April 1, 1982
Dr. O. A. Sperandio
World Health Organization
1211 Geneve 27
Dear Dr. Sperandio:
Enclosed is the |"issues paper" for WHO, "Women and the Decade: Roles, Rights and Responsibilities" which Dr. A. Petros-Barvazian requested that I send directly to you. As he suggested, I have taken some of the material from my paper, "Women, Water and the Decade" (WASH, Arlington, VA Report No. 6, June 1981) but I added some new material on role theory which hopefully will strengthen our arguments for involving women in Decade activities.
If you will notice I have incorporated several sections from a recent paper, "The Role of Women as Partisipants and Beneficiaries in Water Supply and Sanitation Programs," WASH, Arlington, VA Technical Report No, 11, 1981, which I prepared with Dr. Ray Isely, Maternal and Child Health Specialist and Associate Director of WASH. I would like to thank him as well as Helen O'Brien, Health Educator and Public Health Nurse for adding their invaluable help in getting this paper ready in the short time allowed.
I look forward to discussing the paper with you in Washington on the 14th of April. If possible, it would be more convenient for me to meet you at PAHO at 5 p.m. instead of at the hotel at 6:00 as arranged by Ms. Vera Kalm since our Research Advisory Group has just set up an evening session. We can confirm exact details of our appointment after your arrival in the States.
Dr. Mary Elmendorf Consulting Anthropologist
cc: Vera Kalm / ADBN File \S
t-. ...... **t.
WOMEN AND THE DECADE: ROLES, RIGHTS AND RESPONSIBILITIES1^
On 10 October 1980, about 12,000 people died in the El Asnam earthquake in Algeria; another 250,000 were made homeless. The world was rightly shocked into action and millions of dollars of aid poured into Algeria. On the same day, at least 30,000 people died in the Third World because they had inadequate water or sanitation facilities.
Tens of millions of women spent half their day walking in the hot sun to carry home polluted water which would poison them and their families. The same thing happens every day and this "permanent disaster" is the most compelling justification for the Water Decade. The situation has been getting progressively worse. From the host of statistics compiled in preparation for the Water Decade, it has been estimated that today 100 million more people have to drink dirty water than in 1975, and 400 million more than 5 years ago have no sanitation. World Water, November-December 1980
The International Drinking Water Supply and Sanitation Decade 1981-1990 is a massive international effort to tackle what has become a top priority issue on world development agendas. Formally launched at a United Nations General Assembly meeting on November 10, 1980, the Decade involves UN agencies, bilaterial AID organizations, private organizations, and national governments; engineers, health professionals and social scientists; and most importantly, the people in the far-flung areas of the world who will become the participants and the beneficiaries of improved water and sanitation.
1) Prepared as part of WHO's contribution to the International Drinking Water and Sanitation Decade.
2) Consultant, Appropriate Designs for Basic Needs, Inc.
601 Tyler Drive, Sarasota, Florida U.S.A. 33577
/, ;;'! ( Oj iS / "
DRAFT -"2/1^/82 (comments and criticisms welcome)
The World Bank estimates the total Decade cost at between $100 and $300 billion, depending on the types of new facilities provided. The UN agencies UNDP, WHO, UNICEF, ILO, UNEP, FAO, and the World Bank are taking major roles, but the multilateral and bilateral donors combined cannot be expected to contribute more, than 25% of the budgetary goal. By nearly everyone's estimate more than 75% of the funding of Decade projects must be forthcoming from the developing countries themselves. 71 countries have completed assessments of their needs, 60 have formed National Committees, and 32 countries have feasible national plans for covering their populations.
In 1976, the World Bank undertook a two-year research program in order to identify technologies used in successful-water and waste disposal projects in 26 developing countries. Case studies of villages and urban fringe areas in Latin America, Asia and Africa primarily by social scientists, indigeneous to or knowledgeable about the geographic areas, brought to light some of the intricate problems encounteredin developing water and sanitation programs, especially the importance of "software" in successful systems, i.e., understanding socio-cultural factors and including the participation of communities (Elmendorf and Buckles,. 1978, revised 1980).
In this same context it is also, useful to consider the significance of improved water and sanitation facilities for the World Health Organization goal of health for all by the year 2000. ];
Primary health care, which has emerged as the leading strategy for meeting health needs in developing countries, includes, among other elements, community participation, universal coverage, and accessibility of appropriate technologies for improved water' and sanitation Thus the concept, and methods discussed in this paper are firmly linked to the "Health for All by the Year 2000" movement.
Engineers know how to build improved water and sanitation systems, health specialists understand the relationship between the multitude of diseases related to water and sanitation, and planners and economists know how to develop schemes and projects; but this understand ing and know-how are not enough. Increasingly development agencies
are turning to social scientists for better understanding of the sociocultural forces implicit in changes in water and sanitation facilities and the techniques for involving communities in defining and solving problems (Elmendorf, 1978; Buckles, 1978, revised 1980; Elmendorf, 1981; Hollensteiner, 1980; Perrett and Lethem, 1980; McGarry, 1977; Nieves and Farrell, 1982; Salinas and Caceres, 1982).
It is people who accept and maintain new technologies. In international and national organizations the buzz-word for the recognition of this fact is community participation or user-choice (Dobyns, 1952; Kirkby, 1973; Whyte and Burton, 1977). If communities or households feel that new facilities are theirs, they are much more apt to fully accept, use and maintain them. Simple adaptations at the local level increase potential for adoption. Feachem (1978) and others have noted (Elmendorf and Buckles, 1978; revised 1980) that "in general, the design issues that will be improved through user participation are minor in their engineering or financial consequences, but major in the potential effect upon acceptance,and correct use of the new facilities." Often overlooked however is the fact that over 50 percent of the adults in most communities are women. Women in rural and urban fringe areas around the world play major roles in the use and management of water supplies.
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 2000," increased emphasis must be given to the interdependence of these laudable goals for enhancing the quality of life.'
In this paper various issues related to the roles of women in water use and sanitation management in traditional societies are discussed, as well as their rights and responsibilities for the Water Decade with emphasis on health aspects.
* UN Conference on Water in Mar del Plata, Argentina, 1979.
