HSW in PLoS Medicine

Last week and earlier this week PLoS Medicine published a collection of four papers on hygiene, sanitation, and water (HSW) in developing countries. They are:

1. Hygiene, Sanitation, and Water: Forgotten Foundations of Health
2. Water Supply and Health
3. Sanitation and Health
4. Hygiene, Sanitation, and Water: What Needs to Be Done?

You can access and download them here. Check out other PLoS Medicine Collections here.

[PLoS - Public Library of Science, an organization that publishes "open access" papers in a variety of e-journals.]

World Toilet Day

Today is World Toilet Day. Check out the website here and look at the posters here – this is one of them:

Fallacious arguments

In Sandec News No. 11 (published in August) there’s an article (pages 14−15) by Mbaye Mbéguéré, Pierre-Henri Dodane, Ousmane Sow and Doulaye Koné on “Financial Assessment of Dakar’s Sewer vs Faecal Sludge Management”. Here’s the intro. blurb:

In Senegal’s capital Dakar, with its approx. three million inhabitants, investment and O&M costs of the conventional, centralised sewer system are considerably higher than those of the on-site faecal sludge management (FSM) system. The income generated by user fees is insufficient to cover the expenses of the centralised sewer system, yet recovery of FSM charges appears easier.

The implication seems to be that, because FSM is cheaper than conventional sewerage, it’s a good thing to do. This is the “EcoSan fallacy” (see blog of 30 November 2008): if it (whatever "it" may be) is cheaper than conventional sewerage, then you should use it. The nonsense of this way of “thinking” is rapidly understood when you remember that everything’s cheaper than conventional sewerage, as John Kalbermatten found in the 1970s (see here) and as more recently determined in South Africa (here). What’s needed is a comparison between “it” (even “them”) and simplified sewerage.

All rather tiresome!

Graduate education

There’s a brilliant paper by Professor John Briscoe (of Harvard University) in the Journal of Water Resources Planning and Management [American Society of Civil Engineers, 2010: 136 (4), 409−411]: Practice and Teaching of American Water Management in a Changing World. He makes the point that decades ago students came from all over the world to American universities to be well trained at Masters level in water resources and sanitary engineering. Briscoe notes that, while the world has changed (and still is changing), the courses haven’t (at least not sufficiently) and therefore the US is losing its place in the world of graduate education: what happens now in the US simply isn’t relevant any more to the needs of middle- and low-income countries; similarly what’s needed in most countries in Sub-Saharan Africa is not wholly relevant to the needs of most countries in Latin America.

I suspect this sorry state of educational affairs also occurs in most other industrialized countries – in the UK, for example, you can easily count on the fingers of one hand the universities who offer appropriate graduate training in environmental health engineering for warm-climate countries (you might need both hands if you wanted to include western Europe).

►See also Declining by degree in The Economist of 4 September.

UN MDG Summit – 3

►Watch UN MDG Summit: First reaction – an interview on Global Health TV with journalist Madeleine Buntin of The Guardian (a UK daily newspaper). ►Listen to her in this Guardian Focus podcast: Millennium development goals.

►Read WaterAid’s verdict: UN Summit outcome doesn't make the grade. ►Watch Barbara Frost (WaterAid’s Chief Executive) talk about WaterAid's response to the MDG summit.

The Urban Disaster

The International Federation of Red Cross and Red Crescent Societies has just published The World Disasters Report 2010 − Focus on Urban Risk. It’s excellent! Here are some excerpts (not much new to WatSan folk, but good that it’s out there for more people to read):

Chapter 5: “Urban risk to health”:

The rapid rise in the number of people living in urban centres and cities around the globe brings with it new forms of urban risk in the health sector. It is a tragic irony, but millions of people continue to be exposed daily to diseases that medical science has long known how to prevent and / or to cure. Acute respiratory infections, dysentery and diarrhoea, largely under control in cities in high-income countries, continue to exact a significant toll on the health and well-being of a disproportionate number of those who live in the sprawling slums of the developing world. …

The other end of the urban health spectrum can be found in low- and middleincome countries where most of the world’s impoverished urban dwellers live. In households lacking basic shelter services – water supply and sanitation in particular – the prevalence rate of diarrhoea among urban children soars, averaging 38 per cent in Pakistan, 33.3 per cent in Cameroon, 23.9 per cent in the Democratic Republic of the Congo and 32.3 per cent in Jordan. Diarrhoeal diseases account for nearly 2 million deaths out of a total of almost 10 million among children under the age of 5. …

In many cases and especially in the developing world, urbanization has taken place so quickly that governments have struggled to keep up when it comes to providing needed infrastructure. When people are crowded together in unsanitary conditions, disease thrives. A 2005 report in The Lancet estimated that nearly half the urban population in Africa, Asia and Latin America has one or more of the main communicable diseases associated with inadequate water and sanitation – including diarrhoea and worm infections.

and Chapter 7: “Urban governance and disaster risk reduction”:

The quality and capacity of local government in a city have an enormous influence on the level of risk that its population faces from disasters and, in particular, on whether risk-reducing infrastructure serves everyone including those living in low-income areas. Local or municipal governments also influence whether provision has been made to remove or reduce disaster risk from events such as floods and large-scale fires or to build into the city the capacity to withstand potential disaster events such as earthquakes. The quality and capacity of local government also have an enormous influence on the levels of risk from everyday hazards that can contribute much to mortality, injury or illness but that are not considered disasters, such as vector-borne diseases and traffic accidents. These risks are not an inherent characteristic of cities but the result of the limitations of their governments in meeting their responsibilities and, more broadly, of limitations of governance including the quality of their relations with the inhabitants and civil society organizations.

Most of what local governments do, or should be doing, is about reducing risks for their populations through ensuring services such as good provision for water, sanitation, drainage, solid waste collection, healthcare, all-weather access roads, electricity, emergency services and provision for transport and traffic management. They should also ensure health and safety standards are met. Even if provision for some of these are contracted to private enterprises or provided by higher levels of government, it is usually the responsibility of local government to coordinate or oversee their provision. Local governments that support meeting development needs reduce disaster risk.

BUT:
1,105,352
is the number of people reported killed in disasters in the ten years 2000−2009 (Table 2 in Annex 1), whereas
1,600,000
is the number of people killed by diarrhoea in one year − 1.5 million under-fives and 1.1 million over-fives [see Diarrhoea: Why children are still dying and what can be done (WHO/UNICEF, 2009) and Diarrhoea kills over a million over-fives each year (SciDev, 2009)].

Winston Churchill, Ancient Sewers, and the Future

I’ve come across this quote from Winston Churchill:

The farther backward you can look, the farther forward you are likely to see.

How far back can we go with sanitation? Well, there were sewers some 5000 years ago in the city of Moenjodaro (now a World Heritage Site) in present-day Sindh province, Pakistan – see Moenjodaro: A 5,000-year-old Legacy by Khurshid Hasan Shaikh and Syed M. Ashfaque (published by UNESCO, 1981), and Water supply and sewage disposal at Mohenjo-Daro by M. Jansen (World Archaeology 1989, 21 (2), 177−192).

So how much farther forward are we likely to see? Well, clearly not 5000 years, maybe 50 years at best. What are we likely to see? A highly urbanized world, for sure, probably a highly ‘periurbanized’ world. With what sanitation? Well, hopefully by then the world will have come to its senses and simplified sewerage with be the urban/periurban norm. Sewers in the past, simplified sewers in the future. But we shouldn’t wait for the future: we need to start installing simplified sewerage on a very large scale now. When are we going to realise this?

