Clean Water is Life, Dirty Water is Death: The Devastating Consequences of Waterborne Illnesses in the Developing World

Wealth of Nations Podcast

Every year, more than 3.4 million people die of waterborne illnesses across the world, the overwhelming majority of whom are young children. Diseases such as cholera, typhoid fever, and parasitic worms can cause young children to suffer extreme diarrhea, eventually leading to death by dehydration. Moreover, many waterborne diseases are known to cause lifelong effects such as physical stunting and delayed cognitive development. While developed countries have created the infrastructure to provide clean water and sanitation to all, many of the poorest nations in the world struggle to do so. I am going to explore the causes and consequences of waterborne illnesses by exploring how Pakistan and Bangladesh have dealt with waterborne illnesses. Pakistan and Bangladesh were until 1971, united in the same country, and share many of the same colonial, cultural and institutional heritages. However, Pakistan and Bangladesh have diverged in their ability to contain waterborne illnesses. The purpose of today’s podcast episode is to explore why Pakistan has struggled to contain waterborne illnesses, and how Bangladesh has dramatically reduced the death toll from waterborne illnesses.
Every year, an estimated 250,000 Pakistanis die of waterborne illnesses a year, with 30% of all illnesses and 40% of deaths caused by waterborne illnesses. Part of Pakistan’s problems with waterborne illnesses stems from the scarcity of water in Pakistan. Much of Pakistan is arid and semi-arid, and groundwater levels have been falling due to overuse of water for agricultural purposes. Pakistan is expected to have less than 500 cubic meters of water per capita in 2025. One of the consequences of this is that Pakistanis relying on tubewells for water digging deeper and deeper to get access to water. However, substantial amounts of arsenic have leached into this water, putting 60 million people at risk of arsenic poisoning. Water scarcity is an especially large burden for women in rural areas. Women in water scarce areas must often travel as far as an hour away multiple times a day to fetch water. As a result, it is common for women, who overwhelmingly are in charge of household decisions, to fetch water from whatever source they can find, regardless of whether the water is bracking or possibly contaminated by fecal matter. These problems are exacerbated by the extreme lack of knowledge about basic health among women. 41% of Pakistan in women are illiterate, and one study found only 4% of women saw dirty water as the primary source of diarrhea.
Furthermore, Pakistan has serious problems with water infrastructure. 42% of households in Pakistan do not have access to a sanitary toilet, and 37% of households have no means of disposing wastewater and there is virtually no piped water in rural areas. Urban informal settlements also suffer from serious water problems. No city in Pakistan offers 24 hour access to water, and Karachi only has access to 4 hours of piped water a day. Moreover, much of the investment already made has proven to be poorly planned. Large numbers of households have built latrines on their own recognizance, allowing for open defecation to fall from 29% of the population to 13% of the population between 2004 and 2015. However, most of the toilets being built do not have a good way to dispose fecal waste, and as a result have limited benefit to public health. Rates of diarrhea show no improvement between 2006 and 2012, and stunting has actually grown more prevalent over this same period of time.
Today, only 8% of all the waste water in Pakistan is collected and treated. The remaining 92% is dumped into rivers and streams allowing fecal matter to get into the food supply and to seep into the groundwater. According to one survey, 89% of tap water samples suffered from bacterial contamination in Karachi. Pakistan’s water problems are compounded by the fact public investment in providing water for all is extremely limited. Current spending on water, sanitation and hygiene is only .16% of GDP, substantially below the .5% recommended by the World Bank and the .4% in Latin American countries at a similar level of development. Furthermore, government spending is poorly aligned, with far more funding devoted to new projects and wages, and little invested in upkeep. Moreover, far more money is spent in wealthy urban districts than in poor rural water and sanitation systems where it is needed the most. For example, Karachi receives nearly 100 times as much WASH funding as the rest of the state per capita.
While Pakistan’s water, sanitation and hygiene picture is bleak, there are some important bright spots. One major success has been the Orangi Pilot project. The Orangi Pilot Project’s sanitation program was partnership between local communities and the state where the state would build out secondary sanitation such as infrastructure, while local residents would build lane level pipes and drains themselves. The government and non-profits provided technical assistance to ensure everything built by the residents of Orangi Town was well built. The results have been impressive. Between 1982 and 1991 the infnat mortality fell from 130 per thousand to 37 per thousand, a much faster fall in Infant mortality than in Karach as a whole. Just as impressively, the program mobilized $1.6 milliom from the 1.2 million residents of Orangi Town, and cost the government $100 million, showing massive returns on investing in the health of the urban poor.
