Faecal Attraction

So I’m reading a book about poo, and its contribution to civilization. Somehow this got left out of my undergrad class on Western Civilization at Georgetown.

The book I reference is Poop Culture: How America Is Shaped By Its Grossest National Product. I haven’t reached the end yet, but I don’t expect any real surprises – I think I know how this one ends. It’s an awfully interesting read, with insights about poo that I hadn’t considered (or wanted to). We all would benefit by paying closer attention to this issue, and Poop Culture adds some interesting blue-sky approaches to human waste treatment that we should consider – e.g. converting it to energy.

Executives from the Water Environment Federation consistently and justifiably argue that what separates developed from developing countries is not human rights, respect for the environment, or Internet access but PIPES – unglamorous infrastructure. E.g. what happens to poo once it leaves the body?

My challenge is seeing that what happens to that poo around the world doesn’t result in unnecessary mortality and morbidity such as from diarrheal diseases. Over 2.6 billion around the world lack adequate sanitation facilities, or quite literally a place to go to the bathroom. This doesn’t mean that they are NOT going to the bathroom, but rather that 2.6 billion people do so in a way that often negatively impacts their health and the health of their neighbors, kids, passersby. Many organizations are struggling with a way to make this massive public health challenge more compelling. What would make it as cool to talk about poo/defecation/shit at cocktail parties as it is to talk about HIV/AIDS?

Dave Praeger’s book gives us a hint, or at least a lesson to be learned from history:

“By the end of the nineteenth century, state and social reformers in both England and America were working hard to spread the flush toilet across society and alleviate critical sanitary threats. Much of the strategy involved the state extending and maintaining modern sewer and water infrastructures, but reformers still needed to convince skeptics that the new bathroom technology was a boon and not a power-grab by the government. To overcome resistance in people who had been pooping in privies or chamber pots all their lives and were quite content with them, they associated health, happiness, refinement, and civilization with the flush toilet. The corollary of that, of course, was that people who didn’t use flush toilets were the opposite.”

This approach hits close to that of today’s social marketing experts, primus inter pares PSI. Social marketing is defined as “the systematic application of marketing alongside other concepts and techniques to achieve specific behavioral goals for a social good.” The bottom line is that 2.6 billion people need the health benefits associated with improved toilet facilities – the best way to make that happen may well NOT be preaching about those health benefits, but rather finding clever ways to make toilets/pit latrines more cosmopolitan, hip, cool, fun, refined, or alternatively to make it embarrassing to NOT have one.

So what can we learn from PSI’s approach and late nineteenth century America and England. Hopefully a lot – precisely zero people died from cholera in these two countries in 2007.

Comfortably Numb

Hello…hello…hello.
Is there anybody in there?
Just nod if you can hear me.
Is there anyone home?

The world’s gravest public health crisis is unsafe drinking water and inadequate sanitation. Diseases related to this problem kill 5x more kids than HIV/AIDS, and twice as many as malaria. Four billion cases of debilitating diarrhea occur each year, and diarrheal diseases alone kill well over two million kids on an annual basis.

So, the good news: The world came together last week at the Stockholm International Water Institute’s World Water Week to discuss precisely this issue.

And the bad news: the three of you who read this blog are hearing more about World Water Week through this medium than most other people through what I'll humbly call more popular media.

Those mainstream media may well tackle water and climate change, ocean conservation, the bottled water industry, water as a human right, privatization and related issues. But they shy away from unsafe water as the gravest – and most solvable – global public health challenge. This was manifested by the paucity of coverage of World Water Week in at least the U.S. media. Neither The New York Times nor The Washington Post had even a poorly-turned phrase on World Water Week. The only Associated Press story picked up (according to a Google news search) in the U.S. media focused entirely on bio fuels, never even mentioning the severity of this global problem. (Way to go John Sauer at Water Advocates for tracking this.)

Solving the world’s drinking water and sanitation crisis is difficult – it is not a soundbite or silver bullet issue. As my cohort Dennis Warner of Catholic Relief Services says, it’s not rocket science – it’s harder than rocket science. How long did it take to train your kids to wash their hands after they use the bathroom? Do you wash your hands after each trip to the john even today? What’s our water infrastructure financing gap in the U.S. up to now?

But solving this problem is possible. How many English die of cholera in 2007? How many Japanese die of diarrhea? How many Americans have guinea worm, schistosomiasis or malaria?