* WHO/UNICEF Primary Health Conference at Alma Ata, Russia, 1978
THE RIGHTS OF WOMEN WITH RESPECT TO WATER SUPPLY AND SANITATION
A fundamental concept in social science is that of sex roles: expected attitudes and behaviors connected with sex-determined status positions (Linton, 1936). This differentiation of roles is universal but locally highly variable (Mead, 1935, 1949). Females in all communities have specific but different rights, duties and expected norms of behavior, and populations have beliefs about what women as mothers, wives, and daughters ought to do, their expected behaviors (Elmendorf, 1977) .
Women, in fact, form a large part of the work force in many countries and constitute a substantial economic resource, but their status is often disadvantaged. This status of women varies from country to country depending on the cultural framework or the level of development yet basic similarities do exist.
In traditional societies, women are the primary drawers, carriers and users of domestic water supply (Obeng, 1980). In most cases, in fact, women's emotion, energy, and attention are focused on meeting these and other basic needs. Children share in these responsibilities. Women and children are caught as it were in a complex web of responsibilities that sap their physical and emotional energy, with implications for their health and social well-being (Russell, 1979). Time expenditure, too, secondary to both distance and frequent low pressures at public taps, may be considerable. Women may use from 9-27% of their caloric energy in drawing and carrying water, depending on the terrain and the distance to the source (White, et al, 1972). When these calories are combined with those expended for agricultural tasks, wood gathering, and other household chores, the proportion of caloric intake is higher. Pregnancy and especially lactation make additional caloric demands, such that the pregnant woman may be left with only 45% and the lactating woman with only 17% or less of her caloric reserves (Isely, 1981).
The value of breastmilk relative to the caloric needs of the infant declines progressively after the fourth to fifth month of life, and the woman whose caloric expenditures are otherwise great may
actually experience a diminution in breastmilk volume. These women, seeing that their infants are not satisfied when exclusively breast-fed,may start supplemental feedings as early as the third month, with a concomitant earlier introduction of enteric pathogens. The implications for morbidity and mortality from gastroenteritis in younger infants are only too apparent (Vis et al, 1981). Studies in Zaire and the Gambia (McGregor, 19 76) have demonstrated the negative influence of distance to fields (and by implication to water source) on maternal nutritional status, duration of breastfeeding, output of breastmilk, and infant mortality from gastrointestinal disease (see also Fig. 1). When the distance is too great, apparently, many women prefer to leave a breastfeeding infant with a caretaker in the village (elderly woman or another child), thereby reducing the number of breastfeedings to two a day.
Children and adolescents, particularly girls, who have to traverse great distances, may find their educational opportunities as well as their nutritional status affected adversely.
The location of the water source (or fields) may also influence the health status of women, children and the infants and. toddlers they carry with them. Bathing or washing in ponds, or canals inhabited by snails and mosguitoe larvae, drawing water, gathering wood, or field work near breeding grounds of disease carrying Vectors pose obvious risks.
During the last decade public opinion at national and international levels has been focused on the reality of these problems, prompting the United Nations to proclaim 19 75 as International Women's Year. The objectives of the year was "to define a society in which women participate in a real and full sense in economic, social and political life, and to devise strategies whereby such societies could develop" (United Nations, 1975).
As part of a sustained, long-term effort to achieve these objectives, guidelines'for national action were provided for the ten-year period from 1975-1985 included the provision of "improved, easily accessible and safe water supplies, sewage disposal and other sanitation measures...both to improve health conditions of families and to reduce the burden of carrying water."
Other recommendations for this "Plan of Action" included the same right of access for women as for men to any training programs, with the right to continue to the highest levels. Women also have the right to be fully informed and included as active participants in the health planning and decision making process at all levels. Educational programs to overcome taboos, superstitions, and prejudices that prevent women from using existing facilities should be developed.
Women thus have rights to more accessible water supply and more adequate sanitation, to greater convenience in both, and to access to training and participation in management and decision-making in both.
UNDERSTANDING WOMEN'S ROLES IN WATER SUPPLY AND SANITATION
Some of the roles that women play in relation to domestic water and household sanitation are summarized below. These roles may be either public or domestic, but more often restricted to the latter. In domestic roles women are involved more than men in the "grubby and dangerous stuff of social existence: giving birth and mourning death, feeding, cooking, disposing of feces and the like" (Rosaldo and Lamphere, 1974).
Although in most communities men exercise positions of authority in the public domain, women often have a great deal of power in decision-making, particularly decisions that impinge on the domestic domain(Chinas, 1973; Elmendorf, 1973; Rosaldo and Lamphere, 1974; Farrell, 1978; Oppong, 1981). In fact, within their confined roles, women, individually or in groups, develop strategies to reach valued goals. In order to exercise this decision-making power effectively and make considered choices about changes in traditional activities, knowledge about alternatives must be available. Information about these alternatives is often presented by male outside agents in the public domain, even though it may primarily affect domestic activities. For instance, agents may deal with only defined "leaders" in considering improvements in water supply and sanitation without being aware that they are not providing for equity in use (Holmberg, 1952). Often, after installa-
tion, the real choices are made by women, the primary users.
Oppong (1981) has designed a framework in which women have seven roles. A woman as individual, mother, wife, and kinswoman on the one hand and as worker, producer (of income, goods, and services), and community member on the other, moves into and out of the private and public spheres, but finds all these roles, even the latter three, usually concentrated in the private domain. The roles women play in relation to domestic water and household sanitation draw on all seven of Oppong1s role classifications. The four key roles women can play include:
- Women as acceptors of new technologies
- Women asusers of improved facilities
- Women as managers of water supply and -sanitation programs
- Women as agents of behavioral change in the use of facilities.
(Elmendorf and Isely, 1981)
Women as Acceptors of Improved Water and Sanitation Technologies
It is primarily women that use any water system whether new or traditional. Their domestic managerial role means that in food preparation, washing and bathing, women are the primary users and the mediators between the water source and household demand. Any planned change in water availability or excreta disposal should be based on information about their present knowledge, attitudes, and practices. Careful intense observation and discussion, not just standard surveys, are needed to elicit perceptions and beliefs about water preferences and defecation behavior and about the politics of technology transfer (Elmendorf and Buckles, 1978; Montgomery, 1980).
