Module 4: Unique Urban Sanitation Issues

Poor sanitation is one of the most accurate indicators of urban poverty and health problems.(1)  According to the World Health Organization (WHO), over 600 million urbanites live in low quality shelters or other areas plagued by overcrowding and inadequate provision of sanitation services, including potable water and safe waste disposal.(2)  The number of people without access to these services is still increasing, despite general improvements in urban sanitation programs.  In the last twenty years, sanitation coverage has made great strides, but it continues to be less accessible to the urban poor.  According to the UNDP-World Bank Water and Sanitation Program, in 1990, 453 million urbanites “had no sanitation services,” and despite efforts to ameliorate this crisis, in 1994, this number had increased to 589 million people.(3)  The challenge of sanitation intervention is to keep up with the growing population.  Currently, the rate at which sanitation programs are being introduced to communities is far lower than the rate of overall population growth, resulting in more underserved people, despite these attempts to increase coverage.  Furthermore, the population growth results in overcrowding, exacerbating sanitation issues.                     

In many instances, the urban poor live illegally in areas “deemed unfit for habitation,” making the residents “officially invisible”.(4)  Without permission to live on the land, they have no access to government support for sanitation or health care programs.  These conditions do not only affect the people who live in them; their effects influence the rest of the city as well.  Public health officials regard slums and encampments as threats to the health and safety of people who live or work nearby.(5)  In this way, the plight of the “invisible” spills into the visible sector, producing recognized health outcomes.

Sanitation issues (such as a lack of proper waste disposal methods) are at the root of dozens of fatal contagious diseases, many of which are particularly prevalent among children.(6) Diarrhea is one of the most common of these illnesses, and is often prevalent in populations with limited access to clean water.(7) Other prominent diseases spread by improper sanitation include dengue fever, cholera, and tuberculosis.(8) 

Low Quality Living Conditions and Services

Many urban poor live in cramped housing structures with a multitude of health hazards such as mold, rats, and potential toxicity from lead paint, all of which can induce infections, diseases, and injuries.(9) Poorly constructed buildings house insects that become vectors for disease by hiding in the walls or in water, sometimes carrying dengue fever or malaria.(10) At the same time, inadequate housing can act as a catalyst for mental health and general nutrition problems.  Housing is a tremendous monetary expense, resulting in high levels of stress, and less money available for other necessities.(11) 

The problems afflicting these informal housing settlements are also intertwined with the larger infrastructure of the city.  Many of the conditions described are not only dangerous for inhabitants, but they also prove difficult to remedy.  As described by the Water and Sanitation Program cited earlier, “construction of latrines or conventional sewers is much more difficult in the congested narrow streets and alleys of many peri-urban settlements.”(12)  Fortunately some communities have begun to find ways to alleviate these infrastructural problems.  One such program in Mexico found that using cement, rather than dirt floors, was associated with improved child health, including a decrease in cases of diarrhea and infection.(13)

Many people living in poor areas are not able to maintain a proper level of domestic hygiene, whether they are uninformed of health hazards or cannot afford toilet paper.  Hand washing is difficult in houses or shelters without running water, and safe food preparation and storage is often impossible to achieve in urban slums, where there is often limited running water and sewage systems, and garbage collection are rare.  Nearly 100 million urban dwellers of Africa, Asia, and Latin America reportedly use the “wrap and throw” method of defecating in the open due to lack of home toilets; public restrooms are often low quality, too far away, or too expensive.(14) In urban areas, typically less than half of all solid garbage waste is collected, and low-income neighborhoods have the least access to that service.  This affects the immediate surrounding areas; waste accumulates in the streets, drawing in disease-carrying animals and insects.  These practices have environmental ramifications as well, since waste subsequently pollutes the water supply.(15) When sewage is dumped into bodies of water, seafood quickly becomes contaminated, resulting in disease epidemics, such as the cases of hepatitis A in Shanghai and cholera in Peru.(16)   In Peru, this outbreak affected more than just those who fell ill; within weeks, the country lost “US$1 billion from reduced agricultural exports to the United States and from the collapse of tourism.”(17)

Case Study: Sanitation in Cape Town Settlements

Examples of many of these issues were found in a study of sanitation and related health risks in low-cost housing developments in Cape Town, South Africa.  Most of these housing structures contained “informal dwellings” outside (with more residents), which the owners of the houses viewed as sources of income.  This set-up resulted in the severe overcrowding of an area that was already ill equipped to accommodate the residents. 

Unsurprisingly, these housing settlements began to see a rise in health hazards, many of which arose from the low quality construction combined with the dense population.  Most homes had structural problems that the owners could not afford to repair, including cracks in the walls that caused leaking.  The lack of maintenance subsequently induced immune problems among residents; poor construction, damp interiors, and overcrowding are known to facilitate the spread of diseases such as tuberculosis.  Diarrhea was extremely widespread, in part due to limited water and sanitation resources.  According to surveys of the settlements, 58% of the toilets did not function, 66% of the bathrooms substituted newspaper for toilet paper, and 82% of the bathrooms lacked soap.

