Sanitation is Sexy.
Make it Obvious.

The fate of Victorian London’s poor living amid abysmal sanitation was forever altered by both a compelling soap opera of its time, and a simple yet creative instance of vandalism on government property. The soap was the serialized novel of Charles Dickens’ Bleak House – a howl of outrage at the city’s appalling slums in which the toxic open sewers became the novel’s real villain. The vandal was physician Dr. John Snow who removed the handle to a pump in a slum ravaged by cholera, forcing its dwellers to seek beer instead of the contaminated water. The epidemic was thererby halted proving that this dreaded blight was borne by the water supply, not from the miasma or noxious mist believed to exude from sewage. Dicken’s appeal to the heart and the doctor’s inspired and heroic act contributed toward the reforms that were to improve and save many of the lives of London’s poor.

The past 50 years has seen the London of Bleak House reemerge in the slums of Jakarta, Accra and other cities in the developing world, with even worse conditions in the rural countryside. Regrettably, today there is no single voice like Dickens to evoke so heart felt a reaction to the current global tragedy of poor sanitation. Nor is there an obvious contemporary Dr. Snow to enlighten the world with a single act of fierce inspiration.

Yet as in Dickens’ time, it is children -especially those younger than 5 – who comprise most of the victims. Diarrhea from contaminated water – kills 1.5 million small children annually and generates a toll every 3 years equal to the population of Ireland or Costa Rica. The hardier ones who survive often endure such complications as intestinal worms – infections that afflict a mind numbing 400 million children. These parasites deplete children daily of blood and nutrients, thereby leading to anemia, malnutrition and stunted growth. This weakened state increases their risk to other infections like pneumonia or TB. Perhaps worst of all they deprive children of the energy and concentration required to learn or even attend school. Risk of contagion leaves many others in dread of using school facilities.

Typical is 10-year-old boy Nguyen Tuan of Hanoi, who was too frightened by the filth of the school’s toilet to ever go near it. He would wait to return home before relieving himself. His mother feared this would lead to urinary problems, a realistic possibility. In fact, Nguyen’s revulsion was protecting him. School toilets in developing countries – especially if government run - usually have the worst sanitation in the city or village.

With girls, many are required to help fetch water for their families, preventing any school attendance. Those fortunate enough to go to class and also succeed in navigating the bathroom hurdle, are still forced to drop out at the onset of menstruation. These barriers contribute to the lower literacy rate among women who represent 2/3 of the 900 million illiterate people in the developing world.

Grown women must tolerate the indignity of 30 minute rest stop queues – that is – if public toilets exist. Where there are none, a common absence in the developing world, women search for remote and secluded sites before sunrise or after dark to ensure privacy. One Ethiopian woman confided to UNICEF about her fear of attack by wild animals or drunkards while on such outings. A woman from India recalled having to look out for poisonous snakes, and of one jolting interruption when a snake reared up beside her.

Globally, 2.6 billion people lack toilets – 43 per cent of the world – and another 900 million are without reasonable access to safe water. As a direct and indirect source for illness, poor sanitation also becomes the major ball and chain preventing escape from poverty through a circle of misery. Sick people are less able to contribute to their family which must also provide attention to the needs of the ill member. This can push even productive families below the poverty threshold. Poverty, in turn, is a major risk for disease which increases the likelihood of low education and continued poverty.

A Unitied nations report in 2008 concluded that dramatic improvement in sanitation and safe water access would do more to end poverty, reduce child death and improve world health than any other approach. More recently, health professionals surveyed by the prestigious British Medical Journal voted sanitation to be the most important medical invention of the past 150 years. Neither the UN or the surveyed professionals are the first to observe this. Mahatma Gandhi stated that sanitation was even more important than independence and Charles Dickens warned that “sanitary reforms must precede all other social remedies.”

Moreover, leading economists indicate that sanitation and clean water deliver a greater bang per buck than any other pathway to furthering development. Improvements mean greater work productivity and significantly increased school attendance – especially for girls – with resulting higher literacy and fewer lost work days from sickness. Public health savings would be profound, given that half the hospital beds in Sub-Saharan Africa are occupied by patients with water borne illness. Every dollar invested in sanitation, say UN economists, ultimately generates a nine dollar return.

Technology for improved sanitation already exists: the humble latrine, since this eliminates waste flowing into rivers and waterways – a problem that exists with indoor plumbing in developing countries. Yet despite favorable economics and simplicity in the science, progress has lagged behind the Millenium Development Goals. Globally in the past 20 years, those living without toilets has decreased from 51 percent to 42 percent, a change the UN Development Program shrugs off as disappointing. Not unusual was the World Bank sanitation project in the state of Harayana, India - in which people ignored the health message and consigned the toilets for use as storage bins and lean-tos.

Yet just as Dickens’ public health contribution was emotional rather than rational, development leaders are learning that people accept change based on its appeal to the same dreams that attract consumers to cars and cosmetics, and not necessarily from the public health information. This insight may be as important for global sanitation as Dr. John Snow’s inspired vandalism. A soap and cleanliness campaign in Ghana gained traction because its message emphasized scent and attractiveness, rather than health.

The appeal to consumers’ aspirations also explains why far more people in India own cell phones than have safe toilets. Nearly half the population have cell phones and predictions estimate this to rise to 80 percent in 5 years. The prestige and glamour of a cell apparently far outweigh realistic concerns about inconvenience, sickness or even death.

But toilets, given the right subliminal shine, can develop their own luster. The challenge and opportunity is to create a business model appealing to people as savvy consumers rather than as uneducated and needy charity cases. There already exists affordable hardware to permit latrines to function as recycling reservoirs – in which local entrepreneurs recover the waste with a special pump, and then pay the household that owns the latrine. But to launch this enterprise involves distracting people from taboos about such work with the prospect of small business promise and profits.

Haryana, India, the region of the failed World Bank project is also the site of an unplanned success story in which the common toilet achieved its greatest allure and triumph by an unlikely alliance with courtship. The practice of illegally aborting female fetuses – in a society that favors boys – lead to young men outnumbering young women. These numbers now compel males to compete for the decreased selection of females, permitting women to exert unusual demands from their suitors. It is in this prenuptial arena that young women, goaded by their mothers, came to associate toilets with empowerment and male appreciation. An eligible groom must give his bride a toilet. Local radio trumpets “no loo, no I do,” and popular soap operas weave this campaign into their melodramas, all leading to the recent installation of 1.4 million toilets in Haryana. Women’s rights activists call this phenomenon a revolution.

If global sanitation campaigns now appeal to dreams as much as to health, these projects are still driven by the voices of their most vulnerable victims. Shortly before the publication of Bleak House, The London Times printed a plea from members of the city’s slum, declaring, “we live in muck and filth … and if the Cholera comes, Lord help us.” In 2006, UNICEF assembled activist children of the world’s slums to give testimony before a rapt audience of government ministers and development leaders. An ll-year-old told of his struggle to bring toilets and clean water to school. A 16-year-old girl from a Bangladeshi slum who teaches schoolchildren how to keep their hands and homes clean, bore witness to children too ill from disease to ever attend class. UNICEF informed all present that “as children suffer, so do nations.” Dickens who saw only 5 of his 10 children reach adulthood, possessed the same conviction. He put a human face to the misery of London’s poor, causing England to mourn the death of a fictional street urchin. As if inspired by Dickens’ own tales, UNICEF has the young activists and 13,000 other children telling their stories on an interactive website. And if today no single voice like Dickens commands the world’s attention, then it is these children who provide the many faces of courage and survival against this current global tragedy.