The Optimist

The Civil War That Killed Cholera

Why the best ideas for fighting some diseases may come from poor countries, not rich ones.

This Saturday marks the 40th anniversary of Bangladesh's war for independence from Pakistan. Given how bloody the war proved to be, and how limited development progress in the country has been since then, it might seem like a dubious occasion for those of us far from Dhaka to celebrate. But the war does have one unambiguously positive legacy: It gave the world an approach to dealing with cholera and other diarrheal diseases that has since saved many more lives than were lost during the fighting.

Cholera outbreaks have been a regular feature of urban living worldwide for centuries. The disease spreads through contaminated water and produces a toxin in the small intestine that leads to muscle spasms, abdominal pains, vomiting, and -- deadliest of all -- gushing diarrhea. This highly infectious liquid is the usual culprit in cholera outbreaks --  it contaminates water supplies, thereby reaching new hosts.

After a series of outbreaks in mid-19th century London took tens of thousands of lives, doctors and civic leaders pinned the blame, accurately, on the city's appallingly inadequate sanitation system. Writers at the time described huge piles of human and animal excrement collecting in the streets and fetid rivers almost solid with waste. The solution, devised by civil engineer Joseph Bazalgette and completed in 1865, was a network of five new sewer lines that transported waste out of the city. With that momentous project, London freed itself from major cholera outbreaks.

The problem, however, was that such solutions were expensive and complicated. Lacking the genius of Bazalgette and the wealth of empire, most of the rest of the world went on suffering from diarrheal disease without much respite well into the 20th century. But while it is still the case today that only half of the developing world's population has access to well-built latrines or septic and sewage systems, the death toll from waterborne disease has been dropping dramatically around the globe. And the gains against cholera and its relatives are mostly due not the model of Victorian England, but to the type of approaches pioneered in war-torn, poverty-stricken Bangladesh.

As troops loyal to West Pakistan fought Bengali paramilitaries and Indian troops over the course of 1971, 9 million refugees flooded across the border of what was then East Pakistan into India. At the time, Dr. Dilip Mahalanabis was working in a refugee camp in Bangaon, in India's state of West Bengal, home to more than 350,000 refugees. He faced an epidemic of diarrheal disease spreading death throughout the camp, with mortality rates among infected patients running as high as 20 to 30 percent. At the time, intravenous salt solution was the standard response to diarrheal dehydration. But Mahalanabis had only two aides capable of administering intravenous drips, and supplies were running out. Overwhelmed, he turned to what hospital workers considered a decidedly inferior approach to tackling dehydration: giving people sugar-salt solution to swallow, or oral rehydration.

We usually rehydrate orally: it is called drinking. Unlike intravenous drips, downing a glass of solution doesn't take skilled assistance -- it also tastes great to people who are dehydrated (though less so to the rest of us -- imagine drinking sweetened sea water). Mahalanabis just set up drums of the solution and told family members to keep on coming back with cups and bottles to fill until their relatives refused to drink more of the stuff. Rather than treating a few lucky victims who managed to make it to the clinic, the doctor was reaching people all across the camp. Death rates dropped from 20 to 30 percent to a stunning 3 percent.

Since 1971, and with the active support of the World Health Organization and donors, this type of oral rehydration has become a standard treatment for diarrheal disease. Sugar-salt packages mixed in the right proportions are now widely available for a few cents a dose, and even cheaper tools of prevention are available. There are bottles designed to use sunlight to disinfect water; programs encouraging people to add a small amount of bleach to drinking water have reduced diarrhea cases by between 50 and 80 percent.

As cheap prevention and treatment techniques have spread around the globe, cholera deaths are increasingly rare worldwide. (An exceptional outbreak in Zimbabwe that took the lives of more than 4,000 people in 2008 and 2009 was a sign of how far Robert Mugabe's regime had driven public health provision into the ground in that country.) Related to this change, the impact of piped water and network sanitation access on health outcomes has declined, to the extent that one multicountry study of child mortality in the developing world suggested that universal access to improved water and sanitation would reduce global child mortality rates by as little as 3 percent. The potential impact of parents learning more about prevention and treatment -- and acting on the knowledge -- was more than 10 times as great.

