Conclusion

Unfortunately, it is time for me to bring this blog to a close. Throughout the weeks I have raised the issues of disease, open-defecation, taboos and lack of discussion in water and sanitation. Alongside these issues, I have assessed possible solutions to the water and sanitation crisis which include the Millennium Development Goals, World Toilet Day, community involvement, the opening of the discussion about shit, and finally the Sustainable Development Goals; all of which have their own successes and failures.

I began this blog with a very limited and preconceived notion of what water and sanitation in Sub-Saharan Africa was like, I never imagined it would be such a complex topic. From reading extensively about water and sanitation I have become truly shocked by some of the realities, one thing I find so frustrating is the link between water and sanitation and health care. From my blog about the diseases in Sub-Saharan Africa, I highlighted how many of these diseases are easily prevented and eradicated by the provision of adequate water and sanitation, however, thousands of people still die every day from water and sanitation related diseases, which is so infuriating. What I also find infuriating is that it makes economic sense to invest in water and sanitation, globally $260 billion is lost annually due to inadequate water and sanitation. But, it is estimated to cost only $60 billion annually to provide adequate water and sanitation worldwide (World Health Organisation, 2012), to me it seems frustrating that this has not occurred as there are clearly so many benefits to the provision of water and sanitation.

Despite the above paragraph water and sanitation has not been all doom and gloom within Sub-Saharan Africa. Community-led approaches have helped encourage the building and use of latrines across Sub-Saharan Africa, which has been very successful for some countries, for example in Sierra Leone alone this approach has resulted in 300 villages becoming open-defecation free. The Guinea Worm which once infected 3.5 million people in 1986, now only infects 22 people a year (2015), this reduction has been a result of improvements in education about contaminating drinking water sources. All of these successes lead us towards a more equitable world in regards of water and sanitation.

As we edge ever close to 2030 (the end of the Sustainable Development Goals) we still have a long way to go in providing adequate water and sanitation in Sub-Saharan Africa and the rest of the world. But perhaps we should not just rely on the Sustainable Development Goals to achieve world-wide water and sanitation, but instead use our voice to share the message that providing water and sanitation is important, or perhaps like Matt Damon you may wish to go on strike (figure 1)? It has been a real joy writing this blog, and it has really opened my eyes to the issues of water and sanitation around the world, hopefully in 2030 we will all be able to celebrate when SDG 6 has been met. 

Figure 1 - Matt Damon goes on strike 

Source: https://www.youtube.com/watch?v=jQCqNop3CIg

Sustainable Development Goals

Throughout my blog, I have looked at the past and the present, and so it seems fitting that my penultimate post should finish on a look to the future. The Millennium Development Goals (MDGs) aimed to improve the lives of the most impoverished people in the world, they were successful in many aspects, but still had a long way to go, this resulted in the formation of the Sustainable Development Goals (SDGs), and the creation of hope for a more equal future. The SDGs are an extension and improvement of the MDGs. The MDGs were designed to get us halfway to worldwide equality, whereas the SDGs are designed to make the world achieve global equality. In September 2015, the UN released the 17 SDGs (Figure 1), these goals strive to make the world a more sustainable and equitable place by 2030 (Fleming et al, 2017).

Figure 1 - The Sustainable Development Goals 

Source: http://www.undp.org/content/undp/en/home/sustainable-development-goals.html

Why are the Sustainable Development goals better than the Millennium Development Goals?

Rather than just being an extension of the MDGs the SDGs have been improved, below I have listed some of the improvements:

• The MDGs were orchestrated by OECD countries with little input from medium and low-income countries, whereas the SDGs have resulted from discussion among numerous countries, meaning input has come from developed and developing countries. 
• The SDGs encourage more community participation in achieving the goals, meaning the SDGs are not as much of a top-down approach as the MDGs. 
• The SDGs highlight how important global peace is, something which was not included in the MDGs. Peaceful countries are more likely to develop and economically prosper.

