NEW DELHI — Of all Indian Prime Minister Narendra Modi’s campaigns, none, perhaps, is more consequential than the renewed push for his Swachh Bharat — or Clean India — Mission launched in October 2014.  

At first glance SBM was a mere rehash of a campaign to build toilets across rural India that was launched several decades ago and has been run by successive governments, but it goes a step further by combining social engineering and developmental economics. In Modi’s view, it has the potential to upend stereotypes of poverty, malnutrition and inequality that plague India’s image. Studies show that high infant mortality, poor maternal health and stunted growth all take a wider economic toll.  

When Modi won power in 2014, more than 600 million Indians, about half the population, practiced open defecation. The government claims that number has since fallen to 320 million. Modi vowed to end open defecation by Oct. 2, 2019, the 150th anniversary of the birth of India’s independence leader Mahatma Gandhi.  

New bank notes printed after last November’s demonetization sport the SBM logo — Gandhi’s reading glasses. The SBM website features a whirring ticker of rising toilet numbers. On July 26 it said a total of 44.83 million household toilets had been built so far during Modi’s rule. This is not revolutionary: About 90 million toilets were built by the previous Congress government during its decade in power, but most lay unused. 

A new book, “Where India Goes: Abandoned Toilets, Stunted Development and The Costs of Caste,” says the 2019 goal will not be achieved, because too much attention is still being paid to building more toilets, and not enough to whether they are cleaned or even used.  

The book blames India’s centuries-old caste system for the continuing stigma attached to cleaning toilets. Although “manual scavenging,” or the employment of people from the lowest caste to clean out latrines, was banned in 1993 and a more extensive prohibition was enacted in 2013, the practice persists in several north Indian provinces as well as in Modi’s home state of Gujarat, according to Bezwada Wilson, a winner of the prestigious Ramon Magsaysay Award for transformative leadership and who heads a national union of sanitary workers.  

Diane Coffey, one of the book’s co-authors, says this is because many people in rural India recoil from having to clean the low-cost pit latrines the government is building.  

“This is an intellectual puzzle for economics and for global health, but for Indians themselves, it is an ongoing catastrophe,” Nobel prize-winning economist Angus Deaton, who is an authority on poverty and inequality in India, writes in his foreword to the book. “Beliefs about purity, cleanliness, caste and untouchability generate a steel fence that prevents change in traditional ways of disposing of human feces.”  

But Parameswaran Iyer, the Ministry of Drinking Water and Sanitation official who heads the flagship SBM-Gramin (rural) program, says there has been a big push for behavioral change under Modi. “This is not about building toilets, it is about changing behaviors, which is not easy. No one said it was,” Iyer told the Nikkei Asian Review.  

Harnessing the community

He says the focus has shifted from outputs to outcomes, which meant moving from constructing toilets to measuring open defecation free areas. “ODF” has a special connotation. What it implies is, unless the entire community comes together, understands the importance of the dignity of women and [the costs of] childhood stunting, unless the entire village becomes ODF, the health impact will be less than what it should be.”  

The government says the number of ODF districts has risen from five to 152 in just over a year (India has 717 districts). Nearly 214,000 villages have been declared ODF out of a total of nearly 650,000. Five of India’s 29 states have announced that they are free of open defecation.  

Coffey, a demographer, wrote the book with economist Dean Spears. Together they set up the Research Institute for Compassionate Economics, better known as r.i.c.e., in 2011 to study poverty and child health in India. Coffey says the government has not carried out any credible measurement on the extent of open defecation.  

Iyer counters that after village councils and district administrators make sure there are no feces visible anywhere outdoors in a village, multiple audits kick in. National level monitors were dispatched earlier this year to inspect ODF villages, especially those situated on the banks of the River Ganges. Government body the Quality Council of India is surveying 100,000 ODF households across the country; the results will be published in August. The same month, the National Sample Survey Office, part of the ministry of statistics, will launch a national survey.  

In addition, the World Bank signed a $1.5 billion loan agreement for the SBM in March 2016, but made disbursements conditional on the independent verification of ODF progress. Finally, more than a year later, the sanitation ministry signed up an independent verification agency to conduct an intensive audit.  

A World Bank spokesperson said tranches from the loan would be released to Indian states only after it receives the agency’s reports on three indicators: the number of people that had stopped defecating in the open; the number of villages that sustained their ODF status; and the number of villages with solid and liquid waste management procedures. “Self-reported ODF status needs to be verified regularly, and behavior change support needs to be continued to ensure that outcomes are sustained,” the bank said.  

Leading by example  

Iyer, a water and sanitation expert who calls himself the traveling salesman for Swachh Bharat, believes that behavioral change starts from the top. In February, this year he led a group of senior state sanitation officials to a village in southern Andhra Pradesh state where they cleaned out toilet pits.  

Modi’s government is about to launch a nationwide campaign that touts the “twin pit pour flush” government-subsidized toilets — improved pit latrines with two alternating pits connected to a pour-flush toilet — as environmentally friendly and easy to clean. When one pit fills up, human excreta is diverted to the second pit. After about a year, the solidified waste becomes compost and can be used as fertilizer. Authorities are hoping that people will accept that it is easy for them to clean their toilets themselves without hiring somebody from a lower caste.  

The odds are enormous. India has worse sanitation than its poorer South Asian neighbors — especially Bangladesh which boasts total ODF status — or Sub-Saharan Africa. Open defecation persists despite India’s status as one of the world’s fastest-growing economies.  

Government data show that the infant mortality rate, or deaths per 1,000 births, stood at 41 in 2015-16, an improvement from 57 a decade earlier. According to the World Bank, the IMR in Bangladesh was 31 in 2015, in the U.S. it was 6, and Sweden just 2. Infant deaths and childhood stunting are worst in India’s most heavily populated states like Uttar Pradesh and Bihar. “Open defecation is particularly deadly in India because so many people live close together and close to one another’s germs,” the Coffey-Spears book says.  

Pathogens spread by poor sanitation particularly affect the health of women, who also must worry about their safety when they venture out into the fields to defecate. “According to one calculation, at the current rate of progress, it will take 250 years for Indian women to catch up with British women, even if the latter get no taller than they are today,” Deaton writes in his foreword.  

In March 2017, Modi’s government announced a new national health policy that aims to take spending on health care to 2.5% of gross domestic product, from 1.4% in 2014; the global average is 6% of GDP. For the Swachh Bharat campaign, Modi has set aside a total of 368 billion rupees ($5.6 billion) over four annual budgets.  

Iyer asserts that India is at a tipping point because of rising rural incomes, increased migration to cities and improving education. But the World Bank sounds a cautionary note. “The task is not easy,” it said. “Bangladesh, for instance, took 15 years to become open defecation free, while Thailand — where the campaign was personally led by the late King Bhumibol Adulyadej — took 40 years to do so. Given India’s vast size and diversity, progress across states is bound to vary.”