ABUJA, Nigeria – The role of water, sanitation and hygiene (WASH) practitioners in Nigeria’s response to the COVID-19 pandemic cannot be overemphasized as working on the front line of the fight against the coronavirus requires both courage and commitment.
Mr Benson Attah, National Coordinator of the Society for Water and Sanitation (NEWSAN) – an umbrella body for civil society organizations (CSOs) working in the WASH sector – is a WASH practitioner, whose commitment has been unwavering in implementing and monitoring Nigeria’s COVID-19 response framework.
When Mr Attah heard about the number of COVID-19 cases in the country, his first action was to alert NEWSAN’s state chapters to immediately commence community sensitization and ensure compliance with the safety protocols of the World Health Organization and Nigeria Centre for Disease Control (NCDC). With his colleagues at NEWSAN, Mr Attah also created an action plan for the pandemic at various state levels, which became a vital tool for awareness creation and COVID-19 prevention activities at the community level.
“The COVID-19 pandemic didn’t come as a surprise and my experience with professional emergency management equipped me for this type of emergency,” he says. “We had thought the N1H1 virus between 2008 and 2009 was going to be a pandemic but it was not. It was just a matter of time.
Nigeria’s coronavirus cases have begun to soar with no less than 29,286 laboratory confirmed cases as of 7 July 2020. Mr Attah states that the ongoing community spread of the disease is concerning, but more worrisome are Nigeria’s hygiene and sanitation statistics.
Mr Attah explains that these statistics expose worrying gaps both in light of COVID-19 safety protocol’s insistence on personal hygiene and Nigeria’s growing population, which is currently estimated at 200 million people.
Also of significant concern is the impact of these statistics on rural and hard-to-reach communities in Nigeria, where the likelihood of misinformation about the disease is high and medical interventions can be challenging.
The pandemic has overstretched Nigeria’s already weak healthcare sector, which suffers from a shortage of manpower and equipment, requiring many to step in as frontline workers to support the fight against the virus. Despite the challenges, Mr Attah, who is a member of Nigeria’s Federal Capital Territory’s COVID-19 task force team, says he is not scared to be on the frontline.
I would not be part of the team if I was scared. I keep myself safe and sane by making sure that I don’t compromise my safety and I religiously follow preventive protocols.
WSSCC has been providing support to the Nigerian government in response to the pandemic by tailoring one of its flagship initiatives, Rural Sanitation and Hygiene Programme in Nigeria (RUSHPIN), and supporting organizations like NEWSAN to address COVID-19 related issues.
Coronavirus brings several points of reflection for WASH experts in Nigeria.
“In NEWSAN, we have always regarded WASH as the ‘gateway to development’ as it affects every aspect of development, health, education, economy, labour and productivity. In Nigeria, the WASH sector should be more professional in its set up and outlook,” explains Mr Attah.
“Government across different levels should take immediate responsibility by recognizing the prominent role of the WASH CSOs in ensuring that coronavirus does not spread beyond its present point and, this should be allowed to gradually transit and consolidate into an all-round development that is sustainable.”
ANTANANARIVO, Madagascar – Dr Fano Randriamanantsoa is the Community Mobilization Specialist at the Fonds d’Appui pour l’Assainissement (FAA), WSSCC’s Global Sanitation Fund programme in Madagascar.
A medical doctor by training, Fano Randriamanantsoa has worked in the WASH sector for over ten years. His role with FAA is to coordinate and monitor sanitation and hygiene activities in communities that have been declared open defecation-free (post-ODF activities). He spoke with us on how his work has been impacted by COVID-19.
WSSCC: Could you tell us about your work?
Dr Fano Randriamanantsoa, Community Mobilization Specialist at the Fonds d’Appui pour l’Assainissement: I coordinate and monitor the post-ODF activities of the implementing agencies we fund. For that, I first define specialities needed to support these agencies in their post-ODF activities, and then I recruit consultants for each speciality, including, among others, sanitation marketing, capacity building and Village Saving and Loan Association (VSLA) expertise.
A key aspect of my work is going in the field to collect feedback, learn and share knowledge, and test with partners the approaches we have developed.
According to WSSCC’s “EQND” handbook, post-ODF activities refers to any structured activity taking place in a community after they have been certified as ODF, with objectives ranging from sustaining changed sanitation and hygiene behaviour to promoting the use of more hygienic and sustainable facilities and addressing other aspects of environmental hygiene, including safe water treatment and solid waste management.
WSSCC: Based on your experience, what are some of the challenges to sustainability for ODF communities in Madagascar?
Dr Randriamanantsoa: I can give four prevailing challenges in our work:
Behavioural challenges arise when residents are not fully convinced that they don’t want to eat “shit” anymore. It is the result of using the wrong approach. Implementers often tend to be either too strict or too easygoing. Sometimes, they get too involved in the community, preventing the population from taking full responsibility for improving their own sanitation and hygiene.
Economic hardship is a challenge we often encounter in the field, where the majority live on less than 2 dollars a day. It automatically excludes the poorest as they are unable to afford even the most basic sanitation and hygiene services.
Non-access to resilient and sustainable infrastructure is tied to economic hardship. Due to limited resources, communities cannot build durable facilities and instead resort to using cheaper local materials, which are not sustainable and tend to become non-functional either because of weather conditions or overuse.
Environmental challenge includes external factors that aren’t necessarily sanitation and hygiene-related but potentially affect them, such as weather conditions, soil type, political atmosphere, unsupportive local leaders, and crowd-gathering cultural events.
WSSCC: When communities are having difficulty sustaining their ODF status, what support does the programme provide to address the situation?
Dr Randriamanantsoa: We have seen many cases of slippage over the years, and what we do is provide implementing agencies with tools and approaches to tackle them.
For instance, when a community is experiencing slippage due to behavioural issues, we facilitate the establishment of the Local Community Governance (GLC), where residents are trained in methods to uphold changed behaviours. Where it is caused by economic hardship, we guide the agencies in the creation of a VSLA to help community members, especially the poorest, maintain or upgrade their facilities.
As for slippage originating from non-resilient infrastructure, we encourage agencies to promote sanitation marketing with local technicians, who have been trained to build durable latrines.
Slippage is used to describe the return to previous unhygienic behaviours due to the inability of some or all community members to continue to meet all ODF criteria.
WSSCC: Again, based on your experience, can you talk about the difference between working in rural areas and sub-urban/urban areas?
Dr Randriamanantsoa: We have seen that working in rural areas is more productive thanks mainly to our ability to use what is called continuum community-led total sanitation (CLTS) —implemented from the beginning until long after ODF certification—without any disruption.
CLTS is more effective in rural areas because of existing socio-cultural norms such as tight-knit communities, respect for elders and handcrafting skills. Most rural communities are also more open to innovations from outside as long as those innovations don’t contradict their values. On the contrary, the closer you move to urban settings, the more challenging post-ODF work becomes. We usually combine various approaches in these areas and sometimes request the help of other partners to carry out activities.
WSSCC: How has COVID-19 affected your post-ODF activity programming?
Dr Randriamanantsoa: Because of the lockdown, we have suspended most activities in our 19,000 ODF-certified communities. We have, however, a few implementing agencies carrying out post-ODF activities while adhering to COVID-19 prevention rules. In other cases, the agencies follow up remotely by connecting with members of Local Community Governance (GLC) and Local Institution Governance (GLI).
Otun Adewale recounts the story of two doctors in a private hospital in Abuja, Nigeria. One who washes his hands after he is with a patient, the other who does not. One who contracts Covid-19 and one who does not.
Adewale is a senior medical officer in maternal and child health. Since the beginning of the year, the doctor has been working with Wellbeing Foundation Africa (WBFA), an organization that focuses on women’s and children’s health in Nigeria through education, advocacy, and better care. For the past few months, Adewale and the team at WBFA have had a new mission: breaking the transmission of Covid-19 by improving water, sanitation, and hygiene practices.
“This story actually got me interested,” Adewale told Circle of Blue, referring to the parable of the two doctors. “That as simple as handwashing can be, as simple as observing these precautionary measures can be, it can actually save you from the dangers of Covid-19. The other person who takes it for levity is facing the music now.”
Though it had a late start, the disease is spreading through Nigeria with increasing speed. As of June 30, Nigeria had more than 25,000 confirmed Covid-19 cases, the second highest number in Africa. Forty percent of the cases were recorded in the last two weeks. Vulnerable populations such as frontline healthcare workers are at a greater risk without proper water or hygiene.
That is where organizations like WBFA step in. The foundation notes that hospitals and clinics often have inadequate water supplies and lack soap to prevent disease transmission. According to Rita Momoh, a midwife with WBFA, expecting mothers might be scared doctors will bring Covid-19 to their homes when they have a checkup, or the mothers may not be comfortable going to the healthcare facility when they need to.
“The atmosphere surrounding handwashing and personal hygiene in response to Covid-19 [in Nigeria] can be rated very, very low.” Adewale explained. “A majority of Nigeria still believes Covid-19 isn’t real. Some believe it is a scam.” He added: “People will only take responsibility for their health when they are convinced of Covid-19.”
‘It All Comes Back to WASH’
A leading organization for water, sanitation, and hygiene before Covid-19, the foundation has since intensified its educational outreach due to the virus. WBFA workers teach classes to healthcare facility employees and engage with hospital officials to install handwashing stations. The foundation holds meetings with community leaders and passes out flyers in the local language so residents can understand and value the information. WBFA also has a virtual program for adolescents across states, to educate and demonstrate how to wash.
Most rural communities do not have easy access to clean water, and residents will often travel long distances to find wells or creeks. Urban Nigeria has better water and sanitation access rates than rural areas, yet cities face their own challenges with the virus. The expansion of unplanned settlements such as slums puts more lives at risk because of crowded living conditions and inadequate water, sanitation, and hygiene, known collectively by their acronym WASH.
According to WaterAid, 57 million people in Nigeria do not have access to clean water, and 130 million do not have basic sanitation or hygiene. This is in a country of about 200 million people. Nigeria operates as a federation of 36 states, each with a different institutional framework. The fragmentation has its drawbacks. According to Alero Roberts at WBFA, the water board that is responsible for clean water and sanitation in every state is often aging and ineffective.
“What this pandemic has taught us is how easily our health system can be stretched beyond capacity,” Roberts told Circle of Blue. “We’re talking infection prevention and control, but with infection prevention and control we’re talking water and sanitation hygiene. It all comes back to WASH.”
For now, WBFA will continue to educate individuals and advocate for healthcare adaptation in Nigeria. So when a patient needs a checkup, there’s no doubt about handwashing and proper procedures.
“Because what we need to do is change hearts and minds,” Roberts said.
In African traditional folklore, we have a proverb: “Every dance starts with a clap.” Just watch us and you’ll find this proverb is indeed true. We clap at least once from a primordial pre-instinct, to find our rhythm and set the tone, before we begin to dip, sway, and swirl.
