Pathways to universal and equitable access to safe water and sanitation - part 2

For part 1 click here.

One such example of a project which aims to investigate the alternative pathway of low-cost, on site provision of safe water and sanitation is AfriWatSan, which aims to develop the scientific evidence to inform policies and practices sustaining low-cost, on-site water supplies and sanitation systems within Urban Africa. I really hope further research will help in the acceptance, understanding and formalisation of such an approach.

However, what if evidence of urbanisation within Sub-Saharan Africa and other developing regions more widely is not quite what it seems. A paper by Potts, (2012) argues, using evidence from census and satellite imagery, that there is in fact evidence that within Sub-Saharan Africa of a slowing and stagnation of the urbanization process. Furthermore, analysis from Nigeria, which has a significant weighting in overall population trends for the region suggest that levels of urbanization are in fact much lower than  presumed previously.

One interpretation of this trend may be that Sub-Saharan populations may in fact be moving from stage two of Drangert et al., 2002 hypothetical relationship between population increase and infrastructure to stage three. Perhaps the relevant authorities can therefore be expected to take much greater responsibility in the near future. However, from Potts (2012) analysis, these findings may in fact be an even greater reason to investigate and pursue low-cost, on site provision of safe water and sanitation on two counts. First, evidence suggests that much of Africa's population will remain rural for the foreseeable future. This further supports arguments that solutions to urban water and sanitation problems founded in North America and Europe, in highly populated conurbations are not appropriate and are incompatible in less densely populated (both urban and rural) settings, requiring an alternative solution. Second, for rural-urban migration to re-establish itself as a significant demographic trend, African urban economies must strengthen and provide greater economic security. This suggests that the very reason people are not migrating is because urban environments are not delivering great enough security and are unlikely to unless something significant changes. The use of an alternative pathway of low-cost on site provision of safe water may provide this very alternative. However this may trigger increased urbanisation, but if formalised such an approach appears to have the capacity to cope with increased urbanisation.

I hope these last two blogs have demonstrated how the promotion of private sector investment within urban environments following the path set by North America an Europe should not be taken as the only way of achieving universal and equitable access to safe water and sanitation. Instead, urban areas of cities in sub-Saharan Africa with much lower population densities (and rural areas) potentally require an alternative approach which includes an alternative pathway of  low-cost, on-site provision of safe water and sanitation. Much greater research is required in this area such as projects including AfriWatSan to develop scientific evidence and accurately inform policy making.

I personally believe that there is mounting evidence that continued dependence upon low-cost, on site systems is a reality in urban Africa and should be actively supported, formalised and improved.

Coupled with earlier findings on the availability of groundwater aquifers which could support widespread small scale community hand pump, a strong case for the conjunctive (and careful) use of the subsurface is building.

Pathways to universal and equitable access to safe water and sanitation - part 1

Concepts of urbanization within Sub-Saharan Africa have argued that urbanisation is taking place at a rapid rate. Indeed figures from the Joint Monitoring Program have highlighted how within Sub-Saharan Africa in particular, improvements in urban sanitation are struggling to keep apace with population growth.

As a result, one of the papers I read when researching this blog topic suggested that demographic pressures in urban areas can only be controlled in two main ways, both of which involve the curtailing population growth (Fox, 2011). The first (lack of) approach, is to 'permit draconian mobility restrictions or permitting disease and hunger to re-surface in urban areas'. This cannot be allowed to dominate. Instead, Fox argues that the only humane policy option is to focus on family planing and fertility decline thus easing the stresses, such as poor urban sanitation and water supply, associated with rapid urban population.

I'm not sure I really buy into the suggestions above.. Further research led me to a paper which offers a very different approach.

A paper by Dranget et al., (2002) argues that water and sanitation improvements in urban areas are usually are as a result of interrelated factors such as physical, economic and social. Yet, demography also has a large part to play. Instead of rapid population growth just serving as an argument for urgent action,  it is suggested that it is an important factor itself in determining the likelihood and success of water infrastructure improvements. The study uses the example of the town of Kisumu in Kenya to analyse actual phases of urban water  and sanitation developments.

Drangert et al., arguments are founded on the principle that hydrological conditions and demographic characteristics are vitally important in the instillation and maintenance of water management solutions. As an aside, it is interesting to note how these  arguments fit within the broader arguments I made earlier in this blog series about physical and socio/economic factors determining water access. Demographics, and specifically population growth within an urban area directly affects the ability of the urban area to manage access to water management solutions and this can be defined into three broad stages (figure 1).

