Contribution of Water Pollution From Inadequate Sanitation and Housing Quality to Diarrheal Disease in Low-Cost Housing Settlements of Cape

Town, South Africa

Govender, Thashlin; Barnes, Jo M, PhD; Pieper, Clarissa H, MBChB, MMed, PhD. American Journal of Public Health 101. 7 (Jul 2011): e4-9. Turn on hit highlighting for speaking browsers Hide highlighting

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Translate Abstract We investigated the effects of failing sanitation, poor housing conditions, and fecal pollution in runoff water on the health-particularly the incidence of diarrheal disease-of residents of low-cost housing settlements in Cape Town, South Africa. In November 2009, we conducted a cross-sectional survey with structured interviews in 4 communities (n=336 dwellings; 1080 persons). We used Colilert defined-substrate technology to determine Escherichia coli levels in runoff water samples taken from the study communities. Almost 15% of households disposed of soiled products in storm water drains and 6% disposed of soiled products in the street. In only 26% of the dwellings were toilets washed daily. Approximately 59% of dwellings lacked a tap near the toilet for hand washing, and 14% of respondents suffered 1 or more attacks of diarrhea in the 2 weeks preceding their interview. E.coli counts of runoff environmental water samples ranged from 750 to 1580000000 per 100 milliliters. A holistic and integrated approach is needed to improve housing quality and sanitation among Cape Town's low-income citizens.

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Headnote Objectives. We investigated the effects of failing sanitation, poor housing conditions, and fecal pollution in runoff water on the health-particularly the incidence of diarrheal disease-of residents of low-cost housing settlements in Cape Town, South Africa. Methods. In November 2009, we conducted a cross-sectional survey with structured interviews in 4 communities (n=336 dwellings; 1080 persons). We used Colilert definedsubstrate technology to determine Escherichia coli levels in runoff water samples taken from the study communities. Results. Almost 15% of households disposed of soiled products in storm water drains and 6% disposed of soiled products in the street. In only 26% of the dwellings were toilets washed daily. Approximately 59% of dwellings lacked a tap near the toilet for hand washing, and 14% of respondents suffered 1 or more attacks of diarrhea in the 2 weeks preceding their

interview. E.coli counts of runoff environmental water samples ranged from 750 to 1580000000 per 100 milliliters. Conclusions. A holistic and integrated approach is needed to improve housing quality and sanitation among Cape Town's low-income citizens. (Am J Public Health. 2011;101:e4-e9. doi:10.2105/AJPH.2010.300107) Shelter, access to adequate potable water, and sanitation are basic human needs that pose serious challenges to developing countries.1 In South Africa, these challenges are greatly heightened by the rapid rate of urbanization driven by low-income migrants from rural areas and the rapid expansion of informal urban settlements.2 South Africa is facing a low-income housing crisis, with the current unmet need estimated at more than 3 million units.3 South African housing policy mostly promotes state-funded home ownership for the poor.4 One of the 6 principles of the South African government's low-cost housing scheme, now called the Breaking New Ground initiative (formerly the Reconstruction and Development Program) is to improve the living conditions and therefore the health of the recipients of the new houses.5 Low-cost housing units are usually allocated to residents of makeshift dwellings in the many informal settlements surrounding cities and towns. Unfortunately, ownership of a new formal house has not been accompanied by any increase in recipient income in these resettlement programs. The owners of low-cost houses exploit one of the few resources they have- spaceby allowing others to build informal structures (called ''shacks'' by the inhabitants) in their backyards, creating rental income. This practice has greatly increased population density in low-cost housing communities, placing infrastructure under significant strain.6 The interrelated effects of water quality, human waste disposal, and health status, especially disease transmission via the fecal-oral route, are well established.7,8 Improved water quality and sanitation confer both health and nonhealth benefits.9 Water has 2 contrasting roles affecting health: it can be a disease vector by carrying pathogens, and it can prevent disease when it is available in sufficient quantity for personal and domestic hygiene. Indirect effects related to health include, for example, improved quality of life and decreased medical expenses.8 Diarrheal diseases are an important cause of morbidity and mortality in low- and middleincome countries. In these countries, such diseases kill an estimated 4.9 of every 1000 children younger than 5 years10,11 and are the third most frequent cause of death and the third greatest contributor to the burden of disease in this age group, constituting 8.8% of all disabilityadjusted life years.12,13 The World Health Organization estimates that there are 0.75 cases of diarrhea per person worldwide annually.13 In South Africa, diarrheal diseases account for 3.1% of total deaths-the eighthmost frequent cause of death in the country.12,14 Problems of environmental pollution of living space and of domestic hygiene are almost always related to poverty and sanitation.15 Pathogens, especially enteric pathogens, are transmitted at household level through a complex set of interdependent pathways, such as contaminated food and water, poor waste disposal that contaminates living spaces, and intricate household and community person-toperson interactions.16 We investigated the interplay of inadequate housing and poorly functioning sanitation with ill health and environmental pollution in formal low-cost housing settlements in Cape Town, South Africa.

