RotaFlash, April 2016
A toilet as an aspiration? In countries where we take flushing for granted, this perspective might be hard to understand. But when family finances are so scarce that school fees, nutritious food, and even basic health care stretch income beyond its limits, a toilet is often an unattainable extra: It would be nice, not to mention help keep my family safe and healthy, but how can I even begin to afford it? Further, when open defecation is a routine behavior—a mobile phone in hand while venturing out in the field at dawn is a usual sight—how can you sell toilets that are aspirational and affordable?
PSI and PATH have been working in rural India to help families bridge this gap between aspiration and ownership. Considering not only income limitations but also the preferences and needs of poor communities in Bihar, our collaboration has helped build a market for the sale of 20,000 toilets that are designed to be cost-effective and user-friendly—and we’re just getting started. Financing options, coupled with user-centered design, will remain essential as we aim to advance our impact to 150,000 homes.
(Top photo) A typical latrine in Bihar, for those who could afford to construct it. Durability, privacy, and security were among key user requirements for an updated, aspirational design. Community members evaluated the updated designs (bottom photo) and provided important input.
PSI dug deep to find out where the supply chain failed consumers. One example is the sprawl of materials, often spread among more than 10 separate vendors – from bricks to build walls and cement rings to line the pit to materials to construct a roof and latches to secure the door.
Applying PSI’s market evaluation and a rapid user assessment, PATH worked with families, community leaders, and manufacturers to design a toilet based on what was essential, what was practical, what was appropriate, and also aspirational. PATH continually iterated and refined the manufacturing process from a disparate set of material suppliers to an efficient, semi-centralized approach focused on consistently producing high-quality latrines. We added design features that garnered appreciative feedback from users, like handles to help children and older individuals balance; a shelf to hold soap or menstrual hygiene products, or to stash a mobile phone. One particular interview with users took an interesting turn during a lashing rainstorm: the importance of a strong, durable design was impossible to ignore once five adults (plus one small boy) piled into a model latrine to escape the elements!
Community feedback was crucial to informing design updates as well as understanding opinions about appropriate financing options and factors of affordability.
We were then able to go to market with an innovative design for a toilet that reduced the cost by about $200 on the typical toilet in Bihar. But even with a price reduction plus more aspirational design and marketing, a toilet remains out of reach for many. Existing financial systems were inadequate; for example, the Indian government provides a sanitation subsidy, but only after a toilet is built. To take that first step, families often need a loan, but no sanitation loan products existed.
PSI helped facilitate loans to sanitation entrepreneurs, which allowed them to partner with other vendors to organize labor and materials. They can manufacture more products, too, and pass savings onto consumers. In collaboration with Friends of Women’s World Banking as fund manager, PSI was able to infuse cash into microfinance institutions that made it possible for households to take out loans to purchase a toilet. Usually microfinance loans are reserved for income-generating activities, but this alteration in terms allowed for direct loans to consumers, and provided many families access to an essential product that would ensure better health for their community.
Manufacturers added pivotal perspectives on materials, supply logistics, production processes, practicality, and affordability.
Calling Bihar rural can be a misnomer: Communities are dense, and homes are grouped closely. Living in such proximity, environmental health issues affect everyone, and people have to look out for one another. Without broad sanitation coverage, pathogens remain in the environment, and even those with toilets are exposed. That is why 20,000 toilets are not enough. That is why we will continue pushing for total coverage, keep breaking down barriers, overcoming challenges, and working with communities to find innovative sanitation solutions.
This photo is the November feature for DefeatDD's 2015 toilet calendar. See how we "go" around the world. Photo credit: Marco Betti/WaterAid.
Sandwiched between World Pneumonia Day (November 12) and World Toilet Day (November 19) is this funny week where we don’t really know what to do with ourselves. Do we keep talking about pneumonia or do we start talking about toilets? Oh what to do.
To solve this pickle, I tried to think about what every sandwich needs to bring it together. Meat. (For non-vegetarians, that is.) And what’s the meat that bridges the space between pneumonia and toilets? Well, sanitation, of course.
I’ll spare you the poorly crafted jokes about washing your hands before eating sandwiches and go straight into why sanitation and hygiene are key links between coughs and commodes.
