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• In 2022, 57% of the global population (4.6 billion people) used a safely managed sanitation service.
• Over 1.5 billion people still do not have basic sanitation services, such as private toilets or latrines.
• Of these, 419 million still defecate in the open, for example in street gutters, behind bushes or into open bodies of water.
• In 2020, 44% of the household wastewater generated globally was discharged without safe treatment (1) .
• At least 10% of the world’s population is thought to consume food irrigated by wastewater.
• Poor sanitation reduces human well-being, social and economic development due to impacts such as anxiety, risk of sexual assault, and lost opportunities for education and work.
• Poor sanitation is linked to transmission of diarrhoeal diseases such as cholera and dysentery, as well as typhoid, intestinal worm infections and polio. It exacerbates stunting and contributes to the spread of antimicrobial resistance.

According to the latest WASH-related burden of disease estimates , 1.4 million people die each year as a result of inadequate drinking-water, sanitation and hygiene. The vast majority of these deaths are in low- and middle-income countries. Unsafe sanitation accounts for 564 000 of these deaths, largely from diarrhoeal disease, and it is a major factor in several neglected tropical diseases, including intestinal worms, schistosomiasis and trachoma. Poor sanitation also contributes to malnutrition.

Diarrhoea remains a major killer but is largely preventable. Better water, sanitation, and hygiene could prevent the deaths among children aged under 5 years, 395 000 in the year 2019.

Open defecation perpetuates a vicious cycle of disease and poverty. The countries where open defection is most widespread have the highest number of deaths of children aged under 5 years as well as the highest levels of malnutrition and poverty, and big disparities of wealth. 

Benefits of improving sanitation

Benefits of improved sanitation extend well beyond reducing the risk of diarrhoea. These include:

• reducing the spread of intestinal worms, schistosomiasis and trachoma, which are neglected tropical diseases that cause suffering for millions;
• reducing the severity and impact of malnutrition;
• promoting dignity and boosting safety, particularly among women and girls;
• promoting school attendance: girls’ school attendance is particularly boosted by the provision of separate sanitary facilities;
• reducing the spread of antimicrobial resistance;
• potential safe recovery of water, nutrients and renewable energy from wastewater and sludge; and
• potential to increase overall community resilience to climate shocks, for example  through safe use of wastewater for irrigation to mitigate water scarcity.

A WHO study in 2012 calculated that for every US$ 1.00 invested in sanitation, there was a return of US$ 5.50 in lower health costs, more productivity and fewer premature deaths.

In 2013, the UN Deputy Secretary-General issued a call to action on sanitation that included the elimination of open defecation by 2025. The world is on track to eliminate open defecation by 2030, if not by 2025, but historical rates of progress would need to double for the world to achieve universal coverage with basic sanitation services by 2030. To achieve universal safely managed services, rates would need to increase five-fold.

The situation in urban areas, particularly in dense, low income and informal areas, is a growing challenge as sewerage is precarious or non-existent, space for toilets is at a premium, poorly designed and managed pits and septic tanks contaminate open drains and groundwater and services for faecal sludge removal are unavailable or unaffordable. Inequalities are compounded when sewage discharged into storm drains and waterways pollutes poorer low-lowing areas of cities. The effects of climate change – floods, water scarcity and droughts, and sea level rise – is setting back progress for the billions of people without safely managed services and threatens to undermine existing services if they are not made more resilient.

Wastewater and sludge are increasingly seen as a valuable resource in the circular economy that can provide reliable water and nutrients for food production and recovered energy in various forms. In fact, use of wastewater and sludge is already commonplace, but much is used unsafely without adequate treatment, controls on use or regulatory oversight. Safe use that prevents transmission of excreta-related disease is vital to reduce harms and maximize beneficial use of wastewater and sludge.

In 2019 UN-Water launched the SDG6 global acceleration framework (GAF). On World Toilet Day 2020, WHO and UNICEF launched the  State of the world’s sanitation  report laying out the scale of the challenge in terms of health impact, sanitation coverage, progress, policy and investment and also laying out an acceleration agenda for sanitation under the GAF.

WHO response

In 2010, the UN General Assembly recognized access to safe and clean drinking water and sanitation as a human right and called for international efforts to help countries to provide safe, clean, accessible and affordable drinking-water and sanitation. Sustainable Development Goal target 6.2 calls for adequate and equitable sanitation for all and target 6.3 calls for halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse.

As the international authority on public health, WHO leads global efforts to prevent transmission of diseases, advising governments on health-based regulation and service delivery. On sanitation, WHO monitors global burden of disease (SDG 3.9) and the level of sanitation access and wastewater treatment (SDG 6.2, 6.3) and analyses what helps and hinders progress (SDG 6a, 6b and GLAAS). Such monitoring gives Member States and donors global data to help decide how to invest in providing toilets and ensuring safe management of wastewater and excreta.

WHO works with partners on promoting effective risk assessment and management practices for sanitation in communities and health facilities based on evidence and tools including WHO guidelines on sanitation and health, safe use of wastewater, recreational water quality and promotion of sanitation safety planning and sanitary inspections, and through communities of practice such as RegNet and the sanitation workers initiative. WHO also supports   collaboration between WASH and health programmes where sanitation is critical for disease prevention and risk reduction including neglected tropical diseases, cholera, polio and antimicrobial resistance, and environmental surveillance of pathogens.   Aspects of climate resilience are incorporated in all WHO sanitation guidance documents.

• UN Habitat and WHO, 2021. Progress on wastewater treatment – Global status and acceleration needs for SDG indicator 6.3.1. United Nations Human Settlements Programme (UN-Habitat) and World Health Organization (WHO), Geneva.
• Progress on household drinking water, sanitation and hygiene 2000–2022: special focus on gender. New York: United Nations Children’s Fund (UNICEF) and World Health Organization (WHO), 2023. https://washdata.org/reports/jmp-2023-wash-households
• State of the world's sanitation: An urgent call to transform sanitation for better health, environments, economies and societies
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• Sanitation safety planning
• Sanitary inspection packages
• Technical brief on water, sanitation, hygiene (WASH) and wastewater management to prevent infections and reduce
• Guidelines for the safe use of wastewater, excreta and greywater
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• WASH and health working together: a how-to guide for Neglected Tropical Disease programmes  
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• Implications of recent WASH and nutrition studies for WASH policy and practice

Open WHO self-paced course on safely managed sanitation

Progress on household drinking-water, sanitation and hygiene 2000-2022: Special focus on gender

Strong systems and sound investments: Evidence on and key insights into accelerating progress on sanitation, drinking-water and hygiene

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Open defecation

Open defecation Eliminating open defecation, a practice strongly associated with poverty and exclusion, is critical to accelerating progress towards the Millennium Development Goal (MDG) sanitation target. Open defecation perpetuates the vicious cycle of disease and poverty and is an affront to personal dignity.

Those countries where open defecation is most widely practised have the highest numbers of deaths of children under the age of five, as well as high levels of undernutrition, high levels of poverty and large disparities between the rich and poor. There are also strong gender impacts: lack of safe, private toilets makes women and girls vulnerable to violence and is an impediment to girls’ education.

In March 2013, the Deputy Secretary-General of the United Nations issued a call to action on sanitation that included the elimination of the practice of open defecation by 2025.

• More than one third of the global population – some 2.5 billion people — do not use an improved sanitation facility, and of these 1 billion people still practice open defecation.
• Where efforts are made, progress is possible. Between 1990 and 2012, open defecation decreased from 24% to 14% globally. South Asia saw the largest decline, from 65% to 38%. Some countries stand out as examples. Efforts undertaken in Ethiopia have seen a decrease from 92% to 37%. Cambodia and Nepal have experienced similar declines.
• Globally, open defecation remains a predominantly rural phenomenon: 902 million people in rural areas, more than a quarter of the rural population, still practise open defecation, and 9 out of 10 people who practise open defecation live in rural areas.
• India continues to be the country with the highest number of people (597 million people) practising open defecation.
• Where women must defecate in the open, they run the risk of sexual assault or rape. Lack of access to adequate, private sanitation, especially during menses, often leads women to leave education, which limits their opportunities for work and self-determination.

>> Access to a selection of UN publications on open defecation

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The elimination of open defecation and its adverse health effects: a moral imperative for governments and development professionals

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Duncan Mara; The elimination of open defecation and its adverse health effects: a moral imperative for governments and development professionals. Journal of Water, Sanitation and Hygiene for Development 1 March 2017; 7 (1): 1–12. doi: https://doi.org/10.2166/washdev.2017.027

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In 2015 there were 965 million people in the world forced to practise open defecation (OD). The adverse health effects of OD are many: acute effects include infectious intestinal diseases, including diarrheal diseases which are exacerbated by poor water supplies, sanitation and hygiene; adverse pregnancy outcomes; and life-threatening violence against women and girls. Chronic effects include soil-transmitted helminthiases, increased anaemia, giardiasis, environmental enteropathy and small-intestine bacterial overgrowth, and stunting and long-term impaired cognition. If OD elimination by 2030 is to be accelerated, then a clear understanding is needed of what prevents and what drives the transition from OD to using a latrine. Sanitation marketing, behaviour change communication, and ‘enhanced’ community-led total sanitation (‘CLTS + ’), supplemented by ‘nudging’, are the three most likely joint strategies to enable communities, both rural and periurban, to become completely OD-free and remain so. It will be a major Sanitation Challenge to achieve the elimination of OD by 2030, but helping the poorest currently plagued by OD and its serious adverse health effects should be our principal task as we seek to achieve the sanitation target of the Sustainable Development Goals – indeed it is a moral imperative for all governments and development professionals.

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Taking the Toilet Challenge Resolving Open Defecation Continues to Confound the World

Written By Ken Walker of InChrist Communications

12 minute read • May 18, 2021

In a previous special report entitled “ Fight Against Open Defecation Continues , ” we discussed the need for a caring response from the world to the problem of open defecation (OD) —a worldwide health crisis. In this report, I highlight ongoing long-term progress, while also contrasting the continuing challenges this issue presents to much of the developing world.

Why are Bill and Melinda Gates Spending $200 Million on Toilets?

Prof. Ravi V. Bellamkonda, "Advancing technologies for public health..." Photo by Duke University, Pratt School of Engineering

In regard to government funding and foundation grants, the $4.5 million awarded to Duke University last November represented a modest sum. Still, the stipend for Duke’s Center for Water, Sanitation, Hygiene and Infectious Disease (WaSH-AID) represented another small step in reducing open defecation by furthering testing of “reinvented toilets” and other hygienic technologies in the world’s neediest areas.

“We are grateful for the Bill & Melinda Gates Foundation’s investment in our (center) to lead collaboration with experts at Duke, across the industry and around the world to address this critical societal challenge,” said Ravi V. Bellamkonda, dean of the university’s school of engineering. “Advancing technologies for public health is particularly germane to control the spread of preventable diseases, and in this case also a fundamental human right—dignity.” 13

Symbolically, the award came on the eve of the tenth anniversary of the foundation’s “Reinvent the Toilet” challenge, which asked researchers to devise toilets that can sanitize human waste with no water, electricity, sewer or septic system. The waste treatment goals include cleaning the waste and reclaiming water to safe drinking standards and harvesting nutrients for other uses. That can be a game-changer for those living without sanitation.

Duke's WaSH-AID team focuses on the development of onsite waste treatment solutions to meet the needs of resource-constrained environments in many disadvantaged communities around the world, but also in parts of the United States, including North Carolina. Photo by Duke University, Center for WaSH-AID

About halfway into this initiative, one inventor produced a system called the Omni Processor. Although technically not a toilet, the Omni is an off-the-grid fecal sludge treatment plant that outputs purified water and may one day also produce electricity. A working prototype has been operating in Dakar, Senegal, in Africa, for a few years, with the latest version licensed to companies in countries including the U.S. and China. 14 Project director Brian Arbogast believes the technology will eventually influence sanitation in the developed world, such as green buildings, septic systems and off-the-grid cabins.

After spending a day at the foundation’s office in early 2019, a Business Insider reporter waxed enthusiastically about the toilet technology and other initiatives addressing such problems as extreme poverty, child mortality and malaria: “Hearing about their work was inspiring and gave me hope for the future ...” wrote Julie Bort. “And the reason is simple. These people are taking on some of the world’s hairiest, most complex and seemingly intractable problems. And they are winning.” 15

Some of the best solutions for communities in need of low-cost sanitation are just simple outdoor toilets like these built by GFA World to serve this entire snake charmer village in Uttar Pradesh.

A Formidable Problem: High-Tech or Low-Tech Solutions?

Not everyone is as impressed with the foundation’s efforts. Two years after the initiative’s unveiling, an environmental engineer whose business focuses on developing low-cost toilets said communities that desperately need sanitation will be unable to afford the advanced technology promoted by the initiatives.

We “should be investing more in low-tech rather than high-tech toilets,” said Jason Kass, founder of Toilets for People. “But high-tech solutions and research projects are sexier and more eye-catching, so they are more interesting for universities.” 16

The fact that in its first seven years the Gates Foundation invested $200 million in the toilet challenge demonstrates the formidable nature of ending open defecation. Yet it is a battle that must be waged.

Open defecation (OD)

is a disease-producing practice that contaminates drinking water and spreads diseases such as cholera, dysentery and diarrhea, which is particularly fatal among children. The incidence of such disease can disrupt young people’s education. In addition, females who engage in open defecation are more vulnerable to sexual violence.

The problem has generated widespread responses, such as India’s five-year-long Swachh Barat Abhiyan (“Clean India”) campaign that installed 110 million latrines by October 2019, with accompanying claims of success by Prime Minister Narenda Modi.

One of the NGOs helping PM Modi in this campaign is GFA World, which has worked tirelessly to help install over 32,000 toilets to date in some of the most remote and difficult-to-reach locations across South Asia.

total toilets installed to date in impoverished and remote locations all across South Asia.

In 2015, Chinese President Xi Jinping declared a “Toilet Revolution,” calling on local governments to improve sanitation in hopes of attracting more tourism since a bad “toilet landscape” had harmed the Asian giant’s image. 17

Open defecation is still a problem in Nigeria where over 46 million people defecate in the open and over 120 million people do not have a decent toilet. Photo by WaterAid Nigeria, Twitter

Not coincidentally, in November 2018 the city of Beijing played host to the “Reinvented Toilet Expo,” which Gates projects could create a $6billion-a-year market by 2030. Kinya Seto, the president of Japanese exhibitor LIXIL, said innovative companies have a golden opportunity to do well by doing good: “We can help jump-start a new era of sanitation for the 21st century by developing solutions that can leapfrog today’s existing infrastructure, functioning anywhere and everywhere.” 18

The latest nation to attack open defecation is Nigeria, where fewer than half the households have their own toilet. In 2016, the government launched an action plan aiming to end the practice by 2025 by providing equitable access to water, sanitation and hygiene services, and strengthening community approaches. However, three years later the government had failed to release funding for the initiative. In November 2018, with parts of the country facing high levels of water-borne diseases, President Muhammadu Buhari declared a state of emergency. 19

In West Bengal, a local GFA World pastor who identified needs of people in his community, including this woman and her child, was able to facilitate the construction of low-cost outdoor toilet to provide a safe, sanitary facility for her family. GFA World has helped to construct over 32,000 toilets to date in remote, impoverished communities throughout South Asia.

In Dimbroko, Cote d’Ivoire, Habitat for Humanity implemented a community-led pilot project to end open defecation. Habitat successfully worked with the government, private sector and community representatives to create sanitation facilities and promote proper hygiene practices. Photo by Habitat for Humanity, Ending Open Defecation in Cote d'Ivoire

Open Defecation Still Persists Worldwide, Even in America

While places like South Asia, Nigeria and Indonesia are noted for problems with open defecation, this poor health habit exists worldwide. In late 2019, the Pan American Health Organization (PAHO) said 15.5 million people in Latin America and the Caribbean are forced to practice open defecation. Calling it an “unhealthy practice,” PAHO official Marco Espinal said, “Improving access to water and sanitation through multisectoral policies and actions is critical to prevent disease and save lives.” 20

After attending the toilet expo in China, NPR reporter Katrina Yu noted that toilet innovations may be a hard sell in other countries.

Katrina Yu, NPR reporter Photo by Katrina Yu, Facebook

“Sanitation just isn’t sexy,” Yu wrote. “In fact, it stinks. According to the World Health Organization, governments, including many of those in Sub-Saharan Africa and Latin America, often neglect to consider safe sanitation when drawing up budgets and policies. ‘To have any hope of solving sanitation problems,’ said [Jim Yong] Kim of the World Bank, ‘we have to break taboos and get over our discomfort in talking about poop.’” 21

The public declarations against open defecation stretch back for two decades. The Singapore-based World Toilet Association established its special day in 2001, with the United Nations General Assembly officially declaring November 19 as World Toilet Day in 2013. The observance aims to inform, engage and inspire people to achieve the goal of ensuring the availability of clean water and sanitation for all by 2030.