But we have another African proverb that says, “You cannot clap with one hand.” And so I embarked on clapping with two hands, advocating on behalf of women, girls, and children around the world.
In hindsight, the roots of my global work are found in my baby’s nursery. I was expecting twins but tragically, only one child would survive. I returned home with my new baby daughter and replicated in the nursery what I had seen in the neonatal intensive care unit. I quickly had water pipes installed so her nursery would have a handwashing basin just inside by the door. I knew for my newborn to be safe, I needed two clean hands.
In 2003, I became a very young and very new First Lady to the north-central Nigerian state of Kwara, where my husband was elected governor. I took time to get to know the people, their needs, and the basic services that existed for Kwara’s 3 million inhabitants. I would visit dilapidated hospitals and schools, untouched since 1974. Whenever I wanted to shake hands or hold a baby, and wished to wash my hands, water was not available and there was invariably a 10-minute or more delay while someone would have to fetch a bowl of water from a well, borehole, or tank.
Photo Credit: Wellbeing Foundation Africa
I continue to encounter the inability to wash hands in places of critical care. In April 2018, I visited my Wellbeing Foundation Africa’s MamaCare Midwives Antenatal and Postnatal Session at a Primary Health Care Centre in Abuja, Nigeria’s capital. I was there to encourage mothers to allow their infants to receive oral polio vaccinations during World Immunisation Week. When I asked to wash my hands, I again faced that delay while a bucket of water was fetched.
At home that evening, I looked into current data and found that only 5% of health facilities in Nigeria have combined basic water, sanitation, and hygiene (WASH) services. The absence of WASH during birth plagues 17 million women across least-developed countries every year. It is clear that we are still trying to clap with one hand.
Now the need for two clean hands is being recognized as more urgent than ever — and perhaps that’s the only good news to come from the coronavirus pandemic. The handwashing that the WASH community has so long advocated for has come out of its echo chamber, and become a thunderous resounding clap for global health.
COVID-19 has made “wash your hands” a daily adage and has reinforced the need to invest in safe and dignified health care. This renewed urgency calls us to ensure that the WASH and health communities unite indivisibly to activate, actualise, and accelerate WASH investments to match the behavioural change.
Image: Courtesy of Wellbeing Foundation Africa
I see this need in my country. Despite the slower pace of COVID-19 across the African continent, Nigeria’s eventual burden could be one of the worst in Africa. Reality on the ground is showing weak health systems already stretched to a breaking point, according to reports from medical and public health officials.
Valuable programs are gaining needed steam, like WaterAid’s “Clean Nigeria” campaign for homes and hospitals, and the London School of Hygiene & Tropical Medicine’s global “Teach Clean” campaign, to achieve infection prevention and control, and prevent maternal and newborn sepsis.
Our midwives persevere. As our “WASH for Wellbeing” midwives work every day, teaching over 8,000 young pregnant and nursing mothers and their medical colleagues in hundreds of health facilities, they are my frontline warriors for WASH. Too often, the photos they send me still show a water tank in the far distance, and a bucket of water on a table.
In this inaugural UN Year of the Nurse and Midwife, we must ensure that health care workers everywhere have access to WASH. Hands, all around the world, are working tirelessly. Let’s be sure they can do so, safely.
Join the momentum tomorrow! From the mountains for Nepal to leadership at USAID, Water.org, the Vatican, and funders:
First Anniversary Leaders Gathering: WASH in Healthcare Facilities: Accelerating Action to Meet the Urgent Need
As Founder-President of Wellbeing Foundation Africa (WBFA), Mrs Toyin Saraki is a Nigerian philanthropist with two decades of advocacy covering maternal, newborn and child health, gender-based discrimination and violence, improving education, socio-economic empowerment and community livelihoods in Africa.
The hospital—a referral hospital in Bahir Day, Ethiopia—served a population of 25 million. Dozens of mothers gave birth daily, some of whom were sent from other facilities in order to deliver by emergency Cesarean section. It was a bustling institution, yet it was without some of the most basic amenities—I saw broken water taps, unsanitary toilets, and no soap or other supplies for cleaning. The nurses of the neonatal intensive care unit, where there were no sinks for handwashing, recognized what the conditions meant. Their job is to care for the most vulnerable, yet they were unable to drop the spread of infection within their unit.
The neonatal intensive care unit at the referral hospital in Ethiopia lacked soap and water for health workers to wash their hands. Photo courtesy of Lindsay Denny.
This hospital isn’t the exception in low- and middle-income countries. According to a recent report from WHO and UNICEF, two billion people must rely on health facilities that lack basic water services and 1.5 billion people visit facilities without toilets. Without these basic amenities, it is impossible to provide safe care and live up to the doctrine of “do not harm.”
Learn about WASH in health care facilities during a virtual event on June 24, 2020.
The lack of water, sanitation and hygiene (WASH) services also endangers health workers. Consider the 2014 Ebola outbreak. Ebola not only killed some 11,000 people, it was 103-fold higher in health workers in Sierra Leone than in the general population, 42-fold higher in Guinea health workers, and Liberia lost 8% of its health workforce. These losses were in part due to that fact that health workers did not have access to adequate WASH. The situation has not improved. In the Democratic Republic of the Congo, where Ebola killed thousands, 50% of facilities have no water, 59% have no toilets, and just 62% have soap and water or hand sanitizer at points of care. Now global health care staff addressing COVID-19 face similar challenges and threats. Additionally, given that the majority of midwives, nurses, and cleaners are women, the lack of WASH disproportionately affects women. For example, without proper toilets, female health workers may be forced to hold their bladders through their shifts—a recipe for a urinary tract infection.
This problem of WASH in the health facility has long been neglected, but it is solvable and momentum is building. UN Secretary-General António Guterres issued a global Call to Action in 2018 to get WASH into health facilities; WHO Member States then unanimously adopted in a 2019 World Health Assembly Resolution that includes eight practical steps towards successful implementation by 2030. WHO and UNICEF responded with metrics to chart progress by governments, and dozens of national governments are now exploring concrete plans and resource requirements. In 2020, WHO prioritized the absence of WASH in HCFs as among the most urgent global health challenges in the coming decade for the first time.
Last June, 92 diverse organizations announced commitments to WASH in health facilities. In the past year, these organizations have been translating commitments into action. At the same time, the COVID-19 pandemic has brought the global need into even sharper focus. Now more than ever, WASH in health facilities must be a foremost priority for governments, funders, and development assistance organizations alike. Progress demands an adequate level of support for sustainable, and accountable, WASH services in health facilities, regularly monitored by professional authorities.
On June 24, 2020, Global Water 2020 and Global Health Council are hosting a virtual event recognizing the first anniversary of these commitments. Global health and WASH leaders will come together to reflect on efforts to reach every health facility with WASH services. We urge our global health colleagues, in particular those working on the front lines of health care delivery, to join the discussion. It is critical that we continue to drive progress towards WASH in all health facilities, everywhere. And in the process, we must elevate the voices of frontline health workers, for whom this deficit has the greatest impact.
NAIROBI, Kenya – In Nairobi’s Korogocho slums, the sudden closure of schools in March was a double tragedy for 15-year-old Consolata. It meant she would lose out not only on learning, but also on free access to sanitary towels provided under a government scheme to promote menstrual health and hygiene.
As the global lockdown occasioned by COVID-19 has forced people to stay home and live on reduced income, she and millions of girls around the world who live in informal setlements are struggling to access sanitary pads.
The form-two student says she is lucky to get menstrual pads from a local non-governmental organization known as Miss Koch that empowers young girls and women in Korogocho slums.
“We can’t access these (government) pads until we go back to school. Our mum cannot afford to buy us pads and also provide for food. So we mostly depend on what Miss Koch provides,” Consolata said.
“We are five girls in our house, and the pads are usually not enough for all of us. Sometimes we ask our brothers to chip in.”
The Kenyan government, through the State Department for Gender Affairs, runs a programme to provide free sanitary towels to some 3.7 million girls in public primary schools, special primary and secondary schools in the country.
The scheme is essential in a country where over 65% of people who menstruate cannot afford sanitary towels, according to figures cited in the 2016 report Menstrual Health in Kenya, published by non-profit consulting firm FSG.
It also showed that 6 out of 10 girls in Kenya had never heard about menstruation until their first period.
The government-funded sanitary towel program was initiated in 2011 and has so far benefited over 11.2 million girls, mostly in marginalised and slum areas, according to the ministry. The closure of schools in March due to COVID-19 halted pad distribution.
Consolata is one of 600 children in Korogocho slum that benefit from a mentorship programme by Miss Koch that seeks to support child-parent relationships, said Emmie Erondanga, the organization’s executive director.
The NGO also distributes sanitary towels donated by well-wishers to girls through private and apex schools within the informal settlements that do not benefit from the state scheme.
“But with COVID-19, things have changed. Schools closed abruptly and these girls are out of school,” Erondanga said.
“Sometimes we get short of supplies, which means the girls that we have not reached will go for alternative avenues. These could lead to dropping out of school or even teenage pregnancies.”
According to a UNESCO report, Puberty Education & Menstrual Hygiene Management, one in ten girls in sub-Sahara Africa misses school during their periods, losing up to 20 school days a year and increasing their chance of dropping out altogether.
Patricia, one of Consolata’s four sisters, says that while she benefited from the free sanitary pads while in school, it has become harder to afford them after she finished her secondary school education in 2019.
“Sometimes we have to use rags or borrow from friends,” Patricia said.
“Girls here end up having sex with men so that they can get money to buy pads. Some of my friends have even ended up pregnant just because they could not afford pads.”
Inadequate knowledge of sexual and reproductive health among adolescents has meant that over 3.9 million school-going girls aged between 15 and 19 undergo unsafe abortions annually, according to the World Health Organization.
For Consolata and girls and women across the country, there is hope for more robust support as they continue to face their menstrual challenges. On this year’s Menstrual Hygiene Day (28 May), the Government of Kenya launchd a landmark stand-alone policy dedicated to menstrual health and hygiene.
The Menstrual Hygiene policy 2019-30 will create an enabling environment for implementation of menstrual hygiene and management interventions in Kenya. It will also ensure women and girls have access to safe and hygienic products.
As global health donors gather virtually for Gavi’s Global Vaccine Summit on 4 June, hosted by UK Prime Minister Boris Johnson, Julie Truelove and Katie Tobin make the case for why they should be talking about investing now in improving access to hygiene services, and how this should go hand in hand with investing in vaccines.
Hygiene is a first line of defence against COVID-19
While the world waits for a vaccine, we collectively rely on critical measures of prevention to control the transmission of COVID-19 – and to avoid future health crises caused by the disruption of key global health interventions during the pandemic.
