Karen Burton Mains, author
Karen Burton Mains, author

Karen Burton Mains, author

Since I first wrote about open defecation a few years ago, efforts to combat the problem have gathered momentum. A report compiled by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) in June shows the percentage of people practicing open defecation declined from 21 percent (1.3 billion) in 2000 to 9 percent (673 million) by 2017.1

While this is encouraging news, there is much more to be done. The United Nations (UN) says “some 2.2 billion people around the world do not have safely-managed drinking water, while 4.2 billion go without safe sanitation services and three billion lack basic handwashing facilities.”

“Mere access is not enough,” said Kelly Ann Naylor, UNICEF’s associate director of water, sanitation and hygiene. “If the water isn’t clean, isn’t safe to drink or is far away, and if toilet access is unsafe or limited, then we’re not delivering for the world’s children.”

In addition to the UN, this multi-faceted effort includes governments, non-governmental organizations and various Christian and non-Christian charities. All have launched initiatives that include long-term goals for ending this threat to the world’s health. The UN’s global sustainable development goals include ensuring that everyone has a safe toilet and that open defecation ends by 2030.

Children investigate new toilet

Children in Cote d'Ivoire investigate their community's newly improved toilets, one of the UNOCI’s “quick impact projects” (QIPS) which supported the rehabilitation of schools and toilets in Abidjan. UN Photo/Patricia Esteve

People using the bathroom outdoors with no toilet nearby nor sanitary treatment of their discharge has fueled disease, created serious health problems and endangered female safety by exposing them to possible rape or other abuse. Then there is the particularly stomach-turning incident from July 2018, when a 3-year-old South African boy drowned in a pit latrine—a type of crude toilet that collects feces in a hole in the ground. Four years earlier in the same province, a 5-year-old boy drowned in a school toilet.2

Such horror stories help explain the need for “World Toilet Day,” which falls every year on November 19. Inaugurated in 2013, the UN-sponsored observance urges member states to encourage behavioral changes and implement policies to increase access to sanitation among the poor. Despite progress in recent years, the situation is serious, as shown by the June UN report.

Among key sanitation facts from WHO:

  • In 2017, only 45 percent of the global population used a safely managed sanitation service.
  • Two billion people do not have basic sanitation facilities, such as a toilet or latrine.
  • At least 10 percent of the world’s population is thought to consume food irrigated by wastewater.
  • Poor sanitation is linked to transmission of diseases such as cholera, diarrhea, dysentery, hepatitis A, typhoid and polio.3

In short, open defecation is a worldwide health crisis, one that demands a caring response from the world—especially those who profess to follow Christ.

GFA World supporters visit outdoor toilet installed by Believers Eastern Church in South Asia

GFA World supporters get the opportunity to visit an outdoor toilet installed by Believers Eastern Church for the benefit of multiple families in this neighborhood around Lucknow, Uttar Pradesh. During 2019, 5,428 toilets like these were installed by GFA across South Asia to help improve the sanitation challenges in many developing communities.

Hanging Out with “Renegades”

For much of my adult life, I have hung out with the “renegades” of Christian missions. Namely, the relief-and-development crowd that rushes to help during natural disasters, struggles to alleviate the suffering and abasement of refugee displacement, and pays concerted attention to the struggles of people in developing nations. My first trip around the world came at the invitation of Food for the Hungry; I traveled with Larry Ward, the executive director at the time, and his wife, Lorraine.

The purpose of the trip was an international field survey with an emphasis on the world’s refugee crisis, which in the l980s was the largest since World War II. We started in Hong Kong and ended seven weeks later in Kenya, Africa. My assignment was to observe with fresh eyes and write about what I had seen. I wrote my book, The Fragile Curtain, with the help of daily briefings from the U.S. State Department and the excellent international reporting of The Christian Science Monitor (and some generous coaching from a Pulitzer Prize-winning newspaper reporter). It won a Christopher Award, a national prize for works that represent “the highest values of the human spirit.”

“I never realized,” he said, “that I would eventually measure the impact of the Gospel by how many toilets had been built in a village.”

Eventually, I brought the accumulated exposure of my world travels—some 55 countries in all—and the learning I had gathered through research and dragging through camps and slums to the board of Medical Ambassadors International (MAI), a global faith-based health organization.

