Water and Waste:
a discussion paper
Equity Policy Center
WOMEN, WATER AND WASTE
: Mid-Decade Forum
World Conference of the United Nations
Decade for Women
Equity Policy Center
p 1302 18th Street, NW
Washington, D. C. 20036
535 Boulevard of Presidents
Sarasota, Florida 53577
BEYOND ACCESS TO IMPROVED
WATER SUPPLY AND SANITATION:
IMPACTS ON AND OF WOMEN AND CHILDREN
Introduction and Background
In attempts to meet the 1990 target for providing all peoples
with safe drinking water*/ and improved sanitation, and "health for all
by the year 2,000,"**/ increased emphasis must be given to the inter-
dependence of these laudable goals for enhancing the quality of life.
Because a disproportionate number of the poor is made up of women and
children, a concerted attempt must be made to assess the social impact
of interventions in water supply and sanitation on this group. The
major thrust of this paper, therefore, will be to: (1) examine the
impact of improved water supply and sanitation programs on the lives of
women and children and (2) highlight those ways in which women can be
the key agents in assuring that such projects will have a more signi-
ficant impact on all the target population.
It has been stated that: "If the drinking water of the world
could be cleaned up overnight it would, by some estimates, cut the
infant mortality worldwide by 50 percent." (Bourne: 1980). Not everyone
is in agreement with this statement, however. Feachem, in his excellent
book on rural water supply programs in Lesotho, states: ". our
conclusions are that no measurable reduction in water-related disease
has resulted so far from village water supplies. It is possible that
benefits might result were other health measures to be implemented
together with water supply improvements." (Feachem et al: 1978)
At the recent annual PAHO Conference, the Ministers of Health
from Latin America pledged their full support for the Water Decade,
reviewed the past accomplishments of their Ministries, and presented a
*/ UN Conference on Water in Mar del Plata, Argentina
**/ WIIO/'1ICEF Primary Health Conference at Alma Ata, Russia,
An earlier version of this paper was presented at the Seminar on Impact
of Interventions in Water Supply and Sanitation in Developing Countries
sponsored b- USAID and PAHO March 25-26, 1980 in Washington, D.C. The
paper was al I used as background material for the Equity Policy Center's
International. Symposium on Women and Their Health, June 8-11, 1980.
revealing chart which showed a close correlation (in most of the 23
countries listed) between the percentage of the population served by
potable water and the incidence of death among children under four years
of age from gastro-intestinal and other diarrheal diseases.*/ There
are, however, some startling exceptions which need further analysis to
determine why some countries with the same percentage of people served
by potable water show a much higher infant mortality rate. For
Guatemala and Honduras, the 1976 data indicate that although both
countries have an equal percentage of the population served by potable
water, the infant mortality rate for children in Guatemala was nearly
800 per 100,000 whereas in Honduras the death rate was approximately 200
per 100,000. Paraguay, with the same infant mortality rate as Honduras,
had less than one-third the amount of water available. Cuba, for in-
stance with such a small percentage served, has one of the lowest infant
mortality rates from enteritis and other diarrheal diseases of all the
countries, even those that have greater access to water.**/
To what extent can these substantial differences be attributed
to a well-functioning primary health care program or responsible com-
munity participation? To what extent were women involved? As we now
plan, we need to know more about the reasons for the variation in
impacts in both the successful and unsuccessful programs. And yet as
McJunkin pointed out so succinctly
"the tortured, contrived estimates of monetary
benefits for health improvements, reduction
in the toil of housewives, increased gardening,
etc., piling assumption upon assumption, to a
preconceived answer is a bureaucratic
extravagance, a useless diversion of funds and
manpower at the expense of the beneficiaries."
It is important to understand both the constraints and motivations in
order to promote activities and programs that will have positive impacts.
*/ World Health Organization, 1979 (PAHO:12).
