Our guest today is Barbara Evans. Barbara is an associate professor at the University of Leeds and she's also director of the Water Leeds Program in WASH. Barbara's worked in that sector for over 25 years and much of her work careers much spent in South Asia. Her current research focuses on the challenges of Fecal Sludge Management, and Barbara it's great to have you here today. >> Thank you, it's nice to be here. >> Yeah, I'd like to talk with you about community lead total sanitation today. Now been about 15 years since this idea sort of burst on the water sanitation scene. So what was the context when this started, how do this began? Can you tell us a little about the history? >> Yes, so looking back with 15 years ago I suppose the sanitation field was in rural sanitation. And there had been probably 10 or 15 years of work where people were quite dissatisfied with national programs that were delivering subsidies. We could see, particularly in South Asia, that national subsidized programs weren't reaching very many people, that the whole subsidy program was being captured. And so if you had a big program, you spent a lot of money, you built a lot of toilets. What you weren't really achieving was any kind of step-changing coverage. Now, the CLTS movement- >> Why weren't you getting more coverage? >> kind of bunch of problems, really. What we could see, certainly in India, where I was working at the time. The amount of money looked big, but the incentives in the subsidy programs were essentially leading to the construction of very expensive toilets and an awful lot of rent seeking and capture of the resources. A huge amount of miscounting, miscalculation. And really, the outcomes are not measured in terms of step change in sanitation behavior in a community. They were measured in terms of disbursement, so all the incentives were about shoveling the money out of the door, really, rather than changing the life of a community. I think the other thing that was going on at that point was that sanitation for a very long time had been seen as a very individual household issue. So all of the interventions were very much focused on I'm engaging with you as an individual person in the household. CLTS came from a group of people working in Bangladesh who were really not sanitation people at all. VERC was the name of the organization who really pioneered this idea. And they were a group of people who engaged with communities on a whole range of social development issues. So they might be working in a community on issues of education, land rights, and generally, when they talked to a community, they talked to the community. So, for whatever reason, and I actually don't know why they started working on sanitation specifically, but, when they did, they took the same approach. They basically engaged with the community at large rather than As a sort of one to one process. And very quickly they came to realize that what you need in sanitation, the way they perceived it, was a whole community commitment to a change in behavior. So they saw sanitation not as an infrastructure intervention, but as behavior change intervention. And it sort of seems extraordinary to say it now because they have really changed the landscape. But that really was quite radical news. Probably way back in the sort of 60s and 70s there had been a sense that sanitation was about behavior. But that had really got lost in a very necessary development of technologies and then this sort of move towards centralized subsidized programs. So it was a very different sort of way of engaging, really. >> So how was this idea received by the sector? >> Well, as many radical ideas are, with a great deal of skepticism, doubt. I mean one of the problems was just dissemination of the idea really. And one of the problems with that is that CLTS which triggers, or if it works in the way it's supposed to work, it triggers this step change in community behavior. What you don't see is the construction of a whole bunch of concrete toilets, or certainly we didn't see that in Bangladesh in the early days. So I think a lot of sanitation professionals simply didn't notice it happening, to start with. There was also, I think, a lot of resistance at the government level because we had a whole structure of service delivery in most South Asian countries. Certainly Bangladesh, India, Pakistan at the time had these national sanitation programs. And people were corked in to those programs, so there was quite a lot of resistance. Probably our good fortune was that at about the same time or about four to five years after VERC had been sort of pushing this idea, we had the first regional sanitation conference in South Asian, Zakistan. And it happened to be hosted in Bangladesh, which wasn't entirely a coincidence, there were people who were really trying to sort of showcase this change in attitude. But what was good about that, was that it meant that the government of Bangladesh had an incentive to sort of step up and say, look we are pioneering this very new approach. So, I think a lot of credit has to go both to the NGO community and civil society groups, who've initially pushed the idea. But I think to the government of Bangladesh as well, for embracing it. Which was quite brave at the time. >> So fast-forward 15 years. How is it perceived? [CROSSTALK] >> Well, yeah. It's kind of, in a funny kind of way, it's a bit of a sort of state religion these days, you can say. I still think it's mixed. There are still a lot of people who have doubts and uncertainties. One of the problems with CLTS or challenges I should say, like