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New Delhi: Economists and health experts have long been intrigued by the fact that the average child in India is shorter than the African child, although Africans are poorer.

After studying the problem for years, experts say the answer to this puzzle lies in sanitation and open defecation.

In 2013, the World Bank published a study, How Much International Variation in Child Height Can Sanitation Explain. Open defecation, the study said, can statistically account for most of the differences across poor countries in average child height.

A 2009 study by Jean Humphrey of Johns Hopkins University in the US said repeated faecal contamination which increases the small intestine’s vulnerability to disease-causing germs while reducing nutrient absorption could cause malnutrition, stunting and cognitive deficits, even without necessarily manifesting as diarrhoea.

Of the 1.1 billion people who defecate in the open, nearly 60%, or around 597 million people, live in India. The 2011 census showed 53.1% of all Indian households—and 69.3% of rural households—usually do not use any kind of toilet or latrine. The World Bank paper explained that open defecation is particularly harmful to children’s health where population density is high, making Indians even more vulnerable to stunting.

More children globally die due to diseases related to sanitation than from AIDS, malaria and measles put together, according to WaterAid, an international non-profit organization. In India, every year, 400,000 children die of diarrhoea, and 88% of the diarrhoeal deaths are linked to incomplete water and sanitation services. Other diseases like gastro-intestinal disorders such as tropical enteropathy, along with worm-related diseases, have been linked to poor sanitation in past studies.

Experts and studies have echoed, time and again, that when a country has poor basic sanitation, children and women are the most affected.

In the capital city of Delhi, 52% of children living in slums and resettlement colonies defecate in the open, according to a study by charity Child Rights and You (CRY) in 2014.

In resettlement colonies in Delhi where basic facilities are often unavailable, sanitation is the first casualty. “Open defecation is quite prevalent here as flats are really small, 12x18x24 square yards. People don’t have toilets at home, and are supposed to use community toilets," said Shehfair, coordinator at Plan India, a non-governmental organization that works on issues including sanitation in slums and resettlement colonies.

One of their projects is in Madanpur Khadar, a resettlement colony on Delhi’s outskirts, where more than 70% of the population defecated in the open till 2004. After intense campaigning and efforts to maintain community toilets, some blocks in the area have latrines. But the problem persists. “Six months ago my friend died. Her mother said it was because of diarrhoea," said a 15-year-old girl in the area. She proudly says she is part of the Green Force and used to wake up at 4am everyday to blow the whistle on people who defecated in the open.

On the other side of the open defecation-free block is a block where one cannot walk without stepping on human excreta. Children run across a bridge over a canal to get to an area covered with tall grass to defecate. “Open defecation is still a huge problem. There are 21 toilets in this area, 14,000 families, and the average family size is six," says Ashok Sharma, project director, Plan India. “Eight of these toilets are functional, so what choice do they have," he asked.

The water coming out of hand-pumps in front of houses which is used for drinking has a tinge of yellow. The community toilets that are functional are also not used to their capacities. “Sometimes people don’t want to spend money, there is lack of maintenance in community toilets, sometimes toilets are locked and defunct, there is an attitude problem, too, as they break the toilets," he added.

Women complain people often beat the person hired to clean the community toilet, while women using the toilets leave their used sanitary cloths strewn about inside. “Life has improved. But diarrhoea, loose stomach, jaundice are common. What else will happen if children are playing where there is water coming from sewage," asks Sudha Thakur, a 35-year-old resident who has two children.

Last year, a research paper by the World Bank studied the effects of early life exposure to Nirmal Bharat Abhiyan, a large government programme that encouraged local governments to build and promote inexpensive pit latrines, on childhood cognitive achievement. In the early years, six-year-olds exposed to the programme were found to be more likely to recognize letters and simple numbers.

“The results suggest both open defecation is an important threat to the human capital of the Indian labour force, and that a programme feasible to low capacity governments in developing countries could improve average cognitive skills," the World Bank study said. The decline of open defecation has not been as rapid as the growth of gross domestic product in India, the bank says.

“According to our calculations, Indian rural households on an average spend 500-1,000 per month on diseases like diarrhoea, cholera, dysentery and other vector-borne diseases. After these children are not able to go to school because of these diseases, parents have to miss days at work to take care of them and the economy of the house is affected," says R. K. Srinivasan, technical adviser for water and sanitation at Plan India.

Srinivasan said the main challenge of open defecation is in rural India where 60-70% people still defecate in the open, affecting women and children the most. “We are focusing on adolescent girls who face a lot of health and security problems because they are forced to defecate after sunset," he said.

This is the second part of a Mint series on Toilets for India.

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