There is still a long way to go in spreading knowledge, of course. According to the World Bank, in sub-Saharan Africa only one-third of children under 5 with diarrhea are treated with oral rehydration and continued feeding. As I noted in my most recent book, the percentage of parents in India who think the correct treatment for a child with diarrhea is to reduce the amount they are given to drink -- absolutely the wrong thing to do -- varies considerably from state to state. Less than 5 percent give this wrong answer in states like Kerala. More than 50 percent suggest this response in West Bengal, the original proving-ground of oral rehydration therapy -- where child mortality in the 1990s was about three times higher than it was in Kerala.

Nonetheless, progress in the technologies of public health and the spread of health knowledge have dramatically reduced cholera's toll. It used to take armies of engineers and considerable wealth to achieve what today's illiterate parent can achieve for cents. And that suggests something about policymaking.

In the perfect world, everyone would have 24-hour access to clean water and networked sanitation services. In the meantime, it's important to remember that each networked sewage connection costs magnitudes more than home-based prevention and other underutilized treatment options. Perhaps governments and aid agencies should take some of the money dedicated to recreating Bazalgette's subterranean cathedrals like the troubled Fallujah sewage project in Iraq and spend it instead on teaching people how to mix oral rehydration solutions or disinfect water. As we learned from Dr. Mahalanabis 40 years ago, a little sweetened seawater goes a long way.


The Optimist

Seismic Inequality

Rich countries have gotten very good at keeping people alive in earthquakes. But that doesn't mean poor countries should try to emulate them.

The death and destruction in Japan may be horrifying, but the record earthquake that struck March 11 off the east coast of Honshu island still suggests one important lesson: Building codes and land use regulations can save lives. Japan's strict guidelines have been widely credited for keeping the death toll down to a fraction of the casualties in Haiti's quake last year. But that doesn't mean we should import them lock, stock, and barrel to the developing world, where the great majority of earthquake-related mortality occurs. The regulations are also complex and expensive. And there are much cheaper and more straightforward ways to save lives.

It is too early to know the full extent of the tragedy still unfolding in Japan. But one thing we do know is that the great majority of deaths -- and most of the problems at the nuclear plants -- are the result not of the quake itself, but of the resulting tsunami. Things could have been much worse. Although the YouTube images of shaken workers and crashing shelves in Tokyo were frightening, there were very few injuries or deaths reported in the capital city -- or anywhere else where flood waters didn't come rushing ashore. This despite the earthquake being the largest recorded in Japan's history -- and orders of magnitude larger than the devastating Haiti quake.

That means the usual pattern has been repeated: Earthquakes don't kill people in rich countries; they kill people in poor countries. The 1988 earthquake in Armenia was half as strong as the 1989 quake in Loma Prieta near San Francisco, and yet caused 25,000 deaths compared with 100 in San Francisco. The 2003 Paso Robles quake in California had the same power as the Bam quake in Iran in 2003; the death toll was two in California and 41,000 in Iran. Again, Chile's recent earthquake was more powerful than Haiti's, but the death toll was considerably lower. Chile is a member of the OECD club of rich countries; Haiti is the poorest country in the Western Hemisphere.

Regulation keeps people safe in rich countries. Japan is a perfect case study. The last major earthquake that country experienced hit Kobe in 1995, resulting in 6,000 deaths. But buildings constructed after a 1981 revision of Japan's building codes were far less likely to collapse than older buildings. As the regulation gets better, the death tolls get smaller.

The story is very different in poor countries. The 2010 Haiti quake was closer than the Japan quake to a large population center (Port-au-Prince) but, perhaps more crucially, the Haitians in that population center were mostly living in shoddily constructed buildings. Building regulations and land use codes were mostly disregarded, and rarely enforced. The result was 230,000 people dead. Similarly, many of the 17,000 deaths from the 1999 Marmara earthquake in Turkey were blamed on collapse due to poorly constructed reinforced concrete frames, construction using concrete diluted with too much sand, or construction near fault lines.

