Despite the gains in recent years, far too many children still die before their fifth birthday. Childhood mortality in low income countries is 76 per thousand live births compared with 7 per thousand in high income countries. Now that pneumococcal vaccine is in a widespread use we may expect diarrhoea to take over from pneumonia as the number one killer of children. Certainly in slums – soon to be home to over 1 billion people – diarrhoea is the greatest threat not just to life, but also to child health. Diarrhoea predisposes to chronic enteropathy, especially in malnourished children, which in turn predisposes to stunting and perhaps reduced cognitive development.
But it does not have to be this way. The first ‘sanitary revolution’ in the second half of the 19th century in Europe and North America yielded massive gains in child survival. Less than 4% of all development assistance has been allocated to urban water and sanitation improvement over the last few decades, according to Prof David Satterthwaite. Moreover, it is not as though Europe and America were awash with money; the per capita GDP of Britain in the 1860s ($703.1) was roughly equivalent to that of Rwanda today ($697.3). This suggests that a lack of political will is also to blame for poor sewage and water installations in modern day slums. And the pitiful state of sanitation in modern slums has been thoroughly documented. Hardly surprisingly, improving sanitation is the number one priority for people who live in slums. Water and sanitation is not a middle-class concern foisted on slum dwellers; it is a critically important issue that results in millions of child deaths and that local people want tackled.
There are of course barriers to tackling this problem relating to relative powerlessness of people in slums, poor local governance, immature financial markets, and so on. But there is another problem that is created entirely by a certain type of armchair academic – this is the pernicious idea that nothing can be done pending improvements in local and national governance. Such people argue that it is first necessary to improve security of tenure, functioning financial markets, and so on. An extension of this argument, for which empirical support is absent, is that water and sanitation is not enough; it must be part of an improvement in the whole slum ‘nexus’ to include solid waste disposal, street drainage, home improvement, etc. We cannot wait for extractive elites to disappear, the judiciary to be made independent, or every slum holder to achieve title before acting; Paris famously installed a functioning sewage system during the dictatorship of Napoleon the third following his coup d’état. Fortunately water and sanitation was prioritised at a recent WHO Technical Working Group on “Addressing Urban Health Equity Through Slum Upgrading” attended by the CLAHRC WM Director.
So, let the water and sanitation revolution begin. Let it be driven by political and social zeal but do not let it be undisciplined, and let us never forget that water and sanitation is a socio-technical innovation – it needs to be supported (ideally initiated) by local people themselves. Ensuring proper use and maintenance of sanitary facilities requires alignment of supply and demand.
A number of international organisation promote water and sanitation in low- and middle-income countries, for example the UN-HABITATs Water and Sanitation Trust Fund. But good intentions are not enough when it comes to sanitation – even where sanitation and water have been improved, the benefits on health are often nugatory.  This is because the installations are inadequate, and/or because facilities are underused or poorly maintained. It is thus crucially important that interventions meet local needs, that they can be maintained, and that their effects in reducing exposure to infection and improving health are evaluated. Installation of improved water and sanitation utilities needs to be accompanied by research into how to make this socio-technical intervention work well and also summative evaluation of the effects on health and well-being.
— Richard Lilford, CLAHRC WM Director
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