Today, one billion people live in informal urban settlements outside of city planning and regulation. This means one in seven people on this planet are spatially marginalized and less likely to lead healthy lives. Many of these are also the fastest-growing cities in the world and likely will become the world’s major commercial centers of this century. Extending public amenities such as water, sanitation, and health services equally, despite massive population growth and unprecedented urbanization, remains the most formidable challenge for 21st-century cities.

As Chelsea Clinton, vice president of the Clinton Foundation and global health advocate, noted at a water and sanitation event sponsored by the Deutsche Bank Americas Foundation last fall: “It’s past time to start talking about diarrhea.”

Seriously: Globally, diarrheal disease causes one in every five child deaths each year. This may be shocking, but is not unprecedented, even in the world’s wealthiest cities. In New York City, for example, availability of basic sanitation could have prevented one third of all deaths in 1851. As the relationship between disease and spatial-planning emerged, the city’s urban planners worked to develop systems and infrastructure that could effectively and safely provide sophisticated services for public health, enabling the city to expand into the booming commercial and cultural capital that it is today. But before we look to New York to solve the problems of 21st-century cities, let’s remember that it wasn’t until 138 years after this cleanup that the city stopped dumping its sewage into the Atlantic, so there is certainly room to expand on last century’s successes.

In today’s emerging economies, myriad organizations are working to address the determinants of poor public infrastructure. Models are emerging to provide stand-alone toilets, emergency medical care, and clean water distribution—all through the development of novel technological solutions that provide an alternative in the absence of formal public infrastructure. It is absolutely true that we need major investments in innovation, such as those by the Gates Foundation, but we must also acknowledge that these interventions address only part of a larger municipal problem. While a stand-alone toilet prototype is an amazing innovation, without strong local networks and a sanitation system to ensure that waste is carried away and toilets are maintained, even the best inventions will fail. It’s also important to remember that a functioning toilet system will still not lower rates of diarrheal disease if the water is still dirty and people are still sick.

We need to ask the right question: Rather than a piecemeal alternative, how do we improve a system at a municipal scale when there isn't municipal capacity to implement a new system?

We must collectively work within communities—including local leaders, municipal authorities, and NGOs—to provide bridge solutions that extend public services until we can build out formal infrastructures. This also requires a process of contextual due diligence to understand the broad spectrum of needs in different neighborhoods, and feasibility studies to ensure that an intervention will be sustainable and impactful. This approach is guiding a new future of development work in Haiti and is replicable globally.

In Port-au-Prince, where we are working to develop water, sanitation, and health infrastructure, the population is comparable to Manhattan, yet two-thirds of people lack access to a clean, private toilet; only 64 percent have potable drinking water; and two-thirds live below the international poverty line (less than $1.25/day). One diarrheal disease in particular, cholera, has claimed 8,500 lives in Haiti, and diarrheal disease overall is one of the two most common causes of under-five child mortality. The current plan to build subterranean wastewater infrastructure in the capital is estimated to take a minimum of 20 years, and the extent to which piping will be citywide remains ambiguous to local partners.

In addition to running a free health center that provides integrated health services, Les Centres GHESKIO, a Haitian healthcare nonprofit and sister organization to Weill Cornell Medical College, is providing microcredit, nutritional support, a vocational school, and a primary school program for 1,300 children. The organization employs community health workers to visit homes and distribute vaccines and oral rehydration salts, monitor patients, and refer the sick to its facility nearby. It also trains the community to use chlorine solutions and provides education programs on sanitation. The organization developed these programs after extensive relationship building and needs assessment among the human networks central to the model’s success—health officials, community representatives, other NGOs, and many others. Now, Les Centres GHESKIO and MASS Design Group are working to expand and scale these programs in Port-au-Prince, including building a permanent center for the control of diarrheal diseases and elimination of cholera (which we will complete early this year).

Expansion of these types of partnerships, and more localized and focused research within communities is vital to successfully delivering lasting public amenities. For example, what if we mobilized a coalition of the community leaders, public health professionals, NGOs, and the Haitian government to jointly develop holistic interventions? Consider presenting such a coalition with the toilet prototype we mentioned above. The coalition’s collective expertise could answer questions such as, “What happens when this toilet breaks?” “Where should it go?” “How do we empty the tank?” and “Why would people use this alternative?” before implementing the prototype. This saves time and money; it also helps the technology fit within the system of other programs and technologies under consideration and development.

Controlling diarrheal diseases in countries like Haiti is not a matter of which service to improve—water, sanitation, or health—but how to integrate these public goods with education and economic opportunities to control disease and improve lives. Our experience in Port-au-Prince has taught us three lessons with global applicability:

  1. Avoid interventions that operate in isolation from one another.
  2. Instead of coming up with solutions for communities, develop solutions within communities so that you can structure programs to last and scale up.
  3. Collectively support the holistic development of services that provide the foundations for the eventual independent operation of public infrastructure by the government.

There is immense innovation, energy, and potential in Port-au-Prince and in the emerging cities of today, but the equitable development of public infrastructure is essential. We can think of no better place to develop a replicable model for this global challenge than in Haiti.

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