Feature Health in Developing Countries

Toiling for toilets

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c5027 (Published 15 September 2010) Cite this as: BMJ 2010;341:c5027
  1. Rebecca Coombes, associate editor
  1. 1BMJ, London WC1H 9JR
  1. rcoombes{at}bmjgroup.com

    Sanitation has been the poor relation of the millennium development goals, but without it the chances of meeting many of the other goals are much reduced. Rebecca Coombes reports

    Lobbyists, government leaders, and health activists gather in New York next week for tense talks on the millennium development goals. Ten years after the goals were first set by the United Nations as a means of lifting millions of people in developing countries out of poverty and ill health, many goals remain way off track, and none more so than sanitation. Bolted on as something of an afterthought in 2002, the goal is to halve the number of people worldwide without access to a clean and safe toilet. An estimated 2.6 billion people are living without this basic facility. But on current progress, the 2015 goal will not be met until 2049 globally, and not until the 23rd century in sub-Saharan Africa.

    Why has it been so hard to reach the countless communities where people are daily exposed to their own and others’ faeces? In part, it’s the failure to make the link between improved sanitation and better health—and attract the resultant aid dollars—but also because governments’ and the aid communities seem to have a blind spot on this issue.


    “I think we have to face up to the hard fact that sanitation is unpalatable because it is about shit,” says Clarissa Brocklehurst, chief of water, sanitation, and hygiene, at Unicef.

    Her language might be direct but it’s typical of an increasingly bolshie sanitation lobby, frustrated that the issue is too often politely side stepped. “It’s also about toilets, which make people giggle and go shy. Toilets aren’t very exotic—everyone needs them—and the diseases associated with the lack of them seem very mundane: diarrhoea and worms. Sanitation is also less obviously associated with something you can supply, like bed nets, vaccines, or tablets, and the way to do good sanitation programming is complicated by debates over how much is bricks and mortar and how much is behaviour change. All this makes it an unsatisfying sector to get involved in as a politician.”

    Health threat

    Clean water and sanitation are among the most important determinants of public health. Diarrhoeal disease caused by poor sanitation and unsafe water kills around 1.4 million children a year, more than AIDS, malaria, and measles combined. In Africa, diarrhoeal disease is now the biggest killer of children, killing almost one in five before the age of 5 years.1

    Without basic clean toilets and hand hygiene, excrement is transmitted between people by flies or fingers and also contaminates the water source. In a report published last week in advance of the UN summit, the international non-governmental organisation WaterAid noted that 1 gramme of faeces can contain 10 million viruses (including hepatitis A and E), one million bacteria (such as cholera and shigella), parasite cysts, and eggs.2 In terms of child health, repeated diarrhoea and nematode infections are associated with half of childhood malnutrition.3

    There are signs that sanitation is creeping up the millennium development goal agenda. In January 2007, a poll of 11 000 BMJ readers voted sanitation as the greatest medical advance of the past 166 years.4 Sanitation beat the discovery of antibiotics and the development of vaccines. A year later Maggie Black and Ben Fawcett’s influential book The Last Taboo5 broached the topic of excrement and the problem poor sanitation poses for girls in the developing world, who are forced to miss school during menstruation.

    Self help

    However, the debate on how to run sanitation programmes has stymied progress. So what works? One thing is clear: universal sewerage is not the answer. Toilets in many parts of the world will not have water piped in and contents piped away. It is too expensive and, in areas of severe water shortage, it is impossible to replicate conditions in Europe and North America where gallons of water are used to flush a toilet.

    A key breakthrough has been the rapid growth of a self help movement called Community-Led Total Sanitation (www.communityledtotalsanitation.org). Pioneered by Kamal Kar, a charismatic development consultant from India, in 1999, the movement has led to thousands of low cost latrines and toilets springing up all around South East Asia, Asia, Africa, and beyond. Importantly, the goal is not to build toilets but to get communities free from open defecation. Instead of top-down schemes that foist heavily subsidised hardware on unimpressed local communities, the approach of Community-Led Total Sanitation (CLTS) is to roll out low cost latrines built by local people with local materials, such as bamboo, tin, and jute.

    Sociologist Lyla Mehta, a research fellow at the Institute of Development Studies who led a large study on CLTS funded by the Department of International Environment and Development Studies, thinks CLTS won’t be just another development fad.

    “CLTS spread quickly out of Bangladesh to India, Indonesia, and other parts of Asia, largely through exposure visits facilitated by the Water and Sanitation Programme (WSP). It has also moved to Africa and Latin America, where Unicef, WSP, and non-governmental organisations such as WaterAid and Plan have played a big role; 10-20 million people have benefited from it. Kamal Kar is a gifted facilitator, is very blunt, and has succeeded in getting people talking about shit, so it is not a taboo subject. This has given much more awareness to sanitation. In the 1980s and 1990s there was all this money spent on toilets, which were then used for storage or for visitors from the city. CLTS believes that if you build your own toilets you will use them, and then you move up the sanitation ladder.”