Standard surveys related to water supply and sanitation frequently include only rudimentary questions on water use (volume, distance, preferred sites) or on knowledge of health aspects of water and sanitation, but fail to probe the beliefs and attitudes of underlying practices. They may not even be addressed to women; rather to heads of households. The choice of water for drinking, cooking, laundry, bathing, and other household functions is a result of women's careful decisions, based on what they have learned from their
mothers and grandmothers, and on their observations of the costs and benefits, both social and economic, of any change of system and are often based on sensory or macroscopic perceptions color, taste or smell rather than microscopic qualities of technical purity.
Beliefs too may limit the use of water systems and even household latrines. Water related beliefs and practices vary from country to country, and even from region to region within countries, yet there are a number of similarities. Streams, pools, and wells not infrequently are perceived to be the habitations of spirits and thus not to be disturbed or covered. Taboos on the use of household latrines by both sexes (Eoff, 1977), the belief that menstrual blood is sterilizing to males who use the same latrine as women (Hall, 1978), or the idea that stools of small children are innocuous and therefore need no special handling are recurring themes. More cross-cultural examples of fears and constraints are needed for effective planning.
Limited attention has "been given to matters of local pride and aesthetics with respect to the introduction of excreta disposal facilities. Families may prefer brightly colored cement stools and slabs over drab gray facilities or shiny porcelain seat or a brightly painted cement floor or stool even if the cost of labor involved is more (Rodriguez et al, 1982; Elmendorf and Buckles, 1978, revised 1980; McGarry and Elmendorf, 1978, revised 1982).
More detailed information concerning these variations may be needed at least on a regional basis to avoid inappropriate project design and ultimate project failure.
The number of successful water supply and sanitation projects is often# in fact, surpassed by the number of failures (Warford and Saunders, 1976). There is increasing evidence, however, that the user-choise approach combined with community participation may be able to reverse this trend (Kirkby (White), 1973; Miller, 1965; Miller and Cone, 1978, revised 1982; Buckles, 1976; Jorgensen, 1980), Most failures are due to inadequate maintenance of facilities. With government technical services frequently overstretched and undersupported, responsibility for maintenance falls on the popula-
FECAL CONTAMINATION OF SOIL, FINGERS
INFANT CARE SET-UP
ACCURACY OF OBSERVATIONS
CONTAMINATION OF: WATER, FOOD, ARTIFICIAL FEEDINGS, TOYS, OBJECTS
DISTANCE TO FIELDS/ WATER SOURCE
KNOWLEDGE OF MANAGEMENT OF DIARRHEA
ATTITUDES TOWARD RISK OF DIARRHEA
EFFICACY OF PERSONAL EFFORTS
LOCAL RS USE OF STARVATION, PURGES, ETC.
DURATION OF BREASTFEEDING
SEVERITY OF DEHYDRATION 0 TO 15%
FOOD INTAKE AFTER 6 MOS. -7f>-
PREVIOUS HISTORY OF DIARRHEA
OBSERVANCE OF TABOOS ON COITUS
FOOD PRODUCTION OR AVAILABILITY
NUTRITIONAL STATE BEFORE DIARRHEA
PARITY AND BIRTH INTERVAL OF MOTHER
WEIGHT GAIN IN PREGNANCY
Fig. 1. The Socioeconomic Matrix of Diarrhea and Dehydration in Infants and Children -
Source: Isely, R.B. (1982) Evaluation of Health Education Strategies in the
Prevention of Diarrhea and Dehydration. Journal of Tropical Paediatrics (in press).
tion served. If a population is willing and able to pay for a facility, it will generally maintain it (Dworkin, 1982). In fact, fairly sophisticated piped water systems in Thailand were often maintained when "simple" but less convenient facilities were inoperable (Dworkin and Pillsbury, 1980). A facility installed by an outside agency with only the passive consent of a community stands a good chance of breakdown (McGarry, 1977; Iwanska, 1981; Elmendorf, 1978).
This need for local participation and ownership of facilities is of particular importance to women who are often hidden participants accepting or rejecting a new water supply or sanitation technology.
Women as Users of Improved Water and Sanitation Technologies
A central question confronting each new water and sanitation project at the threshold of its execution is whether or not those for whom they are intended will really use the new facilities, once installed. Effective use after construction should always be a part of program objectives, although this fact is often sighted in improvement of facilities. Women, as the primary users of water the world over and as frequently the first to use sanitary installations, should always be singled out for the intensive user education so necessary for project success.
Although reduction of water-related diseases is one of the primary justifications for water supply projects, water is only one requirement for maintenance of good personal and domestic hygiene. Increased quantities of water will not necessarily result in improvements in health status without other changes (Feachem et a^L, 19 82). Water can help a community to improve health status in many ways: where water is abundant and safe, a number of diseases will be greatly reduced or eliminated; where water is scarce and polluted, little can prevent the high infant mortality associated with constant attacks of gastrointestinal disease (O'Brien, 1980).
Contaminated water used for bathing, cooking, washing food can transmit diarrheal diseases, but diseases such as shigellosis and rotavirus infections may be transmitted through non-water borne routes, particularly contaminated food. In addition to the supply
of safe water, therefore, there must be a combination of efforts to provide means of waste disposal and to education of the public (and especially women) on proper personal and food hygiene practices (WHO, 1978).
Even the most sophisticated sanitation technology will not bring health improvements unless properly used and combined with good personal hygiene habits- (Feachem et al, 1978). Or, as has been noted in many projects, improvements in water and sanitation must go BEYOND ACCESS (Elmendorf, 1980). /
Women are the first obvious target for health^ education for water and sanitation projects both as a means and as an end since they have the major responsibility for the health and home environment of their families and for socialization of children in good habits of hygiene and sanitation.
Education of women should focus on:
1. Increasing knowledge of the water/health and the excreta/ water/food/health relationships.
2. Promoting positive attitudes toward hygienic use of covered transport and storage receptacles. (It will also be necessary for appropriate vessels, receptacles and cleaning materials
or supplies to be locally available and at prices within reach of the population.)
3. The practice of household hygiene: handwashing after defecation and before food preparation, covering left-over food to protect it from insects and rodents, washing fruits and vegetables thoroughly before eating them.
