The Crucial Role of Faith Leaders in the Ebola Response: Unrealised Potential?

The following joint statement was released last week by Tearfund, CAFOD and Christian Aid. 

Faith leaders, as trusted and respected members of their community, have played a hugely significant, and often unsung, role in the Ebola crisis. In the midst of confusion, fear and panic, communities have often turned to them for guidance. They have assisted in preventing an Ebola outbreak spreading even further by disseminating key messages and mobilising their communities to do the same. Many pastors, priests and imams have worked tirelessly to change unsafe burial practices and other previously deep rooted cultural practices and attitudes which contributed so much to the spread of the virus.

A high proportion of the population of Sierra Leone and Liberia are believers and regular attenders at a place of worship. As experienced communicators, the regularity of religious gatherings such as weekly services at churches and mosques has provided faith leaders with a unique opportunity to speak to their congregations. The supportive teaching on love and inclusivity, found in religious texts, means they have been ideally placed to speak out against the destructive stigma associated with Ebola. Faith leaders have invited recovered Ebola patients to give testimony at religious services in order to address stigma and discrimination that recovered people have faced.

Many faith leaders have organised food assistance to families in 21 day quarantine and have set up programmes to care for orphans and help families rebuild their lives. They have often been a first point of call for those experiencing financial hardship. They have brought love and solace to people who are frightened, angry and bereaved, and to those who are sick and dying.

Beyond the community level, the President of Sierra Leone acknowledged the role of faith leaders and encouraged different religious denominations to work together in the fight against Ebola. The Inter-religious Council of Sierra Leone (IRCSL) founded the Religious Leaders Task Force on Ebola in order to address the Ebola crisis from a united interreligious perspective. At the international level, faith-based organisations such as Caritas Internationalis have been advising UN WHO experts on the revision of the Safe Burial Policy.

Ebola has caused huge disruption to people’s well-being at an individual and a collective level. For many people their sense of security and well-being, built up slowly in the years since the terrible conflicts in Liberia and Sierra Leone ended, have been shaken to the core. As the Ebola response moves into the recovery phase it is essential that faith leaders are proactively supported with the right training and related materials, ongoing mentoring and other resources to help them fully utilise their role in the Ebola response. Given their influence in communities and the potential harm of wrong messages, well trained faith leaders, who receive ongoing mentoring and support, can be a crucial part of the countries’ recovery and healing.

Independent, in-depth research should be prioritised by research institutions and donors to analyse the unique role of faith leaders in behaviour change including preventing the spread of Ebola, and also of mitigating the devastating impacts of stigmatisation during the recovery phase.

One particular challenge is that although faith leaders are well trained to provide spiritual care, most have not been trained in counselling and therefore there is a strong need for skilled personnel in this area. This skill shortage should also be considered in Ebola Recovery Plans going forward.

As Ebola Recovery Plans are developed it is of the utmost importance that faith leaders are fully involved and represented in high-level decision making processes which occur at an international, regional and country level. Faith leaders should be involved in the drafting process and the plans should recognise faith leaders as a key target group to work with. This includes the United Nations, European Union and World Bank ‘Ebola Recovery Plan’ which has ‘Peacebuilding, Social Cohesion, Institutions and Core Government Functions’ as one of its ‘four pillars’ and the Health Recovery Plan from the Ministry of Health in Sierra Leone has ‘Community Engagement’ as a key input. This should also apply to country specific Ebola prevention plans such as those facilitated by the WHO.

The role of faith leaders has often been overlooked and in many cases their potential contribution to the Ebola crisis is still not being fully realised. There was a significant missed opportunity in not involving faith leaders further at the very start of the outbreak. Evaluations of the response to the current outbreak will need to consider whether the role of faith leaders has been fully utilised. They will need to consider what steps should have been taken to include them more in planning and to mobilise them from the very outset of the outbreak.

These lessons will need to be applied to help prevent future outbreaks occurring in the affected countries and should also be applied to countries that are currently unaffected. Future programmes centred on Ebola prevention must ensure faith leaders are involved as a pivotal part of the focus.

