In India, the installation of toilets comes with no guarantee that people will use them. Again and again, government agencies and nonprofit organizations have brought clean sanitation facilities to rural villages, only to find that villagers continue the endemic practice of open defecation. Researchers have established that eliminating open defecation is not just a logistical or financial problem, but also (indeed, mainly) a cultural and political problem. Because of social norms that have deep roots in religious practice, certain groups of people—particularly women, members of lower castes, and members of indigenous tribes—come to believe that they cannot or should not use toilets or other forms of contained sanitation.

Since 1991, the Indian NGO Gram Vikas has conducted a program that embeds the provision of water and sanitation facilities within a broader effort to transform the patterns of social interaction that make open defecation such an intractable problem. Originally known as the Rural Health and Environment Program, or RHEP, this effort is now part of an initiative called MANTRA—the Movement and Network for the Transformation of Rural Areas. The purpose of MANTRA is to provide every household in a given village with piped drinking water and with its own toilet and bathing facilities. As of January 2015, Gram Vikas had implemented the program in 1,140 villages across 28 districts in the state of Odisha. (The organization has also brought a variation of this program to several other Indian states and to certain African countries.)

In Odisha, as elsewhere in India, the practice of open defecation and the use of polluted water sources cause waterborne diseases to spread widely. Odisha (formally called Orissa) is one of India’s poorest states: Nearly half (47 percent) of its population lives below the official poverty line. It’s also a state where patterns of social exclusion are prevalent. Gram Vikas, founded in 1979, focused in its early years on tackling challenges related to education, housing, and other areas of concern to people in the villages of rural Odisha. Over time, its leaders turned their attention to health issues, and they identified the installation of water and sanitation facilities as a goal that would appeal to villagers in all social categories.

Through MANTRA, Gram Vikas has found a way to confront the problem of sanitation by confronting the problem of inequality, and in doing so it has achieved discernible improvements in health outcomes. A study of 100 villages that have implemented this program shows that the availability of clean water and adequate sanitation reduces the incidence of waterborne diseases by up to 50 percent.

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