**/ In an excellent study made between 1968 and 1971 of 35,000 families
in 13 Latir American communities made in countries with different socio-
economic c-naicions, cultures, climates and population density the authors
found a direct relationship with lack of water service and higher post
neo-natal mortality. (Puffer and Serrano: 1973)
.''.-- Percentage of the population served by potable water and deaths from enteritis
and other diarheal diseases per 100,000 children aged 1-4 year, by country, 1977 or latest
age serveda) deaths per 100.000 (b)
(1-4 years of age)
50 100 0 200 400 600 800
I I I I I I I
Trinidad and Tobago
I I a
I I I
I r I
I I I '
'i I I
i I~ -1
I ( i
-I 1 r
1 i I
(a) around 1977.
(b) around 1976.
Source: World Health Organization. 1979:12
,e ~-t~5~ ~c
- -- ------- ---^9-----Yr~'I ---.-I -lur '
Before looking specifically at some of the other impacts on
women, I want to review this world-wide tragedy of infant death caused
by diarrhea and dehydration. Recognizing that the value of children is
a universal one and that infant mortality takes a serious toll on the
psychological and physical well-being of mothers, there is no way to
separate the incidence of water and sanitation-related morbidity and
mortality from the overall social impact, particularly on women.
Aware of this serious health problem resulting in high infant
mortality, the United States Agency for International Development has
among other activities launched a five-year Mass Media and Health
Practice Project aimed at rural mothers and other child-rearing family
members. An integral part of this mass media campaign is the use of
face to face intervention in promoting the adoption of practices that
will help to treat and alleviate acute infant diarrhea. Midwives will
serve as one vital link in the development communication process,
reinforcing project messages relevant to environmental sanitation,
personal hygiene, continued breastfeeding and oral rehydration.
Sanitation and Behavior
But here once again we are offering primarily curative -- not
preventative solutions. To a great extent, diarrheal diseases are
related to a lack of adequate sanitation or safe water. And yet, as far
as I know, there has been no attempt to investigate the integration of
other health sector programs such as rehydration, nutrition, and popu-
lation with the planning for increased investment in water supply and
sanitation -- ard particularly with the need for scatalogical data in
order to understand attitudes toward human excreta and diarrheal in-
The perception that children's faeces is "harmless" (PRAI, 1968)
can be a continuing link in chains of reinfection whether the faeces is
thrown on a nearby garbage heap or baby diapers are washed with dishes
in an urban home with a newly installed standpipe. These practices
should be understood and analysis of them included in the preparation of
audiovisual messages. In the Yucatan, no diapers are used, but mothers
are so attuned to their children's needs that they merely hold them away
from them usually over the dirt floor of the hut or just outside to
urinate or defecate.
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Evidence shows as mothers begin to understand the dangers of
even infant faeces not necessarily the "germ theory," but the
cause/effect relationship between water and diarrehea-they will change
their behavior. For instance, Chan Kom, the Maya village where I have
lived off and on for the last ten years, has had piped water since 1974.
In 1976, when the water system was inoperable for the first time, the
women started complaining that their children were suffering from
diarrheal illnesses. They clearly saw the relationship between the lack
of clean water and the increased incidence of illness and went to the
mayor to complain.
Mothers are the socializers, the teachers of their children in
personal hygiene and sanitation practices. Where are the toddlers to
defecate? In many villages where latrines have been installed they
have not been used because: (1) the distance from the house makes trips
during the day infrequent and at night impossible and (2) the size of
the hole and the dark pit below frightens mothers and children. Dire
tales of children falling into the pit abound.
What can be done? Do latrines have to continue to be so far
from the.homes when there is no well to pollute? Do privies have to
emit such an unpleasant odor that they cannot be nearer to or attached
to the home? Sanitary engineers say there are ways to make aesthetically
pleasing as well as healthy and safe latrines. Rather than continue to
spend millions of dollars on malodorous, unattractive, inconvenient
latrines as we enter the Water Decade, let us focus on the accelerated
interventions in water and sanitation characterized by more appropriate
Another point to think about is the relationship of water
availability to the latrine. The faecal-oral reinfection route is well
known, but there has been very little designing of facilities to help
break this vicious circle. How can water for hand-washing be made
easily available to the latrine? How might people be successfully
motivated to adopt hygienic practices such as handwashing? What are the
usual behavior patterns? Can there be more dialogue with the women with
respect to where they wash clothes, dishes' hands, their children and
themselves? Behavioral mapping, as well as participant .observation, are
needed as we work together on designing culturally acceptable solutions.
