised people to relieve themselves far from home, a practice that Gandhi sought to curb.
The first statement confuses bigotry for poetic justice, and the second, a glaring ignorance of the historic context of Hindu scripture. And both hide in plain sight that culture is, to quote Ta Nehisi Coates, a toolbox, not a Bible.
It is true that housing discrimination is an urban reality in parts of India and Harris previously wrote about the difficulties Muslims found in renting homes in parts of the Indian state of Gujarat's cities. But here is where the statistics Harris so enthusiastically cites come back to bite: in Gujarat, the rate of urban open defecation is only 5 percent, while open defecation is much more common in the rural areas where housing discrimination is a bit of a wash -- everyone struggles for proper housing.
So while the Harris narrative is that Muslims enjoy lower rates of infant mortality because they are protected from filthy Hindu bigots laying waste to their neighborhoods, open defecation happens in rural areas where housing discrimination is not a factor. Even more, the study that Harris cites, without, perhaps, a deeper understanding of the statistics, has a figure that shows that in many states of India, the difference is infant mortality between Hindus and Muslims is minimal, and infant mortality even favors Hindus. Harris had no grounds on which to make the revolting inverse conflation of housing discrimination and infant mortality.
The "ancient Hindu text" that Harris helpfully cites, the Manu Smriti, was written in 500 BCE--latrines were not exactly outfitted with cultured marble or bidets! That text gives exacting guidelines as to the distance to be maintained from a water source such as a river while urinating or defecating. There are several rules regarding the direction to look, and how to clean oneself after defecation. The essence of the rules are the same: defecate in the open, well away from home and water sources.
Hindu texts classified as Smritis, such as the Manu Smriti referred to here, are not considered among the eternal, realized (revealed) texts classified as Sruti. So Smritis are interpretable to time and space, and to make an incredible claim that this text is guiding Hindus in how to defecate today, without any surveys or interviews given as evidence, seems wildly irresponsible.
Defecating far away from home likely was quite sensible up to the point when one's far away became someone else's backyard. And in the modern era, as Harris himself points out, toilets are no panacea; effluent pipes get blocked and overflow during the monsoon season; water is not always flowing such that they could be flushed; and so on. Heck, camping guides kind of echo what the Manu Smriti said of clean defecation in a time when people lived in a bit more basic environs.
Moreover, why even invoke religion in this piece? Getting to 40 percent open defecation (the Muslim rate in the study) from 66 percent (the Hindu rate) would be a major improvement, and getting infant mortality from 75 births per 1000 to 65 per 1000 would also be a major improvement (if misleadingly presented on a graph with truncated axes). But getting to 3 percent as in Bangladesh will require making significant strides in all religious groups.
Open Defecation isn't just about toilets
It's a little amazing that Harris can quote certain statistics without any sense of context. He cites the SQUAT report on open defecation, noting that folks with a latrine still often practice open defecation. But why would they do this? Well, maybe it's because the effluent pipes flood, or because water simply doesn't flow at certain times of the day. And where will all this sewage go--will it be dumped directly back into the same rivers that supply the water to the village or the city?
The process of moving from open defecation to more sanitary practices isn't linear, and there are many ways one can imagine toilets making things worse before they make things better. Perhaps talking to individuals in Bangladesh or elsewhere would be helpful in this regard.
None of this is to say that open defecation is either a good idea in this day and age, or even defensible. But making sweeping claims, using them to justify near-bigotry, and papering over obvious challenges hardly advances the conversation.