Sanitation, Water and Waste

Malin Udén - Master in Public Health

Presentation for Disaster Medicine, MDH - 17 September 2009
Today
9:15 – 10:15 Overview of sanitation, water and waste
What do we mean?
Why is it important?
Where are the connections?
Discussion of the ways of spreading
pathogens
10:15 – 10:45 Coffee

10:45 – 12:00 Continued overview

Factors for improvement
Examples of disasters – Cholera in Zimbabwe
Premises for today’s presentation
! Master thesis in public health about sanitation in rural
Mozambique – a low income country in southeast Africa

! Personal interest: equity and the fact that sanitation is

often cast in the shadow of more ‘glamorous’ potable
water

! Today’s main focus

" The link between water and sanitation
" An overview of societies’, individuals’ and natures’
connection to sanitation and water
Sanitation, water and waste – An overview
! Strictly sanitation means that, to stay healthy people need to
be… separated from human and animal feces (while urine is
practically sterile)

! Water is simply H2O. Today we will touch upon

" Black and grey water – feces, urine, cleaning, washing

" Usable water – for cleaning, washing

" Potable water, drinking water, high quality water

! low salt
! free of disease pathogens
! low levels of harmful chemicals and other compounds

! But to us everyday people water and sanitation is actually

more then that!
Sanitation, water and waste – an overview
! Waste, sanitation and water management are all inextricably linked.
" Waste – from homes, nature, factories, community services and farming
" Sanitation – mainly human, also from animals.
" (Potable) Water – comes from nature

! Part of the same system, but must be kept separate. Links are
" Water can become contaminated by both waste and lack of sanitation
" Sanitation cannot be achieved without water

! Managed differently over the world, from sewage systems, water piping
and recycling to open defecation, groundwater wells and burying and
burning waste.

! In richer countries an elaborate system managed so that users can

forget about it on an everyday basis. Meaning we do not have to worry
about cholera and malaria – but use large amounts of energy

! In low income countries simple systems, less demanding on nature but

more diseases and more fragile
MDG’s – Where are we at?
! Target 7: Ensure Environmental Sustainability
" Target 7.C: Halve, by 2015, the proportion of
people without sustainable access to safe
drinking water and basic sanitation

Measures
" 7.8 Proportion of population using an improved
drinking water source
" 7.9 Proportion of population using an improved
sanitation facility
MDG’s – Where are we at?
About water
Half the world’s population face a
scarcity of water – but the target will be met!
" Not in sub-Saharan Africa
" Not in rural areas. In 2006 96 % of the
urban population had improved drinking
sources, but only 78 % of the rural populations.

! 40 % live near insecure fresh-water sources (Africa, Western Asia,

India, China)
# environmental degradation, sporadic droughts and
competition for water.

! 10 % has economic water scarcity: enough fresh water, but

inaccessible due to political/financial reasons (sub-Saharan Africa).
MDG’s – Where are we at?
About sanitation

! 1.1 billion more people use improved facilities today then

1990. But target will not (?) be met.
! If so, we in the next 7 years we must increase the number
with 1.6 billion

! 2.5 billion people live without improved sanitation.

" Proportionally largest in sub-Saharan Africa
" Largest numbers in Asia.
" Most problems in rural areas. 50 % live in there, but they represent 70 %
of those lacking sanitation
" Massive economic differences: In 21 countries in sub-Saharan Africa,
only 16 % of the poorest quintile of the population have access to
improved sanitation, 79 % of the population in the richest quintile.
Overview of sanitation and water issues
! Why should we care about it?
" Infections/ Physical well being
" Mental well being
" Effects on opportunities
" Our environment

! What else decides the circumstances?

" Technical factors
" Economics
" Social perceptions
" Politics
" Religion
Water – some checkpoints
! Covers 71 % of the worlds’ surface! So what’s the issue?
" 1,6 % is groundwater

" 0,6 % in rivers, ponds and lakes (Great Lakes in US

and Lake Baikal swallows most…)
" And: agriculture uses 70 % of our fresh water

! Can additionally become polluted by

" Nature (Bangladesh)

" Pollution (70 % of Chinese rivers from factories, 3 %

of Swedish lakes acid)
" Salt (Sea water)

" Lack of sanitation (John Snow)

Why do we need water and
sanitation?

Infections and physical well being

 INFECTION
! The importance of sanitation
was discovered in 19th century
London.
#The birth of modern
epidemiology
! People thought that diseases
spread by air – hygiene was
terrible
! John Snow mapped cholera
cases and found them all close
to a well.
! Removed the handle and the
epidemic stopped!
! Probably a pit latrine in the
proximity of the well.
 INFECTION

Ground rule: we all need to defecate

and urinate several times a day

! Feces may hold bacteria, virus and parasites

! Diseases like typhoid fever, cholera, trachoma and
intestinal worms all cause: diarrhea
! … might be followed by anemia, dehydration and
malnourishment
! Especially risky for pregnant women, ill adults and
children
! May cause physical and mental disabilities if not
treated or often repeated
INFECTIONS (We need to stay clear of our own feces)
 Physical well being
! We should be able to perform our needs at all times, otherwise
we risk
" Urinary tract infections
" Dehydration
" Constipation

! Important adjustments for individuals

" Disability adjusted

" Sit- or squat?

