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.

No more excuses

How to prevent a tenth of the global disease burden...

Actually, unsafe water and inadequate sanitation cause in many cases up to 15% of the disease burden according to a new World Health Organization report Safer water, better health.

The connections between water, sanitation, hygiene and health are becoming more clear with each passing report, conference, and Lancet editorial. The latest is here:

How to prevent a tenth of the global disease burden

Take the time to read, and forward the editorial or this post to those doubting Thomases who need to better see the linkages between water and health. Some of its findings:

• 9·1% of the global burden of disease could be prevented by improving water, sanitation, and hygiene
• in 32 worst-affected countries, this figure is 15%
• health-care agencies could save US$7 billion a year on health-care costs
• 320 million productive working days could be gained, and
• there could be an extra 272 million school attendance days a year.

In summary, there could be a total payback of $84 billion a year from the $11·3 billion annual investment needed to meet the drinking water and sanitation target of MDG 7.

The piece goes on to say the links between water and health "have been neglected by policy makers in strategies aimed at improving child survival and development" and "this issue remains largely neglected in international development efforts."

"So what?" I whinged halfway through this editorial - another report expressing in ever more graphic terms the disease burden attributable to bad water and no toilets, not to mention the suffering and economic privations associated with hauling water and thus not attending school. Thankfully, the Lancet asked the same question: "But is the international community paying any attention to this wealth of information and evidence?"

The answer is increasingly yes - this piece mentions specifically the recent African Union meeting in Egypt and a number of other reports/series on the issue due soon from The Lancet, WaterAid, etc. All will contribute to the record, and all should call out the global health community and child survival organizations in the strongest terms for not adequately dealing with one of major - if not the largest - contributors to childhood morbidity and mortality.

Save The Date - March 12, 2008

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Save the Date -- March 12, 2008

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For: The Launch of a Water, Sanitation and Hygiene (WASH) in Schools Initiative

Where: The National Geographic Society Auditorium, Washington, D.C.

When: Wednesday, March 12, 2008, 9:00am - 11:00am

Water Advocates and a growing list of non-governmental organizations, foundations, corporations, and schools will launch a Water, Sanitation and Hygiene (WASH) in Schools Initiative on Wednesday, March 12, 2008 at the National Geographic Society Auditorium in Washington D.C. While much is already being done for WASH in Schools, there is still an enormous unmet global problem - half the world's schools lack adequate water and sanitation. This initiative will focus on expanding WASH to 1,000 schools in developing countries while creating the momentum to help as many additional schools as possible worldwide. Water Advocates encourages interested corporations, foundations, organizations, and individuals to use this event as a platform to highlight their activities or to pledge their support to do more for WASH in Schools.

Doors will open at 8:30am and a half hour social will follow the event.

Media interview opportunities will be available from 11:00am - 11:30am.

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.

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...

Beat the Rush

One of the things that keeps me awake at night is that the global safe drinking water and sanitation sector can't compete with Heifer International during the holiday buying frenzy and the end-of-year search for tax breaks. Buying two shares of a pig or a flock of chicks strikes me as more fun than buying a toilet or a pump.

But WaterAid comes close:

How about a puppet show for hygiene promotion for 31 quid, or a soap-making business for 100?

One of the keys to attracting more financial and political support for the water is telling the right stories to the right people, and making it fun. Go WaterAid.

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.

October 11 - Art Opening and Reception, Washington DC

Less blogging today, more partying. Carl Ganter is a rock star of the safe water sector. No one tells a story like this guy - check out www.circleofblue.org.

Please join the Woodrow Wilson Center’s Environmental Change and Security Program and Mexico Institute for the opening of:

Water Stories: A Focus on Mexico

Thursday, October 11, 2007

Art Opening and Reception
5:00 p.m. - 7:00 p.m.

Comments by Circle of Blue director J. Carl Ganter at 5:30 p.m.

Fourth Floor Atrium
Woodrow Wilson International Center for Scholars
1300 Pennsylvania Avenue, NW
Washington, DC

Please RSVP to ecsp@wilsoncenter.org.

