How to reduce poverty? Fix homes

In 1985, architect Paul Pholeros was challenged by the director of an Aboriginal-controlled health service to "stop people getting sick" in a small indigenous community in south Australia. The key insights: think beyond medicine and fix the local environment. In this sparky, interactive talk, Pholeros describes projects undertaken by Healthabitat, the organization he now runs to help reduce poverty--through practical design fixes--in Australia and beyond.

The idea of eliminating poverty is a great goal.

I don't think anyone in this room would disagree.

What worries me is when politicians with money

and charismatic rock stars

use the words,

it all just sounds so, so simple.

Now, I've got no bucket of money today

and I've got no policy to release,

and I certainly haven't got a guitar.

I'll leave that to others.

But I do have an idea,

and that idea is called Housing for Health.

Housing For Health works with poor people.

It works in the places where they live,

and the work is done to improve their health.

Over the last 28 years,

this tough, grinding, dirty work

has been done by literally thousands of people

around Australia, and more recently overseas,

and their work has proven that focused design

can improve even the poorest living environments.

It can improve health, and it can play a part

in reducing, if not eliminating, poverty.

I'm going to start where the story began, 1985,

in central Australia.

A man called Yami Lester, an Aboriginal man,

was running a health service.

Eighty percent of what walked in the door,

in terms of illness, was infectious disease --

third world, developing world infectious disease,

caused by a poor living environment.

Yami assembled a team in Alice Springs.

He got a medical doctor.

He got an environmental health guy.

And he hand-selected a team of local Aboriginal people

to work on this project.

Yami told us at that first meeting, there's no money.

Always a good start, no money.

You have six months.

And I want you to start on a project which in his language

he called "uwankara palyanku kanyintjaku,"

which, translated, is "a plan to stop people getting sick,"

a profound brief.

That was our task.

First step, the medical doctor went away

for about six months,

and he worked on what were to become

these nine health goals, what were we aiming at.

After six months of work, he came to my office

and presented me with those nine words on a piece of paper.

[Washing, clothes, wastewater, nutrition... ]

Now, I was very, very unimpressed.

Come on.

Big ideas need big words

and preferably a lot of them.

This didn't fit the bill.

What I didn't see and what you can't see

is that he'd assembled thousands of pages

of local, national and international health research

that filled out the picture as to why these

were the health targets.

The pictures that came a bit later

had a very simple reason.

The Aboriginal people who were our bosses

and the senior people were most commonly illiterate,

so the story had to be told in pictures

of what were these goals.

We work with the community,

not telling them what was going to happen

in a language they didn't understand.

So we had the goals, and each one of these goals --

and I won't go through them all —

puts at the center the person and their health issue,

and it then connects them

to the bits of the physical environment

that are actually needed to keep their health good.

And the highest priority, you see on the screen,

is washing people once a day, particularly children.

Now I hope most of you are thinking,

"What? That sounds simple."

Now, I'm going to ask you all a very personal question.

This morning before you came,

who could have had a wash using a shower?

I'm not going to ask if you had a shower,

because I'm too polite. That's it. (Laughter)

Okay. All right.

I think it's fair to say, most people here

could have had a shower this morning.

I'm going to ask you to do some more work.

I want you all to select one of the houses

of the 25 houses you see on the screen.

I want you to select one of them and note

the position of that house

and keep that in your head.

Have you all got a house? I'm going to ask you

to live there for a few months, so make sure you've got it right.

It's in the northwest of Western Australia, very pleasant place.

Okay. Let's see if your shower in that house is working.

I hear some "aw"s and I hear some "aah."

If you get a green tick, your shower's working.

You and your kids are fine.

If you get a red cross,

well, I've looked carefully around the room

and it's not going to make much difference to this crew.

Why? Because you're all too old.

And I know that's going to come as a shock to some of you,

but you are.

Now before you get offended and leave,

I've got to say that being too old in this case

means that pretty much everyone in the room, I think,

is over five years of age.

We're really concerned with kids naught to five.

And why? Washing is the antidote to the sort of bugs,

the common infectious diseases of the eyes, the ears,

the chest and the skin

that, if they occur in the first five years of life,

permanently damage those organs.