CAFOD, Christian Aid and Tearfund recommend the following:

  1. There will be numerous reviews and evaluations of the Ebola outbreak and response. Policymakers should use these as opportunities to consider whether the role of faith leaders was fully utilised from the start of the outbreak and what lessons must be learned.
  1. In order to build a robust evidence base, independent in-depth research should be commissioned to investigate the role of faith leaders in catalysing behaviour change within the Ebola outbreak and response.
  1. Ebola prevention plans and programmes, such as those facilitated by the WHO, must ensure faith leaders are involved as a pivotal part of the focus.
  1. Ebola recovery plans currently being produced, such as the UN, EU and World Bank Ebola Recovery Plan, as well as national level plans must include clear strategies for working with faith leaders. Faith leaders must be fully involved and represented in these high-level decision making processes.
  1. Faith leaders and faith based organisations must be allocated dedicated funding for training and related material, and on-going mentoring, particularly in counselling.

An exciting day in the world of diarrhoea…

Yes that’s right, for those of us ‘special few’ who pride ourselves in working on this subject, today Picture 1marks the launch of a WHO & UNICEF global plan with the ambitious title ‘Ending Preventable Deaths from Pneumonia and Diarrhoea by 2025 – The integrated Global Action Plan for Pneumonia and Diarrhoea’ (or GAPPD as its affectionately called). This launch coincided with a launch of a series of The Lancet on Childhood Pneumonia and Diarrhoea.

Now no blog on the launch of a new report would be complete without some statistics – so here is run down in bullet point form of why this matters (taken from GAPPD and The Lancet)

  • Diarrhoea and Pneumonia are the leading killer diseases of children under five.
  • Together these account for 29% of all deaths in children under 5 – this amounts to 2 million lives each year.
  • In 2010 there were nearly 2 billion episodes of diarrhoea in children under 5 and a 120 million episodes of pneumonia.
  • 72% of deaths by diarrhoea, and 81% of deaths by pneumonia occur in children under the age of 2

What is significant about these illnesses (and what I have expressed many times as beyond belief) is that we know how to prevent children from contracting these in the first place and we know how to treat children and prevent them from dying if they do get it.

The plan lays out the different interventions to do this and what is unique is that it really does emphasise the need for an integrated response across the sectors, policies and programmes. It goes on to ‘provide a roadmap for national governments and their partners to implement integrated approaches’. This is something that Tearfund has been a long-term champion of, especially with calling for the key role of sanitation and hygiene in preventative health to be recognised and not ‘fall through the gaps’ between sectors.

In our report Diarrhoea Dialogues we called for the WHO and UNICEF to ‘encourage the promotion and uptake of their guidelines’ in their previous work on diarrhoea and it is exciting to see this be re-launched together with pneumonia.

We highlighted the role of community health workers as critical for delivering preventative water, sanitation and hygiene messages and it is encouraging to note the plan talks about this too. In addition, we pointed out that when programmes containing behaviour change aspects are implemented (such as community-led-total-sanitation, or work done by community health workers), this should be done in a coordinated way to ensure that households are supported through the long-term process of behaviour change.

While it is promising that this is referred to in the plan, it was highlighted at the launch event today that more needs to be done to look at behaviour change at a community level, especially given the importance of handwashing in preventing both diarrhoea and pneumonia.

The big question of course is ‘will this plan actually make any difference at all?’

In many ways the easy part is done – we have the evidence, we have a plan. There is a key issue of funding to consider – it was stated at the launch today that the cost of saving 95% of diarrhoeal deaths of diarrhoea is around $3 billion (which to put it in perspective is around a quarter of the cost of the Olympics!)

Now I, along with many others, will be waiting to see when and how it will be implemented. We will be waiting to see what difference it makes in communities and whether the proposed ambitious benefits of saving and improving the quality of thousands of young lives comes to fruition.

I for one – certainly hope so.

 

World Water Day 2013: Making cooperation and integration key priorities for development policy

 

Friday was a busy day in the world of water, sanitation and hygiene as we marked World Water Day. At Tearfund we’ve been working on these issues for many years, and our latest reports highlight the important of WASH for both child health, specifically in tackling diarrhoea, and also for wider impacts of improving peace and stability in a local area. Continuing to raise awareness and today, we are pleased to have the support of Lord Avebury with this guest blog below. You might also be interested in blogs from Baroness Kinnock and MP Jim Dobbin last week on the importance of WASH for child survival

By Lord Avebury

Friday was World Water Day and an opportunity to celebrate the excellent work being done to promote water, sanitation and hygiene (WASH) in the developing world. The UK has played a leading role in making WASH a priority for international development funding and the Government’s commitment to doubling the number of people reached by WASH by 2015 sets an ambitious target for us, and other developed nations, to follow.

