Clean Water: UNICEF Shows More Children Die from Diarrhea than Direct Violence in Conflict Zones

By Jerri-Lynn Scofield, who has worked as a securities lawyer and a derivatives trader. She is currently writing a book about textile artisans.

Friday was World Water Day and the United Nations International Children’s Emergency Fund (UNICEF) produced a report, Water Under Fire, documenting how deadly tainted water can be to children in war zones.

Lack of access to safe water, sanitation and hygiene (WASH) is far more dangerous to children in conflict zones than direct violence. From the report:

In protracted conflicts, children younger than 15 are, on average, nearly three times more likely to die from diarrhoeal disease linked to unsafe water and sanitation than violence directly linked to conflict and war. For younger children, the impact of unsafe water, sanitation and hygiene is greater: Children under 5 are more than 20 times more likely to die from diarrhoeal disease linked to unsafe water and sanitation than violence in conflict (report, p. 3)

The report isn’t based on anecdote and examined World Health Organization (WHO) mortality estimates in 16 countries undergoing protracted conflict: Afghanistan, Burkina Faso, Cameroon, the Central African Republic, Chad, the Democratic Republic of the Congo, Ethiopia, Iraq, Libya, Mali, Myanmar, Somalia, South Sudan, Sudan, the Syrian Arab Republic and Yemen. World Health Organization (WHO) mortality estimates were used for ‘collective violence’ and ‘diarrhoeal disease’.

Using HO data covering 2014-2016 and published in 2018, the report concluded that 85,700 children under the age of fifteen died from WASH-related diarrhea, compared to 31,000 deaths due to direct violence. Most deaths were of children under the age of five, 72,000 of whom died due to diarrhoea, compared to 3,400 from direct violence (report, p. 5).

Wider Problem

The report didn’t offer much by way of solutions, other than a call to combatants to stop targeting water infrastructure during such conflicts.

The problem of WASH fatalities isn’t limited to war zones, and it is expected to get worse, due to increased water scarcity, some of which may be exacerbated by climate change. As the Guardian reports in Diarrhoea kills more children in war zones than war itself – Unicef more than 4 billion people and 844 million lack access to water close to home.

WaterAid, a non-profit set up in 1981, estimates diarrhea caused by dirty water and a lack of sanitation kills nearly 800 children a day.

Solutions: Bangladesh’s Success

But countries don’t have to capitulate. One country that’s slashed the number of childhood deaths due to diarrhoea is Bangladesh,  a country that was itself a war zone not so long ago, when in 1971 it fought a liberation war against what was then called West Pakistan and achieved its independence.

During a month-long visit in 2009, I learned about the work of BRAC, now the largest non-governmental development organisation in the world (in terms of employees). Sir Fazle Abed established BRAC in 1972 immediately after the 1971 war.  Wikipedia reports that BRAC is present in all 64 districts of Bangladesh as well as 13 other countries in Asia, Africa, and the Americas

As I travelled around the country conducting research about its textile traditions, I visited many villages. In these, many people – mostly women – produced handicrafts and textiles, in operations organized and overseen by BRAC and its social enterprise, Aarong.

Much more than any details about textiles or their production, what’s stuck with me now, a decade later, is how one simple, low-cost initiatives could save so many lives. In the humblest of villages, I saw women with mstrings or simple necklaces hung around their necks,from which dangled a small, two headed spoon – about the size of a teaspoon on one side, and a tablespoon on the other. They were taught that when I child caught diarrhoea, it was necessary to find fresh water, and make homemade Oral Rehydration Solution (ORS), by dissolving roughly one teaspoon salt to one tablespoon of sugar into IIRC a liter or so of water.

Now, as I was researching this post today, I learned a bit more about the history of ORS treatment, which is credited with having saved 50 million lives worldwide and which The Lancet described in 1978 as potentially the most important medical advance of the 20th century, according to PRI’s account,  A simple solution: The history of ORS in Bangladesh.

The ORS treatment – originally a simple electrolyte blend used to treat cholera- was developed by Bangladeshi and US researchers in the late 1960s, at the Pakistan-SEATO, the predecessor of what is now the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), located in Dhaka.

