To Seriously Improve Global Health, Reinvent the Toilet
The toilet is a magnificent thing. Invented at the turn of the 19th century, the flush version has vastly improved human life.
The toilet has been credited with adding a decade to our longevity. The sanitation system to which it is attached was voted the greatest medical advance in 150 years by readers of the British Medical Journal.
Unfortunately it is an impractical luxury for about two-thirds of the world’s 7 billion people because it relies on connections to water and sewerage systems that must be built and maintained at great expense. About 40 percent of all people, an estimated 2.6 billion of them, have no access to even a minimally sanitary facility, according to the World Health Organization.
The result is illness and early death. Diarrheal diseases, including those linked to improper sanitation, are the second largest killer in the developing world, taking 2 million lives annually. A cholera outbreak in Haiti, which has so far killed more than 7,000, for instance, apparently began when sewage from a base housing Nepalese peacekeepers contaminated a water source.
Vaccines and medicines against these diseases help. But the ultimate solution is to address the problem at its root.
Doing so requires reimagining the toilet. First, new designs are required for toilets that are hygienic, pleasant, and cheap to make and use, and that work without being connected to a grid. Because such a facility would have to be periodically emptied, ideally excretions would be treated not as waste but either recycled on site or turned into profitable resources.
Among the designs being developed by eight university teams funded by the Bill & Melinda Gates Foundation are several that divert and capture urine, from which water can be recovered. Others produce energy from excrement by turning it into charcoal or gas. Governments and universities should fund similar grants aimed at encouraging additional innovative toilet redesigns.
The Gates Foundation requires that the overall cost of a future toilet, including maintenance, not exceed 5 cents per user per day -- a price developing world consumers can afford. That would enable the private sector to step up production and distribution once practical new models have emerged. Cities would have to build a new generation of waste-processing centers, but the investment would quickly pay for itself. A World Health Organization study suggests that every dollar devoted to improving sanitation and drinking water produces economic benefits ranging from $3 to $34, because of health-care savings, deaths averted, and improved productivity and school attendance.
Because operating a toilet will ultimately cost individuals a little money, the uninitiated -- the 1.1 billion people who defecate in the open -- will have to be persuaded of the benefits. This will require huge education and advocacy efforts, for which UN agencies and nongovernment organizations that deal with the world’s poor have proved to be well-suited, based on their rollout of HIV drugs, for instance.
For gridless sanitation to be economical, commerce needs to flourish around the collection and treatment of excrement. Government agencies and charitable business associations could help by offering local businesses small grants, loans and expert guidance to encourage this enterprise. One model is the U.S.-based Acumen Fund, which offers loans to or equity in companies that provide consumers in the developing world with essential needs. In 2004, the fund invested $600,000 in WaterHealth International, established to bring safe drinking water to rural Indians, and today the company serves more than 5 million people.
More than anything, these potentially helpful actors must go beyond recognizing sanitation as an issue and embrace it. So far, squeamishness has been an impediment. As a result, other public health causes have claimed greater attention and funding.
According to an annual report by the George Institute for Global Health, of the money spent on research and development of new products for diseases that disproportionately affect the developing world, AIDS accounts for 39 percent, malaria 18 percent and tuberculosis 15 percent. Diarrheal diseases get 5 percent, though they cause more morbidity and mortality than anything but lower respiratory infections, mostly pneumonia (which attracts a lousy 3 percent of the research total).
Bad sanitation is a problem not so hard to solve, if only we devote ourselves to spreading the wonders of the toilet.
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