Water is life [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • AUGUST-SEPTEMBER 1982 • 2 Cover : WORLD HEALTH International ..., Drinking Water and Sanitation Decade. Cover design 4 by Peter Davies IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor : John Bland Deputy Editor : Christiane Viedma Art Editor : Peter Davies News Page Editor : Peter Ozorio World Health appears ten times a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Persian. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents We must not lose hope by Willy Brandt 3 It looks untidy—but it works by Maggie Black 4 The Decade in Europe by Gregor Watters 9 Health messages on wheels by Orlando Lopez Orozco 12 The music of water by Jitendra Tuli 15 Taps, pipes, latrines 20-21 Training people for the job by Walter Pinto Costa 22 Pakistan 24 Republic of Korea 25 Where there's a will, there's a way by Terence Niyungeko 26 News Page 30 WATER AND SANITATION DECADE We must not lose hope by Willy Brandt Former Chancellor of the Federal Republic of Germany, and since 1977 Chairman of the Independent Commission on International Development Issues (the Brandt Commission) Human energy and innovation depend on good health, as the Independent Com- mission on Interna- tional Development Issues declared in its 1980 report, " North-South : A Programme for Survival". Despite recent improvements, more people in the South suffer from poor health than in the North. There are still countries in Africa where one child in four does not survive until its first birthday. Blindness afflicts 30 to 40 million people in the Third World and threatens many tens of millions more, whether from river-blindness, vitamin-A deficiency or water-borne infections. Lack of safe water is a major cause of ill-health. In virtually half the world, water supplies are uncertain. Four out of five people living in the rural areas of developing countries Over virtually half the world's land surface, water supplies are uncertain. As here in Pakistan, countries ambitious to become self- reliant in water supply face almost insuper- able odds. Photo P. Almasy do not have reasonable access to even relatively unpolluted water. Sanitation is an even worse problem, causing numerous water-borne dis- eases, to which children are particu- larly susceptible. Hunger and malnutrition are prime causes of ill-health, together with the lack of safe water supplies and sanitation. Improvements in these fields are the objectives of the International Drinking Water Sup- ply and Sanitation Decade. Safe water and improved sanita- tions are a necessary condition for better health, and there can be no lasting improvement of public health without them. We all know that determined gov- ernment action is needed to change the prevailing situation. We also know that clean water and sanitation will remain an unattainable objective in poor countries without develop- ment assistance. Many countries are making efforts towards implementing the objectives of the International Drinking Water Supply and Sanitation Decade. But much still needs to be done—and can be done. Above all it is necessary that we do not fose hope, and that we do not waste time in discussing what it would be best to do first. I sincerely hope that governments and international organizations will strengthen their cooperation in this literally vital area, and I trust that WHO will receive increasing support in its task of helping the developing countries to attain the goal of Health for all by the year 2000. There is clear evidence that man- kind could come to grips with prob- lems like safe water supplies and sanitation. We know the problem and we know what needs to be done. We have the technical capability to tackle the problem. We even have the financial resources—which unfortunately we squander on armaments. It is a matter of humanity to con- quer hunger and disease on our way towards the next millenium—to prove wrong those forecasters who say we will have to face the distress of hundreds of millions of people suffering from starvation and pre- ventable diseases at the turn of the twenty-first century. ■ 3 It looks untidy but it works Why can't our slogan be : " Let water enter the village" ? asks a women's group leader in West Sumatra. If every family could have a piped water supply, they wouldn't get cholera any more by Maggie Black The distinguished vis- itors from Jakarta, with their hosts, file into the hall in orderly fashion and take their seats be- hind the white-clothed table. On the walls are green stars and fluttering streamers in red and white, the national colours. The audience—the 39 men and six women who make up the health teams for the district of Solok in West Sumatra—wait with customary Indonesian politeness. They have been summoned to Solok hospital on the authority of the Bupati, the head of the district administration, to hear about the new training plans for the village health workers. Once the Bupati has completed his opening remarks, Dr Arbunta, the rep- resentative from the Ministry of Health in Jakarta, takes the microphone. In turn, his gentle admonitions fill the hall, and are broadcast over the compound through the hospital's tannoy system. Some of the more curious and able- bodied patients peer in through the windows. A reporter from the local newspaper seated in the front row starts to take notes. Flash bulbs pop, and two girls in printed sarongs distribute tea and sticky sweets. Health, says Dr Arbunta, is not sim- ply a question of being free of diseases such as smallpox and cholera. People need to be socially and economically healthy, and that takes time—far longer than the two years which have elapsed since the community health programme began in Solok. Dr Arbunta constantly repeats one central theme : coordina- tion. He talks about the Village Devel- opment Committees, and their working groups. He exhorts his audience to build up ties between school teachers, tradi- tional birth attendants and village health workers so that they can work together as a team. The new training programme will emphasise leadership : the need to involve religious leaders and village leaders, so that they can " get the village ready" for this new concept of health. Dr Arbunta explains the goals of the Decade. He illustrates his point : "Try- ing to introduce water and sanitation will go nowhere if some old fellow stands up and says 'I have been drinking this water all my life, and nothing has happened to me', and everyone nods wisely and carries on just as before." Dr Arbunta's audience nods wisely. Un- questionably, they have heard this message before. It is striking that whenever people in West Sumatra open their mouths to talk about health—from the Director of Health Services in his spacious office in the provincial capital of Padang, down through all the strata of health and administrative personnel, to the village health worker in the sparse comfort of her little upstairs room—references to illnesses, hospitals, doctors, surgeons, operations, epidemics or patent medi- cines, represent only a minute fraction of their conversation. The main to- pic—and this has been particularly the case since 1979—is the improvement of community health. Activities are based on the health centre, or Puskesmas, of which there are now 116, covering roughly 35 per cent of the 3,400,000 population in West Sumatra. All are doing what is called "the basic seven", and 60 per cent are undertaking "the basic 12" : sanitation, nutrition, immunization, medical care, community diseases control, health edu- cation, mother and child health, family planning, mental health, dental atten- 4 The little house with the painted initials in a West Sumatra village brings under one roof a whole series of programmes carried out at village level, all of them known in Indonesia by their acronyms. Photo WHO/UNICEF/M. Black tion, the collection of health statistics, and health classes in schools. The pri- mary health care programme, which is known in Indonesia as Pembangunan Keshatan Masyara kat Desa, or more often by its acronym PKMD, is only one of these many activities. PKMD was launched in West Sumatra in 1979, in two districts initially, one of which was Solok. In West Sumatra, therefore, it is difficult to disentangle the primary health care approach, whose emphasis on preventive activities and community involvement permeates both Dr Arbun- ta's speech and the list of the " basic 12 ", from PKMD, the primary health care programme. Disentanglement becomes even more difficult at village level. The key PKMD personnel are the Prokesas, or volunteer health workers, whose qualifi- cations must include that they are resi- dent in the village, have some means of support, and are widely respected and well-liked. They are responsible to the Village Development Committee, and through its principal officer, the village headman, to the local administrative authorities ; and they receive their train- ing and medical back-up from the health centre. On paper, the programme looks tidy. In practice, in the village, it often looks extremely confused. For the Village De- velopment Committee, and its working groups, are " coordinating " not just the PKMD programme, but all the other de- velopment programmes, for nutrition, family planning, weighing the under- fives, fishponds, vegetable gardens, and women's activities. And all of these programmes have their equivalents of Dr Arbunta, exhorting teamwork and coordination, emphasising leadership and the recruitment of volunteers who, since they are resident in the village, are widely respected and well-liked. The result is that the same people are Pro- kesas and volunteers for all the others as well. The fact that the same people wear different hats—or rather uniforms—to de- liver different, or sometimes even the same, messages, may make for adminis- trative and evaluation difficulties. But villagers are less anxious about neat paperwork than about visible improve- ments : latrines being built, children be- ing weighed, more mothers taking the pill. Calls from local officials for coordina- tion sometimes get thrown back at them, with the rejoinder that the villagers are coordinating very well already. At a sub-district meeting in Kubung Chili, a village headman rises to his feet. "You have told us about the value of clean water and washing regularly, and we are convinced. But we have no water in our village. Where are the pipes ? Where are the