One of the most effective methods of disease prevention, hand hygiene is at the core of public health advice from the World Health Organization (WHO). Evidence suggests handwashing with soap can reduce cases of pneumonia by 50% and acute respiratory infection by 16–23%, while reducing risk of endemic diarrhoea by 48%.
Neglecting investment in hygiene undermines health system strengthening
The case for joint delivery of hygiene and vaccines
To mitigate the long-term impacts of COVID-19 on global public health, joint delivery of hygiene and immunisation services is essential. Because immunisation programmes reach more people than any other health intervention does, they are a crucial entry point to integrate WASH – with particular emphasis on hygiene behaviour change. Hygiene-integrated approaches must become the new normal for vaccine delivery.
Our recent research with SHARE and numerous partners presented the case for integrating WASH and context-specific hygiene behaviour change interventions into immunisation sessions. The research showed potential positive outcomes from this hygiene-integrated model to include:
Improving cost effectiveness and operational efficiency – an important factor in resource-constrained settings for both service providers and to reduce time demands for service users across vital health services.
Reaching underserved populations to support them to attend and complete immunisation sessions, increase trust in health services and engage in hygiene behaviour change practice.
Synergistic effects of increasing demand for and uptake of immunisation and other child health services, while increasing success of child caring behaviours such as exclusive breastfeeding and food hygiene.
Potential for improved vaccine performance, based on emerging evidence that supports the biological plausibility that improved hygiene, sanitation, clean water and soap could increase oral vaccine performance through improved gut health – a key area for further research.
Global guidance from WHO emphasises that linking prevention and control efforts for diarrhoeal diseases could lead to greater health outcomes compared to results from single interventions, including preventative measures like improved living conditions and WASH. Context-specific planning, budget allocation, implementation and evaluation can establish robust, integrated platforms for hygiene and immunisation.
In Nepal, we worked with the London School of Hygiene and Tropical Medicine (LSHTM) to undertake a scoping study to assess the feasibility of incorporating hygiene behaviour change into the country’s already successful immunisation programme. The intervention improved key hygiene behaviours (related to exclusive breastfeeding, handwashing with soap, food hygiene, faeces management and water and milk treatment) from 2% at baseline assessment to 53% after one year. The project also increased immunisation coverage and led to a 10% decrease in diarrhoea prevalence in those who took part in the pilot.
Based on this successful intervention, the integration of hygiene promotion with routine immunisation will be scaled up to national level with the introduction of a rotavirus vaccine, scheduled for June 2020. Despite the COVID-19 pandemic, massive training programmes for these interactive sessions have already taken place across health offices in Nepal. Watch our short film about the project, below.
‘No regrets’ actions for disease prevention
Investing in hygiene-integrated approaches now is a no regrets action to confront COVID-19, help maintain the essential provision of vaccines, and build resilience against subsequent health crises related to preventable diseases. Building towards longer-term strategies, urgent action must start now, at all levels:
Ensure every immunisation clinic has basic handwashing facilities with water and soap, accessible to all staff and patients.
Build on a ‘do no harm’ approach to actively promote hygiene and handwashing through immunisation platforms, clinics and with clinic staff through visual cues and behaviour nudges, alongside radio, music and mobile messaging platforms.
Accelerate development of context-specific integrated intervention packages, drawing on national guidelines and hygiene behaviour change science.
Initiate training of frontline health workers for integrating hygiene and immunisation.
Ministries of health and related line ministries for WASH and social development should actively promote hygiene behaviours embedded with immunisation communications.
Include in health and immunisation budgets ringfenced funding for immediate improvements to handwashing and hygiene practices for immunisation clinics.
Make best use of Gavi’s flexibility to reallocate up to 10% of health system strengthening funding to prioritise hygiene integration and infection, prevention and control training.
Accelerate collaboration across sectors to develop national guidelines and action plans for hygiene-integrated approaches for immunisation, including readiness plans for launch of a COVID-19 vaccine.
Key allies for immunisation and WASH should champion a hygiene-integrated approach to immunisation as a ‘no regrets’ action for global health.
Donors to Gavi should voice support for a hygiene-integrated approach to immunisation, and amplify Gavi’s flexibility to reallocate up to 10% of existing health system strengthening funding to prioritise investment in hygiene integration, hand in hand with immunisation, as a critical preventative measure in the COVID-19 response.
Accelerate actionable global guidance on integration of hygiene and immunisation, on the basis of existing evidence and ‘no regrets’ actions for hygiene and handwashing, to inform Gavi’s health system strengthening strategy.
WaterAid/ Mani Karmacharya
A hygiene-integrated immunisation approach: a female health volunteer conducts a hygiene session with parents and children who have come to the district hospital for immunisations. Jajarkot, Nepal.
Prioritising investment in hygiene now will ready plans and mechanisms for joint delivery of hygiene and immunisation
Prioritising joint delivery of hygiene and immunisation programming, including critical funding for integrating hygiene with immunisation, is essential to establish a new normal – and particularly vital in this period of vulnerability before a COVID-19 vaccine is universally available. The pandemic has exacerbated inequalities along lines of income, gender, age, location, disability and health status, and these factors of discrimination – which already play out in terms of who has access to clean water and soap and to sanitation – will likely also be manifest in who has access to a vaccine and when.
Supporting the call by UNAIDS, Oxfam and more than 150 world leaders for a People’s Vaccine, we emphasise the need to act now to prevent the continued spread of the pandemic. Prioritising hygiene now will ready national plans and delivery mechanisms across ministries for health, immunisation and WASH; help strengthen critical routine and mass immunisation services with hygiene interventions for the long term; and prepare hygiene-integrated approaches to improve the effectiveness of the eventual roll-out of a COVID-19 vaccine. We hope to hear Gavi and its donors supporting this call when they make their commitment on 4 June.
Julie Truelove is Senior Policy Analyst for Health and Hygiene at WaterAid UK. She tweets as @JulieTruelove. Katie Tobin is Advocacy Coordinator at WaterAid. She tweets as @travelingKT.
Salimata Dagnogo, matron at a health center in Mali, washes a piece of equipment in the delivery room. Photo by: Guilhem Alandry / WaterAid
BELFAST, Northern Ireland — Hand-washing is the first line of defense against COVID-19 and many other diseases. Yet 1 in 4 health care centers around the world has no hand-washing facilities, and in the lowest-income countries, almost half have no clean water.
A lack of facilities means over 2 billion people are forced to seek care in a place where there is no clean water and 1.5 billion people visit health care facilities with no sanitation services at all.
Advocates say that needs to be understood in order to help low- and middle-income countries control the virus.
“The vital role of good hygiene in preventing hospitals [from] becoming breeding grounds for disease is being woefully overlooked as part of the global response to COVID-19,” said Tim Wainwright, chief executive of WaterAid.
In a statement for WaterAid, Rhoda Phandama, a nurse and midwife in Malawi, added that the Katimbira Health Centre in Nkhotakota, where she works, doesn’t have enough soap.
“We need to have enough supplies so that we are protected and that the clients who come here with issues like injuries and other diseases do not end up catching coronavirus,” she said.
Aside from hand-washing, soap and water are needed to clean floors, operate some medical devices, and deliver babies, said Lindsay Denny, health advisor at Global Water 2020, an initiative focused on water access and security. Over 1 million deaths annually are associated with unclean births.
“We’ve heard stories of people using swamp water because it’s the only water available and that causes infection in the lungs of newborns,” Denny added. “And can you imagine being told ‘oh there’s an outbreak but you can’t wash your hands?’ If anyone needs to have access it’s nurses and doctors,” she said.
As well as patients, the lack of hygiene puts health care workers themselves at risk.
“We know of midwives who don’t go to the toilet on a 12-hour shift because the toilets are on the other side of the freeway from the health center or because it’s not safe,” Denny said, which can lead to infections.
Salimata Dagnogo, matron at a health center in Mali, collects dirty water from an open well. Photo by: Guilhem Alandry / WaterAid
Ahead of this year’s World Health Assembly — which is taking place online due to the pandemic, on May 18 — WaterAid issued a call for change.
“As leaders meet virtually at the World Health Assembly we want to see rapid commitments that will mean that no nurse, midwife, or doctor has to work without somewhere to wash their hands,” Wainwright said.
In the Democratic Republic of the Congo, health care workers in rural areas often have to travel long distances to collect water from the nearest well or river, which means less time providing care, according to Amuda Baba Dieu-Merci, a former community health worker and director of the Panafrican Institute of Community Health.
Dieu-Merci blamed an absence of water companies focused on rural areas and the costs being higher than many facilities can afford.
For Denny, the siloed approach to global health and WASH is the main culprit. “When you have a breakdown of water in your health care facility you don’t necessarily have the expertise there to solve these problems. Similarly, the people working in the health system have a health perspective and they may not see water as important to the work they’re doing,” she said.
Zoe Pacciani, country director for Uganda at Freshwater Project International — an organization that provides WASH to villages, schools, and health centers — said many rural health centers were built years ago when building hand-washing facilities outside of the operating rooms wasn’t thought of.
Of the facilities that once had a water supply, many have deteriorated due to a lack of operation and maintenance, Pacciani explained, “rehabilitation on its own is not enough.” Mechanisms to enable district governments to maintain new water systems and local operators to perform routine operations and minor maintenance are needed alongside more funding, she said.
Just 3% of Uganda’s national budget is allocated to water and environment, and that figure drops to 1.5% in Malawi. Pacciani hopes the pandemic will highlight the need to prioritize water supply and hand-washing facilities in health centers.
“It’s shining a light that we’ve ignored this issue for so long. It’s been such a neglected crisis,” Denny agreed. “The outbreak will help countries and major organizations reprioritize and think about how we really focus on what the key elements of a health care facility are.”
In the meantime, Dieu-Merci hopes NGOs will step in, especially in places like DRC where conflict and displacement remain higher priorities for the government.
WaterAid constructs water tanks, towers, and toilets for health centers in several countries including Malawi, Ghana, Zambia, and Mali, while also working to put plans in place for their maintenance. In partnership with Engineers Without Borders, Freshwater Project International is also upgrading and replacing pumps, tanks, sinks, and taps in health care facilities in Malawi.
But this is not something that the WASH sector can solve alone, Denny said. “It’s about coming together, prioritizing, and budgeting. If we don’t have the money for it, it’s never going to be something that’s prioritized,” she said.
Visit the Duty of Care series for more coverage on how health systems can function better so that health care workers are supported and protected. You can join the conversation using the hashtag #DutyOfCare.