Drangert et al., hypothetical relationship between population increase and infrastructure.

1.  At stage 1 (A-B, figure 1), when population levels are low and only growing slowly, a large proportion of the population falls within the economically active age group They hypothesize that although the investment capital may be available, central government are often engaged else where and thus the majority of citizens needs for water and sanitation will be met through arrangements made either at local community or household levels.
2. Stage 2 (C-D) marks a period of rapid population growth, not too dissimilar from that experienced within Sub-Saharan Africa at present. In such times, the authors argue that during such times, provision and maintenance of the public infrastructure that is required, is poor and experiences very little (if any) expansion and improvement. This is primarily because tenancy, and tax collection have not been formalized, again requiring residents to make their own water management arrangements and community and household levels. Furthermore, even if infrastructure provision are put in place they often fall into disrepair or are misused.
3. Stage 3 ( E-F): Over time and once population growth slows down and stabilizes, only then will the relevant authorities have the capacity and financial strength to invest in and effectively manage water management solutions.

So Sub-Saharan Africa population growth is increasing rapidly. What should be done about it - wait around until population growth begins to slow and the governments can finally take up the slack?... NO!

The solution: Going small when the city expands rapidly:

Kisumu, Kenya: Source

Drangert et al., call for improvements to focus locally and that can act independently, without reliance on central, and potentially unreliable sources of financial revenue. These arrangements are common place, and are built upon demographic, hydrological and socio-economic circumstances. However, one of the greatest problems is that they are often not viewed as appropriate or acceptable. 

These arguments are well demonstrated through the use of the Kisumu case study with high rates of population growth and increasing strains on the municipal council, which has failed to provide water management solutions with issues compounded by conflicts of interest within the council. Despite the rapid growth in small scale, local and community provision due to a lack of municipal support, the council refused to support or endorse such improvements.

Local solutions in Kisumu, have come to the fore with the majority of residents living in lower density suburbs, with resident installed latrines and wells, with members of the community providing water on a commercial basis in some places. Surely it makes more sense to encourage or at least not actively discourage such schemes when they are providing at the very least, a stop gap in water management solutions. Although reticulated sewerage and piped water were practical and financially viable in the densely populated 19th century Europe North America, they may not provide the long term solution in Sub-Saharan Africa and other developing areas. In Rapidly growing but less densely populated areas, going small when the city grows, providing low-cost, on-site provision of safe water and sanitation may be a more sustainable and appropriate long term solution for developing areas moving forward. Developing areas do not need to follow the trajectories of North America and Europe. Yet, as I hope this blog has argued successfully, one thing that is certain is that demographics are important and should be considered.

For part 2, click here

Faecal-oral paradigm: part 5 - Good summary paper

When researching my mini-series of blogs on the faecal-oral paradigm I found this paper provides a nice context for the arguments outlined in part 3. 

The study by Tumwine et al., (2002)  revisits the work of the original Drawers of Water study, surveying 1015 households in 33 sites across Uganda, Tanzania and Kenya. Results showed that 1/3 of households which relied on an unprotected surface source as the main source of water reported at least one case of diarrhea in the week before the survey with the type of surface source important too. The use of streams and rivers had lower incidence than using springs, reservoirs and ponds. Water vendors also appear to be much safer sources of water than communal piped connections. The type of sanitation facility also appeared important. For instance, out of piped households, 14% with a pit latrine had at least one incidence of diarrhea, where as for piped households with a flush toilet households this was lower at 7.4%. The piped vs unpiped disparity was also apparent with unpiped households without sanitation displaying much higher prevalence at 66%, whereas those with pit latrines reduced prevalence to 20%.

Examples of unsafe vs improved sources of drinking water.
The use of unpiped surface water was found to be significant in increasing
 diarrhoeal prevalence. Source: UCL lectures: Credit: Richard Taylor.

In addition to these observational results, the study also performed multiple regression analysis, with particularly interesting results. The chance of a diarrhea case was higher for unpiped households. However, rather surprisingly, the results showed that the use of unimproved toilet facilities, and or observed faces near the toilet was not significantly correlated with diarrhea. Furthermore, the type of sanitation facility was not important but ownership of any form of toilet or pit latrine was. This supports earlier findings which have argued for the particular importance of improving satiation, but suggests the type of sanitation facility should be of lesser concern. As suggested above, the use of surface water as a primary source was significant in in creasing diarrhoeal prevalence. Furthermore, supporting the arguments of Esrey et al. (1991) in part 3 of this mini-series,  the use of water for household cleaning can prevent disease prevalence, with each increase in litres per capita per day reducing the odds of diarrhoeal prevalence by 0.96.

