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.

USAID / WASH Training Package for the Prevention of Diarrheal Disease

Handy training tool on WASH/Diarrheal Disease from USAID:

WASH Training Package for the Prevention of Diarrheal Disease

The "Water, Sanitation, and Hygiene Improvement Training Package for the Prevention of Diarrheal Disease," provides information for organizations worldwide that seek to add WASH activities to their current programs or to start a diarrhea reduction program. It is intended to support the training of local outreach workers and their work in communities to promote improved WASH practices to reduce diarrhea. The Training Package consists of three separate parts: (1) a step-by-step "Guide for Training Outreach Workers," (2) an "Outreach Worker’s Handbook" for community outreach workers to use during and after training, and (3) a "Collection of Resource Materials" to use as a source for visual aids.

--To request a free copy of the WASH Training Package on CD, please send an email to hip (at) aed (dot) org.

You can also listen to a recorded webinar here:
 
Webinar on WASH Improvement Training Package for the Prevention of Diarrheal Disease
 
Recording of HIP's webinar on the "WASH Improvement Training Package for the Prevention of Diarrheal Disease," held January 28, 2010. Presented by Elizabeth Younger, HIP senior behavior change advisor.

OU International Water Prize Winner: Steve Luby

I don't go in for the 'hero worship' one bit, but if I did Steve Luby would be a good candidate: he has dedicated his career - at least a great portion of it - to preventing and treating waterborne diarrheal disease. Recognition is long past due, and rah rah for the University of Oklahoma and its Selection Committee for awarding Steve Luby the International Water Prize. Please join them in October (27th - 29th) for the International WaTER Conference and choice prize ceremony if you have the means.

Oklahoma University International Water Prize

Purpose: The purpose of the OU International Water Prize is to recognize and honor an individual who has made significant international contributions, either through research or teaching or service activities, in the field of water supply and sanitation, with a focus on the world's poorest living in small villages/communities in rural or remote regions.

Details: The Prize is a biennial award sponsored by the WaTER Center at the University of Oklahoma and made possible by generous gifts from alumni and friends. The inaugural prize winner will be selected in 2008 and awarded at the 2009 OU WaTER Conference to be held in late October 2009. The winner will receive a $25,000 cash reward with half of the reward going directly to the recipient and half going to the WaTER-related non-profit organization of his/her choice. The winner will also receive replica of the WaTER symbol cast in silver and a bronze plaque. This is one of the first and largest prizes dedicated to the field of water supply and sanitation in remote areas of emerging regions.

Dr. Stephen P. Luby - 2009 OU International Water Prize Winner

Dr. Luby has worked for the International Centre for Diarrhoeal Disease Research, Bangladesh since 2004. He is head of the Program on Infectious Diseases and Vaccine Sciences and also functions as the head of Agency for the Centers for Disease Control in Bangladesh. He earned a bachelor of arts in philosophy from Creighton University in 1981 and a medical degree from the University of Texas Southwestern Medical School at Dallas in 1986. He completed his internship and residency in internal medicine at the University of Rochester-Strong Memorial Hospital. Dr. Luby studied epidemiology and public health in the Epidemic Intelligence Service and the Preventive Medicine Residency of the Centers for Disease Control and Prevention. Dr. Luby has authored over 120 scientific articles, the majority concerning communicable disease epidemiology in low-income countries.

Jurors for the 2009 Prize included:

Greg Allgood, Director of Procter & Gamble Pur Program
Michael Campana, Director of the Institute for Water and Watersheds, Oregon State University
Henock Gezahegn, PSI-Ethiopia
Daniele Lantagne, Centers for Disease Control, Atlanta, GA
Malcolm Morris, Chairman of Stewart Title Company in Houston, TX and co-founder of Living Water International and the Millennium Water Alliance

USAID Hiring Water and Sanitation / Diarrhea Expert

I have received this note through various channels from USAID in Washington DC – a very interesting senior watsan position at USAID on its Environmental Health Team. Note the focus on ‘diarrheal disease and associated mortality’.