4. Encouraging the belief that the stools of young children are dangerous and that they should be disposed of in a hygienic manner. Children are not only the chief sufferersfrom sanitation/water-related diseases, but they are also the main source of infection. Since many of these diseases affect primarily children, a large proportion of these children are excreting substantial quantities of pathogens. The importance of understanding attitudes toward children's excreta cannot be overemphasized. The widespread perception that they are "harmless" or the failure to perceive their infectious potential (Imboden, 1968; Feachem et al,
1978; Elmendorf, 1980; Isley, 1982) can contribute to a continuous chain of infection and re-infection wherein feces may be thrown on a nearby garbage heap or diapers washed with dishes in an urban home with a newly installed standpipe.
5. Raising fruits, vegetables, chickens and small stock in homes to improve family nutrition and/or increase household income at the same time environmental sanitation is enhanced. Time saved by more accessible water, and more water can be channeled into productive uses by women, individually and in groups.
Two additional key strategies need to be employed in seeking these cognitive and behavioral objectives:
Women as Water and Sanitation Promoters
Women themselves have been found to be the most effective peripheral agents in family planning, nutrition, home extension and other programs where women are the primary focus (Storms, 1979; Elmendorf and Buckles, 1978, revised 1980; Elmendorf, 1978; Poston, 1962). Women workers generally understand more intuitively the problems and issues faced by other women and can communicate more openly with other women. Communication on improved hygienic practices related to water, supply and sanitation can be most effectively communicated to local women by other women. In cultures where most information received by women comes from other women -primarily their mothers or grandmothers it is the best way of reaching them.
In Ghana, affective use has been made of home extension agents to deliver combined nutrition, family planning, agricultural extension, and child health education services."'" So in the promotion of proper use of water and sanitation facilities, women should be recruited wherever possible as health inspectors, assistant sanitarians, agricultural extension workers, and primary health care workers for these educational tasks. In Thailand, an example of such an integrated project was developed by the Women's Bureau. In Kenya, women have already demonstrated through their "Harambee", or pulling together, programs that women can be a potent force for influencing changes. In Lesotho, women will be the chief motiva-
tors for health education programs in rural villages where water projects are being implemented (O'Brien et al, 1979).
Women have already proven their worth as workers and volunteers in national development (Poston, 1962; Elmendorf, 1978). Becoming active participants providing the initiative and direction for the health education component of the water and/or sanitation project offers an excellent opportunity for women and women's groups to make a lasting contribution to home and community life and to national development (Schweser (O'Brien), 1976).
Supportive Social Structures
If women are to benefit from user education services, the program should focus not only on information and motivation for individuals, but on the strengthening of existing women's groups, or the creation of new ones as necessary to build peer support for desired change.
Many kinds of women's organizations, both formal and informal, exist throughout the world and their contributions to community life are many and varied. Women's groups are found in almost every village and can be used to reach out and contact rural women throughout a country. Supportive social structures such as savings and loan associations, religious organizations, tribal societies, family planning groups, and kinship and friendship networks need to be identified and become recipients of program inputs (Elmendorf (ed.), 1978, revised 1980; Clark, 1979; Elliott and Sorsby, 1979).
In addition to the enhancement of women's groups, other ways should be found to mobilize the more general community organization in support of user education of women. Where feasible, women should participate in community-wide organizations in order to forge these supportive links.
Certain sites may also lend themselves to more effective education of women than others: markets, clinics, hospitals, washing sites, grain-grinding sites, etc. (Colle and Colle, 1977). Schools may well serve as an effective vehicle for reaching young girls who are already intensely interested in motherhood and household man-
agement and long experienced in hauling water. At each of these sites where women gather, user education can be delivered to a group which will provide the individual woman with peer support. In addition, school children, both boys and girls, can become teachers of their younger siblings, leading to changed behavior in the home and further support to their mothers.
Women as Managers of Water and Sanitation Facilities
Women are usually the managers of household water supplies. Whether it is recognized or not, they also have a strong potential role as managers of community water supplies. Women are bound more tightly to the household than their male counterparts, who must often leave the home or community in search of work. Women who are usually responsible for obtaining water and seeing that it is available for daily use often select water sources, and in some instances play key roles in seeing that funds and/or labor are available to maintain them. Women thus make ideal candidates for training in tasks associated with the management and maintenance of community water supply and sanitation facilities.
Several tasks in the maintenance and repair of facilities must be
learned by someone in each community: monitoring systems for leaks
and other defects, testing water quality, keeping stock of spare
parts, overseeing a small budget, doing routine maintenance and
minor repairs, maintaining liaison with authorities and technical
services and training other community and household members in
the care and upkeep of facilities. Women, as those who already
exercise considerable influence over water supplies, are in a
good position to benefit from training for such tasks. (Cardenas, 1978).
Armed with such skills, women can plan for more accessible and more reliable water sources for their households and communities and communities can acquire an increased sense of owning a water source or a sanitation facility. As a result, there may be a greater willingness to change from an old water source to a new one managed by the community, or from defecating in the bush to using a latrine built and maintained by the household.
Women as Trainers
The central roles that women play in socialization of the young in health education and in traditional health care networks, and their permanence within the household make them suitable as trainers for water and sanitation projects of the community and household levels. In many cultures women as trainers or as trainers of trainers are effective and, in fact, required if females are among the trainees. Every effort should be expended to recruit women for these roles. The key to success is task-specific training related to existing roles, including information and skills necessary to practice, teach and supervise others.
Effective training of women for roles in the management of water supply and sanitation systems will require an adaptation of- training-methods to the traditional ways in which new skills are acquired in local systems of learning (Roark, 1981). The degree to which women can assume roles within the management of community facilities will depend of course on the degree to which the local culture can adjust to a more public role for women (Foster, 1973; Paul and Demarest, 1979; Pillsbury, 1978; Clark, 1979). Women, in any case, still need training in water use since they are the household managers of water supply. The training period is only the beginning. Trainees can be introduced to problem-solving skills, but provision should be made for support and supervision after training so that the trainee can continue to learn (Austin, 1979; Roark, 1981). In Bolivia, young women who were trained in the care of water and sanitation facilities as part of an integrated development program are now in charge of some of the installations not just cleaning them (Stein, 1977) .