Limited sanitation and open defecation in the world’s poorest regions spread germs that make children vulnerable to repeated and deadly diarrhea. When toilets are available, however, the risks for spreading disease don’t end there.
Touching a toilet transfers all of those human waste germs to your hands. Everything you touch after that without washing your hands gets exposed to those germs. In this light, it’s easy to see how diarrheal disease can spread pretty quickly in communities without ready access to handwashing facilities.
Ok, so the toilet-diarrheal disease link is a bit obvious.
Perhaps a little less obvious is that other diseases, like pneumonia, can also spread by lack of sanitation and hygiene. Pneumonia has many causes, bacterial and viral. Together with diarrheal disease, it kills more kids than any other infectious disease worldwide. (It’s also a major risk in an infant’s early days, and a threat, too, to premature babies—who happen to be another focus of advocacy efforts this week.) The most common cause of severe childhood pneumonia—the pneumococcus bacterium—can live for long periods on surfaces like toilets. Anyone coughing or sneezing on their hands and then touching a toilet can transfer those pneumonia-causing germs to others using the toilet later. Then all it takes is a rub of the nose or touching food (say, a sandwich) for a germy hand to lead to infection.
Luckily, studies show that handwashing with soap can reduce the incidence of diarrheal diseases by more than half and acute respiratory infections like pneumonia by roughly a quarter. A seemingly simple solution for such enormous impact.
But for many parts of the world without ready access to clean water, handwashing isn’t very simple at all. That’s why the global health community’s activities under the Integrated Action Plan for the Prevention and Control of Pneumonia and Diarrheal Disease are so important for making sanitation, hygiene, and good health accessible for everyone under a united pneumonia and diarrhea prevention strategy.
At first glance, pneumonia and toilets may not seem to fit on the same plate, but sandwiched side by side as they are this week, their common link to sanitation interventions puts their natural pairing in a clearer light. As we leave World Pneumonia Day behind and look toward World Toilet Day, let’s remember that these events are not mutually exclusive. They’re linked by a goal of saving lives and are opportunities to advocate for ways to leverage common resources toward that end—across diseases, across interventions, and across the table.
If you have room on your plate, a few other cross-cutting interventions might tempt your palette. Nutrition, vaccines, and breastfeeding are other overlapping tools to address diarrhea and pneumonia. Advocating for the full menu of integrated solutions can help save children’s lives faster. So keep spreading the word. Not only this week, but year-round.
Just some food for thought.Read more
Together, pneumonia and diarrhea kill more children under the age of five each year than any other infectious disease. Luckily, a number of prevention and treatment solutions (like vaccine delivery systems, handwashing/sanitation, antibiotics, and exclusive breastfeeding) can be applied to both, warranting an approach that leverages common resources to fight them in an integrated way. The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea is the roadmap for doing just that. This post originally appeared on the PATH blog. Photo credit: PATH/Doune Porter.
Fifteen years ago, roughly two million children under age five died from pneumonia annually. Today, that number is down by more than half thanks to improved prevention and treatment interventions and their growing presence in traditionally underserved countries.
Despite this progress, pneumonia still kills more children than any other infectious disease, especially in the developing world. Why? Because it is a complex disease with many causes and the tools to fight it are still not equitably accessible. To finish the job, we must harness an integrated array of solutions (vaccines, treatments, clean air, nutrition, and diagnostics) that can hit pneumonia from multiple angles.
Here’s my list of five particularly exciting solutions that are vital for enhancing the fight against pneumonia and overcoming systemic barriers that inhibit children from getting the prevention and care they need.
There are vaccines on the horizon that hold great promise to protect against all pneumococcal strains. Photo: PATH/Heng Chivoan.
1. Vaccines to provide broad protection
Vaccines against the leading cause of severe childhood pneumonia—pneumococcus—are effective against a number of the bacterium’s many varieties, but not all. They are also too expensive for many countries to afford without substantial donor assistance. By design, they’re doing their job, but what if a vaccine could provide affordable protection against all pneumococcal strains? The good news is vaccines designed to do just this are on the horizon. Public-private partnerships are advancing the development of vaccines that hold the promise to potentially change the pneumococcal prevention game.
Dr. Amy Ginsburg demonstrates a user-friendly application for mobile phones and tablets called mPneumonia that aims to help health care providers detect and manage pneumonia. Photo: PATH/Patrick McKern.
