The Big Necessity

by Rose George

  There are some subjects that politicians just don’t like, and sanitation is among them. A sanitation expert with several decades of experience tells me he can list the influential political figures in sanitation on one hand. He rethinks. Half of one hand. “Maybe politicians will run on a platform of water for all or houses for all,” he says. “But you’ve never seen one run on a campaign of no shit for all or sanitation for all.” They think it won’t bring votes. Voters don’t generally complain about poor sanitation. Even the ones with sewage in their living rooms stop protesting once the stink has gone. This is mistaken in all sorts of ways. In the Indian city of Pune, for example, a local councillor who had been trying for years to get latrines for his slum ward was overjoyed when they were finally built. “The next two elections are in the bag for me,” he said. “All I have to do is stand outside the toilet with my hands folded and a smile on my face.”

  People with decent sanitation have fewer diseases and take fewer days off work; they don’t have to pay for funerals of their children dead from cholera or dysentery. They save on medicines, and the state saves because it’s not providing expensive hospital care. Every dollar invested in sanitation brings an average $7 return in health costs averted and productivity gained. That simple number is the result of years of complex calculation of variables by development economists. But Joseph Chamberlain, mayor of Birmingham, England, knew in 1875 that lost wages and medical costs due to preventable disease were £54,000 a year, two to three times what it would cost to build sanitary accommodations. Globally, if universal sanitation were achieved by 2015, it would cost $95 billion, but it would save $660 billion.

  Such economic theory has been bolstered by real-world proof. When Peru had a cholera outbreak in 1991, it cost $1 billion to contain but could have been prevented with $100 million of better sanitation measures. During the first ten weeks of the epidemic, losses from agricultural revenue and tourism were three times greater than the total money spent on sanitation during the previous decade.

  Sanitation is one of the best investments a country can make. It can benefit health, education, productivity, and tourism revenues. But its all-round benefits contribute to the problem. Excreta disposal is a political football, kicked between departments. A cartoon calendar published by the World Bank’s Water and Sanitation Program (WSP) shows a young girl dressed in brown who looks anxious. She is Sanitation. Three bureaucrats stand nearby, one each from the Ministries of Health, Water, and Local Government. “She’s your responsibility,” says Water. “No, you take her,” says Health, and Local Government echoes him. And Sanitation holds out her hand hopelessly, surrounded by flies.

  One obstacle to progress is the way the advantages of improved sanitation are calculated. Health economists measure benefits by something called a DALY (Disability Added Life Year). This is supposed to calculate the value of a life “saved”—actually prolonged—by a health intervention. Averting a child’s death is worth 30 DALYs, for example. Most sanitation benefits are more life-changing than life-saving, and earn fewer DALY points as a result. A $100 latrine can’t compete with a 20-cent bag of Oral Rehydration Salts (used to combat diarrhea) on a strict cost-benefit calculation.

  Eddy Perez of WSP says these priorities are reflected in government aid budgets. He tells me that there is “almost zero money” for water and sanitation in the budget of USAID, Washington’s largest aid donor. “They still fund some water and sanitation but it comes out of their environment budget, which is much smaller. And a lot of it has to do with politics and reconstructing areas that they’ve blown up, like Iraq. The health sector of USAID does not see investment in sanitation as a public health investment. That’s a huge problem.”

  Even in countries that have a water supply and sanitation ministry, “watsan”—the development shorthand for water and sanitation—always trumps “sanwat.” Water always comes first. Governments already dedicate only 0.5 percent of their budgets to watsan, on average. (Pakistan, for example, spends 47 times more on its military budget than on water and sanitation, though it loses 120,000 people to diarrhea a year.) Of that, most goes to water. This ordering of governmental priorities causes what Darren Saywell of the International Water Association (IWA) calls a capacity constraint problem. “The best and the brightest of people generally don’t end up in your environmental sanitation department. It’s not seen as a particularly clever career move.” People talk of the twin sectors of “wat” and “san,” says Perez, but that’s a misnomer. “They’re not twinned by any stretch of the imagination. One’s tall and healthy and the other is short.” When Perez gives presentations, he shows a slide of Arnold Schwarzenegger and Danny DeVito from the film Twins. He doesn’t usually have to spell out who represents what.