Women as Agents of Behavioral Change in Water and Sanitation
Women as diffusers of information about improved water and sanitation technology and as agents of behavior change must be taken into account in planning for project outcomes. This contention holds true whether one is concerned with household or community-wide effects (Elliott and Sorsby, 1979; Dixon, 1980; Elmendorf (ed.), 1978, revised 1980).
To a large extent the achievement of household level benefits> both health and social, are dependent on the ability of women to understand the new facilities and to diffuse information and attitudes toward water and sanitation-related behavior to other household members. As carriers of water where household taps do not exist, women influence directly the volume consumed (White et al, 1972) and thus the possibility of achieving health effects related to increased quantity of water (i.e., decreased diarrheal morbidity, diminished skin infections, trachoma and other so-called water-washed diseases). As the selectors of water sources, women determine the quality of water delivered to the house based on their perceptions of what is a good and acceptable source. As those who select the transport and storage vessels, wash them and cover them, women influence both the volume of water consumed (size of container) (White et al, 1972) and its quality. Finally, as those who feed and care for infants and small children they determine decidedly the cleanliness of their eating and drinking utensils and the quality as well as the quantity of the food/water they consume. Thus, women are responsible to a considerable degree for both the prevention of diarrhea and the recovery of the infant or toddler with dehydration (Smith, 1980).
All potential health benefits of improved water and sanitation are in turn influenced by the woman's behavioral change in response to perceived dangers inherent in excreta, unclean hands, leftover food, uncovered water, and flies. It is she who forms a constant link in the chain of contamination from feces to fingers to food and she who in turn can break the chain by latrine use, hand-washing and protection of left-over food (Smith, 1980; Elmendorf, 1980). (See also Fig. 2.)
In the vast majority of communities where a single water source serves from 30 to 200 or more persons, the achievement of health and socio-economic benefits also depends on the role of women. Women as the drawers of water control to a great extent the possible contamination of the source through the manner in which they use
Fig. 2.CYCLE OF CONTAMINATION OF THE ENVIRONMENT THROUGH THE STOOLS OF INFANTS AND SMALL CHILDREN
Source: Glimpse, Vol. 3, No. 4, April 1981.
the installation. For example, in the case of open wells, the use of a clean bucket and the prevention of spilled water running back into the well (prevention of Guinea worm transmission) depends on the positive actions of women. Women may be the first to notice defects in the structure of the well or break-downs in the pump or other lifting mechanism and be therefore in a good position to call attention to these problems, apply simple solutions, or arrange for repairs if possible. In these and other ways the roles of women must be accounted for when one attempts to evaluate the community level outcomes of introducing improved water technologies.
Regarding sanitation, although most installations for excreta disposal are at a household rather than a communal level, the crucial role of women as the most frequent users of such facilities (Belcher and Vazquez-Calcerrada, 1972; Elmendorf and Buckles, 1978, revised 1980) should be remembered where communal sanitation blocks and other forms of public sanitation installations are the prevailing pattern. The installation of hand washing facilities and the provision and use of soap may depend for their effectiveness on focusing user education efforts on women.
In evaluation of programs,' whether one is describing the function of a pump or its use by villagers, if one is to effectively evaluate results one must talk with the women to find out what the real impacts are. Women's roles as diffusers of knowledge, attitudes, and behavior associated with new water and sanitation technologies must be taken into account. In effect, if one has not included the roles of women as a key moderating variable, one is likely to miss a large share of the factors explaining the end-products of a given project, especially the health impacts.
Women in rural and urban fringe areas around the world play the major roles in the drawing, carrying, use and management, of water; consequently they understand the urgent need for improved and more accessible water for domestic consumption. Many women spend an hoursome four to eight hoursa day drawing, carrying, managing
and using water (White et aJL, 1972; Elmendorf, 1977, 1980b; O'Kelly, 1978; Russel, 1979; UNICEF, 1976; Whiting and Krystall, 1977). (See also Table 1.) Women themselves are well aware of the time and energy spent in obtaining this basic necessity and thus lost from more productive or rewarding tasks. Many of them however, are not aware of alternative sources of water or of how to become involved in improving existing supplies. Only by being included early in the project planning stages will their participation be assured and alternative options realized.
For example, when only "community leaders" are involved in needs assessments and women are not, domestic water as opposed to water for agriculture or livestock is rarely given priority as an urgent community need (Miller, 1965; Miller and Cone, 1982; Nieves, 1980; Elmendorf (ed.), 1978, revised 1980, and Elmendorf, 1980b). On the other hand, when community needs assessments include the views of women, water for home consumption seldom fails to be among the top three felt needs (Nieves, 1980).
Women may not be aware of the germ theory of disease or may not be able to see a direct relationship between improved water supply and health, but once water is more accessible they quickly evaluate the benefits in terms -of improved health and reduced fatigue. The women of Chan Kom in Yucatan noted an increase of diarrheal disease after a pump breakdown and requested repairs to the water system (Elmendorf, 1978) .
Women also are well aware of additional time and energy savings, and the possibilities for additional productive activities. This new time may be used in income-producing activities such as growing food for sale in the market, or cottage industries or other commercial activities, employment as health promoters, in agricultural extension or in water and sanitation service operations and maintenance, or simply better care and nurturing of themselves and their families (Elmendorf, 1981; Isely, 1981; Whiting and Krystall, 1977). No matter what the activity, they can contribute to improving the quality of life for their households and communities.
By understanding the potentialities of women's roles and relating these to their rights and responsibilities during the Decade, there will be more hope of reaching our goal of "health for all by the year 2000." _lf-_
Relationship of distance to source to time spent and percentage of time in fetching water
Distance of source Time spent in Percentage of average
From the consumer fetching water daily working time spent
in.miles in.hours in fetching water
0.25 0.166 2.8
0.50 0.333 5.5
1.00 0.667 11.1
2.00 1.333 22.2
3.00 2.0 33.3
4.00 2.667 44.4
5.00 3.333 55.5
6.00 4.000 66.6
7.00 4.667 77.7
8.00 5.333 88.8
9.00 6.000 100.0
Source: As cited by Kirsten Jorgensen in "Water, supply in rural Africa: implications for women", BISWAS, 1978.