The unsafe water issue will soon drive the international development agenda itself – it’s unfortunately a matter of time before the media are forced to come to terms with this global challenge whether they like it or not.

I suggest instead that the 1.1 billion people without safe drinking water throughout the developing world need the U.S. and European media to lead the target. As the NYT looks to the FT for story ideas, and as the Economist looks to The New Yorker, one well-placed story on unsafe water as the world’s biggest cause of preventable infant/child mortality and morbidity will punch well above its weight (and win a Pulitzer or two, people).

Some get it: one particularly insightful, clever piece comes from Carl Ganter at the Pacific Institute’s Circle of Blue: Navigating the Mainstream: The Challenge of Making Water Issues Matter. Read it and visit Circle of Blue. Seriously.

Another: Gil Garcetti (yes, that Gil Garcetti) is now an amazing professional photographer covering the world’s water crisis. See his new book Water is Key.

Another: Matt Damon’s new movie Running the Sahara is scheduled for release this fall.

There are stories lined up - there are high profile testimonials lined up – there are convincing water experts lined up. If that’s not enough, there’s always the crushing grip of reason which is tightening. We need to act – there are billions of the world’s poorest waiting for their governments to properly prioritize this issue. There is an opportunity for the Western media to get out ahead of this issue and pull the world along.

None of My Business

Typically, I try always to be open-minded - to walk a mile in the other guy’s shoes, even if it is just to be a mile away and have his shoes when the deal goes sour. However, there are some things to which I cannot possibly relate, and even trying to gets me in trouble. One of those things is the female menstrual cycle.

So I find myself today getting caught up on some reading, in particular a NY Times article from December 23, 2005 entitled “Another School Barrier for African Girls: No Toilet.” I made it about three sentences into the article when this phrase caught my eye: “the realities of menstruation in a school with no latrine, no water, no hope of privacy other than the shadow of a bush, and no girlfriends with whom to commiserate.”

I quickly stopped my halfhearted attempt to relate to this, and am now working on the more simple reality that this is a bad thing and needs fixing.

So… Although the article’s protagonist (Fatimah Bamun, pictured above) is in Ethiopia, this is a reality which unfortunately is not isolated to Ethiopia or even Africa. Fifty percent of the world’s schools do not have access to safe water and single-gender sanitation facilities, and those parts of the world with such luxuries are in the fortunate position of not having to relate to this reality.

In Guinea, enrollment rates for girls from 1997 to 2002 jumped 17 percent after improvements in school sanitation, according to a recent Unicef report. The dropout rate among girls fell by an even bigger percentage.

This post is not about water – it can’t be. This post is about water as a direct conduit to additional educational opportunities for girls, and as a less direct but perhaps more compelling conduit to corresponding increases in economic development and decreases of fecundity rates.

Water and sanitation are statistically validated as significant contributors to education, whether it’s the Education Millennium Development Goal or any other success metric. A recent WaterAid report quantifies the impact of safe water and sanitation on not just the quantity of education, but also on the:

• quality of education - children suffering from diarrhea or thirst (or holding back until nightfall to urinate) cannot concentrate on their lessons, and


• teachers - particularly female teachers who often suffer the same consequences as do their pupils. It is very difficult to recruit and retain qualified teachers where the schools don’t have water and sanitation.

I’d also suggest a quick glance at least at the summary of the Proceedings of the 2005 Water, Sanitation and Hygiene Education for Schools Roundtable Meeting which begins with this quote from former UN Secretary General Kofi Annan:

Water is intimately linked with education and gender equality. Girls who have to spend time gathering water for the family tend not to be in school. And where schools have sanitation, attendance is higher, especially for girls. Water is connected to health, since millions of children get sick and die every year from water-borne diseases and for lack of basic sanitation and hygiene.

I’m not asking readers to relate to this gruesome reality, or even to solve the world’s water problem. More pragmatically I am asking you to consider what it would take to catalyze a situation whereby each of the world’s schools achieves safe, affordable and sustainable access to safe drinking water and single sex sanitation facilities? How many schools are there, how many suffer from these shortages, and what would it take for every government in the developing world to meet its responsibility and fill that gap? Last and least, what could the international donor community do to jumpstart this sort of commitment to life and livelihood?