According to PRI:

The American researchers, a group of young doctors, had opted to go overseas as part of a US government program, in lieu of serving in the Vietnam War. At the time, the United States was more insular, and Third World diseases like diarrhea were not typically discussed in medical schools, said Dr. Richard Cash, one of the researchers.


In the 1970s, BRAC … collaborated with icddr,b to devise a rigorously monitored process to teach mothers to make the mixture at home. Starting in 1980, more than 12 million Bangladeshi mothers were taught to make ORS, a program that saved countless lives, according to Cash’s book, “A Simple Solution.’’

That knowledge took hold: Since 2007, the 2011 Bangladesh Demographic and Health Survey reports, about 78 percent of children with diarrhea have been treated with ORS, which is readily available at shops and clinics today.

A 2018 account in The Economist, How Bangladesh vanquished diarrhoea, tells more of this success story:

IN THE 27 years since he became headmaster of a school in Trishal, in northern Bangladesh, Mohamed Iqbal Baher has noticed some changes in his pupils. Although boys and girls are often absent because they are helping their parents in the fields, they miss fewer lessons because of illness. Mr Baher does not recall an outbreak of cholera in the past ten years. And, although he cannot be sure, he thinks that pupils are taller than they used to be.

If so, it is probably because they were healthier infants. In 1993-94, 14% of Bangladeshi babies aged between 6 and 11 months had suffered an attack of diarrhoea in the previous two weeks, according to their parents, who were responding to a household survey. That is an important stage in a child’s development, but also a period of great vulnerability to stomach bugs, as babies are weaned. By 2004 the proportion of stricken babies had fallen to 12%, and in 2014 it had dropped below 7%. Stunting—being extremely short for one’s age—has declined roughly in parallel.

Between 2006 and 2015, BRAC has helped more than 5 million households construct toilets.  Constructing toilets has, to be sure, been important in reducing the incidence of enteric disease – but so also has been the use ORS to treat it. Over to the Economist again:

The abating of enteric disease, together with the growing use of salty rehydration solutions to treat it, has spared many lives. In Matlab, a part of Bangladesh with good data, deaths from diarrhoea and dysentery have dropped by about 90% since the early 1990s (see chart). That decline helps to explain how Bangladesh has pulled off a remarkable feat. Though it is still one of Asia’s poorest countries, with only half the GDP per person of India, Bangladesh now has a child-mortality rate lower than India or Pakistan, and indeed lower than the world average (Jerri-Lynn here: my emphasis).

I should mention that Bangladesh has a GDP per capita of roughly half of India, but has a lower child mortality rate.

What Is To Be Done?

The latest Unicef report makes for depressing reading. Diarrhea will continue to be a major cause of childhood fatalities in war zones.

But outside of such conflict zones, Bangladesh has shown that even the poorest countries can reduce such deaths with treatment as simple as some sugar, and a pinch of salt.

What’s more difficult is to ensure wider access to clean water. There, Bangladesh has also shown how that can be done.

And must.

The alternative is too dire.

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  1. Chauncey Gardiner

    Thank you for a thoughtful and informative post. Water quality and sewage is a global issue, particularly in nations where the populace is subjected to protracted military conflict and/or climate change issues, as well as poverty. NGOs, the World Health Organization, and some national governments have been active in reducing the risks, but this issue indeed remains beyond depressing in too many places. Instead of making speeches about “sh**hole countries” and supporting conflict, it would be useful to consider turning the page to sponsor soft power initiatives.

    1. Jerri-Lynn Scofield Post author

      Thanks. If Bangladesh can make such progress in tackling this problem, other poor countries can too.

  2. David

    This is news? In Africa, anyway, diarrhoea kills more children than any of the better known and more glamorous diseases, even in peacetime. Clean drinking water and draining of mosquito swamps would transform the health and life-expectancy of ordinary people in a way that no amount of AIDS research would. But although there are initiatives, donors don’t find it sexy enough.
    More generally, be very careful with “casualty” or “death” statistics from conflict areas, particularly when preceded by expressions such as “conflict-related.” In general, direct deaths as a result of conflict are a small part of the total (as they were in Europe until recently). It’s disease and malnutrition that do the killing, although there’s a complex debate about how to count such deaths, and whether you try to allow for people who would have died anyway. But that said, it’s good to get any coverage of the real causes of death and suffering in conflict areas.