UN MDG Summit − 2

Just a few of the many webpages and blogs on the UN MDG Summit:

1. Vivien Foster, World Bank (blog): ‘Infrastructure − paramount issue for Africa’ + excellent video.

2. WHO (webpage): Millennium Development Goals.

3. WaterAid (webpage): Heads of State and UN Secretary General urge action on sanitation and water.

4. Jesse Garcia, Transparency International (blog): Countdown to the millennium development goals summit.

5. Craig Fagan, Transparency International (blog): Live from the MDG summit, or perhaps not?

6. Anthony Painter (blog): Must try harder- NGOs verdict on MDG Summit.

7. IDS, University of Sussex (webpage): World leaders meeting at UN MDG Summit must agree new direction – check out the ‘Related publication’ at the foot of the page (it’s well worth reading).

8. BBC (webpage): Uneven progress of UN Millennium Development Goals.

9. The White House (webpage): Obama’s Remarks at Millennium Development Goals Summit.

10. Amnesty International (webpage): MDG Summit: World leaders fail to uphold rights of the poorest.

11. Simon Trace, Practical Action (blog): From the ‘Millennium Development Goal’ (MDG) summit in New York.

12. DFID (webpage): 2010 UN MDG Summit.

►The last of these, DFID’s news story, starts off like this:

With only five years to go, we can no longer afford to talk in vague terms about “accelerating progress” on the Millennium Development Goals (MDGs).
This September we are calling on world leaders to come together at the UN to agree in concrete terms a global development action plan to meet the millennium promise to halve global poverty once and for all.
In order to achieve this plan, we will need three things: accountability, credibility and political will.

No chance then.

The Economist, The Lancet and the MDGs

1. Read (1) The Millennium Development Goals: Global targets, local ingenuity, (2) Child malnutrition in India: Putting the smallest first, and (3) Household access to energy (The Economist, 25 September).

2. Watch The necessity of educating women (The Economist online, 23 September) – “the former president of Ireland on why the Millenium Development Goals are not being met, and why they are still worth pursuing”.

3. Read Soul searching at the UN (The Lancet, 25 September) – “the UN seems to be an institution suffering a crisis of confidence, looking inwards (with the exception of UNICEF), while the major players in everything from climate change to the financial crisis look elsewhere for strategic leadership”.

Sanitation videos

Watch all five videos (each 5−12 minutes) in the Sanitation Video Contest and also watch the Vanguard programme ‘The World’s Toilet Crisis’ (44 minutes) and the 3-part BBC Earthwatch programme on ‘CLTS in Bangladesh’ (total of 21 minutes) [links to these last two are given on the Sanitation Video Contest page]. Enjoy!

Sanitation at the UN MDG Summit

This week has seen the 3-day UN MDG Summit in New York – and it even has a song ‘Eight Goals for Africa’. How did Sanitation fare? Well, there’s the Factsheet on Goal 7 (‘Ensure enironmental sustainability’, which includes the WatSan targets) – specially prepared for the UN MDG Summit. Then there’s the Background Note for Round Table 3 ‘Promoting sustainable development’ which starts off with the question “What are the most cost-effective national policies to increase the availability of safe drinking water on a sustainable basis and to improve sanitation?” − the answer given is:

A sustainable development approach incorporates environmental sustainability issues ‒ such as increased access to basic services, including safe drinking water and sanitation, addressing biodiversity loss and ecosystem degradation, slum rehabilitation, along with managing the natural resource base ‒ into the design and implementation of coherent and effective national development strategies.

Achieving universal access to clean drinking water and sanitation is critical for reducing poverty and malnutrition, and realizing the gender and health-related MDGs. While notable progress has been made in increasing access to improved water sources, explicit efforts are needed to monitor water safety, accessibility, affordability and reliability (or continuity). Greater emphasis on sanitation is particularly urgent as access to sanitation is still far from being achieved in many countries.

The most effective national policies are those that catalyze, facilitate and support effective local action. Local management and community initiatives play a key role in ensuring and sustaining the success of enhancing water supply and sanitation services to poor communities. National strategies can prioritize sanitation and water coverage by, for instance, setting norms and targets, and locating them within the framework of integrated water resource management. Successful policies have focused on:
• Building local community arrangements and capacity for developing, maintaining and expanding new systems to ensure sustainability of the benefits.
• Mobilizing local leadership and participation of community women in local water management institutions as well as training local people in maintenance and repair.
• Establishing management committees or groups that manage water systems beyond the completion of projects, instituting user fee arrangements, as appropriate, to ensure financing for management, maintenance and repair.

This seems to me to have too much of a rural focus. The three bullet points aren’t really that relevant for the large-scale infrastructure interventions needed in high-density low-income urban areas. And you can see that water gets more attention than sanitation.

What about Sanitation at the Summit?
It’s true that sanitation is mentioned in the ‘Outcome Document’ of the Summit Keeping the Promise: United to achieve the Millennium Development Goals, but it doesn’t figure that strongly. The new Global Strategy for Women’s and Children’s Health, launched at the Summit does better, with eleven references to sanitation, and there’s the ‘unofficial transcript’ “Everyone should have access to water and sanitation services that we in this room take for granted,” says Secretary-General on persistent, pressing challenge, not to mention the video of the ‘UN/MDG Maternal Sanitation Wrap’ at a ‘high level UN breakfast’. There was the ‘Partnership Event’ Addressing the Global Water and Sanitation Challenge: The Key to the MDGs on 22 September, but no info. on any outcomes (at least not yet). Almost all full of “platitudes [that] hog space that should be occupied by radical ideas” (to use a nice phrase in the Baobab blog of 20 September in The Economist).

There’s much more information on other websites − for example, read WaterAid’s newsroom item of 22 September ‘Heads of State and UN Secretary General urge action on sanitation and water’; see also the newsroom item of 8 September ‘Ten years on: hope stuck in the mire’ and the release of WaterAid’s new report Ignored: Biggest Child Killer – The World is Neglecting Sanitation.

What about Sanitation beyond the Summit?
I can foresee that the international sanitation agenda will be mainly dominated by Sanitation and Water for All (see here), Sustainable Sanitation – the 5-year Drive to 2015, and the United Nations Secretary-General’s Advisory Board on Sanitation (UNSGAB) (see here, for example), and this doesn’t fill me with much (if any) confidence that the MDG sanitation target will be met or that Sanitation for All will happen by, say, 2050. Of course, many other agencies (WaterAid, World Bank, ADB, WHO, UNICEF, Gates, SCF, Oxfam, …) will also be doing their bit (and some will be doing it better than others). However, what those without adequate sanitation need is better joined-up-thinking (and action, of course) – but where’s this going to come from, and how do we get it to those who need it?

Africa’s WatSan Progress

I’ve just come across the Africa Progress Report 2010 “From Agenda to Action: Turning Resources into Results for People” published in May by the Africa Progress Panel in Geneva. If, like me, you’ve not come across the Africa Progress Panel before, here’s what it has to say about itself:

The Africa Progress Panel brings together a unique group of leaders under the chairmanship of Kofi Annan. The Panel monitors and promotes mutual accountability and shared responsibility for progress in Africa. Its three focus areas are economic and political governance; finance for sustainable development, including ODA [Official Development Assistance]; and MDG achievement – notably in light of climate change. The work of the Panel aims to track progress and draw attention to critical issues and opportunities for progress in Africa.

The Africa Progress Report 2010 (page 30) has this to say on access to water and sanitation:

Remarkable advances have been made in several African countries, including Angola and Botswana, but overall progress on the continent is insufficient. … At current rates, Africa will achieve the targets only in 2040, with some of the poorer countries not meeting them before 2050.

The challenges are enormous. Despite an increase of 11 per cent since 1990, only 60 per cent of Africans have access to improved sources of drinking water and more than half still do not have access to improved sanitation facilities. In 14 countries, more than a quarter of the population still takes longer than 30 minutes to make one round trip to collect water. Disparities between rural and urban areas have also been growing fast.