Villagers from the village that received outdoor toilets

Women and girls are often at risk when open defecation is the only option for relieving themselves. Thankfully, these precious faces can smile because a toilet facility was recently built in their village.

GFA’s Story, Helping to Improve Sanitation in Asia

As I mentioned earlier, Christianity has a vital role in ending these problems. One of the organizations involved is Gospel for Asia (GFA), long close to my heart and that of my husband, David Mains. We met K.P. Yohannan, GFA’s founder, when the ministry was a mere vision in the heart of a young Indian man. It was a divine nudge that would not let up. Since then, David has traveled to Asia at the invitation of GFA eight times; I have visited once. We’ve watched as K.P.’s vision grew from a dream to reality, with numbers beyond anything we could have considered possible.

GFA’s website tells its vast story: In 2018 the ministry fed, clothed and schooled some 70,000 impoverished children, operated 1,128 free medical camps and constructed 6,431 toilets with dual-tank sanitation systems.

A family stands in front of a India toilet - a GFA-installed latrine or squatty potty.

This family stands in front of a latrine or “squatty potty” that was installed by GFA-supported national workers.

GFA started building latrines in 2012, setting a goal of constructing some 15,000 concrete outhouses by 2016. It long ago surpassed that mark. Figures for 2016 alone: 10,512 toilets installed, with another 6,364 following in 2017, and another 6,431 in 2018. Potable water, of course, travels hand in hand with sanitation. In 2018, the ministry’s field partners constructed 4,712 Jesus Wells and distributed 11,451 BioSand water filters to purify drinking water. Touching vignettes on GFA’s website make the statistics personal.

“Our family is blessed both physically and spiritually,” said one villager in Asia. “We are free from problems and sickness.…It is because of the people who have spent their money to drill a Jesus Well in my place.”

“This saved the lives of people from illness,” said another—and indeed, toilets, when and if they are used, do just that.

There, indeed, is a thread that runs through Gospel for Asia’s stories of toilets: The pastor of the church in this village or that hamlet seems to be the catalyst for health improvements.

Organizations Tackling the Sanitation Crisis

Matt Damon, founder of Water.org

Matt Damon, the founder of Water.org (photo credit Water.org)

Much of the world is in a war against the perils caused by inadequate or non-existent sanitation. People as diverse as Matt Damon, a Hollywood celebrity, award-winning actor and producer/screenwriter, and India’s Prime Minister Narendra Modi are battling uphill against open defecation (in the sewers, in running streams, by the roadsides, in the fields and the forests, on garbage dumps, etc.).

Damon, driven by a desire to make a difference in solving extreme poverty, discovered that water and sanitation were the two basic foundations beneath much of what ails the world. Through his charity, Water.org, he and his business partner, Gary White, use microfinance loans to help underserved people connect to a service utility or build a home latrine. By 2020, more than 30 million people in 17 countries have been affected by this approach.4

Prime Minister Modi campaigned to end open defecation and build latrines for India

Prime Minister Modi campaigned to end open defecation and build latrines for India.
Photo by narendramodiofficial on Flickr / CC BY-SA 2.0

During his campaign for office in 2014, Modi spoke of “Toilets Before Temples.” His party’s Swachh Bharat Abhiyan (Clean India Mission) campaign has undoubtedly made progress, thanks in part to the $28 billion (U.S.) originally allocated, plus World Bank loans totaling another $1.5 billion.

After a Reuters News Service story last May portrayed the government as using overly optimistic results about the initiative, India’s Ministry of Drinking Water and Sanitation issued a release, saying its program had “succeeded in lifting more than 550 million people out of open defecation in a short period of less than 5 years.”5 His re-election last year may be partly due to the progress of the initiative he organized to curtail the practice.

Talking Openly About Open Defecation

Another key dilemma in this discussion—open defecation, hardly a dinner-table topic or a missions committee agenda item—is that accessibility to toilets does not always indicate usage. Changing habits is mostly a matter of changing mindsets in the face of deeply entrenched beliefs.

Some 1.5 million people die globally each year from polluted water diseases alone.

Elizabeth Royte, in a comprehensive August 2017 National Geographic magazine article, reported visiting Parameswaran Iyer, India’s secretary of drinking water and sanitation, in 2016. A hand-numbered sign on his wall tracked progress.

