Below is my column, online this week, for the Rwanda Edition of the Independent magazine.

Tackling Global Health: Women and Water

Published online November 29, 2011

History suggests that women and water are essential in conquering the developing world’s health challenges

World Toilet Day came and went without much fanfare. In between using the toilet yourself, you probably missed it. Talking about toilets is not sexy, and discussing water and sanitation is probably not at the top of your list, but it should be. Women and water, specifically clean water, have been responsible for major improvements in health in the developed world and hold enormous potential for tackling its health challenges.

At the turn of the 20th century, some of the top killers in the United States included tuberculosis, pneumonia, typhoid, meningitis, influenza, and diarrhea (for children under two years of age).  In 1900, approximately one in six American babies would not live to see their first birthday, according to one recent estimate. In just thirty years, however, infant deaths in the U.S. had fallen by more than half, to an estimated 70 deaths per 1000, approximately equivalent to infant mortality rates in Rwanda today. What accounts for this tremendous improvement in child health in America?

It is tempting to suggest that new medical technologies led to massive improvements in health, and particularly child health. In the course of the 20th century we saw an unprecedented period of medical innovation, which ultimately led to the widespread availability of life-saving vaccines, antibiotics, and other medical technologies we take for granted today. But what is remarkable is that the decline in mortality, particularly due to infectious disease, occurred before the spread, and often before the invention, of these technologies.

Deaths due to scarlet fever had fallen to nearly zero by the time penicillin, a common antibiotic today, was invented in 1946. Similarly, deaths from typhoid and tuberculosis fell dramatically before the introduction of antibiotics to treat these bacterial infections were invented in 1948 and 1950, respectively. It was not until 1963 that a vaccine to prevent measles was invented, by which point very few people died of measles in the U.S. Most of the decline in mortality from infectious diseases in the U.S. occurred before the introduction of medical technology used to prevent or treat them.

So what accounts for the decline in mortality due to infectious disease? To a large extent, women and water. Recent research by Grant Miller of Stanford University finds that women’s suffrage in the U.S. directly contributed to increases in public health spending in the 1920s. Much of this health spending went toward public campaigns to improve hygiene. Around 20,000 child deaths were averted as better hygiene prevented the spread of deadly infectious diseases. Miller argues that legislators anticipated women support of public funding for health, and voted for more progressive public reforms as soon as they won the right to vote.

In related work, Miller and economist David Cutler find that improvements in water systems in the U.S. between 1900 and 1940, specifically filtration and chlorination, contributed to three quarters of the decline in infant mortality and two thirds of the decline in child mortality during this period. Waterborne diseases were responsible for a large proportion of deaths during this time, particularly in U.S. cities, and water treatment and filtration led to a major decline in these waterborne illnesses.

Today, over one billion people around the world do not have access to clean water, and over two billion to not have access to sanitation facilities. In Rwanda, only an estimated 23 percent of the population had access to adequate sanitation in 2006, and in Uganda only 33 percent. In Uganda’s capital city, Kampala, only eight percent of homes are connected to a sewage line. A greater proportion of the population have access to clean water—64 percent in Uganda and 65 percent in Rwanda—but nearly one third of the population continues to consume unsafe water on a daily basis.

Much of the emphasis on public health today focuses on supply-side factors – on health care rather than health, on curative rather than preventive treatments, on hospitals rather than homes. But history suggests that the greatest improvements in health have taken place within the home, with a focus on preventing infectious disease rather than treating it. Women play a key role in this process. Women are more likely to be in charge of feeding children and ensuring their homes have clean water and adequate sanitation, and some research suggests women tend to place greater value on child welfare (this is why cash transfers programs often target women in the household, rather than men). As we have seen in the U.S., women voters can have a profound impact on legislator behavior and consequently, public policy.

Survey evidence from the Afrobarometer suggests that health is a major concern for ordinary Ugandans, and populations throughout sub-Saharan Africa. In 2011, 26 percent of Ugandans said that “improving public services such as education and health” was their top concern, and 50 percent said that health was among the “most important problems facing this country that the forthcoming 2011 elections should address,” and ranked health higher than any of the thirty-odd other policy issues. Whether legislators act on the policy preferences of their constituents is another matter altogether. Nevertheless, the potential of the electorate, and women in particular, to influence public policy should be taken seriously, especially with regard to health.

A focus on hygiene may be as efficacious, if not more so, than the antibiotics and antimalarial drugs that are ubiquitous in public health today. The difference between 1920s America and the developing world in 2011 is that we are not forced today to rely on prevention of disease, because the momentous gains in medical technology allow us to treat the most common causes of death and disability. But this new technology should not become a crutch, and we should not forget the tremendous gains in population health that can be made by focusing on hygiene rather than a vaccine. Toilets may not be sexy, but life without adequate sanitation just stinks.