I have been puzzling to understand why I found this conference so energising and such a good experience.  In part it was the choreography and facilitation by Barbara Evans and others – what a difference it makes to have inventive ways of involving everyone and keeping us awake with bits of serious fun, and what a difference when facilitators and presenters are on top of their topics, have new things to share, are driven by controlled passion, and really enjoy themselves.  And maybe there is something Ozzie about this – welcome, openness, informality, climate. And for me there was such a mass to catch up on and learn in this exploding and expanding WASH field, and about SouthEast Asia and Pacific experiences. 

The International Water Centre (University of Queensland, and a consortium of others) does this every two years. 2014 was WASH for everyone everywhere, much on the post-2015 wavelength.   340 people from at least 36 countries (Pacific well represented, hardly any from India), 5 days of which 2 for conference, and 3 for ‘training’ sessions (about a dozen topics) which were probably more like sharing, updating and brainstorming than training as such. A good format. A lot for other conference organisers to learn from how this was done. CLTS was not on the main programme formally but came up repeatedly, and we had a lively and informative breakout meeting.

So, what’s new? The four themes for parallel sessions during the first two days tell their own story of where the organisers thought it was at and where we should be going, pointing to current frontiers.  The headings of themes and sessions are illuminating (You can get more from the IWC website)

• Equitable access, universal services (gender and disability, pro-poor approaches, menstrual hygiene management, measuring progress in reducing inequalities)
• Achieving health outcomes with WASH (focus on nutrition, focus on maternal mortality, neglected tropical diseases, policy points for integration
• Sustaining services and outcomes (urban WASH – reflections from Africa, planning WASH in an era of climate change, optimising public, private, civil society and donor roles, sanitation marketing
• Equitable access/sustaining services and outcomes (Right to water and sanitation and challenging environments, achieving universal access, sanitation beyond toilets, monitoring sustainability)

How on earth do you decide which to go to?  My choices are in italics, wishing I could have gone to more.  Then I went to one of the training sessions - on Sanitation, stunting, poverty and health.

So what stood out? Framing the context, there was respect for the original owners of the land, and a moving speech by one of them.  Then magisterial overviews of WASH by Jamie Bartram (University of North Carolina) and Almud Weitz (WSP Asia and the Pacific) which I recommend as sources for anyone wanting to know where we are now and to look forward.  An inspiring address by Archana Patkar ‘Getting to everyone, everywhere – new operating principles for an old reality’. Much of all this pointing to what she called putting the last mile first.   She made the powerful point that if WASH is a right, we who already have it have obligations to those who do not: if we are not proactive in ensuring access to all, we are being discriminatory. And Sanjay Wijesekera (Unicef) in a debate made a fundamental point (which counters some of the equity/efficiency trade-off arguments for serving first those easier to serve) that the gains in wellbeing and other positive externalities are greater from WASH with those who are in the lowest quintile (and including those who are disabled, weak, vulnerable, very poor, socially isolated, excluded…) than for those higher up.

Then there was the Plan Australia/Plan UK research on sustainability in communities declared ODF in Plan CLTS programmes in four African countries – Sierra Leone, Ethiopia, Kenya and Uganda, and a poster presentation by Paul Tyndale-Biscoe who led and managed the project (you can access the study here).  There were 22 posters, to be viewed on computer screens and voted on.  This research was one of the two with most votes, and so presented in a lunch break.  Well deserved for a very significant piece of research with findings that are both encouraging and point to an agenda of post-ODF support, sanitation marketing and enabling movement up the sanitation ladder.

Overall, the boundaries of WASH, as of CLTS, have been spreading to cover more aspects.  Here are some things that hit me and stick in my mind.   Most of them leave me thinking and seeing things differently:

• The environment and also river pollution.  The Citarum river in Indonesia, reputedly the dirtiest river in the world, contributes to the water supplies of Bandung (10 million people) and Jakarta (25 million people).  The economic benefits of WASH are underestimated currently because the environmental benefits are difficult to estimate (but watch this space for a toolkit) (Almud Weitz). 
• Dire water shortages in some Pacific islands.  With climate change, sea surges, sea level rise and saline intrusion in groundwater, available fresh water per head is dropping dramatically, in one case estimated to be down to 5 litres a head by 2030.  Forms of waterless Ecosan toilets might mitigate this trend.
• Faecal sludge. An escalating problem/opportunity, linked also with emptying toilets.  In Bangladesh there is a BRAC initiative for making a profit from faecal sludge, with major potential as fertiliser but challenged by subsidies to imported chemical fertiliser (Barbara Evans).  Around the world, only a smallish minority of urban dwellers are on sewer systems (10 per cent in Africa, elsewhere up to 25 per cent).   Problems are becoming increasingly acute in urban and periurban areas but faecal sludge is also a rural problem.  Are rural latrines filling up and difficult to empty a growing reason for partial reversion to OD?  Faecal sludge is ‘somehow invisible to policy-makers’ (Isabel Blackett, WSP)
• Maternal mortality: mothers are three times more likely to die in childbirth in dirty than in clean environments.  But this connection has been known for a long, long time.
• The stigma of blood.  In both menstruation and childbirth.  How can this be turned on its head, so that blood is seen as a sign and symbol of fertility, something to be proud of and celebrated?
• Concepts of cleanliness vary between cultures and contexts.  There were surprises when people were given cameras to show how they perceived it.
• Mobile accountability.  96 per cent of the population of SubSaharan Africa, we were told, have access to mobile phones.  When MajiVoice in Nairobi introduced complaints about water through mobiles, these leapt from 400 a month to 400 every three days

The training I went to on Sanitation, stunting, poverty and health  by Sanjay Wijesekera, Almud Weitz and Dean Spears was lively and very informative  This took as basic that the first thousand days are forever – that by the age of 2 pathways and potentials (for height, cognitive ability, see Dean Spears' article even average earnings, see this presentation by Nicholas Lawson) have been largely and irreversibly set.  Almud showed how very far we have come in our understanding of sanitation and stunting (undernutrition) in the past three years – it is indeed staggering how much our perceptions have changed, especially with the significance of environmental enteropathy.  Dean brought in India with its 60 per cent of the open defecation in the world and a third of the undernourished children, and in North India with by far the greatest density of those children.   He brought us up to date with his ground breaking research and insights Dean’s Brisbane handout.  This shows how levels of OD explain the ‘Asian enigma’, that has puzzled many.  The enigma has been that Africans though poorer are on average are taller than Indians who are richer on average.  He has found from Demograhic and Health Surveys that across national averages a combination of open defecation and population density accounts for over 60 per cent of stunting (see these slides).  Also comparing (genetically similar if not indistinguishable) West Bengalis and Bangladeshis at the same economic levels, Bangladeshis with less OD are taller than Bengalis who have more OD (Arabinda Ghosh).   Similarly, the paradox of lower child mortality among Muslims in India than among Hindus, although Muslims are poorer on average, is explained by lower levels of OD among Muslims.  A survey Dean and his colleagues are conducting in North India is finding that many regard latrines as disgusting and OD as healthier, showing what a mountain there is to climb.   See his one-pager in which he says that ‘there is no one answer to the grand challenge of open defecation in rural north India’. In summary, he gave us three parting bullets:

• Open defecation kills babies and children
• What doesn’t kill makes you shorter
• The effects of OD are worse where people live close together  

(For more and to keep up to date visit www.riceinstitute.org)

Some parting notes:

• The next JMP report will have data on inequality including ethnicity.
• Archana: make sanitation something politicians fight over
• Some focus groups were asked:  if you service provider were a person, what would that person look like?
• ‘It is easier now to use the word shit than subsidy’ (laughter)
• Mali research found a 26 per cent reduction in stunting with a CLTS intervention, but no change in reported diarrhoea.  This suggests that other FTIs (faecally transmitted infections) were reduced or eliminated by ODF and more hygienic behaviour and conditions.  This in turn reinforces the case that these other FTIs are far more significant causes of undernutrition than the diarrhoeas which are the visible tip of the proverbial iceberg.
• (repeatedly, rhetorically) ‘How much evidence do we need before acting? ‘  implying that we often do not need to wait but should engage straight away and learn more and how to do better as we go.  The word HYPOTHESIS is still being used to describe environmental enteropathy.  But what is hypothetical about it?  Is there anyone who seriously doubts that it is a major, widespread phenomenon?  Just because it is asymptomatic and difficult to measure and we do not have numbers for its prevalence is no reason for treating it as a hypothesis.  It does not need to be proved in some ‘rigorous’ way before we can believe it exists and take action.
• The WASH community has come a long way in a short time learning about the major impacts of poor WASH on nutrition.  But as someone asked – how far has the nutrition community come? 
• A student in the final session said that unlike academic conferences, this one was real and live.  Yes.  A well-deserved tribute. 
• And in this rapidly evolving field, what should be and will be the themes and topics in two years’ time?

Robert Chambers is a Research Associate and part of the CLTS Knowledge Hub at IDS.