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Monday, 29 July 2013

No Menstrual Hygiene For Indian Women Holds Economy Back

Sushma Devi, a mother of three in Northern India, stores her “moon cup” on the window sill of the mud-brick veranda that shelters the family goats.
In a village where few have indoor toilets and the Hindi word for her genitals is a profanity, 30-year-old Sushma struggles to talk about how she manages her period and the changes brought by the bell-shaped device she inserts in her vagina to collect menstrual blood.
Cloth sanitary napkins are shown to village women in Rupaspur, around 60 kms from Agra. Many Indian women make do with little more than scraps of old cloth when menstruating, often risking their health, say aid workers trying to make clean and cheap sanitary napkins available. Photographer: Manan Vatsyayana/AFP via Getty Images
Sustainable Health Enterprises (SHE), with technical assistance from North Carolina State University and Massachusetts Institute of Technology, has designed the SHE LaunchPad, a menstrual pad that utilizes patent-pending technology to transform agro-waste, in this case, banana fibers, into highly absorbent material without the use of chemicals. Photographer: Elizabeth Scharpf/SHE via Bloomberg
“It’s a thing from hell,” she says of the malleable, silicone cup, which she received from a Massachusetts Institute of Technology research group. “I have to keep it far from the house, from where I pray.”
Across the world’s largest democracy, where a decade ofeconomic growth nearing 8 percent a year has tripled per-capita income, millions of women are held back by shame around their most basic sanitary needs.
Teenage girls and young women are encouraged to go to school and enter the workforce, yet have little access to the infrastructure and products -- separate bathrooms, sanitary pads -- that will help them succeed. Taboos around sexual health reflect a level of discomfort with the female body that affects women’s contribution to the economy and marks India as the third-worst nation in Asia for gender inequality.
“When our periods start, it becomes much harder,” explains Sushma, who wears a faded floral-patterned sari with silver toe rings and colorful glass bangles jangling on her arms. She was 15 years old when her mother showed her how to use fabric torn from discarded saris to handle her monthly period.

Economic Impact

Until a team of researchers from MIT’s Abdul Latif JameelPoverty Action Lab taught her how to use the menstrual cup, which she washes and re-uses, she’d sneak out at night to bury her soiled rags in the dirt.
For Sushma and many others in India, puberty didn’t just mark the process of becoming a woman. It brought a source of humiliation and an obstacle to learning.
“Many girls, when they get their period, say it means the end for them,” says Lizette Burgers, who headed Unicef’s water, sanitation and hygiene program in India from 2004 to 2011. “It’s taboo to talk about it.”
Persistent differences in women’s health, education and economic participation can only become detrimental to India’s growth, the World Economic Forum said in an October report on the global gender gap. Giving women more opportunities could boost the country’s economic growth rate by about 4 percentage points, Lakshmi Puri, the assistant secretary-general of UN Women, estimated in 2011, according to a report from the Center for Strategic and International Studies in Washington.

Gang Rape

India ranked equal to Congo on the United Nations Development Programme’s gender inequalityindex for 2012. Female participation in the labor force was 29 percent in 2011, 2 percentage points below Sudan and less than half of China’s 68 percent, according to World Bank data. Only 65 percent of women can read or write, compared with 82 percent of men, according to India’s census data for the same year.
The vulnerability of women attracted international attention last December when a female medical student was gang-raped aboard a bus in New Delhi one evening. Her death sparked nationwide demonstrations calling for a government and police crackdown on sex crimes.
Sushma says she was never molested when she left the house at night to bury her rags, though she knows women who were and she felt exposed and fearful.
“I’ve always struggled to understand why there is such little attention on this issue that impacts dignity, education, health and women’s involvement in the workplace,” says Virginia Roaf, an adviser to the United Nations Special Rapporteur on the right to water and sanitation.