Public Health Advisor – Environmental Health
U.S. Agency for International Development (USAID)

The USAID Bureau for Global Health, Maternal and Child Health Division (MCH), based at USAID headquarters in Washington DC, is seeking a Public Health Advisor to provide leadership in its environmental health activities. The major activities of the MCH environmental health team are focused on reduction of diarrheal disease and associated mortality for vulnerable populations in developing countries, especially children under 5, through improvements in drinking water quality and availability, sanitation, and hygiene. Other areas of activity vary over time, but may include improvement in indoor air quality, reduction of health vulnerabilities from climate change, and other topics related to health impacts from environmental degradation.

The successful candidate will participate in and provide leadership to the development of USAID environmental health strategies, plans, program guidance, and dissemination of results. S/he will provide specialized expertise to USAID Missions and host-country governments on new developments and the most effective approaches to environmental health problems in a region or country. S/he will be responsible for communicating such strategies and program results to diverse audiences within and outside USAID, including the U.S. Congress, external partners, and senior USAID and U.S. government staff.

This is a senior position requiring effective program management and communications skills. For further details on qualifications and to apply for this position, please see http://www.avuecentral.com/vacancy.html?ref=NRKVN.

Note that U.S. citizenship is required. Application deadline is 9/9/2009.

Global Water Survey: Results

Some encouraging news from Carl Ganter and the always-impressive Circle of Blue at World Water Week:

NEW GLOBAL PUBLIC OPINION SURVEY FINDS WATER ISSUES ARE THE TOP ENVIRONMENTAL CONCERN WORLDWIDE

A quick summary from WaterTechOnline.com:

A close look at the results shows that people around the world view water pollution as the most important facet of the freshwater crisis, and that shortages of fresh water are very close behind. Across the 15 countries surveyed:

• 93 percent say water pollution is a very serious (72 percent) or somewhat serious (21 percent) problem.

• 91 percent believe that a shortage of fresh water is a very serious (71 percent) or somewhat serious (20 percent) problem.

Across the seven focus countries:

• Government is considered among the most responsible for ensuring clean water.

• 78 percent say “solving drinking water problems will require significant help from companies,” indicating that partnerships are an important component to resolving the world’s freshwater sustainability challenges.

• 76 percent say “I need more information to be able to do more to protect water.”

While people around the world agree on the importance of the issue, some key differences between the countries surveyed support the idea that solutions will have to be carefully tailored to local conditions.

These findings are helpful for water writ large, and highlight a couple of really important topics:

- At the end of the day, meeting peoples' needs for safe drinking water and sanitation is the responsibility of the governments around the world. If those governments chose to outsource some of the infrastructure provision, I have no issue with that per se. Those governments need to maintain the intellectual capacity to manage that relationship so that the outsourced provider is not simply focused on profit, but on the social contract.

- Solutions will indeed need to be tailored for each local condition. There are so many social externalities associated with water and sanitation/hygiene that the cultural piece of this puzzle may prove to be the most challenging.

- I need to dig into the report further, but I hope that its definition of 'pollution' includes not just industrial/chemical contaminants running into water supplies, but nasty biological contaminants like rotavirus and vibrio cholerae, which kill millions of people unnecessarily each year. However, considering that quality typically lags quantity, it's good to see quality taking the spotlight in this survey period.

And of course MUST give shout out to Molson Coors Brewing Co. for their support for this survey. Molson can spend its money (part of it from me...) on many things, and I am glad they chose this.

Cholera in Africa: More crappy news

It really (really) pisses me off when cholera is in the news - again. Cholera should not exist. It angers me even more when it is featured so prominently in so much of the reporting reaching my desk from many parts of the developing world, particularly in Africa. Cholera is preventable. If cholera kills someone, the world is doing something wrong.

The latest piece of shitty news is this disturbing piece from Kenya, where cholera is hitting a little too close to home:

Obama Brother May Have Cholera


and from the Associated Press:


Official: Obama's half-brother falls ill in Kenya


We hope that it is just a nasty case of diarrhea. We hope that this will be treated (as it can be quite easily) and that Malik Obama will be back at work soon. We hope that it is not cholera, and if it is, we hope even more that it doesn't kill him like it does many other Africans, preventably.

Keys to cholera:

- It is dangerous (viz. fatal all too often).
- It is easily spread through lack of simple safe drinking water and sanitation facilities.
- It is treatable.
- Most importantly, it is preventable, and both the international donor community and every government throughout the developing world can do something about it.

Sources:

• My other recent blog post on the issue. There will likely and distressingly be more such posts.


