Monday 30 August 2010

Child health in Brazil

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

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

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

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

Saturday 28 August 2010

Agricultural R&D in Brazil − 2

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

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

Agricultural R&D in Brazil

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

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

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

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

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

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

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

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

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


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

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

Simplified sewerage: health impacts

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

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

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

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

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


Safe water, improved sanitation and diarrhoea

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

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

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

Climate change and WatSan services

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

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

This is what the authors say about unconventional sewerage:

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

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

Monday 23 August 2010

Dig Toilets, not Graves

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

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

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

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

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

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

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

Saturday 21 August 2010

SIWI’s publications online

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

Over the last 20 years, SIWI has produced a wide range of publications in the field of global water issues. Now you can find them all at 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.

Tuesday 17 August 2010

Globalization and Health

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

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

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

Sunday 8 August 2010

Multidimensional Poverty Index

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

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

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

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

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

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

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

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

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

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

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

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

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