Recently, a Unicef warning announced that an alarming 41 million people in Pakistan lack access to adequate toilets; forcing them to defecate in public. Pakistan is in fact the third largest country, behind India and Indonesia, where people are forced to defecate in the open.

This troubling practice which has become the norm for 41 million Pakistanis has profound health and nutritional consequences. Open defecation has significant consequences and it is imperative that we explore this topic.

Also read: Finding a phone easier than finding a toilet: UN

The city of Lahore is home to millions of people and has only 21 public bathrooms. Many of these are in dire condition and in a state of chronic decay. It is tragic that in a country that receives millions of dollars of aid annually, we have failed to provide the most fundamental necessities such as clean bathrooms to our people! Forcing individuals to seek out places to defecate leads to stool withholding behavior, constipation, and stunting.

These consequences have lifelong implications and must be addressed immediately.

Stool withholding behaviour

When children are confronted with psycho-social stressors such as not being able to defecate in private or adequately; they have a tendency to develop stool withholding behavior – they refuse to defecate in a setting where they are uncomfortable or embarrassed, causing them to reflexively withhold bowel movement.

For a child to defecate in open, it is very embarrassing and anxiety-provoking. This can lead to serious problems known as Encopresis, in which children begin to soil their undergarments.

The colon normally removes water from our faeces, but stool remaining in our gut for too long from conditioned withholding will inevitably lead to constipation. The stool becomes so hard that it is difficult to expel and stretches the colon, impairing the sensations associated with a normal bowel movement. As a result, softer stool often leaks around the blockage, soiling a child’s undergarments.

As anyone can imagine, this has devastating effects on an individual's overall level of hygiene. The faecal contamination of hands, garments, and other clothing will allow infectious diseases to disseminate with ease.

Constipation

The health ramifications of constipation are severe, and unfortunately, frequently overlooked.

Our colon is home to a bacterial flora which is essential for maintaining gut health. Constipation leads to an imbalance in this bacterial flora giving rise to unfriendly strains of bacteria and impaired gut health. The normal helpful bacteria within the colon is disturbed when hard stools associated with constipation persist.

Also read: CDA to upgrade public toilets in Islamabad

Constipation can lead to abdominal pain and a decreased desire to eat as well. In cases where constipation goes unchecked, forceful straining and attempts to evacuate stool can lead to tears and bleeding around the lining of the rectum.

Stunting

A child’s degree of stunting can be evaluated by calculating a child’s height for age as a percentage of the population median. The severity of stunting is determined as a percentage of the expected height for age.

Stunting, along with wasting, is a universal marker of protein energy malnutrition in a child.

Chronic malnutrition is frequently characterised by stunting. Due to open defecation, children are unable to adequately wash themselves and consequently, a bacterial contamination of water ensues. This leads to chronic diarrhoea and malabsorption states in children. Such chronic malnutrition leads to cognitive deficiencies and insufficient brain development.

Read on: Pakistan among top five diarrhoea death victims

Sanitation, hygiene, and constructing more public toilets must become a priority in Pakistan.

Failing to provide our children with the basic necessity for living is inhumane, and detrimental to their well-being.

Instructing the masses on adequate hand hygiene, providing ample toileting facilities will help with combating this problem.

Open defecation must be discouraged. And, massive efforts must be implemented to create behavioural change, provide adequate facilities, and increase awareness about overall hygiene.

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