Health crises thrive where toilets don't exist. Rotary Images/Alyce Henson
I n the bustling main street at the entrance to Shanti Nagar, off Mumbai’s western expressway, men in suits go about their business. Women carry containers, hurrying to fill them in the two hours that water comes through the taps.
The shopkeepers and doctors and quacks and barbers do a brisk trade. It looks and sounds like any Indian street – only narrower and darker – and looking in, perhaps you wonder what makes Shanti Nagar a slum. So you turn around and see, on the dusty roadside, as the cars zoom past, a series of little children’s bottoms, perched nakedly and shamelessly in public, defecating with composure. After the children jump up and scamper down the embankment, disappearing back into the slum, you notice that the roadside is dotted with feces, as far down as you can see.
The 4,000 people who live in Shanti Nagar share one community toilet block, with 26 stalls. You’ll have to ask directions if you want to see it, because smell is no guide when the whole place stinks, and when you can easily be lost down the dim passageways, where you stumble clumsily and where kind hands occasionally reach out to guide your head away from an overhanging tin roof, or to move you out of the way of a pile of filth. Shanti Nagar is definitely a slum, because to live in a slum is to live among excrement, and this place has plenty of it.
This may be horrifying, but it is not extreme. In fact, Shanti Nagar’s appalling sanitation is normal. It must be, when 2.6 billion of the world’s people have no sanitation facilities whatsoever, not even a bucket or a box. If they’re lucky, as in slums such as Kibera, Kenya, they might have a plastic bag to defecate into, which they then tie and throw (hence the nickname “helicopter toilets”). That’s a luxury. But 4 in 10 of the planet’s people have no private or hygienic facilities to do their business in.
Driving through the Indian countryside at dusk – through settlements with decent enough houses, functioning shops, and cell phone kiosks everywhere – you can see, on leaving a village, people squatting on the side of the road, clasping a lota (water vessel) with which to cleanse themselves. Elderly women try to hold their saris over their private parts while simultaneously covering their faces. “Ten years ago,” says Indian sanitation activist Joe Madiath, “she would have jumped up at every passing car. Now there are too many. She can’t be up and down like a yo-yo.”
Weapon of mass destruction
Why does it matter? It’s not simply a dereliction of dignity. Human waste is a highly efficient weapon of mass destruction. Feces can carry 50 communicable diseases, including cholera, hepatitis, and schistosomiasis. Where people have poor or no sanitation, human excrement gets tramped into living environments on people’s feet and carried in on fingers. It finds its way into food and drink, with desperate consequences. Diarrhea – 90 percent of which is caused by contaminated food or water – kills up to two million people a year, most of them children. It kills more children under five than AIDS, tuberculosis, or malaria. In graphic terms, diarrhea’s death toll is equivalent to two jumbo jets full of children dying every four hours, or one child every 15 seconds. Several have died in the time it has taken you to read this far. Read that sentence again, and there’s another one gone.
Diarrhea is the reason you can find a malnourished child in a well-fed family. Feed a child a high-protein biscuit by all means, but it will be of little use if she can’t keep it in. Diarrhea also affects vaccination efforts. Polio immunization workers sometimes need to administer the oral vaccine 10 times instead of once, because diarrhea washes it straight out again, or because a child’s immune system is already overwhelmed with fighting the pathogens in unsanitary environments. Nor is that all. Respiratory tract infections, the No. 1 killer of children, are also linked to poor sanitation, as they can be spread by unwashed hands.
The breadth and depth of the destruction caused by poor sanitation is stunning, but no more so than the way sanitation continues to be neglected, by donors and by politicians. Almost 90 percent of water and sanitation budgets in developing countries goes to providing clean water, even though a good latrine reduces diarrhea by 36 percent (clean water only reduces it by 20 percent).
Poor sanitation is linked to a quarter of all child deaths, but money still flows more readily to more fashionable diseases and causes. In Madagascar, less than 0.1 percent of the population is estimated to be living with HIV/AIDS, and in 2007, UNAIDS found that there were too few AIDS deaths to estimate. Yet HIV/AIDS receives five times more funding there than sanitation, though diarrhea kills 14,000 Madagascan children every year.
There are all sorts of reasons sanitation continues to be treated like dirt. Nobody protests about it, for a start. Not even in great cities such as London, where 40 percent of public toilets have closed in the last decade, or New York, where it’s an achievement to find a toilet without having to buy a coffee or a muffin first. Ronnie Kasrils, previously proud to be known as South Africa’s minister for toilets (his official title was water affairs and forestry minister), says, “No one wants to talk about [human waste], do they? I’d go to public meetings, and no one ever says, ‘You know, man, I’m sick and tired of this disgusting latrine I’ve got.’”
"Diarrhea is the reason you can find a malnourished child in a well-fed family."
The flush toilet may be to blame. The wonderful disposal device did an excellent job of separating us from our potentially cholera-laden waste, but it also flushed sanitation out of the conversation. Yet language is crucial if one of the world’s biggest unaddressed public health crises is to get the attention it needs.
In the 1980s, the Indian government installed hundreds of thousands of new latrines. But those highly subsidized facilities went unused – at least for their intended purpose. Maybe because they were nicer than people’s houses, so they were turned into extra storage space, or temples. Maybe because people didn’t want a latrine near their house, or because they liked to stroll to the woods after eating. Either way, the government learned a lesson that is resonating throughout the sanitation world today: Toilets, and toilet behavior, is never just about the hardware. The software – human psychology and language – is critical.
