Diarrhoea kills more people than war, terrorism and murders combined. In 2017, 2.5 percent of global deaths (1.3 million in total) were caused due to intentional causes such as suicide, homicide, war, conflict or terrorism meanwhile 3 percent (1.6 million in total) were caused by diarrhoea alone. This completely preventable condition is the third leading cause of death in children below the age of five – claiming more than half a million (533,768) children in 2017. In other words, diarrhoea kills more than one child per minute and forces 1,462 parents to bury a child per day. The most common cause of diarrhoea is an intestine infection due to virus, bacteria or parasitic intake from faeces-contaminated water or food. Subsequently, such an infection hinders the body from retaining nutrients or liquid and the final cause of death is dehydration. But how to prevent the exposure to this critical contamination and thereby the deaths of so many people worldwide? The answer lies in the acronym WASH: Water, Sanitation and Hygiene. The umbrella term emerged from the observation that improved drinking water supply, sanitation and personal and domestic hygiene prove to be critical for human health in preventing pathogen transmission and by extension diarrhoea. The term is also central for the Austrian Red Cross, which has been engaged in the WASH area for decades in both emergency response and long-term development intervention.

In many areas of the world, water is still a very dangerous-if not deadly-cocktail. Even when stemming from improved sources such as wells, there is no guarantee that it is free from faecal pathogens and thus safe for human consumption. Even if sources are not contaminated or the water has been treated, it may subsequently face contamination during transport, handling or storage. At the Austrian Red Cross Headquarters in Vienna, WASH expert Georg Ecker explains: “In our emergency responses, we do not only treat water to fit quality standards, but also to ensure hygienic handling throughout its delivery. This includes checking how people work at the treatment stage, coordination with potential distributors and controlling the hygiene status of tank trucks and final storage tanks on-site. Our job is to guarantee safe delivery to the most vulnerable on household level, which is extremely difficult in emergency situations.”

While subsequent household water treatment and safe storage can offer additional help to protect from diarrhoea, cleaning water is only one piece of the puzzle. Another one is crap, the prime source of faecal water contamination and a main culprit for transmission of pathogens. Sanitation is key in health protection, yet it is often overlooked because of the taboo surrounding human defecation. “For a long time, sanitation was not ‘sexy’ enough to attract development funds. Yet, this imbalance is slowly shifting,” Alex Öze, WASH expert for long-term interventions, explains. However, the topic of open defecation (disposing of human feces in open spaces) remains a deadly taboo. This practice exposes people to dangerous pathogens and, with every rainfall, feces and faecal sludge can enter surface waters. Thus, the containment of human faeces is of prime importance. In this context, Ecker shares his experience from Haiti, which was devastated by the 2010 earthquake. He states, “In our African interventions, we followed a regular pattern in providing sanitation: construction of pit latrines, decommissioning once full including cover-up and protection, and construction of a new latrines in the direct vicinity. In Haiti, we suddenly faced extreme limitations in terms of space.” Ecker illustrates the severity of the situation by describing that every free space was occupied, even the green space at the center of four-lane city highways: “Tents were everywhere, they would even reach to the very edge of the outer cobblestones in such a way that trucks would rush by 20 centimetres from the head of a sleeping child.” In this extremely difficult and densely populated situation, pit latrines were not an option and removing human faeces was a priority.

Regarding long-term interventions, Alex Öze emphasizes: “We need people to break taboos and talk.” An established approach to achieve this is the so-called Community-Lead Total Sanitation (CLTS). In this method, communities mobilise and eliminate open defecation together with their own solutions, as opposed to using foreign subsidies. This requires “a trigger,” however, Öze states, to make people talk. The expert elaborates: “It is contested, but these triggers work with emotions like disgust, embarrassment, but also laughter. They help people realize and publicly talk about the problem and themselves as a part of it.” For example, an outsider could come to a community and hold community discussions in the most polluted “shitting areas” and leave again without prescribing a solution. It is important for the community to become aware and act as a whole, since a single latrine in a household would not prevent diarrhoea–protection is only effective on a community level.

Apart from drinking water and sanitation, hygiene is another piece of the diarrhoea puzzle. As one example, inadequate hand-washing accounted for a total of 297 thousand diarrhoea-related deaths in 2012. According to estimates by the WHO on average, 81 percent of the world’s population does not wash their hands with soap. Although hygiene promotion campaigns occur in every country of the world, it remains a severe problem–even in terms of data collection: “it is a difficult topic because you rarely get honest answers on hand-washing after defecation.” Öze goes on: “although everybody knows it is a good idea, many people still don’t do it as a consequence of habituation, even in Europe.” One solution–and quantifiable proxy–is in the provision of physical infrastructure for personal hygiene, hygiene items and sufficient quantities of clean water.

At this stage, the intertwined nature of WASH becomes clear: it is more than the sum of its components of drinking water, sanitation and hygiene. Solutions to the world’s toilet problem require integrated approaches and interventions, such as UN Sustainable Development Goal 6, which addresses water and sanitation. With regard to big players like the $5 billion Bill and Melinda Gates Foundation, Öze applauds their efforts in research and development, yet underlines that “the technical solutions exist: shortages in clean water and sanitation are less physical than economic and political. That’s why we cooperate and coordinate closely with government entities.” The experts acknowledge the fine line between emergency responses in WASH and a state’s responsibility in providing the respective infrastructure. “In extreme cases as in South Sudan and Syria, Red Cross Organizations may take up a lot of this responsibility. But wherever there is a governmental structure providing these essential services, it should be their responsibility.” In fact, many governments do increase their efforts. Ethiopia, for example, managed to eradicate open defecation in a lot of communities by officially implementing the CLTS. As a final point, the Red Cross Team emphasizes: “lack of budget is often the killer argument, but we believe it is more a matter of budgeting priorities: with enough political will, Europe managed to end the threat of cholera in the late 19th and early 20th century, despite the great costs involved. In the end, the benefits were even greater. Not without reason, the sanitary revolution was voted by health experts as the most important medical advance in the last 150 years, even before vaccination.”