S a n i t a t i o n

Research imperialism/nepotism

2012-01-24T08:05:00.001Z

What on earth is “research imperialism”? It’s a phrase I use to describe the situation whereby a researcher from an industrialized country with his or her pockets full of research dollars says to a more impoverished researcher in a developing-country university “Come on, let’s research this, I’ve got the dollars, and the funds will cover a trip or two by you to my university”. This is OK, of course, if the research topic is of genuine interest to both parties, but not if it’s only of real interest to the industrialized-country researcher. However, the developing-country researcher might well be tempted to go along with it as it will most probably look pretty good on his or her c.v. and the trip to Europe or the USA (or wherever) would be pretty good too. Does research imperialism exist? You bet it does! Constructed wetlands in East Africa, for one.

Say No to research imperialism!

And what about what I call “research nepotism”? Possibly even worse than research imperialism, research nepotism is giving large chunks of research money to your mates – and this includes people like your PhD supervisor. Does this occur? You bet it does! [Does Bwana Bill know? Sijui.]

Say No to research nepotism!

Latrines more expensive than sewers!

2012-01-23T18:14:00.000Z

I normally assume that low-cost sanitation technologies are cheaper than conventional sewerage. Not necessarily so, at least according to Sophie Trémolet’s presentation “Effective Public Finance for Sanitation: A study for WaterAid” presented at the IRC Symposium ‘Pumps, Pipes and Promises: Costs, Finances and Accountability for Sustainable WASH Services’ which was held in The Hague from 16−18 November 2010. Here’s part of what she said:

In Dar es Salaam, the Government chose to concentrate 99% of public funding on building network sewerage and sewage treatment facilities, even though these systems benefit only 10% and 3% of the city’s population, respectively. Household on-site sanitation receives very limited funding for software support[which is] provided in a decentralised and uncoordinated manner, with no evidence of impact. This results in an inequitable situation, as the costs to households of building and maintaining a latrine are about 2 to 3 times higher than those of a network connection [emphasis added]. Public funding for the sanitation sector in Dar es Salaam is therefore not effective, as it does not significantly increase coverage, achieve environmental results or improve public health.

So latrines can be more expensive than sewerage. Ain’t that really strange!

►All the presentations made at the IRC Symposium are available here. Quite a few are well worth reading, especially those on costs.

Right advice?

2012-01-23T17:44:00.000Z

How do you know that you’re getting the right advice? EcoSan toilets? Arborloos? DEWATS? UASBs? Even simplified sewerage? Do you, can you, trust the person(s) giving you this advice? Well, there’s nothing like knowledge – at least the knowledge that you should query all advice given to you. If you don’t know all the sanitation alternatives in detail (where they’re appropriate, how to design them, how much they might cost), then you need to find out about them and then query the advice you’ve received – for example you could look at Urban sanitation planning: A technology check list for planners or Sanitation for a healthy nation: Sanitation technology options (DWAF, Government of South Africa, 2002) [there are, of course, other publications but these two are at least both concise and comprehensive].

Let’s make 2012 the Year Of Good Advice!

Sewer gradients 2

2012-01-21T11:50:00.000Z

The Orangi Pilot Project (OPP) in Karachi, Pakistan is a very well known low-cost sewerage project, but what is not so well known perhaps is that the site gradients in Orangi were greater than the minimum required sewer gradient, so hydraulically at least the project was bound to succeed. However, when this low-cost sanitation technology was applied in other cities in Pakistan, problems occurred as the site gradients were lower than the minimum sewer gradients.

I remember, after I gave a talk on simplified sewerage some years ago at a WaterAid meeting in London, a young woman engineer from OPP came up to me and asked if I’d go to Karachi and teach OPP staff how to design sewers! Well, nothing came of that, other than a realisation on my part that sewer hydraulics are incredibly important – a fact that really needs to be more widely appreciated.

Sewer gradients

2012-01-19T10:03:00.000Z

I’ve been told that simplified sewerage projects haven’t worked well in Sub-Saharan Africa. Is this because they’ve been run by NGOs with little or no previous experience of sewerage? Possibly. Here’s a test for you: due to ground conditions you have to have a sewer gradient larger than 1 in 200. Would you go for 1 in 300 or 1 in 100? [Simple if you’re an engineer, but maybe not if you’re not?]

Tempus fugit!

2011-11-25T08:33:00.000Z

Time passes. A few excuses: quite a bit of work, despite retirement; some ill health; a lot of grandparenting; and a few spells of general indolence! But I’m more or less back on track, so watch this space again.

