Category Archives: WASH

Eight Million Toilets and Counting

By Alice Carter

world toilet day 2015Normally, we don’t like to talk about bathrooms. That is a private space that most of us would largely like to avoid thinking about. But on World Toilet Day, we give thanks for our sanitary facilities and celebrate the invention of the toilet, which has saved countless lives as a disease control mechanism, and gives us privacy to, you know, go.

There is a Sesame Street song, a global “urgent run,” and an art show in New York. All of these types of events are celebrations for the often overlooked efficiency of the mundane technology that is a toilet, but also are opportunities to spread awareness of just how precious our access to toilets really is. One in three people around the globe don’t have access to adequate sanitary infrastructure, leaving them at increased risk for neglected tropical diseases (NTDs) that are spread through contact with fecally-contaminated soil. Half of the people who practice open defecation globally live in India, where 1.1 million liters of human excrement enter the Ganges River every minute. Recognizing the toll that open defecation takes on health, education and economic output, the government of India is trying to increase access to sanitation infrastructure and put an end to open defecation.

Prime Minister Modi has pledged that India will be open defecation free by 2019, and under his leadership the government has set up incentives for toilet construction and usage. Swachh Bharat Abhiyan — the Clean India Mission — is a sanitation campaign run by the Indian government, with the joint objectives of reducing open defecation and changing behavior to increase the use of sanitary facilities. Prime Minister Modi launched Swachh Bharat on Mahatma Gandhi’s birthday in 2014. The government also plans to raise Rs 3,800 crore (approximately 550 million USD) from the public to support this initiative, which gives subsidies for toilet construction and helps villages become certified as open defecation free. As of August 2015, 8 million toilets have been constructed as part of the campaign.

Unfortunately, it is tricky to measure the prevalence of open defecation and people’s toilet usage. Simply constructing a toilet in every home and school won’t make people start exclusively using toilets, especially if they don’t know the benefits of sanitation infrastructure and the risks of open defecation. For this, public awareness campaigns are also needed, and people need to be given plenty of reasons to use the toilet exclusively. One motivating factor for people to switch from open defecation to toilet use is awareness of the health risks of open defecation.

In communities that continue to practice open defecation, children playing outside or walking to school with no shoes can be exposed to contaminated soil, putting them at risk for infection by soil-transmitted helminths (STH). Similarly, clean drinking water sources and uncooked fruits and vegetables can be contaminated, increasing the risk of infection.

On the other hand, access to a household latrine has been found to reduce the risk of infection with STH by 40%. Nadia, a district in West Bengal, India, was the first district to be certified as open defecation free, and has since noted a decreased incidence of diarrhea and malnutrition. Reduced NTD infection is a strong indicator of the success of the Swachh Bharat campaign. Including an NTD indicator in Swachh Bharat would give the mission concrete targets to measure exclusive toilet use in communities where the campaign has built toilets, and it would help spread awareness of the negative health impacts of open defecation.

Perhaps on Gandhi’s 150th birthday, in 2019, India will have achieved its goal of ending open defecation. He would be proud, as he often stressed that a society’s approach to private and public sanitation reflects its commitment to true freedom and dignity.


Untouched: How 284 Liberian Communities Remained Ebola-Free

By Piet deVries, Senior WASH Advisor, Global Communities


A community hand washing station in Liberia. Credit: Global Communities

Everything changed with Ebola.

For four years, Global Communities had been busy creating access to safe sanitation for communities in Liberia, helping to fight the spread of disease and improve health outcomes. Utilizing Community-Led Total Sanitation, we were making consistent progress, beginning work through the USAID-funded Improved Water, Sanitation and Hygiene (IWASH) program in 2010 in the three Liberian counties of Nimba, Lofa and Bong. Our program gained the support of the national government, and we worked with them to develop their sanitation strategy to improve the health of rural communities across the country. By early 2014, we had helped 284 communities become “open defecation-free” and were working with more communities.

Suddenly we and our partners in the Liberian County Health Teams and the Ministry of Health found ourselves at the center of a maelstrom. To combat Ebola, we scaled up our community engagement work, training community leaders who were already working to prevent open-defecation in how to provide information about Ebola prevention. As the epidemic swelled, our community engagement approach shifted again, focusing on acceptance of vital services like dead body management, and eventually, health screenings. In just a few months, our work scaled up from three to all 15 Liberian counties.

It was during this time that we received reports of an astonishing statistic. All 284 open defecation-free communities were reporting that they were also Ebola-free — despite being located in some of the regions hardest hit by the virus.

