Everyone defecates, but ‘how’ and ‘where’ are questions that highlight class, gender and cultural differences between us. 

While Westernised habits of wiping with toilet paper provoke disgust in some, the idea of using a hand and water appalls others. Among the Masai in Kenya, tradition has it that men don’t defecate; for some communities in South India, crapping outdoors is an age-old social event; while for many women and girls, “going” outside can be downright dangerous.

Sanitation remains an issue before, during and after humanitarian emergencies. For those working to end open defecation, practiced by over two billion people, there is a taboo-laden bog of issues to wade through. IRIN explores some of them. 

The benefits

The “sanitation revolution” in Europe in the 1840s recognised the need to separate waste and water – and has been pursued ever since with evangelical zeal. The health benefits of reform are clear. According to the World Health Organization, 842,000 people die from inadequate water and sanitation access every year, with 280,000 deaths from diarrhoea directly linked to poor sanitation. 

Diseases like cholera and typhoid, intestinal worms, malnutrition and stunting are other consequences. Work and school days missed due to ill health are just some of the hidden costs of having no place to “go”. For every $1 invested in sanitation, around $5.50 will be saved in health and productivity costs, estimates the WHO

How far do we have to go? 

Although steady progress has been made in recent years, around 2.4 billion people still lack access to basic sanitation and handwashing facilities. For far too long, sanitation has been a “silent taboo” says water and sanitation expert Lyla Mehta of the UK's Institute of Development Studies. Sanitation only made it onto the global health agenda when it was incorporated into the Millennium Development Goals in 2002. (It’s now Sustainable Development Goal 6 – clean water and sanitation for all).

The biggest challenges lie in sub-Saharan Africa, where less than half the people in 47 countries have toilets or latrines, and in India, where 600 million people still defecate in the open. What complicates delivery is the steady stream of people into cities and urban settlements. 

How do we measure success? 

Not by counting the number of toilets rolled out by government, NGO or community-led programmes, says Mehta, co-editor of the study Shit Matters. “The global attention for sanitation is great, but it’s still very target driven, focusing on stopping open defecation and delivering toilets. Really it should be about equity and inclusion [the extent to which the most marginalised in a community are reached] rather than counting toilets.”  

The danger in focusing on toilet delivery is you can lose sight of the ultimate goal – improved health. Providing a community with toilets does not necessarily mean that community will use or maintain them. Toilets and latrines are all too often abandoned, ignored or improperly managed. Half-baked solutions resulting in overflowing latrines, coverless fly magnets or contaminated water tables, or portable toilets housed inside shacks, often pose greater health hazards than no intervention at all.  

The ‘toilet wars’ in the Cape Town township of Kayelitsha, South Africa, in 2013 were testament to this. Communities revolted against inadequate sanitation, including portable toilets that were an insanitary excuse for the real thing, and faeces was thrown in protest at government officials.  

What is the most effective strategy – top-down or bottom-up? 

There is no one-size-fits-all strategy – or toilet type, for that matter – say the experts. Most point to the need for a mix of state, NGO-led and community approaches that line up with cultural norms. Certainly top-down strategies that dump toilets on communities in the hope that they will then use, maintain and pay for them has often failed, says Preetha Prabhakaran, programme manager for Africa and Asia for the Community-Led Total Sanitation (CLTS) Foundation.

Patronising approaches that rely on “experts” who impose the need for sanitation on a community won’t work if the community does not feel that need, she says. This realisation has led to the hugely popular CLTS approach, pioneered by foundation chairman Kamel Kar

What is CLTS?

The premise of CLTS is that unless the community itself drives and owns the process – which is first and foremost about changing behavior – it won’t be sustainable. CLTS advocates try to motivate collective behaviour change by making people aware of the link between their faeces and disease and then triggering shame and disgust towards the health risks of open defecation, so that the community gets inspired to come up with its own solutions. 

In realising that everyone needs sanitation for the health of all, the whole community then comes on board, says Prabhakaran. “The focus in a collective approach is not on acquiring a toilet but on adopting sanitation and hygiene behaviours, one of the outputs of which is a toilet,” she adds. 

Can this lead to stigma and discrimination?

While CLTS, now used in many countries, has proved very effective and sustainable, particularly in rural areas, and is being lauded for being driven by the communities themselves, some observers are ringing alarm bells. They argue that it can be dangerous if the common good tramples on the rights of some individuals – the poorest people in a community unable to keep up with new sanitation and hygiene norms, or women who are often expected to be more hygienic than men, for example. 

Mehta agrees that CLTS works best in homogenous communities, not those riven by caste or ethnic divisions, where some less powerful groups may end up being the losers in a programme that the community drives itself.  

Prabhakaran says shaming people is not a part of CLTS. However, she adds: “When people realise that due to open defecation they are eating each other’s shit, they themselves feel shame, disgust and other emotions. It is this trigger – that they feel themselves – that gets them to stop.” 

Strategies to induce behavioural change, that often involve children, can include blowing a whistle when someone goes outdoors, putting flags on faeces with people’s names on them, even presenting ‘culprits’ with their own faeces, according to a paper on the subject.  

The authors site instances in Bangladesh where individuals have been stoned for defecating outside, coerced into signing contracts to build latrines and locked out of their homes for not doing so, among other punishments. They argue for more scrutiny of how CLTS programs are playing out. 

“Social inequality is very resilient and crops up in different ways,” says anthropologist Amber Wutich, director of the Centre for Global Health at Arizona State University. Sanitation is “a very complex problem because it deals with issues that are connected to strong felt human emotions of disgust. We need a diversity of solutions to be tested. There isn’t a one-size solution that fits all.” 

pg/oa/ag