POVERTY: MADAGASCAR: Addressing toilet taboos to improve sanitation

TAMATAVE, 23 March 2012 (IRIN)

 Photo: Guy Oliver/IRIN
A lack of latrines has led to rivers being contaminated

In Madagascar's east coast city of Tamatave, a local taboo against having a toilet in your house or on your land has complicated the task of trying to improve the region's dire sanitation situation.
Nationwide, more than 10,000 people, of whom two thirds are children under five, die prematurely from diarrhoea annually, according to the World Health Organization, which attributes 88 percent of these cases to poor quality water and sanitation.
In the under-developed and flood-prone coastal regions of the country, sanitation is particularly poor and deteriorates even further following a cyclone, a regular event during the rainy season.
“Within three hours, water levels go up so much that everything gets contaminated. In some places, people use traditional pits instead of adequate latrines. When they fill up and overflow, they contaminate the whole environment, including the water wells,” said Edwin Joseph of the faith-based organization, Frère St Gabriel, which is working on sanitation projects in the region.
No one needs to convince Joseph of the importance of adequate sanitation. Shortly after his arrival in Madagascar in 2000, the Indian Ocean island was hit by three successive cyclones, and in the aftermath an outbreak of cholera claimed 3,000 lives and hospitalized over 20,000 people.
“The hospitals refused to take in new patients, as they were already too full," he recalled. "Even the verandas of the hospitals were filled with people. In some cases people burnt the dead with all their belongings, as they were afraid of the disease spreading. Our own neighbours - a family of five - died of cholera.”
According to the UN Children’s Fund (UNICEF), an estimated 7.4 million Malagasy who lack latrines defecate along beaches and rivers. “Sometimes people drink the water from the river," said Joseph. "During the rainy season, all the dirt washes into [that] water.”
Overcoming local taboos and convincing people that they need latrines has required some drastic measures. “Our trainers go to the villagers and offer them water with excrement in it to drink. When they refuse, they take them to the river and show them that this is what they drink every day,” said Joseph.
Our trainers go to the villagers and offer them water with excrement in it to drink. When they refuse they take them to the river and show them that this is what they drink every day
The NGO also recruits the help of local youth and women’s groups. “There was one stretch of beach in Tamatave which was used [for defecation] by 20,000 people. We worked with the youth groups to clean up the place and make it into a soccer field. This way, the young take care others won’t use their fields,” explained Joseph.
Once a village has decided to be part of the process of improving sanitation, aid workers start a programme called Community-Led Total Sanitation, which encourages households to find their own ways and means of constructing latrines, often by helping them obtain loans from micro-credit institutions.
With UNICEF leading the push for improved sanitation nationally and providing technical assistance, this approach has led to the construction of more than 7,500 latrines in 1,750 villages in Madagascar since 2008.

Campaign with ambitious goal
A nationwide Sandal (Sans Defication Air Libre) 2018 campaign was launched by UNICEF and the Ministry of Water in October 2011. The campaign aims to reduce the 32 percent of Madagascar's population who currently practice open defecation to less than 1 percent by 2018.
Evariste Kouassi-Komlan, water and sanitation manager at UNICEF, told IRIN that reaching this ambitious goal would require 440 villages a year in each of the country's 22 regions to be declared open-defecation free.
“This is a huge job and UNICEF is engaged to push this campaign further," he said.
Frère St Gabriel has already nearly achieved the 1 percent goal on the tiny tourist island of Ile St Marie, off the coast of Tamatave. “They shortly will be the first district in Madagascar to be completely Sandal,” said Joseph, adding that he had seen similar campaigns in other African countries achieve impressive results.
“When a government is enrolled, it becomes a mass movement and the whole country stays focused on it. In Madagascar, it’s the NGOs that are taking it up. We might not meet the deadline, but it will happen,” he said.
http://www.irinnews.org/Report/95136/MADAGASCAR-Addressing-toilet-taboos-to-improve-sanitation

