Globally, 2.6 billion people remain without access to any kind of improved sanitation, and sanitation-related diseases and poor hygienic conditions cause approximately 2.2 million annual deaths, mostly of children under the age of five years.
The World Health Organization defines the term "sanitation" as follows:
"Sanitation generally refers to the provision of facilities and services for the safe disposal of human urine and faeces. The word 'sanitation' also refers to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal."
Sanitation includes all four of these engineering infrastructure items: Excreta management systems, wastewater management systems, solid waste management systems, drainage systems for rainwater.
The overall objective of a sanitation system is to provide a healthy living environment for everyone, to protect the natural resources (such as surface water, groundwater, soil), to provide safety, security and dignity for people when they defecate or urinate, and break the cycle of disease.
Lack of Sanitation
Lack of sanitation or poor sanitation refers to the absence of sanitation. In practical terms it usually means lack of toilets or lack of hygienic toilets that anybody would want to use voluntarily. Lack of sanitation also refers to the lack of maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal. The result of lack of sanitation is usually open defecation (and open urination but this is of less concern) and indiscriminate dumping of garbage and ill liquid waste disposal, with the associated serious public health issues.
For any social and economic development, adequate sanitation in conjunction with good hygiene and safe water are essential to good health. Lack of proper sanitation causes diseases. Most of the diseases resulting from sanitation have a direct relation to poverty.
The lack of clean water and poor sanitation causes many diseases and the spread of diseases. It is estimated that inadequate sanitation is responsible for 4 percent of deaths and 5.7 percent of disease burden worldwide.
Lack of sanitation is a serious issue that is affecting most developing countries and countries in transition. The importance of the isolation of excreta and waste lies in an effort to prevent diseases which can be transmitted through human waste, which afflict both developed countries as well as developing countries to differing degrees.
It is estimated that up to 5 million people die each year from preventable waterborne diseases, as a result of inadequate sanitation and hygiene practices. The effects of sanitation have impacted the society of people throughout history. Sanitation is a necessity for a healthy life.
Diseases Caused by Lack of Sanitation
Diseases and conditions caused by lack of sanitation and hygiene include:
Waterborne diseases, which can contaminate drinking water
Diseases transmitted by the faecal-oral route
Infections with intestinal helminths (worms) - approximately two billion people are infected with soil-transmitted helminths worldwide; they are transmitted by eggs present in human faeces which in turn contaminate soil in areas where sanitation is poor.
Stunted growth in children
Malnutrition, particularly in children
The list of diseases that could be reduced with proper access to sanitation and hygiene practices is very long. For example, in India, 15 diseases have been listed which could be stamped out by improving sanitation:
Ascariasis (a type of intestinal worm infection)
Japanese encephalitis (JE)
Ringworm or Tinea (a type of intestinal worm infection)
Typhoid and paratyphoid enteric fevers
Polio is another disease which is related to improper sanitation and hygiene.
Main Types of Infectious Agents
- Bacteria are very simple microscopic organisms. Some types of bacteria are essential to human life, playing a part in the digestive system. Others have other benefits, such as decomposing wastes. Pathogenic bacteria are responsible for many diseases, including tuberculosis and pneumonia and several waterborne diseases such as typhoid and cholera.
- Viruses are not living organisms themselves but are infectious agents able to invade cells and cause them to manufacture more virus material. Polio, HIV/AIDS, influenza and rotavirus are examples of diseases caused by viral infections.
- Protozoa are the simplest members of the animal kingdom. They are microscopic, consist of a single cell and are found in water, soil and the sea. Some types are beneficial to humans, breaking down pollutants in water, but others are parasitic, causing diseases including malaria, amoebic dysentery and sleeping sickness.
- Parasitic worms live inside the bodies of their human host, usually in the intestines. There are several different types of parasitic worm including tapeworms, flukes and roundworms. Roundworms, also known as nematodes, include Ascaris, hookworm and whipworm . Most worm infections are not fatal, but they do cause long-term debilitating illness. Parasitic worms are sometimes collectively known as helminths. Note however, that there are many types of worm that are not parasitic or harmful in any way. For example, earthworms decompose dead plant matter and improve soil structure and fertility.