all ideas, is if you really want it to work you have to do it well. So one of the big challenges over the years has been to disseminate the ideas and to try and push it to scale without losing quality. And we've certainly seen a huge raft of things done in the name of CLTS all over the world, which may or may not actually be containing the real elements. I mean, what CLTS really means, it's interpreted differently by different people. One thing that's also very interesting about it I think is that, I think in Bangladesh, there was a very powerful sense that this is something that's come from us, and is our sort of culturally owned approach. And most countries which have adopted have almost had to go through an adoption process. >> At the national level. >> At the national level. The typical scenario seems to be, trainers arrive, people are promoting the idea. Maybe there's a study tour to Bangladesh. And then there has to be a national discussion about, well this is a good idea, but it won't work for us in its original form. We have to reinvent it. >> What does that mean exactly? Talk about reinvention. What kind of things have happened in other countries? >> Yeah, well in many cases, nothing at all. I mean for me. >> They use the original model. >> Yeah, exactly but I think it's more like people have to go through the process of imagining it and trying it. So a very typical scenario is CLTS as you know relies a lot on getting people to acknowledge their disgust at feces lying around and. >> Open defecation. >> Yes, and a lot of stories is put on getting people to discuss shit using vernacular words and really to kind of not embrace the problem, but acknowledge the problem. And in most countries people have unease about that and particularly well educated health professionals and engineers. They feel that that's not appropriate, so one of the processes that you often have to go through is to re-imagine how those disgust-based triggers are going to work. And most countries claim that they do it in their own sort of unique and special way. My sense, and I've not looked at this scientifically, but whenever I've seen it happening around the world It looks pretty much the same, actually, it's just that people, I think, have to feel that they've worked through that themselves, and that's fine. >> Mm-hm, let's talk about communities that have already been through the CLTS process. And it's been a success, they've stopped open defecation. What challenges do they face? >> Well, yeah, obviously, yeah. >> Huge, huge problems. And again, amazingly, it's Bangladesh where we can see exactly this in progress. So Bangladesh has more or less achieved a sort of nationwide triggering. So open defecation in Bangladesh in the most recent mix, we're looking at probably OD rates of around 4% nationally, so very, very low. That's down from more than 50%, 10, 15 years ago, so a radical change. And although 15 years sounds like a long time, that's a huge behavioral change for 160 million people, so really impressive. But what does that mean? That means we now have 160 million people using pretty basic pit latrines all over Bangladesh. >> Could you describe, sort of what that means for our students here in the MOOC? I mean, what does a pretty primitive latrine look like in Bangladesh? >> [LAUGH] A pretty basic pit latrine? Yeah, so you kind of have three levels, really. In the first stage, you see people very often sharing, but somehow making use of what amounts to a hole in the ground often without a slab over it. So in places where the soils are strong enough, literally just a hole in the ground, maybe with a wooden platform or a cast concrete platform. >> No place to wash your hands. >> No place to wash hands, no beautiful superstructure. We're not talking brick toilets, we're talking four bamboo poles with some jute sacking. I mean, many people who don't work in the profession or who aren't use to it are horrified when they first see the toilets. And there's a huge amount of debate about is this actually a toilet? And so for me that type of toilet represents not necessarily a holy hygienic separation of feces, but it represents a massive behavior change. From open defecation wherever you, well not wherever you feel like it, but in the open, to using a fixed place, and that's a big cultural shift. Step up from that, you see people starting to modify those toilets. So people, for example, in Bangladesh it's quite easy and very cheap to buy a plastic latrine pan with a little U bend on it. And people use water, so just enough water to create a water seal, so then you're toilet is really effectively separating feces from flies, which is very important. And it prevents odors of course, so the toilet becomes instantly a much nicer place. Lots of innovations, lots of people who don't want to spend 40 Taka, which is about 80 US cents. People who don't want to spend even that much who've taken plastic fertilizer bags, for example, and tied them around the pan. And it creates a seal, because the plastic sticks together, so lots of small scale innovation. At the kind of right hand end of the spectrum, if you like, or sort of top end, the government of Bangladesh and the big end Joes in Bangladesh. When they promote improved sanitation, they use what's generally called the ring and slab method. So what you're really moving towards now in Bangladesh is people having a cast slab with a plastic pan set into it. With a water seal, and then a pit with somewhere between three and six precast concrete rings to secure the pit and make sure it doesn't collapse. And increasingly, people