News and Opinions  –  2022

Access to clean water – a fairly inexpensive way to avoid infections

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Andreas Berglöf has worked with advocacy for more than 20 years, from HIV, to Sexual and Reproductive Health and Rights (SRHR) - and since a year back for WaterAid Sweden. Right now he is at the World Water Forum in Dakar, Senegal. During the conference, WaterAid participates to urge leaders around the world to prioritize water, sanitation and hygiene issues, to strengthen health systems, climate adaptation and economic recovery after COVID-19.⁠ Work that will have positive effects on addressing antibiotic resistance.

WaterAid Sweden are one of the actors engaging in antibiotic resistance. In this article Andreas speaks about water, sanitation and hygiene, actions needed at global and country level, the coming pandemic treaty and lessons learned from HIV work.

Andreas Berglöf has worked for WaterAid Sweden for little more than a year. He is engaged in antibiotic resistance issues relating to water, sanitation and hygiene. Photo: WaterAid Sweden

Andreas Berglöf, tell us a little about yourself

– Since a year back I work as a Health Policy and Advocacy Advisor for WaterAid Sweden. I have worked with advocacy for more than 20 years. I started at HIV Sweden and for many years I worked as a Policy Advisor for RFSU focusing on Sexual and reproductive health and rights (SRHR).

What motivates you to work with advocacy, previous in other fields, now for WaterAid Sweden?

–  I must say the human rights perspective. There are many similarities with HIV and sexual and reproductive health and rights and WASH-rights. Access to water sanitation and hygiene (WASH) is a very urgent topic for people in low- and middle income countries – it is a basic human right.

– Travelling overall, and to countries with low resources in particular, has made me aware of how vulnerable we all are. It only takes a a small cut to develop an infection where the bacteria can be resistant, this could even happen at a health care facility.

Photo: Unsplash.

Water facts

  • Today 771 million people lack access to clean water.
  • 1,7 billion people do not have access to a toilet.
  • Half of the health care facilities in the world’s low-income countries lack clean water.
  • People living under these extreme conditions are mainly people on the country side, patients and health care workers.

Source: WaterAid


Why is access to clean water, sanitation and hygiene relevant to help address antibiotic resistant?

Social Issues in Africa: Child drinking fresh water from tap.
Child drinking fresh water from tap. Photo: AdobeStock.

– It is very simple and basic actually. Access to clean water, sanitation and hygiene facilities help keep many infections away.

 Lack of access to water, sanitation and hygiene creates infections and it is more likely you will get sick. This is particularly challenging in low resource settings, where access to clean water and toilets is a daily problem.

–  No access to water, sanitation and hygiene also forces health care facilities to overuse antibiotics – to try to prevent infections that way instead.

–   In Zimbabwe 1998, I think I had my first real experience that made me aware of how lack of access to water and soap effects you. Something I did not think much about before this, living in Sweden where access to water and soap is not a challenge right now. Also, travelling in Eastern Europe made me realize how common it is with wells and outdoor toilets in the countryside.

Lack of access to WASH increases use of antibiotics

Photo: Rohan Basak, India.

Andreas says:

–  We can see that people who visit hospitals get antibiotics because there is no access to proper water, sanitation and hygiene facilities. So, you as a patient, get the medicine for preventive purposes, regardless whether you have undergone an operation, have given birth or you made a regular hospital visit. This can happen in a smaller town or village, or in a larger hospital.

– Health care hygiene exists for a reason. We work extremely hard with this in Sweden and in other parts of the world as well – and this should be possible in all countries. An interesting set up to address the issue is the Swedish strategic programme against antibiotic resistance (STRAMA) – which has played an important role in Sweden’s strategic work to address antibiotic resistance within the health care system.

“It is very simple and basic actually. Access to clean water, sanitation and hygiene facilities help keep many infections away.” Photo: Andreas Berglöf, WaterAid Sweden.