If water development projects are to have a successful impact, con-
siderable attention must be paid to certain socioeconomic variables, such
as minimum equipment to use it effectively.
As more water is made available from pumps or standpipes, there
will be a need for appropriate vessels and safe patterns of use'and re-
use of water to enhance the health aspects. We cannot expect women to
bring their stones from the river to their back yards to wash. If water
is being used for laundry and bathing, can it be reused in an aqua-
privy? Do we only think of bathroom planning for urban areas?
In various remote villages, bathing areas have been set aside.
In some instances, a stone inset in the dirt floor of a Yucatec-Maya
hut. In Guatemala and Chiapas, a temascal, the water-efficient sweat
bath, is usually used. Small huts for bathing were also noted in Honduras
These existing patterns can be incorporated in a privy program
as explored in designing "dream latrines" in rural Nicaragua. (Rodriguez
Pineo and Elmendorf: 1977) If there cannot be dream latrines, there
can at least be recognition of the need to understand present attitudes,
beliefs, and health knowledge to motivate behavioral change in latrine
usage and hand-washing following the introduction of new technology.
In Guatemala, as an incentive to promoting personal hygiene, a
simple package containing a wash basin, soap dish, pails, and shelf to
attach to the latrines, was given as a reward to each household follow-
ing inspection of their new privy. (UNC/AID 1978) For such a kit, I
would also add a mirror and soap.
With respect to the introduction of excreta disposal facilities,
limited attention has been given to matters of pride and aesthetics. A
case study of water supply and excreta disposal revealed that Colombian
families preferred brightly colored cement stools and slabs over drab
gray facilities. (Rodriquez) When asked about latrine preferences and
practices in the Yucatan, women also cited their preference for an
aesthetically attractive latrine with a shiny porcelain seat or a
brightly painted cement floor or stool. (Elmendorf and McGarry: 1978)
The low impact of past programs on women and children is pri-
marily attributable to nonuse and misuse. In thinking through the whole
cycle of water supply and waste disposal.it is important to go beyond
the number of water pails carried by the women or the number of latrines
built, to a consideration of the overall impact once the technology is
In Bangladesh, a study of 120 villages showed usage of the
latrine by only 12.8 percent of the children, while adult usage (mostly
women) was 59.9 percent. (Skoda et al: 1977) A similar study of 525
latrines in India also revealed that many more women used the latrines
than men, while the children's faeces were thrown on garbage heaps.
(PRAI: 1968) This behavior ties in with the widespread belief that
children's excreta is harmless. (PRAI: 1968) It is also interesting to
note that adopters of latrines in Gorakhpur, India, appreciated the
privacy and convenience more than a decrease in disease (PRAI: 1969)
This was noted in most of the World Bank Studies (Elmendorf and Buckles:
1977 and 1978) A commonly held belief in Honduras that women should not
use the same latrine as men lest they become pregnant, limits the use of
even household latrines to female members of the family. (Eoff: 1980)
In Tanzania it was noted that the excreta of fathers and daughters
should not be mixed. (Hall: 1978)
In some areas, women and children use the same latrines, but in
many places the children defecate just outside since they are afraid of
falling through the large opening. In our case studies concerning water
supply and waste disposal in Latin America, we found that this fear was
widespread. In fact, in Nicaragua several women in the urban barrios of
Managua who had just installed flush toilets had kept their older,
stepped latrine with two openings -- the smaller, lower one for children.
These UNICEF model latrines were being maintained as training devices
for children. A similar model was well accepted in Yugoslavia.
Even in the U.S. as recently as 1972, Belcher reported that
although many families built toilets in their homes, many people,
especially men, continued to use the old privies or the fields:
one man said that he just did not feel
comfortable responding to nature in the home.