Most African countries have established national task forces and developed plans to reach the MDGs on water supply and sanitation. But plans are often neither country-owned nor actively implemented. Despite increased activity on the intergovernmental level, including through meetings of the African Ministers’ Council on Water (AMCOW), the establishment of the African Water Facility (AWF), the dedication of the 11th AU Summit to water and sanitation, and the institutionalization of an annual African Water Week, African leaders have been slow to act at the national level. Many of the recommendations and commitments enshrined in documents such as the African Water Vision (2000), the Tunis Ministerial Declaration on Accelerating Water Security for Africa’s Socioeconomic Development (2008), and the Sharm El-Sheikh Commitments for Accelerating the Achievement of Water and Sanitation Goals in Africa remain unfulfilled. The 2010 targets included in the eThekwini Declaration, including the allocation of 0.5 per cent of GDP for sanitation and hygiene, will also be missed by most countries.

So political will is lacking and the main reason why Africa’s so far behind on the MDGs, not external aid as Jeffrey Sachs claims (see blog of 17 September).

And here’s an excerpt from the speech by Angela Merkel, the German Chancellor, at the ‘High-Level Plenary Meeting of the UN General Assembly on the Millennium Development Goals’ which has been taking place this week in New York:

There is one thing that we all have to accept: the primary responsibility for development lies with the governments of the developing countries. It is in their hands whether aid can be effective. Therefore, support to good governance is as important as aid itself. Today's emerging economies show that development policy can ultimately only be successful if there is national stewardship and national implementation. This also applies to mobilising the necessary resources. ODA funding can, apart from emergency situations, only be a contribution to national resources, never a substitute for them.

[I’m waiting to see what the outcomes of this ‘High-Level Plenary Meeting’ (better known to most of us as the UN MDG Summit) might be. Just more weasel words? We’ll have to wait and see − at least Secretary General Ban Ki-moon has been making the right sort of noise: Lack of access to safe water perpetuates poverty (to be fair, he did mention sanitation)].

‘Improved’ WatSan

Jeremy Allouche and Lyla Mehta (of IDS) have written an interesting piece in the Eldis Environment News Group Exchange Blog (17 September): Water and sanitation for all: the need to go beyond numbers and beyond the MDGs, which questions the appropriateness of the JMP definitions of improved WatSan − though I wouldn’t go as far as suggesting that CLTS interventions might count as ‘improved’ if they are “just be pits in the ground, and not with slabs or pour flushes”. That apart, it’s a good read.

MDGs

This week’s issue of The Lancet has a paper and a couple of commentaries on the MDGs, all free-to-view and doubtless in preparation for next week’s UN Summit on the Millennium Development Goals in New York:

The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015 by The Lancet and the London International Development Centre Commission (the ‘webappendix’ to this paper is a particularly good review of progress/lack of progress on all the MDGs, though nothing new on WatSan),

The MDG decade: looking back and conditional optimism for 2015 by Jeffrey Sachs, and

Africa faces an uphill struggle to reach the MDGs by Wairagala Wakabi.

Sachs says:
All of the estimates [of costs needed to implement a basic primary health system in a low-income setting], when appropriately updated to 2010 conditions, suggest a cost of around US$50–60 per person per year in current dollars … [whereas] the plausible level of domestic resource mobilisation for public health is of the order of $15 per person per year. … That leaves a financing gap of around $40 per person per year to be filled by external donors. … Many large donors are letting poor regions down. … Most poor countries are ready to lead domestically, and have the management and technical capacities to do so with local skills
and internal technical support when needed. The key limiting factor for success is external aid. If the high-income countries build on their successes of the past decade, and deliver a mere 0.1% of GDP for health-sector official development aid as part of a larger overall aid programme, they and their low-income partners will celebrate great MDG successes as of 2015.

So, if low-income countries don’t meet all the health targets of the MDGs, then it’s all the fault of the high-income donor countries? I don’t think so!

Wakabi, a Ugandan journalist, certainly doesn’t put the blame on donor countries, more on the low-income countries: “Despite scoring some notable successes, funding shortfalls and a sapping of political will are stymying progress towards attaining the health MDGs in Africa” – shortfalls, that is, in local funding and a lack of local political will.

Toiling for toilets

There’s a “feature” article in this week’s British Medical Journal: Toiling for toilets by Rebecca Coombes (a BMJ associate editor) – quote: “Sanitation has been the poor relation of the millennium development goals, but without it the chances of meeting many of the other goals are much reduced”. Nothing new, but a useful piece of advocacy (and good for medics to read).

CLTS and STEPS

The STEPS [Social, Technological and Environmental Pathways to Sustainability] Centre at the University of Sussex has just published a working paper on CLTS: The Dynamics and Sustainability of Community-led Total Sanitation: Mapping Challenges and Pathways. Here’s a quote:

Even though CLTS has the makings of a development success story, many obstacles remain before it can truly be said to offer a viable route to meeting the MDGs. For example: How does CLTS accommodate dynamism and complexity inherent in social-technological-ecological systems? How are women’s, children’s and men’s often diverging needs accounted for? How can CLTS be scaled up to become a major force rather than an approach characterised through piecemeal, scattered projects? Are there lingering assumptions and power relations that hinder or obstruct the spread of CLTS? In short – how sustainable is CLTS, and in what ways is the notion of sustainability understood? This paper offers some perspectives that may help structure thinking around these questions.

Good down-to-earth stuff!

The list of all STEPS working papers is here. A few of the WatSan-relevant ones are:

Liquid Dynamics: Challenges for Sustainability in Water and Sanitation

Going with the Flow? Directions of Innovation in the Water and Sanitation Domain

On the Edge of Sustainability: Perspectives on Peri-urban Dynamics

Back-end users

Here’s an interesting commentary on sanitation: Back-end users: the unrecognized stakeholders in demand-driven sanitation by Ashley Murray and Isha Ray of UC Berkeley (recently published online in the Journal of Planning, Education and Research). This is the Abstract:

Inadequate wastewater and fecal sludge treatment, disposal, and end use systems are arguably the greatest obstacles to achieving sustainable urban sanitation in unserved regions. Strategies for planning and implementing urban sanitation are continually evolving. Demand-driven sanitation with household and community participation is broadly thought to be the way forward. We are skeptical that more time and resources spent garnering household and community demand for sanitation will amount to the much-needed improvements in the treatment and end use components of sanitation systems. We propose shifting the incentives for sanitation from “front-end users” to “back-end users,” thereby leveraging demand for the products of sanitation (e.g., treated wastewater, fertilizer, alternative fuel) to motivate robust operation and maintenance of complete sanitation systems. Leveraging the resource value of wastewater and fecal sludge demands a reuse-oriented planning approach to sanitation, an example of which is the Design for Service approach presented in this commentary.

“Design for Service” is defined as “a five-step planning approach that results in a site-specific, reuse-oriented sanitation scheme. The ultimate reuse (or “service”) of the wastewater/fecal sludge is the starting point for the planning process”. The five steps are:

1. Generate a list of all of the potential “services” (e.g., irrigation, fertilizer, energy generation) that wastewater, fecal sludge, and treatment by-products can provide.
2. Assess the demand for these services in and around the city of interest.
3. Assess the business-as-usual performance of the provision of these services according to economic, social, and environmental indicators.
4. Design sanitation infrastructure for the provision of that service where it can have the greatest marginal impact.
5. Assess the intrinsic environmental and cost characteristics of the technology options available for rendering the wastewater/fecal sludge/treatment by-products suitable for the service of choice.

The paper details the rationale for each of these five steps.

As the authors say in their Conclusions, “designing for reuse exacts a nontrivial time and resource cost on sanitation planning processes” − but, if it increases the chance of system success/sustainability, then it’s clearly worth doing. Up to now we’ve concentrated on the “front-end users”. It’s clearly time to bring the “back-end users” into the sanitation planning process.