“You see that?” he asked. “One hundred thousand is the number of villages that are ODF today.” (ODF is the acronym for open defecation free.)6

Royte, a sanitation expert traveling widely and reporting extensively, noted that Modi aimed to build more than 100 million new toilets in rural areas alone by 2019. But she added that “deep-seated attitudes may present an even bigger barrier to improving sanitation than a lack of pipes and pits.”

Echoing that observation, on World Toilet Day in 2018, The Washington Post reported: “Although increasing the number of toilets and improving their quality is important, the larger challenge is how to ensure that they actually will be used. ... In our survey of 810 households in Delhi’s slums, where private toilet ownership is rare, we found that many people do not regularly use nearby public toilets, known as community toilet complexes, built specifically for slum dwellers.”7

Facing the Facts about India Toilets

That being said, let’s look at data regarding the state of toilets and open defecation in Asia. Then let’s examine what development organizations, sanitation technologies and mission groups, namely Gospel for Asia, are attempting to help Asia become ODF.

Although Modi has emphasized improved sanitation, it’s worthwhile to note that India struggled with these issues even before winning independence from Great Britain in 1947. In fact, Gandhi insisted, “Sanitation is more important than temples.” Now, due to population growth, a conundrum exists: While the percentage practicing open defecation has dropped substantively, birth rates are creating an environment where more people live in geographic locations where fecal exposure is increasing, not decreasing.


of the urban population—some 157 million urban dwellers—lacked a safe and private toilet, according to UK-based charity WaterAid in November 2016.8

Even sewers are no guarantors of healthiness: In the capital city of Delhi, pipes are corroded; they ooze waste; and nearly a third of the booming city isn’t connected to underground lines. Many latrines flush into open drains.


—4 percent—of this urban population still defecated outdoors.


only of the sewers are safely managed.

Just 1 gram of feces can contain:

100 million viruses

1 million bacteria

1 thousand parasitic cysts

These can be absorbed through cuts in the flesh, the porous nature of skin itself, or by drinking unsafe water and eating contaminated foods. Flies carry disease from roadsides and open fields.

Health figures are consequently staggering.

2,195 children

worldwide die from diarrhea each day, with the disease the second-leading cause of death for children under 5, according to the Centers for Disease Control.9 The chronically distressed digestive system doesn’t absorb nutrients or medicines well. Underweight mothers give birth to underweight babies.

149 million

children worldwide under the age of 5 are affected by stunting, according to the World Health Organization in 2018.10 And all of the above and much, much more could be cured and eliminated by the installation and use of proper sanitation systems in slums, hamlets, rural villages and large cities across India.

Photo by Kristian Bertel

What Do the World’s Sanitation Problems Have to Do with Us?

A slum in Asia without outdoor toilets

In this part of the slums in Mumbai, India, many people live in close proximity in unhygienic surroundings—lacking facilities like toilets and proper drainage.

For those of us with indoor flush toilets—and clean ones at that—with sewer lines that carry waste to treatment facilities, and who live in places where waterborne and airborne bacteria are not a hazard, our response to this crisis is probably, So what? We don’t say this out loud, but like so many other dire extremes jockeying for our attention, it doesn’t really touch our lives.

However, in a majority of places, America is starting to suffer from failing infrastructure. Most of us think of that in terms of roads and bridges needing repair or major overhauling, a transportation issue. Yet infrastructure means water service, too.

Just two years ago, reporters from the Chicago Tribune conducted an exposé of the high bills being charged for water in underserved metro area neighborhoods. Maywood residents in a western suburb paid one of the region’s highest water rates, because older pipes allow major seepage. Of the 946 millions of gallons that Maywood bought from neighboring Melrose Park in 2016, some 367 million gallons, or 38.7 percent, never made it to taps. That cost residents in an already cash-strapped population nearly $1.7 million more than residents paid in other towns of similar size. And the poor are tapped for a disproportionate share of the bill.11

What if I had to stand in line to use a communal latrine where flies buzzed, the floor was filthy, someone had evacuated due to acute diarrhea, and no one wanted to clean the mess? Now we’re getting closer.

