Sanitation in India

ADB, the best regional development bank for water and sanitation, has published a couple of excellent reports this year on sanitation in India: India’s Sanitation for All: How to Make It Happen and, just the other day, Sanitation in India: Progress, Differentials, Correlates, and Challenges. The second section of the first report is “Sanitation in India: How Bad is It?” and here’s a quote:

However, while India may be “on track” in achieving the MDG sanitation target, it is important not to be complacent. MDG goals simply represent achievable levels if countries commit the resources and power to accomplish them. They do not necessarily represent acceptable levels of service.
This is especially true for India’s sanitation situation. Despite recent progress, access to improved sanitation remains far lower in India compared to many other countries with similar, or even lower, per capita gross domestic product. Bangladesh, Mauritania, Mongolia, Nigeria, Pakistan and Viet Nam − all with a lower gross domestic product per capita than India − are just a few of the countries that achieved higher access to improved sanitation in 2006.
An estimated 55% of all Indians, or close to 600 million people, still do not have access to any kind of toilet. Among those who make up this shocking total, Indians who live in urban slums and rural environments are affected the most.
In rural areas, the scale of the problem is particularly daunting, as 74% of the rural population still defecates in the open. In these environments, cash income is very low and the idea of building a facility for defecation in or near the house may not seem natural. And where facilities exist, they are often inadequate. The sanitation landscape in India is still littered with 13 million unsanitary bucket latrines, which require scavengers to conduct house-to-house excreta collection. Over 700,000 Indians still make their living this way.

The second report has some pertinent figures: if you’re rich you’re OK, but if you’re poor you’re not – as shown in the following two charts (prepared from Table 1 in the report).



The report estimates that US$ 7.9 billion is needed to provide toilets for all households that currently lack toilets in India (US$ 4.7 billion for rural areas and US$ 3.2 billion for urban areas). The report goes on to say that it would cost about U$ 7.7 billion to connect all currently unconnected urban households to sewer systems (but the report doesn’t mention simplified/condominial sewerage, so this is likely to be an overestimate). “Since these financing requirements are so huge”, the report suggests “progressive improvement in the types of sanitation solutions. Sewerage systems tend to benefit richer households; hence, some form of capital cost recovery could be considered to finance sewerage-related infrastructure.” I should think so (and it should be “should” not “could”): the rich shouldn’t get subsidised sewerage when so many have no sanitation at all.

All in all, both reports are definite “must reads”. Well done, ADB!

Africa’s infrastructure

The World Bank has just published online its 2010 report Africa’s Infrastructure: A Time for Transformation. The current situation is really very depressing but the report is wholly realistic about the need for Transformation and how it might be achieved. The chapters on water supply and sanitation are well worth reading, as are the 2008 water supply and sanitation background papers. The 2008 report Cost Recovery, Equity, and Efficiency in Water Tariffs: Evidence from African Utilities is also very good.

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PS: Today is International Anticorruption Day.
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IWA Mexico: Plenary addresses

The presentations given at the plenary sessions of the first IWA Development Congress (Mexico City, 15−19 November – see blog of 19 November) are now online here. The two I found most interesting are those by Professor John Briscoe and Professor Jamie Bartram – both well worth looking at.

South Africa!

No comment!

India’s Greatest Shame

The December issue of IRC’s excellent Source Bulletin draws our attention yet again to India’s Greatest Shame with its article The Worst Job in the World − here’s a quote:

About 1.3 million Indians are still trapped in the degrading and dangerous job of manual scavenging of human excreta sixteen long years after the country passed a law to make the health threatening job illegal. Even in modern India, manual scavengers are still working to clean what Wilson Bezwada of Safai Karmachari Andolan calls “shit from the pit” of people who then discriminate and look down on the scavengers.

Watch the video The Worst Job in the World − also well worth watching is The Scavengers − India.

It’s all just a Total Disgrace. India, especially the Government of India and all the State Governments, should be truly ashamed of this unbelievably awful practice of manual scavenging. Just read this (also from Source Bulletin #58):

Without any protective clothing such as boots, masks or gloves, manual scavengers, clean toilets and clogged sewer lines. They collect the faecal matter into baskets lined with leaves, an activity which leaves many sick. About 80 per cent of these workers are women, the majority of them are Dalits. They are paid a paltry 900 rupees (15 Euro) a month and can afford only cheap drugs to treat their illnesses. [INR 900 = EUR 12.88 = USD 19.320 = GBP 11.70 − today’s rates from Oanda]

Safai Karmachari Andolan has a three-year programme to eradicate manual scavenging by the end of 2010, called Action 2010. We should all do what we can to support this, and this “we” includes all Indians, the Government of India and all State Governments.

Sanitation in emergency camps

Dominique Porteaud, UNHCR’s senior water and sanitation officer, was interviewed on World Toilet Day (19 November) about his work (interview here). When asked what happens if no latrines are installed, he replied:

A good example is Goma in 1994 [see here], when a million people crossed the border and, I think, about 50,000 people died because there was no proper sanitation and water supply. One of the major problems in Goma was that it was impossible to dig latrines because the [volcanic rock] ground was so hard and all the waste was spread around and contaminated the water that people were drinking. As a result, there was cholera everywhere.

So, what can you do if you can’t dig pits? It has to be an above-ground solution, such as eThekwini latrines − urine-diverting alternating twin-vault ventilated improved vault latrines (UD-VIVs, for short). But you don’t actually need twin vaults in emergency camps − a single-vault UD-VIV is fine; and in the initial aftermath of an emergency you can do without vent pipes. Urine diversion is needed to keep the vault contents as dry as possible and, of course, it can be used to fertilize food crops. So, what’s needed is a urine-diverting single-vault latrine, but the vault has to be pretty big. Many years ago Oxfam developed a big butyl-rubber septic tank to receive both faeces and urine from a multi-compartment latrine block (designed specifically for emergencies − the packing case became the superstructure), so something like this is what’s needed, but with each compartment discharging directly into the butyl-rubber tank (no flush water) and with urine diversion into a second butyl-rubber tank. Anyway, it’s worth thinking about.

Instituto Cinara

Cinara is the Instituto de Investigación y Desarrollo en Abastecimiento de Agua, Saneamiento Ambiental y Conservación del Recurso Hídrico (Research and Development Institute in Water Supply, Environmental Sanitation and Water Resources Conservation) in the Faculty of Engineering at the Universidad del Valle in Cali, Colombia. I’ve been a visiting professor here since 1996, but today was the first day I was interviewed (by Professor Mariela García) on what I thought was good (and bad) about Cinara. Well, I said, Cinara’s excellent because its staff are very enthusiastic and highly motivated and because they train engineers in low-cost water supply and sanitation for the poor, there aren’t enough institutes like Cinara in the world, and the world needs engineers properly trained in low-cost water supplies and sanitation for the poor − and lots of them. One of the other questions was: ‘Why are there institutes of development studies in industrialized countries but not in developing countries?’, and I said that, because the remit of IDSs is much broader than WatSan for the poor, they tend to be overpopulated with sociologists, anthropologists, planners, economists, etc. but underpopulated with engineers − people who can actually do something about providing the poor with low-cost water supplies and sanitation . Of course, these other professionals have a role, an important role, to play in WatSan for the poor (John Kalbermatten taught us this in the 1970s − see here), but you have to have engineers. As Jamie Bartram says: “Infrastructure? Yes please, and lots of it”. And who gives you Infrastructure? Engineers, that’s who.