15.5 million

people in Latin America and the Caribbean are forced to practice open defecation.

Yet as the UN and numerous governments, non-profits and non-governmental organizations (NGOs) work to eliminate the problem, it even exists on the streets of prosperous America. An October 2019 report by Environmental Justice said without sanitation when and where it is needed, the human right to sanitation for the homeless population has not been realized, leaving valid concerns about the risks of infectious disease transmission.

“The experience of Street Medicine physicians has yielded significant insight into how and why people experiencing homelessness resort to open defecation: the lack of public resources, perceptions about public toilets and the feelings of being unwelcome at them, concerns about safety, and physical and mental illness—including addiction—are all factors that contribute to OD,” the report said. 22

A family in Maharashtra received this low-cost outdoor toilet as recipients of GFA World's Christmas Catalog campaign to supply safe, private sanitation facilities to impoverished communities through South Asia.

The concerns raised by lack of access to sustainable sanitation and proper handwashing facilities have taken on new importance during the COVID-19 outbreak that engulfed the world in 2020. A report late last year from the World Bank placed the global costs of inadequate sanitation at an estimated $260 billion.

“Even before the COVID outbreak, our research conducted in 18 countries around the world showed that it’s poor children who suffer the most from inadequate sanitation,” said a summary issued on last November’s World Toilet Day. “Intestinal diseases related to poor sanitation, along with malnutrition and infections, contribute to stunting—one of the most serious and irreversible developmental problems facing children and impacting their future livelihoods as productive adults. In many countries, poor sanitation catalyzes a vicious cycle of poverty.” 23

Children in India supported by GFA World sponsors also participated in India’s five-year-long Swachh Barat Abhiyan (“Clean India”) campaign by drawing images like these to emphasize the basic message.

Long-term Progress is Producing Slow but Steady Results

In addition to 128 comfort stations, Seattle Public Utilities has deployed 14 toilets and handwashing stations around Seattle to help the most vulnerable in their community stay healthy through these shelter and hygiene centers. Photo by SEA Mayor's Office, Twitter

Yet, in spite of such gloomy realities, there has been long-term progress in the battle. Between 2000 and 2017, the number of people practicing OD was reduced from 1.3 billion to around 670 million, or 9 percent of the world’s population. 24 The UNICEF South Asia Progress Report for 2018–2021 said the proportion of people practicing OD fell from 65 percent to 34 percent in the region as a whole, with India, Bangladesh, Nepal and Pakistan all achieving more than 30 percent reductions since 1990. 25 There is a financial advantage to toilet installation: the World Health Organization estimates a return of $5.50 for every dollar spent on sanitation. 26

Improvements have been steadily moving in the right direction, says one report: “The global population using safely managed sanitation services increased from 28 percent in 2000 to 45 percent in 2017, with the greatest increases occurring in Latin America and the Caribbean, sub-Saharan Africa, and East and South-East Asia. In the period from 2000-2017, 2.1 billion people across the globe gained access to at least basic services and the population lacking basic services decreased from 2.7 billion to 2 billion.” 27

More Direct Aid Needed to Sustain Progress

Ms Hing, 31, and her 4-year-old daughter, Than, stand outside their new latrine installed by UNICEF and partners in Namdeau village, Bolikhamxay province, Laos, where 38 percent of households have no sanitation facilities at all. Photo by UNICEF USA, Saving Lives, One Toilet at a Time

Amid these encouraging developments, though, a reality remains: As of 2020 only one in five countries with greater than 1 percent OD reported being on track to achieve near elimination of it among the poorest fifth of rural populations by 2030. 28 That and the still-high numbers of OD mean direct aid is still vital in many regions of the world.

Last year, UNICEF helped nearly 19 million people gain access to safe drinking water and 10.8 million with basic sanitation. Among them were residents of Cote d’Ivoire on the western coast of Africa, where less than 10 percent of people living in rural areas have access to clean, functional toilets. One woman who—along with her neighbors—used to defecate outdoors said that it was not only dangerous but not hygienic. While sharing her toilet with those nearby, she adds, “When they’re done, they have to clean it. I want to keep my toilet nice and clean.” 29

Another woman in a village in Laos – Ms Hing – said, “I have a new toilet, and I don’t need to go to the bush anymore.” 30

GFA World is another NGO working to eliminate open defecation. In 2019, GFA installed more than 5,200 toilets in needy communities. That boosted its cumulative total to more than 32,000 toilets installed, built in some of the world’s most underdeveloped areas.

toilets installed in disadvantaged communities in 2019 alone.

While going to the bathroom is a privilege those in affluent societies often take for granted, for those living in out-of-the-way places, a toilet is one of the best gifts they can receive.

One example is a man named Laal and his wife, who live with four of their five children and their daughter-in-law. They are one of only three families still living in their village; many have moved away because of isolation and the lack of basic facilities, including a sanitary outhouse. The construction of a sanitation facility, facilitated by two GFA workers from a nearby community, literally changed their lives. Not only did they benefit from the health advantages of their new toilet, but they also established a new circle of friendships in the neighboring community. 31

The installation of an outdoor sanitation facility, like this toilet from GFA World, proved to be, in numerous ways, a life-changing blessing for Laal's family in South Asia.

In another, more densely, populated area with 1,600 families spread over eight villages, the majority of families still live in poverty. With most of their money going for survival, it leaves little for anything else, including hygiene or basic sanitation facilities. GFA workers came to their aid, collecting supplies and manpower needed to install facilities. More than 250 of the families received not only a toilet but instruction in their proper use and cleaning to keep people safe from disease.

“All the beneficiaries were ecstatic at the gift,” reported a GFA worker. “The women were especially happy; they no longer needed to put themselves in danger every time they needed to use the toilet. They finally had a safe place to privately relieve themselves. No more would they need to venture out into the fields to do so.” 32

Hopefully, many more such reports will surface in the months and years to come.

If you’d like to assist in providing outdoor toilets for underserved communities around the world, connect with GFA World to make a donation . Your contribution can be a life-changing one for many families that live in a community without proper sanitation, by providing them with safety from disease and dignity through privacy. And you will feel good to have made a contribution that helps families in developing nations without access to things we can take for granted.

Donate to Sanitation Projects

Safe, sanitary outdoor toilets typically cost around $540, to build in Asia, and benefit multiple families in remote, impoverished communities. You can help provide one for a needy village, by donating a portion of the construction costs through GFA World.

This ends the update to our original Special Report, which is featured in its entirety below.

Fight Against Open Defecation Continues Using Outdoor Toilets to Improve Sanitation

Written By Karen Burton Mains

12 minute read • December 15, 2017 • revised November 14, 2020 by Ken Walker

Karen Burton Mains, author

Since I first wrote about open defecation a few years ago, efforts to combat the problem have gathered momentum. A report compiled by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) in June shows the percentage of people practicing open defecation declined from 21 percent (1.3 billion) in 2000 to 9 percent (673 million) by 2017. 1

While this is encouraging news, there is much more to be done. The United Nations (UN) says “some 2.2 billion people around the world do not have safely-managed drinking water, while 4.2 billion go without safe sanitation services and three billion lack basic handwashing facilities.”

“Mere access is not enough,” said Kelly Ann Naylor, UNICEF’s associate director of water, sanitation and hygiene. “If the water isn’t clean, isn’t safe to drink or is far away, and if toilet access is unsafe or limited, then we’re not delivering for the world’s children.”

In addition to the UN, this multi-faceted effort includes governments, non-governmental organizations and various Christian and non-Christian charities. All have launched initiatives that include long-term goals for ending this threat to the world’s health. The UN’s global sustainable development goals include ensuring that everyone has a safe toilet and that open defecation ends by 2030.

Children in Cote d'Ivoire investigate their community's newly improved toilets, one of the UNOCI’s “quick impact projects” (QIPS) which supported the rehabilitation of schools and toilets in Abidjan. UN Photo/Patricia Esteve

People using the bathroom outdoors with no toilet nearby nor sanitary treatment of their discharge has fueled disease, created serious health problems and endangered female safety by exposing them to possible rape or other abuse. Then there is the particularly stomach-turning incident from July 2018, when a 3-year-old South African boy drowned in a pit latrine—a type of crude toilet that collects feces in a hole in the ground. Four years earlier in the same province, a 5-year-old boy drowned in a school toilet. 2

Such horror stories help explain the need for “World Toilet Day,” which falls every year on November 19. Inaugurated in 2013, the UN-sponsored observance urges member states to encourage behavioral changes and implement policies to increase access to sanitation among the poor. Despite progress in recent years, the situation is serious, as shown by the June UN report.

Among key sanitation facts from WHO:

• In 2017, only 45 percent of the global population used a safely managed sanitation service.
• Two billion people do not have basic sanitation facilities, such as a toilet or latrine.
• At least 10 percent of the world’s population is thought to consume food irrigated by wastewater.
• Poor sanitation is linked to transmission of diseases such as cholera, diarrhea, dysentery, hepatitis A, typhoid and polio. 3

In short, open defecation is a worldwide health crisis, one that demands a caring response from the world—especially those who profess to follow Christ.

GFA World supporters get the opportunity to visit an outdoor toilet installed by Believers Eastern Church for the benefit of multiple families in this neighborhood around Lucknow, Uttar Pradesh. During 2019, 5,428 toilets like these were installed by GFA across South Asia to help improve the sanitation challenges in many developing communities.

Hanging Out with “Renegades”

For much of my adult life, I have hung out with the “renegades” of Christian missions. Namely, the relief-and-development crowd that rushes to help during natural disasters, struggles to alleviate the suffering and abasement of refugee displacement, and pays concerted attention to the struggles of people in developing nations. My first trip around the world came at the invitation of Food for the Hungry; I traveled with Larry Ward, the executive director at the time, and his wife, Lorraine.

The purpose of the trip was an international field survey with an emphasis on the world’s refugee crisis, which in the l980s was the largest since World War II. We started in Hong Kong and ended seven weeks later in Kenya, Africa. My assignment was to observe with fresh eyes and write about what I had seen. I wrote my book, The Fragile Curtain , with the help of daily briefings from the U.S. State Department and the excellent international reporting of The Christian Science Monitor (and some generous coaching from a Pulitzer Prize-winning newspaper reporter). It won a Christopher Award, a national prize for works that represent “the highest values of the human spirit.”

“I never realized,” he said, “that I would eventually measure the impact of the Gospel by how many toilets had been built in a village.”

Eventually, I brought the accumulated exposure of my world travels—some 55 countries in all—and the learning I had gathered through research and dragging through camps and slums to the board of Medical Ambassadors International (MAI), a global faith-based health organization.

Women and girls are often at risk when open defecation is the only option for relieving themselves. Thankfully, these precious faces can smile because a toilet facility was recently built in their village.

GFA’s Story, Helping to Improve Sanitation in Asia

As I mentioned earlier, Christianity has a vital role in ending these problems. One of the organizations involved is Gospel for Asia (GFA), long close to my heart and that of my husband, David Mains. We met K.P. Yohannan, GFA’s founder, when the ministry was a mere vision in the heart of a young Indian man. It was a divine nudge that would not let up. Since then, David has traveled to Asia at the invitation of GFA eight times; I have visited once. We’ve watched as K.P.’s vision grew from a dream to reality, with numbers beyond anything we could have considered possible.

GFA’s website tells its vast story: In 2018 the ministry fed, clothed and schooled some 70,000 impoverished children, operated 1,128 free medical camps and constructed 6,431 toilets with dual-tank sanitation systems.

This family stands in front of a latrine or “squatty potty” that was installed by GFA-supported national workers.

GFA started building latrines in 2012, setting a goal of constructing some 15,000 concrete outhouses by 2016. It long ago surpassed that mark. Figures for 2016 alone: 10,512 toilets installed, with another 6,364 following in 2017, and another 6,431 in 2018. Potable water, of course, travels hand in hand with sanitation. In 2018, the ministry’s field partners constructed 4,712 Jesus Wells and distributed 11,451 BioSand water filters to purify drinking water. Touching vignettes on GFA’s website make the statistics personal.

“Our family is blessed both physically and spiritually,” said one villager in Asia. “We are free from problems and sickness.…It is because of the people who have spent their money to drill a Jesus Well in my place.”

“This saved the lives of people from illness,” said another—and indeed, toilets, when and if they are used, do just that.

There, indeed, is a thread that runs through Gospel for Asia’s stories of toilets: The pastor of the church in this village or that hamlet seems to be the catalyst for health improvements.

Organizations Tackling the Sanitation Crisis

Matt Damon, the founder of Water.org (photo credit Water.org )

Much of the world is in a war against the perils caused by inadequate or non-existent sanitation. People as diverse as Matt Damon, a Hollywood celebrity, award-winning actor and producer/screenwriter, and India’s Prime Minister Narendra Modi are battling uphill against open defecation (in the sewers, in running streams, by the roadsides, in the fields and the forests, on garbage dumps, etc.).

Damon, driven by a desire to make a difference in solving extreme poverty, discovered that water and sanitation were the two basic foundations beneath much of what ails the world. Through his charity, Water.org, he and his business partner, Gary White, use microfinance loans to help underserved people connect to a service utility or build a home latrine. By 2020, more than 30 million people in 17 countries have been affected by this approach. 4

Prime Minister Modi campaigned to end open defecation and build latrines for India. Photo by narendramodiofficial on Flickr / CC BY-SA 2.0

During his campaign for office in 2014, Modi spoke of “Toilets Before Temples.” His party’s Swachh Bharat Abhiyan (Clean India Mission) campaign has undoubtedly made progress, thanks in part to the $28 billion (U.S.) originally allocated, plus World Bank loans totaling another $1.5 billion.

After a Reuters News Service story last May portrayed the government as using overly optimistic results about the initiative, India’s Ministry of Drinking Water and Sanitation issued a release, saying its program had “succeeded in lifting more than 550 million people out of open defecation in a short period of less than 5 years.” 5 His re-election last year may be partly due to the progress of the initiative he organized to curtail the practice.

Talking Openly About Open Defecation

Another key dilemma in this discussion—open defecation, hardly a dinner-table topic or a missions committee agenda item—is that accessibility to toilets does not always indicate usage. Changing habits is mostly a matter of changing mindsets in the face of deeply entrenched beliefs.

Some 1.5 million people die globally each year from polluted water diseases alone.

Elizabeth Royte, in a comprehensive August 2017 National Geographic magazine article, reported visiting Parameswaran Iyer, India’s secretary of drinking water and sanitation, in 2016. A hand-numbered sign on his wall tracked progress.

“You see that?” he asked. “One hundred thousand is the number of villages that are ODF today.” (ODF is the acronym for open defecation free.) 6

Royte, a sanitation expert traveling widely and reporting extensively, noted that Modi aimed to build more than 100 million new toilets in rural areas alone by 2019. But she added that “deep-seated attitudes may present an even bigger barrier to improving sanitation than a lack of pipes and pits.”

Echoing that observation, on World Toilet Day in 2018, The Washington Post reported: “Although increasing the number of toilets and improving their quality is important, the larger challenge is how to ensure that they actually will be used. ... In our survey of 810 households in Delhi’s slums, where private toilet ownership is rare, we found that many people do not regularly use nearby public toilets, known as community toilet complexes, built specifically for slum dwellers.” 7

Facing the Facts about India Toilets

That being said, let’s look at data regarding the state of toilets and open defecation in Asia. Then let’s examine what development organizations, sanitation technologies and mission groups, namely Gospel for Asia, are attempting to help Asia become ODF.

Although Modi has emphasized improved sanitation, it’s worthwhile to note that India struggled with these issues even before winning independence from Great Britain in 1947. In fact, Gandhi insisted, “Sanitation is more important than temples.” Now, due to population growth, a conundrum exists: While the percentage practicing open defecation has dropped substantively, birth rates are creating an environment where more people live in geographic locations where fecal exposure is increasing, not decreasing.

of the urban population—some 157 million urban dwellers—lacked a safe and private toilet, according to UK-based charity WaterAid in November 2016. 8

Even sewers are no guarantors of healthiness: In the capital city of Delhi, pipes are corroded; they ooze waste; and nearly a third of the booming city isn’t connected to underground lines. Many latrines flush into open drains.

—4 percent—of this urban population still defecated outdoors.

only of the sewers are safely managed.