More than 1 billion people lack access to potable water and more than 2.6 billion do not have adequate sanitation. The Woodrow Wilson Center’s new photography exhibit, “Water Stories: A Focus on Mexico,” in collaboration with Circle of Blue, offers a vivid glimpse of the lives that lie behind these statistics. Circle of Blue director J. Carl Ganter chronicles water and sanitation challenges facing families in the Iztapalapa region of Mexico City. World Press-winning photographer Brent Stirton documents how water shapes everyday life in the Tehuacán Valley southeast of Mexico City, as residents struggle to obtain enough clean water to meet their basic needs. In Mexico, as with many other places around the world, the quest for water consumes time, energy, and valuable resources. Understanding this human struggle is one step toward ameliorating the global water crisis. In conjunction with the photography exhibit, the Woodrow Wilson Center is launching a new publication, entitled Water Stories: Expanding Opportunities in Small-Scale Water and Sanitation Projects, that features photographs taken by J. Carl Ganter. For more information please visit www.wilsoncenter.org/water.

This exhibition and the Navigating Peace Initiative are made possible by the generous support from the Carnegie Corporation of New York. Circle of Blue’s Mexico coverage, Tehuacán: Diving Destiny, was made possible with generous support from the Ford Foundation. Additional support from FEMSA and the Woodrow Wilson Center’s Mexico Institute.Location: Woodrow Wilson Center at the Ronald Reagan Building, 1300 Pennsylvania Ave., NW (“Federal Triangle” stop on Blue/Orange Line), Fourth Floor Atrium. A map to the Center is available at www.wilsoncenter.org/directions. Note: Due to heightened security, entrance to the building will be restricted and photo identification is required. Please allow additional time to pass through security.

Turning Coffee into Water

Thanks to a wee bit of lobbying (it was actually a very easy sell), the Clinton Global Initiative organized a breakfast/coffee table discussion on Safe Drinking Water which I had the pleasure of moderating today.

As I was tasked with reporting back to the appropriate authorities at CGI, my careful note-taking has revealed some compelling ideas from the table:

1) First of all, the suggestion was made to encourage the Clinton Global Initiative to better prioritize the global safe drinking water, sanitation and hygiene issue throughout all of the tracks (Global Health, Poverty Alleviation, Education and Energy/Climate Change for 2007 - tbd for 2008). Water is everywhere, but is rarely addressed directly and specifically (with an increasing number of exceptions like P&G’s PUR commitment, WaterHealth International’s commitment with Dow). The availability of water and sanitation will make all other sustainable development efforts, regardless of who funds them, more successful initially and more sustainable over the long run.

2) There needs to an increased advocacy effort to raise awareness of safe drinking water and sanitation as a major public health challenge, both in the developed and developing world. In particular, this awareness-raising needs to focus on the solutions to water and sanitation challenges, not just attest to the gravity of the problem. One participant focused specifically on ways to broadcast the water, sanitation and health message throughout the developing world, and getting those governments to better prioritize the issue in their own budgets. One useful precedent is the International Network to Promote Household Water Treatment and Safe Storage. Use such a tool to raise public awareness of the safe water issue throughout the world, use it to educate policymakers, use it to urge corporations, civic organizations, faith communities and private givers to focus on the opportunity to address the cause of development challenges, not just on the symptoms.

3) There is a bottleneck in delivering health-related products and services across the board. Think bednets, vaccines, pharmaceuticals. Also think safe drinking water, latrines, hygiene promotion programs. Although a debate emerged around the issue, the table’s thinking was that there is a reasonable amount of new, innovative and sustainable ideas in the water and health sector, and what is now needed are innovative ways of scaling those doable solutions up, out and over. One example was raised of using village health shops on a grand scale around the world to promote not just bars of soap but hygiene promotion messages. And the option of bolting on microfranchised water purification systems to such village health shops was discussed, as well as using these shops as a foundation from which to deliver social marketing techniques aimed at increasing the number of people with access to improved sanitation systems (e.g. pit latrines). And how about Trainers Without Borders to deal with some of the lack of institutional capacity to grow the sector?

4) Behind every commitment at CGI this year, and there have already been a LOT, there is an exceptional narrative story that if told eloquently and broadly will result not only in progress in the water sector, but additional such commitments at next year’s CGI.

