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Economic Outlook: Malnutrition and Sanitation in India

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Original article:

So why was Vivek malnourished?

It is a question being asked about children across India, where a long economic boom has done little to reduce the vast number of children who are malnourished and stunted, leaving them with mental and physical deficits that will haunt them their entire lives. Now, an emerging body of scientific studies suggest that Vivek and many of the 162 million other children under the age of 5 in the world who are malnourished are suffering less a lack of food than poor sanitation.

Like almost everyone else in their village, Vivek and his family have no toilet, and the district where they live has the highest concentration of people who defecate outdoors. As a result, children are exposed to a bacterial brew that often sickens them, leaving them unable to attain a healthy body weight no matter how much food they eat.

“These children’s bodies divert energy and nutrients away from growth and brain development to prioritize infection-fighting survival,” said Jean Humphrey, a professor of human nutrition at Johns Hopkins Bloomberg School of Public Health. “When this happens during the first two years of life, children become stunted. What’s particularly disturbing is that the lost height and intelligence are permanent.”

“Our realization about the connection between stunting and sanitation is just emerging,” said Sue Coates, chief of water, sanitation and hygiene at Unicef India. “At this point, it is still just an hypothesis, but it is an incredibly exciting and important one because of its potential impact.”

Half of India’s population, or at least 620 million people, defecate outdoors. And while this share has declined slightly in the past decade, an analysis of census data shows that rapid population growth has meant that most Indians are being exposed to more human waste than ever before.

Other developing countries have made huge strides in improving sanitation. Just 1 percent of Chinese and 3 percent of Bangladeshis relieve themselves outside compared with half of Indians. Attitudes may be just as important as access to toilets. Constructing and maintaining tens of millions of toilets in India would cost untold billions, a price many voters see no need to pay — a recent survey found that many people prefer going to the bathroom outside.

One analysis found that government spending on toilets pays for itself in increased tax receipts from greater productivity, but the math works only if every member of a family who gets a toilet uses it.

“We need a cultural revolution in this country to completely change people’s attitudes toward sanitation and hygiene,” said Jairam Ramesh, an economist and former sanitation minister.

India now spends about $26 billion annually on food and jobs programs, and less than $400 million on improving sanitation — a ratio of more than 60 to 1.

The present research on gut diseases in children has focused on a condition resulting from repeated bacterial infections that flatten intestinal linings, reducing by a third the ability to absorb nutrients. A recent study of starving children found that they lacked the crucial gut bacteria needed to digest food.

Just building more toilets, however, may not be enough to save India’s children.

Phool Mati lives in a neighborhood in Varanasi with 12 public toilets, but her 1-year-old grandson, Sandeep, is nonetheless severely malnourished. His mother tries to feed him lentils, milk and other foods as often as she can, but Sandeep is rarely hungry because he is so often sick, Ms. Mati said.

“We all use the bathroom,” she said.

The effluent pipe that served the bathroom building is often clogged. Raw sewage seeps into an adjoining Hindu temple, and, during the monsoon season, it flooded the neighborhood’s homes. The matron of the toilet facility charges two rupees for each use, so most children relieve themselves directly into open drains that run along a central walkway.

Much of the city’s drinking water comes from the river, and half of Indian households drink from contaminated supplies.

“India’s problems are bigger than just open defecation and a lack of toilets,” Dr. Laxminarayan said.

When determining the efficacy of social programs, one must consider both supply and demand side factors:

Supply Side — Investment in public toilets, clean water / sanitation infrastructure.

Demand Side — People in India do not seem to think funding for sanitation is a priority. An Educational / media / social media campaign to increase demand is required alongside greater investment (supply side). Furthermore, even a small fee can be enough to discourage toilet use when an alternative (public defecation) exists, particularly in a country such as India where extreme poverty makes such fees prohibitory to society’s most vulnerable.

My World 2015 survey results show global demand for nutritious foods and sanitation / clean water at roughly same priority level across level development / education level–this is clearly not the case in India.

In a democracy such as India, supply side impediments can sometimes be caused by (or blamed on) inadequate demand (voters do not think the issue is important). Therefore, people must be better educated about the costs of open defecation and benefits of modernized sanitation systems.

There are temporal / necessity reasons that nutritional support receives such greater attention and resources compared to sanitation support. There is no substitute for food–without food, people die relatively quickly (typically 10-14 days). One can always defecate in public, with little immediate risk to their health (although, as the article highlights, there are real health problems and externalities associated with public defecation).

Furthermore, compared to food delivery, the upfront costs associated with sanitation infrastructure may seem very high (even if, as the article proposes, these costs “pay for themselves” in the long run). One potential solution could be the proliferation of composting toilets, which do not need to be attached to plumbing systems.

