Leaders | Of sanity and sanitation

Bangladesh shows how to keep children alive

First, dig pit latrines. Then persuade people to use them

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FOR adventurous travellers, it is merely an embarrassing nuisance. But among poor people diarrhoea is a killer. As many as half a million children are thought to die every year from enteric diseases, including cholera and dysentery. Repeated infections also weaken them, laying them open to attack from other killers such as pneumonia. Diarrhoea can even change a population’s appearance. One reason Indian children are shorter than sub-Saharan African children from families of similar means is that they fall sick more often.

So it is delightful to report that one of Asia’s poorest countries, Bangladesh, is making huge progress against this scourge (see article). In one part of the country with particularly good data, deaths from diarrhoea and other enteric diseases have fallen by 90% in the past two decades. Along with a far-reaching vaccination programme and steady economic growth, that has helped drive down the number of childhood deaths. In 1990 the under-five death rate in Bangladesh was 54% higher than the world average. Now it is 16% lower.

In a country with more than 160m inhabitants, this represents a vast decline in human misery. And Bangladesh’s success holds lessons for other poor countries that are trying to beat back disease. The first is that cheap, simple, imperfect solutions are often good enough.

In an ideal world, with limitless cash and universally good governance, everybody would drink chlorinated water out of taps and flush their sewage through pipes into treatment plants. In the real world, however, you can go a long way with half-measures. Bangladeshi villages are studded with small pit latrines and tubewells for water. Most are built by the householders themselves, or by labourers whom they pay out of their own pockets. Although the tubewells are often alarmingly close to the latrines, that seems to be fine. Researchers have found that germs do not travel far underground. What matters is having lots of water pumps and lots of toilets. The more convenient they are, the more people will use them.

A second lesson is that hardware is not enough—the software of human behaviour is just as important. Bangladesh’s neighbour, India, has subsidised and built a great many latrines. Despite that effort (and although the country is roughly twice as wealthy as Bangladesh per head) many Indians continue to defecate in the open. Bangladesh’s government and charities have built latrines, too, but they have worked harder to stigmatise open defecation. Often they install latrines for the poor and then prod richer folk into following their example. A new, surprising, finding is that this works better than expecting people to copy their social superiors.

Many lives have been saved by parents doing something simple. Beginning in the 1960s American military doctors and researchers in Dhaka developed a therapy for acute diarrhoea—a sweet, salty oral rehydration solution. This is now dirt cheap and widely available. At the last count, fully 84% of Bangladeshi parents with stricken children fed it to them (only a third saw a doctor). Thinly populated African countries are struggling to match that. One promising idea is to distribute the sachets along with Coca-Cola—which gets everywhere.

Bog standard

The simplest message is about the importance of basic hygiene. Bacteria often live on people’s hands, and multiply on food. A mother in a poor country who hand-feeds cool porridge to her infant can introduce many more germs than the nipper would get from drinking water from a tap. Randomised controlled trials in Bangladesh and elsewhere have shown that teaching mothers to wash their hands and reheat food can wipe out most bugs. The training is cheap. The benefits, in disease avoided and lives saved, are enormous.

This article appeared in the Leaders section of the print edition under the headline "Now wash your hands"

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