Was there a link between being open defecation-free and Ebola-free? Or between our program’s process and Ebola resistance?

Earlier this year, we employed two independent public health consultants to conduct research into the informal reports we had received. They came back with extraordinary findings. Focusing their research on 551 households in Lofa County, they established with a representative sample that the communities that had reached open defecation-free status were indeed Ebola-free.

They also found that communities that had only started the Community-Led Total Sanitation process — but not reached full open defecation-free status — were 17 times less likely to experience a single case of Ebola. This suggests a statistically significant correlation between our work to become open defecation-free and being Ebola-free.

Still, it would be wrong to assume that these findings mean that simply becoming open defecation-free stops Ebola. Rather, they suggest that people who had been exposed to the program’s education were far more likely to develop healthier behaviors and practices that lead to Ebola resistance — especially when led by a member of their own community.

Perhaps most encouraging, these behavior changes don’t just defend against Ebola. By utilizing CLTS, individuals can help prevent a variety of water, insect-borne and diarrheal diseases, including many neglected tropical diseases. In addition, such methods are inexpensive; in Liberia, incentives of only $130 per community can result in far better sanitation practices. Make household latrines, hand washing facilities, garbage pits and dish racks available, and you have a safe, hygienic and resilient community.

Disease spreads at the community level, and only by engaging with the community to create sustainable change can we hope to control and eliminate many of the diseases that are so prevalent in the developing world. CLTS does just that, and any focus on water and sanitation must recognize the importance of empowering communities to make wise decisions to help improve their health.

Eliminating Diseases by Investing in WASH



This blog was originally posted in Huffington Post as part of the “WASH and the MDGs: The Ripple Effect” blog series, in partnership with WASH Advocates.

At the turn of the century, world leaders came together at the United Nations in New York to develop the Millennium Development Goals (MDGs), a set of eight ambitious goals and targets meant to significantly reduce poverty by the year 2015. As the window to achieve these goals closes this year, we reflect on progresses made and look ahead to the sustainable development goals (SDGs) that will shape the development agenda for the next 15 years.

A number of MDG targets have already been met, including efforts to reduce cases of HIV/AIDS, malaria and other diseases (MDG 6) and improving access to safe drinking water (MDG 7). Moving forward, addressing neglected tropical diseases (NTDs) will be a critical component when working toward meeting both of these goals. NTDs are bacterial, parasitic and viral infections that affect the most marginalized communities across the world and are often the result of inadequate water supply, limited access to sanitation facilities and poor hygiene. Areas with stagnant water are breeding grounds for insects that carry NTDs, notably mosquitoes which transmit malaria, but also dengue fever, lymphatic filariasis and chikungunya. By promoting integrated vector management and improved water control measures in endemic countries, we can simultaneously work to combat HIV/AIDS and malaria, while also working to control and eliminate NTDs.

Since 2000, there has been significant advancement in the fight against HIV/AIDS, particularly by increasing access to life-saving antiretroviral therapy (ART) for people living with HIV. The United Nations estimates that ART has saved 6.6 million lives since 1995. As with malaria, there are additional opportunities for integration that not only have the potential to reduce rates of HIV infection but also significantly improve water, sanitation and hygiene (WASH) conditions. For example, in many developing countries, women remain disproportionately vulnerable to HIV infection due to greater social safety issues, such as lacking access to safe and accessible latrines. By not having access to a safe lavatory, women are forced to use public spaces to openly defecate and manage their menstrual needs, making them increasingly susceptible to infections as well as sexual violence. Globally, more than two billion people lack access to a proper toilet. Many common, poor hygiene practices, such as open defecation and failure to wash one’s hands, promote the spread of disease. These factors combined perpetuate the cycle of NTD infections and other serious infections.

The proposed SDGs currently consist of 17 goals with 169 targets that aim to end poverty and hunger, improve health and education, make cities more sustainable, combat climate change, and protect oceans and forests. Goal 3 encompasses a number of health-related objectives and targets, including ending the epidemics of AIDS, tuberculosis, malaria, NTDs and water-borne diseases by 2030. Meeting these targets will go hand-in-hand with Goal 6 — achieving access to adequate and equitable sanitation and hygiene for all, ending open defecation, and paying special attention to the needs of women and girls and those in vulnerable situations.

There are many ways that enhancing WASH conditions unswervingly leads to NTD control and elimination. For example, by improving access and quality of water, sanitation and hygiene, we can significantly reduce the number of people suffering from trachoma, an infectious eye disease and leading cause of preventable blindness, which results from limited access to clean water and proper sanitation. By simply providing access to clean water, we can reduce the number of trachoma cases by 27 percent. Similarly, having better sanitation in place can decrease cases of schistosomiasis, a parasitic disease carried by fresh water snails infected with parasites. Women are especially vulnerable, given that cases of female genital schistosomiasis (FGS) result in three times greater chances of contracting HIV. It is estimated that at least 16 million women may be infected with FGS in Africa.

