This blog post is going to be gross: I’m going to write about poop.

I’m warning you now, but I’m not apologizing. People live longer, happier lives because policy-makers and public health experts who work on reproductive health have become comfortable talking about sex. But whenever I talk in the U.S. about my work, somebody always suggests that I might make people more comfortable if I didn’t talk so much about “open defecation.”

It’s time to get comfortable talking about poop. Over a billion people defecate openly – outside on the ground, maybe near somebody’s house – because they don’t have access to a toilet or a latrine. These unsanitary conditions cause kids to get sick. Over 2 million children die each year of diarrheal disease. The children who survive don’t grow as tall as they could, and their brains don’t develop as fully as they could, because of chronic infections they suffer as babies.

These are big, uncomfortable problems. The most important reason to get comfortable talking about poop is evidence that these problems can be solved.

Everybody knows that it is better for your health not to eat food or drink water that has been contaminated by fecal germs. There is good evidence that pipes and infrastructure improved health when the U.S. was developing. But very poor people living in rural places are not going to get modern sanitation infrastructure any time soon: even if it were affordable, their governments could not manage it.

What could be achieved for health by a rural sanitation program that could actually be implemented by a poor country government?  So far, the great practical importance of this question hasn't been matched by great evidence. To help offer an answer, I have been studying the Indian government’s Total Sanitation Campaign, sometimes called the TSC.

According to its official statistics, the TSC has built about one pit latrine per ten people in rural India over the past 10 years. Pit latrines may not sound exciting to those of us accustomed to toilets, but because they keep the poop safely away from mouths and fingers, they can get the job done.

Perhaps more importantly, in addition to subsidizing the latrines, the TSC offers a carefully designed incentive for people to actually use them. If the village is certified as “open defecation free,” the chairman of the village is invited to an official ceremony to receive a cash prize. By motivating the village chairmen, the program makes use of the social hierarchy that already exists in Indian villages.  Thus, latrines are built and used, and the program achieves its health and sanitation goals.

The hardest part of statistical research is verifying whether the results you find are actually due to the factors you are investigating, and not just a coincidence. In this case, there are many reasons to believe that the TSC is improving children’s health.

The TSC, on average, appears to have reduced rural infant mortality in India by about four deaths per 1,000 babies. Moreover, children who were exposed to more TSC latrines in the first year of their lives grew up to be taller, and may have eventually had more success learning letters and numbers. Despite an imperfect bureaucracy, this was accomplished by the Indian government: a complex collaboration spanning bureaucrats in Delhi office towers and village leaders.  

Perhaps most importantly, all of this was accomplished relatively inexpensively, on average, compared with other programs to improve the health of the poor. Not every reported latrine was actually built, and not every latrine that was built is being used as the government intended. But my statistical analysis reflects the average of the good and the bad, including whatever inefficiency or corruption exists.

If my analyses are correct, then simple rural sanitation is achievable even for low-capacity governments, and it saves lives. And that is a reason to talk about poop.