2 August 2008
2008 is the ‘International Year of Sanitation’. What will it take, asks *Maggie Black*, to launch a new sanitary revolution?
A girl in Java, Indonesia, enjoying her new school toilet.
Photo: UNICEF / Josh Estey
Exactly 150 years ago, an exceptionally hot summer reduced the Thames flowing through London to a disgusting trickle. The ‘Great Stink’ off the river was so excruciating that Parliament at Westminster could barely sit. The terrors of cholera were relatively new and almost everyone believed that the fumes were pestilential.
This threat had a concentrating effect on retching MPs’ legislative faculties. The act they rushed through voted an unheard-of public sum – three million pounds sterling – for the transformation of sewerage in London by Sir Joseph Bazalgette, and led to revolutions in local government and public health engineering throughout the industrializing world.1 ‘Laissez-faire,’ declared a contemporary editorial in the Illustrated London News, ‘is an excellent maxim where trade is concerned. But in the manufacture of poisons, laissez-faire is not to be tolerated except by political and municipal idiots.’
If only such sentiments were as vividly expressed today. Great Stinks are routinely emanated by rivers all over the world swollen with raw sewage and reduced to a trickle in the hot season. The Choluteca flowing through the steep-sided city of Tegucigalpa, Honduras, renders the valley air vile, for example. But Great Stinks do not instil the level of dread they once did – more’s the pity. Equivalent attention and massive public investment are desperately needed today on behalf of the 40 per cent of the world’s population – 2.6 billion people – without a proper means of dealing with the personal emissions of pee and shit that everyone on the planet has to manage on a daily basis.
Laissez-faire is not only tolerated, but characterizes public policy towards this hidden international scandal. Consider the implications. Because they don’t have toilets, millions of people practise what is known as ‘open defecation’. They wait for darkness to set off for the fields; or they dump the foul contents of their household bucket in an open drain when no-one is looking; or they squat down on a bread-wrapper or plastic bag and throw the parcel on a dump. Rainfall or a local stream, or maybe scavenging dogs and pigs, help tidy the mess away, or the sun may oblige by baking it dry. But in an increasingly crowded world, millions of people inevitably pick up excreta-related diseases from faecal particles lying about in the open, and 1.5 million small children thereby annually lose their lives.
Why on earth is this scandalous lack of basic facilities not better known and addressed? Part of the problem is the abhorrence surrounding the subject in every society. No-one wants to mention either the act or the substance, and many people are squeamish about even mentioning the receptacle or cubicle we visit several times a day. Except for those with a taste for scatological humour, euphemism is the rule. We talk about ‘water rates’ and ‘water connections’ as if no sewerage pipes exist. In the US, there are ‘restrooms’ where people go to… sleep? Toilet training of the young in every culture seems to include teaching them to avoid mentioning anything to do with the human evacuation process.
When it comes to public health, diseases such as cholera and other diarrhoeas, even worms and parasitic infections such as bilharzia (also known as schistosomiasis, bilharzia is transmitted by a parasitecarrying snail. It is usually contracted by wading in water with infected snails, but the parasite gets into the water/snail by being emitted in human faeces), are described as ‘waterrelated’ – even by World Health Organization (WHO) experts who know better. Although water has important roles to play in spreading the causative pathogens about, and also in washing them away by handy use of a tap and soap, they are not strictly water-related. They are not even ‘excreta-related’ because urine is virtually sterile. They are uncompromisingly shit-related – brought on by particles sticking to hands, feet, lips and utensils, either via human contact or from insects and bugs, from where they land up in digestive tracts.
Because no-one will call a spade a spade, a false diagnosis of the worldwide sanitation crisis and faulty prescriptions are often advanced. ‘Clean water supplies’ are not the answer. All the evidence shows that in the triumvirate of water, hygiene and sanitation, water supplies make the least impact on health, and sanitation much the greatest, followed by hygiene.2
Disconnecting ‘wat’ from ‘san’
‘Water and sanitation’ are invariably conflated in programmes for poorer citizens. In an industrialized society, where the press of a handle flushes our detritus away, this may make sense – although the profligacy of supplying 15,000 litres of drinkable water to every European and North American just to flush their toilets is mind-bending once you think about it. But in large parts of the world, the means by which people get rid of their excreta is entirely separate from their water supply. Their toilet – if they have one – cannot have its water supply piped in and its output piped away. Neither they nor their authorities can afford the investment required, not just in pipes and underground infrastructure, but in sewage treatment and disposal. Plus, in many countries of Africa and the Middle East (as well as India and China), there is acute water stress. So universal sewerage is a non-starter.
