In 2015 there were 965 million people in the world forced to practise open defecation (OD). The adverse health effects of OD are many: acute effects include infectious intestinal diseases, including diarrheal diseases which are exacerbated by poor water supplies, sanitation and hygiene; adverse pregnancy outcomes; and life-threatening violence against women and girls. Chronic effects include soil-transmitted helminthiases, increased anaemia, giardiasis, environmental enteropathy and small-intestine bacterial overgrowth, and stunting and long-term impaired cognition. If OD elimination by 2030 is to be accelerated, then a clear understanding is needed of what prevents and what drives the transition from OD to using a latrine. Sanitation marketing, behaviour change communication, and ‘enhanced’ community-led total sanitation (‘CLTS + ’), supplemented by ‘nudging’, are the three most likely joint strategies to enable communities, both rural and periurban, to become completely OD-free and remain so. It will be a major Sanitation Challenge to achieve the elimination of OD by 2030, but helping the poorest currently plagued by OD and its serious adverse health effects should be our principal task as we seek to achieve the sanitation target of the Sustainable Development Goals – indeed it is a moral imperative for all governments and development professionals.

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