Making More Than Mention of an unmentionable crisis

May 1, 2009
With the International Year of Sanitation just past, champions are needed for new ‘Great Stink’ to address the global sanitation crisis, says co–author of The Last Taboo.

By Ben Fawcett

With the International Year of Sanitation just past, champions are needed for new ‘Great Stink’ to address the global sanitation crisis, says co–author of The Last Taboo.

The simple VIP toilet, like this one in Zambia, provides an effective and affordable sanitation solution for some villagers. [Credit: Jon Spaull/WaterAid]
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Exactly 150 years ago, an exceptionally hot summer reduced England’s river Thames to a scandalous condition known as the “Great Stink”. Water closets had multiplied in London and huge amounts of human waste found their way into the river. The smell was so excruciating Parliament could barely sit, and sessions in the adjoining Courts of Law were frequently curtailed. Disastrous cholera epidemics broke out every few years and it was believed such diseases were carried on the miasma, the smelly air, coming from the drains and river. The Stink powerfully concentrated MPs’ minds and they rushed through legislation to fund massive intercepting sewers to collect waste and deliver it further downriver. Sewers, one on either side of the river, were designed and built by Joseph Bazalgette, in a remarkably short time. Only seven years later, in 1865, the Prince of Wales, Archbishops of Canterbury and York, and 500 other distinguished guests dined on salmon at the Crossness pumping station, as the new sewers were inaugurated and the city’s excreta flowed beneath them. A huge public health revolution had begun, one that would eventually transform the lives of millions living in towns and cities in the industrialising world — and from which many valuable lessons can be drawn for the 21st century.

Today, another revolution is urgently needed. Two of every five people in the world – men, women and children — don’t have a safe, hygienic and private place to “go”. Only 30% of people globally use flushing toilets connected to sewers. A further 30% use on–site facilities, including septic tanks, composting toilets or simple pits. But the remaining 2.6 billion people, most in Africa and South Asia, have to relieve themselves every day in filthy holes in the ground, in the fields or behind bushes, in alleyways, on river banks and railway–lines, or in buckets or plastic bags to be thrown away wherever they can — the so–called “wrap–and–throw” approach, or “flying toilet”. As illustrated in the recent Oscar–winning movie of the year, “Slumdog Millionaire,” the results of all this, on health and other aspects of people’s lives, are appalling — as is summarised in Figure 1.

In a recent survey by the British Medical Journal, its readers voted the sanitary revolution as the most important medical milestone of the last 170 years, ahead of antibiotics, anaesthesia, vaccines and the structure of DNA. This underscores the importance of the toilet for all. The World Health Organization has calculated that economic benefits of improved health, productivity and environmental impact far outweigh costs of providing sanitation by a staggering factor of 9 to 1. This makes provision of the toilet one of the most cost–effective improvements that can be made in people’s lives. So why are developing countries still afflicted by this crisis, in which so many people suffer huge indignity and terrible ill–health, in this new millennium?

Principally, this is because we don’t discuss excreta. The subject is taboo — one of the last about which people don’t talk freely in any society. Engineers talk about water and sanitation but do much more to improve water supplies than to build toilets, feeling much more comfortable with water than with defecation and resulting faeces. Those of us with easy access to water closets can flush and forget our waste, not thinking about what happens to it next. The result of this taboo is that far fewer people are without a reasonable water supply than lack a basic toilet. But most disease commonly termed water–related would be actually more usefully termed “excreta–related”.

The 19th century provides a valuable lesson about this in Dr. John Snow, who in possibly the best known incident of public health history, studied cholera transmission during the 1854 epidemic in London’s Soho area. He showed that the disease, in contrast to the airborne theory, was actually transmitted by water from one well in Broad Street. Rev. Henry Whitehead, a local curate, is a less celebrated hero of this incident. He, by equally careful study, showed it was a nearby latrine used by a cholera–sufferer that infected the well. To stop cholera’s spread, it wasn’t only necessary to close the pump, from which local people were taking water, but also to isolate the latrine from the well. Those working in environmental health know very well that excreta from infected children and adults are potentially dangerous, and effective measures are needed to isolate them from other people — in other words, faeces need to be disposed of safely. Those of us who live with flushing toilets take this for granted, but elsewhere improved sanitation is essential.

Technologies needed to provide appropriate, affordable, hygienic toilets are well known, as they’re based on simple principles known in the 19th century. Although there was little talk about the need for waterborne sewerage in London then, there was much debate in other places about conflicting attributes of sewers and “dry conservancy”. Pollution of waterways with untreated sewage, wastage of water in its transport and squandering of nutrients valuable to farming were all argued in favour of dry toilets, as much as they are today in praise of “ecological sanitation”. But there were many problems with recycling of urban excrement as manure; and, eventually, use of water for sanitary disposal — however illogical and extravagant it may seem to some now — won the day throughout the industrialised world.

