Now wash your hands

Every day, 5,000 children die because of poor sanitation. Villagers in Madagascar tell Barbara Gunne

"What did we tell you last time we were here?" shouts the man with the microphone.

"Wash Your Hands!" yell back 200 children aged around 5-11. They are seated on the grass verges of the crossroads at Amparatanana, a village on Madagascar's east coast, the audience for a travelling marionette show spreading the word about hygienic use of latrines, keeping water uncontaminated and, above all, hand-washing.

As Mr Clean upbraids Mr Dirty for his bad habits, the children scold along; as Mr Dirty goes home to his wife clutching his stomach with diarrhoea pains, they giggle uncontrollably.

The puppets are part of this region's response to the international rural water, sanitation and hygiene (WASH) project that got under way in Madagascar soon after the country suffered a severe cholera outbreak early in 2000. Water Aid, the key international NGO in this field in the country, is working here with local partners, the Frères Saint-Gabriel.

Yvon, one of the FSG hygiene educators, regularly updates the puppet-show scripts to keep the children hooked on the message. His aim, he told me, is to use storylines as close to the children's home lives as possible, so that hand-washing becomes second nature. This sounds easy until you consider that, in the middle of our own culture of abundant soap and hot water, medical staff still manage to spread MRSA because they fail to wash their hands between patients.

In fact, educators like Yvon have to work miracles. The wood and thatch huts of these east-coast villages are tightly packed in to small compounds without running water. Soap is a luxury and such latrines as exist are poorly designed, badly sited and almost always a health hazard.

Yet the children do absorb the hand-washing message and the impact of the singing, dancing, 12-foot-high marionettes has been rapid in the schools. Albertine-Rosalie Clode, a teacher for 37 years, whom we met fetching water at the new water kiosk, told us that her school of 1,686 pupils aged 6-17 was already seeing improvements.

"Awareness has changed in just one year [since WaterAid and FSG came to this village], particularly among the children. When the ice-cream seller comes by, they ask him, 'What water did you use to make it?' The puppets show families as they know them. In the past we could have 20 children off sick out of a class of 44-60, particularly in the rainy season," says Mme Clode, who lives alongside the families of her pupils, and whose many grandchildren are as vulnerable to the debilitating water-borne diseases of the area as the children of poorer neighbours.

The hand-washing message - enormously effective in its own right - also underscores the urgent need to speed up provision of clean water and appropriate sanitation. The poorest villagers here still depend on river collection for some water and still manage without toilets. The few existing wells, some provided only in the past few years, are uncovered and vulnerable to impurities from the buckets of different users. And, as the area has an unusually high water table, there is considerable risk of groundwater contamination from badly designed and sited latrines.

The proportion of people with safe water and adequate sanitation in the villages of the Analanjirofo district (to which New Statesman subscri bers' contributions are directed) is estimated to be as low as 9 per cent, inflicting a heavy penalty on the local economy in hours lost to education and productive work.

Persuading officialdom of the economic good sense of developing a national sanitation strategy has been an important part of WaterAid's work in Madagascar. In 2003, its research showed that the country was losing five million working days and 3.5 million schooldays each year as a result of ill-health caused by dirty water and inadequate sanitation. To this must be added the human cost. Every day around the globe, 5,000 children die from the diarrhoeal diseases associated with contaminated water; it is the second-biggest childhood killer after tuberculosis and respiratory disease.

"Sanitation is the invisible sector," says Lucky Lowe, WaterAid's representative in Madagascar. She confirms that it is far easier to get politicians to talk about water and to promise pumps and new mains supplies than it is to get a constructive debate going about pit latrines. Clean water is a good election promise. Talking about building latrines that help make that possible isn't.

On top of the hard statistics must be added less tangible human costs: the drudgery of walking miles each day to collect contaminated water for the family, or the sheer unpleasantness and indignity of using a foul-smelling, poorly draining communal latrine day in and day out. Or, for those who have nowhere else, a patch of land that has become accepted as the local open-air toilet. We should not suppose that force of habit appreciably lessens the disgust.