Old Rags

Of the 355 million reproductive-age women in India, only 12 percent use absorbent pads or another sanitary method to stem the blood flow during their periods, a report by AC Nielsen and Plan India found in 2010. The rest tend to rely on old fabric, husks, dried leaves and grass, ash, sand or newspapers.
Menstrual cups, designed to be re-used and collect rather than absorb blood, have been around since the 1930s. Brand names and manufacturers include Diva International Inc., maker of the DivaCup; Mooncup Ltd., the U.K. company that was first to make the device with silicone; and Mumbai-based MediAceso Healthcare Pvt., supplier of the device Sushma uses.
The consequences aren’t just economic. There’s a public health toll. India accounts for 27 percent of the world’s cervical cancer deaths, according to World Health Organization data. The incidence rate there is almost twice the global average, and doctors studying the disease say poor menstrual hygiene is partly to blame.

Cringe Factor

The homespun solutions raise the risk of vaginal infections that can suppress the reproductive tract’s natural defenses. A weaker immune response can compromise the body’s ability to fight the sexually transmitted human papillomavirus, the microbial cause of most cervical cancers, says Robert Tindle, an emeritus professor of immunology at the University of Queensland in Brisbane who has studied HPV.
There isn’t good data to show the role menstrual hygiene plays in the prevalence of cervical cancer in India, according to Rajesh Dikshit, chief of epidemiology at Mumbai’s Tata Memorial Hospital, India’s biggest cancer treatment center. Some analysis points to a link by way of clean water access, he says.
“Where there is no water in India, there are very high rates of cervical cancer,” Dikshit says. “Where you have water, you don’t have the cervical cancer.”

Busting Myths

Kimberly-Clark Corp. (KMB)Procter & Gamble (PG) Co. and other makers of feminine hygiene products are working to wrench open a market that could be worth billions. Things are moving slowly.
Sales of sanitary protection products in India reached $236 million last year and that number will probably only swell to $442 million by 2017, according to London-based researcher Euromonitor International. That compares with a projection of $13.2 billion that year for China, whichaccording to the United Nations has 42 million more women.
Procter & Gamble, the maker of Whisper sanitary pads, found by working with local schools to educate girls and their mothers about feminine hygiene and biology that they were “busting myths and cultural superstitions,” says Shweta Shukla, a spokeswoman based in Mumbai. Kimberly-Clark is also conducting awareness programs for school-age girls to help them understand the changes the body undergoes at puberty.
“Women asking for more comfortable desks is one thing,” says Clarissa Brocklehurst, a water and sanitation consultant in Ottawa who headed Unicef’s water, sanitation and hygiene division in New York until June 2011. “Being forced to speak out about an issue that everyone gets a bit shy and cringing about is another.”

School Dropouts

Companies tend to focus on schools because that’s where the exclusion begins. At least one in five girls drop out when periods begin, according to research by AC Nielsen and Plan India, a New Delhi-based non-profit organization. Those who persist typically miss five days of school each month due to inadequate menstrual protection.
“The schools they study in, the spaces they play or relax in, the markets, farms and offices they work in, do not design facilities with this simple and recurrent biological need in mind,” Chris Williams, executive director of the Geneva-based Water Supply and Sanitation Collaborative Council, wrote in a May note.
Procter & Gamble’s Shukla says the Cincinnati-based company has worked to bring sanitary napkins “out of the closet” by showing actual pads in advertising instead of relying on euphemisms, and encouraging retailers to move the packs from the back of the store to the front.

Banana Pad

Besides Procter & Gamble and Kimberly-Clark, India’s health ministry is working to bolster awareness by selling pads at a subsidized rate of 6 rupees per pack of six to adolescent girls under the brand name Freedays.
There is also research into cheaper products better suited to developing countries. New York-based Sustainable Health Enterprises has developed technology to make a sanitary pad with cheap local materials such as banana stem fibers as the absorbent core.
And the research team from MIT’s Abdul Latif Jameel Poverty Action Lab last year introduced the moon cup -- a device used by a handful of environmentally conscious women in the U.S. and Europe -- to Bihar, where 54 percent of the population lives below the poverty line, more than in any other Indian state.
The lab dispatched 50 field staffers to a district called Jehananbad, an expanse of green paddy and wheat fields dotted with tiny mud-hut villages outside Bihar’s capital, in SUVs to reach villages so remote many weren’t connected by roads.