building twin pit latrines rather than single latrines. And the superstructure may still be quite rudimentary, although another thing that's very interesting in Bangladesh, and different to many other places is that you find a lot of very competent masons. Who are selling quite nice, I mean nice, robust [FOREIGN] As we would say in Bangladesh. And super structures as well as the pit latrine. >> So you've described a big change from 160 million people open defecation to basic pit latrines. Dowe know anything about the health benefits of that in Bangladesh? >> Yeah, that's a really great question. Funny enough, I've just come back from Bangladesh, and I was looking at the health impact work that's been done on a big program. Which used a lot of CLTS methodology, plus a lot of hygiene promotion. It's a program called SHEWA-B. It was carried out between 2007, 2012. And it was really looking at promoting effective use of sanitation and hand washing. A huge amount of infrastructure that has been built, either paid for by the project or most of it actually self funded. But a lot of promotional work. So we can see that in the areas where that program's been functional, a big change has happened in terms of people's access to sanitation facilities, somewhat to hand washing facilities, and certainly to water supply. To everybody's constenation, I have to say that the results of the healthy impact study are inconclusive at best. There is a little bit of evidence that the impact of this intervention on diarrheal disease in those intervention areas is possibly slightly higher than in the neighboring areas. But for me, what's interesting about those results,well several things, one is that of course there's a focus on diarrhea and respiratory tract infections. And of course, there are a whole bunch of other health benefits that we might have looked for which weren't looked for whatever reason. Incidently, I should say some methodology very excellent study. I don't have any problems with the work that's been done. It's a great piece of work. But I think what's more interesting is that what you can see is a very significant improvement in outcomes in those study areas. But what you can't see is a difference between the impact in the study areas and in the control areas. And in a funny kind of way, for me, that's quite a lot of evidence of the success of this focus on promotion. Because the truth of the matter is, there isn't a single district in Bangladesh that hasn't seen this step change. So really, we shouldn't be that surprised that we can't pinpoint this specific health game. And yes, so tricky to say whether we know that there's a health benefit or not from the Bangladesh experience. There are other studies going on in other places and we can hope to see a bit more evidence. But for me, I would like to say that I think this sort of focus on behavior change in a country will always mask, if it works really well, will always mask these health gains. >> That's an interesting point. So let's go back to all these unimproved pit latrines that are filling up in Bangladesh. What's going to happen? >> Who knows? Yeah, so you can do the math, and you can work out. So 160 million people. Let's say that 120 million of those were in the rural districts. Really, Bangladesh is trying to move very fast now to not only eliminating open defecation. But their next target is for 100% access to improved toilets. So a really big push now to move people from these very simple, basic latrines to latrines with a washable slab and a water seal and all of those things. >> You're a fecal sludge- >> I know. >> Expert, that doesn't solve the problem. [LAUGH] >> So that doesn't encourage me at all, no. >> What's going to happen to the sludge? >> Yeah, and the numbers vary, but the sort of scary number that we like to use is 30,000 metric tons of fecal sludge every day, so it's quite a scary number. And that's a big challenge. So there is the beginnings, in Bangladesh, of a discussion about fecal sludge management. And I should make a very strong distinction here between the rural and the urban. So thinking only about rural districts, a lot of people are hoping to find a sort of magic intervention that would enable us to collect and process fecal sludge and convert it into a high-value product either for the agricultural sector or possibly for energy generation. Are any of the Gates Foundation toilets going to help you on this? >> [LAUGH] I'm not a big fan of the magic toilet, I have to say. I think there will be elements, there will be ideas, there will be pieces in there that will work. One of the things that I think is very important to understand about fecal sludge is that I think density, I don't mean don't stiff density of the sludge, I mean density of the- >> Population. >> Population is a real key here. I think some of the toilets that allow us to safely store and perhaps partially process fecal sludge on site will be interesting and useful. Although I would say that I'm very old fashioned and I think latrine pit, pour/flush latrine is not a bad option in those cases. And if you've got space, the old fashioned Arborloo approach, dig your pit, fill it up, move your latrine, plant a tree. That works too. >> Excellent, works too, works fine. >> Right. >> Once you have to move sludge, once you don't have space to process on site and you have to move it, that's where it gets tricky. Moving sludge is expensive, it's heavy, it's hazardous, it's wet. So there are a whole bunch of trials going on, the Gates Foundation supporting quite a lot of them. BRAC with support