Wherever sewerage is impracticable – which includes most of the rural developing world, where two billion of those without toilets live – ‘sanitation’ mostly consists of an ‘on-site’ facility. This means a cabin over a dug pit or septic tank. It could be a ventilated earth closet, a squatting plate with a drop-hole and cover, or a pan flushed by a jugful of water or a handful of ash (see ‘For our convenience’, page 14). Over the years, pioneers have upgraded the item derogatively known as ‘a latrine’ to make it more congenial, cleaner, and able to compost or biodegrade its content. Some enthusiasts for recyclable systems recommend ecological sanitation for everyone. But the popularity and superiority of the water closet means that wastewater recycling and lower-volume flushing are as far as ‘ecosan’ is likely to get in happily sewered environments.
So toilets – not so fancy as porcelain pedestals but decent, affordable and useable nonetheless – exist in many models and variations. There is toilet take-up on a slowly growing scale (see box below). But numbers lag. One reason is that many ‘watsan’ programmes spend the lion’s share of their resources on water. In Madagascar, 95 per cent of funds allocated to ‘water and sanitation’ are for water, leaving six US cents per head a year to spend on sanitation. ‘What on earth can I do with that?’ asks the government’s chief of sanitation. Madagascar is typical. Sanitation has rock bottom political priority, barely appearing in national development or assistance plans.
The excuse offered by politicians and planners is that there is popular demand for water supplies – indeed, in India, politicians outspokenly campaign on promises of new and cost-free supplies. By contrast, no-one calls for shit removal. True, life is impossible without water while a toilet cannot make this claim, however hard economists argue that the toll of ill-health is a costly burden. But the reason why demand for sanitation is not expressed is because the subject is taboo, not because people don’t feel it. For women, having to manage with nowhere to ‘go’ is not just inconvenient, but an assault on their personal dignity. The night-time expedition can lead to sexual harassment and attack (see ‘Dignity and the decent facility’, page 16), and reputation is also at stake. In urban South Africa, a woman seen cleaning or emptying a public latrine is unmarriageable. Unless the topic is tackled sensitively, it is not going to surface in a meeting with the local MP.
Even when it is tackled sensitively, eliciting demand is tricky. For a start, no-one installs a toilet as a health aid. Sanitation may be publicly rated the greatest medical advance in 150 years – as a British Medical Journal poll recently discovered – but the benefit is public. Privately, people are more often motivated by comfort, convenience, privacy, safety for women and children and social status.3 Actually, this makes sense. We want decent toilets because we want to manage our bodily output needs in a satisfactory and dignified way. And unless the ‘home improvement’ does this, health advantages are meaningless.
In one Nigerian village, the foolishness of glorifying excreta by building a house for it was greeted with mirth
Too often, targeted customers among the poor have not been offered a system or cistern they regard as an improvement on the great outdoors. Every society has a sanitation system – imagining they don’t because they don’t have ‘toilet cabins’ is part of the baggage of prejudice and lack of information surrounding the subject. They allocate special places, what is to be done in them, and who may go when. But search the anthropological literature, and you will find that the silence on shit-related behaviour is as deafening as if a blackout had been imposed. A few travel writers have broken the taboo. In 1964, VS Naipaul complained that Indian society was collectively blind to the sight of people squatting everywhere and anywhere to relieve themselves, and that the Indian peasant suffered claustrophobia if ‘he has to use an enclosed latrine’. His book was unofficially banned for its temerity.
Informal enquiry into people’s lavatorial customs reveals that people everywhere have reasons for what they do. In one Nigerian village, the foolishness of glorifying excreta by building a house for it was greeted with mirth. Only when their chief was threatened with arrest did the villagers comply by building one: the idea conflicted with strong beliefs which no-one had enquired into, and of course they never used it. In parts of Madagascar, digging a pit to contain excreta is similarly unthinkable. Fady (taboos) require that no-one should put their shit on top of another’s, and in a society that venerates the ancestors it cannot be put underground where it will contaminate the dead. Only after a terrible cholera epidemic in 1999-2001 did the question of fady, how real they were and how to tackle them, begin to be addressed.4
New facilities, new jobs. A toilet production centre in West Bengal.
Photo: UNICEF WEST BENGAL
It’s got to be nice
It is easy to understand why entrenched behaviours favour the air, wind, sunshine, and natural ecological processes over a hot and stinking toilet house. Unless ‘improved’ pit toilets are well maintained, they do not remain congenial for long. What happens in a ‘dry toilet’ with a drop-hole when people miss? Some sanitary enthusiasts build toilets all over the place with missionary enthusiasm. In rural Nicaragua, family plots may have two or even three ugly cabinets on plinths, so prolific has NGO effort been. But do people invariably use them? The evidence is that, even after renouncing the devil of ‘open defecation’ and bringing excretion indoors, regular exhortation by community volunteers is needed to stop people slipping back to the fields. In large, crowded townships, where space and privacy are at a premium, things may be different.