No Praying

The workers often had to walk the final 3 to 4 kilometers (2-2.5 miles) of dusty terrain to meet the research team’s goal of introducing the cup to almost 200 women. More than 40 percent of the women approached had never seen a sanitary absorbent.
“Going to these villages is like going back in time,” says Vivian Hoffmann, an economist and the lead researcher on the project investigating whether the menstrual cup can become a viable alternative to pads and rags for rural women. “There’s a real gap in the literature when it comes to this population. So if we’re going to find an impact from menstrual hygiene anywhere, we’re going to find the impact here.”
Menstruating women can’t perform religious rituals, touch idols, pray, visit temples, cook, serve food and touch drinking water in many traditional Hindu homes because they’re considered impure. Sushma, who says the cup has improved her life and stoked envy from other women, will still cook but not pray.
A few households in rural Uttar Pradesh, the state just west of Bihar, have a separate area for menstruating women to sleep, according to a report from Unicef.
Sushma isn’t ready to ditch the taboos she grew up with. While she says she will discuss these issues with other women, and has showed them her cup, she goes out of her way to keep her husband and sons in the dark.
“We absolutely don’t talk about it with men,” she says, protectively cupping the head of her 6-year-old son. “It is dirty. Why should they know about it?”

Wednesday, 24 July 2013

Extreme flooding must be ‘turning point’ on disaster response

Climate-related disasters like flooding are on the rise. Photo:IRIN/Tung X. Ngo

25 June 2013 – A United Nations senior official today stressed that this year will be a “turning point” in how governments view and respond to extreme weather events, and floods in particular, which are currently affecting several countries across the world.
“India, Nepal, Canada and many countries in Europe have experienced huge losses over the last two months due to intense precipitation events which have triggered extreme flooding affecting millions of people’s well-being and livelihoods,” said the Special Representative of the Secretary-General for Disaster Risk Reduction, Margareta Wahlström.
Monsoon rains in India this year are believed to be the heaviest in 80 years, according to media reports, which noted that some 7,000 people are still stranded in the mountains after flash floods and landslides. More than 600 people are confirmed dead so far, while 80,000 have been rescued.
“The shocking loss of life in India underlines how vitally important it is that we start planning for future scenarios far removed from anything that we may have experienced in the past,” Ms. Wahlström said.
In the Canadian province of Alberta, more than 100,000 people were forced to flee their homes this month as floods triggered by torrential rains hit the region. The floods have washed away roads and bridges, cut off electricity and submerged hundreds of homes.
“When we look at the worldwide escalation in economic losses from disasters over the last five years, it is clear that our exposure to extreme events is growing and this trend needs to be addressed through better land use and more resilient infrastructure as we seek to cope with population growth and rapid urbanization.”
According to the UN Office for Disaster Risk Reduction (UNISDR), some 250 million people have been affected annually by floods over the last 10 years, and floods are the single most widespread and increasing disaster risk to urban settlements of all sizes.
Major contributing factors include poor urban planning which increases flood hazard due to unsuitable land use change, increases in paving and other impermeable surfaces, poorly maintained drainage, sanitation and solid waste infrastructure.
“Flood management systems need to be designed so that even if they are overwhelmed by floodwaters, the failure is not catastrophic,” Ms. Wahlström said, adding that UNISDR emphasizes the need for early warning systems, reduction of social vulnerability through land use planning and leadership at local government level.

Sunday, 14 July 2013

Gender crimes haunt women who head to field for nature's call

When Anita Narre, a newly-wed bride in Jheetudhhana village of Madhya Pradesh's Betul district, refused to stay at her husband's home for there was no toilet in it, she lent a voice to the problems women face when they head to the fields. While eve-teasing is more or less a daily affair with men singing vulgar songs, making cheap gestures and throwing stones off and on to draw their attention is a routine affair, there is perennial risk of molestation and rape. The plight indicates towards a preventable social reason behind incidents of rapes and other crimes against women.