Take Samiapalli. This village in the Indian state of Orissa was typical, riven by caste problems and wracked by serious alcohol abuse and domestic violence. There was no sanitation; rather, open defecation in nearby woods and along roadsides was the norm. Today – although it took 162 meetings to get everyone to agree (and to contribute to the cost) – everybody has access to a latrine, a bathing room, and running water. With the confidence gained through those 162 meetings, village women kicked out the illegal alcohol brewers and tied the most persistently violent men to a lamppost. Eighty percent more girls now go to school, according to the village leader. Women earn money by growing peanuts and selling other goods at market with the free time they’ve gained from no longer having to spend hours finding somewhere private to do their business, or to fetch cripplingly heavy water. The incidence of diarrhea has dropped dramatically.
“It’s the hardest entry point,” says Madiath, whose nongovernmental organization, Gram Vikas, helped bring the toilet revolution to Samiapalli. “But once you succeed in getting people to talk about sanitation, you can do anything.” In other words, sanitation isn’t a symptom of development. It can be a trigger for it.
Sanitation is also a bargain. Every dollar invested in it reaps an eightfold return, because people spend less on health costs and miss fewer days of work. In a 2008 report, the World Bank calculated that poor sanitation cost Cambodia, Indonesia, the Philippines, and Vietnam 1.3 to 7.2 percent of their gross domestic product. When Peru had a cholera outbreak in 1991, tourism and agricultural losses amounted to three times more than what it would have cost to invest in proper sanitation over the previous decade. And as a disease-prevention mechanism, sanitation is hard to beat, in either effectiveness or price. Treatment of lower acute respiratory illnesses in children under five costs as much as US$264 per DALY (disability-adjusted life year, a standard health prevention unit of calculation). Sanitation costs $11. Hygiene promotion costs $3.
Gram Vikas and the villagers of Samiapalli are not alone. Countless foot soldiers, with little public support and no public champion, are trying to change things. There is Wang Ming Ying, a tiny Chinese woman who is trying to get rural villagers to install household bio-gas digesters, which convert latrine waste into cooking gas and thus lessen deforestation. There is Jack Sim, founder of the World Toilet Organization, a man who jokes that the world can talk about eating – he calls this “uploading” – so it should be able to talk about downloading too. There is Willem-Alexander, Prince of Orange and heir apparent to the Dutch throne, who heads the UN Secretary General’s Advisory Board on Water and Sanitation. And there is David Kuria, a member of the Rotary Club of Nairobi-Langata who works in the Kibera slum, installing community toilets to cut down on those awful helicopter versions.
An architect, Kuria worked in the civil service before turning to toilet provision. The change made perfect sense to him. “I understood that the biggest stimuli for development were water and sanitation,” he says. If they’re in place, then education, public health, and all aspects of livelihood improve – this is widely known. Kuria’s innovation was to understand that toilets have to appeal to people. “Toilets aren’t in people’s top priorities,” he says. “They should be, so what’s the problem? I realized it’s about the way we package a toilet’s social aspects.” To this end, he built a community toilet near Kenya’s parliament building, then persuaded politicians to hold meetings inside the new facility. Music plays, and there is a snack bar. “People told me that was taboo. They said no one would eat food prepared near a toilet. Now there are queues for the snacks.” Kuria also has plans for a “toilet reality show,” where contestants will travel the country in search of good toilets and recommend appropriate solutions for schools and neighborhoods.
Soap manufacturers learned how to market hygiene products over a century ago. Like Kuria, they realized that people don’t usually respond to health messages. Manufacturers never got anywhere by telling people that soap made them more hygienic. Only when their product was sold as sexy did sales flourish. Research in Benin, meanwhile, found that even mothers who see their children suffer again and again from diarrhea aren’t receptive to health advice. No one likes to be nagged. Instead, the mothers said that one of the main motivations for installing a latrine was learning that Benin’s royal family had them.
In some ways, these are exciting times in the sanitation world. The International Year of Sanitation was 2008. The Prince of Orange is a sensible man with access to powerful ears. In 2005, the United States passed the Water for the Poor Act and put real money behind it, mandating that at least $300 million a year go toward water and sanitation.
But the foot soldiers – princes and paupers – need more help than that. Despite the vast benefits that good sanitation can bring, according to Kasrils it was only reluctantly included as a target in the UN Millennium Development Goals, even though failing to meet that target would have domino effects on at least three other goals. A girl dying of diarrhea won’t go to school (Goal 2, achieve universal primary education), or be properly nourished (Goal 1, eradicate extreme poverty and hunger), or be alive past the age of five (Goal 4, reduce child mortality).
And yet few politicians dare to kick up a stink about sanitation. Kasrils was an exception, and he only saw the light because a cholera epidemic taught him that supplying clean water wasn’t much use when people were defecating near it or into it because they had no latrines. Sanitation sorely needs a new champion. Step up, then, celebrities who happily promote a clean and shiny water faucet in a dusty village, with a photogenic child in tow, but don’t bother to take the few steps over to the latrine that has enabled that child to go back to school and prolonged her life. Sanitation, after all, was voted the best medical advance since 1840, over antibiotics and vaccines, by the knowledgeable readers of the British Medical Journal. Kuria says, “The toilet is at the heart of everything.” Yet still children die from plain and simple diarrhea, because we think sanitation is a dirty word.
See A field guide to toilets