Editorial – The elusive effect of water and sanitation on the global burden of disease. Tropical Medicine and International Health, Feb 2014.
by Wolf-Peter Schmidt, Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK. Tel.: +44-20-7636 8636, E-mail: Wolf-Peter.Schmidt@lshtm.ac.uk
About 2.5 billion people lack access to improved sanitation, and 1 billion have no access to any form of sanitation (UNICEF 2013). About 780 million people lack access to an improved water source, a figure that is based on a fairly generous definition incorporating little with respect to reliability, proximity and convenience of access (UNICEF 2013).
While the ancient Romans may already have been aware of it (Bradley 2012), water and sanitation came to be regarded as key to improve health in the growing cities of Europe and America in the late 19th and early 20th centuries. A number of notable observational studies were carried out that even with the limited epidemiological tools available at the time all but proved the direct link between water, sanitation and health (Snow 1860; Pringle 1910). By contrast, in the early days of development aid in the post-colonial era, water and sanitation were often not regarded as a health issue, but primarily provided with the aim of making people’s life easier and enable developmental activities. Whoever tried to argue for more investment on health grounds was faced by a lack of epidemiological studies conducted in low-income settings, which led to a renewed interest in research from the 1970s.
Simple before/after and case-control studies to evaluate water and sanitation programmes
The studies on water and sanitation conducted in low-income settings since the 1970s were usually simple in design (Rubenstein et al.1969; Aziz et al. 1990; Zhang et al. 2000, 2005; Azurin & Alvero 2007). Typically, a programme to improve water access would be implemented in one or two villages, with latrine construction and some form of hygiene education being provided at the same time. Disease (for example diarrhoea, schistosomiasis or soil-transmitted helminths) would be measured at baseline and then again after the intervention. A couple of not too distant villages with ‘similar socio-economic conditions’ would have been followed up as a control group. Allocation of the intervention was unlikely to be random. Villages might have received the intervention because they had many diseases or were the poorest in the region. They might have been chosen for having been the least or the most accessible, the politically most influential or the most neglected. The commonly small number of allocated villages enabled a close supervision of the intervention, assuring that everything was carried out according to plan. However, the within-village (‘-cluster’) correlation of disease meant that statistically not much could be made of any difference between intervention and control arm if there were <5 or 6 villages on either side. Accounting for the baseline levels of disease allowed strengthening the causal inference (Norman & Schmidt 2011), but only to some extent. Larger, randomised studies were deemed unfeasible given the logistical and engineering complexities involved, and the low budgets available at the time.
Given these constraints, case-control studies came to be seen as the most cost-effective way to evaluate the health impact of water and sanitation (Briscoe et al. 1985). If well done, case-control studies can be logistically efficient and as valid as cohort studies. The problem for the investigator lies in proving that his particular case-control study was carried out well, that is, that cases were adequately defined, the control group was sampled from the same source population as the cases, and confounding was adequately accounted for (i.e. no major confounders were left out or imprecisely measured).
Several case-control studies on water and sanitation came up with plausible results, suggesting reductions in diarrhoea by about 20–30% following an intervention, for example, (Daniels et al. 1990). Still, the studies usually fail to meet the inclusion criteria of systematic reviews, for example those following Cochrane guidelines, where for good reason, observational studies are viewed with suspicion, especially when included in meta-analyses.
Randomised controlled trials – adding to the uncertainty
In contrast to water supply and sanitation interventions, it is relatively straightforward to conduct large randomised controlled trials for hand washing and household (‘point-of-use’) water treatment (for example householders using a water filter or adding chlorine to their drinking water). These are interventions that can be delivered to and randomised at the level of single households, and do not require construction of hardware such as water pipes, sewerage or latrines. Many of them have attracted the interest of the commercial sector such as soap manufacturers or producers of water treatment devices, which has brought with it much research funding for this area.
A large number of randomised trials were conducted – often with spectacular results, suggesting a 30–50% reduction in self-reported diarrhoea (Curtis & Cairncross 2003; Clasen et al. 2007; Ejemot et al. 2008). One study from Pakistan found that childhood pneumonia diagnosed by non-clinical staff was reduced by 50% if people washed their hands (Luby et al. 2005). One study found that hand washing or household water treatment alone is as effective as combined water and hygiene interventions (Luby et al. 2006). The results of these studies attracted great interest, propelling, for example, hand washing promotion to the top of the list of single most cost-effective interventions to improve health in low-income settings (Laxminarayan et al. 2006). Consortia were established to promote hand washing and household water treatment at large scale, such as the Private Public Partnership for Handwashing (Curtis et al. 2005) or the WHO’s network for household water treatment (WHO 2013). Hand washing and household water treatment, two seemingly simple health behaviours, came to be regarded as the best answer to diarrhoeal diseases since the widespread adoption of oral rehydration. To some extent, hand washing and household water treatment received attention because it was relatively easy to conduct randomised controlled trials. Water access and sanitation, being much more fundamental interventions that are likely to be associated with a whole range of health and developmental benefits, looked rather old school by comparison: ‘We used to drill wells in the 70s but now we enable households to take health into their own hands!’ By focussing on hygiene and household water treatment, donors expected to obtain results quickly, and more cheaply than by supporting complicated engineering projects, involving drilling and engaging with governments.
The trials giving rise to such hopes had one problem that became increasingly difficult to ignore: almost all of them were unblinded and used self- or carer-reported diarrhoea as primary outcome measure. There is usually little bias in a trial using an unblinded intervention if the outcome is objective (Savovic et al. 2012). It is also acceptable that a trial uses a subjective outcome if treatment allocation is effectively blinded. It is the combination of lack of blinding and use of a subjective outcome such as self-reported diarrhoea that causes bias. Hand washing cannot be blinded, but interestingly, several household-level chlorination trials were conducted that did use self-reported diarrhoea as primary outcome, but were adequately blinded. These trials did not show a 50% reduction in diarrhoea: they showed no reduction in diarrhoea at all (Schmidt & Cairncross 2009). And there were other signs that the unblinded trials were severely biased: a household water treatment trial in Colombia demonstrated a 25% reduction in diarrhoea despite only 30% of the trial population using the product (Reller et al. 2003). A trial in Ethiopia testing a personal portable filter found a similar diarrhoea reduction despite good evidence that virtually the whole study population had long given up touching the device (The author tried it – it is unusable) (Boisson et al.2009). Bias could explain even the largest observed impacts on disease in studies that were neither blinded nor used a reasonably objective primary outcome.
By moving from case-control studies to the seemingly more rigorous randomised control trial as the preferred study design, researchers in the field may have produced effect estimates that were ‘all an illusion’ (Schmidt et al. 2010). The former were prone to selection bias and confounding; the latter subject to observer and responder bias. The act of randomisation after informed consent when carried out at the household level almost precludes an unbiased response in symptom-based questionnaire surveys – the standard method of assessment. It seems that the severity of responder and observer bias in unblinded trials outweighed even the risk of confounding and selection bias in observational designs.
Trials are almost impossible in settings where they are most needed
In recent years, the interest in public health in low-income settings gained momentum, partially fuelled by the Millennium Development Goals. More public and private funds for research became available. Governments of low-income and donor countries and many funding organisations accepted the principle that water and sanitation are necessary cornerstones for public health. Yet they demanded evidence as to the magnitude of this effect and in particular the relative cost-effectiveness of investing in particular interventions. Unlike in previous decades, village-level cluster-randomised trials on a large scale became financially possible. Of note, funders and researchers alike avoided sanitation trials in urban areas, where the impact on disease and well-being is likely to be greatest, as the logistical and engineering constraints of cluster randomisation in cities were deemed insurmountable. Likewise, there were no serious attempts to conduct large cluster-randomised trials on improved water access in rural mountainous or dry areas where water access is likely to be most beneficial. It was perhaps assumed that villagers and local politicians may not agree to any delay in receiving water access just for the sake of science – everyone wants water now. Further, the challenges of laying pipes or drilling bore holes in difficult or dry terrain proved little amenable to randomisation.
The sanitation trials ended up being carried out in rural settings, usually within ongoing large-scale programmes such as the Total Sanitation Campaign in India. Again most trials used self-reported diarrhoea as primary outcome, but village-level randomisation (with household consent restricted to health surveillance, not intervention delivery) offered the opportunity to make health surveillance visits appear unconnected to the intervention, reducing the potential for bias. Indeed, bias turned out not to be the driving methodological problem – the problem was time.