Threat that comes with nature's call
The lack of functional household toilets in the state could be one of the biggest reasons for women getting raped. As per NGO estimates more than 75% of the rape cases in rural areas take place when women move out of their homes to attend nature's call. "The vulnerability of women at that time is perhaps the highest," said Prof Roop Rekha Verma, founder of Saajhi Duniya. "So many rape victims coming to us for help have shared their stories of horror. And the fact that they fell prey to the evil male instinct when they went to attend nature's call turns out to be a common thread in 75-80% womens," she added. This is something which international organisations have acknowledged in letter and spirit. "Women and girls disproportionately face risks of sexual violence when they have to walk long distances to sanitation facilities, especially at night," argued Catarina de Albuquerque, UN expert on the human right to safe drinking water and sanitation at a function when access to water and sanitation was declared as human rights in 2010. "Inaccessible toilets and bathrooms make them more vulnerable to rape and other forms of gender-based violence," she added.
Risk increases when women are alone
The probability of getting raped increases significantly when women venture alone for defecation or urination. Though women prefer to go in groups, but this is not possible all days and at all times. Needless to say that the risk spells doom for some women. Take the example of Lakshmi, a bride in Mathura who wasn't as bold as Anita to be telling her husband to get a toilet constructed inside their house if he wanted Lakshmi to stay with him.
Like most women in her family and neighbourhood, this 22-year-old bride went to the nearby fields at the break of dawn but didn't return home. Her husband Jeetu and others launched a search and found her body, wounded and soaked in blood, in a hedge next to the field where she usually went to attend nature's call. Local police officials believed that some unknown men had raped and killed her. Then there is the story Kshama, who lived in Seevana village of Lucknow. The girl went missing since she left her home for nature's call in the evening one day in April 2012. The frantic search launched by her parents ended with the bad news of her body being found under mysterious circumstances. The examples only hint towards the magnanimous extent of the problem which may be estimated from the fact that more than 85% households in UP do not have a functional toilet.
Household toilets ensure safety
In July 2012, the Madhya Pradesh government launched a campaign called Maryada in which they acknowledged the association of lack of sanitation facilities with the risk of crimes against women. "Through the campaign, awareness is being created among villagers about environmental improvement, sanitation and safeguarding women's modesty," said an official release issued by MP's department of Public Relations.

Experts at Unicef who helped the government take up the issue to the grass root levels, say that rural women admit that they risk their lives and modesty when the venture out of home to attend nature's call. However, they categorically assert that though no planned study has been undertaken to examine the association, there is no dearth of anecdotal evidence. They quickly added that studying the phenomenon was not a bad idea. Certain NGOs in Gujarat found that proper sanitation facilities create a sense of dignity among women advocated facilitating construction of toilets through micro finance and self help groups. Acknowledging the same, the UP government is also looking at the model of associating house hold toilets with safety of women to achieve better sanitation. Recently, Amit Mehrotra, water and sanitation expert at Unicef, was seen telling field officers to use sanitation and safety of women as a tool to convince rural populace get a proper toilet constructed in their homes.
Eye opener
In a mid term analysis of national programmes by ministry of rural development:
* Open defecation was observed and reported in 89.03% of the homes.
* Over 40% of the school toilets were found be defunct, out of use or locked.
* More than 20% of the toilets in the anganwadi centers were not being used.
* Community awareness about sanitation was poor in 40.32% districts.

Tuesday, 2 July 2013

Water, sanitation, hygiene and enteric infections in children

Open Access
  1. Jeroen H J Ensink
+Author Affiliations
  1. Environmental Health Group, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence toDr Jeroen H J Ensink, Environmental Health Group, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; Jeroen.ensink@lshtm.ac.uk
  • Received 13 November 2012
  • Revised 13 May 2013
  • Accepted 14 May 2013
  • Published Online First 12 June 2013