HSW in PLoS Medicine

2010-11-19T06:56:00.005Z

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

2010-11-19T06:52:00.001Z

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

Fallacious arguments

2010-11-04T06:47:00.003Z

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

2010-11-04T06:44:00.002Z

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

2010-10-01T03:08:00.002+01:00

►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

2010-09-30T05:23:00.001+01:00

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

2010-09-24T07:46:00.001+01:00

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

2010-09-24T07:36:00.000+01:00

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

2010-09-24T07:32:00.002+01:00

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

2010-09-23T10:06:00.000+01:00

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

2010-09-23T09:51:00.001+01:00

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

2010-09-23T03:26:00.003+01:00

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

2010-09-21T06:02:00.000+01:00

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

2010-09-17T22:55:00.003+01:00

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

2010-09-16T06:52:00.000+01:00

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

2010-09-15T20:31:00.002+01:00

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

2010-09-14T06:37:00.000+01:00

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

2010-09-12T07:42:00.000+01:00

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

2010-09-12T07:39:00.000+01:00

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

2010-09-12T06:56:00.004+01:00

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

2010-08-30T04:17:00.000+01:00

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

2010-08-28T17:59:00.002+01:00

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

2010-08-28T16:00:00.003+01:00

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

2010-08-28T13:17:00.002+01:00

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

2010-08-28T09:39:00.002+01:00

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

2010-08-28T08:42:00.002+01:00

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

2010-08-28T08:36:00.001+01:00

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

2010-08-23T01:07:00.004+01:00

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

2010-08-21T10:52:00.000+01:00

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

2010-08-17T09:28:00.000+01:00

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

2010-08-08T18:14:00.004+01:00

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

2010-07-31T06:53:00.002+01:00

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

2010-07-31T06:46:00.002+01:00

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

2010-07-31T06:43:00.002+01:00

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

2010-07-28T09:20:00.000+01:00

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

2010-07-19T18:52:00.000+01:00

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

2010-07-19T18:49:00.000+01:00

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’

2010-07-05T04:48:00.001+01:00

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

2010-07-04T06:00:00.005+01:00

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

2010-07-01T18:27:00.002+01:00

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

2010-06-30T08:24:00.000+01:00

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

2010-06-30T03:51:00.004+01:00

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 …

One of the 50 best blogs for civil engineers!

2010-06-29T10:32:00.002+01:00

This blog is one of the "50 Best Blogs for Civil Engineers" as posted on the Top Online Engineering Degree website. Very gratifying to know this − thank you!

Environmental disease transmission

2010-06-29T10:28:00.000+01:00

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.

Fomites? See here.

WASH and diarrhoea

2010-06-29T09:55:00.001+01:00

I’ve just come across a really good paper: Effectiveness and sustainability of water, sanitation, and hygiene interventions in combating diarrhoea, by Hugh Waddington and Birte Snilstveit, both of the International Initiative for Impact Evaluation (3ie) in New Delhi, which was published in last September’s issue of the Journal of Development Effectiveness (volume 1, issue 3, pages 295–335). Here’s the Abstract:

This paper presents a synthetic review of impact evaluations examining the effectiveness of water, sanitation, and hygiene interventions in reducing diarrhoea among children. The evaluations were conducted in 35 low- and middle-income countries during the past three decades. The paper challenges the existing consensus that water treatment at point-of-use and hygiene interventions are necessarily the most effective and sustainable interventions for promoting the reduction of diarrhoea. The analysis suggests that sanitation ‘hardware’ interventions are highly effective in reducing diarrhoea morbidity. Moreover, while there is a wealth of trials documenting the effectiveness of water treatment interventions, studies conducted over longer periods tend to show smaller effectiveness and evidence suggests compliance rates, and therefore impact, may fall markedly over time [emphasis added].

Arborloos

2010-06-29T09:52:00.001+01:00

Catholic Relief Services (see their Water and Sanitation page) have just published Rapid Assessment of CRS Experience with Arborloos in East Africa by Paul Hébert. It’s a really interesting account of the large-scale implementation of this terrific rural sanitation technology. Here’s an excerpt from the Executive Summary:

From 2005 to 2009 in Ethiopia, 53,840 households in 7 regions installed Arborloos with the help of CRS and partners. … In Ethiopia, the large number of Arborloos constructed by households from 2005 to 2009 was nearly ten times the number of conventional latrines built between 1995 and 2004, which were found to be more costly and difficult for households to construct. CRS considers this expansion to be a major breakthrough with the potential for significant scale up.

The cost per household? Very little: USD 16 in Ethiopia and USD 19−21 in Kenya, Tanzania and Uganda.

Hygiene and Sanitation Software

2010-06-29T09:16:00.001+01:00

The Water Supply and Sanitation Collaborative Council has recently published Hygiene and Sanitation Software: An Overview of Approaches by Andy Peal, Barbara Evans (who works with me in Leeds) and Carolien van der Voorden. A truly excellent publication! Here’s what it says it’s all about:

This document describes the various hygiene and sanitation ‘software’ approaches that have been deployed over the last 40 years by NGOs, development agencies, national and local governments in all types of settings – urban, informal-urban and rural.