The perceived sanitation needs in many rural low-income populations are driven by convenience, traditions and culture. A farmer may perceive defecating in the open on the way to his field as convenient and refreshing compared with a claustrophobic and smelly latrine. For a newly married daughter-in-law, going to the fields may be the only opportunity in the day to get out of the house and meet friends. A bad latrine design may easily lead householders to perceive a latrine as a source of infection rather than a way to prevent it. These are not just deeply held beliefs and superstitions that hinder the progress of mankind: in many rural settings, they make perfect sense. Nevertheless, people are willing to give up open defecation if they can get access to an attractive looking, solid latrine that is easy to clean, does not smell and comes at an affordable price (Watershed/USAID 2004; Jenkins & Curtis 2005). To establish a sanitation market offering good products and to persuade people that a latrine can make their life easier, cleaner and healthier, or even be a sign of social status, requires time – time that researchers conducting an RCT do not have.
For example, a recent trial from Indonesia reported that 16% of intervention group households had built a latrine over the 2-year trial implementation period, compared with 13% in the control group, a difference the authors somewhat optimistically described as a 30% increase in the rate of toilet construction (Cameron et al. 2013). A large World Bank funded trial in rural Maharashtra, India, achieved a bare 8% difference in latrine coverage between intervention and control villages (Hammer & Spears 2013). Why this trial found a substantial increase in height-for-age (an outcome that is slow to change) at 18 months remains unclear. Before considering ‘sanitation externalities and children’s human capital’, one may want to look at data quality. A good sanitation marketing campaign may require 5–10 years to achieve a marked increase in latrine coverage with the potential to impact on health. It would be hard to design an RCT where a control group would be deprived of access to sanitation for such a long period of time.
The ‘best available evidence’
Given the severe constraints in implementing water and sanitation trials, especially in settings where they would be most informative, it seems unlikely that we will get useful health impact estimates in the near future. The feasibility of trials alone can bias public health decision-making. The predominance of drug therapy in contemporary medicine is likely in part a consequence of the relative ease of obtaining hard evidence from double-blind drug trials, as opposed to methodologically inferior evidence for other potentially important treatments such as physiotherapy.
It is often said that in the absence of evidence from randomised trials, we need to go with the ‘best available evidence’. As there is no evidence from trials or cohort studies on the effect of sanitation on mortality, various authors have used ecological analyses as the next best option, for example by comparing state-level mortality and sanitation coverage across different states of India (Boone 2005), making use of national census data and population-based health surveys. For example, a multicountry comparison found that almost all variation in child mortality is due to health care, mothers’ child care knowledge and treatment-seeking behaviour, and none due to water and sanitation (Boone & Zhan 2006). By contrast, two studies using similar data found that sanitation ‘can statistically explain a large fraction of international height differences’ (Spears 2013) and that – within India – changes in sanitation coverage explain a substantial proportion of between district differences in child mortality (Spears 2012). India may be colourful but that is nothing compared with econometric analysis. While applying the ‘best available evidence’ may not always lead to military invasions in search of a smoking gun, the consequences in the field of public health can be dire, too.
It is difficult to escape the conclusion that the literature on the impact of water, sanitation and hygiene is unreliable in its entirety, and in any case, it only represents results from those trials and studies that are feasible – they would not be there, otherwise. Meta-analyses do little but average biased estimates. Conducting a meta-analysis without being able to include urban sanitation trials and rural water access trials is a bit like reviewing the effect of insecticide-treated bed nets on malaria based on studies from Norway.
The Global Burden of Disease Study – the ultimate number game
No evidence may be better than bad evidence. However, influential studies such as the Global Burden of Disease study (GBD) cannot do without data. A recent publication of the GBD including a comparative risk assessment of burden of disease and injury attributable to various risk factors suggested that inadequate access to water and sanitation accounts for only 0.9% of the global burden of disease (Limet al. 2012). To some extent, this figure reflects how the world has changed since the 1990s when water and sanitation were believed to account for about 6.8% of the global burden of disease. Globally, child mortality has come down, and life expectancy has increased with non-communicable disease becoming more dominant. The estimated number of deaths in children under five attributable to diarrhoea has fallen from more than 2 million in the 1990s to perhaps 700 000 per year (Walker et al. 2013). Focussing largely on diarrhoea (Engell & Lim 2013), the recent GBD estimates that the number of disability adjusted life years lost due to inadequate access to water and sanitation has more than halved since 1990, from 52 to 21 million, as has the number of deaths (from 716 000 to 337 000).
Still, there are reasons to question the figures. The relative contribution of a single risk factor to the global burden of disease depends on many factors such as (i) the relative risk between exposed and unexposed groups, (ii) the definition of what ‘exposed’ and ‘unexposed’ means, (iii) the size of the exposed population, and (iv) the number and effects of competing risk factors included in the assessment. As shown above, the relative risk of the poor access to water and sanitation is uncertain, especially in settings where they matter most. Perhaps, the most arbitrary decision to be made, however, concerns defining the ‘unexposed’ control group. The GBD defines it largely based on the criteria of the Joint Monitoring Programme (JMP) (WHO 2014) that aim to measure the progress of the Millennium Development Goals, pragmatically categorising water and sanitation access as either ‘improved’ or ‘unimproved’. The JMP definition of ‘improved access’ was never meant to constitute a ‘gold standard’ or a ‘theoretical-minimum-risk exposure’ (Lim et al. 2012) that ideally everyone should have. A water source may be defined as improved if it takes a 30-min uphill walk to collect the water at a source that only works 4 days per week. A smelly pit latrine that each day produces 2000 culicine mosquitoes able to transmit filariasis (Maxwell et al.1990) may be defined as improved. By contrast, the control group for high blood pressure (the globally leading risk factor) was defined as 110–115 mmHg systolic, a range at the low end assumed to be associated with the lowest risk of all possible values. The equivalent control group for water access would probably be ‘a tap in the house that provides safe water 24 h a day, every day’, and for sanitation, a ‘household and all its neighbours having access to a private flush latrine connected to a sewer or septic tank’. Choosing more stringent criteria for the control group obviously results in higher relative risks. Further, the definition of ‘exposed to poor access to water and sanitation’ impacts on the estimated size of the globally exposed population. A generous definition of improved water access that ignores reliability and distance inevitably reduces exposure prevalence. Finally, the competing risk factors included in the GBD merit attention. The large number of cardio-vascular risk factors included in the GBD not only reflects the widespread occurrence of cardio-vascular disease, but also the widespread occurrence of cardio-vascular disease research, where epidemiologists go fishing with a large net (Beaglehole & Magnus 2002; Ioannidis 2007). Water and sanitation may affect many different conditions such as diarrhoea, soil-transmitted helminths, schistosomiasis, respiratory infection, trachoma, lymphatic filariasis, urinary tract infection and back pain (Hunter et al. 2010; Mara et al.2010), many of which are not accounted for by the GBD. By reducing the overall pathogen load in the environment (possibly a key factor for diarrhoea in poor settings (Taniuchi et al. 2013)), better water and sanitation access may improve gut function, immunity and nutritional status (Humphrey 2009; Ryan 2013). However, little research has been carried out on causal pathways through which water and sanitation may impact on health, a challenge even with a large research budget. In addition, by contributing to education and socio-economic development (Black & Fawcett 2008), water and sanitation (unlike blood pressure drugs) are likely to produce long term, indirect health effects, which will be almost impossible to quantify.
Investing in water and sanitation despite lack of evidence
Even if there was no health impact, the educational, developmental and gender-related benefits of water and sanitation access are large enough to merit investment. The World Bank, in a moment of institutional wisdom during the 1980s, declared that investments in water and sanitation could be economically justified on the basis of time savings alone (Churchill et al. 1987). However, the lack of reliable health impact data remains an obstacle in the health policy arena. New research methods including microbial source tracking and molecular methods may in the future shed more light on gastro-intestinal transmission pathways and the role of water and sanitation (Jenkins et al. 2009; Taniuchi et al. 2013). For now, accepting the often fatal methodological flaws in quantifying health effects of water and sanitation may be an intellectual challenge, but perhaps a necessary step. We may at some point be forced to get out for a bit and walk through an urban slum during the wet season. The lack of high-quality trials on urban sanitation or rural water access should not stop us from opening our eyes – the oldest form of impact assessment. This may sound fantastical, but perhaps, only to the ears of a 21st century academic. There are scientifically plausible and less plausible beliefs. To say that homoeopathy can cure the tubercular miasm inherited from one’s grandfather may sound esoteric to some. It is not esoteric to believe that water and sanitation are upstream interventions, likely to have a broad impact on well-being and health (Hunter et al. 2010; Mara et al. 2010). Whether we like it or not, it could be that beliefs, not randomised controlled trials, will determine whether children in slums will continue to wade through open sewage, and whether school-aged girls in the hills will continue to spend most of their mornings fetching water.
