11/19/2014 11:16 am ET Updated Jan 19, 2015

India's Sanitation Crisis

I struggle with the fact that some of my best friends in the world are forced to defecate outside. They belong to the latest generation of poverty-stricken Indians, enduring the indignity of not having a toilet. My friends represent just a handful of the 550 million Indians living without toilets. But to me, they are the faces of this tragic statistic.

India's Prime Minister, Narendra Modi, thrust this crisis into the limelight of development issues when, in his inauguration speech, he promised every Indian a toilet by 2019. This pledge signals an overcoming of political inertia that will mobilize much needed human and financial resources.

Unfortunately, India's sanitation crisis is not solely a function of inadequate infrastructure. Yes, in certain areas toilets need to be constructed. But encouraging sustained use of toilets must be prioritized as research suggests that many Indians continue defecating outside despite access to toilets. A study conducted by the Research Institute for Compassionate Economics (RICE) highlights that out of 3,235 rural households in northern India fitted with a toilet, 40 percent had a member of the home who still opted to defecate outside.

Advances in access to key infrastructure (toilets in this case), are not always accompanied with effective strategies to motivate people to modify health behaviors. It cannot be assumed that providing a toilet will automatically translate in to use, especially when defecating outside has been normalized over generations. It is incumbent upon those of us fighting with communities to improve sanitation based health outcomes to facilitate an understanding of why toilets are necessary. Allocating resources to health education and health marketing is just as important as reserving funds for constructing toilets.

Additionally, interventions must be designed with long-term sustainability in mind. The Indian government's scheme that builds toilets for families, the Total Sanitation Campaign, does not account for maintenance. People revert back to defecating outside when pit latrines fill up causing toilets to backflow. Those promising to build toilets must be pushed to provide maintenance plans.

Access to household toilets does not account for the need to use a toilet when not at home. Many day laborers in rural India work outside of their villages to scrape together meager wages to provide for their families. Work sites rarely come equipped with toilets. Thus many continue defecating outside, because while they might have a toilet at home, they do not have one at work.

Lastly, the ability to construct toilets is inextricably tied to land rights. In Bihar, where I work, over 150,000 families who qualify for land through a Ghandian era land distribution program still wait in vain. How, and more importantly where, are these families who are already so marginalized and dispossessed of land expected to construct toilets?

Eliminating outdoor defecation in India has been a Gandhian dream since the 1920s. Almost 100 years later, nearly one half of all Indians still relieve themselves outside. Simply building toilets will do very little to realize this dream. Changes in the built environment must be coupled with community-based outreach programs to motivate shifts in behavior. Those of us implementing programs must not assume that our benevolence in providing toilets is enough -- it must also be designed to encourage sustained use.

We must confront antiquated policies in an effort to reshape them so that they tilt in favor of the poor. Only a holistic assault on this tragedy will yield the results we are all hoping for.