Disgust was certainly written on the face of eight-year-old Sidonie when we talked to her mother before the puppet show about the field "toilet" in her village. We had gone there with Claudia Lemalade, FSG's hygiene educator for Amparatanana, to talk to a family due to receive one of the project's new latrines. We stood on a pathway that led down to a small river with the typical wooden huts on one side and lush vegetation - banana plants, coconut palms and vivid, flowering shrubs - on the other.

The path, even before the rainy season, was wet in patches and drained into the small river below, as, inevitably, would the open-air defecation site a few yards from the path.

Claudia chatted with three generations of one family: Toto Suzanne, her daughter Marceline and Sidonie, Marceline's daughter. Finally the family was to get a latrine - paying around 10 per cent of the cost price (approximately £30). They had been able to pay their £3 contribution as and when they liked, in whatever instalments suited them, but the contribution had to be paid upfront before work could begin on the structure. The family had been targeted because of financial need; FSG has set families' contributions low enough to put latrines within reach of most of the poorest.

It is not hard to understand why Marceline wanted to divert her family's limited budget to pay for a latrine. "Down there is where we have to go. After dark it is really horrible for the children." Sidonie refused to discuss the matter though she had been lively enough before. As we talked, a young woman came up the hill from the river carrying a bucket. "This is to wash my baby's feet," she told us, as if to assure us that the murky water would not be used for drinking or cooking. For household use, she explained, she had limited access to a neighbour's well (itself also contaminated, according to Claudia). She understood clearly the WASH message that the puppets would later be blasting out across the village, but what, she asked us, could she do?

There is a standard image of hopeless poverty that we see on television and in poster campaigns, images usually connected with appeals for emergency aid. Yet life in these villages is far from miserable or hopeless. Men and women are visibly industrious - most have family members in work as fishermen or farmers; good-quality food is available and at this time of year the trees are laden with coconuts, lychees and jackfruit. The literacy rate of 71 per cent is reasonably high and, despite a high poverty rate of 70 per cent, when news spreads of a visit from the WaterAid people, the women come out to meet us in well-kept best clothes.

Quite small investments in sanitation could turn around that high poverty rate. But at the moment, for the vast majority of Madagascar's people, energy that could be put into education and wealth creation is being dissipated by avoidable ill-health. The Madagascan economy loses to illness around 300 times the amount the government has allocated to sanitation in its national budget, according to WaterAid.

WaterAid estimates that if Madagascar is to achieve its Millennium Development Goals (MDGs), the country has to increase the number of rural households being newly supplied with adequate sanitation, from roughly 485 households per month now to more than 12,000.

More and carefully focused international aid is, as always, one solution. Determined local politicians unafraid to champion an unpopular cause is another. Mme Clode said she intends to run as a local councillor next year and wants politicians to speak up for the Cinderella sector of sanitation.

Of Madagascar's local MDG targets, she said: "I expected things to move faster. Many things need doing. For example, there is no water in the market in Fenerive Est [the nearby town]. And we need more latrines." Against current orthodoxy, Mme Clode believes in communal latrines as a way of speeding things up, while government and international policy very much favours and directs finance towards family-based facilities, on the grounds that only families will keep them clean enough to prevent water-borne disease.

But her concern about the slippage in local millennium targets exactly mirrors WaterAid's concern about the big picture. The millennium goals included halving the proportion of those living without water and sanitation by 2015. Of all the targets (including poverty, education, health and environmental concerns), sanitation is most off-track. At the present rate of progress, the goal would be reached 61 years late. Yet hopes of eradicating extreme poverty and hunger depend more on sorting out safe sanitation than on any other intervention.

A report commissioned by WaterAid and released in October spelled out that, for every dollar spent on sanitation, the return on investment is roughly $9. Worldwide, the need is enormous, but tiny interventions and local ingenuity can still have a big impact. In Madagascar, a puppet show costing just £31 can make 200 children laugh. And possibly save their lives.

