Maggie Brown, MS, ELS is Senior Production Editor at PLoS
2.6 billion people around the world have no access to “improved sanitation.” Translation: Much of the global population go to the toilet not in toilets, but behind their houses, in the bush, or at best in leaky privies that do nothing to prevent the transmission of diarrhea, parasite infection, trachoma, and a host of other preventable causes of misery, illness, and death. As a result, the sanitation Millennium Development Goal is to “Reduce by half the proportion of people without sustainable access to safe drinking water and basic sanitation.”
When you do the math, this noble goal seems to fall short: Even if the goal were on target, by 2015 some 1.3 billion people would still be defecating in back yards, stinking privies, ditches, or buckets. But by now it’s clear that the goal will not be met on time. Why? After all, is not as if sanitation is particle physics.
– It is a complex issue of health, culture, politics, and even the MDGs themselves; it affects or is affected by many of the other goals, for example through poverty and malnutrition (goal 1), school attendance (goal 2), gender disparities in safety (goal 3), and child mortality due to infectious diseases (goal 4).
– No one solution fits every situation; successful efforts must fit a given locale’s hydrological and geological profiles, cultural norms, available resources, community structure, and funding sources.
– No consensus yet exists on how to evaluate outcomes of interventions, nor even whether standard research-driven agendas with predefined, measurable outcomes are appropriate.
This all makes sense intellectually; in fact, these problems often plague important global health issues. What makes sanitation so different, and so difficult? As Clarissa Brocklehurst (Chief of Water, Sanitation and Hygiene at UNICEF and a coauthor in one of the recent PLoS Medicine collection articles) recently stated, “I think we have to face up to the hard fact that sanitation is unpalatable because it is about shit.” (1)
Dealing with this powerful social taboo is at the center of some newer approaches that rely more on education and community participation than on delivery of “heavily subsidised hardware [to] unimpressed local communities” (1). For example, WHO’s PHAST (Participatory Hygiene and Sanitation Transformation) targets hygiene behavior and community involvement in management of water and sanitation
A much-watched and discussed project, CLTS (Community Led Total Sanitation) focuses on training, education, blunt talk, and community self help. Started in Bangladesh in 1999, the approach has now been introduced to 28 countries in Africa, Asia, Central America (2) and directly or indirectly benefited an estimated 10-20 million people (1). One commentary states, “[W]orkers for the Community Led Total Sanitation movement have achieved what top down sanitation programmes have failed to do. By overcoming taboos and cultural barriers rather than providing bricks and mortar, they have improved the sanitation and life chances of millions of the world’s poorest people.” (3)
The approach is apparently not only effective but inexpensive. Kamal Kar, who leads CLTS, says of one of the core efforts – training community trainers – that the cost to pay these people is “a peanut” compared to the cost of latrine construction at around US$300 each (2).
At this point, only time will tell whether these bottom-up solutions will be the key to improving sanitation – and both survival and quality of life – for the world’s poorest millions.
1. Coombes R (2010) Toiling for Toilets. BMJ 341: c5027. Available: http://www.bmj.com/content/341/bmj.c5027.full?sid=f1555e02-a349-4827-8098-7d4fee245a96
2. (2010) Shit Happens. BMJ Podcast. Available: http://podcasts.bmj.com/bmj/2010/09/17/shit-happens/
3. Godlee F (2010) Let’s Talk Shit. BMJ 341: c5066. Available: http://www.bmj.com/content/341/bmj.c5066.full?sid=f1555e02-a349-4827-8098-7d4fee245a96
- The Sustainable Sanitation Alliance presents case studies: http://www.susana.org/lang-en/case-studies
- SoM blog postings by Angela Ni on sanitation in China: http://blogs.plos.org/speakingofmedicine/2010/11/09/biogas-toilets-in-a-chinese-village/
- UNESCO discusses the Millennium Development Goals at http://www.unesco.org/water/wwap/facts_figures/mdgs.shtml
- WHO environmental sanitation programs are listed at http://www.who.int/water_sanitation_health/hygiene/envsan/en/index.html