from the Gates Foundation are running a bunch of composting trials. We're actually involved in one of those. >> You say we, Leeds? >> The University of Leeds working with the International Water Management Institute, and Bangladesh University of Engineering and Technology. And we're by no means alone. There's a whole group of people doing really excellent work. I was just in Bangladesh hearing about a great piece of work being done on sludge drying in Faridpur, supported by Practical Action and WaterAid so there's some good trials. My own instinct tells me that the value of the product will never be as high as people want it to be, and I think it's unlikely, although I'll be happy if I'm proven wrong, that we can find a solution that funds itself. I think what we should be really thinking about is, we still will need a public policy commitment to managing fecal sludge. >> You mean subsidies >> Subsidies, absolutely. And that's what we've seen everywhere else in the world, so it won't surprise me. The key question is how smartly you can Insert your subsidy into the process so it's as efficient as It can be. Because obviously, ending up with a product that has some value, even if marginal, is a good thing, reduces the amount of subsidy you would need. In Bangladesh, the biggest challenge we have if we look at agricultural use of fecal sludge is that we're competing against highly subsidized chemical fertilizers. The chemical fertilizer market in Bangladesh is run by the government. So no surprise that people don't want to pay higher prices for a fecal sludge derived product in that environment. But there's some interesting ideas there, and one of the things that we're really keen to look, as I say, is the economy as a scale. So with different densities of population, we presume that there are some optimum scales of processing that give you the lowest possible costs and that's about minimizing your cost of transporting raw fecal sludge. And then your cost of moving the product around subsequently. And so we're hoping to work with the government of Bangladesh looking at some models for that. What I hope is that people aren't expecting one magic answer. Definitely, in fecal sludge management more than in any other area of sanitation, I think we're going to see multiple treatment routes, multiple transport models, multiple things that we can do with the waste. Just to give you another example, parts of Bangladesh have a big brick kiln industry, brick firing industry. And one of the interesting questions to ask is, can you just use your fecal sludge as a fuel and get rid of your problem that way. And we don't know yet, but we're looking at a whole range of possibilities. >> Let's switch gears and move out of Bangladesh. [LAUGH] >> [LAUGH] Sorry. [CROSSTALK] Bangladesh. >> CLTS now has been spread over 50 countries, right? So what we do know about successes in other places? >> In other places, yes, that's a very good question. And you will hear different interpretations of that story. If we see CLTS as an indicator, if you like, of this shift in understanding from sanitation as an infrastructure to sanitation as a behavior change, I think it's a great success story. I think you can see this conversation going on in countries all over the world. Certainly, it spread very rapidly through South Asia and that's quite an achievement, actually, given the kind of regional relationships in South Asia. It's spread to Africa. You will hear many people say it's not appropriate for Africa, but there's no denying that a lot of African countries now have CLTS or CLTS type interventions in their national policies, or they're rolling them out at quite considerable scale. The effect on the ground in terms of, is it as successful as in Bangladesh or has it has been in South Asia is mixed, I would say. My own view is that an aspect of CLTS which has been perhaps a little bit ignored is the fact that once you trigger behavior change at the very simplest level, perhaps it's possible for people to change their behaviors, cut and cover type interventions, and small sort of simple changes in behavior. But as soon as you want, and I think most people do want to move onto a more robust, reliable type of infrastructure which can support their behavior change. One of the big challenges in Africa is the supply chains of goods and services. I think a very neglected aspect of the Bangladesh story is that Bangladesh had had 20 or so years of really quite significant, sophisticated support for private sector development, supply chain development. It has quite sophisticated markets for equipment, masons, plastics, all sorts of things which you don't necessarily find in Africa. So I haven't looked at the data for this, but I think in Africa, one of the things you find is that the rates triggering works just about as well as it has done everywhere else. But getting triggering to convert into a sort of embedded, secure behavior change is perhaps not quite as successful or it takes a longer time. >> You think that's largely a supply chain issue as opposed to cultural or other kinds of issues. >> I think that. It's something I would really like to look into in a lot more detail, but that's my hypothesis, yes. I see no real reason why the cultural issue should be a barrier. I kind of believe the discourse which says, inherently, human beings can be triggered to be quite disgusted by shit. I think that's quite a compelling story. But I think the question is, however disgusted you are, are you able to act and to sort of secure that behavior change, and I think that's hard. >> What about