POVERTY: ZIMBABWE: Growing risk of waterborne diseases in rural areas

MHONDORO, 3 January 2012 (IRIN)

 Photo: Médecins Sans Frontières (MSF)
An aid worker treats a cholera patient in Beitbridge, Zimbabwe, on the border with South Africa during the 2008/2009 outbreak of the waterborne disease

Barbra Phiri, 20, a single mother living on a farm settlement in rural Mhondoro, about 45km southwest of the Zimbabwean capital Harare, does not think twice about letting her two-year-old twins splash about in a pool of greenish water close to her hut.
Since the rains began several weeks ago, dirty water has been accumulating on the settlement, now home to hundreds of former farmworkers and others displaced during Operation Murambatsvina in 2005 which razed illegal structures and left thousands without shelter.
Phiri remembers the 2008-2009 outbreak of cholera which killed more than 4,000 people and infected nearly 100,000 others, but sees it as a thing of the past and is still ignorant of how waterborne diseases are spread.
Her twins have a skin infection and frequent bouts of diarrhoea but, like most residents, she attributes such ailments to witchcraft, consulting a traditional healer for a cure.
Phiri told IRIN her first child died two years ago from diarrhoea. “We don’t use dirty water for drinking or cooking. We get clean water from the dam or the wells, so how can our children die from waterborne diseases?” she asked.
A few metres from Phiri’s hut is an overflowing pit latrine. Many inhabitants have resorted to relieving themselves in the open since most of their pit latrines are overflowing and unusable.
The 2009 Multiple Indicator Monitoring Survey (MIMS), compiled by the government and UN Children’s Fund (UNICEF), listed diarrhoea as one of the major causes of infant mortality resulting in around 4, 000 deaths in Zimbabwe annually.
With the advent of the rainy season and poor sanitary and hygienic facilities, people living in rural and peri-urban settlements like Phiri’s are vulnerable to waterborne diseases.
The survey said: “Recent assessments show a significant decline in rural sanitation sector performance,” adding: “The inability of vulnerable populations to access safe water and basic sanitation… has resulted in frequent diarrhoeal and cholera outbreaks.”
The Consolidated Appeals Process (CAP) for Zimbabwe, launched in early December 2011, said “a third of rural Zimbabweans still drink from unprotected water sources and are thus exposed to waterborne diseases,” and noted reports of cholera cases in rural Chipinge, in the eastern province of Manicaland, and Chiredzi in the southeast of the country.

More people seek treatment
A senior nurse at a clinic in rural Seke District, about 50km south of Harare, who preferred anonymity, told IRIN the number of people seeking treatment for diarrhoea and dysentery had increased since the onset of the rains.
“Typical of this time of the year when the rains fall, we treat a high number of people suffering from waterborne diseases… We have not received any cases of cholera but there is need to be on the alert all the time, because the surrounding villages are characterized by poor hygiene and sanitation. Many villagers tend to relieve themselves in the open because they cannot rehabilitate the Blair pit toilets that were built long ago,” she said.
Blair pit toilets were constructed in large numbers to improve rural sanitation in the 1980s. A fine wire mesh allowed gases produced by decomposition to escape, but prevented flies around the faecal matter from exiting the septic tank and so prevented the spread of diseases.
The boreholes that were drilled in the 1980s have broken down and only a few that were sunk in recent years still function
According a 2011 report by the UN Children’s Fund (UNICEF) and the government entitled A Situational Analysis on the Status of Women’s and Children’s Rights in Zimbabwe, 2005-2010 42 percent of people in rural communities practised open defecation, while cholera, which used to see significant outbreaks every 10 years or so in the 1980s and 1990s, has now become an annual event.
Poor household income, the senior nurse said, prevented some villagers from seeking treatment, “meaning that the number of people suffering from waterborne diseases could be higher as some of the cases go unreported [as people cannot afford to travel to clinics].”
David Shoniwa, 65, from Dema village in Seke District, said people in his community tended to relieve themselves along river beds during the dry season.
“The boreholes that were drilled in the 1980s have broken down and only a few that were sunk in recent years still function while, due to poor rains, it is difficult to sink new wells. When the rains fall, people turn to the rivers for water to drink and use for cooking, thereby exposing themselves to the diseases carried by the human waste,” Shoniwa told IRIN.

http://www.irinnews.org/report.aspx?reportID=94575

MALNUTRITION: What is malnutrition?