2. Technologies to diagnose and treat low oxygen levels
By afflicting the lungs, pneumonia can result in fatal oxygen deficiency. A pulse oximeter is the gold standard for non-invasively diagnosing this deficiency; easily and painlessly clips on a finger or other extremity to measure blood oxygen levels; and can inform the best use of lifesaving oxygen treatments. In low-income countries, however, supply, policy, training, and cost hurdles make pulse oximetry and oxygen scarce resources, particularly for children. Investing in creative ways to address the challenges (like mobile phone applications or alternative energy for pulse oximetry) is critical for expanding use.
Fast-dissolving tablets are an easy and cost-effective way to administer antibiotics to children. Photos: PATH/Patrick McKern.
3. Child-friendly antibiotics ideal for low-resource settings
The recommended first-line treatment for childhood pneumonia is the antibiotic amoxicillin. In its traditional forms, it’s difficult to use in the harsh conditions of many low-resource countries because of factors like heat and light sensitivity and the need for precise measurement. In these settings, amoxicillin dispersible tablets are a better option, particularly for children who can’t swallow pills. They have a longer shelf-life, are cost-effective, don’t need refrigeration, and are easy to administer because the tablets quickly disperse in clean water or breastmilk. Their lack of availability in countries where most needed, however, underscores the urgency of resolving barriers to access so these tablets can be put to work.
Cleaner-burning fuels can reduce indoor air pollution, which causes 4.3 million deaths—of which 12 percent are children with respiratory infections like pneumonia. Photo: PATH/Heng Chivoan.
4. Clean household fuels to clear the air
Nearly three billion people use coal, wood, and crop residue for cooking, but the smoke these fuels produce can cause serious illness. Indoor air pollution causes 4.3 million deaths of which 12 percent are children with respiratory infections like pneumonia. Clean-burning fuel like liquid-petroleum gas is a potential solution, but is often too costly for poor, rural communities. However, there are interventions streamlining supply chains, providing consumer financing, and using direct marketing to bring clean fuel into more households, but further investment is needed to maximize reach.
Thanks to a thriving human milk bank, an infant receives donor breastmilk in the neonatal intensive care unit at Mahila Chikitsalaya Government Hospital in Jaipur, India. Photo: PATH/Tom Furtwangler.
5. Human milk banking to protect vulnerable infants
Exclusive breastfeeding provides infants with the nutrients and hydration they need; prevents exposure to contaminated food and water that cause deadly illnesses like diarrhea; and confers protective antibodies against many illnesses, including pneumonia (a particularly dangerous infection for newborns). When infants don’t have access to their own mother’s milk, donor breastmilk is the next best thing. Human milk banks are an innovative solution that gives otherwise deprived infants access to safe donated breastmilk—and a chance to thrive.Read more
Health workers transport pneumonia and rotavirus vaccines across Tanzania. Photo credit: PATH/Doune Porter.
Two years ago, Dr. Namala Mkopi, pediatrician and Shot@Life Global Immunization Fellow, celebrated Tanzania’s dual introduction of pneumonia and rotavirus vaccines with a blog here on DefeatDD. We were lucky to catch him in during a visit in DC just ahead of World Pneumonia Day 2015 to hear about the changes he’s seen first-hand since the nationwide vaccine introduction.
Before we focus on the past couple years in Tanzania, let’s go back a bit further. What first inspired you to go into the medical field?
I always said I wanted to treat kids before I even knew what it took! I never really liked biology, to be truthful – I liked math and physics – but at the end of the day that was the path I had to take to practice medicine and help children.
I’ve spent my whole education and medical career in Tanzania, and I find that in working with children for such a long time you find yourself driven to do so many things. Especially when you realize that no matter what you do for treatment, there’s only so much one person can do. You find yourself being an advocate and trying to train and mentor as many people as you can. Eventually, when you hear there is a vaccine that is effective – that is really something. There are many entry points to prevent pneumonia, but in my experience, one of the best and easiest to deal with is vaccination.
Your day-to-day experiences as a pediatrician in Tanzania certainly underscore the importance of pneumonia and diarrhea prevention. What is a typical day like in the clinic?
