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Alumni Dispatches

Art Cohen

JD, MPH ’80

The Fault in Ourselves: Finishing the Sanitary Revolution

art cohen As a lawyer in public health, my career has been varied. I have worked in the U.S. at the federal, state and local levels of government, and in the not-for-profit sector. Work roles have included staff assistant, program director, legislative draftsperson, consultant, attorney, and administrative law judge—in mental health and environmental health. However, it was as a child of a United Nations family, and later as a traveler through Central and South America, that the spark was first ignited for my chief public health mission and preoccupation over the past twenty years—as an advocate, along with hundreds of others both in and out of public health, for decent urban sanitation worldwide.

It is presently estimated that two of every five persons on earth still have to live without adequate sanitation—that is, hygienic means for disposing of their human waste. Over half of the world's people now live in cities. The resulting deaths of children and debilitation for adults due to greatly increased risk of exposure to infectious disease are totally preventable.  Also preventable are the threats to the personal safety of women and girls who have to leave their homes at night to relieve themselves under cover of darkness. Oral rehydration, which we have had available for thirty years, is useful as a tertiary prevention method but is not as effective as or an adequate substitute for primary prevention.

Those of us fortunate enough to live in the industrialized cities of Europe, North America, Japan, and a few other nations have benefited for at least 100 years from such prevention. Yet, public health's much vaunted “sanitary revolution” has remained incomplete and unfinished for too many of the world's people. Such basic disease prevention is not yet available for hundreds of millions of city dwellers in Africa, Asia, and South and Central America. When over 11,000 readers of the British Medical Journal were asked in 2007 what they considered to be the most important medical milestone since the year 1840 in preventing death and disease, they accorded first place to sanitation (clean water and sewage disposal)—ahead of antibiotics, anesthesia, vaccines, discovery of DNA structure, germ theory and others.

The international quest for adequate sanitation officially began in 1981 as "The International Drinking Water Supply and Sanitation Decade," and its target dates have constantly gotten pushed forward. The year 2008 was the United Nations’ “International year of Sanitation.” The original target year of 1990 has now morphed into Millennium Development Goal #7, Target 3 for 2015—“Halve, by 2015, the proportion of the population without sustainable access to...basic sanitation.” However, it has recently been predicted that at our present rate of progress on sanitation coverage, achieving that goal will require many, many more decades beyond the five years remaining until 2015.

Why has prevention through better sanitation been so elusive? The technology has been there, both for wet and dry toilets. The means for providing it has been there. There also has been a clear understanding of the importance of sanitation, and its necessity as a basic underpinning to all other public health efforts.

The usual response is that what has been missing is “political will.” But just what does this mean? Does this mean political will to overcome the cultural taboos, the disgust factor, the unglamorous nature of human waste disposal (as contrasted, for instance, with the more acceptable, less repugnant need for potable water)?  Does this mean that politicians are indifferent to the health and quality of life of millions of their constituents, so many of whom are poor? Does this mean that the same politicians are ignorant about the effects of poor sanitation on economic productivity? All of the above?

Or should the failure be laid more at the doorstep of public health leaders around the world who have somehow not been able or, in some cases, even willing to mobilize governments to elevate sanitation to the top priority it deserves among social and economic programs requiring immediate achievement? To borrow from the words of Cassius, written by the Bard of Avon over four centuries ago: “Men at some time are masters of their fates: The fault, dear ... [public health], is not in our stars, but in ourselves, that we are underlings.” This absence of adequate sanitation for so many continues to be our “Caesar,” which needs to be eliminated for the good and public health of us all.

Art Cohen, a retired local public health director, advocates locally for better public transportation in the Baltimore Metro Region [www.] as well as globally for improved urban sanitation [].

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