There are many different software approaches and there is often confusion over, for example, what a particular approach is designed to achieve, what it comprises, when and where it should be used, how it should be implemented or how much it costs. There is currently no reference material that explains the different approaches available or helps practitioners
decide which one would be best to use for a particular situation. Moreover, the many ‘acronyms’ and ‘brand names’ in use frequently mean different things to different people.

Therefore, the purposes of this document are to clarify some of the confusion in the sector about the terminology and language used and provide a ‘ready reference’ or introduction to some of the more commonly used approaches. It is intended to be used as a resource tool both by a newcomer to the subject and by the more experienced practitioner who wishes to gain knowledge of other approaches with which he or she is not familiar.

Last year WSSCC published Public Funding for Sanitation: The Many Faces of Sanitation Subsidies by the same authors. Another crackingly good report!

Wastewater management

2010-05-16T08:37:00.000+01:00

I’ve just bought and read the book Sustainable Wastewater Management in Developing Countries: New Paradigms and Case Studies from the Field by Carsten Laugesen and Ole Fryd with Hans Brix and Thammarat Koottatep (published this year by ASCE Press – ASCE is the American Society of Civil Engineers). It’s quite expensive (USD 75), so is it any good?

Well, on balance, ‘No’, though it does have a few good bits. Why do I say this? Because (a) there’s much too much emphasis on wastewater treatment (and mostly on constructed wetlands, as might be expected with Professors Brix and Koottatep as contributing authors); (b) there’s far too little emphasis on wastewater collection – simplified sewerage is mentioned, but not correctly (Figure 3-3 is labelled “A simplified sewerage system”, but it shows a settled sewerage system; Figure 3-4 is better: it correctly shows a “condominium sewerage system”); and (c) there’s nothing on design.

ASCE Press says the book “will urge practitioners, decision makers, and researchers to approach these systems in new ways that are practical, innovative, and − best of all − sustainable.” I don’t think so. I think they’ll all end up very confused.

“International Glossary of Shit”

2010-05-13T11:00:00.000+01:00

The Community-led Total Sanitation (CLTS) website has an “International Glossary of Shit”. The reason given is “In CLTS, the crude local word for shit is always used, cutting through the deadly silence around open defecation.” So now you can say ‘ess aitch one tea’ in many languages − ain’t you the lucky one!

Don’t neglect “old” knowledge!

2010-05-08T08:17:00.000+01:00

There’s an interesting article in the Spring 2010 issue of Planet Earth* Groundwater − returning to the sources. Here’s what the intro. blurb says:

Many people in Africa depend on groundwater, but exploiting it effectively depends on accurate information about where to find it – and this information is expensive to obtain. Yet in many cases, researchers did the work years ago – it's just a matter of tracking down their results. Jude Cobbing and Jeff Davies describe a new initiative to make data from old studies more accessible – and in doing so, improve scientific cooperation and the availability of water in Africa.

Many people (students in particular) think useful data have to come from recent sources – they have to be available on the Internet, otherwise they ain’t much use. So an initiative like this, to get “old” knowledge on the Internet, is very welcome. After all, reinventing wheels is expensive and a massive waste of time.

This article is about groundwater, but in sanitation there’s also lots of good “old” knowledge (some of which is on the Internet) which many of today’s professionals (never mind students) simply don’t know about. So they reinvent some wheels – e.g., sanitation planning tools, latrine designs, and so on. Time to get real!

* Planet Earth is a free magazine published by NERC (the UK Natural Environment Research Council) and aimed at non-specialists with an interest in environmental science.

ITT’s World Water Day Campaign

2010-05-08T08:14:00.000+01:00

“ITT employees and water supporters rallied together to support ITT Watermark’s nonprofit partners, adding 4,486 fans to the ITT Watermark Facebook page in just one week and raising US$ 4,486 through ITT’s commitment to donate $1 to safe water solutions for every new fan between March 22 and 26 in honor of World Water Day” – see blog of 19 March. Well done, ITT!

Japanese flush toilets!

2010-05-04T09:12:00.001+01:00

Read The weird and wonderful world of the Japanese Washlet (Daily Telegraph, 24 November 2009) – truly amazing! Let’s hope they don’t catch on in developing countries!

10 million trees a year!

2010-05-04T09:02:00.000+01:00

“Worldwide, the equivalent of almost 270,000 trees is either flushed or dumped in landfills every day and roughly 10 percent of that total is attributable to toilet paper”, says Noelle Robbins in the May/June issue of World Watch Magazine. That’s flushing down toilets nearly 10 million trees a year! It certainly makes you think.

IRC electronic library

2010-04-29T07:55:00.000+01:00

The IRC International Water and Sanitation Centre has just published a library of all its e-publications in English, Spanish, French and Portuguese (up to this month); it’s also available on a CD-ROM. This is a really helpful move, especially as IRC publications are of such high quality. The Thematic Overview Papers are particularly useful. Well done, IRC!