To him, this was an act that could not be
satisfactorily carried on within the confines
of a house because it was something that was
rated as unclean and he felt compelled to get
away from living quarters to carry out such
functions. (Belcher: 1972, p. 4)
The occurrence of regular patterns for excreta disposal in the field
have been reported in many countries (Kochar et al: 1976; Kochar: 1977)
As we noted in our Latin American case studies, defecation habits in the
field may point to informal uses of excreta for productive purposes:
Reuse of human excreta in Latin American is an
understood technology and is practiced traditionally
in a less advanced and systematic form than in
Asia. Re-use is informal -- often not verbalized
because of the taboo nature of the subject and
it takes place primarily in the individual house-
holds. Defecation in cornfields or on coffee
plants is considered to have a fertilizing function.
Similarly, fruit trees are purposely planted over
olde..filled latrine pits. In some areas, human
excreta deposited near the house is consumed by
pigs as an aid to maintaining sanitation. This
last practice is sometimes formalized when penned
pigs are released periodically to clean areas
designated for depositing human waste. (Elmendorf
and Buckles: 1978)
Perhaps these various findings indicate a need to include
latrines in the field -- similar to our portable johns -- but designed
as demonstrations for the introduction of latrines with fertilizer re-
use capacity. Such a program might also be used in the fields where
schistosomiasis is a problem, such as in Egypt. (Sanbach: 1975) If we
are looking at the impact on women and children, greater care should be
taken in designing segregated facilities which would solve not only the
problem of decreased use in the home, but also of inadequate facilities
in the field for men.
It is, however, significant to mention the observation made in a
recent World Bank study of the socio-cultural aspects of water supply
and excreta disposal. (Elmendorf and Buckles: 1977 and 1978) Findings
indicated the practice of latrine sharing even in urban slums among
relatives or intimate friends who had previously established a rela-
tionship through daily interactions in their work. (Nieves and Farrell:
The design of the facility for excreta disposal may not be in
accordance with the local motoric patterns, of which latrines not adapted
to a squatting position are the best known examples (Foster: 1952;
Rogers and Shoemaker: 1971). The opposite may also occur. In a case
study in Yucatan, squat plate latrines were not acceptable for the
majority of the population who knew about flush toilets through their
work in the tourist industry and other outside contacts. These people
wanted a stool-type rather than a squat plate. (Elmendorf and McGarry:
1978) In Quatemala seats were preferred also; as a place to rest, and
to prevent falling in. (Buckles: 1978)
Socio-cultural variations among villages and sexes in the same
country, as well as those of different continents and climates, are to
be expected. However, amazing similarities with respect to fears and
constraints appear in cross-cultural studies. For purposes of effective
project design, more detailed information concerning these constraints
In the Moslem world, cleaning after defecation is performed
using bare hands and water as opposed to cloth, leaves, or paper.
(Simpson: 1979) Women here, as in many parts of the world, wait to
relieve themselves until after dusk or in the dark of early morning for
reasons of female modesty and dignity. In Yucatan and Guatemala, where
women wear wide skirts, many urinate standing in market areas since no
private facilities are available.
Impact of Children on Intervention
in Water Supply and Sanitation
Because cultural inhibitions can and do provoke the misuse and
underuse of safe water supply and waste disposal systems, it is critical
that adequate health education and community participation efforts
involving women become integral components of planning strategies for
eradicating this problem. Third World women, the traditional drawers
and carriers of water, can play a significant role in promoting com-
munity acceptance of improved water supply and sanitation programs.
During the 1977 United Nations Water Conference in Mar del Plata, 30
non-governmental organizations recommended that developing countries
give serious consideration in their national plans to the following five
(a) include strategies to develop human resources
at the community level to meet local needs;
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(b) ensure equal access for women to training
with regard to the maintenance, management
and technology of water sources and
(c) ensure that women be included in any
educational programs on the use of water
and its protection from contamination;
(d) ensure the participation of women in local
councils and planning boards responsible
for making decisions on community water
(e) recognize the increasingly effective role
that women, NGOs and other women's organi-
zations can play in the education of public
opinion for needed change.
