submitted by Samyuktha Varma and Emily Madsen
05/05/2016 at 09:17

Emily and Samyuktha at their last Broken Toilets face-to-face meeting in Hong Kong, 2015.

As development practitioners we constantly ask ourselves if we’re sharing the “right” stories about the work we’ve seen and done. Global development projects are complex. They are (or at least should be) more complicated than the headlines we’re used to seeing: “4 million dollars was spent to build 20,000 toilets for 10 villages.”  We often miss the most interesting aspects of how people – NGOs, governments, and, most importantly, communities – are trying to address problems.  Between the technical reports and the press releases, what we learned from a project and how it may not have lived up to our expectations, tends to be relegated to water cooler conversations with our colleagues.

We started Broken Toilets magazine to tell these stories, hopefully in an interesting and engaging way. The two of us [BT’s co-founding editors] met while working on sanitation projects in Bangalore. Samyuktha worked in wastewater reuse in agriculture, but always with health partners, and Emily worked for a health NGO, with a focus on water, sanitation, and hygiene.

At the center of our intersecting work Venn diagram was poo, and a desire to speak candidly about it and other critical topics in developing communities around the world.

As we’ve been developing this magazine, we’ve become more and more convinced that the most interesting and impactful stories are those that tell how communities are working to address challenges in health, sanitation, infrastructure, education, women’s rights, etc. themselves. These are the stories and anecdotes that get the most agreeing nods at the conference tea breaks. But for some reason, it’s challenging to get funders to pay attention to them and they aren’t exciting or sensational enough to appeal to large media outlets. However, we know that without them readers will never get the whole picture.

A great example comes from our first issue of Broken Toilets, Sludge, where our contributor Avinash Krishnamurthy wrote on the value of informal practices for waste reuse in a peri-urban town outside Bangalore, India. In Fecal Sludge, A Local Story, he described how listening to informal responses during interviews with community members revealed how farmers prevented contamination of crops that were fertilized with fecal sludge. The farmers weren’t taught this method by outsiders coming in with indicators and evaluation checklists, but by following the practices of generations before them.

We usually feel constrained to speak only to the specific work that we were tasked to do going into a community, so these informal discussions usually go unreported.

Emily was once part of a field team evaluating nutrition programs in rural India. Part of the program’s objective was to curb the high levels of diarrheal disease (DD) by building the capacity of village health workers to recognize and treat DD. Her team reported the challenges faced, the program’s shortcomings, failures, and the small successes. When she read the final report written many tiers above her, she found that most of these important factors – both the good and the bad - didn’t make the final cut. The village health workers’ creative methods of reaching and educating mothers about DD got lost in the pie charts and impact indicators.

Development work, as we know it, demands a steep learning curve, listening and sharing. It involves a lot of different of people, and at a fundamental level, requires us to spend time understanding local practices: how people eat, grow food, and take care of their families and their environments.

As practitioners, we have a larger obligation regarding the work that we’re doing, to make sure it positively impacts the people it’s meant to serve.

We hope to be an alternative source for development journalism and we’re trying to do this by bringing in more voices. Broken Toilets magazine features independently reported stories and views by narrative journalists, citizen journalists, as well as the opinions of researchers and practitioners. We want to explore the processes behind development and aid, the implications of this work for those affected by it the most, and ideas of progress along with the compromises they demand. Let us know if you have a story to tell! 

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submitted by Dr. A.P. Dubey
04/24/2016 at 21:40

This post is part of the #ProtectingKids story roundup. Read all the stories here.




In 1982, remember how a mother with two children with measles helped save many others. 



Sadly, she lost one of the ailing children to a subsequent bout of pneumonia and mentioned to me that her children were not the only ones suffering. A visit to her village saved 18 children whose families believed that measles was a “divine curse,” that there was no cure, and that therefore, it was not worth bringing the children to the hospital! When these children recovered after visiting the hospital, it established the community’s confidence in measles treatment.  



This incident happened when I first began working at the Mahatma Gandhi Institute of Medical Sciences (MGIMS) in Sewagram, Wardha, which has great engagement with communitiesI realized then that apart from treatment, it is important to reach out to communities to help them prevent diseases. To minimize the disease burden on children, immunization is one of the most cost effective methods, but this requires educating community members first. MGIMS doctors would set up temporary health camps to treat community members, they also increased awareness about prevention of disease, and immunization and hygiene were important topics. MGIMS adopted one village every year and medical students educated many families this way. 



Infant mortality in India is down to 39 per 1,000 and neonatal mortality, too, is on the decline. In spite of the progress in immunization in the past four decades – notably 80 percent coverage –infectious diseases like respiratory, diarrheal diseases, and tuberculosis continue to cause major challenges, especially in underprivileged communities. In comparison to neighboring Sri Lanka – which has been able to bring its infant mortality rate to single digits – India, by far a much larger country with nuanced complexities, continues to struggle with the burden of infectious diseases. A case in point is that we continue to have outbreaks of measles, which for a long time in most advanced countries has not been heard of.  



