The New York Times, October 2015
"What if there were a remedy that could save more children...
Jordan hanging out with her newest source of inspiration for her work in WASH: her third niece.
Over the last few years with my four nieces and nephews, I have become intimately familiar with breastfeeding, poopy diapers, introductions to solid foods, potty training, and the process of cognitive development in young children, among many other things. All along, we’ve had running water that was safe to drink, toilets to flush, a place to dispose of diapers, and a sink with soap to wash our hands. During each of their first 1,000 days I have hardly worried that they might have too many bouts with diarrhea or other illnesses that would cause them to suffer from undernutrition. The same cannot be said for many other aunties, mothers, and families around the world. In places where WASH conditions are poor, even if there is enough food to eat, children can suffer from undernutrition due to frequent diarrhea or a condition called environmental enteropathy.
Recognition of this relationship has been gaining momentum in the WASH and nutrition sectors over the last few years. In the Lancet series on nutrition in 2013, WASH was named a nutrition-sensitive intervention. A core component of the Scaling Up Nutrition Movement’s Framework for Action is a multi-sector approach to integrating nutrition, including WASH. USAID released its Multi-Sectoral Nutrition Strategy in 2014, which includes WASH as a high-impact action for improving nutrition and has “committed to making its nutrition initiatives more effective” by integrating WASH components as essential in all its nutrition programs.
Enthralled by the impact that nutrition in the first 1,000 days has on the rest of a child’s life and even more fascinated by the effect that WASH has on nutrition, I set out in 2013 to research how WASH and nutrition were being integrated, what was working, and why. Very quickly, my research turned into why weren’t WASH and nutrition being widely integrated and what needs to be done to make that happen. I interviewed key stakeholders in both the WASH and nutrition sectors on the barriers these organizations encountered when attempting to integrate these two sectors and what solutions there might be to these challenges.
Stakeholders identified 11 common barriers to integration. The top five were:
- Insufficient or siloed funding
- Staff capacity and/or interest
- Lack of knowledge of different sectors and programs
- Lack of coordination between sectors
- Lack of evidence of the collective impact of integration
“It takes a new way of thinking about programming”
Fourteen action items or next steps were identified as enablers for effective integration, and the five most commonly mentioned were:
- A comprehensive strategy for integrated programs
- Coordination and communication between sectors
- Integrated funding and donor support for these efforts
- Increased evidence of the collective impact of integration
- Leadership to drive these efforts forward
These findings result in a few concrete next steps for the WASH and nutrition sectors. Operational research is needed in order to generate the evidence base of the additive or multiplicative effects of integrated programs and to formulate a standard methodology for integration. Donors need to supply flexible funding that can be used for innovation and to integrate programs in appropriate contexts. The WASH and nutrition sectors should improve knowledge sharing and increase cross-training of staff. Finally, we need to design incentives in these programs for staff to work in collaboration toward common goals and objectives. A lot of smart people are thinking about and doing these things, and I look forward to seeing where WASH and nutrition integration goes from here!
To learn more, visit the following links:
- The 1,000 Days partnership
- WASH Advocates’ fact sheet and resource guide on nutrition
-- Jordan Teague is the Program Associate at WASH Advocates and the proud auntie of one handsome nephew and three beautiful nieces.Read more
Sanitation is a serious challenge for India. Even though it has had sanitation programmes since the 1950s, more than half the population continues to defecate in the open because toilets are poorly made, because they do not have a toilet, or because of ‘cultural’ reasons. A third or more newly constructed toilets lie unused, as people do not understand why they should use them.
Research suggests India has the highest rates of morbidity and mortality at all ages from water-borne diseases caused by faecal pathogens and high rates of malnutrition. The absence of toilets at home forces women to ‘hold on’ the whole day making them susceptible to urinary tract infections. When they go to defecate in the open, they are vulnerable to harassment or assault.
Last year, Prime Minister Narendra Modi launched his high profile ‘Swachh Bharat’ (Clean India) campaign to eliminate open defecation by 2019. This clearly shows the eagerness of the government to deal with the crisis, but the problem at hand is too big to be dealt with just good intent. Early indications are the programme is going the way of earlier ones with single-minded emphasis on hardware.
As per the 2014 Millennium Development Goals Report, 66% of rural India still defecates in the open. Research by RICE Institute has suggested that most rural Indians can afford a toilet but don’t want one because they are comfortable with the idea of defecating in the open. Thus, the new Prime Minister will only meet his goal if he can create a social movement that changes people's attitudes, and builds demand for toilet use by making people aware of the health and environmental risks attached to open defecation.
