It is common knowledge that there is an acute lack of water and sanitation in developing countries; one consequence of this is that people find it difficult to keep themselves clean, and as a result face severe health hazards. Many of these risks can be minimised, and even eliminated, by relatively simple methods. But at the Water Week held in Washington in March, it was also obvious that good ideas alone aren't enough; those advocating them must be seen as trusted messengers of those ideas too.
In Washington, several experts dwelled on how important it is to get the hygiene message across. Valerie Curtis from the London School of Health & Tropical Medicine, who is considered the foremost authority on handwashing, cited the slogan "Health in Your Hands". She observed that handwashing can prevent between 24 and 36% of diarrhoeal diseases - which account for the death of one child every 30 seconds, according to UNICEF. Handwashing also, surprisingly, cuts down respiratory infections by 19-45%. For example, the connection between unwashed hands and SARS and Asian flu is seldom made. Together, as WHO figures show, diarrhoea and respiratory diseases are responsible for two-thirds of all child deaths. (Just to complete the abysmal picture, malaria accounts for 13% and AIDS for 5%.)
Curtis referred to "disgust" - the antipathy that people everywhere have towards faeces and all that is associated with it, especially odour - as a prime motivating factor in getting people concerned about hygiene. As she overstated, bluntly: "Poo is the public enemy number one!" The connection with health, needless to say, is not commonly perceived. As Curtis' studies show, even in a developed country such as the UK, only 60 per cent of people wash after defecation, and only around a fifth of mothers after changing their babies' nappies. If that is the situation in an advanced industrial country, the scenario in a poor country, where water is difficult to come by, can be well imagined.
Warming up to her theme with the zeal of a preacher, Curtis likened hands to mosquitoes - both were vectors of fatal ailments. There were five Fs associated with the transmission of disease by faeces: fluids, fields, flies, fingers and foods. However, she warned that a threatening or hectoring approach to people - especially mothers - wouldn't work. In the UK, people had adopted hygienic habits early in the 20th century after Unilever began marketing Lux soap.
According to "The Handwashing Handbook", produced by the World Bank, Bank-Netherlands Water Partnership and Water & Sanitation Program of the Bank, women in Ghana were asked what they looked for in soap. They came up with a number of factors, of which smell was the most important, mild lemon/lime featuring most prominently. However, it mustn't to be too powerful, because that would interfere with the enjoyment of eating with one's hands. Next came the cost, followed by texture or durability and whether it had multipurpose functions - such as being usable for laundry as well.
The three agencies named above were the partners in an experimental "public-private partnership" in several countries, including India. The Global Handwashing Partnership involved the three biggest soap MNCs in the world - Unilever, Procter & Gamble and Colgate-Palmolive, which were already promoting handwashing as part of their marketing or corporate social responsibility programmes. The attempt was to market soap by targeting "consumers" - as distinct from the urban or rural poor - and to change their behaviour by requiring them to wash their hands after defecation and before meals, among other occasions.
In 1998, for example, Colgate-Palmolive launched a global promotional campaign titled "Clean Hands, Good Health". In Mexico, Safeguard bar soap has been running a campaign to encourage schoolchildren to wash their hands and has even roped in a nationally known newscaster. Unilever has launched the Lifebuoy Swasthya Chetna for handwashing and bathing in India, targeting, in the words of the Bank document, "children, parents, influencers and young mothers - at all possible places of interaction, with every possible media".
The Bank does not appear as yet to have been able to measure the impact of its global campaign, except to say that there had been a behavioural change of between 13 and 41%, "the share of head space". In Senegal, it ran into some unexpected opposition. Devout Muslims believed that using soap during ritual cleansing before prayers at a mosque robs some of the purity of the spiritual cleansing with holy water!
However, the programme came unstuck in one place - Kerala. The document cites that the partnership began in this state in early 2001 with the Indian Soap & Toiletries Manufacturers' Association (ISTMA). "Hindustan Lever Ltd, the largest private soap manufacturer in India and a key member of ISTMA, played an active role in developing the public-private partnership," the document relates. "UNICEF, the London School of Hygiene & Tropical Medicine and a number of NGOs were also involved." This correspondent recalled how Hindustan Lever executives were also present at the World Summit on Sustainable Development in Johannesburg the following year to publicise the campaign.
As Param Iyer, a Bank official in Washington, told participants at Water Week, after a couple of years there was a "lukewarm response" in Kerala. There was political opposition as environmental journalists - in particular, he mentioned a highly critical article by Vandana Shiva - and opposition politicians joined hands in criticising the scheme. For one thing, Kerala's health indices were high and it was not clear what the role of the MNCs was.
In a box titled "A Lesson in Public Relations", the document states: "As the handwashing program design and business plan began to receive public attention, environmental and anti-globalisation activists began criticising the program through the print media. They were soon joined by other high-profile groups, including doctors, local newspapers and opposition groups. The main points of criticism were: (a) the choice of Kerala for the program in view of its already high human development indicators; (b) unclear linkage between handwashing and health improvement; (c) the potential adverse effect on the indigenous and local soap industry by increasing the market share of multinational soap companies; and (d) the suggestion that the state government was capitulating to World Bank pressure. In the face of media attacks and after a long period of inaction, the state cabinet decided to abandon the program in August 2003."
Iyer admitted that the Kerala government didn't respond quickly enough to the criticism. The perception gained ground that the campaign was backed by HLL as the main donor. A politician claimed that it would be better for the government to spend on providing safe water and sanitation infrastructure rather than handwashing. This was buttressed by the assertion that the former were "tangible and based on hardware", while a communication-based initiative was "largely ephemeral, intangible, and therefore prone to wastage and misuse".
In retrospect, this would be a fascinating case study for international business students on how not to go about marketing such a strategy. For one thing, to launch it in Kerala, of all places in India, may have been akin to waving a red rag to a bull. It is jocularly said that in Kerala that the moment a factory sets up shop, there will be 20 different union flags fluttering outside it, which indicates how politicised this state is. In many ways, Kerala shows the way to all developing countries by emphasising education as the key to empowerment and human development, in the absence of investment, national or foreign, in the state. As the Bank document itself states, as many as a third of people in Kerala wash after defecation or cleaning a child - as against 3% in Ghana. The Handwashing Partnership ought to have realised that they were in totally different terrain and acted accordingly.
Kerala's cottage and small-scale soap manufacturing units were never brought into the picture, which would have lent community support to the programme. This was pointed out to this correspondent at the Johannesburg summit by Paul Calvert, a British expert who popularises ecological sanitation - how to use minimal water - among fishing villages in the very state of Kerala. There is hardly any doubt that a campaign to spread such a message would be far more beneficial. It could work particularly well in "rur-urban" Kerala, where the distinction between town and country is very thin and most houses have ample space for such sanitation. But the MNCs wouldn't be able to peddle their soaps!