In 2007, readers of the British Medical Journal voted that the introduction of clean water and sewerage—the ‘sanitation revolution’ of the Victorian era—was the most important medical milestone since the 1840s,1 over anaesthesia, antibiotics, or vaccines. These improvements led to a dramatic reduction in morbidity and mortality associated with faecal-oral infections, such as typhoid fever and cholera. Today, water, sanitation and hygiene (WSH) measures remain critically important to global public health, especially among children in lower income countries, who are at greatest risk from enteric infections and their associated symptoms, complications and sequelae.
In this article, we review the evidence linking WSH measures to faecal-oral diseases in children. Although continued research is needed, existing evidence from the last 150 years supports extending life-saving WSH measures to at-risk populations worldwide.2 One recent estimate3 held that 95% of diarrhoeal deaths in children under 5 years of age could be prevented by 2025, at a cost of US$6.715 billion, through targeted scale-up of proven, cost-effective, life-saving interventions. These include access to safe and accessible excreta disposal, support for basic hygiene practices such as hand washing with soap, and provision of a safe and reliable water supply. We present estimates of the burden of WSH-related disease followed by brief overviews of water, sanitation and hygiene-related transmission routes and control measures.i We conclude with a summary of current international targets and progress.

Transmission routes and health impact

Human excreta can contain over 50 known bacterial, viral, protozoan and helminthic pathogens. The majority of excreta-related infections are obtained through ingestion, less often through inhalation. Excreta-related infections travel through a variety of routes from one host to the next, either as a result of direct transmission through contaminated hands, or indirect transmission via contamination of drinking water, soil, utensils, food and flies (figure 1). The importance of each transmission route varies between pathogens and settings, and different pathogens are more prevalent in some populations.
Figure 1
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Figure 1
The F-diagram, showing the different faecal-oral transmission routes, and possible barriers to prevent excreta-related pathogens from finding a new host.

Diarrhoea, malnutrition and environmental enteropathy

Although great strides have been made in reducing diarrhoea mortality, especially as a result of the increased use of oral rehydration therapy (ORT), diarrhoea remains the second leading cause of death in children under 5 years of age, after pneumonia.4 It is responsible for an estimated 1.7 billion cases of diarrhoea, or on average 2.9 episodes/child/year, and an estimated 1.87 million deaths among children under 5 years of age.5 The highest burden of disease is in children in the age range of 6–11 months: 4.5 episodes/child/year.6 It has been estimated that 50% of diarrhoea deaths can be attributed to persistent diarrhoea,7 and while ORT can prevent many deaths from acute diarrhoeal diseases,8 access to appropriate treatment is often limited in resource-poor settings.
The relationship between diarrhoeal disease and malnutrition is complex, though it is well accepted that malnourished children suffer more frequent episodes of diarrhoeal disease, while a child's nutritional status is affected following a diarrhoeal episode. A multiple country study found that 25% of stunting in children aged 24 months could be attributable to five or more diarrhoeal episodes experienced in the first 2 years of life.9 Malnutrition and stunting can lead to poorer school performance, early school drop-out and, as a result, lower economic well-being in later life.10 Over 440 million school days are missed annually due to WSH-related illnesses.11 Extended exposure to faecal pathogens may, in part, cause environmental enteropathy, a postulated condition (Humphrey, Lancet) characterised by malabsorption, villus atrophy, crypt hyperplasia, T-cell infiltration and general inflammation of the jejunum.12 This chronic infection of the small intestine could explain why sanitation may have a stronger association with gains in growth than with reductions in diarrhoea incidence.13 For example, a study in Peru found that diarrhoea could explain 16% of stunting, while access to sanitation and water services could explain 40%.14 Environmental enteropathy may reduce vaccine efficacy, either though induction of regulatory T cells which dampen the vaccine-specific immune response, or through the destruction of the live attenuated vaccine by an over-vigorous local immune response in the gut.15 This could explain why oral vaccines for the control of rotavirus have shown a lower efficacy in sub-Saharan Africa (39.3%) and Asia (48.3%), in contrast with efficacy in Europe/USA (85–98%).16–19
An estimated 88% of all child deaths as a result of diarrhoeal disease may be prevented through improvements in WSH.20 While there are promising emerging vaccines, including for rotavirus and cholera, there are several dozen pathogens transmitted in faeces, and WSH will remain critical to prevention of diarrhoeal diseases.