the issue of subsidies? I mean, the original model was no subsidies, but how does that work in Africa? >> Yeah, that's a very good question. It's quite interesting how many versions of CL tests you see which still contain subsidies, and not just in Africa either. I I have to say that where I have, I still think a lot of this problems of subsidy delivery persist. So I would almost say that we don't know really whether subsidies damage CLTS. We know that subsidies when they're done badly damage CLTS, because they damage all sanitation interventions. I think there's also quite an interesting question about timing. I mean just going back to Bangladesh for a moment with your permission, we have this persistent 4% problem in Bangladesh now. >> I'm sorry, the 4%? >> The 4% of people who are still open [INAUDIBLE] >> Even though people have tried to- >> Well most people have, but that 4% actually exists in two different environments. Some communities which have not yet been triggered. And, particularly in some of the more remote districts, Hill Tracks, for example, tribal areas, maybe not so much attention yet. And then you have within communities, your little persistent group, who are either unable or unwilling to change. Or excluded in some way through complex social relations. Now, the interesting question is, if you have a community that's by and large triggered, and behaviors changes happen, and you still have this small group left. Is that a good moment to start thinking about either smartly targeted subsidiaries or even, although this is a little bit of anathema to some people, sanctions? I mean in its positive sense, in regulation, requirements. After all, in Manchester it's not all right to defecate on the street. And at a certain point when the facilities and the behavior change, and the social norm has shifted, perhaps you have to move more to that sanctions-type approach. But also subsidies. >> Has been tried in Bangladesh? >> Well, that's interesting, because sanctions of course are an inherent part of a lot of CLTS implementation anyway. And I think it's a very interesting and not yet very well studied question. Who are the people for whom the existing sanctions haven't worked? And those tend to be locally and community-based sanctions. Here I'm really talking about whether a moment arrives where you actually need a governance sanction, more a local government type intervention. But obviously not a sanction that takes away your human rights. But a sanction that requires every house that's built should now have a toilet or whatever the mechanism would be. So the subsidy question there I think becomes much more sophisticated. If those people are simply not able to participate, that seems possibly like an area to investigate a smartly targeted subsidy for the last 2%. In the really poor communities where triggering isn't working, I think it's time for a very sophisticated discussion about what the barrier is. Something that's very badly understood I think in CLTS is why triggering doesn't always work. I'm sure you will have heard, and your students will probably read, a great many pieces of literature that suggest that CLTS always works. And the evidence tells us it doesn't. I sort of think about it as a strike rate, and it seems to me that you kind of lose at each point. So you have an intervention, and, the question is, does the intervention lead to triggering this kind of sudden aha moment? >> So, Barbara, could you explain the strike rate again? I'm not sure I understood really what you're talking about here. >> So with CLTS you have a set of interventions. There's a kind of standard menu of things you can do with a community. And that's actually something, going back to my earlier point that people have to kind of have to work through in any given country. But essentially you end up with the same types of interventions with a community. When you do those interventions, CLTS practitioners talk about, and I myself have seen it, this moment of triggering. Where essentially the whole community has an aha sort of moment. At which point you can start to talk about what are we going to do about this? We're all now disgusted by all this shit lying everywhere, how are we going to change our behaviors? Now, from the intervention to the triggering is not 100% success rate. Some communities don't trigger and that's a function of a whole bunch of stuff. Certainly the quality of the intervention, whatever has happened before, cultural norms, priorities. The whole bunch of reasons why that might not work. Once you get triggering, you may get a sort of aha moment and a community commitment and some community planning. But there's always a question whether that actually results in change behavior, and then over time- >> You mean they could have sort of an aha moment but still not building latrines, right? >> But still not building latrines. And still not, sort of say, yes, this is really terrible but actually it's harvest time now so off we go. Or we tried to do it but we didn't really know what to do. And we never got the support we needed so we're kind of left at sea. And then the question is over time is that change in behavior secure? So quite a nifty measure of that is if you have a community that's committed to ODF and maybe even achieved it, what happens when new households are formed? Is it a strong enough cultural norm that it impacts on new households as they form? Incomers, young people setting up home, or is it just a sort of a change that was made but is not really socially embedded? Now around the world you see this. If you take all