RotaFlash, April 2016
I know of at least two toilet museums (a toilet shaped one in South Korea and Sulabh International Museum of Toilets in India). It would be great if, like many museums, they were just documenting the history of a problem that was solved long ago. But the world missed the global sanitation targets under the Millennium Development Goals.
In my role at Improve International, I often feel like a Negative Nelly, because I highlight the challenges faced by the water and sanitation sector. So at the beginning of this new year (at least for this blog), I will try being a Positive Polly. It’s good timing, as 2016 is also the year we embark on the journey to Sustainable Development Goal 6, “Ensure access to water and sanitation for all.”
For a recent research project for CRS, I felt like an archaeologist, trying to dig up evidence of long-term sanitation successes. Based on what we found, I believe universal sanitation is achievable.
Depending on where you live, you might be experiencing 100% national coverage right in your own house. (Full disclosure: I live in the US and I have one toilet in my home. TMI: It isn’t always as clean as it should be.) If you live in the US, have you been anywhere lately (besides Manhattan) where you couldn’t easily find a toilet, and handwashing facilities? So how did that happen? Governments of developing countries who still have a way to go toward universal coverage and NGOs who work there can learn from the successes of other countries.
Examples of sanitation achievements that are well documented include Bangladesh, Brazil, Malaysia, Singapore, South Korea, and Thailand. While some consider these countries to be more developed, the gross domestic products (GDP) per capita in 1960 for Bangladesh, South Korea, and Thailand, for example, were lower than those of Ghana, Liberia, Senegal, Zambia, and Zimbabwe. Singapore seems like a totally modern city now, but in the 1960s, it was a “polluted, congested city where open defecation was rampant.”
Examples of GDP and national improved sanitation coverage trajectories 
And while the lowest levels of sanitation coverage are found in the least developed countries, particularly those in sub-Saharan Africa, Ethiopia kicked butt. They achieved the largest decrease in the proportion of the population practicing open defecation (from 92% in 1990 to 29% in 2015).
From these countries we can see that universal sanitation starts with political will and leadership, along with adequate funding, cooperation and coordination, affordable technology, and development of sustained local capacity. We are also starting to accept that a long-term drive (i.e., decades) toward a cultural shift is required to raise awareness and change behavior. These are things that are difficult to do (especially for project-oriented NGOs) and harder to measure. But we need to get past the “Build more cheap latrines!” mentality. Sanitation does not solely refer to containment of feces. Toilets are only one element in an entire sanitation system, which should include collection, transport, treatment, and use of excreta. And a crappy toilet (literally or figuratively – i.e., low quality) can be worse than no toilet at all.
Before and after latrines in a suburb of Blantyre, Malawi.
What can you do to help the countries that are already “there” and those that aren’t there yet? If you work for an NGO, your organization could help promote:
- Consideration of menstrual hygiene
- Promotion of hygienic use of toilets, especially with access to water for cleaning and handwashing
- Helping to link users with finances and services for pit emptying or building new latrines, as well as upgrading their services
- Help communities with animal excreta management, solid waste management, and managing young children’s feces.
It feels good to be optimistic, but realistic. We need to learn from the past, question the build on the good, and resolve the bad. Join me soon after 2030 at the “Museum of How We Got to Universal Sanitation.” I hear they’ll have a great coffee shop.