Sanitation is, of course, not a substitute for nutritious / vitamin fortified foods. Even with perfect sanitation services, people can still go hungry / be malnourished. They are compliments; investing in sanitation yields greater returns on investments in nutrition, education, etc. Public resources must more closely reflect that (reduce the 60:1 discrepancy).

For example, providing school meals has been a popular program in developing countries, meant to improve attendance rates. But the ultimate goals of education, human development and social mobility,  are decidedly less effective if parasites and infections divert nutrients from cognitive / physical development towards survival.

This article highlights a general realization in the field of development economics, the need for a context-sensitive, human rights based approach to poverty alleviation and human development.

Without taking into consideration cultural attitudes towards public defecation present in India (but not in many other developing countries), and providing a wide variety a basic services (sanitation, nutritional support, healthcare, education, etc.–a human rights based approach to development that recognizes human rights violations as interconnected), the malnutrition epidemic in India might never improve, regardless of the amount of resources dedicated to nutritional support alone.

The situation in India also presents an prime opportunity for information sharing, what those in the field of development call “South-South cooperation“. This concept is simple; by sharing experiences of what has worked (and failed) in other developing countries, a country may be able to avoid common policy mistakes (and the subsequent misallocation of scarce financial resource). At first this may seem antithetical to a context sensitive approach to human development, but it is not. While lessons learned from other countries through south-south cooperation must be amended to reflect the context of the country considering them (in this case India), this does not mean that there is not real value in the information shared through South-South cooperation.

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Economic Outlook: Shortsighted Austerity

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In the aftermath of the global economic crisis, more than 70 per cent of the world population is without proper social protections, the United Nations labour agency today reported, urging governments to scale up investment in child and family benefits, pensions and other public expenditures.

“The global community agreed in 1948 that social security and health care for children, working age people who face unemployment or injury and older persons are a universal human right,” said Sandra Polaski, Deputy Director-General of the International Labour Organization (ILO).

“And yet in 2014 the promise of universal social protection remains unfilled for the large majority of the world’s population.”

As many as 122 governments are contracting public expenditures in 2014, of which 82 are developing countries, according to the findings of the World Social Protection Report 2014/15: Building economic recovery, inclusive development and social justice.

“The case for social protection is even more compelling in these times of economic uncertainty, low growth and increased inequality,” Ms. Polaski added, noting that it is also an issue that the international community should embrace prominently in the development agenda following the Millennium Development Goals deadline in 2015.

At the beginning of the 2008-2009 economic crisis, at least 48 high- and middle-income countries put in place stimulus packages totalling $2.4 trillion that devoted roughly a quarter to social protection measures.

But from 2010 onwards, many governments reversed course and embarked prematurely on fiscal consolidation, despite the urgent need to continue supporting vulnerable populations and stabilizing consumption.

In the European Union, cuts in social protection have already contributed to increases in poverty which now affect 123 million people or 24 per cent of the population, many of whom are children, women, older persons and persons with disabilities, the ILO reported.

The report also shows that about 39 per cent of the world population lacks any affiliation to a health system or scheme. The number reaches more than 90 per cent in low-income countries.

The report also highlights the cases of Thailand and South Africa, which have achieved universal health coverage in just a few years, showing that it can be done.

“It is now a matter of political will to make it a reality. Modern society can afford to provide social protection,” Ms. Polaski stated.

Macroeconomic Implications:

The Macroeconomic implications of premature austerity are fairly straightforward. Keynesian national income accounting tells us that insufficient private demand can be compensated for with increased public spending (Y = C + I + G + M-X). For the world as a whole, net exports (X-M) are, by definition, 0. Therefore, when global private demand (consumption, “C”) goes down, it can be compensated for by only be increasing stimulus spending (or cutting taxes, but the economic multiplier of tax cuts is lower than for stimulus spending, especially in a liquidity trap when even near zero interest rates are insufficient to stimulate private demand to full employment levels).

If C and G are both insufficiently low, we get dangerously close to deflation–something almost every modernized economy is aggressively trying to avoid at the moment. High levels of debt and deflation causes a vicious economic cycle, where government spending cuts results in a higher level of “real” debt (even though the gross number associated with debt is reduced, the real value of that debt–what it can buy–goes up). This is one of the things that made the Great Depression so painful for so many people; as the programs that would have helped them were cut, the countries fiscal position worsened, leading to further cuts.