References/Full text – (Link)
Filed under: Sanitation and Health Tagged: Global Burden of Disease
12 March -16h00 : SuSanA–WASHtech webinar on Technology Applicability Framework (TAF)
SuSanA secretariat and WASHtech invites you to participate in a webinar that will present and discuss the Technology Applicability Framework (TAF) developed during the WASHtech project: www.washtechnologies.net
When: 16h00 CET on 12th March 2014 (Time converter: www.worldtimebuddy.com/)
Webinar outline:15h30- Webinar room open 16h00- Welcome by Trevor Surridge (SuSanA secretariat) 16h05- Introduction to TAF by André Olschewski (Skat Foundation) 16h15- Questions on André’s presentation 16h20- Experiences using TAF in Ghana by Benedict Tuffuor (TREND) 16h30- Questions on Benedict’s presentation 16h35- WaterAid’s experience adapting and applying the TAF to a pour-flush toilet option in the Nicaraguan Caribbean by Joshua Briemberg (WaterAid) 16h45- Questions on Joshua presentation leading into an open Q&A session 16h59- Closing and wrap-up from Trevor 17h00- End of Webinar
Webinar Chair: Trevor Surridge (SuSanA secretariat)
Moderation Support: Sean Furey (Skat Foundation)
To participate you need to register:
To register send an email to firstname.lastname@example.org and clearly state “TAF webinar” in the subject and you will be sent an invitation link to the Webinar.
For the technical requirements for WebEx:
- For using WebEx you must have Java installed in your browser and the WebEx plug-in.
- Here you can check and update your java version: java.com/en/download/help/testvm.xml
- Here you can install the WebEx plug-in by joining the testmeeting: www.webex.com/test-meeting.html
If you have any questions about the webinar post them in reply to this post or email them to email@example.com.
Filed under: Education & training, Progress on Sanitation, Sanitary Facilities Tagged: SuSanA, Sustainable Sanitation Alliance, WASHTech, webinars
Hygiene is missing from an important United Nations document on Sustainable Development Goals (SDGs) that will be submitted to the 68th Session of the UN General Assembly.
Several organisations including End Water Poverty, WaterAid, Practical Action and Helvetas have written to the Open Working Group on SDGs saying they regret that hygiene was left out of the Group’s Focus areas document.
The Global Public-Private Partnership for Handwashing (PPPHW) is calling on its supporters to advocate for the inclusion of hygiene alongside water and sanitation in the SDGs in the Open Working Group consultations before the closing date of 14 March 2014. Similarly, the PPPHW is requesting support for hygiene in the Sustainable Development Solutions Network (SDSN) consultation, which also ends on 14 March.
The PPPHW offers talking points to advocate for hygiene in the SDGs, such as:
The word “hygiene” means different things to different people. In the post-2015 WASH proposal, hygiene focuses on handwashing promotion, including access to a designated place for handwashing with soap and water, and menstrual hygiene management or the presence of gender-segregated sanitation facilities in schools and health centers with access to soap and water and a place for safe disposal of menstrual hygiene materials
More information: PPPHW Soapbox – Handwashing Advocacy Edition
Filed under: Campaigns and Events, Hygiene Promotion Tagged: advocacy, Global Public-Private Partnership for Handwashing, Sustainable Development Goals
UN partners WSSCC and OHCHR gather diverse stakeholders to foreground sanitation, rights and dignity for women
Grass-roots activists shared inspirational experiences on reducing female circumcision in Senegal, raising awareness of lesbian and transgender issues in Nepal and working for the dignity of sex workers in India at a special meeting at the United Nations headquarters in Geneva on Friday, 7 March 2014.
Ahead of International Women’s Day on Saturday 8 March, joint hosts the Water Supply and Sanitation Collaborative Council (WSSCC) and the Office for the High Commissioner for Human Rights (OHCHR) organized a one-day event on Inspiring Change to Promote Women’s Rights and Dignity.
“This meeting focused on the fundamental rights of women, to examine current policy and practice as well as challenges to women’s empowerment across their life cycle, looking at vulnerable groups through the lens of water, sanitation and hygiene,” said WSSCC Executive Director Chris Williams as he welcomed some 70 participants from health, sanitation and rights groups across the world.
In keeping with the 2014 International Women’s Day theme of ‘Inspiring Change’, representatives from India, Nepal and Senegal shared often very personal experiences of fighting for change and improving women’s rights in their home country. The experiences shared showed how human rights and access to water, sanitation and hygiene are inextricably linked.
“Women [in Nepal] are treated as second class citizens and among these women, lesbian and transgender women are considered even lower,” said Shyra Karki, a lesbian activist working for the lesbian and transgender community in Nepal.
As a result of this low-status, such women are extra vulnerable to health complications or are excluded from accessing basic sanitary facilities.
“Transgender women who dress as men,” said Karki, “they are embarrassed to go and buy sanitary napkins, they are embarrassed to go to the hospital if they are ill or to go to have gynecological check up.”
OHCHR and WSSCC hope that this jointly sponsored event will inspire the UN community, governments and business to take action to fulfill all women’s rights, including access to sanitation, water and hygiene.
“Water, sanitation and hygiene are internationally agreed human rights with attending obligations,” said Craig Mokhiber, Chief, Development and Economic and Social Issues Branch, OHCHR. “And as we have heard today, the obligations of meeting these rights are different with regard to women than regard to men.”
According to Mr Mokhiber, the right to water, sanitation and hygiene is “an enormous human rights challenge of the twenty first century that has yet to be met.”
WSSCC will prepare a summary report from the event for publication in the coming weeks. To receive a copy of the report, send an email to firstname.lastname@example.org.
Filed under: Uncategorized
UN Women and Water Supply and Sanitation Collaborative Council in partnership to improve access to hygiene and sanitation for women and girls
Louga, 9 March 2014 – On the margins of International Women’s Day commemorations across Senegal and West and Central Africa, the United Nations Entity for Gender Equality and Women’s Empowerment (UN Women) and the Water Supply and Sanitation Collaborative Council (WSSCC) have formed an official partnership. The aim is to take action and to strengthen policies in health, hygiene and sanitation in order to contribute to improving economic and social living conditions for women and girls in West and Central Africa.
The programme was launched during a ceremony in Louga, in northern Senegal. It will directly affect women, who are the main users and managers of water and sanitation in sub-Saharan Africa. The programme will be regional in scope. More specifically, it will cover Senegal, Niger and Cameroon, as well as Benin, Liberia, Niger, Sierra Leone and Togo through ECOWAS, the Economic Community Of West African States.
Equity and inclusion are key areas WSSCC’s work and an essential part of the UN Women mandate. They are among the main priorities of WSSCC, which has menstrual hygiene management as one its flagship programmes.
“Women must be involved in the decision-making processes. They must be equipped and informed, and must have areas for managing their personal hygiene. In this regard, sanitation is an entry point for their empowerment. It will allow them to pursue their education and, later, to be more productive in working areas that are clean and have proper facilities,” said Archana Patkar, WSSCC Programme Manager for Networking & Knowledge Management.
Lack of equity and inclusion are among the most serious obstacles to achieving the goals set by governments for water, sanitation and hygiene. In terms of service access and use, significant inequalities remain between rural and urban areas, marginalized and excluded groups, and the most vulnerable people.
Women represent one of the most marginalized groups. Lack of sanitation has harmful consequences for their health, education and environment. For women, in addition to a lack of privacy and dignity, there are also serious effects on their reproductive and maternal health. These are due to poor management of menstrual hygiene, faecal-oral contamination, and diseases caused by various factors including a lack of infrastructure and lack of appropriate information and facilities.
In delivering UN Women’s Executive Director message at the occasion of International Women’s Day, Dr Josephine Odera, UN Women Regional Director for West and Central Africa stressed on the importance of sanitation and hygiene as part of women’s access to health “this partnership comes just at the right moment. This year, the theme for International Women’s Day reminds us that equality for women is progress for all. That is valuable for all sectors. The water, hygiene and sanitation sector is a key sector. Outcomes can be achieved through programmes like this, with gender-specific budgets and greater awareness-raising.”
In 2014, “some 2.5 billion people around the world, approximately one third of the world’s population, still do not have access to toilets. The number of people practising open defecation fell by 244 million to 1.04 billion in 2011.”1 In sub-Saharan Africa, that figure continues to increase. Throughout Africa, over 25 per cent of the population practices open defecation. In Cameroon, the figure is 6 per cent, compared with 17 per cent in Senegal and 78 per cent in Niger.
