SANITATION, an important component of WASH actions.

Sanitation services are scarce in developing countries where 37% of the world's populations live without improved sanitation (UN/WHO, 2012). According to Bartram, approximately, 2.4 million deaths could be prevented annually if people practiced good hygiene and had reliable sanitation and drinking water (Bartram, 2010).

Due to the fact that 1.1 billion people around the world practice open defecation, the United Nations General Assembly has designated 19 November as World Toilet Day to highlight the urgency of the importance of improving sanitation in developing countries.  Most of these people live in rural areas and they do not have a private place to defecate and urinate; therefore, they use fields, ditches or just plastic bags for their fecal or urine needs.

Behavior change activities are necessary to increase sanitation effectiveness in developing countries. Unfortunately, behaviors are difficult to modify since they are automatic actions which do not require much thought to perform. There are communities which are slow or show resistance to change because, for example, they have lived without latrines for 30 years and they are still alive.

Thus, before applying water, sanitation and hygiene actions, it is necessary to learn about the main patterns of each community to define realistic expectations about the possibility of change,  the problems to address and the speed of the behavior change process.

Lack of sanitation leads to intestinal helminths infections which cause late entry to school, low school attendance and impaired cognitive function (Bartram, 2012). If the above mentioned effects are considered in the labor market, the economic costs would double to 9% of the gross domestic product (GDP) (Van Minh, 2011).  Also, the absence of sanitation involves extra time spent on seeking somewhere to defecate.   WHO estimated in a study that the time lost could be valued at US$63 billion annually (Bartram, 2012).

MAIN FACTS (World Toilet Advocacy Report):

• 1 in 3 women worldwide risk shame, disease harassment and even attack because they have nowhere safe to go to the toilet.
• 526 million women have no choice but to go to the toilet out in the open.
• Sanitation would make 1.25 billion women’s lives safer and healthier.
• Women and girls living without any toilets spend 97 billion hours each year finding a place to go.
• Every day, around 2000 mothers lose a child due to diarrhea caused by a lack of access to safe toilets and clean water.

SAFE DRINKING WATER

Water and sanitation services are scarce in developing countries where 11% of people do not have access to improved drinking water (UN/WHO, 2012). According to Bartram, approximately, 2.4 million deaths could be prevented annually if people practiced good hygiene and had reliable sanitation and drinking water (Bartram, 2010). 

In this blog, I would like to discuss a second WASH intervention: Biosand filters.

Biosand filters are a type of technology that households have used to remove pathogens from drinking and cooking water for over 200 years. This technique permits improvements in water quality with a reduced cost and low environmental impact and therefore, produces a high reduction of diarrheal diseases.

Source: CAWST - The Centre for Affordable Water and Sanitation Technology (www.cawst.org)

This intervention consists simply of pouring water into a biosand filter (layers of specially selected prepared sand and gravel) of about 1m tall, 0.3m wide on each side that is allocated in a container made of concrete or plastic.  The sand helps to remove pathogens and suspended solids from contaminated drinking water through a biological community of bacteria and other micro-organisms called a biolayer that eats many of the pathogens in the water.

CAWST - The Centre for Affordable Water and Sanitation Technology (www.cawst.org)

In order to measure the efficiency of this intervention in removing pathogens, turbidity and iron, the following table summarizes the effects:

	Bacteria	Viruses	Protozoa	Turbidity	Iron
Laboratory	Up to 96.5% (BUZUNIS 1995; Baumgartner 2006)	70 to >99% (Stauber et al. 2006)	>99.9% (Palmateer et al.1997)	95% (BUZUNIS 1995);	Not available
Field	87.9 to98.5% (Earwaker 2006; Duke & Baker 2005)	Not available	Not available	85% (Duke & Baker 2005)	90-95% (NGAI et al. 2004)

Health impact studies estimate a 30 to 47% reduction in diarrhoea among all age groups, including children under the age of five, an     especially vulnerable population group. 