of those steps cumulatively, depending on the circumstances we see a kind of overall strike rate somewhere between 40 to 60, or 70%. >> And that's sort of uniform across country? >> Yeah, I mean, I haven't looked in detail more recently. I've just looked at an evaluation that UNICEF had done of there CATS program which contains a CLTS element. And it seems to come up all the time, 50, 60, 70% something like that, you don't seem to very often get the 100% trigger. And that's why Bangladesh is interesting because we clearly have close to that high rate in Bangladesh. And in my opinion, that's because we've been at it for a long time and the whole external cultural norm has now shifted. Whereas in other countries you're still at an early stage in that overall cultural shift. Now, the interesting question is what do you do in those circumstances, with the communities which backslide or the communities which never triggered? >> Never triggered in the first place. >> Yeah, and one of the things that I would say is fairly obvious is you don't go back and keep going on and on and on, triggering in the same way. Because the ha process, as far as I can see, doesn't work twice. If it didn't work, it won't work if you sort of mean the shock thing, your moment is gone. So the interesting question then is definitely at that point, you need to start thinking about modifications, additional interventions, additional support. And that brings me back particularly to this supply chains issue. People who are actually more on the marketing side, here's a way in which you could modify your behavior, here's a simple thing you can do. I think it's very hard for people who are poor, who have a whole bunch of other things to do with their time, to kind of expend energy creatively solving this problem from nothing. I think that's a lot to ask. >> What does it cost to have a triggering moment? I mean, How do we think about the cost of CLTS? >> Yeah, so I have a bit of a bee in my bonnet on this topic. I don't think there's a whole bunch of good cost data. There's some work going on now, thank goodness, interestingly also at the University of Leeds at the moment. Along with the London School of Hygiene, Tropical Medicine and Oxford policy management, we're doing some work with DFID on value for money and their programming. And time and again, we keep coming up against the problem that people don't actually know what behavior change programs cost. So you very often will see a typical figure, for example, to see is, it's ever so cheap. It costs us $7 per latrine. >> This is what every engineer tells me about every intervention, right? >> Yes, exactly. >> Every water and sanitation is cheap, right? >> Yeah, exactly. It's cheap, it's cheap. It's not cheap. It is cheaper than building $3000 latrines for a small number of people. >> And it still may be worth it, I mean. >> Absolutely. I mean, yeah, nobody's saying it's not. So we did some work quite a while ago now, about five years ago now, well maybe even six, for WaterAid looking at three of their CLTS programs. And the interesting thing is the answer to the question was very varied. So in Bangladesh, we saw that you could say per household this $7 figure looked plausible. >> $7 per- >> Per household engaged in the process. But at the time, what was happening was that a lot of the latrines that were being built were shared latrines. So if you actually looked at the total cost per latrine that you ended up with, the number was higher. It was somewhere, if I recall rightly, about 25 to $30 [CROSSTALK]- >> That includes the cost for constructing the latrine? >> That includes- >> Or is that just the cost of the triggering? >> That was the total cost of the intervention plus the household contribution to the latrine. Now, since then, I would be very confident in those communities that households will invested a lot more. So the total investment will have risen quite considerably, but the initial step was reasonably good value. Now, the same sorts of programs being rolled out in Nepal, for example, we're costing a lot more and getting close to $100 per effective household with access to a toilet. But that's no big surprise. Nepal transport is difficult, the cost of moving cement around is a lot, the cost of triggering's expensive because people have to walk a long way to get to the villages. So, it varies is perhaps the most useful thing I can say. But one of the things that I would say very much is that the cost which is never included, or very rarely counted, is the institutional support you need to make sure that the people doing the triggering do it excellently and are supported. It's like social work, and I think there is a bit of a sort of idea that you can just train someone. So I train you and you will go out for next five years and do excellent triggering and I don't think it's like that. I think what you need is observation and support and oversight and training, quality control. And I think when you embed it in the national government system, we tend to underestimate the amount of, resources you have to put in, you need to pay extension health worker good money, to do excellent triggering. >> Who makes a good person to trigger a community? >> Yeah that's a good question. The CLTS literature talks a lot about natural leaders and you do find people in the communities who do it very well. I've seen all sorts of people do it well and in NGO stuff, local people just coming out from the community. Some ferocious women in all sorts of places who get the bit between the teeth and really kind of push. I've seen excellent