With such infrastructural failure and the dearth of hygienic resources, the Cape Town settlements suffered from increased disease prevalence.  Interestingly, most of these unhealthy practices did not emerge from a lack of knowledge.  On the contrary, the study suggests that inhabitants had sufficient knowledge about sanitation.  However, knowledge does not always translate into practice.  This phenomenon indicates that efforts to improve conditions within these housing settlements should focus less on awareness campaigns, and more on practical action, tailored to the layout and facilities of the housing structures.(18)

Urban Malaria

Though it is still more common in rural areas, malaria is a primary cause of illness and death for people in many cities in the developing world, in part because the disease vectors have adapted to urban conditions.(19) In the cities of sub-Saharan Africa, approximately 200 million residents are at risk for malaria.(20) The disease is prevalent in urban areas because infected mosquitoes breed in standing water left by the lack of drainage systems.  Additionally, most urban populations are not immune to the disease, and overcrowding exacerbates its spread.  A recent study showed that urban agriculture, while improving food security and nutrition, has “created new mosquito breeding grounds” that have increased the risk of malaria in these cities.(21) Urban malaria is a growing issue that needs to be further addressed.  Fortunately, the types of programs that focus on (and have succeeded in) rural areas have the potential to be equally beneficial to city dwellers, when adjusted to the needs of urbanites.

Tuberculosis

Though tuberculosis (TB) has decreased over the past few centuries, it remains one of the leading causes of death for adults living in low- and middle-income countries.  In 2005, it caused 1.6 million deaths, with rates that corresponded to socioeconomic status.(22) TB is more dangerous in cities because of urban crowding and poor housing conditions, so people living in impoverished areas suffer the most from this disease.  For example, in Karachi, Pakistan, the rate of TB in the poorest parts of the city is double the TB rate of the country on average.(23) Additionally, TB is highly prevalent in Japan, but varies drastically between regions.  This characteristic is relatively unique to TB, and explains why cities can have such diversity in such small areas.  The living conditions of small pockets within cities are typically correlated with TB risk, independent of the national averages.(24)

Footnotes

(1) Wright, A. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007. 

(2) Satterthwaite, D. (2003). The links between poverty and the environment in urban areas of Africa, Asia, and Latin America. The Annals of the American Academy of Political and Social Science, 590(1), 73-92.

(3) Wright, A. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007. 

(4) Ibid.

(5) Cousineau, M. R. (1997). Health status of and access to health services by residents of urban encampments in Los Angeles. Journal of health care for the poor and underserved, 8(1), 70-82.

(6) Wright, A. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007. 

(7) World Health Organization.  World Health Report 2002: Reducing Risks, Promoting Healthy Life. World Health Organization, 2002. 

(8) Zarocostas, J. (2010). Wide inequities in health are hidden in urban settings, says report. BMJ: British Medical Journal (Online), 341.

(9) Harpham, T. (2009). Urban health in developing countries: What do we know and where do we go? Health & Place 15: 107–116.

(10) Dye, C. (2008). Health and Urban Living. Science 319: 768-769.

(11) Harpham, T. (2009). Urban health in developing countries: What do we know and where do we go? Health & Place 15: 107–116.

(12) Wright, A. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007. 

(13) Montgomery, M. (2009). Urban Poverty and Health in Developing Countries. Population Bulletin 64: 2-15.

(14) Satterthwaite, D. (2003). The links between poverty and the environment in urban areas of Africa, Asia, and Latin America. The Annals of the American Academy of Political and Social Science, 590(1), 73-92.

(15) Ibid.

(16) Wright, A. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007. 

(17) Ibid.

(18) Govender, T., Barnes, J. M., & Pieper, C. H. (2011). Housing conditions, sanitation status and associated health risks in selected subsidized low-cost housing settlements in Cape Town, South Africa. Habitat International, 35(2), 335-342.

(19) Satterthwaite, D. (2003). “The Links between Poverty and the Environment in Urban Areas of Africa, Asia, and Latin America.”The ANNALS of the American Academy of Political and Social Science 590: 73-91.

(20) Montgomery, M. (2009). “Urban Poverty and Health in Developing Countries.”Population Bulletin 64: 2-15.

(21) Stoler, J., Weeks, J. R., Getis, A., & Hill, A. G. (2009). Distance threshold for the effect of urban agriculture on elevated self-reported malaria prevalence in Accra, Ghana. The American journal of tropical medicine and hygiene, 80(4), 547-554.

(22) Montgomery, M. (2009). “Urban Poverty and Health in Developing Countries.” Population Bulletin 64: 2-15.

(23) Shetty, P. (2011). Health Care for Urban Poor Falls Through the Gap. The Lancet 377: 627-628. 

(24) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.