Diana Nabiruma : 15 December 2010

Malnutrition manifests in two forms; under-nutrition and over-nutrition.
Under-nutrition, according to a booklet titled Malnutrition: Uganda is Paying Too High a Price, “occurs when the body fails to get the right quantities and proportions of nutrients for it to maintain health and proper function.”
In Uganda, under-nutrition mostly occurs in children and it presents with stunting (child being too short for their age) or too thin for their height (wasting). The most severe forms of wasting are marasmus and kwashiorkor.
A nutritionist at Mwanamugimu unit of Mulago hospital says that although signs of marasmus and kwashiorkor are obvious, child caretakers are usually in denial or ignorant of the fact.
According to this nutritionist, caretakers instead blame witchcraft when their children show signs of malnutrition or think their children are simply fat.
As if to demonstrate the point, the day we visit the unit, a father taking care of his daughter bugs the nutritionist to have his child moved to a ward with stabilised children.
“Ono simulwadde. Mutusindike eri,” he says meaning, “This one is not sick. You should send us to the other ward”. However, the child looked wasted, something even the sunny dress she wore couldn‘t hide.
Nutritionists point to poor sanitation and hygiene (which cause diseases like diarrhoea), teenage pregnancies and frequent pregnancies (pregnancies and lactation require high amounts of nutrients which are sometimes not met), poor feeding habits where people feed on only staple foods (usually containing carbohydrates and proteins), poverty and a lack of prioritisation of nutrition by the government as the major causes of malnutrition.
And despite Uganda being a food basket, the nutritionists say all regions are afflicted. Case in point, south-western Uganda has the highest number of stunted children.
Over-nutrition, on the other hand, is a condition that occurs when the “body gets more nutrients than it needs, to the point that the person becomes unhealthy.“ The condition usually presents with obesity and is common in urban areas.

Measures
It is said that malnutrition starts from the womb; when a mother feeds poorly, the child also feeds poorly and it is estimated that one in every 10 children born in Uganda is already malnourished.
This puts the child at risk of dying from diseases like malaria, diarrhoea and HIV/AIDS. The estimated number of child deaths as a result of diseases closely related to malnutrition is 47%.
Overall, 60% of deaths in child deaths are attributed to malnutrition in all its forms (low birth weight, underweight and Vitamin A deficiency). Clearly, there is need to address the problem to reduce child mortality.
In addition, curbing malnutrition would reduce on mental retardation, brain damage and physical disabilities in children. These occur because of an Iodine Deficiency Disorder (IDD), largely found in children from mountainous areas in western Uganda who eat locally mined salt as opposed to iodised salt.
The mothers in these regions also face the same problem, putting their children at the risk of having lower learning abilities, poor speech and hearing disabilities.
In 2009, 2,100 children were born as cretins as a result of IDD in mothers, while those who lack Vitamin A could suffer blindness.
As a measure, Uganda, through the National Development Plan of 2010-2015, hopes to achieve sustainable economic development through increased agricultural productivity, improved health and survival and improved human capacity development through education.

dnabiruma@observer.ug
http://www.observer.ug/index.php?option=com_content&view=article&id=11357:what-is-malnutrition&catid=58:health-living&Itemid=89

