Now wash your hands

Murals help promote hand washing, which can reduce diarrhoeal diseases by 40%.

Credit: WaterAid / Lisa Martin

Every day, 5,000 children die because of poor sanitation. Villagers in Madagascar tell Barbara Gunnell of the New Statesman how cheap interventions can transform their lives.

"What did we tell you last time we were here?" shouts the man with the microphone. "Wash your hands!" yell back 200 children. As Mr Clean upbraids Mr Dirty for his bad habits, the children scold along; as Mr Dirty goes home to his wife clutching his stomach with diarrhoea pains, they giggle uncontrollably.

This travelling marionette show in Amparatanana is part of Madagascar's water, sanitation and hygiene project that got underway soon after the country suffered a severe cholera outbreak in early 2000.

Yvon, a Hygiene Educator with WaterAid's partner Frères Saint-Gabriel (FSG), regularly updates the puppet-show scripts to keep the children hooked. His aim, he told me, is to use storylines as close to the children's home lives as possible, so that hand washing becomes second nature.

Educators like Yvon have to work miracles. The wood and thatch huts of Madagascar's east-coast villages are tightly packed into small compounds without running water. Soap is a luxury and the only existing latrines are poorly designed, badly sited and almost always a health hazard.

Yet the children do absorb the messages about hand washing and the impact of the singing, dancing, 12-foot-high marionettes has been rapid in the schools.

Fun puppet shows help children learn about good hygiene.

Credit: WaterAid / Lisa Martin

The hand washing message also underscores the urgent need to speed up provision of clean water and appropriate sanitation. The poorest villagers here still depend on the river for some water and many manage without toilets.

The proportion of people with safe water and adequate sanitation in the Analanjirofo district is estimated to be as low as 9%, inflicting a heavy penalty on the local economy in hours lost in education and productive work.

Persuading officialdom of the good economic  sense of developing a national sanitation strategy has been an important part of WaterAid's work in Madagascar. In 2003, its research showed that the country was losing 5 million working days and 3.5 million schooldays each year as a result of ill-health caused by dirty water and inadequate sanitation. To this must be added the human cost. Every day across the globe 5,000 children die from the diarrhoeal diseases associated with contaminated water.

"Sanitation is the invisible sector," says Lucky Lowe, WaterAid's representative in Madagascar. She confirms that it is far easier to get politicians to talk about water and to promise pumps and new mains supplies than it is to get a constructive debate going about pit latrines.

On top of the hard statistics must be added the less tangible human costs: The drudgery of walking miles each day to collect contaminated water, or the sheer unpleasantness and indignity of using a foul smelling, poorly draining communal latrine day in and day out. Or, for those who have nowhere else, a patch of land that has become accepted as the local open-air toilet. We should not assume that force of habit appreciably lessens the disgust.

Disgust was certainly written on the face of eight-year-old Sidonie when we talked to her mother Marceline about the field 'toilet' in her village. "Down there is where we have to go," she explained. "After dark it is really horrible for the children." Sidonie refused to discuss the matter though she had been lively enough before.

Finally the family was to get a latrine - paying around 10% of the cost. They had been able to pay their contribution how they liked, but it had to be paid upfront before work could begin on the structure. The family had been targeted because of financial need; FSG has set families' contributions low enough to put latrines within reach.

It is not hard to understand why Marceline wanted to divert her family's limited budget to pay for a latrine. Quite small investments in sanitation could turn around the high poverty rate here. But at the moment, for the vast majority of Madagascar's people, energy that could be put into education and wealth creation is being dissipated by avoidable ill health. The Madagascan economy loses to illness around 300 times the amount the government has allocated to sanitation in its national budget.

A women's group makes rings for pit latrines as part of FSG's sanitation programme.

Credit: WaterAid / Lisa Martin

WaterAid estimates that if Madagascar is to achieve its Millennium Development Goals (MDGs), the country has to increase the number of rural households supplied with adequate sanitation from roughly 485 per month now to more than 12,000.

More and carefully focused international aid is, as always, one solution. Determined local politicians unafraid to champion an unpopular cause is another. Mme Clode said she intends to run as a local councillor next year and wants politicians to speak up for the Cinderella sector of sanitation. "I expected things to move faster," she explains. "Many things need doing. We need more latrines."

But her concerns exactly mirror WaterAid's about the big picture. The MDGs included halving the proportion of those living without water and sanitation by 2015. Of all the targets (including poverty, education and health), sanitation is one of the most offtrack. At the present rate of progress, the goal would be reached 61 years late in sub-Saharan Africa. Yet hopes of eradicating extreme poverty and hunger depend more on sorting out safe sanitation than on any other intervention.

Worldwide, the need is enormous, but tiny interventions and local ingenuity can still have a big impact. In Madagascar, a puppet show costing just £31 can make 200 children laugh - and can possibly save their lives.

This article first appeared in New Statesman.