The Developing World Needs Plumbing, Not Just Vaccines

I've always thought that if Bill Gates really wanted to make his mark, he should build sewer systems in the developing world (and provide endowments to maintain them). Because I'm getting tired of reading excellent articles like this:

The recent outbreaks of cholera in Haiti, Pakistan, and Zimbabwe suggest that our current global action plans against cholera are failing. This issue contains two important articles that will help inform our discussions on ways to respond to the global cholera situation. Cholera is a severely dehydrating illness caused by Vibrio cholerae, a Gram-negative organism. V. cholerae exists in environmental aquatic reservoirs, and, as a result, cholera is not an eradicable disease, but it is controllable. Humanity has recognized seven cholera pandemics since 1817, all originating in Asia. The most recent pandemic began in 1961 in Indonesia, making it at half a century the longest cholera pandemic on record. As opposed to burning out after 5-20 years as all previous pandemics have done, this pandemic, if anything, seems to be picking up speed. Cholera outbreaks are occurring with increasing frequency and severity, as demonstrated by the recent major outbreaks in Nigeria, Angola, Pakistan, Vietnam, Zimbabwe, and now Haiti. This is on top of all the endemic infections that largely go "unnoticed". In fact, cholera is now endemic in approximately 50 countries worldwide, and V. cholerae infects 3-5 million individuals each year, killing approximately 100,000, only a minority of whom die in outbreaks that garner media attention.

The simple reason we don't have shigellosis or cholera outbreaks in the U.S. is that we don't have to drink our own shit. But, in the developing world, sewer systems are too often not an option:

One of the constant refrains I always hear is that diarrheal diseases, such as shigellosis, cholera, and other bacterial dysenteries, could be easily solved if there were adequate potable water and sanitation. That's completely correct. It's also completely unrealistic, as a recent editorial by Lorenz von Seidlein in Tropical Medicine & International Health argues.

The problem is that this 'ultimate' solution of massive infrastructure investment often means that foreign governments and NGOs are discouraged from effective, short-term solutions. One such solution is the oral cholera vaccine ('OCV'). While it is a highly effective vaccine, public health officials in developing nations have had very little success in generating the finances needed for an OCV program.

Cholera outbreaks are blamed on the healthcare system--and thus, the healthcare officials. Sanitation improvements (pipes, sewage treatment, water filtration), when even possible, often fall under a different ministry over which the health officials have no say. Considering that most developing nations face larger health crises, such as AIDS, it would be impossible to galvanize a mass movement to deal with the problem of cholera by a massive investment in sanitation and water infrastructure (if such grassroots mobilization is even possible in the political environment). Consequently, healthcare officials have no choice but to advocate for strategies like the OCV.

Before you blithely dismiss this political reality, just think about how long it took for many mass public health movements, such as smoking prevention and AIDS prevention, to become effective in the U.S. where resources are not desperately scarce.

Like I said, let's build some sewers.

Cited article: Ryan ET, 2011 The Cholera Pandemic, Still with Us after Half a Century: Time to Rethink. PLoS Negl Trop Dis 5(1): e1003. doi:10.1371/journal.pntd.0001003

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You don't even need sewers as such (as noted, that's a massive infrastructure investment with lots of practical problems), you just need half-decent latrines, a clean(ish) water source, and to teach people to stop shitting in the river. Composting toilets or pit latrines can be constructed easily and (comparatively) cheaply with fairly minimal resources.

It's not as easy as it sounds. See this article for some background:

"In previous decades, NGOs and governments often focused on building new latrines or toilets for people, but far too often the facilities weren't used. In some cases, people turned toilet sheds into storage facilities and continued practicing open defecation. Having learned from less-than-successful experiences, aid organizations are now supporting "demand-driven" water and sanitation services, in which governments and donors focus on creating demand rather than supplying hardware."

By Grep Agni (not verified) on 10 Feb 2011 #permalink

Let's hope they get a sanitation system that's not modeled on our unnecessarily wasteful one. Loss of soil fertility, wasted water, and emissions from sewage treatment have the potential to make a bad situation even worse. Developing and maintaining a sanitary composting toilet system would help restore fertility to the soils, protect water supplies, and be cheaper and less environmentally destructive than industrial sewage treatment. We should convert to safe methods of composting human waste here.

