It’s time to talk openly about sanitation

end open defecation
A group of Nigerian students call for an end to open defecation. Source: Concern Universal

Today is World Toilet Day, “a day to raise awareness about all people who do not have access to a toilet.” This year marks the second time that that United Nations has recognized this event.

Now, some may find it odd that the world’s supranational governing body would devote an entire day to the symbol of sanitation, a topic which two British scholars said “is not..inherently attractive or photogenic.” That is surely the understatement of the century.

For most of us in the developed world, sanitation is not only an afterthought, it is taboo. Anthropologist Horace Mitchell Miner famously satirized America’s aversion for discussing sanitation in his 1956 article “Body Ritual among the Nacirema.” (Nacerima is American spelled backwards.) In his article, Miner wrote,

The fundamental belief underlying the whole system appears to be that the human body is ugly and that its natural tendency is to debility and disease. Incarcerated in such a body, man’s only hope is to avert these characteristics through the use of ritual and ceremony. Every household has one or more shrines devoted to this purpose…While each family has at least one such shrine, the rituals associated with it are not family ceremonies but are private and secret. The rites are normally only discussed with children, and then only during the period when they are being initiated into these mysteries.

Sanitation is taboo; we are not to discuss it in public. If we do discuss it in public, it is only to be in a joking manner. There’s a reason we call things “potty humor.” But the distance that Americans and residents of other developed countries have placed between themselves and their bodily functions was never a given. In fact, it appears to be a product of our affluence. It’s a lot easier to avoid discussing sanitation when you have a Water Sense-certified flush toilet inside a full bathroom with travertine tile floors and double sinks than when you have to defecate openly in a field or ditch. And, tragically, this remains a daily reality for 1.1 billion people.

The water and sanitation crisis affects poor people who live in poor countries — not exactly the constituency that drives global policy discussions. The majority of people who lack access to improved sanitation live on less than $2 per day.

Access to proper sanitation has supported much of human and economic development throughout history. Archaeologists have found evidence of water pipes and toilets in the remains of Mohenjo-Daro, a city built by the Indus Valley Civilization in around 2600 BC that is located in modern-day Pakistan. Many ancient civilizations developed large and complex water infrastructure, particularly the Romans. Wherever they went, the ancient Romans designed intricate networks of aqueducts, pipes, fountains, and baths to deliver water to towns and cities and remove the associated wastewater. The Cloaca Maxima allowed Roman engineers to drain the marshes along the Tiber River, which facilitated the growth of the city of Rome. Subsequently, this “greatest sewer” became the backbone of the most elaborate wastewater system the world had ever seen.

While neither the Romans nor Greeks had the means or know-how to really eliminate the impacts of poor sanitation, their complex waterworks demonstrated clearly their political and engineering prowess. But these systems did not come cheap, and they required constant, diligent upkeep. Calcium carbonate incrustation regularly threatened to stop the flow of water through the aqueducts unless they were cleaned. But as the centralized Roman empire began to fall apart by the fourth century AD, so too did the imperial bureaucracy that performed such maintenance. Beginning in the medieval period, Europeans lost the sanitation systems that Roman subjects had enjoyed. As one group of scholars noted, this period represented “a move from luxuria to necessitas.”

It was not until the 19th century, when the combination of urbanization, industrialization, and the rise of Enlightenment ideals combined to facilitate the development of modern water and sanitation systems. In the interim, Europeans suffered through one wave of waterborne diseases after another. It’s no coincidence that many attribute the rise of modern public health to John Snow’s Broad Street pump experiment, which helped prove that London’s continued cholera outbreaks stemmed not from breathing dangerous “miasmas,” but from contaminated water supplies.

By the beginning of the 20th century, the Western world had begun to filter and then chlorinate its water supplies, helping to relegate the scourge of water-related illnesses to the trash bin of history. We may not think about this history when using the “facilities” today, but there can be no question that the sanitation revolution helped facilitate the modern world in which we live today.

