Toilets hold key to improving child mortality

In a city of 2.13 million-slum dwellers, over 1 in 10 children in Nairobi die before the age of five. Diarrhoeal disease, the leading culprit, is the result of poor hygiene and dismal access to toilets and clean water.

However, the sprawling slums provide unique challenges that so far have hindered efforts by the Kenyan government, multi-lateral and community based organisations to tackle the crisis.

Without sewers, residents instead use either makeshift pit toilets, defecate on the ground or in plastic bags. Those with access to toilets share little more than a hole in the ground with dozens of other families.

The pits are often dirty, full and cannot be accessed at night because of safety concerns. Plastic bag use is common in those with and without access to communal toilets. The used bags, aptly named 'flying toilets' are thrown onto the ground or into drains. Inadequate excreta disposal facilities increase residents' exposure to faecally-derived pathogens, resulting in diarrhoeal disease.

However, childhood deaths from diarrhoeal disease are easily preventable. The tools to tackle diarrhoeal and other waterborne diseases have been known for decades, forming the crux of early public health interventions.

Yet despite effective solutions being available, Nairobi's slums are still plagued with disease. But this need not be the case.

The infrastructure taken for granted in most of the developed world – sewers, toilets and water pipes are not easily implemented within large slums. Spatial limitations, poor quality soil and unsystematic layout of the area make the execution of large-scale infrastructure development extremely costly and complex.

Instead, the Kenyan government seems eager to press ahead with wholesale slum relocations and land redevelopment.

But with the failure of slum relocation attempts and without large-scale, on-site slum infrastructure upgrading, efforts to decrease child mortality have shifted toward the implementation of smaller-scale interventions that have shown promising results in studies from Mumbai to La Paz.

The most effective, easily implemented and sustainable small-scale interventions to decrease diarrhoeal disease are point-of use water treatment, communal toilet facilities and increasing hand washing.

Communal toilet facilities provide the most effective and feasible method of improving sanitation within Nairobi's slums. Whilst inhibited by night time access, they nonetheless provide a significant improvement on current facilities and have been demonstrated to significantly reduce the incidence of diarrhoeal disease, particularly in children.

Whilst a number of communal facilities have been constructed in recent years, the number of toilets is still inadequate to serve the rapidly expanding population. Further facilities, with sustainable management and improvements in night-time access are required to resolve the unsanitary practices that drive the high rates of childhood diarrhoeal disease. Only then can the staggering infant mortality rate be expected to fall.

Hand-hygiene education programs, combined with the promotion of hand washing with soap have also been shown to be highly effective. As they are not limited by infrastructural or spatial constraints, such programs are easily implemented and extremely cost-effective.

However the sustainability of hand-washing behavioural change has not been well established. Individual and community behavioural changes may decrease over time, reducing the intervention's long-term efficacy. Researchers suggest that this may be overcome by marketing hand soap as a desirable consumer product (to look and smell clean, and follow social norms) rather than through health promotion campaigns.

The evidence based implementation of small-scale interventions promises to help reduce the dire child mortality rate that still plagues Nairobi's slums. Support for community based initiatives from the Kenyan government and UN-Habitat under the K-WATSAN program indicate that progress is underway toward reducing the still shocking number of preventable deaths in Sub-saharan Africa each year.