by Rose George
It’s time to leave Nancy Holt. My stomach is stuffed with gumbo, cornbread, and cobbler, and my brain is buzzing. I feel tired and spooked, perhaps due to the prospect of another six-hour drive back to Washington, D.C., on a dark and boring highway. It’s also because once, Nancy stopped talking midsentence as if she had been switched off, and her husband carried on reminiscing about stock car racing although his wife looked like she was barely living. Partly it’s because Nancy told me that the holes in her brain are so rare—children are born with them, but adults rarely acquire them—that when she dies the University of Maryland will collect her brain, slice and dice it and deliver it to 620 medical centers around the world “who want to look at that sucker,” and I realized that she’s probably going to die sooner not later, but I don’t have the nerve to ask when. So I leave the Holts’ bungalow in the late afternoon, wiser and none the wiser. As I pull out of the drive, I look at the field facing me. There is no visible sign of its “guff-proof fertilizer”—as Milorganite is described—sinking slowly into the soil. There is nothing to see but an innocent field, like thousands of others, unremarkable in the darkening light.
_______________________
Wall of shame, Kalyani, India
(Author)
OPEN DEFECATION–FREE INDIA
HUSBAND WANTED; MUST HAVE TOILET
____________
In a village in the eastern Indian state of Orissa, far from any city, our car is stopped by an oxen traffic jam. It’s harvest time, and the oxen are on their way home. All day, I’d seen women in roadside fields forking hay with pitchforks in Thomas Hardy scenes, their bright saris and gold jewelry glittering amid yellow grass. There is no point sounding horns at the oxen, because horns are blared so often on Indian roads they have long lost any effect of outrage or advantage. There is nothing to do but wait, so I open the car door to get out.
“Be careful,” says Joe Madiath, who is traveling with me. “You are about to step on the village toilet.”
Joe is a thoughtful host. He is a busy man with a huge job, as his organization, Gram Vikas, is trying to install latrines and water supply in as many Orissan villages as possible. Nonetheless, he always remembers to point out the sights. “That’s where the toilet starts,” he says, often, pointing to the side of a road just outside a village. I don’t need to specify which village, as only 4 percent of the population of Orissa has a latrine, and the sanitation story is the same everywhere. Sometimes, returning in the dusk, I play a safari game. There: an old man squatting, his buttocks exposed. Over there: a woman who has stood up suddenly at the sight of a car, and hastily pulls down her sari, but her face is resigned, not embarrassed. Here: two men walking back companionably, each holding a plastic lota that contained the water they have used to clean themselves. This standing up straight and the carrying of water vessels—these are the signs of the open defecator.
Every day, 200,000 tons of human feces are deposited in India. I don’t mean that they are dealt with, or sent down sewers or given any treatment or containment. These 155,000 truckloads are left in the open to be trodden on, stepped over, lived among. It is a practice known as “open defecation,” and it is done on a scale, in the words of Sulabh International, that compares to “the entire European population sitting on their haunches from the Elbe in the east to the Pyrenees in the the west.” Indians sit on their haunches from the deepest forest to the heart of the cities. They do it beside train tracks, as V. S. Naipaul recorded with disdain in 1964, and still do. The Indian journalist Chander Suta Dogra recently described an early morning scene familiar to any train traveler in India: “Right in your face are scores of bare bottoms doing what they must.” Open defecation is so endemic, people do it even outside public toilets in the center of a modern city. I see this one afternoon in the bustling city of Ahmedabad, where by early afternoon the pavement outside the toilet entrance is dotted with shit. I choose not to examine the interior.
An Indian businessman called Milon Nag tells me that when foreign clients came to visit his plastics factory near Pune, he kept a folder in the car, ready to hold up to distract his visitors from the sight of a roadside defecator. Nag is a considerate man, and the sight of people defecating in the open distressed him enough that he decided to do something about it. His accountant and sales manager became self-taught sanitation specialists. After years of research, his factory developed the most lightweight plastic latrine squatting platform on the market, now used by many aid agencies in emergencies. “For an Indian,” Nag says, “open defecation is the maximum embarrassment.” That’s not quite true. The maximum embarrassment for Indians is trying to defecate in traffic or a wheat field, keeping one hand free to cleanse and yet managing to keep faces covered with saris, all the while watching for lurkers and lookers. Open defecation damages women most, because modesty requires them to do it under cover of darkness, leaving them vulnerable to sexual assault, snakes, disease, and infection. Blocking natural body functions like urination and defecation can cause bladder and urinary tract infections and worse.
In some Indian villages, things have changed. We drive past a woman squatting and my companion says, “Years ago, she would have stood up when a car passed, from shame. Now there’s too much traffic. She can’t be up and down like a yo-yo.” Also in times past, she would have covered her face. Joe calls this technique “Cover the face, expose the base.” A woman in an Orissa village now equipped with toilets told me how things used to be: “Anyone could see the bottom as long as they didn’t know whose it was. We had to keep our dignity somehow.” How? She laughs. “With difficulty!” (I think of a joke someone told me in Moscow: How do you use a latrine in a Russian winter? Quickly.)
