On 28 May, 2014, the United Nations launched a new campaign to end the practice of open defecation worldwide and improve access to toilets and latrines for the 2.5 billion people living without basic sanitation (UN, 2014). The reason for this focus and urgency is that without toilets people defecate in the open and the faecal contamination of the environment that results is responsible for tragic and preventable death and disease. In fact, the urgency of this issue is so great that consideration has been made of making eradicating open defecation a separate UN development goal for theperiod 2015-2030 (Mollins, 2012).
While the diarrhoeal diseases responsible for a high number of deaths among young children and vulnerable persons receive the most attention, open defecation is also a virtually sure route for the spread of helminthic infections which interfere with growth and cognitive development and impede educational and vocational aspirations. However, while the provision of toilets to all is an important strategy in the fight to eradicate open defecation, the assumption that open defecation ends where toilets begin is faulty. This flawed assumption can be found in many of the campaigns and reports produced by organisations promoting improved sanitation which often declare areas which have been provided with toilets as “open defecation free”. As a result of this error, the data on open defecation is often skewed, presenting the picture that it has been eliminated while in reality it may well be continuing concurrent with the availability of basic sanitation. This means that sanitation interventions are not as effective as they may be considered to be, and this gap represents a serious health problem that is not being properly mapped or understood.
As a result of open defecation, not only harmful microbes but a vast number of helminth eggs are passed from infected individuals into the soil. Depending on the environmental conditions, these eggs may remain infective for a very long time. Consequently, where open defecation occurs or occurred in the past, the environment may remain contaminated for years after any visible evidence of a faecal deposit has vanished. While helminthic infections often occur through accidental consumption of eggs from soil on dirty hands, a factor which makes the presence of this "egg bank" in the soil even more hazardous is the practice of intentionally eating soil --called geophagia. Where the practices of open defecation and geophagia occur at the same household the risks of these combined behaviours as a route of transmission for helminthic and other infections may be particularly high. While the literature on the practice of geophagia is slim, what literature exists demonstrates that globally the practice is widespread; anecdotal accounts suggest that it is a very common practice in South Africa.Because of the health implications of geophagia and open defecation in terms of helminthic infections and diarrhoeal diseases in particular, it is vital that health and hygiene interventions address these practices and provide clear information about disease transmission and the hygiene practices which can prevent it.