They leave a lifelong remnant.

That means that, by the age of five,

you can't see as well for the rest of your life.

You can't hear as well for the rest of your life.

You can't breath as well. You've lost a third

of your lung capacity by the age of five.

And even skin infection, which we originally thought

wasn't that big a problem,

mild skin infections naught to five give you

a greatly increased chance of renal failure,

needing dialysis at age 40.

This is a big deal, so the ticks and crosses on the screen

are actually critical for young kids.

Those ticks and crosses represent the 7,800 houses

we've looked at nationally around Australia,

the same proportion.

What you see on the screen -- 35 percent of those

not-so-famous houses lived in by 50,000 indigenous people,

35 percent had a working shower.

Ten percent of those same 7,800 houses

had safe electrical systems,

and 58 percent of those houses

had a working toilet.

These are by a simple, standard test:

In the case of the shower, does it have hot and cold water,

two taps that work,

a shower rose to get water onto your head

or onto your body, and a drain that takes the water away?

Not well designed, not beautiful, not elegant --

just that they function.

And the same test for the electrical system and the toilets.

Housing for Health projects aren't about measuring failure.

They're actually about improving houses.

We start on day one of every project -- we've learned,

we don't make promises, we don't do reports.

We arrive in the morning with tools, tons of equipment,

trades, and we train up a local team on the first day

to start work.

By the evening of the first day, a few houses

in that community are better

than when we started in the morning.

That work continues for six to 12 months

until all the houses are improved

and we've spent our budget of 7,500

dollars total per house.

That's our average budget.

At the end of six months to a year, we test every house again.

It's very easy to spend money.

It's very difficult to improve the function

of all those parts of the house,

and for a whole house, the nine healthy living practices,

we test, check and fix 250 items in every house.

And these are the results

we can get with our 7,500 dollars.

We can get showers up to 86 percent working,

we can get electrical systems up to 77 percent working,

and we can get 90 percent of toilets working

in those 7,500 houses.

Thank you. (Applause)

The teams do a great job, and that's their work.

I think there's an obvious question

that I hope you're thinking about.

Why do we have to do this work?

Why are the houses in such poor condition?

Seventy percent of the work we do

is due to lack of routine maintenance,

the sort of things that happen in all our houses.

Things wear out.

Should have been done by state government or local government.

Simply not done, the house doesn't work.

Twenty-one percent of the things we fix

are due to faulty construction,

literally things that are built upside down and back-to-front.

They don't work. We have to fix them.

And if you've lived in Australia in the last 30 years,

the final cause -- You will have heard always

that indigenous people trash houses.

It's one of the almost rock-solid pieces of evidence,

which I've never seen evidence for,

that's always ruled out as that's the problem with indigenous housing.

Well, nine percent of what we spend is damage,

misuse or abuse of any sort.

We argue strongly that the people living in the house

are simply not the problem.

And we'll go a lot further than that.

The people living in the house are actually

a major part of the solution.

Seventy-five percent of our national team in Australia,

over 75 at the minute,

are actually local, indigenous people

from the communities we work in.

They do all aspects of the work.

(Applause)

In 2010, for example, there were 831,

all over Australia, and the Torres Strait Islands,

all states, working to improve the houses

where they and their families live,

and that's an important thing.

Our work's always had a focus on health. That's the key.

The developing world bug trachoma, it causes blindness.

It's a developing world illness,

and yet, the picture you see behind

is in an Aboriginal community in the late 1990s

where 95 percent of school-aged kids had active trachoma

in their eyes doing damage.

Okay, what do we do?

Well, first thing we do, we get showers working.

Why? Because that flushes the bug out.

We put washing facilities in the school as well,

so kids can wash their faces many times during the day.

We wash the bug out.

Second, the eye doctors tell us that dust scours the eye

and lets the bug in quick. So what do we do?

We call up the doctor of dust, and there is such a person.

He was loaned to us by a mining company.