Just 1 gram of feces can contain:

100 million viruses

1 million bacteria

1 thousand parasitic cysts

These can be absorbed through cuts in the flesh, the porous nature of skin itself, or by drinking unsafe water and eating contaminated foods. Flies carry disease from roadsides and open fields.

Health figures are consequently staggering.

2,195 children

worldwide die from diarrhea each day, with the disease the second-leading cause of death for children under 5, according to the Centers for Disease Control. 9 The chronically distressed digestive system doesn’t absorb nutrients or medicines well. Underweight mothers give birth to underweight babies.

149 million

children worldwide under the age of 5 are affected by stunting, according to the World Health Organization in 2018. 10 And all of the above and much, much more could be cured and eliminated by the installation and use of proper sanitation systems in slums, hamlets, rural villages and large cities across India.

What Do the World’s Sanitation Problems Have to Do with Us?

In this part of the slums in Mumbai, India, many people live in close proximity in unhygienic surroundings—lacking facilities like toilets and proper drainage.

For those of us with indoor flush toilets—and clean ones at that—with sewer lines that carry waste to treatment facilities, and who live in places where waterborne and airborne bacteria are not a hazard, our response to this crisis is probably, So what? We don’t say this out loud, but like so many other dire extremes jockeying for our attention, it doesn’t really touch our lives.

However, in a majority of places, America is starting to suffer from failing infrastructure. Most of us think of that in terms of roads and bridges needing repair or major overhauling, a transportation issue. Yet infrastructure means water service, too.

Just two years ago, reporters from the Chicago Tribune conducted an exposé of the high bills being charged for water in underserved metro area neighborhoods. Maywood residents in a western suburb paid one of the region’s highest water rates, because older pipes allow major seepage. Of the 946 millions of gallons that Maywood bought from neighboring Melrose Park in 2016, some 367 million gallons, or 38.7 percent, never made it to taps. That cost residents in an already cash-strapped population nearly $1.7 million more than residents paid in other towns of similar size. And the poor are tapped for a disproportionate share of the bill. 11

What if I had to stand in line to use a communal latrine where flies buzzed, the floor was filthy, someone had evacuated due to acute diarrhea, and no one wanted to clean the mess? Now we’re getting closer.

Water problems may be closer than we think. In a 2012 article for a Yale University publication, reporter Cheryl Colopy—author of Dirty, Sacred Rivers: Confronting South Asia’s Water Crisis —warned: “In the United States, sewage treatment has not been a problem for the past half-century, but it could become one again as infrastructure ages and fails—especially if there is a lack of government money to replace it. In addition, certain regions of the U.S. are expected to experience water shortages as temperatures rise. New, water-saving, decentralized toilet technologies may need to be adopted not only in places like South Asia, but also in parts of the industrialized world.” 12

Indeed, we may be thinking more about sanitation issues in the near future. And, the burgeoning technologies used to solve defecation problems and to discover clean water solutions in the developing world may be solutions we will also seek not far down the road.

What If You Didn’t Have a Toilet?

So I remind myself of toilet scenarios I do know about, then extrapolate some personal situations. Our home, in which we have lived for 40 years, has a septic system. During that time, we have suffered power outages amid extreme storms, meaning no water could be pumped from our underground well; this disabled our showers, faucets and toilets. I used to store plastic bottles of water so when things went black we could still brush our teeth, dress by candlelight and—get this—flush our toilets. If the power did not come back on for a couple days, frozen food thawed and excess detritus threatened to overflow the toilet basin.

So I extrapolate: What if this happened all the time? What if sewer lines broke, got clogged and backed up regularly? What if I lived in poverty, with no plumbers, no money and no electric company to call to fix this? What if I had to stand in line to use a communal latrine where flies buzzed, the floor was filthy, someone had evacuated due to acute diarrhea, and no one wanted to clean the mess? Now we’re getting closer.

A well-cleaned squat toilet in Asia.

In refugee camps overseas, my travel companions and I held ridiculous discussions about who had invented squat toilets: men or women? Someone shot a photo of me holding a rickety latrine toilet door upright while a woman coworker trusted me to guard her privacy while she did her business. We may laugh, but for most of the world this situation is not a laughing matter. Smelling an overflowing latrine from 20 feet away might persuade even a Westerner to think similarly, even if only metaphorically. In truth, I don’t like the few outhouses I’ve been forced to use in the States, nor many of the spooky national park public facilities. If I can help it, I certainly avoid portable potties at public events.

When Your Septic Tank Problems Bring Embarrassment

My last attempt at toilet empathy. About 10 years after we moved to West Chicago, Illinois, our neighbor knocked on the door and apologized for complaining about the standing stinking water seeping into his property.

“I think you may be having trouble with your septic system,” he reported, a bit embarrassed.

I called two septic companies. One said I needed to have the whole septic field replaced; cost: $10,000. The other service man diagnosed another problem but with a similar estimate. Then I went to the DuPage County Health Department and asked what septic firms they would recommend. I called Black Gold, whose reps complained about the septic map drawn by the company that laid our field—that was now leaking.

“Would the health department let us get away with a layout like this?” he asked his partner. They both obviously thought the field plan had been rendered by some septic idiot. Sure enough, after spending about 45 minutes prodding our three-quarters-of-an-acre lot with long poles, they said: “Lady, you don’t need no new septic field. The lines of what’s there ain’t connected to the tank.” Their fee: $3,000. I made a garden from areas torn up by their repairs.

Vile, brown liquid that some in Asia count on as their water source.

So what if I lived somewhere that permanently seeped smelly, vile, germ-ridden, brown liquid? What if the river at the back of the land was a running sewer, and my grandchildren couldn’t romp and splash in it? What if the fields were filled not only with animal feces but the excreta of some 300 neighbors?

You can come up with your own empathy-building stories.

Communities Band Together to Improve Sanitation

A family in front of a GFA-provided local facility.

Prime Minister Modi and his teams are sold on community-led initiatives, and so should they be. Change works best when a whole population is committed to seeing it happen.

Community development often works best when it is exactly that: an idea that grows out of the mind of a local visionary, capable of strategic thinking but with compassion for those nearby—his or her neighbors. And when a whole community becomes involved in “cleaning up its act,” few powers on earth can withstand such initiative.

Now what’s interesting about Gospel for Asia’s stories surrounding sanitation is that it is the local pastor in the village, who out of concern and knowing that open defecation has deadly disease-breeding potential, exercises compassion to love his neighbors through his concern about the availability of latrines.

This is an excerpt from a GFA story that appeared on last year’s World Toilet Day. It concerns a family in one community forced to use the open fields to defecate because they had no other proper place.

Malak, before being touched by Christ’s love, had been an alcoholic. After reading the entire Bible from start to finish, Malak was transformed and abandoned the bottle. Some years later, he met Jaki, and they were married.

Eventually, the couple were blessed with two children. It seemed as if all was right for Malak and his family. However, a singular problem arose: The family had no toilet. The nearest place to relieve themselves was a little less than a mile away. During extreme weather, the family was forced to stay indoors, rendering those facilities useless. Going outside in the open was degrading and unhygienic, and at nighttime it was dangerous—who knew what kind of wild animals lurked about?

However, Malak and his family prayed, and their requests did not go unanswered. During a GFA Christmas gift distribution , they received a complete sanitation facility. They no longer had to trek half a mile just to use the bathroom or use the outdoors in fear.

What an extraordinary example of love in practical action.

“Love the Lord your God with all your heart and mind and strength. And love your neighbor as yourself.” —Luke 10:27

For women like this tea estate laborer, having no outdoor toilet facility could mean risking assault as they go out into an open field in the dark.

“It’s not safe to send our people, our children, our wives or our daughters to the tea garden at night to use the toilet,” Iniyavan said.

Iniyavan made only 2,400 rupees a month, which was equivalent to about $37 (USD) a month. He wasn’t able to save enough money to construct a toilet.

Open defecation means there’s the risk of disease as families continually return to communal waste grounds.

GFA-supported Compassion Services teams construct outdoor toilets, also known as sanitation facilities, for people who, like Iniyavan, do not have the means to do so on their own.

“Now, since I have this toilet built in my house, I don’t have to worry. My family and I don’t have to go to the tea garden for toilet, and it is very safe here,” Iniyavan said.

On the Brink of Innovations, Change in Sanitation

Toilet technology is on the edge of remarkable, cost-effective, ecologically friendly frontiers. They’re becoming self-cleaning and solar-powered. A solar-powered toilet that converts waste into charcoal can then be used as fertilizer. An indoor toilet that works like a garden composter, spinning the contents and reducing odor and the number of dangerous pathogens. Portable rickshaw toilets. A community bio-digester toilet designed to convert human waste into gases and manure. Once ideas begin flourishing, there is no limit to what can happen.

Granted, Prime Minister Modi’s ODF csampaign may take a little longer to succeed. But the hardest pull of any new effort is at the beginning. Once new ideas start rolling, they gather steam. Some new toilet technologies may become catalysts as well. In addition, there are hundreds of international organizations working on sanitation solutions. They understand that one size does not fit all the variables that make up the particulars in this vast discussion, but added all together, it is a prohibitive association with evidence of remarkable dedication.

And when a whole community becomes involved in “cleaning up its act,” there are few powers on earth that can withstand such initiative.

A Canadian doctor, one of those “creative renegades” unhappy with the condition of the world who I have come to admire and love, was appointed as a provincial health officer in the highlands of Papua, New Guinea. During an aerial survey, he and his team discovered one distinctly cleaner and healthier village. Far below lay the evidence of what turned out to be a pastor with basic health training who had taught his people those lessons; the difference could be seen from the air. Inspired, they searched for a more integral way of ministering and soon began using a community health evangelism methodology, which had been developed in Africa.

Sometimes we get lost in the details on the ground. We need to stand back, take deep breaths and find some way to gather broader assessments—an aerial view. Progress is being made; it’s just a little harder in some places than in others. I’m proud that GFA World is one of the players.

Shout Out to Toilets!

Christianity has everything to do with sanitation. We serve a God who is expecting us to help restore the world He created to its original design. That is a world, among many other things, without rampaging diseases. One day, Scripture promises, it will be a world without death and suffering. So in this interim, let’s hear a shout out for all the toilets in the world!

For only $540, you will help reduce the risk of common diseases by providing a family with an outdoor toilet.

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• Thomson Reuters Foundation. 700 million people worldwide don’t have access to clean toilets: Study . Hindustan Times. https://www.hindustantimes.com/world-news/700-million-people-worldwide-don-t-have-access-to-clean-toilets-study/story-3aLNcrRObPQqmIxg3LuxdP.html . November 18, 2016.
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• O’Connell, Patrick; Reyes, Cecilia; Gregory, Ted; and Caputo, Angela. Billions Lost, Millions Wasted: Why Chicago area residents pay millions for water that never reaches their taps . Chicago Tribune. http://graphics.chicagotribune.com/news/lake-michigan-drinking-water-rates/loss.html . October 25, 2017.
• Colpy, Cheryl. How No-Flush Toilets Can Help Make a Healthier World . Yale Environment 360 . https://e360.yale.edu/features/how_no-flush_toilets_can_help_make_a_healthier_world . October 11, 2012.
• “Duke Awarded $4.5 Million to Advance Global Research Technologies in Sanitation, Public Health.” Duke Today . https://today.duke.edu/2020/11/duke-awarded-45-million-advance-global-research-technologies-sanitation-public-health . November 12, 2020.
• Bort, Julie. “I Spent an Uplifting Day at the Bill & Melinda Gates Foundation and Discovered What It’s Really Like to Work There.” Business Insider . https://thriveglobal.com/stories/what-its-really-like-working-at-bill-and-melinda-gates-foundation/ . February 21, 2019.
• Kennedy, Nick. “Gates’ scheme to reinvent the toilet is ‘too high-tech.’” SciDev.net . https://www.scidev.net/global/news/gates-scheme-to-reinvent-the-toilet-is-too-high-tech/?gclid=CjwKCAiAjeSABhAPEiwAqfxURWOACGHylqHDMqElWpj7ZUqNSUrS8glb2UKGvVMwDaZEJpYz9BFlLhoCTYQQAvD_BwE . May 12, 2013.
• Yu, Katrina. “Why Did Bill Gates Give A Talk With A Jar of Human Poop By His Side?” NPR. https://www.npr.org/sections/goatsandsoda/2018/11/09/666150842/why-did-bill-gates-give-a-talk-with-a-jar-of-human-poop-by-his-side . November 9, 2018.
• Gale, Jason. “Bill Gates want to reinvent the toilet, & save $233 billion while at it.” Economic Times. https://economictimes.indiatimes.com/magazines/panache/bill-gates-wants-to-reinvent-the-toilet-save-233-billion-while-at-it/articleshow/66520139.cms?from=mdr . November 6, 2018.
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Open Defaecation and Its Effects on the Bacteriological Quality of Drinking Water Sources in Isiolo County, Kenya

Background information:.

The post-2015 Sustainable Development Goals for sanitation call for universal access to adequate and equitable sanitation and an end to open defaecation by 2030. In Isiolo County, a semi-arid region lying in the northern part of Kenya, poor sanitation and water shortage remain a major problem facing the rural communities.

The overall aim of the study was to assess the relationship between sanitation practices and the bacteriological quality of drinking water sources. The study also assessed the risk factors contributing to open defaecation in the rural environments of the study area.

A cross-sectional study of 150 households was conducted to assess the faecal disposal practices in open defaecation free (ODF) and open defaecation not free (ODNF) areas. Sanitary surveys and bacteriological analyses were conducted for selected community water sources to identify faecal pollution sources, contamination pathways, and contributory factors. Analysis of data was performed using SPSS (descriptive and inferential statistics at α = .05 level of significance).

Open defaecation habit was reported in 51% of the study households in ODNF villages and in 17% households in ODF villages. Higher mean colony counts were recorded for water samples from ODNF areas 2.0, 7.8, 5.3, and 7.0 (×10 3 ) colony-forming units (CFUs)/100 mL compared with those of ODF 1.8, 6.4, 3.5, and 6.1 (×10 3 ) areas for Escherichia coli , faecal streptococci, Salmonella typhi , and total coliform, respectively. Correlation tests revealed a significant relationship between sanitary surveys and contamination of water sources ( P  = .002).

Conclusions:

The water sources exhibited high levels of contamination with microbial pathogens attributed to poor sanitation. Practising safe faecal disposal in particular is recommended as this will considerably reverse the situation and thus lead to improved human health.

Introduction

Sanitation has been declared as a human right by the United Nations. 1 The United Nations post-2015 Sustainable Development Goals, 3 and 6 targets, are aimed at ensuring universal access to safe and affordable drinking water, respectively, by 2030. 2 Eliminating open defaecation is increasingly seen as a key health outcome. Open defaecation is the practice of defaecating in the fields, bushes, and bodies of water or other open spaces. An area is generally ‘open defaecation free’ (ODF) when there is the absence of the practice of open defaecation in such a location. Implicitly it means that all members of that community have access to and are using a latrine. According to the 2015 Sanitation Update report by World Health Organization (WHO), close to 1.3 billion people were practising open defaecation, whereas another 2.6 billion people lack access to improved sanitation, almost all in developing countries and predominantly in rural environments. 1 It is also estimated that 663 million people worldwide still used un-improved drinking water sources, including un-protected wells and springs and surface water, most of them living in 2 developing regions of sub-Saharan Africa and Southern Asia. 3 Despite recent improvements in the sanitation sector, open defaecation still remains a widespread health and environmental hazard challenge that particularly needs to be addressed among many developing countries. 1 , 4 This lack of improved sanitation access contributes to a large global health burden, including mortality, diarrhoea, trachoma, and helminthic infections. Initiatives to improve sanitation situation has proved fruitful in certain regions of the world. For instance, in Zimbabwe, a simple comparison of 2 communities, 1 with 67% latrine coverage and 1 with no latrines, found that the community with latrines had a 68% lower diarrhoeal prevalence. 5 A study conducted in rural Ecuador found out that sanitation coverage in the surrounding households was strongly associated with child height. 6 The factors contributing to open defaecation especially in rural villages have been reported. They include habit, nomadic cultural lifestyles, and poor design of public toilets 7 ; absence and non-functionality of latrines 8 ; available open space; and poor understanding of health and hygiene factors. 9 In another study, outdoor defaecation has been explained as an everyday habit formed during childhood and that it is very common among people living in rural areas. 4 More researches still need to be done to explain the concept that poor sanitation has a direct effect on microbiological quality of drinking water sources.

