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West Africa desperate for cleaner toilets to save slums from cholera

A common latrine in Kroo Bay slum in Sierra Leone's capital Freetown. Photograph: Anna Jefferys/IRIN West Africa desperate for cleaner toilets to save slums from cholera

Sierra Leone, Ghana, Niger and Guinea are falling short of their millennium development goal on access to sanitation

IRIN, part of the Guardian development network

Aid agencies are scrambling to treat thousands of cholera patients in Sierra Leone's capital, Freetown, where the number of infections is mounting by more than 250 per day. Most patients are from the city's urban slums, where open defecation is rife, toilets are rare, sewage is improperly disposed of and awareness of cholera is low. Water and sanitation specialists say unless these problems are addressed, cholera will continue to flourish both in Sierra Leone and throughout west Africa.

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By 15 August, more than 19,000 people had contracted cholera in west Africa, the most affected countries being Sierra Leone, Ghana, Niger and Guinea, according to the UN Children's Fund Unicef.

"There is a massive failure to take cholera seriously in this region, and to publicise it," said a west Africa cholera specialist. "Ultimately, if you want to get rid of cholera you need to address the structural issues that cause it." The money is there, "it is a question of tapping into it and taking responsibility for your citizens".

Take cholera seriously

Most west African countries are falling far short of their millennium development goal to double the proportion of citizens with access to proper sanitation facilities – only 37% of inhabitants can access a clean toilet, according to the World Health Organisation (pdf).

As in Freetown, a high proportion of the cholera cases in Conakry, the Guinean capital, and Accra, Ghana's capital, are concentrated in urban slums, where there are few clean toilets and most people openly defecate, often dangerously close to open wells that are the source of water for most residents.

Governments tend to clean up the cholera mess once it is in full swing rather than working on prevention, said an independent water, sanitation and hygiene (Wash) specialist, adding: "It is government's responsibility to address the very basic sanitation rights of its citizens."

Donors, too, prefer to fund reactively, hence "Unicef's sword and shield [response-prevention] strategy is more sword than shield," said Patrick Laurent, west Africa Wash co-ordinator at the organisation.

When aid agencies approached the African Development Bank last year for cholera prevention support in the Central African Republic, the response was: "When you report a cholera case, we'll give you the money." In Guinea, just a few aid agencies – Action Against Hunger and Unicef – work on cholera prevention with the government, while one – Médecins sans Frontièrs – is doing the bulk of the treatment and transmission containment.

Ghana: prosecution over publicity

In Greater Accra, with 77% of the country's cholera cases, at least 20,000 people have no toilet or use bucket latrines, according to the Accra health department director, Simpson Boateng. Those living near the sea defecate on the beach.

The Ghanaian government banned open defecation and bucket latrines in 2010, and arrests all perpetrators, said Boateng. "We need to continue to educate them [people], but more importantly, you will be arrested when caught," he told IRIN. "As I speak, over 1,000 landlords have been prosecuted for still using pan latrines in their houses." The city council is establishing a "sanitation court" to try the culprits. "We are simply enforcing the bylaws that frown upon this conduct," he said.

Unlike in neighbouring Guinea and Sierra Leone, where the governments are weak and rely on aid agencies to drive the response, the Ghanaian authorities are leading the cholera action but have "underplayed it" for political purposes, said Laurent. The recent death of President John Atta Mills and the approaching parliamentary elections have drawn the attention of most government officials for weeks.

Give them an alternative

Arrests may be a temporary deterrent, but people will continue to defecate in the open as long as they have no alternative, say aid agency staff. Only 17% of Accra's residents, and 8% of rural Ghanaians, have access to an adequate toilet, according to the government's 2008 health survey.

The key is to get communities across west Africa to want to use and maintain clean toilets. In Sierra Leone, Unicef is pushing community-driven total sanitation, in which communities move away from open defecation once they understand its consequences, and go on to build and maintain clean toilets themselves.

In this model, Unilever, which manufactures cleaning products, has worked with Unicef and local partners in Gambia, and with Water and Sanitation for the Urban Poor, a non-profit group, in Ghana to form the Clean Team. The process is: trigger a demand for toilets through behaviour change; arrive at a price that works for everyone; make clean toilets available.

A project in Kumasi, in south-central Ghana, targeted 100 families, most of whom were sharing dirty latrines. Each was given a free chemical toilet with a sealed waste container that was exchanged two to three times per week. A family of five pays about $15 per month for the service, which is less than it costs to use the public toilets.

The waste is processed in the city's septic tank system, but the municipality hopes to use it to produce biofuel. So far the scheme has improved hygiene, lowered household costs and reduced the use of plastic bags for defecation, said Clean Team manager Asantewa Gyamfi. The plan is to expand it to 1,500 families.

Keeping toilets clean

Transferring such an intensive approach to an urban slum setting in Freetown is a challenge, said Unicef's Sierra Leone communications specialist, Gaurav Garg. Most of Freetown's flood-prone slums are hemmed in by the ocean and/or mountains, and there is simply no room to build toilets – public latrines are the only option.

An urban Wash consortium – made up of Oxfam, Action Against Hunger, Save the Children, Goal and Concern – charged with helping the government improve sanitation in Freetown's slums, has decided that improving and rebuilding public toilets is the only option, but keeping them clean is the real challenge, said Marc Faux, the group co-ordinator.

Community committees have been set up to run the toilets. Each is given four roles: collect money for their use, use the money to clean and repair the toilets, communicate the community's sanitation concerns to political decision-makers, and make sure waste is dumped safely. Health officials say until each of these jobs is done well, use will continue to be low.

Most of the waste from public latrines has been dumped in nearby rubbish tips or into the sea. The NGO consortium is experimenting with a low-technology device that pumps waste into containers that can be taken to trucks. Another method being tested is a device used to separate urine from faecal matter, which can then be turned into compost.

These and other innovations are an important start to addressing the myriad challenges in unsanitary, densely populated, coastal cities such as Freetown, Conakry and Accra. But they will only make a dent in cholera prevention. The issue must be addressed "not on a project-by-project basis, but holistically, involving education, health systems, water and sanitation infrastructure – the lot", said Mariamme Dem, west Africa head of WaterAid.

That looks a long way off. For now, NGOs are hastily setting up treatment centres to care for the cholera victims who come their way – as they have done every few years since the 1980s.

Cholera in Niger

In Niger, the situation is different in terms of topography and humanitarian context. Around 99% of the cholera cases are in the Tillaberi region in the south-west, on the Niger river. The rest are in refugee camps in Ouallam, in south-western Tillaberi.

Cholera has broken out against a backdrop of high rates of malnutrition and food insecurity, and large numbers of refugees who fled the takeover of northern Mali. The rains and insecurity make it difficult to access some cholera-hit villages, said Unicef's Laurent.

"If you add all of the above conditions, plus the rainy season, floods and poor sanitation, it's not surprising to see a cholera outbreak," he said. The government has a low capacity to respond to cholera but is willing to collaborate with the many relief and aid agencies working to alleviate the emergency there, said Laurent. "For me, this is half the battle."

Source: The Guardian UK



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