For example, there are 54,000 schools in South Africa. If 50% of those do not yet have water and sanitation that defines our universe as 27,000 schools. At a conservative (on the high side) $20,000 a pop for water, sanitation and hygiene promotion, that’s $540m. Couldn’t the international donor community come up with $54m to goose the GoSA to make that commitment? Then wouldn’t the governments of Zambia, Mozambique, Botswana and Namibia be embarrassed…

I’ll be damned if I’m gonna pay to take a piss

Direct quote from a tourist during a recent trip to Paris: “I’ll be damned if I’m gonna pay half a euro to take a piss. I’m going to McDonald’s!”

So people have a difficult time paying to go to the bathroom in France. Not exactly a newsflash, and I think the same will be said once public toilets start becoming more prevalent in NYC. Tourists will still whistle nonchalantly through hotel lobbies to get away with doing their business for free.

In several woredas (districts) in Ethiopia, however, it’s now the hip thing to not only have your own pit latrine by your home, but to pay for the privilege. How did this happen, and in Ethiopia of all places, where the per capita GDP is $US1,000, and where only 6% (sic) of the population has access to improved sanitation facilities? What’s the secret?

Trachoma is the world’s leading cause of preventable blindness, and is caused by a lack of safe water and inadequate sanitation facilities. Transmission of trachoma can be decreased significantly by using improved sanitation facilities like pit latrines. The Carter Center’s Trachoma Control Program, in cooperation with the Ethiopian Ministry of Health, launched a program in 2002 to catalyze the building of 10,000 pit latrines to stem trachoma. If there is one global public health story over the past few years that deserves to be above the fold in every mainstream periodical, it is this one:

Pit Latrines for All Households: The experience of Hulet Eju Enessie Woreda, Amhara National Regional State, Northwest Ethiopia

The full report (in Amharic) is a bit of a read. The gist of this executive summary (in English) is this:

• 89,000 pit latrines were built (the actual number is now 225,000)
• Ethiopians have for the most part done this themselves
• Most households paid nothing for their latrines; of those who paid anything, the median amount was USD$2.80.
• The secret to success was not throwing money at the problem, or pushing some inappropriate top-down technology or infrastructure.

The secret to success is what the Carter Center calls "community mobilization, the presence of a strong political commitment among local leaders, and integration into the pre-existing community structures and practices." The latin taxonomic name for that is “Ethiopicae grandmae,” less technically “Ethiopian grandmothers,” or “informal village leaders.”

Pit latrines do not sell themselves in most cases, particularly in rural and peri-urban areas where the need to find an unspoiled place to leave a #2 is less urgent because there is simply more real estate. Latrines are frequently expensive to build and maintain, even if the local demand exists. It is often very difficult even to create that demand though, particularly in more rural communities, and difficult to ensure that those latrines are used for their intended purposes, not as homes or as cow-dung storage sheds.

This particular Carter Center program did not have the resources to build latrines themselves, but only to do the community mobilization and training. I spent several years in the late 1990s working for USAID and U.S. Department of State contractors on democracy and governance initiatives throughout Africa. Not infrequently I found that the fewer financial resources we had available for a project, the more successful it turned out to be. This was because less money led to non-financial commitment(s) being provided by local leaders, and by women’s groups in particular. Once those local commitments were made available, the sustainability of our work increased dramatically.

This Carter Center report indicates similar results from a similar approach. If Patty Stonesifer would come to me today with the “How would you spend $5b” question, my answer would be “Scale the sanitation work of both the Carter Center and Sulabh International by customizing their approaches for every country/community in the world, and blow the sanitation MDG out of the water.”

It is not cost-effective to vaccinate a newborn against polio or mumps if that child will die at three years old from a preventable waterborne disease like diarrhea or malaria or be forced into a life of leading a trachoma-blinded adult around for the rest of his/her life.

“Using a pit latrine is freedom, comfort, and honour!” — Villager from Hulet Eju Enessie Woreda

Hearts and Minds

Rear Admiral William McRaven had an intriguing quote in The Economist on June 14, 2007:

American officials insist that AFRICOM will not be all about building bases and airstrips but will co-operate with development agencies, NGOs and diplomats to win African hearts and minds and so deny terrorists havens from which to operate. Rear Admiral William McRaven, head of the special forces now operating in the Sahara, says his men are much more likely to drill boreholes and build houses than to shoot at anyone. “I don't want a fragile state collapsing any more than Greenpeace or USAID does,” he says.

