More cell phones than toilets: Mobile technology emerges as the new lifeline for the world’s poor

A report on inadequate sanitation, released by the UN University, made waves earlier this year when it reported that while 45% of India’s population owned cell phone, only 31% of them had access to improved sanitation in 2008.1  Headlines proclaiming “India has more cell phones than toilets” found their way into several of my e-mail news digests.  “It is a tragic irony to think that in India, a country now wealthy enough that roughly half of the people own phones, about half cannot afford the basic necessity and dignity of a toilet,” said Zafar Adeel, Director of United Nations University’s Institute for Water, Environment and Health (IWEH), and chair of UN-Water.  With the focus on the Millennium Development Goals growing more acute as the deadline approaches, people were understandably astonished.  

It is shocking to think that so many of the world’s poor cannot access appropriate sanitation.  However, the widespread use of cell phones should not be juxtaposed against the conditions of poverty, but should rather be seen as a way to empower the poor to improve their conditions.  The cell phone market has seen explosive growth in the last decade: 90% of the world’s population will soon be within the coverage of wireless networks,2 and there are already an estimated five billion cell phones used globally.3  Villages without running water or electricity often have at least one mobile phone, and people can switch out their own SIM cards for access.  They are being adopted faster than basic services such as routine medical care and schools.2  When a basic toilet costs 15 times more than a basic cell phone ($3001 compared to $203), it becomes easier to understand the discrepancy between access to sanitation vs. mobile technology.  If mobile penetration is so widespread, then, should it not be viewed as a tool and an opportunity for innovation?  

A man holds a cell phone in front of a woman with four children.
Photo taken from mHealth Alliance Executive Director David Aylward's blog entry in the Global Health Magazine.

Some governments and organizations have already caught on.  In Rwanda, for example, the government provides free cell phones to rural health workers to register expectant mothers, get answers to their questions from a health expert, and send monthly status reports to doctors.2  Other programs send reminders to HIV-positive pregnant women to take ARVs and work to reduce stock-outs of drugs in rural clinics.  Pharmaceutical companies are also working with application developers to fight drug counterfeiting: customers will be able to submit a numeric code on drug packaging via SMS and get a reply that states whether the drug is “NO” or “OK,” along with the drug’s name, expiration date, and other information.4  And I have already featured Tostan’s Jokko Initiative, which applies their literacy lessons to cell phone usage and includes a lesson on the health-related utility of SMS.  Other applications include facilitating electronic banking and providing information on crop disease and weather to farmers.2  

Progress on the MDGs should not be overlooked, and the importance of access to sanitation is should certainly not be downplayed at all.  With an expected return between $3-34 for every dollar spent on sanitation, it is absolutely worthwhile to stress the importance improving people’s access to this need.  Now, if only we could develop an app to improve sanitation – that would be perfect.

Dark Star Safari: Is aid in Africa making things worse?

I was encouraged to read Paul Theroux’s Dark Star Safari by a co-worker in back in Texas when I mentioned that I was interested in a career in international health.  “You should definitely read this book.  It tells the truth about the corruption of aid agencies and how they’re actually hurting Africa.”

Map of Africa, with Paul Theroux's route from Dark Star Safari drawn in a dotted line
Theroux’s travel route in Dark Star Safari

She was at least partially right.  Over the course of Theroux’s “safari” across the continent, he lapses into several ranting session about selfishness and self-importance of aid workers (“they were, in general, oafish self-dramatizing prigs, and often complete bastards,” p. 146), the futility of various aid projects, and the corrupting influence that foreign aid has on African governments and people.  He takes it upon himself to diagnose the problem.  “Where are the Africans in all this?  In my view, aid is a failure if in forty years of charity the only people still dishing up the food and doling out the money are foreigners.  No Africans are involved – there is not even a concept of African volunteerism or labor-intensive projects.” (p. 272)  Unfortunately, Theroux never bothers to actually visit an aid agency at all during his trip.  If he had, he might have learned the majority of employees of aid agencies in Africa are Africans.1

Despite this lack of research, there is some truth to Theroux’s perceptions of and rants about the damage that foreign aid does to African countries.  It creates a culture of dependence, stifles sustainable growth, discourages investment, and burdens poor countries with massive debt.  Real per-capita income on the continent is lower now than in the 1970s, and the number of people who live on less than a dollar a day has doubled in the last two decades.2  Corruption siphons off huge amounts of donor funds, and the continuous flow of aid keeps inefficient and abusive governments in power. 

Fortunately, there are organizations that seek to promote education and economic programs that will have lasting effects in the region.  For example, Tostan works with villages in Sénégal and neighboring countries by training local people to lead education modules that focus on hygiene, literacy, and human rights; through their program, they’ve gotten over 4,500 villages to collectively abandon FGM.3  The Acumen Fund provides mid-size loans to early-stage enterprises providing healthcare, water, housing, or agriculture; one of their loans financed the Kenyan Company Advanced Bio-Extracts, the first African company to produce artemisinin for antimalarial drugs.4  These groups bring a fresh approach to the decades-old problem of the stagnation of African communities and economies.

I was not discouraged by Theroux’s tirades; as a field, I feel, or at least I hope, that public health is less prone to “throwing money” at problems and seeks to implement long-lasting behavior changes.  However, despite the author’s vitriol and lack of knowledge on his chosen tirade, his observations are still a powerful reminder that public health professionals can fail people by not giving them the tools to continuously implement the changes we try to effect.