Sustainable Development Goal 6 - Ensure availability and sustainable management of  water and sanitation for all

SDG 6 is a great advancement on MDG 7, which aimed to halve the proportion of the population without access to water and sanitation by 2015. SDG 6 incorporates hygiene, something which was not previously addressed, from my previous blog posts I have highlighted the importance of practising good hygiene to help eliminate diseases associated with poor water and sanitation - so this is a great start! SDG 6 has numerous goals incorporated into it that it hopes to achieve by 2030, and so I have included a few of my favourite below:

• End open defecation.
• Provide access to water and sanitation for all.
• Improve the management and handling of sanitation, and, 
• Strengthen the role of community participation. 

Achieving or making substantial advances in SDG 6 is vital to the success of other goals. Adequate water and sanitation facilities are needed to create sustainable towns and cities, which in turn helps meet SDG 11. Meeting SDG 6 also increases peoples general health and well-being, SDG 3 (Milan, 2017). Perhaps one of the most important relationships between SDGs is between goals 5 and 6, improving access to adequate water and sanitation in the long-run increases women's abilities to work due to a reduction in time spent collecting water and dealing with sanitary needs, thus helping to reduce gender inequalities.

From the graphs produced by the World Health Organisation 2017 report, it is clear to see that Sub-Saharan Africa has a long way to go before achieving the SDGs. Figure 2 displays the world's basic sanitation coverage, showing Sub-Saharan Africa to be lagging significantly behind the rest of the world. Figure 3 shows high numbers of open defecation still being practised in Sub-Saharan Africa, Sub-Saharan Africa is one of the only regions (Oceania being the other) in the world where rates of open-defecation are increasing, this is a result of high rates of urbanisation. However, what some might find comforting in these figures is that Sub-Saharan Africa is not battling these issues alone, there is a global crisis, which requires a global response - which the SDGs aim to deliver. 

Figure 2 - Coverage of sanitation across the world. 

Source: http://www.who.int/mediacentre/news/releases/2017/launch-version-report-jmp-water-sanitation-hygiene.pdf

Figure 3 - Regional trends in open-defecation 

Source: http://www.who.int/mediacentre/news/releases/2017/launch-version-report-jmp-water-sanitation-hygiene.pdf

Due to the numerous ways the SDGs are looking to battle water and sanitation issues around the world I have been unable to highlight them all in this blog, and so here is the link for the 2017 report, which provides the most up-to-date figures and a breakdown of SDG6: 

http://www.who.int/mediacentre/news/releases/2017/launch-version-report-jmp-water-sanitation-hygiene.pdf

A look to the future

The SDGs started in September 2015, having been in operation for just over two years it is difficult to truly assess the impact they have had so far and the impact they will have, however, several academics have made their predictions, both optimistic and pessimistic, regarding the 2030 end date of the SDGs. 

Pessimists argue that the SDGs are just an extension of decades of failed development promises. The 1960s was dubbed 'The Development Decade', really very little development had occurred, and so the 1970s was named the 'The Second Development Decade', once more there were mediocre advancements in development (Madeley, 2015). By the 1980s traction began to grow in an attempt to reduce poverty, this saw poverty and hunger reduction campaigns rise, with the Hunger Campaign aiming to end world hunger by 2000, and of course, you know this was unsuccessful. The MDGs failed to universally meet all of its targets, and so the pessimists and sceptics are not holding the SDGs as the answer to the problems of our world, due to decades of developmental failure. 

However, many optimists see the SDGs as something different, this is the first universal approach to tackling the world's greatest issues, it has required great consultation from countries all around the world, including low-income countries, for example, Amina Mohammed, a former Nigerian politician has been one of the leading voices within the SDG movement. I managed to stumble across a fascinating TEDtalk by Michael Green who truly believes achieving the SDG by 2030 is manageable. And so, I wish to leave this blog post on the optimistic stance taken by Michael Green, although we might need to make some changes soon, take a look:

Source: https://www.youtube.com/watch?v=o08ykAqLOxk

New Year, new calendar

Just a quick blog from me today. As we approach the New Year I thought it would be a good idea to share with you all the World Banks 2018 water calendar.