Energy and Monkeypox

There’s a good article on energy in the developing world − Power to the people – in the 4 September issue of The Economist. Quote: “Around 1.5 billion people, or more than a fifth of the world’s population, have no access to electricity, and a billion more have only an unreliable and intermittent supply.” Not too dissimilar to WatSan provision then.

The same issue has an article on emerging infections – No good deed goes unpunished. Smallpox is being replaced by monkeypox, at least in the DRC (see the original PNAS paper here). Similar to rotavirus and norovirus (see blog of 27 June 2009)?

Global Atlas of Helminth Infections

Check out the Global Atlas of Helminth Infections website (developed by the London School of Hygiene and Tropical Medicine and the Partnership for Child Development). This is “an open-access information resource on the distribution of soil-transmitted helminths and schistosomiasis”. Country maps are currently available only for Sub-Saharan Africa, but will eventually be available also for Latin America and Asia.

Note: there are better life-cycle diagrams on the CDC website – Ascaris, Trichuris, hookworms, and schistosomes.

World Water Week

Last week (5−10 September) was World Water Week in Stockholm – an annual event ably organized by the Stockholm International Water Institute (SIWI) and with now a good emphasis on sanitation. There were many parallel sessions and side events, so impossible to attend everything. Here are just some of the events I found interesting…

Sunday

Wastewater use in agriculture this afternoon and early evening. The afternoon session was
on “Reducing the Risks of Wastewater Irrigation: Strategies and Incentives” based, more or less, on the following three recent publications:

1. Improving Wastewater Use in Agriculture: An Emerging Priority (World Bank, 2010)
2. The Wealth of Waste: The Economics of Wastewater Use in Agriculture (FAO, 2010)
3. Wastewater Irrigation & Health: Assessing and Mitigating Risk in Low-income Countries (Earthscan/IDRC, 2010)

The early evening session was the launch of the Second Information Kit on the 2006 WHO Wastewater Use Guidelines – not yet online (but my part is here). My presentation was on choosing a sensible value for the maximum tolerable additional burden of disease – i.e., the maximum DALY loss per person per year (pppy). The default value used for this in the 2006 WHO Guidelines is 10−6 pppy for this, but this is very ‘extravagant’ and I recommended a value of 10−4 DALY loss pppy as it reflects epidemiological reality in developing countries and some industrialized countries (e.g., Australia and the USA) much more closely. [Actually this also applies to Drinking-water Quality Guidelines, but that’s a real can of worms – for WHO, US EPA and the EU, amongst others − waiting to be opened…]

Tuesday

I attended the lunchtime side event on “What knowledge do we need to do better on Sanitation?” This was basically how the London School of Hygiene and Tropical Medicine and its partners see how their ‘Sanitation and Hygiene Applied Research for Equity’ (SHARE) research consortium, funded by DFID, will progress. Check out the SHARE website when it gets going by the end of the month (in the meantime there are some details here).

Then I went to the afternoon seminar on “Water quality issues and new approaches in Latin America”. Interesting couple of papers – one on water and wastewater problems in Mexico City by Dr Blanca Jiménez (UNAM). The other was by Professor Eduardo Jordão (Federal University of Rio de Janeiro) on the use in Brazil of UASBs + some form of secondary treatment serving populations of 20,000−1,500,000 – but little mention of costs or cost-effectiveness, and no mention of high-rate anaerobic ponds.

As I was rushing from the lunchtime session to the afternoon session my colleague Dr Jan-Olof Drangert (University of Linköping, Sweden) shoved a leaflet into my hand – all about his new website Sustainable Sanitation for the 21st Century, which comprises a free e-book and a set of PowerPoint presentations for training professionals in the sanitation and water sector. There’s a certain EcoSan emphasis, but it’s certainly very well worth taking a look. You can download the PowerPoints as ppt files, so you can use them as they are or select which slides you want to use in your own presentations. Excellent idea!

Wednesday

I went to the workshop on “Improved water use efficiency through recycling and reuse” and gave a presentation on Natural wastewater treatment and carbon capture. Professor Emeritus Takashi Asano (UC Davis), in a keynote presentation, told us all about water demand and wastewater recycling and reuse in California – a complex system necessitated by building a megacity (Los Angeles) in a desert and by California being the nation’s major table-food (vegetables, fruits) producer. Then Dr Ashley Murray (UC Berkeley) gave a really interesting paper on wastewater-fed aquaculture: set up a local business to grow fish in maturation ponds and the business returns half its net profit to the wastewater treatment works (waste stabilization ponds) to help pay for O&M – a very neat concept which she developed in Ghana.

Thursday

Interesting morning session on the “Five-Year countdown to the water and sanitation MDG targets: status, trends and challenges”. The main findings of the 2010 JMP Report and the 2010 GLAAS Report were presented, and there was considerable discussion on how WatSan monitoring should progress. Good data are, of course, essential but, while I think they can tell us what to do in some areas, they don’t/can’t in other areas. For example:

(1) While they tell us that there are still far too many open defecators and so helping communities to become OD-free (i.e., to move to fixed-place defecation) is really important, it’s equally important that the fixed defecation place they move to is at least improved sanitation, but so often it’s not.

(2) They can’t tell us a lot about the future, but we know from the World Urbanization Prospects: The 2009 Revision that almost all population growth in the next few decades will be in urban areas of developing countries (see blog of 28 August for the figure showing this). This means that, while we can’t forget about rural sanitation, we’re going to have to concentrate on sanitation in high-density low-income slum and non-slum urban areas. Is the world remotely prepared for this? No, it is not.

►One statistic that came out this morning was that, as we’re unlikely to meet the MDG sanitation target, there’ll be around 2.7 billion people at the start of 2016 who’ll need ‘improved’ sanitation. Now that’s a hideously sobering thought: in purely numeric terms we’ll be back where we started in 2000…

Not a brilliant note to finsh World Water Week on. Just, depressingly, more of the same. Clearly we’re going to need, and sooner rather than later, an annual World Water & Sanitation Week. Sanitation really does need to be mainstreamed more, not just mostly left to side-event organizers. Anyone in SIWI listening?

****************************
PS: check out the World Water Week videoclips on the WaterCube!

Child health in Brazil

I’ve just come across the paper Infant mortality and child health in Brazil by Denisard Alves and Walter Belluzzo of the University of São Paulo (published in Economics & Human Biology in December 2004). The authors end their paper by saying:

Among the factors considered, education is by far the most important as one additional year of schooling leads to a decline of more than 7% in average infant mortality rates. Improvement in sanitation services, meaning more availability of treated running water and sewage services, also led to a decline in infant mortality [emphasis added]. Economic growth as measured by per capita income is also a strong factor in reducing infant mortality. … From a policy perspective, the conclusion is clear: education [i.e., “education level measured by the average years of schooling of the municipal population”], improvement of sanitary services [i.e., connection to a piped water supply and sewerage], higher per capita income, that should be brought about by economic growth, are all important factors to improve child health in Brazil.

More evidence to persuade recalcitrant politicians to roll out WASH programmes!

Brazilians say “Saneamento básico: aqui começa A Saúde” – ‘Health begins with basic sanitation’, with ‘basic sanitation’ meaning not just sanitation but also water supply, stormwater drainage and garbage disposal (the term is close to ‘environmental sanitation’).

Agricultural R&D in Brazil − 2

The Editorial on Brazilian agriculture in today’s issue of The Economist ends by saying that “change will not come about by itself. Four decades ago, [Brazil] faced a farm crisis and responded with decisive boldness. The world is facing a slow-motion food crisis now. It should learn from Brazil”.

Brazil also realised it had an urban sanitation crisis on its hands some three decades ago and it responded with the equally bold development of simplified sewerage. We all know that the world is facing a slow-motion sanitation crisis, so it should learn from Brazil about this too. But will it?

