PESHAWAR, Pakistan – Nasreen Bibi, 27, is busy preparing lunch for her family outside their squalid tent. Ten years ago, poverty drove her and her husband to move their three children and a camel from Sheikhupura, Punjab, to Peshawar in Pakistan to look for work. Since then, they have been living in a tent in a nomad camp in Khyber Pakhtunkhwa, selling camel’s milk on the roadside for $2.50 a day. Their makeshift home has no water, electricity or toilets.
“To answer the call of nature, we have to go to nearby fields. Sometimes men try to [watch] us secretly when we defecate in the open,” Bibi says. “In order to ward off harassers, my husband or my son accompany me to the field and stand watch.”
Around 2.4 billion people – roughly one third of the world’s population – don’t have access to toilets, according to a 2015 report by UNICEF and WHO. Among them are over 945 million people who, like Bibi and her family, are forced to defecate in the open. Lack of access to clean, private toilets puts women at risk of infection and disease, say health experts. And as these women suffer the indignity of having to defecate behind bushes or out in a field, every trip to the bathroom makes them vulnerable to harassment, sexual assault or even animal attack.
“Going to the fields for defecation is full of danger, and I am concerned about the security of my daughters,” says Inayat Mai, 26, a mother of six whose family moved to the camp in Khyber Pakhtunkhwa from Muzaffargarh, Punjab, in 2010 when floods washed away their home. “My husband can’t go with me and my daughters every time we go to the field for defecation because he is supposed to earn a living for us.”
But few women are willing to talk about the threats they face when they go outside to relieve themselves. “No one who defecates in the open will disclose that they face harassment because of the taboo associated with it,” says Mai, adding that if a woman complains about the unwanted attention, she is blamed for encouraging it. So, most women, especially in conservative communities, never report the harassment or abuse they endure on a regular basis.
According to WaterAid, one in three women – most of them in the developing world – have nowhere safe to go to the toilet. “Inaccessible toilets and bathrooms make women vulnerable to rape, sexual attacks and other forms of gender-based violence,” says WaterAid Pakistan communications officer Ayesha Javed, adding that women and girls don’t only need toilets for defecation, but also for privacy during menstruation. “And women and girls who defecate in the open, especially in the bushes, also face the risk of animal attacks,” she says.
And there are health consequences to repeatedly going to the toilet outside. Dr. Sultana Barlas, a gynecologist at Khyber Teaching Hospital in Peshawar, says women and children who defecate outdoors are especially at risk of a range of infections and diseases, including Pelvic Inflammatory disease, worm infections, hepatitis, diarrhea, cholera, polio and water-borne diseases.
“Some of these diseases result in the deaths of millions of people, particularly women and children, in the country annually,” she says. Cholera alone kills up to 143,000 people globally, but those figures exclude many cases labeled as “acute watery diarrhea,” which occur mainly in southeastern and central Asia, meaning actual figures could be higher.
A 2016 study by WaterAid suggests that large numbers of people going to the bathroom outside also contributes to stunting, when children are lower than the average height for their age. The study showed that 54 percent of international variation in children’s height can be linked to open defecation, which spreads diseases and makes children more susceptible to diarrheal illness and infection. The study ranks Pakistan third in the world based on the number of children under five suffering from stunted growth, with 9.8 million children shorter than they should be.
In Pakistan’s population of over 190 million, 25 million people practice open defecation, largely in poor rural dwellings and informal urban settlements, putting the country in fifth place for the highest number of open defecators in the world. Of the urban population alone, 16.9 percent are currently living without safe and private toilets.
“Access to improved sanitation facilities, water and decent toilets could save millions of people from being killed by lethal diseases and make women and girls safer from harassment,” says Barlas.
Efforts to help people in Pakistan find alternatives to open defecation are showing promise. With the support of several organizations, including UNICEF, the Pakistani government is making progress in its bid to achieve the Millennium Development Goals for sanitation. Over the past 10 years, the number of open defecators in the country has dropped from 46 million to 25 million, largely thanks to a series of programs in the government-led Pakistan Approach to Total Sanitation.
And there are improvements at the grassroots, too. ACTED, the humanitarian relief NGO, recently celebrated the results of its Community-Led Total Sanitation program, which encourages communities in North Sindh to analyze the drivers and alternatives to open defecation in their villages. By last year, 12 of the 26 villages in the program had succeeded in eliminating open defecation with a combination of new, low-cost sanitation systems and awareness-raising campaigns.
At the nomad camp in Peshawar, women still have few options but to put themselves and their families at risk of assault or illness every time they need to relieve themselves. When Parveen Sajjad and her family arrived from Muzaffargarh, Punjab after escaping the floods in 2010, her husband tried to give the family some privacy by cobbling together a makeshift toilet out of old clothes and bamboo sticks. But even their homemade toilet isn’t as safe as they would like. “My husband stands guard outside until I relieve myself,” says Sajjad. “My children fetch water from nearby shops so that I can use it in the toilet.”
Even with the need for Sajjad’s husband to protect her while she goes to the bathroom, many women in the camp would consider any kind of privacy a luxury.
“We have to go out to excrete in the open behind bushes or in open bodies of water,” says Mai, the mother of six. “Because of lack of toilet facilities, many women of the tents have to defecate in the open with no dignity or privacy.”