There’s a reason that the British Medical Journal named the sanitation revolution the greatest medical advance in the world since 1840. The introduction of water purification practices account for nearly half of all mortality reductions in the United States during the first third of the 20th century. At the turn of the century, 40% of schoolchildren in the American south suffered from hookworms, a water-related parasite. Its eradication through improved sanitation and medication boosted school enrollment, attendance, and literacy rates. And evidence suggests that sanitation investments in the 1880s increased British life expectancy 15 years by 1920.

But this sanitation revolution has not trickled down to everyone. Despite decades of economic growth and a significant reduction in global poverty, approximately 2.5 billion people still lack access to improved sanitation facilities. In India, which accounts for 60% of all people who practice open defecation, more people have access to mobile phones than toilets. Economic growth pulled more than 180 million Indians out of extreme poverty since 2000. In contrast, the percentage of Indians practicing open defecation only fell to 53% in 2010 from 63% in 1998, an increase of 3 million people due to population growth.

We need to abandon the notion that economic growth will solve the sanitation crisis in the developing world. In fact, it may very well be that the lack of adequate sanitation is holding back economic growth. According to the World Bank, per capita GDP growth rates in low-income countries with adequate sanitation are significantly higher (3.7% per year) than in those without such access (0.1%).

Worldwide, the costs of inadequate sanitation are staggering. The combined health costs, lost time and productivity, and premature mortality total more than $260 billion. On average, inadequate sanitation costs developing countries 1.5% of their GDP. This number is 3.9% in Pakistan. There’s a certain perverse irony that modern Pakistanis living around Mohenjo-Daro have similar sanitation options as their ancestors from 4,500 years ago.

This is why World Toilet Day matters. It provides a clarion call to the need for action on this staggering problem. The sanitation crisis is not a given; it is “is manufactured through political processes and institutions that disadvantage the poor,” as UNDP argued.

The deleterious impacts of poor sanitation are as severe as they are varied. It has created a health crisis. The World Health Organization notes that water-related illnesses account for 10% of the global burden of disease. If everyone had access to property hygiene practices and adequate water and sanitation facilities, we could avoid 2.4 million premature deaths per year. The impacts are particularly acute for children. Diarrheal diseases are the second leading cause of child mortality, killing more than 760,000 children under the age of 5 annually. They also leave children susceptible to a variety of other ailments, including respiratory infections and malnutrition. Evidence suggests that open defecation explains nearly two-thirds of the international variation in child height. All told, poor sanitation kills more children each year than HIV/AIDS, tuberculosis, and malaria combined.

Sanitation is also a women’s rights issue. Open defecation leaves women and girls highly vulnerable to physical and sexual violence. In May, two girls in the Indian state of Uttar Pradesh were raped, beaten, and murdered. Women took to the streets throughout the country, arguing that the girls would have been safe if they had just had access to a toilet.

Most importantly, sanitation is a fundamental human rights issue. In 1923, Gandhi said “sanitation is more important than independence.” He was right. But it’s more than that. Sanitation is independence. People are not lacking access to sanitation because we lack the resources or the technologies to deliver it to them. They lack it because of our political choices. They lack it because we don’t pay attention to the issue. They lack it because the international community focuses on the crisis du jour.

As UNDP wrote,

Water, the stuff of life and a basic human right, is at the heart of a daily crisis faced by countless millions of the world’s most vulnerable people—a crisis that threatens life and destroys livelihoods on a devastating scale. Unlike wars and natural disasters, the global crisis in water does not make media headlines. Nor does it galvanize concerted international action. Like hunger, deprivation in access to water is a silent crisis experienced by the poor and tolerated by those with the resources the technology and the political power to end it. Yet this is a crisis that is holding back human progress, consigning large segments of humanity to lives of poverty, vulnerability and insecurity.

So the next time you use a toilet, be thankful that you had that opportunity. But don’t stop there. Talk about sanitation. Tell your family members, your friends, your colleagues. We cannot guarantee the human right to sanitation if we continue to treat it as a taboo.