2010 GLAAS report

2010-04-29T07:34:00.000+01:00

GLAAS is UN Water’s ‘Global Annual Assessment of Sanitation and Drinking-Water’ and the 2010 GLAAS report has just been published. Read it!

The Press Release for its launch in Washington, DC on 21 April contains a startling statement under the heading “Sanitation and water must no longer play second fiddle to other priorities. Countries with the greatest unmet sanitation and water needs most often receive little or no aid”:

Between 1997 and 2008, aid commitments for sanitation and water fell from 8% of total development aid to 5%, lower than commitments for health, education, transport, energy and agriculture. … This drop occurred despite compelling evidence that achieving the water and sanitation target of the Millennium Development Goals would lower health-care costs, increase school attendance and boost productivity. Despite these clear benefits for human and economic development, many countries and donors are still not allocating sufficient attention and resources to water and sanitation.

“Unsafe water, inadequate sanitation and the lack of hygiene claim the lives of an estimated 2.2 million children under the age of 5 every year. Of these deaths, 1.5 million are due to diarrhoea, the second leading contributor to the global burden of disease,” said Dr. Neira [WHO’s Director of Public Health and Environment]. “The impact of diarrhoeal disease in children under 15 is greater than the combined impact of HIV and AIDS, malaria, and tuberculosis.”

Nothing we didn’t already know, of course, but still very useful to have these things said again and again − and again and again.

We’ve just had the WHO/UNICEF Joint Monitoring Programme’s 2010 report. I just wonder if these JMP and GLAAS reports shouldn’t somehow be combined. There’s also the 2009 Millennium Development Goals Report which has a rather good 2½-page summary on sanitation and water.

Stunting in Brazil

2010-04-02T05:56:00.006+01:00

There’s a brilliant paper in this month’s Bulletin of the World Health Organization: Narrowing socioeconomic inequality in child stunting: the Brazilian experience, 1974–2007 [stunting is low height-for-age*]. The findings of the paper, taken from the Abstract, are:

Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators.

This figure shows the results:

Prevalence of stunting (%), by wealth quintile, over the 33 year period 1974−2007

The authors conclude:

In Brazil, socioeconomic development coupled with equity-oriented public policies has been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles.

The paper has good data on the percentages, by wealth quintile, of households served by public water supply, by public sewerage systems, and with flush toilets:

Percentage of households with piped water supply connection, by wealth quintile, in 1996 and 2007/07

Percentage of households with flush toilets, by wealth quintile, in 1996 and 2007/07

Percentage of households with sewerage connection, by wealth quintile, in 1996 and 2007/07

So Brazil seems to be doing rather well for its poor!

*Note: two good references on stunting:
(1) Early childhood diarrhoea and helminthiases associated with long-term linear growth faltering (International Journal of Epidemiology 2001: 30, 1457−1464), and
(2) Child undernutrition, tropical enteropathy, toilets, and handwashing (The Lancet 2009: 374, 1032−1035) [see also blogs of 18 September and 23 September 2009].

Sick Water?

2010-03-29T11:34:00.000+01:00

UNEP and UN-Habitat have just produced Sick Water? The Central Role of Wastewater Management in Sustainable Development which is a remarkable little book, extremely well presented – basically it is (well, it seems to me to be) an advocacy document, but nonetheless very well worth reading. (It’s actually much better than I thought it would be: when, a few weeks ago, I was sent a Word version to comment on, I thought it was a bit “tatty” and short on design recommendations, but it’s turned out very well.)

UK aid for toilets in Mumbai?

2010-03-22T13:32:00.001Z

The BBC News website had an interesting piece last week: Should the UK fund toilets in Mumbai slums? You would hopefully say Yes, but after reading the article you might not be so sure, you might have a doubt or two. Why? Well, the article makes two points: (1) India has a USD 1 billion space programme; and (2), quoting Prasad Shetty, a local urban planning consultant, “ The Mumbai government does not require British taxpayers’ money. It has money. The government institutions are loaded with money.”

The article also quotes Gareth Thomas, the UK Government’s Minister of State for International Development as saying: “ Look behind the glitter because there are very different Indias with many poor people living in the slums in Mumbai. We believe that some of our aid should be used to help build up institutions and try and get more effective state more able to protect its citizens, and more able to invest in its own basic services as well. I also think it’s in Britain’s interest that we help developing countries improve the situation for their poorest people because that in turn helps in range of other ways that makes a difference in the UK.”

I’d agree with the Minister – we definitely should do our bit to help poor Indians living in urban slums to gain access to good sanitation, but we shouldn’t forget (and I’m sure DFID isn’t forgetting) about the rural areas where a staggering 69% of the population has to defecate in the open, as opposed to “just” 18% in urban areas [figures on open defecation in India are in the 2010 JMP report].