taps ? " The holistic view of health as a social and economic condition has penetrated the headman's mind to the point where the absence of a proper water supply has become a fixation. He may also, of course, be under pressure from his vil- lage " constituents ". At any rate, no- one need tell his Village Development Committee to " coordinate " health care with clean water. The blockage is further up the line. As Dr Arbunta puts it, the new health creed has caught on to such an extent that demands are coming forward that the authorities are not yet able to meet. Painted signboards In the village of Balipandan Chupa, the style of coordination is physically illustrated by the little house standing squarely in the middle and straddling the stream—or drain—which runs along- side the main street. It has two tiny rooms below, and one reached by a perilous ladder above. This house is covered with painted signboards out- side, amounting almost to a full glossary of Indonesian acronyms for village-level development programmes : PKMD (pri- mary health care), UPGK (nutrition), LKMD (village council), PKK (women's group), and UKS (school health educa- tion). Downstairs in one of the tiny rooms, about 20 children are being given a nutritious lunch-time meal (UPGK). But it is the leader of the women's group (PKK) who explains that they have virtually eradicated malnutrition. In the other room, an impressive hand-written chart records the dramatic increase in the number of family planning acceptors. It 5 is a Prokesa, putting on her plain blue health volunteer jacket over her brown batik women's group outfit, who de- scribes their persuasion tactics. Balipandan Chupa is a comparatively large village, with obvious agricultural wealth. Fishponds—promoted by the male Prokesas—are definitely desirable things to have. So are latrines, another novelty the Prokesas have pushed. They have partly caught on because of a cholera outbreak in 1979, which caused many deaths and greatly scared the village families. But Mrs Rosni, the dynamic leader of the women's group and much else besides, is as keen as the village headman from Kubung Chin on getting a proper piped water supply. "At the moment we share latrines which are common to several families," she explains. "The problem is that we can't keep them clean. Each family wants their own, but not until they have piped water. If they could only have a water supply coming in pipes which ran past their houses, they wouldn't get cholera any more. The government wants to give us electricity. The slogan is : 'Let electricity enter the village '. Why can't it be : ' Let water enter the village' ? " Imposing midwives It is not only the younger, more energetic and modern women who are water-, washing-, and hygiene-con- scious. In Indonesia today, around 80 per cent of newborn infants are still delivered by traditional birth attendants, or Dukuns. In West Sumatra, the Du- kuns belong decidedly to an older gen- eration. They are gnarled old ladies with toothless smiles, often assertive and even imposing. They have nothing in the way of what is conventionally regarded as training or education, but recently, with UNICEF assistance, they have been brought into the orbit of health centre activities and given some training and a midwife's box of equipment. What are the various steps that Dukun Nurulan undertakes in the course of a delivery? She stands theatri- cally to answer the question by play- acting her part. First, she checks the mother's stomach. No, first she washes her hands. Then, after her hands are clean, she takes a piece of cloth and washes the stomach with hot water, and massages it. Then she prepares her clamps and her string (she takes them from her midwife's box), and washes her scissors and gets them ready. If she sees the head of the baby, she grabs the baby under the arms. Then she clamps the two sides of the cord, ties and cuts it. Then she washes the baby, she gives the baby a bath. Mrs Nurulan concludes her perform- ance with a final reference to her props in the midwifery kit (which include a It looks untidy— but it works Left : A regular visitor to the day-care centre in West Sumatra, this little boy receives affection as well as a nutritious lunch from the caring personnel. Right : Like the traditional houses in this region, the crop storage bins are built with graceful up-curving roofs. Photos WHO/UNICEF/M. Black 6 torchlight and a plastic raincoat with a health message printed on it), and with the complaint that no-one will replace her torn plastic gloves. She takes her seat again. Washing and cleanliness have been the recurring theme of her recitation. In Magek village some distance away, it is not the Dukuns nor PKMD nor the women's group but the nutrition volun- teers who are in the vanguard of health activities. They too are weighing the under-fives, growing vegetables and in- stalling latrines. In the village meeting hall there is a platform, the mandatory microphone system, a display of handi- crafts, and rows of smiling nutrition workers dressed in their plain grey sarongs and jackets. Audience participation After the welcomes and the introduc- tions, the passing round of tea and the singing of songs about " Health for all by the year 2000", one of the visitors decides to involve the whole assembly in an audience-participation exercise. She embarks upon the story of a village, a story with a "gap" in it which she invites the audience to fill in. There is a "be- fore" picture : the village is untidy, the children sick ; and an "after" picture, with neatly fenced gardens, and healthy kids. Members of the audience are in- vited to explain what happened to bring about this change. The first answer is that the people swept the paths and cleaned up the village. The second, that they planted gardens for traditional medicines and vegetables. The third, that they installed a water pump and a well. The fourth, that they built latrines. The fifth, that they built some roads. The sixth—the last—that the mothers took their children to the health centre. All the preventive activities had come to mind first. In the countryside of West Sumatra there is constant evidence that the cen- tral image of the primary health care approach—health as a state of social well-being not merely associated with the absence of serious illness or bodily damage, and not principally associated with doctors and health institutions—has penetrated the collective consciousness. Whether this has happened because of the primary health care programme it- self, or as a result of any of the other activities, is ultimately immaterial. If, to the visiting planners and development specialists from Jakarta, fishponds are impossible to disentangle from family planning, that is their problem ; it is certainly not one for the villagers. As far as the villagers themselves are con- cerned, what is happening seems neither disorganized nor confused. It reflects their lifestyle and their values. Its "un- tidiness" is the very quality which indi- cates that it works. ■ 7 Jim 41`11"11Milltb■-, 71111. - • -00111110 :slaZimbs*ProAlP.,„ The Decade in Europe Until a Rapid Assessment Exercise was carried out, the feeling prevailed that the Decade's goals were directed elsewhere. This viewpoint changed dramatically as it became clear that the levels and the quality of services in Europe were far from satisfactory by Gregor Watters During the period im- mediately following the Mar del Plata Confer- ence in 1977, wi-) undertook a pro- gramme of preparatory activities which in- cluded a Rapid Assessment Exercise of the water supply and waste disposal services in its Member States. It was clear then that the biggest deficiencies in service and the greatest need for action during the Decade were in the developing countries of Africa, Asia and South America, where particu- lar emphasis would have to be placed on areas with severe water shortages or frequent droughts. In fact, there was a feeling that the Decade would be of little or no concern to Europe, since almost all countries of the European Region were advanced, highly indus- trialized and, in global terms, relatively rich. They also had a long history of public services, including water supply and waste disposal, as well as the necessary legislative and administrative infrastructure. The Rapid Assessment Exercise (RAE) had possibly more effect or impact in the European Region of WHO than in the rest of the world. In Africa, Asia and South America, the water supply and sanitation services were known to be poor, and were recognised as a major contributor to unsatisfactory health con- ditions. The RAE was therefore not so Water supply systems come in many shapes and sizes. This one, in an Istanbul suburb, is old-fashioned—but it works. Facing page : Detergent foam pollutes long stretches of the River Seine in France, up- river from Paris. Photos C. Stauffer © and P. Almasy much an exercise designed to identify problems but rather to quantify the tasks to be undertaken before 1990 if the Decade's goals were to be achieved. In Europe, on the other hand, it could be said that—until the results of the Rapid Assessment Exercise were avail- able—a certain complacency existed. A general feeling prevailed that the De- cade was directed elsewhere, while the countries of Europe were looked to as possible donors, using their overseas development organizations to assist the less developed countries. This viewpoint has changed dramatically since the analysis of the situation clearly demon- strated that the levels and quality of service in all European countries were not as satisfactory as had originally been assumed, and that work had to be done in even the most developed Member States if the goal of "providing all people with water of safe quality and adequate quantity and basic sanitary facilities by 1990" was to be attained. So what are the deficiencies in service and problems which the Rapid Assess- ment Exercise exposed ? Basically, the level of service coverage was not as high as was generally supposed. In the more developed coun- tries, between one and ten per cent of the urban population were not con- nected to a water supply system and as many as 40 per cent were not connected to a sewer. The situation in the rural areas was far worse ; the level of service varied much more, so that anything between five and 60 per cent were not connected to a water supply system, and between 70 and 100 per cent