The figures cited in this press release come from the 2013 report of the WHO/UNICEF Joint Monitoring Programme. They can be found by following this link:http://www.wssinfo.org/fileadmin/user_upload/resources/JMPreport2013.pdf
- Mariam Kamara, UN Women Regional Communications Officer│Mariam.email@example.com
- Rockaya Aidara, WSSCC Advocacy & Communications Programme Officer│ Rockaya.firstname.lastname@example.org
Filed under: Uncategorized
How can Community Led Total Sanitation (CLTS) and other programmatic approaches be integrated into a service-led rural sanitation delivery? This was the topic that attracted around 70 practitioners from 16 different countries to Cotonu, Benin in November 2013 for a Learning and Exchange workshop ”Towards sustainable total sanitation”. The workshop was organised by IRC International Water and Sanitation Centre in partnership with WaterAid, SNV and UNICEF.
The key findings of the workshop a presented in a new report, which is divided into four categories, covering the four conditions to trigger a service:
- strengthening the enabling environment
- demand creation and advocacy to change behaviour
- strengthening the supply chain, and
- appropriate incentives and financial arrangements.
Filed under: Africa, Campaigns and Events, Publications Tagged: behaviour change, Community-Led Total Sanitation, IRC International Water and Sanitation Centre, rural sanitation, sanitation service chains, sanitation services, SNV, unicef, WaterAid, West Africa
Despite the widespread implementation of Community Led Total Sanitation (CLTS) programs and many claims of success, there has been very little systematic investigation into their sustainability. A new study, which aims to change that, is creating a stir in the WASH sector.
A study commissioned by Plan International on the sustainability of CLTS programs in Africa revealed that 87% of the households still had a functioning latrine. This would indicate a remarkably low rate of reversion (13%) to open defecation (OD) or “slippage”.
However, if the criteria used to originally award open defecation free (ODF) status to villages are used, then the overall slippage rate increased dramatically to 92%. These criteria are:
- A functioning latrine with a superstructure
- A means of keeping flies from the pit (either water seal or lid)
- Absence of excreta in the vicinity of the house
- Hand washing facilities with water and soap or soap-substitute such as ash
- Evidence that the latrine and hand washing facilities were being used
The study, conducted by Australian-based consultants FH Designs, investigated results in CLTS programs operated by Plan International in Ethiopia, Kenya, Uganda and Sierra Leone. Data was collected in 4960 households in 116 villages where CLTS had been triggered and communities declared ODF two or more years before the study commenced in March 2012.Key factors preventing or causing slippage
The study looked at the main motivators/enablers and de-motivators/barriers for households and communities to invest in and maintain use of latrines. The results of this analysis, based on interviews with 1200 households across more than 50 communities, are summarised below.
In contrast to previous research and perceptions, one remarkable finding was that health was the most cited motivator for initially building a latrine in both ODF and OD households and for maintaining a latrine in ODF households.Key recommendations
The study identified several key practice implications for future CLTS programs including:
- a need to more effectively address improved hand washing behaviours as part of sanitation programs;
- the value of incorporating at appropriate times in the CLTS process health messaging as a motivator for both uptake of sanitation and maintenance of latrines;
- greater (and more targeted) post-triggering follow up and support for households;
- the value of ensuring maximum household and family member participation in triggering events; and
- the importance of improved access to finance and market supplies of higher quality latrine materials to allow households to upgrade from basic latrines – in the absence of this the study found virtually no movement up the sanitation ladder from simple pit latrines built using local bush materials
Source: Tyndale-Biscoe, P., Bond, M, and Kidd, R., 2013. ODF sustainability study. Plan International. Read the 2-page summary + full report at: www.communityledtotalsanitation.org/reso…inability-study-plan
Filed under: Africa, Hygiene Promotion, Publications, Research, Sanitary Facilities Tagged: Community-Led Total Sanitation, Ethiopia, handwashing, Kenya, Plan International, Sierra Leone, slippage, Sustainability, Uganda
George Washington University Study Highlights Limited Progress in Water and Sanitation Access Among Major Sub-Saharan African Cities | Source: George Washington University, School of Public Health |
Sub-Saharan Africa’s urban population is predicted to nearly triple by 2050, increasing from 414 million to over 1.2 billion. This growth challenges municipalities attempting to provide basic access to water supply and sanitation (WS&S). A new analysis published in BMC Public Health by researchers at the George Washington University School of Public Health and Health Services (SPHHS) looks at how well cities in sub-Saharan Africa are doing when it comes to providing their urban residents with access to basic public health infrastructure.
Mike Hopewell, a recent graduate of the MPH program at SPHHS, and Jay Graham, an SPHHS assistant professor of environmental and occupational health, estimated changes in access to water supply and sanitation in the largest cities across sub-Saharan Africa between 2000 and 2012. They then explored the relationship of city-level and country-level factors to progress or regression in these cities.
The authors found that cities appeared to be making the most progress in gaining access to WS&S along metrics that reflect specified targets of the Millennium Development Goals (MDGs), global targets for improved wellbeing that countries aim to achieve by 2015. Nearly half of the cities, however, did not make progress in reducing open defecation or the time households spent collecting water. This may reflect a focus on “improved” services that are MDG targets while other measures, potentially more relevant to the extreme poor, are being neglected. This study highlights the need to better characterize access, beyond definitions of improved and unimproved, as well as the need to target resources to cities where changes in WS&S access have stalled, or in some cases regressed.
Filed under: Africa, Progress on Sanitation Tagged: urban WASH
WSUP believes that the issue of gender inclusion is fundamental to effective WASH service provision. To mark International Women’s Day and to recognise the importance of this issue, we have produced a new Practice Note which provides a contextual background on gender issues in WASH, before illustrating what a gender-inclusive approach looks like in practice. This Practice Note is based on direct experience of communal sanitation in Maputo (Mozambique) and Naivasha (Kenya), and demonstrates how the concerns of women and girls can be addressed at every step of programme planning and implementation.
This is a free resource and is available for download by clicking on the image above or visiting our online resource library.
Filed under: Africa, Publications, Resources, Sanitary Facilities, Uncategorized Tagged: communal sanitation, gender, inclusive sanitation, International Women's Day, Kenya, Maputo, Mozambique, Naivasha, sanitation, urban sanitation
The Sustainable Sanitation Alliance (SuSanA) and GIZ together with Goethe Institute Max Müller, the Indian Institute for Cartoonists and EAWAG/Sandec invite creative minds to submit fun and striking ideas about toilets and sanitation in the form of Cartoons, Caricatures or Infographics that will create a humorous atmosphere around sanitation concerns. Because sanitation in India is still a taboo; the media doesn’t address the issue often enough and people feel uncomfortable talking about it, even though it’s an issue that concerns all of us – several times a day, every day. We are flexible with the entry’s format as long as it:
Surprises the silent majority and makes them laugh and talk about sanitation!
So what’s the cartoon competition all about?
- The idea is to have a cartoon competition on the topic of sanitation and toilets.
- The inspiration comes from the ‘Reinvented Toilets’ Programme by the Gates Foundation.
- The approach taken by the Cartoon-Competition is, however, one both smaller in scale and more abstract in style.
- The essence of the endeavour is to break the taboo that surrounds talking about sanitation and toilets in India with humor and laughter.
The deadline for submitting entries is Monday, 10 March, 2014 (midnight Indian Standard Time).
20 Cartoons, Caricatures and/or Infographics will be pre-selected and exhibited during the celebration of the World Water Day, 22 March in Jor Bagh, New Delhi. The five member pre-selection jury will consist of representatives of the organising and partner institutions:
- Three representatives from GIZ/SuSanA
- One representative from the Indian Institute of Cartoonists
- One representative from Max Mueller Bhavan
The event to award the winners will be held on 22 March, 2014 as part of the celebration of the World Water Day at GIZ-premises in New Delhi. During the celebration of the World Water Day, five outstanding works will be chosen by the guest in attendance voting for their favourite work. The five most favoured works will be awarded with:
- 1st Prize of ₹ 50,000
- 2nd Prize of ₹ 20,000
- 3rd , 4th and 5th prizes of ₹ 5.000 respectively.
If you too are excited by this idea, you are more than welcome to participate and to spread the word among friends and colleagues. You are also invited to share the cartoon competition in your blog, your homepage, facebook, twitter etc.
Filed under: Campaigns and Events, Hygiene Promotion, Progress on Sanitation, South Asia Tagged: cartoon contest, India
Adam Smith International are procuring for external evaluators (consultants or firm) to evaluate the Sierra Leone WASH Facility.
The Facility, which has a total budget of £5 million (US$ 8.4 million), is managed and administered by Adam Smith International, on behalf of DfID and the Government of Sierra Leone (particularly the Ministry of Water Resources, and Ministry of Health & Sanitation).
The evaluation covers the Facility mechanism itself, and its portfolio of 36 projects funded by small grants all less than £200,000 (US$ 330,000) each.
It is expected the evaluation will require approximately 60-80 days total level of effort. Organisations or individuals that have been financed by the WASH Facility cannot apply.
