Saturday 31 July 2010

Child deaths in Sub-Saharan Africa

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

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

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

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

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

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

Sanitation and gender

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

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

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

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

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


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.

Wednesday 28 July 2010

Graphic TV programme on sanitation

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

Monday 19 July 2010

WASH prevention of diarrhoea

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

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

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

Slum upgrading

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

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

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

Quite an interesting way of measuring health outcomes.

Monday 5 July 2010

‘Easy latrines’

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

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

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

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

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

Sunday 4 July 2010

Pathogens, parasites and IQ

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

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

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

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

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

Thursday 1 July 2010

Mothers and daughters

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

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

But read it all!