Why don't we learn our lesson? Why can't we at least earthquake-proof the most vulnerable major cities of the world? Simply put, it costs too much. Earthquake-resistant engineering solutions are expensive and technically demanding. In Istanbul, the cost of reinforcing 3,600 public structures to make them better able to withstand earthquakes, or retrofitting, was estimated at $1 billion -- approximately $280,000 per structure and a full third of the cost of rebuilding them from scratch. And that's just public buildings -- retrofitting all the private dwellings in the city would undoubtedly have cost far more.

Moreover, it's probably not money well spent -- at least in the developing world. The cost-effectiveness of these solutions is often unfavorable compared with other interventions designed to save lives in risk-prone countries. In part, that's because a lot of people live in areas at risk of an earthquake, but only a few actually witness large earthquakes in any particular year and deaths are concentrated in only a very few locations. It is impossible to predict where serious quakes are going to happen with any accuracy -- seismic risk maps had only put Haiti at moderate risk of a large quake before last January, for example. So earthquake preparedness necessarily involves spending a lot of money on strengthening buildings that may never be put to the test.

By contrast, countries like Haiti witnesses many thousands of deaths from very easily -- and cheaply -- prevented diseases in every month of every year. Choosing one over the other may be unfortunate, but it's hardly irrational. In Istanbul, the cost efficiency of retrofitting public buildings has been estimated at about $2,600 per healthy year of life saved. But in developing countries, millions of people die each year from diseases that can be cured using a simple regime of oral antibiotics, which costs as little as $0.25. More broadly, there are a range of interventions that cost less than $2 per healthy year of life saved in the developing world.

It is particularly tragic when children die when their schools collapse during earthquakes, as was the case in Sichuan, China, in 2008 when some 7,000 students died. In an average year, as many as 2,500 kids worldwide die each year in school collapses. And schools and hospitals should be first in line both for inspection to make sure they meet standard building codes and for resources to strengthen them against earthquakes.

But consider this tragedy: 10 million children under age 5 die each year from other causes before they can even make it to school -- the majority of which can be easily and cheaply prevented. And getting girls into school in the first place is one of the best ways to reduce future child mortality, as well as infant and maternal mortality. If there's $10 million for school construction and the choice is between building more schools (thus admitting more students) that may collapse in a large enough earthquake or building fewer schools that are completely earthquake-proof, you may actually save more lives by making the first choice than the second.

Even if the money is available, it takes more than cash to ensure safe construction. The regulations regarding reinforcement and design have to be enforced. Turkey's Marmara quake was of a magnitude and type accounted for by existing design specifications in the Turkish seismic code -- but it was lack of enforcement that led to deaths. Turkey, in short, wasn't Japan: Municipalities had weak and underfunded engineering and planning departments staffed with unaccredited engineers prone to corruption. In 2006, 40 municipal officials in three towns in Turkey were arrested for taking bribes in return for allowing unlicensed construction. Across a range of countries, construction permitting appears to be a regulatory area particularly prone to corruption.

That means that strict codes that are unenforced not only fail to save lives, but can also carry significant costs on the poor. Because non-code construction is illegal, it provides ongoing opportunities for officials to demand bribes while denying many owners legal title. At the turn of the millennium, as much as half of Turkey's urban population lived in illegal settlements with no rights to sale or transfer. That's a major factor in keeping them poor.

Earthquake deaths aren't "acts of God" -- they are the result of poverty and weak governance. And in poor, weakly governed countries, there are a lot of deaths cheaper and more straightforward to prevent -- from malaria, diarrhea, or measles, for example. In rich countries with well-functioning regulatory systems, building regulations and land use codes specifically responding to earthquake threats have a place. In poor countries where regulation is capriciously enforced, they may even be harmful. If we want to change that grim calculus, we have to learn to treat earthquake deaths as a symptom of misery -- not the cause.