WASH and Drugs (The Good Kind): The Three-Legged Race Against Neglected Tropical Diseases

Years ago, I trained women in rural and remote areas of Central America to be community visual health promoters. They knew the very basics of eye disease and visual impairments, and could offer solutions to simple problems, or referrals to expert, affordable care. But, we never thought of eye disease as related to water, sanitation, and hygiene (WASH). We never thought that encouraging families to wash their faces, or that ensuring water access and building latrines, could help to prevent blindness in one person every fifteen minutes worldwide. 

Now, at the Task Force for Global Health, I help coordinate WASH activities to control a group of diseases with tongue-twister names: soil-transmitted helminths, schistosomiasis, lymphatic filariasis and blinding trachoma. They are a diverse set of diseases that comprise a group known as the Neglected Tropical Diseases (NTDs). Together they account for nearly one billion cases of blindness, debilitating swelling of the limbs, chronic abdominal pain, malnutrition, and diminished livelihoods and well-being. Not to mention, the NTDs affect as many people with pain and suffering, lost educational opportunity, and economic loss as HIV or malaria. Many of these diseases can be treated with medicine, but they can only be prevented by improved access to water, sanitation, and hygiene.

The NTDs are diseases of poverty, and have been relatively neglected by research and large-scale political action. But, for years, the WASH sector has been working in and impacting the communities where these diseases are endemic. WASH programs have acted as a silent weapon against the NTDs, but this impact isn’t being measured. As it is, WASH has an underfunded and under-applauded role in ongoing NTD control strategies. More than just lip service, a coordinated, targeted approach between the WASH and health communities is needed to ensure long-term health gains in endemic areas. Real mechanisms for coordination, measurement, and monitoring must be established and supported from both sides of the sector divide.

Top Photo:  Water access and hand-washing programs in Guatemala help to reduce the transmission of diseases such as soil-transmitted helminths and trachoma. Credit: Stephanie Ogden

Bottom Photo: Hygiene education materials in Lao PDR which depict common transmission pathways of intestinal worms. Credit: Kim Koporc

Earlier this year, a global public-private partnership, formalized by the London Declaration on NTDs, pledged to eliminate or control 10 NTDs by 2020. In some ways, it seems like an easy win. A few pills can treat many of the current infections, and generous drug donations by companies, like Johnson & Johnson, Pfizer, and GlaxoSmithKline, have enabled countries to conduct mass drug administration (MDA) to treat infection at a national scale. But drugs do not prevent re-infection, nor do they address the underlying causes that lead to infection in the first place. The focus on NTDs must shift from treatment to a more balanced approach that includes both treatment and prevention. This is where the WASH sector is essential. After all, addressing the primary environmental factors that lead to transmission of disease, such as water access, safe excreta disposal, and hygiene, is the WASH sector’s bread and butter. While continuing its good work, the WASH sector should also push for partnership with the Health sector to measure impact beyond immediate WASH coverage. Both sectors must realize that eliminating the NTDs is a three-legged race. Treatment, through drug administration, and prevention, via WASH programs, are tied together, and one will cross the finish line only at the pace of both together.

There have been remarkable examples of joint-sector collaboration and integrated programs. The health and WASH communities continue to collaborate to eradicate guinea worm worldwide — a campaign that has been markedly successful from a disease control perspective; in twenty years, cases of guinea worm infection have dropped from 3.5 million to less than 5,000 globally. This shouldn’t be a one-off case of collaboration among sectors. We need more of this kind of joint-sector collaboration in order to reach the goal of controlling 10 NTDs by 2020. The health community and private partnerships have pledged to work together towards this goal, but the involvement of the WASH sector is indispensable. 

That is why it’s especially timely that Emory University’s Center for Global Safe Water,Children Without Worms (CWW) and the International Trachoma Initiative (ITI), have committed to a partnership that will help to encourage actionable dialogue and increased coordination between the NTD and WASH sectors. This partnership aims to call stakeholders in the WASH and NTD sectors to better understand each other, to define common indicators, explore integrated mapping and targeting, and determine further opportunities for collaboration. 

So how exactly should the WASH sector get involved? I suggest we start with the simplest measures:

• Partner with the NTD sector to champion the role of WASH in prevention of the most common NTDs that affect more than 800 million people worldwide.
• Hold WASH and NTD organizations jointly accountable for measuring and monitoring impact on decreasing the burden of disease.
• Seize opportunities for integrated data collection regarding NTDs in WASH program areas.
• Add WASH indicators to health programs, and NTD indicators to WASH programs, to help ensure the effectiveness and long-term sustainability of each.
• Use these indicators to draw the connection between WASH programs and lowered NTD rates in annual reports and program assessments.
• Continue to allocate resources to research and development of sustainable sanitation programs, as safe sanitation may have the greatest single impact on decreasing the burden of disease. 

The conversation about how these two sectors can work together is still in the early stages. What’s vital now is to promote dialogue and keep this momentum going. We know there is a critical link between improved WASH access and lower NTD rates, but we still have a lot to learn about how one affects the other. For example, what elements of WASH most effectively impact the transmission of diseases, like soil-transmitted helminths, schistosomiasis, and trachoma? Do all types of sanitation facilities have equal impact on reduction of these diseases? If not, which have the most impact? Collaboration, coordination, and open dialogue are important first steps in answering these questions. And ensuring partnership between the WASH and Health sectors — between treatment and effective prevention — is the only route to sustainable long-term control of disease.