Audio Transcript: Global Waters Radio — Emily Rand on Improved Child Feces Management

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Global Waters Radio: You are tuned in to Global Waters Radio, a podcast series produced by the Water Team at the U.S. Agency for International Development. The series offers listeners insights from USAID officials, development partners, thought leaders, and experts from across the water sector, as they discuss current USAID water programming and cutting edge research from around the world.

This week on the podcast, Emily Rand. Emily is a water supply and sanitation specialist at the World Bank, and she also teaches about the design, implementation, and evaluation of WASH programs at George Washington University. She has spent time living and working in Sudan, Indonesia, and East Timor, and today she speaks with WASH Knowledge Management Specialist Dan Campbell about key findings from recent research produced by the World Bank and UNICEF in the growing public health field of child feces management.

Could you tell us why is child feces management an important issue?

ER: Well last year we published results of a data analysis using surveys in 25 locations with UNICEF. And we found that in most countries we looked at, over 50 percent of households with children under the age of three reported that the feces of their children were unsafely disposed of. And what is surprising there is that this was even among households with improved toilets or latrines. Some unsafe child feces disposal was reported in every country that we looked at. And this is similar to results that SHARE and the London School [of Hygiene and Tropical Medicine] have found, and actually, really recently a study came out from SaniPath and they showed that in Ghana, adults will actually pay for toilet use. But in those same locations, children are basically open defecating. Why does all this poor child feces management matter?

It is estimated that 161 million children worldwide in 2013 were stunted. The technical definition is that they were two standard deviations from the length for height, height for age, according to World Health Organization growth child standards median. But what that really means is that they were short.

So I myself am vertically challenged. It is not just the height growth we are worried about, but also stunted brain growth. There are lots of things that we can do to reduce stunting: breastfeeding, complementary feeding, caregivers handwashing, these are all great important things that we can do to reduce child stunting.

But it is important to remember that poor sanitation leads to diarrhea and other illnesses, and this results in poor absorption of nutrients, and undernutrition. So while there hasn’t been much research — child feces management is a very small field — so there hasn’t been much research directly linking child feces management and stunting. There are several studies linking poor child feces management to undesirable health outcomes.

In the Philippines, Burkina Faso, Indonesia, and Ethiopia, it has all been shown that poor child feces management is linked to diarrheal disease, intestinal worms, malnutrition, and death. Now, there are many, many things making a child’s environment dirty. But one of those things is child feces. So child feces management is an important issue, because kids are around other kids all day, right? And we know that young kids ingest dirt, and if child feces isn’t managed correctly, some of it is going to end up in some of those kids nearby.

GWR: Could you tell us what are some of the important lessons learned so far in child feces management?

ER: So one of the items the data analysis we did with UNICEF highlighted was that households with younger children were more likely to report unsafe disposal methods. So while older children perhaps are increasingly likely to use a toilet or latrine themselves — and thus ensure some safe disposal of their own feces. For a younger child, the behavior of the child’s caregiver is what is really crucial.

Throughout the world, we see some great examples of child feces disposal. There are positive deviance who are disposing of child feces safely at these younger ages. For example, for very small children, caregivers are rinsing cloth diapers and soiled clothing in pour-flush latrines, so that most of the feces is contained right there. Now, where pour-flush toilets aren’t an option, caregivers are cleaning diapers in basins, and then dumping water used to clean the soiled diapers in latrines. In Madagascar, caregivers actually hold very young babies over a small basin to defecate, and then they will go and empty that basin into a toilet. Whereas in Ethiopia, caregivers hold a child between their feet, so the child can defecate onto something. The feces are then scrapped into the latrine, or a leaf, or paper is transported with the feces and all of that is put in the latrine.

One of my favorite examples though are those that eliminate the soiled clothes or the need to transport child feces at all. In Vietnam, caregivers start toilet training quite early, frequently reminding children with cues like “Shhhhhhh” or whistling. And while this may result in occasional accidents, there are many reports of children being trained to defecate only with the cue sounds by nine months of age, and completely on their own by 24 months.

In China, children are using split pants, even in cold places. So these split pants separate when the child’s legs are held apart or they squat, so there is actually then no dirty diaper to clean, and if the child goes in the first place in a designated spot, then there is also no feces to move.

GWR: What are some of the major challenges and problems still faced in child feces management?

ER: One of the major challenges are harmful myths. For example, there is a common belief that feces of infants and [a] young child are not harmful. Yet this is not true. And there is actually some evidence that children’s feces are actually more risky, due to a higher prevalence of diarrhea and pathogens in children, rather than adult feces. Another, almost opposite, myth that the International Water Center shared, is that in Papua New Guinea, men in the community feel that men lose their strength when coming into contact with infant feces. Not surprisingly, this means the burden of disposal of child feces is then left to women.

Given these beliefs, there is quite a bit of work to do to create a demand for safe management of child feces. More and more organizations, governments, and universities are including management of child feces in perhaps larger WASH or health programs. As with many good behavior change programs, they all start by listening and observing, and I have got to share this little tip. There is some primary research going on right now in Nigeria by Femi Aluko, and his work is revealing that caregivers have really different behaviors during the day and at night. Some organizations are taking this information — UNICEF for example created counseling cards for feeding centers in Madagascar; USAID’s Hygiene Improvement Program in Ethiopia and a WASHplus program together with WaterAid in Bangladesh created some small doable actions that households can choose from. I should also say that the government of Nigeria includes disposal of child feces as part of a key family best practices in their expanded WASH training manual.

Another key challenge is how to create an enabling environment for child feces management. So Nigeria, Bangladesh, Ghana, India, Syria — they all mention that child feces is to be disposed of effectively as a criteria for a community to be declared open defecation free. So in those locations using community-led total sanitation, this is one approach.

A final challenge is really the supply side. What kind of products are caregivers using? So WASH Benefits experimented with a squat plate in Kenya, and a feces stoop in Bangladesh. A different USAID program in Bangladesh added a bar on the latrine wall to help a child stay steady over the squat plate. And in Cambodia, WaterSHED conducted this formative research, and they found that on this front the private sector is really not waiting for the WASH community. There are a lot of different reusable and disposable diapers, split pants, and child potties with a wide range of options and designs.

GWR: Do you have any additional comments you would like to make?

ER: Well, if you want to learn more, go to http://www.wsp.org/content/ensuring-safe-sanitation-children-0. And honestly if you are actually working on this issue, I would love to learn about your work. So please contact me via Twitter at @Emily_PE, and lastly, if you want to get more involved, there are more and more people really interested in this topic, and it is fascinating, and there is so much depth to it.

GWR: For more information about the child feces management study produced by the World Bank’s Water and Sanitation Program, and UNICEF, please click on the link below. And as always, if you have a topic you would like to see covered in a future edition of the podcast, drop us a line at waterteam@usaid.gov.

This is Global Waters Radio.