Talking dirty: how to save a million livesV. CURTISLondon School of Hygiene and Tropical Medicine, London, UKInfectious diseases are still the number one threat to public health in developing countries. Diarrhoealdiseases alone are responsible for the deaths of at least 2 million children yearly – hygiene is paramount toresolving this problem. The function of hygienic behaviour is to prevent the transmission of the agents ofinfection. The most effective way of stopping infection is to stop faecal material getting into the child’senvironment by safe disposal of faeces and washing hands with soap once faecal material hascontaminated them in the home. A review of the literature on handwashing puts it top in a list of possibleinterventions to prevent diarrhoea. Handwashing with soap has been calculated to save a million lives.However, few people do wash their hands with soap at these critical times. Obtaining a massive increase inhandwashing worldwide requires a sea-change in thinking. Initial results from a new programme led by theWorld Bank, with many partner organisations, suggest that health is low on people’s list of motives,rather, hands are washed to remove dirt, to rinse food off after eating, to make hands look and smell good,and as an act of motherly caring. Professional consumer and market research agencies are being used towork with the soap industry to design professional communications programmes to reach wholepopulations in Ghana and India. Tools and techniques for marketing handwashing and for measuring theactual impact on behaviour will be applied in new public–private handwashing programmes, which are tostart up soon in Nepal, China, Peru and Senegal.Keywords: Infectious disease; diarrhoea; public health; handwashing; soap; effective practice; public–private partnership; marketing.IntroductionDiarrhoeal diseases are the forgotten killers of children. Every year about 2 million children diefrom these neglected diseases (WHO Report 2002), the equivalent of a full jumbo jet every 2 h.However, there are ways to prevent these deaths, and one of the best is also one of the simplest:washing hands with soap.According to the WHO, the Acute Respiratory Tract Infections (ARIs), and the diarrhoealdiseases (DDs) together account for more than 6 million deaths each year. Public health effortsare, however, directed elsewhere. For instance, the Global Fund convened by the Group ofEight (G8) is targeted at AIDS, tuberculosis and malaria (www.globalfundatm.org). Similarly,the Global Alliance on Vaccines and Immunisation (GAVI) is targeting HIV and malaria(www.vaccinealliance.org). A further large-scale international partnership aims to ‘Roll BackMalaria’ (www.rbm.who.int). Why is it that only these diseases are receiving all the attention?Why are the diarrhoeal and respiratory tract infections seemingly being neglected?Correspondence: V. Curtis, London School of Hygiene and Tropical Medicine, Keppel Street, LondonWC1E 7HT, UK. Tel.: + 442079272214. Fax: + 442076367843. E-mail: [email protected] Journal ofEnvironmental Health Research 13, S 73 – S79 (June 2003)ISSN 0960-3123 printed/ISSN 1369-1619 online/03/S10S73-07#2003 Taylor & Francis LtdDOI: 10.1080/0960312031000102822There are a number of reasons for this. Firstly, evidence about the effectiveness and cost-effectiveness of approaches to control and prevent ARIs and DDs has been confusing orlacking. Secondly, interventions to reduce diarrhoeal diseases fall under the scope of manyinstitutions and are hence the ‘darling’ of none. Thirdly, initiatives, such as the water decade ofthe 1980s and the global push for the introduction of oral rehydration, have lost momentum.The diarrhoeal diseases lack champions, possibly because this is a difficult issue to makeattractive, dealing as it does, with faeces. Though respiratory tract infections kill more childrenthan diarrhoea does, no simple, preventive interventions have yet been proposed that can bepractically implemented on a wide scale. But there are signs that the tide may be turning. Thispaper reviews what we know about interventions to prevent diarrhoea, and proposes that wemay be at a turning point, with better evidence for new, feasible and effective interventions,such as the promotion of handwashing with soap, and renewed political will to defeat thesekiller infections. We further propose that handwashing may also turn out to be a key means ofpreventing respiratory infections.How to prevent diarrhoeal diseases?Diarrhoeal diseases come from excreta. At least 20 viral, bacterial and protozoan entericpathogens, including Salmonella spp., Shigella spp., Vibrio cholerae and rotavirus provoke theshedding of liquids from the gut, leading to dehydration, loss of nutrients, complications andsometimes death. This shedding of liquids used to be seen as a defence mechanism by the bodyto get rid of microbes, but might better be thought of as a way in which the parasitic organismsmanipulate their hosts to enable the parasite progeny to reach new hosts more easily (Ewald1994). Hygiene is hard to maintain when large volumes of liquid stools are being pumped out ofa sick child. One gram of faeces can contain as many as 100 million viruses and 10 millionbacteria. Faeces should therefore be regarded as ‘public enemy No. 1’.If diarrhoeal disease is to be prevented, ways have to be found of stopping the pathogenicagents from getting from the faeces of one person to the mouth of another. The best means ofdoing this is, of course, the safe disposal of faeces. Whether a flush toilet is installed with asewage system, a Ventilated Improved Pit latrine, or a simple hole in the ground, faecal materialhas to be removed from the home, which is, after all, the place where the susceptible childspends most of his or her time. And toilet facilities have to be used, especially for the disposal ofinfant and child stools. Handling child stools safely is, clearly, not always easy, when nappies,potties, wipes and other ‘technological’ aids are hard to come by. A second major route bywhich faecal material gets into the household environment is on hands that have not beenwashed after coming into contact with excreta. Studies from developing countries across theworld show that on average less than 20% of mothers wash their hands with soap after cleaningup a child or after going to the toilet themselves. Even in the UK, with all modern facilities, onestudy showed
View Full Document
Unlocking...