By: H.E. Toyin Saraki, Wellbeing Foundation Africa
Today, on 5th May, we celebrate the most momentous day in a century for the midwifery profession, the International Day of The Midwife, in the first ever Year of the Midwife, as the world is currently at a standstill fighting the coronavirus pandemic, an invisible enemy that has claimed hundreds of thousands of lives. It cannot be a coincidence that today we also celebrate World Hygiene Day, a day set aside to focus on hand hygiene: that simple act of handwashing with soap. Hand washing was originally propagated by the 1840 Physician Ignaz Semmelweis to midwives at his maternity wards, as the best means to prevent and control childbed fever infection—as puerpural sepsis was then known. Thus, midwives and their clean hands have established and led life-saving and life-enhancing infection prevention and control protocols for centuries. They are at the very frontlines of health, safely guiding new life, as the first eyes to see and first hands to touch a newborn child, as they stand by women all over the world in their hours of labour, delivery and need.
And they are not alone.
Health care workers, midwives, nurses, doctors, and the entire medical profession are at the forefront to save lives because they took an oath, an oath to serve regardless of the situation. They risk their lives to save the world in these unprecedented times. It is sad that during this crisis we have pushed to the background the work that we have put in over the years in various development aspects. I fear that this progress of prominence on the work we have put in reducing maternal mortality through they essential role of the midwifery profession in standing with women to ensure safer births will be threatened by a recession of recognition, and subsequent key investments as the focus shifts.
My thoughts and prayers are with the families of all the nurses and midwives who have lost their lives to Covid-19. Their deaths are a tragedy and I join their colleagues standing with midwives around the world in mourning their beautiful souls. Each and every one of them will be remembered in our hearts as a heroine.
As always in times of crisis, the most vulnerable among us will be the ones hit hardest. Women and girls will suffer the most from this disease which has already seen a rise in gender-based violence, and rights violations of pregnant women forced into giving birth alone. Some will face child-birth complications risking the lives of both the mother and child, some will have stillbirths and some others will successfully give birth to the future leaders that will hold us accountable for the lives of their mothers lost during child birth.
The repercussions will be a constant reminder that for years we have failed and continue to fail women and children where public health is concerned.
While the world grapples in its response to COVID-19, we must be mindful that everything else still functions as before. We still require access to SRHR, women will continue to require prenatal care and safe spaces to deliver in order to reduce maternal mortality.
For years midwives have joined the battle and reduced maternal mortality ensuring that even in the poorest communities, women still had access to safe births. This is most likely one of those challenging situations for midwives in various communities.
Midwives continue to be an essential service in this crisis and we should do more than just applaud their hard work and dedication. How are we ensuring their access to protective clothing and reaching women in need. This is why on this International Day of the Midwife we are launching the We Must Applaud Midwives with WASH campaign that seeks to remind people on the importance of washing hands. As well as protecting frontline healthcare workers, WASH plays a vital role in stopping disease transmission yet two out of five healthcare facilities still lack hand hygiene facilities at points of care.
Ten Immediate WASH Actions in Healthcare facilities to Respond to COVID-19
Handwashing: Set up handwashing facilities, like a bucket with a tap with soap, throughout the facility. Prioritise the facility entrance, points of care and toilets, as well as patient waiting areas (and other places where patients congregate). If the facility is piped, repair any broken taps, sinks or pipes.
Water Storage: Consider the water requirements to perform WASH/IPC activities with an increased patient load. If inconsistent or inadequate water supply is a concern, increase the water storage capacity of the facility, such as by installing 10,000L plastic storage tanks.
Supplies: Solidify supply chains for consumable resources, including: soap (bar or liquid), drying towels, hand sanitiser and disinfectant. Ensure cleaners have Personal Protective Equipment (PPE) for cleaning. If ingredients are available locally, produce hand sanitiser at the facility (or at district-level) – see WHO protocols.
Cleaning & Disinfecting: Review daily protocols, verifying based on national guidelines or global recommendations for resource-limited settings and noting additional levels and frequency of cleaning in clinical areas with high numbers of COVID-19 cases, including terminal cleaning. Ensure adequate supplies of cleaning fluids and equipment, making allowance for additional cleaning requirements. Ensure handwashing stations and toilet facilities are cleaned frequently.
Healthcare Waste Management: Strengthen healthcare waste management protocols by making sure bins are located at all points of care, that they are routinely emptied, and waste is stored safely.
Staff Focal Points: Assign staff member(s) – cleaners, maintenance staff, or clinicians — whose job it is to oversee WASH at the facility, including: refilling handwashing stations, auditing availability of supplies in wards, reporting on WASH maintenance issues, monitoring cleaning and handwashing behaviours of staff and communicating updates to the director daily.
Training: Organise training for all staff on WASH as it relates to their role at the facility, including a specific training for cleaners based on the protocols reviewed above.
Daily Reminders: Remind staff of WASH protocols during morning meetings. Post hygiene promotion materials throughout the facility, particularly next to handwashing facilities.
Hygiene Culture: Encourage a culture of hygiene at the facility. Emphasise that all staff members, including cleaners and maintenance staff, are part of a team working to prevent the spread of infection. Recognise individual WASH champions in the HCF.
IPC Team: Work with the Infection Prevention and Control (IPC) team at the facility to make sure efforts are reinforced and aligned, avoiding duplication. Encourage WASH focal points/partners to participate in IPC meetings. Coordinate WASH/IPC activities based on plans to isolate COVID-19 patients.
BONUS – Preventative maintenance: Check on WASH infrastructure and undertake any necessary preventative maintenance, such as repairing possible disruptions to the water supply, storage, distribution or treatment.
There is much work to be done to ensure that the focus on WASH lasts beyond this crisis and translates into a radical change in how we understand and prioritise water, sanitation and hygiene. A key part of achieving that will be demonstrating that without good WASH standards, global health security is impossible.
Clean water is health and security, and clean hands save lives.
The ripple effect of COVID-19 runs far beyond the disease itself. We must stand in support of midwives, and the entire medical profession, to build a strong bridge between the global health community and WASH, in order to mitigate and heal the scars of this modern-day pandemic on medical workers, women, our newborns and humanity for the many years to come.
My prayers are thus reinforced as 2020 marks not only the Year of the Midwife but also heralds the Decade of Action and Delivery, designed for us to take deliberate steps towards the 2030 Sustainable Development Goals. Because midwives have supported women for centuries by delivering routine maternity care and counsel on a daily basis, we must use this opportunity to advocate louder and stronger together. We must mobilise women and policymakers to stand with midwives as midwives stand with women, newborns and their families. We must stand for the midwifery profession around the world to be recognised, respected and remunerated, and routinely provided with whole-system support.
There is not one standardised approach to coronavirus response and context adaptation is important. Irrespective of what your organisation decides to do we recommend that you use these three principles to guide your work and ensure it remains relevant and that you minimize harm.
It is complex to stay up to date on coronavirus during this pandemic. SARS-Cov-2 is a new virus. There are still many things we are learning about this virus and the disease it causes (COVID-19 or coronavirus disease). Because so much new information is being produced, our first key principle for guiding coronavirus hygiene programming is: stay informed.
With so much new rapidly emerging information, it can be hard to stay up to date. Below we include some advice for staying informed:
Identify key information sources: We recommend regularly checking the websites of your National Ministry of Health, World Health Organisation, and the Centres of Disease Control and Prevention. Following these organizations on social media (Facebook, Twitter) will also allow you to stay up to date on recent news and updates. The COVID-19 Hygiene Hub will continue to update all our briefs and resources based on the latest information too.
Check information before you act on it: If you see a surprising news story; don’t immediately assume it is true. Take time to look at the sources it is using and see whether that same information is reported elsewhere. If you are unsure it’s best to rely on major international media sources as these will have had to have gone through a range of validation checks prior to publication.
Plan to adapt your programme: When designing a COVID-19 response programme you will need to make decisions without perfect evidence to back it up. It’s important to continue to pay attention to new information and adapt your programme based on this.
Involve others and stay connected
The scale of the COVID-19 pandemic is unlike anything we have ever seen before. In order to reduce transmission we need to act fast and at scale. To do this, we need as many people and organisations involved as possible. Our second principle is: involve others in the coronavirus response.
Below we recommend some practical actions for involving and coordinating activities where possible:
Identify people in your existing networks who you could partner with. This could include businesses, community leaders or social and religious organisations. Remember that for businesses their most important asset is their staff, and that social groups couldn’t exist without their members. This is the time where they can show that through clear actions.
Identify where partners can add value: When you are working with different stakeholders get them to focus on their employees or community first by setting up handwashing facilities at the entrance to buildings and in places where they meet. Then get them to think about the various ways they could contribute to your work. Local groups and businesses can provide financial support if that is what is needed but partners can also contribute to your response through skills sharing. Examples of useful skills could include graphic design, media development, IT skills, and website design.
Set up communication channels: When you are working with others make sure to set up communication channels for you to stay in touch should it not be possible for you to meet in person or work from an office. Mechanisms may already exist to support this in your country. For example countries commonly affected by crises often have a National WASH Cluster and the Global Handwashing Partnership is working to establish national handwashing partnerships in many countries. Establishing localised communication channels to bring together key leaders within your community is advised so that you can continue to learn about what is working and share information.
Learn from and build on local community action: Communities will develop their own coping mechanisms in response to COVID-19. Make sure you take time to establish mechanisms to learn from your communities about what is working well and use this to shape and adapt your organisation’s work.
Align your work with the national response
At the moment many organisations and individuals are motivated to play a role in COVID-19 response. However it is important that all efforts are coordinated and adapted to your context. Each country is at a different stage in the pandemic and has a different set of national or local control measures that have been enacted. Therefore our third principle focuses on aligning your work with the national response.
Below we recommend some practical actions to ensure that your work is consistent with national guidance and responsive to the situation in your country.
Be familiar with the government strategy and current guidelines. Normally these guidelines will be widely available or can be found via the Ministry for Health. Countries are also being encouraged to share their plans more widely, for example, this website provides updates about how each nation is responding (this does not cover all countries yet but is expanding). It is important that staff within your organisations adhere to national guidelines since they will often be involved in role-modelling good behaviours during their work with communities.
Be aware of what stage of the response your country is in. The WHO has defined 4 levels of preparedness, readiness and response based on localised patterns of COVID-19 transmission. Organisations should be encouraged to put together a plan for how their work will be adapted at each one of these stages. There are also several global data trackers so that you can keep up to date with confirmed cases and mortality in your region.
Identify high risk areas. Not all areas of a country are at equal risk during the current COVID-19 pandemic. For example COVID-19 will spread more rapidly in areas with high population density such as informal settlements in urban areas or displacement camps. If these settings exist in your country it makes sense to try to prioritise prevention measures in these settings.
Assess the risk locally and based on your organisational capacity
Our fourth guiding principle is take time to assess risk and err on the side of caution. Make sure that you are not putting your staff or communities at risk through your programming. Here are some practical tips for mitigating risk:
Avoid community gatherings: At this point we would recommend that all COVID-19 response programmes avoid using large community gatherings. If, through assessment, you identify that there are no other ways of reaching a community then you could consider organising events where people are physically distanced (such as in the image below where circles have been marked out with coloured sand).