" Different views on what is most important: shelter, lack of smell,

comfortable and so on (not the same as health professionals
views!)
" Carrying water hard on small (and large) bodies. Can cause
! Chronic back pain
! Misscariges
! Uterine prolapse – worsened by constipation
Physical well beeing
! Safe constructions
" Accidents in the dark
" Accidents by deteriorated buildings
" Snakes and insects
" Assaults

! Women’s needs
" Possibilities to wash oneself and cloths during sanitation
! For own peace of mind

! To avoid infections

" Pre- and post natal periods

Why do we need improved
water and sanitation?

Mental well being

Mental well being

! Pride
! Relaxed moment of privacy
! Feeling of cleanliness
! Stress reduction
Discussion on water and
sanitation at household level
A simple and pedagogic picture of the
ways of spreading pathogens
HOUSEHOLD DISCUSSION

! Identifying risks
" Where might these ways of spreading pathogens
become important in your work?
" Is there any arrow that does is not important?
" Should we ad other ways?
" How (why) do they appear? Think of both
practical, economic and social reasons!
Why do we need improved
water and sanitation?

Effects on women’s opportunities

Effects on women’s opportunities
! African women’s empowerment is closely
linked to sanitation

! Views on women’s bodies and their products is

a loaded factor
" We are expected to be more private. Which in
parts of the world leads to effects such as:
! Forced to wait to eat and drink
! Leave school (The same for fetching water!)
# May cause dehydration, constipation and
urinary tract infects
Effects on women’s opportunities
! Responsibilities for health, sanitation and water are often, but not
always, women's
" Work division means women inside, cleaning toilet, cooking,
washing clothes (babies nappies) and gathering water
#Women more exposed to bacteria when caring for the household
" Are also exposed in the work situation at the field if open defecation
is used

! Thus security, dignity, comfort and privacy are often especially

important for woman

! But… Views the view on women’s capabilities for technical solutions

is often poor. Men construct, control the budget and the main
decision-making (at home, at work and at governmental offices)
Effects on women’s opportunities
! Why do we have these differences, for example in construction?
" Are men stronger? (But make a comparison with Sweden!)

" Is it cultural values?

! On the other hand women's responsibilities of the household

means
" That they have more vested interest

" That they know a lot about what works, what does not work and
how it can be improved
" Several studies show that women’s involvement makes for more
sustainable solutions on water and sanitation
Why do we need improved
water and sanitation?

Environmental factors
Ecosan?
Ecosan – Ecological sanitaiton
What else decides the
circumstances?

Technical factors
Techincal
We cannot expect everything to go as planned. People cannot
uphold perfect hygiene with their sanitaiton and water at all
times. Therefore people need to prepare homes and cities for…
" Animals

! Runs in the food, dishes

! Spreads their feces with their feet

" Children, should ideally not be able to get to water, waste and
food
Techincal factors
In structural terms
" Living rural
! Most difficult thus most expensive to construct piped
water and sewage. Percs:
! A lot of space for burrying waste
! Possibility to have one latrine per family
" In the (poor) city
! More sanitation and water covarege
! Crowding makes it easier to spread diseases

" It is more difficult for you to stay clear of diharroeal

diseases as for example a caring Mozambiquan, then a
sloppy Swede
Technical factors
About defecation options
" The simple latrine
" Deteriorating walls
" Smell
" Risk of snakes, insects and rats
" Difficult to clean
" Hard and unhygienic work to
move them
" Lacks running water for hygiene
" Collapses during rain season
" May risk infecting water –
should be kept far from wells
Technical
" The simple latrine
! Offers relative privacy and can be visited when needed
! Can separate people from faeces if lid is used
! Much more hygienic then open defecation in the field – very high
risk of infection
" Can be transformed into an entirely hygienic option!
Technical

! Water handling
" Gathered from wells and
high ground water
" Often not covered airtight
" Should be boiled
" … but boiling requires wood

! Food
" Food can become exposed by animals and insects
" Must be cleaned in water and then heated above 72oC

! But women caring for their families health are

exposed high levels of air pollution from combustion
Techincal
! Intimate hygiene
" Most wish for improved

showers (bathtubs and running water)

" Walls keeps eyes, snakes and
eyes away
" Canalization needed to keep
mosquitoes away

! Waste water from keeping hygiene

" Washing nappies (ideas!)

" Intimate hygiene

" Washing the latrine
What else decides the
circumstances?

