Poor sanitation perpetuates a vicious cycle of disease

  • A homeless man defecates in the open on the side of a main road in Delhi, India, Aug. 2014.
  • Homeless people sleeping under a bridge in Old Delhi, India, Aug. 2014.
  • Homeless people sleeping out in the open on the street in Old Delhi, India, Aug. 2014.
  • A man defecating in an open field in the early morning hours near Brahamsarover, a large water tank in Kurukshetra, India, Aug. 2014.
  • A group of extremely poor people trying to recover anything of value from an immense dump in the center of Delhi, India, Aug. 2014.
  • People performing rituals at the start of a Hindu festival on the banks of the Yamuna River, the largest tributary river of the Ganges. The Yamuna River is considered a very sacred place for Hindu devotees but has become extremely polluted as a result of the area’s large industrial complex that dumps toxic waste into the water.
  • A young man has just finished defecating along the canal flowing aside the GT Road close to Kurukshetra city, India, Aug. 2014.
  • The village of Murtajapur, India where very few people have constructed toilets or latrines opting instead to go to the bathroom in open fields surrounding the village. There are few public latrines available and those that do exist are often off-putting because of the smell or are not properly working, Aug. 2014.
  • Street scene at Murtajapur village, India where few people have bathrooms in their homes. This farming community has traditionally practiced open defecation, there are very few public latrines, Aug. 2014.
  • The Gandhi Nagar slum in Kurukshetra, India where few people have toilets in their homes. Most residents prefer to jump a wall and use the area around the railway station rather than use the slum’s few available public latrines. They are very dirty and the stench is overwhelming, Aug. 2014.
  • A young girl cries after her mother bathes here. Her family is one of few in the village that has a bathroom in their home, Aug. 2014.
  • Gandhi Nagar slum of Kurukshetra, India, Aug 2014. Most of residents prefers to jump a wall and use the area surrounding the railway tracks rather than use the few public latrines in the slum because they are so dirty and the smell is overwhelming.
  • Public toilets near Brahamsarover left largely unused because of how dirty they are inside, Kurukshetra, India, Aug. 2014.
  • Two homeless men bathing early in the morning in Mela ground near Brahamsarover a large water tank in Kurukshetra, India, Aug. 2014.
  • A family living in makeshift tents aside a main road in New Delhi, Aug. 2014.
  • A man defecating in the open aside a main road in Delhi, India, Aug. 2014.



Sanitation has important implications for health and human capital development. Poor sanitation causes intestinal diseases that reduce the absorption of calories and nutrients and contribute to malnutrition. These diseases kill babies, stunt the physical and cognitive development of surviving children, and ultimately reduce their human capital development and earning potential later in life.

According to WHO/UNICEF Joint Monitoring Programme estimates for 2012, over 1 billion people still defecate in the open. Although considerable progress has been made since 1990, the prevalence of open defecation is nevertheless very high in countries in Africa and South Asia. The world is very far from meeting the Millennium Development Goal on sanitation.

Of those who still go in the open, 600 million of those live in India alone. This represents almost two-thirds of the problem. More importantly, because India is such a densely populated country, it has the highest number of people going in the open per square kilometer. Research has shown that it’s not just the proportion of a population that goes in the open that’s important, but the number of people. This is because if more people in the neighborhood go in the open, a child is more likely come into contact with the bacteria and germs that will make her sick.

India has the most open defecation per square kilometer by a very wide margin: 200 people per square kilometer go in the open in India while the second and third worst performing countries are Haiti and Nepal, where 79 and 77 people per square kilometer go in the open, respectively. Much poorer countries than India like Bangladesh, Pakistan, Afghanistan, and in fact every other country in the planet, has a better disease environment than India.

Even though the fraction of households without a toilet has been decreasing at about one percentage point per year in recent years in India, the size of the problem is actually still growing. Because population growth has outpaced the rate of sanitation improvements, the number of people going in the open has actually been increasing in many parts of north and central India. The disease environment in which children are growing up is becoming even worse in these areas, posing an increasing threat to the physical, cognitive, and human capital of children in these areas.

The recent SQUAT – Sanitation, Quality, Use, Access, and Trends – Survey studied the sanitation attitudes and behaviors of over 3,200 rural households across five states of north India. What the researchers found is that many people go in the open because they want to.

It’s not because people are poor. Some people believe that open defecation in India is just because people are poor. In fact, there is very little relationship between a country’s GDP and the fraction of people who defecate in the open. Many, many poorer countries than India have less open defecation – such as Bangladesh, where only about 4% of people defecate in the open, or most of sub-Saharan Africa. People in these other countries use inexpensive latrines that people in India could already afford to use if they wanted to. Latrine access is not the main problem.

It’s not because of a lack of water. It is a common supposition that rural people defecate in the open because they do not have enough water. In fact, WHO/UNICEF statistics say that more than 90% of rural Indians have access to improved sources of water. Moreover, many countries with much less access to water than India have much lower rates of open defecation. In our field research, almost no households in the rural north Indian plains suggested that anybody might think lack or scarcity of water would be a reason to defecate in the open rather than use a latrine. Villagers are happy to explain that water is not the issue.

Open defecation stubbornly persists in India because people prefer open defecation to latrine use. The researchers found that over 40% of households with a working latrine in their study have at least one member who still goes in the open. Strikingly, most people who live in a home with a government latrine still go in the open. This is true for both men and women. Most people also do not understand that going in the open is harmful to the health of oneself and one’s neighbors; over half of people who go in the open think that doing so is actually better for one’s health.

To have any hope of meeting global sanitation targets, the world will need to focus on India. Unfortunately, the easy solution of building latrines is not going to solve the problem. The Indian government has pledged to eliminate open defecation by Gandhi’s birthday in 2019, and in order to do so, it will need to launch a nation-wide campaign to promote latrine use that reaches from politicians offices to every remote village. All eyes should be on India and its government now as it formulates its new Clean India Campaign. Will it be able save the lives of hundreds of thousands of babies, and improve the health, cognitive development, and future prospects of countless others? Or will it continue with the same old policies of the past that have done little to improve the lives of its citizens?

Massimo Berruti is an award-winning photographer based in Rome. He has worked extensively in south Asia where he has focused his efforts on documenting changing society. 

Sangita Vyas is Associate Director at the Research Institute for Compassionate Economics, an organization based in Delhi that focuses on research and policy advocacy on issues that affect child and maternal health.

For more feature photography, go to msnbc.com/photography