Albener Pessoa

Much has been made recently about the appalling rates of open defecation in India, a country that has on other development indicators shown stunning successes. Almost 600 million people in India defecate in fields, forests, bodies of water, or other open spaces rather than in closed latrines or toilets—that’s more than 10 times the number of any other single country, and 60% of the world’s total.

Why, in contrast, does neighboring Bangladesh—a country not only sharing a border but many religious, social, and cultural norms of South Asia—show such sanitation success?

So vast are the differences in current open defecation rates—3% of the population in Bangladesh compared to around 50% in India—that insights from the Bangladesh experience are worth examining.

Open defecation pollutes groundwater, contaminates fruits and vegetables, and spreads disease. Furthermore, traveling to fields threatens women’s safety. Unicef estimates that every gram of feces contains 10 million viruses, 1 million bacteria, and 1000 parasitic cysts. Two thousand children a day die from diarrheal diseases and other diseases linked to poor sanitation. Experts now believe that half of the world’s malnutrition and stunting burden is attributable to poor sanitation. Even when compared with their much poorer and underfed contemporaries in sub-Saharan Africa, Indian children have persistently high rates of malnutrition, despite remarkable economic growth in the country.

Indeed, the negative effects of poor disposal of fecal matter will undo the positive effects of improved nutrition and healthcare. Energy and nutrients used to fight diarrheal and other infections are taken away from children’s growth and brain development. Worse, losses in height and cognitive ability owing to stunting are irreversible. Later in life, the missed development opportunities result in increased risks of heart disease and diabetes.

So sanitation is the key to a cascade of development challenges. There is growing awareness of, and commitment to, sanitation goals. The task is to translate those efforts into the intended outcome, as Bangladesh has done by reducing open defecation rates to a single digit number in just 20 years (the proportion of the population practicing open defecation was 34% in 1990, 19% in 2000, and 3% in 2012). Bangladesh achieved this by recognizing early on that attitudes and behaviors are as important as any technology or infrastructure.

Access to toilets is not enough, which the current Indian scenario illustrates: billions of rupees have been spent or pledged to spend on building toilets in the past 15 years, but the majority of people with government latrines don’t use them. A trial last month in PLOS Medicine revealed the failings of an Indian government program providing financial incentives to build improved latrine facilities: most families continued to practice open defecation, and, even among those who received improved sanitation, rates of infections in children did not improve. More important factors are at play here: traditions, religious customs, and perceptions that open defecation is healthy, social, or “wholesome.” “Feces don’t belong under the same roof as where we eat and sleep,” Bloomberg reported a young Indian woman saying.

The Indian government’s recent promise to achieve total sanitation by 2019 earmarks just 15% of the $657m budget for education and communication. Bangladesh seems to have seen it differently: changing social, cultural, and religious norms are central to changing the practice. As early as the late 1980s, the government committed itself to a unique combination of community mobilization strategies, social marketing, private sector stimulation, and systems of incentives and accountability, which have all helped rapidly change sanitation behavior.

A national sanitation campaign by the Bangladesh government was launched in 2003 to specifically meet the millennium development goal on improved basic sanitation. It brought non-governmental organizations, international agencies, and government together to mount what was called a community led total sanitation approach, focusing on rural populations. This involved “including the people in all parts of planning and action,” says Dr Farzana Begum, a senior programme manager in water, sanitation, and hygiene at icddr,b. Public education was provided on the dangers of spreading feces, the costs of treatment for the resulting diseases, the benefits of latrines for families, plus how community wide use was necessary to stem the spread of disease. Social pressure was key: families and school children monitored the defecation practices of other families. Mapping was carried out to illustrate how close open defecation sites were to mosques or homes.

And it wasn’t just health messages, but “shame and disgust” messages that were part of the campaign, says Dr Begum. Messages such as: “if we openly defecate, you will be eating other people’s feces.”

Social norms changed too: having a household toilet became a status symbol signifying dignity. Marriage arrangements began to include latrine reviews in the homes of prospective spouses. Gender sensitivity was recognized: women were included in making decisions about the location and type of latrines, and they sat on the community committees, while men were given tailored health promotion about hygiene.

Incentives were key: local leaders were chosen as champions of sanitation and held accountable to targets, small businesses selling concrete parts for latrines were rewarded, and financial assistance was provided to help households buy equipment.

It has been described as a “biplob” (revolution) or a “jagaron” (social movement), and remembering the national campaign was found to be one of the factors associated with sustained use of latrines in a 2010 study.

Later efforts in Bangladesh involved more sophisticated sanitation marketing, and a combination of social mobilization techniques and commercial incentives to stimulate entrepreneurship and revenue generation. The World Bank and national and local NGOs helped fuel private sector involvement, which has resulted in a flourishing rural industry of latrine sales and service.

Still, like many success stories, there is more to be done. While Bangladesh has impressive sanitation coverage (57%), only about a quarter of those latrines meet the hygienic standards necessary to stop the spread of disease. And, even though it is a tiny proportion of people overall who are estimated to still be openly defecating, 3% still amounts to over 4 million people in a densely populated country where land is limited.

With the rapid urbanization of Bangladesh, many of the millions moving from rural villages to cities for work reside in slums that have no sanitation infrastructure. Indeed, one of the limitations of Bangladesh’s national sanitation campaigns is that they have mostly focused on household latrine construction in rural areas, rather than on public toilets.

Toilet use for defecation is but one challenge in the larger water, sanitation, and hygiene conundrum. In my Dhaka neighborhood, no open defecation is visible but relieving oneself publicly is commonplace. Hand washing rates are abysmal. A recent survey showed that only 45% of schools had a clean toilet for students to use, which means girls miss school for days each month when menstruating.

Bangladesh’s success in sanitation is good and offer lessons for others, but more can be done.

Jocalyn Clark (@jocalynclark) is executive editor of the Journal of Health, Population and Nutrition, and other external publications at icddr,b (a global health research organization in Dhaka, Bangladesh). She was a former senior editor at PLOS Medicine (2008-13), and a former editorial registrar, assistant editior, and associate editor at The BMJ (2002-08).

Competing interests: The author has no further interests to declare.