Prioritising clean water and sanitation.

Every minute, 1·1 million litres of human excrement joins the river Ganges. It is a staggering statistic but hardly surprising since some 627 million Indians practice open defecation, roughly half the country’s population, and more than half of the estimated 1 billion people around the world who defecate openly. Most of these people live in ten countries in Asia and sub-Saharan Africa. Indonesia has the second highest burden of open defecation in the world (roughly 54 million people), followed by Pakistan (41 million people), and Nigeria (39 million people). Four other nations from sub-Saharan Africa are among the top ten: Ethiopia, Sudan, Niger, and Mozambique. It is a huge problem. Inadequate sanitation and hygiene is implicated in about 50 infectious diseases. Foremost of these are the diarrhoeal diseases, which kill 580 000 children younger than 5 years every year; nearly all of these deaths can be attributed to the ingestion of faeces. But there is growing recognition that the eff ects of poor sanitation can greatly undermine public health in a wide-ranging and insidious manner. “The nutritional and health significance of many non-diarrhoeal faecally transmitted infections has also been masked by their diversity, their multiple presence in the same child, and their often subclinical nature, hindering the absorption of nutrients, even without the child seeming sick”, wrote UNICEF’s Gregor von Medeazza and Sussex University’s Robert Chambers in a 2013 paper. These children are vulnerable to all kinds of infectious diseases, including pneumonia. 35–50% of malnutrition is attributable to poor sanitation. “Undernutrition is the underlying cause of about half of the deaths of children under 5 from infectious diseases in conditions like in rural India”, noted von Medeazza and Chambers.