"I am alone now, my wife died last night and my daughter died this morning. How I am going to survive?Why doesn't this killer attack me?"

These words were uttered by a villager from Jajarkot, during the deadly outbreak of diarrhoea in August of last year. By that time, over 300 people had died in 20 districts in the mid and far-western regions of Nepal. This year, as summer sets in and we begin to receive reports of diarrhoea cases again, we should consider: how can we prevent another public health disaster?

Diarrhoea is one of the leading causes of morbidity and mortality among children under five in Nepal, with 10,500 dying every year. Most of these deaths could be avoided through simple measures like safe drinking water, sanitary latrines and proper hygienic practices, including hand-washing. But due to the lack of public awareness and low government priority, the hygiene and sanitation situation of the mid and far western development regions is in a critical state.

Jajarkot is one of the poorest and remotest districts of Nepal. Access to drinking water is estimated to be 49.4 per cent, though the quality of water available needs to be further investigated. Access to sanitation is less than 22 per cent, compared to the national average of 46 per cent. Open defecation is a common phenomenon and the lack of safe drinking water and hygienic practices make communities more vulnerable. It was no surprise that Jajarkot became the epicentre of last year's epidemic of diarrhoea and cholera, exacerbated by the monsoon that followed a prolonged drought.

Sanitation and hygiene promotion are the most cost-effective public health interventions. The simple act of hand-washing with soap can reduce the risk of diarrhoeal disease by up to 45 per cent. Though the importance of Water, Sanitation and Hygiene (WASH) is recognised by the health sector in Nepal, the curative aspects of health promotion or technology- driven water and sanitation interventions often overshadow basic awareness and preventative measures.

Though outbreak response activities succeeded in controlling the diarrhoeal epidemic to some degree last year, many more deaths could have been averted if preventive activities had been intensified immediately after the outbreak. Key areas for future interventions include:

* an early warning system with proper mapping and a contingency plan to focus immediate attention on outbreaks
* availability of medical staff in duty stations with back-up resources
* coordination among government and non-government actors
* improving information management and communication channels, including through the use of security forces
* focus on logistics to transport oral rehydration solutions and other drugs in time and in adequate quantities
* social mobilisation using local volunteers, health workers, political leaders and their cadres, and teachers for water purification and promotion of hygienic sanitation practices, including setting up health camps
* providing better access to health care services: most deaths last year happened at home or on the way to health institutions.

The epidemiology of diarrhoea indicates that there will be outbreaks this summer and monsoon too. If we are to prevent the loss of human life this year and in the future, it is imperative that we learn from our recent past.

Om Prasad Gautam is a public health professional with WaterAid Nepal omprasadgautam(at)wateraidnepal.org.np