Student Asks. SHARE Responds

Earlier this month a high-school student from Ontario, Canada, got in touch with SHARE Research Fellow and Monitoring & Evaluation Officer, Dr Elisa Roma, to pick her brains on all things sanitation-related. The student was completing a project on a social issue she would like to change, in this instance, the lack of sanitation facilities in developing countries, and whilst researching the issue had read the Toilets for Health report Elisa co-authored back in 2012, so reached out to Elisa with the following questions:

1. What are the biggest obstacles to improving the quality of sanitation in developing countries?

Improving sanitation has been one of the most important public health interventions in history. Before governments built modern sewerage systems in European cities in the 19th century, cities like London had similar conditions to slums in Low and Middle Income Countries (LMICs). The River Thames, for example, was known to be an open sewer producing bad smells and causing horrendous epidemics such as cholera.

Whilst the problems experienced in the past by cities like London is not dissimilar to those encountered in LMICs today, the solutions employed must be different because LMICs face many different and unique challenges. For example, the toilets and conventional sewerage systems used in High Income Countries (HICs) require space, energy and water, things that often are missing in LMICs. Similarly, LMICs’ governments typically cannot afford to build, maintain and operate conventional sewerage systems.

It is clear then that creating sanitation solutions that work for everyone means taking into consideration a host of cultural, socio-economic and environmental factors. Existing sanitation options such as pit latrines (a hole in the ground where people defecate) or open defecation are inexpensive, but are not effective at killing pathogens that cause diseases. They also produce odours and attract insects. LMICs must, therefore, prioritise other on-site, innovative sanitation solutions.

This in itself is a difficult task to accomplish in vast rural areas where road systems are poor and transportation options for moving the materials required for constructing latrines are lacking. LMICs’ governments frequently do not have the resources or capacities to serve every individual household in rural or urban areas.

In urban areas, additional obstacles to universal sanitation are present. By their very nature, densely populated settlements – slums – lack the space required for building toilets. Furthermore, often people live in informal houses and do not own the land on which they live and are therefore less keen on investing in constructing a toilet.

2. What are the best ways to help improve the situation?

Improving sanitation conditions in LMICs requires governments, international organisations, donors, researchers and the private sector to think about the challenge differently. We need new, innovative toilet designs that are appealing to the people who will use them, are affordable, and can be built with local resources on a large scale. Innovation is especially needed in densely populated areas, where billions of people will be migrating in the next decades. One way to improve services is to involve the private sector. It can provide affordable sanitation options that users pay for either monthly or per usage.

However, we must remember that building a toilet and treating human waste is not enough. If people do not have the means (water or soap) to wash their hands after defecation, the health benefits of latrines are almost entirely negligible.

Imagine a scenario in which a mother uses a latrine and then moves to the kitchen to prepare food for their child without washing her hands with soap. The risk of contaminating the child’s food with faecal pathogens is extremely high. This can cause diarrhoea, which is one of the major causes of mortality in children under the age of 5.

Therefore, to stop contamination and the transmission of diseases, we need to consider the entire household setting. To do so, behaviour change campaigns (like those taking place in our countries against smoking for instance) which alter the way people think of toilets and hand washing are required. We also need the governments in LMICs to be involved in delivering and supporting these type of campaigns.

3. Why is this issue overlooked so often?

I am not sure this is the case any longer. I think sanitation is now on the agendas of many international funders and governments in developed and developing countries.

Since the International Drinking Water Supply and Sanitation Decade (1981-1990), which highlighted the importance of sanitation as a development and health issue, the international community has begun to pay more attention to and invest more in improving sanitation. Experts in developed countries first sought to solve the sanitation crisis through large engineering projects, which often used materials which were not locally available. More recently, there has been a shift towards solving the crisis through behaviour change.

Promisingly, there are currently several prominent studies looking at the links between diarrhoea in children and undernutrition. The more we shed light on the negative impacts of poor sanitation, the easier it is becoming to convince governments and donors to invest in improving sanitation. Indeed, there is strong global momentum for greater integration of sanitation (and water and hygiene) interventions with the interventions of other sectors such as nutrition and maternal health.

4. In your opinion, will the Millennium Development Goal (MDG) 7 target be reached by 2016, or will it take more or less time than that? Why do you believe that?

The MDGs ended in October 2015, with the conclusion that although progress was made, much still needs to be done to improve conditions.

Importantly, the MDG taught us that coverage alone is not enough. We need to consider sustainability, i.e. solutions that last, as well as other challenges such as gender, access for those with disabilities, and the effect of climate change on water availability.

As such, the international community has developed new goals called Sustainable Development Goals which aim to tackle these challenges. Building on lessons learned from the MDGs, they seek to address human rights and achieve gender equality and the empowerment of all women and girls in having appropriate sanitation and hygiene facilities. This is a very exciting time to be working in sanitation.