Impact on the Economy
A healthy community has many economic advantages over an unhealthy one. If people are healthy they will spend less money on health care and the loss of work days due to diarrhoea and other related infections is reduced. Illness can affect both the sick person and their family, for example when women have to take time off work to care for sick children.
Improving solid waste management has economic advantages in addition to the health advantages discussed above. Consider the following example.
It is said that a firm that throws something away pays towards it three times over. Imagine a firm that uses raw materials and puts them through a manufacturing process to make a final product. First, the firm has to pay its suppliers for the raw materials. Secondly, it pays its staff to transform the raw materials into products, and pays for the water and energy that it uses. Finally, the firm has to pay for disposal of what it throws away. So a firm that reduces the amount of waste it produces makes savings in all three areas.
A firm that uses basic materials such as glass or metal faces large energy bills for the processes required in converting these materials into products. But if they follow the principles of the 3 Rs (reduce, reuse and recycle) and substitute some of their input raw material with scrap glass or metal, they can reduce their energy bills and buy less raw materials. These materials are often imported, so using recycled scrap reduces Ethiopia’s expenditure abroad, which benefits the national economy as well as individual firms.
There are further benefits from recycling. The initial stages in the recycling process (collecting material from households and businesses) is labour-intensive and provides employment for the poorest people in society. Giving them an income improves their health, which, in turn, reduces the country’s healthcare expenditure.
· A householder in an urban area goes shopping for food. How can they apply the 3 Rs when it comes to packaging materials?
· They can reduce packaging waste by buying loose fruit and vegetables rather than pre-packaged goods.
They can reuse carrier bags to take the shopping home rather than picking up new bags each time they shop.
They can recycle by taking any glass or metal food containers to collection points or by giving them to people who earn their living by collecting recyclable wastes.
Impact on the Environment
What do we mean by ‘the environment’? You may think of it as your immediate surroundings in the town where you live or work. However, it can also mean the wider natural world on a much larger, even global, scale. Poor sanitation and waste management have direct impacts on the local environment, but human practices can also have broader consequences.
There are obvious local environmental benefits from improved sanitation. This means that defecation only takes place in properly constructed latrines, areas of land are not contaminated with faeces and watercourses no longer act as sewers. This in turn allows plant life, fish and other aquatic organisms to flourish.
Improving waste management improves the local environment and also benefits the national and even the global environment. Good waste management means less litter in the streets and in the neighbourhood of waste disposal sites. It also reduces the smell in the streets from decomposing wastes.
Benefits of Improved and Proper Sanitation
Using proper toilets and hand washing - preferably with soap - prevents the transfer of bacteria, viruses and parasites found in human excreta which otherwise contaminate water resources, soil and food. This contamination is a major cause of diarrhoea, the second biggest killer of children in developing countries, and leads to other major diseases such as cholera, schistosomiasis, and trachoma.
Improving access to sanitation is a critical step towards reducing the impact of these diseases. It also helps create physical environments that enhance safety, dignity and self-esteem. Safety issues are particularly important for women and children, who otherwise risk sexual harassment and assault when defecating at night and in secluded areas.
Also, improving sanitation facilities and promoting hygiene in schools benefits both learning and the health of children. Child-friendly schools that offer private and separate toilets for boys and girls, as well as facilities for hand washing with soap, are better equipped to attract and retain students, especially girls. Where such facilities are not available, girls are often withdrawn from school when they reach puberty.
In health-care facilities, safe disposal of human waste of patients, staff and visitors is an essential environmental health measure. This intervention can contribute to the reduction of the transmission of health-care associated infections which affect 5% to 30% of patients.
Wastewater and Stormwater Management
Wastewater management consists of collection, wastewater treatment (be it municipal or industrial wastewater), disposal or reuse of treated wastewater. The latter is also referred to as water reclamation.