Deadline for applications: 6pm (GMT) 14th March 2014
For full details and application guidelines please consult the attached Terms of Reference.
Please do not send applications or requests for information to Sanitation Updates.
Filed under: Africa, Funding Tagged: Adam Smith International, Evaluations, Sierra Leone, tenders
“SuperAmma” campaign results in significant improvements in people’s handwashing behaviour | Source: SHARE, Feb 27 2014 |
A unique handwashing campaign jointly funded by SHARE and the Wellcome Trust has shown for the first time that using emotional motivators – such as feelings of disgust and nurture – rather than health messages, can result in significant, long-lasting improvements in people’s handwashing behaviour, and could in turn help to reduce the risk of infectious diseases.
“Every year, diarrhoea kills around 800,000 children under 5 years old. Handwashing with soap could prevent perhaps a third of these deaths”, explains study author Dr Val Curtis, from the London School of Hygiene & Tropical Medicine (LSHTM).
“Handwashing campaigns usually try to educate people with health messages about germs and diseases, but so far efforts to change handwashing behaviour on a large scale have had little success. Understanding the motivating factors for routine hand washing is essential to any initiative likely to achieve lasting behaviour change.”
An evaluation of the behaviour-change intervention, published by the Lancet Global Health journal today, shows that 6 months after the campaign was rolled out in 14 villages in rural India, rates of handwashing with soap increased by 31%, compared to communities without the programme, and were sustained for 12 months.
The intervention adapted the open access SHARE-funded global toolkit, and targeted emotional drivers found to be the most effective levers for behaviour change: disgust (the desire to avoid and remove contamination), nurture (the desire for a happy, thriving child), status (the desire to have greater access to resources than others), and affiliation (the desire to fit in).
At the start of the study, handwashing with soap was rare in both the intervention and control groups (1% vs 2%). After 6 weeks, handwashing was more common in the intervention group (19% vs 4%), and after 6 months, compliance in the intervention group had increased to 37% compared with 6% in the control group. One year after the campaign, and after the control villages had received a shortened version of the intervention, rates of handwashing with soap were the same in both groups (29%).
According to study co-author Katie Greenland, from LSHTM, “the SuperAmma campaign appears to be successful because it engages people at a strong emotional level, not just an intellectual level, and that’s why the behavioural change was long-lasting. Whether the observed increase in handwashing with soap is sufficient to reduce infection remains unclear, but in view of our promising results, public health practitioners should consider behaviour change campaigns designed along the lines of our approach.”
- Access the journal paper
- Listen to study author Dr Val Curtis talk about what drives handwashing behaviour
- Listen to a podcast by co-author Katie Greenland
- Access the SuperAmma Campaign website – includes all information on the campaign, including a video
- Access the Choose Soap open access toolkit
Filed under: Hygiene Promotion Tagged: handwashing, Superamma
Toilets, trash and social status: the top 10 emergency hygiene challenges | Source/Complete article: Kathy Migiro, Thomson Reuters Foundation | Feb 17 2014
Excerpts: NAIROBI (Thomson Reuters Foundation) – More than 900 beneficiaries, field practitioners and donors named their most pressing gaps in emergency water, sanitation and hygiene promotion (WASH) services in a 2013 survey.
Here are the top 10 gaps HIF will tackle (in no particular order):
1) Latrine lighting - In many refugee camps, latrines are not lit at night making them dangerous for women to use.
Challenge: To light communal latrines at night in a cheap and sustainable manner.
2) Space saving jerrycan - In emergencies, agencies traditionally buy and distribute jerrycans, which can mean transporting 15 or 20 litres of air. Collapsible jerrycans only last a couple of months before they start leaking.
Challenge: To design a 15 litre jerrycan, costing less than $5, with limited volume when stored, lasting one year.
3) Excreta disposal in urban emergencies - Earthquakes and floods often cut off urban water supplies and damage toilets. When large numbers of displaced people gather in safe places like schools, sanitation facilities get overwhelmed. Many agencies build raised latrines. But they need to be emptied frequently, with waste being dumped in purpose-built pits or rivers, creating health risks.
Challenges: To develop new products to provide safe excreta disposal in urban environments after disasters. Solutions should consider not only containment, but also emptying and disposal mechanisms.
4) Hygiene promotion - It is extremely difficult to get most people to wash their hands during or after an emergency. Affected populations often do not use water and sanitation facilities because they consider them inappropriate to their needs or social status or were not involved in their design.
Challenges: To design an approach to enable agencies to better include affected populations and ensure they adopt safe hygiene practices. How can hand-washing products be combined with social marketing to make it desirable for affected communities to wash their hands?
5) Low cost desalination - In coastal Asia, there is a substantial increase in brackish water due to tidal surges, sea level rise and over abstraction. In drought-prone regions, people have to walk further to get potable water because of high evaporation and poor irrigation practices.
Challenge: To develop desalination technologies to provide sufficient drinking water in different emergency scenarios.
6) Drainage solutions - Spillage from taps in camps, waste water from washing areas and rain can create large muddy ponds where mosquitoes and parasitic worms breed.
Challenge: To propose a new, low-cost drainage system that eliminates standing water where soil has low permeability.
7) Rubbish management - Rubbish builds up where there are large groups of displaced people. Some agencies burn waste in pits but it can be difficult to incinerate completely while others have set up recycling projects.
Challenges: To design a low-cost, environment-friendly incinerator for rapid deployment to disaster zones. Secondly, to develop a new approach for solid waste management in camps.
8) Groundwater mapping - There is often conflict with local communities when displaced people rely upon shared ground water supplies.
Challenge: To develop a system to map and share information about aquifers in emergencies and estimate the sustainable abstraction rate throughout the seasons.
9) Public health risk mapping - There is little documented evidence of the public health risks in emergencies. Agencies focus on providing water and sanitation without a detailed analysis of the causes, sources and vectors of disease transmission.
Challenge: To collate evidence on the impact of public health risks and design a tool to assess these risks.
10) Marketing latrines - After disasters, people are often reluctant to invest in their own latrines because they do not see the need or cannot afford to buy construction materials.
Challenge: To promote the construction of latrines after disasters. The focus should be on comfort, convenience, avoidance of filth or promotion of social status as research shows these motivate people more than health issues.
Filed under: Emergency Sanitation, Hygiene Promotion Tagged: emergency relief, hygiene
Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study. PLoS One, Feb 2014.
Fiona Majorin, et al
Background – An estimated 2.5 billion people worldwide lack access to improved sanitation facilities. While large-scale programs in some countries have increased latrine coverage, they sometimes fail to ensure optimal latrine use, including the safe disposal of child feces, a significant source of exposure to fecal pathogens. We undertook a cross-sectional study to explore fecal disposal practices among children in rural Orissa, India in villages where the Government of India’s Total Sanitation Campaign had been implemented at least three years prior to the study.
Methods and Findings – We conducted surveys with heads of 136 households with 145 children under 5 years of age in 20 villages. We describe defecation and feces disposal practices and explore associations between safe disposal and risk factors. Respondents reported that children commonly defecated on the ground, either inside the household (57.5%) for pre-ambulatory children or around the compound (55.2%) for ambulatory children. Twenty percent of pre-ambulatory children used potties and nappies; the same percentage of ambulatory children defecated in a latrine. While 78.6% of study children came from 106 households with a latrine, less than a quarter (22.8%) reported using them for disposal of child feces. Most child feces were deposited with other household waste, both for pre-ambulatory (67.5%) and ambulatory (58.1%) children. After restricting the analysis to households owning a latrine, the use of a nappy or potty was associated with safe disposal of feces (OR 6.72, 95%CI 1.02–44.38) though due to small sample size the regression could not adjust for confounders.
Conclusions – In the area surveyed, the Total Sanitation Campaign has not led to high levels of safe disposal of child feces. Further research is needed to identify the actual scope of this potential gap in programming, the health risk presented and interventions to minimize any adverse effect.
Filed under: Sanitation and Health Tagged: child feces disposal, India
The African Ministers’ Council on Water (AMCOW) needs the services of a training service provider to carry out a sanitation and hygiene policy training needs analysis and training of focal persons in Burundi, Chad, Sierra Leone and Zimbabwe.
The aim of this small (20 days) but interesting assignment is to:
train the focal countries on the process of developing a policy document and costed implementation plans and strategies for ending open defecation in those countries, and how to operationalise them.
The assignment supports a US$ 2 million Gates Foundation funded policy and advocacy project being implemented by AMCOW .
Closing date for receipt of applications is March 7, 2014.
Read the full Terms of Reference.
Please do not submit applications or requests for information to Sanitation Updates.