Microeconomic Implications:

It is the effect on people, on human development, that we truly care about here at Normative Narratives. In the context of high unemployment, one could see how cutting welfare programs, government jobs, etc. could be particularly painful on already vulnerable groups. I would need to conduct more in depth analysis of specific cuts in specific countries to speak on exactly how these cuts have negatively impacted people. The report highlights high unemployment and lack of access to healthcare as specific impacts of premature austerity movements.

One human rights violation opens the way for others, often resulting in [extreme] poverty. For example, without access to safe drinking water or sanitation services, people become sick. Lack of access to healthcare can cause a person to lose their job. Lack of access to a quality job means a person is reliant on personal savings (which poor people tend not to have) and welfare programs (which, remember, are being cut). A shock or crisis that may result in a minor inconvenience for someone whose human rights are fulfilled can be catastrophic for those less fortunate. In Europe, the combination of high unemployment and austerity is resulting in a “lost generation” of potential, and that’s Europe! In places with extreme poverty, weak financial institutions, and unresponsive governance, the human costs of premature austerity are naturally greater.

While I think a basic income guarantee is probably fiscally unsustainable (and in a country like the U.S., politically impossible), I do strongly believe in government job guarantee programs. Anyone who is willing to work hard to make their community / city / state / country a better place should be able to make an honest living doing so (just as anybody who is willing to defend U.S. national security can get a job in the military). Of course this would require greater levels of taxation and public spending, not less.

The combination of corporate income tax minimization (from “inversion“, off-shore tax dodging, and government subsidies / tax breaks / and other loopholes in tax codes) and companies forgoing workers for capital is unsustainable–companies are reaping record after tax profits while people suffer without having their basic rights fulfilled. As a result, tax reform and guaranteed public employment must figure more prominently in future political economy debates and policies.


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Conflict Watch: Hard Power, Soft Power, and Sustainable Human Development

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The Importance of Soft Power:

May 3rd marked World Press Freedom Day, during which high ranking UN officials recognized the important roles that freedom of expression, press, and access to information play in the development process:

The United Nations is marking World Press Freedom Day today with an appeal to all States, societies and individuals to actively defend press freedom as a fundamental right and as a critical contribution to achieving and sustaining the Millennium Development Goals (MDGs).

This call was made in a joint message by Secretary-General Ban Ki-moon and Irina Bokova, Director-General of UN Educational Scientific and Cultural Organization (UNESCO), who said UN bodies are already working together and with other partners under UNESCO’s leadership to create a free and safe environment for journalists and media workers around the world.

Their message goes on to stress that this year, the international community has a once-in-a-generation opportunity to prepare a long-term agenda for sustainable development to succeed the MDGs when they end in 2015.

“Successfully implementing that agenda will require that all populations enjoy the fundamental rights of freedom of opinion and expression, the officials said, underscoring that those rights are essential to democracy, transparency, accountability and the rule of law. “They are vital for human dignity, social progress and inclusive development.”

Also marking the Day, 31 specialists from the largest body of independent experts in the UN Human Rights system called on all Governments to promote and protect the rights to freedom of expression and information, freedom of peaceful assembly, and freedom of association and public participation.

Protection of these fundamental freedoms is essential for full realization of all human rights for all and for the achievement of related development goals. “States must develop more inclusive political processes and allow the media to play a key role in guaranteeing the right of everyone…to freely access information and engage in meaningful development related discourse.”

The experts, known as Special Procedures of the Human Rights Council, comprise the Organization’s largest body of independent fact-finding and monitoring mechanisms that address either specific country situations or thematic issues in all parts of the world.

“Without free media to advocate for and monitor the implementation of the new set of post-2015 targets, there can be no real development for all marginalized, vulnerable or discriminated against. Not now, not ever,” declared the experts.

Mr. Ban said that every day of the year, the fundamental freedom to receive and impart ideas through any media is under assault, “to the detriment of us all.” Indeed, journalists are being singled out for speaking or writing uncomfortable truths – kidnapped, detained, beaten and sometimes murdered.

“Such treatment is completely unacceptable in a world ever more reliant on global news outlets and the journalists who serve them,” said the UN chief.

He told the briefing that last year, 70 journalists were killed; many caught in the cross-fire of armed hostilities. Fourteen more have suffered the same fate this year. Also last year, 211 journalists were being held in prison. Some 456 journalist have been forced into exile since 2008. And since 1992, well over 1,000 journalists have been killed – nearly one per week.

As for the post-2015 agenda, he said free media, traditional and new, are indispensable for development. They can promote transparency about the new goals that Member States will adopt – progress as well as shortfalls. “Social media and mobile technologies offer new tools for accelerating citizen participation and economic and social progress,” he said, adding that the media’s watchdog function is essential for holding Governments, businesses and others to account.