More soon. However, a quick news flash: Bill Clinton announced in a press conference this morning that CGI intends to expand to Asia this year (they are shooting for a meeting in Hong Kong). One might consider lobbying CGI Hong Kong to make sure that the 700 million Indians without improved sanitation are represented, and that the 23% of Chinese (300 million!) without safe drinking water are well-represented in Hong Kong.

Clinton Global Initiative Part 1: Water, water, nowhere

Sorry for the gap in posts – have been on the road a lot lately, including a couple of very interesting visits to water development groups in Guatemala – check out Agua del Pueblo here or google them to find out more about their work for those of you interested in Guatemala. They are primarily funded by a bilateral relationship with the Spanish government now, but looking to diversify and expand their work with water, sanitation and hygiene promotion.

I’m blogging today from right in the middle of the 2007 Clinton Global Initiative, waiting patiently for a direct mention of water, sanitation, hygiene, diarrhea, cholera, or anything… Throw me a bone people! There has been a great deal of optimistic, inspiring discussion in the plenary and breakouts so far from 52+ current and former heads of state and probably 1000 other people, representing 600+ commitments, tens of millions of lives impacted or saved, in over 100 countries.

Five significant commitments have been made public so far, the most interesting of which is the “Global Campaign to Reduce Maternal and Child Deaths in Poor Countries” launched by Norway’s Prime Minister Jens Stoltenberg with others.

Finally, a discussion early this afternoon in the Global Health session about Prime Minister Stoltenberg’s commitment elicited an interesting remark from CARE’s President and CEO Helene Gayle. She suggested that in order to meet the goals laid out by the Prime Minister, it is necessary to take a broader approach to child and maternal health, and focus on the causes of that mortality and morbidity – and she mentioned safe water and sanitation specifically.

More to come.

PS Off to question Jane Goodall about the nexus of biodiversity conservation (viz. great apes) and homo sapiens need for safe drinking water. See earlier related post here.

PPS Best quote ever: Development is about much more than safe water, but never about less.

15,200 miles to go for safe drinking water

The New York Inquirer is duly impressed by several statistics associated with the Blue Planet Run: the 15,200 miles the BPR runners are putting in around the world to raise awareness of the global safe drinking water and sanitation challenge, over four continents and 95 days.

Even more meaningful statistics, however, compellingly link the issues of safe drinking water and human mobility:

• Poor women in Africa and Asia walk an average of six kilometers a day to collect water.


• Poor rural women in developing countries may spend eight hours a day collecting water, carrying up to 20 kilos of water on their heads each journey.

We have all seen and cooed at the glorious, romantic photographs of women in the developing world carrying those buckets of water on their heads with a baby strapped to their backs while dressed in colorful saris.



You think that’s romantic? You try it. A twenty liter bucket of water weighs 45 pounds, in some cases half the body weight of the woman carrying it. Add wild animals, snakes, and unduly interested men to the commute, and you’ve got a recipe for trouble.

The Blue Planet Run is performing admirably in raising ‘name recognition’ of the global health crisis of unsafe water and inadequate sanitation (which remains largely unreported in the U.S.) Name recognition will get an issue far, but not far enough (who hasn’t heard of Howard Dean?). It is up to everyone now to capitalize on the awareness that has been raised by the Blue Planet Run and move toward meaningful political and financial support:

• How can we keep each of the actors who designed sneakers for the campaign engaged in the issue (Hilary Swank, Courteney Cox, Rosie O’Donnell, Lance Bass, Alan Cumming)? Thanks to the Blue Planet Run they are now aware of this issue, and likely interested in doing more.
• How can we all encourage the New York Giants, also supporters of Blue Planet Run, to dedicate a day at the field to global safe water?
• How can the Blue Planet Run Foundation best prepare for its 2009 round-the-world footrace, which is expected to travel through the southern hemisphere? What can the world community do now to encourage the governments in the countries through which the 2009 runners will travel to greet those runners with increased budgetary commitments to water and sanitation infrastructure, particularly in rural communities? How many of those countries will commit at that point to universal coverage of water and sanitation (such as we enjoy in the US, Europe and Japan)?

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.

Comfortably Numb

Hello…hello…hello.
Is there anybody in there?
Just nod if you can hear me.
Is there anyone home?