community health extension workers, I've seen excellent women's health workers for example, traditional birth attendants, all sorts of people. It's very unpredictable actually who makes good. >> How long does it take to train somebody to do this? >> That's a good question. Not two days. Considerably more than that. And I would say the training, I mean there's been a lot of store put on training of trainers and cascade training. But I think, to really embed it well, I mean again it comes back down to this 15 years in Bangladesh. A lot of exposure, a lot of sort of experience sharing. And that leads to quite an interesting question because whereas mislightly now that in a lot of this countries where this is really sort of taking hold. You have a cohort of people who know a lot about triggering. Who are now widely seen as the sanitation professionals. And I'm not entirely sure that they trained to deal with for example of a problems. So we can have another whole training question on our hands any minute now. >> What do we know about the applicability of CLTS in urban areas, urban slums, very urban areas? >> Few people trying this. There are definitely some elements which are interesting and important. The whole idea of community wide engagement. One thing I would say is that there is no such thing as urban community of course. So I'd say pick your urban community. One of my concerns about CLTS in the urban space is a technical one. A lot of urban places, it's simply not possible to resolve a sanitation problem from within the community alone because you live at the bottom of the hill. The shit is all arriving in your community. And if you want it out of your community you need power. You need pumping or trucking. And you need to be able to engage with the city-wide system. So, one of the things that I think is perhaps almost a moral point about doing cell test in urban areas, is to take care but we are triggering communities who are able to take action. And not triggering communities who are unable to take action. And not expecting poor communities to take responsibility for everybody else's crap that's arriving in their space. Pete Colscale at UNC often talks about the fact that we expect poor, low-income people to take responsibility for rich people's crap because it all ends up in their neighborhoods if they live at the bottom of the hill, which they very often do. So I think there's still a way to go really to work that out. I have seen in urban spaces where some kind of self-contained intervention is possible. I've seen some success. But I think we have to be a bit wary. I believe quite strongly that you can't solve urban sanitation without the engagement of local government. So we need to think that through, I think. >> Well this has been great, thank you so much. I have one last question for you. We have thousands of students out here watching this interview on the MOOC, what advise would you have for them about getting engage in this sanitation problem? What are the big issues coming up that you like to see them contributed to, yeah. >> How long is a piece of string and I've said this to you before. 25 years ago when I started working I worried that by now, there wouldn't be work to do, right? But go figure. There's tons of things to do. As a general principle, the one thing I would say is that a sanitation intervention never takes place in a vacuum. So the skill that I would urge everybody to learn is the skill of looking before you leap. Actually understanding the nature of the sanitation problem that exists before you jump in. >> Eyes wide open right? >> Absolutely, I've seen people triggering in places where everybody's already committed to ODF. I've seen people doing fecal sludge management in places where nobody's crapping in a fixed place. So first of all, learn to describe the problem. My students would laugh at me because I would say draw a map, basically draw a physical representation of your problem before you think about the intervention. So that's a skill thing. In terms of research, there's tons of work to do, definitely, on this fecal sludge question. We have to get smarter about understanding the costs, understanding the benefits. I think there's a whole interesting debate to say, 15 years ago at the beginning of the MDG period, we were obsessed with environment and the whole Rio sort of approach was all about holistic environmental management. To the detriment of basic service provision to households, I think. The MDGs have been very good focusing attention on households. And in the new arena we'll definitely be broadening our ambition in terms of whole sanitation solutions. But I would urge people to keep their eye on the impact on individual families and households. And I think monitoring that and understanding who benefits if you do fecal sludge. Actually you can argue who cares as long as the fecal sludge is away from my community who cares? So, understanding not just what the benefits are but who's benefiting and making sure there's equity. Lots of work still to do on costs, we haven't got close to really describing the costs. And I think perhaps this whole question of markets and in Africa particularly, market failure was a huge problem. Not only in sanitation same thing in water supply. Why is in Africa full of people manufacturing hand pumps? Why is it full of people selling toilets? There is a huge market. So understanding the market failure and the possible ways, we haven't really found effective ways of triggering market developments so tons of work to do. >> Thank you so much. That was great, Barbara.