Therefore, according to Tumwine et al., the biggest determinants in preventing faecal-oral transmission appear to relate to:

1. Water source
2. Amount of water used for personal and household hygiene
3. Ownership of a latrine or sanitation facility - type is less important

The next mini-series of blogs will focus on the varying pathways for enforcing these factors to prevent faecal-oral transmission. 

Faecal-oral paradigm: part 4 - Hygiene behavior in a Sub-Saharan context.

In addition to part 3 of this mini-series which presented a range of arguments as to the most effective methods to restrict faecal-oral transmission, this short blog focuses on a paper which provides an eye opening example of observed hygiene behaviors from North East Botswana which forms a part of Sub-Saharan Africa (where 700 million people are without access to improved sanitation), reiterating the importance of education alongside other approaches to tackle faecal-oral transmission.

A study by Kaltenthaler and Drasar (1996) focused on the relationship between hygiene behavior and diarrhoeal diseases  for young children. Although the investigation was relatively narrow in scope, considering only two villages in North East Botswana over a one year period, the study raises awareness to some interesting themes concerning hygiene and faecal-oral transmission. Similar to findings from Ethiopia (Tucker et al., 2014),  water sources were chosen not based on whether it was improved and protected but instead on factors such as distance from home and water taste. One of the findings that surprised me most is that diarrhea was often not considered to be caused by faecal-oral transmission but thought instead to be caused by a sunken fontanelle, child bewitchment, cold weather and bad food. Prevention and treatment was also found to differ from that provided by health services and included visiting a traditional healer. Furthermore, understanding of what is contaminated or dirty differs somewhat from bacteriological concepts. For instance cow dung and infant faeces were reportedly not traditionally considered contaminated, whereas adult faeces and menstrual blood were considered very dirty. It is clear that these findings cannot be generalised, specifically because of the small study size. Nonetheless, the study supports the arguments of Esrey et al. 1991 (click here), highlighting how existing beliefs have the capacity to undermine improved hygiene behavior and therefore should be considered when wider improvements to water and sanitation are being made. Even if the best water and sanitation systems are installed, they will be wasted if their usefulness and importance are not fully understood or trusted. 

Faecal-oral paradigm: part 3

Stagnant water in a setting of poor urban sanitation in a Ljegun suburb, Lagos
Source: (Reuters, 2008)

Within this mini-series of blogs  I have outlined the discovery of the faecal-oral paradigm within the urban setting (part 1), and the current state of affairs within Urban Africa (part 2). This blog discuss the range of arguments as to the most effective methods to restrict faecal-oral transmission. Much debate has ensued over recent decades on which factors are required to achieve maximum impact. Furthermore, problems in identifying these factors have often been exacerbated by study limitations whereby they have often focused on one type of service improvement at one level (i.e community pumps or household supply) with often inefficient study size (Esrey in 1996).

At its simplest level, strategies for reducing diarrhoeal disease must break the source-receptor pathways between faecal-oral transmission between sewage and the point of consumption. In a study in 1985, Esrey at al. found that investment in water supply and excreta disposal can lead do significant reductions in diarrhoeal related morbidity and mortality, with investments in water quantity and quality appearing particularly effective. Drawing on comparisons with how improvements in the physical environment in reducing diarrhea and cholera in 19th century Europe (see part 1), Esrey et al. argue that these improvements still hold particular significance. In a review of 67 studies diarrhoeal morbidity was reduced by 25% for improved water availability, 22% for improved excreta disposal and 16% from water quality improvements. .

However, other studies, including one by Esrey in 1996 which collected and analysed data from eight countries including Sub-Saharan Africa, argue that improved sanitation brings 'overwhelmingly larger benefits to health than improved water supplies' with positive health impacts at all levels of existing water supply, whereas improvements in water (both quality and quantity) did not result in health impacts unless tied with improvements in sanitation. However, that does not mean water improvements should be ignored with the effect of both water and sanitation improvements combined the greatest.

Similarly results were found in a review of 144 studies on the effects of improved water supply and sanitation on a selection of widespread waterborne diseases including diarrhea (Esrey et al. 1991) The review focused on four main mechanisms for improving health:

1. Improvements in sanitation and excreta disposal
2. Water quality
3. Personal hygiene
4. Domestic hygiene

The paper concluded that improving one or more of these factors, can substantially reduced the levels of morbidity and severity of selected diseases with reductions ranging from 26% for diarrhea to 78% for dracunculiasis (WHO definition here). Reductions in mortality were even more impressive, with a median reduction specifically occurring from diarrhea of 65%. Interestingly, the study also found that improvements in excreta disposal and water quantity, both of which are important for improving hygiene practices, had greater impacts than improvements in water quality. Arguments such as these echo the findings of the original Drawers of Water study which which highlighted how across many examples, water quantity is more important in improving health than water quality. Improvements in health resulted from improved quantity regardless of quality Thompson et al., (2000), with greater supply increasing the amount of water available for personal and household hygiene.