Bangladesh: Sustainability and equity aspects of total sanitation programmes: A study of recent WaterAid-supported programmes in Bangladesh, Community-Led Total Sanitation in Rural Areas: An Approach That Works, Lessons Learned from Bangladesh, India, and Pakistan: Scaling-Up Rural Sanitation in South Asia, Community Led Total Sanitation in Bangladesh: Chronicles of a Peoples Movement, Citizen's report on sanitation
Brazil: Community-driven sanitation improvement in deprived urban neighbourhoods, Low-cost Sanitation Improvements in Poor Communities: Conditions for Physical Sustainability, The Experience of Condominial Water and Sewerage Systems in Brazil: Case Studies from Brasilia, Salvador and Parauapebas
Singapore: Successful Sanitation Projects in Thailand, Malaysia, and Singapore, Achieving total sanitation and hygiene coverage within a generation – lessons from East Asia, 50 years of sanitation in Singapore
Thailand: Achieving total sanitation and hygiene coverage within a generation – lessons from East Asia; Successful Sanitation Projects in Thailand, Malaysia, and Singapore, Evaluating the effectiveness of public finance for household sanitation in rural Thailand, Universal Sanitation – Thailand Experiences
United States: The Sanitary City: Environmental Services in Urban America from Colonial Times to the Present, City Water, City Life: Water and the Infrastructure of Ideas in Urbanizing Philadelphia, Boston, and Chicago, The Cholera Years
World: The Big Necessity
 Table adapted from Northover, H., Ryu, S., & Brewer, T., 2015. Achieving total sanitation and hygiene coverage within a generation – lessons from East Asia. London: WaterAid.
 World Bank Data 1960 GDP per capita, data for Bangladesh, Brazil, Malaysia, Singapore, South Korea, Thailand (accessed January 6, 2016)
 World Bank Data Improved sanitation facilities (% of population with access) 1986-1990
 World Bank Data Improved sanitation facilities (% of population with access) 1996-2000
 World Bank Data Improved sanitation facilities (% of population with access) 2011-2015
Photo credits: Susan Davis.
Erin Fry Sosne's cutie pie is the star of two of your favorite 2015 blogs.
The best advocacy movements maintain momentum by reflecting on powerful, personal victories and large-scale milestones. Our list of reader favorites from 2015 has something for everyone to help fortify your resolve for the year ahead. If you don’t find the topic you’re looking for, contact us about writing a blog in 2016!
5. When diarrhea gets personal: One girl’s fight against rotavirus
By: Laura Edison, PATH
Laura had been working as a rotavirus vaccine advocate at PATH for more than a year before her parents dropped a major bombshell: “We felt so helpless when you had rotavirus.” Her story was featured in the World Immunization Week Protecting Kids blog series.
4. Becoming open defecation-free: For Bangladesh, it was strong political will
By: Sushmita Malaviya, PATH
Why has Bangladesh achieved significant progress while neighboring India still has so much further to go? It’s a fascinating question with important takeaways for sanitation programs. DefeatDD caught up with Akramul Islam, the director of BRAC’s WASH programme, which has reached more than 66 million people in eight years for his take on must-have elements for successful initiatives.
3. Would you go back?
By: Erin Fry Sosne, PATH
Six months ago, Erin Fry Sosne faced a dilemma that until then she’d only written about: a rotavirus vaccine stock out when her son needed his last dose. It was easy enough for her to return with her son a few days later, but how, she wondered, do moms around the world weigh a decision to return to the clinic when it carries so much more weight and burden?
2. Help us advocate to save moms and kids around the world
By: DefeatDD and partners
The Reach Act was introduced into Congress this year, with the support of more than 20 diverse nonprofits and severalcute baby lobbyists. To start of chain reaction in support the bill, advocates from around the world “linked up” and shared their photos on social media. This blog is your one-stop-shop for information about the bill, and even though the photo campaign is over, it’s not too late to show your support by tweeting with the hashtags #ReachAct and #SaveMomsAndKids!
1. Vaccination: From policy analysis to personal practice
By: Erin Fry Sosne, PATH
It was a full circle moment when rotavirus vaccine advocate Erin Fry Sosne became a mom for the first time and took her son to get his first protective dose against rotavirus.
Do you have another favorite that didn’t make the cut? Share it in the comments below and we promise to reminisce with you.Read more
This study was funded by the National Science Foundation. Blogs featuring this study have appeared on the Center for Disease Dynamics and Economic Policy’s website. Ali Akram conducted this work independently and the following does not reflect the views/opinions of Evidence Action. Photo credit: PATH/Glenn Austin.
