| Colleagues like to joke that I'm obsessed with poop (I'm not!), but it's true that since shadowing polio vaccinators in India in 2008, I've reported on sanitation quite a lot. It began with stepping repeatedly over narrow canals of fetid sewage to watch children get immunized. Polio is a crippling disease that spreads via the fecal-oral route. When I saw hand pumps — a source of household water — an arm's length from sludge-filled drains, it occurred to me that safely disposing of fecal waste wouldn't just prevent polio transmission, it could also stop hepatitis, cholera, dysentery, and a myriad of other ailments. Sadly, 15 years later, 3.5 billion people – or 2 in 5 – around the world still lack safely managed sanitation. This is a problem for the whole planet, and Pakistan illustrates why. Before the 1940s, typhoid fever plagued many major cities. In the developed world, clean water, sanitation, and the advent of antibiotics made it a "disease of the past." But in Pakistan and other low-resource countries, it's a stubborn malingerer, sickening mostly preschool and school-age children, and killing about 110,000 people every year. Antibiotics can usually treat the disease, which becomes life-threatening when Salmonella enterica typhi bacteria perforate the intestine wall and cause hemorrhage and sepsis. But a half-century of over-reliance on these miracle cures has trained the germs to resist one class of antibiotic after another. Fast-forward to 2016, when more than 5,000 people in Hyderabad, in Pakistan's Sindh province, were in the grip of the world's first outbreak of extensively drug-resistant typhoid. The superbug — then impervious to five antibiotic classes — spread to Karachi, the country's economic hub, and then to most of provinces, aided by abysmal sewage systems and drinking water rife with fecal germs. The problem isn't confined to Pakistan; it's now global. International travel has propelled so-called XDR typhoid to the Middle East, North America, Europe, and Australia. Nine cases were reported before Covid hit among Americans with no history of recent international travel, and it was linked to contaminated water in a Beijing apartment block in February 2022, the same month a case was detected in Hong Kong. Increasing urbanization, climate change, and the rapidly weakening potency of antibiotics are escalating the global threat. This month, researchers reported a case of typhoid in a 7-year-old girl in Peshawar, Khyber Pakhtunkhwa province, whose XDR infection was resistant to the two remaining effective antibiotics. The girl eventually recovered, but her case raises the ominous specter of untreatable typhoid. Just like with polio, there are better vaccines for typhoid now that provide strong protection against illness after a single inoculation, and reduce reliance on antibiotics. But there's no inoculation for the root cause of these enteric diseases. Around 10% of Pakistan's 240 million people lack a household toilet — one of the most important medical advances of the past two centuries. Deprivation of that basic necessity results in 53,000 Pakistani preschoolers dying needlessly from diarrheal diseases each year. If that tragic toll isn't enough to spark more action on poop, the global threat of untreatable typhoid should.— Jason Gale | 
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