METHODS In November 2009, we conducted a crosssectional survey in 4 subsidized housing communities in the City of Cape Town Metropole: Driftsand, Greenfields, Masipumelela, and Tafelsig. We selected these sites to represent the geographic spread of all the subsidized housing settlements in the city, regardless of the local or central authority that erected them. We selected only communities that had existed longer than 3 years, because newer settlements might not yet show the structural wear and tear that was evident in older settlements. We also selected only communities with distinct boundaries that did not blend into informal settlement areas (squatter settlements), to avoid garbage and water pollution introduced from neighboring areas. All 4 settlements had numerous low-cost houses (main houses) with informal dwellings made of temporary building materials in the backyards (shacks). Displaying the legacy of previous spatial disparities in the city, all communities comprised 1 predominant ethnic group. Three settlements had mostly Black inhabitants and 1 had predominantly Colored, or mixed ancestry, inhabitants. This was representative of the overall demographic profile of the settlements in the city. We did not ask questions about race in the questionnaire. Structured Interviews We pilot tested our questionnaires in 2 different settlements (Mfuleni, which had mostly Colored residents, and Westbank, which had mostly Black residents) in the Cape Town Metropole. We randomly selected 4 plots from each settlement and administered the survey to a total of 15 heads of households, which were home to 60 persons. As in the main study, T. G. conducted structured interviews in participants' homes, assisted by a registered nurse who spoke all 3 languages prevalent in the area; no problems or confusing questions were noted. Characteristics of the pilot and main study sites were similar. We therefore added the data from the pilot study to the data collected in the main study. We used a systematic randomized sampling procedure to select 165 plots in the 4 study settlements. We separately recorded each dwelling on a selected plot (main house and shacks). We then randomly selected 321 dwellings for participation in the study. The response rate was 100% among the heads of households. The 321 dwellings housed a total of1020 persons. With the inclusion of the pilot study participants, our total sample was 336 survey respondents living in 173 main houses and 163 shacks, which housed 1080 persons. We designed the questionnaire to record data from all dwellings on a plot. Questionnaires were available in all 3 languages and administered with the head of the household in the language of preference. We solicited information on demographic characteristics, health, home ownership, and the condition of the dwelling and its surrounding yard. We included questions formulated specifically for the main house and the shack(s), such as home ownership or rental paid and operational costs. To obtain a complete picture of the community setting, we also asked about safety and residents' needs. We obtained informed consent and provided a copy of the consent form to all participating households. The survey was anonymous, and participants could inspect the completed questionnaire answer sheet for anonymity. They then posted the form into a sealed box with a postal slot. The box was only unsealed when all interviews were completed.

Analyses We determined the presence and number of fecal bacteria and Escherichia coli with Colilert defined-substrate technology (IDEXX, Westbrook, ME). We sampled environmental water (6 samples per study site, n=24) according to the guidelines of the South African Bureau of Standards, which incorporate the standard methods described by the American Public Health Association, American Water Works Association, and Water Environment Federation. 17-19 Our environmental water samples came from runoff water from houses and shacks, water running alongside the street into the storm water drain, and puddles of water in the streets. All samples were transported on ice and delivered to the Department of Food Science Water Research Laboratory, University of Stellenbosch, within 90 minutes. For the analysis of fecal contamination, we used the Colilert Quanti-tray 2000 technique, with 8 serial dilutions (108) per 100 milliliters of sample water. We recorded data from the survey in a database created in Statistica version 9.0 (Stat- Soft, Inc, Tulsa, OK). We computed means and standard deviations for continuous variables and frequency distributions for categorical variables. We used the c2 test for statistical differences between frequencies. RESULTS We found that living conditions in the lowcost housing settlements posed a considerable risk to the health of the inhabitants. The 173 main houses surveyed were in a state of disrepair (Figure A, available as a supplement to the online version of this article at http:// www.ajph.org). Drains overflowed with sewage- laden water in 92% of the houses, and the toilet area was visibly dirty in 72%. Sanitation status was poor. In all 4 communities, each plot contained only 1 toilet connected to piped water; 51% were outside the main house and 49% were inside. A summary of the results of our inspections of sanitation infrastructure is presented in Table 1. Nearly all respondents (99%) agreed that using a dirty toilet can cause illness. Only 26% of respondents, however, reported that they cleaned their toilets daily; 34% said they cleaned once a week, and 18% cleaned ''sometimes.'' A majority of inhabitants of main houses (63%) reported using soap and a cloth for toilet cleaning. Only 25% reported cleaning the toilet with a brush. Most respondents (79%) agreed that failing to wash hands can cause illness, but approximately 59% of dwellings did not have a tap near the toilet, and inhabitants were therefore forced to use the kitchen sink for this purpose. Disposal of household waste was also problematic (Figure 1). Respondents in 68% of dwellings reported they had no indoor waste bin. The cleanliness of the outside yard was poor in 76% of cases, and 49% of households had solid waste (much of it broken glass) lying around outside the home. Tafelsig was the only community in which main houses had an outside drain. Of these, 92% were in a poor state (blocked, dirty, or spilling wastewater). Some 60% of participants did not know whom to contact about blocked or overflowing drains, and 15% said that nothing would happen if rubbish was thrown into a toilet. We found other indictors of an unhygienic home environment in both types of dwellings. All respondents complained of disease-carrying household pests in their immediate home