The world’s gravest public health crisis is unsafe drinking water and inadequate sanitation. Diseases related to this problem kill 5x more kids than HIV/AIDS, and twice as many as malaria. Four billion cases of debilitating diarrhea occur each year, and diarrheal diseases alone kill well over two million kids on an annual basis.

So, the good news: The world came together last week at the Stockholm International Water Institute’s World Water Week to discuss precisely this issue.

And the bad news: the three of you who read this blog are hearing more about World Water Week through this medium than most other people through what I'll humbly call more popular media.

Those mainstream media may well tackle water and climate change, ocean conservation, the bottled water industry, water as a human right, privatization and related issues. But they shy away from unsafe water as the gravest – and most solvable – global public health challenge. This was manifested by the paucity of coverage of World Water Week in at least the U.S. media. Neither The New York Times nor The Washington Post had even a poorly-turned phrase on World Water Week. The only Associated Press story picked up (according to a Google news search) in the U.S. media focused entirely on bio fuels, never even mentioning the severity of this global problem. (Way to go John Sauer at Water Advocates for tracking this.)

Solving the world’s drinking water and sanitation crisis is difficult – it is not a soundbite or silver bullet issue. As my cohort Dennis Warner of Catholic Relief Services says, it’s not rocket science – it’s harder than rocket science. How long did it take to train your kids to wash their hands after they use the bathroom? Do you wash your hands after each trip to the john even today? What’s our water infrastructure financing gap in the U.S. up to now?

But solving this problem is possible. How many English die of cholera in 2007? How many Japanese die of diarrhea? How many Americans have guinea worm, schistosomiasis or malaria?

The unsafe water issue will soon drive the international development agenda itself – it’s unfortunately a matter of time before the media are forced to come to terms with this global challenge whether they like it or not.

I suggest instead that the 1.1 billion people without safe drinking water throughout the developing world need the U.S. and European media to lead the target. As the NYT looks to the FT for story ideas, and as the Economist looks to The New Yorker, one well-placed story on unsafe water as the world’s biggest cause of preventable infant/child mortality and morbidity will punch well above its weight (and win a Pulitzer or two, people).

Some get it: one particularly insightful, clever piece comes from Carl Ganter at the Pacific Institute’s Circle of Blue: Navigating the Mainstream: The Challenge of Making Water Issues Matter. Read it and visit Circle of Blue. Seriously.

Another: Gil Garcetti (yes, that Gil Garcetti) is now an amazing professional photographer covering the world’s water crisis. See his new book Water is Key.

Another: Matt Damon’s new movie Running the Sahara is scheduled for release this fall.

There are stories lined up - there are high profile testimonials lined up – there are convincing water experts lined up. If that’s not enough, there’s always the crushing grip of reason which is tightening. We need to act – there are billions of the world’s poorest waiting for their governments to properly prioritize this issue. There is an opportunity for the Western media to get out ahead of this issue and pull the world along.

None of My Business

Typically, I try always to be open-minded - to walk a mile in the other guy’s shoes, even if it is just to be a mile away and have his shoes when the deal goes sour. However, there are some things to which I cannot possibly relate, and even trying to gets me in trouble. One of those things is the female menstrual cycle.

So I find myself today getting caught up on some reading, in particular a NY Times article from December 23, 2005 entitled “Another School Barrier for African Girls: No Toilet.” I made it about three sentences into the article when this phrase caught my eye: “the realities of menstruation in a school with no latrine, no water, no hope of privacy other than the shadow of a bush, and no girlfriends with whom to commiserate.”

I quickly stopped my halfhearted attempt to relate to this, and am now working on the more simple reality that this is a bad thing and needs fixing.

So… Although the article’s protagonist (Fatimah Bamun, pictured above) is in Ethiopia, this is a reality which unfortunately is not isolated to Ethiopia or even Africa. Fifty percent of the world’s schools do not have access to safe water and single-gender sanitation facilities, and those parts of the world with such luxuries are in the fortunate position of not having to relate to this reality.

In Guinea, enrollment rates for girls from 1997 to 2002 jumped 17 percent after improvements in school sanitation, according to a recent Unicef report. The dropout rate among girls fell by an even bigger percentage.