Furthermore, as highlighted in my earlier blogs on access to water, interventions do not automatically lead to their actual usage and uptake. If instillation of new facilities do not change behaviors, remain underused, break down and do not work the resulting impacts on improving health and water supply will be negligible (Esrey et al. 1991). Therefore the paper recommends not only a greater focus on excreta disposal and use of water for personal and domestic hygiene but with a focus on access with facilities built as close to the home as possible coupled with an emphasis on hygiene education . A clear example of a need for this focus is within rural Ethiopia where accessibility is severely undermined by water availability and collection times, accentuated by the inability of the poorest to release labour for water collection. As a result, although the use of water for drinking and cooking (which is very low already) does not decline in the dry season, alarmingly, water use for personal health and hygiene is elastic and forfeited (Tucker et al. 2014). 

This blog has outlined  the main arguments surrounding the most effective methods to restrict faecal-oral transmission, morbidity and mortality, improving public health within urban areas. Coming full circle back to the start of this mini-series of blogs on the faecal-oral paradigm, it is interesting to note 

how many of the suggestions made by John Snow to tackle Cholera in 19th century urban Britain still underpin modern approaches to the problem. Snow's preventative measures focused on thorough personal hygiene and the controlling of the disease through the physical environment. Yet, poor health resulting from the faecal-oral paradigm remains as prevalent as ever in urban areas within Africa, particularly within Sub-Saharan Africa. 

Faecal-oral paradigm: part 1

The Broad Street pump, London, was pivotal in 
John Snows identification of the faecal-oral paradigm.
Source:  (Secret cities, 2015).

Despite the groundbreaking identification of John Snow, Sutherland and others in the 19th century Britain of the link between cholera and many other diarrhoeal diseases to the consumption of faecal matter through water,  faecal-oral transmission and consumption still remains significant in disease incidence throughout urban areas with poor urban water and sanitation within Africa. 

This four part mini-blog series aims to revisit Snow et al. fundamental contributions to the faecal-oral paradigm as well as look at the range of arguments now within academic literature as to what factors primarily restricts faecal-oral transmission, thus preventing disease incidence.

The first officially recorded case of cholera in 19th century Britain occurred in 1831 in Sunderland. Over the proceeding 30 years,  Britain suffered four pandemics with the most serious occurring in 1849 with 53,000 registered deaths for England and Wales (Snow, 2002). The fear created by cholera led to over 700 individual works on its cause and transmission published between 1841 and 1856. Snow (2002), (not John Snow!) highlights how miasmatic theories, whereby disease was thought to be caused by 'bad air', were central to debates surrounding the causes and transmission of Cholera. Prevention took the form of sanitary improvements and this was echoed in the Board of Health's report on the 1849 cholera outbreak which argued that the best approaches to tackling cholera revolved around cleaning up the physical environment including air purification and waste disposal

In an independent report by John Sutherland, who also worked for the Board of Health, he recognised whilst still affirming the importance of sanitary improvements,  water as a predisposing  and casual factor (but not a primary cause) in relation to cholera epidemics. He used statistical evidence to show that cholera cases occurred in houses using a contaminated pump in Hope street, Sutherland (Snow, 2002). However, John Snow was the first to suggest that contaminated water was in fact instrumental in the spread of cholera and not just disposing using the infamous outbreak in Broad/Broadwick street and on differing suppies of water to south London . Snow argued that cholera was introduced into the alimentary canal though swallowing of cholera poison, when cholera faeces entered the public water supply 'either by permeating the ground and getting into well, or by running long channels and sewers into the rivers' (John Snow in Snow (2002). The preventative measures suggested focus on thorough personal hygiene (doctors rarely rarely were infected by patients) and the controlling of disease though its environment (in line with the Board of Health's core responses). It is interesting to note that these suggestions are still central to arguments as to what factors restrict faecal-oral transmission today (see part 3).