environment. The pests that respondents considered to be their single greatest problem were rats (50%), cockroaches (30%), fleas (16%), and flies (4%). A total of 153 respondents reported 1 or more cases of diarrhea during the 2 weeks preceding the survey (Table 2). The most frequently reported signs and symptoms of an unhygienic home environment are summarized in Table 3. Of those reporting symptoms, 80% still suffered from these ailments at the time of the survey. Children younger than 10 years are especially vulnerable, and in our sample, these children composed 1 of the 2 age categories most affected by diarrhea. Residents of shacks reported significantly fewer diarrhea symptoms than did residents of main houses. As the number of dwellings and inhabitants per plot grew, so did the volume of household wastewater generated from various household activities. The only accessible entry points to the sewage system for all households on a plot (main houses and shacks) were 1 single communal sink and toilet. Inhabitants of all dwellings reported disposing of household wastewater onto open land, down the toilet, and into stormwater drains (methods of disposal are summarized in Table A, available as a supplement to the online version of this article at http://www.ajph.org). During inspection of the premises, we found puddles of dirty water outside 64% of the homes. In these communities, wastewater commonly puddled outside homes and in the roads and entered storm water channels draining into the nearest river system. Storm water volume in built-up areas correlates with the extent of hardened surfaces. The total roof area covered by the formal houses in the 4 settlements was 5550 square meters, and the total roof area added by the shacks was 1587 square meters-an increase of 29%. The runoff environmental water samples taken from the yards or the adjoining streets showed gross fecal pollution. The total coliform and E. coli counts are presented in Table 4. DISCUSSION Housing is a basic need.20 A fundamental tenet of most government-subsidized housing is the goal of improving, among other factors, the health status of the urban poor.21 Inadequate housing has an extensive history of sanitation failures and ensuing environmental degradation. 15,16,22 Research also indicates that the burden of illness is greater among minorities and lower-income communities.23,24 The lowincome population of cities is increasing faster than service delivery in a time of urbanmigration and population growth.2 Informal dwellings in the backyards of low-income urban living areas occur across the world,25,26 but the extent of this unplanned construction in South African urban communities is unusually great. Research on the impact of backyard dwellings on this scale has been minimal. 6 With a few exceptions,4,6,27-29 housing studies have not considered backyard dwellings. We found no previous research on the health status of backyard dwellers in low-cost housing settlements in South Africa, but our sample was representative of these communities in Cape Town. Housing is an important mechanism for improving the health of vulnerable populations, and rehousing them should reduce the burden on the government of supplying health services for theoretically preventable secondary infections.30 All the main houses in our study were statefunded structures provided at no charge to inhabitants, who previously lived in informal urban slum areas. The government intended to raise residents' living standards, but the