Agricultural R&D in Brazil

Today’s issue of The Economist has an amazing article on Brazilian agriculture: The miracle of the cerrado: Brazil has revolutionised its own farms. Can it do the same for others? [‘cerrado’ = savannah]; there's an Editorial here and you can listen to an audio version of the article here. Basically it’s the story of Brazil’s recent agricultural development:

The increase in Brazil’s farm production has been stunning. Between 1996 and 2006 the total value of the country’s crops rose from 23 billion reais ($13 billion) to 108 billion reais, or 365%. Brazil increased its beef exports tenfold in a decade, overtaking Australia as the world’s largest exporter. It has the world’s largest cattle herd after India’s. It is also the world’s largest exporter of poultry, sugar cane and ethanol. Since 1990 its soyabean output has risen from barely 15m tonnes to over 60m. Brazil accounts for about a third of world soyabean exports, second only to America. In 1994 Brazil’s soyabean exports were one-seventh of America’s; now they are six-sevenths. Moreover, Brazil supplies a quarter of the world’s soyabean trade on just 6% of the country’s arable land. No less astonishingly, Brazil has done all this without much government subsidy.

And it did all this on land that had been considered wholly unsuitable for arable farming. Big is good, too:

… half the country’s 5m farms earn less than 10,000 reais a year and produce just 7% of total farm output; 1.6m are large commercial operations which produce 76% of output. Not all family farms are a drain on the economy: much of the poultry production is concentrated among them and they mop up a lot of rural underemployment. But the large farms are vastly more productive.

The article describes how this transformation, this ‘miracle’, was achieved. Much of the detail is agricultural (but still very interesting), but the real point is that, because Brazil wanted to modernise and expand its agriculture, and so increase employment, farm profits and exports, it was done.

►There’s a lesson here for water supplies, sanitation and hygiene (WASH) in developing countries, and the argument should go something like this:

Do you, as the government of your country, genuinely want socio-economic development in both your rural and urban areas? [No government is going to say ‘No’.] So you need a healthy productive labour force. To make sure your labour force is healthy and productive you need to facilitate good WASH for all your citizens. There are several other things you need to do as well, of course [good primary health care, good schools (and good schools have separate sanitation facilities for girls and boys), good technical training, good extension workers, etc., etc.] − but, if you don’t do good WASH, then the return on your investments in these other areas is very likely to be suboptimal (especially if your schools don’t have good sanitation).

Remember: poor WASH leads to repeated diarrhoea and polyparasitism in very young children; this leads to impaired cognition in these children when they’re at school; and this in turn leads to low productivity in adult life – precisely the opposite of what you need for socio-economic development.

You can’t say you can’t afford to invest in WASH for all your citizens (any development bank will gladly lend you the money for a well-designed WASH programme). Rather it’s a question of whether you can afford not to invest in WASH for all your citizens. If you can’t be bothered (and many of you seem to be like this), then on your head be it – although, of course, it won’t be your head, but the heads of your rural and urban poor. So, do everyone a favour (everyone of your rural and urban poor, that is): get real, and think BIG.

Urbanization

In March this year the Department of Economic and Social Affairs, Population Division, of the United Nations published World Urbanization Prospects: The 2009 Revision – Highlights. There’s a very nice chart in this:


The message is clear: sort rural sanitation and stop open defecation, but the long-term problem is going to be sanitation in low-income high-density urban areas, including slums. It’s bad enough now, but it could well get a whole lot worse before it gets better – and it’ll only get better if politicians in developing countries wake up to the realities of urban poverty in their own back-yards.

Simplified sewerage: health impacts

The city of Salvador, capital of the Brazilian state of Bahia, has one of the largest simplified sewerage systems in the country (details here). In a recent paper in Environmental Health Perspectives: Impact of a city-wide sanitation programme in northeast Brazil on intestinal parasites infection in young children, by Professor Barreto and colleagues at the Universidade Federal da Bahia in Brazil (including Professor Sandy Cairncross of the London School of Hygiene and Tropical Medicine), it was found that, in children under five:

The prevalence of Ascaris lumbricoides infection was reduced from 24.4% to 12.0%, Trichuris trichuria from 18.0% to 5.0% and Giardia duodenalis from 14.1% to 5.3%. Most of this reduction appeared to be explained by the increased coverage of each neighborhood by the sewerage system constructed during the intervention. The key explanatory variable was thus an ecological measure of exposure and not household-based, suggesting that the parasite transmission prevented by the program was mainly in the public (as opposed to the domestic) domain.

[For ‘public’ and ‘domestic’ domains see the 1996 paper by Cairncross et al. in Tropical Medicine & International Health: The public and domestic domains in the transmission of disease.]

This EHP paper is a sequel to the same group’s 2007 paper in The Lancet: Effect of citywide sanitation programme on reduction in rate of childhood diarrhoea in northeast Brazil: assessment by two cohort studies, which reported that in children less than 3 years of age:

Diarrhoea prevalence fell by 21% (95% CI 18−25%) − from 9.2 (9.0−9.5) days per child-year before the intervention to 7.3 (7.0−7.5) days per child-year afterwards. After adjustment for baseline sewerage coverage and potential confounding variables, we estimated an overall prevalence reduction of 22% (19−26%) … Our results show that urban sanitation is a highly effective health measure that can no longer be ignored [emphasis added].

Quite!

Safe water, improved sanitation and diarrhoea

Earlier this year the Centre for Environmental Economics and Policy in Africa at the University of Pretoria published the excellent Discussion Paper Household Environmental Conditions and Disease Prevalence in Uganda: The Impact of Access to Safe Water and Improved Sanitation on Diarrhea by Ibrahim Kasirye of the Economic Policy Research Centre in Kampala. Here’s the Abstract:

Although governments in sub-Saharan Africa have increasingly devoted more resources to water and sanitation interventions, many households in the sub-region still do not have access to safe water and improved sanitation. We utilize data from the 2005/06 Uganda National Household Survey to investigate the impacts of inadequate access to safe water and improved sanitation. In addition, we examine the cost-effectiveness of the provision of piped water by either a household connection or community standpipes, for a hypothetical poor urban town in Uganda. We find that only piped water within the household and access to private covered pit latrines significantly impact diarrhea prevalence. In addition, we examine the cost-effectiveness of the provision of piped water by either a household connection or community standpipes, for a hypothetical poor urban town in Uganda. We find that providing community standpipes results in the largest reduction in the burden of disease. Overall, our results present a targeting dilemma because, although water in Uganda is publicly provided, the construction of sanitation facilities is considered a private matter. Nonetheless, either health information campaigns, conducted to persuade households to construct personal latrines, or local government ordinances making toilet construction mandatory could go a long way toward reducing the burden of disease due to diarrhea in Uganda.

So piped water supplies (in-house connections, yard taps or public standpipes) plus good sanitation (simplified sewerage or on-site systems), depending on costs and ability/willingness to pay). Nothing new, but good to have good data from a country like Uganda.

Climate change and WatSan services

Read this very illuminating paper: Securing 2020 vision for 2030: climate change and ensuring resilience in water and sanitation services, by Guy Howard, Katrina Charles, Kathy Pond, Anca Brookshaw, Rifat Hossain and Jamie Bartram, which has been published in the Journal of Water and Climate Change [2010: 1 (1), 2−16]. Here’s the Abstract:

Drinking-water supply and sanitation services are essential for human health, but their technologies and management systems are potentially vulnerable to climate change. An assessment was made of the resilience of water supply and sanitation systems against forecast climate changes by 2020 and 2030. The results showed very few technologies are resilient to climate change and the sustainability of the current progress towards the Millennium Development Goals (MDGs) may be significantly undermined. Management approaches are more important than technology in building resilience for water supply, but the reverse is true for sanitation [emphasis added]. Whilst climate change represents a significant threat to sustainable drinking-water and sanitation services, through no-regrets actions and using opportunities to increase service quality, climate change may be a driver for improvements that have been insufficiently delivered to date.