Soil-transmitted helminths (STH); Ascaris lumbricoidesTrichuris trichiura and the human hookworms (Necator americanus and Ancylostoma duodenale) are our most common parasites and are estimated to infect up to 807 million, 604 million and 576 million people worldwide, respectively.21 Roughly a third of all Ascaris and Trichuris infections and 20% of hookworm infections are in children under the age of 15 years.22 STH ova leave the human body in excreta, and must mature in soil before they become infective. STH infections have shown a strong association with open defecation,23 and the use of fresh excreta or wastewater in agriculture.24 ,25 Consumption of dirt or soil (pica) by children, pregnant women, and others has also been suggested as a risk factor for STH.26 ,27 Schistosomiasis is estimated to infect 207 million people worldwide,21 and is caused by open defecation or anal cleansing28 close to or in water bodies where the miracidia can hatch and find a snail host to complete their lifecycle. The use of surface water sources like lakes, rivers and irrigation canals for domestic water needs, like washing, bathing and water collection have been associated with an increased risk of infection.29 Children are especially at risk as a result of their lower immunity, and because they may have more contact with contaminated water through play or water collection.30 Although direct mortality as a result of a helminth infection is low, morbidity is high. The global burden of disease has been variously estimated (as few as 3 million and as many as 50 million Disability Adjusted Life Year (DALY)31 ,32), and is uncertain but high.33 The burden of disease is attributable to the long-term impacts related to helminth infections, including anaemia, low birth weight, preterm birth, retarded growth, poorer cognitive performance and early school drop-out. Hookworm, in particular, is associated with undernutrition and possibly greater risk of malaria34–36 and HIV.37 ,38 The delivery of anthelminthics through schools has lately been the intervention of choice for reducing STH infections in children. The effectiveness of these programmes, especially with respect to improving cognitive performance, has recently been questioned, however, a large meta-analysis did not find a significant improvement,39 underscoring the need to interrupt transmission via effective sanitation in home and school environments.40



Sanitation aims to prevent contamination of the environment by excreta and, therefore, to prevent transmission of pathogens that originate in faeces of an infected person. A wide range of technologies and methods exists to achieve this, which include sophisticated and high-cost methods like waterborne sewage systems and simple low-cost methods like the cat method, which involves the digging of a hole and covering faeces with soil after defecation. The WHO/UNICEF Joint Monitoring Programme (JMP) classifies the following as ‘improved’ sanitation that is more likely to be hygienic: a connection to a sewerage system, septic tanks, pour-flush toilets, ventilated improved pit latrines and pit latrines with a concrete slab. According to the 2010 JMP estimate, 11 countries make up 76% of the 2.5 billion people lacking improved sanitation, with one-third in India. Over one billion people practise open defecation, mostly in rural areas.41 Systematic reviews of the impact of sanitation on health have estimated a mean reduction of 32–36% in diarrhoea,42–44 though a Cochrane systematic review did not calculate a pooled effect due to heterogeneity of studies.45 The number of rigorous studies that have investigated the impact of sanitation on soil-transmitted helminth infections is very limited, as most of the sanitation interventions were conducted in conjunction with improvements in water supply. In Salvador, Brazil, neighbourhoods with storm water drains to prevent seasonal flooding with sewage, or full waterborne sewerage, were compared with neighbourhoods having neither. The study found that, when the level of community sanitation was better, the prevalence of ascariasis declined by up to 40%, and that domestic domain risk factors were more numerous and more significant in areas with better community sanitation.46

Safe child stool disposal

Many cultures consider the stools of infants fed on breast milk harmless, or at least less harmful than those of adults, because they are smaller, their faeces smell less, and contain less visual food residues.47–49 Additionally, most latrines are not designed for use of, and may not be used by, small children. They might be afraid to use them for the risk of falling in, bad smells, or the fear of dark spaces. Because nappies, child-sized potties and washing machines are not available in many poor settings, defecation on the floor is common and potentially seen as the most practical option until the child is potty trained. As a result, latrine use by children is low, as was shown by a study in Lima, Peru, where less than 25% of under five-year-olds used a toilet.49 Because of a much higher prevalence of diarrhoea and higher egg counts for STH in children, child stool often poses a greater health risk than those of adults.50 To date, safe disposal of children's stools has received relatively little attention in sanitation programmes.