While much progress is undoubtedly being made, great inequality of access still remains with too many communities reliant on unclean water and inadequate sanitation facilities, whilst simultaneously employing poor hygiene practices. One of the biggest concerns about this inequality is the prevalence of diarrhoeal disease. This is of particular concern in Africa and Asia, where eighty percent of diarrhoea related child deaths occur. Staggeringly, around 80 children die every hour from diarrhoeal disease, making it the second largest killer of children under five worldwide, after pneumonia, and the most common cause of childhood illness. It is worth reflecting that in Britain we consider the condition little more than inconvenient.

Effective methods to both prevent and treat diarrhoeal disease exist and are being rolled out across the developing world. Improving access to WASH is a vital stage in this process. However we must also utilise all available tools to prevent and treat the condition, including vaccines, antibiotics, oral rehydration therapy (ORT), exclusive breastfeeding and zinc and other micronutrients. UNICEF estimates that combining all of these into one single package of care would cut deaths due to diarrhoea by around 60 percent.

This strategy of integrating care is gaining significant momentum in the development community, particularly in light of constrained public finances. In the vaccines sector, we are already seeing the benefits of integration in vaccine effectiveness and delivery. Vaccines are far less effective in environments where WASH access is poor and infrastructure development is becoming a key part of vaccine roll-out. Without adequate cold chain storage facilities and serviceable roads, it is extremely difficult to ensure that effective vaccines against a number of preventable diseases reach children in rural areas.

As Co-chair of the All Party Group for Child Health and Vaccine Preventable Diseases, I have met with a number of the leading organisations in the WASH sector to establish how integrated packages of care can work on the ground. The theme for this year’s World Water Day, with events throughout the year, is Water Cooperation and today we are supporting our partners at WaterAid, Tearfund and PATH in calling on the Government to make cooperation and integration key priorities for future development policy. By working together and joining up our efforts, we can significantly reduce diarrhoeal disease, and other preventable conditions, and make substantial progress on attaining our Millennium Development Goal targets for improving child and maternal health.

Some good news about loos in the news?

Horaay! Some good news in the news… maybe… at least in theory anyway. According to this BBC article here India’s Supreme Court has given the central and state governments six months to ensure that all schools have proper toilets and drinking water. This follows on from a court order made last year that toilets, especially for girls, should be built in all schools.

The fact that the importance of this issue has been recognised at such a high level is definitely news to be welcomed – and the BBC article points out that around 10% of schools in India lack drinking water facilities, 40% lack a functional communal toilet and another 40% lack separate facilities for girls.

This is part of a wider sanitation crisis in India, with two thirds of the population not having access to improved sanitation facilities and just over half carrying out open defecation (JMP 2012). With a population of over a billion people living in India – the importance of addressing water and sanitation in India is unquestionable.

It is not just in India where the lack of proper water, sanitation and hygiene (WASH) facilities in schools is an issue – more than half of all primary schools in the developing countries do not have adequate water facilities and nearly two thirds lack adequate sanitation (UNICEF 2010). While it is encouraging that the BBC ran with this story, perhaps what is lacking is recognition of the significance – both within India and globally – aspects of which I attempt to summarise below;

(c) Will Boase Photography

Impact on education

  • Diarrhoea is one of the top global killers in the world and 88% is caused by poor WASH (WHO 2008). Each year children lose 272 million school days due to diarrhoea (UNICEF 2010).
  • 93% of the 181 million school-aged children in sub Saharan Africa suffer nematode (worm) infections. Nematode infections impact physical growth and impact intellectual development.  This is wholly attributable to poor WASH (Hotez & Kameth 2009).

Impact on girls

  • About 50% of girls in sub-Saharan Africa who drop out of primary school do so because of poor water and sanitation facilities (UN 2006).
  • Girls in particular need privacy and the impacts of poor WASH on girls are especially detrimental once girls hit puberty: absenteeism can reach 10-20% of school time due to lack of WASH facilities at schools when girls are menstruating (UNICEF 2010). One study found over half of girls interviewed had missed school at least once while on their period with lack of privacy being cited as the number one cause (WaterAid 2009).

