Mini-Review

Water, Hygiene, and Sanitation: Progress Made on MDG 7

Sally E. Hunter 1*
1

University of Idaho, E-Mail: hunt6094@vandals.uidaho.edu

* Author to whom correspondence should be addressed Received: / Accepted: / Published:

Abstract: This paper focuses on Millennium Development Goal 7 and the interventions that have been implemented to reach the goal. MDG 7 focuses on quality water access and basic sanitation for the global population. Several methods have been implemented to achieve this goal, but there are still several barriers to effective implementation. In fact, MDG 7 has been achieved in regards to water access, but is far off track in regards to sanitation.

Keywords: Sanitation; Water Access; Millenium Development Goals; Disease Reduction

1. Introduction

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Access to clean water, sanitation and good hygiene are the three most powerful tools to fight disease. A lack of access to clean water, sanitation, and hygiene contribute to 69% of all diseases seen in our global population [1]. While the MDG for access to clean water has already been reached, we are woefully behind schedule in regards to sanitation access [2]. If improvements arent made quickly, it is unlikely that the sanitation goal will be met by the 2015 deadline. The MDGs were outlined and adopted in 2000 by 189 heads of state. It is a declaration of goals to address several world development issues, one of which was access to clean water and basic sanitation. A goal was specifically set to halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation [2]. 2. Access to Clean Water

2.1. Defining the problem Great strides have been made since data was taken in 1990 regarding clean water access. Today, only 11% of the worlds population uses water that does not come from an improved water source [2]. An improved water source is defined as piped water into dwelling, plot or yard; public tap; tubewell or borehole; protected dug

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well or spring; and collected rainwater [3]. For a water source to be considered improved it must also produce 20L per capita per day within one kilometer of the users home [3]. Though we have already reached the MDG goal for water access, in fact surpassed it, there are still roughly 875 million people collecting their water from unprotected sources [1]. Most of these users are in rural areas. With this unclean water use comes disease and death. Over two billion adults and children are effected yearly by water-borne diseases. Without access to modern medicine, many of these cases are deadly. Surprisingly, only ten countries make up 2/3 of the entire population that doesnt have access to clean drinking water. India and China are two of these countries, representing 28%, even though both have significantly increased access for their populations. Part of their difficulty is their relatively high population growth rates. Additionally, six of the ten countries are in Africa. Sub-Saharan Africa has the lowest water access rates of any region, due largely to its rural makeup [2].

2.2. Interventions

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There are a few reasons why the water access goal has already been surpassed 5 years ahead of schedule. The dominant reason is national policy. Of all money spent on water and sanitation access, 4/5 of the budget goes specifically to developing water access. Between 1990 and 2000, $15.7 billion US per year was spent on water and sanitation access and only 1/5 of this went to sanitation [4]. Water storage techniques have also improved dramatically. While getting clean water is the first step, keeping it clean is just as important. Without a method to keep the water clean, its of little use as clean water. Proper storage is a cheaper, easier and faster method to clean water access than directly piping it to a home [5]. Research has shown the following storage specifications to make the biggest impact on keeping water clean: a narrow opening for filling the container, a handle, a container made of lightweight, UV resistant plastic, a spout for dispensing the water and lastly, a clear label denoting the contents. In addition to these storage techniques, SODIS (solar disinfection) is effective at disinfecting suspect water sources. SODIS works by a combination of UV radiation and heat to kill microbes. Unfortunately, very turbid water is harder to disinfect as the foreign material prevents the penetration of both the UV rays and the heat from reaching the microbes [5].

