Despite large government and NGO programs, despite substantially increased public spending on sanitation, and despite sustained economic growth, open defecation is declining very, very slowly in rural “Hindi heartland” north India. Widespread resistance to using simple latrines in the rural north Indian plains states is a human development crisis and a serious puzzle: this is exactly the place on earth where open defecation is most common and where high population density most raises the human and economic costs of open defecation.

Access to improved sanitation can increase cognition in children, according to a new World Bank study. The study contributes to a growing body of research linking stunting and open defecation. Currently, more than 2.5 billion people worldwide lack access to toilets, and one billion people practice open defecation.