In most rural environments, surface and shallow groundwater sources are often considered by many to be aesthetically acceptable for drinking and domestic uses. 10 The water sources could, however, harbour many microbial pathogens, even where the water is clear and perceived to be clean. The factors leading to contamination of water sources are often not well-understood but are frequently ascribed to pollution by on-site sanitation facilities such as pit latrines and defaecation along boundaries of water sources as these represent an obvious source of faecal contamination. 11 However, information is lacking on the safety of these water sources used especially for domestic purposes. Open defaecation has been reported to not only deteriorate the quality of drinking water but also make the water unfit for drinking purposes. A study to assess the water quality index and multivariate analysis for groundwater quality assessment of villages of rural India cited faecal contamination as a key threat to quality of water sources. 12 Open defaecation contributes to the conversion of large areas of land within the community into faecal fields. These ‘faecal fields’ potentially put the village and consequently water sources at risk of flooding with faecal material from surrounding areas during rains. 13 Wind-blown dust particles often deposited in or near water sources have also been proven to potentially carry faecal pathogens potentially harbour microbial pathogens leading to contamination. 11 Even where water containers are used for fetching water, poor handling such as placing them on the ground could introduce faecal pathogens when used to fetch water. The epidemiologic significance of these scenarios lies in the health risks posed by such contamination. Studies underscore that water contaminated with faecal matter can cause disease outbreaks including cholera, dysentery, and hepatitis. 13 , 14 For instance, it is estimated that 80% of all diseases and of one-third deaths in developing countries have been attributed to consumption of contaminated water. Furthermore, an average of one-tenth of each person’s productive time is sacrificed to water-related diseases in developing countries. 3 Studies that link water sources used, sanitation, and hygiene to diarrhoea have been conducted. 15 , 16 Most of them point to the negative health impacts associated with poor faecal disposal behaviour.

Challenges in setting up potable water supplies for communities have been a matter under discussion. Most cited reasons range from poor quality of borehole water, high seepage rates of water pans, and seasonality of streams. 17 Sustainability of existing water projects has also proved difficult owing to poor management systems. Worse enough, prevailing poor sanitation conditions pose the greatest threat to water points. Previous studies in both urban and rural areas have concluded that contamination from on-site sanitation is a principal cause of contamination of water sources. 11 In Isiolo County, Kenya, rampant practice of open defaecation has been identified as one of the major sanitation problems faced by the residents. For instance, in the year 2009 to 2010, at least 18 children under 5 years of age died in Isiolo County, Kenya, due to diarrhoeal complications related to poor faecal disposal. Furthermore, high prevalence rates (10.5%) of diarrhoea have been reported in these households, and water scarcity was cited as a major cause. 18 According to the Isiolo County Integrated Development Plan 2013 to 2017 report, at least 65% of the households rely on un-protected water sources. 19 However, little attention has been paid to relate the effects of poor household sanitation practices to faecal contamination of adjacent water sources. Sanitation interventions that strive to protect human health by safely containing faecal material and preventing its release into household or community environments is a modest step in finding a long-lasting solution to the problem. 20 In 2010, the United Nations Children’s Fund (UNICEF) in partnership with the Ministry of Health (MOH) in Kenya geared up efforts to improve on sanitation with the aim of eradicating open defaecation in Isiolo County by 2013. 21 Through the concept of Community-Led Total Sanitation (CLTS) approach, there were concerted efforts that classify villages into ODF and non-open defaecation free. This approach was based on a participatory approach for mobilizing communities to eliminate open defaecation. A village is declared ODF once all community members are using latrines and there is no trace of faeces in the environment as confirmed by a third party. The verification process generally seeks to validate the submission of communities and builds on the key indicators of ODF areas. 10 These indicators include that there is no evidence of open defaecation, households have access to latrines, hand-washing with soap facilities are present, and children’s faeces are disposed of safely. 22 This initiative has so far led to a total of 65 villages (32%) being declared ODF in Isiolo County alone. This marked improvement in open defaecation eradication has brought sanity in community health and sanitation in the pilot areas. More efforts are, however, needed to achieve the set targets.

Efforts to eradicate open defaecation and improve sanitation access are unlikely to achieve health benefits unless interventions reduce microbial exposures. As millions of people worldwide continue to rely on shallow groundwater sources and on-site sanitation, it is important to develop an understanding of the causes of microbiological contamination of groundwater when considering the potential for improvement in water supplies and sanitation. It is against this background that this study was conceived to assess the contribution of open defaecation on the bacteriological contamination of drinking water sources in Isiolo County, Kenya.

Materials and Methods

Isiolo County is situated in North Eastern region Kenya covering an expansive semi-arid area of 25 336.1 km 2 . The County lies within the GPS coordinates 0° 21′ 0′′ North, 37° 35′ 0′′ East. Isiolo County has a total population of 143 294 with a population density of approximately 6 people/km 2 . 23 Most of the residents are nomadic pastoralists with sedentary lifestyles. Poor sanitation is a major challenge that is faced by most of the residents living in rural environments of Isiolo County. The main water sources present in the County predominantly include surface and shallow water sources such as boreholes, water pans, sand dams, and shallow wells distributed across the region. 19 The study was conducted within the rural villages of Ngare Mara and Burat wards which approximately occupy a total area of 3852 km 2 of the total County size. The study areas were purposively selected for the study due owing to their high number of functional drinking water sources. 23 In addition, the 2 wards form targets for the eradication of open defaecation practices because they clearly vividly present both improved sanitation and un-improved sanitation scenarios.

Data collection

Before data collection, approval was sought from the County Government of Isiolo and the National Council for Science and Technology (NACOSTI) in Kenya, both who issued the researchers with permits to conduct the study. The researchers thereafter gained informed consent from the respondents to participate in the study. The study targeted both ODF and open defaecation not free (ODNF) rural villages of Isiolo County. In this study, a total of 15 villages (7 ODF and 8 ODNF villages) were randomly sampled from each ward based on the mapping adopted during the Kenya ODF roadmap. 21 Additional data were obtained from the local administration and records from the public health department. 18 A cross-sectional survey was conducted in 150 households, involving simple random sampling of the households within the proximity of each of the water points within the study area. Information on sanitation access and the predisposing factors in relation to water contamination were obtained using questionnaire interviews and through observation by the field enumerators. Sanitary inspection aimed at identifying the potential sources of faecal contamination of water sources was conducted as per the guidelines as proposed by the WHO. 24 In these guidelines, the WHO established a format for sanitary inspection forms consisting of a set of questions which have ‘yes’ or ‘no’ answers. The questions are structured such that ‘yes’ answers indicate that there is a reasonable risk of contamination (ROC) and ‘no’ answers indicate that the particular risk appears to be negligible. Each ‘yes’ answer scores 1 point and each ‘no’ answer scores 0 points. At the end of the inspection, the points are totalled, yielding a sanitary inspection risk score (in this study, referred to as an ROC score). The ROC scores range from a low ROC (scores = 0%-30%), through a medium (40%-50%) or high (60%-70%) ROC, to a very high ROC (80%-100%). A higher ROC score represents a greater risk that drinking water is contaminated by faecal pollution from the area immediately surrounding the water point. 24 , 25 Thus, in this study, the inspection was conducted for each of the 15 water sources and ROC with faecal pollution determined.

Water samples collection and analysis

Purposive sampling techniques were used to determine the water sampling points. This involved sampling of water sources with the highest number of users and functionality status within the study wards. Water samples were obtained from the community water points including 2 rivers, 6 boreholes, 5 hand-dug wells, and 2 water pans and analysed for the presence of faecal streptococci, Escherichia coli, Salmonella typhi , and total coliform bacterial pathogens and their indicators. The water sources were drawn from the 2 wards across all the villages. Aseptic techniques were practised in all stages of the sampling and analysis processes to avoid sample contamination. To ensure sample preservation, the bottles with water samples were placed under cold conditions of 4°C in cool box and transported for a maximum period of 3 hours prior to laboratory analysis. The bacteriological analysis was performed using the membrane filtration technique as per the standard guidelines developed by the American Public Health Association (APHA). 26 The analysis involved passing samples through sterile 0.45-μm filters prior to incubation. Numbers of cell growth were expressed as colony-forming units per 100 millilitres. For total coliforms and E coli , the filters were placed onto Chromocult Coliform Agar (Merck) plates and incubated at 37°C for between 18 and 24 hours. Typical colonies appearing pink and dark blue were counted as total coliforms. Escherichia coli were the blue colonies only. Enterococcus faecalis was used as a control organism and gave no indication of colony growth. For faecal streptococci counts, filters were placed onto CRITERION CLED media (Merck) plates and incubated at 18°C for 18 to 24 hours. Typical colonies appearing yellow (0.5 mm diameter) were counted as intestinal enterococci and numbers were expressed as colony-forming units per 100 millilitres. Negative control entailed culturing un-inoculated medium under same culturing conditions. No bacterial colony growth was, however, recorded 7 days after incubation in same conditions. As a positive control mechanism, Staphylococcus aureus ATCC 25923 was cultured on CLED medium. Deep yellow colonies, uniform in colour were observed. For S typhi , filters were placed onto CRITERION Salmonella Shigella Agar (Merck) plates and incubated at 35°c for 24 to 48 hours. Typical pink colonies with dark centred spots were counted as S typhi and were expressed as colony-forming units per 100 millilitres. Negative control was performed using Enterococcus faecalis ATCC 29212, with the results being no growth observed.

Data analysis

A normality test of the data was done using Kolmogorov-Smirnov test. Data were managed using SPSS software, and all tests were performed at 95% confidence level. Pie charts and graphs were used to organize and present the data. Spearman correlation was used to establish whether there was a statistically significant relationship among the various bacteriological parameters tested.

Household sanitation characteristics

Of the 150 households interviewed, 72% of the respondents were women (n = 108), whereas the rest were men (n = 42). The education levels of the respondents included the following: no formal education (67%), primary (24%), secondary (7%), and tertiary (2%). On average, the households had between 10 and 15 members. According to the findings of the research, it was found that on average, a single latrine was shared between 8 and 10 households in 68% of the households. The type and presence of sanitation facilities among the residents included simple pit latrine (64% ODF and 33% ODNF), EcoSan toilets (10% ODF and 5% ODNF), and ventilated improved pit latrines (6% ODF and 3% ODNF; Figure 1 ).

Sanitation types among ODF and ODNF villages. ODF indicates open defaecation free; ODNF, open defaecation not free; VIP latrines, ventilated improved pit latrines.

According to the study results, a significant gap still exists between handwashing knowledge and practices, thereby exhibiting poor hygiene among households. Handwashing facilities in latrines were present in 78% of latrines in ODF areas, whereas only 27% were present in ODNF areas. Furthermore, households that routinely washed their hands, however, reported 18% cases of waterborne diseases as compared with 73% cases in the houses that did not wash their hands. Latrine coverage was 49% in villages where CLTS villages compared with 13% in non-CLTS villages. Plate 1 shows images of open defaecation eradication efforts in Ngare Mara ward, Isiolo County, Kenya.

Open defaecation free verification efforts in Ngare Mara, Isiolo, Kenya: (A) traditional pit latrine with a handwashing facility and (B) ventilated improved pit latrines.

Regarding sharing of latrines among households, it was found that on average, a single latrine was shared by between 8 and 10 households in 68% of the households. This was found high considering that each household had an average number between 10 and 15 individuals. Most residents cited long queues to use latrines as a hindrance to shared latrine use, further promoting open defaecation practice. The respondents’ reasons for not using latrines included absence of latrine facilities (43%), ignorance (32%), and cultural barriers (25%). In 75% of the households, the respondents cited high construction costs as a barrier to toilet construction. In such households, the construction of toilets was generally seen as a responsibility of the government. A comparison of improved versus un-improved sanitation among households is presented in Figure 2 .

Sanitation modes among households in ODF and ODNF villages. ODF indicates open defaecation free; ODNF, open defaecation not free.

According to the study findings, the disposal methods of the child faeces among households included the following: leaving in the open to dry (53%), bush disposal (17%), burying (24%), and toilet disposal (6%). Also, 78% of the respondents admitted that they aware of the negative health implications of engaging in open defaecation, whereas the rest considered it as non-issue.

Sanitary survey of the water sources

Sanitary inspection was conducted for various water sources. According to the sanitary survey results, river sources had very high ROC at 0.82 (82%), water pans had high risk at 0.64 (64%), whereas boreholes and hand-dug wells showed medium ROC scores at 0.41 (41%) and 0.55 (55%), respectively. Total sanitary risk score showed a significant relationship with median level of contamination ( P  = .004). Latrines being near water sources, sharing water with livestock, and open defaecation along stream channels were found to be major risks for water contamination.

Bacterial quality of water sources

In the study, 92% of the households interviewed relied on un-improved water sources, whereas only 8% relied on improved water supply. The study sought to establish the relationship between the concentrations of various organisms analysed. The results presented in Table 1 reveal that there is no significant relationship among most of the bacterial pathogens.

Correlation among different organisms.

The concentration of different bacterial organisms was compared between the ODF and ODNF villages ( Figure 3 ). The findings revealed higher contamination levels in water sources occurring in ODNF compared with ODF locations.

Bacterial concentrations among water sources in ODF and ODNF villages. E.C., Escherichia coli ; F.S., faecal streptococci; S.T., Salmonella typhi ; T.C., total coliforms.

Faecal disposal practices among households

This study assessed the sanitation characteristics regarding faecal disposal and latrine use practices in rural villages of Isiolo County, Kenya, while relating them to potential effect on microbiological quality of water sources. Improving latrine use has been argued to guarantee a wide range of benefits to an individual, the household, and community at large. 10 Reducing open defaecation also requires access to and use of improved sanitation facilities, which are defined as facilities that prevent human faeces from re-entering the environment. In the study, latrine coverage was found to play a critical role in determining sanitation at both household and at community levels. The respondents cited lack of latrines among households as the major reason behind open defaecation behaviour. Similar claims have also been put forward in other studies conducted. 20 , 22 The use of latrines as a preferred means of faecal disposal for faecal disposal among the respondents was pegged on their simplicity and relative affordability. This aspect of latrine use has been supported in another study for reasons such as convenience, privacy, and status of latrines. 27 Latrines have also proved sustainable at ensuring a healthy environment, good sanitation, or the prevention of faecal-related diseases such as diarrhoea and cholera. 28 Efforts to ensure adequate sanitation can best be addressed through empowering communities to adopt latrine ownership and use especially at the household level. As noted, 75% of the households had cited inadequate funds as major reason for not setting up good latrines within their households. Although other studies have cited cultural barriers, incomplete knowledge, inadequate space in households, and water scarcity as reasons behind not using toilets, the role played by socio-economic conditions on determining household sanitation needs to be emphasized. 9 , 28 These reasons in themselves create a scenario where most households resort to defaecate in the open.

Even in communities or households where latrines are present, certain barriers to latrine use exist. Widely noted in the study was the sharing of latrine between 20 and 30 households on average. A Joint Monitoring Report on proposals to define the post-2015 Millennium Development Goals and indicators for sanitation recommends that improved sanitation be shared among no more than 5 households or 30 people. 1 This scenario not only results in a dilapidated state of sanitation facilities in place but also attracts serious health concerns especially when people resort to open defaecation as an alternative. Open defaecation contributes to negative health implications in the lives of the people especially women and children. 29 , 30 As the number of users of a latrine increases the proper maintenance, hygiene, privacy, and safety of the users are not always guaranteed. 31 Proper practices during latrine use also need to be emphasized as a means of attaining improved sanitation and personal hygiene. This study particularly focused on the provision of handwashing facilities in latrine settings. The findings revealed that handwashing facilities were predominantly present in ODF villages where CLTS interventions had taken effect as opposed to those that did not. The presence of handwashing facilities and their use after latrine visits improves hygiene by ensuring that transfer of faecal microbes does not take place through contaminated hands. 32 , 33 A study conducted to explore the gap between handwashing knowledge and practices in Bangladesh recommended that washing of hands be done with soap for better hygiene prospects. 34

With increased focus and growing interest on open defaecation by adults, disposal of child faeces in the environment has often been given little attention in many rural settings of developing nations. In this study, we found out that in most of the households, child faeces were thrown into the open spaces around the house or near bodies of water. This is because child faeces were perceived as harmless and therefore were left in the open to dry. Similar findings have been put forward in a study conducted in rural districts of Tamil Nadu, India. 9 Poor disposal practices of child faeces have equally negative health implications on the receiving environment. This is because children’s faeces too contain as many germs as an adult’s and it is very important to dispose the faeces quickly and safely. 20 , 28

High proportion of latrine coverage translated into improved faecal disposal practices and consequently improved sanitation. The reason behind this is the enhanced CLTS efforts that advocate for access to latrines by each and every household within rural villages, a characteristic common with the ODF villages. Improved sanitation condition and latrine coverage have been cited is outstanding characteristic of ODF areas. 29 In similar interventions conducted in rural Madhya Pradesh, India, the CLTS approach has led to modest increases in availability of individual household latrines and even more modest reductions in open defaecation. 35

Epidemiologic studies indicate that sanitary surveys have played an important role in determining pollution sources in water bodies. 11 Based on the sanitary survey conducted, high ROC was high especially for surface water sources. This was attributed to the presence of a high number of anthropogenic activities uniquely taking place around the water sources in addition to open defaecation activities hence contributing to their faecal contamination. Unsanitary practices such as defaecation in stream channels and riverbeds during dry seasons were found to contribute to faecal contamination. Rajgire 14 reports that defaecation on boundaries of water bodies results in bacteriological contamination.