Today as I work within a Government hospital in New Delhi, ensuring treatment for children on a variety of ailments, I also teach young doctors about prevention and treatment of childhood diseases. In my lifetime, I have seen the decline of diseases like tetanus, cholera, and Indian childhood cirrhosis. With the introduction of diarrhea management guidelines and ORS, there has been a reduction in diarrheal diseases too, especially if you look at morbidity and mortality. 



As part of the Government of India’s National Adverse Events Following Immunization (AEFI) Committee, the National Technical Advisory Group on Immunization (NTAGI), the pulse polio program, and various other programs, I advocate for immunization to save children from preventable diseases. I was the convener of the Indian Academy of Pediatrics (IAP) committee on immunization, which reviewed immunization practices, incorporated new evidence in support of immunization, and made guidelines that are now used by most pediatricians in the country. I was also part of the committee that advocated for the introduction of the new vaccines in the Universal Immunization Programme  


I am a vaccine advocate because it is important to have greater communication around this and it is critical for the media to address this issue. In India, public awareness about immunization still lacks. Greater awareness will help increase immunization coverage. India can succeed in eliminating vaccine-preventable diseases.     



Photo credit: PATH.

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submitted by Laura Edison
04/20/2016 at 10:49

In observance of Earth Day, we examine how climate change poses both threats and opportunities for the future of human sanitation, nutrition, and diarrheal disease. Photo: PATH/Patrick McKern.

Here at DefeatDD, we love our home planet. We love its mountains, trees, oceans, rivers, flowers, and the beautiful diversity of animals and humans that inhabit it. But on Earth Day and every day, we’re thinking about poop.

Everyone poops, and humans have learned throughout history how to develop a variety of sanitation systems that ensure poop and its diarrheal disease-causing germs stay away from our food and our mouths. In the process, we’ve learned that sanitation actually protects the environment and helps us live in greater harmony with our surroundings. By pumping waste into treatment facilities instead of dumping it into streams, rivers, and oceans, we clean up our water, prevent illness, and help plants and animals thrive. And in turn, these thriving plants and animals help feed and support people in a sustainable way.

However, climate change is threatening to change our relationship with our planet in an unprecedented way, and we have work to do. Melting ice, hotter temperatures, rising sea levels, and more extreme weather events such as floods, droughts, hurricanes, and tsunamis will alter natural habitats, put agriculture at risk, and damage vital infrastructure—such as our sanitation systems. In a natural disaster, sanitation systems can be destroyed, damaged, or flooded, causing waste water to contaminate food and drinking water sources with deadly pathogens, which can continue to prey on their victims long after the storms have passed. In fact, it is estimated that diarrheal diseases cause over 40 percent of the deaths in disaster and refugee camp settings.

For example, the 2010 earthquake in Haiti was followed by one of the worst epidemics of cholera in recent history due to water and sewage treatment failures. The outbreak is ongoing, with over 770,000 cases and over 9,200 deaths attributable to dehydrating diarrhea caused by Vibrio cholerae bacteria so far. Diarrheal diseases pose an even greater risk to communities without strong sanitation systems already in place—particularly in refugee camps and crowded megacities in the developing world.

Indeed, the most dangerous storms spread not only wind or water—but also waste.


The good news, however, is that climate change is also an opportunity. By adapting to climate change, we could promote significant health and development benefits now and in the future, much like sanitation systems have done throughout history. Climate change is just one more reason why we need to act to improve water and sanitation systems now. Adaptation measures that protect us from climate variability can also create resilience to storms and floods and enhance water security, directly contributing to health and development. 

Community members use the SE200 to treat borehole water in rural Zimbabwe. Photo credit: PATH.

In order to adapt, we need innovative technological practices and implementation strategies. The MSR SE200™ Community Chlorine Maker, co-developed by PATH and Mountain Safety Research® Global Health, is one such technological innovation with potential to improve access to clean water and sanitation and, in doing so, help prevent future diarrheal disease outbreaks. Chlorine is an effective method for destroying pathogenic microorganisms in water and has been shown to reduce the threat of waterborne disease and infection. Using just salt, water, and electricity to produce enough chlorine in five minutes to treat up to 55 gallons of water, the MSR SE200™ became available on the commercial market in 2015. A new, larger version that produces enough chlorine to treat 4000 gallons of water per hour—or enough for 1000 people—is currently being field tested in refugee camps in Kenya and Rwanda. Once finalized and launched, the new device will be poised for adoption by ministries of health and aid organizations for use in rural health care settings, refugee camps, or during disaster response efforts.

Our home planet sure is beautiful, and it’s the only home we’ve got. By prioritizing, investing in, and accelerating innovations and improvements in water and sanitation systems, we can protect Planet Earth, the plants and animals we share it with, and—ultimately—ourselves. 

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submitted by David A. Sack, MD
04/12/2016 at 13:48

Cholera is an acute diarrheal disease that can lead to rapid dehydration and death if not immediately and correctly treated. While the global burden of cholera is not precisely known, estimates showthat there are more than 2 million cases per year leading to about 95,000 deaths annually. Cholera occurs mainly in areas with poor water and sanitation conditions and is transmitted through the ingestion of contaminated food or water. Therefore, efforts to prevent cholera often involve improving water, sanitation and hygiene (WASH) conditions and the promotion of healthy behaviors. Oral cholera vaccine (OCV), while perhaps less known, is also an essential component for cholera prevention. OCV can decrease the severity of an outbreak, reduce rates of disease in endemic settings, and prevent cholera from occurring in times of humanitarian crisis or emergencies.