World Water Day: Give for Free!

2010-03-19T08:53:00.000Z

To celebrate World Water Day (22 March) the ITT Corporation will donate US$1 to safe water solutions for every new fan of the ITT Watermark Facebook fan page who signs up during 22−26 March. The money raised will be distributed by ITT Watermark, the company’s corporate citizenship programme, to Water For People and Mercy Corps, two non-profit organizations (based in the US) dedicated to providing clean drinking water and sanitation to people in need.

Sign up!

Rural Bulgaria and Romania

2010-03-19T04:00:00.004Z

Women in Europe for a Common Future – a truly excellent organization − invited me to a 1-day roundtable discussion in Sofia on how to reach sustainable and cost-effective sanitation and wastewater collection and treatment in rural areas in Bulgaria and Romania – especially in small towns of up to 10,000 p.e. Both Bulgaria and Romania (and the other new EU Member States) have to meet their obligations under the Urban Waste Water Treatment Directive during the next few years.

Rural sanitation is poor in many parts of Eastern Europe, a heritage of decades of communist neglect. So it’s good that there are organizations like WECF working with local NGOs to do something sensible in this important area. What did I talk about? Simplified sewerage and wastewater treatment in waste stabilization ponds, of course. To produce an effluent that complies with the UWWTD (≤25 mg filtered BOD/l and ≤150 mg suspended solids/l – see the footnote to Table 1 on page 12 of the Directive), all you need is a single, correctly designed, facultative pond.

Getting “new” solutions adopted in these countries can be bureaucratically complicated. There were several senior civil servants from various ministries in Bulgaria and Romania present at the roundtable discussion, but I got the impression that they were just ‘stonewalling’. Clearly they need a big shove from their political masters. What’s required to get the ball rolling is a really good, and preferably charismatic, elected politician to act as a sanitation champion − if the civil servants are left to their own devices, there won’t be much progress in the immediate future.

PS (26 March): there's a report on the Sofia meeting here.

Africa’s infrastructure

2010-03-16T09:35:00.001Z

Do you want a shockingly good read? Try Africa’s Infrastructure: A Time for Transformation (Agence Française de Développement and World Bank, 2010). There’s a chapter on sanitation Moving People Up the Ladder, and the chapter summary is:

A third of Africans continue to practice open defecation, and half rely on unimproved latrines, the health effects of which are largely unknown. Despite this sobering picture, progress has been made in recent years by individual households eager to protect their health and improve their quality of life. The immediate sanitation challenge differs depending on prevailing practice. Where open defecation prevails, the policy focus should be on hygiene education. Where there is already widespread adoption of latrines, the challenge is how facilitate upgrading to improved models. Where improved sanitation is already prevalent, the key question is how to develop low-cost sewerage in the most densely populated areas [emphasis added].

Quite. Get simplified sewerage into high-density low-income areas of African cities and towns and start doing so now.

Latest JMP report

2010-03-16T06:33:00.003Z

The 2010 WHO/UNICEF JMP report Progress on Sanitation and Drinking-water 2010 Update was published yesterday. No real surprises, nor indeed much progress, if any: 2.6 billion are without improved sanitation, 1.1 billion of whom still have to practise open defecation. The report's Fast Facts give the basics. As for drinking water, the good news is that the world's on track to meet, even exceed, the MDG target.

[You can find all the JMP reports since 2000 here.]

East Africa Sanitation Conference

2010-03-16T06:22:00.001Z

The Second East Africa Sanitation Conference, organized by ANEW − the African Civil Society Network on Water and Sanitation, was held in Kampala during 2−4 March (the East African countries involved are Burundi, Djibouti, Ethiopia, Eritrea, Kenya, Rwanda, Somalia, Sudan North and South, Tanzania and Uganda).

The final point of the conference Declaration is disturbing: the conference participants noted their “shared concern regarding the inadequate commitment of AMCOW to sanitation and hygiene”. So why isn’t AMCOW – the African Ministers’ Council on Water – doing its bit for sanitation and hygiene? Well, you could argue that it’s doing something – there’s a whole section on sanitation at least in the Roadmap for the Implementation of the Sharm El-Sheikh Commitment (dated 13 November 2009), but ANEW doesn’t seem to think this is enough. We should be told all the details − and soon, as AfricaSan3 is going to be held next year.

Connection fees

2010-03-02T08:58:00.002Z

In parts of the UK the Energy Saving Trust is being funded by the Department of Energy and Climate Change to pilot the Pay As You Save (PAYS) scheme which “is an innovative finance solution that will give households the opportunity to invest in energy efficiency (such as solid wall insulation) and microgeneration technologies (such as solar panels) in their homes with no upfront cost. Householders will make repayments spread over a long enough period so that repayments are lower than their predicted energy bill savings, meaning financial and carbon savings are made from day one [emphasis added].”