  It takes a rare politician to see the economic sense of good sanitation. The one that everyone talks about, four years after he left office, is Ronnie Kasrils, former Minister for Water Affairs in South Africa. He’s the most successful sanitation minister ever, a UN official tells me. He’s the only minister who was “willing to stand up and say that sanitation is where it’s at,” says Darren Saywell. A South African friend describes him as “quite a character.” All South Africans know who Ronnie is, he says, because he was a guerrilla commander for the African National Congress (ANC), and consequently exiled for decades. Kasrils is now South Africa’s Minister for National Intelligence, and its top spook. I had to meet him.

  In South Africa, sanitation has been political for decades. During apartheid, water and latrine supplies were distributed according to color. White settlements, even poor ones, usually got flush toilets and waterborne sewerage. Blacks had bucket latrines—a bucket with a seat on top—or nothing. By the time democracy came to South Africa in 1994, a relatively rich country had, for reasons of racism and politics, desperate sanitation figures comparable with those of poorer African countries with fewer resources. The new government gave the responsibility of sanitation to the Ministry for Water Affairs and Forestry, but mostly got on with more pressing matters like leavening racism, alleviating poverty, and trying to run a new, wounded country.

  President Thabo Mbeki appointed Kasrils to Water Affairs in 1999. He was already a well-known figure. A Jew from Johannesburg, he joined the South African Communist Party after the Sharpeville massacre in 1960, then joined Umkhonto we Sizwe, ANC’s armed wing. He was instrumental in blowing up some electricity pylons around Durban and went into exile in 1963. Over the next two decades, he spent much time in guerrilla camps in the bush. Those years, he likes to say, are what prepared him for his sanitation future. When the ANC was elected in 1994, Kasrils became Deputy Minister for Defense. He didn’t expect to be moved to water. He was a soldier and knew about soldiering. But soldiers know about sanitation because they have to. Shit can win and lose wars. Accounts of the Battle of Agincourt describe half the English archers fighting while naked below the waist, because dysentery was ravaging their troops so. (This led Voltaire to conclude that England had “taken victory with its pants down.”) During the First World War, France’s general staff ordained that latrines be painted light blue because this was the color that flies liked least. In Vietnam, the Viet Cong laid thousands of sharpened wooden stakes topped with excrement—pungi—and caused thousands of casualties (the stick only pierces the boot and foot; the excreta is deadly).

  So Kasrils didn’t have trouble seeing the connection. He joked that when he was a guerrilla, he had known the rivers and forests of the whole region. He said, “I’m going from fire to water.”

  We meet in the Ministry for National Intelligence, which is an unsign-posted building off a highway leading into Pretoria. There is little visible security. The staff, who have the quiet courtesy common to powerful corridors, don’t bother checking me for recording equipment or cameras or anything else, and Kasrils seems equally at ease. He is a handsome sixty-year-old, courtly for an ex-guerrilla, and wearing a dark pinstriped suit and waistcoat. He refers to himself as “one,” and I w
onder if one did that in the bush. I’m surprised that he agreed to meet, when he’s the equivalent of the head of MI5 or the CIA, whom I’d never get to see. There’s also the fact that he no longer has anything to do with sanitation. But South Africans tell me he loves press attention—he published an autobiography called Armed and Dangerous—and he loved his past job. And why shouldn’t he, when he got to be photographed sitting on toilets?

  In the beginning, the new Minister for Water Affairs did what water ministers do: he concentrated on the “wat” and didn’t pay much attention to the “san.” South Africa’s water problems were certainly dire. Millions had no water supply thanks to decades of discrimination, and “service delivery” became the political demand of the new South Africa. So Kasrils got water to people, and only changed tactics when cholera broke out in KwaZulu-Natal in 2000. He had an epiphany about what he calls the human waste factor. “You see that people’s water supplies are contaminated, and you see that it’s because of pollution, so you start to analyze it and you get to human waste.”