Economics
Sanitation and drinking water can be created almost
anywhere as long as someone can pay
Economics
" Poverty may be the single most important factor keeping
sanitation and water coverage low.
Economics
! Equity in health is not upheld: disproportional burdens unemployed
(women and children)
! Women represent 70 % of the worlds poor

! A family with a pit latrine has to care more about their water safety
because
" They always have to remember the lid

" They lack running water to clean their hands

" With a septic tank other families do not have to remember

covering water or washing hands as good

! But a family with a pit latrine are more likely to be

" A single mother (instead of many adults)

" Not have the opportunity to employ maids

" Those who have to pay for a new latrine (since it is not women’s
work)
What else decides the
circumstances?

Social circumstances
Social circumstances
! We view feces differently
" Some are too afraid, causing avoidance of cleaning
! It is much less glamorous and prestigious then providing
fresh water
! Lack of sanitation is more deadly then lack of fresh water
! Governments often fail to acknowledge this problem
! On the other hand embarrassment can be positive: it forces
us to clean. But we do not want to care more about how
things looks then if they are clean

" Some embrace it and uses feces as fertilizer

" Most of us end up in between those options
Social circumstances
Keeping a clean house, a toilet and fresh water is serious
business
" It shows that the household is a good family
" Religion can be important. For example the bible
references feces together with sexual morality and
personal hygiene
" It is in accordance with Christian believes: ‘God does not
want us to live in an unclean household, because it brings
diseases’
" It shows of success

! No believers are troubling – critical for

understanding why clean water is necessary
Factors for improvement

(Other then economic improvement)

! The conditions
" Sanitation and water is a system, it does not know human
perceptions of boundaries
" Water and sanitation are mostly a
household issue in practical terms
in low income countries…
" But… it is a community issue
when it comes to knowledge,
practical help and when it
comes to spreading diseases!

! When traditional sewage systems are too

expensive to be realistic options in rural
areas, the best and only solution is the
locally adjusted alternative.
Important factors for change
! Talk openly!
! Walk around – face the facts, inspect unsanitary
places
! More construction knowledge
! Release women’s ideas and interest
! Things that can come in the way of spreading
knowledge are:
" Embarrassment
" Misunderstandings between generations
" Jealousy
" Denial of own risk in ones household
" Gender disparities
Important factors for change
Improved cooperation
! There is often cooperation between people on common grounds

! Who realizes that lack of water and sanitation is everyone's

business?
! Make common agreements

" Abandon field defecation

" Keep areas close to water sources free of feces.

SOCIAL AND CULTURAL ISSUES

! Where can fear of speaking/acknowledging

problems with personal hygiene become an
obstacle in your line of work?

! Do have examples of national differences?

Examples of disaster – Cholera in
Zimbabwe
Cholera in Zimbabwe
Background

! In 1980 Robert Mugabwe took controll of the then

Rhodesia, forcing the white Europeans out of the
country.
! The state was on the uprise in early independence but
has since then sunk deeper in to poverty.
! Life expecancy from 60 years for men to 37 for men and
34 for women. (Extrely low, right at the bottom compared
to other nations).
! More or less constant food shortage
! Hyperinflation
Cholera in Zimbabwe
! HIV
" Prevalence 15 % - mid 90’s it was as high as 30 %
" Hits mainly hits young people and women
" Is eastimated to have lowered the population with about 4
million people
" Main reason for Zimbabwe having the highest proportion of
orphans in the world.

! After the 2008 elections

" New previosly unknown of inflation rates
" Political unstableness
" Mass migration
Cholera in Zimbabwe
The Outbreak
! Started August 2008 – Ongoing
! 100 000 suspected cases. 4 300 confirmed deaths.
! Spread
" 55 of 62 districts
" 8 000 cases reported per week February. Case fatality rate
6%
" 100 cases reported per week May. Case fatality rate 1,5 %

! Numbers propably under estimated to to under

reporting. Even in Sweden it is not unusal for it to be
up to 100 times as many infected as first guessed.
Cholera in Zimbabwe
Collapse of
! Urban water supply
! Sanitation supply
! Garbage collection system
! Plus rain season
#Cholera bacteria washed in to water sources
! Open drains washed feces in to living areas.
Cholera in Zimbabwe
Other helpers
" Shortage of purification chemicals as chlorine
" Christmas hollidays
" Burial of infected corpses in rural areas
" Collapse of public health system.
! Only one of four major hospitals operating.
! No medical education
! No operation theaters
! No staff or medicines (the hyperinflation!)
Cholera in Zimbabwe
! Political consequences
" Europe and the US blames Robert Mugabwe and his
administration.
" … which made American and British leaders call
Zimbabwe a ‘failed state’
" Mugabwe on the other hand meant that it was the
former colonial powers fault.
#Organizations and nations where stopped from
entering with expertise

" Spread in to neighboring countries

" Contributed to South Africa restricting migration
policies for everyone
Cholera in Zimbabwe
! Medical implications
" Cholera cannot be cured
" Vaccine taken twice was impossible to administer,
not recommended by the WHO.
! To costly
! Increase antimicrobial resistance

! WHO recommendations
" Food safety
" Personal hygiene
" Oral rehydration therapy
Thank you!
Questions?