What must happen now?

The Supreme Court should be applauded for this move and for both prioritising and bringing attention to this issue. However we must not forget that there is a big step from ordering toilets to be built and actually seeing it happen – I hope that it does happen, and that it happens well. Building toilets in themselves will not have the desired impact unless the following points are considered and accounted for;

  • Hygiene promotion is alongside the implementation of these facilities.
  • The facilities are well maintained, and that soap is always available. An evaluation conducted in India showed soap was used by only 2% or less of children when washing their hands – thus severely cutting their effectiveness as use of soap has an enormous impact on reducing the presence of pathogens (UNICEF 2010).
  • Involve the communities in this process –the families of the children, the teachers and the local authorities as this can have multiplier effects when people respond to improve hygiene and sanitation within their homes as well.
  • The toilets are not isolated far away from the protective environment of the school – a study in South Africa revealed more than 30% of the girls attending school had been raped at school – many of those in the school toilets (UNICEF 2010).

Finally the health sector needs to have a key role in this process and work closely with the education authorities. They must play a key role in advocating for effective and adequate WASH facilities in schools and holding the government into account – in 2008 the Lancet stated wrote ‘the shamefully weak presence of the health sector in advocating for improved access to water and sanitation is incomprehensible and completely short-sighted’.

I will watch with interest over the next six months to see what the outcome will be – and hope that this decree does have an immense impact – on the education, dignity, safety and quality of life of children in India. 

Flushing money down the toilet?

So Bill Gates has actually been flushing his money down the toilet – as the BBC reports here! In between addressing malaria, TB and other killer diseases, Mr Gates has been trying to re-invent the toilet – an endeavour that has received a good deal of media coverage recently, with good reasons too.

The current flush toilet doesn’t make a lot of sense –about 10 litres of drinking water are used when flushing a toilet and then the waste has to be filtered out. This is followed by the challenge to then clean up the water again to a quality that can be drunk – or flushed down the loo once more…

The competition stipulated that designs did not require running water and was especially aimed at countries where piped water to that volume is a constant challenge. The entries to the competition were quite something – with the winner being a solar-powered toilet that can generate hydrogen gas and electricity.

Sanitation, or lack of it, is a problem faced by over a third of the world’s population. The statistics about the lack of sanitation in the world are both well rehearsed and shocking – 2.5 billion people lack access to a basic toilet and around 4000 children everyday die as a result of poor sanitation from diarrhoea.

It’s easy to forget the human story behind every statistic but I was strongly reminded on my recent trip to Ethiopia. I met 30 year old Aeylech Tomas who lives in village, Kisho, about 300km south of Addis Ababa. She talked about the fears she experiences everytime she has to go to the toilet – ‘I am always afraid that someone might see me. If the boys or men see us they might attack or rape us. I feel sad; this is not a good life.’

I am pleased to see that in between reporting on the various toilet inventions the The Gates Foundation have highlighted the health impacts of the sanitation crisis and I hope that some positive public awareness comes from this. For people like Aeylech, it is not necessarily a toilet producing hydrogen gas and electricity she needs, but somewhere safe and clean that will provide her with dignity. Let’s hope that out of this competition, positive public awareness is raised and that ultimately, lives like Aeylech’s can be radically transformed.

Why dialogue on diarrhoea?

‘Oh Stephanie NO, not while we’re eating our dinner!’

This is how the conversation usually goes when my parents make the mistake of asking me how my job is going over a family meal. I have become so used to discussing this subject, I forget that for most people it is perhaps more of an unrefined issue – certainly not a suitable topic of conversation during a meal at least.

But it IS a subject that we need to talk about – in fact we need to ensure lots of people talk about it. Rather than being embarrassed to discuss this over dinner we need to be embarrassed that in the twenty-first century diarrhoea is allowed to prevail as one of the top child killers in the world.

In fact we should be horrified.

Horrified that each year hundreds of thousands of children die from diarrhoea when we know how to prevent it and we know how to treat it. In 2009 UNICEF and the WHO laid this out in a 7-point plan – that brings together both the treatment (rehydration solution, Zinc) and prevention (water, sanitation, hygiene, vaccines and exclusive breastfeeding).