"people turned toilet sheds into storage facilities and continued practicing open defecation."

This may be wacky, but could acceptance of sanitation facilities (outhouses) in European countries be due to cold winters? You are much less likely to squat outdoors when it is cold outside.

And once you get into the habit in the winter, you just keep using the outhouse all year.

And to continue, excepting the sanitation problems, going outside is not all that bad (in warm weather!). As it said in "The Complete Walker" - a backpacking book - "All else being equal, choose a john with a view."

Vaccination is a far more easier problem than sanitation.

Sanitation will require someone far richer than Bill Gates.

Think of it. For many illnesses one or a handful of shots and that is it. At the worst there are things like flu shots that take a few minutes once a year. Sanitation is a 24/365 concern.

Building and maintaining toilets is not free. Clean running water is not free. Soap and/or any other cleaning supplies are not free. Trash collection is not free. Health departments are not free. Punishing people or organizations that don't practice safe practices is not free. Education is not free.

(Yes I know some of those non-free things will pay for themselves many times over the long run, but if you don't have the money to pay for them in the first place or are unwilling to spend the initial investment then it is all moot.)

If you can vaccinate someone properly, for most people it will certainly work no matter what they do when you leave. Sanitation requires changes in everyone's everyday behavior. Heck, even in America after over a century of continuous indoctrination of the populace, we still have problems with people not washing their hands.

By Childermass (not verified) on 10 Feb 2011 #permalink

I've always thought that if Bill Gates really wanted to make his mark, he should build sewer systems in the developing world (and provide endowments to maintain them).

I actually was laughing at this. Not because its a bad idea. But because contrary to logic sometimes it actually makes the situation worst. Anticholera measures in Bangladesh actually resulted in the mass poisonings of people because what was thought to be clean water was actually naturally laced with arsenic.

there is only so much that Bill Gates can do. improving sanitation, education involves extensive effort and large manpower not to say large investments too. it is much beyond the reach of any one person or a group of persons. it needs the active support of the local government ... to be able to quarantine infected people, to be able to fumigate large swathes, mobilize an army of health workers in countryside you need sovereign power, something no amount of money can buy. it also follows that these are precisely the things that governments are supposed to do, precisely things for which governments are designed. it follows that improving governance can work wonders to elimination of diseases too. now we are perhaps crossing the breaking point limit of anybody's ability to do such things. very unfair to expect Bill Gates to do it.

moreover even if governance is not perfect, disease eradication is still possible. as India's experience shows, even Cholera can be contained. though India cannot be said to have very good sanitation facilities (or very good grassroot level governance), it has been able to limit the water borne diseases. I am not sure how they have done it, but some straightforward studies may reveal it.

Isn't this the reason why they are "developing" not very effectively? Don't they need to figure this out for themselves?

n some cases, people turned toilet sheds into storage facilities and continued practicing open defecation. Having learned from less-than-successful experiences, aid organizations are now supporting "demand-driven" water and sanitation services, in which governments and donors focus on creating .

Efforts to "guide development" should be driven solely by clear request or desire on the part of the recipient.

Let me quickly clarify that I am as "progressive" as the author of this blog. I am the strongest possible advocate of public health and sanitation, and I am deeply upset and concerned by the current level of teabagger ignorance in the US, which seems to forget that some degree of social cooperation is necessary for such things.

Breaking the cycle of excess morbidity and premature mortality due to infectious and parasitic disease would be a wonderful breakthrough for developing countries. By my subjective standards of what is or is not "wonderful".

Having said that, the patronizing urge to force other sovereign countries, which are not harming us, to mimic our development, seems to be a remnant of cold war competition with the Soviet Union for global dominance.

If you built some guy a toilet and he wouldn't use it, either you built a poorly designed toilet, or he doesn't want to change his habits cholera be damned, or both. In either case everyone's money and time were wasted.

Colonization did terrible harm to some areas, but perhaps the only correction for that is to grant and respect autonomy.