were not connected to a sewerage network. Of course, non-connection to a sewerage system is not a true indication of unsatis- factory service, since the appropriate means of waste collection treatment and disposal for isolated dwellings and com- munities is bound to be some system of individual sanitation. But such systems 9 should be accompanied by regular and routine servicing, and this is generally not the case. The need to improve the coverage and quantity of water supply and sanita- tion service in Europe is clear. The Region's approach to the Decade will therefore be the same as elsewhere in the world, even if the scale of the problem is not so large. Since all the developed countries of Europe have the technical capability and financial re- sources to attain the goals of the Decade in terms of eliminating shortfalls of service, the main problem to be solved is that of protecting resources and main- taining acceptable water quality. Drinking water is obtained from sur- face or ground water sources, both of which are liable to pollution. The hazards are increased as industrial activ- ity intensifies and as new chemicals are developed, many of which are toxic or have carcinogenic, mutagenic or other long-term effects which cannot yet be fully appreciated. A common means of obtaining water is extraction from a river upstream of a community. After appropriate treat- ment, the water is distributed, consumed and discharged back to the same river downstream of the community. The next community downstream repeats the process so that, in effect, the wastes of one town act as the supply for the next and so the process continues along the course of the river. This practice is quite acceptable pro- vided sufficient time for self-purification elapses before the second point of ex- traction, and provided adequate treat- ment and disinfection takes place after extraction and before distribution to the second community. As the demands for water increase and as the quantities of waste water discharged rise, the dilution and self-purification capabilities of the receiving stream are reduced and the need for treatment grows. Preferably, the waste water should be treated before discharge, which has the advantage of reducing the damage to the receiving water and generally protecting the envi- ronment. But this is not always done, so that the safety of the drinking water supply depends entirely on the adequacy of the treatment and disinfection of the raw water before distribution. Ground waters, which in many areas are by far the most important source for potable supply, are equally—if not even more—at risk than surface waters, while improving their quality after pollution has taken place is much harder. Rivers are relatively fast-flowing, and once pollution control measures are intro- duced, the quality improves rapidly. One example which has been widely These pools are slow sand filters—a tradition- al, well-tried and effective method of treating water to make it safe for human consump- tion. Photos WHO/G. Watters and C. Stauffer © Right : These ancient fountains in a Turkish community provide water which is compara- tively safe but has not yet been safeguarded by chlorination. publicised is the River Thames in the United Kingdom, where several species of fish which had long disappeared have now returned as a result of pollution control measures. But ground waters are concealed ; they generally flow slowly, with a flow direction which is not always consistent, and once polluted they can remain so for long periods of time, particularly when the polluting agent is a non-biodegradable chemical or toxic substance. Again, a discharge to a river can be seen, while seepage to ground waters from the dumping of wastes, spillage of chemicals or infiltration of polluted surface wastes cannot be observed. Water supply and sanitation services, as preventive measures, are clearly iden- tified as an important component of primary health care and, as such, the Decade will have an important role to play in WHO's overall strategy towards Health for all by 2000. The contribution of water supply and sanitation in the fight against diarrhoeal diseases in de- 10 veloping countries is clear, and a great number of lives can be saved, particular- ly those of young children, in Africa and Asia. But diarrhoeal diseases are still a major health problem in the warmer regions of southern Europe and North Africa, where most progress in the European Regions remains to be made towards attaining the Decade goals. This problem was highlighted in 1980 by WHO at a meeting in Rome on surveil- lance and control of acute diarrhoeal diseases. The meeting was attended by representatives of Mediterranean coun- tries where the problem is most acute. However, in northern European coun- tries too, it is not uncommon for there to be 10 cases per 1,000 population each year ; indeed, this will be a serious underestimation of the actual number. One country at the Rome meeting re- ported a ten-fold apparent increase in cases which was wholly attributable to an improved system of notification. Analysis of the alternative approaches to prevention of enteric infections and diarrhoeal diseases suggested that sani- tation on its own could provide 50 per cent prevention against all enteric infec- tions on a long term basis, and that this could be increased if the provision of new services was accompanied by an effective programme of health educa- tion. The only real disadvantage of this approach is cost, since a relatively high initial investment is required. Another element of the EURO Decade approach is the encouragement of ap- propriate technology to enable services to be provided in the most effective way, from both the technical and economic standpoint. The adoption of appropriate technology in the form of handpumps, hand-flush toilets and so on has not the same scope for application in Europe that it has in other parts of the world. However, there is a great need to identify and apply technology which will suit specific geographic and topographic conditions such as small islands, arctic areas, mountainous regions, and arid zones. A fluctuating population that is usually seasonal in nature and often swollen by tourists is another phenome- non which calls for an appropriate tech- nology approach. The tourist traffic in Europe is to a large extent towards the shores of the Mediterranean. During the summer months, non-existent or over- loaded services seriously add to the risk of epidemics of diarrhoeal diseases, par- ticularly amongst the visitors who do not have the same natural level of resistance as the local people. Among all the technical problems to be faced during the years between now and 1990, a poor organization and man- agement structure within the water sup- ply and sanitation sector, and a lack of adequately trained and experienced manpower will need special attention. Such problems are several times com- pounded in country areas, where large numbers of smaller installations have to be managed. Once again, this results in the rural communities having in general far inferior services than their urban counterparts throughout the whole of the European continent. Because political systems and ad- ministrative structures differ, proposals for improvement can only be underta- ken on a country-by-country basis. Technical innovations and massive capi- tal investment are likely to prove in vain unless the infrastructure is developed in parallel, in order to manage the systems and ensure that the service intended is provided. Obviously, a broad-based approach to cover a wide spectrum of development levels is called for. WHO's Regional Office has accordingly developed its Basic Sanitary Measures activities with- in a programme which pays full regard to the identified needs of its Member States, is designed to contribute effec- tively towards the goal of Health for all by the year 2000, and is in accordance with the WHO Global Strategy for the Decade. ■ Colombia's Rural Basic Sanitation Programme is concerned mainly with providing drinking water and proper excreta dis- posal for villages with fewer than 2,500 in- habitants. To do this will involve community participation, which means in practice that the community contributes 20 per cent of the total cost of the sanitary installations and reimburses about 40 per cent of the investment made by the Government, and that the adminis- tration, operation, maintenance and ex- tension of the facilities are the responsi- bility of those who actually use them. Qualitative and quantitative partici- pation by the community on such a scale cannot be obtained by coercion. In Col- ombia, we try to ensure that the com- munity understands its role as both beneficiary and agent of the health work undertaken. We have to see to it that the people themselves play a conscious, active and sustained part in their own development. So the Rural Basic Sanitation Pro- gramme—which comes under the Na- tional Institute of Health, an autonom- ous agency attached to the Ministry of Health—uses the only possible way of getting results : EDUCATION. The educational component of the programme—which covers both water supply and sewage disposal—consists of a team belonging to the Community Promotion Section and composed of sociologists, health educators, com- municators and environmental health promoters, together with the requisite instruments and materials to back up the educational processes set in motion by the team in the community. Notable among these instruments is the " mobile audiovisual unit" (Mau), which has been used in the Programme for 15 years with excellent results. There are now four of these units operational. Basically the mAu is a motor vehicle fitted out to house a variety of audio- visual equipment and materials; these in turn are designed to give direct field support to the educational work of the Local Promoters of Rural Basic Sanita- tion. The object is to reinforce the verbal communication established with the communities where the programme operates, intensifying the impact of new knowledge about health so that it is assimilated more efficiently. Various studies have shown that in the learning process it is vision which plays the major role, contributing 87 per cent of the total input from all the senses. We use a medium-sized van with four-wheel drive as it has to operate in some rough country. To make sure that it cannot be used except as a