I work at the National Hospital in Dar es salaam, Tanzania. We have more specialized equipment because we are in an urban setting, and I deal with critically ill children who have been transferred from municipal hospitals because their cases are life-threatening. Everything moves so quickly, especially when several children arrive at once needing oxygen or a blood transfusion, and there are only two or three medical staff with varying degrees of experience. I need to make several major decisions at one time. I scan patients for prompt issues. Divide and deal. Children have died simply because they are waiting for blood or oxygen to be available.
I also mentor medical staff in districts and hard-to-reach areas so that they learn how to evaluate and assess children well. This is the place where there is opportunity to make a difference. If kids are getting interventions early, they have a better chance.
Because of poverty, parents delay bringing kids to the hospital. The health of one child is important, but they may have other kids, too. For many who cultivate farms, today’s meal will be determined by what they do on that particular day. If they go to the hospital, what will they eat? Where will they leave the other kids?
I can’t change the health statistics of my country, even if I see kids 24 hours a day. But if we give children vaccines, I can at least go sleep at home!
You blogged for DefeatDD after Tanzania’s dual introduction of pneumonia and rotavirus vaccines in 2013. What changes have you seen since then?
I was so excited that the advocacy efforts were paying off. Back then, we had some hope because of success stories we’d heard from other countries, but now we are living that hope. It is no longer a told story.
I used to see so much pneumonia that we had to swap oxygen cylinders from one child to another because there were not enough to go around. We do not struggle that way anymore. In the diarrhea ward, there are days when I see only one child, and my colleagues can’t believe it; they say, “Are you sure?!” Yes, there have been other health interventions that have made an impact, but why this big of a change within two years? It tells me that the pneumonia and rotavirus vaccines are doing what they’re supposed to be doing.
People need to hear these stories so we can implement this model in other countries.
I am amazed by Tanzania’s extraordinary vaccination coverage rates. How do you account for it?
The secret of Tanzania’s 90% plus vaccine coverage rate is in public-private partnerships and, from region to region, a solid cold chain infrastructure and health system. This means that parents, regardless of region or type of hospital, can access vaccines for their children.
The other thing that motivates parents is that they’ve seen the changes since they started vaccinating their children. They become local ambassadors because they’ve seen the changes with their own eyes. And now they are even becoming more curious, asking, “Is my child getting all the necessary vaccines?” Even the third dose of the pneumonia vaccine, where participation tends to drop off, still has a high coverage rate of over 90%, which speaks volumes about the commitment of parents.
The role of media – tools like radio – has been important as well.
At the briefing “The Fight Against Pneumonia: From Global Immunization Partnerships to Local Impact,” you mentioned that you want to help start a grassroots advocacy movement for vaccines in Tanzania. Why is this a priority for you?
I think of advocacy as operating on a macroscopic and microscopic level. I work on the macroscopic level: talking on the radio, teaching medical students.
But I am only one voice. Grassroots advocacy is like a wildfire spreading underground – by the time you see it, it has covered everything. Like looking through a microscope, just because an organism is tiny doesn’t mean it’s not there. Engaging youth in grassroots advocacy is important because parents might hear me on the radio and get bored and turn the station, but they will listen to their children. Our youth need to be equipped to become good ambassadors – and good future parents.
Youth also have leverage with policymakers. More than 60% of the people who voted in the last election were under 30 years old. Politicians care about votes, and if the youth are demanding something, they will have nowhere to run!Read more
I’m grateful to Chelsea Clinton for her admission that she is “obsessed with diarrhea,” and her total lack of embarrassment in bringing it up repeatedly. In an interview with Fast Company, it was the first thing she wanted to talk about.
I’m grateful to her because she is, as far as I know, the only well-known public figure to champion the prevention and treatment of diarrhea, the world’s second biggest killer of children under five years old, even though we have cheap and effective ways of dealing with it.
“It’s completely unacceptable that more than 750,000 children die every year because of severe dehydration due to diarrhea,” said Clinton last year. “I just think that’s unconscionable.”
We need more champions of the diarrhea issue.
Four years ago, I wrote a blog bemoaning the fact that oral rehydration therapy (ORT) seemed to be on life support, even though The Lancet once called it “the most important medical advance of the 20th century.” ORT and its practical application, oral rehydration solution (ORS), have long been found to be both effective and cost-effective in treating the dehydration caused by diarrhea.