Still, an effective, conventional sewerage system is very expensive to build and maintain — and also requires a reliable supply of water to every toilet and good management. This rules it out for most of the growing numbers of poor people flocking to water–short towns and cities in the developing world, to live in ever–expanding slums. Sewers provide an even less feasible solution for rural areas, where most of those without toilets still live in dispersed villages. Nevertheless, municipal authorities, engineers and the public too often feel water–flush toilets and sewers provide the only, acceptable sanitation solution. As resources are lacking for both construction and operation of sewers, little is done. A range of on–site solutions exists, including composting toilets, improved pit toilets such as the VIP (ventilated, improved pit), and pour–flush toilets. These are well proven, for both rural and urban areas, and are affordable, effective in protecting the human environment, acceptable and culturally appropriate. Simplified, cheaper sewers also are being installed in towns and cities from Brazil to Pakistan as an alternative to conventional sewers that need so much water. Local engineers and environmental health promoters must be encouraged to understand, accept and promote these technologies, and users need to be helped to make appropriate choices.

Another important lesson from the 19th century is that sanitation is about public health and, therefore, requires public support as well as private initiative. Although the household flushing toilet is a family device, to be kept clean by family–members, it’s connected to a public sewer. These sewers are built and maintained by municipal authorities or by private companies overseen by public bodies. Edwin Chadwick was the far–sighted and imaginative public servant who led the campaign for public health improvements in Victorian Britain. Support of national and local politicians was an essential component of the first sanitary revolution, enabling the necessary reforms to be pushed through. Massive funding also was required, as well as development of a complex administrative system. Chadwick and his followers, through years of lobbying and argument, eventually managed to persuade taxpayers they should finance sewerage systems in their neighbourhoods. They were helped with generous government loans to both construct and maintain sewers, for both rich and poor households. In this way everybody’s health was protected and, after several decades, life expectancy began to rise.

The same philosophy should apply in developing nations now: Every household needs an operating toilet, everyone must use it and it must be useable in the long–term, otherwise collective health is at risk from germs spread by indiscriminate defecation. To achieve this, a collaborative effort is needed between a range of partners, including private householders, community leaders, entrepreneurs, taxpayers, municipal and local authorities, national governments and international donors. Good financial and administrative systems, including subsidies for the poor, are needed for a working sanitation system. The same commitment, skill and enterprise as was required in Britain 150 years ago, is needed now in the developing world, with support from the wealthy world. The process is complex and time–consuming but ican be done, as has been shown in many examples. Otherwise, a credible estimate suggests — with population growth and without a massive acceleration from present efforts — it may be 2076 before the Millennium Development Goal to halve the proportion of people without a toilet, is achieved in Africa. Even then hundreds of millions will still live in unhygienic squalor, without acceptable sanitation.

Last year, 2008 was the UN International Year of Sanitation, declared to achieve more publicity for this scandalous situation and to give impetus to efforts to build more toilets. But few heard about it, which makes one question whether it has done its job. There were a number of international meetings and a lot of discussion about the problem amongst those already “in the know”, but a further big push is needed. Most importantly, a major campaign is required by local people in developing nations where the crisis is most severe to lobby their governments and representatives, both national and local, to take the issue more seriously. Sanitation must be included, explicitly, in development planning. It needs a well–publicised, governmental home, with inspired leadership, a strong mandate, adequate resources and a network of skilled staff.

Champions are needed for sanitation worldwide, modern–day Chadwicks, Bazalgettes and Snows, both in the richer world and in Africa, Asia and Latin America. International celebrities are content to campaign to improve water supplies and be photographed alongside happy children beside a new well. None are yet prepared to stand up on behalf of the toilet, even during the International Year of Sanitation. After the year ended, much work was being done, but a lot more is needed. A massive effort is needed to bring about the revolution that will provide adequate toilets to those currently suffering poor health and terrible indignity. This subject must be taken out of the closet and our taboo must be overcome.

Author’s Note: Ben Fawcett , of Mullumbimby, Australia, has over 25 years’ experience in environmental health engineering in Africa and Asia. He is co–author, with the UK’s Maggie Black, of “The Last Taboo: Opening the Door on the Global Sanitation Crisis”, published by Earthscan in 2008. Contact: [email protected]

Health and social impacts of poor or no sanitation

A slum in Kolkata, India, illustrates the appalling public health conditions in which some 900 million people live in cities of the developing world. [Tim Marshall/University of Southampton]
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  • 1.5 million children die of diarrhoeal disease each year;
  • 133 million cases of roundworm, hookworm and whipworm,cause malnutrition, anaemia, asthma and poor physical and intellectual development;
  • Transmission of both bilharzia, of which there are 200 million cases worldwide, mostly among children, and trachoma, the most common cause of infectious blindness, is greatly reduced by better sanitation;
  • Most children in villages in Africa and Asia still go to schools without toilets; girls, on reaching puberty, then drop out of education;
  • About 200 million women in India, and more elsewhere, are forced, by the socially conditioned issue to not be seen going to relieve themselves, to wait until nightfall, when they risk abuse and attack in seeking a secluded place to squat;
  • Young girls and women have no place private to manage menstrual hygiene;
  • At least 800,000 low–caste dalits in India are still employed in the grossly demeaning task of handling other people’s fresh faeces, and numerous others around the world, from the ‘frogmen’ of Dar–es–Salaam to the baye pelle of Senegal, are required to empty pit latrines by hand.