• An insightful piece from the Centers for Disease Control and Prevention.


• Cholera at the World Health Organization

This steady stream of cholera in the news has to stop. Cholera mortality and morbidity must stop. The White House is in an extraordinarily strong position to contribute to the elimination of fatal cholera and other diarrheal disease. For an interesting and related take on unnecessary and preventable childhood mortality please see Nicholas Kristof's piece Good News: Karlo Will Live. And call the White House.

Cholera BAD: A Lion in Our Village

If you read one journal article this year, make it this one, from the New England Journal of Medicine:

A Lion in Our Village — The Unconscionable Tragedy of Cholera in Africa

A lion in our village indeed. This is the under-recognized story of cholera in Africa powerfully told by Drs. Eric Mintz and Richard Guerrant.

We know that cholera is caused by unsafe water and inadequate sanitation, and solved by safe water and improved sanitation. This is not an intractable problem.

From their first handful of words "inexcusable,...completely preventable" to even more potent language later on "Epidemic cholera represents a fundamental failure of governance, and bold and visionary leadership is required if we are to attack its root causes," the authors do justice both to the gravity of the problem and to its solvability in Africa as elsewhere in the developed and developing world.

What's missing is the governance and the political and financial capital to get to solutions - both prevention and treatment - this is fixable and unnecessary.

The Big Necessity - Book Signing with Rose George, the Scribe of Sanitation

Did you know that even though disease spread by human excrement kills more children each year than HIV, TB and malaria combined, nobody talks about it because it’s not sexy?

While we’re ignoring this silent killer, 2.6 billion people (that’s four in ten!) today do not have a toilet and instead are forced to do their business on roadsides, in bags or bushes, or anywhere they can. Open defecation is the leading cause of some of the deadliest, but most ignored, communicable diseases affecting our world’s population today.

Diarrhea – usually caused when flies, feet or fingers introduce feces into the food (dig the alliteration) or water supply - needlessly kills nearly 2 million children a year and is the second leading cause of child death worldwide. We hope you will join us and help tell the story about the billions of people whose lives can be saved by the simple introduction of a toilet – a privilege we take for granted each and every time we flush. Journalist Rose George will join us in Washington, DC on October 22nd to launch her new book:

The Big Necessity:

The Unmentionable World of Human Waste and Why it Matters

It's an entertaining, educational and insightful ride through the world’s sanitation systems, or lack thereof. From the slums of Dar Es Salaam and the villages of Bangladesh back to the squeaky-clean sewage plants that serve Washington DC, George exposes the taboos and disparities that surround human waste – and shows us in no uncertain terms why confronting them is essential to our global health, dignity, and prosperity.

Double click on image below for more details. The event is free, but please RSVP.

Global Health Council - The Link Between Clean Water and Health - event

Join me and others on Capitol Hill this Wednesday:

The Link Between Clean Water and Health
Wednesday, March 26, 2008
12:30-2 pm
Rayburn House Office Building Room B338
Washington, D.C.

Most importantly: Lunch will be served

Congressional Briefing

More than 1 billion people live without access to safe water and 2.6 billion people do not have access to basic sanitation. Please join the Global Health Council in commemorating World Water Day at a briefing focusing on the importance of clean water as a health intervention. Diarrheal diseases - in large part caused by unclean water - result in the deaths of 1.8 million people annually and contribute to the deaths of many more. In addition, the burden of collecting clean water more often than not lies with women, increasing their vulnerability to neglected diseases and violence.

Speakers:

Greg Allgood, Director, Children's Safe Drinking Water, Procter & Gamble
Eric Mintz, Leader of the Diarrheal Diseases Epidemiology Team, Centers for Disease Control
Joan Timoney, Director of Advocacy and External Relations, Women's Commission for Refugee Women and Children
John Oldfield, Director of Partnership Development, Water Advocates

Moderator: Maurice Middleberg, Vice President of Public Policy, Global Health Council

If you want to attend, click here to RSVP.