Despite John Snow publishing his findings on cholera in 1849, as Smith (2002) argues in a commentary on mid 19th century epidemiology, success in fighting cholera must be 'judged against the fact that cholera is still an endemic disease in in many poor parts of the word. Knowledge of how to prevent cholera has not been translated into action'. Smith also highlights how in the mid-19th century links between cholera and poverty were being made with calls for the rich to act to help the poor. William Bud in 1848 argued that 'we are all more nearly related here than we are apt to think...he that was never yet connected with his poorer neighborhoods by deeds of charity or love, may one day find, when it is too late, that he is connected with him by a bond which may bring them both, at once, to a common grave' (Bud in Smith (2002). Smith suggests that this has a close resemblance to some arguments on the role of income inequality in health today with arguments that higher levels of inequality is associated with worse health among the poor but also for the rich.

The key findings of the 2015 Joint Monitoring Program for water supply and sanitation demonstrated that 2.4 billion people still lack access to improved sanitation facilities further showing how despite the faecal-oral paradigm being discovered in the mid-19th century sanitation improvements are still not sufficient.  Within this context, part 2 of this blog outlines the current global situation with regards the faecal-oral paradigm.

For part 2 click here.

Faecal-oral paradigm: part 2

As shown in part one of the blog, the discovery of the fecal oral paradigm in urban areas is not new thanks to the fundamental contributions of John Sunderland, John Snow and others in the 19th century, linking cholera and many other diarrhoeal diseases to the consumption of faecal matter.  Despite this issues of poor urban sanitation and faecal-oral transmission remain prevalent in urban areas within Africa and in many other parts of the world. This blog outlines the current situation with regards the faecal-oral paradigm.

Despite significant attempts  to improve urban water and sanitation facilities, ill health remains of significant concern in many developing countries and has been found to be the primary cause of numerous childhood illnesses in African countries including Kenya, Uganda and Tanzania (Tumwine et al., 2002). Diarrhea and the faecal-oral paradigm remains one of the most prominent health problems. At the end of the International Drinking Water Supply ad Sanitation Decade in 2000, there were four billion cases of diarrhea a year and 2.2 million deaths, the majority of which were children under the age of five (JMP, 2000). Furthermore, Tumwine et al., (2002) revisited the original Drawers of Water study, surveying 1015 households in 33 sites across Uganda, Tanzania. They found that since the original study in 1967, diarrhea in the week before the survey increased from 6 to 18% and 16 to 21% in Kenya and Uganda. Tanzania was the only country out of the three to reduce the prevalence of diarrhea modestly from 11 to 8%.

These figures are now 13 years old and since then the Millennium Development Goals have challenged the global community to improve access to freshwater and improved sanitation. However, the recent UNICEF/WHO JMP report seem to point to a similar state of affairs. The MDG sanitation target has been missed by a significant margin. The 2000 JMP reported that '2.4 billion people have no access to any form of improved sanitation services' (JMP, 2000). The 2015 report (JMP) reads '2.4 billion [are left] without access to improved sanitation facilities'. Most live in three regions including Sub-Saharan Africa were 700 million are without improved sanitation which equates to less than 20% of its population have access to improved facilities . (figure 1). Within Nigeria for instance, the percentage of the population with access to improved sanitation has fallen from 38% (1990) to 33% (2015). Levels of open defecation have increased from 7% to 15% (JMP,2015).

Population in 2015 without improved sanitation, Source: JMP (2015)

 Overall, nothing has changed despite 2.1 billion people gaining access to improved sanitation since 1990 (JMP,2015). One of the main reasons for this is that within many parts of the world urban sanitation improvements are not keeping up with population growth.  Population growth presents a In particular challenge for urban areas within Africa (and globally). Within Sub-Saharan Africa for instance, where urban population has increased by 169% since 1990, there has been a decline in water or sanitation coverage in urban areas in 14 out of 46 countries (JMP, 2015). Figure 2 highlights how gains in access to improved sanitation are struggling to outpace population growth, particularly in urban areas. In Sub-Saharan Africa, growth in improved sanitation coverage is just 0.4 times population growth.

Population growth is outpacing improvements in sanitation, especially in urban areas, Source: JMP (2015)

Furthermore, in addition to the potential for illness and death, evidence from a study which undertook analysis from nine cohort studies in five developing countries indicated that high exposure to diarrhea prior to 24 months of age was associated with a greater frequency of stunting past 24 months of age and this was constant across the range of studies (Checkley et al. 2008). The chance of stunting at 2 years increased multiplicatively with each exposure to and day of diarrhea prior to 24 months.

In part 3 of this blog I discuss the range of arguments as to the most effective methods to restrict faecal-oral transmission and thus which approaches  should be pursued to prevent disease incidence.