In a world worried by carbon emissions and chemical and nuclear pollutants, the pollution of pathogenic excreta emitted by a huge urban population does not excite the same sentiments as it once did. Since the Great Stink of London (see “The Great Stink”) the industrialised world has dedicated significant resources to clean and sanitise the built environment. In developing countries, a better understanding of pathogenic agents has reduced fear of the “bad airs” (mala aria), thought for centuries to cause disease. But today’s ever more rapid urbanisation produces new concerns.
Many urban dwellers live in slums, townships, shanties, bidonvilles or favelas: around a billion suffer the consequences of a lack of sanitation, in indignity and ill-health. Yet the squalor on the peripheries, and sometimes in the heart, of rapidly expanding cities in Africa, Asia and Latin America is rarely seen as threatening to the social and municipal fabric. Medical infrastructure is generally enough to contain the significant spread of epidemics – especially cholera.
After more than 7,000 cases of cholera and 162 deaths – 30 in the capital Lusaka – Zambia aims to invest $2.7m in a risk reduction programme, employing prisoners to unblock drains and launching television soaps and concerts to educate the community (1).
The 19th century triumph of flushing toilets and water-borne sewerage gave everybody the idea that clean water supplies would resolve the business of excreta disposal. The connection of disease to faecal contamination was forgotten and health authorities placed diarrhoea and other infections in the category of “water-related”. Householders today pay water rates for water connections as if sewerage pipes did not exist. By these euphemisms, an unpleasant subject was proscribed not only in polite society, but in policy-making circles.
In some parts of the developing world, rivers running through cities are as sluggish and turbid as the Thames, the Rhine and the Seine were in 19th century Europe, and as unable to digest the untreated human waste with which they have been burdened. But these “stinks” do not cause the dread they once did, and as long as they are distant from downtown areas with smart hotels and tourist attractions, they are left as they are.
For 2.6 billion people – 38% of the world’s population – the daily problem of excreta evacuation and disposal has not been resolved. They have no toilet; their homes are not connected to a sewer. If they use a toilet where the content is stored in a pit or septic tank, there is no regular service to remove the detritus. Where people are connected to water-borne sewerage, only 10% of faecal matter is treated; 90% ends up untreated in rivers, where the consequences to fish stocks, plant life and to human health can be devastating.
In many cases, these same rivers are used for bathing, washing, laundry, and sometimes drinking water for people and livestock. Water is a superlative agent for absorbing and transporting waste, but it is also an efficient carrier of pathogenic material, including the billions of microscopic bacteria contained in the smallest amount of excreta.
To clean up the Ganges, polluted by industrial chemicals and untreated sewage, India has recently secured a $1bn loan over five years from the World Bank (2). But even if it constructs enough functioning treatment plants at the sewer outlets all along the river, there is no hope, even with this huge investment, of linking the houses of the poorest to the sewer system. Almost all of those without access to sanitary installations live in the country in simple dwellings (70%), or in urban bidonvilles (30%).
In most rural parts of the developing world, people practise “open defecation”. At nightfall they set off for the fields. Women cannot be seen defecating if they wish to preserve their modesty and respectability. Physical or sexual attack during these nightly excursions is not unusual and the effort to contain themselves during the day may lead to urinary tract and other health problems.
Where there is no place to go (in towns for example) or where children are too young and shy, or elderly people too infirm or sick to venture out, they must use a bucket or squat down over a discarded food wrapper or plastic bag. This package is thrown on to a nearby dump, where scavenging dogs or pigs may help tidy the mess. These squalid packages are known as “flying toilets”.
Worse in the cities
In the country, some of the arrangements for human waste disposal – primitive though they appear – are preferable to a small and stinking closet. Rural populations often resist the idea of a toilet house: they are inclined to keep the offending material as far as possible from their living space. The desiccating and deodorising properties of the sun and wind, plus the landscape-cleansing attributes of water bodies ebbing and flowing have served them adequately in the past.
But in a congested world, open defecation is no longer safe. Millions of people pick up diseases from faecal particles in fields, on paths and alleyways, on seashores and on the banks of rivers. Pathogens are transferred to feet, hands, food, eating and drinking utensils and clothing, and are ingested by bathers using lakes and ponds – or by children who play there.
Every year 1.5 million small children die from diarrhoeal infection. Millions of others suffer repeated bouts of fever and running stomach, keeping them from school, impairing their growth and absorbing maternal care and family resources. Parasitic infections, contracted from bare feet in faecal contact, are even more common, over 133 million cases a year. Ascaris, a roundworm nestling in the stomach, can absorb a third of the food a child takes in, and often causes asthma. A child living in a very poor environment may carry 1,000 parasites.
But even if the health consequences of inadequate sanitation cause public concern, people may see the toilet more as a personal convenience than as a health aid. As the world becomes more urbanised, finding privacy becomes more difficult without a dedicated facility and is opening demand among the poorest, especially those who are beginning to climb the social ladder. The toilet, like a television set, is becoming a marker of modernity even in a humble home.
At the same time, the need for a washroom or simple shower, and for a drain to discard wastewater, is leading to the same demand for household improvements as Europeans experienced over a century ago. But commitment and resources from municipal authorities have been lacking. There has not been the political push – either from influential establishment figures or from consumers.
Aid donors have also been neglectful. In general, they commit 10 times more resources to water than they do to sanitation. In programmes designated “water and sanitation” they often omit to specify contributions for hygiene education, promotion of toilets, or construction of disposal systems for wastewater and excreta, so that the word “sanitation” is ornamental.
Universal it isn’t
When the UN defined the Millennium Development Goals in 2000, sanitation was not included. Only after intense lobbying at the second Earth Summit in Johannesburg in 2002 was it agreed to add the target of reducing by half by 2015 the proportion of those who were without access to basic sanitation in 1990. According to Unicef, this target – modest since it would leave out 1.8 billion people – is unlikely to be met.
The sluggishness of progress in sanitation – financial, political, institutional, and promotional – led the UN to designate 2008 as the International Year of Sanitation (IYS). This has begun to make a difference. Water supplies and sanitation are finally being decoupled in the minds of policy-makers.
In many regions of the world, even if toilets could be installed in the poorest areas, they could not be supplied with water or sewer pipes. Neither community members nor the authorities can afford to invest in the pipes and underground infrastructure, let alone in sewage treatment and disposal. And in many countries of Africa and the Middle East (as well as in India and China) there is acute water stress. So universal sewerage is a non-starter.
The IYS concentrated minds on previously unnoticed educational and technological breakthroughs and the unsuspected seriousness of the situation. Many towns and cities in developing countries had reported much higher figures for both domestic water provision and sanitation than the latest surveys reveal. The inclusion of populations living in “illegal” settlements has increased the numbers of those living in inadequate conditions. Many countries, for fear of losing tourists, regularly underestimate numbers of cases of cholera. This is made easier by the silence of many of the sick who are ashamed to be associated with a “dirty illness” (3).
Before any progress can be made, we need to find alternative technologies which are cheaper – and easier to install and manage than the conventional water-borne systems the developed world knows.