Intended for healthcare professionals

Editor's Choice

Let’s talk shit

BMJ 2010; 341 doi: (Published 16 September 2010) Cite this as: BMJ 2010;341:c5066
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

    Back in 2000 when most of the world’s nations committed themselves to the millennium development goals (MDGs) to reduce poverty, hunger, lack of education, illness, and premature death, the deadline of 2015 must have seemed a comfortable distance away. Suddenly there’s only five years to go. When world leaders meet next week at the United Nations in New York to review progress, they can be in no doubt of the immense and immediate challenges ahead.

    As Joy Lawn recounts in her editorial (doi:10.1136/bmj.c5045), 8.8 million of the world’s children still die each year, including 3.6 million newborns, and at least 342 900 women die as a result of childbearing. Although some countries are on track, including four low income countries in sub-Saharan Africa, there is a growing gap between the richest and poorest countries. Africa has only 11% of the world’s population but carries more than half of all maternal and child deaths. Inequities are also growing within countries, as Peter Moszynski reports (doi:10.1136/bmj.c4940). Aid agencies have warned that global average figures can be misleading and are calling for countries to focus their efforts on their poorest people. Citing Ghana and Bolivia, Unicef and Save the Children suggest that this is one of the surest ways of achieving the MDGs.

    What should be the top priorities for the next five years? Lawn highlights the need for data at national and subnational levels as a means of targeting and tracking programmes and holding governments to account. At a round table discussion in Geneva, Karen McColl heard that the new focus is on strengthening accountability, with a range of new mechanisms for bringing governments to book when they fail (doi:10.1136/bmj.c5017).

    As for what works best on the ground, top down, disease specific interventions have a mixed track record. Successes such as immunisation, prevention of mother to child transmission of HIV, and malaria prevention are balanced by important and expensive failures, notably as Rebecca Coombes reports, in sanitation (doi:10.1136/bmj.c5027). Only added as an MDG in 2002, the sanitation goal to halve the number of people worldwide without access to a clean and safe toilet has struggled to attract attention and funds. Those working in the field are clear about the reason. According to one expert interviewed for the article, “We have to face up to the hard fact that sanitation is unpalatable because it is about shit.”

    Diarrhoea due to poor sanitation and unsafe water kills more children than AIDS, malaria, and measles combined. Encouragingly Coombes finds that sanitation is at last gaining attention. It was the surprise winner of the BMJ’s reader poll in 2007 for the greatest medical advance in the past 166 years (BMJ 2007;334:111, doi:10.1136/bmj.39097.611806.DB). She also finds that, appropriately, bottom up solutions are where the action is. Armed with more than 100 different words for shit, workers for the Community Led Total Sanitation movement have achieved what top down sanitation programmes have failed to do. By overcoming taboos and cultural barriers rather than providing bricks and mortar, they have improved the sanitation and life chances of millions of the world’s poorest people.


    Cite this as: BMJ 2010;341:c5066


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