Make a context-specific decision about household visits: In many countries household level visits may still be safe to conduct but before doing this make sure first follow government advice and guidelines and to assess the risk locally. If your staff are in communities make sure they have the ability to practice hygiene regularly and that they maintain physical distancing. You can find out more about how to do this safely in this brief.
Focus on mass media, social media and handwashing infrastructure: Identify or establish ways of reaching populations if in-person work is not possible. This could include radio, television, social media or text messages. Creating handwashing infrastructure will also be key at this time. You can find out more about how to do this here.
To learn about hygiene and handwashing behaviour in the Department of Gracias a Dios, Pure Water for the World Honduras and CAWST partnered with UNICEF to complete a Knowledge, Attitudes, and Practices (KAP) study in 2016. Focused on the communities and schools of Puerto Lempira and Villeda Morales municipalities, the study collected and analyzed qualitative and quantitative data from students, teachers, and parents from 12 selected communities.
David Weatherhill, Global WASH Advisor for CAWST reflected, “The Honduras team have great communication skills and they put these skills to masterful use in completing the KAP study, especially when dealing with some sensitive issues such as menstrual hygiene management.”
This 2016 study informed our interventions and education on water, sanitation, and hygiene (WASH) in schools in the region. It remains relevant as a case study, especially now as we influence and motivate hygiene behaviour change all over the world to combat COVID-19. Findings emphasized the need for maintenance of existing handwashing infrastructure and enhancing community norms around hygiene to motivate consistent hygiene practices, and building on the strong, preexisting knowledge of handwashing practices in the communities.
The team used the RANAS model of behaviour change, which looks at the factors of risk, attitude, norm, ability, and self-regulation . More recently, CAWST has been using the Behaviour Centered Design model, which focuses on changes in the environment, triggering changes in the brain and body of target individuals, which then changes behaviour .
Washing hands with soap is a simple yet effective way to prevent diseases. It is recommended that family members wash hands with soap and running water at critical times including after visiting the toilet, after changing diapers, before food preparation and before eating.
But not everyone washes their hands due to various barriers. For instance, families may not have access to enough water or soap, the practices is not reinforced as a norm, especially among younger children.
USAID’s Afya Uzazi Program promotes handwashing as part of a package of water, health and sanitation (WASH) interventions to protect the health of households.
Working with the community health strategy teams at the counties, Afya Uzazi has trained community volunteers, local elders and other trusted champions to promote handwashing alongside other healthy behaviours that include treatment of drinking water, use latrines and keeping their compounds clean.
One of the most successful approaches to encouraging handwashing is community led total sanitation (CLTS) which uses powerful motivators to encourage people to build latrines and handwashing stations, including the easy-to-make tippy tap.
Another strategy is the population, health and environment (PHE) intervention that empowers communities to integrate health promotion in environmental conservation activities.
“ Children ever used to wash hands after visiting the toilet, but after making a tippy tap they always do and even encourage visitors to,” says Mary Sang, a mother of three in Kuresoi sub-county, Nakuru County.
Mary’s case is replicated in thousands of homes across Baringo and Nakuru counties where the two approaches have been used.
At health facilities in the two counties, Afya Uzazi and county teams have helped to position handwashing as a key infection prevention and control measure.
Frequent and proper handwashing with soap is one of the most important measures that can be used to prevent the spread of the Covid-19 virus, along with physical distancing, avoiding touching one’s face (eyes, nose and mouth) and practising good respiratory hygiene. However, like physical distancing measures, frequent handwashing with soap and water is next to impossible for huge swaths of the global population.
Changing handwashing behaviours is notoriously difficult
Approaches to tackle handwashing usually include a focus on ‘hardware’ (handwashing stations, soap etc.) and ‘software’ (handwashing promotion and behaviour change communication often done through face-to-face engagement and community meetings). Changing handwashing behaviours is notoriously difficult unless people see an imminent threat and believe their actions will help mitigate it. A systematic review published in 2017 reviewed evidence from 42 impact evaluations and 28 qualitative studies across low and middle-income countries concluded that community-approaches were most effective but even these approaches struggle with sustaining handwashing behaviours.
We still do not know how communities in different parts of the world are going to react to the threat of Covid-19. We do know that messaging needs to take care it does no harm – that handwashing is not viewed as the sole solution but as one of different behaviours needed to slow the spread. We also know that handwashing promotion and behaviour change activities, including tackling the spread of misconceptions, will only work if communities are fully engaged.
Community engagement is key
Experts who worked on Ebola response and on the HIV/AIDs pandemic have also stressed the importance of community-engagement – empowering people to be able to take actions to protect themselves. Therefore rapid community engagement is vital to tackle handwashing and the pandemic more widely.
How we go about physically distanced community-engagement and hygiene promotion is a question we do not have a definitive answer for. Yes, there are people with smart phones and social media accounts but they cannot be relied upon to spread messages to the most vulnerable who may not have access to these.
Logistical challenges of community engagement
In the UK, for example, news reports have highlighted the challenges of interacting with elderly relatives using newer forms of communication, like WhatsApp or FaceTime, that many of us take for granted. We need to think through the different ways to engage communities remotely and maintain their central role in interventions as well as answer the logistical challenges of providing services to those who need them most. Both of these will require rapid action learning and sharing: learning and research methods that produce timely findings that are in-touch and up-to-date and which can be acted on. Platforms such as the Social Science in Humanitarian Action can be utilised for sharing these lessons.
In this highly dynamic and uncertain global situation, we need to be both innovative and coordinated in how we respond, as practitioners attempt to increase handwashing facilitates and influence behaviours. We need to be innovative in ways we can learn and share lessons from across different governments and agencies and adapt to this ever-evolving crisis.
What is working and what is not?
We need to be identifying what is working, as well as what is not, and disseminating lessons learnt rapidly to others. Building on each other’s successes and avoiding making the same mistakes twice. This includes government-led activities and citizen-led actions where governments have failed to act in a timely way.
In Nicaragua, a civil society coalition, Unidad Nacional, together with a scientific committee are creating a movement to get correct information to families and communities – inspiring citizen-let solutions in the streets, shops and markets. This includes setting up handwashing stations and developing communication materials.
If we can achieve this in this time of crisis, we need to ensure that we maintain momentum on handwashing as normality resumes and with a strong learning agenda in order to achieve safely managed sanitation and hygiene for all by 2030!
Caught off-guard by the rapid novel coronavirus (COVID-19) transmission, governments and implementing partners are scrambling to develop prevention responses. To be effective, prevention communication must effectively spur individual and household actions. By now we’ve all seen the communication messages and know the recommended behaviors – for example, wash your hands frequently and at specific times, and don’t touch your face. But the question is: will current communications effectively trigger and sustain behavior change? I’ve been looking at behavior change evidence for many years, specifically in the context of handwashing. Success depends on how a message is crafted and how current evidence is applied. In this post, I explore some of my favorite evidence on fear-based messaging, the use of nudges to reflexively trigger behaviors, and specific determinants that influence handwashing behavior that I find useful. These studies can inform an evidence-based COVID-19 prevention and communication response.
Fear-based messaging alone doesn’t work to change behaviors
A common tactic to spur behavior change is the use of shock or fear. This tactic is too commonly used by health and communication professionals, government officials, and educators as well. But lessons learned from HIV prevention show that using fear tactics alone is ineffective, without a close link to a protective action and a high sense of efficacy to perform the action.
The Extended Parallel Process Model is a framework developed by Kim Witte (1992) to explain how individuals will react when exposed to fear messaging, considering both emotional and rational considerations as fundamental to the equation. Emotional factors include the individual’s perception of risk and severity of risk. The rationale sphere is perceived efficacy (Bandura, 1982) or one’s self-assessment of having the confidence, skills, social support and supplies to mitigate the risk. When fear is high, but efficacy is low, the individual will manage the fear – by minimizing the risk or ignoring the messaging – rather than managing the risk by taking protective action. When perceived efficacy to act is higher than fear, the individual will take the desired preventive actions.
The implications for COVID-19 prevention are clear. Avoid fear appeals, particularly without a close link to “small doable actions” that your target audience feels are feasible to take. If positive prevention actions are to be taken, the audience’s sense of efficacy must be greater than their fear. I developed figure 1 based on Witte’s model to illustrate the impact of fear-based messaging with and without efficacy and action. You can clearly see that fear messaging alone doesn’t change behaviors. With fear alone, people act to manage their fear, not the danger, in this case the danger of COVID-19.
Figure 1: Developed based on Witte’s Extended Parallel Process Model (1992)
Incorporate reflexive cues or “nudges” into messaging
As I describe in a recent blog post, nudges are physical cues that influence individuals to behave in a certain way, without particular messaging or promotion of any behavior. Nudges avoid direct instruction, mandates or enforcement. The term “nudge” became popularized in 2008, after publication of Thaler and Sunstein’s book by that name. Nudges engage audiences at a subliminal level and work reflexively, rather than providing information to audiences to reflect upon and then act. An easy way to think of it: nudges are reflexive not reflective.
Nudge theory operates by designing elements or architecture in an environment which encourages positive or improved behaviors. Nudge principles have been applied for social good as well as in commercial marketing. For example, when searching for a hotel room on priceline.com, the pop-up saying “5 people are looking at this hotel right now!” nudges individuals to not lose the opportunity and book now! without actually promoting this action. Another example can be found at an airport or food court, where bakeries intentionally emit sweet cinnamon scents to spur you to buy donuts or cinnamon buns. Nudging has also been successfully used for traffic safety, recycling and toilet etiquette.
In what has now become the iconic handwashing nudge example, cheerful footsteps in demarcated pathways led Bangladeshi school children from school latrines to handwashing stations brightly decorated with handprints. Findings show these nudges to be an effective way to nudge children to wash their hands after the toilet. Without additional handwashing education or motivational messages, handwashing with soap among school children increased from 4% at baseline to 68% the day after nudges were completed – and 74% at both two-weeks and six-weeks post-intervention (Dreibelbis et al., 2016).
Photo credit: Dreibelbis et al., 2016; https://doi.org/10.3390/ijerph13010129
Findings show the nudge intervention and the hygiene education intervention to be equally effective at sustained impact over five months post-intervention (adjusted IRR 0.81, 95% CI 0.61-1.09). The simultaneous delivery of the hygiene education intervention significantly outperformed the sequential hygiene education delivery (adjusted IRR 1.58 CI 1.20-2.08), whereas no significant difference was observed between sequential and simultaneous nudge intervention delivery (adjusted IRR 0.75, 95% CI 0.48-1.17). These findings generated high interest in integrating nudges into behavior change programs; including, handwashing in health facilities (iNudgeyou, 2016), schools (Thrive Networks, 2017), and communities.A second, larger trial showed nudges to be as effective as intensive health education without the intensive or expensive effort (Grover et al., 2018). Researchers designed this study as a cluster-randomized trial, comparing rates of handwashing with soap after using the latrine (the primary outcome) between various intervention groups among primary school students in rural Bangladesh. Eligible schools were identified (government run with on-site sanitation and water, no hygiene interventions in the last year, and fewer than 450 students), and 20 randomly selected schools were then assigned to one of four interventions (with five schools per group): simultaneous handwashing infrastructure and nudges; sequential infrastructure then nudges; simultaneous high-intensity hygiene education and infrastructure; and sequential handwashing infrastructure and hygiene education.
