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Start with sanitation

Start with sanitation


Improved health practices and sanitation are an obvious starting point for improving health in rural Cambodia, writes John Macgregor.

A shift in thinking away from rigidly rational development models to a more random, spirited approach may also help, he argues.


The most visually striking thing about rural Cambodia might be the abysmal state of people’s health. If you were someone who liked log-frame diagrams, you might have arrows emanating from poverty, dirty water, outdoor defecation and poor nutrition to pictures of listless adults, kids infested with parasites, and just about everyone some inches shorter than their optimal height. In villages far from a main road, that’s certainly the visual which hits you in the face.

In some places, nearly everyone is sick. Work is slow, and learning largely absent. Ratanakkiri province, for example, has worse child stunting, and child mortality, than Sierra Leone.

Battambang province has more of a mixture of pluses and minuses. Knach Romeas commune on the Thai border, for example, has high rice production – but no clean water. A recent study there by the NGO I work with, Lom Orng, found that residents spend 18 per cent of their disposable income on expensive, untreated, trucked-in water. This water (and sanitation in general) is so bad that villagers spend another 27 per cent on medical bills. At a guess, bad water might steal away a third of local income.

But every aid practitioner knows that single issues are a bit of an illusion. How do you tease water apart from sanitation, or sanitation from education, or education from income? And what if you overlay factors like high birth rate and global warming? Or the downstream effects of the latter, such as the flooding of the Mekong Delta and the millions this will displace on Cambodia’s doorstep? At this point your log-framer might start to go mad (assuming log-framers aren’t this way already).

Given the infinity of problems, and the finitude of money, the best anyone can do is to arm themselves to the teeth with a love of the poor (incidentally, a solution par excellence to Western neuroses), and to pick the high-yield targets.

The US$1.4m After the Flood project – being run across three northwestern provinces by four local NGOs – is providing seeds and training for a quick short-term rice crop, re-stocking chicken coops and vegetable gardens, and building food-dense Permaculture “safe grounds” above the flood line. It is also repairing schools, education being the specialty of one consortium member, PKO.

The psychological software is being addressed as well: here we judged that poor hygiene and sanitation habits are the most compelling target, given that they poison both water sources and food. In lieu of crowding people into rooms with whiteboards, the hygiene trainers have opted for a little drama. Perhaps 40 villagers are brought together to draw a map of the village in the dirt. Various coloured sands are provided to represent walkways, homes, streams, and so on. They are then asked to mark areas where they shit. (I’ll use that word rather than “defecate”, as our Khmer teams are rather taken with its naughtiness, which chimes well with colloquial Khmer. They now laughingly refer to themselves as “shit experts”.)

Drawing a village map can take all morning. Trainers might step in sometimes and ask, for example, what people make of the fact that they are shitting within a few feet of their water source. But mostly they allow villagers to draw their own map and reach their own conclusions.

Then walks are done to outside toilet areas, and shit collected. Flies are observed gathering on it, and then on people. It’s mixed with drinking water in a plastic bottle, and offered round as a drink, to general guffaws. Basic facts about the fecal-oral route of water and food contamination are introduced – but 95 per cent of it is letting villagers describe their own patterns of behaviour, see them in a slightly new light, and make their own connections.

We haven’t gauged results yet, but this Community-Led Total Sanitation training is certainly confronting enough to grab villagers’ attention. And as they are driving the process; they feel free to have noisy debates. Getting a birds’ eye view of things seems to be another clincher: seeing the relationships in graphical form.

After the Flood has no consultants, no SUVs, and one meeting a month, which no one enjoys. It is succeeding partly because it is lean, but mostly because my Cambodian colleagues are so good at what they do. While they possess the Khmer impatience with theory and detail – and so tend to jump straight in – this is because they know their communes like the backs of their hands. These are the men and women who jumped into boats with supplies last October, and saved 6,000 inundated people from malnutrition, disease and death – on two days’ notice.

The project to date has been characterised by cross-fertilisation. The CLTS training was taught to the other NGOs by Ockenden, which has experience in it. Lom Orng has shared its knowledge of short-term rice cropping and horticulture; while DCO – more of a nuts-and-bolts operation – racked up large tallies of ponds, safe grounds, chicken coops and vegetable gardens in the first month, spurring everyone else to get moving. Several times staff from the various NGOs have pooled their salaries to build houses for flood survivors they found living on the dirt.

The project is having some effects beyond its bounds. Its Permaculture demonstration farm, begun by Ockenden in Battambang’s Rukha Kiri district, will long outlive the project, and will hopefully become a permanent feature of the country’s agricultural landscape. For Lom Orng, After the Flood has strengthened our grasp of the link between water and health, and we have drafted a plan to bring cheap, reticulated water to scores of communes – using the profit from one commune to seed a venture in a neighbour: a kind of commune-leapfrogging revolving fund.

Seeing a village boy with tuberculosis last week – the disease that killed my grandmother back in 1931, a decade before antibiotics – reminded me of the distance left to travel. Much of that distance will be covered in a motley rather than a rational way. But leaving certain things to the gods of randomness is the heart of Asian psychology, and if we mean what we say about allowing local communities to design and lead their own development, allowing for some happy accidents would be in the spirit of things.

John Macgregor is communications director at the Lom Orng Organisation (formerly the Cambodian War Amputees Rehabilitation Society). Lom Orng is part of a consortium of NGOs running After the Flood in Bantheay Meanchey, Battambang and Pursat. The others are Ockenden Cambodia, Disadvantaged Cambodians Organisation and Puthi Komar Organisation.


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