This post is not about water – it can’t be. This post is about water as a direct conduit to additional educational opportunities for girls, and as a less direct but perhaps more compelling conduit to corresponding increases in economic development and decreases of fecundity rates.

Water and sanitation are statistically validated as significant contributors to education, whether it’s the Education Millennium Development Goal or any other success metric. A recent WaterAid report quantifies the impact of safe water and sanitation on not just the quantity of education, but also on the:

• quality of education - children suffering from diarrhea or thirst (or holding back until nightfall to urinate) cannot concentrate on their lessons, and


• teachers - particularly female teachers who often suffer the same consequences as do their pupils. It is very difficult to recruit and retain qualified teachers where the schools don’t have water and sanitation.

I’d also suggest a quick glance at least at the summary of the Proceedings of the 2005 Water, Sanitation and Hygiene Education for Schools Roundtable Meeting which begins with this quote from former UN Secretary General Kofi Annan:

Water is intimately linked with education and gender equality. Girls who have to spend time gathering water for the family tend not to be in school. And where schools have sanitation, attendance is higher, especially for girls. Water is connected to health, since millions of children get sick and die every year from water-borne diseases and for lack of basic sanitation and hygiene.

I’m not asking readers to relate to this gruesome reality, or even to solve the world’s water problem. More pragmatically I am asking you to consider what it would take to catalyze a situation whereby each of the world’s schools achieves safe, affordable and sustainable access to safe drinking water and single sex sanitation facilities? How many schools are there, how many suffer from these shortages, and what would it take for every government in the developing world to meet its responsibility and fill that gap? Last and least, what could the international donor community do to jumpstart this sort of commitment to life and livelihood?

For example, there are 54,000 schools in South Africa. If 50% of those do not yet have water and sanitation that defines our universe as 27,000 schools. At a conservative (on the high side) $20,000 a pop for water, sanitation and hygiene promotion, that’s $540m. Couldn’t the international donor community come up with $54m to goose the GoSA to make that commitment? Then wouldn’t the governments of Zambia, Mozambique, Botswana and Namibia be embarrassed…

Since you asked...

This is what keeps me awake at night (or at home on a Friday evening):

No matter how much I do, or anyone I work with or consort with does, no matter how much the international donor community does to support safe drinking water and sanitation around the world, no matter if every international donor dollar is spent in exactly the right, highly coordinated way, all we can hope for is for all of those resources collectively to be the cherry on top of the cake, or at best a little gas to get the water development engine going.

Where's the real money? Approximately 70 cents of each dollar that is invested in water/sanitation/hygiene in the developing world comes from public sector finance in developing countries themselves - Ghanaian, Nicaraguan, Vietnamese, Indian taxpayer dollars/rupees/cedis etc. Ten percent give or take comes from the international donor community, with the rest coming from international and domestic private investments in water and sanitation infrastructure.

The end game - universal coverage of water and sanitation, like we enjoy in the States, Europe, Japan - must be played and won by the developing country governments themselves. They must do a much better job of prioritizing water/sanitation in their own budgets over the long run, and do a better job of prioritizing water in international aid requests in the short/medium term (e.g. Millennium Challenge Corporation compacts). [So shouldn't I/we be lobbying those governments instead of the donor community here? Now you try to get some sleep with that question hanging over your head...]

Government subsidies, tax incentives, and grants are all partial answers to how developing country governments should tackle this problem. There are also a number of regulatory paths to take, and I just read of a couple more today:

The Disease Control Priorities Project (DCPP) is an "ongoing effort to assess disease control priorities and produce evidence-based analysis and resource materials to inform health policymaking in developing countries." They recently published a very insightful piece on Water, Sanitation, and Hygiene: Simple, Effective Solutions Save Lives.

It's a clear, short (4pp!) paper detailing both the problem and at least hinting at some interesting partial solutions. One example: with respect to sanitation infrastructure (e.g. building pit latrines), government subsidies are often unruly, inequitable and highly politicized. The DCPP recommends a regulatory approach to address the challenge:

In Bobo Dioulasso, Burkina Faso, for example, the local administration withdrew land tenure rights from owners who did not build a latrine on their plot within a specified time. As a result, 90 percent of households now have their own latrine. Another effective regulation requires landlords to provide latrines for their tenants.