IWA Development Congress

I’m now in Mexico City at the 1st IWA Development Congress on “Water and sanitation services: what works for developing countries” (15−19 November). According to the homepage blurb it “will set the practice and research agenda for water and sanitation services in developing countries” and “it will have a strong focus on what works in a development setting and those projects that have potential for large-scale delivery” − well, that should exclude EcoSan!

Monday
The morning started off with the opening plenary addresses − all good stuff, of course, but I was glad to get some coffee when they were over!

Erdos Eco-Town: in the afternoon Dr Arno Rosemarin, of the EcoSanRes Programme at the Stockholm Environment Institute, gave a presentation on Striving for innovation: Dry and wet sanitation in multi-story apartment buildings with on-site compost and greywater treatment – the Erdos Eco-Town project − this was a good, honest (‘warts and all’) evaluation of the project, listing all the problems the project had had and why it’s now been replaced by settled sewerage. The paper’s well worth reading if only to make you happily realise that you’d never have considered doing anything like this yourself! [If you’d like a copy of the paper, it would be best to email Arno (arno.rosemarin@sei.se).] A little more detail on costs would have been nice − but the paper does say “Materials input for the ecosan system is higher than for the waterborne one [i.e., conventional sewerage] by about USD 920 for each household”, so it was always far from being a low-cost solution!

Tuesday
More opening plenaries! But later there were some good presentations, especially the one by Dr Juliet Waterkeyn (of Africa Ahead) on community health clubs in Uganda and Zimbabwe. Very interesting meeting in the late afternoon on sanitation in emergencies.

Wednesday
Yet more plenaries! The one by Dr Graham Alabaster was really good: the lessons learnt from some of UN-Habitat’s regional WatSan programmes and what they tell us about the best ways forward. In the afternoon Dr Elizabeth Kvarnström (EcoSanRes/SEI) gave a spirited presentation on the need to revamp the ‘sanitation ladder’ by using function-based (rather than the JMP technology-based) indicators, and Professor Christine Moe of Emory University gave an excellent account of her rural EcoSan work with indigenous communities in Mexico. The afternoon ended in splendid style with Professor Jamie Bartram (UNC) giving the final plenary of the Congress on What Works. Excellent gala dinner in the evening!

Thursday
Only rather unexciting field visits today, so I’m flying back to Cali for meetings on the giant American bamboo!

Overall this was a very good conference indeed. IWA should be proud that it has started this series of biennial development congresses. Special thanks are due to Dr Darren Saywell (IWA Development Director) and Professor Blanca Jiménez (Chair of the Technical Programme Committee) − you both (and your countless helpers) did us all and IWA proud! Muchísimas gracias!

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PS: Today − 19 November − is World Toilet Day.
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EcoSan in Africa

The WSP-Africa report Study for Financial and Economic Analysis of Ecological Sanitation in Sub-Saharan Africa, by Richard Schuen, Jonathan Parkinson and Andreas Knapp, is based on three case studies, which all promoted urine-diverting dry toilets, in Kabale (Uganda), eThekwini (South Africa) and Ouagadougou (Burkina Faso). Here’s an excerpt from the Executive Summary:

Based on the case study analysis, none of the currently implemented systems are seen to provide an obvious model for scaling up without considerable external support. Much research is still required to assess the costs of marketing ecosan compared with conventional sanitation, and to assess the costs of different management arrangements. ... There is need to look in more detail, at the different management arrangements and costs for setting up and operating house-to-house collection services. There may also be ways of introducing more cost effective technologies to enhance the efficiency of the operation. [Emphasis added]

‘Without considerable external support’ means massive subsidies. So now we know (again): EcoSan just hasn’t yet reached a stage where it can be implemented at scale in urban areas without the need for huge subsidies. So why is it so heavily promoted? Will all the EcoSanologists please wake up?!

Agua 2009

This week I’m in Cali, Colombia at Agua 2009, the biennial international conference on all things water. On Monday the main theme was water and climate change with some excellent presentations on Coping with climate change through adaptive management (by Professor Henk van Schaik of the Cooperative Programme on Water and Climate Change), effects on human health, on biodiversity, plus a few on the local situation in Andean countries. On Tuesday there were parallel sessions − I was at the one in nearby Palmira on New paradigms for urban water supplies and sanitation. On Wednesday I went to the session on wastewater treatment and presented a paper on Natural wastewater treatment and carbon capture − collect the biogas from a high-rate anaerobic pond to generate electricity and then use the final effluent to irrigate bamboo. In this way you not only produce a useful product but you should be able to earn carbon credits as some bamboos can capture over 30 tonnes of C per ha per year, so you could substantially reduce the cost of wastewater treatment − well, that’s idea anyway. Very swish conference dinner/dance on Thursday evening!

Dr Peter Morgan

During the 2nd Africa Water Week being held this week in Johannesburg the winners of the AMCOW AfricaSan Awards 2009 were announced. A press release dated Monday 9 November on the Department of Water and Environmental Affairs website gives all the details, including:

The AMCOW AfricaSan honor for Technical Innovation was awarded to Dr Peter Morgan, a Zimbabwean national, who for four decades has provided Africa with the most innovative technical ideas in sanitation and hygiene directly affecting poor people.

Peter’s achievements in sanitation are, quite simply, outstanding: the VIP latrine, the Arborloo, the Fossa Alterna, the Skyloo, and he’s also made equally brilliant innovations in water supply and hygiene − so the AMCOW award is very richly deserved. Well done, Peter!

Peter’s website is here.

Governments behaving badly

I’ve just re-read the excellent paper Institutional challenges in water supply and sanitation in Pakistan: revealing the gap between national policy and local experience (Water Policy 11, 582–597, 2009) by Bahadar Nawab (Department of Development Studies, COMSATS Institute of Information Technology, Abbottabad, Pakistan) and Ingrid L. P. Nyborg (Department of International Environment and Development Studies, Norwegian University of Life Sciences, Ås, Norway). Here’s a quote from the Abstract:

Wide gaps were found between local people’s needs, desires and expectations and government policies and services, between people’s practices and historical and proposed institutions, and between local people’s and policy-makers’ understanding of the issues. The study warrants the formulation of realistic and people-centred water supply and sanitation institutions and engaging local actors in the processes. Along with regulatory mechanisms, the findings argue for the use of cognitive and normative instruments in the implementation of policies while tailor-making solutions to local culture, working together with local actors, rather than imposing solutions on them.

Amazing, isn’t it, that governments still don’t understand what they should do? It’s ain’t rocket science: they just have to work with their people. Over 30 years ago John Kalbermatten realised that the intended beneficiaries had to be part of the sanitation planning process (details here) − clearly a lesson that still needs to be learnt in Pakistan (at least in rural Pakistan, where the study by Nawab and Nyborg was done) and, of course, in many other developing countries.