Rear Admiral McRaven is Special Operations component, SOCEUR (Special Operations Command, Europe). His comment comes in the broader context of The Economist article called Policing the undergoverned spaces.

This post is not to suggest that the U.S. will win the long war by drilling boreholes, nor is it to suggest that U.S. military forces, much less the Special Forces, should be taking care of the water needs of the developing world (in fact I argue against this). There is, however, a growing recognition that along with traditional military operations we should be pursuing less militaristic methods of winning hearts of minds, particularly in countries deemed most likely to become breeding grounds for terrorists. The provision of water and sanitation becomes a particularly salient intervention in this equation. The U.S. intelligence community has realized for some time that overlaying the map of water scarce countries with the map of countries deemed the biggest threats to U.S. national security gets an almost perfect match. Plus the USG gets the biggest bang for its development dollar (in both direct and indirect returns) by investing that dollar in relatively simple water and sanitation initiatives.

One good recent example where this all comes together is CSIS's recent post on Below the Surface: U.S. International Water Policy. Erik Peterson notes:

Targeting water would also yield other geopolitical dividends—including removing what is a serious obstacle to stability and security within states and reducing the possibility for conflict or tension between countries with shared water resources. Finally, water represents an avenue for the United States to demonstrate leadership in the world at a time when its image has eroded so considerably. In short, a water-centered set of policies could represent a remarkable opportunity for the United States to “do good” while “doing well” when it comes to pursuing its own interests in the world.

So maybe this post is about how to win the long war after all.

Since you asked...

This is what keeps me awake at night (or at home on a Friday evening):

No matter how much I do, or anyone I work with or consort with does, no matter how much the international donor community does to support safe drinking water and sanitation around the world, no matter if every international donor dollar is spent in exactly the right, highly coordinated way, all we can hope for is for all of those resources collectively to be the cherry on top of the cake, or at best a little gas to get the water development engine going.

Where's the real money? Approximately 70 cents of each dollar that is invested in water/sanitation/hygiene in the developing world comes from public sector finance in developing countries themselves - Ghanaian, Nicaraguan, Vietnamese, Indian taxpayer dollars/rupees/cedis etc. Ten percent give or take comes from the international donor community, with the rest coming from international and domestic private investments in water and sanitation infrastructure.

The end game - universal coverage of water and sanitation, like we enjoy in the States, Europe, Japan - must be played and won by the developing country governments themselves. They must do a much better job of prioritizing water/sanitation in their own budgets over the long run, and do a better job of prioritizing water in international aid requests in the short/medium term (e.g. Millennium Challenge Corporation compacts). [So shouldn't I/we be lobbying those governments instead of the donor community here? Now you try to get some sleep with that question hanging over your head...]

Government subsidies, tax incentives, and grants are all partial answers to how developing country governments should tackle this problem. There are also a number of regulatory paths to take, and I just read of a couple more today:

The Disease Control Priorities Project (DCPP) is an "ongoing effort to assess disease control priorities and produce evidence-based analysis and resource materials to inform health policymaking in developing countries." They recently published a very insightful piece on Water, Sanitation, and Hygiene: Simple, Effective Solutions Save Lives.

It's a clear, short (4pp!) paper detailing both the problem and at least hinting at some interesting partial solutions. One example: with respect to sanitation infrastructure (e.g. building pit latrines), government subsidies are often unruly, inequitable and highly politicized. The DCPP recommends a regulatory approach to address the challenge:

In Bobo Dioulasso, Burkina Faso, for example, the local administration withdrew land tenure rights from owners who did not build a latrine on their plot within a specified time. As a result, 90 percent of households now have their own latrine. Another effective regulation requires landlords to provide latrines for their tenants.

Yay. Another opportunity for developing country governments to more effectively encourage the construction of pit latrines is through what is commonly known as social marketing, much and well-practiced by Population Services International in the donor arena. Governments are encouraged by the DCPP to promote latrines by almost any means possible, as it is perhaps the most cost-effective way to ensure their construction. It is also likely to come out ahead in any cost-benefit analysis. Pit latrines do NOT sell themselves, so governments stepping in to make them more compelling one way or another is part of the solution. And the scale of the solution matches the scale of the problem and I get to go out on Friday nights...

I also have self-doubts about the fact that if only the world's agriculture were 10% more water efficient, there might not be a drinking water supply problem at all, so maybe I should be working on that issue?!? But that's for another post.