Source: SOBSEY (2007); STAUBER et al. (2007)

As you can observe, there are many benefits of using biosand filters mainly in developing countries. The total cost of biosand filter interventions consist of the purchase of filters (sometimes subsidized in part by the local or national authorities) and training activities on the maintenance of filters (Whittington, 2012, p.1158).  According to the study Impact of BiosandFilter on Access to Safe Drinking Water in the Rural Communities of thePhilippines, the annual total economic benefit of households who use biosand filters was US$814.92 with a benefit-cost ratio at 12.48.

How can we spread these benefits to those countries that are still not using this intervention?

The importance of HANDWASHING

During one of my last classes of ECON 309, we discussed health policies in developing countries and it was interesting to see that communicable diseases are #1 cause  of death in these countries. 

Many of these diseases can be prevented using inexpensive actions such as handwashing. Handwashing is an intervention consisting of a frequent cleansing of hands with soap and water in order to reduce fecal-oral transmission through hand contact.  This intervention helps to reduce the risk of diarrhea or other parasitic diseases. Many studies have been carried out to analyze the effects of hand-washing on neglected infectious diseases in developing countries concluding that this intervention can reduce 32% of diarrhea cases in these countries.

However, the paper “Setting priorities,targeting subsidies among water, sanitation, and preventive healthinterventions in developing countries” summarizes results from 10 studies on hand-washing, concluding that hygiene education should be accompanied with this action to guarantee the most effective results. There is evidence that free distribution of soap to households, for example, does not guarantee high levels of usage if this intervention does not come with health education to emphasize its value.

A project developed in Peru, called “Global Scaling Up Handwashing”, which consisted of mass media and community level interventions to disseminate hand-washing actions in 800 randomly selected districts, demonstrated that mass media was not effective; however, community interventions were more effective in reaching the targeted population through promotional hand-washing  messages.

Notwithstanding the potential benefits from hand-washing, according to the World Bank, only 3% to 34% of people wash their hands routinely in developing countries. Therefore, there is a need to continuing advocacy on handwashing actions.

The Global Handwashing Day was celebrated on October 15^th to promote the importance of handwashing worldwide and it was interesting to observe the correct way to wash hands: Do you know how?

Below you can see the appropriate way to do it:

 Resource: World Health Organization. http://www.who.int/gpsc/clean_hands_protection/en/

Why WASH?

I have been working in an international public health organization for 4 years and I have just started supporting the Neglected Infectious Diseases Program for a year. I am not a doctor, a nurse or an epidemiologist. I have a degree in Business Administration and Accounting from Peru and now I am working towards a degree in Economics. During the last year, I have learnt many things about the technical part of neglected infectious diseases, such as prevalence, mass drug administration, sentinel surveys, protocols, etc. However, my program is moving towards a new approach at the request from countries that we are working with: WASH which stands for Water, Sanitation and Hygiene.

I have found this approach very interesting because not only is it related to health but it is also related to other sectors, such as education, sanitation, water among others. Nevertheless, before explaining the results from my research about WASH's actions, I want to define the concept of Neglected Infections Diseases (NID, also called NTD, neglected tropical diseases). NID are diseases that affect the poorest populations characterized by lack of access to health services and basic sanitation; in addition, these people live in remote rural areas or urban slums.

Many interventions have been done to reduce the burden of these diseases as well as their negative impact on the economic and social well-being of the populations at risk. One of these interventions is mass drug administration, a health intervention that reduces the prevalence of these diseases through the supply of drugs to people having NID diseases or being at risk of getting them. Nonetheless, this intervention does not have long term effects if it is not accompanied by water, sanitation and hygiene actions (WASH).

Children Without Worms (CWW) is an organization that makes advocacy to link NID with WASH actions and they explain very well the benefits of these interventions in its article:  Promoting Collaboration between WASH and NTD Control Sectors.

The main WASH interventions are: a) Promotion of hand-washing and improved hygiene; b) Sanitation campaigns; c) Biosand filters; and d) Point of use of chlorination of drinking water. The following graphic gives an idea of the impact of WASH controlling STH (soil-transmitted helminths) whose is a parasitic disease.

Working for Controlling STH. Resource: PAHO (Pan American Health Organization)

In my next blog, I will explain with more detail each intervention and its impact on the economic burden reduction of neglected infectious diseases. Up till now, I can only add that these actions are inexpensive but their impact is huge!