Water supply

While all communities have access to water, the quantity and quality available may be insufficient to meet basic needs, and access may not be near to the household. The physically demanding job of water collection is usually allocated to women and children. A study in 25 countries in sub-Saharan Africa estimated that children spent a collective four million hours every day fetching water, and keeping them away from school.41 Carrying water can also lead to injuries and growth stunting.51 When water is available within 1 km, or a 30 min return round trip from the household, water use does not change significantly until water is provided on the plot or very nearby (figure 2). When a tap is available within the household, or shared with a close neighbour, per capita water use can go up from 10–30 L/person/day to 30–100 L/person/day. Greater volumes of water available to a household tend to result in better hygiene, including increased hand washing.
Figure 2
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Figure 2
Distance to water source and use.
Over 780 million people now lack access to an ‘improved’ water source, and one study has estimated the number of people who rely on microbiologically or chemically unsafe water to be 1.8 billion, or about 28% of the global population.52 According to WHO/UNICEF JMP, ‘improved’ water sources include piped water, rainwater, protected springs and protected wells, which are thought to be less likely to be contaminated with pathogenic microbes. Recent research has shown, however, that even such improved water supplies may be subject to faecal contamination (ibid.) and that even occasional exposure to unsafe water—for example, from intermittent service or inadequate treatment—can undermine health benefits.53 Providing safe, reliable, piped-in water to every household is an essential goal, yielding optimal health gains, while contributing to the Millennium Development Goal (MDG) targets for poverty reduction, nutrition, childhood survival, school attendance, gender equity and environmental sustainability.

Food hygiene

Weaning food hygiene may be among the most important determinants of diarrhoeal disease risk in young children,54 ,55 although the current evidence is insufficient to arrive at conclusions about its relative importance in control of infections. It has been shown to be important in some contexts, with estimates of up to 70% of all diarrhoea caused by contaminated foods,54 and microbial counts that may exceed those found in drinking water.54–60 Food hygiene interventions, such as the promotion of reheating foods, preventing contact with flies and hand washing before feeding are the subject of current research, but effects on diarrhoeal disease risk have not been estimated from multiple trials. The sustained effects of behaviour change from food hygiene interventions have not been assessed.

Hand hygiene

Hand washing with soap before feeding children and after cleaning them can interrupt the transmission of faecal-oral microbes in the domestic environment. A review of the literature on hand hygiene suggests that hand washing with soap (HWWS) can reduce micro-organism levels close to zero,61 ,62 mainly through the mechanical action of rubbing and rinsing.62 ,63Good hand washing practice should include water, a washing agent such as soap and a drying phase.50 ,64–66 Estimates of the impact of HWWS on health from systematic reviews suggest large effects (up to 48% reduction in diarrhoea).42 ,44 ,67–70 Hand washing with soap can also cut the risk of acute respiratory infections by 23%.71–73 Critically, persistent changes in behaviours may be possible following interventions,74 although more research is needed on the longer-term effects of behaviour change campaigns.