As straightforward as it sounds, to prevent people from getting it and give treatment once they have it, when it comes to policies and – most importantly implementing those policies – it is often challenging. Countries need to coordinate effectively between and within government departments responsible for water, sanitation, hygiene, and health. Dialogue and, most importantly, action is needed to overcome these barriers.

This is why Tearfund and PATH gave their new report the title ‘Diarrhoea Dialogues: from policies to progress’.

The report examines how three high-burden countries are addressing diarrhoea –Mali, Ethiopia and Zambia. It analyses both the opportunities and challenges in diarrhoea control. It concludes with recommendations that the international community need to shout about this issue and catalyse political will to give this issue the priority it deserves. Countries also need to review their policies and improve coordination.

When UNICEF and WHO re-launch their 7-point plan in March 2013, we need to ensure that it doesn’t simply get lost or put on a shelf, but it turns into action.

If we want to see lives saved and this avoidable suffering stopped we need to make a noise about this issue… even if it does make for an uncomfortable dinner time conversation.

New report launched today: Join up, scale up – how integration can defeat disease and poverty.

Its all about integration…  

A new Tearfund policy report is launched today Join up, scale up – how integration can defeat disease and poverty’, written in collaboration with Action Against Hunger, Action for Global Health, End Water Poverty, PATH and WaterAid.  The report focuses on the benefits of taking an integrated approach to policies and programmes – with a particular focus on water and sanitation, primary healthcare and nutrition, of which significant improvements are needed to meet the MDGs.

Integration is increasingly being recognised across development fields as a more effective and sustainable solution to some of the challenges of poverty – through implementing programmes that more closely reflect how these areas overlap in people’s lives.

Former President of Cape Verdeand recently appointed Nutrition Advocate for West Africa, Antonio Monteiro rightly states “Combining and coordinating services makes common sense – and fiscal sense too, but most importantly it creates greater impact for those who most need these essential services.”

However up until now, little has been written about what this actually looks like in practice.

This report aims to address this gap by providing examples of a range of programmes including; education, urban agriculture, water and sanitation, nutrition, HIV/AIDS and maternal health, from across 17 countries.

 Nutritional gardens & water supply -Zimbabwe

One of the case studies features the work of Tearfund’s partner in Zimbabwe- Churches in Bulawayo (CiB). In response to rising food prices, high unemployment and lack of clean water, CiB, working closely with Bulawayo City Council and the local community implemented a combined nutritional garden and borehole rehabilitation programme, focused in high-density western suburbs. The City Council provided land for 20 communal gardens – each of about 2500 square meters that was divided into household plots. Each garden was close to a borehole that was rehabilitated during the project. 

The most vulnerable sectors of the population were chosen to be beneficiaries, including child headed households, widows, orphans and people living with HIV. They were able to grow vegetables and sell the excess and so the local community have been able to purchase fresh vegetables locally at an affordable price. In addition health assessments by the City Council health department indicate improved health. 983 families benefit from gardens and 20,000 people benefited from water supply. Some of the most vulnerable beneficiaries, including those with HIV report that they no longer feel stigmatised and have gained a new dignity in the community with their vegetable sales. Other residential areas are now asking if they can have similar projects.

Water and sanitation & reducing sexual violence – DRC

The report also mentions the work of Tearfund’s partner working in the Democratic Republic of Congo, ‘Programme de Promotion de Soins Santé Primaires’ (PPSSP). PPSSP takes an innovative approach to addressing the needs of women and children. Sexual violence is a common tragedy facing women and children, and recent estimates suggest 48 rapes occur each hour in DRC. Diseases, such as cholera, diarrhoea and nematode infections resulting from poor water, sanitation and hygiene are also commonplace in the area.

The links between sanitation and sexual violence become apparent when, due to lack of access to private latrines, women faced no choice but to walk outside of their village, often at night, to defecate – increasing their exposure to sexual violence. PPSSP have responded with an integrated and holistic approach. Adopting a CLTS approach, and working in schools and health clinics, maternal and child health in the area has improved, and the increase in household latrines have reduced the vulnerability of women. In addition, through establishing community protection committees, survivors of sexual violence are able to speak out, receive counselling and seek justice.