Water problems may be closer than we think. In a 2012 article for a Yale University publication, reporter Cheryl Colopy—author of Dirty, Sacred Rivers: Confronting South Asia’s Water Crisis—warned: “In the United States, sewage treatment has not been a problem for the past half-century, but it could become one again as infrastructure ages and fails—especially if there is a lack of government money to replace it. In addition, certain regions of the U.S. are expected to experience water shortages as temperatures rise. New, water-saving, decentralized toilet technologies may need to be adopted not only in places like South Asia, but also in parts of the industrialized world.”12

Indeed, we may be thinking more about sanitation issues in the near future. And, the burgeoning technologies used to solve defecation problems and to discover clean water solutions in the developing world may be solutions we will also seek not far down the road.

Women are prone to assault, disease runs rampant, and lives are at risk: all a result of using the bathroom outdoors.

What If You Didn’t Have a Toilet?

So I remind myself of toilet scenarios I do know about, then extrapolate some personal situations. Our home, in which we have lived for 40 years, has a septic system. During that time, we have suffered power outages amid extreme storms, meaning no water could be pumped from our underground well; this disabled our showers, faucets and toilets. I used to store plastic bottles of water so when things went black we could still brush our teeth, dress by candlelight and—get this—flush our toilets. If the power did not come back on for a couple days, frozen food thawed and excess detritus threatened to overflow the toilet basin.

So I extrapolate: What if this happened all the time? What if sewer lines broke, got clogged and backed up regularly? What if I lived in poverty, with no plumbers, no money and no electric company to call to fix this? What if I had to stand in line to use a communal latrine where flies buzzed, the floor was filthy, someone had evacuated due to acute diarrhea, and no one wanted to clean the mess? Now we’re getting closer.

A Squat Outdoor India Toilet

A well-cleaned squat toilet in Asia.

In refugee camps overseas, my travel companions and I held ridiculous discussions about who had invented squat toilets: men or women? Someone shot a photo of me holding a rickety latrine toilet door upright while a woman coworker trusted me to guard her privacy while she did her business. We may laugh, but for most of the world this situation is not a laughing matter. Smelling an overflowing latrine from 20 feet away might persuade even a Westerner to think similarly, even if only metaphorically. In truth, I don’t like the few outhouses I’ve been forced to use in the States, nor many of the spooky national park public facilities. If I can help it, I certainly avoid portable potties at public events.

When Your Septic Tank Problems Bring Embarrassment

My last attempt at toilet empathy. About 10 years after we moved to West Chicago, Illinois, our neighbor knocked on the door and apologized for complaining about the standing stinking water seeping into his property.

“I think you may be having trouble with your septic system,” he reported, a bit embarrassed.

I called two septic companies. One said I needed to have the whole septic field replaced; cost: $10,000. The other service man diagnosed another problem but with a similar estimate. Then I went to the DuPage County Health Department and asked what septic firms they would recommend. I called Black Gold, whose reps complained about the septic map drawn by the company that laid our field—that was now leaking.

“Would the health department let us get away with a layout like this?” he asked his partner. They both obviously thought the field plan had been rendered by some septic idiot. Sure enough, after spending about 45 minutes prodding our three-quarters-of-an-acre lot with long poles, they said: “Lady, you don’t need no new septic field. The lines of what’s there ain’t connected to the tank.” Their fee: $3,000. I made a garden from areas torn up by their repairs.

Many people in Asia draw water from smelly, vile ponds

Vile, brown liquid that some in Asia count on as their water source.

So what if I lived somewhere that permanently seeped smelly, vile, germ-ridden, brown liquid? What if the river at the back of the land was a running sewer, and my grandchildren couldn’t romp and splash in it? What if the fields were filled not only with animal feces but the excreta of some 300 neighbors?

You can come up with your own empathy-building stories.

Communities Band Together to Improve Sanitation

A family in front of a GFA-provided outdoor toilet facility

A family in front of a GFA-provided local facility.

Prime Minister Modi and his teams are sold on community-led initiatives, and so should they be. Change works best when a whole population is committed to seeing it happen.

Community development often works best when it is exactly that: an idea that grows out of the mind of a local visionary, capable of strategic thinking but with compassion for those nearby—his or her neighbors. And when a whole community becomes involved in “cleaning up its act,” few powers on earth can withstand such initiative.