However, Pakistan is showing the world the way in urban areas − read The Urban Resource Centre, Karachi by Arif Hasan (Environment and Urbanization 19 (1), 275−292, 2007). Here’s part of the Abstract:

The Urban Resource Centre is a Karachi-based NGO ... set up in response to the recognition that the planning process for Karachi did not serve the interests of low- and lower-middle-income groups. … The Urban Resource Centre … has created a network of professionals and activists from civil society and government agencies who understand planning issues from the perspective of these communities. … This network has successfully challenged many government plans that are ineffective, over-expensive and anti-poor and has promoted alternatives. It shows how the questioning of government plans in an informed manner … can force the government to listen and to make modifications to its plans, projects and investments.

So rural Pakistan needs to learn from urban Pakistan. A good NGO shouldn’t find this too overwhelming.

►Clearly an Urban Resource Centre of the type described above is needed not just in Karachi but in almost every developing-country city!

CLGS, not CLTS

I’ve had two nice emails in response to my CLTS blog of 27 October. Here’s an excerpt from one − from sometime who works for an NGO/charity in southwest England:

CLTS is excellent when it mobilises people, but to expect them to dig their own pits and use locally available material to construct a covering is absolutely absurd. And then do the same thing again when nobody is around to encourage them! In Sierra Leone they are telling people to build pit toilets in a flood area. Goodness knows what happened to common sense.

The other was from a Health & Sanitation Specialist working for the Rural Village Water Resources Management Project in Nepal − here’s a quote:

After one year most of the pit latrines were unused, unimproved and [people were not] motivated to rebuild the same; so we changed model and technology which found success − people's willingness to pay for choices are found for pour flush, easier to clean, looks fancy and available at local market. However, for same standard of latrine poorest of poor need to be financially supported by local governments and other in kind.

Stopping open defecation is just not enough. So I think what’s needed is not CLTS but CLGS − community-led good sanitation. Something to mull over, anyway!

EcoSan and the phosphorus crisis

I’ve never thought much about the argument that EcoSan is a good sanitation solution in developing countries because of the impending phosphorus crisis (see here and blog of 20 March 2008). It’s true that the cost of DAP (di-ammonium phosphate) reached an all-time high of USD 1200 per tonne in 2008, but prices are falling back to their pre-peak levels of around USD 320 per t, as shown in the figure below (from here; details also here − the World Bank’s Commodity Price Data for January 2007 − September 2009):


The World Bank projects DAP costs of USD 300 per t in 2010, rising to USD 360 in 2015 and USD 400 in 2020 (details here).

So perhaps all is not as bleak as the EcoSanologists would have us believe. Of course, industrialized countries should use less P than they do at present, but let’s not continue the argument that poor people in developing countries should have expensive EcoSan toilets because of this P crisis.

PS (again): can we please have details, including costs, on the Erdos EcoTown project?

CLTS: A word of caution

In the October issue of the Water and Sanitation Program’s excellent Access Newsletter there’s a salutary piece on ‘Moving Beyond Open Defecation Free Sanitation in Pakistan’. According to this report:

Pakistan has taken an important step towards improved sanitation through a major sector assessment and setting up of a core group that seeks to move communities beyond open defecation free (ODF) status. The Community Led Total Sanitation (CLTS) approach has already enabled more than 1,500 villages in Pakistan to achieve ODF status and is expected to reach 15,000 villages by June 2011. This will mean that a third of the rural population of Pakistan would be covered. To consolidate this progress and scale up learning, a Core Group was formed in August 2008 to advise the government in policy refinement and implementation of its nation-wide sanitation policy. ... The group commissioned an assessment of CLTS pilots in nine villages in the country. The evidence gathered revealed that CLTS had the potential to motivate communities to achieve ODF status.

So far so good − but then it goes on to say:

However, it did not create demand for “improved sanitation,” which, according to the Joint Monitoring Program, implies use of sanitation facilities “that ensure hygienic separation of human excreta from human contact. The surveyed communities were found using unimproved and unhygienic latrines without taking any substantial effort to upgrade or replace damaged latrines due to limited knowledge of different latrine options available at the household level.

So now we know what many of us had long suspected: the whole CLTS ‘process’ needs to be upgraded so as to ensure people get at least ‘improved’ sanitation. Actually what people need is ‘good’ sanitation and ‘improved’ does not necessarily mean ‘good’ (after all, ‘improved’ sanitation includes a “pit latrine with slab” − see here − and we’ve all seen hundreds of these that are far from satisfactory).

Erdos EcoTown − again

I’ve looked at the various EcoSan websites (such as Ecosanres, GTZ and WASTE) and there’s no mention of the abandonment of the complex EcoSan system in Erdos (see blog of 6 June), and nothing on the SIDA website or the website of the Swedish Embassy in Beijing either. No surprise, I suppose, but disappointing nonetheless.

There’s a new report on the Ecosanres site: Comparing Sanitation Systems Using Sustainability Criteria. No mention at all of Erdos! Even so, worth a quick look − read the Conclusions and make up your own mind!

Tropical enteropathy − 3

OK, now for an enterology lesson! In a healthy gut (actually the small intestine − see first figure below) there are tiny, finger-like projections called ‘villi’ that allow the body to absorb nutrients from the food we eat into the blood − the average healthy villus is around 1.0 mm long and around 0.5 mm in diameter.


This figure shows the villi in a healthy gut:


In a child with tropical enteropathy the villi become inflamed and flattened − this is termed ‘villous atrophy’ (see next figure below). With the villi damaged in this way, the body can’t properly absorb all the nutrients from food − a process called ‘malabsorption’.



This figure shows a photomicrograph of healthy villi on the left and one of atrophied villi on the left:


[First three figures from here; last from Google Images here.]

And this is a slightly more detailed explanation (from here):

Good health requires proper digestion and absorption. Digestion is the mechanical and chemical breakdown of the food we eat. As food is digested it needs to be absorbed. Absorption is the process of bringing the nutrients from our gastrointestinal tract into the rest of our body’s tissue. Digestion is initiated when we chew food and begin to break it down with digestive enzymes. Food then enters the stomach where further breakdown occurs due to the presence of hydrochloric acid and pepsin, which together begin the breakdown of proteins. From the stomach the products of digestion enter the small intestine.

The small intestine is called “small” because it is smaller in diameter than the large intestine. However, it is in fact longer and in many ways more crucial to our health than the large intestine. The lining of the small intestine consists of villi − finger-like projections that stick out from the wall of the intestine into the lumen. These villi are between ½ and 1½ mm long, just barely visible to the human eye. On the ends of the villi are microvilli. These two adaptations, villi and microvilli, increase the surface absorption area of the small intestine up to 1,000 fold. It’s estimated that the entire absorptive area of the small intestine is roughly the size of a basketball court [i.e., ~435 sq. m − amazing!].

This total area for absorption can be compromised by any condition that irritates the lining of the small intestine. This leads to poor digestive function and affects many vital structures on the intestinal wall. Inadequate absorption of nutrients is referred to as malabsorption − the inability to get the vital nutrients your body needs delivered to your cells.

So, if a child has malabsorption then most of the nutrients in the food (s)he eats just passes through and out. Thus malabsorption → malnutrition → low weight-for-age and low-height-for-age → impaired cognition and then reduced productivity in adult life. Exactly what’s not needed for socio-economic development in developing countries.