It is evident that WASH interventions have a multiplier effect and positively impact other health issues and development goals. As the window to achieve the MDGs comes to a close this year and we grow closer to confirming the goals and targets that will shape the next 15 years, we must emphasize the important synergies between WASH and the control and elimination of NTDs.

This blog post is part of the “WASH and the MDGs: The Ripple Effect” blog series, in partnership with WASH Advocates, addressing the importance of water, sanitation and hygiene (WASH) to global development. To see all the other posts in the series, click here. To learn more about WASH, visit the WASH Advocates website, and for more information about the Millennium Development Goals, click here.

Water is Crucial to Ending Blinding Trachoma


Photo from International Trachoma Initiative

Photo from International Trachoma Initiative

By Elizabeth Kurylo
Communications manager, International Trachoma Initiative

Every morning and every night, I turn on the hot and cold water taps, adjusting them so the temperature is just warm enough to wash my face. I take for granted that the water will flow. I would be shocked if it didn’t. This easy access to water is a luxury not enjoyed by hundreds of millions of people around the world.

As we mark World Water Day, it is worth noting that 748 million people do not have access to an improved source of drinking water and 2.5 billion do not use an improved sanitation facility. For them, the lack of water can mean poor health, disability and even death.

Water and sanitation is especially important in the prevention and control of trachoma and other neglected tropical diseases (NTDs). Trachoma is an ancient eye disease caused by a bacterial infection. Left untreated, it can lead to blindness. But we can stop it with the World Health Organization-endorsed SAFE strategy – Surgery, Antibiotics, Facial cleanliness and Environmental improvement.

Water is crucial to facial cleanliness, and key to ending blinding trachoma.  But in many places where trachoma is endemic, water is scarce, and rationed for uses other than hygiene, such as cooking. Face washing is not a priority.

The global trachoma community has made much progress since 1998, when Pfizer began donating the antibiotic Zithromax®, which treats and prevents trachoma. More than 444 million doses of Zithromax® have been shipped to trachoma endemic countries to date. And seven countries have reported reaching their elimination goals.

Under the leadership of WHO and the Alliance for the Global Elimination of Blinding Trachoma by the year 2020 (GET 2020), national trachoma programs have steadily scaled up implementation. In 2014, WHO’s Weekly Epidemiological Report (WER) said trichiasis surgeries and antibiotic distribution were tenfold higher in 2013 compared to 2004.

The International Coalition for Trachoma Control (ICTC) has galvanized the global trachoma community’s commitment to reaching elimination by 2020.  Collaboration on game-changing initiatives with governments, health officials and trachoma endemic communities has led to the mobilization of more than 150 million dollars of new funding from DFID, USAID and the Queen Elizabeth Diamond Jubilee Trust.  That is in addition to the national government domestic budget allocations and support already provided by many non-governmental development organizations as well as other donors such as the Lions Clubs International Foundation, Conrad N Hilton Foundation and the Bill & Melinda Gates Foundation.  The WASH sector also is collaborating with the NTD sector to achieve shared goals of improving health and eliminating disease.

Still, there is much work to do. An estimated 232 million people in 51 countries live in trachoma endemic areas. Globally, 31 countries are implementing the SAFE strategy to eliminate trachoma, which signifies that 20 countries are still in need of help.

In 2015, ITI plans to ship 115 million doses of Zithromax®, donated by Pfizer. That is more than twice the amount approved for shipment in 2014.  “We are doing everything we can to accelerate access to Zithromax® needed by people who are at risk of blindness from trachoma,” said Dr. Paul Emerson, Director of ITI. “We are empowering national programs so that those at risk of going blind from trachoma can be treated.”

Empowering people in trachoma endemic communities to prioritize water for hygiene also has lasting benefits. I saw this in Ethiopia, where I met Amarech Haluka, the mother of three young girls, one of whom had experienced the pain of trachoma. Health workers introduced the SAFE strategy to Amarech’s community, which received donated Zithromax® and education about the importance of using latrines and keeping their faces clean to avoid trachoma. Amarech and her husband got a loan to install a water pump in their back yard, and she now routinely washes her children’s faces twice a day. Even though she cannot adjust the temperature of the water that flows from her pump, her children’s faces are clean, and her family is free of trachoma.