Every year the World Bank creates a calendar about the most serious issues facing water worldwide, the 2018 calendar has a specific focus on the provision of adequate water and sanitation. Throughout the 12 cartoon pictures, the World Bank has highlighted the main issues facing water and sanitation. Below I have included my favourite. Each of the months come with a fact about water and sanitation which I have included in the caption of each figure. 

Figure 1: January 

'$114 billion per year in overall global investment is needed to meet SDG targets for water supply and sanitation'
Source: http://www.worldbank.org/en/news/feature/2017/12/14/water-cartoon-calendar-2018

Figure 2: February

2 in 5 people live in parts of the world affected by water stress
Source: http://www.worldbank.org/en/news/feature/2017/12/14/water-cartoon-calendar-2018

Figure 3: March 

2.1 billion people lack access to safe, readily available water at home.

Source: http://www.worldbank.org/en/news/feature/2017/12/14/water-cartoon-calendar-2018

Figure 4: May 

Sub-Saharan Africa loses more than 40 billion potential work hours per year collecting water.

Source: http://www.worldbank.org/en/news/feature/2017/12/14/water-cartoon-calendar-2018

Figure 5: October 

Avoidable diarrheal diseases kill one child every minute

Source: http://www.worldbank.org/en/news/feature/2017/12/14/water-cartoon-calendar-2018

I think this is a great idea by the World Bank to try and highlight the issues of water and sanitation in a 'fun' way. Unfortunately, however, I do not see the calendar being used by the masses, perhaps only those who work for the World Bank and those who are greatly interested in water and sanitation around the world. And so, I urge all of you to make the World Bank water and sanitation your calendar for 2018, you can download it here: 

http://www.worldbank.org/en/news/feature/2017/12/14/water-cartoon-calendar-2018

Great news for Lilongwe!

"Lilongwe City faces considerable water security challenges that must be addressed urgently to serve the growing population and enhance economic activities in the capital"

Greg Toulmin - World Bank Country Manager for Malawi.

Lilongwe's population of one million are currently struggling with inadequate water and sanitation facilities. Rapid urbanisation is leaving the city unable to meet growing demands, resulting in many using unsafe water supplies. 95% of Lilongwe's population is currently not connected to a sewer system, leaving many having their waste collected as illustrated in figure 1.

Figure 1: Waste collection in Lilongwe

Source: https://www.dutchwatersector.com/news-events/news/14840-vei-extends-water-operator-partnership-with-lilongwe-water-board-malawi.html

Scrolling through the news I found a very promising story for Malawi's capital city, Lilongwe. On the 20th December, the World Bank approved a US$100 million investment into the capital city's water and sanitation facilities. The World Bank is investing in a six-year-long scheme called Lilongwe Water and Sanitation Project (LWSP).

Lilongwe's existing water and sanitation systems are under great pressure as a result of rapid urbanisation into the capital city. The LWSP is not only going to improve existing infrastructure but also expand the network, which involves increasing the distribution network by 186km to parts of the city which are currently un-piped. Currently, only 5% of Lilongwe's population is served by a sewer system, consisting of a mix of latrines and septic tanks. The LWSP aims to improve sanitation facilities for 250,000 people in Lilongwe, these are just a few of the key changes being made in Lilongwe:

• Construction of four storage reservoirs with a combined capacity of 2,600m3.
• Reducing the amount of water lost due to leakages.
• Installation of 5000 new sewer connections.
• Construction of 8000 improved sanitation facilities.
• Upgrading the existing Kauma sewage system. 
• Improving sanitation facilities in 10 schools.

