One out of every two persons in the world compelled to defecate in the open is an Indian. This is one of several unsavoury facts brought out in a recent report by the World Health Organisation and UNICEF. According to the report, out of the 1.2 billion people who defecate in the open worldwide because they have no access to toilets, more than half are Indian. An astounding 667 million people in this country have no option but to defecate in the open, a country that would like people to believe that it is on the cusp of becoming a global economic giant.

Why then does sanitation remain a subject that is accorded a relatively low priority compared to many other needs, including water and energy? Could it be because for the middle classes, policy makers, those who live in permanent housing with built-in toilets, sanitation is not an issue? But the lack of water and electricity is? Could it be because the problem is essentially that of the poor and the homeless? Could it also be because the worst affected are poor women?

These are questions that come to my mind almost every day when I walk past a woman with two young children. She is a rag picker. She has permission to sort through the garbage of the large government colony in the area. Usually, she sleeps near the garbage bin. Recently, she was asked to move. So she has found a spot in the colony where she sleeps surrounded by a few plastic bags that contain her meagre belongings.

Each day, the municipal truck clears the garbage bin after she has already rummaged through it and retrieved everything that is reusable and recyclable. This woman has no shelter, although she has an income from the sale of rags. As a result, she has no access to water or sanitation. Her children defecate on the road. I have no idea what she does. She probably has to wait until nightfall to locate a secluded spot. Yet, she “lives” in one of the more expensive parts of Mumbai. And she sorts the garbage of the very people who populate our government -- the civil servants.

Larger realities

But this woman's life is more than just a curiosity. It is illustrative of an ugly and larger reality. The absence of sanitation is not just a question of personal hygiene, or terrible indignity for poor people. It is also principally responsible for the spread of several diseases. According to the international charity Water Aid, which assembled data on this issue for world leaders meeting in Japan for the G8 summit, 40 per cent of the world's population lack access to improved sanitation and this in turn kills more children than malaria, HIV/Aids and measles put together.

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 •  Sanitation for urban poor: model Water Aid believes that as many as 9,10,000 child deaths could be avoided from diarrhoea each year through provision of improved sanitation. An estimated 85 per cent of the 1.6 million deaths due to diarrhoea each year can be linked to poor sanitation and unsafe drinking water, it states in its report.

None of these facts is new. Yet, every few years new reports have to be issued, organisations like Water Aid run campaigns, some statements are made by leaders endorsing the concern -- and then little happens.

India has agreed to developmental targets set under what are called the Millennium Development Goals (MDG) that should be reached by 2015. One of these is ensuring that the sanitation coverage reaches at least 46 per cent of the country's population. Yet this is the one area on which the country is falling short.

Once again, you are forced to ask: Why? Why when we want recognition as a nuclear power, why when we want recognition as a growing economic power, why when we want to boast of our educated and trained manpower should we not come to grips with the issue of sanitation?

One reason, as I have suggested above, is that the people most affected are often the most powerless. And those who have the power to make decisions do not feel the need in the same way. Hence, the lower priority.

Not just a question of choice

Secondly, clean and healthy living has now been reduced to a personal choice. Health is all about what we eat or don't eat, how much we exercise and what kind of exercise, what medicines we take, the kind of doctors we consult etc. But what happens if you live in an area where there are no pipes to carry water, where there is no sewerage? How can you make such personal choices when your environment negates any desire you might have to remain clean and healthy?

This is the reality that confronts my rag picker woman every day. Others of her kin probably live in slums, many located on low-lying flood prone areas that have never been serviced with water or sewerage. Sometimes, the municipal corporation receives funds to build toilets. And these are constructed on land incapable of absorbing the waste from these toilets because it is already sodden. Within a short time the toilets are blocked and overflowing -- and people continue to defecate in the open all around the toilets. For this they are blamed -- for creating dirt and spoiling the environment.

If I were to make a wish list for whichever party comes to power next in India, I think I would put toilets at the top of that list. Of course, livelihoods are also important. As are pucca houses. And water. And power. And education. And healthcare. But sewerage systems connected to individual or shared toilets would overnight change the look and smell of so many of our cities -- and provide enormous relief and dignity to millions of poor people.