Originally posted on the Badlaav Blog

54% of India’s population defecates in the open, without the use of a toilet. This statistic inevitably includes women and girls, who often must wait until the cover of darkness to relieve themselves, miles from home, and who often report that they experience sexual harassment and violence while doing so. And during menstruation, they have no privacy to wash and change their sanitary napkins – assuming they have access to old cloth or costlier disposable supplies. If not, they must use whatever absorbent material they can find, be it ash, sand, or leaves.

Open defecation has also been linked to malnutrition and height stunting, possibly because bacteria in the feces is transmitted to children, leading to infections that limit their ability to absorb nutrients. The bacteria find their way into community water supplies, including streams, rivers, springs, and wells, causing diarrhea and other illnesses. Any way we slice it, people are getting sick.

And yet, no matter how dire the problem, the solution is never as simple as ‘building more toilets.’ Poor communities, especially in rural areas, typically lack access to water to flush toilets, space to build them, or money to fund them. Without a proper sewerage or collection system, the waste will simply pile up where it always has – in the open. Also, Indian contractors are notorious for their corruption and willingness to cut corners, resulting in poorly-built, unusable toilets. Infrastructure is a sticking point, as it usually is.

So last week, the Gates Foundation announced a new phase of its Reinvent the Toilet Challenge, aimed at funding Indian entrepreneurs who create affordable, environmentally-friendly toilets that use no water or electricity – seemingly perfect for the global South. Previous iterations of this project have solicited talent from places as diverse as the USA, Switzerland, Singapore, and the Netherlands.

It sounds great. And new technology is part of the answer. But the other part, the harder part, the part no one likes to talk about, is this: people don’t want to use toilets. Indeed, they don’t even want to wash their hands after pooping – and this is when someone gives them soap and water. They simply don’t subscribe to the germ theory of disease, which is seen as ‘school learning’ and not relevant to their daily habits. Conceptions of ‘clean’ and ‘dirty’ are so deeply embedded in a community’s social fabric, and vary so greatly, that changing these beliefs and behaviors is a huge task. Community-Led Total Sanitation (CLTS) is one approach, in which facilitators take community members on a walk of shame, pointing out spots of open defecation and driving home the message that they are essentially eating each other’s feces. While it has shown some positive results, I question the ethics and compassion of such a ‘naming and shaming’ approach.

Really, it comes down to one question. What good is a cheap, waterless, eco-friendly toilet if no one is using it? We have to find ways of convincing people that defecating in the open is less desirable than using a toilet. People might not want toilets for health reasons. They might want toilets for privacy, convenience, and social status. They might fear using toilets at night because of snakes, mosquitoes, and supernatural spirits. They might want separate toilets for men and women. They might not want a toilet in their home, or anywhere nearby, because they see it as dirty. Women might balk at the extra labor involved, including fetching water, cleaning the toilets, and making sure children use them. These factors must be addressed from the ground up, rather than as an afterthought to the technological aspects.

The Gates Foundation is doing a good thing; there is no question about it. However, instead of focusing solely on technology, they should give equal weight to community mobilization and behavior change communication (BCC) programs. The research shows that communities with a greater sense of ‘community spirit’ participate more in intervention activities. Once empowered and educated, teachers, women, and children are great agents of change. Person-to-person visits, with regular follow-ups, are also effective at changing people’s habits, but they are so labor-intensive that many organizations cannot implement them. This is precisely where the Gates Foundation, with its vast network and resources, can step in and fund grassroots organizations that have the deep community connections and knowledge to truly effect change.