This investment into Lilongwe's water and sanitation is great news, however, a report created by the World Bank has highlighted that there are significant risks involved with this investment, some of the most important risks I have listed below:

• Corruption and fraud 
• Limited experience - The Lilongwe Water Board has limited experience in managing complex infrastructural projects, meaning there is a high risk involved with the deliverance of this project.
• Social risks - The project is expected to disturb settlements, however, there has been no mention as to whether these people will be re-housed, and so there are negative social implications of completing this project.
• Climatic risks - Lilongwe in recent years has been experiencing difficulties with unpredictable rainfall and droughts as a result of global warming, which has reduced the amount of water available for extraction. This creates large issues for the future of Lilongwe and Malawi as it appears that water stress conditions are likely to get worse. 

Despite the risks I have mentioned this investment is a great step forward for Lilongwe, and I hope investments like this continue throughout the whole of sub-Saharan Africa, inching the continent ever closer to good quality water and sanitation for all.

If you wish to have a more in-depth knowledge of the Lilongwe Water and Sanitation Project here is the recently published World Bank Report:
http://documents.worldbank.org/curated/en/419171513998119839/pdf/MALAWI-PAD-12012017.pdf 

The Guinea Worm Eradication Programme

Contributing to my previous blog about diseases in sub-Saharan Africa, this blog looks at the Guinea Worm Disease, a disease that can easily be eradicated by providing access to safe and protected drinking water. As the Guinea Worm Disease is mostly found in remote villages, there is often not scope for boreholes or wells, therefore changing behaviour towards water sources is the most appropriate way to provide safe water.

The Guinea Worm Disease, also known as Dracunculiasis, is a water-borne disease caused by the parasite Dracunculus medinensis.  In the 1980s the Carter Centre, a charitable organisation founded by the former US President Carter, alongside other supranational bodies, campaigned to eradicate the Guinea Worm Disease globally by 1995 (Ciantia et al, 2013). Before the eradication programme, Guinea Worm was a largely unreported disease, Nigeria estimated that it annually only had around 3000 cases in the 1980s, however, in 1989 Nigeria carried out a nationwide survey which returned with an actual figure of 650,000 cases annually (Hopkins and Ruiz-Tiben, 2011). The 1995 goal of eradication was not achieved and was therefore extended to 2009, again there were still isolated cases of Guinea Worm and the eradication date was set in line with the Millennium Development Goals (Ciantia et al, 2013).

Causes:

Eradicating the Guinea Worm Disease directly relies on the provision of safe drinking water (Hopkins, 1981). Humans can become infected with the Guinea Worm Disease by drinking stagnant surface water. This water has been infected as a result of copepods eating the young of the parasite, thus infesting the water. Figure 1 below shows an illustration of how a water source can become contaminated.

Figure 1

Source: http://edition.cnn.com/2010/WORLD/africa/10/08/guinea.worm.eradication/index.html 

Once infected the parasite remains in the body for over a year, growing up to 1 metre long. Towards the end of the year, the worm begins to slowly and painfully exit the human body through a ruptured blister on the skin, usually found on the legs or feet. The Guinea Worm Disease is not usually fatal but can have great consequences on villages, due to the painful way the worm exits the body this can result in the infected person being temporarily disabled for around 1 to 2 months, leaving the infected unable to work or attend school (Hopkins and Ruiz-Tiben, 2011). The Guinea Worm Disease commonly has no long-term effects, however, some cases report early onset arthritis, and 0.5% of cases result in permanent disability (Hopkins, 1981). 

Solutions:

There is no medical cure for the Guinea Worm Disease. Providing water from boreholes and wells would be the ideal way of preventing this parasitic disease, however, this is often a very slow and expensive approach, and often not suitable for remote villages (Hopkins and Ruiz-Tiben, 2011), and therefore other approaches are required to tackle the disease.

Through the Guinea Worm Eradication Programme (GWEP), numerous approaches were taken to make the water supply free from Guinea Worm. A vital aspect of the eradication programme involved sending village volunteers to villages impacted by Guinea Worm. The role of the village volunteers was: to educate about disease prevention, record and report cases of Guinea Worm, distribute cloth filters among villagers, and finally administer first aid to those suffering from the disease (Ciantia et al, 2013).