Water quality

Because universal safe, reliable, on-plot water supply remains an elusive goal for the majority of the world's population, household-level water treatment (HWT) has been proposed as an interim solution to provide safer drinking water at the point of use.75 ,76 In many settings, both rural and urban, populations may have access to sufficient quantities of water, but that water may be unsafe for consumption as a result of microbial or chemical contamination. Effective HWT, such as boiling, filtration or chlorination, has been shown to improve microbial water quality significantly.77–79 Safe storage of treated water is necessary to prevent recontamination through unsafe water handling.80
Improving water quality at the point of consumption can protect children from waterborne disease. The findings of meta-analyses show a much stronger protective effect for water quality interventions at the household level (rather than at source level) on diarrhoeal disease outcomes (up to 40%42 ,44 ,81: but no blinded trials of household water treatment have shown protective effects. HWT is unique among WSH interventions in that it may, in some forms, be possible to blind with a placebo device, chemical, or method. A review by Cairncross et al67estimated diarrhoea risk reductions of 17% associated with improved water quality, which is consistent with earlier reviews by Esrey et al,43 ,68 and issues of bias potentially affecting the evidence base for water quality interventions have been articulated.81 ,82
One of the challenges that promoters of HWT have reported is low adherence—consistent, correct and sustained use—which can limit expected health gains.83 ,84 Unlike centrally treated, piped-in water supplies, HWT is normally a batch process that must be undertaken by the end users on a daily basis in order to provide consistent protection against waterborne pathogens. A number of studies of HWT have reported reduced use of interventions over time, suggesting that low adherence may limit the usefulness of HWT as a strategy.77 ,85–88

Progress toward and beyond the MDGs

Improvements in water supply and sanitation, if implemented sustainably, will have an important impact on a wide variety of different infectious diseases, and could improve the quality of life of millions of children worldwide, and provide them a proper start in life. In 2010, the UN General Assembly affirmed that clean drinking water and sanitation are human rights, with the UN Human Rights Council later recognising these rights to be derived from the rights to an adequate standard of living, health, life and dignity.41 These pronouncements cannot by themselves drive progress in expanding services, but do add moral weight to the pursuit of universal coverage. Although great strides have been made in the provision of sanitation and water, it is estimated that if current trends continue, 605 million people will still lack access to an improved water source in 2015, and 2.4 billion people will lack access to basic sanitation.41Implementing better measures of what constitutes ‘access’ to water and sanitation—currently, monitoring is based primarily on technology types, without regard to key quality or accessibility factors—would paint an even bleaker picture of the global shortfall in coverage.
Households with a so-called ‘improved’ water supply connection that is intermittent and provides microbiologically unsafe water are counted among those with access to water meeting the MDG target for ‘sustainable access to safe drinking water’.89 Similarly, sanitation progress made in some areas have accounted only for construction of latrines, when there are no good options for treatment or disposal of waste after they fill up (figure 3).
Figure 3
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Figure 3
An improved form of sanitation: a household pit latrine in Tanzania.
In order to consolidate the gains of the last decade, and contribute to lowering the burden of childhood morbidity and mortality, post-MDG goals for water and sanitation should focus on strengthening key WSH institutions, creating demand and ownership, and fostering sustainable behaviour change. This requires an acknowledgment that the motivations for improving access are different for policy makers and intended recipients. The MDGs include language on reducing poverty and disease mortality, but for most of the beneficiaries the advantages and motives for the adoption of WSH measures are not directly health-related, but improvements in quality of life, including factors related to privacy, comfort, status, dignity, protection from harassment and savings in cost and time. Harnessing the power of these motivations to expand access to WSH, by leveraging investment by households—not only by governments and donor agencies—may help increase coverage of these life-saving measures among those who would most benefit from them.


  • Contributors All authors wrote and reviewed the paper, JHJE acts as guarantor of the content.
  • Funding SC's and JHJE's time was funded by the DFID research programme consortium on Sanitation and Hygiene (SHARE: grant no. P04990).
  • Competing interests None.
  • Provenance and peer review Commissioned; externally peer reviewed.
  • Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/
  • i Although we do cite pooled estimates of effect for WSH interventions on child health from a number of systematic reviews, readers should note that there is a rich emerging literature that attempts comparisons of impact between water supply, water quality, hygiene and sanitation; Waddington et al 2009 provides a good summary that is still current. WSH interventions are not very amenable to randomisation (in the case of infrastructure) and are almost never blinded in trials, with the exception of a minority of water quality intervention trials. Therefore, randomised, controlled trials (RCTs) may be subject to significant bias, and RCTs constitute the majority of studies included in systematic reviews of WSH interventions. We cite these reviews where appropriate as important but potentially flawed estimates that may be considered suggestive only. A broader perspective on the evidence base may be more helpful.
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