Despite the availability of inexpensive and easy-to-use technologies and simple behaviors that can prevent diarrhea, it was an unpleasant surprise for me to learn that it kills more than half a million children a year, predominantly in the developing world. More troubling still, social scientists have found it challenging to get high adoption rates and maintain participation amongst poor households, even when the technology is provided free. This got me curious: why is this the case?
What I Did: The Experiment
In a randomized controlled trial in Karachi, Pakistan, I test the hypothesis that perhaps families need tools that clearly demonstrate the impact of health interventions – in this case, chlorine tablets for water purification.
Info-Tool required weekly recording of diarrheal incidence and monthly comparison to a reference level.
I provided households with a simple visual tool (called Info-Tool) to help them assess the efficacy of using tablets. Info-Tool allowed households to record incidences of diarrhea using simple bar charts. Additionally, at the end of each month, I provided them a bar chart of the normal rates of diarrhea they could expect for that month. Diarrhea varies with season, so the norm I provided was a moving monthly reference (related to the number of children under five in the household) and Info-Tool allowed households to visually compare their bar charts to the reference level.
Form of the experiment: control group in blue and treatment in green.
The experiment had a control group and treatment group, and rolled out in three phases. In Phase 1, which lasted three months, the treatment group used Info-Tool and built up a pre-tablet record of diarrhea prevalence. Info-Tool allowed them to understand where their levels tracked in comparison to the provided reference. In Phase 2, which also lasted three months, the treatment group continued to use Info-Tool but both groups were offered the option of accepting free chlorine tablets. In Phase 3, I discontinued the treatment group’s use of Info-Tool but both groups continued to receive freely provided chlorine tablets.
What I Found: Remarkable Results
Chlorine tablet use was significantly and persistently higher in the treatment group. At 74 weeks from the start of tablet delivery (beginning of Phase 2), the treatment group was almost twice as likely as the control group to accept the tablets, with the control group acceptance rate at 26% and the treatment group at almost 60% (see Figure 3).
Two results really struck me. First, my data show that as we enter the subsequent summer season (near the 46 week mark), both groups demonstrated higher tablet acceptance. Significantly, the treatment group’s summer increase in uptake was higher than the control group. To me, this suggests an impact of Info-Tool on households’ fundamental understanding of disease seasonality i.e. households seemingly better understood the “dynamics” of diarrhea.
A more striking result to me, however, was the fact that children in treatment households tended to measure significantly better than control households on health outcomes such as weight (22% gain), height (6% gain), and mid-upper arm circumference (3.5% gain). This suggests that the use of tablets had real measurable health impacts.
Predicted probability of accepting offered chlorine tablets by treatment arm. The x-axis has time (weeks) while the y-axis shows predicted probability of uptake in a given week. The control group is shown in blue while the treatment group is shown in red. Dotted vertical lines indicate specific dates and phases of the experiment.
The results suggest that allowing households to track and reference their disease prevalence increased their ability to detect the efficacy of chlorine tablets, thus making the intervention far more successful. More specifically, I believe that households were able to better learn about the effectiveness of tablets because Info-Tool provided a more precise signal about tablet effectiveness. It is also apparent that households possess a general sense of the seasonality of the problem but with the augmented learning from the Info-Tool, treatment households show a higher likelihood to accept offered tablets as the “danger” (summer) season started.
What this Means: Policy Recommendations
I believe this study points the way forward in two important ways. First, it demonstrates a powerful new way to address a major global health challenge i.e. under-five diarrhea with its associated health costs. I found that the intervention had strong and persistent effects a year after it began, inducing people to adopt chlorine tablets when they otherwise would not have.
Second, it confirmed to me that people can and do make beneficial health decisions – we’ve just got to help them “see” that those decisions have real benefits. Giving people clearer signals on how they benefit from their use of supposedly beneficial technology sparks greater participation. Moreover, I can imagine analogues to this technique being applied to other domains where health technology adoption is critical such as adoption of anti-malarial bed-nets and drug regimens for diseases like TB and HIV.Read more
How are we going to save the 550,000 children who still die of diarrhea each year? It’s a daunting question. While vaccines against the leading cause of severe childhood diarrhea are key to prevention, treatment should also remain an important focus. We know that oral rehydration solution (ORS) and zinc are the cornerstone treatments for diarrhea and that this combination already saves many children. While we still need to improve awareness about, access to, and use of ORS and zinc, we also need to identify the underlying causes of severe diarrhea in children and develop new approaches and innovations in treatments, diagnostics, and nutrition to address those causes. In fact, a recent report by Innovation Countdown 2030 highlighted new treatments for severe diarrhea as having the potential to save an estimated 251,000 children’s lives. That’s a very attractive opportunity!
