Sanitation is called the most important health initiative in history. It saves more lives than vaccines, antibiotics, and anesthesia combined. The solution to high infant mortality rates and the way to fix malnutrition are the same: toilets. In my work I have also learned that hand washing at critical times proves to be as important as access to toilets and costs much less to implement. But if a toilet and simple hygiene regimen are all it takes to greatly reduce mortality rates, why does it seem that things have gotten worse?

Women and children suffer disproportionately from a lack of toilets. Due to social edicts they are forced to wait until dark to find a place to privately defecate. Not only is not being able to regularly relieve oneself unhealthy, women fall victim to rape and violence because they must find dark, isolated places. Furthermore, girls drop out of school once they begin menstruating because they become so far behind their classmates that there is no reason to continue attending classes. In the Alwar District of India, sanitation at schools increased female attendance by one-third and improved academic performance for girls and boys by 25 percent.

In Nepal hand washing by mothers and birth attendants reduced the risk of neonatal deaths by 41 percent. However, sanitation is not just integral to neo-natal health; it also affects the statistics associated with HIV/AIDS. In order to take antiretroviral medicine, HIV/AIDS patients must have access to clean water. A patient in Zambia “had been readmitted (to the hospital) up to 20 times as he was taking his medicine with bad water, so every time we discharged him he went home and got sick again. The drugs were working on him but what killed him was poor hygiene and diarrhea”.

How does one classify this kind of death? My guess is it was filed away under HIV/AIDS mortalities, but there is no telling how long this man could have lived if he had access to clean water and hygiene. This is often the situation - while HIV/AIDS or malnutrition might be listed as the primary cause of death, lack of sanitation is listed as the secondary cause of death and thus is frequently ignored. In truth, poor sanitation is the underlying cause that led to premature death by exposing this man to so many bacteria his weakened immune system failed. Sanitation touches everything and everyone all the time. For people who have constant access to proper sanitation this is easy to forget.

Since sanitation is so important, why is there not greater attention being paid to achieving 100 percent sanitation internationally? Because people do not like to talk about poop. In fact, I am pretty sure most people do not even like to participate in the act of pooping, and if we could do away with it altogether we would. Yes, poop is dirty and it carries disease, but it is also pretty amazing. In developed countries we are wasting fuel with every flush! Instead of using chemical fertilizers that destroy ecosystems, we could be using the fertilizers our bodies are producing. With simple systems, poop can be dehydrated, composted, and transformed into an ultra nutrient rich fertilizer. The trick is to keep it away from human contact until the pathogens have died. We have the technology for this, as well as the knowledge to combat lack of sanitation sustainably, yet we refuse to do so. It is not rocket science, it is toilet science.

The second reason that sanitation does not get the attention it deserves is that there is a misunderstanding about the relationship between sanitation and diarrhea. Often we call diarrheal diseases “waterborne illnesses,” but this is a misnomer - if you let water sit out it goes stale. It starts to smell. It oxidizes. But it will not make you sick. Water does not breed typhoid, cholera, or hepatitis A. These diseases are actually caused by fecal matter, and dirty water is not the only way to contract these diseases. However, people hear waterborne disease and think it is more important to secure new water sources than focus on sanitation. One can also become sick from houseflies or by handling food without washing one’s hands first - hand washing at critical times reduces fecal disease by as much as 40 percent. Any contact with fecal matter can lead to illness, so it is crucial that we address the need for sanitation and that behavior changes are made throughout the entire community. If even one person continues openly defecating it means that diarrheal disease will continue being passed through the community.

The final reason I think sanitation goes ignored is because people have a hard time relating to it on an emotional level. It is easy to feel an emotional connection to women who cannot take care of their families, men who are dying of HIV/AIDS and are visibly ill, or children who are forced to work instead of go to school. Development is filled with sad stories, painful images, and massive social injustice. It is easy to get caught up in a single cause and develop tunnel vision. But if we are going to create real change, problems have to be looked at holistically.

Imagine getting up before sunrise to walk a mile to relieve yourself, all the while risking rape or physical violence by the kind of unsavory types who tend to be up when the sun is not. And if you make it to a safe distance it is likely that you are surrounded by other people’s feces, which you must tiptoe around to the best of your ability. If it is rainy season there is no avoiding the poop, and while you squat you risk being bitten by a snake or stung by a scorpion. When it is all over, you work for ten hours and do it all over again once the sun has set. As terrible as this scenario is, the part that drives my passion is how that lack of sanitation ties into everything. No toilets and girls drop out of school. No toilets and a child dies every 20 seconds. No toilets and HIV/AIDS patients die sooner than they have to. No toilets and women get raped.

November 19th is World Toilet Day, a day about celebrating all the incredible things a toilet does. A toilet keeps girls in school, insures that children live to see their 5th birthday, saves women from violence, and allows men to go to work and support their families. World Toilet Day is a chance to praise the porcelain, recite odes to our commodes, and love our latrines. But more importantly it is a chance to bring awareness about the 2.6 billion people who do not have toilets.

I invite you to join me for my favorite World Toilet Day activity, The Big Squat. Squatting is a very healthy bathroom stance, but it also mimics the pose which nearly 40 percent of the population does every day when they openly defecate. By getting friends, family members, and colleagues join you in a public place and squatting you create a place where talking about poop is not embarrassing, but liberating. For more information on this and other World Toilet Day activities visit The World Toilet Organization.

About the Author:
Tonopah Greenlee was born in raised in Las Vegas, Nevada, USA. Since then she has worked in Kampala, Uganda with a female run community based organization. She is currently working at the World Toilet Organization as an advocacy and communication intern.

Tonopah earned her bachelor of arts degree in philosophy/history of mathematics with a minor in linguistics/history of science from St. John's College in Santa Fe, New Mexico and is currently working on her master's degree in Sustainable International Development from Brandeis University. After her graduation in May she hopes to pursue a career in food security or sanitation and water advocacy in order to attain a future where no child grows up without access to these basic human rights.