This is what the authors say about unconventional sewerage:

Unconventional sewerage (including ‘condominial’ [i.e., simplified] and small bore [i.e., settled] sewerage) is more resilient that conventional sewerage. Small-bore and condominial sewers use less water than conventional sewerage and as a consequence they are less vulnerable to decreasing water availability. Modified sewers will still be at risk from damage from floods and other extreme events.

Unfortunately no mention of low-cost combined sewerage – which we might expect to become more widely used as the incidence of flooding increases.

Dig Toilets, not Graves

UN Secretary-General Ban Ki-moon has called on world leaders to attend a summit in New York on 20−22 September to accelerate progress towards the MDGs. In his report ‘Keeping the promise: a forward-looking review to promote an agreed action agenda to achieve the Millennium Development Goals by 2015’ he says:

Some progress has been achieved towards the target of halving the proportion of people without access to clean water, but the proportion without improved sanitation decreased by only 8 percentage points between 1990 and 2006.

The UN is rather more forthright (taken from here):

● The world is on track to meet the drinking water target, though much remains to be done in some regions.
● Accelerated and targeted efforts are needed to bring drinking water to all rural households.
● Safe water supply remains a challenge in many parts of the world.
● With half the population of developing regions without sanitation, the 2015 target appears to be out of reach.
● Disparities in urban and rural sanitation coverage remain daunting.
● Improvements in sanitation are bypassing the poor.

The United Kingdom government will be represented at the Summit by Nick Clegg, the Deputy Prime Minister. WaterAid has an “urgent message” for him:

2.6 billion people worldwide still don’t have access to clean, safe toilets – a basic human right. This is more than an inconvenience. It’s a killer. Diarrhoea kills more children than AIDS, malaria and measles combined. The solution to the problem is simple − safe toilets will save thousands of lives. Deputy Prime Minister Nick Clegg will be attending a Millennium Development Goals summit in New York to discuss global poverty targets and we are asking him to make building toilets a priority. We call on our coalition Government to tackle this global crisis and prove their commitment by increasing aid to sanitation and water to £600 million. Please help us shout so loud the UK Government has to listen. There is no time to lose, so please put your name to our petition right now and together we can work to dig toilets, not graves.

Visit WaterAid’s ‘Dig toilets, not graves’ website where you can sign the petition – please do so by 19 September.

SIWI’s publications online

The Stockholm International Water Institute (SIWI) has put all its publications online and in one place. Here’s what an email from SIWI says:

Over the last 20 years, SIWI has produced a wide range of publications in the field of global water issues. Now you can find them all at www.siwi.org/publications. This section of the SIWI web was recently re-launched with a new appearance and improved search functionality so that you can easily find any publications in your field of interest. Do you wish to read more about a specific topic such as IWRM, corruption in the water sector or the Nile River? Search freely for words that are commonly used in a publication to narrow down your findings even more. You can also search for the year of publication and what type of publication you are looking for such as reports, policy briefs, scientific papers, brochures, World Water Week publications, Water Front Magazine, or specific articles. Welcome to explore our new and improved publications archive online.

What a good idea – IRC has already done this (see blog of 29 April 2010), but it needs to be copied by many others.

Globalization and Health

Here’s a good paper just published in World Development: Good for Living? On the Relationship between Globalization and Life Expectancy, by Andreas Bergh and Therese Nilsson. Here’s the Abstract:

This paper analyzes the relationship between three dimensions (economic, social, and political) of globalization and life expectancy using a panel of 92 countries covering the 1970–2005 period. Using different estimation techniques and sample groupings, we find that economic globalization has a robust positive effect on life expectancy, even when controlling for income, nutritional intake, literacy, number of physicians, and several other factors. The result also holds when the sample is restricted to low-income countries only. In contrast, political and social globalization have no such robust effects.

So economic globalization is good for your health. See also Richard Feachem’s 2001 paper in the British Medical Journal “Globalisation is good for your health, mostly” (which created a fair amount of controversy – see here).

Multidimensional Poverty Index

The working paper Acute Multidimensional Poverty: A New Index for Developing Countries by Sabina Alkire and Maria Emma Santos was published last month by the Oxford Poverty & Human Development Initiative, Department of International Development, University of Oxford. Here’s the paper’s Abstract:

This paper presents a new Multidimensional Poverty Index (MPI) for 104 developing countries. It is the first time multidimensional poverty is estimated using micro datasets (household surveys) for such a large number of countries which cover about 78 percent of the world´s population. The MPI … is composed of ten indicators corresponding to same three dimensions as the Human Development Index: Education, Health and Standard of Living. Our results indicate that 1,700 million people in the world live in acute poverty, a figure that is between the $1.25/day and $2/day poverty rates. Yet it is no $1.5/day measure. The MPI captures direct failures in functionings that Amartya Sen argues should form the focal space for describing and reducing poverty. It constitutes a tool with an extraordinary potential to target the poorest, track the Millennium Development Goals, and design policies that directly address the interlocking deprivations poor people experience.

Regarding the ‘Standard of Living’ indicators, the paper says:

The MPI considers and weights standard of living indicators individually. It would also be very important and feasible to combine the data instead into other comparable asset indices and explore different weighting structures. The present measure uses six indicators which, in combination, arguably represent acute poverty. It includes three standard MDG indicators that are related to health, as well as to standard of living, and particularly affect women: clean drinking water, improved sanitation, and the use of clean cooking fuel [emphasis added]. The justification for these indicators is adequately presented in the MDG literature. It also includes two non-MDG indicators: electricity and flooring material. Both of these provide some rudimentary indication of the quality of housing for the household. The final indicator covers the ownership of some consumer goods, each of which has a literature surrounding them: radio, television, telephone, bicycle, motorbike, car, truck and refrigerator.

The Economist (issue of 31 July) has a digestible one-page summary of this Working Paper A wealth of data: A useful new way to capture the many aspects of poverty, with a nice chart:


Here’s a bit of what The Economist has to say:

By and large, as the chart shows, countries’ poverty rates as calculated using the MPI differ quite a lot from those based on their $1-a-day rates. In India, for instance, many more people lack basic things, as measured using the MPI, than earn less than $1.25 a day. The opposite, however, is true of Tanzania, which is doing better at getting its people fed, housed and educated than its income-based poverty rate would suggest.

Since the MPI is calculated by adding lots of different things up, it is possible to work backwards and see what contributes the most to poverty in specific places. In sub-Saharan Africa, the material measures contribute much more to poverty than in South Asia, where the biggest contributor is malnutrition. The authors argue that having this information readily accessible makes it easier for development agencies and governments to decide what to focus on. The MPI also does a better job of uncovering long-term trends. Successful reforms in health or education increase earnings only many years into the future but will show up quickly in the MPI poverty rate.

Earlier this year there was another paper which questioned accepted statistics – this time on infant mortality: Global infant mortality: Correcting for undercounting by Rebecca Anthopolos and Charles M. Becker, both of Duke University, USA, which appeared in World Development (vol. 38, pp. 467–481). Here’s the Summary:

The UN Millennium Development Goals highlight the infant mortality rate (IMR) as a measure of progress in improving neonatal health and more broadly as an indicator of basic health care. However, prior research has shown that IMRs (and in particular perinatal mortality) can be underestimated dramatically, depending on a particular country’s live birth criterion, vital registration system, and reporting practices. This study assesses infant mortality undercounting for a global dataset using an approach popularized in productivity economics. Using a one-sided error, frontier estimation technique, we recalculate rates and concurrently derive a measure of likely undercount for each country.

So IMRs are higher than we previously thought (and they were bad enough then).

And, of course, there’s the big WatSan statistics ‘mess’: just ‘improved’ (sensu JMP) or ‘adequate’ (sensu UN-Habitat)? See blogs of 17 December 2008 and 14 January 2008.

