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Hi James

Although the evidence is weak, another way to look at this is from the perspective of pride and cleanliness of our households and our communities. I have seen some excellent work done in Ethiopia by a partner of ours called the "flag" system. They work with a community to agree a number of hygiene behaviours that a household shoudl achieve and then they agree what levels of achievement d=get rewarded with what colour flag that a household then gets to fly above their house. If memory serves, in the village I visited, households achieving 15 behaviours got a red flag, 12 green, 10 white and below this nothing.

The behaviours included: Dish rack, handwashing station, a used toilet, a clean toilet, a clean yard, animals kept outside the house and in a separate fenced area, using a smokeless stove in a separate kitchen, clean kitchen area, covered food storage etc

All this was driven through positive pride messaging. And then the idea was that if you achieved this in all households and then public areas, then the entire community could claim to be a clean and healthy community - so really at this point much like CLTS declaration.

The point of this is that there is some evidence that point to soil and environmental contamination as others have pointed out. We know that animal faeces do contaminate water sources if it gets washed into them (surface and groundwater). So therefore, should hygiene programmes do something about it? I would argue yes.

How much to do this at scale is the real question of course. Do we focus on communities, do we focus on national campaigns, do we do this through school curricula, do we strengthen health extension programmes - or ll of the above? Lots of space to try and innovate big things!