Filed under: Africa, Education & training, Policy Tagged: AMCOW, Bill & Melinda Gates Foundation, Burundi, Chad, consultancy, Sierra Leone, Zimbabwe
SHARE-funded research  has found that Moringa oleifera, a common plant in many tropical and subtropical countries, can be an effective handwashing product if used in the correct concentration. Laboratory tests show that the plant has antibacterial activity against different pathogen, but its potential effect as a hand washing product had not been studied before.
By testing the effect of Moringa oleifera leaf powder on hands artificially contaminated with E. coli and comparing this to the effect of non-medicated liquid soap, the researchers from the London School of Hygiene and Tropical Medicine and SBI Consulting Ltd in Mozambique found that four grams of Moringa oleifera powder had the same effect as non-medicated soap when used for hand washing.
The next step will be to try this product in real conditions and study its acceptability and convenience for potential users.
SHARE stands for Sanitation and Hygiene Applied Research for Equity, and is a five year initiative (2010-2015) funded by the UK Department for International Development
 Torondel, B., Opare, D., Brandberg, B., Cobb, E. and Cairncross, S., 2014. Efficacy of Moringa oleifera leaf powder as a hand- washing product : a crossover controlled study among healthy volunteers. BMC complementary and alternative medicine, 14 (57), pp. 1-7. doi:10.1186/1472-6882-14-57
Source: SHARE, 21 Feb 2014
Filed under: Africa, Hygiene Promotion, Publications, Research Tagged: handwashing, London School of Hygiene and Tropical Medicine, Moringa oleifera, Moringa oleifera powder, SBIConsulting, SHARE Consortium, soap
Benin – Behaviour change, a must for improved sanitation | Source/complete article: Edmund Smith-Asante | Graphic.com – 21 February 2014
Excerpts - Benin’s Minister of Health, Professor Dorothéme Kinde Gazard, has called on African nations to lay emphasis on behaviour change communication, as it is the surest way to achieve improved sanitation.
Disclosing that 87 per cent of Africans were still engaged in open defecation, while only three out of 10 people washed their hands with soap, she stated, “So the challenge is also on behaviour change.”
The Health Minister therefore urged African countries to strike a balance between change in behaviour and the provision of sanitation facilities.
Governments’ Commitments to WASH
Professor Dorothéme Gazard made the statements when she addressed the opening of a three-day regional workshop on “Advocacy, Communications and Monitoring of [water, sanitation and hygiene] WASH Commitments” for selected journalists, in Cotonou on Tuesday.
The workshop, which is being organised by the Water Supply and Sanitation Collaborative Council (WSSCC), WaterAid West Africa (WAWA) and the West Africa Water and Sanitation Journalists Network (WASH-JN), in collaboration with Benin’s Ministry of Health, has attracted over 30 participants from West and Southern Africa.
Countries being represented include Ghana, Liberia, Cote d’Ivoire, Guinea Bissau, Burkina Faso, Nigeria, Niger, Sierra Leone, Senegal, Guinea, Benin, Togo, Gambia, Mali, Cameroun, and Malawi.
The aim of the workshop is to alert the media on their responsibility to hold their governments accountable on the commitments made towards the improvement of water, sanitation and hygiene services, especially in international conventions and at national, regional and international fora.
Use of Local Languages
Professor Gazard advocated the use of local languages by non-governmental organisations (NGOs), civil society and the media, for behaviour change communication, saying; “It is only through this, that we can achieve change in behaviour.”
She said although African nations faced immense challenges in the provision of water, sanitation and hygiene services, countries had not given them much attention, adding that because the issues had gained international recognition, they would be an essential component of the post 2015 millennium development goals (MDGs) evaluation.
Urging participants to support their government’s commitment towards the provision of potable water and improved sanitation, she said ‘No other issue suffers such disparity between its human importance and its political priority,’ quoting former United Nations Secretary General, Kofi Annan.
- Source/complete article: Edmund Smith-Asante | Graphic.com – 21 February 2014
Filed under: Africa, Progress on Sanitation, Sanitary Facilities Tagged: Benin
Issue 135 February 21, 2014 | Focus on WASH-Related Diseases
This issue contains recent studies and reports on several WASH-related diseases: neglected tropical diseases (NTDs), malnutrition, cholera, diarrhea, fluorosis, and malaria. Some of the resources include: a WASH and NTDs global manual and country reports from the Sightsavers Innovation Fund; an article on the origins of the cholera outbreak in Haiti; a review of evidence linking WASH, anemia, and child growth; Cochrane Reviews on the prevention and control of malaria; and additional studies and resources.
We welcome your suggestions for future issues of the Weekly. Topics for upcoming issues include World Water Day 2014, WASH and nutrition, behavior change, community-led total sanitation, household water treatment, and menstrual hygiene management.
Human Health and the Water Environment: Using the DPSEEA Framework to Identify the Driving Forces of Disease. Science of the Total Environment, 2014. J Gentry-Shields.(Link)
There is a growing awareness of global forces that threaten human health via the water environment. A better understanding of the dynamic between human health and the water environment would enable prediction of the significant driving forces and effective strategies for coping with or preventing them. This report details the use of the Driving Force–Pressure–State–Exposure–Effect–Action (DPSEEA) framework to explore the linkage between water-related diseases and their significant driving forces.
Seasonal Effects of Water Quality: The Hidden Costs of the Green Revolution to Infant and Child Health in India, 2013. E Brainerd. (Link)
This paper examines the impact of fertilizer agrichemicals in water on infant and child health using water quality data combined with data on child health outcomes from the Demographic and Health Surveys of India. The results indicate that children exposed to higher concentrations of agrichemicals during their first month experience worse health outcomes on a variety of measures; these effects are largest among the most vulnerable groups, particularly the children of uneducated poor women living in rural India.
Water, Sanitation and Hygiene: Evidence Paper, 2013. Department for International Development. (Link)
This paper aims to provide an accessible guide to existing evidence, including a conceptual framework for understanding how WASH impacts health and well-being and a description of methods used for ascertaining the health, economic, and social impacts of WASH. It also presents the available evidence on the benefits and cost-effectiveness of WASH interventions.
NEGLECTED TROPICAL DISEASES
WASH and the Neglected Tropical Diseases: A Global Manual for WASH Implementers, 2014. Sightsavers, et al. (Link) | (Blog post)
These manuals are free to download and distribute. New users must create an account to download the manuals, which are divided into disease-specific chapters that describe the transmission cycle, symptoms, and disease burden of the WASH-related NTDs. Each chapter includes information about WASH activities that are most essential to the control of each disease. Maps of disease prevalence are provided to enable identification of disease-endemic communities most in need of sustainable WASH services. Country-specific versions of the manual are available so far for Brazil, Burkina Faso, Cameroon, Chad, Ethiopia, Indonesia, Kenya, Malawi, Mali, Mozambique, Nigeria, Sudan, Tanzania, and Uganda.
Integrating WASH into NTD Programs: A Desk Review, 2013. WASHplus. (Link)
This desk review found that the international community recognizes that drug administration alone is insufficient to break the cycle of disease transmission. Although past programs have largely left out a WASH component, there is current renewed interest in securing WASH to any global NTD control or elimination strategy and adding WASH interventions to NTD treatment programs, which are considered essential to achieving sustained control and elimination.
Water, Sanitation, and Hygiene (WASH), Environmental Enteropathy, Nutrition, and Early Child Development: Making the Links. Annals of the New York Academy of Sciences,Jan 2014. F Ngure. (Link)
The authors review evidence linking WASH, anemia, and child growth and highlight pathways through which WASH may affect early child development, primarily through inflammation, stunting, and anemia. Environmental enteropathy, a prevalent subclinical condition of the gut, may be a key mediating pathway linking poor hygiene to developmental deficits. Current early child development research and programs lack evidence-based interventions to provide a clean play and infant feeding environment in addition to established priorities of nutrition, stimulation, and child protection.
The Cholera Outbreak in Haiti: Where and How Did It Begin? Current Topics in Microbiology and Immunology, 2013. D Lantagne, Tufts University. (Link)
Findings indicated that the 2010 Haiti cholera outbreak was caused by bacteria introduced into Haiti as a result of human activity; more speciﬁcally by the contamination of the Meye Tributary System of the Artibonite River with a pathogenic strain of the current South Asian-type Vibrio cholerae. Recommendations were presented to assist in preventing the future introduction and spread of cholera in Haiti and worldwide.
Cholera Transmission Dynamic Models for Public Health Practitioners. Emerging Themes in Epidemiology, Jan 2014. Chun-Hai Fung. (Link)
This paper provides a brief introduction to the basics of ordinary differential equation models of cholera transmission dynamics. The authors discuss a basic model adapted from Codeço (2001), and how it can be modified to incorporate different hypotheses, including the importance of asymptomatic or inapparent infections, and hyperinfectious V. cholerae and human-to-human transmission. The paper also highlights three important challenges of cholera models: model misspecification and parameter uncertainty, modeling the impact of WASH interventions, and model structure.