OCV has been used sporadically since 1997, but it was not until it was prequalified by the WHO in 2011 that its use has become more widespread. To date, over 30 million doses of vaccine have been administered in various countries and settings. The cholera vaccine most used currently is Shanchol, since it is available through the global stockpile. Shanchol can be administered to anyone over the age of one year, generally given in two doses, the second occurring two to four weeks after the first. Trials have shownan efficacy of 65% over a period of five years. For this reason, it is important to provide information to vaccine recipients about healthy behaviors such as drinking safe water, practicing good food hygiene, washing hands at key moments, using latrines, and maintaining clean latrines. The vaccine has also been shown to provide indirect (herd) protection to communities, lowering the risk of contracting cholera even among those who have not been vaccinated.  OCV is not an alternative to safe water, but should be used in conjunction with improving water and sanitation.

Recognizing both the benefits of the vaccine and its underutilization, in 2013, the World Health Organization (WHO) established a stockpile of OCV with an annual two million doses. Initially, the stockpile was intended for use during outbreaks and humanitarian crisis settings and was accessible through an application submitted via the OCV international coordinating group. In January 2016, with the addition of another vaccine manufacturer, the WHO announcedthat the available supply will increase significantly and that the vaccine may also be used for high- risk areas as a preventive measure. With increased availability of OCV and potential higher demand, it’s essential that policy makers understand when and where the vaccine should be used and that health workers have the information to effectively implement vaccination campaigns and administer the vaccine.

In an effort to provide the necessary information for those implementing vaccine campaigns, administering the vaccine, or making decisions regarding its use, we have created the StopCholera Toolkit. The Toolkit is a series of four modules that help decide if, when, where, and how to use OCV to reduce mortality, prevent cases, and halt outbreaks. The Manual for OCV Campaigns: For adaptation by program managers for training health care workersprovides a comprehensive overview on cholera, the vaccine, and the steps involved in conducting a vaccination campaign, including important key WASH messages to prevent cholera. 

I am personally looking forward to hearing how the additional vaccine supply is used. I invite you to share your experiences implementing OCV campaigns with us at:


Photo credits:
Jon Lascher, Partners In Health, 2012.
Louise Annaud, Médecins Sans Frontières, 2015

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submitted by Dr. Rajiv Tandon
03/28/2016 at 09:43

On March 26, 2016, India joined the growing number of countries that have introduced rotavirus vaccine into their national immunization programs. The Indian Minister for Health and Family Welfare, Mr. JP Nadda, launched the rotavirus vaccine through the Universal Immunisation Programme (UIP) in Bhubaneswar, Odisha. Mr. Nadda called it a "historic" moment and an "exemplary" step in India’s immunization programme as well as an essential investment in children, the future of the country. Union Minister of State Dharmendra Pradhan, and Atanu Sabyasachi Nayak, Minister of Health and Family Welfare (MoHFW) in Odisha, were also in attendance at the launch event.

In the first phase of the roll-out in the UIP, besides the eastern state of Odisha, the vaccine also will be provided to children in the southern state of Andhra Pradesh and the two northern states of Haryana and Himachal Pradesh. Later, the roll-out will be expanded across the country. The vaccine, called ROTAVAC®, is an indigenously developed vaccine that was licensed by the Drugs Controller General of India in 2014.

Rotavirus accounts for approximately one-third of the nearly 600,000 global child deaths attributable to diarrhea. Ninety-five percent of these deaths occur in developingcountries.  The impact of rotavirus vaccines on the burden of diarrhea has been dramatic in countries that have introduced the vaccine.

India continues to have one of the highest rates of diarrhea in the world. Along with pneumonia, it is one of the leading causes of child illness and death, and rotavirus is the most common cause of severe diarrhea. In India, an estimated 11.37 million episodes of rotavirus gastroenteritis occur each year, with 78,000 cases resulting in death.  Rotavirus is responsible for almost 40 percent of diarrhea-related hospitalizations in India. That is a total of 291,756 hospitalizations each year. 

At the launch, Dr. CK Mishra, Additional Secretary and Mission Director National Health Mission, MoHFW, stressed that the introduction of the rotavirus vaccine in the UIP had strengthened health systems and this would faciliate faster introduction of other new vaccines like the pneumococcal vaccine.  Dr. Bhanu Pratap Sharma, secretary health, MoHFW emphasized that the cost effective vaccine would not only reduce under-five mortality but pave the way for achieving the Sustainable Development Goals.

While rotavirus diarrhea can be treated, the urgent medical care needed is not always accessible to many children, especially among poor populations in India. Vaccination is, thus, the best way to prevent death of infants from severe diarrhea caused by rotavirus.

And, now India has just joined the ranks of 80 other countries around the globe who are helping to save the lives of their children from this terrible disease.


Photo credit: Dr. Rajiv Tandon.

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