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Open defecation and health: it’s all about your neighbors

Indian men urinating in public. --denisbin/flickr

There is a noteworthy gap in the child mortality rates among Hindus and Muslims in India. A novel analysis of the situation reveals that it has to do with the practice of open defecation. Most surprising is the fact that the problem is not so much about whether a household has a place to go to the bathroom, it is a matter if the neighbors do.

Mahatma Gandhi is credited with saying, “Sanitation is more important than independence.” Now, more than ever, his words ring true.

Hindus are 40% more likely to defecate in the open as opposed to their Muslim counterparts. Researchers Michael Geruso and Dean Spears say that this difference can account for the 18% child mortality gap between the two groups. However, a family installing a latrine is not enough when their neighbors do not have one. This community-wide problem has deadly implications.

If correct, that means that improving access to proper sanitation can have a greater impact on child mortality that getting wealthier. The link that poor sanitation causes child deaths is not certain, but the evidence paves the ways for other studies to understand what changes take place when communities stop defecating in the open. Tucked behind the major findings is also evidence that breastfeeding has a positive health impact on children.

“We find that moving from a locality where everybody defecates in the open to a locality where nobody defecates in the open is associated with a larger difference in child mortality than moving from the bottom quintile of asset wealth to the top quintile of asset wealth,” wrote Geruso and Spears.

They answer the “Muslim mortality puzzle” posed by a 2010 research paper. In The puzzle of Muslim advantage in child survival in India, Sonia Bhalotra and her colleagues found that Muslims in India have higher child survival rates as compared to their Hindu counterparts, despite being less well off, having poor access to healthcare and giving birth to more children. They posited that something beyond socioeconomic status was behind what was happening.

Correlates of religion that may plausibly influence survival without exhibiting a strong positive correlation with socioeconomic status include diet, attitudes to women’s work, personal hygiene, political clout or social norms and networks. Some of these effects may be better cast as historical, cultural or biological factors in that they are unrelated to religious belief per se even if they have gelled around a community that is identified by its religion.

Geruso and Spears’s research confirms the initial hunch. The difference is in the poop. By being significantly more likely to use pit latrines or toilets, Muslims see lower child mortality rates, despite economic challenges. More importantly, Muslim communities are more likely on the whole to not practice open defecation. The overall cleaner environment and improved health makes the biggest difference.

The research also connects to previous work done by Spears. He found that sanitation is also closely connected to the problem of stunting in India. Poor health during childhood can slow down physical growth. It is a problem in low and middle-income countries due to factors like poor nutrition and inadequate sanitation. Spears determined that the high rate of stunting is linked to the nation’s high rate of open defecation.

The implications of the findings are immense. Since Hindus make up the majority of the Indian population, increasing access to latrines and better sanitation could save hundreds of thousands of lives each year. With growing evidence that sanitation is behind health problems faced by Indian children, ending the practice of open defecation could go a long way to supporting the country’s citizens.

“It is time for communities, leaders, and organisations throughout India to make eliminating open defecation a top priority. This means much more than merely building latrines; it means achieving widespread latrine use,” wrote Spears in an OpEd for The Hindu last year.


About Author

Tom Murphy

Tom Murphy is a New Hampshire-based reporter for Humanosphere. Before joining Humanosphere, Tom founded and edited the aid blog A View From the Cave. His work has appeared in Foreign Policy, the Huffington Post, the Guardian, GlobalPost and Christian Science Monitor. He tweets at @viewfromthecave. Contact him at tmurphy[at]