The standard sanitation technology in urban areas is the collection of wastewater in gravity driven sewers, its treatment in wastewater treatment plants for reuse or disposal in rivers, lakes or the sea. Sewers are either combined with storm drains or separated from them as sanitary sewers. Combined sewers are usually found in the central, older parts or urban areas. Heavy rainfall and inadequate maintenance can lead to combined sewer overflows or sanitary sewer overflows, i.e., more or less diluted raw sewage being discharged into the environment. Industries often discharge wastewater into municipal sewers, which can complicate wastewater treatment unless industries pre-treat their discharges.
The high investment cost of conventional wastewater collection systems are difficult to afford for many developing countries. Some countries therefore promote alternative wastewater collection systems such as condominial sewerage, which uses pipes with smaller diameters at lower trench depth with different network layouts from conventional sewerage.
In developed countries centralised treatment of municipal wastewater is now quite widespread. In developing countries most wastewater is still discharged untreated into the environment. For example, in Latin America only about 15% of collected sewage is being treated.
In many suburban and rural areas households are not connected to sewers, and they rather use on-site sewage facilities or decentralised treatment if they are connected to piped water and use flush toilets. They discharge their wastewater into septic tanks or other types of on-site sanitation systems (e.g. Sequencing batch reactors or constructed wetlands). On-site systems include drain fields, which require significant area of land. This makes septic systems unsuitable for most cities.
The reuse of untreated or partially treated wastewater in irrigated agriculture is common in developing countries. The reuse of treated wastewater in landscaping, especially on golf courses, irrigated agriculture and for industrial use is becoming increasingly widespread.
Solid Waste Disposal
Disposal of solid waste is most commonly conducted in landfills, but incineration, recycling, composting and conversion to biofuels are also avenues. In the case of landfills, advanced countries typically have rigid protocols for daily cover with topsoil, where underdeveloped countries customarily rely upon less stringent protocols. The importance of daily cover lies in the reduction of vector contact and spreading of pathogens. Daily cover also minimises odour emissions and reduces windblown litter. Likewise, developed countries typically have requirements for perimeter sealing of the landfill with clay-type soils to minimize migration of leachate that could contaminate groundwater (and hence jeopardize some drinking water supplies).
For incineration options, the release of air pollutants, including certain toxic components is an attendant adverse outcome. Recycling and bio-fuel conversion are the sustainable options that generally have superior lifecycle costs, particularly when total ecological consequences are considered. Composting value will ultimately be limited by the market demand for compost product.
How to Improve Sanitation
• Safe collection, storage, treatment and disposal/re-use/recycling of human excreta (faeces and urine)
• Proper management/re-use/recycling of solid wastes (trash or rubbish)
• Well channelled drainage and proper disposal/re-use/recycling of household wastewa- ter (often referred to as sullage or grey water)
• Well channelled drainage of storm water (rain water)
• Proper collection and management of industrial waste products
• Proper management of hazardous wastes (including hospital wastes, and chemical/ra-dioactive and other dangerous substances).
For countries with very low access to basic sanitation, increasing the effectiveness of management of excreta at the household level may have the biggest health implications and it may be the biggest challenge. For this reason some countries may legitimately decide to focus their efforts at this level in the short term.
In other cases, specific inter-linkages between elements of sanitation mean that a more complete solution may be better – for example in a particularly congested urban community some form of off-site (sewers) sanitation may be the only viable technical choice – in which case there will probably need to be some interventions to improve management of solid wastes and storm water drainage - otherwise the sewers won’t work. Yet other countries or communities may try for a more complete solution which includes a focus on protecting the environment from contamination (as is the case in countries which already have universal access).
In some cases, it will be possible to start with an “ecological” approach to sanitation which seeks to contain, treat and reuse excreta where possible – thus minimizing contamination and making optimum use of resources. The key issue here is that each community, region or country needs to work out what is the most sensible and cost effective way of thinking about sanitation in the short and long term and then act accordingly.
Flexibility and pragmatism should be the key words – and both professionals and politicians need to try and see past “experience” and ideas which are developed elsewhere – a pragmatic local approach with an eye to wider environmental issues is likely to result in more progress than blind adherence to a rigid global definition.
Why Focus on Sanitation?