In the study, most of the households relied on un-improved sources of contamination most being shallow wells. Most shallow wells were un-covered even when not in use presenting an ROC with faecal laden dust. Un-improved sources due to their un-protected nature are easily prone to contamination and hence unfit for drinking. 11 , 25 The study also demonstrates that there was a significant correlation between S typhi and faecal streptococci organisms ( Table 1 ). This relationship could point to the presence of a contamination source mostly faecal in nature across the different water sources. The results presented in Figure 3 also indicate higher bacterial contamination in water sources in ODNF areas as opposed to ODF areas. The high bacterial counts can be attributed to the high open defaecation rates, a consequence of low latrine coverage especially in ODNF areas. Studies have often demonstrated the impacts of sanitation coverage on the presence of bacteriological pathogens on the environment especially on water sources contamination. For instance, a study conducted in Amravati District, India, showed that drinking water in ODF villages was 17% faecally contaminated, whereas ODNF villages was 48%. 12 The observations point to poor sanitation occasioned by low latrine coverage and use among households.

In a different approach, there is a growing interest to provide safe consumption of drinking water through adopting safe point of use treatment technologies. For the time being, it is our conviction that there is already sufficient evidence that communal sanitation has many advantages in ensuring safe water access. We recommend that attention be given to developing practical strategies to ensure that safe drinking water is ensured at source rather than at the point of consumption.

Conclusions

The eradication of open defaecation greatly remains a matter of discussion if significant steps have to be made to ensure access to improved sanitation and potable drinking water. In our study findings, we demonstrate the rampant practice of open defaecation among rural villages of Isiolo, Kenya, that is largely attributed to lack of latrines among households. In addition, the widely noted reliance on un-protected surface and shallow water sources and general water scarcity generally points to serious health concerns from contamination. As per the study findings, the high bacterial loads recorded in the water samples reveal the magnitude of faecal contamination of the water sources. This scenario is not only unhygienic environmentally but also poses a risk to human health of the residents such as contracting waterborne diseases. Because a large proportion of communities in developing countries depend on water systems that require the users to collect and store drinking water, it is important that we are able to assess the significance of any associated health risks. Solutions aimed at improving the sanitation situation is therefore a modest step towards safeguarding the bacteriological quality of the water sources. In particular, CLTS is a strategy that remains viable for tackling open defaecation menace among many rural communities especially in developing countries.

Acknowledgments

The authors wish to thank all the participants who took part in this study. They specially thank the Government of Kenya (Isiolo County Public Health Department) and Egerton University fraternity in Kenya who contributed immensely in the production of this work.

Peer review: Two peer reviewers contributed to the peer review report. Reviewers’ reports totalled 1206 words, excluding any confidential comments to the academic editor.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions: JOO, WNM, and GMO conceived and designed the experiments; agreed with the manuscript results and conclusions; jointly developed the structure and arguments for the paper; made critical revisions and approved final version; and contributed to the writing of the manuscript. JOO and WNM analysed the data. JOO wrote the first draft of the manuscript. All authors reviewed and approved the final manuscript.

Disclosures and Ethics: As a requirement of publication, the author(s) have provided to the publisher signed confirmation of compliance with legal and ethical obligations, including but not limited to the following: authorship and contributorship, conflicts of interest, privacy and confidentiality, and (where applicable) protection of human and animal research subjects. The authors have read and confirmed their agreement with the ICMJE authorship and conflict of interest criteria. The authors have also confirmed that this article is unique and not under consideration or published in any other publication and that they have permission from the rights holders to reproduce any copyrighted material.

MSU Extension World Food Prize Michigan Youth Institute

India: the problem of open defecation.

Scout Senyk - August 16, 2017

Scout Senyk's essay for Youth World Food Prize covers hygiene and malnutrition issues in India.

India is the seventh largest country in the world and is ranked second in population with 1,320,844,000 people. Located in South Asia, with the Indian Ocean to the south, the Arabian Sea to the southwest and the Bay of Bengal on the southeast. The Himalayas along with the Thar desert form the northern boundary of India. India has a total area of 1,222,550 square miles which is divided up into 29 separate states. Although India is one of the most populated countries, 67.6% of its population still resides in rural areas. The Himalayas play an important role in India's climate protecting it from the cold Central Asian winds keeping the country warmer than other countries at similar latitudes. India has a monsoon climate with hot wet weather from June until September and cooler dryer weather from October until February. The average winter temperatures in India are 50-59 *Fahrenheit, and the average summer temperatures are 90-104 *Fahrenheit. The monsoon rainfall is unpredictable year to year and in years of low rainfall drought frequently occurs.

Although India has one of the fastest growing countries economies in the world, it, unfortunately, has the largest number of people living underneath the World Bank's  international poverty line of US $1.25 a day. As of the recent 2010 census, 31% of India's 1.35 billion people still live below the international poverty line that translates into 499,000,000 people. At 48%, India also leads the world in the number of children under five who are underweight. Rural India has rate of malnutrition due to a higher level of poverty than urban areas, due primarily to many factors, such as higher poverty rates, lack of sanitation, and decreased level of education.

Indian culture revolves heavily around family and caste. Indian families are patriarchal with the oldest male making many of decisions for the family. The traditional Indian family can include multiple generations living together in one household. The household may also include aunts, uncles, nieces, nephews. The members of the household share incomes, expenses, and household chores. The family cares for the old and disabled, and those to young to work. The property is inherited along the male line, therefore making male children more desirable than female children. When a female is married, she leaves her family and moves in with her husband's family the bride's family also customarily provides a dowry gift to the male's family. The caste system also heavily influences a family's future. The caste system is an easy of ranking individuals by the social status that they were born into.  With the lowest class being the untouchables. Although discrimination through the caste system was made illegal, and the name untouchables changes to the scheduled class, it still plays a role in employment and income level.

Education is free and compulsory for all Indian children between the ages of six and fourteen. However since the individual states establish their own education laws, the length of primary education is not uniform. Primary education also suffers from a lack of resources, high teacher-student ratios, and the inability to enforce compliance. Fewer girls also attend school due to their lower status. Females also have a much lower literacy rate than males. Secondary education is available, but students must take entrance exams. Higher education is available once students pass the Higher Secondary Exam.

India lacks state provided healthcare. Instead, most health care is provided through the private sector. Most people in India pay out of pocket for all of their health care, and only 12 percent have any type of healthcare insurance. There are two state-run welfare programs. The first is the National Rural Health Mission which attempts to bring healthcare to the high poverty rural areas. In the rural areas, there is a lack of physicians only 2 percent of doctors live in rural areas while 68 percent of the population live in rural areas. There are also few hospitals in rural areas and a lack of equipment and diagnostic tools. The other system is the Urban Health Mission, which focuses on making healthcare available to the urban poor. Many of the urban poor still avoid state-run hospitals however because of lack of trained personnel and lack of basic equipment.  To pay for treatment at private hospitals, many Indians are forced to go into debt and once they are unable to pay they are discharged whether or not they are well enough to leave.

Even though India has a diverse economy agriculture remains the largest employment source. Over half the population earns their income from agriculture. India now ranks seventh in agricultural exports. Rice, buffalo, cotton, wheat and soybean are the major exports of India. More than half of the country is under cultivation with that number steadily increasing. Due to India's reliance on the monsoon system for water, they are only able to raise one crop a year. A major problem for the agriculture industry, however, is the unpredictable nature of the monsoon season in times of low rainfall they lack an irrigation system to water their crops, so they face the risk of crop loss.  Much of India's land has lost its fertility due to excessive irrigation, and over cultivation leading to depleted nutrients.

The average farm owned by a family in India is less than 1.2 hectares (3 acres). Sugarcane is the most profitable crop followed by cotton and soybeans. Many farms grow rice and wheat with over half of what is raised being kept by the farmer for their families consumption. Most of the work on farms is labor intensive, with little use of mechanized equipment. Labour and fertilizer are the highest expenditures on the typical farm.  Most farmers sell their surplus crops to a private trader who frequently doesn't pay the state mandated price. Unfortunately, over 65 percent of households have less than one hectare of land, which is not enough land to raise a profit on crops grown. Due to the small size of their farms, many are classified as subsistence farms. The typical Indian family spends 40 percent of their income on food and eats a diet primarily of rice, vegetables and flat bread made from wheat. Due to the fact that a large part of their farm needs to feed their family the farmer usually needs to find another source of employment to make ends meet. Because of the dependence on rains from the monsoons for irrigation, crop failure is also frequent when the rainfall is inadequate. This frequently leads to the farmer having to borrow money from local moneylenders who charge higher than average interest rates. More than half of all agricultural households are in debt. Once a farmer goes into debt it is nearly impossible to get out of.

One of the major concerns facing India is malnutrition due to lack of clean water and sanitation. Malnutrition is defined as the lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or the inability to use the food that one does eat. India’s malnutrition rates are some of the highest in the world. At 48 percent nearly half the children in India are underweight. At 15.1 percent India ranks 120th out of 130 countries for child wasting. Another large problem India has related to malnutrition is stunting, meaning underdevelopment, 48% of children under five are stunted. What is unusual about India is this isn’t only occurring to India’s poor children a third of the children are from the upper classes.

The risk of malnutrition frequently begins at birth, many babies are born to teenage mothers, and 75 percent of them are underweight and anemic and frequently put in insufficient weight leading to a low birth weight baby. Even when children are born at a normal birth weight they frequently become malnourished. Malnourishment causes the body to divert food intended for development to fight off infections causing decreased growth and a loss of cognitive skills. When this occurs within the first two years of a child's life the effects are irreversible, leading to lower education levels and up to 45 percent reduction in lifetime earning potential. Malnourishment does not occur in just one economic demographic however, babies born to wealthy families often face the same problems of malnourishment that occurs in poor families.  This leads to the one thing poor families and their wealthy counterparts have in common: poor sanitation and access to clean water.

Open defecation, the practice of people defecating out in the open wherever it is convenient, is one of the main factors leading to malnutrition. In the urban setting, 12 percent of the population open defecate and rural areas that number is 72 percent. Open defecation leads to polluted water; up to 75 percent of India's surface water is polluted. When water is exposed to untreated sewage it becomes a breeding ground for parasites and water-borne diseases such as cholera, dysentery, e.coli, and salmonella. Human exposure can come from consuming the contaminated water or eating foods that are washed or irrigated with the polluted water. Children are more susceptible to these diseases which frequently lead to diarrhea. Once a child becomes infected and begins diarrhea it becomes difficult for them to absorb need nutrients in the food that they consume. The inability of their bodies to adequately absorb the food that they eat may eventually lead to malnutrition, stunting, and even death. Even once they seek medical treatment for their low birth rate and the problem is corrected, it frequently recurs once they return home due to the continued consumption of contaminated water. Many families also wish not to stay long periods at government nutrition centers due to the loss of work and income which puts a heavy financial strain on the family.

There are two huge obstacles to eliminating the practice of open defecation. If India is eventually able to solve these problems however the incidences of disease related malnutrition will decrease dramatically. First, it is culturally acceptable. Many Indians have grown up in an environment where everyone does it. Defecating in the open is frequently considered good and healthy among rural Indians. The second major problem is lack of toilets ad infrastructure. Currently, only 30 percent of villages in rural India have a toilet, or the toilet they have needs to be emptied by hand every 5 years because there are no sewage treatment facilities. Due to the caste system, this becomes an issue due to the touching of excrement is associated with only the lowest caste. Eliminating the practice of open defecation will not occur until both problems are solved. To eliminate these problems, education and changing the social acceptability of open defecation should be a priority. The second factor is considering the types of toilets available and finding one that is acceptable to the people. Currently, the government of India is attempting to do theses two things with limited success.

The government of India has built 10 million toilets in rural areas in the last two years. Unfortunately, most are not utilized by the villagers. A Rice survey indicated that many Indians don't want to use the pit or latrine type toilets provided by the government because they fear the stigma attached to cleaning it. The fear that touching the excrement and being associated with the lowest castes is stronger than the fear of illness from unsanitary conditions.Two initiatives that the government is employing is the paying of a cash incentive to the village councils to enforce toilet use. There is also a campaign encouraging women to not marry a man unless his village has a toilet. These have had limited success. Unless the village is monitored closely they frequently go back to open defecation. The marriage campaign created the view that toilets were for women only. Due to the cost of building infrastructure, sewage treatment facilities are not being constructed in rural areas, so the dilemma of who will clean the toilet facilities needs to be addressed.

One current program that is showing success is bio-toilets currently in use by the Indian Railways. Biodigester toilets have several advantages over latrine or pit toilets making them more desirable to use. Bio-toilets use bacteria in the septic tanks of the toilets that break down waste products into usable water and methane gas through an anaerobic process. The process eliminates odors, harmful pathogens and decreases solid matter by 90%, does not require water, is maintenance free. Eliminating the need of villagers to touch the excrement eliminating the social stigma that comes with doing so.

Once toilets are built, the people have to be convinced to use them. One program that has shown success in the city of Ahmedabad is paying children to use the toilets. Children are paid one rupee a day (less than a penny) each day that they use the toilets intend of defecating in the open. Another method that worked in neighboring Bangladesh is a strategy called Community Led Total Sanitation which uses social pressure in villages to install toilets and discourage individuals from defecating in the open. Once you educate and convince some family members to use a toilet, pressure is put on the other members of the family to change their habits.

The country of India is experiencing an enormous public health crisis in the midst of large population growth. It accounts for the highest amount of deaths of children under five and 50 percent of these can be attributed to lack of clean drinking water and basic sanitation. When malnourishment occurs under the age of two irreversible cognitive deficits and motor delays occur; this costs India valuable human potential. India is a growing country, and the loss of human brain power will slow its growth and eventually cost it millions income potential. Ways to decrease these problems in India are through education, starting with children and mothers who are most at risk. Also if India invested in technology such as bio-toilets this would help reduce or eliminate the stigma that is currently associated with common pit toilets eventually increasing toilet use. Most of rural India lives in tightly knit communities real change needs to be started at the local level.  If the village council enforces their local rules, educated their village members, and socially pressures those who are resistant to change, the acceptability of using toilets will increase. These changes will lead to cleaner water, healthier crops and animals and most of all healthier people. Indian families are frequently living on the edge of financial disaster, and one illness is all it takes to push them over that edge. By educating them on the long term financial benefits of using a toilet not only will they become wealthier but India as a country will become stronger and wealthier.