1 E. Brabble, American Home Economics Association, personal communication.
2 In Angola, where women have been recruited as water source monitors, the breakdown rate has fallen decidedly. Dr. Nimi Divengele Ambrosio, personal communication, Directorate of Maternal and Child Health Services, Ministry of Health, Luanda.
1979 "How Will Developing Nations Train Their Manpower for Quality Water Management?" Proceedings of Dialogue in Development: Towards the 21st Century, Tel Aviv.
Belcher, J.C., and P.B. Vazquez-Calcerrada
1972 "Cross-Cultural Aspects of Sanitation Norms," Proceedings of the Third World Congress of Rural Sociology, Baton Rouge, LA.
1976 Documentation of the CARE/Ministry of Health Potable Water and Latrine Project, CARE/Ministry of Health. Guatemala.
1980 "The Introduction of Potable Water and Latrines: A Case Study of Two Rural Communities in Guatemala," In M.L. Elmendorf, editor, "Seven Case Studies of Rural and Urban Fringe Areas in Latin America" Appropriate Technology for Water Supply and Sanitation. Vol. 8, World Bank, Washington, D.C. (Appeared first as a World Bank mimeo in 1978).
1978 Community Participation and Sanitation Education in Water Supply and Sanitation Programmes in Rural Areas of Paraguay, UNICEF/World Health Organization, Joint Committee on Health Policy, Geneva.
Chinas, B. .
1973 The Isthmus Zapd^a-s", Women's Roles in Cultural Context,
Holt Rinehart and Winston, New York.
1979 "Tracing the Learning Approach," World Education Report, November.
Colle, R., and F. de Colle
1977 The Communication Factor in Health and Nutrition Programs: A Case Study from Guatemala, World Health Organization, Geneva.
1980 Assessing the Impact of Development on Women, Agency for International Development Program Evaluation Discussion Paper No. 8, Washington, DC.
1952 Thirsty Indians: Introduction of Wells among People of an Arid Region, Human Organization, 9:33-36.
1982 Community Water Supply Evaluation Summary. A Working Paper, Washington, Office of Evaluation, Bureau for Program and Policy Coordination, USAID.
Dworkin, D. and B. Pillsbury
1980 The Potable Water Project in Rural Thailand, 1966-1972, AID Project Impact Evaluation No. 3, Washington, D.C.Elliott, V. and V. Sorsby
Elliott, V. and V. Sorsby
1979 An Investigation into Evaluations of Projects Designed to Benefit Women (mimeo), Agency for International Development, Washington, DC.
1973 La Mujer Maya y el Cambio. SEP-setenta 1973, Ministry of Education, Mexico.
1977 The Many Worlds of Women: Mexico. In Smock and Giele, eds. Women and Society: Roles and Status, an International and Comparative Perspective. John Wiley, New York.
1978 "Public Participation and Acceptance," Environmental Impacts of International Civil Engineering Projects and Practices, American Society of Civil Engineers Publications, New York.
1980a Field Notes from Sri Lanka, Excerpts in Decade Plan for Water Supply and Sanitation, American Public Health Association, Washington, DC.
1980b Women Water and Waste: Beyond Access. Paper presented at the Forum of the United Nations Mid-Decade Conference on Women, Copenhagen (Available from the WASH Coordination and Information Center, Arlington ... VA) .
1980 "Seven Case Studies of Rural and Urban Fringe Areas in Latin America," Appropriate Technology for Water Supply and Sanitation, Vol. 8, to be published in 1982 by The World Bank, Washington, DC. (originally released in mimeo in 1978 as "Eight Case Studies of Rural and Urban Fringe Areas in Latin America".)
1981 "Women, Water and the Decade" (WASH, Arlington, VA Technical Report No. 6.)
198> "Community Participation: a Human Dimension with Promise and Problems." In Safe Water and Waste Disposal for Health: a Reference Manual, National Demonstration Water Project, Washington, DC.
Elmendorf, M. and P.K. Buckles
1980 Sociocultural Aspects of Water Supply and Excreta
Disposal, in Appropriate Technology for Water Supply and Sanitation, Vol. 5, The World Bank, Washington, DC.
(originally released in mimeo 1978). Elmendorf, M. and R. Isely 1981 "The Role of Women as Participants and
Beneficiaries in Water Supply and Sanitation Programs" (WASH Technical Eoff G* Report #11, Arlington, VA.)
1977 "Las Cafanas: A Case Study of a Traditional Subsistence
Oriented Peasant Community." AID, Honduras, mimeo. Farrell, T.
1978 "Appropriate Technology for Water Supply and Waste Disposal." Mimeo prepared for the World Bank Research Project on Appropriate Technology for Water Supply and Sanitation.
Feachem, R.G., D. Bradley, H. Garelick, D. Mara,
1982 Health Aspects of Excreta and Sullage Management. A State-of-the-Art Review in Appropriate Technology for Water Supply and Sanitation, Vol. The World Bank, Washington, DC. (originally released in mimeo 1978).
Feachem, R.G., E. Bruns; S. Caincross; A. Cronin; P. Cross; D. Curtis; M.K. Khan; D. Lamb; and H. Southhall 1978 Water Health and Development: An Interdisciplinary Evaluation, Tri-Med Books, London.
1973 Traditional Cultures and Technological Change, Harper, New York.
1978 Mtunl Afya: Tanzania's Health Campaign Clearing House on Development Communication, Publication 9, Washington, D.C.
1952 "The Wells that Failed: an Attempt to Establish a Safe Water Supply in the Viru Valley, Peru." In Human Problems in Technological Change, Edward Spicer. Russel Sage, New York, pp. 113-123.
1980 "People Power: Community Participation in the Planning of Human Settlements". Contact, Special Series No. 3. Christian Medical Commision, Geneva, pp. 43-52.
- 1968 Induced Change in Health Behavior: A Study of a Pilot Environmental Sanitation Project in Uttar Pradesh, Publications No. 356, Planning Research and Action Institute (PRAI), Lucknow.
1982 "Focusing Sanitation Programs On Mothers and Older
Siblings of Small Children". Tropical Doctor (in press).
1981 "The Relationship of Accessible Safe Water and Adequate Sanitation to Maternal and Child Health," Water and Management, 5(6) 417-424.
1981 Purgatory and Utopia, Schenkman Press, Cambridge, MA. Jorgensen K.
1980 Water Supply Problems in Rural Africa: The Implications for Women, Centre for Development Research, Copenhagen.
Kirkby (Whyte), A.U.
