An estimated 2.5 billion people lack access to proper sanitation around the world, and more than a billion defecate openly. Some 4 billion cases of diarrhea each year lead to more than 2 million deaths, mainly among children. That's more than AIDS and malaria combined.
In India, where 550 million people practice open defecation, 45 percent of children are stunted. The culprit in most cases is poor sanitation and lack of access to clean water. Studies show that lack of toilets and the resulting spread of disease is literally making Indian children shorter.
"When people don't use any form of toilet, they go into fields, roadside ditches or along railroad tracks," Thorsten Kiefer, founder and CEO of Wash United, a German NGO that works to increase access to sanitation, told VICE News. "It means it's impossible to effectively separate human beings from their own shit. People step in their own shit and carry it in their house, flies land on their shit — people end up eating and drinking each other's shit."
Kiefer is blunt, but the problem is as basic as it is widespread. In sub-Saharan Africa, the UN estimates that a quarter of the population still defecates in the open, mostly in rural areas. Urbanization has increased access to proper toilets, but increased population densities can magnify disease. In May, authorities in Nigeria's Lagos State urged police to arrest people for going to the bathroom in the open.
The problem is most severe in India. In April, as part of UNICEF's Poo2Loo campaign, the government released an animated video featuring a "fecal mascot" that urged Indians to use toilets. Shortly after he was elected Prime Minister, Narendra Modi beseeched the country to improve sanitation, telling them "toilets before temples."
Millions have gotten the message, but not as many understand the science that makes toilets so important. A single gram of human feces can contain as many as 10 million viruses, 1 million bacteria, and 100 parasite eggs.
'People step in their own shit and carry it in their house, flies land on their shit — people end up eating and drinking each other's shit.'
The Indian government has built toilets for decades, and they are often utilized. But they can just as easily end up as chicken coops, bicycle sheds, or a place to store fertilizer — just not the fecal kind.
"People often see defecating in the open as something that is more pleasant and more comfortable and enjoyable than using the confines of the small toilet," said Kiefer. "There's a whole culture around open defecation, there are age old traditions that need to be opened up to get people to want to have a toilet and fundamentally change the norms in society."
Pooping in public doesn't just spread disease. It can also put women in danger.
"When girls and women have to leave their village to defecate behind a bush, they render themselves more fragile and vulnerable to attacks," Catarina de Albuquerque, UN Special Rapporteur on the Right to Water and Sanitation, told VICE News.
Out of a total of 870 rape cases that took place in 2012 in the Indian state of Bihar, police say the vast majority occurred when women went out to defecate or urinate.
"Lack of sanitation has a very negative impact on women's rights and girl's rights," de Albuquerque said.
De Albuquerque was careful not to single out individual countries for fear of hindering the UN's efforts, but she noted that the Indian government has not allowed her to carry out an investigation in the country.
"Since 2008, I have been asking for a fact-finding mission India," de Albuquerque said. "I ask almost every year, and send a letter restating my will, and I always met with ambassadors to India, but the government never allowed me to enter the country."
Though it is widely viewed as a problem that is unique to the developing world, some industrialized countries are actively backtracking on the issue of toilet access. As cities in the United States and Europe close public restrooms, homeless populations have no choice but to defecate outdoors.
De Albuquerque said "there is a policy of systematically shutting down public toilets so as to get rid of homeless people," in some countries, which "poses enormous problems in terms of dignity and privacy and makes them prone to attacks."
Modi says he wants to rid India of open defecation by 2019. In August, he began a cleanliness drive and ordered government officials to clean their office buildings and toilets.
Kiefer is optimistic, but he knows that India's problem with open defecation is a stubborn one.
"It's not just building the toilets but getting the people to use them," he said.
Follow Samuel Oakford on Twitter: @samueloakford
Photo via __Flickr