On a personal level, we are passionate about saving the lives of children and both of our organizations—icddr,b and PATH—have a strong history of innovations to address diarrheal disease. icddr,b (a global health research institution based in Bangladesh) was central in developing ORS and in demonstrating the effectiveness of zinc to treat diarrhea, and has an extensive portfolio of diarrheal disease research, particularly focusing on vaccines, behavioral and environmental interventions, diagnostics and treatment; PATH’s history and current work is rooted in advancing health technologies for low-resource settings, as well as improving access to proven interventions and strengthening healthy behaviors like handwashing with soap and exclusive breastfeeding for the first six months of a child’s life. Because of our passion and the work of our respective organizations, we agreed to serve as co-chairs of the newly-formed Diarrhea Innovations Group (DIG)—an open source, global network of innovators committed to reducing child deaths from diarrhea by assembling like-minded organizations to accelerate the pace of innovative tools and approaches.
Modeled on the successful Pneumonia Innovations Team, the principle behind DIG is simple. If we bring together innovators and experts from industry, research, and implementing organizations, we can break down the research and innovation silos, foster review and debate around the needs and the associated innovations, and crowd source solutions to bottlenecks. Note that we’re focused on not just ameliorating the most obvious symptom of this deadly disease, we’re looking to address the underlying conditions – infection, environmental enteropathy, and malnutrition – that may cause and result from diarrheal disease. It’s an important challenge that is going to require a sustained collaborative effort.
The DIG will play a specific role in contributing to this effort by:
Ø Convening bi-monthly group conference calls when we will hear a member speak about their research or innovation followed by all of us brainstorming on potential impact and solutions to challenges.
Ø Holding sub-group calls for members with special interest areas in treatment, nutrition, or diagnostics.
Ø Matchmaking—because we’ll be familiar with the research focus and innovation of many organizations, we will connect organizations and individuals from different sectors who are working in complementary areas. The matchmaking might focus on connecting members around similar research and technology or, in some cases, supporting the identification of funding sources to advance an innovation with particular promise.
We welcome participation from anyone around the world working in the diarrheal disease space. At the same time, one of DIG’s core operating principles will be to intentionally feature and listen to voices in countries where diarrheal diseases take the highest toll. These innovators and experts are on the front lines. They see the challenges on a daily basis and have special insight into the potential solutions and what will work.
As a member, there is no expectation that you will join us in every discussion, but we hope that you will join us in this exciting journey to engage, exchange opportunities, build new partnerships, and advance this neglected field. Want to DIG in with us? Please visit or contact us at email@example.com for more information.
Photo credit: PATH.Read more
Last week, we marked World Toilet Day 2015, focusing on the fact that 2.4 billion people around the world today lack access to proper sanitation. Especially in South Asia, there are huge disparities in access to toilets, clean water, and properly handled and prepared food.
Good sanitation practices are important to highlight not only on World Toilet Day but every day, and they go hand-in-hand with other important health indicators: researchers studying the impact of water, sanitation, and hygiene (WASH) interventions and their implications for other outcomes like nutrition are revealing that they are inextricably linked.
With decades of experience studying WASH interventions in low-income settings, researchers at icddr,b (the International Centre for Diarrhoeal Disease Research, Bangladesh) and elsewhere have generated evidence on a range of interventions with the potential to significantly improve health outcomes for the world’s poorest people. Because WASH is often central to good health, we proudly present our top ten (evidence-based) toilet tips!
