A Simple Solution

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Birhanu Worku, who cultivates half a hectare or so of potatoes and barley, was one of the first in Banja to build a pit latrine three years ago. It's a simple affair: a hole in the ground, 1 m across and 3 m deep, covered with a concrete slab and surrounded by mud walls, a thatched roof and a bamboo door. Outside the toilet is a plastic watering can, which Worku has jerry-rigged to dispense a trickle of water for flushing. His neighbors, he says, "came and asked me why I built it and how it worked ... I told them what I had learned and they listened and then went home and built their own toilets." More than 25,000 households joined the latrine-building boom in just three years. The number of people with access to a latrine in Banja district rose to 86% today from 3% in 2001. Toilets became status symbols. "Some people are building latrines nicer than their houses," says Gabeyew Tarekegn, who lives in a nearby village. Worku says that his children have been sick less often since the family began using the latrine and washing their hands afterward.

At the Gafft Primary School, amid the eucalyptus trees of Adet, up to 40% of the students used to suffer regular diarrhea attacks, especially after the rainy season when sewage seeps into water supplies. "If the students get sick," says teacher Tesfaye Birhanu, "they can't learn their lessons and think freely." Until recently, the four toilets shared by Gafft's 1,266 pupils were filthy, and girls like Genet Solomon avoided using them. "Before, I would get sick once a month," says Solomon, 12. Then the school built three simple pit latrines in cinder-block cubicles. A sanitation club began encouraging students to wash their hands after using the toilet and before meals, a simple way of reducing the risk of diarrheal illnesses. Now, fewer than 20% of the students fall ill. Solomon has been sick once in the past six months. "Hand washing is such a simple thing, but it can have a major impact on a child's health," says Unicef's Dooley.

Simple remedies such as oral rehydration and pit latrines don't make the world's headlines. Yet recurrent bouts of diarrhea not only disrupt a child's schooling, but also retard physical development as vital nutrients are continually flushed out of the body. One ray of hope: preliminary studies suggest that zinc supplements protect the intestine's lining and significantly reduce the duration of diarrhea episodes as well as the risk of recurrence. At ICDDR's field research center southeast of Dhaka, children who were given a 10-day course of zinc tablets after developing diarrhea had 30% fewer relapses, and 20% fewer developed pneumonia, reducing overall deaths by 50%. The cost of a course of zinc: about 25. With funding from the Bill and Melinda Gates Foundation and support from the U.S. Agency for International Development, an ICDDR program now aims to provide zinc tablets to every child under 5 in Bangladesh.

Vaccines also hold promise for preventing some types of diarrhea. The most common cause of diarrhea in children is rotavirus, which leads to severe, watery diarrhea. Researchers believe it infects almost every child in the world by age 5 and kills 600,000 of them a year in poor countries. (Children who contract the virus in rich countries, by contrast, usually recover quickly because they are treated aggressively.) The first vaccine approved for prevention of rotavirus, Wyeth's Rotashield, was taken off the market in 1999 after several children who received it developed a rare but serious complication in which the bowel folds in on itself. Preliminary studies suggest this problem has been overcome by Merck's RotaTeq, which was approved by regulators in Europe and the U.S. earlier this year, and GlaxoSmith-Kline's Rotarix, approved in Europe in February. Like other vaccines, they work by provoking the development of antibodies that protect against future infection. Both are given orally. Clinical trials of both drugs have been encouraging. Evan Simpson, a public-health specialist at the Seattle-based Rotavirus Vaccine Program, says the new vaccines have the potential to reduce deaths from rotavirus-related diarrhea to 200,000 a year. As with oral rehydration treatment and zinc supplements, though, distribution remains a hurdle. "The rotavirus vaccine is a potential silver bullet," Simpson says, "but you've still got to get it to them."

The cost of a vaccine — about $60 a dose in countries such as Canada, France and South Korea — makes distribution difficult in poor parts of the world. Beatrice De Vos, Glaxo's director of worldwide medical affairs, says her company has adopted a "south first" strategy of pricing to provide steep discounts on Rotarix for poorer countries if they have a system for vaccinating all young children. Diarrheal disease experts say Glaxo is selling its vaccine for as little as $7 a dose in Brazil. "For the poorest developing countries that's still unaffordable, but with greater use and greater manufacturing, that price will go down," says Roger I. Glass, director of the U.S. National Institutes of Health's Fogarty International Center and former chief of the viral gastroenteritis unit at the cdc in Atlanta, Georgia.

One dollar is about the price that Thai doctor Wandee would like to pay for the rotavirus vaccine. Rotavirus is the leading cause of diarrhea in Thai children today. In the 40 years since Wandee began championing oral rehydration at the Ramathibodi Hospital in Bangkok, deaths from diarrhea have dropped to 1 in 10,000 diarrhea patients from 1 in 1,000, she says. Thailand has followed a cost-effective approach by organizing education and training workshops on oral rehydration for pediatricians, hospital staff, pharmacists and — most importantly — health workers and volunteers in tiny, remote villages. The country has also developed a system to track outbreaks so that doctors and scientists can work to prevent repeats. That's in contrast to most of Africa and to neighboring Burma, Cambodia and Laos, which Wandee says resist public counts of diarrhea cases lest they put off foreign investors and tourists. "If the governments do their job and allow ngos to reach down to the community level," Wandee says, "we could save more people. We could prevent 2 million deaths a year if we could reach out to all the villages."

Saving 2 million lives a year, you might think, is a cause with which politicians and movie stars would fall over themselves to be associated. But tackling diarrhea has never had the high profile of other public-health crises. There's much to do; though experts know what interventions can reduce needless deaths, getting them in place is not always easy. There are thousands of villages in places such as Bangladesh's muddy delta and the dry northern expanses of Ethiopia that still lack the infrastructure, education and methods of treatment that would protect their children's lives. To be sure, there is some good news; a recent report by unicef found that global access to safe drinking water rose from 1990 to 2004. But 1.1 billion people still don't have clean water; 2.6 billion lack a basic toilet. "That's an infrastructure problem and a development problem that we have not been able to deal with," says Greenough of Johns Hopkins. If the world wants to avoid the needless deaths of yet more children, it's time that we did.