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3. Access to Basic Sanitation 3.1. Defining the problem Sanitation access is so far off track from meeting the MDG that it is astounding. Even with efforts to increase access amongst all populations, over 2.4 billion people will be without sanitation access by the 2015 deadline [2]. Sanitation access is defined as flush or pourflush toilet to piped sewer system, septic tank or pit latrine; a ventilated improved pit-latrine (VIP); pit latrine with slab; or composting toilet [3]. Even while water access has increased dramatically, absolute numbers of those without access to sanitation access has increased (though the proportion is slowly decreasing), due in large part to population growth [6]. This is troublesome as contact with feces leads directly to disease. There is a generally accepted loop regarding the fecal-disease link: feces is transferred to one of the following: fingers, fields, flies, and fluids. In turn, these four hosts transfer the material to an intermediary- food- or directly to a new human host [7] There are several reasons why sanitation access will not meet the MDG: national and international policy, socio-cultural beliefs, cost of intervention, and lack of education. Both nationally and internationally, sanitation is not seen as a pretty topic. It doesnt garner much attention, a grievous mistake. Some believe that at least

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part of the problem is with the MDG itself [1]. The MDG benchmarks only account for latrine numbers; that is, one private latrine per house. Latrines are often expensive and often households cant afford their own. Many times multiple households will share a hygienic latrine and therefore, technically, have access to basic sanitation; these homes are not included in the benchmarks. Individual household latrines can be costly without a subsidy and lead many to continue to practice open defecation [8]. While this is not the only contributing factor, it is an important one when considering the extreme poverty of many regions. Lastly, lack of education and socio-cultural beliefs play a role in a communitys willingness to convert to latrine use. WaterAid, an organization working to promote sanitation, reports that local beliefs can inhibit the desire to switch to latrines [9]. These beliefs include: shame at being seen entering a toilet, believing that demons will possess a person who uses a latrine, or that they will lose magical powers, believing that it is good manners to defecate in the field of someone who feeds you, and defecating in a latrine will decrease a persons life span. In addition to these cultural beliefs, some simply dont know about the fecal-oral route of disease transmission. Even

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when 90% of an Indian community indicated awareness of the fecesdisease link, it was not enough to stop open defecation [8]. 3.2. Interventions Several interventions have been attempted in regards to sanitation access. These most significantly include education and subsidy. Within education, one of the best practices to date has been the development of Community Led Total Sanitation (CLTS). This program builds rapport with a local community and then works with them to increase their awareness of the feces-disease route [9]. Facilitators use group discussion and community walkabouts to make them realize the disease pathways that are present because of the poor sanitation. By working with the community, rather than lecturing at them, communities are able to own the process and feel a deep sense of achievement when they can declare themselves ODF or open defecation free [4]. Programs are maintained by local leaders in the community. Some communities report using shaming, punishment, and fining to enforce compliance. The CLTS programs work so well because they allow the community to make its own decisions. Surprisingly, some of the reasons for choosing sanitation are not health related. Some of the reasons stated include: wanting to be modern,

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desiring privacy, avoiding dangerous bush areas (rape, pests, snakes), convenience, and avoiding embarrassment [7]. Subsidy is another approach towards reaching the MDG by 2015. Building a latrine can be costly, as much as 85% of a

households monthly salary in India [8]. Without a subsidy, no amount of education could likely change the habits of the most poverty stricken. The CLTS program disagrees with subsidy, reporting that subsidizing latrines has adversely affected their programs. When the subsidies run out, there is little intrinsic motivation to continue the new cleaner sanitation practices. They report that given the right triggers and education, most communities will make due and find a way to build latrines with materials on hand [4]. While subsidy is helpful, even necessary for the poorest population, it is not required for all [8]. 4. Good Hygiene 4.1 Defining the Problem The last tool of the triad is hygiene. Hygiene gets little attention but without proper hygiene, the effectiveness of clean water and sanitation declines [10]. No matter the how much clean water they are