Why do I draw attention to this? Well, it’s actually a lesson for water and sewerage utilities in developing companies how not to charge massive upfront connection fees – especially for the poor. In a manner somewhat analogous to PAYS, customers can simply either repay a loan for their connection fee as a small monthly surcharge on their water and sewerage bill (simplified sewerage, of course) or pay a slightly higher tariff. Read what the Asian Development Bank has to say on connection charges here.

No excuses: improve health of the poor in high-density urban areas by piping water into their homes and taking the wastewater out!

A $30 toilet?

2010-03-01T17:22:00.007Z

Well, according to the news item In the market for proper sanitation in this month’s Bulletin of the World Health Organization, that’s what the World Toilet Organization, together with Rigel Technology (S) Pte Ltd, are hoping to develop. Here’s part of the item:

“Our idea is to manufacture bright, colourful toilets that are simple to use, easy to maintain and can be bought for less than US$ 100. The only way to supply toilets in a sustainable way is to create a market and a demand for them. When people invest their money in a toilet, they are more likely to accept it and use it.” Sim and others at the World Toilet Organization have been collaborating with Christopher Ng and Rigel Technology to develop an alternative to the “sticks and stones” self-built latrine. “The basic concept is to provide an economically sustainable and yet affordable toilet. Hence, with Rigel, we are trying to develop toilets for as little as US$ 30 each. The products will be ready around March to April this year” [emphasis added], says Ng, the managing director of the Rigel Technology Group, based in Kaki Bukit, Singapore. Rigel exhibited its latest toilet at the World Toilet Organization Summit in December 2009. It is attractive and ecologically sound, turning excrement into fertilizer. “It doesn’t need running water to flush it, although water is still needed for washing and hygiene,” says Sim. In Cambodia, toilets are being provided to villages, where families work together to pay by monthly installments. “This is arranged on rotation, with one family receiving a toilet each month. At the end of the year, all 12 families have toilets,” says Sim. He is promoting a franchise concept to encourage people to become distributors and suppliers in their area. “Then the market model becomes a no-brainer”, he says.

Ah well, it’s EcoSan – but at least someone’s paying attention to costs. Take note, you Swedes and Germans!

PS: if you look at Rigel's website you can see they're a real up-market company. So they deserve to be wholeheartedly congratulated for getting into low-cost sanitation (actually ultra-low-cost sanitation). Too many such companies ignore the sanitation needs of the poor.

NTDs

2010-03-01T16:51:00.001Z

NTDs are the “neglected tropical diseases”: the soil-transmitted helminth infections, lymphatic filariasis, onchocerciasis, schistosomiasis, dracunculiasis, zoonotic helminthiases, dengue/dengue haemorrhagic fever, rabies, yaws, leishmaniasis, human African trypanosomiasis, Chagas disease, and Buruli ulcer. They affect over a billion people − see the WHO webpage Control of Neglected Tropical Diseases. Four of them have been targeted for elimination in the South-East Asian region of WHO (Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives ,Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste), according to the paper Elimination of neglected tropical diseases in the South-East Asia Region of the World Health Organization which appears in this month’s issue of the Bulletin of the World Health Organization. Here’s part of its conclusion:

Eliminating leprosy, lymphatic filariasis, kala-azar and yaws will greatly improve the lives of the poorest people and stimulate productivity and economic growth in remote, impoverished areas of the region. Ultimately, attempts at disease elimination will be most successful if accompanied by improved housing conditions, sanitation, nutrition and education, all of which affect vector control and access to preventive measures. If all these goals can be achieved together, the most damaging effects of poverty will be overcome [emphasis added].

So: improved housing, sanitation, nutrition and education. Not a philosophically difficult proposition, is it?

Hygiene in the Home

2010-02-17T04:24:00.001Z

Further to the bit on hygiene at the end of the last blog, a good read is The Global Burden of Hygiene-related Diseases in relation to the Home and Community published last June by the International Scientific Forum on Home Hygiene, whose website has a wealth of information and resources on hygiene, so it’s well worth visiting.

Ed-loo-cation!

2010-02-14T08:13:00.001Z

Even in so-called developed societies people need reminding not to chuck inappropriate objects down their flush toilet. Here in Yorkshire, England, the local water supply and sewerage undertaker, Yorkshire Water, has all sorts of problems due to this. Here what it says on its webpage Bin it. Don’t flush it:

Yorkshire’s sewers are being abused and it’s causing all kinds of problems. You wouldn't believe some of the things we find down the sewer − nappies, false teeth, fat, Christmas trees and even a Spacehopper! As funny as that sounds, all of these things can cause the sewer to stop working and this can lead to flooding. 50% of all blockages are caused by people putting the wrong things down the sewer and the effects can be very unpleasant.