Tropical enteropathy − 2

It’s difficult for an engineer like me to understand exactly what tropical enteropathy is. There’s a reasonably informative entry on ‘Malabsorption syndromes in the tropics’ on pages 600−603 of volume 2 of the Oxford Textbook of Medicine, 4th ed. (OUP, 2005). You should be able to read these pages on Google Books here. I’ll keep looking for an even more understandable explanation.

Global health

In International Health, a new journal launched this month by the Royal Society of Tropical Medicine and Hygiene, Richard Horton, the distinguished (and indeed controversial) editor-in-chief of The Lancet, has written a highly erudite paper which is an excellent and important read: Global science and social movements: towards a rational politics of global health (free access to the pdf as it’s in the very first issue of the journal).

Houses, mosquitoes, and evolutionary control

This week’s issue of The Lancet has two interesting papers on mosquito control: a ‘Comment’ paper: House screening for malaria control, and a full paper Effect of two different house screening interventions on exposure to malaria vectors and on anaemia in children in The Gambia: a randomised controlled trial. Both worth reading. But Professor Paul Ewald of the Department of Biology at the University of Louisville, in his 1994 book Evolution of Infectious Disease (OUP), was ahead of the game: read the section ‘Evolutionary control’ on pages 53−55 of the book on Google Books here. And you can watch his 2007 Ted Talks lecture Can we domesticate germs? on the evolutionary control of diarrhoeal disease pathogens and also on mosquito-proof houses − very thought provoking!

Tropical enteropathy

The Lancet has published today a really relevant ‘Viewpoint’ article: Child undernutrition, tropical enteropathy, toilets, and handwashing by Dr Jean Humphrey (of the Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health in Baltimore, MD and the ZVITAMBO Project in Harare). The article starts off in a pleasingly forthright way:

Of the 555 million preschool children in developing countries, 32% are stunted and 20% are underweight. Child underweight or stunting causes about 20% of all mortality of children younger than 5 years of age and leads to long-term cognitive deficits, poorer performance in school and fewer years of completed schooling, and lower adult economic productivity.

The hypothesis of the paper is simply:

that a key cause of child undernutrition is a subclinical disorder of the small intestine known as tropical enteropathy, which is characterised by villous atrophy, crypt hyperplasia, increased permeability, inflammatory cell infiltrate, and modest malabsorption [details here]; that tropical enteropathy is caused by faecal bacteria ingested in large quantities by young children living in conditions of poor sanitation and hygiene; that provision of toilets and promotion of handwashing after faecal contact could reduce or prevent tropical enteropathy and its adverse effects on growth; and that the primary causal pathway from poor sanitation and hygiene to undernutrition is tropical enteropathy and not diarrhoea [emphasis added].

Dr Humphrey concludes her Viewpoint with:

Undoubtedly, the complex problem of child undernutrition will not be solved with toilets and handwashing alone. Interventions focused on gut microbial populations and improved drinking water quality might be important, together with continued efforts to improve infant diets. However, I hypothesise that prevention of tropical enteropathy, which afflicts almost all children in the developing world, will be crucial to normalise child growth, and that this will not be possible without provision of toilets. Randomised controlled trials of toilet provision and handwashing promotion that include tropical enteropathy and child growth as outcomes will give valuable evidence for this premise, and might offer a solution to the intractable problem of child undernutrition [emphasis added].

The African Report on Child Wellbeing: 2008 has some relevant quotes (the whole report is excellent − I’d not come across it before yesterday: it’s really quite disturbing):

Despite some progress, life for millions of Africa’s children remains short, poor, insecure and violent (page 90),

Too many children die needlessly before they reach the age of five, and too many have no access to health and medical services, adequate nutrition, safe water and improved sanitation services (page 11),

The best way of combating child death is to improve and expand access to primary health care, nutrition and improved water supplies, sanitation and hygiene – therefore to increase the budget allocated to public health (also page 11).

In August this year The Lancet had an excellent ‘Comment’ article: Child survival and IMCI: in need of sustained global support. Here’s a quote:

The broader determinants of child survival are crucial to understanding the potential effect of any set of interventions and the obstacles to reducing child mortality. An analysis of data from 152 countries [abstract here] noted that gross national income per head, female illiteracy, and income equality predicted 92% of the variance in child mortality. In low-income countries, where most child deaths occur, female illiteracy was more important than was gross national income per head, and both were more important than was public expenditure on health. A study from The Gambia [pdf here] showed that community and social networks, personal support for caregivers in the home, and financial autonomy were more important determinants of child mortality than was access to health services. Improvement of the quality of care in primary health clinics and referral hospitals will be essential to increase child survival, but as Arifeen and colleagues’ study [abstract here] shows, these interventions alone will be insufficient. Improvement of education of girls, social supports and networks for parents, economic equity, and sustaining broad-based maternal and child health services are all parts of what is necessary to reach targets for Millennium Development Goal 4. [MDG4 is to ‘Reduce child mortality’ − 2008 UN fact sheet here].

So the message: clean up the environment, especially the immediate domestic and peri-domestic environment, by the provision and sustained use of sanitation and handwashing facilities, educate girls, and put public health right up very high on the political agenda. Fingers crossed − it could just work, especially if politicians, civil servants and local-government employees were to get off their asses and on with their job.

And here’s a brilliant quote from the paper International Efforts to Control Infectious Diseases, 1851 to the Present (published in the Journal of the American Medical Association in September 2004):

Public health is ... an investment that works best when purchased in advance rather than paid out as each crisis arises.

Quite. But the trick is to get those politicians to understand this, and understand it fully.

I’m indebted to the authors of the April 2009 World Bank Policy Research Working Paper No. 4907 How Can Donors Help Build Global Public Goods in Health? for this quote. This policy paper is very well worth reading in its own right − here’s its Abstract:

Aid to developing countries has largely neglected the population-wide health services that are core to communicable disease control in the developed world. These mostly non-clinical services generate “pure public goods” by reducing everyone’s exposure to disease through measures such as implementing health and sanitary regulations. They complement the clinical preventive and treatment services which are the donors’ main focus. Their neglect is manifested, for example, in a lack of coherent public health regulations in countries where donors have long been active, facilitating the spread of diseases such as avian flu. These services can be inexpensive, and dramatically reduce health inequalities. Sri Lanka spends less than 0.2% of GDP on its well designed population-wide services, which contribute to the country’s high levels of health equity and life expectancy despite low GDP per head and civil war. Evidence abounds on the negative externalities of weak population-wide health services. Global public health security cannot be assured without building strong national population-wide health systems to reduce the potential for communicable diseases to spread within and beyond their borders. Donors need greater clarity about what constitutes a strong public health system, and how to build them. The paper discusses gaps in donors’ approaches and first steps toward closing them.

[The only thing I’d add is that many, if not most, developing-country governments also “need greater clarity about what constitutes a strong public health system, and how to build them”, not just donors.]

And it starts with another good quote:

Focusing on clinical services while neglecting services that reduce exposure to disease is like mopping up the floor continuously while leaving the tap running.

