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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