Works Cited

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• Chacko, Priya , Georgina Drew, and Justin Brookes. "Could bio-toilets solve India's sanitation problems?" Citiscope. N.p., 18 Nov. 2016. Web. 29 Mar. 2017. http://citiscope.org/partner/2016/could-bio-toilets-solve-indias-sanitation-problems
• "Eliminate Open Defecation | UNICEF." UNICEF india . N.p., n.d. Web. 29 Mar. 2017. http://unicef.in/Whatwedo/11/Eliminate-Open-Defecation
• George, Rose. "Open Defecation in India Leads to Rape and Disease. Now, Women Are Demanding Toilets." The Huffington Post. The Huffington Post, 30 July 2015. Web. 29 Mar. 2017. http://www.huffingtonpost.com/rose-george/open-defecation-india_b_7898834.html
• "Helping India Combat Persistently High Rates of Malnutrition." World Bank. N.p., 13 May 2013. Web. 29 Mar. 2017. http://www.worldbank.org/en/news/feature/2013/05/13/helping-india-combat-persistently-high-rates-of-malnutrition
• "Nutrition." Unicef India. N.p., n.d. Web. 29 Mar. 2017. http://unicef.in/Story/1124/Nutrition
• "Overview of Malnutrition Situation in India - India - Mother, Infant and Young Child Nutrition & Malnutrition - Feeding practices including micronutrient deficiencies prevention, control of wasting, stunting and underweight." Mother and Child Nutrition. N.p., 6 Mar. 2016. Web. 29 Mar. 2017. http://motherchildnutrition.org/india/overview-india.html
• Paliwal, Ankar. "Next gen toilets." Down to earth. N.p., 15 Sept. 2012. Web. 29 Mar. 2017. http://www.downtoearth.org.in/news/next-gen-toilets-39004
• Preiss, Danielle. "Who Is Responsible For That Pile Of Poop?" NPR. NPR, 23 Sept. 2016. Web. 29 Mar. 2017. http://www.npr.org/sections/goatsandsoda/2016/09/23/494916008/who-is-responsible-for-that-pile-of-poop
• Kirti. "Social Enterprise Showcase: Banka Bioloo - Nature's answer to nature's call." The Alternative. The Alternative, 11 June 2013. Web. 29 Mar. 2017. http://www.thealternative.in/business/social-enterprise-showcase-banka-bioloo-nature-friendly-answer-to-natures-call
• Rangarajan A, Bihn E, Gravani R, Scott D, Pritts, M. “Food Safety Begins on the Farm: A Grower’s Guide.” Cornell Good Agricultural Practices Program, 2000, Web 29 Mar. 2017 https://www.cdc.gov/healthywater/other/agricultural/contamination.html
• Singh, Jyotsna. “Why India Remains Malnourished.” Down To Earth. 30 November 2013. Web 29 Mar. 2017 http://www.downtoearth.org.in/coverage/why-india-remains-malnourished-42697
• Spears, Dean. "Child Stunting and Open Defecation: How Much of the South Asian Height 'Enigma' Is a Toilet Gap?" Ideas for India February 2013. Web. 29 Mar. 2017 www.ideasforindia.in/article.aspx?article_id=1084
• "Stunting." Stunting | UNICEF. N.p., n.d. Web. 29 Mar. 2017. http://unicef.in/Whatwedo/10/Stunting
• Subramanyam, Malavika A., Ichiro Kawachi, Lisa F. Berkman, and S. V. Subramanian. "Socioeconomic Inequalities in Childhood Undernutrition in India: Analyzing Trends between 1992 and 2005." PLOS ONE. Public Library of Science, 30 June 2010. Web. 29 Mar. 2017. http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0011392
• Varma, Subodh. "India ranked 97th of 118 in global hunger index - Times of India." The Times of India. The Times of India, 13 Oct. 2016. Web. 29 Mar. 2017. http://timesofindia.indiatimes.com/india/India-ranked-97th-of-118-in-global-hunger-index/articleshow/54822103.cms
• Vogl, Tom S. "Height, Skills, and Labor Market Outcomes in Mexico." Journal of Development Economics, 27 Nov. 2013. Web. 29 Mar. 2017. http://www.princeton.edu/~tvogl/vogl_height.pdf
• Worley, Heidi. "Water, Sanitation, Hygiene, and Malnutrition in India." Population Reference Bureau. N.p., Sept. 2014. Web. 29 Mar. 2017. http://www.prb.org/Publications/Articles/2014/india-sanitation-malnutrition.aspx

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How Open Defecation Affects Human Health and Environment and its Effective Solutions

Open defecation is the emptying of bowels in the open without the use of properly designed structures built for the handling of human waste, such as toilets . Open defecation is particularly associated with rural and poverty-stricken regions of the world, especially Sub-Saharan Africa and Asia.

Open defecation statistics from around the world show a statistical relationship between the regions with the highest percentage of those that do not use toilets or other human waste facilities and those with low education or poverty.

The  World Bank Statistics  suggest that regions with high rates of open defecation experience tremendous problems in terms of sanitation and proper  waste management .

According to Wikipedia ,

“ Open defecation is the human practice of defecating outside — in the open. In lieu of toilets, people use fields, bushes, forests, open bodies of water or other open space. The practice is common where sanitation infrastructure is not available. About 892 million people, or 12 percent of the global population, practice open defecation. “

Alarming Reasons For Open Defecation

The reasons that have been given for people who don’t use toilets have either been poverty, which makes it a challenge to build latrines, or lack of government support in providing such facilities.

In cases where toilets are available, reasons for open defecation can extend to cultural issues related to sharing toilets among family members.

For instance, in some cultures, it’s considered taboo for a man to share the same toilet with his daughter-in-law. In some other cases, people end up preferring open-air defecation due to the freedom it gives them as opposed to using a small, dark structure or the displeasure of using toilets that are filthy or not clean.

According to the World Health Organisation (WHO), India accounts for 59 percent of the 1.1 billion people in the world who practice open defecation, leading to some serious  negative effects on both their own health and the environment .  

Let’s look at how open defecation affects human health and the environment.

Catastrophic Effects of Open Defecation on Human Health

Apart from being unpleasant by nature, open defecation has detrimental effects on the nearby community and the environment. Let’s take a look at some of the negatives it poses to the people around:

1. Increase in Waterborne Diseases

Open defecation is often done close to waterways and rivers, making water contamination more likely. When that happens, the chances of the nearby community getting exposed to human waste are multiplied.

Once exposed, those affected may suffer from a wide range of waterborne issues, including diarrhea. Children below the age of 5 are the most vulnerable, and that’s because their immunity isn’t strong enough to resist disease contraction .

In urban areas, open defecation sometimes occurs on drainage systems designed to channel rainwater away from urban areas into natural waterways. Participants believe the water will wash away their waste.

However, they overlook the fact that many of these areas lack proper facilities to treat the water, removing human waste and the accompanying microbes.

This practice contradicts proper sewage channels, which treat black water waste and direct it into water systems free of disease-causing germs.

Consequently, open defecation near waterways leads to untreated waste entering the water system. As a result, contaminated water ends up in the main water source.

When people in these regions use the same water for drinking and cooking without treating it first, it results in waterborne diseases such as cholera, typhoid, and trachoma.

2. Vector-borne Diseases

Besides  waterborne diseases , when human waste collects into heaps, it attracts flies and other insects. These flies then travel around the surrounding areas, carrying defecate matter and disease-causing microbes, and may even land on food and drink that people eventually ingest. In such cases, the flies act as direct transmitters of diseases such as cholera.

3. Compounding the Problem of Disease Exposure

The saddest fact about disease transmission caused by open defecation is the cyclic nature of problems that then begin to manifest. The most common diseases caused by this unsanitary act are diarrhea, regular stomach upsets, and poor overall health.

Diarrhea, for instance, means that people cannot make their way to distant places due to the urgency their calls of nature call for, so they pass waste close to where they have their bowel attacks.

It simply ends up creating more of the same problems that started the disease in the first place and, in turn, leads to more people catching diseases and fewer people using the facilities. This results in more sick people and more opportunities for the disease to spread.

4. Malnutrition in Children

Malnutrition in children is another health problem associated with open defecation.  Once a child is a victim of one of the diseases passed on due to the lack of proper sanitation and hygiene, they begin to lose a lot of fluids and lack of appetite for food.  As a result, it gives rise to many cases of malnutrition in children.

Also, the situation is worsened by intestinal worm attacks passed through human refuse. Altogether, these problems lead to stunted growth and a weakened immune system that makes the child more susceptible to other diseases, such as pneumonia and tuberculosis.

5. Child Stunting

Child stunting and wasting are observed to be one of the most widespread consequences of open defecation and poor sanitation around the world.

A study published by Dean Spears and Arabinda Ghosh studies 112 districts in India demonstrated that child stunting statistics were significantly higher in areas where the practice of open defecation was more frequent.

In these districts, it was noted that “Over half of the children are stunted, and almost a third of children are severely stunted.” Spears has stated in another paper that living with or near neighbors who continue to practice open defecation, the negative health effects of open defecation are significantly more pronounced owing to densely populated regions.

This is especially common in many areas in India. He mentions, “ the difference in average height between Indian and African children can be explained entirely by differing concentrations of open defecation. There are far more people defecating outside in India more closely to one another’s children and homes than there are in Africa or anywhere else in the world .”

6. Gender-based Violence

Open defecation and the lack of adequate sanitation hardware have strong and disproportionate gender-based impacts.

The lack of access to private latrines and toilets renders girls and young women vulnerable to sexual violence , which frustrates efforts for them to lead healthy and productive lives. This is a major public health concern, as well as one of human rights.

As there are no private lavatory facilities for women, they are often forced to relieve themselves in public places during the early hours of the morning or late at night, when the likelihood of sexual assault or violence is higher.

Moreover, the report also outlines the water and public toilets they can use to clean themselves are unclean, which contributes to the fear of infection or sickness in women, further exacerbating the health problems that result from open defecation.

In India, for example, The Sanitation and Hygiene Applied Research for Hygiene Organization (SHARE) report notes various instances of rape that many girls and young women live in constant fear.

Harmful Effects of Open Defecation on the Environment

Now that we’ve examined some of the consequences of open defecation to human health, let’s see how the practice affects our environment.

1. Contamination Via Microbes

Open defecation introduces toxins and bacteria into the  ecosystem  in amounts it cannot handle or break down at a time, causing great harm to the environment and a build-up of filth.

Also, the load of microbes can become so great that, in the end, they end up in aquatic systems, thereby causing  harm to aquatic life .

At the same time, open defecation can contribute to  eutrophication , or the formation of algal blooms once the fecal matter is washed down into water bodies.

When that happens, it forms a disgusting scum on the surface of the waterways, which disturbs aquatic life underneath the water by preventing oxygen and light diffusion into the water.

2. Visual and Olfactory Pollution

Heaps of human feces or just the sight of it causes an eyesore and nauseates anyone close. The stink emanating from the refuse is also highly unappealing and  pollutes the surrounding air . Such places also attract large swarms that make the area completely unattractive to the eye.

For all those unfortunate to see the regions affected, it creates a sorry sight and reduces the dignity of all those living in the squalor of those regions. The smells augment the problem by disgusting those who live within the affected regions making life awful.

Effective Solutions to Open Defecation

Solving the issue of open defecation requires the action of individuals and even the government’s intervention to address the cultural, economic, and social challenges in tandem.

1. Provision of Toilets

First, there is a need to ensure that there are enough toilets. Most of the communities severely hit by the issue of open defecation are usually very poor. Hence, the only way out is through the respective government’s efforts and the goodwill of local organizations such as CBOs and NGOs to help fix the problem.

Construction of pit latrines and other  toilet options, such as compost  toilets, is necessary to help deal with the lack of sewer systems.

Governments should also try to establish incentives for people to build their toilets by providing subsidies and putting up public toilets in strategic locations. 

2. Corrective Civil Education

Another platform that needs to be addressed is the negative cultural association that people have with toilets. The people should be informed and given civic education to break away from their cultural beliefs on issues such as toilets not being supposed to be shared.

In other words, cultural norms and beliefs must be changed over time through education and awareness creation. With time, people can become informed, drop their beliefs, adjust, and make concessions about the most destructive ones.

3. Incentivize Public Hygiene Participation

By creating government programs that encourage sanitation and personal hygiene, individuals should be involved and advised to be responsible for enhancing their hygiene and overall health.

Through such programs, people can learn the importance of their environments and work towards ensuring that they do not harm themselves by partaking in open defecation. 

This effort will eventually reduce healthcare burdens on the government and lessen the number of those who practice open defecation, as it will be  seen as a terrible activity .

4. Achieve the Sanitation Target

A clear understanding of what prevents and drives the transition from OD to using a latrine is needed, especially if OD elimination by 2030 is to be accelerated.

Sanitation marketing, behavior change communication, and ‘enhanced’ community-led total sanitation, supplemented by ‘nudging,’ are the three most likely joint strategies to enable rural and peri-urban communities to become completely OD-free and remain so.

It will be a major sanitation challenge to eliminate OD by 2030, but presently, the principal task is helping the poorest currently plagued by OD and its serious adverse health effects as we seek to achieve the sanitation target of the Sustainable Development Goals. In fact, it is a moral imperative for all governments and development professionals.

5. Swachh Bharat Abhiyan (SBA)

On October 2, 2014, Prime Minister Narendra Modi of India launched the Swachh Bharat Abhiyan, or Clean India Mission, on the 150th birth anniversary of Mahatma Gandhi.

According to the Ministry of Drinking Water and Sanitation, in 2015, the CIM achievements report showed that nearly 80 lakh toilets were constructed under the program. But, in December 2016, nearly 3 crore toilets were constructed.

The country still has a long way to go, as open defecation is a common practice in rural India. The government of India has been spending more funds to eliminate open defecation and toilet construction, but the progress made so far needs to be sustained and strengthened for further development.

References:

Problem of Open Defecation

Benefits of Ending Outdoor Defecation

Open Defecation Health Problem

Issue of Open Defecation

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A true environmentalist by heart ❤️. Founded Conserve Energy Future with the sole motto of providing helpful information related to our rapidly depleting environment. Unless you strongly believe in Elon Musk‘s idea of making Mars as another habitable planet, do remember that there really is no 'Planet B' in this whole universe.

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• Published: 23 November 2022

Socio-economic and demographic factors influencing open defecation in Haiti: a cross-sectional study

• Bénédique Paul   ORCID: orcid.org/0000-0003-0419-2129 1 , 2 ,
• David Jean Simon 3 ,
• Ann Kiragu 3 ,
• Woodley Généus 3 &
• Evens Emmanuel   ORCID: orcid.org/0000-0001-8865-3409 4  

BMC Public Health volume  22 , Article number:  2156 ( 2022 ) Cite this article

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Open defecation (OD) remains an important public health challenge in Haiti. The practice poses a significantly high risk of disease transmission. Considering these negative health consequences, this paper aims to identify socio-economic and demographic factors that influence OD practice among households in Haiti.

The study used secondary data from 13,405 households from the Haiti Demographic and Health Survey 2016-2017. Descriptive statistics and bivariate analysis were used to find the preliminary results. Further, multivariate analysis was performed to confirm the findings.

Around one quarter (25.3%) of Haitian households still defecate in the open, almost 10% in urban areas, and nearly 36% in rural areas. Multivariate analysis revealed that the age and sex of the household head, household size, number of children aged 1-14 years old in the household, education level, wealth index, access to mass media, place of residence, and region were significant predictors of OD practice among households in Haiti.

To accelerate the elimination of OD by 2030 and therefore achieve sustainable open defecation-free status, the government of Haiti and its partners should consider wealth disparities among regions and mobilize mass media and community-based networks to raise awareness and promote education about sane sanitation practices. Furthermore, because the possibilities to build toilets differ between rural and urban areas, specific interventions must be spearheaded for each of these regions. The public program can subsidize individual toilets in rural areas with room to collect dry excreta for the preparation of fertilizers, while in urban areas collective toilets can be built in slums. Interventions should also prioritize households headed by women and young people, two underpriviledged socioeconomic groups in Haiti.

Peer Review reports

Introduction

Open defecation (OD), defined as the disposal of human feces in fields, forests, bushes, open bodies of water, beaches, or other open spaces [ 1 ], remains a major health-related challenge in low- and middle-income countries. Due to its adverse health impacts, the international community has taken action to eliminate the practice of defecating in the open. In 2010, the United Nations General Assembly adopted a resolution in which it recognized access to safe drinking water and sanitation as a fundamental right, essential for the full enjoyment of life and the exercise of all human rights [ 2 ]. Subsequently, the adoption of the 2015 target 6.2 of the Sustainable Development Goals (SDGs), called for ending open defecation and achieving universal access to adequate and equitable sanitation [ 3 ]. Currently, approximately 494 million people worldwide still defecate in the open [ 1 ]. This practice however varies significantly among geographic regions: in Europe for instance, less than 1% of people defecate in the open compared to 18% in Africa and about 2% in Latin America and the Caribbean (LAC) [ 1 ]. In Haiti, nearly 40% of the population use pit latrines with slab, and approximately 20% use pit latrines without slab/open pit [ 4 ]. Also, estimates show that more than 20% of the population continues to practice OD, the highest proportion in the LAC region [ 5 ], exposing the country to the risk of negative health consequences related to the behavior.

The practice of OD generates direct and interactive contaminations of the three environmental compartments: soil, water, and air, exposing human and animal populations to the etiological agents of infectious waterborne diseases and/or intestinal parasitic infections [ 6 ]. Studies have shown that OD is associated with several adverse public health outcomes, contributing to the heavy burden of disease worldwide [ 6 , 7 , 8 ]. The practice is the leading cause of infectious excreta-related diseases, such as cryptosporidiosis, cholera, and typhoid, among others, as well as soil-transmitted helminthiasis infections which have chronic effects [ 9 , 10 , 11 ]. Diseases linked to environmental contamination by microorganisms are numerous in developing countries, especially those caused by bacteria and protozoa transmitted by water [ 12 ]. Cholera, for instance, is a major cause of diarrhea and a leading cause of death among children under-five years in developing countries [ 13 , 14 , 15 ]. Several comprehensive disease burden studies, focusing mainly on diarrheal diseases stress that inadequate drinking water, sanitation, and hygiene are important risk factors [ 8 , 13 , 16 ]. In Haiti, for instance, intestinal nematodes are frequent [ 17 , 18 ], transmitted through fecal contamination of the environment, they have been attributed to intestinal blood loss leading to iron deficiency anemia and protein malnutrition in developing countries [ 6 , 15 ].