►Who was it who said “Lies, damned lies and statistics”?! [If you really want to know, read this.]

Child deaths in Sub-Saharan Africa

WaterAid’s brochure for the 15th African Union Summit held in Kampala, Uganda, from 19 to 27 July, Biggest killer of children in Africa cannot be addressed without sanitation and water, has this to say:

Diarrhoea is now the biggest killer of children in Africa [1]. Every day, 2,000 African children die from diarrhoea – deaths that are entirely preventable. Nine out of ten cases of diarrhoea can be prevented by safe water and sanitation – proven cost-effective interventions. Despite this, today only four in ten Africans have access to a basic toilet. This failure will undermine efforts to accelerate progress on the MDG for child mortality.

[1]. Black. R. et al., Global, regional, and national causes of child mortality in 2008: a systematic analysis, The Lancet, 5 June 2010: 375, 1969–87 (free pdf download). Here’s an excerpt from this paper:

Of the estimated 8,795 million deaths in children younger than 5 years worldwide in 2008, infectious diseases caused 68% (5,970 million), with the largest percentages due to pneumonia (18%, 1,575 million), diarrhoea (15%, 1,336 million), and malaria (8%, 0,732 million). 41% (3,575 million) of deaths occurred in neonates. … 49% (4,294 million) of child deaths occurred in five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan, and China.

Most countries in Sub-Saharan Africa are not on-track to meet the MDG sanitation target:


Why do these governments continue to let their children die in such large numbers from preventable sanitation-related diseases like diarrhoea?

Sanitation and gender

Here’s a really good report published by Amnesty International on 7 July: Insecurity and Indignity: Women’s Experiences in the Slums of Nairobi, Kenya. Quote:

The majority of Nairobi’s residents live in informal settlements and slums, in inadequate housing with little access to clean water, sanitation, health care, schools and other essential public services.
Women and girls living in these informal settlements are particularly affected by lack of adequate access to sanitation facilities for toilets and bathing. Not only do women have different physical needs from men, (for example, related to menstruation) but they also have greater need of privacy when using toilets and when bathing. Inadequate and inaccessible toilets and bathrooms, as well as the general lack of effective policing and insecurity, make women even more vulnerable to rape and other forms of gender-based violence. Violence against women is endemic in Nairobi’s slums and settlements, goes widely unpunished and significantly contributes to making and keeping women poor.
Recent positive attempts by the government to improve access to essential services in informal settlements do not address the immediate needs for access to essential public services, including sanitation. Nor do the proposed solutions fully take into account the specific needs of women and girls in these settlements.
This report shows that for many women living in informal settlements, poverty is both a consequence and a cause of violence. Many women who suffer physical, sexual or psychological violence lose income as a result and their productive capacity is impaired. Violence against women also impoverishes their families, communities and societies. For women in abusive relationships, poverty makes it harder to find avenues for an escape. While economic independence does not shield women from violence, access to economic resources can enhance women’s capacity to make meaningful choices. The violence women face helps keep them poor in part because their poverty inhibits their ability to find solutions.

There’s also a good article on this in the 10 July issue of The Economist: Sexual equality and sanitation: Flushing away unfairness. Quote:

In poorer countries unequal provision [of toilets] means more than just discomfort. Studies in countries such as Ghana and Cameroon suggest many girls at secondary school miss a week of classes when they have their period, or drop out altogether when they reach puberty. Rude boys plus inadequate or missing girls’ toilets make calls of nature embarrassing or outright dangerous. In India some 330m women lack access to toilets. Many wait until night, raising the risk of rape, kidnap and snake bites.

The article goes on to make the point that, in public/communal places, women need more toilets than men – a point made in the 2003 ABC radio programme Bathroom Blues (this is a .ram audio file, so to listen to it you’ll need RealPlayer on your computer). See also this photo of public toilets at a market in Mozambique.

Handwashing

WSP has just put up a webpage on Enabling Technologies for Handwashing with Soap Database. It contains a wealth of information and is really useful. An excellent contribution!

And here’s a good paper to read: Hands, water, and health: Fecal contamination in Tanzanian communities with improved, non-networked water supplies (published ahead-of-print in Environmental Science & Technology in March this year). Here’s the Abstract:

Almost half of the world’s population relies on non-networked water supply services, which necessitates in-home water storage. It has been suggested that dirty hands play a role in microbial contamination of drinking water during collection, transport, and storage. However, little work has been done to evaluate quantitatively the association between hand contamination and stored water quality within households. This study measured levels of E. coli, fecal streptococci, and occurrence of the general Bacteroidales fecal DNA marker in source water, in stored water, and on hands in 334 households among communities in Dar es Salaam, Tanzania, where residents use non-networked water sources. Levels of fecal contamination on hands of mothers and children were positively correlated to fecal contamination in stored drinking water within households. Household characteristics associated with hand contamination included mother’s educational attainment, use of an improved toilet, an infant in the household, and dissatisfaction with the quantity of water available for hygiene. In addition, fecal contamination on hands was associated with the prevalence of gastrointestinal and respiratory symptoms within a household. The results suggest that reducing fecal contamination on hands should be investigated as a strategy for improving stored drinking water quality and health among households using non-networked water supplies.

Graphic TV programme on sanitation

Current TV has a wonderfully graphic programme on sanitation – specifically on open defecation and what’s being done to end it. Watch the full episode here or the trailer here. Good stuff!

WASH prevention of diarrhoea

There’s an excellent review paper published earlier this year in the International Journal of Epidemiology: Water, sanitation and hygiene for the prevention of diarrhoea by Sandy Cairncross, Caroline Hunt, Sophie Boisson, Kristof Bostoen, Val Curtis, Isaac Fung and Wolf-Peter Schmidt (all of the London School of Hygiene and Tropical Medicine, except the penultimate author who’s from the University of Georgia in Athens, GA). Here’s part of the Abstract:

Results: The striking effect of handwashing with soap is consistent across various study designs and pathogens, though it depends on access to water. The effect of water treatment appears similarly large, but is not found in few blinded studies, suggesting that it may be partly due to the placebo effect. There is very little rigorous evidence for the health benefit of sanitation; four intervention studies were eventually identified, though they were all quasi-randomized, had morbidity as the outcome, and were in Chinese.

Conclusion: We propose diarrhoea risk reductions of 48, 17 and 36%, associated respectively, with handwashing with soap, improved water quality and excreta disposal as the estimates of effect for the LiST model. Most of the evidence is of poor quality. More trials are needed, but the evidence is nonetheless strong enough to support the provision of water supply, sanitation and hygiene for all [emphasis added].

Slum upgrading

There’s a good ‘article in press’ in Social Science & Medicine: Improved health outcomes in urban slums through infrastructure upgrading by Neel M. Butala (Yale School of Medicine) and Michael J. Van Rooyen and Ronak Bhailal Patel (both of Harvard School of Public Health). Here’s part of the Abstract:

Upgrades in slum household water and sanitation systems have not yet been rigorously evaluated to demonstrate whether there is a direct link to improved health outcomes. This study aims to show that slum upgrading as carried out in Ahmedabad, India led to a significant decline in waterborne illness incidence. We employ a quasi-experimental regression model using health insurance claims (for 2001−2008) as a proxy for passive surveillance of disease incidence.

We found that slum upgrading reduced a claimant’s likelihood of claiming for waterborne illness from 32% to 14% and from 25% to 10% excluding mosquito-related illnesses. This study shows that upgrades in slum household infrastructure can lead to improved health outcomes and help achieve the MDGs. It also provides guidance on how upgrading in this context using microfinance and a public-private partnership can provide an avenue to affect positive change.

Quite an interesting way of measuring health outcomes.

