Why promote sanitation?
Author: Sandy Cairncross,
It is essential for health
Thanks largely to improved case management of diarrhoeal diseases, these cause fewer deaths than they used to. Now that ORT (oral rehydration therapy) has helped to bring the total down, it has become increasingly true that only the prevention of diarrhoea, particularly by improved sanitation and hygiene, can reduce the toll any further. The role of sanitation is obvious; the chief source of infection is other people's excreta.
Hygiene is important too; recent studies have shown that hygienic disposal of children’s stools is associated with 30-40% less risk of serious diarrhoea.
Recent studies in Brazil and the Philippines have found that, once community sanitation had reduced the level of faecal contamination in the general environment, this increased the impact on child health of other measures such as improved water supply.
Sanitation is a public good
When a family installs a latrine, it not only protects them from their own excreta; it also helps to protect their neighbours. Indeed, there is an impact on the health of the community as a whole from the overall level of sanitation (see table 1). For advocates of sanitation this is good news, as it means that sanitation is not only a private good, but also a public good, and that there is therefore a case for public measures (subsidy or regulation) to promote it. Individuals cannot be expected to pay voluntarily for a benefit which others will enjoy.
In a study of over 1,000 children in nine favelas (shantytowns) in the city of Salvador, Brazil, children in households without a latrine suffered from diarrhoea twice as often as those with sanitation. On the other hand, those whose communities had no drainage had diarrhoea three times more frequently than those in neighbourhoods with drains and sewers. Statistical analysis showed that these were independent effects; even in the unsewered neighbourhoods, three out of four households had a latrine of some sort. Similar patterns were found for each of the three types of intestinal worms.
This example shows that there are health benefits for individual families who improve their sanitation, but even greater benefits when a whole community does so.
Incidence of diarrhoea in episodes per child per year, among children under five.
Source: L R S Moraes, PhD thesis,
London School of Hygiene & Tropical Medicine, 1996.
Intestinal worms are the most common infections of humanity; they too come from human faeces, and they tend to affect children more than adults. In poor communities without sanitation, it is typical to find well over half the children infected with intestinal worms. Their nutritional effect is evident from cases where stunted children have been treated with de-worming drugs, producing an immediate spurt in growth. Treatment, however, is not a sustainable option as the children are quickly reinfected; the sustainable option is sanitation.
Other health benefits are less well known, such as the impact of sanitation on trachoma; the second most important cause of blindness world-wide; where much of the infection is carried by flies, latrines can prevent this by depriving the flies of their breeding sites in scattered human faeces.
Hardware is not enough
To provide sanitation hardware alone is not enough; changes in behaviour are required for the full health benefits to be achieved. An example illustrates this. Nine out of ten households in the town of Bobo Dioulasso in Burkina Faso had a latrine, and half had a tap or well in the yard. Nevertheless, diarrhoeal diseases were identified as a major local health problem. Researchers found that basic hygiene practices, such as hand washing and children's excreta disposal, showed room for improvement.
Sanitation is a priority for women
There are at least three reasons why sanitation is a feminist issue:
(i) Freedom from imprisonment by daylight
In many cultures, the only time when women or girls can defecate, if they have no latrine, is after dark. Apart from the discomfort caused by the long wait until evening, this can cause serious illness.
(ii) Protection from harassment and rape
The walk to the defecation field, often in the dark, is when millions of women run the greatest risk of sexual harassment and assault.
(iii) School enrolment and attendance
The lack of adequate, separate sanitary facilities in schools is one of the main factors preventing girls from attending school, particularly when menstruating. In Bangladesh, a school sanitation programme increased girls' enrolment by 11%; what educational reform could achieve that?
Sanitation is about more than health
The health and gender impacts are good reasons to promote sanitation, but they are by no means the only benefits, and not even the most important factor for most users. For example, latrine owners in the rural Philippines gave the following responses when asked why they were satisfied with their new facilities. Note the order:
- Less embarrassment when friends visit
- Less gastrointestinal disease
The benefits people rate most highly (cleanliness, privacy, convenience, self-respect and so on) are not just selling points. Poor people are willing to pay cash for them, so they have a money value
Children have a right to it!
The Convention on the Rights of the Child requires governments to take appropriate measures:
- to diminish infant and child mortality;
- to combat disease and malnutrition; and
- to ensure that parents and children are supported in the use of basic knowledge of hygiene and environmental sanitation.
Why promote sanitation? It is an obligation on us all, for all the world's children.
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