The arguments against open defecation are more than aesthetic. In public health terms, the practice is incredibly dangerous. Excrement is not automatically toxic. You could probably eat your own, if you wanted to (and some people do, as do most dogs), with no harm done. The trouble with excrement is other people, and specifically other people’s diseases.
Worms, for example, love to travel in it. Public health experts use the term “worm burden,” a pretty way of describing an ugly reality. The world’s worm burden is heavy: at any one time, about one billion people are carrying hookworm in their guts and expelling it in their feces; over a billion people have Ascaris lumbricoides, better known as ringworm, which can survive in human excrement for years. In the warm environment of a human gut, an egg can produce worms half a meter long. A public health bible, Health Aspects of Excreta and Wastewater Management, puts the number of infections that feces can transmit at fifty. These include salmonella, schistosomiasis, and cholera. Cryptosporidiosis and campylobacter. Giardia, meningitis, shigellosis (which leads to dysentery). Hookworms, roundworms, tapeworms. Dengue, leptospirosis, hepatitis A. Typhoid, scabies, and botulism.
These are all called water-related diseases because most travel from one host to another in water. More accurately, they’re shit-related diseases. Water gets contaminated by excrement, and people then drink or wash in it. Or they ingest feces directly by the 5 F’s, various fecal-oral contamination pathways summed up in the famous “F-diagram” developed in 1958. Feces can get into fluid and onto fields, fingers, flies, and foods. The goal of sanitation is to prevent excrement traveling from anus to mouth. Basic, adequate sanitation is containment.
Nearly 800 million Indians are spreading possibly contagious bugs around with abandon. The scale of open defecation in India may shock because it persists in a country with a galloping GDP growth rate of 8 percent a year. Or because the Indian government has been trying to combat it for decades. Over the last twenty years, millions of latrines have been constructed throughout the country, and billions of rupees have been set aside for sanitation targets. Between 1986 and 1999, the Government of India Central Rural Sanitation Program (CRSP) installed 9.45 million latrines, and 7.4 million more people a year gained access to sanitation. Population growth makes all targets immediately outdated (
between 1990 and 1999, India’s population increased by 144 million). Even so, the state’s efforts increased latrine coverage by 15 percent. But numbers deceive. Millions of Indians may have received a new latrine, but that doesn’t mean they use it.
On a road somewhere else in Orissa, Joe makes the driver stop the car. By the roadside are some modest houses, and in the yard are two small brick structures. Their walls rise shoulder high, and they have no roof. Their interiors contain grain sacks and, barely visible, a latrine pan, broken and clearly never used. Joe is scornful. “Look! There’s the Government of India’s sanitation program. There is what passes for a latrine.” He says you can find unused latrines everywhere. The country is covered with them.
All over India, in fact, those millions of government-built latrines have been turned into millions of firewood stores or goat sheds. Surveys found latrines that were unused, misused, or ignored. There are some obvious reasons why: the CRSP latrines were expensive. They were made of brick and cement. Consequently, some people found themselves with a structure that was nicer than their house. They didn’t want to waste it by using it as a toilet when there was a perfectly good bush out back, and so the latrine became a temple, or an extra room. Some people had a latrine but no water supply, so they preferred to carry on defecating near a water source rather than heft the water to the new latrine. Many people didn’t want to defecate anywhere near where they ate and slept—religious texts recommend defecating away from habitation—and a stroll to the defecation grounds was good for the digestion. Some latrines were badly designed for the terrain, so when their pits filled too quickly, they were abandoned. Some were badly designed in the first place. They didn’t have screens on the vent pipes, so flies got in. People used to the open air naturally preferred it to a dark, fetid, infested concrete box.
The lesson of the Indian government’s latrine-building program is a strange and perplexing truth: giving someone a latrine—even someone whose only other option is open defecation—doesn’t mean they’ll use it or maintain it. In development-speak, the government’s methods were “top-down.” They hadn’t bothered to ask people what they wanted before giving it to them. At a sanitation forum, West Bengal’s health minister, Dr. Suryakant Mishra, illustrated this with a cartoon that showed a man balancing a toilet on his head. “Earlier,” Dr. Mishra said, “instead of a person sitting comfortably on a toilet, the toilet was imposed on him.”
The government program concerned itself with supply. It didn’t bother looking at whether there was demand. Rural people had been defecating out of doors forever. They didn’t necessarily think there was anything wrong with it. Over the last decade, two new approaches have arisen to deal with this. Their strategies are different but their purpose the same: they want to make people want a toilet.
I had first met Joe Madiath in a cold hall. It was the second day of a sanitation conference, and despite the freezing temperature of the air conditioning, energy was diminishing. I was about to join the considerable numbers of delegates who had snoozed through “Safeguarding the Health of Public Toilet Users” and “Air Hygiene Control in Public Washrooms,” when a bearded Indian man wearing a striped kurta pajama went up to the podium. “Good afternoon,” he said in Indian-accented English. “My name is Joe Madiath and I work for a shit organization.” This woke me up. No one had yet used the word shit. (I once attended a conference of cemetery managers, and they didn’t use the word dead, either.) But Indians do, and especially Indians who want to sort out their country’s execrable sanitation situation. They have no time for verbal niceties. Even so, Joe apologized for his “unparliamentary language. But these words are used everywhere every day so allow me to use them.” Then he told a story.