‘Easy latrines’

The Industrial Designers Society of America has given one of its Gold International Design Excellence Awards to ‘Easy Latrine’, a pour-flush toilet developed for rural Cambodia. The IDEA ‘Easy Latrine’ webpage says:

The Easy Latrine is the first $30, affordable and sustainable latrine design that consists of a squat pan, slab, catchment box, pipe and offset storage rings, making household sanitation decisions easy.

The IDE Canada ‘Easy Latrine’ webpage says it costs USD 25.

See the YouTube video here [costs are reported as USD 25 minimum and USD 30 maximum.].

►Check out the 1984 World Bank TAG Technical Note ‘Manual on the Design, Construction and Maintenance of Low-Cost Pour-Flush Waterseal latrines in India’ by the late A. K. Roy (the pioneer of low-cost sanitation in India) and his colleagues. You’ll find a pour-flush toilet design essentially the same as the ‘Easy Latrine’.

Pathogens, parasites and IQ

The 3 July issue of The Economist has an interesting article Disease and Intelligence: Mens Sana in Corpore Sano. It’s based on the paper Parasite prevalence and the worldwide distribution of cognitive ability by Christopher Eppig, Corey L. Fincher and Randy Thornhill (all of the University of New Mexico), published ahead-of-print online as part of the Proceedings of the Royal Society B. Here’s their Abstract:

In this study, we hypothesize that the worldwide distribution of cognitive ability is determined in part by variation in the intensity of infectious diseases. From an energetics standpoint, a developing human will have difficulty building a brain and fighting off infectious diseases at the same time, as both are very metabolically costly tasks. Using three measures of average national intelligence quotient (IQ), we found that the zero-order correlation between average IQ and parasite stress ranges from r = −0.76 to r = −0.82 (p < 0.0001). These correlations are robust worldwide, as well as within five of six world regions. Infectious disease remains the most powerful predictor of average national IQ when temperature, distance from Africa, gross domestic product per capita and several measures of education are controlled for. These findings suggest that the Flynn effect may be caused in part by the decrease in the intensity of infectious diseases as nations develop.

Flynn effect? ‘Large increases in IQ over short periods of time as nations develop’ (reference in the Proc. Roy. Soc. B paper).

I would venture that tropical enteropathy (see blogs of 18 September, 19 September and 23 September 2009) has a role to play as well.

Here’s the figure that accompanied the article in The Economist:

Mothers and daughters

The July issue of the Bulletin of the World Health Organization has a splendid 1-page editorial: Swimming upstream: why sanitation, hygiene and water are so important to mothers and their daughters by Clarissa Brocklehurst (Chief of Water, Sanitation and Hygiene, UNICEF) and Jamie Bartram (Professor of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina). Here’s the final paragraph:

The vicious cycle in which inadequate water, sanitation and hygiene contributes to keeping women in poor health, out of education, in poverty and doomed to bearing sickly children can be reversed. The tools to do this exist. Water, sanitation and hygiene also enable women to play roles in their community’s development, including, of course, decision-making and management of water and sanitation systems.

But read it all!

Rose George

Rose George, author of the splendid The Big Necessity: Adventures in the World of Human Waste, has written a short article “Beating boring, banal diarrhoea” in last Saturday’s issue of The Guardian (a UK daily newspaper). As to be expected from such a good writer, it’s a brilliant piece – read it!

Water, sanitation, women and children

Here’s an interesting World Bank Policy Research Working Paper: Access to Water, Women’s Work and Child Outcomes, by Gayatri Koolwal and Dominique van de Walle (both of the World Bank), published in May this year. This is the Abstract:

Poor rural women in the developing world spend considerable time collecting water. How then do they respond to improved access to water infrastructure? Does it increase their participation in income-earning market-based activities? Does it improve the health and education outcomes of their children? To help address these questions, a new approach for dealing with the endogeneity of infrastructure placement in cross-sectional surveys is proposed and implemented using data for nine developing countries. The paper does not find that access to water comes with greater off-farm work for women, although in countries where substantial gender gaps in schooling exist, both boys’ and girls’ enrolments improve with better access to water. There are also some signs of impacts on child health as measured by anthropometric z-scores.

Anthropometric z-scores? See here.

Could the same approach be taken for rural sanitation? I don’t see why not.

There’s another very pertinent World Bank Policy Research Working Paper: Water, Sanitation and Children’s Health Evidence from 172 DHS Surveys, by Isabel Günther of ETH Zürich and Günther Fink of the Harvard School of Public Health, published in April. Here’s the Abstract:

This paper combines 172 Demography and Health Survey data sets from 70 countries to estimate the effect of water and sanitation on child mortality and morbidity. The results show a robust association between access to water and sanitation technologies and both child morbidity and child mortality. The point estimates imply, depending on the technology level and the sub-region chosen, that water and sanitation infrastructure lowers the odds of children to suffering from diarrhea by 7–17 percent, and reduces the mortality risk for children under the age of five by about 5-20 percent. The effects seem largest for modern sanitation technologies and least significant for basic water supply. The authors also find evidence for the Mills-Reincke Multiplier for both water and sanitation access as well as positive health externalities for sanitation investments. The overall magnitude of the estimated effects appears smaller than coefficients reported in meta-studies based on randomized field trials, suggesting limits to the scalability and sustainability of the health benefits associated with water and sanitation interventions.

Mills-Reincke Multiplier? The following explanation comes from the 1910 paper On the Mills-Reincke phenomenon and Hazen's theorem concerning the decrease in mortality from diseases other than typhoid fever following the purification of public water supplies by W. T. Sedgwick and J. S. MacNutt, published in the Journal of Infectious Diseases (volume 7, issue 4, pages 489–564):

It is nowadays commonly understood that the purification of a polluted water-supply produces a marked decrease in the mortality from typhoid fever among persons using the water for drinking and other domestic purposes, but it is not as yet generally recognized that such purification produces also a marked decrease in deaths from other diseases. In 1893−94 it was observed, independently, by Messrs. Hiram F. Mills, C.E., of Lawrence, Massachusetts, and Dr. J. J. Reincke, of Hamburg, Germany, that the purification of the polluted public water-supplies of Lawrence and of Hamburg, respectively, was producing a notable decline in the general death-rate of each of these cities. The attention of Mr. Allen Hazen was about the same time turned to the subject, and some years later, in a paper presented to the International Engineering Congress held at the St. Louis Exposition in 1904, he drew from an examination of the death-rates of certain cities which had radically improved polluted water-supplies the following conclusion:

Where one death from typhoid fever has been avoided by the use of better water, a certain number of deaths, probably two or three, from other causes have been avoided.

This novel statement has not hitherto received the attention which it deserves …

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Environmental disease transmission

Here’s a very interesting and splendidly mathematical paper: Dynamics and control of infections transmitted from person to person through the environment by Sheng Li, Joseph N. S. Eisenberg, Ian H. Spicknall and James S. Koopman published in May last year in the American Journal of Epidemiology. Here’s the Abstract:

The environment provides points for control of pathogens spread by food, water, hands, air, or fomites. These environmental transmission pathways require contact network formulations more realistically detailed than those based on social encounters or physical proximity. As a step toward improved assessment of environmental interventions, description of contact networks, and better use of environmental specimens to analyze transmission, an environmental infection transmission system model that describes the dynamics of human interaction with pathogens in the environment is presented. Its environmental parameters include the pathogen elimination rate, µ, and the rate humans pick up pathogens, ρ, and deposit them, α. The ratio, ρN/µ (N equals population size), indicates whether transmission is density dependent (low ratio), frequency dependent (high ratio), or in between. Transmission through frequently touched fomites, such as doorknobs, generates frequency-dependent patterns, while transmission through thoroughly mixed air or infrequently touched fomites generates density-dependent patterns. The environmental contamination ratio, α/γ, reflects total agent deposition per infection and outbreak probability, where γ is defined as the recovery rate. These insights provide theoretical contexts to examine the role of the environment in pathogen transmission and a framework to interpret environmental data to inform environmental interventions.

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