Nothing exists in a vacuum
In Afghanistan’s East Region a holistic new approach to eradicating polio - combining community awareness of polio transmission and good hygiene with improvements to sanitation – yields its first fruits.
It is a well-known truism that nothing exists in a vacuum – including polio. Its spread and containment are closely bound with hygiene practices, adequate sanitation and access to clean water. Alongside ensuring that children are in good health and well-nourished, good hygiene and sanitation are critical for eradicating polio. The areas of the country where the virus persists are also areas where access to sanitation is below average - including the East Region.
In the first half of 2024, UNICEF embarked on a new pilot project in areas of the East where water sources tested positive for polio in 2023. Specifically conceived to tackle the transmission of the virus, the project combined community mobilization efforts with improvements to latrines and drainage systems.
Eastern Afghanistan is a place of great natural beauty: a landscape of plunging river valleys bordered by great mountain ranges to the north and west. The region’s geography is the stuff of picture books, but it also poses significant challenges for access to basic services - including sanitation and clean water for drinking and washing. The water table is a long way below the surface, and sinking boreholes for clean drinking water involves jackhammering through 100 metres or more of solid rock. In some parts of the country, climate change is causing the ground water table to drop further.
The correlation between polio and access to adequate sanitation in the East is irrefutable. Eight children in the region have contracted polio since the start of 2023 - all of them are from rural villages where sanitation is scant at best.
Saima, now 11 years old, lives in Qalawal village in Nangarhar province. When she contracted polio last year, Dr Abdulbasir, a friend of her father’s, was on hand to help. Thanks to the swift action of her parents and good medical care she has since made a full recovery, but as Dr Abdulbasir warns, without improvements in sanitation, Samia and her friends remain at risk.
“You must understand the sanitation situation here,” said Dr Abdulbasir. “You see these streams running through the village? Waste from the houses goes into them, and our children play in them, running the risk of contracting waterborne viruses every day. Without better sanitation, we live in fear of polio.”
Over the last thirty years, access to clean water and sanitation has improved in Afghanistan, but progress has been slow and piecemeal. At present, less than half the population of Afghanistan benefits from basic sanitation infrastructure and just over half have access to handwashing facilities, according to UNICEF data1. Access to sanitation also has a heavy urban/rural split: two thirds of urban communities enjoy basic sanitation, in comparison with just over a third in rural areas.
Over a quarter of rural communities have no sanitation infrastructure whatsoever, which, combined with the still-widespread practice of open defecation, leaves children in communities like Qalawal at heightened risk of contracting polio and other diseases. Open defecation is a critical factor in the spread of polio, and one that has seen the slowest advancement over the last three decades. The new pilot scheme made it a central focus, with close to 300 latrines either improved, under construction or in the works.
When it comes to eradicating disease, hygiene behaviours are as important as access to facilities, especially handwashing and hygiene around food preparation and water storage. In Afghan culture, women take care of the home, making them the most important players in improving household hygiene. Education sessions for the communities in target areas engaged over 6,000 people – almost two thirds of them women.
The scheme drew to a close in June, and the results herald notable improvements in the communities where it was piloted. Safe excreta disposal improved twelvefold, and latrine use went up almost two and a half times. Handwashing with soap went up almost fourfold, and the number of families treating water to make it safe for drinking increased seven times.
Improved practices are one thing; how they impact the prevalence of the poliovirus in the environment is another. Again, the news is good. The number of routine water samples from the East testing positive for polio more than doubled between 2022 and 2023, but since the scheme was introduced in early 2024, positive samples have dropped off sharply.
The bottom line is that while communities lack access to adequate sanitation, children will remain at risk of contracting polio and other diseases carried by contaminated water. 2024 has seen the number of polio cases rise sharply countrywide, with 22 confirmed cases as of mid-October, but not one of them is from the districts where the integrated scheme ran. If it can be successfully replicated elsewhere, the scheme offers a ray of hope.