Akbar was a great Mughal emperor. One day, Akbar asked his favorite minister Birubar what the most compelling need of a human being was. When Birubar said, “Sire, to shit and piss,” the emperor was offended and dismissed him. A few days later Akbar was on his boat in the river Ganges and he came to need the toilet. But Birubar had made sure there were no toilets on the boat, and Akbar became desperate, until Birubar sent him to a secret place where there was a toilet. Akbar came back and said, “You are right. The most compelling need of the human is to shit and piss and it is also something that gives you the greatest amount of relief.” Birubar kept his job.
Akbar’s epiphany came late to Joe. In 1971, equipped with a degree in English, he went to work with refugees who had fled from the newly created Bangladesh. Later that year, a cyclone hit Orissa, bringing a poor state already on its knees flat to the ground. With a few friends, Joe headed for Orissa to see what he could do. He meant to stay for a year and hasn’t left since.
Today he runs Gram Vikas (Village Development), whose headquarters consists of a rural wooded campus in beautiful scenery five hours from Bhubaneshwar, Orissa’s capital. There are no mobile phone signals, there are bicycles to borrow, and the campus canteen makes excellent Indian chow mein for breakfast, at least when the monkeys aren’t baiting the cooks. The place runs efficiently and confidently. Gram Vikas has won major international awards, like the 2006 Kyoto World Water Grand Prize, a big deal in the watsan world.
Yet its mission didn’t start with toilets. The young Madiath began by lobbying for land reform, because people were moving to the cities when life on the land got too hard, and the land was suffering. Eventually, his focus shifted to biogas, which also made poor farmers’ lives easier. Over 50,000 cow-dung digesters were installed over ten years. Still it wasn’t enough. Gram Vikas conducted field surveys to find the most acute problem stifling village development. They concluded that it was poor health linked to excrement. More than 80 percent of diseases were caused by contaminated water supplies. Sixty percent of women had skin and gynecological diseases because they were bathing in feces-contaminated water.
Orissa is not a water-starved state. Each village has a bathing pond, but this is also the animal trough, washtub, and toilet. The most pressing problem, Joe realized, was endemic open defecation. Shit was in the drinking water, on food, on the roads, on the bottom of flip-flops, on bare feet. Diarrhea was a weekly event for most people, and many children died from it. The obvious solution was to build latrines.
If Joe had been an engineer, or a bureaucrat in the CRSP program, he would have done only that. Orissa would have had a lot more goat sheds. But it seemed obvious to him that imposing toilets on some people wouldn’t work unless everybody had one. It had to be total, and it had to be consensual. “I knew there was [no] point in doing anything if eighty families had toilets and ten shat in abandon.” The ten open-defecating families would continue to contaminate the water and the living environment of everyone else. If sanitation were supplied, it would have to be to 100 percent of families.
These realizations, the result of observation, investigation, and common sense, were significant policy shifts from traditional development practices. Until recently, sanitation programs always focused on the household. The family unit was the one to be persuaded to change its habits and to build the toilet. But that was treating sanitation like water, when the two are nothing like. A family can be the only household to install a water pipe in a village, and it can use clean water without harming anyone else or being harmed by anyone else. But it only takes one family without a latrine to pollute all common areas and drinking water. The irony of defecation is that it is a solitary business yet its repercussions are plural and public.
Joe thought the solution was twofold: all families in a given village would have to agree to build a toilet and bathroom, and they would all have to agree to pay for it. He calls this method “one hundred percent sanitation.” It is also radical. It has been a standard in development thinking that poor people need subsidies. They aren’t supposed to be able to pay for things without help. In fact, poor people have money, but their money is busy. They prioritize. A toilet is rarely considered urgent when there is food to buy and school fees to pay, even when the lack of a latrine
contaminates that food and makes children too ill to go to school.
Gram Vikas’s job was to persuade people otherwise. Joe could see that there was no point supplying latrines unless he also provided water to cleanse with. That had been the government’s mistake. He tells the story of a daughter in a village where toilets had been installed. “We assumed that people would bring the water needed for the toilets from nearby hand pumps. This job was relegated to the wife, daughter, or daughter-in-law. One day, a daughter ‘accidentally’ dropped a small stone in the U-trap of the toilet, making it unusable. Pretty soon, similar accidents were taking place in other households, and it wasn’t long before people went back to open fields for their sanitation needs. Our lesson was clear. If water-based toilets are to function, we need to make sure running water is available.” The lesson was also that humans are complicated, and that sanitation is never only about bricks and latrine pans.
Gram Vikas chose to pilot their method in the village of Samiapalli. It’s now the Gram Vikas success story, where visitors are always taken. But it used to be an unhappy place. There were several castes, including ostracized Dalits, who rarely got along. Alcoholism was endemic, as was domestic violence. Women had no say and kept their faces covered whenever they left the house. No one had a latrine and everybody did open defecation. All this had to be changed. The weapons were patience, wits, and bribery.