  This awareness led him to the Water Supply and Sanitation Collaborative Council (WSSCC), a small Geneva-based UN agency run under the auspices of the World Health Organization. At the time, it was directed by an Indian engineer, Gourisankar Ghosh, and chaired by a forthright Briton, Sir Richard Jolly. Ghosh came to South Africa. The minister and the UN’s top man for excreta disposal found they had much in common. Both men, like Mechai Viravaidya in Thailand, were trying to speak about the unspeakable with people who didn’t care to listen. “No one wants to talk about shit, do they?” says Kasrils. “I’d go to mbizos [public meetings] and no one ever says, ‘You know, man, I’m sick and tired of this disgusting latrine I’ve got.’”

  The same applied in cabinet meetings. But after the cholera outbreak, Kasrils began to bang his new drum. Soon, he’d banged it loud enough to be nicknamed Minister for Toilets. In league with Ghosh and the WSSCC, he began to strengthen networks, such as an African alliance of water ministers. The ministers knew each other already, but “whenever we came together we’d talk about dams and water.” Sanitation was an afterthought, if anything. He changed that. “Whenever we’d go through documents and come to something about water blah blah, we’d always add ‘and sanitation.’” With a strong network in place, they could go global. Kasrils agreed to host a sanitation forum in South Africa called AfricaSan. It would be held a few weeks before the Earth Summit—the UN’s summit on sustainable development—that would convene in Johannesburg in August 2002, and its job would be to get sanitation noticed.

  At this point, and to this day, the development and aid world was obsessed with the Millennium Development Goals (MDGs). This set of eight goals had been agreed upon at the UN Development Summit in 2000. The goals are not modest. They commit signatories—191 countries at last count—to do things like halve the number of people living on less than a dollar a day (Goal One); educate boys and girls equally (Goal Two); halt and begin to reverse the spread of HIV/AIDS, malaria, and other major diseases (Goal Six)—and all by 2015. Yet when the MDGs were announced, there was a notable absence. HIV/AIDS killed fewer children than sanitation-related disease, but sanitation was nowhere to be seen. An impact needed to be made. At the AfricaSan conference, a video was played. It showed an old man washing the hands of a young girl. It was nothing that hadn’t been seen on a thousand UNICEF videos. Then the camera pulled away and the old man was shown to be Nelson Mandela, who said, “Now we must all wash our hands.” In the words of one audience member, the effect was “Wow. Bang.” (That a not very creative video could be “Wow” showed how stagnant and unloved the sanitation sector felt.)

  The effect was strengthened by colorful photo opportunities, including one that featured Richard Jolly and Ronnie Kasrils seated on toilets brandishing toilet paper. Stunts, admittedly, but they made sanitation visible because no one had done such things before. Behind the scenes, Kasrils and others “argued like the blazes” to add sanitation to the MDGs. The Americans didn’t want any more targets, but eventually agreement was made, and Target Seven was added to Goal 10. This enjoined the world to “reduce by half the proportion of people without sustainable access to safe drinking water.” “Access to improved sanitation” was added as Indicator 31. The targets that have to be reached for Indicator 31—those 2.6 billion toiletless—are larger than the targets for HIV, safe water, malaria, or nutrition.

  There is no doubt the MDGs are flawed. Darren Saywell of the IWA calls them “a useful political tool, but not a professional one.” Reducing the number of people who don’t have something means knowing how many people don’t have something in the first place, but only 57 out of 163 developing countries have counted the poor more than once since 1990. Ninety-two have never counted them.

  The anointing of sanitation as being worthy of UN and MDG attention was important. In the world of development and donors, money was freed and some priorities changed. Two years later, WSSCC capitalized on the revamped MDG by launching probably the best media campaign about sanitation and hand-washing that has been seen since the Lever brothers persuaded a grubby Western world to think of soap as a vital necessity. Their WASH—Water, Sanitation, Hygiene—campaign was sharp and clever. In development terms, it was called advocacy. I call it good advertising. There were posters and postcards with smart slogans, such as “Hurry Up! 2.6 billion people want to use the toilet”; or “One billion people have a drinking problem.” There was poetry, such as:

  Jack and Jill went up the hill

  To fetch a pail of water

  After a drink of the water

  Jack died of cholera

  And Jill died from amoebic dysentery.