– You can easily understand, with major procedures in hospitals – it is easier for bacteria to enter the body – all sorts of bacteria, including resistant bacteria.

– The skin is in general a good invention, it protects us a lot. But it is also vulnerable. If you can not wash your hands before performing an operation, help deliver a baby or sew a knee, the risk increases that you as a patient will get infections and diseases. Therefore, access to water sanitation and hygiene is a very important – and in fact a fairly inexpensive way to avoid these infections.

Lack of clean water, sanitation and hygiene in healthcare leads to over- and incorrect use of antibiotics. It also leads to increased spread of antibiotic-resistant bacteria. Improved access to clean water, sanitation and hygiene, in healthcare and in communities, reduces the spread of infections and thus also needs for antibiotics and the spread of antibiotic-resistant bacteria.

WaterAid’s focus – prevent infections

– WaterAid’s starting point is the preventive work. Of course, we see the whole cycle of manufacturing of new antibiotics and the political part, but our entry point is the preventive work and this is done, for example, through good health care hygiene, hygiene at home and in public environments.

–  So, it all relates. Access to water, sanitation and hygiene facilities are key factors in preventing infections – and by this addressing antibiotic resistance.

What does WaterAid do to prevent infections?

–  WaterAid consists of 7 member countries and about 30 program countries. It is in the program countries that the practical work is in progress. For example, drilling wells, setting up water taps, informing about the importance of water sanitation and hygiene, building toilets, talking to decision makers at the local and national level. We are an enabler for the practical work.

Logo for the ReAct Toolbox with grey world map

Learn more about infection prevention

Improving infection prevention reduces the spread of pathogens. This reduces the need for antibiotic treatment and in turn decreases the selection pressure caused by antibiotics and thereby the development and spread of resistance. Visit the Infection Prevention Section in the ReAct Toolbox.

Does any of the WaterAid’s member countries or program countries address antibiotic resistance in a more targeted way?

– It is pronounced differently in our program countries – if and how – you work directly with antibiotic resistance.

–  For example WaterAid Australia participates in a program lead by the Australian government which has a direct focus on antibiotic resistance. In Cambodia, we have worked more specifically on antibiotics and antibiotic resistance, it is well integrated there.

–  Antibiotic resistance is one of the important issues for WaterAid in general and our focus is mainly on the human side. However, 1,7 billion people do not have access to toilets – which means that feces go directly into water sources and into the ground, with various types of bacteria, including those that are resistant. This are water sources where people also go and fetch their water for their daily needs.

Dr Dramane Daou with a patient at the communal health centre in Bougoura, Mali. Photo: WaterAid/ Basile Ouedraogo

Dr Dramane Daou, Technical Head at the communal health centre in Bougoura, Mali:

“I arrived in this health centre in September 2014. The health centre was not like it is nowadays. There was no hygiene, no safe water point and no biomedical waste management. We were just doing things as we could. As a professional I was using my professional conscience to try and develop some hygiene and sanitation practices but without support and WASH facilities it was really hard. As I said, there was no safe water point inside the health centre and people, including myself and the other health agents, the patients and their caretakers, were obliged to go out and fetch water with cans and buckets at a school’s borehole, about 200 metres away from the health centre.

Dr Dramane Daou, Technical Head, washing his hands at a washbasin installed inside his office in Bougoura Communal Health Centre, Bougoura Village, Mali. Photo: WaterAid/ Basile Ouedraogo

Thanks to WaterAid Mali’s project support, the communal health centre in Bougoura is how people wanted to see it. I’m happy, the health centre is now well used by patients which is interesting to see. All those who come and visit it find it clean. They often say that the health centre is in top condition, it’s pretty and well-cleaned. Safe water is available and easily accessible. It has a water tower, taps and washbasins inside, and hand washing devices outside. There are also toilets and an incinerator. Hygiene and sanitation also exist. Everything is ok on that front. We’re all happy as health centre staff, patients, caretakers, visitors and all the community. This project is work that people can observe and appreciate here. It’s not just been talked about. It’s practical, technical and the results are evident.