HARDtalk: Helen Clark

HARDtalk, the BBC programme showing “in-depth interviews with hard-hitting questions and sensitive topics being covered as famous personalities from all walks of life talk about the highs and lows in their lives”, today features an interview with Helen Clark, the head of UNDP (and former prime minister of New Zealand), on the Millennium Development Goals. The programme blurb is: “In September 2000, the Millennium Declaration was ratified. One hundred and eighty nine nations committed themselves to the Millennium Development Goals - a plan to reduce poverty, tackle hunger and improve education and healthcare by 2015. Jon Sopel talks to Helen Clark, the woman tasked with delivering this on behalf of the United Nations. But how much progress has been made and can these sweeping targets ever be achieved?” It’s available here for the next 12 months. Well worth watching.

Agroforestry

The Second World Congress of Agroforestry, which has been taking place in Nairobi, ended today and, as far as I can tell from the Programme, not a mention of Arborloos (see blog of 6 April 2008) − another wasted opportunity?

WaterAid interview

Watch this video in which Barbara Frost, Chief Executive of WaterAid, interviews Douglas Alexander, MP, the UK Secretary of State for International Development − DFID is “the part of the UK Government that manages Britain's aid to poor countries”.

Peepoo Bags

Watch this video on YouTube to see what a Peepoo bag is and have a look at the Peepoople website. There’s also a paper by the inventors of the Peepoo bag which was published earlier this year in Water Science and Technology: Peepoo bag: self-sanitising single use biodegradable toilet [this link takes you to the paper’s abstract − well worth a read].

Now, would you recommend the widespread use of Peepoo bags in urban slums? Before you answer, read this excerpt from the executive summary of Impact Assessment Report on the Peepoo Bag, Silanga Village, Kibera, Nairobi − Kenya by Thomas H. M. Ondieki and Maurice Mbegera of Jean Africa Consultants in Nairobi (this study was partially funded by GTZ):

At least 90% of the users of the Peepoo bag strongly recommended it as the absolute sanitation solution within Kibera and the same percentage also felt that the Peepoo bag is safe and clean to handle. More than 80% of the respondents were of the opinion that the Peepoo bag be sold for less than KES 5 (USD 0.0625) to make it affordable to the majority of the slum dwellers.
There was a significant need for Peepoo bag usage in Silanga Village because more than 50% of the respondents admitted that they throw their waste using the flying toilet approach. On the distribution of the Peepoo bag, the majority of the respondents were of the opinion that group leaders, community based organizers, church leaders, youth and village elders be used in coordinating the distribution process.
The size of the Peepoo bag elicited concern among the respondents. Over 60% suggested a bigger bag to fit both urine and faeces at the same time. The use of the Peepoo bag would save valued time that is otherwise spent queuing to access toilet facilities. It was noted that the fertilizer benefit seemed most valuable for the majority of respondents because of the implied financial benefits that such a venture would bring to the community.

All good stuff − well, good business: there are about a million people in Kibera slum, and if they all used one Peepoo bag a day at a cost of USD 0.0625,* that’s USD 62,500 per day or close to USD 23 million per year!

How many SPARC-style community-managed sanitation blocks (see blog of 28 January 2008), I wonder, could be built in Kibera for this? Well, a two-storey sanitation block costs KES 1.7m−2m (USD 23,000−27,000) and a single-storey one KES 1.2m−1.4m (USD 16,000−19,000) − information kindly provided by Josiah Omotto of the Umande Trust (based in Kibera) by email yesterday. You can do the math yourself and so figure out which solution you’d choose.

*Actually Peepoo bags cost EUR 0.04 (info. by email from Ms Camilla Wirseen, the project manager @ poopoople.com, on 15 August). At current exchange rates this is equivalent to USD 0.057 or KES 4.51 − so we’re talking about USD 20.8m (EUR 14.6m), not the USD 23m above. Even so, a lot of money in any currency!

PS: Some people get a bit mystified by currency abbreviations. Every currency has a unique 3-letter code (KES = Kenyan shilling) − details at oanda.com.

Interview

Out today on the IPS News site: Nergui Manalsuren interviews Duncan Mara − “Q&A: Knowledge Barriers Key Factor in Sanitation Crisis”.

IPS is the Inter Press Service − this is what it says it is on its homepage:

WatSan in Pakistan

A really good, insightful paper has just been published in Water Policy: Institutional challenges in water supply and sanitation in Pakistan: revealing the gap between national policy and local experience, by Bahadar Nawab and Ingrid L. P. Nyborg. Here’s a bit of what they say:

“... making policies, setting goals and objectives, passing legislation and restructuring administration are relatively easy tasks. The larger problem in developing countries lies in the implementation of policy, mainly due to the lack of capabilities, intention and commitment of the governments and scarcity of financial and skilled human resources. Developing countries, including Pakistan, have until now focused more on policy formulation and legislation. But these policies usually lack capable administration, and efficient and legitimate regulatory instruments which are pre-requisites for effective implementation of policy. Local people usually question and even resist the experts’ formulated policies and rules, as they often clash with their daily practices, socio-cultural values systems and economic considerations. In developing countries, therefore, policies are made, funds are allocated and projects are undertaken but most of those countries are still not on track to meet the UN goal on water supply, especially on sanitation.”

It all sounds depressingly familiar. They conclude:

“The government, therefore, needs to focus on innovative and alternative approaches for handling water supply and sanitation issues and must consider local and traditional institutions and involve all actors. A much better outcome can be achieved through cognitive and normative instruments and adopting a dialogue and negotiation approach with local people. In the study villages, local people otherwise showing a blind eye to their poor sanitation situation got motivated through discussions within the framework of their traditional norms, values and institutions. Organized debates on the sanitation issue where almost every household could participate and put forward ideas could craft innovative water supply and sanitation option contrary to the government traditional supply driven and service provider approach. Local people could be easily convinced and willing to change their water and sanitation practices by practically demonstrating to them scientific findings of the links between practice and possible negative health outcomes. Therefore it is important to bring scientific words into local dictum and making it everyone’s language.

The current move of water and sanitation reforms in developing countries is encouraging. However, to make realistic water and sanitation policies, we need to understand water and sanitation problem in a holistic way and then build on local men and women’s practices, norms, values, and institutions and try to make their existing practices safer rather than imposing on them new regulations and foreign solutions. The respective governments and departments need to create an enabling environment and find legitimate instruments for the implementation of water and sanitation policies.”

Really good for rural sanitation, especially Community-led Total Sanitation. The approach might need a bit of tweaking in periurban areas, but that shouldn’t prove too difficult.

Advocacy!

The August issue of the Bulletin of the World Health Organization has a really pertinent paper: A social explanation for the rise and fall of global health issues by Dr Jeremy Shiffman of the Campbell Public Affairs Institute, Maxwell School of Syracuse University in New York state. The abstract is:

This paper proposes an explanation concerning why some global health issues such as HIV/AIDS attract significant attention from international and national leaders, while other issues that also represent a high mortality and morbidity burden, such as pneumonia and malnutrition,[*] remain neglected. The rise, persistence and decline of a global health issue may best be explained by the way in which its policy community – the network of individuals and organizations concerned with the problem – comes to understand and portray the issue and establishes institutions that can sustain this portrayal. This explanation emphasizes the power of ideas and challenges interpretations of issue ascendance and decline that place primary emphasis on material, objective factors such as mortality and morbidity levels and the existence of cost-effective interventions. This explanation has implications for our understanding of strategic public health communication. If ideas in the form of issue portrayals are central, strategic communication is far from a secondary public health activity: it is at the heart of what global health policy communities do.