Numptee is the cartoon star of Yorkshire Water’s campaign to get people to stop doing this – you can “check out his videos to find out how he’s creating all kinds of havoc in his home by putting the wrong things down his toilet and sink.”

In Victorian times ‘Cleanliness was close to Godliness’ – but we don’t seem to really value hygiene as we did a hundred years ago. I wonder why. See: Health/hygiene, sanitation, and water: Is cleanliness next to whatever has replaced godliness? by Astier Almedon.

Hashimoto II

2010-02-10T05:23:00.003Z

The United Nations Secretary-General's Advisory Board on Water and Sanitation (which Kofi Annan set up in 2004) released the Hashimoto Action Plan in 2006 − pdf here. Read what it said on sanitation on pages 6−7 of this file. [Actually part of what it said was that it would “call on the academic and scientific community for accelerated research on alternative models and technologies to improve sanitation such as eco-sanitation, the vacuum car and treatment plant system, and urine separation from sewage” – so somewhat odd. Who on earth, you might reasonably ask, advised this Advisory Board?]

I’ve just received an email announcing the release of the Hashimoto Action Plan II which sets out UNSGAB’s “Strategy and Objectives through 2012”. Here’s part of what the email said:

The United Nations Secretary-General's Advisory Board on Water and Sanitation (UNSGAB) is embarking on their next strategic phase with the release of the Hashimoto Action Plan II. In only a few years, world leaders will assess progress made towards the Millennium Development Goals, including the targets to halve by 2015 the number of people without sustainable access to safe drinking water and basic sanitation. Getting the right policies, strategies and actions in place during the next three years is absolutely critical. The Hashimoto Action Plan II contributes to this effort by motivating, convening and galvanizing its partners to achieve objectives in five key areas: financing, sanitation, monitoring & reporting, integrated water resources management, and water and disaster.

The Hashimoto Action Plan II articulates a time-bound vision, targeted actions and clear outcomes aiming to ensure a future where each child, woman and man enjoys clean water and safe sanitation.

The HAP II brochure says that, concerning sanitation, UNSGAB will “Bring pressure and attention to commitments undertaken during the International Year of Sanitation” and “Improve sanitation and water for schools”. There’s to be a new focus on “Building new impetus for wastewater collection, treatment and reuse”. And there’s more:

Since developing countries treat just a fraction of their wastewater, we need to encourage a move beyond toilets to the other side of sanitation — collecting, reusing and disposing of municipal waste as well as storm water. HAP II includes action on wastewater to protect human health, economic development and ecosystems while also alleviating growing water scarcity in many regions.

Isn’t there a major non sequitur here? Is UNSGAB really saying that, because so little wastewater is treated in developing countries, they should be encouraged to collect, reuse and dispose of municipal [solid, presumably] waste, and stormwater as well? And to do everything by 31 December 2015? Not a chance! But UNSGAB is right to keep reminding the world that it has to do more, much more, for sanitation.

A cynical observer (not that I’m one, of course) might look at the list of where UNSGAB has held its meetings (New York, Tokyo, Rome, Berlin, Mexico City, Paris, Tunis, Shanghai, Bogotá, Tokyo again, Riyadh, Sofia) and wonder if most shouldn’t have been held in countries where local watsan needs were [and still are] at least a little more pressing?

In case you’re interested, the Hashimoto Action Plans are named after the late Ryutaro Hashimoto (1937−2006), who was Prime Minister of Japan during 1996−1998 and the first chairman of UNSGAB.

Manual scavenging − again

2010-01-30T11:11:00.001Z

I’ve just come across WaterAid India’s excellent 2009 report Burden of Inheritance: Can we stop manual scavenging ? Yes, but first we need to accept it exists. Here’s an excerpt from the Preface:

The issue of manual scavenging in India evokes reactions ranging from disbelief and disgust to despair. It is widely believed to be a social practice rather than an occupation, which has its roots in the caste system of India. Almost all scavengers are Dalit and most of them are women. They are forced into this practice from an early age. Their untouchability and loathsome occupation forces them into living a life of indignity.

and one from the Executive Summary, which has the subtitle “Let’s stop the stink”:

It is very hard not to feel less human while talking about manual scavenging. More than three lakh [300,000] people, mostly women, are consigned to this inhuman occupation in India. In India it is illegal to employ or to indulge in manual scavenging. But in practice, it is very much present across the country irrespective of states’ performance on social and economic development parameters.

Why have we not been able to eradicate manual scavenging? This report – Burden of Inheritance – tries to seek answers to this question. To get to the bottom of this scourge, the report has first explored the question: why are people continuing in this occupation despite availability of other dignified livelihood sources? Why is manual scavenging in practice in towns and cities where other cleaner options for survival exist? When there are feasible and viable technological alternatives to dry toilets, one of the drivers of this occupation, why does the practice continue?