Water, Sanitation, Hygiene and HIV/AIDS

Thought I'd do a little research on the nexus of safe drinking water, sanitation, hygiene and HIV/AIDS tonight. I found a very interesting presentation given recently by USAID staffperson Merri Weinger at AfricaSan 2008 in Durban:

http://www.ehproject.org/PDF/ehkm/weinger-africasan2008_presentation.pdf
(PDF document)

It's a quick, introductory read. I'm not sure if you all will find anything new there but for me it does a good job of laying out the linkages between water, sanitation, hygiene and HIV/AIDS, and of quantifying the positive impact of WASH on HIV+ patients and to a certain extent the larger communities.

Note that Pepfar funds can be used for drinking water and hygiene improvements. Sanitation improvements (latrines) need outside sources of funding.

Page 14 discusses 'small doable actions' that need to be scaled up, out and over.

Then I thought of the ongoing debate (as seen in the recent LA Times article "Unintended victims of Gates Foundation generosity") between vertical (viz. disease-specific) and horizontal (viz. basic public health care) approaches to global public health challenges. The facts are, plenty of financial and political capital is flowing to one individual disease: HIV/AIDS. In my mind, it is premature to determine whether that is a good or bad idea (and there are others: malaria, TB). But how can the global watsan community work within the current situation of HIV getting a lot of attention and water getting relatively less?

Every water development organization (UNICEF, CARE, WaterPartners, WaterAid, Water For People, Living Water, and myriad others) that is working in a community where there are HIV positive people should approach Pepfar and ask for support for drinking water and hygiene promotion. Those water development organizations could make that more attractive to Pepfar by agreeing to provide sanitation facilities from their own funds. Essentially the water community should do a better job of grabbing onto the coattails of the HIV/AIDS juggernaut and get a bigger piece of the pie. The end game? - Every HIV clinic, and perhaps the surrounding families and communities could not only have ARVs and medical professionals trained in treating HIV, but also safe drinking water, sanitation and hygiene, and therefore significantly less diarrheal morbidity and mortality.

Sanitation Hits It Big

Sanitation has a few things going for it:

There is a realization that the ROI of an investment in basic sanitation infrastructure in the developing world is high: $1 gets you $9, to be more precise - good return. (WaterAid and WHO)

There is also a growing recognition that, like it or not, meeting the water Millennium Development Goal will not have the impact on public health we all want it to unless there is significant progress on the sanitation MDG as well. (Lancet)

But today, sanitation takes one more step toward being recognized as the marquee player we all know it is by getting prime billing at the World Business Council on Sustainable Development:

The Sanitation Challenge: What Does it Mean for Business?

The article itself doesn't come up with any groundbreaking answers to the question it poses, likely because those answers aren't readily apparent. But inadequate sanitation and water-related illnesses fill 50% of the world's hospital beds, with an obvious and significant impact on corporate activity. A healthy employee is a happy, productive employee. If that employee's family and community are healthy, so much the better.

I look forward to what the WBCSD's newly-launched Sanitation Workstream can produce...

And would one of you please attend what's being billed as the "sanitation session" at Davos this year and report back?

Sat 26th January 2008: 14.00 - 15.15 Interactive session "Death, Disease and Dirty Water"

Untold Stories

Even in the under-reported water and sanitation sector, we are constantly bombarded by stories and reports about what doesn’t work, what hasn’t worked, how we are failing as a planet to meet the water and sanitation MDGs. So in a belated Happy Thanksgiving post, I offer a couple of stories and snaps that show the progress the sector is making in small but meaningful ways:

There is a child in school in Niger because she doesn’t have diarrhea thanks to an extraordinarily simple bucket half full of clean water and a little sliver of soap that she and her family use to wash their hands every day.

A woman’s hands in Guatemala are no longer calloused because her village recently acquired a borehole with a handpump. The story – more of a human dignity story than a water story - involves her coming up with gratitude to the project leader and insisting that he feel how soft her hands were. (Thanks to Gil Garcetti for the great photo.)

There is a village in Tibet that is 100% free of open defecation because of some bold little kids running around sticking ‘poo flags’ in each pile, with the names of their shamed depositors written on those flags.


There is a woman in Senegal who no longer has to wait until nightfall for cultural reasons to defecate, because her family invested $4 in a household pit latrine. I couldn’t find a picture of ‘less severe constipation’ or ‘fewer liver problems’ to post, but you get the point.

Onward.

Vaccinations vs. safe drinking water and sanitation

An interesting article in The Lancet late last year didn’t receive the attention that it – or at least one sentence in it – merits.