MAU, there is seating room in the cab only for the driver/operator and one other person, generally the local promoter responsible for the community to be visited. The cab is partitioned off from the rear part, where most of the audiovisual equip- ment is housed in compartments. The vehicle had to be especially converted for this purpose ; plans and drawings are available to anyone running a water supply project and interested in install- ing similar equipment. The vehicle and most of the audiovisual equipment were donated to the Programme by UNICEF. The audiovisual apparatus includes : a 16 mm cine-projector, used for showing educational and recreational films. The Programme has its own lib- rary of films, some of them produced internally and others acquired from commercial firms in Colombia and abroad. Many films are on loan from foreign embassies and diplomatic missions. a slide projector with built-in cas- sette recorder. This is used for showing sets of 35 mm slides with a synchronised commentary. Every MAU has a good stock of these slide-shows, which are prepared beforehand by the headquar- ters technicians of the Community Promotion Section. a professional tape-recorder which can present sound programmes lasting up to two hours and consisting of stories for radio, or pop music interspersed with educational messages. One programme might be aimed at making people aware of the problems caused by lack of drink- ing water and inadequate excreta dis- posal ; another, at encouraging proper use of the health services by the com- munity. a public address system, consisting of amplifier, microphones and speakers. With these the operator, the accom- panying promoter or the community leaders themselves can address messages to the population, or amplify the sound produced by the audio-visual equipment. Health messages on wheels A sturdy four-wheel drive van carrying audiovisual equipment spearheads Colombia's campaign to motivate remote village communities into im- proving their own water and sanitation by Orlando Lopez Orozco 12 Hay que progresar compadre ! Instale en su case un SANITARIO CAMPESINO ******** Salud e higiene porn In familia a bajo mecio. "We must make progress", urges this poster. "Install a rural latrine in your house. Health and hy- giene for your family-at low cost." Left : Health messages relayed to the public are motivating more and more communities in Co- lombia to cooperate in laying water pipes and building latrines. Photos WHO and WHO/UNICEF/H. Cerni • a petrol-driven electricity generating plant to supply energy to the various equipment. Each mobile unit also carries such minor equipment as a portable battery- operated cassette recorder, a radio, a small battery-operated amplifier with microphone and speaker, and a sound control switchboard. Colombia is a vast country, and many regions simply cannot be reached by motor vehicle. In such cases, all the equipment can be removed from the van and installed on some other form of transport. Responsibility for operating the MAU is assigned to a middle-grade technical official, who has to be an excellent driver, a skilled motor mechanic, and a person with a bent and aptitude for educational work with rural people. For MAU work, four operational zones have been established, each subdivided into six sections. Each section gets a visit from the MAU about three times a year, and each has on average six local pro- moters of Rural Basic Sanitation. They are responsible for direct community promotion and health education ac- tivities in the community and also for all technical work in the public health en- gineering field assigned to them by the sanitary engineer. The film and slide-show session is usually held in the local school. As it begins to get dark and the public have assembled (there is always a big turn- out), the local promoter addresses them and tells them the purpose of the visit. One of the local leaders also puts a word in, calling on the community to support the project. The films and slide-shows are intended to further the educational objective of the visit. The resources of the mAu are brought to bear upon such health education lessons as the proper use of the drinking water supply service, the import- ance of good quality drinking water, why excreta and garbage disposal are necessary, importance of the daily bath and domestic hygiene, and the suitability, use and storage of water. The promoter starts a discussion with the community on what they have seen. This reinforces the educational work which the local promo- ter is doing and for which he uses other educational tools, particularly direct con- tact with the inhabitants through home visits. Aside from this work, the unit under- takes such equally important activities as educational work in schools and col- leges, where pupils are asked to cooper- ate in looking after the various compo- nents of the water supply and sewage systems, and special emphasis is laid on conservation of trees and protection of water sources. It is certainly exhausting, nomadic work, but the operator is a mystic, a missionary in lay clothing, convinced that he is working to bring health to his fellow citizens in the rural and disadvan- taged areas. The programme tries to compensate him for his sacrifice with an adequate salary, proper allowances and a modicum of equipment. But that is not what inspires him and keeps him going. What encourages him is the recognition of his work by the community itself and the tangible results that stem from it : drinking water supply and sanitation systems for the welfare of his country's rural people. ■ 13

Durga Devi's world changed dramatically on 20 September, 1981. Months later, she still does not quite believe her luck. "I do not think I will ever fully get used to it," she says, a bright smile lighting up her friendly face. Has she won a lottery? Inherited a piece of land, or a pair of bullocks ? No, she has not. But, as she is quick to add, what she has got is worth more to her than all the riches in the world. Water. Clear, pure, sweet drink- ing water, and what is more, it is literally at her doorstep. Durga Devi's feelings are fully shared by her fellow villagers in Balanwala, one of over 33,000 villages in the Indian State of Rajasthan. To Gyarsi, an energetic 60-year-old grandmother, the novelty of handpumped water is no less than a miracle. "I remember, when I was young, how I used to spend four to five hours every day in fetching and carrying water. These younger women," she says, pointing to a group at the pump, "could not really ask for more." Even as we were talking to Gyarsi, Durga Devi returned to fill up yet another bucket of water. "I now do For residents of many villages in Rajasthan, particularly the womenfolk, the sound of water trickling from newly installed pipes is music indeed. Photo WHO/A. S. Kochar more washing and cleaning than I have ever done," she explains. For one thing, she has the time, since she no longer has to trudge for miles as she did earlier. To the village children, the new hand- pumps, developed initially with WHO/ UNICEF assistance, and now produced by several manufacturers all over the coun- try, are a great attraction. They are easier and smoother to handle because of the new design, so the children do not have to be told twice to fetch water. Earlier, because of the distance involved and the fact that a deep well is not a place for children, the water fetching and carrying chores were largely, if not exclusively, the responsibility of the womenfolk. Today in Rajasthan, one of India's problem states as far as water supply is concerned, a new sound is to be heard in the villages. The sound of handpumps, the welcome sound of water as it fills buckets and earthenware pots. "It is the best music I have heard in my life," says Ram Swarup, a wizened village elder, as he watches his grand-daughter taking water from the pump, one of four that have been installed in the village re- cently. The story is repeated in other parts of the State, in other States in the country, and in other countries in the South-East Asia Region. Slowly, but surely, the countries are moving towards the goal of providing safe drinking water for their people, as spelt out in the objectives of A water tap is also a meeting place. A Rajasthan woman beams her satisfaction. For children too, running water is a joy. Photos WHO/A. S. Kochar The music of water In the Indian State of Rajasthan, a new sound is to be heard in the villages—the sound of handpumps, the welcome sound of water as it fills buckets and earthenware pots by Jitendra Tuli 15 the International Drinking Water Sup- ply and Sanitation Decade, 1981-1990. As in India, other countries in the Re- gion have identified problem areas and villages, and have formulated guidelines to provide drinking water to them on a priority basis. First priority will be given to what are termed as "no-source vil- lages." These are villages with no water source or where water is only available beyond a distance of two kilometres. According to Mr G. L. Mathur, Chief Engineer, Public Health Engineering Department, Rajasthan, the Govern- ment has made a ruling that one water source, usually a handpump, is to be provided for every 250 to 300 people. An additional source is to be provided in localities inhabited by socially and economically backward classes. For hard rock areas, tubewells with hand- pumps are to be the first preference. The extent of the problem can be gauged by the fact that, according to India's Sixth Plan (1980-85), 57,000 problem villages have yet to be covered in the country as a whole. Rajasthan alone has many thousands of such vil- lages, which still remained to be pro- vided with safe, assured water supply facilities at the beginning of the Sixth Plan. As Mr Mathur and other officials concerned with the implementation of water schemes under the Decade ac- tivities point out, the participation and involvement of the community is vital for the continued success of the pro- gramme Unless the community is will- ing and is enabled to look after the handpumps once they are installed, the problem of scarce water will remain. Then again, the same degree of involve- ment will be required for the village community to set in motion activities related to sanitation. It is now well Hardly the most suitable place to do the weekly laundry: the sluggish stream is in effect an open sewer. Right : Progress is pipe-shaped. Within