Yay. Another opportunity for developing country governments to more effectively encourage the construction of pit latrines is through what is commonly known as social marketing, much and well-practiced by Population Services International in the donor arena. Governments are encouraged by the DCPP to promote latrines by almost any means possible, as it is perhaps the most cost-effective way to ensure their construction. It is also likely to come out ahead in any cost-benefit analysis. Pit latrines do NOT sell themselves, so governments stepping in to make them more compelling one way or another is part of the solution. And the scale of the solution matches the scale of the problem and I get to go out on Friday nights...

I also have self-doubts about the fact that if only the world's agriculture were 10% more water efficient, there might not be a drinking water supply problem at all, so maybe I should be working on that issue?!? But that's for another post.

Bush/Cheney and Global Public Health Challenges

Let's consider for a moment the article currently front and center on WaPo:

Bush Appointee Blocked Surgeon General's Draft

I don't yet have a copy of the report, but its draft includes the following:

"we cannot overstate . . . that problems in remote parts of the globe can no longer be ignored. Diseases that Americans once read about as affecting people in regions . . . most of us would never visit are now capable of reaching us directly. The hunger, disease, and death resulting from poor food and nutrition create social and political instability . . . and that instability may spread to other nations as people migrate to survive."

Yes. And without provoking a flame war by getting involved in the partisan debate associated with the release (or non-release) of this report, let me tie this article to the world's largest public challenge: unsafe water and inadequate sanitation. They are not only the world's largest public health challenges but also the most solvable.

Safe water is not gun control or abortion or Iraq. It is noncontroversial, and supported by all save a few rabid isolationists. So let's ask this White House to fully fund 2005's Senator Paul Simon Water for the Poor Act and include this request in their FY09 budget to Congress this fall. Further updates shortly on how the FY08 process is going, btw.

Water, Education, and American Express: priorities...

Just this morning I received an email from an old (I should say long-time) friend of mine suggesting I vote for the DonorsChoose project for education at the Amex Members Project contest here:

Members Project

She positioned DonorsChoose as the "David" and the UNICEF Children's Safe Drinking Water Project as the "Goliath," as does a recent interesting NY Times article here. My response to her (and to the dozens of other friends she had included in her To: line (most always a bad idea) was that Yes, UNICEF is large, but the word"Goliath" unjustly positions the Amex contest as a David vs. Goliath battle which fails to account for the real beneficiaries of both projects: children who either die from unsafe water or do not receive an adequate education.

Unsafe water is the #1 killer of children throughout the developing world. Period. Bad water kills five times as many kids as HIV/AIDS, twice as many as malaria. Period. More germane to this conversation: Without safe water, girl children in particular will not have the opportunity to enroll in school (they spend their childhoods either sick and hauling 45 pound buckets of dirty water on their heads). If their schools do not have single-gender sanitation facilities, they will drop out of school once they start menstruating and lack privacy. Safe water is in many cases the single biggest determinant of whether or not a girl receives an education.

For more information on the water/education nexus:

Water and Sanitation: The Education Drain (WaterAid)

The Education Millennium Development Goal: What Water, Sanitation and Hygiene Can Do

Water, Sanitation and Hygiene Education for Schools - Oxford Roundtable Statement

UNESCO – Focusing Resources on Effective School Health

John Edwards first of 2008 U.S. field to tackle safe drinking water

Democrat John Edwards recently became the first (of many - stay tuned for reports on Brownback, Obama and others) of the 2008 U.S. presidential contenders to thoughtfully tackle the global safe drinking water and sanitation issue.

His campaign website includes the following commitment:

"Invest in Clean Water: The World Health Organization has found that every $1 invested in clean water yields an economic return of $8. Edwards will double the U.S. investment in clean water. He will also convene an international summit of government, businesses, and non-profits to agree on necessary investments to make water safe worldwide by 2015."

The return on that one dollar investment may be even higher in many instances as reported here. These are both direct financial returns to individuals, families and communities, as well as significant time savings and healthcare cost savings.

For a broader look at the 2008 field and what the candidates are doing to prioritize solutions to global health challenges and extreme poverty, check out One Vote '08.