("Special Situation of Women in Regard to Water"
Statement prepared by the
Non-Governmental Organizations Committee on
UNICEF for the Preparatory Committee,
United Nations Water Conference
3 7 January 1977 mimeo)
In 1975 the World Plan of Action adopted at the International
Women's Year Conference in Mexico City had stressed that "improved
easily accessible safe water supplies (including wells, dams, catch-
ments, piping, etc.), sewage disposal and other sanitation measures
should be provided both to improve health conditions of families and to
reduce the burden of carrying water which falls mainly on women and
How much has happened since 1975? since 1977? What is going to
happen before 1990? Before the year 2000? Jane Stein noted in 1977 in
her informative report entitled: Water: Life or Death, that planners
had begun to include women in development schemes. As an adjunct to an
agricultural development project in Bolivia, a program was underway to
train young women 17 25 years of age to administer immunization shots,
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provide information on good nutrition for children, and lecture on the
proper maintenance of water and sanitation facilities. (Stein: 1977) A
number of these young women now are in complete charge of repair and
maintenance of the facilities, not just to keep them clean.
Such examples however are still rare. There are successful
pilot projects, such as the ones in Mexico in 1958 where women/village
workers played key roles in community participation in multi-sectoral
programs with water supply and sanitation components. Women supervisors
and planners were also relevant to the success of these projects.
Poston: 1962. These projects are easily replicable but have not become
the model. Usually women-oriented projects last through one administra-
tion at most. Others dwindle as private agencies change focus.
Training programs such as these in Mexico bode well in terms of
ensuring that inhabitants will benefit from development projects.
Moreover, the utilization of indigenous resources for diffusing in-
formation will enable many developing countries to realize their self-
reliance objective. With respect to community water supply and waste
disposal facilities, it is important to recognize that the target
population may accept facilities without altering their hygienic be-
havior. For this reason "good" planners stress the relevance of creating
educational programs which focus upon the "intended" as well as "per-
ceived" benefits if development efforts are to exceed the mere adoption
of the innovation. (WHO: 1979)
Understanding the needs for better sanitary habits is not a
simple process, particularly in the area of human defecation -- a taboo
subject in many cultures, with overtones of magic, witchcraft, or just
Victorian prudishness in others. One key concept central to diffusion
of appropriate technology in sanitation is understanding the way taboo
subjects are communicated. Taboo subjects are perceived as extremely
private and personal in nature because they deal with proscribed be-
havior. As we know, and as the literature confirms, taboo communication
occurs between individuals who are highly similar in certain character-
istics such as social status, education, beliefs, and often sex. This
limiting factor is a barrier to widespread and rapid diffusion of taboo
messages/information which, in turn, "perpetuates the taboo status of
the topic." (Rogers et al, 1971) Another recognized characteristic of taboo
communication is that it usually occurs in interlocking, closed networks
rather than in open, radical networks so the flow of messages is further
The implications of these facts for effective programs in the
field of improving or changing behavior patterns or technologies related
to human defecation and personal hygiene are obvious: The decision-
makers/leaders in the communities and in the agencies are usually men,
and they communicate with other men and not with the women. Until women
are involved and understand the importance of good sanitation we can
expect limited acceptance. Once the women understand, they can play key
roles in household decisions relating to changing behavioral patterns
and to socializing children in similar behavior and attitudes in areas
such as personal hygiene and sanitation.
As we enter the Mid-Decade Conference of Women in Development
and the Decade of Water and Sanitation within the context of health for
all, we have the opportunity the challenge, really to combine our
development strategies. Intersectoral, multidisciplinary planning
should involve women at all levels, from the village household to the
Rhetoric about including women in development will become a
reality when we go beyond access. Women are the key to the realization
of our goals of water and health for all. But even with the help of
women these goals cannot be achieved unless more is done.
As soon as there is a demonstrable relationship not necessarily
the germ theory between childhood deaths caused by diarreheal diseases
and use of improved water supply and sanitation, the mothers will become
the caretakers of these resources/facilities. -
Some say that people won't change their unhygienic personal
habits because of custom, religion, education, economics, or laziness
No one wants to be sick or die . Regardless
of history or culture, people learn to protect
themselves when given the opportunity and under-
standing. "Abel Wolman's Charter" World Health,
Jan. 1977: 17
- 13 -
Neither the peasants nor the scientists seem to be able to prove
that interventions in water supply and sanitation (WS/S) bring about
better health. The problems in our programs today are not primarily in
the engineering aspects but, in the
o ways they are introduced and the
o missing links in the effective use of them.