Target the factors that most influence handwashing behavior change
Also essential for effective COVID-19 prevention communication is integrating what we know about relevant behavioral determinants. The final study included in this post is a bit of a cheat because it is a review of the literature (not findings from a single study) to identify the most influential determinants of handwashing behaviors in crisis and routine settings, synthesizing findings from 78 studies that met strict quality criteria. It’s hot off the presses, published after the emergence of COVID-19.
The review by White et al. concluded that our understanding of the determinants of handwashing “remains suboptimal” and found many limitations in how determinants are defined and measured. Unfortunately, the authors are not able to draw solid conclusions about the determinants of behavior in outbreaks or crisis. They did more generally identify the most commonly reported determinants: risk, psychological trade-offs or discounts, knowledge, demographic (non-behavioral) traits (like gender, wealth and education), and infrastructure. The authors conclude, “Hygiene promotion programmes are likely to be most successful if they use multi-modal approaches, combining infrastructural improvement with ‘soft’ hygiene promotion which addresses a range of determinants rather than just education about disease transmission.”
In conclusion, even though the situation with COVID-19 feels new, it turns out we have a lot of existing evidence from handwashing promotion that’s highly relevant to inform prevention interventions. Applying the findings from these studies sets you on the road to effective COVID-19 prevention and communication efforts. Nudges work to influence behavior; I encourage you to develop and test nudges for prevention behaviors like physical distancing! Also, fear doesn’t trigger protective behaviors, but assuring individuals have the skills, supplies, social support and efficacy to carry out feasible behaviors will make it more likely that they try and maintain preventive practices. And build in the evidence on determinants into your planning of COVID-19 behavior change activities.
Here in the Philippines, as in many parts of the world, there’s been an outbreak of hand sanitizers. Since late January, pump dispensers and bottles have appeared everywhere: airports, schools, dining tables, handbags. In SM, the country’s largest chain of shopping malls, large containers of hand sanitizers greet visitors as they pass through security. “This is a sanitized zone,” SM’s posters read. “Thank you for using the alcohol/disinfectant provided.”
When the enhanced community quarantine started here on March 17, sanitizer showed up at road checkpoints. And though the shops in the mall are closed, customers can still shop at mall supermarkets—after the staff sprays alcohol on their hands.
This is not surprising. The COVID-19 pandemic has spurred people around the world to panic-buy Purell and other hand sanitizers, soaps, and antibacterial wipes. What is surprising is that, until the pandemic hit Western countries, the trend was going in the opposite direction.
Over the past decade, there’s been a growing concern that the impulse to kill all germs could have serious consequences, such as the creation of resistant superbugs. This has certainly impacted people’s hand hygiene habits.
Still, before the current pandemic, some health experts urged people to cut back even on alcohol-based hand sanitizer. That’s partly because some bacteria are becoming more tolerant of alcohol. And it’s partly due to concerns that sanitizers might harm the microbiome—the trillions of microbes living on and in the human body that are essential for healthy immune function, digestion, and more.
In recent years, many researchers have expressed concerns that over-sanitized societies are contributing to autoimmune disorders, allergies, and inflammatory conditions. This “hygiene hypothesis” is controversial, but there’s no question that scientists and the public have been awakening to the fact that some microbes can be beneficial.
Yet in the midst of the COVID-19 pandemic, everyone is understandably consumed by the process of hand sanitizing, and many people are finding it nearly impossible to buy sanitizer online or in stores. People who just weeks ago purposely petted dogs to boost the diversity of their microbiomes now find themselves disinfecting their hand sanitizer bottles with antibacterial wipes.
To understand this sudden change, it is revealing to explore the complex history and anthropology of hand cleansing. What motivates people’s handwashing habits? How do beliefs about sanitizers and microbes figure in? How have previous epidemics led to shifts in these notions? And what might the post-COVID future hold for hand hygiene?
Even before 19th-century scientists discovered that germs cause disease, handwashing was important for hygienic and symbolic purposes in many societies and religious traditions. The Prophet Muhammad, for instance, called on Muslims to wash their hands in a variety of situations, including “before and after any meal,” “after going to the toilet,” “after touching a dog, shoes, or a cadaver,” and “after handling anything soiled.”
In other societies, hand hygiene practices primarily originated from secular discoveries. In 1846, Hungarian doctor Ignaz Semmelweis observed that mothers giving birth were more likely to die if they were treated by doctors who handled cadavers beforehand. So, Semmelweis mandated that hospital staff wash their hands with soap and chlorine. He later became known as the father of hand hygiene. A few years later, forward-thinking nurse Florence Nightingale implemented handwashing in British army hospitals.
Despite the efforts of these pioneers, the practice of widespread, regular handwashing was slow to take off in most of the world. In the U.S., the first national hand hygiene guidelines weren’t published until the 1980s, spurred by several foodborne outbreaks and hospital-associated infections. It was in that decade that a global hand cleansing movement was born.
The rise of hand sanitizers mirrors this move of hand hygiene from the hospital to the world at large. Some accounts claim that Lupe Hernandez, a nursing student in California, invented hand sanitizer in 1966 when she realized alcohol mixed with gel could help hospital staff clean their hands in a jiffy.
Others trace its beginnings to Gojo, a family-owned Ohio company that launched a hand cleanser for auto mechanics then tweaked the recipe and released it in 1988 as Purell. After a slow start, the product achieved the near ubiquity it enjoys today.
Incidentally, alcohol-based hand sanitizers once caused ambivalence among Muslims, owing to alcohol being haram (forbidden). But today, Muslim health care workers largely accept them, even though the question of whether hand sanitizers are halal (permissible) continues to spark debate.
Epidemics have repeatedly stimulated the popularity of hand sanitizers. In the Philippines, a clothing store called Bench introduced Alcogel shortly after the 1997 H1N1 outbreak. It attained “phenomenal success,” according to Bench’s CEO Ben Chan. A similar sanitization surge occurred in the U.S. during the H1N1 epidemic of 2009.
As The Guardian’s Laura Barton wrote in 2012, “Thanks to the heightened fear of contamination experienced during recent flu epidemics, there is now a value judgment attached to carrying and using an antibacterial gel.”
Infectious disease outbreaks have also influenced societies’ soap-and-water habits. A 2003 study of six international airports found that in Toronto—which was hit by a major outbreak of severe acute respiratory syndrome (SARS) that year—95 percent of male travelers and 97 percent of female travelers washed their hands in the public restrooms. By contrast, in New York’s John F. Kennedy Airport, only 63 percent of men and 78 percent of women washed their hands.
So, is fear of disease a great motivator for soaping up or squirting hand gel? Perhaps during a pandemic, the answer is yes. However, fear generally has only a temporary effect on ablutions, according to a review led by anthropologist Valerie Curtis. Furthermore, Curtis has warned, creating cleanliness campaigns that play on people’s anxiety is not good for mental health.
Instead, she recommends harnessing a different emotion.
In the early 2000s, Curtis was aiming to change the handwashing habits of people in Ghana, where only 4 percent of adults regularly used soap after going to the bathroom. Previous campaigns had failed, and the situation was urgent, since an estimated 84,000 children were dying of diarrhea each year.
So, Curtis created a campaign designed to generate disgust. At the time, bathrooms were considered cleaner alternatives to pit latrines, so they didn’t inspire an ick factor that might prompt Ghanaians to lather up. Curtis and her group developed ads that showed mothers and children exiting bathrooms with their hands covered in purple pigment, which they then transferred to everything they touched. Soap use subsequently rose by 13 percent following trips to the toilet and by 41 percent before eating.
Such a campaign could inspire future efforts in the wake of COVID-19. In a study released in December 2019, researchers at the Massachusetts Institute of Technology (MIT) and the University of Cyprus calculated that if travelers at airports raised the bar on their soap-use habits, the impact of a future pandemic could be reduced by 24 to 69 percent. Yet the same researchers estimated that, although 70 percent of air travelers wash their hands, most do not wash them adequately (frequently, with soap, for at least 20 seconds), so only 20 percent actually have clean hands.
Pandemics arguably tip the scale back to a Pasteurian paradigm.
Shifting views about microbes may complicate the issue of disgust. MIT anthropologist Heather Paxson has written that many people hold a Pasteurian worldview, in which they “blame colds on germs, demand antibiotics from doctors, and drink ultra-pasteurized milk and juice, while politicians on the campaign trail slather on hand sanitizer.”
But Paxson also points out that there is an emergent, alternative paradigm: a “post-Pasteurian” view. Post-Pasteurians “might be concerned about antibiotic resistance” and embrace microbiome diversifiers like probiotics, unpasteurized milk, kombucha, and unsanitized handshakes.
Pandemics arguably tip the scale back to a Pasteurian paradigm. Currently, people are bombarded with images (and imaginings) of a potentially deadly virus for which there is, at least at the moment, neither vaccine nor cure. Thus, hand sanitizers and wipes emblazoned with the statement “kills 99.9 percent of germs” give people a sense of control over an unseen, and suddenly hostile, microbial world.
But people’s hand hygiene practices are also motivated by a visible and often friendlier force.
In 2016, researchers found that doctors and nurses at a California hospital washed or sanitized their hands 57 percent of the time when they knew that designated “hygiene patrol” nurses were watching them but only 22 percent of the time when volunteers who they didn’t recognize observed them.
Just like the wearing of face masks, social pressure can certainly motivate people to clean their hands. A recent review from Curtis and other researchers showed that people were more likely to lather up when there was more than one person present in a public restroom.
Prompted by the COVID-19 pandemic, some health experts are attempting to “responsibilize individuals” by framing handwashing as a selfless act that saves lives. Social media campaigns like #SafeHands and #HandwashingHeroes are also making appeals to social responsibility by showing celebrities and adorable children getting sudsy to prevent disease.
Similarly, face masks became an emblem of “public spiritedness” during the 1918 influenza pandemic. In some places, for instance, Japan, the practice of wearing masks continued and became part of the country’s hygiene culture.
In the aftermath of past pandemics, people have generally returned to their previous handwashing habits. But the COVID-19 crisis is different from other outbreaks. Never before have hand sanitizing and social distancing practices been enacted on such a global scale.