1. Wash hands after using the toilet
Handwashing has proven to reduce transmission of many diseases, from enteric (diarrheal) diseases to respiratory infections. Research has demonstrated that just a small amount of clean water used for handwashing after using the toilet can reduce the chances of transmitting disease by as much as 95%.
2. Provide a safe space for girls and women to use the toilet
Girls and women need access to basic sanitation facilities, particularly when they are menstruating. In Bangladesh, 45% of schools lack clean sanitary facilities, leading to girls missing classes during their periods. Based on icddr,b-led research, the Bangladesh Government recently released a circular recommending improved access to toilets in schools, particularly for girls.
3. Use facilities if and when they are available and dispose of waste properly
Open defecation has many negative side effects: waste can get into water systems and food, and it is generally unpleasant. In the South Asian subcontinent, Bangladesh has seen great progress in reducing the rates of open defecation: from 34% in 1990 to 3% in 2012.Publiccampaigns and awareness-raising have greatly contributed to this reduction in numbers.
4. Even when using basic sanitary facilities, make sure to clean them after use
Aside from being generally thoughtful toward the next user, leaving sanitary facilities clean can reduce transmission of disease from one person to another. Even in basic sanitary facilities like pit latrines, it is essential to leave behind as little trace as possiblefor the next user. When lacking running water, even a small amount of water can help clean up a facility after use, and will certainly help in reducing odours and ensure a clean facility.
5. Encourage parents to dispose of their children’s waste properly, and not in the open
Parents of young children who are not toilet trained should avoid disposing of their kids’ waste openly. Providing parents with a potty for toilet training their children and encouraging parents to dispose of the waste properly, i.e. in a toilet or latrine, can prevent contamination of the environment and promote good sanitation practices from an early age. In Bangladesh, promotion of good sanitary practices and changing behaviour to apply these has been a key success factor in reducing the rates of open defecation. On-going research by icddr,b includes behaviour change messages as a key success factor for improving hygiene conditions, even in basic sanitation facilities and latrines.
6. Promote basic hygiene and sanitation practices in the community
A key component in Bangladesh’s success in reducing open defecation has been the involvement of community leaders in promoting good toilet hygiene. In fact, by mapping out the placeswhere open defecation was practiced, and demonstrating this to communities, people were surprised at how close these practices happened to homes and mosques. This contributed to a trigger in attitude and practice, which is a key element of behaviour change.
7. Take extra care in practicing sanitation when feeling ill
Practicing basic hygiene is extra important in ensuring that infections do not spread. Basic hand-washing practices and ensuring the toilet is left clean for the next user can help avoid spreading disease. Studies have shown that washing hands, even with a little water, can reduce the spread of both gastrointestinal and respiratory infection.
8. Ensure a proper distance between your sanitary facility and where you cook, eat or sleep
Studies have shown that there is a correlation between the distance from sanitation facilities to living places and reduction in the spread of disease. Ongoing research presented at the 2015 University of North Carolina Water Microbiology Conference (see Abstract Book, p. 23)is investigating the impact of maintaining a safe distance, or an enclosed space, where the toilet can be properly placed to ensure good health for the entire family, and even the community.
9. Make sure your septic tank/waste pit is appropriately sealed, and regularly checked
In areas where access to running water is limited or lacking, a septic tank or latrine pit is the most sanitary option. A current icddr,b study of dual-pit latrines in Bangladesh aims to encourage families to switch septic pits when they are full. In doing so, sanitary conditions are improved and at a safe distance from family and community activities. What’s more: the waste from a full tank becomes solid after 8-10 months and can be used as fertilizer in the fields.
10. Good sanitation leads to better general health outcomes, and may even contribute to good nutrition and reduction in growth stunting
Good sanitation practices have long-term benefits: by preventing the spread of diarrheal disease, in particular recurring bouts of diarrhoea, we can help improve nutrition outcomes for children and infants. New ongoing research on the interaction between diarrheal disease and gut health is beginning to show that recurring intestinal infections can have long-term effects on nutrition uptake in children, which impacts growth and cognitive development later in life.
Photo credits: PATH.Read more