Changing Sanitation in Haiti

In our November 3rd class meeting we discussed communicable diseases and using intervention to address public knowledge, attitudes and practices. One of the diseases discussed was cholera, an intestinal, bacterial infection that causes diarrhea and vomiting that can lead to severe dehydration and death. The emergence of cholera in Haiti, after 100 years without a reported case, is sometimes discussed as an example of international aid efforts gone awry. After the 2010 earthquake in southern Haiti, Nepalese troops representing the United Nations discharged raw sewage, believed to have carried a strain of cholera, into a tributary of the Aribonite river. This theory has not been conclusively confirmed, but many have accepted it as fact and the US Center for Disease Control has said there was strong evidence supporting it.

Fundraising to fight the disease and campaigns to improve sanitation are still underway as a part of the UN's effort to mitigate the damage done in Haiti by the spread of cholera, 4 years later. In a country where 50 percent of citizens lack access to adequate sanitation systems, a wide variety of interventions will be needed. These interventions will have to address public knowledge, attitudes and practices to be successful. Currently, the UN and the World Bank are training Haitians to construct latrines and install water filter systems in public buildings in areas of high population density. These are positive steps that may improve public practice in the short-term, but may not adequately tackle issues of knowledge of proper sanitation and attitudes about sanitation (a personal subject for many people around the world).

The 2010 earthquake forced an influx of temporary clean water sources and sanitation into the island nation, but little progress in the way of lasting improvements has been made. Now, there is a push to bring sanitation infrastructure to the city of Port au Prince, the capital city of about 4 million people. Pause for a second, and think about a city the size of Los Angelos or Chicago without a sewer system. For now, all the raw sewage of the city is collected in open canals or in public outhouses that empty into the ocean. Haitians who can afford a latrine have their cesspools cleaned by bayakou. The role of the bayakuos is simple: one goes down into the pit with a bucket to fill, one pulls the full bucket of waste out of the hole, one carts the waste away. Where the waste eventually ends is a mystery to the clients, who never meet the bayakous. The stigma associated with being a manual sanitation worker and essentially being Haiti's sanitation system is so strong that the word "bayakou" is used as a pejorative slur. Some never tell their wives what it is they do for a living, and contacting one for hire involves the use of secretive middlemen.



Historically, international donors have not been particularly helpful in funding sanitation projects, and the money is still slow to come in. Soon enough, though, sewage in Haiti's capitol will be carried through underground pipes to the city's first sewage treatment plant. Two years ago, Haiti's new water and sanitation agency debuted. Using funds secured from the Spanish government, the agency has finished construction of the sewage plant (the infrastructure to move the sewage is still in the works) and is in the process of constructing a second. The city's sanitation engineers recognize the need for time to normalize utilization of a sanitation system.

Etienne (one of the engineers) says better sanitation will take a lot more than building treatment plants. "Not much attention has been paid to sanitation over the years," he says, "so people do not normally think of sanitation, in terms of their approach, their behavior and so on. So the first thing is changing that sort of mentality.

Etinne, in his interview with National Public Radio, goes on to explain that sanitation has taken a lower priority to other, more pressing needs. The poorest nation in the western hemisphere, Haitians make an average of 2 dollars a day. Etinne recognizes the need to increase knowledge of proper sanitation and change attitudes about the importance of sanitation as a means of combating cholera and a host of other infectious diseases caused by pathogens found in untreated water. Technology alone cannot address health issues, they're too human. Health decisions are personal decisions shaped by personal values and cultural norms, concepts that can be difficult to incorporate into technological innovations. As Etinne suggests, technological fixes need to be supplemented with efforts to increase awareness of the importance of changed behavior and to convince stakeholders of public projects to become engaged in the success of the project. The Bill and Melinda Gates Foundation and other non-governmental organizations emphasize the usage of small-scale projects outside of the public sector, despite studies that show spending on sanitation infrastructure can yield returns of up to 5 times initial investment and sanitation-related diseases work to damage economic production.

I'm convinced that every person deserves the opportunity to live a healthy life. A healthy life is one that doesn't involve daily contact with human bodily wastes. It is my opinion that any intervention devised to address cholera and sanitation issues in Haiti has to start with the public sector. The role of organizing and providing sanitation has fallen to local governments in modern history for good reason: the financial resources, technical knowledge and political strength to complete large projects that don't privatize easily cannot be accomplished by individuals. Setting the need to change cultural norms aside, designing stop-gap solutions like latrines with bio-composting ability and solar-powered flush toilets is not a real solution. There is no feasible way to disperse this technology to a huge number of impoverished people, certainly not at a price tag of $1000 per solar-toilet. Engaging the Haitian public sector in the process of creating a system capable of handling the waste of 4 million people will take money, time and effort. As Haiti's cholera epidemic spreads to other nations (it has appeared as far away as Mexico), the need to finally spend the money, time and effort to increase Haiti's sanitation capacity will continue to increase, if only to keep cholera contained.

Media Sources:

1. Haiti's Shadow Sanitation System, Jonathon M. Katz, The New Yorker, March 12, 2014
2. Why Cholera Persists In Haiti Despite An Abundance Of Aid, NPR Staff, National Public Radio, March 21, 2014
3. In Haiti, Waiting for the Grand Bayakou, Amy Wilentz, The New York Times, November 25, 2010
4. UN chief steps up fight against Haiti cholera epidemic, Staff, The Guardian, July 16, 2014
5. Port-Au-Prince: A City Of Millions, With No Sewer System, Richard Knox, National Public Radio, April 13, 2012