Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

  • DaniBarrington
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Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

Hi all,

Over the last few years my colleagues and I (Jamie Bartram, Kate Shields, Regina Souter, Srinivas Sridharan and Stephen Saunders) have conducted a systematic review of sanitation marketing programs, what practices they use and what outcomes they measure. The journal article is available here (or ping me a message and I can email you a copy as unfortunately it's paywalled).

In addition, Jamie and I wrote an editorial for The Conversation based on this work, which is free to access: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable . We are keen to continue this discussion on whether sanitation programs should be using shame (we are not just talking about CLTS, but also the advertising materials used in sanitation marketing - links to posters in the editorial) or promoting conspicuous consumption (i.e. keeping up with or outdoing your neighbour) to promote uptake. In particular, we are concerned that these assaults on dignity cannot be remedied by those who do not acquire safe sanitation through the program.

We would really love to hear your thoughts on this.

Dani Barrington, PhD, BE (Hons), BSc

Lecturer in Water, Sanitation and Health
University of Leeds

Editor in Chief
Journal of Humanitarian Engineering

Honorary Fellow in Public Health
The University of Quuensland
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  • JKMakowka
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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

Having only read the editorial, I would say that it does indeed raise some relevant questions.

What I miss in regards to the "conspicuous consumption" approach is that ultimately it is probably counter-productive if you want to reach 100% coverage. It probably helps to go from from 40 to 70% or so coverage, but the remaining 20-30% or so will just give up as the perceived necessary high construction standard is totally beyond their means (even with a modest subsidy). And as recent research has indicated, this last few percent are really the ones that count from the public health perspective.

However where exactly do you draw the line between probably harmful "conspicuous consumption" marketing and something that is more aimed at dignity improvements? I see for example a very thin line between say a marketing campaign that advocates to male heads of households (usually the decision makers) building toilets to provide a "dignified" solution for the females of that household and one that uses the same arguments but in a "conspicuous consumption" kind of way.

Regarding the other argument about loss of dignity... well I do think that the mentioned argument about temporary loss of dignity can be justified to solve a public health or otherwise community wide issue has a lot of merit. Of course there can be situations where it is economically nearly impossible for a certain percentage of families to yield to that social pressure (or if they do, it might have other adverse effects, like not being able to continue paying extra school fees for that girl-child etc.).
But most often this is not the case, or rather doesn't have to be the case if there weren't unrealistic expectations towards what a "proper" toilet has to be/cost... which brings us back to the first argument.

Also in my experience having worked quite a bit with targeted subsidies for these specific poorest families, I have strong doubts about the effectiveness and efficiency of such subsidy programmes. Yes on paper it sounds like the best option, but you end up getting bogged down with issues over fair beneficiary selection, strongly negative effects on the motivations of those households that just barely do not qualify for the subsidy, and so on. Add to that the high overhead costs of managing such a subsidy and predatory effects related to the fact that these most vulnerable households often can neither manage or construct the toilet themselves (elderly, sick, child-headed etc.); which both usually ends up eating up most of the subsidy.

Spinning that idea further: has anyone tried a smaller general subsidy to all households for toilets construction, with the condition that the community must to help all poorest households to build a toilet? You could probably disburse quite a lot more funds to the community by opting for such a low overhead solution and the likely quality outcomes are probably better as well. Edit: I am not talking about "ODF community rewards" that usually only benefit the local politicians, but direct cash subsidies to all households.

Last but not least, I would also like to add a further dimension to this idea of toilet marketing campaigns and other such efforts hurting the dignity of people:
In south Asia (Nepal, India etc.) open-defecation is terribly endemic and often so deeply ingrained "culturally" (not sure if that's the best word for it), that entire communities mostly stick to it and see little wrong with it internally either. However these entire communities or regions are then stigmatized by their more urbanized compatriots, often also with strong ethnic overtones or caste discrimination.
Having a global target of eradication of open defecation further strengthens this discrimination of entire cultures.
I also wouldn't be surprised if a similar effect was noticeable in other parts of the world regarding the discrimination of nomadic live-styles / nomadic ethnic groups for which it is often almost impossible to practise no open-defecation at all.

Because of that, I personally think we need to have an open ended discussion about when and where open-defecation is really harmful. Furthermore we need to think about what kind of behaviours could be promoted that effectively render it mostly harmless under certain circumstances, instead of trying to attain the unattainable (global 100% ODF) and having all those negative effects on the dignity of people along the way.

