thank you. water, sanitation, infrastructure, cholera.

someone said something helpful here. about cholera. but not about a new vaccine, a new super-antibiotic, or engineering a new vector that can be lulled to sleep by harp music, along with plans for a helicopter drop of harps or new ways to subsidize harps.

whenever epidemics of cholera occur, the global public health community is energized. experts meet, guidelines for control are reviewed and reissued, and new and modified interventions are proposed and promoted… [but]

the best intervention for long-term cholera control and, for that matter, for the control of the great majority of diarrheal diseases is the strategy that eliminated epidemic cholera from the united states and northern europe long before either marketed antibiotics or effective vaccines existed. the development and maintenance of water and sewage treatment systems assured safe drinking water and safe disposal of sewage for all, keeping contaminated sewage out of water, foods, and the environment. the strategy not only eliminated cholera but also dramatically reduced mortality related to diarrheal diseases of all causes.

among others, culter’s articles on mortality determinants are worth reading.

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off-the-grid, profitable toilets? / why would you do things that way? (I)

i am pretty sure this is the beginning of a cool idea for improving water & sanitation, which is ever-so-critical for public health (still the #2 cause of under-5 mortality globally – though it’s not clear if these new toilets have potty-training options and what that actually means for the spread of disease…). skipping the toilet grid might be an example of a leap-frogging technology and the argument runs that if the waste could be made profitable (in addition to the initial unit), there would be incentive to maintain facilities.

the article reads:

the flush toilet… credited with adding a decade to our longevity… is an impractical luxury for about two- thirds of the world’s 7 billion people because it relies on connections to water and sewerage systems that must be built and maintained at great expense.

first, new designs are required for toilets that are hygienic, pleasant, and cheap to make and use, and that work without being connected to a grid. because such a facility would have to be periodically emptied, ideally excretions would be treated not as waste but either recycled on site or turned into profitable resources… the Gates Foundation requires that the overall cost of a future toilet, including maintenance, not exceed 5 cents per user per day… that would enable the private sector to step up production and distribution once practical new models have emerged. Cities would have to build a new generation of waste-processing centers, but the investment would quickly pay for itself… for gridless sanitation to be economical, commerce needs to flourish around the collection and treatment of excrement.

is the assumption that low- and middle-income states cannot or need not have responsibility for water & sanitation? water & sanitation seem like fairly classic examples of public goods and even of rights as citizens or humans, depending how you like your rights. what role can and should the state play if we move forward sans grid? does sanitation represent a natural monopoly or is it fair ground for competition? what role can/should the state play in regulation and/or provision of free or low-cost (or micro-financed) options for those who cannot pay — either as a public good for public health or as a right?

the main example of private water – if not sanitation – provision that comes to mind are the different water companies that provided water in John Snow’s day — allowing for a nice epidemiological experiment and the near-conclusion of an important disease transmission debate — but also for a lot of cholera. is there an example of scaled private sanitation provision that could provide a model for how the whole system – provision, collection, & maintenance, not just individual toilets (though, rock on, engineers) — might work?

fun fact! John Snow tested his anesthetics on himself, recording just before he passed out and first thing when he woke up. (see The Ghost Map)

rethinking the use of the word ‘simple’ in global health & development (III)

suvojit made some great points that turned into (what i think is) an interesting conversation. check it & think about what ‘best buys‘ in development really mean.

plus, generally check out suvo! we’re all better off since he decided to stop and blog every now and then.

rethinking the use of the word ‘simple’ in global health (II) – asking the right questions

i am not saying this is going to be all-time best solution (ha! ors pun!) but it does seem to be the result of asking the right questions, which include, if this (ors(+zinc)) is such a ‘simple’ intervention (in this case, meaning low-tech and cheap), why is not being taken-up?

it is not clear to me that the question was asked to all the right people. who, for example, answered this question by suggesting that supply chains and lack of suitable water were the main hindrances to the use of ors and, by implication, reducing child mortality from diarrhea? smart people, perhaps, and even people ‘on the ground’ but… it is not clear that anyone asked local people (anywhere – but in this case zambia) why they don’t use ors now.

if they did and the answer had to do with lack of clean water, awesome. if they did and the answer was something else, slightly less awesome. and, if they didn’t ask, less awesome.

there is plenty of discussion about stimulating demand among potential consumers — but that’s different than understanding why demand is not presently there, which may or may not have pointed to other ways of addressing the problem.

more here.