Cholera Toolkit, 2013. UNICEF. (Link)
This toolkit provides guidance primarily for the health and WASH sectors; nevertheless, guidelines are presented in an integrated manner to avoid the continuation of “silo” approaches for cholera prevention, preparedness, and response. In addition, the toolkit includes specific content linked to education, nutrition, communication for development, child protection, and other relevant sectors.
Comparing Sociocultural Features of Cholera in Three Endemic African Settings. BMC Medicine, 2013. C. Schaetti. (Link)
This comprehensive review identified common and distinctive features of local understandings of cholera. Classical treatment (that is, rehydration) was highlighted as a priority for control in the three African study settings and is likely to be identified in the region beyond. Findings indicate the value of insight from community studies to guide local program planning for cholera control and elimination.
Impact of Water and Sanitation Interventions on Childhood Diarrhea: Evidence from Bangladesh 3ie Grantee Final Report, 2013. S Begum. (Link)
This paper analyzes the possible relevance of water and sanitation improvements for diarrhea reduction in the context of Bangladesh. Much of the public policy thinking in the past was guided by public investment in providing improved access to water. The paper provides evidence that the relevance of water as a tool for fighting diarrhea may have changed over time.
Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The Integrated Global Action Plan for Pneumonia and Diarrhoea, 2013. WHO/UNICEF.(Link)
This action plan proposes a cohesive approach to ending preventable pneumonia and diarrhea deaths. It brings together critical services and interventions to create healthy environments, promotes practices known to protect children from disease, and ensures that every child has access to proven and appropriate preventive and treatment measures.
The Lancet Series on Childhood Pneumonia and Diarrhea, 2013. (Link)
This series provides evidence for integrated control efforts for childhood pneumonia and diarrhea. The first paper assesses the global burden of these two illnesses, comparing and contrasting them, and includes new estimates of severe disease and updated mortality estimates for 2011. Findings from the second paper show that a set of highly cost-effective interventions can prevent most diarrhea deaths and nearly two-thirds of pneumonia deaths by 2025, if delivered at scale. The third paper presents the results of consultations with several hundred frontline workers in high-burden countries and explores the barriers and enablers they face in dealing with these two diseases and potential ways forward. The final paper represents a call to action and discusses the global and country-level remedies needed to eliminate preventable deaths from these illnesses by 2025.
Heavy Rainfall Events and Diarrhea Incidence: The Role of Social and Environmental Factors. Am J Epidemiol. Feb. 2014. E Carlton. (Abstract/order info)
The impact of heavy rainfall events on waterborne diarrheal diseases is uncertain. The authors conducted weekly, active surveillance for diarrhea in 19 villages in Ecuador from February 2004 to April 2007 to evaluate whether biophysical and social factors modify vulnerability to heavy rainfall events. Heavy rainfall events were associated with increased diarrhea incidence following dry periods and decreased diarrhea incidence following wet periods. Drinking water treatment reduced the deleterious impacts of heavy rainfall events following dry periods. Sanitation, hygiene, and social cohesion did not modify the relationship between heavy rainfall events and diarrhea.
Fluorisis Factsheet, n.d. World Health Organization. (Link)
Ingestion of excess fluoride, most commonly in drinking water, can cause fluorosis, which affects the teeth and bones. Moderate amounts lead to dental effects, but long-term ingestion of large amounts can lead to potentially severe skeletal problems. Paradoxically, low levels of fluoride intake help to prevent dental caries. The control of drinking-water quality is therefore critical in preventing fluorosis.
Health Based targets and Integrated Fluorosis Mitigation: Findings from Madhya Pradesh, India, 2013. S Godfrey, UNICEF. (Presentation)
This presentation gives an introduction to fluorosis, its health impacts, and mitigation methods.
De-Fluoridation, n.d. Akvopedia. (Link)
Treatment at the household level has several advantages over treatment at the community level. Costs are lower, as defluoridation can be restricted to the demand for cooking and drinking, which is usually less than the total water demand. This treatment option may be feasible in less developed countries especially in rural areas, where settlements are scattered.
For Sustainable Control of Malaria in Sudan: No More Broken Water Pipes and Water Containers! Malaria World, Jan 2014. B Knols. (Link)
Leakages of broken water pipes are becoming a major resource for the main malaria vector in Sudan. Reporting and /or treating of these pipes and water containers by community members, through affordable rational choice of larvicides, and by using citizen reporting tools, can have effective results that might support the sustainability of the tremendous malaria control efforts on the part of health observers.
Larvivorous Fish for Preventing Malaria Transmission. Cochrane Library Review, Dec 2013. D Walshe. (Link)
Research evidence is insufficient to show whether introduction of larvivorous fish reduces the number of Anopheles larvae and pupae in water sources (nine studies, unpooled data, very low quality evidence). However, larvivorous fish may reduce the number of water sources with Anopheles mosquito larvae and pupae (five studies). None of the included studies examined the effects of introducing larvivorous fish on other native species present, but these studies were not designed to do this. Before much is invested in this intervention, better research is needed to determine the effect of introducing larvivorous fish on adult Anopheles populations and on the number of people infected with malaria. Researchers need to use robust controlled designs with an adequate number of sites. Also, researchers should explore whether introducing these fish affects native fish and other non-target species.
Mosquito Larval Source Management for Controlling Malaria. Cochrane Summaries, Aug 2013. L Tusting. (Abstract/order info)
Larval source management (LSM) aims to reduce malaria and targets immature mosquitoes, which are found in standing water, before they develop into flying adults. This is done by permanently removing standing water, for example by draining or filling land; making temporary changes to mosquito habitats to disrupt breeding, for example by clearing drains to make the water flow; or by adding chemicals, biological larvicides, or natural predators to standing water to kill larvae. Where larval habitats are not too extensive and a sufficient proportion of these habitats can be targeted, LSM probably reduces the number of people that will develop malaria, and probably reduces the proportion of the population infected with the malaria parasite at any one time. LSM was shown to be effective in Sri Lanka, India, the Philippines, Greece, Kenya, and Tanzania, where interventions included adding larvicide to abandoned mine pits, streams, irrigation ditches and rice paddies where mosquitos breed, and building dams, flushing streams, and removing water containers from around people’s homes.
WASHplus Weeklies will highlight topics such as Urban WASH, Indoor Air Pollution, Innovation, Household Water Treatment and Storage, Hand Washing, Integration, and more. If you would like to feature your organization’s materials in upcoming issues, please send them to Dan Campbell, WASHplus Knowledge Resources Specialist, at email@example.com.
Filed under: Sanitation and Health Tagged: cholera, diarrhoeal diseases, fluorisis, malaria, malnutrition, neglected tropical diseases
Don’t Look, Don’t Touch! Brains and behaviour from a disgust perspective, by Valerie Curtis, Ph.D. | Source/complete article: Psychology Today.
Valerie Curtis, Ph.D., is a Disgustologist and Director of the Hygiene Centre at London School of Hygiene and Tropical Medicine.
Disgust Has Us in Its Grip – Five things disgust tells us about ourselves
Disgust is one of our most powerful emotions, it drives what we do in the privacy of our homes, as well as out in the world. It drives our most intimate habits, our social interactions and our moral judgement. Yet it’s still not very well understood. That’s a pity, because disgust can teach us a lot about ourselves. Here’s five things we can learn from disgust:
1. Brains are for behaviour.
You may think that your brain is for thinking, for cogitating, for solving problems. But thinking is only the icing on the cake. Brains evolved because they made the animals that were our ancestors behave in ways that got them what they needed. One fundamental need of all animals is to not get eaten. Hence all animals have behavioural strategies to keep safe from predators. The brain system that drives such behaviour is called FEAR. But it’s not just predators that want to eat you. Billions of microbes and parasites want a free meal and a free ride out of you too. The brain system that keeps us away from these micro-predators is called DISGUST. Our brains instinctively recognise yucky, smelly, sticky, contaminated stuff as potentially risky and the disgust system in the brain dictates the appropriate behaviour: ‘Don’t look, don’t touch, don’t eat!’ Brains evolved to make us do such tasks (others include nurturing, hoarding, pair bonding and status seeking) without invoking conscious, rational calculation. Our brains are for behaviour.
2. You are disgusting.
Unpleasant as it may be to contemplate, you are a walking mass of infectious material. You are home to billions of microbes, millions of worms and plenty of other parasitic creatures. You are therefore a disease threat to other people and, hence, you are disgusting. (So am I!). But being disgusting is a bit of a problem for a social species like ourselves. How to get all the benefits of cooperating with friends and acquaintances, alike, without turning them off you? The answer is simple – good manners. You learnt from your Mom and your mates at an early age not to wear stinky clothes, to breathe in someone’s face, to wee in their front room or to offer them your dirty towel. If you did they’d be disgusted, and you’d lose an ally. Because you are disgusting you have good manners and that’s how you tip the balance between being disgusting and being accepted as a member of society.