Project information

The three-year WASH in health care facilities project was launched in April 2015 by WaterAid Mali. It covers 23 health centres in the circles of Bla and Koro in Mali. It aims to improve the quality of health care services through WASH infrastructure installation (water tower, taps, toilets, handwashing devices, dustbins, incinerators) and hygiene promotion and over the long term, support the Ministry of Health to develop a health centre WASH strategy in the country. Bougoura is a village in the commune of Yangasso in the circle of Bla, Segou region. According to estimates, the population of Bougoura is about 1,564.

Text from: WaterAid Sweden

What can we do to change this? What key actions are needed to address antibiotic resistance and WASH?

Andreas Berglöf at World Water Forum in Dakar, Senegal. During the conference, WaterAid participates with the aim of urging leaders around the world to prioritize water, sanitation and hygiene issues, to strengthen health systems, climate adaptation and economic recovery after covid-19.⁠ Photo: Andreas Berglöf

–  It is important to make governments and also the public aware of antibiotic resistance and how it affects us, everyone should think twice before using antibiotics. So, we need to raise awareness and bring antibiotic resistance higher up on the political agenda.

–  The fact that National Action Plans on AMR exist in many countries is good, at the same time many countries lack action plans. And there is a varying scale how to implement and finance the plans that do exist. This needs to be addressed.

–  Governments and organizations can support WHO and the Multi-Partner Trust Fund financially. The fund has received fundings from a few different stakeholders, Sweden is one of them – but in relation to other global health investments – these investments are small. We need more.

–  Stop misuse of antibiotics – both from a health care personnel perspective and from a patients perspective.

–  We also need to invest in preventive measures. Unfortunately, you can not get vaccinated against resistant bacteria, as you can with other diseases.

No access to water, sanitation and hygiene creates infections.

No access to water, sanitation and hygiene forces Health care facilities to overuse antibiotics to try to prevent infections.

No toilets make enhanced spread of resistant bacteria in water for instance.

We need improved infection prevention control, for example through Infection Prevention Control Action Plans. Photo: WaterAid Sweden

On a global scale?

–  Secure access to water, sanitation and hygiene in health care facilities and access to personal hygiene, not least in schools.

–  We need to address health care related infections in low- and-middle income countries in particular.

–  We need to strengthening primary health care, we need stronger political leadership and stronger cooperation between countries and sectors.

–  We need new antibiotics and improved infection prevention control, for example through Infection Prevention Control Action Plans.

–  We also see a need for a global research institute for new antibiotics.

–  Overall, we need globally coordinated actions, with a multi-sectorial approach. In the end – antibiotic resistance has no boarders.

In countries?

–  I would say same as on a global scale. The National Action Plans are important to implement. Training in infection prevention control is a very important and effective way to avoid infections and the spread of resistant infections. Proper hand hygiene and access to water, sanitation and hygiene in health care facilities, both in public and in private settings. Finally, that use of infection prevention control standards also are connected to water, sanitation and hygiene standards.

 In Sweden, especially in light of the upcoming Swedish EU presidency in 2023?

– I will be important to raise antibiotic resistance higher up on the political agenda and push countries into realizing that antibiotic resistance is an urgent global health challenge we need to address now. We need a strong push from countries and more financing to be able to act stronger on antibiotic resistance.

Which actors do you think are most critical to help create change around the issue?

–  Overall, we know what to do. We “only” have to implement the national action plans and make everyone aware and on board – from decision makers on different levels (not least governments), private citizens, private companies in many areas (not least pharmaceutical), farmers, health care institutions, government agencies, multilateral organizations such as the UN system, WHO in particular.

What are your thoughts on the coming global pandemic treaty?

–  The world was taken by surprise of the Covid-19 pandemic. We all realized International Health Regulations is not enough.