MALNUTRITION: Pakistan heled by Merlin

12 Aug 2010
Now into its second week, the Pakistan flooding emergency has already affected more than 14 million people and claimed the lives of 1,600. The floods may only be the start of the crisis, though.
Our health workers in Pakistan are already reporting more cases of diarrhoea, caused by people drinking dirty water. Reports also state that 80 per cent of Pakistan's crops have been destroyed by the floods. In Upper Swat, the figure is thought to be closer to 100 per cent.
The last harvest took place before the monsoon season, so all the crops for the year were picked immediately before the floods hit. Since then, all these food stores have been washed away.
Where diarrhoea and food shortages combine, widespread malnutrition results.
Patrick Parsons, Merlin's Country Director in Pakistan, says:
"There are huge issues with access to safe, clean drinking water. The increased reports of diarrhoea make malnutrition look more and more likely."
No end in sight
The situation in Pakistan has been significantly worsened by further heavy rainfall and flash flooding across the country over the last few days. Worryingly, the monsoon rain season has only just begun.
Since Merlin's emergency response began we have treated over 30,000 patients. To tackle the growing needs, we are operating 28 health clinics and 16 mobile health teams in three of the worst-affected districts.
Our medical experts are treating survivors and delivering much-needed emergency food supplements and distributing water purification tablets to combat the risk of malnutrition, as well as basic hygiene kits to help stop the spread of infectious diseases.
http://www.alertnet.org/thenews/fromthefield/218926/722e18a740bd1a6038e18439ad3fec30.htm

MALNUTRITION: Southern Sudan

At dawn, an old woman in a bright but tattered dress picked her way along a muddy, trash-strewn path. She stopped at a pile of garbage and carefully removed the remains of a dirty onion. Then she sat and slowly began to eat it for breakfast.
I was in southern Sudan as part of a medical team from Massachusetts General Hospital — my first foray into international medical work. The goal of this pilot project was to teach Sudanese hospital staffs the basics of newborn care and resuscitation.
Southern Sudan has barely emerged from more than two decades of civil war, in which at least two million people died. Since the war ended in 2005, many of the aid agencies that were sustaining education, nutrition and health care have pulled out, and despite the heroic efforts of those that remain, most citizens’ day-to-day existence is shocking. As a tent camp manager in the town of Wau observed, “The peace is killing us.”
Pictures of these war-torn regions do no justice to the physical and emotional realities. It was boiling hot each day as we trekked over dusty, crater-filled streets filled with noisy motorcycles and honking jitneys. After lugging our equipment to the hospital, we were sweaty and exhausted by the time we began rounds in the children’s ward with the sole pediatrician.
The hospital was beyond imagination. Beds were overflowing with infants and children, many of them desperately ill with malaria, malnutrition or viral diseases. Babies with diarrhea wore no diapers, but were wrapped in simple cloths that their mothers would rinse out periodically in the hospital yard.
Patients of all ages were urinating and defecating around the hospital grounds. Water to wash hands was not available in the ward — only outside at a common pump. The smells were overwhelming, and the heat was barely relieved by a single ceiling fan. Flies buzzed around, and persistent tubercular coughs filled the air.
Filled with admiration for the medical teams — and aware that the doctors had not been paid for six months — we offered our meager help. We began our courses with a willing group of medical assistants, nurses and the local pediatrician, who served as translator.
Much to our surprise, we were called one day to practice what we were preaching. A mother who had lost three babies was about to deliver her fourth. The obstetrician asked that we be present in the delivery room.
The baby came out limp and blue, making no effort to breathe. While the medical team watched, we re-enacted the resuscitation we had been teaching all week.
Finally the baby began to cry and then, with great effort, to breathe. We were exultant. Not only had we saved the baby, but the staff could see the value of our teaching.
Such is the smugness of do-gooders. When we visited the next day, our wonder baby was grunting and struggling to breathe. Since there are no intensive care units, he was going to have to make it on his own. His mother looked sad and tired.
Meanwhile, in the next room, a grandmother sat looking out the window while a tightly wrapped premature baby lay on the bed. As I unwrapped the baby, I realized the infant was cold and still. The grandmotherly stoicism suggested that death was a familiar companion.
Southern Sudan is still defined by a tribal culture, with groups living in wood huts with dirt floors. Children are not in school. In Juba, the region’s capital city, garbage is piled high, the stores are empty of fresh food and canned goods are covered with dust. Water is dirty. Toilets are mostly nonexistent, or just filthy holes in the ground.
The challenges of providing health care in this setting were so overwhelming that I found myself questioning the mission. What were we doing there? Whom were we helping? Or were we simply assuaging our first-world consciences? Shouldn’t basic needs — roads, water, food, housing — be met before all else?
The aid groups still stationed in Juba seemed to be a mixed blessing. Many Africans have written about the passivity and dependency spawned by an “aid culture,” and I could see for myself the lack of initiative that seemed to pervade the towns. Trucks of soldiers frequently roared by, bristling with armed militants. Had years of tribal warfare, malnutrition, disease, heat and poverty sapped the will of the once proud Sudanese?
Few would question the inspiring rescue efforts taking place in Haiti. The outpouring of food, dollars and labor affirms our humanity. But when human suffering goes from the acute to the chronic stage, does the strategy need to be revised? Caregivers who have spent years in Sudan suggest that without sweeping changes in government and infrastructure, the misery will continue.
I returned home feeling less happy about our successful baby-saving exercise, and wondering what would happen to that child. Still, I remembered the oft-quoted observation that if you help one person, then you help one person. That is surely better than doing nothing, and I am continually inspired by the many health professionals who selflessly offer their time and expertise to those in dire need.
But I resolved that my future efforts would be more defined. As a neophyte in international health, I needed more direction. Partners in Health, a Boston-based charity that has done pioneering work in H.I.V. prevention and treatment of tuberculosis, has demonstrated that focused, strategic efforts will produce the best results.
My baptism in the world of international health was bewildering and challenging, and I left with many unanswered questions. And while I may not return to Sudan, I hope to return to an area of need where I might make a small difference.
Dr. Victoria McEvoy, an assistant professor of pediatrics at Harvard Medical School, is the author of “The 24/7 Baby Doctor.”
http://www.nytimes.com/2010/08/10/health/10case.html?_r=1