weeks these monsters will be bringing an additional water supply to the city of Ajmer. Photos WHO/A. S. Kochar recognised that, although the priority is for safe water, the sanitation aspect cannot be ignored if the full benefits of safe water supply are to be enjoyed by all. Keeping this in mind, several inno- vative schemes have been launched with the help of voluntary agencies, such as the Social Work and Research Centre at Tilonia, 70 kilometres from the capital city of Jaipur. Managed by a group of young professionals—doctors, social scientists, geologists and administrators —the Centre has a wide range of ac- tivities aimed at rural development with 16 the involvement of the community. Mr Sanjit Roy, the Centre's Director, explained that the water supply and sanitation programme has been ex- tended so as to cover areas like social forestry and to help in generating income for the villagers. A remarkably successful example of this could be seen at the small hamlet of Nalu. At the Government school, the children and teachers had joined hands to use the waste water from the hand- pump to nurture a nursery of seedlings. Every time the pump was used, care was taken to collect the spilt water for the seedlings, which were planted in small soil-filled polythene packets. The seeds were provided by the Centre, which, in turn, would buy the seedlings from the school and give them to the social for- estry department at half price. Last year, the children said excitedly, they were able to collect over 3,000 rupees. This year, to judge from the way the nursery seemed to be stocked with packets, would be even better. "It has opened up new vistas for all concerned," com- mented one schoolteacher. In other countries of the Region, such as Maldives and Nepal, the problems are similar, in the sense that there is a shortage of potable water, but the reasons are totally dissimilar. In Maldives, for instance, the major source of drinking water is rainfall. What adds to the problem is the generally high water-table—only two or three metres down—which makes it prone to pollu- tion. Every effort is being made to evolve economically feasible schemes to collect more rainwater and to make the existing ground-water courses safe through appropriate excreta disposal facilities and sanitation measures. In Nepal, the rough and mountainous character of the country needs an en- tirely different approach, usually involv- ing a practical engineering solution. As part of the Decade activities, steps are being taken to provide piped water from streams and other natural sources to villages perched on top of steep hills, thanks to the use of flexible PVC pipes. Water is thus being provided to villages where it was normal for womenfolk to travel for several kilometres and for many long hours, just to get a couple of pots of drinking water. As all the people connected with the water supply projects stress, it is essen- tial to view the scheme in its entirety, and to keep in mind the need for sani- tation. Therefore, whatever activities are taking place to ensure the provision of safe water, steps are also being taken to deal with the sanitation aspects. In several villages that I visited in Rajasthan recently, it was obvious that a tremendous transformation had taken 17

A hand-pump in action in the village of Ramchandpura. Left : Children tending to seedlings they have planted beside the outflow of water from the school hand-pump. The children get a share of the earnings from the garden produce they sell. Photos WHO/A. S. Kochar place in areas where water had been provided. Apart from alleviating the overwhelming burden on women who are the traditional drawers of water, it had given people enough spare time to take care of other important things which were usually pushed way down in the list of priorities. In areas like Udaipur, guinea-worm infestation had totally disappeared from places where safe water had been provided. Indicative of this welcome change was the rapid dwindling, if not the total absence, of shops where previously sufferers from " Balu Nahru "—or guinea-worm dis- ease—were treated. At Padampura, where the peacocks proudly prance around the water source in their multicoloured glory, quite un- mindful of the people, stray dogs and cattle, the water has been brought from a central reservoir more than nine kilometres away. The same reservoir feeds five other villages within a radius of ten kilometres. Since Padampura is also an important pilgrim centre, the new water source has proved to be a boon in more than one way. Earlier, says the village headman, the visitors would not stay, since the available water was very brackish. Now, many more visitors come to the village as word has spread that the water is available 24 hours of the day, and that it is sweet. The Padampura example is not the only one where water has been brought through pipes over long distances. In Ajmer district, nine million litres of water are supplied through a network of pipelines which stretch more than 70 kilometres from the source. Through a system of pumping stations, the water is raised to a level of over 500 metres. In a short while, this system will be aug- mented to cover 26 more villages in the same district. As the officials emphasise, the first priority is to provide water where there is none. For water, it has truly been said, is life. And where there is life, there is hope—for a better, healthier and more peaceful life. ■ 19 A girl in Sarawak brings the water home in well-sealed bamboo tubes. Photo WHO A new tap saves the children the chore o fetching water. Photo WHO/UNICEF/J. Danois Because of what the Decade will imply in end results to peo- ple, I am utterly convinced that the number of water taps per 1,000 population will be an infi- nitely more meaningful health in- dicator than the number of hospi- tal beds per 1,000 population. Dr Halfdan Mahler, WHO Director-General Clean water and plenty of soap for a com- munal hair-washing in southern Africa. Photo WHO/D. Sebina Every drop is precious during the annual dry season. Photo P. Almasy Right : An arm-stretching task for a young lad in Colombia. Photo WHO/UNICEF/H. Cerni Taps, Pipes, Latrines The malodorous outflow from a fish-process- ing plant pollutes slum dwellings in Latin America. Photo WHO/UNICEF/D. Briggs _ •-• The provision of safe water and sanitation does not merely mean happier, healthier citizens; it also means increased eco- nomic productivity.... It must be recognised that the goal of clean water and sanitation for all by 1990 is eminently achievable. Mr Kurt Waldheim, former UN Secretary-General Below: Let's hope the latrine is downhill from the well! Photo WHO/A. S. Kochar 1 I „5.PIAGGIAi cliI5ERVATA PING ., .• .., N .' , 1 t '.". ."' — •-41 ‘f k iS. i ' ! I' ; . r ' 31 ■VI , . I R• . ... . , , • . ' - -3,--- ' ti-,,,, .....," .... ..,..s. ...,.. ,4,... ..„,..... _ ...„ s -,_ . .‘ .....,, ...„.... ... ..14--. Inset: Bystanders supervise the fitting of a latrine slab in Sri Lanka. Photo WHO/A. S. Kochar Above: Another kind of pollution on a Mediterranean beach. Photo WHO/Publifoto Since the start of its National Water Supply and Sanitation Plan (PLANASA) in 1971, Brazil has been imple- menting a large pro- gramme of investments aimed at expanding and improving water supply and sewerage services in urban areas. In these areas live 80 mil- lion people—two-thirds of the country's population. Investments made on behalf of PLANASA, up to 1981, had reached ap- proximately US $6,000 million. These investments have made it possible to match the targets set for the 1970s, which were for 80 per cent of city- dwellers to have water supply and for 50 per cent to have sanitary sewerage systems. In human terms, the numbers of people with water service were to increase from 30 million to 64.6 million, and those with sewerage systems from 15 million to 40 million. PLANASA'S 1990 targets aim at supplying 90 per cent of urban dwellers with water and 65 per cent with sewerage services. The work force engaged in Water Supply and Sanitation (wss) is currently of the order of 90,000 employees, 70,000 of whom are employed by the State agencies and 20,000 by the inde- pendent municipal services. These range from high-level professional engineers, chemists, managers and economists to unskilled labour. In order to ensure the necessary tech- nological and human resources, a tech- nical support programme was estab- lished in 1972, which includes training, technical assistance, research, standardi- sation, transfer of technology, and so forth. The training programme sought to use the human resources in the most appropriate and productive ways, and involved personnel at all levels. It man- aged to use the existing technology and training institutions without establishing new ones. There was major participa- tion from the National Housing Bank (BNH) at the start, but progressively in- creased participation on the part of the wss agencies. Training was decentralised as much as possible throughout all Brazil's 23 States, so as to reduce the need for travel and the corresponding expenditure. The programme actively promoted the publication of manuals and technical books by national writers and the pro- duction of audio-visual material. It also encouraged the transfer of technology through technical cooperation, and ex- changes of experience with similar pro- grammes and with national and foreign institutions. The planning, establishment and coordination of this programme were entrusted to the Brazilian Association of Sanitary and Environmental Engineer- ing, by agreement with the 23 State wss agencies and the BNH, the central or- ganization of the system. The Associa- tion is country-wide and has a sound reputation in Brazilian sanitary en- gineering circles, with a membership of about 7,000. The training programme called for a flexible and dynamic approach to cope with the large variety of tasks and of professional staff working in the wss services, as well as with the high number of employees and their continuous growth, dictated by the expansion of services. Deficiencies of the educational system as regards the training of lower level personnel had to be overcome, and so had the high rate of personnel turn- over. In addition, the huge distances between the States and the consequent communications problems act as con- straints and increase costs. So too do social and cultural differences between regions and between