I’d like to change that with the help of my now six readers:In Vol. 368, Issue 9543 (Oct 7 – 13, 2006) The Lancet published an editorial to coincide approximately with the release of the UNDP 2006 Human Development Report “Beyond scarcity: Power, poverty and the global water crisis”.

The Lancet piece dealt with the primacy of water and sanitation in global development, and drew attention to the likelihood that the world will fail to meet the MDG on sanitation. It also highlighted the regional disparities which are masked by global progress on the water MDG (viz. progress in India and China masking a lack of such progress in subSaharan Africa). Also of note in the one page editorial was the continued/continuing lack of prioritization of water and sanitation in budgets throughout the developing world.

The sentence at the heart of the argument I want to make on this blog is:

"It is dangerously short sighted to pour immense time and resources into vaccinating children only for them to die a few years later from diarrhoeal illnesses."

I don’t care if the solution to the global safe drinking water and sanitation problem is not a “traditional” health intervention like passing out antiretrovirals or vaccinations. There is clearly not a silver bullet, or even a silver shotgun solution to the water challenge – each situation (unfortunately) requires its own unique solution. Those solutions involve fewer traditional health interventions, and more engineering and infrastructure projects, more behavioral change and education programs (think massive handwashing campaigns for women and kids like this one).

Public health officials in any country, state, province or elsewhere should support and lobby for these non-health initiatives to provide safe water and sanitation, as should the international donor community:

a) they save lives and livelihoods, and

b) less water-related mortality and morbidity frees up hospital beds, staff and other health care resources for those more traditional health interventions. A person sick from preventable waterborne diarrheal disease is occupying a hospital bed whose purpose would be better served by hosting an HIV or TB or malaria patient (plus that girl suffering from diarrhea would be better off in school thank you very much).

Health systems are burdened beyond capacity in many areas already – advocates for public health, water and sanitation throughout the developing and developed world should focus more cogently on preventing preventable illness.

Donde esta el baño?

What is the first thing you learn in any foreign language, other than perhaps the name of the most popular intoxicating beverage in the country (e.g. cerveza, vino, slivovitza)? It is:

"Where is the bathroom?"

If that isn't the best way to communicate the primacy of sanitation I don't know what is. Brilliant (thanks David!)

OK - now imagine that the answer, in whatever language, is "We don't have one, or any paper, or any water." NOW what would you like to be able to say in that foreign language? You will find those phrases here.

I should change the name of this blog to Blogging on Sanitation the way recent events have been going...

World Dunny Day! Cheers!

I imagine that all six of my readers already know that it is World Toilet Day today, but just in case one of you out there just woke up, Happy World Toilet Day! Or as the Aussies say World Dunny Day.


To the 2.6 billion without such amenities, hold on, I'll be right out.

A Good Scratch

I made the mistake recently of asking a British friend of mine “What are the first three things you do in the morning?” His reply: “Well, I finish me gin from the night before, I smoke a ciggy, and I have a good scratch.”

I suspect that safe, clean water will be more important for those of us with less vigorous mornings.

Imagine your morning without water. Imagine your bathroom trip, your shower, your coffee/tea, imagine brushing your teeth without water. If you woke up and realized your home didn’t have safe water, what would your first three actions that morning look like? Forget the first three things – what is the first ONE thing you would do?

Water is vital not only to our morning rituals in the developed world; water is life in its barest essence. Water is security, human security.

Without water, women and families in Africa, Asia, Latin and Central America and elsewhere spend significant parts of their days NOT learning, NOT working, NOT being productive members of society, NOT watching their children play. We in the States are increasingly aware of this challenge abroad – throughout the developing world – and are increasingly active on behalf of the issue. Yet effectively tackling the global safe drinking water and sanitation problem is not as easy as driving to the local soup kitchen and ladling soup to homeless people on Thanksgiving - which reminds me - do that too. Ensuring that poor communities in Africa, Asia and elsewhere have safe water and sanitation is tough work – and requires money, political support, thoughtfulness, and patience. And of that list the most important may well be thoughtfulness.

The recent announcement of the Howard G. Buffett Foundation’s commitment to the sector - called the Global Water Initiative - is an important one, and one which displays many of the best – or at least emerging practices in the sector. It is also an announcement which merits MUCH more attention in the media than it received. John Sauer nailed it in The Huffington Post, trying valiantly to get this announcement the coverage it deserves.

