Intended for healthcare professionals

Feature Sanitation

More temples than toilets?

BMJ 2013; 346 doi: (Published 30 January 2013) Cite this as: BMJ 2013;346:f525
  1. Ankita Malik, freelance journalist, New Delhi
  1. mail.ankitamalik{at}

India’s dearth of sanitary toilets means it tops the world leader board when it comes to open defecation, with huge implications for health, but times are changing, writes Ankita Malik

India has more temples than toilets, berated Jairam Ramesh, controversially making headlines last October. The union minister for rural development also urged women not to marry into families that do not have a toilet at home, and he also proposed a cut to defence budgets to fund toilets.

India is home to an estimated 626 million people who practise open defecation because of inadequate sanitation—nearly 60% of those who practise open defecation in the world, according to a report from Unicef, released recently.1

Open defecation leads to waterborne diseases and diarrhoea. Every year, about 2.2 million people die from diarrhoea; 90% of these deaths are of children, mostly in developing countries.2

Open defecation also contaminates groundwater and agricultural produce and promotes manual scavenging—that is, people clearing up untreated human excreta.

According to the Water and Sanitation Programme, a multidonor partnership administered by the World Bank, the economic impact of inadequate sanitation is about 2.4 trillion rupees (£0.028 trillion, €0.033 trillion, $0.044 trillion) or 6.4% of India’s gross domestic product.3 “Costs include health costs attributed to poor sanitation,” said Guy Hutton, author of the report, including “healthcare, lost productivity from sickness, and the value of lost lives from premature death.” He went on to explain that degradation of water quality and treatment also comes with a cost, as does “time spent accessing off-plot (out of house) sanitation facilities,” he said.

In 1993 the government introduced the Employment of Manual Scavengers and Construction of Dry Latrine (Prohibition) Act, which outlawed the …

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