The positives attached with the ‘Swachh Bharat’ campaign is that it ensures funds and support from the government, but realising the fundamental need to change people’s attitudes about sanitation and channeling the funds into the right direction will be its true test. Thus, the government should learn from past failures, and recognise that policies to address open defecation should be tailored to Indians' attitudes towards sanitation.
Sanitation policy needs a radical restructuring in India. What India needs is a concerted effort to change the attitudes and behaviours of its citizens to get them out of the fields and into toilets!
WaterAid believes this is an unprecedented opportunity not only to really raise the issue of sanitation and the safe disposal of human waste, but also for all those involved in the campaign to ensure that we work together and learn from our previous experiences, successes, and failures.
With decades of experience in India and around the world in managing and scaling up programmes, providing technical assistance, and testing new solutions, WaterAid looks forward to supporting the government in its ambitious agenda to solve the sanitation crisis in India.
To achieve this, WaterAid, along with the Ministry of Drinking Water & Sanitation and the Ministry of Urban Development, are organising a three-day ‘India WASH Summit’ from 16-18 February 2015 in New Delhi. The first event of its kind, it will bring together the government, private sector, and the civil society working to make clean India a reality by 2019. Participants at the Summit will discuss and deliberate on the sanitation crisis facing India and ways to solve it through the Swachh Bharat Mission and beyond.
More information regarding the Summit can be accessed at: www.indiawashsummit.org.
-- Nitya Jacob is the Head of Policy with WaterAid in IndiaRead more
A full circle moment: My son receives his rotavirus vaccine.
With the measles outbreak dominating the US vaccine-related news (and jeopardizing a trip my two-month old baby and I planned to take to visit family in southern California), I wanted to share some positive news.
Last week, I joined mothers (and fathers) around the world and took my baby boy to receive his first series of childhood vaccines, including the vaccine against rotavirus. As a person working on vaccine-related policy issues, I awoke with a number of emotions and thoughts running through my head:
Admiration – for the mothers who walk miles and wait hours to receive the same vaccines for which my husband and I carried our baby four city blocks and waited ten minutes; for the science that made it possible to prevent these diseases; and for the complex systems that bring the vaccines safely from their point of manufacture to their place of delivery (a much more complex challenge than one might realize).
Disbelief – How is it that far too many American parents could make the choice (and have the choice!) not to vaccinate their children, and in turn, leave mine and many others young and immunocompromised children unprotected from diseases that had almost been erased from the US? What so many families in developing countries would give to have the privilege of easy access to these lifesaving tools, yet these parents refuse without scientific basis!
Pride – to live in a country whose scientists, including those at PATH, helped develop and manufacture many of these vaccines with the support of the US Government. These decision makers and citizens have prioritized making vaccines affordable and accessible to people living in low-resource settings around the world through financial contributions to organizations such as Gavi, the Vaccine Alliance, and through the programs of federal agencies, including the US Agency for International Development (USAID) and the Centers for Disease Control (CDC). Americans know that protecting the world against vaccine-preventable illness protects Americans at home and abroad, and is the right thing to do.
I am grateful that my son joined the millions of children who will be vaccinated this year. I am glad that the unfortunate news of the vaccine refusers has stimulated discussion about the value of vaccines among American families, and hope that we can all learn from this tragic outbreak the importance of immunizing ourselves and continuing to make existing and to-be-developed vaccines available to families around the world. While it was hard to watch the jabs go into my son’s tiny little thighs, when I swaddled him in my arms I felt content.
For more information:
-- PHOTOS: Rotavirus vaccines make their steady march across the African continent.
-- Visit PATH's Vaccine Resource Library for scientific documents and specific diseases and topics in immunization addressed by PATH's work.Read more
For most people, the new year means a bit of champagne, a reason to celebrate, and resolutions about personal changes. For Bill and Melinda Gates, the new year brings their annual letter and thoughts about global issues, world progress, and changes for billions of people. And this new year included a bet: in their annual letter, the Gates’ bet that “the lives of people in poor countries will improve faster in the next 15 years than at any other time in history. And their lives will improve more than anyone else’s.” Gutsy? You bet.
Their ambitious goal is comprised of four pillars, one of which is cutting the number of children who die before age 5 in half… again. Twenty five years ago, one in ten children failed to reach their fifth birthday. Increased access to vaccines and to commodities like oral rehydration salts, zinc, and antibiotics children cut that rate in half: today, in 2015, about one in 20 children die before their fifth birthday. And here’s where the gutsy prediction starts: the Gates’ are betting that by 2030 – just the next 15 years – that rate will be cut in half again, to one in forty.