structural failures of the houses precluded this improvement. The design of the sanitation infrastructure and its deterioration with use actually increased residents' risk of ill health. This paradoxical effect stemmed from the large number of nonfunctional toilets, the deterioration of the buildings (cracked walls and leaking roof tops in the main houses and flimsy construction of the shacks), and the hazardous condition of sanitation facilities (Table 1). Diarrhea Transmission The health profile of the communities we surveyed was poor. An unexpected finding was a significantly lower prevalence of diarrhea among inhabitants of shacks than among residents of main houses. One possible reason was proximity to a source of infection. The only toilet on the premises was inside the main house in 2 of the 4 study communities and next to the house in the other 2. The inhabitants of the main house therefore lived close to the greatest source of infection. Shack dwellers used-and contributed to the poor condition of-toilet facilities, which were inadequately cleaned and maintained and often not functioning, but did not have to live close to them. Hygiene amenities near the toilet (toilet paper, soap, towel, etc.) were scarce; 83% of homes had no soap available and 95% had no clean towel to dry hands. Another factor that might contribute to disease prevalence among main house residents was the disposal of all water used for washing and bathing at the kitchen sink or down the toilet. A single tap at the kitchen sink, when used for all ablutions, could contribute to the transfer of diarrheal pathogens into food. Planners and designers of low-cost housing should consider these important public health issues. Some of the other symptoms our respondents reported, such as vomiting and fever, are sometimes caused by gastrointestinal illness. Overall, findings from the survey and from analyses of environmental water samples suggest high exposure to gastrointestinal pathogens. Education in basic home maintenance and household domestic hygiene is urgently needed in low-cost housing communities to reduce the risks of transmission of diarrheal disease. Waste Disposal Although backyard shack dwellers had access to water and toilet facilities, the plots had insufficient solid waste and wastewater disposal facilities for all occupants, resulting in dispersal of wastewater and untreated sewage into the yards and ultimately into the streets and sewers. Many households admitted to disposing of human excreta in unsafe ways, which contributed to a reservoir of pathogens in the environment (both inside and outside houses). The cumulative impact of this pollution challenge was evident in the E. coli counts we found in the water samples (Table 4). This runoff water ultimately made its way into formal or informal storm water channels, subsequently polluting nearby rivers, which may become further sources of infection. We found widespread problems with solid waste disposal. Contaminated waste was discarded in the immediate surroundings of dwellings, rubbish bins leaked, and 22% of households deposited solid waste on the street, all of which contributed to environmental pollution. Rego et al. found that exposure to garbage was the most important factor associated with diarrhea in children living in an informal neighborhood in Salvador, Brazil.31 Moraes et al. showed that improvements in community sanitation can lower the prevalence of diarrheal disease even without measures to promote hygiene.32 Improper waste disposal at the household and

community level also created a favorable environment for disease-carrying pests such as rodents, flies, and cockroaches. These pests not only transmit disease directly but also expose inhabitants to allergens.33,34 Better waste disposal and sanitation infrastructure could improve the health of the communities we studied. Studies by Carden et al.35 and Armitage et al.36 revealed that management of household wastewater has a low priority among inhabitants of urban low-income communities in South Africa. Our findings support this conclusion. Disposal methods for household wastewater were inappropriate (e.g., on open land, in the storm water drain, or down the toilet) in 56% of all households in our survey (Figure 1). Inappropriate disposal methods contribute to environmental pollution. Flushing away household wastewater (a method reported by 44% of households) wasted scarce potable water resources, as well as adding pressure to the already overburdened wastewater purification infrastructure. This inappropriate behavior is a direct consequence of poor hygiene habits and inadequate or inconvenient access to the formal sewage system in these state-funded housing schemes. Because the properties were so small and the backyards were filled by shacks, the small front yards and the streets were the only open spaces for children to play in. The surface runoff water we sampled from outdoor areas was heavily polluted (Table 4), presenting serious health risks: the highest E. coli count per100 milliliters of water that we found was 1.58 . 109. People and pets entering the dwellings walked though this polluted water. This pathway of pathogens in the immediate home environment may help explain the high prevalence of diarrhea we found. Our findings of household wastewater in the environment with high levels of fecal pollution made clear that household wastewater could not be managed separately from the other waste streams, namely, sewage, solid waste, and storm water. The conditions we observed harm community health, pollute the environment (especially water sources), and risk deepening poverty in the very settlements created to ameliorate it. Although conditions in the settlements we studied were fairly typical of such housing schemes in South Africa, our findings may not be generalizable to other areas. Our study had a cross-sectional design and only captured a snapshot of the conditions prevailing in the settlements at the time. Although we took care to randomly select the study sites and dwellings, inadvertent selection bias cannot be excluded. Interventions The incidence of diarrhea we detected showed that community members needed information about household and personal hygiene. A cost-effective initiative for addressing community health needs would recruit and train community members as health assistants to visit families and give advice on basic health matters.37 They could also liaise with clinics and serve as a link between formal medical providers and the community. Pilot studies have demonstrated the efficacy of such an intervention, but it should be systematically coordinated with local primary health care services and supported by local governments.37 Failure to address the situation will inevitably lead to a health crisis that will be difficult or impossible to manage. Eisenberg et al. pointed out that much is known about the natural history of disease transmission but little about the interaction of different transmission pathways, information that is vital to determining the efficacy of an intervention.16 Their research showed that the

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