Sanitation by numbers

£15 Cost per head of hygiene education and good sanitation
£31 Cost of puppet show promoting hand-washing
£31.25 Cost of effective latrine with simple concrete pit lining
$23.4m Most expensive toilet in the world (for space shuttle)
$10bn Annual cost of achieving Millennium Goals
$20bn Global annual spending on bottled mineral water
1.1bn People worldwide without access to clean water
2.6bn People worldwide without an adequate toilet

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This article first appeared in the 03 December 2007 issue of the New Statesman, Russia’s fragile future

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Brothers in blood: how Putin has helped Assad tear Syria apart

The Syrian catastrophe has created the worst humanitarian crisis since the end of the Second World War. And the world watches helplessly as Putin and Assad commit war crimes.

Sometimes we know the names. We know Omran Daqneesh, the five-year-old boy who, covered in mud and dust, was pictured on the back seat of an ambulance in the aftermath of an air attack. We know his name because pictures and a video of him were released on social media and travelled around the world. The outrage that followed was widespread and sincere, the image of the dazed little boy seeming to symbolise the greater plight of the beleaguered residents of Aleppo. But then the moment passed. Few will know that a few days later doctors announced that Omran’s elder brother Ali, who was injured in the same air strike, had died from his injuries. He was ten.

Sometimes we know the names of the babies pulled from the rubble of collapsed buildings – occasionally alive, but often dead; or the names of the children weeping over lost parents; or the women grieving over lost husbands and children; or the elderly simply waiting (and sometimes wanting) to die.

We know Bana Alabed, the seven-year-old girl trapped inside Aleppo whose Twitter account has gone viral in recent weeks. “Hi I’m Bana I’m 7 years old girl in Aleppo [sic],” reads the on-page description. “I & my mom want to tell about the bombing here. Thank you.”

A series of pictures depicts Alabed and her mother, Fatemah, struggling to live as normal a life as possible, one showing the little girl sitting at an MDF desk with a book. Behind her, in the corner, is a doll. “Good afternoon from #Aleppo,” says the caption in English. “I’m reading to forget the war.”

The conflict, however, is never far away. Alabed, whose mother taught her English, has repeatedly tweeted her own fears about dying, followed by stoic messages of defiance whenever the immediate threat of an impending air strike passes. On the morning of 3 October, her words were simply: “Hello world we are still alive.” On 17 October, Fatemah tweeted: “The airstrikes ended in the morning, all the last night was raining bombs.”

But in most cases we never know the names of the victims of air assaults led by Presidents Bashar al-Assad and Vladimir Putin. One of the most haunting images to emerge in recent weeks was that of a mother and child, killed while sleeping in the same bed. The scene had an eerily preserved-in-amber feel to it: a snapshot of snatched lives, frozen in the act of dying. Pictures of ruined buildings and distraught civilians have become routine now, holding our attention briefly – if at all.

As many as 500,000 people are believed to have been killed since the beginning of the Syrian uprising in early 2011. According to a report released in February this year by the Syrian Centre for Policy Research, a further 1.9 million have been wounded. Taken together, those figures alone account for 11.5 per cent of Syria’s pre-revolutionary population. Combine that with the number of Syrians who have been displaced – more than ten million (almost 50 per cent of the population) – and the sheer scale of the disaster becomes apparent.

The conflict has become the worst humanitarian crisis since the Second World War. Today it centres on Aleppo, in north-west Syria, one of the oldest continuously inhabited cities in the world, and a cradle of human civilisation. Various conquerors from the Mongols to the French have fought battles there but none, so it would seem, has been quite as ruthless or committed to the city’s annihilation as Bashar al-Assad.

Aleppo remains the most significant urban centre to have been captured by the anti-Assad rebels, most of whom will (by now) be strongly influenced by an Islamist world-view. Indeed, the most prominent fighting groups on the rebel side are overwhelmingly Islamist in their troop composition and beliefs, a sad marker of Western failures to support secular forces that led the anti-regime resistance in the incipient phases of the uprising.