the categories of workers making up the labour force. Training people for the job A large training programme for the drinking water supply and sanitation sector has been running continuously for over ten years in Brazil, helping to ensure a supply of manpower for the country's National Water Supply and Sanitation Plan by Walter Pinto Costa 22 A young trainee in water management checks a rain gauge. Launched ten years ago, Brazil's training programme seeks to use human resources in the most appropriate and productive ways. Right : A windmill pumps water both for farm use and for the coffee plantation workers. Photos WHO/L. Solmssen These differences are limiting factors and can be serious obstacles, in develop- ing countries, to the setting up of large training programmes, such as will be necessary for the achievement of the Decade targets. The training programme includes four separate projects : the preparation of written and audio- visual aids, as mentioned above ; the preparation of instructors, specialised technicians and training managers ; large-scale technical and professional training for all sector employees, at all levels, using this instruction material and these instructors ; managerial training and develop- ment, aiming at institutional develop- ment and improvements in the adminis- trative, operational and technical sys- tems of the State wss agencies. An important feature of the pro- gramme is that it uses the capacity and potential of the teaching, training and technology institutions already existing in the country, without creating new ones. The results have been positive, since a great number of personnel have been trained in a short time and at reduced costs. It turned out that the best instructors were to be found within the existing agencies, among the technicians or supervisors. They rapidly developed the ability to teach and train their col- leagues under real working conditions, transferring their knowledge to new col- leagues. The Brazilian experience re- veals the success of this method, through which no fewer than 657 trainers and 76 training managers have been created who now plan, manage and implement all the training activities in the agencies. The programme has edited and pub- lished 33 technical books, printing a total of 100,000 copies. It has also produced manuals for the operational training of skilled labour in the water distribution and sewerage services, en- gaged in pipe laying and house connec- tions. A set of 76 technical films demon- strate the techniques and operations included in these manuals, and were shot under real working conditions. Between 1972 and 1981, approxi- mately 117,000 training opportunities have been made available to personnel at all levels throughout Brazil. The di- rect total costs of the programme were about US $12.5 million, which repre- sents an average direct cost of US $105 per trainee. All forms of training were employed, including courses, seminars, symposia, in-service training, field training, fellow- ships and correspondence courses. The number of training opportunities was larger than the number of sector employees during the period under study ; that is, the programme offered more than one training opportunity per employee. Some employees had two or three training opportunities, especially those involved in the managerial devel- opment of human resources. With the objectives of the International Drinking Water Supply and Sanitation Decade in mind, the programme has already made a major contribution towards training and improving the capabilities of those personnel whose task it will be to imple- ment the Action Plans of the Decade. The knowledge and experience we have acquired and the instruction material we have prepared for the programme are at the disposal of other developing coun- tries which face similar problems. ■ 23 Pakistan During the past four years," declared General M. Zia-Ul-Haq, President of the Islamic Republic of Pakistan, "I have been touring the length and breadth of the country, including its remote areas, to find out the problems of our people at first hand and to take measures for their speedy removal. Invariably, the supply of water has figured prominently in the demands of the people. There are areas where the people have to fetch water over long distances in extreme weather conditions, and this con- sumes a considerable part of the day, espe- cially for the women folk. We cannot allow this to continue. The population of our rural and remote areas must be provided with clean water at an accelerated pace. After all, as the well-known quote of the Decade puts it—" Water is life and safe water means a better life." At present only 34 per cent of Pakistan's total population of 83.7 million is served with water supply, while modern sewerage and drainage facilities are available to only about 13 per cent. So the Decade's target of 100 per cent coverage with water supply and sanitation by 1990 represents a formidable task. The country's planners decided to avoid sticking rigidly to highly sophisticated standards, and to apply both traditional and modern methods. Water supply will be pro- vided through piped house connections as well as stand-posts in urban areas, and through the extensive use of hand pumps in the countryside. Priority is being given to villages where the source of water is over three kilometres away. As for sanitation, the system for conveying solid and liquid wastes away from communities will be based on low-cost and appropriate technologies that best suit the needs of individual com- munities. Who is to pay for all this? The govern- ment is aiming at financial viability for urban systems, so that water supply and sewerage facilities will be provided on no- profit-no-loss terms, and steps will be taken to recover the total cost of the projects from the beneficiaries. For rural supplies, the objective will be to recover from the villagers at least the cost of operation and maintenance. ■ Building an irrigation canal in a desert area. Photo P. Almasy 0 A public faucet in a street in Lahore. Photo WHO/G. S. Khokhar Buffalo milk delivered while you wait. Photo WHO/G. S. Khokhar 24 Republic of Korea The supply of clean piped water to villages in the Republic of Korea has already resulted in a sharp reduction in the incidence of water-borne diseases. Cases of typhoid, for instance, dropped from 3,500 some ten years ago to only 500 in 1977. The decline of this and of other water- related diseases (thanks also in part to immunization campaigns) has contributed to a drop in the Republic's mortality rate over the past decade. The government took the initiative long before the current Decade was launched, when it decided to build simple piped water systems in almost 1,000 villages, as a hygienic alternative to often polluted village wells. The results were so striking that the government extended the idea to other parts of the country from 1971 on- wards. The big problem was financing this scheme, so the authorities sought help from the World Food Programme (wFp), which was established by the United Nations and by the Food and Agriculture Organization (FAO) to aid development projects in Third World countries through grants of food. In due course, the WFP approved a project to construct 4,000 piped water systems and 55,200 public wells over a five-year period, and this became operational in 1976. By that time, however, sufficient electricity was available in the countryside to eliminate the need for open wells. So the whole project was now rededicated to installing pump- powered water pipe systems. WFP promised 76,000 tons of wheat flour to assist the project ; adding the dollar value of this food to other costs, total WFP aid amounted to $21.3 million. Villages had to ask to be included in the scheme, and the villagers had to agree to pay for skilled labourers and for the construction materials—estimated at one-third of total costs. In May last year, WFP granted the Repub- lic of Korea's second request for assistance and committed a further $15.5 million (in- cluding wheat flour worth almost $12 million) to the rural piped water programme ; techni- cal assistance was also promised from wHo. The net result has been that the country is already well placed to face the challenges of the Water and Sanitation Decade. ■ A piped supply brings water close at hand for drinking and domestic use. 1111W,Orr::: Drawing water from the well: another fast-disappearing sight in the Republic of Korea. iotakt: Use of a yoke to carry water was a commonplace sight ten years ago. Photos WHO, FAO, WFP World Health: Let me invite you first of all, Mr Niyungeko, to de- scribe your own in- volvement in WHO's technical cooperation related to the Decade. programme Where there's a will, there's a way by Terence Niyungeko A sanitary engineer, responsible for the Decade activities in seven African states plus Haiti, describes what still remains to be done there. Interviewed for World Health by Diana Gibson, he insists it is not too early to speak of progress. T. Niyungeko: WHO has of course many programmes of technical coopera- tion aimed at promoting activities in the drinking water and sanitation sector during the ten years from 1981 to 1990. Its main partners in this field are the Federal Republic of Germany, through its Agency for Technical Cooperation (GTZ), Sweden with its Swedish Interna- tional Development Authority (SIDA), the World Bank and the UN Develop- ment Programme (UNDP). The WHO/GTZ Programme, with a budget of US $2.1 million over a three- year period, covers 15 countries of Afri- ca, Latin America, Asia and the Carib- bean ; among these are seven French- speaking countries of Africa and one in the Caribbean, namely Benin, Burundi, Mali, Niger, Rwanda, Togo, Upper Vol- ta and Haiti. For the past two years, I have been WHO's sanitary engineering expert responsible for these countries, based in Ouagadougou, Upper Volta. W. H.: So what are the aims of the Programme in these countries and how are those aims to be achieved? T. N.: The broad objective of the WHO/GTZ Programme is to promote more Decade-oriented investment in the drinking water and sanitation sector, priority to be given to the most needy populations in cities and in the country- side. Our experience during the 1970s showed us the urgent need for good planning. This need was underlined for us, for instance, when the Sahel coun- tries bordering the Sahara Desert, dur- ing the