Thursday, April 1, 2010

Safe Drinking Water, Sanitation, and HIV/AIDS

Recently published on the Pulitzer Center's World Water Day Writing Contest:

It's springtime 2010 and you are traveling through sub-Saharan Africa, say Malawi, Botswana, South Africa, back up to Uganda, in rural farming communities, in slums, in burgeoning cities. You see farmers supporting their families, workers putting in long days, parents stretching to send their sons and daughters to school and trying to save for a rainy day, presented with opportunities and obstacles similar to those facing many others across the planet.

You also see those same people struggling to escape from two massive public health challenges that for most of the rest of the planet are increasingly rare: a lack of safe drinking water and toilets, and HIV/AIDS. You return to your relatively comfortable home inspired to do something tangible and holistic about both issues.

In trying to figure out the linkages between WASH (Water, Sanitation, and Hygiene) and HIV/AIDS, your research reveals that the two issues are more closely connected than you realized.

According to USAID, "People living with HIV/AIDS (PLWHA) are at increased risk for diarrheal diseases, and are far more likely to suffer severe and chronic complications if infected. Recent evidence demonstrates the efficacy of hand washing, safe water and sanitation in reducing diarrhea among PLWHA by 25% or more." That makes sense, and is even more convincing to you than the brutally true soundbite "You can't take antiretrovirals without safe drinking water, because you'll either throw them up or lose them out the other end because of diarrhea."

And on the flipside, USAID continues: "And people living without safe water and sanitation, with the dire poverty that often accompanies it, are likely less educated and more likely to contract HIV." So people living with HIV need safe water and toilets to prevent potentially fatal opportunistic diarrhea, and those people with safe water and toilets are less likely to become the next victims of HIV.

So what do you do?

You start by volunteering with a water and sanitation nonprofit focused on providing HIV/AIDS treatment centers and surrounding communities in Tanzania with safe drinking water, with toilets, and with handwashing stations and soap. That nonprofit with its holistic approach to both drinking water and HIV works with entire communities to make sure there is 100% handwashing with soap, and zero open defecation, thus reducing the risk of waterborne diarrhea (e.g. cholera) transmission, particularly for those with immune systems compromised by HIV. All brought to you by safe water.

You write letters to Congress, suggesting that taxpayer-funded HIV treatment initiatives like PEPFAR continue their life-saving work with ARVs, but also include complementary safe drinking water and sanitation programs both for outpatients at HIV clinics and for their families and communities.

You blog and tweet that HIV/AIDS is receiving an enormous amount of funding, and justifiably so, but diarrheal disease, 90% of which is caused by unsafe drinking water and inadequate sanitation, continues to kill millions of under fives annually. You underscore to your followers that the world has known how to solve the water problem for over a century and that fatal waterborne diarrhea should be eliminated across the planet.

You acknowledge to yourself that if every human life is indeed equal, you can ignore neither HIV-positive people nor those susceptible to easily preventable, fatal waterborne diarrhea.

This holistic approach will take a big bite out of the 4,500 daily child deaths associated with unsafe water and sanitation, and contribute to a better quality of life and longer survival times for people living with HIV/AIDS.

So the next time you travel through sub-Saharan Africa, you will see farmers farming, workers earning their paychecks, girls going to school, without the twin scourges of unsafe water and HIV shadowing their lives.


prakash said...

Dear John
Congratulations for the good articles. Let me share my experience of working in the Water and sanitation sector in rural India.

Lack of Sanitation or the poor access has been a result of many a factors of which poverty is one . Cultural habits and existence of vast open lands and jungles etc. have been used by the locals for defecation. Safe practices in sanitation were never a priority. The adverse impacts of open defecation had been quite high with huge diaroheal deaths and casulaties. But the important thing had been the populace never could link open defecation with the diseases. But we are past this debate now. People thanks to different communication and awareness programs and measures understand the link . But still the condition are not good. If we look beyond projects and programs and initiatives still something is lacking.

Poverty though is a factor but not the sole one. The national and global think tanks missed out this point and rallied around poverty as the single most factor while designing projects and programs on sanitation. As a result hardware subsidy for latrines were the mainstay of these designs and outsiders (not the community) were supposed to educate the community on safe sanitation. You must be knowing billions were spent and still being spent but the behaviour change had/has not been forthcoming.still a major chunk who were the beneficiaries under national and global programs defecate in the open.

The assumption under these initiatives was that "when you build a latrine for a household it would use it" or "if monetary assistance is given the house hold will build and use a latrine".

While these programs targeted the individuals and households many of the beneficiaries took the money and either never built their toilet or those who built used it for purposes other than sanitation.

These initiatives failed in making sanitation a community agenda and relied heavily on materials rather than people. Construction of latrines superseded behaviour change. Outsiders bcame the drivers instead of the community.

In view of these experiences there is a growing realisation that sanitation is more behaviour change than latrine or toilet.This to take effect there is a need for sensitive support from institution and a complete mind set change at the institutional levels. People who believe community can do it should be given preference to handle programs, than those who believe only construction of toilets can bring about the desired behaviour change.

This observation comes from the experience that whenever and whereever communities (not individuals) are facilitated to analyse their own sanitation situation vis a vis its adverse impacts, they have found the ways and means to change their practices together. The change has been fast and total.The states such as Himachal Pradesh, Haryana, Maharashtra and more recently MP and Meghalay are examples.


John Oldfield said...

Hi Prakash,

Thank you for your very insightful and accurate comment. I was going to ask you what you think about Community Led Total Sanitation, then I visited your blog at CLTS is something I need to cover on my blog as well. Keep up the good work!


prakash said...

Hi John


I have been doing quite a bit of CLTS in India when it started. I am one of the early trainers in the concept , principle and practice of CLTS.

While Water Aid ,Unicef and Plan have been the major supporters of CLTS in countries other than India ,Water and Sanitation Program - South Asia, World bank is the only institution providing some support to CLTS in India.


rolly said...

Globally 1.73 Million people stood up against poverty in 2009, a Guinness World Record!

Let us break this record in 2010!

Be the voice for the millions of poor people living across India.

~ Aamir Khan stood up against poverty! ~

~ AR Rahman stood up against poverty! ~

~ Rahul Dravid stood up against poverty! ~

~ Rahul Bose stood up against poverty! ~

~ Kiran Bedi stood up against poverty! ~

Join us on Facebook at and check out the photo album section for the event pictures.

Follow us on Twitter at