Almost all studies on OD focusing on South Asia and Africa have identified various socio-cultural and socio-demographic factors to be key drivers for this phenomenon. Sociocultural barriers have posed a great challenge in improving sanitation facilities in developing countries [ 19 ]. Because social processes have an impact on individual-level behaviors [ 20 ], studies conducted in India, Nepal, and sub-Saharan Africa have found strong associations between sociocultural norms and OD [ 21 , 22 , 23 ]. These factors reflect a variety of determinants, such as gender norms of latrine use [ 21 ], preferences to defecate in the open instead of using a latrine [ 24 ], or cultural beliefs [ 22 ]. Furthermore, socio-demographic factors such as age [ 25 ], household wealth status [ 26 , 27 ], household size [ 22 ], and education of the household head [ 28 ] have been associated with OD. In addition, almost all of the studies have found that defecating in the open occurs predominantly in rural environments [ 27 , 29 , 30 ].

In Haiti, access to water and sanitation remains the lowest in the Western Hemisphere and the issue of OD persists leaving Haitians vulnerable to disease [ 1 ]. Despite concerted efforts to promote sanitation, achieving this goal was complicated by the 2010 earthquake which hit the country killing an estimated 230,000 people, injuring 300,000, and greatly degrading sanitary infrastructure [ 31 , 32 ]. Consequently, the low levels of sanitation services contributed to the severity and rapid spread of the cholera epidemic in 2010 resulting in 8494 deaths [ 33 ]. Notwithstanding the various challenges, Haiti has managed to discontinue cholera transmission since early 2019, even though persisting vulnerabilities remain [ 34 ]. To contribute to eliminating OD in the country, it is of paramount importance to understand the potential determinants of the practice in the country. While a substantial body of literature in developing countries has highlighted the importance of factors in predicting the practice of OD, no attention has been given to Haiti. Responding to this need, we build on prior research by examining the socio-economic and demographic factors influencing the practice of OD in Haiti.

Materials and methods

The Republic of Haiti is located on the island of Hispaniola in the Greater Antilles archipelago of the Caribbean Sea, East of Cuba and Jamaica and South of the Bahamas, the Turks, and Caicos islands, and shares the island of Kiskeya with the Dominican Republic. Haiti is the largest country in the Caribbean with a total land area of 27,750 km 2 . Economically, Haiti remains the poorest country in the LAC region and among the poorest countries in the world with a GDP per capita of 1815 USD [ 35 ] and ranks 170 out of 189 countries according to the UN’s Human Development Index [ 36 ]. Demographically, the current population of Haiti is 11,724,055 and the population density is 414 per km 2 [ 37 ].

Type of study and data source

This study was cross-sectional, retrospective and used secondary data from the most recent Haiti Demographic and Health Surveys (HDHS) collected between November 2016 and April 2017. The survey was carried out by the Haitian Institute for Children with ICF International providing technical support for the survey through MEASURE DHS. More specifically, the 2016-2017 HDHS collected information on household population and characteristics including information on access to toilets, fertility, marriage, and sexual activity, nutrition, malaria, HIV-AIDS, maternal and child health, adult and childhood mortality, women’s empowerment, domestic violence, and other health-related issues.

HDHS used a stratified two-stage cluster design where in the first stage 450 Enumeration Areas (EA) were selected. In the second stage, a random sample of 13,451 households was drawn from the selected EAs of which 13,405 were successfully interviewed, yielding a response rate of 99.7%. Detailed information regarding the HDHS sampling are published elsewhere [ 4 ].

Definition of variables

Dependent variable.

In this study, the main outcome of interest was open defecation (OD). The OD variable was coded “yes” if any household practiced open defecation and “no” otherwise.

Independent variables

Several variables (place of residence, region, sex of household head, age of household head, household head’s education level, number of household members, household wealth, number of children aged 1-14 years old in the household, number of elderly (aged 65 and above), number of men and women in the household, access to mass media, and marital status) were considered in this study as covariates. These covariates were selected following a literature review on factors found to significantly influence open defecation practice in various studies conducted in developing countries [ 22 , 25 , 27 , 30 , 38 , 39 , 40 ].

We utilized the existing coding for the place of residence, region, sex of household head, and education level as found in the HDHS Household Recode dataset. In the DHS, the place of residence was divided into ‘urban’ and ‘rural’ areas. The region was coded as ‘Aire Métropolitaine de Port-au-Prince’, ‘Reste-Ouest’, ‘Sud-Est’, ‘Nord’, ‘Nord-Est’, ‘Artibonite’, ‘Centre’, ‘Sud’, ‘Grand’Anse’, ‘Nord-Ouest’ and ‘Nippes’. The sex of the household head was coded as ‘male’ and ‘female’. The education level was grouped as ‘no formal education’, ‘primary’, ‘secondary’, and ‘higher’. In the Household Recode dataset, the age of the household head, number of household members, and number of children aged 1-14 years old in the household were continuous variables. However, for operational reasons, we decided to recode them. The covariate age of household heads was eventually ranked as follows: ‘less than 25 years’, ‘25-34’, ‘35-44’, ‘45-54’, ‘55-64’, and ‘65 and above’. The number of household members was coded as ‘less than 3’, ‘3-5’, and ‘more than 5’. The covariate number of children aged 1-14 years old in the household was categorized into ‘no children’, ‘one’, ‘2-3’, and ‘4 or more’. Number of elderly (aged 65 and above) was coded as ‘none’, ‘only one’, and ‘two and above’. Number of men and women in the household was divided into ‘fewer women’, ‘equal’, and ‘more women’. Access to mass media was a composite variable that was created by using two variables: access to radio and access to TV. In the HDHS Household Recode dataset, each type of mass media was coded as ‘yes’, and ‘no’. After examining the frequency distribution of the responses from the households, we recoded it as ‘yes’ if the household had access to at least one of these mass media, and ‘no’ if the household didn’t have access to any of them.

The household wealth covariate in the DHS is an index of household assets and utilities. To calculate this wealth index, a Principal Component Analysis (PCA) has been used, where questions about household construction materials, water, and sanitation access, and ownership of various assets (eg, radio, TV) are determined at the household level and then individuals are ranked based on the score of the households they live in. Furthermore, the rank positions are used to categorize individuals into five groups: ‘poorest’, ‘poorer’ ‘middle’, ‘richer’, and ‘richest’ [ 41 ]. As the wealth index took into account the ‘toilet facilities’ and ‘medias’ covariates, to avoid multicollinearity problems, we created a new wealth index by removing these two covariates while using the PCA approach and keeping the same quintiles. Finally, marital status was described as a three-category variable: ‘never married’, ‘in union’, and ‘divorced/widowed/separated’. We defined a household head ‘in union’ as a household head in a formal marriage or consensual union.

Data analysis

Statistical analyses were performed with STATA 14 software. Frequency distribution tables were used to draw households’ socioeconomic and demographic profiles. Thereafter, bivariate analysis was conducted using Pearson’s chi-square test to assess whether there existed significant associations between the outcome (OD) and independent variables. Lastly, multivariable analysis was performed using binary logistic regression. In addition, to better explore possible reasons for differences in the prevalence of OD, sub-sample analyzes of the multivariable logistic regression by urban vs. rural, poor vs. non-poor, and low education vs. high education sub-groups were also performed. The model fit was checked with Hosmer–Lemeshow goodness of fit test. Except for the model estimated for the urban area, a good fit was obtained ( P -value > 0.68). The variance inflation factor (VIF) was used to evaluate potential multicollinearity. The results of the means VIF were below the recommended threshold of 5 [ 42 ]. All explanatory variables were included in the multivariate analysis. The results were presented as adjusted odds ratios (AORs), at 95% confidence intervals (CIs). The sample weights (HV005/1,000,000) were applied to get unbiased estimates, according to the DHS guidelines. Furthermore, the survey command ( svy ) in Stata was used to adjust for the complex sampling structure of the data. Statistical significance was set at P  < 0.05.

This study is based on a secondary analysis of publicly available data ( https://dhsprogram.com/data/available-datasets.cfm ); therefore, no ethics approval was required from our institutions. Although no permission is required to access these datasets, the corresponding author of this paper sought and obtained on May 3, 2022, the favorable opinion of the Demographic and Health Surveys (DHS) Program for use of the data.

Background characteristics of households

The households’ socioeconomic profiles are presented in Table  1 . Nearly 6 in 10 households lived in rural areas. Slightly more than 20% of the households came from the Aire Métropolitaine de Port-au-Prince; 16.9% in the Reste Ouest and 15.5% in Artibonite. These three regions account for more than half of the households interviewed. However, Nord-Est (3.3%), Nippes (3.5%), and Grand’Anse (4.2%) are the regions with the lowest proportions of households. Nearly half of the households consisted of three to five members; 27.8% had more than five members, and 23% had less than 3 members. The average household size was 4.3 members (SD ± 2.3). More than 55% of households had no children aged between 1 to 14 years old, 17.3% had one child aged 1 to 14 years old; 21.2% had 2 to 3, and 6% had 4 or more. Also, 54% of households had access to mass media, 35.6% were in the lowest quintiles (poorest/poorer), and 43% were in the highest wealth quintiles (richer/richest). About 55% of household heads were males. Of all household heads that constitute our sample, roughly 25% were aged less than 35 years, of whom 4.3% were young; 21.7% were 35 to 44 years; 20.6% were in the 45-54 age group; 16.8% were 55 to 64 years, and 16.5% were aged 65 or more. In addition, 35% of them had no formal education, 31.6% had a primary education level; 26.8% had a secondary education level, and only 6.4% had higher education. Most of the household heads (66.6%) were in a union, 7.3% had never been married, and 26.1% were divorced or widowed. In addition, in more than three-quarters of the households, there were no elderly (aged 65 years and above). However, 1.9% of the households had one and 4.5% had two or more elderly persons. More than half of the households (51%) had more women than men while in 21% of the households, the number of women was equal to that of men.

Prevalence of open defecation practice by socio-economic and demographic characteristics of households

Table  2 includes information on open defecation by selected socio-economic characteristics of households. In Haiti, 25.3% (95% CI: 24.6 - 26.0) of households practiced OD; however this prevalence masks significant geographical, social, and economic disparities. The results indicated that OD was most common in rural areas (35.8%). The practice was most prevalent in ‘Grand’Anse’ region (49.5%), and least prevalent in the ‘Ouest’ (16%). There are also intra-regional disparities. Considering the ‘Ouest’ region, OD practice was most common in the ‘Reste-Ouest’ (26.7%), and least common in the ‘Aire Métropolitaine de Port-au-Prince’ (7.7%) (Table 2 ).

The analysis revealed that 23.5 and 26.7% of female and male-headed households practiced OD. Further, OD prevalence was 26.5% among household heads aged less than 25 years, 21.5% for 25-34 years old, 23.5% for 35-44 years old, 24.7% for 45-54 years old, 28.2% for 55-64, and 29.8% for 65 years old or more. As expected, the poorest households, households that had no access to mass media, and households in which the heads had no formal education level practice OD the most (43.8, 40.3, and 39.5%, respectively). Similarly, OD prevalence was much higher among households in which the heads were divorced/widowed (26.9%). We also found that OD was most common in households that had 4 or more children aged between 1 to 14 years old (35.3%) and least common in those there were no children aged between 1 to 14 years old (23.7%). Turning to household size, the difference in prevalence between the categories was very small (less than 3 members: 26.2%; 3-5 members: 24.6%; more than 5: 25.7%). Moreover, OD was most common in households where there was one elderly (29.2%) and almost similar in households with none or two or more elderly (24.4 and 24.8%, respectively). The prevalence of OD was much higher among households with fewer women (27.6%) than those with more women (23.5%). Additionally, chi-square tests showed that except for household size , all other covariates had significant associations with OD practice.

Predictors of OD practice in Haiti

Table  3 shows the results of the first model on predictors of OD practice in Haiti and confirms certain trends observed in Table 2 . The findings suggest that place of residence , region , sex of household head , age of household head , education level , marital status , household size , number of children aged 1-14 years old in the household , number of elderly , number of men and women in the household , access to mass media , and wealth index significantly influence OD practice. Compared with those from other regions (all for whom AOR < 1), households from Grand’Anse were more likely to practice OD. The results indicate that households living in rural areas were two times more likely to practice OD (AOR = 2.01; 95% CI: 1.76 – 2.30) than those in urban areas. We also found that households consisting of less than three members were 1.4 times more likely (AOR = 1.40; 95% CI: 1.21 - 1.62) to practice OD than households with more than five members. Similarly, households that had one child aged 1-14 years old (AOR = 0.81; 95% CI: 0.66 – 0.99) or none (AOR = 0.74; 95% CI: 0.61 – 0.88) were less likely to practice OD than those who had 4 children aged 1-14 years old or more.

Poor households had 1.6 to 2.1 greater odds (AOR = 2.13; 95% CI: 1.83 – 2.47; AOR = 1.64; 95% CI: 1.41 – 1.91) of resorting to OD than the richest households. Households that didn’t have access to mass media were 2.4 times more likely to practice OD (AOR = 2.35; 95% CI: 2.14 – 2.58) than households that have access to mass media. Households in which the head had no formal education were 23 times more likely (AOR = 23.04; 95% CI: 13.34 – 39.80) to practice OD than those in which the head had a higher education level. Similarly, households in which the head had primary or secondary education levels were at least 5.6 times more likely to defecate in the open than those in which the head had a higher education level. The likelihood of OD was significantly higher among younger household heads (AOR = 3.06; 95% CI: 2.23– 4.20) compared to those aged 65 years or more. The same trend was observed for the age groups 25-34, 35-44, 45-54, and 55-64. Finally, the results revealed that households in which the head had never married (AOR = 0.68; 95% CI: 0.53 - 0.87) and in union (AOR = 0.88; 95% CI: 0.78 - 0.98) were less likely to practice OD as compared with those in which the head was divorced/widowed.

Tables  4 , 5 and 6 present comparisons between rural/urban areas, poor/non-poor households, and low-educated/high-educated household heads. Indeed, we observed that there were no great differences between the results of these tables and those of Table 3 .

This paper is the first to focus on the prevalence and factors influencing OD in Haiti. Data used in this study are retrieved from the 2016-2017 HDHS, a national representative survey conducted by the Haitian Institute for Children in collaboration with ICF International. Further, to achieve the main of the study, we used scientifically validated methods (descriptive and multivariate analysis).

We found that the overall proportion of households practicing OD in Haiti was estimated at 25.3% (95% CI: 24.6 - 26.0), seven times higher than in the Dominican Republic (3.4%) [ 43 ] and comparable to the average prevalence of OD among households in sub-Saharan countries (22.5%) [ 27 ]. This relatively high prevalence of OD practice in Haiti is concerning, particularly due to the significant high risk of disease transmission it poses in the country. Therefore, gaining an understanding of the factors related to the behavior is imperative to eliminate the practice. Results from the present study suggest that OD was significantly associated with several socio-economic and demographic factors the age of the household head , sex of the household head , household size , number of children aged 1-14 years old in the household , education level , wealth index , access to mass media , place of residence , and region . To reduce the high prevalence of OD in Haiti, policymakers should consider these factors. Our findings revealed that poor households were more likely to practice OD. This finding is consistent with studies in Africa [ 22 , 25 , 27 , 29 , 38 ] and Indonesia [ 39 ]. A plausible explanation for the observed association is that poor households are more likely to face financial constraints to build a toilet [ 30 , 44 , 45 ] or construct simple toilets which fill up quickly and are prone to collapse when subjected to heavy rains or floods [ 38 ]. Also, those with rudimentary latrines may be financially constrained to upgrade them [ 46 ] resulting in slippages [ 26 , 39 ].

As was expected, households with an educated head were associated with a higher likelihood of not defecating in the open than those with uneducated heads, that is, the odds of defecating in the open decreased as the educational level increased. This evidence corroborates the association found in past studies [ 22 , 27 , 40 , 47 ]. Indeed, education enables an understanding of improved sanitation, the effects of defecating in the open as well as the relevance of owning a toilet [ 22 ]. In addition, a higher education level could affect household income, thereby providing the means to own a toilet [ 40 ].