$150m is important. Having a name like Buffett associated with its support for the global safe drinking water and sanitation sector is important in that it minimizes the risk of the next philanthropist getting on board. The focus on both water and sanitation is important. However, arguably more important are the Global Water Initiative's (GWI) efforts to streamline and decentralize decisionmaking throughout the entire process. Long before the formal launch GWI was consulting with a select group of several of the finest implementing organizations on the planet. Long before the launch the GWI was looking at ways not simply to build more systems but to catalyze systemic change in the world's most vulnerable communities. Long before its launch GWI was looking at ways not to measure quarterly or even annual results, but looking at what it could achieve over a ten year period and beyond. And long before its launch GWI was streamlining the process of distributing these grants and the process of receiving these grants in-country, so the focus could be on making the work itself as sustainable, as holistic and as inclusive as possible.

I myself would have chosen fewer countries to minimize dissipation of effort, and to make it more likely that this initiative will produce meaningful successes at scale - the sort of successes that generate headlines like "Every School in Guatemala Now Has Access to Safe Drinking Water" and "Every HIV/AIDS Clinic in Uganda Now Has Private Sanitation Facilities." It is money, it is political support, it is lots and lots of technical know-how and elbow grease that will push this sector onward. However, it is thoughtful initiatives like the Global Water Initiative that are likely to demonstrate not the gravity of the water problem or quick technical fixes, but how solvable the problem is if approached thoughtfully.

International Year of Poo

Hooleintelligence has it right - I have been delayed in my posting due to my being a little too excited about the upcoming International Year of Sanitation. I'm not so sure that getting all worked up about another UN Year for something is advisable, but at least I am not alone:

World Toilet Association General Assembly - tickets still available. Seriously. Go. (Seoul, Nov. 21 - 25)

'Mr. Toilet' builds commode-shaped house

World Toilet Summit in Delhi - Check out my friend Dave Praeger's updates from the World Toilet Summit here. Poop humor just never gets old.

So how can we determine whether we are making progress with the global sanitation challenge? How about when news about sanitation shows up in mainstream media and not in the "Offbeat News" or "News of the Absurd."

And now the underlying harsh reality of this post: what kills and sickens more people, water or inadequate sanitation? A recent UNICEF report answers that clearly:

Reduction in diarrhoeal diseases morbidity resulting from improvements in drinking water and sanitation services:

• 25% from improved drinking water
• 32% from improved sanitation
• 45% from improved hygiene (viz. handwashing)
• 39% from household water treatment

Yes, we need all three. But we need an invigorated response to the global sanitation challenge. But Blogging on Sanitation.blogspot.com doesn't have the cachet that toilets deserve.

Faecal Attraction

So I’m reading a book about poo, and its contribution to civilization. Somehow this got left out of my undergrad class on Western Civilization at Georgetown.

The book I reference is Poop Culture: How America Is Shaped By Its Grossest National Product. I haven’t reached the end yet, but I don’t expect any real surprises – I think I know how this one ends. It’s an awfully interesting read, with insights about poo that I hadn’t considered (or wanted to). We all would benefit by paying closer attention to this issue, and Poop Culture adds some interesting blue-sky approaches to human waste treatment that we should consider – e.g. converting it to energy.

Executives from the Water Environment Federation consistently and justifiably argue that what separates developed from developing countries is not human rights, respect for the environment, or Internet access but PIPES – unglamorous infrastructure. E.g. what happens to poo once it leaves the body?

My challenge is seeing that what happens to that poo around the world doesn’t result in unnecessary mortality and morbidity such as from diarrheal diseases. Over 2.6 billion around the world lack adequate sanitation facilities, or quite literally a place to go to the bathroom. This doesn’t mean that they are NOT going to the bathroom, but rather that 2.6 billion people do so in a way that often negatively impacts their health and the health of their neighbors, kids, passersby. Many organizations are struggling with a way to make this massive public health challenge more compelling. What would make it as cool to talk about poo/defecation/shit at cocktail parties as it is to talk about HIV/AIDS?

