Open Defecation in India: A Major Health Hazard and Hurdle in Infection Control

Sir,

“Cleanliness is next to Godliness”, a proverbial adage that traces its inception to ancient Indian times, is the epitome of irony in the current Indian health situation. The lost Indus Valley Civilization, with modern cities like Harappa and Mohenjodaro, was once the gold standard of sanitation infrastructure. Its extensive and efficient sewage system was not only an exemplary gem, but also a gift of knowledge to entire mankind. However history resides in books and has little relevance to the current situation.

Though over the last 50 years, the general health of Indians has improved and the life expectancy has increased, myriad health and sanitation problems still stare one in the face. The biggest one, open defecation, is the mother of all infection and morbidity. The WHO declared the year 2008 as International Year of Sanitation. It was here that the term ‘Open Defecation’ was widely publicized. Community Led Total Sanitation (CLTS) programs helped spread the term all around the globe.

It is a matter of national concern as India has the most number of people practicing open defecation in the world, around 600 million [1], and is followed by Indonesia, Pakistan, Nigeria and Ethiopia. Still these countries come nowhere close to the staggering number contributed by India.

Most of it occurs in villages with a prevalence of 65% [2]. In urban settings the prevalence is close to 16%. The problem has thick deep roots with a multi-factorial origin. Unavailability of proper toilets or toilets with dimly lit, broken or clogged latrines is common. However, the biggest problem is the mindset of people in both rural and urban settings. Children grow watching parents and grandparents practice open defecation. Most farmers believe that waking up early and defecating in the field, not only adds natural fertilizer to the soil, but also rejuvenates the bowel and the mind.

Open defecation is a major cause of fatal diarrhea. Everyday about 2000 children aged less than five succumb to diarrhea and every 40 seconds a life is lost [3]. It is depressing that all this needless suffering is actually preventable. In densely populated countries like India, the health impact is magnified many fold [4]. There is evidence to suggest that water sanitation and hygiene practices are associated with child linear growth [5]. Children have a tendency to put common things in their mouth. In rural settings where open defecation is prevalent, large amounts of fecal pathogens via human and animal feces, are ingested by children. This creates a massive reservoir of bacteria, parasites and viruses that keep spreading gastrointestinal infection. An eventual result is growth stunting and malnutrition.

Though the health challenges seem to compound with time, the health budget allocation by the Government of India is getting smaller every year. This year also it is quite meager, only about 1% of the Gross Domestic Product. This may put financial constraints on dealing with sanitation linked diseases.

In 2013, the United Nations brought world attention to “Open Defecation” for the first time and World Toilet Day was celebrated. The UN has vowed to eliminate open defecation from the globe before 2025. In India, the largest contributor of open defecation to the world, widespread concern about abysmal sanitation practices is being slowly raised as well. An incident in Badaun district, where two teenage sisters who ventured out to defecate due to lack of a private toilet, were raped and murdered, stimulated the masses into anger and dissent. Investigating authorities admitted that 95% of all rapes in India occur when girls go out alone in secluded places, to urinate or defecate. Delinquent men have been known to cluster at such locations, awaiting helpless victims. Similar situation exists in many African countries like Kenya, Zimbabwe and Somalia. Thus, a direct correlation between crime and open defecation seems to exist.

The Government can employ a carrot and stick policy; incentives for building and using toilets and strict penalty if found openly defecating. A multipronged attack at the problem is essential and the Indian media has to play a key role in disseminating information. A vital driving force remains the political will. The incredulous rural population in India is the largest vote bank that determines fate of governments periodically. Lofty promises to eradicate open defecation and establish exemplary sanitation infrastructure have been made on several occasions before. But the problem has only gott worse. Health programs have failed mostly due to a waning momentum and lack of a true belief in the objective.

In order to reach maximum people, the government should explore collaborations with public and private sector organizations that function at the primary level to bring about behavioural change. Health schemes and demerits of open defecation should be advertised clearly on national media channels. Technological options, like self sustaining personal toilets should be explored. Leading think tanks should be encouraged to come up with ingenious and novel ways to curb the problem.

Wary of the burgeoning health threat, newly elected Prime Minister Narendra Modi, launched the nationwide ‘Clean India Mission’, literally with a broom in hand. The government’s promise of “Toilets First, Temples Later” is the call of the hour, in a country where religion is a synonym of fanaticism and where health and hygiene often take a back seat. The movement plans to galvanize 3 million government workers and students to salvage the health of the country. The goal is to create a clean India before Mahatma Gandhi’s 150^th birthday in 2019. Nearly 800 million toilets with extensive sewage systems are to be built. The campaign aims to construct 17 million toilets a year to achieve its tall ambition. The World Bank estimates takes about 6-8 months to convince a village to adopt toilets and give up open defecation. In the CLTS concept, a village can be declared ‘Open Defecation Free”, if all its denizens use toilets regularly. Thus an intervention at the psyche of the people is required. Support from WHO, UNICEF and financial aid from private organizations, seems to show that India is finally making the right noises at the world health stage. Wealth without health is of little consequence. Though India is emerging as an economic power, the overall health of the nation will be a useful barometer to gauge its true developmental progress. Putting an end to the menace of open defecation, requires a mass effort with a personal vendetta. Shying away complaining is no more an option. The National ‘Clean India Movement”, with a deadline of 2019, requires all citizens to get their hands dirty in order to clean the country. Exactly how this concerted effort pans out, remains to be seen.

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