The report uncovers a complex socio-economic web that has trapped the community into this practice. Socially, we need to treat the manual scavengers as humans first, ensuring the fundamental human rights to them. The Indian caste system may be dying out in public perception but for the manual scavengers its grip is as strong as it used to be in the distant past. The report finds convincingly that this single attitude change will trigger a sequence of desirable outcomes for betterment of the community. There must be serious efforts to encourage and make available alternative employment opportunities for the manual scavengers. Examples cited in this report do point out that wherever such efforts have been made, there have been positive changes.

The whole report is a definite ‘must-read’ and let’s hope it’s read in all the ‘high places’ in India by all the ‘high’ officials (who are meant to be servants of their people).

Well done, WaterAid India!

Urban agriculture

2010-01-30T10:50:00.001Z

If you have condominial sewerage (or any sewerage, for that matter) you have the opportunity to practise wastewater-fed agriculture – using treated wastewater to raise fish and/or (but preferably ‘and’) irrigate crops. In urban areas this is termed ‘wastewater-fed urban agriculture’. IDRC Canada has published many reports and books on urban agriculture (UA) in general and wastewater-fed UA in particular – for example, Wastewater Use in Irrigated Agriculture: Confronting the Livelihood and Environmental Realities (2004) and, just out this month, Wastewater Irrigation and Health: Assessing and Mitigating Risk in Low-income Countries (though the hyperlinks to the chapters are not yet in – in the meantime there’s the pdf of the whole book here; hard copies can be purchased from Earthscan). See also Urban Agriculture and, more generally, Wastewater Use in Agriculture and Wastewater Use in Aquaculture.

The World Health Organization has published Guidelines for the Safe Use of Wastewater, Excreta and Greywater in agriculture and aquaculture (3rd edition, 2006).

Remember: “Wastewater is too valuable to waste”.

Sulabh toilets?

2010-01-30T10:41:00.002Z

Read this (from ‘Sanitation Updates’ here):

Experts from the UN and Asian Development Bank (ADB) today [27 January 2010] asked developing nations to adopt low cost Sulabh toilet to streamline their sanitation system.

The Sulabh technology is one of the solutions to the sanitation crisis and this low cost Indian method should be utilised in developing countries,” senior ADB official A Thapan said at a follow-up conference of the International Year of Sanitation being organised here [Tokyo] by UN and Government of Japan.

Thomas Steltzer, Assistant Secretary-General, UN, also advocated Sulabh model for streamlining of sanitation system in developing and third world countries.

[The ‘Sulabh toilets’ are described on the Sulabh website.]

High praise indeed, but is it informed praise? I have my doubts. Anyone really familiar with communal sanitation facilities would prefer the SPARC model over the Sulabh model – read Community-designed, built and managed toilet blocks in Indian cities (Environment & Urbanization, October 2003). See the SPARC website and Community Sanitation Blocks, and also blog of 28 January 2008.

SPARC, The Society for the Promotion of Area Resource Centres, is an absolutely brilliant Indian NGO that “that supports two people’s movements − the National Slum Dwellers Federation (NSDF) and Mahila Milan (MM) [‘Mahila Milan’ means “Women Together” in Hindi]. NSDF and MM organise hundreds of thousands of slum dwellers and pavement dwellers to address issues related to urban poverty, and collectively produce solutions for affordable housing and sanitation.” In truth, an approach that’s all together much better than Sulabh’s, though the Sulabh model does of course have its place in the provision of decent public (as opposed to community-based) sanitation blocks.

Who said “A little knowledge is a dangerous thing”?

[Actually it was Alexander Pope (1688−1744) in An Essay on Criticism published in 1709, although what he said was “A little learning is a dangerous thing”.]

Sanitation in India

2009-12-17T10:42:00.004Z

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

2009-12-09T22:17:00.001Z

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

2009-12-08T11:20:00.000Z

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!

2009-12-03T09:36:00.002Z

No comment!

India’s Greatest Shame

2009-11-30T12:42:00.003Z

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

2009-11-21T14:27:00.000Z

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

2009-11-21T07:52:00.005Z

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

2009-11-19T16:18:00.007Z

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

2009-11-15T08:18:00.002Z

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

2009-11-14T17:42:00.001Z

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

2009-11-12T22:27:00.005Z

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

2009-11-10T03:18:00.001Z

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

2009-11-10T01:01:00.000Z

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

2009-10-31T05:59:00.004Z

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

2009-10-27T19:44:00.002Z

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

2009-10-02T07:27:00.000+01:00

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

2009-09-23T18:50:00.006+01:00

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

2009-09-19T11:45:00.000+01:00

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

2009-09-19T11:28:00.000+01:00

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

2009-09-19T11:18:00.001+01:00

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

2009-09-18T05:06:00.005+01:00

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

2009-09-18T04:57:00.001+01:00

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.