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using or how strict their adherence to sanitation rules, without attention to basic hygiene, the fecal-oral disease pathway can still be present. The two most common hygiene concerns are food preparation and hand washing. Many practices in developing nations do not address the need to properly prepare and handle food to stop this disease pathway. Frequent practices include using human excrement as fertilizer, washing fresh produce in contaminated water, using unclean preparatory utensils and leaving food at an ambient temperature [11]. Food left uncovered at an ambient temperature is a ripe environment for bacterial growth. While the even the dirtiest water can be avoided on appearances alone, this is not the case with food. One cant see the bacteria on food that is still considered fresh. Furthermore, lack of hand and utensil washing, or washing in contaminated water is one more route for the diseases. 4.2 Interventions The World Health Organization lists the following guidelines for food safety and hygiene: hand washing in clean water, protecting fields from fecal contamination (animal or human), using treated fecal waste as fertilizer, managing irrigation water for fecal risks and keeping the household harvest and storage containers clean and dry.

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Studies have shown that if untreated waste is the only fertilizer option, to wait at least 15 days between application and harvest to ensure the soil has sufficiently dried and is pathogen free [11]. Also, containers and utensils should not only be washed regularly in clean water and left to dry in the sun where they can be exposed to UV radiation, they should be boiled whenever possible. Food preparation and storage are the last line of defense. Food should be washed in clean water and cooked to a high internal temperature. If not to be eaten immediately, food can be wrapped in foil and a placed in an airtight, insulated container in the sun to maintain a sufficiently high temperature until eaten [11]. It is unclear whether these methods are in widespread use. 5. Barriers to Effective Intervention Despite many innovative interventions to reach the MDGs, there are still many barriers to implementing these strategies to their full potential. These barriers are present on the individual level, community level, and the national/international level. Individually, the biggest barriers are cost, education, and cultural mores. Human excrement is seen as a cheap fertilizer and latrines are expensive to build. There is very little cost incentive to change their habits. Many

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programs take the time to tell the household heads about the effects that open defecation may have on their family but when they are supremely poor, that is often not enough. On the community level, the CLTS programs have been a tremendous boon for the sanitation problem. The facilitators, however, still report problems with implementation. The program commonly uses shaming to trigger the community into change, but some countries, like Tanzania, dislike this approach and find it offensive [4]. If the CLTS program facilitators wish to continue their programs, they will need to learn to be more socially polite while still making their point. Additionally, it can be difficult to change the behavior of a community that is not very homogenous. Some communities report that they dislike the heat and smell coming from the latrines and therefore will not use them. Even as these programs make the rounds, there has been an increase in population and a change in how many live. The average household size is actually getting smaller but the number of households is increasing [12]. This means it is harder to implement sanitation and much harder to meet the specific criteria in the MDGs, outlined earlier. To qualify, improved sanitation is only counted per household and shared or public facilities do not count.

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Effective intervention needs the biggest change at the national and international levels. Many policy makers view the lack of sanitation access as an effect of being poor rather than as a direct cause of poverty [13]. More policy is needed to direct media and money towards this cause. Without exposure, most of the world doesnt even realize that 15% of the population still practice open defecation [2]. How the money is spent is another large barrier to effective interventions. While there are many subsidy programs available, most dont include money for latrine maintenance after installation and households cant afford to build a new latrine after the old one is full [14]. Money is also needed for wastewater treatment and this is often not included in cost estimates when discussing the MDG [3]. The World Health Organization is considering adding a mandate to MDGs that allow shared facilities to be included as 60% of shared and public facility users are urban and are not currently counted in the sanitation data [2]. 6. Conclusion Water, from the viewpoint of the rest of the world, is a clean subject to discuss. People envision crystal clear, flowing water and are more than happy to support policies and money division so that others

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may too enjoy this most precious commodity. Excrement, on the other hand, is not pretty. Its dirty, smelly, and full of disease and this is precisely why we need to focus on it. If the policy makers dont shift their focus and their budgets to sanitation access, the MDGs will be impossible to meet. Already, it is estimated that over $30 billion US per year will need to be invested to get the goal on track [4]. Again, this number is likely only reflective of initial efforts to provide latrine subsidy and education and does not include funds for maintenance and treatment, which could be as high as another $15-20 billion US per year [3]. Education needs to be focused on the heads of household, namely women, for they are the ones who are often the water fetchers and sanitation and hygiene enforcers within a family unit. Just washing hands with soap before food preparation and after defecation would reduce diarrheal morbidity by 30-35% [15]. It is also important to note that education needs to focus on all three sides of the triad: clean water, hygiene, and sanitation. While sometimes any one of these alone is enough to make a difference, it is obvious that they can be useless if the other two arent monitored at the same time [10].