3. Your ancestors control you
Though disgust may seem rational, it’s not really under conscious control. Try this experiment. Take a glass, spit in it, put it down, pick it up again and now drink it. Difficult? Actually, it’s almost impossible. Rationally, you know that what’s in the glass is the same as what’s in your mouth, slimy saliva with all its millions of viruses and bacteria. But the voices of your ancient ancestors tell you that all spit is bad to drink (because it may have come from someone else). The same applies to all of our body contents. Whilst they are inside us we can just about tolerate them, but once evacuated or spilt, they become disgusting. The ancestral voice of caution tells us to stay away – because that’s what got the genes of our ancestors where they are today – in us. Ancestors with low disgust thresholds got sick and passed on fewer genes. Ancestors with high disgust sensitivity got to be our ancestors. That ancient ancestral brain is still in control.
4. What feelings are for
If asked what disgust is, most people would say it’s a feeling. And indeed the feeling of nausea, crawling skin, clammy hands and wanting to recoil seem to define disgust. And because there is a feeling of disgust we say that disgust is an emotion. But I think that, being a rather anthropocentric species, we’ve got the story backwards. All animals need to avoid pathogenic organisms, hence all animals needed a brain system to drive disease-avoidant behaviour. Nematodes, frogs, swallows, badgers, mice and monkeys all avoid sick cousins, practice hygiene and prefer pathogen-free food. All animals, then, have disgust systems, since without them parasites would have driven them extinct. But do all animals feel disgust? Feelings are probably unique to those higher primates that can do executive control of behaviour, that have the ability to imagine the future and work out what it would feel like. Only humans can decide that they’ll put the food away in the fridge now, because they can imagine, and feel how disgusting the food will become after three days left in a warm room. Feelings are how we humans tap into the wisdom of our ancestors, and how we employ that wisdom in feeling our way through planning for the future.
5. Why we have emotions
Disgust is an emotion. It’s a brain system that makes us behave in ways that get us what we need. Other emotions include fear (to keep us away from predators-see above), nurture (to make us care for kids so as to raise them), love (to make us pair-bond so as to raise kids), affiliation (to make us cleave to groups and so get the social benefits) and justice (to make us want to punish bad deeds). In my view feelings are not what define emotions. (For example happiness and sadness are feelings but they are general and don’t help us meet a specific evolved need, hence, they should not be classed as emotions). Comprehending that emotions like disgust evolved to make our ancestors behave in ways that were good for their genes should help all of us to better understand our feelings, our emotions, where they come from and who we are.
- Source/complete article: Psychology Today.
Filed under: Hygiene Promotion Tagged: disgustology, Valerie Curtis
WSSCC Executive Director Chris Williams highlights key water, sanitation and hygiene challenges and opportunities during UN Post-2015 thematic debate
WSSCC Executive Director Christopher Williams was a key speaker on day one of the Thematic Debate on ‘Water, Sanitation, and Sustainable Energy in the Post-2015 Development Agenda’ convened in New York at UN Headquarters on 18-19 February 2014. Dr. Williams highlighted 7 important areas that the international and national development communities must address in order to speed up progress on current and future water and sanitation goals and targets.
He joined UN Secretary General Ban-Ki Moon, Mr. Girish Menon from WaterAid, and other leading sector professionals at the event. The President of the UN General Assembly (UNGA), John Ashe, in his opening remarks said the thematic debate aims to facilitate discussion on the means of implementation and financing, increasing awareness, and overcoming challenges for water, sanitation and other key issues. A background paper and additional information about thedebate is found here.
Dr. Williams and other speaker remarks can be viewed in the United Nations Web TV coverage of the event, found here. In presenting the challenges and opportunities, he said:
- Segmentation. The water (including water resources, water supply), sanitation and hygiene sector is “atomized,” he said. There are many issues and sector interests, from Integrated Water Resources Management to sanitation to transboundary water management. “We need to come together – the Post-2015 process should engender this conversation (of coming together).”
- Voice. The people impacted by poor water and sanitation – billions worldwide – need to be heard in the Post-2015 discussions, he said.
- Public financing. The vast amount of assistance in water, sanitation and hygiene work comes from the international community, which he said is not sustainable. “How can we diversify sources of funding?” he asked through spearheading local initiatives and leveraging communities and households and their own resources.
- Coordination. Because of segmentation, he said, coordination is a challenge among and between NGOs, governments (including their different ministries, which often have overlapping responsibilities), external support agencies such as WSSCC and others, etc.
- Equity. The aim is universal access to water supply and sanitation services, but does that mean equal access? Underserved populations, women, disabled people, and other peopled traditionally considered marginalized in some way must be included in water and sanitation programming from the beginning, rather than after-the-fact as an “add on.”
- Scale. The scope of the global sanitation problem, in particular, is massive. “How do we achieve results that are not a community here, a community there, a city here, or a town there?” he asked. What works, he said, is to look at approaches that are territorial in scale, where entire districts are covered, and which can inspire other districts and national governments with their operational plans.
- Monitoring. A major challenge, he said, is to get good evidence through improved monitoring systems of what is working and what is not working. Ministers are hard pressed to get this information, and have tough jobs as many interests come to them seeking support. “Where is the evidence that justifies their further investment in water and sanitation?” he asked.
Below are comments from other speakers at the event.
Statements by John Ashe (http://papersmart.unmeetings.org/media2/1731889/pga-statement.pdf)
“We are already in agreement that energy, water and sanitation are essential to the achievement of many development goals. They are inextricably linked to climate change, agriculture, food security, health, gender and education, among others. Ongoing discussions have indicated that there is interest in a sustainable water goal, with a possible target for sanitation.”
“Today, you will be called upon to look at some diverse and challenging questions such as: what are the gaps and obstacles to accessing safe water and sanitation; how can we manage our water resources sustainably; what is the role of various actors, including the private sector and how can we leverage each for the best possible outcome; and given the world’s diverse needs and the many facets of water management – what would a water goal look like, and what kind of target(s) could it have?”
“We are here for this debate because we believe in a post 2015 world that is just, equitable, peaceful and sustainable, where every citizen of every country is able to drink clean water and access sanitation that promotes health and hygiene, both of which our General Assembly has recognized as basic human rights.”
Statements by Ban Ki-Moon (http://papersmart.unmeetings.org/media2/1731881/1-sg.pdf)
“I know you are all busy working to define a post-2015 development agenda. Erradicating extreme poverty is our most urgent priority, sustainable development our guide. Universal access to safe water, sanitation and energy will be critical.”
“Access to safe drinking water, sanitation and hygiene must feature prominently in the post-2015 development agenda […] This is a matter of justice and opportunity”
Statements by Girish Menon, WaterAid (http://papersmart.unmeetings.org/media2/1731890/director-interantional-progdep-chief.pdf)
“We need to recognize that we cannot eradicate poverty unless we tackle the water, sanitation and hygiene crisis. No village, no city, and no country has ever lifted themselves out of poverty without first improving water, sanitation and hygiene. The economic gains of investing in water and sanitation are huge. The World Health Organisation states that as much as $5-$8 is returned for every $1 spent on sanitation.“
“Women and girls bear the brunt of the burden when water, sanitation and hygiene facilities cannot be accessed by them…”
“The sector agrees what can and should be done. Now it’s up to governments to put safe water, sanitation and hygiene at the forefront of the future framework, recognizing that access to water and sanitation is a basic human right, and absolutely central to human development and ensuring dignity. ”
Statement by Thailand, on behalf of Thailand, Finland, Hungary, Switzerland, and Tajikistan (http://papersmart.unmeetings.org/media2/1731879/1-thailand.pdf)
“Therefore, in order to build the future we want, the Friends of Water consider that water shall receive the serious attention it deserves and shall be addressed comprehensively in the post 2015 framework and future sustainable development goals, namely through a dedicated water SDG, as called on by many countries.”
“Thailand is of the view that four important elements in relation to water must be incorporated into the new post 2015 framework, namely ensuring stability, building resilience, reducing inequality and enhancing effective international cooperation.”
Statement by Guinea, on behalf of the African Group (http://papersmart.unmeetings.org/media2/1731891/2-guinea.pdf)
“Therefore, the African Group is over the view that, in addition to being a global goal in the post-2015 development agenda, water could be incorporated as a target of other goals related to poverty eradication, health, food security and nutrition, agriculture, biodiversity, desertification and drought.”
Filed under: Uncategorized