So, could COVID-19 cause permanent changes to handwashing habits around the planet? Could hand sanitizer become an enduring symbol of responsible world citizenship? Could the pro-microbe perspective swing back to a Pasteurian panic over germs?
Only time will tell. But it’s something to ponder while you scrub or sanitize your hands for at least 20 seconds.
Soap is one of our most effective defences against invisible pathogens At the molecular level, soap breaks things apart. At the level of society, it helps hold everything together. It probably began with an accident thousands of years ago. According to one legend, rain washed the fat and ash from frequent animal sacrifices into a nearby river, where they formed a lather with a remarkable ability to clean skin and clothes. Perhaps the inspiration had a vegetal origin in the frothy solutions produced by boiling or mashing certain plants. However it happened, the ancient discovery of soap altered human history. Although our ancestors could not have foreseen it, soap would ultimately become one of our most effective defences against invisible pathogens.
Soap is gentle and soothing – and can be extremely destructive for micro-organisms People typically think of soap as gentle and soothing, but from the perspective of microorganisms, it is often extremely destructive. A drop of ordinary soap diluted in water is sufficient to rupture and kill many types of bacteria and viruses, including the new Coronavirus that is currently circling the globe. The secret to soap’s impressive might is its hybrid structure.
Soap is made of pin-shaped molecules, each of which has a hydrophilic head — it readily bonds with water — and a hydrophobic tail, which shuns water and prefers to link up with oils and fats. These molecules, when suspended in water, alternately float about as solitary units, interact with other molecules in the solution and assemble themselves into little bubbles called micelles, with heads pointing outward and tails tucked inside.
Some bacteria and viruses have lipid membranes that resemble double-layered micelles with two bands of hydrophobic tails sandwiched between two rings of hydrophilic heads. These membranes are studded with important proteins that allow viruses to infect cells and perform vital tasks that keep bacteria alive. Pathogens wrapped in lipid membranes include Coronaviruses, HIV, the viruses that cause hepatitis B and C, herpes, Ebola, Zika, dengue, and numerous bacteria that attack the intestines and respiratory tract.
When you wash your hands with soap and water, you surround any microorganisms on your skin with soap molecules. The hydrophobic tails of the free-floating soap molecules attempt to evade water; in the process, they wedge themselves into the lipid envelopes of certain microbes and viruses, prying them apart.
“They act like crowbars and destabilize the whole system,” said Prof. Pall Thordarson, acting head of chemistry at the University of New South Wales. Essential proteins spill from the ruptured membranes into the surrounding water, killing the bacteria and rendering the viruses useless.
How Soap Works Washing with soap and water is an effective way to destroy and dislodge many microbes, including the new Coronavirus. For more about the how the virus affects the body, see How Coronavirus Hijacks Your Cells.
Photo Credit: Jonathan Corum and Ferris Jabr
In tandem, some soap molecules disrupt the chemical bonds that allow bacteria, viruses and grime to stick to surfaces, lifting them off the skin. Micelles can also form around particles of dirt and fragments of viruses and bacteria, suspending them in floating cages. When you rinse your hands, all the microorganisms that have been damaged, trapped and killed by soap molecules are washed away.
On the whole, hand sanitisers are not as reliable as soap
Sanitisers with at least 60 percent ethanol do act similarly, defeating bacteria and viruses by destabilizing their lipid membranes. But they cannot easily remove microorganisms from the skin. There are also viruses that do not depend on lipid membranes to infect cells, as well as bacteria that protect their delicate membranes with sturdy shields of protein and sugar. Examples include bacteria that can cause meningitis, pneumonia, diarrhoea and skin infections, as well as the hepatitis A virus, poliovirus, rhinoviruses and adenoviruses (frequent causes of the common cold).
These more resilient microbes are generally less susceptible to the chemical onslaught of ethanol and soap. But vigorous scrubbing with soap and water can still expunge these microbes from the skin, which is partly why hand-washing is more effective than sanitizer. Alcohol-based sanitizer is a good backup when soap and water are not accessible.
Soap in water remains one of our most valuable medical interventions In an age of robotic surgery and gene therapy, it is all the more wondrous that a bit of soap in water, an ancient and fundamentally unaltered recipe, remains one of our most valuable medical interventions. Throughout the course of a day, we pick up all sorts of viruses and microorganisms from the objects and people in the environment.
When we absentmindedly touch our eyes, nose and mouth – a habit, one study suggests, that recurs as often as every two and a half minutes — we offer potentially dangerous microbes a portal to our internal organs.
As a foundation of everyday hygiene, hand-washing was broadly adopted relatively recently. In the 1840s Dr. Ignaz Semmelweis, a Hungarian physician, discovered that if doctors washed their hands, far fewer women died after childbirth. At the time, microbes were not widely recognized as vectors of disease, and many doctors ridiculed the notion that a lack of personal cleanliness could be responsible for their patients’ deaths. Ostracized by his colleagues, Dr. Semmelweis was eventually committed to an asylum, where he was severely beaten by guards and died from infected wounds.
Florence Nightingale, the English nurse and statistician, also promoted hand-washing in the mid-1800s, but it was not until the 1980s that the Centers for Disease Control and Prevention issued the world’s first nationally endorsed hand hygiene guidelines.
Washing with soap and water is one of the key public health practices that can significantly slow the rate of a pandemic and limit the number of infections, preventing a disastrous overburdening of hospitals and clinics.
But the technique works only if everyone washes their hands frequently and thoroughly: Work up a good lather, scrub your palms and the back of your hands, interlace your fingers, rub your fingertips against your palms, and twist a soapy fist around your thumbs. Or as the Canadian health officer Bonnie Henry said recently:
“Wash your hands like you’vebeen chopping jalapeños and you need to change your contacts.”
Even people who are relatively young and healthy should regularly wash their hands, especially during a pandemic, because they can spread the disease to those who are more vulnerable.
Soap is more than a personal protectant; when used properly, it becomes part of a communal safety net. At the molecular level, soap works by breaking things apart, but at the level of society, it helps hold everything together.
Remember this the next time you have the impulse to bypass the sink: Other people’s lives are in your hands.
This labor and delivery room has no water. Photo Credit: Haik Kocharian
COVID-19’s multiple frontlines now include at least 46 countries across the African continent. Many, including Ethiopia, have frontline health care facilities battling without one of the most critical tools: adequate water and sanitation.
In an email as truth-telling as it is disturbing, my colleague and friend, Shimeta, ordered his employees to work from home by the time his country was reporting 19 cases (the count is now ~44): “Medical facilities and structures are very weak to handle such pandemic diseases. In Africa and especially in Ethiopia, the death toll will be unheard of up until now. One of the small advantages is that if this outbreak had started in Africa, the world would have heard of it very late, as was the case with the Rwandan genocide and Ebola in DRC.”
Ethiopia’s rural southwest was once my home. My dad moved his young family there from New Mexico and when he volunteered in the local health clinic, I would tag along. When I was 8-years-old, I remember a woman came in, in extraordinary pain. She’d been in labor for days. Her baby was dead and though my father tried, he could not save her life.
I became a doctor. In my work with Ethiopian women suffering from childbirth injuries, things have not improved nearly as much as they should. Women still die in childbirth by the hundreds of thousands globally and health care systems remain dilapidated. In 2016, my organization surveyed 14 rural health posts in Ethiopia. Not one had access to consistent water and sanitation—undercutting everything from the ability to prevent maternal and neonatal injury and death, to the spread of diseases. This fundamental global health problem is solvable and now more urgent than ever with COVID19 spreading across low- and middle-income countries.
Drought can be an issue, but missing infrastructure and broken pipes, pumps, faucets and wells are a massive problem. There are different reasons for poor maintenance—lack of funds, training, prioritization, coordination—but the result is always the same: unsafe, undignified health care. I’ve seen women deliver side-by-side in filthy rooms with little water and blood splattered everywhere in a dilapidated regional hospital that serves 1.5 million people. Mothers tell me they are afraid to deliver in such conditions, but they are also afraid to die in labor at home.
If we think these facilities will be effective against COVID19, consider that health professionals, assistants and cleaners in some areas struggle to wash their hands, let alone much else. Pit latrines overflow in the rainy season spilling patient sewage onto facility compounds; open defecation is common; trash and biohazards are thrown into open, unfenced pits. It’s not just Ethiopia; these conditions are a common sight inside hospitals and clinics in many LMICs. The first UN global baseline report, released in 2019, found that 49% of facilities in sub-Saharan Africa lack basic water services and 64% of health care facilities in eastern and southeastern Asia lack basic hygiene services. 2 billion people must rely on facilities that lack basic water services and 1.5 billion on facilities without sanitation.
Emergency measures to contain COVID19 and prevent resurgence must include global access to Water/Sanitation/Hygiene, WASH. Then health and development leaders, public and private, must make WASH permanent and sustainable. Like other core global health solutions, WASH requires ongoing commitments to funding, training, maintenance and far better coordination.
As leaders focus on vaccines that are months, if not years away, I fear we will continue to overlook the fundamentals of infection prevention and control inside the very places where sick people gather in numbers. Many will die, and we will remain unprepared for the next health crisis. There is simply nothing more effective and nothing more basic to infection prevention and control than WASH. Right now, with a pandemic out of control, what happens in health care facilities is everyone’s frontline.
Margaret “Migs” Muldrow, MD received her medical degree from the Johns Hopkins University School of Medicine and was the Johns Hopkins Centennial Scholar for her humanitarianism in medicine. She is the founder & board chair of the Village Health Partnership based in Denver, Colorado.
The front lines in the battle to limit damage from the new coronavirus are expanding.
Covid-19, the disease caused by the virus, emerged in China and then blossomed in comparatively wealthy countries like Italy, South Korea, and the United States.
Now, the virus is spreading in poorer regions — in sub-Saharan Africa, South Asia, and parts of Latin America — where essential defensive measures against infectious disease are often missing.
Healthcare facilities in low- and middle-income countries are a potential weak link in the fight against Covid-19, health experts say. Hospitals and clinics in countries like Nepal and Tanzania often lack handwashing stations, proper waste disposal, hygienic equipment, and even running water.
“It’s huge,” said Maggie Montgomery about the role of water, sanitation, and hygiene in healthcare facilities. Montgomery is the World Health Organization technical officer for water, sanitation, and hygiene, also called WASH.
“Fundamentally, hand hygiene is the number one means of prevention,” Montgomery told Circle of Blue. “For a disease with no vaccine, no clear course of treatment, it’s even more important. Also, because there is a lack of personal protective equipment” — items like masks and gloves — “hand hygiene becomes the fundamental measure to interrupt disease transmission.”
The World Health Organization says that “frequent and proper” handwashing is one of the most important bulwarks against spreading the virus. But in many healthcare facilities, it is difficult even to find soap.
Absent these basic precautions, global health experts worry that healthcare workers in developing countries could be a vector for spreading the virus.