The programme began with educating the villages susceptible to the disease. Many did not understand that the reason behind their illness, was due to water they had drunk a year ago, many blamed bad spirits (Ciantia et al, 2013), the programme was able to change the villager's perception by magnifying a glass of the contaminated water showing the parasites inside, this was met with disgust from many villagers. This education focused on teaching the infected individuals to stay out of the water and taught the villagers how to effectively filter water, with a special emphasis on educating females, as they are the primary water collectors (Hopkins and Ruiz-Tiben, 2011).

Alongside this education, the programme provided finely woven cloths to villages to use as water filters (Hopkins and Ruiz-Tiben, 2011). The programme also provided portable 'pipe filters', a straw that could be hung around one's neck which allowed water to be filtered immediately, this meant that those who were travelling on long journeys were able to filter water effectively (Hopkins and Ruiz-Tiben, 2011).

The success of the Guinea Worm eradication programme:

The Guinea Worm Eradication Programme was an extremely successful way of combating water-borne disease through introducing behavioural changes and low-cost filtering techniques. Figure 2 illustrates the huge success of the Guinea Worm Eradication Programme, the disease which was originally found in 20 countries is now only found in four, Chad, Ethiopia, Mali and South Sudan.

Figure 2 

Source: https://www.cdc.gov/globalhealth/infographics/guinea_worm.htm

The Guinea Worm disease is the perfect example of an illness that does not need to exist, the only way one can get the disease is through drinking contaminated water. By providing the world access to a safe water source, the Guinea Worm disease would be completely eradicated and would help to further eradicate other diseases. 

The burden of disease

In 2002, it had been estimated that the disease burden, caused unnecessarily from water, sanitation and hygiene, accounted for  4% of deaths worldwide, and 5.7% of all diseases worldwide (Prüss et al, 2002). Despite these figures appearing to be low numbers in the grand scheme of things, these are all preventable deaths and diseases if the appropriate water and sanitation requirements are achieved. The World Health Organisation estimates that improvements in sanitation and water provisions could prevent 9.1% of the total burden of disease worldwide, which equates to approximately 6.3% of deaths (Clasen, 2011).

The first half of this blog will look at a few diseases caused by inadequate water and sanitation facilities. The second half will look at why these diseases are such a burden to sub-Saharan Africa.

Common diseases

This section of the blog will briefly highlight a few of the diseases affecting sub-Saharan Africa today as a result of inadequate water and sanitation facilities. Many of these diseases come with very simple interventions, such as frequent hand-washing, however, without the appropriate water and sanitation facilities, these diseases continue to plague countries in sub-Saharan Africa.

Trachoma:

Trachoma is an infectious disease which commonly ends in blindness; figure 1 illustrates the lifecycle of the disease. The incidence of trachoma can be reduced dramatically when access to water is increased. In order to reduce the incidence of trachoma, hygiene needs to be improved. Face washing and access to a latrine have been linked to reducing rates of trachoma. A study of Ethiopian households revealed that having a 'lack of access to a latrine increased the risk of having active trachoma by 4.36-fold but perhaps more important, absence of a clean face...increased the odds of having trachoma by 7.59-fold' (Cook and Mariotti, 2011:181). The International Trachoma Initiative implemented the SAFE initiative (figure 2), highlighting the steps needed to prevent trachoma, two steps involved the use of water.

'lack of access to a latrine increased the risk of having active trachoma by 4.36-fold but perhaps more important, absence of a clean face...increased the odds of having trachoma by 7.59-fold'

Figure 1: The Life Cycle of Trachoma

Source: https://healthfoxx.com/trachoma-definition-symptoms-treatment-pictures/ 

Figure 2: International Trachoma SAFE initiative

Source: http://www.globalcontagions.com/2017/02/ntds-trachoma-blindness-caused-by-chlamydia-bacteria-yes-that-chlamydia/

Hookworm:

Hookworms are the result of open defecation due to a lack of adequate sanitation. There are three ways in which the incidence of hookworm can be greatly reduced, first by providing adequate sanitation facilities to reduce open defecation. Secondly, the provision of a sufficient water source to enable the washing of food. Thirdly, behavioural changes are required, often it is children who practice open defecation, changing behaviour towards open-defecation will reduce the incidence of hookworm (Blackburn and Barry, 2011). Unfortunately, though, it is more cost effective to provide deworming treatment per person than a latrine, as proven by studies in Vietnam (Blackburn and Barry, 2011).