Microbiologist & emergency WASH specialist
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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

Thanks for your response - I don't really have more to add to the bulk of your message as it is covered in the editorial/journal article. Hopefully this will get the conversation going for others though!

I wanted to chime in on the open defecation side. Having worked a lot in the South Pacific, a few colleagues and I have been discussing for years this idea that perhaps ceasing open defecation is not always the best option, at least in places where there is not stigma associated with open defecation, with limited drinking water resources and sandy soil and where people can only afford (or only have the physical resources around) to build pit toilets. I do tend to think that we are overestimating faecal contamination from pit toilets generally, but on small atolls with freshwater lenses I suspect there is a bigger issue than most places. Perhaps shitting on the ocean side of the atoll (I understand the environmental impacts of shitting on the coral lagoon side!) is actually the most appropriate "technical" solution (and may be very culturally acceptable, may be no dignity issues - we can't just assume things - or at least no dignity issues present before someone brings in various practices to erode dignity). Also of note, I was speaking to a community in Solomon Islands who traditionally defecated openly on the beach where they would put a toilet if they had one and they said halfway between the house and the beach, so that people wouldn't know when they went there; better to have people "think" that you're going for a swim than relieving yourself - so maybe the toilet is a symbol of being undignified? It also means loss of the advantages of toilets being at the household etc, with accompanying argument about safety from violence (if someone is traipsing to a toilet a few hundred meters from the house then that is probably no more safe than making it to the beach).

I'd love to hear more thoughts on this topic!

Dani Barrington, PhD, BE (Hons), BSc

Lecturer in Water, Sanitation and Health
University of Leeds

Editor in Chief
Journal of Humanitarian Engineering

Honorary Fellow in Public Health
The University of Quuensland
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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

Thanks for the links Dani, its is a good read. My honours student, Myles Bateman, and I have also just had a recent contribution on this debate come out. The article "To shame or not to shame that is the question" available here is also behind a paywall, so let me know if you'd like a copy.

We focus particularly on the use of shame in CLTS though the argument applies to marketing materials too. A common argument, as noted, in this thread is that shame helps form and maintain social relationships, however, contemporary psychosocial literature highlights that shame is a volatile and often harmful emotion, particularly in conditions of poverty. Shame's negative psychological outcomes include: low self-esteem, anxiety, depression, anger and even suicide (Turner, 2000, 2009; Scheff, 1988, 2000).

This literature distinguished between guilt as focusing on what a person does versus shame being about who they are. And, as JKMakowka noted in his reply, for the very poorest not being able to build a toilet is beyond those people's means even with a subsity. Also I really liked the note about open defecation being also a "cultural" phenomenon, indeed Dani didn't some of your earlier work say that to overcome such cultural preferences your survey's found that a fairly high standard of toilet was needed?

We use a case study of Cambodia, which rejected the coercive elements of shame in CLTS, however, as we demonstrate shame is so built into CLTS it remains despite the formal rejection. And Dani's article was interesting because it showed how it continues in marketing activities. As we conclude in the article: "The problem with the approach being used by CLTS to coerce rural impoverished communities to implement 'better' sanitation practices is that shame is already salient and it promotes not so much social cohesion as it psychosocial-harm."
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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

Thanks for the response Susan - I am aware of your work and we cited both the paper you mention and one from 2014 in the underlying systematic review for The Conversation piece :-)

I have written previously about needing to provide the toilets people "want" if you really do want to move away from open defecation (particularly based on a R.I.C.E. study in India). On the one hand (as discussed in previous work) this is so that people actually make a change because they want to (and not because they are coerced), and on the other hand, because there are a couple of studies I am aware of that will be published soon demonstrating that health can decrease with a move from open defecation to pit latrines at the household (past claims about this have not been backed up by rigorous studies), which puts an even larger question mark over the practice of CLTS, as this gradual move "up" the sanitation ladder to unimproved (and some improved) toilets may actually be having detrimental effects. Add on the shaming element and I'm very, very concerned about colonialist practices (which I know you discuss in your 2014 paper on CLTS in Indonesia; I read it as soon as it came out!)

On the shame angle, I noticed on the weekend that another piece was published on The Conversation last week, about using shame to change behaviours in high resource contexts: Shaming people about their lifestyle habits does nothing to improve their health . It complemented the work that your team and mine have been doing in low resource contexts.