“It is very vital to offer quality handwashing services and reduce cross infection,” Om Prasad Gautam, global hygiene lead for WaterAid, a charity that focuses on WASH, told Circle of Blue. “If those facilities are not there, workers will act as an epicenter of transmitting disease.”
Where handwashing facilities are limited, especially in countries in Africa and Asia, it may be very difficult to control the virus once it is established, Gautam added.
“If the virus started spreading in these countries, it may spread very fast,” Gautam said.
Underfunded and neglected, clinics in developing countries frequently see doctors tending to ill patients without minimum protections against disease transmission.
University of North Carolina researchers examined environmental conditions in healthcare facilities in 78 low- and middle-income countries. The results, published in 2018, paint a dismal picture. Only half of the nearly 130,000 healthcare facilities in the analysis had piped water. Thirty-nine percent did not have handwashing soap. One-third did not have satisfactory toilets. Nearly three-quarters did not have sterilization equipment. Only two percent of facilities had the complete package of water, sanitation, hygiene, and proper waste disposal.
“The statistics are quite alarming,” Gautam said.
Though alarming, the numbers alone may not tell the whole story, cautions Aaron Salzberg, the director of the Water Institute at the University of North Carolina, Chapel Hill. Data on Covid-19 transmission is limited and healthcare facilities are challenged by a host of other pressures in their efforts to treat and control the disease. Clinics may not have enough masks and gloves. Or their facilities may be cramped, putting ill people in close contact with each other.
“At this point, we have to be cautious stating that the lack of access to WASH services is a major pathway for transmission of Covid-19,” Salzberg, the former top official for water at the U.S. State Department, told Circle of Blue. “Many factors, including overcrowding, the lack of physical space, and the absence of supplies to protect healthcare workers may be bigger issues.”
‘A Story of Coping’
For WaterAid, some of those factors — population figures and potential overcrowding of hospitals — are informing its strategy to respond to the pandemic. The main transmission pathway for the virus is close, personal contact. It is spread mainly through coughs, sneezes, and handshakes. It can survive on surfaces: roughly four hours on copper, 24 hours on cardboard, and several days on steel and plastic. Thus the medical community’s recommendation for social isolation, disinfection of surfaces, and frequent handwashing.
Gautam said that WaterAid’s top-priority countries are those with a trio of risk factors. They have inadequate hygienic services in healthcare facilities, large populations, and have already recorded Covid-19 cases. Those countries are Bangladesh, Ethiopia, India, Nigeria, and Pakistan.
The number of confirmed cases in these countries is quite low as of March 18: 187 cases in Pakistan, 137 in India, eight in Bangladesh, five in Ethiopia, and two in Nigeria.
Low numbers of confirmed cases, however, are an incomplete indicator. Without widespread testing, there is no way to know how bad the situation is, said Lindsay Denny, health advisor to Global Water 2020, a WASH advocacy group.
The true number of cases is one of many unknowns. Other questions center on the environmental conditions that nurture the virus. The survival of similar coronaviruses is dependent on temperature and relative humidity, according to research from Lisa Casanova at Georgia State University.
Lower temperatures and low humidity are more favorable for survival. Higher temperatures kill the virus. Countries with the largest outbreaks to date are in the northern hemisphere, which is transitioning away from cooler winter temperatures.
“The picture of this virus is evolving very rapidly,” Casanova said on a conference call last week.
If there is a coming wave of infections in the southern hemisphere as it moves into autumn and winter, governments need to be prepared, said Michael Ryan, executive director of the health emergencies program at the World Health Organization.
Ryan said that while many countries in sub-Saharan Africa have fragile health systems, they are not helpless against viruses, having gained experience during the Ebola outbreak and with other diseases.
“I have worked with African colleagues and in Africa for many, many years, and what I see is a story of resilience, a story of coping, and an ability to overcome adversity through communities, by building on community intervention and building community acceptance,” Ryan said at a press conference. “If we can match community participation with good governance, then I believe that Africa can succeed. It has demonstrated that time and time again.”
The poorest and least powerful sections of all societies are likely to be worst affected in crises, but we can work to alleviate inequalities through our response. Priya Nath and Louisa Gosling highlight how our emergency response to the coronavirus pandemic can mitigate new and existing vulnerabilities among people affected.
Handwashing with soap is the first line of defence in tackling the COVID-19 pandemic. Yet inequalities abound in access to water, sanitation and hygiene (WASH), services, and following the advice to wash your hands with soap regularly is not as easy for some as it may sound.
Years of experience and evidence show that income, economic context and landlessness; age, disability and health status; geographical location; and ethnicity, race, religion and gender all play huge roles in determining whether individuals, households and communities have appropriate, available, affordable and accessible WASH. At WaterAid, we have committed to tackling inequalities in all aspects of WASH access.
The way we approach the current extraordinary global health crisis can be no different. Tackling new and existing inequalities must be central to our emergency response to coronavirus. During the global COVID-19 pandemic, life-saving clean water for hygiene, safe sanitation and basic healthcare is more critical than ever. And delivering equitable, empowering WASH responses for all is fundamental.
In our support of COVID-19 responses through WASH we are both drawing on what we already know and learning new ways to reach the most marginalised and the most burdened.
What we already know about tackling inequalities in WASH and emergency contexts
1. Gender inequality is exacerbated in health emergencies and economic crises, so must be tackled in all response efforts
As schools close and families head into lockdown, domestic chores and caring responsibilities increase greatly. At the same time, increased calls for washing hands, as well as for cleaning and sanitising, multiply the need for water. Because of gender divisions of labour, it is women and girls who will have to collect this extra water, perform more labour and do more caring for people who become sick.
For the 29% of people who do not have water inside their home, the additional long journeys to water sources caused by increased demand for water will mean more chances of contact with others at waterpoints or kiosks. And for many it will mean spending more of their already scarce resources on buying water at an unaffordable cost.
WaterAid/ Ronny Sen
Women queue up to collect water from the common water source in Anna Nagar Basti, Hyderabad, India.
Health crises also increase risks of violence and harassment of frontline health workers, particularly women nurses. Amid the Ebola outbreak in the Democratic Republic of Congo, for example, the World Health Organization documented attacks on more than 300 healthcare facilities in 2019, leaving six workers and patients dead and 70 wounded.
During times of enforced isolation and closure of many public facilities, women and girls’ ability to manage menstruation can be compromised in communities and households. Finding a clean and private space to change and wash while remaining indoors for much of the time with their family, and accessing menstrual materials and water, can be difficult.
Finally, isolation measures, the inability to access previous social support systems and increases in financial and other stresses are increasing the risks of violence against women everywhere (download report PDF). Although not directly connected to WASH, this has implications for women’s ability to access essential services, and must be factored into our response, to ensure people’s safety and security when accessing WASH and other services.
People with chronic health issues, such as HIV, or other health conditions are dealing with increased fear of acquiring COVID-19, while often already experiencing social stigma and exclusion based on their health status. In an environment where misconceptions around HIV transmission or general discrimination might already prevent them from using communal WASH facilities, crises have the potential to exacerbate the situation, making handwashing and maintaining treatments even harder. Additionally they face the real risk of disruption to essential life-saving services, and concerns over whether they will be able to access treatment for COVID-19 on an equal basis to others.
More than a billion people globally live with disabilities, the rates higher in low-income countries and among those living in poverty or belonging to ethnic minorities. Once again, the health and social inequalities they already face are intensified in crises. For someone with a physical impairment, accessing clean water frequently can be a challenge because of distance, inaccessible infrastructure or reliance on others.
People with disabilities are often already isolated from the outside world, missing out on public health campaigns geared towards people who move around. And public health and information campaigns are rarely targeted to their specific requirements. Those who rely on a carer to help them with daily tasks face either the risk of added exposure to the virus through their carer, or an inability to get the help they need more than ever in challenging times.
WaterAid/ Ahmed Jallanzo
Reuben J. Yankan, Director of the Disable Camp 17th Street Community, who is visually impaired, is helped down the steps from a public toilet by Timothy Kpeh.
Equally, public health messaging and calls to stay inside are hard to follow for people who have little or no access to WASH facilities; those who rely on daily wages to survive; those living in densely populated informal settlements or refugee camps; and street dwellers. This puts them at greater risk of not only COVID-19, but also harsh punishment by authorities. For example, we are already seeing a response that includes clearance of informal markets and housing in the name of ‘sanitisation’ in some places. The Ebola crisis in Monrovia in 2014 set a precedent for quarantining entire informal settlements that were deemed a ‘health risk’. This a deep injustice.
Our response efforts can mitigate both existing and new vulnerabilities
While the poorest and least powerful are likely to be worst affected in crisis situations, we can work to alleviate the inequality through our response:
Support governments and other WASH actors to deliver the human right to water and sanitation as a central part of response efforts, provided in a way that is non-discriminatory and accessible to all.
Develop crisis responses alongside the affected communitiesrather than for them, to ensure solutions meet cultural, social and religious challenges. Disability rights, women’s rights and indigenous rights groups, to name a few, are best placed to help us shape our response in a way that is empowering, does no harm and responds to real requirements.
Tackle and confront any discrimination and stigmatisation in response efforts, related to factors such as age, gender, race, ethnicity, socio-economic status, livelihood type and caste. We must closely monitor our messaging, images and approaches to ensure they are not inadvertently fuelling discrimination.
Promote collection of water, cleanliness of water and sanitation facilities and practising of hygiene as the responsibility of all – not just women.
Recognise the obligations and responsibility of government and sector actors to respond; do not make this an issue of individual action or responsibility.
Ensure we are collecting and disaggregating data to understand differing impacts on all parts of the population. At minimum age, disability, gender and location disaggregation is needed.
Avoid blanket approaches that suggest that everyone can change behaviours without any specific adaptations.
Do not direct messaging or responsibility for ‘change of behaviour’ at one group of people, e.g. mothers, instead talk about parents caring for children.
Do not misrepresent the number of people who have a clean water supply or access to soap.
Do: Adapt communications to suit different target groups.
Consider the communication and learning abilities of all people, including people with visual, hearing and intellectual impairments.
Plan channels for information to reach all, especially those doing caring duties, sanitation work, etc.
Takeaway materials can reinforce messages and make up for some short-term memory loss among older people or people with disabilities.
These should be easy to read, large script, high contrast between text and paper, on non-glare/glossy paper, in local languages/dialects, highly visual.
Do not exclude anyone. Not being inclusive of all can lead to fear, shame and blame.
Do not portray informal settlements or slum areas as ‘vectors of disease’, or poorer areas of the city as being unable to keep clean. This reinforces stigma and increases the chance of a negative reaction. For example, there have already been cases of informal housing being cleared in the name of ‘sanitisation’. The solution lies in guaranteeing adequate and safe levels of service for all, rather than reinforcing stigma towards certain parts of the population.