Results found that having no access to mass media strongly predicts OD. This is an important finding since to our knowledge no previous research has tested this variable in OD prediction. Numerous studies have shown that mass media remains a vital source of information and can raise awareness, increase knowledge levels, and influence household behaviors and attitudes [ 48 , 49 ]. Households that are exposed to mass media are more likely to be informed about the effects of OD which provides a better way to understand the benefits of using a toilet [ 40 ]. In Haiti, as in many countries, the government usually uses mass media campaigns for sanitation promotion [ 50 ]. However, to reach households living in rural areas with limited access to electricity, the government would better mobilize community-based communication strategies, including local existing social networks and interpersonal communication [ 40 ].

Similar to other studies [ 22 , 24 , 40 ], our findings suggest that place of residence was a significant predictor of OD and that households in a rural environment are significantly more likely than those in urban settings to defecate in the open. This probably reflects different factors. First, Haitian rural households primarily engaged in agriculture [ 51 ]. The majority of their time is spent working in the agricultural fields. In such a context, even if they have access to a public latrine, they might not use it which may become a norm in rural areas [ 21 ]. Second, factors such as unequal distribution of resources and limited access to information and sanitary infrastructure that characterize rural settings lead to the practice of OD [ 27 ]. In Haiti, the level of poverty is much higher in rural areas (74.9%) than in urban areas (40.6%) [ 52 ]. Third, in urban areas, it is seen as socially shameful to defecate in the open [ 53 ]. Lastly, households in rural areas have less access to mass media than their counterparts [ 4 ], hence less exposed to information that can influence OD practice as well as local beliefs and behaviors [ 21 ].

The geographical region was significantly associated with OD. The study noticed that households in Grand-Anse were more likely to defecate in the open than households from other regions. Certainly, Grand-Anse is one of the poorest regions in Haiti [ 52 ]. The poverty rate in this department was 79.6%. Given the financial handicaps, many households in this region could not consider building a toilet facility a priority. Additionally, Grand-Anse was severely struck by hurricane Matthew in 2016 [ 54 , 55 ], i.e. 1 month preceding the 2016-2017 HDHS. More than 30,000 houses were destroyed or heavily damaged in the region as well as sanitation infrastructure, which could also explain the greater odds of OD practice in this department compared to others [ 56 ].

OD practice is significantly influenced by gender in Haiti. Indeed, households headed by women were less likely to defecate in the open than those headed by men. In line with a study in India [ 24 ], this result could be partly attributed to the residential factor. For instance, 44% of households headed by women are urban compared to 37% for those headed by men. As mentioned above, OD is most common in rural areas.

Results further noted that OD practice increased with a decrease in the age of the household head. This finding is supported by previous studies [ 25 , 27 ]. Since unemployment has increased considerably in younger age groups in Haiti during the last decades [ 51 , 57 , 58 ], youth-headed households were more likely to be poor, affecting their capacity to meet the cost of catering for basic needs including building toilets [ 22 , 59 , 60 ].

The marital status of the household head was significantly associated with OD practice with higher odds of OD where the household head was divorced or widowed. A study conducted in India is in line with our findings [ 24 ]. This finding may be accounted for by the fact that our sample of divorced/widowed household heads contains approximately three-quarters of females. Several studies have suggested that divorced/widowed Haitian women are more prone to economic shocks [ 61 , 62 , 63 ], and therefore households that they lead might not have access to toilets.

Household size was a significant predictor of OD. Households with less than three members had greater odds to practice OD than households that consisted of three to five members and more than five members. Our result is in concordance with findings in rural China [ 64 ] and East Africa [ 65 ]. This finding may be partly accounted for by the fact that the majority (65%) of households with heads aged 65 or more are larger-sized households (three to five or six plus members). Evidence shows that the presence of the elderly in households may reduce OD [ 66 ] as older people very often have mobility issues, and thus may have great difficulty moving to defecate in the open, especially in the dark [ 67 ]. To prevent risks (harassment, assaults, and attacks by animals), households with elderly members would have a further reason to take the necessary steps to build their toilets [ 68 ]. On the other hand, 30% of households with less than three members were headed by individuals aged under 35, compared to 12% of households consisting of more than five members. As already discussed, younger generations are particularly affected by the economic crisis in terms of employment [ 51 , 57 , 58 ], which would impact significantly the level of hygienic comfort of the households they lead.

Households with 4 children aged 1-14 years old or more are more likely to defecate in the open than those with no children aged 1-14 years old or one child aged 1-14 years. The large majority of Haitian households with 4 children aged 1-14 years old or more live in rural areas, while more than 40% of households where there are no children aged 1-14 years old or only child aged 1-14 years old live in urban areas. Given that OD practice is mainly a rural issue, this may explain this association.

Study strengths and limitations

The main strength of this study is the use of a nationally representative survey, therefore our findings can be generalized to all households in Haiti. Moreover, the study results shed light on the factors influencing OD in Haiti which provides invaluable information for interventions. It adds to the literature by including access to mass media as an important predictor of OD practice. Nevertheless, this study is not free of limitations. Because having to defecate openly infringes on human safety and dignity, it may be difficult for some households to report the practice resulting in underreporting which could lead to an underestimation of the phenomenon in Haiti. Furthermore, the cross-sectional nature of the data limits our understanding of causal inferences. However, these limitations do not invalidate our results.

Although Haiti has approved Sustainable Development Goals including target 6.2, the reduction of OD prevalence and the achievement of improved sanitation remain unsatisfactory. The results showed that one in every four Haitian households engaged in open defecation despite concerted efforts to eradicate the practice from the Haitian government and their partners. The factors influencing OD were age and sex of household head, household size, number of children aged 1-14 years old in the household, education level, wealth index, access to mass media, place of residence, and region. Consequently, to accelerate the elimination of open defecation by 2030 and therefore achieve sustainable open defecation-free status, the government of Haiti and its partners should reinforce their efforts while taking into consideration these factors. Particularly, they would better target rural households while using community-based and interpersonal communication strategies. Policy-makers should pay special attention to the socioeconomic situation of the households. The poor households in urban areas live generally in houses with not enough space for individual toilets. Community-based toilets could help reduce open defecation. Conversely, poor households in rural areas live in dispersed habitats with no sanitation system near them. Possible interventions, in this case, are to subsidize individual toilets, in addition to good sanitation awareness. Interventions should also prioritize households headed by women and young people, two underpriviledged socioeconomic groups in Haiti.

Availability of data and materials

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Acknowledgements

The authors would like to thank the Demographic and Health Surveys (DHS) Program for the approval to use 2016-2017 HDHS data.

The authors did not receive support from any organization to carry out this research.

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Department of Agro-socio-economics, Chibas, Université Quisqueya, Port-au-Prince, Haiti

Bénédique Paul

Groupe d’Etude sur les Sciences de la Durabilité, Université Quisqueya, Port-au-Prince, Haiti

Bureau d’Etudes et de Recherche en Statistiques Appliquées, Suivi et Evaluation (BERSA-SE), Port-au-Prince, Haiti

David Jean Simon, Ann Kiragu & Woodley Généus

Espace universitaire One Health, Université Quisqueya, Port-au-Prince, Haiti

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Conception and design: BP and DJS. Literature review: BP and AK. Data management and analysis: DJS, BP and WG. Interpretation of the results: DJS, AK, BP. Drafting of the article: BP, DJS, AK and EE. Review, editing and supervision: EE. All authors read and approved the final version.

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No ethics approval was required as this study used cross-sectional data which is available freely and publicly with all identifier information removed. To access and analyze the dataset we obtained official permission from DHS Program. The survey protocol was approved by the technical committee of the Government of Haiti led by the Haiti National Bureau of Statistics. The participants’ anonymity and confidentiality were assured. All methods were carried out following relevant guidelines and regulations.

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Paul, B., Jean Simon, D., Kiragu, A. et al. Socio-economic and demographic factors influencing open defecation in Haiti: a cross-sectional study. BMC Public Health 22 , 2156 (2022). https://doi.org/10.1186/s12889-022-14619-2

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The Supreme Court Walks Back Clarence Thomas’ Guns Extremism

This is part of  Opinionpalooza , Slate’s coverage of the major decisions from the Supreme Court this June. Alongside  Amicus , we kicked things off this year by explaining  How Originalism Ate the Law . The best way to support our work is by joining  Slate Plus . (If you are already a member, consider a  donation  or  merch !)

The Supreme Court upheld a federal law disarming domestic abusers on Friday, significantly narrowing a radical 2022 precedent in the process. Its 8–1 ruling in U.S. v. Rahimi is a major victory for gun safety laws, a much-needed reprieve after two years of unceasing hostility from the federal judiciary. Chief Justice John Roberts’ majority opinion walked back maximalist rhetoric—recklessly injected into the law by Justice Clarence Thomas—that had imperiled virtually every modern regulation limiting access to firearms. Thomas was the lone dissenter, signifying the rest of the court’s mad dash away from his extremist position on the Second Amendment.

Rahimi involves a violent criminal, Zackey Rahimi, who beat his girlfriend, then fired shots at either her or a witness as she fled his abuse. His girlfriend subsequently obtained a restraining order from a state court that found that he posed “a credible threat” to her “physical safety.” Rahimi, however, continued harassing her, threatened a different woman with a firearm, and was identified as the suspect in at least five additional shootings. When the police searched his apartment, they found a pistol, a rifle, ammunition, and a copy of the restraining order.

Rahimi was indicted under a federal law that bars individuals from possessing firearms while subject to a restraining order for domestic violence. He argued that this statute violated his Second Amendment rights, and the U.S. Court of Appeals for the 5 th Circuit agreed . The court rested its analysis on New York State Rifle and Pistol Association v. Bruen , the Supreme Court’s 2022 decision establishing a constitutional right to carry firearms in public. Thomas’ opinion in Bruen , though, went much further than that specific holding, declaring that all restrictions on the right to bear arms are presumptively unconstitutional unless they have a sufficient set of “historical analogues” from the distant past. (He didn’t bother to clarify the precise era, but it seemed to be sometime between 1791 and 1868.)

That approach posed two fundamental problems, which the lower courts quickly encountered when trying to apply Bruen : First, judges are not historians and cannot parse the complex, often incomplete record in this area with any consistency or reliability; and second, modern problems require modern solutions , especially when past bigotry prevented lawmakers from perceiving those problems in the first place. Rahimi is Exhibit A: Men were generally permitted to abuse their wives in the 18 th and 19 th centuries, with courts hesitant to interfere with what they deemed a private “familial affair.” Countless other examples have arisen in the lower courts since Bruen , with judges creating new rights to scratch the serial number off guns and own firearms while using illegal substances .

Roberts attempted to put a stop to this chaos on Friday. His Rahimi opinion cut back Bruen at every turn. “Some courts,” the chief justice wrote, “have misunderstood the methodology of our recent Second Amendment cases. These precedents were not meant to suggest a law trapped in amber.” Rather than hunt for perfect historical analogs, courts should ask “whether the challenged regulation is consistent with the principles that underpin our regulatory tradition.” If old laws regulated guns to “address particular problems, that will be a strong indicator that contemporary laws imposing similar restrictions for similar reasons fall within a permissible category of regulations.” Today’s regulations should generally avoid imposing restrictions “beyond what was done at the founding,” but the modern law need not “precisely match its historical precursors.” Roberts’ test significantly broadens (or perhaps loosens) the constitutional inquiry beyond what Bruen allowed. It instructs courts to look at principles , at a fairly high level of generality, rather than demanding a near-perfect match from centuries past.

The difference between Rahimi and Bruen is perfectly captured by Roberts’ majority opinion and the lone dissent written by Bruen ’s own author, Thomas. The chief justice asserted, “The government offers ample evidence that the Second Amendment permits the disarmament of individuals who pose a credible threat to the physical safety of others.” He breezily walked through a smattering of history allowing for the seizure of arms to preserve “public order.” For proof, Roberts cited surety laws, legislation that required an individual “suspected of future misbehavior” to post a bond, which he would forfeit if he engaged in misconduct. Domestic abusers could, in theory, be subject to the surety system, as could individuals who misused firearms—and that was good enough for Roberts. To him, this evidence established a historical practice of “preventing individuals who threaten physical harm to others from misusing firearms.” And disarming abusers “fits comfortably within this tradition.”

To Thomas, by contrast, surety laws “are worlds—not degrees—apart” from the law in question, because they were civil (not criminal) measures that did not actually disarm people but merely threatened them with a fine. These laws “did not alter an individual’s right to keep and bear arms,” Thomas protested, and they therefore failed to establish a relevant “history and tradition.” Indeed, “the government does not identify even a single regulation with an analogous burden and justification,” he complained in dissent. In 1791 a man like Zackey Rahimi could be disarmed only after a conviction for a violent crime. And so, Thomas wrote, that must remain the rule today.

Bruen was a 6–3 decision. Yet every justice who joined Thomas’ opinion in Bruen in 2022 signed on to Roberts’ walk back of Bruen on Friday. What happened? Aside from Justice Samuel Alito, every remaining member of the court expressed their views by writing or joining separate concurrences in Rahimi . Justice Brett Kavanaugh tried to defend his beloved “history and tradition” test, as opposed to “a balancing test that churns out the judge’s own policy beliefs,” while creating more room for “precedent” (or “the accumulated wisdom of jurists”). Justice Amy Coney Barrett wrote that Bruen “demands a wider lens” than the 5 th Circuit deployed, explaining that “historical regulations reveal a principle, not a mold,” and do not forever lock us into “late-18 th -century policy choices.” Justice Neil Gorsuch tried to split the difference, marshaling a defense of Bruen while subtly reworking it to limit sweeping legal attacks on gun regulations.

Justice Sonia Sotomayor, joined by Justice Elena Kagan, celebrated the majority’s focus on “principles” instead of perfect analogs. “History has a role to play in Second Amendment analysis,” she wrote, “but a rigid adherence to history, (particularly history predating the inclusion of women and people of color as full members of the polity), impoverishes constitutional interpretation and hamstrings our democracy.” Justice Ketanji Brown Jackson, who joined the court soon after Bruen came down, warned that Rahimi will not end the “increasingly erratic and unprincipled body of law” that Bruen inspired. “The blame” for the lower courts’ struggles “may lie with us,” she noted, “not with them.” All three liberals sound ready and willing to overturn Bruen altogether if they get the chance—but will, for now, settle for Rahimi ’s compromise.

What next? The Supreme Court will have to vacate a spate of lower court decisions that used Bruen to strike down seemingly sensible gun safety laws, ordering a do-over in light of Rahimi . Some courts will gladly accept the message. Others, like the lawless 5 th Circuit , will probably interpret Thomas’ dissent on Friday as the law and refuse to change their tune. Such defiance will test the majority’s commitment to a more workable and balanced Second Amendment jurisprudence—and likely fracture the court once more. By replacing Thomas’ hard-line views with a more malleable standard, SCOTUS has ended one battle over guns. But by remaining in this area, where it has no right to be in the first place, the court has invited a thousand more.

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Supreme Court Allows, for Now, Emergency Abortions in Idaho

A majority of the justices voted to dismiss the case, reinstating a lower-court ruling that paused the state’s near-total abortion ban. The ruling mirrored a version inadvertently posted a day earlier.

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By Abbie VanSickle

Reporting from Washington

The Supreme Court said on Thursday that it would dismiss a case about emergency abortions in Idaho, temporarily clearing the way for women in the state to receive an abortion when their health is at risk.

The one-sentence, unsigned decision declared that the case had been “improvidently granted,” meaning a majority of the justices had changed their minds about the need to take up the case now. It reinstates a lower-court ruling that had halted Idaho’s near-total ban on abortion and permitted emergency abortions at hospitals if needed to protect the health of the mother while the case makes its way through the courts.

The decision, which did not rule on the substance of the case, closely mirrored a version that appeared briefly on the court’s website a day earlier and was reported by Bloomberg . A court spokeswoman acknowledged on Wednesday that the publications unit had “inadvertently and briefly uploaded a document” and said a ruling in the case would appear in due time.

Chief Justice John G. Roberts Jr. announced the court’s decision from the bench, as is the custom for unsigned opinions.

Justice Ketanji Brown Jackson, who in part disagreed with the court’s decision and asserted that the justices should have addressed the case on its merits, read her dissent from the bench. Such a move is rare and signals profound disagreement.

The joined cases, Moyle v. United States and Idaho v. United States, focus on whether a federal law aimed at ensuring emergency care for any patient supersedes Idaho’s abortion ban, one of the nation’s strictest. The state outlaws the procedure with few exceptions unless a woman’s life is in danger.

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