Pure intentions: improving hygiene to save lives

Children all over the world are dying for lack of basic sanitation. That’s why philanthropists, non-profits and innovators are breaking the toilet taboo to improve hygiene and save lives

Like many 15-year-old schoolgirls, Arushi and Akanksha talk over each other excitedly as they discuss their after-school club. Nevertheless, not many neatly turned out teenagers in perfectly pressed beige suits and immaculate white shirts, would chatter so passionately about visiting Delhi’s slums, cleaning toilets and six-stage hand-washing techniques.

The girls, along with other students from five schools around New Delhi, visit their city’s slums once a month to run music and dance programmes raising awareness around the issue of sanitation. Every week, the Sanitation Club at Sulabh School meets to impress on its young advocates the message of hygiene management, lessons they take back to their own schools.

“I first started going to the club three years ago,” explains Akanksha. “Before, students didn’t want to talk about it. They thought it was a dirty subject and they felt ashamed. Now the students take the initiative with sanitation activities and talk about it with each other.”

Talking about this sensitive, but most basic, of issues matters hugely. Worldwide, 2.5 billion people lack access to improved sanitation – that is, they are using shared facilities or toilets that don’t meet minimum hygiene standards. Worse, more than 1 billion of these people have no toilet at all, forcing them to answer nature’s call in the open, according to a recent joint UNICEF and World Health Organisation (WHO) study.

Children are dying to go to the toilet. Diarrhoeal diseases are the second biggest cause of death among children under five-years-old globally, according to UNICEF, and UN Water estimates 80 per cent of diseases in developing countries are caused by unsafe water and poor sanitation. “More people die as a result of unsafe sanitation than HIV/AIDS plus TB plus malaria,” says Brian Arbogast, director of water, sanitation and hygiene at the Bill & Melinda Gates Foundation. “It’s a huge killer.”

The Gates Foundation is taking one approach to tackling the problem: challenging researchers to come up with a reinvented toilet that can operate without the substantial infrastructure investments that will come too late for the poorest people in India, China and sub-Saharan Africa, where the situation is most acute. The foundation’s challenge sits alongside community hygiene drives, increasing access to toilets, and efforts to treat the resulting waste, that aim to flush away the scourge of poor sanitation.

Doing one’s business is a very private affair, but when there is no toilet the consequences of going in the open – or open defecation – can affect the whole community’s health. If human waste is not adequately separated from human contact, treated, transported and disposed, it can contaminate the environment, says Bruce Gordon, coordinator of the WHO’s water, sanitation, hygiene and health department. This can lead to malnutrition, stunting and impeded cognitive development.

“There’s a huge payback in terms of personal safety, dignity and health”

The issue is particularly urgent in India. There, more than 50 per cent of the population are still affected by the practice and households are cramped together even in rural areas, says Jan Willem Rosenboom, senior water, sanitation and hygiene programme officer with the Gates Foundation. “If we don’t solve the problem in India, we don’t solve the problem globally,” he warns.

This has led to the rise of Community Led Total Sanitation (CLTS) in countries such as India, Bangladesh and Vietnam, where the community works together to become open defecation-free and win rewards for doing so. “They get quite serious about shaming individual members,” says Gordon. “Vietnam is the top country in terms of reducing open defecation. They went from 40 per cent of the population in 1990, to 3 per cent in 2011.”

The demand for improved sanitation is there, says Rosenboom, particularly as there are multiple personal benefits to having a toilet of one’s own. “It’s a huge women’s issue,” says Gary White, co-founder of Water.org, a non-profit that offers water and sanitation loans for the poor. Without a toilet, women often wait until dark to go near railway tracks or riverbanks. “[Women] take out loans in a big way for toilets. There’s a huge payback in terms of personal safety, dignity and health.”

There is an economic spur, too. “In India alone, the estimates are that over $50bn a year is lost from inadequate sanitation,” says Christopher Elias, the Gates Foundation’s president of global development.

The main value is in time saved and averted healthcare costs, explains Gordon. Apart from women spending time finding a safe place to relieve themselves, chronic diarrhoeal diseases leave the poor susceptible to other illnesses that erode their ability to work their way out of poverty. “We know that for every $1 spent on sanitation we get a $5.50 return by keeping people healthy and productive,” he says.

So where are the lavatories? One hurdle is encouraging households to invest in facilities. Unlike access to mains utility water, a toilet offers fewer direct financial returns for the family, says White at Water.org.

One of the Gates Foundation’s grantees, global health non-profit Population Services International, has been working to meet that challenge since 2012 in the north-eastern Indian state of Bihar. Often, the inconvenience and perceived cost put people off. The project has created a one-stop shop where households can purchase materials for a toilet – a concrete structure with a metal roof – in the $90 to $120 price range.

Still in its pilot phase, the project has reached 300 households in two districts of Bihar, and plans to reach 500,000 households by the end of 2016. The project has worked to find a private, low-cost and no-odour model that households would aspire to own. The aspirational element helps spur uptake among neighbours, says Rosenboom at the Gates Foundation.

Not that building toilets is in itself enough: making the waste from toilets safe is an expensive but essential business. “For every dollar it costs to bring water to your tap, it costs $5 to treat once you’ve flushed it,” says Richard Connor, lead author of the UN’s World Water Development Report 2014. “Energy is the largest expense for water treatment.”

This is where the Gates Foundation’s ‘Reinvent the Toilet Challenge’ comes in. The flush system remains essentially unchanged since its invention in 1596 by Elizabethan author John Harington. In 2011, the foundation tasked researchers from all over the world to come up with an affordable toilet that can operate without being connected to mains water, electricity or sewer systems, and which costs $0.05 per user, per day.

Since then, 16 organisations have received grants to develop designs, prove the science and build prototypes, some of which were on display at the first Reinvent the Toilet Fair 2012 in Seattle, US. The innovative designs included using solar power, intense heat and dehydration techniques to kill pathogens and produce electricity or biological charcoal.

In March this year global grantees from as far afield as the US and Africa met in New Delhi to review progress. “The reinvented toilets we’re seeing now prove that their process will absolutely make what comes out of a toilet safe to handle and typically be of value, as a soil amendment or fertiliser,” says Arbogast at the Gates Foundation.

There is still a way to go, he admits, in terms of affordability, making the facilities energy-neutral and sustainable. As with mobile phones, costs will drop as the toilets get smaller and achieve unit scale.

In 2013, the foundation launched country-specific programmes in India and China – the two countries facing the biggest sanitation challenges – for local innovators to develop next-generation toilets. Philanthropy and the private sector have an important role to play in stimulating innovative, low-cost solutions and service delivery, says Elias at the Gates Foundation.

“[Global bathroom brand] Roca provided a low-cost squat toilet pan, an innovation they drove, to pair up with [one of our grantee’s] processing units,” says Arbogast. “As we start to talk to companies, we can show them all the technological risk we’ve taken out for them and get them excited about being pioneers in this new industry.”

By helping to reinvent the toilet, the Gates Foundation hopes to accelerate progress towards Millennium Development Goal (MDG) Seven, which is to halve the population without sustainable access to basic sanitation by 2015. At current rates, this won’t be achieved until 2026.

“Even the MDG target for sanitation, which is focused on access to a toilet, isn’t really adequate,” says Elias. “What we need are comprehensive sanitation solutions.” In the search for those solutions, world-class research institutes and New Delhi schoolgirls alike are determined to change the course of sanitation forever.

Photo credit: WaterAid