Echoing those sentiments, John Ashe, President of the UN General Assembly, said freedom of expression and freedom of the press are fundamental rights that form an essential pillar of democratic societies. “When journalists are able to report freely, they support informed citizen participation in political and social processes and promote civic engagement,” he added.

The Limits of Soft Power:

Access to information can combat corruption, fuel populism, and give a voice to the voiceless; the role press freedom in sustainable human development cannot be understated.

However, as much as it pains me to admit it, there are limitations to what “soft power” can achieve. A free press essentially acts as a “spotlight” on abuses of power and social injustices. There are forces that are directly opposed to “Westernization” or “Modernization”; against such forces, shining a “spotlight” is almost entirely ineffective.

An example of such targeted violence is currently playing out in Nigeria, where Boko Haram terrorists (loosely translated to “Western education is a sin”) last month kidnapped over 200 schoolgirls:

These girls, ages 15 to 18 and Christians and Muslims alike, knew the risks of seeking an education, and schools in the area had closed in March for fear of terror attacks. But this school had reopened so that the girls — the stars of their families and villages — could take their final exams. They were expected to move on to become teachers, doctors, lawyers.

Instead, they reportedly are being auctioned off for $12 each to become “wives” of militants. About 50 girls escaped, but the police say that 276 are still missing — and the Nigerian government has done next to nothing to recover the girls.

“We are now asking for world power countries to intervene,” the desperate father of a missing 18-year-old girl, Ayesha, told me by phone. He said that the parents had given up on Nigerian government officials — “they are just saying lies” — and pleaded for international pressure on Nigeria to rescue the girls.

If the girls aren’t rescued, “no parent will allow their female child to go to school,” Hadiza Bala Usman, who has led protests in Nigeria on behalf of the missing girls, warned in a telephone interview.

The best tool to fight extremism is education, especially of girls — and that means ensuring that it is safe to study. The greatest threat to militancy in the long run comes not from drones but from girls with schoolbooks.

More than 200 teenage girls have just been enslaved because they had the brains and guts to seek to become teachers or doctors. They deserve a serious international effort to rescue them.

According to Modernization theory, democratization and other rights based movements are the result of civil society initiatives, which occur when large portions of society become empowered via human capital investment. If people believe they will become targets for embracing “Western” ideals, and that they will not be protected, they will be less inclined to invest in their futures, stymieing modernization efforts.

To be clear, the sort of security that enables human capital investment comes from police forces, peacekeepers, and armies that are accountable to their people, not by international forces dropping bombs / drone strikes, which actually fuels radical sentiments.

Synergy Between Soft and Hard Power:

In the field of poverty reduction / economic development, it has long been recognized that peace and security are necessary preconditions for sustainable human development. As advances in information and communication technology and improvements in good governance theories shift the focus towards “soft power”, we must not forget the important role that basic security plays in sustainable human development. This is not an either or issue, but a question of finding the right balance between these two synergistic forms of assistance.

While national governments are the primary human rights duty bearers, in the developing world many governments lack the capacity to provide even basic security / public goods. The international community must compliment “good governance” via both “hard” and “soft” support.

Third World Injustices Result In First World Problems:

When discussing injustices in the developing world, people often say (with varying degrees of indifference) “why should I care?”. If the moral / ethical reasons do not get you, there are “selfish” reasons to promote sustainable human development.

Essentially, sustainable human development it is the only way to reverse trade imbalances and the flow of jobs being outsourced to the developing world. Maybe you do not care about people in other countries, but you probably care about having a job and the general state of your countries economy.

If the “Great Recession” has tough us anything, its that we cannot financially innovate our way to prosperity in an increasingly divergent global economy–it does not work for 99% of us even in the developed world! Only through partial global economic convergence can the majority of people in the developed world hope for “a better future”.

In a blog a few months ago, I ran into an interesting study called “I’m The Guy You Pay Later“; written by law enforcement officials, it argues that money not invested in early childhood education ends up being spent on the back-end on criminal justice expenditures. I can’t help but recognize similarities in the debate over official development assistance (ODA); we can support “good governance” now, or pay the prices later (unsustainable levels of military spending / related underinvestment in other aspects of our economy, the decline of living-wage jobs / high unemployment, etc.).

Another argument against ODA is that it is never effective–this is simply not true. ODA (both “soft” and “hard”), when complimenting “good governance” domestic resource mobilization in the developing world (natural resource revenue accountability, stemming illicit financial outflows, tax system reforms) can help finance the various programs (at all levels; global, regional, national, state, local) the vast majority of people in both the developed and developing worlds need.