Wherever humans gather, their waste also accumulates. Progress in sanitation and improved hygiene has greatly improved health, but many people still have no adequate means of disposing of their waste. This is a growing nuisance for heavily populated areas, carrying the risk of infectious disease, particularly to vulnerable groups such as the very young, the elderly and people suffering from diseases that lower their resistance.
Poorly controlled waste also means daily exposure to an unpleasant environment. The build up of faecal contamination in rivers and other waters is not just a human risk: other species are affected, threatening the ecological balance of the environment.
The discharge of untreated wastewater and excreta into the environment affects human health by several routes:
• By polluting drinking water
• Entry into the food chain, for example via fruits, vegetables or fish and shellfish
• Bathing, recreational and other contact with contaminated waters
• By providing breeding sites for flies and insects that spread diseases
How Does Sanitation Prevent Disease?
For a sanitation system to provide the greatest health protection to the individual, the community and society at large, it must:
• Isolate the user from their own excreta
• Prevent nuisance organisms (e.g. flies) from contacting the excreta and subsequently transmitting disease to humans; and
• Inactivate the pathogens before they enter the environment or prevent the excreta from entering the environment.
It is important to understand that sanitation can act at different levels, protecting the household, the community and ‘society’. In the case of latrines it is easy to see that this sanitation system acts at a household level. However, poor design or inappropriate location may lead to migration of waste matter and contamination of local water supplies putting the community at risk.
In terms of waterborne sewage the containment may be effective for the individual and possibly also the community, but health effects and environmental damage may be seen far downstream of the original source, hence affecting ‘society’.
What are the Reasons for Slow Progress on Sanitation?
Many people do not realize the health and economic benefits to the individual, the community and to society from improving sanitation. The high cost of improving sanitation is often cited as a barrier to implementing sanitation projects.
Improving sanitation is often low on the list of priorities. There are so many other pressing needs for the attention of governments: food supply, education, medical treatment and dealing with war and conflict.
Most people are aware that poor sanitation has a health impact, but there is a lack of awareness of the extent of ill-health that it causes.
On the other hand, human society has developed very different socio-cultural responses to the use of untreated excreta. This ranges from deep disgust to practical preference. While determined partly by survival economics, these cultural differences apply to many water poor countries, as well as to water rich areas.
For example, in Africa, the Americas and Europe, excreta use is generally regarded as culturally unacceptable, or at best with indifference. This results from the strongly held view that human excreta, especially faeces, are repugnant substances best kept away from the senses of sight and smell.
Products fertilized with raw excreta are regarded as tainted or defiled in some way. These views are less rigid in the case of using excreta in compost and sludge for agriculture, but still pose a barrier to use of waste.
Routes for Disease Transmission
Most infections occur through the faecal-oral route where pathogens enter a person’s mouth through ingesting (eating or drinking) contaminated food or water, or when contaminated fingers are placed in the mouth. The different transmission routes are shown below, which is known as the ‘F diagram’. Pathogens contained in faeces enter a new host (a person’s body) through the ‘Fs’ – fluids, fingers, flies or fields/floors. Effective sanitation, clean water and good hygiene behaviour provide barriers to this transmission.
The F diagram showing how diseases can pass from faeces to a new host. Sanitation (using a latrine), safe water supply and good hygiene are barriers to disease transmission.
The faeces (on the left of the diagram) come from an infected person. The new host (on the right of the diagram) could be any man, woman or child who is not currently infected with the disease. Infections can be transmitted from faeces to the new host as follows:
Infection from fluids usually involves drinking or cooking with water contaminated with faecal organisms.
In the fingers pathway, a person ingests the organisms (usually during eating) if they have come into contact with faeces and have not washed their hands properly afterwards. This contact can occur from defecation, from cleaning a child’s bottom, from touching dirty surfaces or eating food prepared in an unhygienic manner.
Flies and cockroaches often thrive on excreta. If they land on food they can transfer faecal matter that can be subsequently ingested by a person.
Field (or soil) infection can occur by the ingestion of unwashed raw vegetables and fruit grown in soil contaminated with faeces. Contaminated soil may be transported by feet or shoes for long distances. Infections can also be transmitted through dirty floors, perhaps if food is dropped on the floor and then picked up and eaten.
