Cholera has been eliminated as a public health problem in high-income countries that have implemented sanitation system separating the community’s fecal waste from their drinking water and food supply. These expensive, highly-engineered systems, first developed in London over 150 years ago, have not reached low-income high-risk communities across Asia. Barriers to their implementation in communities at highest risk for cholera include the high capital and operating costs for this technological approach, limited capacity and perverse incentives of local governments, and a decreasing availability of water. Interim solutions including household level water treatment, constructing latrines and handwashing promotion have only marginally reduced the risk of cholera and other fecally transmitted diseases. Increased research to develop and policy flexibility to implement a new generation of solutions that are designed specifically to address the physical, financial and political constraints of low-income communities offers the best prospect for reducing the burden of cholera across Asia.