Please let me know if you ever want to chat more!
Dani

Dani Barrington, PhD, BE (Hons), BSc

Lecturer in Water, Sanitation and Health
University of Leeds

Editor in Chief
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The University of Quuensland
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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

I just wanted to add more information to this discussion.

The CLTS Foundation has published in the past about shame, CLTS and human rights (see "CLTS and the Right to Sanitation" www.communityledtotalsanitation.org/site...Human_Rights_red.pdf from March 2016 or www.susana.org/en/knowledge-hub/resource...library/details/2559 ) and have spoken about CLTS not shaming individuals, creating disgust, as an empowerment process that should not be boiled down to just triggering etc.

I just re-read their publication and found it very useful to remind myself how CLTS is meant to work (i.e. more of a self-shame process rather than shaming others) but how it can get hijacked by government officials who are under pressure to achieve targets.

Their publication says:

CLTS practitioners underline
that the ‘disgust’ and ‘shame’
spoken of in CLTS comes from
self-critique both at the individual
and at the community level. They
maintain that it is not ‘shame’ in
the sense of externally imposed
humiliation (to shame), and
certainly not by the facilitators.
CLTS practitioners argue that
shaming people is not used as
an intentional motivator (House
and Cavill 2015). The primary
motivator for behaviour change,
which comes from the realisation
‘we are eating each other’s shit’,
is often disgust (Bongartz 2012). While shame may be experienced,
there is no intention to stigmatise individuals, ‘but to make the practice
of OD shameful’ (House and Cavill 2015: 8 ).


One of the problems described is:

Government officials at the local level acting in the name of CLTS may employ the
strong arm measures they are accustomed to, failing to grasp the shift
that a community-led approach requires. This calls for pre-triggering
engagement, training and orientation, indeed open and rigorous
assessment of officials who are to promote and support CLTS.


From the conclusion:

It is noteworthy that many of the anecdotal incidents of coercive sanctions
discussed above involve local level government officials. CLTS training
or re-orientation should bring them to the point of realising that their role
is to give support to community Natural Leaders rather than become
central players who hijack community initiative. A preoccupation with
ambitious and unrealistic targets can also undermine quality and may
increase the likelihood of incidents that compromise human rights. In
contexts where local administrators currently wield unchecked power
(such as chiefs in some contexts), training and orientation will need
to make it explicit that this is a community-led approach that will not
tolerate the excesses they may be accustomed to. Public health
officials who, in many contexts, have for a long time functioned simply
as law enforcers or collectors of fees and fines from vendors instead
of hygiene promoters and facilitators of citizen knowledge and action
need to be reoriented when CLTS is formally adopted by governments
and institutional sponsors.


I think this publication is well worth a read and addresses many of the concerns raised about how CLTS might be rolled out in practice - often against how it is meant to be done.

Perhaps a different title is required that distinguishes CLTS in its community-based form versus other approaches by government in the name of CLTS, e.g. we could call it "government lead total sanitation campaign".

By the way, the article by Susan Engel which Dani mentioned in her post is available here (behind a paywall):
onlinelibrary.wiley.com/doi/pdf/10.1111/dech.12075
Shaming and Sanitation in Indonesia: A Return to Colonial Public Health Practices?
Susan Engel, Anggun Susilo
First published: 09 January 2014

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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

Hello everyone

One point to consider here is that there are very few situations in which no-one has access to a toilet. A lot of the literature around CLTS assumes zero toilet coverage and 100% total defecation. I think there is a potential problem with using shame when toilet ownership is fairly high. In such situations, the poorest are most likely to be using open defecation. Using shame in such circumstances runs the risk of singling out the poorest for criticism and disapproval. This is certainly likely to be an issue with results-driven programmes run through government departments but NGOs and local community organisations are not immune from such attitudes. After all, community organizations tend to reflect the societies in which they exist.

It would be interesting to hear something of other people's experience on this.

Kevin Tayler
Independent water and sanitation consultant
Horsham
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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

As much as the text Elizabeth has quoted from the CLTS Foundation is agreeable and should be common sense, there is also the undeniable fact that much of the reason why CLTS came to be so wide spread and influencial is because of local government run and often coersive programmes. Disowning this legacy now is a bit hypocritical in my opinion.