1973 "The Development of a User-Choice Approach in Rural
Water Supply," Rural Water Supply and Sanitation, Working Paper 7, International Development Research Centre, Ottawa.
1936 The Study of Man, Appleton-Century Co., New York. McGarry, M.G.
1977 "Appropriate Technology in Civil Engineering". In
Environmental Impacts on International Civil Engineering Projects and Practices, pp. 202-229.
McGarry, M.G. and M.L. Elmendorf
1982 "What is Appropriate Technology? A Maya Village Asks," in Elmendorf, editor. "Seven Case Studies of Rural and Urban Fringe Areas in Latin America," Appropriate Technology for Water Supply and Sanitation. Vol. 8. World Bank, Washington, DC, originally released in mimeo in
1978. fCoo NJ "ii- .mrrl n | nl 1 )-
1976 Health and Communicable Disease in a Rural African Environment, Oikos, 27:180-192.
1935 Sex and Temperament in Three Primitive Societies. Morrow, New York.
1949 Male and Female, A Study of the Sexes in a Changing World. Dell, New York.
1965 Cultural Change as Decision Making: A Tzotzil Example, Ethnology, 4:53-65.
Miller, F.C., and C.A. Cone
1982 "Latrines in Yaluc: A Twenty Year Perspective," in
Elmendorf, editor. "Seven Case Studies of Rural and Urban Fringe Areas in Latin America,".Appropriate Technology for Water Supply and Sanitation. Vol. 8, World Bank, Washington, DC. (Originally released in mimeo, 1978).
1980 "Beyond Appropriate Technology". In Appropriate Technology and Social Values: A Critical Appraisal, Ballinger, Cambridge.
1980 "Beyond Survival Skills: Providing Basic Services to Satisfy the Needs of Poor Women" (mimeo), Paper prepared for the United States Agency for International Development through the International Center for Research on Women, Washington, DC.
Nieves, I., and W.T. Farrell
1982 "Marginal Urban Communities in San Salvador: A
Behavioral Case Study". In Seven Case Studies of Rural and Urban Fringe Areas in Latin America. M. Elmendorf, ed. (Originally released in mimeo as Eight Case Studies of Rural and Urban Fringe Areas in Latin America, 1978, World Bank, Washington).
1980 "One Vote for Water on Tap". In The Health Needs of the World's Poor Women. Equity Policy Center, Washington, DC, pp. 96-97.
0'Brien, H. et al
1979 Lesotho Rural Water Supply Project, Draft Project Paper, USAID Maseru.
1980 A Model Health Education Component Water-Sanitation Project in Developing Country. Unpublished.
1978 Rural Women, Intermediate Technology Development Group, London.
1981 A Synopsis of Seven Roles of Women: an Outline of a Conceptual and Methodological Approach, Population and Labour Policies Program, Working Paper No. 94, World Employment Program, International Labor Organization, Geneva.
Paul, B.D., and W.J. Demarest
1979 "Intercultural Health Programs: The Problem of Community Participation" (mimeo), Stanford University, Palo Alto, CA.
Perrett, H., and F. Lethem
1980 Human Factors in Project Work. World Bank, staff paper No. 397.
1978 Reaching the Rural Poor: Indigeneous Health Practioners are There Already, Agency for International Development Program Evaluation Paper No. 1, Washington, DC.
1962 Democracy Speaks Many Tongues, Richard Waverly. Roark, P.
1981 The Role of Women in Successful Water Supply Projects, Agency for International Development, Washington, DC.
Rodriguez, R.I., C. Pineo, and M.L. Elmendorf
1982 "A Behavioral Case Study: Urban and Rural Nicaragua", in Elmendorf, editor. "Seven Case Studies of Rural and Urban Fringe Areas in Latin America",. Appropriate Technology for Water Supply and Sanitation, Vol. 8, World Bank, Washington, DC. (Originally released in mimeo, 1978).
Rosaldo, M. and L. Lamphere
1974 Women Culture and Society, Stanford University Press, Palo Alto, CA.
1979 "Report on the Situation of Women in the Target Villages of the UNICEF Domestic Water Supply Project in Bahr El Ghazal Province, Sudan" (mimeo), UNICEF.
Salinas, B. and R. Caceres
1982 "A Behavioral Case Study: San Pedro de la Laguna", in Elmendorf, M.L. editor. "Seven Case Studies of rural and Urban Fringe Areas in Latin America", Appropriate Technology for Water supply and Sanitation, Vol. 8, world Bank, Washington, DC. (Originally released in mimeo in 1978. Also available in Spanish).
Schweser, H. (O'Brien)
1976 Manual for Community Health Education for the Caribbean. Project HOPE.
1980 "Mass Media and Health Practices: Results of Honduras Field Investigation, Academy for Educational Development,
.- Report No. 14, Washington, DC.
1977 Water: Life or Death International Institute for Environment and Development, Washington, DC.
1979 Training and use of Auxiliary Health Workers: Lessons from Developing Countries, American Public Health Association, Washington, DC.
1976 "Alleviating Women's Burdens," Assignment Children, Vol. 34.
1975 Decade for Women, World Plan of Action, United Nations, New York.
Vis, H., P. Hennart, and M. Ruchababisha
1981 Some issues in breast-feeding in deprived areas, UNICEF, Assignment Children, 55/56:183-200.
Warford, R.J., and J.J, Saunders
1976 Village Water Supply, The Johns Hopkins University Press, Baltimore, MD.
White, G.F., D.J. Bradley, and A.U. White
1972 Drawers of Water: Domestic Water Use in East Africa, University of Chicago Press, Chicago, IL.
Whiting, M., and A. Krystall
1977 "The Impact of Rural Water supply Projects on Women" (mimeo), CARE, Nairobi.
Whyte, A., and I. Burton
1977 "Water "Supply and Community Choice" in Feachem, R., M. McGarry and D. Mara (editors), Water, Waste and Health in Hot Climates, John Wiley, London.
World Health Organization
1978 "Control of Diarrheal Diseases: WHO's Programme Takes Shape." WHO Chronicle 32(10) -.369-372.