Yet Aleppo remains too important to fail. Although rebel forces succeeded in capturing only half of the city – the western side remained firmly in the control of the regime – the symbolism of anti-Assad forces holding ground in Syria’s second city (which also served as the country’s economic hub) has buoyed the rebel movement.

Assad is more brazen and bullish than at any other point since eastern Aleppo fell into rebel hands in July 2012. That optimism is born of a strategy that has already worked in other parts of the country where the regime’s troops have slowly encircled rebel-held areas and then sealed them off. Nothing can leave, and nothing can enter. Once the ground forces seal off an area, an aerial campaign of barrel bombs and missile attacks from both Syrian and Russian fighter jets inevitably follows.

To get a sense of just how terrible the aerial campaign has been, consider that the United States accused the Russian air force of potential war crimes when a UN aid convoy was bombed just west of Aleppo last month. It was carrying food and medicines when it was hit. Since then, the UK and France have said that Russia’s bombardment of Aleppo amounts to a war crime.

Putin’s support has come as a boon to Assad ever since Russia formally entered the conflict in September 2015. Despite his administration already using Iranian forces and aligned groups such as the Lebanese Shia militia Hezbollah, rebels had continued to make significant gains throughout the early months of 2015. The most important of these was the capture of Idlib city, 40 miles from Aleppo, which presented Assad with two problems. The first was that it dented the official narrative of revanchist military successes by his forces. The ­second was that it handed the rebels power in a province adjoining Latakia Governorate in the west, where Syria’s Alawites are largely concentrated (Russia has an airbase in an area south-east of the city of Latakia). The Alawites are a heterodox Shia sect to which the Assad family belongs, and which forms the core of their support base.

Keen to reverse these gains – and others made elsewhere – Assad enlisted Putin, given Russia’s long-standing interests in, and ties to, Syria. The Kremlin has long regarded Syria as an important ally, and has served as the country’s main arms supplier for the past decade. There are important assets to preserve, too, such as the Russian naval base in the port city of Tartus on the Mediterranean, which was first established during the Soviet era.

For his part, Putin has felt emboldened by events. The world is changing – not just in the Middle East and North Africa, where the
contours of power continue to be recast, but also closer to home in Ukraine, where the pro-Russian president Viktor Yanukovych was overthrown in 2014.

The West is still haunted by the 2003 invasion of Iraq and has been reluctant to be drawn too deeply into the Syrian War. In 2013, the Assad regime used chemical weapons against its own people. This was a violation of President Barack Obama’s so-called red line against the use of chemical weapons, but no retaliatory action came and there was nothing to prevent the Kremlin from using force to shape events in Syria – as it had done in Ukraine.

All of this has marked a new phase of brutality in a conflict already noted for its barbarism. Civilians who avoid death from combined Russo-Syrian air assaults suffer under Assad’s strategy of “starve or submit”, in which supplies are withheld from besieged areas, slowly choking off those ­inside. It has been used to devastating effect against civilians in towns such as Madaya and in Daraya, on the outskirts of Damascus, both of which fell to government control after being sealed off from the outside world for several years. Such a strategy is not designed to deliver quick victories, however. Consider how the residents of Daraya defied Assad’s forces for four years before capitulating in August 2016.

Assad and his allies (Putin, Iran, Hezbollah) have decided to punish and brutalise, deliberately, civilian populations in rebel-held areas. To invert the famous aphorism attributed to Chairman Mao, they hope to dredge the sea in which the revolutionaries swim. And so, it is the 300,000 residents of eastern Aleppo who must suffer now.




It’s easy to lose track of precisely what is happening in the Syrian War as parcels of land swap hands between rebels and the regime. Assad’s forces first began encircling Aleppo at the start of July this year and succeeded in imposing a siege by the middle of that month, after cutting off the last of two rebel-controlled supply routes into the city. The first was the Castello Road, which leads from the town of Handarat into the north-western part of ­rebel-controlled territory. The second route, via the Ramouseh district (which led into the south-western end of the city), had already been sealed off.