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There is huge opportunity here for economic incentive and cost recovery. Not only does a $1 US investment result in $8-$12 US in economic return (in the form of reduced spending on health care and lost work hours), there is an incredible opportunity for job creation [6]. Many householders report that they are unwilling or unable to do their latrine maintenance and building and have or would consider hiring someone else to do it [14]. There could also be job creation in the sale of safe, treated human excrement as fertilizer or the operation of public toilets [7]. Lastly, it should be mentioned that the MDGs and the majority of the interventions focus on the level of the household. There should be a push to implement these interventions on a wider scale, namely school hygiene facilities, government building and public facilities. With sanitation and water access in these types of settings, the average householder can be exposed to these ideas and bring them home to their communities.

Conflict of Interest The authors declare no conflict of interest. References and Notes 1. Bartram, J., Improving on haves and have-nots. Nature 2008, 452, 283-284.

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Progress on Drinking Water and Sanitation: Update 2012. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation 2012 Hutton, G.; Bartram, J., Global costs of attaining the millennium development goal for water supply and sanitation. Costos mundiales del logro del Objetivo de Desarrollo del Milenio sobre el abastecimiento de agua y el saneamiento. 2008, 86, 13-19. Sah, S.; Negussie, A., Community led total sanitation (clts): Addressing the challenges of scale and sustainability in rural africa. Desalination 2009, 248, 666-672. Thompson, T.; Sobsey, M.; Bartram, J., Providing clean water, keeping water clean: An integrated approach. International Journal of Environmental Health Research 2003, 13, S89-S94. Chaney, K.A., Water for everyone -- the time has come. Phi Kappa Phi Forum 2007, 87, 14-19. Mara, D.; Lane, J.; Scott, B.; Trouba, D., Sanitation and health. PLoS Medicine 2010, 7, 1-7. Pattanayak, S.K.; Yang, J.-C.; Dickinson, K.L.; Poulos, C.; Patil, S.R.; Mallick, R.K.; Blitstein, J.L.; Praharaj, P., Shame or subsidy revisited: Social mobilization for sanitation in orissa, india. Bulletin of the World Health Organization 2009, 87, 580-587. Dittmer, Alison, Towards total sanitation: Socio-cultural barriers and triggers to total sanitation in West Africa . WaterAid 2009, http://www.wateraid.org/documents/plugin_documents/soci al_transformation_study.pdf

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Eisenberg, J.N.S.; Scott, J.C.; Porco, T., Integrating disease control strategies: Balancing water sanitation and hygiene interventions to reduce diarrheal disease burden. American Journal of Public Health 2007, 97, 846-852. Lanata, C.F., Studies of food hygiene and diarrhoeal disease. International Journal of Environmental Health Research 2003, 13, S175-S183. Bartram, J.; Elliott, M.; Chuang, P., Getting wet, clean, and healthy: Why households matter. Lancet 2012, 380, 85-86. Watts, G., Is the food crisis eclipsing the importance of clean water? BMJ: British Medical Journal (International Edition) 2008, 337, 15-15. Carolini, G.Y., Framing water, sanitation, and hygiene needs among female-headed households in periurban maputo, mozambique. American Journal of Public Health 2012, 102, 256-261. Metwally, A.M.; Saad, A.; Ibrahim, N.A.; Emam, H.M.; ElEtreby, L.A., Monitoring progress of the role of integration of environmental health education with water and sanitation services in changing community behaviours. International Journal of Environmental Health Research 2007, 17, 61-74.

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