Report recommendations

Drawing from the evidence gathered, the report makes the following recommendations to international institutions, politicians, donors, and their NGO partners:

  • Commit high-level political leadership and financial resources to integrated approaches, where they can create greater impact.
  • Work with communities to design, implement, and evaluate integrated projects and programmes.
  • Incorporate experience and expertise across different sectors and stakeholders into development programmes.
  • Fund projects that demonstrate integrated approaches at the community level to learn what works, improve national plans, and inform scale-up strategies.
  • Provide flexible funding to partner countries in support of national priorities and integrated programmes.

 The report Join up, scale up – how integration can defeat disease and poverty is available for download here.

Talking Toilets and the Politics of Poo. Musings from AfricaSan3

‘I am the woman standing between you and drinks’.

 I sat up in my chair. We were almost at the end of the opening plenaries at AfricaSan 3 – the third African Conference on Sanitation, being held in Kigali, Rwanda. I, and about 600 others, had been in this room for the best part of five long hours. She continued, ‘and I promise I won’t share with you any statistics or show you a single graph’. Now she had my attention. The final presentation was by Rose George – author of The Big Necessity and, for the past 5 years, journalist about all things sanitation.

 

 Her presentation addressed how we talk about the sanitation problem – the 2.6 billion people that lack access to a toilet – the 1.1 billion who defecate in the open. But is defecation the right word? Is that too much of a nice way of putting it? Is the word sanitation ‘sanitising’ what is really going on here and taking us away from the heart of the problem? 

 Let’s talk about sh*t.

Not a word I hear at Tearfund but it’s a function we all do and is what the sanitation problem is about. Not dealing with it leads to completely avoidable disease, suffering and death. It is the 21st Century, we can access vast amounts of information on a device small enough to fit in our pocket, and yet around 40% of the world’s population do not have a toilet.

 So how do we convince the public and policymakers alike of the need to urgently address this crisis? Do we need to speak about it more bluntly and if we did, would it get the right level of attention? Would it stimulate political will to address this issue once and for all?

And, importantly, would my mother approve?

 Is anyone interested?

Rose asserted that there is a real interest in this issue – her book has been translated into over 10 languages and she has never had a story about sanitation turned down. But she thinks we need to get better at shouting about this issue. She’s probably right but, let’s not forget that a lot of shouting has already gone on. From June 2009 to July 2010 sanitation and water was the issue DFID received most campaign actions on.

 Could philanthropic heavyweight The Bill and Melinda Gates Foundation help with raising the profile of sanitation? They’ve announced their intention to re-invent the toilet. Before your imagination runs wild, let me explain what the plan is. They are investing $41.5 million towards innovative approaches – from latrine design, pit emptying, to the disposal or re-use of waste. As they rightly point out ‘no public health intervention in the past 200 years has done more to save lives and improve health in the world’s wealthy nations’ – and in all fairness to them, it hasn’t really changed much since.

Frank Rijsberman, Director of Water, Sanitation and Hygiene at the Gates Foundation, very patiently answered my bombardment of questions as I quizzed him about demand-driven development, and whether this initiative really gets to the heart of the problem. Their aim is that the new approaches they support, for the moment aimed at urban areas, will go on to stimulate greater demand for better quality, safe and low cost-services in rural areas, which in time they hope to address also.

 Whilst we must remember The Gates Foundation is not the first organisation to look at innovative approaches, they will certainly inject some energy into the sanitation sector. During the week at AfricaSan I heard wide-ranging responses to this initiative – from ‘awful’ to ‘excellent’ and I’m hoping for the latter.

 How important is language?

But we mustn’t lose sight of the complexities involved with sanitation. Take for instance which Ministry takes responsibility for sanitation at a national level. Traditionally it sits under water services, but challenging behaviour, addressing cultural beliefs and building demand require different skill sets from say, drilling a bore hole. Health and education departments also have a vital role to play in sanitation and hygiene promotion and responsibility for sanitation needs to be clearly defined with cross-ministerial coordination.

 Using the right language is important, but this is only one way of trying to break down the taboos associated with sanitation. The word ‘sh*t’ is used by many speakers at sanitation conferences these days which, dare I say, has become a bit trendy in itself. Yet for all the energy and stimulating discussion at the conference, the reality was there were no finance ministers at the conference and few donor representatives who could make strong commitments.

 The challenge remains – the sanitation crisis is avoidable but allowed to prevail.

 And no, my mother would certainly not approve.