Flies and cockroaches are two examples of vectors that can carry pathogens from faeces on to food that is then eaten.
There are other disease vectors linked to poor sanitation and waste management. For example, piles of food waste and other garbage not only provide good breeding sites for flies but they also encourage rats. Rats can contaminate food stores and also carry fleas.
Poor personal hygiene also contributes to disease transmission. Infrequent or inadequate washing of the body and clothes can encourage external body parasites such as fleas and lice, which may carry typhus.
An important example of a disease that is closely related to poor sanitation but is not transmitted by ingestion of contaminated food or water is schistosomiasis, also known as bilharzia. Schistosomiasis is widely distributed in Ethiopia (Dufera et al., 2014). The disease is caused by a parasitic worm that has a complicated life cycle. Its primary host is humans, but its secondary host is a type of freshwater snail. The disease is linked to poor sanitation because it is caused by the faecal contamination of water. However, the worm gets into the body not by the faecal-oral route, but by penetrating through the skin when someone washes, swims or stands in water inhabited by infected snails.
Everyone should wash their hands thoroughly at certain critical times, as listed below. Washing should be done using clean water that has not been used by anyone else and with soap or a soap substitute such as ash. Ideally, the water should be hot. After washing, the hands should be dried using a clean cloth or allowed to dry in the air.
Critical times for hand washing
The occasions in everyday activity when hands should be washed include:
after using the latrine or toilet (or disposing of human or animal faeces)
after cleaning a child’s bottom or changing a baby’s nappy and disposing of the faeces
after contact with blood or body fluids (e.g. vomit)
immediately after touching raw food, especially meat, when preparing meals
before preparing and handling cooked or ready-to-eat food
before eating food or feeding children
after contact with contaminated surfaces (e.g. rubbish bins, cleaning cloths, food-contaminated surfaces)
after handling pets and domestic animals
after wiping or blowing the nose or sneezing into the hands
after handling soiled tissues (your own or others’, e.g. children).
This list is frequently summarised as five critical times, which are:
after using the latrine
after cleaning a child’s bottom
before preparing food
before feeding a child.
Many diseases are caused by eating food that has been contaminated with an infectious agent, usually from faeces. If these diseases lead to diarrhoea or vomiting they are easily spread further if sanitation provision is poor. Food hygiene refers to practices and behaviours that can prevent contamination. For example, food and water should be stored in the home in closed containers to prevent contact with flies, rodents and other vectors. These containers should not be used for any other purpose and must be kept clean. Raw and cooked meats should not be stored together, and meat and dairy produce should be kept in a cool place, ideally in a refrigerator. Food should be prepared on clean surfaces and cooked at the correct temperature for the required time. Particular care should be taken over meat, poultry, fish and dairy produce.
Control of vectors
As mentioned above, all food should be stored in a way that it is not accessible to flies, rodents and other potential vectors. Storing wastes properly is also an important way of controlling vectors. Food waste should be disposed of immediately or stored in a closed container before disposal to discourage the presence of flies, etc. Household solid waste storage containers should be emptied frequently. If the waste is disposed of in a pit it should be covered with soil immediately.
Waste management can also play a part in controlling mosquitoes. Mosquitoes need water to breed, but they can also do this successfully in very small temporary puddles of rainwater. Plastic bags and other plastic waste that is carelessly discarded can hold enough water to enable mosquitoes to reproduce. Collecting and disposing of plastic correctly by burial or burning ensures this opportunity for mosquito breeding is removed.
According to the F diagram, which of the three barriers to faecal-oral disease transmission would be most effective in preventing infection?
The three barriers in the F diagram are sanitation (using a latrine), safe water supply and good hygiene, specifically hand washing. The first two are effective barriers to some of the steps in disease transmission, but hygiene cuts across all the lines of transmission. If the person who is the potential new host washes their hands at all critical times, this will be the single most effective method of preventing infection.
Sanitation is not a dirty word. Sanitation matters.
....making effort to "STAY WELL"