Bangladesh is perhaps the best example of a country that has made stellar progress in fighting diarrhea through ORS. The treatment of diarrhea increased from 58% in 1993 to 81% in 2011. Productive collaborations between the government, the private sector and organizations like the Social Marketing Company, which used social marketing revenues to build Bangladesh’s first ORS factory in 2004, have led to tremendous improvements in diarrheal disease management.
Starting in the 1970s, ORS has saved an estimated 50 million lives, costing less than $0.30 per sachet, according to the WHO. In 1978, the World Health Organization (WHO) established the Control of Diarrheal Diseases Program, and by the early 1980s, most developing countries had their own dedicated national programs.
But even though ORS was cheap and effective, the global health community moved on to other diseases, like AIDS and malaria. In the 1990s, these diarrheal disease programs were merged into broader child health programming, and lost their dedicated funding, staff, and systems. A 2008 analysis that looked at changes in ORS use in children under three found declines in 23 countries and increases in only 11.
A 2009 research study conducted by PATH, a leading NGO working to fight diarrhea, to evaluate the funding and policy landscape found that “diarrheal disease ranked last among a list of other global health issues.”
After years of neglect, diarrhea is back on the global health map. Diarrhea deaths among children under five are down from 700,000 per year in 2011 to around 531,000 in 2015, according to PATH, a drop of 24% in four years. The bad news is that ORS use has stagnated, says PATH, at around 35% over the last 10-15 years.
Why has diarrhea death dropped even though ORS has stagnated?
“It’s been because of increasing access to a set of protection, prevention and treatment interventions,” said Ashley Latimer, senior policy and advocacy officer at PATH. “More children are being vaccinated against rotavirus (a leading cause of diarrhea). Understanding the importance of hand-washing and clean drinking water is improving. Improved nutrition and exclusive breastfeeding probably plays a small role.”
In 2013, the WHO and UNICEF published “Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025,” the first-ever global plan to tackle the two diseases that take the lives of 2 million children every year, which was supported by more than 100 nongovernmental organizations.
There are several efforts underway to fight diarrhea more effectively.
For example, PATH is working to improve the formulation of ORS to make its benefits more apparent to caregivers.
“Reimagining global health” recently highlighted “30 high-impact innovations to save lives.” One of them (see Page 17) included several new treatments to reduce the burden of severe diarrhea, such as DiaResQ, which supplements the use of ORS and provides nutrients for intestinal repair.
An already established innovation is to create “comprehensive diarrhea treatment” by combining zinc with ORS. Zinc is a vital micronutrient that helps the body absorb water and electrolytes, reduces the duration and severity of diarrhea and prevents subsequent infections in the two to three months following treatment. Diarrhea mortality is reduced by 23% when zinc is administered with ORS. Unfortunately, use of zinc is even worse than ORS – only 5% as compared to 35% for ORS.
Diarrheal disease research and development funding is increasing modestly. In 2013, it was $200 million, up from $170 million in 2012. As in previous years, the top three funders accounted for almost three-quarters of total funding – the Bill & Melinda Gates Foundation (25% of funding), the U.S. National Institutes of Health (23%) and industry (22%).
“With the introduction of rotavirus vaccines and advances in WASH interventions, these are exciting times,” said Deborah Kidd, senior communications officer at PATH. “However, what is often overlooked is the burden of diarrhea morbidity among children in the developing world. Chronic, repeated infections, resulting malnutrition and stunted development, and the persistent economic burden on the family all contribute to a destructive cycle that keeps families in poverty. So it’s great news that deaths are declining, but that the problem of childhood diarrhea and its long-term consequences are far from solved.”
UNICEF reports that improvements in drinking water, sanitation and hygiene are reducing diarrheal disease (90% of the world’s population use improved drinking water sources and two-thirds use improve sanitation facilities).
However, the decline in diarrhea deaths should be no cause for complacency: UNICEF also reports that when children do fall ill with diarrhea, only two in five children receive appropriate treatment, including ORS.
Unlike many diseases, for which no cure exists, the cure for diarrhea has been around for decades and is cheap and available. We just have to find the financial, technical and social means to get it to people who need it, and help them use it to protect the health of their families.
This infographic shows the status of the war against pneumonia and diarrhea in the world’s poorest children.
Photo credit: PATH/Tony Karumba.Read more