About half the world's reported cases of polio, a crippling disease virtually wiped out in Western countries, occur in India. Each year, diarrhea kills 500,000 Indian children. A jaundice epidemic strikes a small district of India's Rajasthan state as regularly as the annual monsoon.
Those deadly diseases and others that afflict India can be traced to the same source: drinking water contaminated by human waste. Infected water causes an estimated 80 percent of disease in India, according to the World Health Organization (WHO), making poor sanitation and inadequate sewage disposal the nation's biggest public health problems.
"Waterborne diseases in India are very, very common. Every year, ...view middle of the document...
The government also has joined private organizations in adding bathrooms to rural homes, but at the current rate of construction and population growth it would take 200 years for every Indian to have access to a toilet.
Besides overpopulation, religious beliefs of Hindus, who account for 80 percent of the population, have compounded India's sanitation problems. The cities of an early civilization in the Indus River valley had sophisticated sewer systems and among the oldest known toilets -- brick models that date back 4,500 years. But the development of Hinduism and its caste system in later centuries changed attitudes and practices concerning the disposal of human waste.
Bindeshwar Pathak, whose private organization, Sulabh International, has built 700,000 toilets in 25 years, said an ancient Hindu text gave "firm religious sanction" to unsanitary behavior by forbidding defecation near dwellings. "It's very difficult to bring it into the homes," Pathak said. "It's a cultural problem in India."
In rural areas, where more than 70 percent of Indians live, fewer than 10 percent of homes have toilets. Government officials and aid workers say they have experienced difficulty persuading uneducated villagers to abandon ancient customs and use an enclosed bathroom. In the northern state of Rajasthan, some villagers have converted outdoor latrines into storage areas and resisted construction of indoor bathrooms, fearing they would make their homes smell bad.
Officials involved in programs to install household toilets in villages often neglect to conduct public education campaigns to establish the connection between sanitation and health.
In rural schools, instruction in such basic hygiene as hand-washing is limited and cannot be reinforced in school buildings that lack running water and lavatories.
In cities, hundreds or even thousands of people may use the same public toilet each day, causing them to reek if not cleaned frequently.
Such conditions help explain why one day recently two men could be seen urinating on the outside walls of public toilets on opposite corners of a major intersection here.
Almost two-thirds of urban dwellings have bathrooms, according to a 1991 census, and middle-class city dwellers generally practice good hygiene. Still, public health risks are greater in cities than in rural areas because of cramped conditions in slums where the poor -- nearly half of Bombay's 13 million residents, for example -- live in shanties without toilets or sewer connections.
Under a $300 million project funded by the World Bank, Bombay plans to treat the 60 percent of the city's sewage now discharged raw into the Arabian Sea. The seven-year project, which also will build public toilets for 1 million slum dwellers, is the latest phase of water and sanitation improvements that India's biggest city began in the 1970s.
Traditionally, efforts to improve sanitation in India have not had public health as their main motivation. Instead, it has...