–  The Pandemic treaty important to us, we have followed the process closely and we think antibiotic resistance should be included in the new pandemic resolution. Of course, we want WASH to be included as well.

– It is uncertain how detailed the resolution will be. It might focus more on how to handle pandemics in relation to for example, alert systems, sharing of statistics, needs and gaps – perhaps more comprehensive and general measures. But it still remains to be seen, we will work on both fronts. How much we can engage also depends on how open these negotiations and meetings will be.

What tools would be needed at international and multilateral level in order to strengthen antibiotic resistance

interventions in connection to WASH and infection prevention strategies?

– International agreements that are binding, though it is difficult with investments into water, sanitation and hygiene.

– For all countries to follow international Infection Prevention Strategies.

– Also, create funds to support low- and-middle income countries in WASH work.

Gender and economical aspects

Andreas continues:

–  There are also economic and gender aspects in WASH and antibiotic resistance – there are many girls and women who are forced to go to great lengths to fetch water, hopefully clean water, but it is not entirely uncommon to fetch from streams or rivers or streams that are far from clean.

–  Clean water help you avoid infections. For example many children die of diarrhea, many of which could have been avoided with access to clean water.

COVID-19 and hand washing

–  At the beginning of the Covid-19 pandemic, WaterAid invested a lot in hand hygiene, and of course after  as well. It is a good and effective way to avoid both viruses and bacteria. People’s awareness have increased, but it is too early to say how the pandemic will affect WASH investments in the future.

– During the Covid pandemic, people have opened their eyes extra to how important it is to wash their hands, even at home.

Lessons from HIV

– To help address HIV we worked very preventively. Effective and good medicines were developed in the mid-90s, though it took a long time before the medicines were as good as they are now. It is always harder to work preventively. As human’s our mindset is more here and now. Investing in preventive measures is not the most popular, you solve problems here and now, not preventing them from happening. Unfortunately, HIV AIDS has been portrayed as a lot of death and misery.

– There is a difference between HIV and antibiotic resistance. HIV is treatable antibiotic resistance, or resistant bacteria, are not. Paradoxically, both areas needed and need new and updated drugs. At the same time for antibiotic resistance – we need to use less of the medicine. For HIV, it is new treatments and medications that have helped the success story. Of course, information was important but the new medicines was the big success factor – the fact that we prioritized developing new treatments and medications. To be frank, there was a great need for new HIV medicines, hence there was a large market with profits. The problem for antibiotics are – there are no economic benefits in researching for new antibiotics with the current sales model.

–  For those who understand the problem – antibiotics should be used when it is really needed so we can save the strength of antibiotics for those who really need them for example, cancer patient relies on antibiotics during their cancer treatment and for those with sepsis, effective antibiotics are crucial for their survival. Unfortunately, antibiotics is widely used for preventive purposes.

So there are both similarities and differences between HIV and antibiotic resistance.

– Similar is also the aspect – what you don’t see and what you don’t hear – doesn’t exist. This made it difficult to work with HIV in Sweden, because the numbers were so low. If you do not have someone close to you, it does not affect you as much. Unfortunately, that is often the case.  For example I do not have a personal experience of resistant bacteria but when a close relative got sepsis at a hospital from a surgery a few years ago I was really happy that we still have effective antibiotics. The person would probably not have survived otherwise.

– Of course both HIV and antibiotic resistance are tragedies and they are not comparable.

Further reading

‘Prevention first’ to avert global superbug crisis: WaterAid prescribes water, sanitation and hygiene in healthcare

New report from WaterAid: Groundwater: the world’s neglected defence against climate change (PDF)

Focus Children: Addressing the antibiotic resistance threat – the role of water, sanitation and hygiene (PDF)

Blogpost: WASH services critical to curbing antibiotic ‘quick fix’

WaterAid’s statement at World Health Assembly in 2019

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