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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

On Elizabeth's point, this does not address the fact that shame has been shown to be a very harmful emotion producing a range of negative psychological outcomes including low self-esteem, anxiety, depression, anger and even suicide. Further, as Robert Walker's work has shown, people living in conditions of extreme poverty tend to already be suffering from a high degree of shame. There is no safe way to shame people.

Further, as Kevin and Julius pointed out, CLTS operates in villages that already have socio-economic divides and, given that OD is more prevalent amongst the poorest, it targets them.
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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

I agree the shame inducing behaviour change approaches can re enforce the status quo in mixed caste and class villages.

The early success of CLTS was in Bangladesh Wateraid programmes where relatively homogenous rural communities were motivated to end open defecation. But the process was 3 to 5 days long of community engagement where at the end there was some form of naming and shaming.

Now CLTS has become a business model for several consulting companies who employ naming and shaming as a key technique, identifying any existing trigger that will induce the disgust for open defecation and then coercive naming and shaming follows.

Similarly commercial marketing approaches also take people as consumers who can be tricked into something. Worst case is the sanitary napkins advertisement that play up the shame of stains as an inducement for buying napkins.

A few years ago there was a lovely discussion on WSSCC on this very issue. The discussion is cullled out in one of the Newsletters of India WASH Forum

indiawashforum.com

Depinder Kapur is a senior Development and WASH expert and is currently leading the Sanitation Capacity Building Platform of National Institute of Urban Affairs in New Delhi. He has worked with AKRSP, SPWD, CARE(Director NRM), Oxfam(Program & Advocacy Director), WaterAid India(Country Head) and WSSCC(National Coordinator). Also has 5 years of work experience as a consultant with UNICEF, FAO, WSSCC, FES and World Bank. Principal Trustee of India WASH Forum and part of a Citizens Initiative on Right to Water and Sanitation. Also worked with Ministry of Urban Development for the Clean India Mission and member of the 12th Five year Plan Working Group on Water and Sanitation.

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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

Dear Kris,
Are you arguing that there is harmless open defecation?
Regards,
John

Bringing Clean Close Water & Toilets
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Re: Toilet marketing campaigns in developing countries erode people’s dignity – this is not acceptable

I am not sure it was Kris saying that (there is such a thing as harmless open defecation), but perhaps you are referring to one of my earlier responses?

I don't think that it is about "absolutes" - it is about considering risks. There will always be risks associated with open defecation, my point was that in some cases, the risk associated with installing unimproved (particularly) toilets can be higher/less acceptable than open defecation. And when we speak about risks we need to be considering them broadly - e.g. health risks (which is the one everyone considers), economic risks (is money wasted for no/limited/worse health/dignity/enviro impacts?), dignity risks, violence risks, and so on. I am of the opinion that most WASH happens within complex systems with emergent properties we can't necessarily predict, but we still have a duty of care to think through all of the likely outcomes (A good read on this topic by Susan Davies of Improve International here: www.devex.com/news/opinion-want-to-impro...res-here-s-how-92029 - also, if you're going to be at WEDC this year, come along to our side event on WASH "failures").

To illustrate my point, an example: I know that some research has been done where physical health indicators have gotten worse following the installation of pit toilets where people traditionally openly defecated in rivers. Yes, this needs to be weighed against non-physical health indicators, dignity, etc - as I said, there are no absolutes here. But arguably, from a health risk angle, open defecation would be better than such unimproved pits.

But going a step further, another example for consideration could be where pit latrines are installed to reduce OD (arguably to improve health outcomes, according to the implementing organisation's log frame at least), but health indicators stay the same - is such a program a "failure" because it didn't improve health, which was stated as a goal of the program? A "failure" because households spent (wasted?) money and didn't see the anticipated effect of better health? Or a "success" because in non-physical health arenas, e.g. dignity, it was measured as having improved outcomes?

I guess the basis of my argument is that everything is a trade-off, and it is not always up to "us" (sanitation community of practice) to decide which trade-offs users will/should accept. There will always be risks, and our role is to understand what they are, and perhaps facilitate directly involved stakeholders to decide which ones they are willing to take (without, for example, coercion around it being "disgusting" or "undignified" to shit on the beach).

Dani Barrington, PhD, BE (Hons), BSc

Lecturer in Water, Sanitation and Health
University of Leeds

Editor in Chief
Journal of Humanitarian Engineering

Honorary Fellow in Public Health
The University of Quuensland
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