  3. Synoia

    Transparent plastic bottles are also used to purify water.

    The sediment settles to the bottom, and sunlight kills the pathogens.

    Plastic 5 gal bottles, with a faucet part way up from the bottom, are perfect for this purpose.

    Worst case of diarrhoeal disease I ever had was in the Rainy season in Africa, after the rain flushed the mangrove swamps, and all the captured “future plant food” ended up in the coastal sea.

    1. Jerri-Lynn Scofield Post author

      As the Bangladesh case shows, it doesn’t require massive amounts of money to make a real dent in the problem. Obviously, spending more would alleviate more suffering. Imagine what could be achieved by redirecting a small amount of defense spending.

        1. The Rev Kev

          Yeah. Where is the monetization? The implementation of high-technology, the iPhone mobile app, the highly-paid consultants, the Foundations getting their kick-back, the visits of washed-up, western media personalities, the social media demands for contributions. That is a lot of worthy people missing out on their rice bowl there.

  4. John Zelnicker

    Jerri-Lynn – Another great post. I was also not familiar with ORS, but it’s simplicity and effectiveness is stunning.

    I don’t want to make assignments of work as it’s against site policy. However, have you considered taking a look at the privatization of water services around the world? Yves, IIRC, has said that this is the next great neo-liberal target for takeover; and it’s already happening. I know that Nestle has been completely disgusting and immoral in the ways that it has appropriated local water sources so it can sell more plastic bottles of regular tap water and charge unconscionable prices for it.

    1. Jerri-Lynn Scofield Post author

      ORS is something one learns about when travelling in places with dodgy water or food sanitation and hygiene issues. You use it to rehydrate after having a bout of Delhi belly, Montezuma’s revenge, etc. It’s possible to buy premixed sachets, to be dissolved in clean water. But also possible to make one’s own – as was still the case in rural Bangladesh when I visited a decade ago. I believe the same components go into basic sports drinks: gatorade, etc.

      I used to carry premixed sachets when I travelled. Now I don’t bother – if necessary, I can either buy them at most local chemists, or if I’m really out in the back of beyond, make my own (for which I would look up the formula, rather than relying on my memory).

  5. TG

    Indeed, but missing the main point. Malthus was right. If people try to have more children than they can reasonably support, if they try to double their population every 20 years or so, they will fail, and of necessity they and their children will be crushed into misery.

    It is true, Bangladesh has made some temporary advances against the effects of poor sanitation and chronic malnutrition. And that is a good thing. But the place is still hellishly poor. If the fertility rate had been lower, such fixes would not be needed, and there is no reason Bangladesh could not be as prosperous as South Korea or even Russia (which has problems but not like Bangladesh).

    In 1950 the population of Bangladesh was about 40 million. The West developed the green revolution and helped then acquire chemical fertilizers etc. And for a time it helped – until it was swamped by a tidal wave of people. The experience is that technical fixes don’t last. There is no technology that cannot be – that has not been – wiped out by an exponentially growing population. The iron law of development is: FIRST people lower their attempted fertility rate, THEN, if everything else goes halfway right, they slowly develop prosperity. To deny this is a foolish politeness that makes us complicit in the misery of places like Bangladesh. It is not hyperbole to say that, in terms of the impact on humanity, the anti-Malthusians are literally worse than Hitler (and Stalin and Mao), for even they never dreamed of creating so much suffering on such a scale for so long.

  6. Pink Prince

    I wish India :& Nepal would do the same thing as Bangladesh & more. India & Nepal should build more farms to keep farm animals such as cattle on the farms & crack down on people urinating & defecating on the streets. The caste system keeps the country from progressing except in baby steps. I am Indian & it’s something I don’t like about India.

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