Now what’s interesting about Gospel for Asia’s stories surrounding sanitation is that it is the local pastor in the village, who out of concern and knowing that open defecation has deadly disease-breeding potential, exercises compassion to love his neighbors through his concern about the availability of latrines.

This is an excerpt from a GFA story that appeared on last year’s World Toilet Day. It concerns a family in one community forced to use the open fields to defecate because they had no other proper place.

Malak, before being touched by Christ’s love, had been an alcoholic. After reading the entire Bible from start to finish, Malak was transformed and abandoned the bottle. Some years later, he met Jaki, and they were married.

Eventually, the couple were blessed with two children. It seemed as if all was right for Malak and his family. However, a singular problem arose: The family had no toilet. The nearest place to relieve themselves was a little less than a mile away. During extreme weather, the family was forced to stay indoors, rendering those facilities useless. Going outside in the open was degrading and unhygienic, and at nighttime it was dangerous—who knew what kind of wild animals lurked about?

However, Malak and his family prayed, and their requests did not go unanswered. During a GFA Christmas gift distribution, they received a complete sanitation facility. They no longer had to trek half a mile just to use the bathroom or use the outdoors in fear.

What an extraordinary example of love in practical action.

“Love the Lord your God with all your heart and mind and strength. And love your neighbor as yourself.” —Luke 10:27

For women like this tea estate laborer, having no outdoor toilet facility could mean risking assault as they go out into an open field in the dark.

“It’s not safe to send our people, our children, our wives or our daughters to the tea garden at night to use the toilet,” Iniyavan said.

Iniyavan made only 2,400 rupees a month, which was equivalent to about $37 (USD) a month. He wasn’t able to save enough money to construct a toilet.

Open defecation means there’s the risk of disease as families continually return to communal waste grounds.

GFA-supported Compassion Services teams construct outdoor toilets, also known as sanitation facilities, for people who, like Iniyavan, do not have the means to do so on their own.

“Now, since I have this toilet built in my house, I don’t have to worry. My family and I don’t have to go to the tea garden for toilet, and it is very safe here,” Iniyavan said.

On the Brink of Innovations, Change in Sanitation

Toilet technology is on the edge of remarkable, cost-effective, ecologically friendly frontiers. They’re becoming self-cleaning and solar-powered. A solar-powered toilet that converts waste into charcoal can then be used as fertilizer. An indoor toilet that works like a garden composter, spinning the contents and reducing odor and the number of dangerous pathogens. Portable rickshaw toilets. A community bio-digester toilet designed to convert human waste into gases and manure. Once ideas begin flourishing, there is no limit to what can happen.

Granted, Prime Minister Modi’s ODF csampaign may take a little longer to succeed. But the hardest pull of any new effort is at the beginning. Once new ideas start rolling, they gather steam. Some new toilet technologies may become catalysts as well. In addition, there are hundreds of international organizations working on sanitation solutions. They understand that one size does not fit all the variables that make up the particulars in this vast discussion, but added all together, it is a prohibitive association with evidence of remarkable dedication.

And when a whole community becomes involved in “cleaning up its act,” there are few powers on earth that can withstand such initiative.

A Canadian doctor, one of those “creative renegades” unhappy with the condition of the world who I have come to admire and love, was appointed as a provincial health officer in the highlands of Papua, New Guinea. During an aerial survey, he and his team discovered one distinctly cleaner and healthier village. Far below lay the evidence of what turned out to be a pastor with basic health training who had taught his people those lessons; the difference could be seen from the air. Inspired, they searched for a more integral way of ministering and soon began using a community health evangelism methodology, which had been developed in Africa.

Sometimes we get lost in the details on the ground. We need to stand back, take deep breaths and find some way to gather broader assessments—an aerial view. Progress is being made; it’s just a little harder in some places than in others. I’m proud that Gospel for Asia is one of the players.

Shout Out to Toilets!

Christianity has everything to do with sanitation. We serve a God who is expecting us to help restore the world He created to its original design. That is a world, among many other things, without rampaging diseases. One day, Scripture promises, it will be a world without death and suffering. So in this interim, let’s hear a shout out for all the toilets in the world!

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