    Robert Chambers, another research fellow at the Institute of Development Studies who has worked with Mr Kar, adds: “The simple solution seemed to be to make hardware available so that people could have a toilet. But I know of no subsidised toilet programme in the world that has been successful. Toilets aren’t used because people are used to shitting in the open. And they didn’t ask for these toilets in the first place, and don’t regard them as theirs because they were dumped on them. So construction of toilets does not end open defecation.”

    The CLTS approach enables local people to do their own analysis and appraisal, explains Mr Chambers. “A facilitator will make a map to show all the households in the community, and then asks them ‘where do you shit?’ We’ve an international glossary of more than 100 words for shit. We always use the crude word so it’s not depicted as something nice. Once people show us where they shit, we mark the area with sawdust or yellow powder. People can then see they are surrounded in shit.”

    Critics of CLTS say it depends on there being a community in place, and not one that is riven with conflict and inequalities. But says Ms Mehta, there is more chance a toilet will be used if it is built by those who are going to use it rather than imposed from above.

    Hard evidence

    She talks about the epidemiological challenges in establishing strong links between toilet use and a decline in disease. “It is notoriously difficult to provide conclusive links between toilet construction and improved health outcomes. There are several intervening factors such as breastfeeding, maternal health, nutrition, groundwater quality, and poverty that make causal linkages difficult.”

    Ms Brocklehurst admits that the sanitation lobby has only recently become better at articulating the ways in which sanitation affects other millennium development goals, especially the health ones, as evidence has been scarce. There are no published randomised trials of the effect of toilet provision on diarrhoea, for example. “We now have more health evidence and also better economic arguments. For communities, we have become much better at demonstrating that lack of sanitation in a village hurts everybody.”

    One example of new evidence is recent research that an important cause of child undernutrition is tropical enteropathy, caused by faecal bacteria ingested in large quantities by young children because of a lack of sanitation.6

    Ms Brocklehurst is hopeful that with government backing, the goal can get back on track. She points to Thailand, which made rural sanitation a priority in eight consecutive five year plans, and has now achieved almost universal coverage (and associated drops in diarrhoeal disease). Ethiopia has made promoting sanitation a key task for its health outreach workers and has managed to make progress despite starting from a very low level of coverage. And recent analysis of household survey data has shown that Bangladesh has not only increased sanitation coverage and decreased open defecation but has also seen dramatic changes in all wealth groups, whereas in many other countries, there are huge inequities in sanitation coverage.

    Almost 150 years ago, during an unusually hot summer in London the river Thames was left overflowing with raw sewage. Amid fears of a cholera epidemic, the “great stink” concentrated the minds of members of parliament sitting at the nearby House of Commons, who rushed through a bill to transform the sewerage network in the capital. The message to leaders in New York will be that billions of people still manage this threat to health every day, other millennium development goals cannot be achieved without improved sanitation, and that sanitation needs to be discussed in the same breath as the goals for child health, nutrition, education, and maternal health.

    Uganda: footballs for toilets

    “Sanitation and hygiene is still a huge challenge, both in the city and rural areas,” says Sarah Muzaki, head of programmes for WaterAid, Uganda. This is not to say that progress hasn’t been made. According to the United Nations, in 2008, 48% of Ugandans had access to an improved latrine, compared with 39% in 1990, the baseline year for the millennium development goals.

    One of the challenges, she says, is breaking down engrained beliefs about using latrines. “In the north east of the country, there are beliefs that if a woman uses a latrine she must be barren. Or that if a pregnant woman uses a latrine her unborn baby might fall down the pit by accident. There are also communities who believe that dropping children’s faeces around the compound is a sign of pride, demonstrating how many children you have.” She also points to concerns that it is not “manly” to squat where women and children have been—far better to go in the bush.

    But the Community-Led Total Sanitation philosophy has helped. “We start off by showing communities pictures of areas used for open defecation—pictures which provoke disgust. We then look at photographs of latrines or toilets kept hygienically. We compare the pictures, get a discussion going.”

    After further analysis, people are encouraged to build their own loos, dig latrines, and in some cases are rewarded for doing so. “We look at what communities enjoy doing best,” says Ms Muzaki. “In Uganda, in many cases it is soccer. We award marks for progress in sanitation, which can be used for a soccer kit or a ball, working up to soccer training, competitions, access to facilities. We work in groups of 10 homesteads, so if two are lagging behind you fail to get points. This helps people to mobilise themselves.

    “We are not talking about high standard latrines here. The advice is use what you have—we don’t supply any of the materials. We find this promotes better standards. What I’ve learnt is that it is all about influencing behaviour; it is not just about imposing subsidised facilities. The government’s sanitation initiative went for a coercive approach, penalising those who had not reached set standards of hygiene. It meant people were left feeling negative about the subject. What’s key is to let people go at their own pace. Don’t force it. Communities do not change overnight.”


    Cite this as: BMJ 2010;341:c5027


    • Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from her) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

    • Provenance and peer review: Not commissioned; not externally peer reviewed.