This highlights one of the crucial aspects of what is needed to set a new sanitary revolution in train. Arguments may rage between exponents of ‘ecological’, recycling and non-polluting systems, and the virtues of waterflushes and sewers (see ‘To sewer or not to sewer’, page 12). But what matters most is offering people a toilet they want and are prepared consistently and endurably to use. That means it’s got to be nice. The need to reduce costs sufficiently to make sanitation affordable for the poor may mean that the toilet they adopt has a very short life as a desirable facility. Will they then be able to afford another?
What matters most is offering people a toilet they want and are prepared consistently and endurably to use
In a community on the periphery of Dakar, Senegal, people all want a waterseal toilet with a porcelain pan. This is understandable. But it is not possible without a subsidy. In arid areas or where human fertilizer is valued, cheaper ‘dry’ systems may be fine. But even they are expensive compared to a walk in the bush. In a dusty village far from Dakar, women find a $20 contribution (60 per cent of the cost) for slab, lid and vent-pipe hard to produce. ‘Everyone here is in favour of toilets,’ says a women’s leader, ‘it is simply a matter of means.’
The public health revolution that followed London’s Great Stink required large investments of public funds. Whatever system is installed, it is neither fair nor sensible to expect those without facilities today to pay the whole price – as current policy seems to expect. The rationale is that ‘what people don’t pay for, they don’t appreciate’. But lack of appreciation is not the whole problem. Rather, demand is not being effectively nurtured, and there is no publicly backed, appropriate sanitary economy with cheap, attractive, good quality products ready to meet it.
Needed: decent jobs in muck
What could such a sanitary economy look like? The one thing it must eliminate is shovelling shit by hand. There are still workers today, mainly but not only in India, whose livelihood depends on this humiliation (see ‘A lifetime in muck’, page 10). On the one hand we have porcelain bowls and sewerage connections costing hundreds of dollars, buoyed up by an industry of civil engineering, plumbing, bathroom fixtures and municipal subsidies; and on the other, for poorer citizens, too often nothing at all. But since everyone has to defecate somewhere, there remains a ‘ job’ of clearing the muck away. One of the evils of ‘open defecation’ is that it keeps in existence a class of people to whom this job has been traditionally assigned. Here is a killer argument for decent toilets: better facilities, better jobs.
Intermediate industries have come into being around sanitation – including in India. Back in the 1990s, an NGO called the Ramakrishna Mission set its youth groups the task of cultivating demand for toilets in the densely settled district of Medinapur, West Bengal (eight million population). Motivators visited households as many times as it took to put across their message; and production centres were set up with starter funds where masons (female and male) were employed to manufacture toilet pans and slabs. Prices began at $7.40 and rose to $74. Loans were on offer to those who put down half the price. By the early 2000s, bicycle rickshaw carts delivering toilets to customers were a routine sight on local roads. By 2006, almost every household in Medinapur had installed a toilet. Hundreds of women and men have been trained in a new occupation and earn a good living.
Other examples could be cited, with demand for toilets and supply of an affordable and appealing item actively promoted in tandem. But thanks to most governments’ indifference, corporate disdain, and lacklustre donor engagement, they are not as easy to find as they should be. There is no one ‘toilet fix’ waiting to be rolled out to solve the global sanitation crisis, but there are many promising approaches and ‘lessons learned’. Openness is needed to quell the Great Distaste and get a new Sanitary Revolution moving, with the same resources and political push committed 150 years ago to solve London’s crisis. Let us hope that it will not take a rash of epidemics, stinks, and dying rivers to help it on its way.
Way off course: the Millennium Goal for Sanitation
The Millennium Development Goals (MDGs) were established at a special UN Millennium Summit in 2000, but the goal for sanitation came later. This is another example where ‘sanitation’ was originally subsumed by ‘water’ – and ignored. A goal of halving by 2015 the numbers of people without access to sanitation in 1990 was added to the identical goal for water at the Johannesburg Earth Summit in 2002 – but only after intense lobbying. At present, it is one of the most off-track goals in the pack. In sub-Saharan Africa, on current progress, the MDG will not be met until 2076, indicating the neglect in which sanitation still languishes. The numbers of those without toilets barely alter over the years because the rate of toilet take-up barely matches that of population growth in the places that matter. Failure post-2002 to mobilize the necessary political will led to the UN declaration of 2008 as the International Year of Sanitation, in an effort to galvanize effort and resources behind the MDG. As can be seen below, even if it were met, vast numbers of people would still be toilet-less.
Growth in sanitation coverage, per cent, 1990-2015