The closure lasted for roughly four to five weeks before the rebels re-established access. Aleppo is too important for them, and the siege has forced various groups to work together in breaking it. The effort was led by Jaish al-Fateh (JaF, the “Army of Conquest”), an umbrella group and command structure for several of the most prominent jihadist and Islamist groups operating in northern Syria. JaF also co-ordinated the Idlib military campaigns. One of its key members is Jabhat Fateh al-Sham (JFS, “the Syrian Conquest Front”), which was previously known as Jabhat al-Nusra (JaN or “the Supporters’ Front”) and was recognised as al-Qaeda’s official chapter in Syria.

Several months before the regime began its assault on Aleppo, rebel groups in the north recognised the deteriorating situation there, stemming principally from Russian air strikes. As a result, al-Qaeda urged the various factions to merge and work together to counteract not just Assad, but also Putin. Even the global leader of al-Qaeda, Ayman al-Zawahiri, issued a speech last May titled “Go Forth to Syria”, in which he called on all fighting groups to unite in order to consolidate their control across the north. This opened the way at the end of July for Jabhat al-Nusra to declare that it was formally severing its links with al-Qaeda. It “rebranded” as Jabhat Fateh al-Sham.

There are two reasons for doing this. The first is to erode partisanship among the Islamist groups, forcing them to set aside differences and narrow their ambitions in favour of the greater goal – in this case, the breaking of the siege of Aleppo, while also deepening rebel control across the north. The second aim of rebranding is to win popular support by portraying themselves as fighting in the service of ordinary civilians.

Groups such as JFS and others are succeeding in both of these goals. Responding to the abandoned and assaulted residents of Aleppo, they have repeatedly demonstrated their commitment to alleviating the humanitarian crisis. Much of their messaging echoes this theme. The group’s English-language spokesman is Mostafa Mahamed, an Egyptian who previously lived in Australia. “[JFS] is deeply embedded in society, made up from the average Syrian people,” he explained on Twitter, after the group decoupled from al-Qaeda. “We will gladly lay down our lives before being forced into a situation that does not serve the people we are fighting for . . . jihad today is bigger than us, bigger than our differences.”

It is indisputable that this ethos of “fighting for the people” has endeared the group to civilians living in besieged areas – even when those civilians don’t necessarily agree with the full spectrum of its religious beliefs or political positions. That goodwill was only reinforced when the group helped break the siege of Aleppo (in which approximately 500 rebels were killed) in August, if only for a few days. Assad reasserted control within a week, and entrapped the residents again in the middle of that month. The rebels are now planning how to break the siege decisively, but have not yet launched a major counteroffensive.




A freelance American journalist and film-maker, Bilal Abdul Kareem, who has reported on rebel movements inside Syria more intimately than most, has found himself among those trapped inside eastern Aleppo since the siege was restored seven weeks ago. “We came here expecting a two- or three-day trip,” he told me during an interview over Skype.

Life inside is becoming insufferable for civilians, Abdul Kareem said; every building is potted and scarred by shrapnel damage. Those whose homes remain standing are the lucky ones. “Your day consists of nothing,” he said. “There’s no work, there’s no fuel, no industrial zone, no food to sell. ­People sit around and chit-chat, drink tea, and that’s all they do.”

Food supplies are already running low, with most people limiting themselves to basics of chickpeas and groats – crushed grains such as oats or wheat. Sealed off from the rest of the world, those inside preoccupy themselves with survival and wait for the next wave of attacks.

It is tempting to ask why the inhabitants of Aleppo did not flee when they had the chance. Indeed, the Assad regime routinely accuses the rebels of preventing civilians from leaving besieged areas, though there is no evidence to support this view. On 17 October Russia and the Syrian regime said they would halt their bombardment for eight hours on 20 October to allow rebels and civilians to evacuate the city.

