Raising awareness about the plight of the 2.4 billion people without a
toilet is certainly a worthy cause. Lack of access to sanitation facilities is
an affront to human dignity. It also creates a major public health risk of
diarrheal diseases that kill about 1,300 children a day in the developing
world.
The good news
is the death
rate from diarrheal
diseases almost halved between 2000 and 2015. Does this mean that efforts to
expand access to toilets – efforts promoted by events like World Toilet Day (Nov.
19) – are saving lives? The answer is yes and no.
Parallel developments such as the
introduction of rotavirus vaccination, better and quicker care for those
suffering from diarrheal illness, and nutritional gains for children in some
regions have helped. At the same time, access to toilets is critical for
capturing human waste that can carry disease-causing micro-organisms, thus
reducing the risk that others in the community will be infected. Californians were
reminded of this fact by the recent hepatitis
A outbreak, which emerged in
communities that lack access to housing and sanitation facilities.
Equally
important for public health protection, however, is the transport and treatment
of toilet waste before it is discharged into the environment. A recent UN report estimates that roughly 80% of global urban
wastewater is released without treatment. The World Bank’s Water &
Sanitation Program has helped to make that broad statistic more visible at the
local level with its municipal “shit flow
diagram” project. In the Bangladeshi capital of Dhaka, for
example, 99% of the 15 million inhabitants have access to a toilet—but only 2%
of human waste is adequately treated before being dumped into surface water
bodies nearby. As a result, this low-lying, flood-prone megacity is continually
coated in sewage.
Shifting
international attention from the provision of toilets to ensuring safe
management of human wastes is starting to happen. A few years ago I served on a
technical working group convened by UNICEF and the World Health Organization that
was tasked with developing recommendations for the new UN Sustainable
Development Goals (SDGs) on
sanitation. Along with several other colleagues on the team, I felt strongly
that waste management—and not simply ‘butts on toilets’—had to be given priority
within the new targets.
Our efforts
were successful. The SDG target 6.2 is to ensure universal access to safely managed sanitation service by
2030. A household’s access is defined not simply by whether they have a toilet,
but whether they have a sanitation service that includes safe storage, transport
and adequate treatment of waste. The shift in definition has also drawn
attention to the much larger gap in human waste management as compared to
toilet access. In 2015, 68% of the world’s population had
access to a toilet of reasonably good quality, but only 39% had safely managed
sanitation.
Identifying political, financial,
social, and technical strategies to bring safely managed sanitation service to
the 4.4 billion people without it is a mammoth task. Efforts such as container-based sanitation can
target hard-to-reach communities, and advancing the science and engineering for resource recovery from wastewater can
help improve the economics of sanitation services. Ultimately, it is these
beyond-the-toilet efforts that must be stepped up in order to make definitive progress
against the burden of diarrheal disease.
