A toilet seat sits in a room carved in ice at the luxury igloo ice hotel. (Photographer: Chris Ratcliffe/Bloomberg)

A Simple Way to Save Millions of Lives

(The Bloomberg View) -- Household toilets, one of the most important medical advances of the past two centuries, may be taken for granted in many parts of the world. But in places where they are lacking, people continue to die needlessly from diarrheal infections. The recent emergence of antibiotic resistance has made a terrible problem far worse. Now more than ever, sanitation must be a public-health priority.

Some 4.5 billion people — 61 percent of the global population — live without proper toilets, including 892 million who relieve themselves in fields, rivers and other open spaces. The rest share facilities with other households or use latrines that aren’t connected to septic tanks or sewers.

In such conditions, fecal germs pollute the environment, contaminating food and drinking water. Many people carry multi-drug-resistant bacteria in their intestinal tracts.

In India, where more people have access to a mobile phone than to a proper toilet, 15 percent of clinical E. coli specimens are resistant to all penicillin- and cephalosporin-based drugs, as well as to carbapenems, a last-resort class of antibiotics.

Investing in toilets with sewage infrastructure can thus be money well spent, provided the toilets are used for their intended purpose. Past efforts have failed when beneficiaries found other uses for the fixtures — as places to store food, for instance. So first, non-adopters must be convinced that toilets are an essential part of a clean and comfortable home, and be motivated to use and maintain them. That often requires a significant change in behavior.

How can people be persuaded to change? Tanzania, where most of the rural population relies on rudimentary, unimproved sanitation facilities, has tried airing a TV show in which a relative of a celebrity is caught with a sub-par household toilet, or no toilet at all. An outhouse makeover then turns the person’s source of shame to one of honor. Other public campaigns, including a radio soap opera, feature messages on latrine upgrading and handwashing. Early indications suggest the effort is having some effect.

A more widespread strategy, developed in Bangladesh 20 years ago and since used in more than 50 countries, leverages shame and disgust to trigger collective action to end open defecation. In one community exercise, food is placed next to fresh human feces found in or near a village to demonstrate how flies readily flit between the two, contaminating the food. This helps people recognize how better sanitation would benefit the health of the whole community.

In India, Prime Minister Narendra Modi’s ambitious Clean India Mission includes an effort to build 110 million toilets in five years, and to conduct a massive public relations campaign against open defecation.

Success for India, Tanzania and other countries would reduce the spread of dangerous microbes, including the most dangerous, drug-resistant ones. While all efforts against antibiotic resistance are essential, including limits on overuse of the drugs and work to create new ones, improvements in sanitation can make great progress — at relatively little cost.

Editorials are written by the Bloomberg View editorial board.

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