In truth, what choice do the civilians have? Most do not trust Assad and they are therefore unwilling to move into regime-administered areas. The alternative is to become refugees, with all the uncertainties and trials associated with that. For instance, refugees have found themselves subject to sectarian violence in Lebanon, and they have few opportunities to find employment in Lebanon, Turkey or Jordan, the three countries where most of the fleeing Syrians have found shelter.

For them, merely to exist in rebel territory is an act of defiance, which is precisely why Assad’s forces make no effort to distinguish between combatants and civilians in rebel areas. To be present is a crime.

The effects of this have been devastating. A spokesman for the Syrian American Medical Society told Middle East Eye, an online news portal, that in July, Syrian and Russian jets had hit medical facilities in rebel-held territory every 17 hours.

Only a few hospitals and medical staff remain. The physical conditions are primitive and perilous. Doctors work in makeshift facilities – a former flat, a commercial garage – which makes them unable to provide anything beyond basic emergency care. In-patient facilities are non-existent, not just because of high demand from those newly injured in fresh attacks, but also from fear that the facility itself will be targeted. “People are literally shuffled out of the hospital with IV [intravenous drips] in their arms,” Abdul Kareem says.

The West’s indifference to all this – coupled with its occasional pious pronouncements and diplomatic dithering – has squandered any goodwill Washington might once have had among Syria’s beleaguered civilians. When Sergey Lavrov, Russia’s foreign minister, and John Kerry, the US secretary of state, agreed a ceasefire in September it lasted barely two days because they overlooked the fears of those trapped inside eastern Aleppo.

The deal had stated that no party would try to capture any new territory. That might seem reasonable enough but given that the ceasefire came into effect just days after Assad re-established the siege of Aleppo, those on the inside were being asked, in effect, to acquiesce to their own starvation.

Deprived of food and medication, no one trusted Assad to negotiate access in good faith, especially after he thwarted UN efforts to deliver aid. “People saw it as a conspiracy,” Abdul Kareem told me. Moreover, there were no significant groups inside eastern Aleppo that claimed to have accepted the terms of the ceasefire in the first place. Kerry had negotiated on their behalf without approval and without securing any humanitarian concessions.

“What planet are these people on?” Abdul Kareem asked. “[Do] they think people will turn on their protectors, for people who didn’t do them any good? They look to JFS and Ahrar [Ahrar al-Sham is one of the Islamist groups fighting in JAF]. Western intervention is pie in the sky.”

The rise of these reactionary rebels is a direct result of liberal elements not being strongly supported at any stage in the conflict. Left to fend for themselves, many have deserted their cause. Those who have persisted not only risk the constant threat of being killed by Russo-Syrian bombs, but are also at threat from jihadist elements operating in rebel areas. That much was clear when remnants of the secular opposition protested against the leader of JFS, Abu Mohammed al-Golani, in the southern Idlib town of Maarat al-Nouman earlier this year. Many of those who did were arrested by jihadists and intimidated into silence.

Whereas liberals are fragmented and frayed, the Islamist rebels continue to coalesce into an ever more coherent unit. The overwhelming might of Russian airpower has convinced them of the need to form a united front in order to pool their resources and co-ordinate their efforts. That is one of the reasons why a jihadist group called Jund al-Aqsa (“Soldiers of al-Aqsa”) announced early this month that it was disbanding and being absorbed into JFS.

Herein lies the real story of how Aleppo – and, indeed, Syria itself – has been delivered to the jihadists. A conspiracy of all the external parties has forged a menacing millenarian movement that is embedded in civil society and communities across the north. Whether Aleppo falls or not, the jihadists will endure.

Shiraz Maher is a contributing writer for the New Statesman and a member of the war studies department at King’s College London

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at King’s College London’s International Centre for the Study of Radicalisation.

This article first appeared in the 20 October 2016 issue of the New Statesman, Brothers in blood