Open defecation: A major public health challenges

As cities swell and skylines thicken, urban planning has quietly evolved into a matter of life and health. Decisions about land use,

As cities swell and skylines thicken, urban planning has quietly evolved into a matter of life and health. Decisions about land use, infrastructure, and public services increasingly shape how people breathe, move, work, and survive within expanding urban environments. Walkable neighborhoods, cycling infrastructure, accessible parks, clean water systems, and public transport are no longer viewed merely as amenities but as essential public health interventions. Among these, the provision of sanitation and hygiene infrastructure remains one of the most fundamental yet persistently neglected determinants of community health.

Equity lies at the heart of this challenge. A truly healthy city is one where access to housing, healthcare, mobility, and sanitation is not limited to the privileged but extended to all residents. While each of these elements deserves independent examination, sanitation demands particular attention because of its direct and immediate relationship with disease. This article focuses on the burden of disease associated with open defecation, with specific reference to Pakistan, where sanitation gaps continue to undermine health, dignity, and development.

Access to toilets and safely managed sanitation is central to human well-being. Yet, despite decades of global advocacy and investment, progress remains uneven and fragile. As of 2024, an estimated 3.4 billion people worldwide still lack access to safely managed sanitation services, and approximately 354 million people continue to practice open defecation. These figures represent not only a failure of infrastructure but a profound public health crisis. In parallel, nearly one in four people globally still lack access to safe drinking water, compounding the risks associated with poor sanitation and accelerating the transmission of disease.

In Pakistan, the sanitation crisis is particularly acute. Despite gradual improvements over recent decades, millions of people remain without access to proper toilet facilities. An estimated 25 million Pakistanis still practice open defecation, while tens of millions more rely on unsafe or poorly maintained sanitation systems. The health consequences are severe. According to UNICEF Each year, approximately 53,000 children under the age of five die from diarrhea diseases linked to poor water, sanitation, and hygiene conditions. These deaths are largely preventable, making the persistence of such figures a stark indictment of systemic neglect.

Open defecation refers to the practice of defecating in open spaces such as fields, bushes, riverbanks, roadsides, drains, or open water bodies instead of using toilets or latrines. Human feces carry a dense concentration of bacteria, viruses, and parasitic organisms. When left exposed, these pathogens enter the environment and spread through water sources, soil, flies, food, and human contact. The result is a continuous cycle of contamination and infection that affects entire communities, including those who may have access to toilets but share water sources and public spaces with those who do not.

The most immediate health impact of open defecation is the spread of water-borne and fecal-oral diseases. Diarrhoeal illnesses remain among the leading causes of child mortality worldwide, accounting for roughly nine percent of all deaths among children under five. More than 444,000 young children die each year from diarrhoea, much of it directly linked to unsafe sanitation and contaminated water. Recurrent diarrhoeal episodes weaken the immune system, reduce nutrient absorption, and leave children vulnerable to other infections.

Cholera remains another major threat in settings where sanitation infrastructure is weak. Caused by the bacterium Vibrio cholerae, cholera spreads rapidly through contaminated water and food and can lead to severe dehydration and death if untreated. Pakistan remains endemic for cholera, with periodic outbreaks reported in both urban centres and rural districts, particularly following floods or disruptions to water supply systems. Typhoid fever, hepatitis A and E, and other fecal-oral infections also persist, driven by the same pathways of contamination.

Intestinal worm infections thrive in environments where soil and water are polluted with human waste. These infections, while often overlooked, contribute significantly to anaemia, malnutrition, and impaired physical and cognitive development, particularly among children and pregnant women. Poor sanitation also sustains the transmission of neglected tropical diseases such as trachoma and schistosomiasis, further burdening fragile health systems and deepening cycles of illness and poverty.

Children suffer disproportionately from the disease burden associated with open defecation. Repeated exposure to pathogens during early childhood interferes with physical growth and brain development. Chronic diarrhoea and environmental enteric dysfunction contribute to stunting, a condition that affects millions of children in Pakistan. Stunted children are more likely to struggle in school, earn less as adults, and experience poorer health throughout their lives, perpetuating intergenerational disadvantage.

Women and girls experience additional and often invisible harms. In the absence of safe and accessible toilets, many are forced to wait until early morning or late at night to relieve themselves, exposing them to harassment, violence, and physical danger. Prolonged withholding of urination can lead to urinary tract infections and other medical complications, while inadequate sanitation during menstruation increases the risk of reproductive health problems. Girls’ education is also affected, as the lack of private and hygienic toilets contributes to school absenteeism and dropout, particularly during adolescence.

Beyond health and gender impacts, open defecation imposes heavy economic costs on households and communities. Families already living on limited incomes must spend scarce resources on medical treatment for preventable illnesses. Illness reduces productivity among daily wage earners, while children miss school due to sickness or poor sanitation facilities. At the national level, poor sanitation contributes to billions of dollars in healthcare expenditure, lost productivity, and premature deaths, undermining economic growth and development goals.

Although open defecation is often associated with rural areas, it remains a significant issue in urban slums and informal settlements. Rapid urbanisation, overcrowding, insecure land tenure, and inadequate municipal services leave many urban residents without access to safe toilets. In cities such as Karachi, the shortage of clean and functional public toilets means that workers, vendors, and commuters spend long hours without access to basic sanitation. This daily deprivation not only compromises health but erodes dignity and quality of life.

Breaking the cycle of disease requires more than the construction of toilets. While infrastructure is essential, behaviour change and community awareness are equally critical. Many people remain unaware of the direct links between open defecation, water contamination, and illness. Community-led approaches, such as Community-Led Total Sanitation, emphasise collective responsibility and social change, encouraging communities to abandon open defecation through awareness rather than dependence on subsidies alone.

Public health systems play a central role in reducing the disease burden associated with open defecation. Local health departments, Lady Health Workers, community volunteers, and school-based programmes are vital for hygiene education, disease surveillance, and outbreak response. Non-governmental organisations support these efforts through community mobilisation, construction of affordable sanitation facilities, and capacity building. Donor agencies, including UNICEF and the Asian Development Bank, provide essential financial and technical support to scale interventions and strengthen systems.

Eliminating open defecation is not merely a sanitation objective but a public health imperative. Reducing the disease burden demands an integrated approach that combines infrastructure investment, sustained behaviour change, equitable urban and rural planning, and strong institutional commitment. Safe sanitation protects health, preserves dignity, supports gender equality, and enables social and economic development.

Open defecation-free communities are achievable when governments, communities, civil society, and development partners act together with urgency and resolve. Investing in sanitation today is an investment in lives saved, healthcare costs reduced, and a healthier, more equitable future for generations to come.