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Infrastructure and Disease

May 28, 2008


The crisis created by the cyclone that recently slammed the Myanmar coast highlights once again the importance of certain critical infrastructures. In my discussions about Development-in-a-Box™, I continually stress the importance of certain types of infrastructure (most of them having to do with building the foundation of a good business climate). One too oft neglected area that needs to be addressed is basic sanitation. Myanmar’s junta has admitted that the victims of the cyclone need clean water or thousands more will likely die. Clean water is certainly part of the critical infrastructure that people need whether in crisis or not. They also need to be able to deal with human waste. Rose George, author of the forthcoming book The Big Necessity: The Unmentionable World of Human Waste and Why It Matters, wrote an op-ed piece for the New York Times that shines a light on subject that many people find distasteful [“Send in the Latrines,” 19 May 2008].

“It’s the rainy season in Myanmar. It’s also cholera season. When Cyclone Nargis arrived [at Myanmar’s shores], the waters it unleashed destroyed houses and killed people and livestock. The storm also devastated other things that haven’t made the headlines, but that can mean the difference between life and death: toilets. Even before the cyclone, 75 percent of Burmese had no latrines. Like some 2.6 billion other people worldwide, they do their business by roadsides, on train tracks or wherever they can. But the few latrines that did exist in the Irrawaddy Delta are now flooded or flattened, and their contents have seeped into already filthy waters. So what? There are other priorities, aren’t there? Food, shelter and clean water are what aid agencies emphasize.”

George, of course, knows the facts. She explains the “so what” in very descriptive terms.

“Human excrement is a weapon of mass destruction. A gram of human feces can contain up to 10 million viruses. At least 50 communicable diseases — including cholera, meningitis and typhoid — travel from host to host in human excrement. It doesn’t take much: a small child, maybe, who plays in soil where people have been defecating, then dips his fingers in the family rice pot. The aftermath of a disaster like Cyclone Nargis — with masses of weakened people on the move — is a communicable disease paradise. The priority is containment. That’s as fancy as it sounds: With the water table only 20 centimeters below the surface in Myanmar, it is little use to dig pit latrines, so buckets or tanks for human waste are needed instead. Providing such things is made harder by the refusal of Myanmar’s government to accept help. And it is also hampered by our unwillingness to even talk about it.”

George understands that those of us fortunate enough to live in developed areas with indoor plumbing and functioning sewage systems seldom give thought to such things. In undeveloped areas, however, relieving oneself is literally a matter of life and death.

“As Steven Pinker recently wrote in ‘The Stuff of Thought,’ the vocabulary of excretion has sneaked in and taken the taboo place previously held by religious words, and this switch parallels the rise of sewers and the sanitizing of excrement. A substance common to us all, and as vital to life as breathing, has become unspeakable, and particularly in the polite and powerful circles that could do something about its deadly effects. There’s no place for squeamishness when — even without complicated and difficult disasters like Myanmar’s — diarrhea trails only pneumonia as the biggest killer of small children in the world, greater than tuberculosis, AIDS or malaria, in numbers equivalent to a jumbo jet crashing every hour.”

George’s sense of anger and frustration clearly comes through her every paragraph. She feels the same sense of frustration that anyone would feel who is screaming at the top of their lungs and still can’t attract anyone’s attention.

“Humanitarian aid agencies use the shorthand ‘watsan’ to stand for ‘water and sanitation.’ There’s a reason those two words aren’t in alphabetical order, and it’s not poetry. When it comes to prioritizing aid, water has always received the lion’s share of attention and money. Eddy Perez, a sanitation expert at the World Bank’s Water and Sanitation Program, often shows an image of Arnold Schwarzenegger and Danny DeVito from the film ‘Twins.’ One represents water and the other sanitation, and he doesn’t have to spell out which is which. Most developing countries spend less than 0.5 percent of their gross domestic product on watsan, and only 12 percent to 15 percent of that in Asia and sub-Saharan Africa goes to sanitation, according to the 2006 United Nations Human Development Report. Celebrities like Matt Damon and Jay-Z line up to talk about water. Shiny taps and clean water make good pictures. I’ve never seen a movie star pictured in front of a new latrine, though it can double its user’s life span.”

George, of course, is not arguing that housing, clean water, and food aren’t important. They are. But so is sanitation. She also knows that sanitation is critical for development, not just in mitigating the consequences of natural disasters.

“Of course food and water are crucial. But feces can undermine both. If people are eating fecal particles, no amount of high-energy biscuits will make them well. In poor countries, diarrhea is the reason you find malnourished children in well-fed families. It’s why millions of girls drop out of school, and why millions of dollars’ worth of productivity is lost from workers sick with this week’s bout of dysentery. Good disposal of human excreta can reduce diarrhea by 40 percent. Washing hands reduces it still further. Health economists reckon that every dollar invested in sanitation can save $7 on health costs and lost productivity. No wonder the readers of The British Medical Journal last year voted sanitation the greatest medical milestone ever, over penicillin and anesthesia.”

When businesses start operating in low cost countries, it is not surprising that some of them help pay for “watsan” infrastructure. Their motives are not altogether altruistic. Businesses require healthy and productive workers in order to become or remain profitable. The return on investment in “watsan” projects is pretty good. George concludes:

“This year, the International Year of Sanitation, is a fine time to address a pointless and damaging conversational taboo. Solving sanitation is about more than semantics. But our refusal to talk about it says something about us, and none of it good.”

Proper disposal of human excrement is important for the dignity of people. This is especially true in crowded urban areas. The lowest classes of society have often been required to deal with the excrement of those considered to hold a higher station. This has undoubtedly contributed to the fact that sanitation simply isn’t discussed in proper society. Human dignity, however, is a subject that should be discussed.

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