terrible drought years between 1972 and 1974, constructed a large number of wells and boreholes in rural areas, with massive assistance from other countries and international bodies. Unfortunately, hasty and faulty planning meant that nearly 40 per cent 26 Drought in the Sahel. On the Mali- Upper Volta border, women pick leaves to eat from one of the few green trees left: in the fore- ground—the carcase of a cow which made it to the waterhole, only to die. Photo WHO/FAO/F. Botts of these water sources are actually dry for three-quarters of the year ! As for the local population, who found themselves suddenly awarded these wells, without being consulted and still less being invited to participate, they have simply refused to accept them as their own. As a result the wells are not maintained, and naturally this has shortened their life and reduced their efficiency. Clearly, the only way of guaranteeing the success of our programme is to undertake careful planning which in- volves everybody, from the people of the community who will benefit right up to the administrative and political deci- sion-makers. So our Programme of Technical Cooperation comprises two phases, each one hinged on a national "workshop." The first such workshop runs for six days, and brings together about 40 senior officials from the vari- ous ministries concerned as well as rep- resentatives from the bilateral, multi- lateral and private agencies. Our first ventures, which aroused considerable national interest wherever they were held, enabled us to assemble and dis- seminate all the existing data, to evalu- ate the existing situation, to sensitise public opinion both inside and outside the country and to convince the deci- sion-makers themselves, who generally don't pay sufficient attention to this sector. A work programme was then drawn up to draft a Decade plan for review and adoption at a second nation- al workshop. The second national workshop, held about 12 months after the first one, again involves about 40 individuals but this time at the highest level, so that they have the authority to actually propose a national Plan. It is then for each govern- ment to consider, and eventually ap- prove, the Plan before integrating it finally into the economic and social development planning of each country. 27 W. H.: Did the national workshops that you yourself have organized live up to your expectations ? T. N.: I helped to organize the seven first national workshops between Oc- tober 1980 and November 1981. The first took place in Upper Volta, and in due course the second Upper Volta workshop was held in May this year. Those first workshops gave govern- ments an opportunity to become seri- ously involved in promoting drinking water and clean sanitation, and in fact they marked the launch of the Decade in those countries. The most solemn political commit- ment came from Burundi, since the green light was given by the Head of State himself, in a rural society that had suffered more than most from lack of drinking water. Upper Volta and Niger set up, respectively, a Secretariat of State for Hydraulics and a Ministry of Hydraulics. The President of the Re- public of Rwanda declared 1981 the Year of Rural Hydraulics and, backing words with actions, he multiplied by ten the budget allotted to rural water sup- ply. Togo, where the launching of the Decade was a truly national event, re- quired all its ministers, each in their community of origin, to undertake a campaign for the protection and economic use of water. In Benin, the launch of the Decade placed water and sanitation among the five top national priorities, alongside food, clothing, edu- cation and health. And in Mali , the first workshop turned into both a political demonstration—with a firm commitment from the government in this sector—and a real popular festival. The capital was festooned with brightly coloured banners carrying slogans in support of the drinking water and sanitation pro- gramme. W. H.: And why is Haiti also in- cluded ? T. N.: We organized a first national seminar there in June last year. Haiti is included in this group of countries be- cause it is French-speaking ; and Rwan- da too, of course, usually falls outside In this Benin community, there is no water shortage. But for clean drinking water, peo- ple rely on an artesian well dug deep below the lake surface. Photo P. Almasy the conventional group of West African states. W. H.: So what is the present level of services in all these countries? T. N.: The level of services is low, indeed it may be among the lowest in the world, because these countries are generally poor and mostly quite young —some have only been independent for perhaps 20 years. In this sector, we distinguish, in oper- ational terms, the supply of drinking water in urban areas, the supply of drinking water in rural areas, and sanita- tion. Broadly speaking, water supplies in the towns have a fairly high coverage, because many people living there are likely to be better off and therefore better able to pay for such services—after all, a water supply does not come as a free 28 Where there's a will, there's a way gift. In these countries, the coverage in urban areas is around 50 per cent of the population ; of which half have a private piped water system into their homes, while the other half receive their water from standpoints. W. H.: Let me interrupt you there to ask if it is truly clean drinking water that people receive ? T. N.: That's a good question, but I am not sure if it is quite appropriate in this context. In the Sahel area, for instance, before people speak of drink- ing water, they say : " Give us water, first of all, just water." In the towns, it is treated and checked : we can reasonably claim that it broadly satisfies the norms for drinking water laid down by WHO. In rural areas, I hardly need to tell you, the people are desperately poor and not well-organized ; the water is not treated but our aim is that the source itself is not directly polluted. But when we talk about coverage and satisfaction of needs, we have to realise that in places like the Sahel an individu- al may at best have no more than 10 litres of water per day. That's why, in most of these countries, we have set targets which we call " daily allowance per inhabitant." Thus in Upper Volta, compared with the objectives that have been set between now and 1985—to give each inhabitant at least 10 litres per day—the actual proportion of people supplied amounts at present to only 35 per cent. The goal for 1990 is to make available to each individual 25 litres of water per day. The present coverage, at that level, is only 21 per cent. As regards sanitation in urban areas, which in broad terms includes the evacuation and drainage of rainwater, the disposal of waste water after both domestic and industrial use and of ex- creta, and the safe disposal of solid wastes, well, there the coverage is very low indeed. And in the countryside scarcely five per cent have safe excreta A farmer in Upper Volta uses the simplest of techniques to bring water from the well to irrigate his land. Photo WHO/D. Deriaz disposal facilities. We have to admit that in matters of sanitation the situation is serious and lags far behind the rest of this sector. W. H.: You are speaking here of latrines, I suppose ? T. N.: Yes, in general, less than five per cent have latrines. And in all these countries with which I am concerned, water-borne sewerage scarcely exists at all. It is safe to say that, as regards the installation of sewerage and sewage treatment works, the coverage is practi- cally nil. We have to start from the very beginning. W. H.: Is it then too early to speak of progress ? T. N.: Not at all. It is not too early to speak with optimism of the progress that has been made so far. Because, you know, where there's a will, there's a way. The launch of the Decade, which in each country took concrete form in the shape of the first national workshop, triggered off popular enthusiasm on a national scale, and this has served to reinforce all the efforts being made both inside and outside the country. As a result, in the space of one year alone we have seen good progress. I will just cite one example, again in Upper Volta, since this is where I live and where it can truly be said that people are actively motivated. In the course of the past year, people succeeded in working out projects, drumming up the necessary finance, and putting into execution the necessary works to create 600 water sources in rural areas. That can truly be considered as progress. And in the other countries too, in Niger, Togo and Rwan- da, as I said when I spoke of the first national workshops, there has been very considerable progress. It all amounts to a remarkable intensification of the attention devoted to drinking water and sanitation, on the part of the population, since the launching of the Decade. ■ 29 Hungry children wait patiently to be fed at an emergency feeding centre in Uganda. Photo WHO/UNICEF/H. Dalrymple •••••• 00•0000 ••• 000 000 •••••• •••••• 00000 O OOO ••••••• 00• 00• ••• ••••••• ••••••• ••••••• ••••••• OOOOO •• ••• ••• ••••••• ••• 000 41•0 ••• ••• ••• ••• •• 0•0 1100 ••• ••• ••• ••• ••• ••••••• ••• ••• ••• ••• ••• ••••••• ••••••• 00 ••• ••• 0• 000 ••• 111•••••• ••••••• ■••■••■ ••• ••• ••• site ••• ow**. O ealo O So 006 000 ••••••0 ••• 0• ••• •••••• •••••• OOO 0000 ••••••• ••••••• ••• ••• ••• ••• 000 00000•• 00 000 ••• 0••••••••00 ••• •••••0• 00* 0110 ••• .