*and sanitation!

So, as I’ve said before, good sanitation advocacy is needed, and needed now. Time to get our thinking hats on!

PS: There’s another good paper in the August issue of Bull. WHO: Shame or subsidy revisited: social mobilization for sanitation in Orissa, India − well worth reading!

Fatal neglect

WaterAid, in its 2009 report “Fatal Neglect: How Health Systems are Failing to Comprehensively Address Child Mortality”, says that:

The aid system is not responding to the causes of child mortality in a targeted manner. The Millennium Development Goal to reduce by two-thirds the number of children dying before their fifth birthday by 2015 is seriously off-track. In Sub-Saharan Africa, on current trends, it will not be met until 2064.

and notes that:

The World Health Organization estimates that 28% of under-five deaths are attributable to poor sanitation and unsafe water.

Clearly much more needs to be done! But is this lack of action on MDG4 (not to mention the MDG WatSan targets) because the donors are spending too much on AIDS? Well, Mr Rajalakshmi (who is a correspondent for the Indian newsmagazine Frontline) thinks so – see Is HIV/AIDS skewing the priorities of the public health system? (dated January 2008) (and thanks to Dave Trouba of WSSCC for bringing this to my attention).

Mr Rajalakshmi may be right as far as India is concerned − he writes:

The government does not seem to be terribly bothered about the continuing burden of other communicable diseases. According to the WHO, approximately 988,000 Indians die of all causes, annually. About 462,000 of these die from communicable, maternal and perinatal diseases. An estimated 34,000 die of AIDS according to this report (though the source of this estimate may be debated). Respiratory infections account for 107,000 deaths. Take the example of tuberculosis. India ranks first among the 22 high-burden countries in the world, with some 364,000 deaths annually. According to the WHO’s Global TB Report 2006, there were 1.8 million new cases in 2004, of which 5% were in people with HIV and 2.4% were multi-drug resistant (MDR) requiring very expensive treatment. The government’s revised national tuberculosis programme does not provide free treatment for MDR TB. More than one-fifth of the burden of communicable disease is related to the basic problem of clean drinking water. Look at the impact of diarrhoea which, the WHO estimates, killed an estimated 700,000 Indians in 1999 – over 1,600 deaths each day.

Such diseases are mainly an outcome of an inaccessible and unaffordable health system and a debilitating socio-economic environment. But these diseases are not on the international radar of any funding agency or government. There were 1.8 million reported cases of malaria last year. And this is an underestimation, as blood tests were carried out on less than 10% of people with suspected malaria. It is estimated that four people die due to malaria every day in the country. There are also the scourges of Japanese encephalitis, chikungunya and dengue. As many as 1,000 children died from Japanese encephalitis in Uttar Pradesh in two years, but these figures did not make the headlines or grab national or international attention in the way HIV/AIDS does. [Chikungunya? Similar to dengue − some details here.]

Globally I’m not so sure: diarrhoea kills 1.6−2.5 million children under 5 (details here, for example), but compare this (which is terrible enough) with deaths due to AIDS, as given in the 2005 report “HIV/AIDS, Tuberculosis and Malaria: The Status of the Three Diseases” by the Global Fund to Fight AIDS, Tuberculosis and Malaria: 3.1 million AIDS deaths in 2004 [and 2 million TB deaths and at least 1 million malaria deaths (possibly as many as 3 million)].

So I think the world needs to fight AIDS, TB & malaria, and also, through access to adequate WatSan, diarrhoea. But clearly what we need is very good WatSan advocacy!

Stories from The Economist

I’ve been catching up with last month’s issues of The Economist and a few good stories caught my eye:

(a) Waste disposal in Colombia: Muck and brass plates: Colombia’s Constitutional Court has ruled that the tens of thousands of wastepickers who scratch out a living on Cali’s solid waste dumps be officially recognised as entrepreneurs and, as such, should be given the chance to bid for the city’s waste management contract. A brilliant blow for the poor. Let’s hope a local NGO steps in and helps them prepare their bid (they’ll need help, and soon, as they’re illiterate).

(b) India’s cheap housing boom: The nano home: ultra-low-cost minimal housing is being provided by property developers. Not before time as India needs at least 25 million more homes in urban areas. And what sanitation system is envisaged?

(c) The poor and the global crisis: The trail of disaster: It’s the poorest who are worst affected by the global financial and food-price crises (this is a really good short introduction to UNSCN’s brief Global recession increases malnutrition for the most vulnerable people in developing countries − Pregnant women and children are hardest hit, undated, but 2009). UNSCN? United Nations Standing Committee on Nutrition − no, I hadn’t heard of it either, and more’s the pity as there’s some good material here which could be used in advocacy for urban agriculture and, yes, even EcoSan!

(d) Migration and climate change: A new (under) class of travellers: “Victims of a warming world may be caught in a bureaucratic limbo unless things are done to ease—and better still, pre-empt—their travails.”

(e) Cleaning the Great Lakes: Swimming with E. coli: A USD 26 billion programme to clean up the Great Lakes may soon get underway. The Great Lakes have major problems: “Sewage systems continue to overflow, forcing many beaches to close. Levels of some toxins in fish have declined, but others pose new risks. Atlantic freighters still bring in foreign species − there are now 185”. But the benefits could amount to at least USD 80 billion. A lesson here for the developing world?

Manual scavenging − again

Manual scavenging’s in the news again: the Indian Supreme Court is on the case − according to a report in Source Weekly (IRC’s excellent e-newsletter), it “has asked the Delhi government to explain its failure to implement a central law against manual scavenging that provides for elimination of dry latrines and rehabilitation of scavengers. Earlier, the court had also sent to district magistrates the details of over 2,000 dry latrine owners in over 25 districts in the states of Punjab, Haryana and Rajasthan seeking their explanation for their failure in demolishing the latrines and prosecuting the owners. The notices were sent after the Safai Karmachari Andolan (SKA) (Sanitary Workers’ Movement) provided evidence that the practice of manual scavenging still existed, 16 years after the Employment of Manual Scavengers and Construction of Dry Latrines (Prohibition) Act was passed by the Union Government in 1993.” Let’s hope the Supreme Court does the decent thing and get this dreadful practice banned for good (see blogs of 7 August 2008, 17 April 2008 and 18 January 2008)

India has around ~668,000 “open defecators” (58% of the Indian population, and 56% of the world total of open defecators). There's a Total Sanitation Campaign (basically the same as CLTS), but word has it that it’s not going that well. Now, India is by far the largest recipient of WatSan aid − USD 830 million (2006 USD) in 2006−07, equivalent to 13% of all WatSan aid, according to the OECD report Measuring Aid to Water Supply and Sanitation (published in February this year). So wouldn’t it be a good idea for all these donors to get together and say “Look here, sort out manual scavenging once and for all, and make sure your Total Sanitation Campaign really delivers”. But have the donors got the bottle to say this? It needs to be said loudly and clearly (and India should take on board the old adage: “your greatest critics are your greatest friends”).