Now most people probably ask the simple question – how? The initial halving of the mortality rates took 25 years. How can we make the same progress in just 15? While I won’t claim the answer is simple or easy, I will claim that we have the solutions. Access to vaccines continues to improve with more countries introducing vaccines against rotavirus and pneumococcal to prevent two of the leading infectious killers of children. Oral rehydration salts, zinc, amoxicillin, and litany of other treatment interventions continue to make their way to health clinics, pharmacists, and when appropriate, to community health workers. Importantly, improved sanitation is becoming more accessible to even the most poor and rural communities.
And we can’t forget newborns. The vast majority of improvements in child health will come from reducing newborn deaths. Improved access to newborn commodities, including resuscitation devices and injectable antibiotics, as well as practices such as breastfeeding will continue to drive down the number of children who die within the first 28 days of life.
But here’s the caveat: in order to accomplish the remarkable milestone set forth by the Gates’, we have to reach the last mile. We – government leaders, donors, the collective global health community – have to reach the most rural and remote. We have to make sure the most far-flung health clinic has health commodities available and a trained health provider on staff. We have the solutions, but we have to make them work. To me, this is our true test.
I’ve often hoped that we’re all working ourselves out of a job, collectively doing our individual parts to improve the lives of children. And now, more than ever, I see that materializing. Perhaps we won’t all be out of jobs in 2030, but if the Gates’ bet is right – and something tells me they don’t gamble frivolously – we will all begin to see a world where children are thriving. We certainly have our work cut out for us, but I, for one, can’t wait until we hit this jackpot.Read more
Photo credit: Marco Betti, WaterAid.
See more photos from DefeatDD's 2015 toilet calendar: "Oh, the places we go: Public health's humble hero"
Now that India has the political commitment at the highest level to strive towards an open defecation-free nation, the buzz around sanitation is infectious. Despite the daunting figures – getting 630 million people into ‘aspirational and wonderful toilets every day, preferably without subsidy’ – this could truly be a historic movement in India’s sanitation history.
Significantly, in the plethora of information about building toilets, voices calling for certain types of toilets are also pretty strong. The founder of the World Toilet Organization, Jack Sim, set the tone of the World Toilet Summit held in Delhi in January 2015, advocating that toilets be made the happiest room in any household. More importantly, he advocated the removal of subsidies to encourage communities to aspire for toilets and let that drive is demand. ‘Make toilets a status and fashion statement. Change the toilet experience from a disgusting one to a wonderful one!’
For India, that will be the challenge. There has never been a dearth of funds. The toilets have been built, just not used. Therefore, with the highest level of political commitment and funds pouring in both from Governments and the private sector, the hurdle is how to get people to change a habit. How can India replicate Bangladesh’s progress, which changed attitudes to bring down its open defection from 34 percent to three percent?
It cannot be overemphasized that the enthusiasm of ‘building toilets before temples’ will need rigorous implementation to reach an extremely ambitious goal of 111 million toilets before 2019 – to honor Mahatma Gandhi on his 150th birth anniversary.
At the Summit where businesses, institutions, CSOs and individuals put their might behind one of the most important Millennium Development Goals (MDGs), what was truly inspiring were the endeavors of tweaking already existing systems to leverage water and sanitation initiatives, like building toilets and motivating people to make it a habit to use and maintain them. Where there are more women teachers, building clean, safe toilets on school campus – simple decisions that have been taken by visionary district collectors. That could begin to help check the 23% of girls in India who drop out of school due to lack of clean toilets and begin to bring down the number of schools that do not have functional toilets – currently 400,000.
Almost all the speakers insisted on the need for a new mindset to help communities understand that the cost of treating associated diseases was much higher than building toilets. There is also an urgent need for communities to calculate the economic cost of poor sanitation – a price that the nation as a whole pays.
In scattered and seemingly disconnected bits, India has moved in this direction. Jack Sim wryly recalls not using the Delhi airport toilet years ago, and compliments the toilets in the new terminal. Earlier, no Indian politician would be photographed for a sanitation drive; today it is a done gimmick. Jack Sim’s call to Indians to greet each other by calling out ‘Are you happy?’ to indicate that you have used a clean toilet makes complete sense. What could be better than a healthier and open defecation-free India? After all, the MDG 7C is unlikely to be achieved without India moving ahead.