We have recognized the first point -- the importance of com-
munity participation -- but until the faecal/oral route of infection is
in fact broken we cannot expect much improvement in health.
And village mothers will not know how to break this vicious
circle until they have some important bits of equipment -- primarily
soap and a hand basin, adequate carrying and storage containers', along
with conveniently located unsmelly, safe latrines. And with these
instructions into how to use the new equipment.
At the present time we cannot say that all interventions in
water supply and sanitation bring improved health. Recent research
points out that there is a certain level of socio-economic development
necessary before our present programs in WS/S correlate with better
health. (Shuval et al. 1979) To accept these findings as a reason not
to make WS/S available to the marginal people -- the poorest of the
poor, is unthinkable. Instead it should give us cause to reexamine our
past approaches. Along with the introduction of improved community
facilities there should be provision for new appropriate household
equipment to maximize effective use.and appropriate, relevant instruc-
tions in their use.
If there is only one pail and no money to buy another, of course
it will be used for everything. If there is no top for the pail, a
covering with leaves is a poor substitute. To use a dipper or cup is
much easier than trying to lift a heavy pail or jug.
Making available at inexpensive, subsidized prices or even as
rewards in recognition of labor and/or time contributed inexpensive
ancillary kitchen, laundry and bathroom equipment, and soap will make it
possible for the villages to take advantage of the improved interventions
in water ar.. sanitation.*/ Audio-visual messages and health education
*/ In several countries brightly-colored, lightweight plastic water
jugs and tubs have had ready acceptance.
should relate specifically to the effective use of the new equipment --
both community and household -- so that they can be used efficiently
with pride and pleasure resulting in better health and productivity.
In summary, development planners and implementors must be
cognizant of the fact that there is as much to learn as there is to
impartAdevelopment schemes for improved water supply and sanitation are
to go beyond increased access. It is important that programs include
action plans and techniques for reducing the waste of human energy in
Women and children continue to expend inordinate amounts of time
and energy on arduous tasks that can be alleviated by the acceptance and
continued use of appropriate village technology. Concerted efforts to
ease their burdens would provide released time and renewed energy for
a variety of useful and pleasurable activies, e..., adult education and
training of children, etc. Increased emphasis needs to be placed on
training opportunities which enable women, the ultimate primary care
workers, to serve as interpersonal contacts in persuading people to
accept and continue using innovations for improved basic living con-
Not only must barriers be understood, but acceptable incentives
for change must be identified and considered. Foster suggests that:
people will change traditional behavior, i.e.
innovate (1) if they perceive personal, economic,
social, psychological, health, or other advantages
in so doing; (2) if they perceive change as a
realistic possibility for them; (3) if the economic
costs are within their capabilities; or (4) if
the social costs do not outweigh the perceived
advantage. (Foster 1962)
Together we can explore new and more appropriate techniques,
both hardware and software, to help the poorest of the poor, the mar-
ginal people, meet their basic needs -- including water, sanitation and
health. Thlrc is much fugitive data concerning problems and situations
in social aiyses of programs, in available ethnographic studies and in
anecdote? --al which needs to be gathered, shared, and made a part
of program designs.
More research to obtain relevant socio-cultural data to identify
these problems and constraints should be conducted. There is a dearth
of information. on the roles of women in this field. More specific
research is needed to find existing data as well as to have case studies
in various regions with different technologies to evaluate impact.
(Elmendorf and Buckles 1977) Much of this research can and should be an
integral part of development strategies, particularly if a problem-
solving dialogue approach is used. If we really.believe that community
participation is the key to more effective use and maintenance of
technological innovations in WSIS, then women, as the primary users,
must be involved both in the selection and implementation of programs
and as behavioral change agents within the homes.
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