He controls dust on mining company sites,

and he came out, and within a day it worked out

that most dust in this community was

within a meter of the ground, the wind-driven dust,

so he suggested making mounds to catch the dust

before it went into the house area

and affected the eyes of kids.

So we used dirt to stop dust.

We did it. He provided us dust monitors.

We tested and we reduced the dust.

Then we wanted to get rid of the bug generally.

So how do we do that?

Well, we call up the doctor of flies,

and yes there is a doctor of flies.

As our Aboriginal mate said,

"You white fellows ought to get out more."

(Laughter)

And the doctor of flies very quickly determined

that there was one fly that carried the bug.

He could give school kids in this community

the beautiful fly trap you see above in the slide.

They could trap the flies, send them to him in Perth.

When the bug was in the gut, he'd send back

by return post some dung beetles.

The dung beetles ate the camel dung,

the flies died through lack of food,

and trachoma dropped.

And over the year, trachoma dropped

radically in this place, and stayed low.

We changed the environment, not just treated the eyes.

And finally, you get a good eye.

All these small health gains

and small pieces of the puzzle make a big difference.

The New South Wales Department of Health,

that radical organization,

did an independent trial over three years

to look at 10 years of the work we've been doing

in these sorts of projects in New South Wales,

and they found a 40-percent reduction

in hospital admissions for the illnesses

that you could attribute to the poor environment.

A 40-percent reduction.

(Applause)

Just to show that the principles we've used

in Australia can be used in other places,

I'm just going to go to one other place, and that's Nepal,

and what a beautiful place to go.

We were asked by a small village of 600 people

to go in and make toilets where none existed.

Health was poor.

We went in with no grand plan, no grand promises

of a great program, just the offer to build

two toilets for two families.

It was during the design of the first toilet

that I went for lunch, invited by the family

into their main room of the house.

It was choking with smoke.

People were cooking on their only fuel source, green timber.

The smoke coming off that timber is choking,

and in an enclosed house, you simply can't breathe.

Later we found the leading cause of illness and death

in this particular region is through respiratory failure.

So all of a sudden we had two problems.

We were there originally to look at toilets

and get human waste off the ground. That's fine.

But all of a sudden now there was a second problem.

How do we actually get the smoke down? So two problems,

and design should be about more than one thing.

Solution: Take human waste, take animal waste,

put it into a chamber, out of that extract biogas,

methane gas.

The gas gives three to four hours cooking a day --

clean, smokeless and free for the family.

(Applause)

I put it to you, is this eliminating poverty?

And the answer from the Nepali team who is working

at the minute would say, don't be ridiculous,

we have three million more toilets to build

before we can even make a stab at that claim.

And I don't pretend anything else.

But as we all sit here today,

there are now over 100 toilets built

in this village and a couple nearby.

Well over 1,000 people use those toilets.

Yami Lama, he's a young boy.

He's got significantly less gut infection

because he's now got toilets,

and there isn't human waste on the ground.

Kanji Maya, she's a mother and a proud one.

She's probably right now cooking lunch for her family

on biogas, smokeless fuel.

Her lungs have got better, and they'll get better

as time increases, because she's not cooking in the same smoke.

Surya takes the waste out of the biogas chamber

when it's shed the gas, he puts it on his crops.

He's trebled his crop income,

more food for the family and more money for the family.

And finally Bishnu,

the leader of the team, has now understood

that not only have we built toilets,

we've also built a team,

and that team is now working in two villages

where they're training up the next two villages

to keep the work expanding.

And that, to me, is the key.

(Applause)

People are not the problem.

We've never found that.

The problem: poor living environment,

poor housing, and the bugs that do people harm.

None of those are limited by geography,

by skin color or by religion. None of them.

The common link between all the work we've had to do

is one thing, and that's poverty.

Nelson Mandela said, in the mid-2000s,

not too far from here, he said that

like slavery and Apartheid, "Poverty is not natural.

It's man-made and can be overcome and eradicated

by the actions of human beings."

I want to end by saying it's been the actions

of thousands of ordinary human beings

doing, I think, extraordinary work,

that have actually improved health,

and, maybe only in a small way, reduced poverty.

Thank you very much for your time.

(Applause)