Port-au-Prince is about the size of Chicago. But it doesn't have a sewer system. It's one of the largest cities in the world without one.
That's a big problem, but never more so than during a time of cholera.
Since cholera was introduced into Haiti 18 months ago — most likely by United Nations peacekeeping troops from Nepal, where the disease is endemic — more than a half-million people have gotten sick and at least 7,050 have died.
Public health authorities say cholera will stay in the environment for a long time, because Haiti has the worst sanitation in this hemisphere.
It's hard for Americans to imagine what this means.
The cumulative sewage of 3 million people flows through open ditches. It mixes with ubiquitous piles of garbage. Each night, an all-but-invisible army of workers called bayakou descend into man-sized holes with buckets to remove human waste from septic pits and latrines, then dump it into the canals that cut through the city.
Follow pediatrician Vanessa Rouzier on a tour of a Port-au-Prince slum called Cite de Dieu — City of God — to get an idea of what it means to live in a city sans sanitation. The sprawling slum, close by the earthquake-ruined Presidential Palace, is home to 40,000 Haitians, including a lot of her patients.
We cross over a wide canal that cuts through the slum. The garbage-clogged channel brings sewage down from the hillside precincts of the capital.
"So you can imagine that if human waste goes through there, and if it rains, [it] just really spills into the environment and ends up in the sea," Rouzier says.
She takes us down to a small, garbage-cluttered beach on the edge of the slum and points to a ramshackle structure perched on stilts over the water. Those who have seen the movie Slumdog Millionaire will know what it is — an outhouse.
"If you live close by the water, you may use these over-the-sea hanging toilets during the daytime," Rouzier says. "But at night you wouldn't come out in the dark to use that. You would have a bowel movement in some sort of plastic bag and ... throw it out during the day out here."
Right next to the outhouse, a small fishing boat unloads its cargo. And right there on the beach, a woman sells the fish from plastic buckets.
But there are signs of hope. Only a hundred yards or so from the outhouse is a tidy-looking school for 170 students — with a brand-new, honest-to-god toilet.
The school's principal, Wilfred Elma, proudly shows it off. There are separate chambers, all spotlessly clean and odor-free. "This is for the boys, this is for the teacher, and this is for the girls," Elma says. "This is the first time they are using a toilet that smells so good."
"I think it's amazing!" Rouzier says. "These children have never had the experience of using a toilet! I don't think many ... in North America understand what that represents — that it's the first time they're using a proper toilet!"
And not only that, but this toilet is a biodigester. It recycles waste and turns it into methane gas. The principal says they'll use the gas for cooking.
It's a small step toward solving an overwhelming problem.
An hour's drive outside Port-au-Prince there's something even more exciting — a brand-new sewage treatment plant. It's the first one in Haiti. It sits on a windswept, treeless moonscape at the foot of Morne a Cabrit, or Goat Mountain.
Wilston Etienne, who oversees the facility, stands on the unloading bay as a big tanker truck backs into position. "This is where it all starts," he says, as the truck discharges a great gush of raw sewage into the first of several treatment ponds.
Dozens of trucks bring the stuff here all day every day from Port-au-Prince. They dislodge it from private septic pits, public latrines, canals and other repositories.
Etienne, a sanitary engineer with a booming voice and a hearty laugh, works for DINEPA, Haiti's 2-year-old water and sanitation agency. He says Port-au-Prince will never have the kind of sewage system Americans are used to, with underground pipes that carry waste to a treatment plant. But this one is far better than none at all, and it's much cheaper.
Amazingly, this plant and another one 12 miles away that's about to open will handle the city's entire output. The sludge will be used for agricultural compost, and the detoxified effluent will irrigate a grove of trees to be planted around the treatment ponds. "Come back in two years, and this will look like a park," Etienne says.
Soon there will be treatment plants like this one in seven other Haitian cities. "We already have the funds," he says. The money comes from a post-earthquake donation by the Spanish government.
But Etienne says better sanitation will take a lot more than building treatment plants. "Not much attention has been paid to sanitation over the years," he says, "so people do not normally think of sanitation, in terms of their approach, their behavior and so on. So the first thing is changing that sort of mentality."
For instance, often when Haitians build a house, they don't even think about putting in a toilet. "When you make two dollars a day and you have to feed your family, the last think you think of is sanitation," Etienne says.
In fact, access to sanitary facilities in Haiti has actually gone down over the past two decades, according to the Pan American Health Organization.
Etienne says the facilities don't have to be the sleek flush toilets Americans are used to. A plastic-lined pit with an outhouse is a big improvement. "I remember when I was young, our first toilet was not a sanitary toilet. It was a pit outside that had a piece of board with a hole in it," he says. "And I was fine!"
But, he sighs, people's behavior is not going to change overnight "no matter how many billions of dollars we have."
The first step, Etienne says, is to convince Haitians that when it comes to sanitation, things don't have to be like they are now.
Copyright 2012 National Public Radio. To see more, visit http://www.npr.org/.