Diarrhoea:

Diarrhoea is a leading cause of death globally. Diarrhoea can be prevented by disposing of waste appropriately, improving water quality, improving personal hygiene and washing food before consumption (Zarocostas, 2008). The World Health Organisation estimates 88% of all diarrhoeal deaths are a result of inadequate water and sanitation facilities (Fitzwater et al, 2011). However, if water is to be treated at the household level, 39% of diarrhoeal cases would be reduced, further reductions would take place with the education of handwashing and appropriate waste disposal (Fitzwater et al, 2011).

The burden of disease on sub-Saharan Africa

The diseases described above and many more can easily be prevented through the provision of adequate water and sanitation, for example, piped water and latrines. However, for many, this is not reality. These diseases can have great impacts on the lives of the infected and are often blamed for restricting development, I have highlighted below the three areas which I think are the most important.

The burden on the extended family:

One perhaps overlooked impact is the strain these diseases place on the extended family. If the parents die, as a result of water-related diseases, this can leave the extended family, such as grandparents, with the role of raising the children. Taking on this role comes with a huge financial burden, with many extended families being often unable to financially assist the orphans, placing the extended family at risk of falling into poverty, or the children being at a high risk of being placed in an orphanage, all of which are poor outcomes for an easily preventable death.

Lost education:

Many children who fall ill due to these preventable diseases face missing days, weeks or even months of school. This can have detrimental impacts on their future. The less education a child receives, the less prosperous their future is likely to be, they are likely to be unable to reach their full potential in the job market and therefore maintain in the vicious cycle of poverty, increasing attendance of school drastically reduces the incidence of poverty within a country (Ayiro, 2012), and with the introduction of adequate water and sanitation facilities the issue of missed school days can be reduced.

Fall in productivity:

This can be at both the local and the national scale.  Locally families are impacted when members of the family have to take time off work due to illness, this can lead to a reduction of income leaving families finding it difficult to make ends meet, it also reduces families financial saving potential (Boutayeb, 2010). Whereas on the national scale the higher the incidence of disease, the lower the rate of development, for example, the more a person works this increases their income (something which would not happen if they are regularly ill). An increase in income leads to an increase in consumer spending, this then drives the economy leading to growth in GDP and development (World Health Organisation, 2009).

Conclusion

The diseases discussed in this blog and more can easily be eradicated, or, casualties greatly reduced if the provision of adequate sanitation and water is implemented across sub-Saharan Africa. Next week’s blog will be looking at how a successful intervention programme has almost completely eradicated the Guinea Worm Disease in sub-Saharan Africa.

Let's talk about shit

My previous impromptu blog about World Toilet Day was discussing an entire day dedicated globally to discussing the toilet. In this blog, I am going to do a complete 180 and look at reasons as to why people don’t talk about shit, and how we can get them talking. Below you will see a TEDtalk done by Rose George (figure 1), this video gave me a lot of inspiration for this blog entry and so I thought I would share it with all of you. 

Figure 1

Source: https://www.youtube.com/watch?v=ZmSF9gVz9pg

Why don't we talk about shit more?