Dave Praeger’s book gives us a hint, or at least a lesson to be learned from history:

“By the end of the nineteenth century, state and social reformers in both England and America were working hard to spread the flush toilet across society and alleviate critical sanitary threats. Much of the strategy involved the state extending and maintaining modern sewer and water infrastructures, but reformers still needed to convince skeptics that the new bathroom technology was a boon and not a power-grab by the government. To overcome resistance in people who had been pooping in privies or chamber pots all their lives and were quite content with them, they associated health, happiness, refinement, and civilization with the flush toilet. The corollary of that, of course, was that people who didn’t use flush toilets were the opposite.”

This approach hits close to that of today’s social marketing experts, primus inter pares PSI. Social marketing is defined as “the systematic application of marketing alongside other concepts and techniques to achieve specific behavioral goals for a social good.” The bottom line is that 2.6 billion people need the health benefits associated with improved toilet facilities – the best way to make that happen may well NOT be preaching about those health benefits, but rather finding clever ways to make toilets/pit latrines more cosmopolitan, hip, cool, fun, refined, or alternatively to make it embarrassing to NOT have one.

So what can we learn from PSI’s approach and late nineteenth century America and England. Hopefully a lot – precisely zero people died from cholera in these two countries in 2007.

Throw Money at It

The global safe drinking water, sanitation and hygiene crisis is one which can surely benefit from additional financial resources. There is little donor fatigue in this sector - there is simply a dearth of donors.

If the Wealth and Giving Forum last week in Greenbrier, West Virginia has its say that may soon be changing.

As Tom Watson reports in onPhilanthropy:

The gathering focused on issues surrounding water - from disease and poverty to environmental and security concerns - and participating families were asked a number of questions during a polling session about their attitudes toward philanthropy. Just half-way through the conference, they were asked whether they'd be more likely to give their resources to water-related issues; 80% answered affirmatively.

Of the high net worth individuals and foundations present, 80% are now more likely to give to water-related issues. I'll settle for that.

Unsafe water and inadequate sanitation, and the mortality (between 3-6 million people die each year from unsafe water) and the morbidity (each year there are over 4 billion serious cases of diarrhea) they cause, are not controversial issues. This is not gun control or immigration, and what is possible (and required) is a massive, nonpartisan response by both developing and developed countries. The scale of the solution must match the scale of the problem.

Diarrhea: the unloved red-headed stepchild of the global health debate

We all know that 1.1 billion people do not have access to safe drinking water around the world, primarily in rural communities. We all know that 2.6 billion people do not have adequate sanitation facilities. So let’s jump right into this discussion of issues related to the global safe drinking water crisis with a shout out to what is arguably the world’s largest, most solvable but least compelling public health challenge: diarrhea. For reasons which remain obscure to me, diarrhea remains under-discussed at dinner parties and cocktail hours. But so was HIV/AIDS until a few years ago, and diarrhea also kills millions of people (mostly children) in a very unappetizing fashion.

2008 is the International Year of Sanitation. Will this accomplish anything other than give me the opportunity to say the “S” word in public at the Blue Salon last weekend? Will it result in anything consequential being done by developing or developed countries to tackle this issue?

I am humbled and inspired by Dr. Larry Brilliant’s recent words about diarrhea. In February 2007 he stated “We need to reduce population growth…And the best way to control population is through increasing child survival (and) educating girls…” He continued: “It is counter-intuitive, but eradicating smallpox and vaccine-preventable disease, stopping diarrheal diseases and malaria are the best family planning programs yet devised. With fewer childhood deaths, you get lower fertility rates.” Diarrhea kills five times as many children as does HIV/AIDS, twice as many as malaria, four times as many as measles. And those are just mortality statistics.

How about diarrhea-related morbidity? You can’t compete with the negative health, social and economic impacts of 4 billion cases of diarrhea each year. This isn’t the sort of diarrhea where you spend the evening on the couch getting caught up on Netflix and eating Pedialyte ice pops to rehydrate – all within paces of a bathroom with a nice flushing john. This is the sort of diarrhea which keeps children from school, which keeps adults from working or farming, which prohibits communities and nations from pulling themselves up to the next rung of the economic development ladder. And kills two million kids each year.

Diarrhea is not just treatable, it is preventable. It is preventable through the provision of safe drinking water, adequate sanitation and hygiene education throughout the developing world. So what’s the best way for the international community to invest its limited donor financial commitments? Where’s the best return for governments in the developing world to invest their healthcare resources?