Global, regional, and national causes of child mortality in 2008: a systematic analysis.

BACKGROUND:
Up-to-date information on the causes of child deaths is crucial to guide global efforts to improve child survival. We report new estimates for 2008 of the major causes of death in children younger than 5 years.
METHODS:
We used multicause proportionate mortality models to estimate deaths in neonates aged 0-27 days and children aged 1-59 months, and selected single-cause disease models and analysis of vital registration data when available to estimate causes of child deaths. New data from China and India permitted national data to be used for these countries instead of predictions based on global statistical models, as was done previously. We estimated proportional causes of death for 193 countries, and by application of these proportions to the country-specific mortality rates in children younger than 5 years and birth rates, the numbers of deaths by cause were calculated for countries, regions, and the world.
FINDINGS:
Of the estimated 8.795 million deaths in children younger than 5 years worldwide in 2008, infectious diseases caused 68% (5.970 million), with the largest percentages due to pneumonia (18%, 1.575 million, uncertainty range [UR] 1.046 million-1.874 million), diarrhoea (15%, 1.336 million, 0.822 million-2.004 million), and malaria (8%, 0.732 million, 0.601 million-0.851 million). 41% (3.575 million) of deaths occurred in neonates, and the most important single causes were preterm birth complications (12%, 1.033 million, UR 0.717 million-1.216 million), birth asphyxia (9%, 0.814 million, 0.563 million-0.997 million), sepsis (6%, 0.521 million, 0.356 million-0.735 million), and pneumonia (4%, 0.386 million, 0.264 million-0.545 million). 49% (4.294 million) of child deaths occurred in five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan, and China.
INTERPRETATION:
These country-specific estimates of the major causes of child deaths should help to focus national programmes and donor assistance. Achievement of Millennium Development Goal 4, to reduce child mortality by two-thirds, is only possible if the high numbers of deaths are addressed by maternal, newborn, and child health interventions.
FUNDING:
WHO, UNICEF, and Bill & Melinda Gates Foundation.
Lancet. 2010 May 11.