  Kasrils began to champion WASH. He liked its messages. “Cholera and typhoid,” he tells me, “kill so many million kids a year, which amounts to two jumbo jets full of children crashing every four hours.” In the years after 9/11, this was a powerfully vivid image to use. Kasrils thought the WASH campaign provided him with great soapbox material. “They were giving me gems. I jumped to it.” He describes those heady sanitation times as “tremendous fun. The best period of my life.” It was also busy. When Kasrils took up his post, 18 million South Africans lacked sanitation. The government’s target was to eradicate this “backlog” by 2010. By 2003, Kasrils’s ministry was delivering 85,000 toilets a year. It would need to deliver 300,000 a year to meet the 2010 target, but it was a start. Also, it meant a lot of toilets to be officially opened.

  Kasrils leaps out of his chair at this point. He wants to tell me a story, and because he’s a dramatic man—before he became a guerrilla, he did some theater and worked in advertising—he needs to act it out. A village had installed Ventilated Improved Pit Latrines (VIPs), and Kasrils was invited to open the first one, ceremoniously. Persuading a village to adopt VIPs was already an achievement, because after the end of apartheid, black South Africans reasonably wanted what the whites had. They wanted waterborne sewerage, which was high status. It was also expensive and totally illogical in South Africa, a largely water-stressed country that can’t afford, financially or environmentally, to let everyone flush dozens of liters of water down a toilet. The VIP latrine was a version of the Blair latrine, invented in Zimbabwe in 1973 by Peter Morgan, a British-born engineer who was working with the Ministry of Health’s Blair Research Laboratory. There are endless ways to build a pit latrine well and endless ways to build them badly. Millions of the people who count in statistics as having access to adequate sanitation actually have a dark and stinking fly-infested box. The VIP innovated with an offset pit that could hold an interior vent pipe, a screen on the pipe to keep out flies, and a semi-dark interior to achieve the same effect. It was definitely ventilated, and definitely improved: a three-month experiment in 1975 found that 179 flies a day were caught in a latrine without a vent pipe, while the daily fly toll in a VIP was two. (If flies can’t get into the latrine, they also can’t emerge from it with feces-covered feet, ready to infect nearby food.)<
br />
  In the village of Umzinyathi, near Durban, Kasrils was invited to inaugurate a villager’s new VIP. With his thumbs in his waistcoat pockets, he’s acting the part of the mayor from a film whose title he can’t remember, but which involved the inauguration of a urinal (I think he’s referring to the French novel Clochemerle, made into a BBC series in 1972 and which my mother remembers as being “gripping”). The mayor makes his way with pomp into the new facility. “And it’s one of those where you can see the person’s head and you hear the urine and people are waiting, and then he comes out.”

  In the real-life South African version of this tale, Kasrils duly went into the toilet under the gaze of a crowd of serious onlookers. He shut the door, pretended to use it, and came back out, whereupon the entire crowd began singing the South African national anthem. “And the VIP had been painted in national colors, of course,” he adds. It’s a great story, and I’ve enjoyed the show, because Kasrils is another great persuader. It’s a shame Jack Sim came to toilets after Kasrils had left them, because they would get on.

  Kasrils had a lot of persuading to do, on all levels. “You have these mayors and councillors who don’t want to know about [the VIP], because in their mind, if you don’t have a toilet and wash it away, it’s dirty. They think in terms of the long drops they’ve been in, where there’s flies and buzzing and a stink. You have to break down those barriers.” But waterborne sewerage was out of reach of most municipal budgets. One of the new government’s most popular measures was to put into writing that water is a human right, and to provide each citizen with 20 free liters a day. After that, everyone must pay. “So you tell them if they have VIPs they won’t be spending money, and that it takes ten liters of water to flush a toilet, and that those whites with the toilets, you’ll go into their houses and you’ll find they’re not flushing because they don’t want a high water bill.” It’s all about psychology, says Kasrils. “You take steps and you make efforts to mobilize and educate and then it clicks.”