/ 7 (sitf/lf
DRAFT ,/(: Afi
Statement by WHO at the 9th Meeting of the
Steering Committee for Co-operative Action /flfjsf ~"
Washington, D.C., 15-16 April 1982 / /
WHO was particularly pleased to have an item included on the agenda of the 9th Meeting of the Steering Committee focusing on the important role women can play in the implementation of the Drinking Water Supply and Sanitation Decade objectives. Indeed, the goal of providing all peoples with safe drinking water and improved sanitation by 1990, and WHO's global strategy for achieving health for all by the year 2000, are intimately linked. Moreover, both correspond to some of the provisions of the Plan of Action of the UN Decade for Women 1975-1985. It is our hope therefore that the discussions which will be initiated here today within the framework of these interdependent goals will lead to some concrete, practical action for enhancing the quality of life not only of women but of all peoples.
WHO's participation in the Drinking Water Supply and Sanitation Decade and the main focus of its concerns are well known and need not be recapitulated here. I should, however, mention briefly that the Organization's activities concerning women, health and development, are also an integral part of the global health/2000 strategy and are carried out within the context of existing programmes, grouped around three main issues: a) health needs and problems specific to women, b) the interrelationship of women, health and development, and c) the roie and status of women as health-care providers. All three of these areas have specific applications in connection with drinking water and sanitation. WHO has commissioned a well-known expert in the field to study these issues in more depth and suggest approaches to enhance women's participa-tion in the Decade. The points which I should like to bring to the Steering
Committee's attention are largely based on the preliminary findings of this study.
Primary health care which is the key to the attainment of the health-for-all target, includes among other elements, community participation, universal coverage and access to an adequate supply of safe water and basic sanitation. In regard to community participation, it should be noted that over 50 percent of the adults in most communities are women and that women in rural and urban fringe areas around the world play major roles In the use and management of water supply and sanitation. It is therefore evident that they should be involved in the planning, provision and improvement of these facilities.
Moreover, the impact of water and sanitation on women's lives and health status is so significant that it constitutes in itself a sufficient argument in favour of their involvement in the Decade's programmes.
In traditional societies, women are the primary drawers, carriers and users of domestic water supply. In most cases in fact, women's emotion, energy and attention are focussed on meeting these and other basic needs. Studies have shown that women may use some 9 to 27 percent of their caloric energy in drawing and carrying water and when these calories are combined with those expended for agricultural tasks, wood gathering and other household chores, the proportion of caloric expenditure is higher. Pregnancy and especially lactation make additional caloric demands and pregnant women may be left with only 45 percent and lactating women with only 17 percent or less of their caloric reserves. Studies have also demonstrated the negative influence of distance to fields and by implication to water source, on maternal nutritional status, duration of breastfeeding, output of breast milk and infant mortality from gastro-intestinal diseases. In addition, adolescent girls who have to
traverse great distances may find their educational opportunities as well as their nutritional status affected adversely. The locaLion of the water source, or fields, near breeding grounds oJ disense-carryinr vectors pose obvious risks to the health status of women, children and the infants they carry with them.
In turn women's actions have a direct effect on the health of their households: As carriers of water where household taps do not exist, women influence directly the volume consumed and Linus the poasibJlity of achieving health effects related to increased quantity of water (i.e., decreased diarrheal morbidity, diminished skin Infections, trachoma and other so-called water-borne diseases). As the selectors of water sources, women determine the quality of water delivered to the house based on thoir perceptions of what is a good and acceptable source. As those who select the transport .ind storage vessels, wash them and cover them, women influence Lit. volume of water con5;umed
(size of container) and its quality. Finaliv, as those who feed and care for infants and small children they determine decidedly the cleanliness of their eating and drinking utensils and the quality as well as the quantity of the food/water they consume and their habits of hygiene.
Thus, in considering improvement in quality and in access to safe water supplies and to sanitation, one might examine four key roles women can play as a) acceptors of new technologies, as b) users and promoters of improved facilities, as c) managers of water supply and sanitation programmes, and as d) agents of behavioural change in the use of facilities:
a) Women as acceptors of new technologies Women's role in food preparation and domestic hygiene means that they
are the primary users and the mediators between water source and household demand. Any planned change in water availability or sanitation
facilities should be based on information about their present knowledge, attitudes and practices to avoid inappropriate project design and ultimate project failure. There is increasing evidence that the user/choice approach combined with community participation would improve the success rate of water supply and sanitation projects.
b) Women as users and promoters of improved facilities
As the primary users of water the world over, and as frequently the first users of sanitary installations, women should be singled out for intensive user education and for education on proper personal and food hygiene practices, since they have the major responsibility for the health and home environment of their families.
Moreover, communication on improved hygienic practices related to water supply and sanitation can be most effectively communicated to local women by other women. So, women should be recruited, wherever possible, in various functions in the promotion of proper use of water and sanitation facilities. Becoming active participants would offer an excellent opportunity for women and women's groups to make an important contribution to the health education and user education component of any water and/or sanitation project.
Women's groups, both formal and informal, exist throughout the world and can be used to provide valuable peer support for desired change. In addition, women's groups are by nature multidimensional and would thus lend themselves to the development of health-related activities within an integrated, intersectoral approach. Increasing and strengthening the role of women's organizations in primary health care, for example, could become a focus for promoting the participation of women
in the programmes of the International Drinking Water and Sanitation Decade.
c) Women as managers o water supply and sanitation programmes
Women are usually the managers of household water supplies; they also have strong potential role as managers of community water supplies, which may not always be recognized. Since they are usually responsible for obtaining water, women should be considered ideal candidates for training in tasks associated with the management, and maintenance of community water supply and sanitation facilities.
d) Women as agents of behavioural change in the use of facilities
As both health and social benefits at household and community levels are dependent on the ability of woraui to understand the new facilities and to diffuse information about their benefits, the role of women as diffusers of information about improved water and sanitation technology should be taken into account in planning for projects.
I have outlined some thoughts and suggestions for enhancing the potential
contribution of women, from the point of view of health, to the activities of Supply
the Drinking Water/and Sanitation Decade. WHO would welcome it if the Steering Committee agreed to an appropriate mechanism for a more thorough discussion of these and other issues and for the identification of areas which would deserve priority attention in the context of the cooperative action programme.