In Madagascar's east coast city of Tamatave, a local taboo against having a toilet in your house or on your land has complicated the task of trying to improve the region's dire sanitation situation. Nationwide, more than 10,000 people, of whom two thirds are children under five, die prematurely from diarrhoea annually, according to the World Health Organization, which attributes 88 per cent of these cases to poor quality water and sanitation.