Rotavirus vaccine

WHO issued a News Release on 5 June: “Global use of rotavirus vaccines recommended: Vaccines can protect millions of children from diarrhoeal disease”. The News Release says: “WHO has recommended that rotavirus vaccination be included in all national immunization programmes to provide protection against a virus that is responsible for more than 500,000 diarrhoeal deaths and 2 million hospitalizations every year among children. More than 85% of these deaths occur in developing countries in Africa and Asia. This new policy will help ensure access to rotavirus vaccines in the world’s poorest countries.” [The formal recommendation is in the 5 June issue of Weekly Epidemiological Record − see pdf page 20.] All very well and very good, BUT (it’s a big but) what if, say, norovirus takes over from rotavirus? Norovirus already kills ~200,000 children under 5 in developing countries every year (details here) (see also CDC’s Norovirus: Technical Fact Sheet webpage for details of the virus and its effects). A norovirus vaccine? Well, one’s under development in the US (funded by the military) (details here), but it’ll be years before it’s ready for a WHO recommendation like the one for rotavirus. How many kids in developing countries will die from norovirus disease before it’s ready?

Ocean dumping ...

I came across these slides I took in 1977:


A beautiful beach just outside Accra.


The surf zone turned this colour after one of the regular discharges of untreated nightsoil!

Has anything improved since then? No − these photos were taken in October last year:


Septic tanks are emptied by small-scale operatives (proud of their work − and rightly so),


but the tankers still discharge to the ocean.

Will it ever end? It just might when the British-funded UASB treatment plant becomes operational again (one of its pumps broke down soon after commissioning and it's been put of action ever since). AfDB is proposing to fund the rehabilitation of the plant − with a stock of spare pumps! [You'd have thought, wouldn't you, that ODA or now DFID would have sorted this out years ago. Ain't bureaucrats strange?]

Urban EcoSan in Erdos

Word is out, but not yet in print or e-print, that the much acclaimed Erdos Eco-Town project in China (see blog of 18 April 2008), supported by SIDA, the Stockholm Environment Institute and its EcoSanRes project, has been closed down by the Chinese as it was just too complicated and the householders, especially the women, didn’t like it at all. No surprise here then – after all, there’s water and sawdust going into each house, and dehydrated faeces, urine and greywater all coming out in separate streams. See the EcoSan photos on Flickr if you need convincing.

“Much acclaimed”? Well, it has been – see:
Sweden-China Erdos Eco-Town Project (EcoSanRes Factsheet #11, 2008)
Introduction to the China-Sweden Erdos Eco-Town Project (GTZ, 2006)

I think the world, especially the EcoSan world, deserves a full explanation, so over to you guys at SEI (and we’d like to know the costs please).

Local radio advocacy

Here’s a heartening story from India on the BBC News site yesterday: Radio boost for marginalised women. It seems to me that this kind of initiative could easily be adopted for water and sanitation advocacy to support CLTS and India’s Total Sanitation Campaign (of the 1.2 billion open defecators in the world in 2006 over half − 56% − live in India).

EcoSan again ...

I’ve just been reading Study for Financial and Economic Analysis of Ecological Sanitation in Sub-Saharan Africa − Final Synthesis Report produced by Hydrophil and Atkins (April 2009). It compares the costs (in net present value terms) of VIP latrines, EcoSan toilets and conventional sewerage in urban areas in Burkina Faso, South Africa and Uganda. It’s interesting but it doesn’t attempt to estimate the costs of simplified sewerage. However, there are some cost data from South Africa in Sanitation for a Healthy Nation: Sanitation Technology Options (DWAF, 2002), which gives capital costs of ZAR 600−3000 for single-pit VIP latrines, ZAR 3000−4000 for eThekwini latrines, ZAR 2500−3000 for simplified sewerage, and ZAR 6000−7000 for conventional sewerage. [If you lived in a high-density low-income urban community in South Africa, which would you choose?]

So we can’t conclude much, if anything, from the Hydrophil/Atkins report about what are the best sanitation options in low-income high-density urban areas in Sub-Saharan Africa − and that’s a real pity.

Rio de Janeiro

I spent last Saturday looking at low-cost sewerage schemes in the state of Rio de Janeiro with my good friend (and colleague for over 25 years) Augusto Sérgio Guimarães. We went to the town of Paracambi, located in the flat lands just below the mountains separating the states of Rio and São Paulo − so the well-known orographic effect is active and, when it rains, it rains very heavily and parts of the town often become flooded. Two solutions were tried. One was to collect the all the wastewater discharges into the local stream in a sanitary sewer running along one side of the stream (all the discharges were on this side), treat the wastewater in a septic tank and anaerobic filter, the effluent from which went into the stream; stormwater continued to be discharged directly into the stream − not necessarily the ‘best’ solution but certainly a ‘good’ one and at least the stream wasn’t receiving totally untreated wastewater any more. The other was an innovative low-cost combined sewerage scheme: both domestic wastewater and stormwater go into the same sewer and into a septic tank and anaerobic filter (with the effluent going into the stream), but during intense rain the septic tank and anaerobic filter are by-passed and the combined wastewater goes directly to the stream.

In one part of Paracambi we also saw something else very interesting: a badly designed conventional sewerage scheme. Why badly designed? Well, it was designed only for domestic wastewater but most households (which had no problems before the scheme was put in) discharge rainwater from the roofs into the sewer − so, when it rains, the sewers overflow into the street! Hardly an improvement. The engineers who designed the scheme just hadn’t realised what the householders were doing and so, in ignorance, designed a scheme which simply made matters worse. A lesson for all of us: work with the people and take the local situation into account.

Waste stabilization ponds

Well, this week I’ve been in Belo Horizonte, the capital of the state of Minas Gerais in Brazil, at the International Water Association’s international specialist conference on waste stabilization ponds − a low-cost but highly efficient way to treat wastewater (details here). What a week! Very good conference, very good crowd of people (some of whom I only meet at these events, so it’s good to catch up with them), and excellent Brazilian food! Wastewater treatment is part of sanitation − if you have low-cost sewerage, you need low-cost wastewater treatment, and waste stabilization ponds are the best way to treat wastewater at the least cost. You can collect the biogas from anaerobic ponds and generate electricity (and maybe earn some carbon credits). It’s also possible, although more difficult and more expensive, to harvest the algae from high-rate algal ponds and make algal biodiesel − but this is likely to take a decade or two before it’s commercially viable.

Sanitation choices in the real world

The other night I met up with Rose George, the perspicacious author of The Big Necessity who’s recently moved to Leeds, for a quick drink. Naturally enough we talked about sanitation and she asked at one point what I’d recommend and why. This set me thinking and I have to say that, if we are to have any chance of attaining universal sanitation provision in the relatively near future (and remember it has to be ‘adequate’, not just ‘improved’, sanitation), then we need to be pretty clear about the sanitation systems we can actually use. So I reckon it has to be something like this:

A. High-density urban areas: simplified/condominial sewerage, low-cost combined sewerage, or SPARC-style community-managed sanitation blocks.