The experience of the Orangi Pilot Project shows that the government, working in partnership with civil society, is capable of making massive improvements in the lives of people. However, in Pakistan, a host of social forces impede the ability for grass roots mobilizing that makes the type of successes we see in the Orangi Pilot Project possible, a subject that I hope to cover in much greater detail in a future episode of this podcast. However, the same has not been the case in Bangladesh, where non-profit organizing has been central to social development from the very beginning. Indeed, many of the largest non-profit organizations in the world, including the Grameen Bank and BRAC are based out of Bangladesh.
One of the most important examples of this is the rapid spread of Oral Rehydration Solution, or ORS in Bangladesh. ORS is a combination of water, sugars and salts that help the body retain hydration and nutrients taken out of the body by diarrhea. ORS was first developed by researchers working in Dhaka and Kolkata in the 1960s, and first came into wide usage in the aftermath of the Bangladesh Independence War where those whop did not receive ORS died at 10 times the rate of those who didn’t. From 1980, the government of Bangladesh started promoting ORS. BRAC, today the largest international development non-profit in the world, sent teams of women from village to village to demonstrate the effectiveness of ORS, and to sell ORS at low cost. Moreover, these women were taught how to make ORS on their own using cheap and commonly available material. Eventually, TV and radio broadcasts further popularized ORS, and it was rapidly adopted by Bangladeshi households. More than 90% percent of cases of severe diarrhea are today treated with ORS, and is the most powerful force behind the 80% reduction in infant mortality in Bangladesh over the last 25 years.
Bangladeshi non-profits have also plaid a major role in increasing the production of ORS. Until 1990, due to the lack of domestic production capacity, ORS was primarily made at home or imported. However, starting from 1990, the Social Marketing Company, a non-profit known for manufacturing condoms and contraceptives, became involved in manufacturing ORS satchels. Between 1992 and 2011, the SMC scaled up production from 16 million satchels a year to 300 million satchels a year. Moreover, the success of the SMC in marketing ORS through its wide network of stores incentivized private companies to become involved in manufacturing ORS satchels. Between 1992 and 2011, private sectors share in ORS satchels went up from 20% to 45%. Today, a potentially life saving satchel of ORS costs only $.06, making it affordable to nearly all people in Bangladesh.
The government of Bangladesh has taken other steps beyond making ORS widely available. For example, during the 1970s, the government of Bangladesh encouraged the construction of 10 million tubewells so that people could directly reach groundwater so deep that it was guaranteed to not be contaminated by fecal matter. Unfortunately, the practice has backfired because groundwater that deep is often contaminated by arsenic. However, other steps taken by the government have proven to be far more effective. The government has encouraged early breastfeeding of newborns, fortifying ORS with zinc,and promoted handwashing. Moreover, the government has promoted cooperation through the National Sanitation Campaign from 2003 and 2006 between local residents and the government similar to the Orangi Pilot Project to reach 100% latrine coverage in 10 low income districts in Pakistan. More broadly, Bangladesh has seen a massive increase in all areas of human development. Rapid increases in food availability has dramatically reduced childhood stunting, while dramatic increases in female education has made it much easier for the government to spread public health information.
The experience of Pakistan shows that the loss of life caused by waterborne diseases is massive and that there are deep seated institutional problems that makes this problem difficult to solve. At the same time, the experience of Bangladesh shows that these problems are solvable even in least developed countries. Waterborne illnesses are easy for people in the developed world to ignore. We have largely overcome the institutional and infrastructure barriers that allow for contamination of the water. Moreover, there is little risk of these diseases spreading from the developing world to the developed world. However, the massive loss of life caused by these diseases creates a clear moral obligation for countries and individuals in the developed world to provide the financial and institutional support necessary to eradicate waterborne illnesses across the world.
Selected Sources:
The Challenges of Water Pollution, Threat to Public Health, Flaws of Water Laws and Policies in Pakistan, Azra Jabeen
Evaluation of drinking water quality in urban areas of Pakistan: a case study of Gulshan-e-Iqbal Karachi, Pakistan: Syed Asim Hussain, Alamdar Hussain
Pakistan Pakistan’ s Water Economy: Economy: Running Dry, John Briscoe, Usman Qamar, Manuel Contijoch, Pervaiz Amir, and Don Blackmore
Understanding Water Scarcity in the Socio-Cultural Context in Thar Desert of Pakistan, Tehreem Chaudhry
Water Supply and Sanitation Sector, World Bank
Drinking Water Quality Status and Contamination in Pakistan, Daud Khan
From the Lane to the City: The Impact of the Orangi Pilot Project’s Low Cost Sanitation Model, Akbar Zaidi
History of development of oral rehydration therapy, S K Bhattacharya
Cholera, Diarrhea, and Oral Rehydration Therapy: Triumph and Indictment, Richard L. Guerrant, Benedito A Carneiro-Filho, and Rebecca A. Dillingham
BANGLADESH ORS CASE STUDY, EMILY MOSITES, ROB HACKLEMAN, KRISTOFFER L.M. WEUM, JILLIAN PINTYE, LISA E. MANHART, AND STEPHEN E. HAWES
Arsenic contamination in groundwater in Bangladesh: implications and challenges for healthcare policy, Sk Akhtar Ahmad,1 Manzurul Haque Khan,2 and Mushfiqul Haque2

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