••000 ••••••• •••• ••• ••• 0410 •• O • OOO•000•0000000 •••••• 0111••••• 011• ••• ••• O• ••• ••• ••••••• ••••• 49•00000 ••••••• How much is a child's life worth, asks UNICEF So far from being priceless, a child's life in 1981 was worth less than US $100, according to UNICEF'S "State of the World's Children 1981-82." Wisely spent on each of the world's poorest 500 million mothers and young children, such a sum could have brought im- proved diets and easier pregnan- cies, elementary education and basic health care, safer sanitation and more water. In other words, it could have provided the basics of life and pre- vented the deaths of 17 million young children during 1981. In prac- tice, this proved too high a price for the world community to pay. According to this annual state- ment by Mr James P. Grant, Execu- tive Director of UNICEF, "Only one in ten of those children, for example, was immunized against the six most common and dangerous dis- eases of childhood. The cost of immunizing all of the Third World's infants works out at approximately five dollars per child. The cost of not doing so works out at approxi- mately five million deaths a year." To the extent that this annual decimation of the world's newborn is a reprisal for the failings of economic development, it seems likely to continue into the foresee- able future. In most oil-importing countries, where the vast majority of the very poor live, economic growth has stalled and fallen to its lowest level in a decade. "Hardest hit are the already poorest nations of Africa and South Asia," says the statement, "where most of the world's 'absolute pov- erty' is to be found and where over three-quarters of 1981's infant deaths have occured. In many poor nations, the economic trends indi- cate that progress against poverty is not only slowing down but being thrown into reverse. "Part cause, part symptom, aid for development has declined from an average of 0.49 per cent of the rich world's gross national product 15 years ago to 0.37 per cent today. There is doubt and pessimism about development, and not in a generation have hopes for an end to life-denying mass poverty been at such a low ebb." The additional resources which would need to be made available in developing countries to provide services for children are normally looked upon as "consumption" which sluices resources away from investment and therefore under- mines the process of economic growth. But UNICEF, along with many other development organizations, now believes that this is an old- fashioned view. Labour is as impor- tant as capital in the process of increasing productivity, and a mal- nourished, unhealthy and illiterate workforce is therefore also a se- rious constraint on productivity. Spending on social services for children is, by this token, an invest- ment in economic growth—espe- cially as it is also likely to lead to slower population growth and therefore to greater economic growth per head. Applying some of these lessons, UNICEF has helped to train over three- quarters ofa million paraprofession- al development workers in the last twelve months as well as cooperat- ing in the installation of 100,000 water-supply systems and over a quarter of a million sanitary latrines. Work of this kind by UNICEF and by governmental agencies needs to be backed by broader scale economic and social policies which concen- trate resources on the needs of the one-fifth of the world's people who today are the "absolute poor". The largest ever generation of children cannot wait. Their childhood, which is so threatened by the darkness of today's economic climate, will not stand still to await the restoration of economic growth. For them ac- tion is needed now to shift priorities in favour of mothers and young children, and to make that most crucial investment in today's children and tomorrow's world. ■ Impact of television campaign in Yemen : immunization message lingers several months Like many other countries with recently expanded immunization programmes, Yemen was facing problems of low demand for im- munizations and high drop-out rates for return visits. To increase public participation, a television campaign on immunization was broadcast throughout the country as part of the weekly health educa- tion programme during November and December 1980. As a result, reports the Weekly Epidemiological Record (No. 23), the total number of diphtheria- pertussis-tetanus (DPT) and polio immunizations given during November and December 1980 showed a dramatic increase. For the country as a whole, the number of DPT/polio immunizations more than doubled in November and nearly doubled in December com- pared to the monthly average prior to the television campaign. Further- more, the impact lingered on for several months after the television message was discontinued. Photo WHO/B. Moss A television campaign helped to boost immunization rates in Yemen. The number of immunizations performed remained high during 1981, declining only for the Rama- dan and Eid holidays in July and October. The number of return visits in- creased noticeably as well. The television campaign on immuniza- tion attracted even those vaccinees whose previous visits had taken place more than five months earlier. Since all Expanded Programme on Immunization (EPI) units experi- enced an unprecedented demand for immunization services during the months when the television campaign was in progress, and since this demand lingered on for several months in most regions, it appears that television has high credibility and an effective reach and that it can be used, along with other publicity materials, to ensure and increase public participation. Because of the success of the 1980 television campaign another immunization education pro- gramme was televised nationwide in November 1981. ■ New patterns of labour migration While the number of migrant workers in Western Europe has stabilised at some six million in the aftermath of the 1973 oil crisis, the foreign labour force in the oil- exporting Gulf states has been growing and is expected to expand even more, with thousands of mil- lions of dollars slated for develop- ment activities in this area over the next five years. The International Labour Organ- isation reports that Bahrain, Iraq, Kuwait, Libyan Arab Jamahiriya, Oman, Qatar, Saudi Arabia and the United Arab Emirates employed over 1.6 million foreign workers in 30 1975, and their ranks might in- crease to some four million by 1985. Countries in other parts of the world have also come to depend on migrant workers. For instance, in Africa, migrant labour accounted for about a quarter of the workforce of the Ivory Coast in 1975. The Republic of South Africa, with near- ly 500,000 workers recruited from neighbouring states, remains an important regional centre of migra- tion. According to the ILO, economic forces will continue to build up pressure for labour migration, de- spite a probable clampdown on irregular or illegal entrants and more fine tuning of domestic labour demand by labour import- ing countries. The populations of advanced countries will be better off in the future than they are now, but the number of people in poor Photo WHO/Z. Sestak Economic forces are obliging more people to migrate in search of jobs. countries looking to emigrate will continue to rise. ILO is making efforts to regulate this drain of human resources in order to prevent the developing countries from becoming "anaemic economically, socially and in- tellectually." ■ In the next issue Considerable progress is being made in mental health care in many developing countries, thanks to programmes aimed at controlling mental disorders by drugs and returning hospital pa- tients to their communities. WHO'S Special Programme of Technical Cooperation in Men- tal Health has had particular success in some countries of southern Africa. The October issue of World Health de- scribes how this programme has sharply reduced the num- bers of long-stay patients in mental hospitals, and includes features on other outstanding aspects of mental health care. Newsbriefs PHC in cities. "Primary health care programmes are as relevant to urban problems as to rural ones and must be presented as such." This was the starting point of a regional seminar on Urban Primary Health Care held some months ago in Manila, Philippines. A report on the seminar, published by WHO'S Regional Office for the Western Pacific, stresses the "gross inequalities" in the health of urban communities and in the provision of health and health-related services, and notes "the grow- ing problem of social breakdown in urban communities and the social isolation of individuals." The seminar concluded that it was essential to identify strategies for the primary health care approach which can be developed to respond to the health needs of the urban poor. Disaster. The UN Disaster Relief Co-ordinator (UNDRO) has received over US $11 million from governments, the UN system and voluntary organizations in response to its appeal on behalf of Madagascar, ravaged by a series of five violent cyclones early this year. Flooding killed at least 70 people and left 70,000 homeless, while the damage to houses, agriculture, roads and railways was estimated to exceed $250 million. People. Appointed as Director of WHO'S Division of Public Information and Education for Health, Mr Jack Ling (China). Information Director at UNICEF, New York, for the past ten years, Mr Ling has a wide experience of the media and of communications in both developed and developing countries. He was born in Shanghai, and is a graduate of Syracuse University in New York, and of Stanford University in California. Children. Severely disabled children in developing countries are the target of a new international pilot study jointly sponsored by the Sergievsky Center, Columbia University, United States, and by the Bishop Bekkers Institute, Netherlands. The study is intended to determine prevalence rates in children aged between three and nine years for severe mental retardation and psychiatric disor- ders, cerebral palsy and other motor disorders, blindness, deafness and epilepsy. In many developing countries, this is the first attempt to measure childhood disability. The Rehabilitation International/umcEF Technical Support Pro- gramme has cooperated in developing the project. How many children suffer from severe disabilities? Photo WHO/UNICEF/B. Wolff Authors of the Month Mr Willy BRANDT, former Chan- cellor of the Federal Republic of Germany, is Chairman of the Inde- pendent Commission on Interna- tional Development Issues (the Brandt Commission). Miss Maggie BLACK is a member of UNICEF'S information staff in New York. Dr Gregor WATIERS is Regional Officer for Basic Sanitary Measures, who's Regional Office for Europe, Copenhagen. Mr Orlando LOPEZ OROZCO is head of the Community Promotion Section, Division of Rural Basic Sanitation, in Colombia's National Institute of Health, Bogota. Mr Jitendra Thu is the Public Infor- mation Officer for WHO's South-East Asia Region, based in New Delhi. Mr Walter PINTO COSTA is Adviser to the Directorate of the State Com- pany of Water and Wastes in Rio de Janeiro, and to the Brazilian Association of Sanitary and En- vironmental Engineering. Mr Terence NIYUNGEKO is a sanitary engineer with a wtio programme of technical cooperation, and is based in Ouagadougou, Upper Volta. 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