B. Medium-density urban and rural areas: eThekwini latrines (properly called ‘urine-diverting alternating twin-vault ventilated improved vault latrines’ or ‘UD-VIVs’ for short), simplified/condominial sewerage or low-cost combined sewerage, though alternating twin-pit VIPs and PF toilets could also be used if they can be desludged easily.

C. Low-density rural areas: Arborloos (‘excreta in, money out’) or ‘fossas alternas’, though long-life single-pit VIPs and pour-flush toilets could also be used.

No EcoSan until it’s a financially viable option! (You can argue that Arborloos and fossas alternas are EcoSan systems, but they’re the only affordable EcoSan options at the moment.)

And don’t even think any more about trying to meet the MDG sanitation target − we haven’t a cat in hell’s chance of meeting it, so it’s better to face facts and forget about it, and have instead the more equitable goal of universal provision of adequate sanitation by − well, who knows when? But if you need a date, then 31 December 2025, as recommended in the Global Water Supply and Sanitation Assessment 2000 Report.

Key success factors for WatSan

Once more ex Africa aliquid boni − to paraphrase the Latin tag (original here). I say this as I came across for the first time the other day the excellent paper Managing water supply and sanitation services to developing communities: key success factors by Professor C. F. Schutte of the University of Pretoria. His ‘key success factors’ are:

1. Developing credibility of the organisation providing WatSan services with the community it serves:
(a) Creating an organisation-wide culture of service to customers,
(b) Ensuring reliability in the water supply, and
(c) Ensuring community involvement.

2. The creation of a culture focussing on maximising income and minimising losses:
(a) Create a culture and awareness of focussing on generation and collection of income, and
(b) Create a culture of cost consciousness and focus on minimisation of losses.

The paper has several ‘pearls of wisdom’ − for example:

The typical approach of a bureaucratic type of organisation is that it functions as a cost centre. This means expenditure is budgeted for and the approved budget is spent irrespective of what the income is. To be successful a water services organisation must operate as a business centre which means that expenditure must be linked to income. This requires that the financial systems must support such an approach and furthermore that a culture of cost consciousness must be established throughout the organisation – with management leading by example.

This is a really good paper, well worth reading in full.

Trachoma

Trachoma is a serious water-washed eye infection and the world’s leading cause of preventable blindness. There’s a lot of useful information on the International Trachoma Initiative website, and the Disease Control Priorities Project has posted the good news: The End of Blinding Trachoma among the World's Poor is in Sight.

Have a look at the BBC’s Survival series on tropical diseases − 8 full-length (~45-minute) programmes available to watch online here. Episode 1 deals with trachoma, schistosomiasis, and lymphatic filariasis in Niger, West Africa.

Stockholm Water Prize

The SIWI headline is “Indian Sanitation Innovator and Social Reformer Awarded 2009 Stockholm Water Prize”. The laureate is Dr Bindeshwar Pathak, founder of the Sulabh Sanitation Movement in India − and the first ‘sanitation person’ to receive the award (all previous laureates have been water/wastewater people, with the exception of WaterAid which won the prize in 1995) − so, many congratulations to him (and also to SIWI for making the award for sanitation − why on earth didn’t they do so last year, the International Year of Sanitation? But better late than never). I personally prefer the SPARC approach to communal sanitation (see here), but there’s no doubt that Sulabh has done tremendously good work.

Toilet “theology”

According to the report “Amish man jailed over toilet theology”, in The Independent (a UK national daily newspaper) on 18 March a western Pennsylvania Amish farmer has been sentenced to 90 days in jail and fined $1000 after refusing to bring a pair of outhouses into compliance with state sewage laws. The farmer cited his conservative religious beliefs in refusing to abide by an earlier court order to make the privies used by schoolchildren compliant and pay a $500 fine. “Quite frankly, this is not a religious issue,” said the judge.

I agree with the judge, but maybe a compromise solution should have been sought by the local county “sewage enforcement agency” − a solution that would protect both the health of the schoolchildren and the environment in a way that didn’t offend Amish beliefs, yet was acceptable to everyone else; and if this required modification of local sewage disposal regulations, then so be it. Did anyone say to the Amish “Look, your current sanitary solution is absolutely no good, so how would you improve it in a way that’s acceptable to both you and us?” − that sort of thing. I’d bet good money that this wasn’t even considered!

A couple of fine excuses!

WaterAid, in the Spring/Summer 2009 issue of Oasis, has this: ‘Some West African men refuse to wash their hands because “the cleaner your hands are the more likely you are to drop your money. They think it’s better to have sticky hands”.’

And, even more amazingly, the UN Office for the Coordination of Humanitarian Affairs has this in relation to why women in the largest slum in Karachi won’t use water purification tablets (here): ‘The major excuse that these women have is that they fear these tablets will render [their men] impotent.’

Hygiene education ain’t always as easy as you might think!

Think Globally Radio

Think Globally Radio, based in Sweden, has some interesting podcasts which are well worth a listen:
1. Water, Power, Poverty – How clean water and sanitation will cut poverty in half by 2015 [2007-01-28]
2. Hurry Up! 2.6 Billion People Want to Use the Toilet!! [2008-01-13
3. Water and Sanitation: Do We Mind the Gap? [2008-09-07]
To access/listen/download go to the Think Globally Radio homepage, click on Episode Archive at the top, and then scroll down to the podcast you want to listen to (they're listed in reverse date order).

John Kalbermatten – 3

I should have mentioned in the earlier postings on John that there’s a very good review of his work at the World Bank on pages 21–23 in Science and Technology at the World Bank, 1968–83 by Charles Weiss (of the Edmund A. Walsh School of Foreign Service at Georgetown University in Washington DC), published in History and Technology 22 (1), 81–104 (March 2006; abstract here). Well worth reading!

John Kalbermatten – 2

I don’t have many photos of John Kalbermatten − here’s a slide I took in March 1980 showing John (arrowed) leading the team through a slum in Calcutta.

John Kalbermatten, 1931−2009

Low-cost Sanitation has lost its greatest Champion: John Kalbermatten, who died last Thursday in Bethlehem, Pennsylvania and who is being buried today. In the 1970s and early 80s John was the Senior Water & Wastes Advisor at the World Bank. He realised that the Bank’s investments in sewerage were not reaching the poor and he persuaded the Bank to fund the 1976−78 low-cost sanitation research project. This produced some truly ground-breaking publications − for example, the three books on Appropriate Sanitation Alternatives: A Technical and Economic Appraisal and A Planning and Design Manual (published in 1982 by Johns Hopkins University Press), and Sanitation and Disease: Health Aspects of Excreta and Wastewater Management (John Wiley & Sons, 1983) − some people, including some sector 'specialists', are even now "reinventing" quite a bit of what's in the first two, simply because they haven't read them (and probably don't know about them).

John then obtained funds from UNDP in 1978 for project GLO/78/006 for the Technology Advisory Group (TAG), which he established, to start putting the lessons of the research project into practice. TAG’s successor today is the Water and Sanitation Program. Maggie Black’s 1999 publication 1978−1998: Learning What Works − A 20 Year Retrospective View on International Water and Sanitation Cooperation details the work of TAG.

John was a true visionary and I, for one, will miss him greatly. Requiescat in pace.