Developing world: More handwashing would reduce diarrhea-related deaths, doctor says

NEW DELHI – Dr. Shambhu Nath sees the infectious diseases behind a million deaths in India annually rather differently from international development mandarins at The World Bank in Washington, the United Nations in New York and the Canadian International Development Agency in Ottawa.

Wedged in a tiny New Delhi street-front health clinic beside a public lavatory and shower complex where customers are greeted with a pinch of powdered soap, Dr. Nath’s message is simple but surprisingly novel. “To save millions of lives here in India, we need to go back to the basics,” he says. “What’s needed is more handwashing with soap and water — and more toilets.”

Dr. Nath works for Sulabh International, an Indian social service group which, since 1974, has installed toilets in one million homes and more than 5,500 pay-as-you-go community toilets used by about 10 million people annually across India. In a country where 90% of people in rural areas and 55% of people in urban areas have no access to toilets, public health officials say Sulabh’s promotion of handwashing and public toilets makes perfect sense.

“More toilets and handwashing would prevent huge numbers of diarrhea-related deaths in India,” says Ashok Talyan, a public health physician working for the World Health Organization (WHO) in Uttar Pradesh, a rural province east of New Delhi.

It’s a message that is catching on, and not just in India. According to the WHO, diarrhea kills 1.8 million people worldwide annually — 90% of them children under five in developing countries. Handwashing is the best way to tackle the problem internationally, growing numbers of public health scientists say.

According to a study published in the U.K. medical journal The Lancet last July, a handwashing promotion campaign in Karachi, Pakistan, delivered a 53% reduction in diarrhea among children. That brought down the death rate among them due to diarrhea by 80%.

Promoting handwashing and building toilets in countries with high diarrhea mortality seems simple enough. But progress remains agonizingly slow. According to the Geneva-based Water Supply and Sanitation Collaborative Council, 2.5 billion people –mostly in India, China and sub-Saharan Africa — live without “a clean, private place to defecate and urinate.” The council’s message is aptly blunt: “Excrement kills. It kills by the million.”

But not only are sanitation and hygiene problems surprisingly deadly, says Roberto Lento, the council’s head, they are also surprisingly difficult to solve. Plain old-fashioned embarrassment is a big obstacle, he says.

At a conference last month in Stockholm, which brought together 1,200 water and hygiene experts, Mr. Lento noted that toilets and defecation remain “very much taboo subjects” among senior officials in many countries.

Henk van Norden, a senior advisor with UNICEF’s Water and Sanitation Program, says it is true people are dying from other people’s embarrassment. But that’s not the whole story, he argues. Based on a decade’s experience in India, he thinks water scarcity, not embarrassment, is the real problem. “In India, when water is being rationed during droughts,” says Mr. van Norden, “the toilets are locked up.”

Mamphono Khaketla, Lesotho’s Minister of Natural Resources, made the same point at the conference. “If I have 20 litres of clean water, will I use it to cook, to wash or to go to the toilet?” he asked. “The choice is obvious: to cook. While we are at that stage, sanitation will be on the back burner.”

Val Curtis, who heads the London School of Tropical Medicine’s Hygiene Centre, says it is time international development programs responded to new research suggesting that simple handwashing could save a million lives every year. With the equivalent of a jumbo jet full of children dying from diarrhea every two hours, Ms. Curtis says, action on handwashing is long overdue.

Ms. Curtis says she is puzzled handwashing gets so little attention in light of the resources devoted to the $1.3-billion Global Alliance on Vaccines and Immunization and the $2-billion Global Fund to Fight AIDS, Tuberculosis and Malaria.

“Why is it that only these diseases are receiving all the attention?” Ms. Curtis asked in a recent article. “Why are the diarrheal and respiratory tract infections seemingly being neglected?” At the Stockholm conference last month, Jarso Shiferaw, Ethiopia’s Water Minister echoed Ms. Curtis’s complaint. “Hygiene and sanitation issues have often been ignored,” she said.

“Diarrheal diseases are the forgotten killers of children,” says Ms. Curtis while noting that when deaths from acute respiratory tract infections — also associated with poor hygiene — are added to diarrhea deaths, together they account for more than six million preventable deaths a year worldwide.

That figure roughly matches the combined annual international toll of AIDS, malaria and TB. “Diarrheal diseases lack champions,” Ms. Curtis says, “possibly because this is a difficult issue to make attractive, dealing as it does, with feces.”

Pointing to a series of projects studying and promoting handwashing, which she and other researchers, working with aid agencies and soap companies, have established to fight diarrhea and respiratory tract infections in Ghana, India, Nepal, Peru and Senegal, Ms. Curtis calls for “renewed political will to defeat these killer infections.”

At UNICEF, Henk von Nordem gives credit to Sulabh International for promoting toilets and handwashing long before development agencies recognized their potential.

But he reserves even stronger praise for Val Curtis’s success in delivering scientific proof that handwashing is the world’s fastest, cheapest remedy to prevent millions of deaths.

“They are bringing out the fact that handwashing can have dramatic effects on the incidence of diarrhea among children, and more surprisingly, on respiratory infections as well,” Mr. van Nordem says.

“The evidence on this is getting much stronger. We’re obliged to examine the limited funding we currently have devoted to this.”

© National Post 2005