We have all heard of the phrase 'sex sells', and it couldn't be truer. Sanitation isn't at the forefront of aid efforts, or governmental decisions; it is something we are embarrassed to talk about, something we believe should be kept private, something which isn't sexy - this needs to change. There is no universal term for shit (see figure 1). People are embarrassed or offended to use certain words making poo difficult to talk about, particularly for those who are in a position of power, whether this is a political position or the head of an NGO (Borel, 2013). There are numerous ways we try to be discreet about having a poo, for example, men in Kenyan communities will say they are 'answering the call of nature' when they need the toilet, and many find the use of the word shit extremely offensive and vulgar, preferring the term haja kubwa (David, 2011), a word which is not used universally. It is not just in the developing world where there is a shyness when it comes to sanitation, in the UK, toilet roll companies such as Andrex are not direct about their product (see figure 2), but instead show a puppy running around with toilet roll (Borel, 2013). This reluctance to talk about shit makes global sanitation issues very difficult to engage with. The Gates Foundation was one of the first organisations to start talking about shit using mediums such as competitions among universities, which has been pivotal in getting people to start talking about shit in academia and among NGOs. With The Gates Foundation as a springboard, this has allowed for numerous new approaches to appear encouraging people to talk about shit and changing their behaviour, in the last decade the approach Community-Led Total Sanitation has become increasingly popular within Sub-Saharan Africa. 

Figure 2 

Source: https://www.youtube.com/watch?v=yx6gZAKWLHk

Community-led total sanitation (CLTS)

CLTS is a method of making sanitation issues important within communities by making them talk and work together to reduce open-defecation (OD) and improve toilet facilities. CLTS comes with many challenges, often people are reluctant to talk about shit due to embarrassment, there are also many cultural taboos that need to be addressed. If cultural taboos are not addressed, regardless of whether latrines are available they will not be used, below I have bullet-pointed a few common taboos and superstitions regarding shit in SSA:

• Pooing over someone else's poo is considered to be bad luck (Zombo, 2010).
• It is a taboo for a father-in-law and his daughter-in-law's poo to mix (Bwire, 2010).
• In Kenya, it is believed a person's poo can be used to bewitch them, this stops people using communal latrines and continue to practice OD due to fear of witchcraft (Bwire, 2010).
• In Ethiopia it is considered a taboo for both men and women to share the same latrine, also the sight of faeces is unacceptable resulting in continuing OD (Chambers and Myers, 2016).

CLTS has a variety of techniques to overcome these embarrassments and taboos. CLTS believe that rather than sitting communities down and lecturing them over the importance of good sanitation and hygiene, the most effective outcomes come from generating disgust through demonstrations. Typical demonstrations include putting a pile of food next to a pile of poo and getting the villagers to watch the flies jump back and forth between the two, people were mostly disgusted by the thought of ingesting someone else’s shit (George, 2012), you have to shock people to change their behaviour (Zombo, 2010). Shocking people is the easy part, getting them to talk shit is difficult. CLTS gets people talking by introducing them to shit through songs, proverbs, stories and laughter (Zombo, 2010). CLTS has found laughter to be the most effective tool, in Sierra Leone CLTS has created a lighthearted song to highlight how easily poo can spread:

"Kaka na kaka, big wan, small wan, na the same foot den get for waka go na chop or water."

(A shit is a shit, big shit or small shit, they all have legs and feet that move them to food and water.)

(Zombo, 2010).

In Sierra Leone alone the CLTS approach has helped 300 villages become OD free (Zombo, 2010). The successes of CLTS are very important, OD and unsafe sanitation facilities can be deadly or cause serious illness amongst communities, and so it is of utmost importance we talk about shit. 

Why is it important to talk about shit?

Every day 4000 children die from diarrhoea, a number that is higher than HIV/AIDS, tuberculosis and measles combined (Borel, 2013), however, it receives far less attention. A single gram of poo can contain upwards of 50 diseases, many of which can be fatal (Borel, 2013). Contracting one of these many diseases can have several negative multiplier effects, such as a lack of productivity in the economy, death, embarrassment, and social isolation; it is estimated that each year $260 billion is lost as a result of inadequate sanitation globally (Borel, 2013). This leads me to next week's blog which will be focusing on water and sanitation related diseases, and the cost they have on many lives.