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By Frankie Freeman
ACCRA, Ghana—It’s 7:30 a.m. and the sun is rising fast over Ashaiman. Open gutters steam at the side of the road and the air is alive with the sounds of the crowded Accra suburb waking. Women fry meat over wood fires while the clatter of their cooking cuts through the morning. Patrick Apoya, former executive secretary of the Coalition of NGOs in Water and Sanitation, drives to meet a colleague. His white Toyota pickup truck crawls through the crush of workers on their morning commutes. He loosens the collar on his pressed cream shirt and leans a broad forearm out the window, drumming his fingers on the car’s warm metal. He has been driving for 30 minutes and is dressed for an air-conditioned office. Frowning, Apoya wipes a bead of sweat from his brow. Five minutes from his destination, Apoya sees a crowd gathered around a neatly dressed young man. They are standing at the concrete entrance to a shabby public toilet. A fight is about to break out.
Apoya pulls over, steps out of his car and approaches. The young man is trying to speak, but the group drowns him out. “What’s going on?” Apoya asks a bystander.
“This man takes us for fools because he dresses better than us,” the bystander says. Someone pushes the young man, and Apoya turns to another member of the mob, still looking for an explanation. “This man wanted to jump the queue to use the toilet, pretending he was late for office and feared his supervisor would be angry,” someone explains. “If he knew his supervisor would be angry, he should have been here at 4 a.m.”
The young man, clothes tussled, sheepishly retreats to his original place in line. He anxiously looks at his watch and turns to Apoya. He’s usually at the public toilet no later than 5 a.m., he explains, but felt unwell last night and overslept. “Thank God I’m not suffering from a bout of diarrhea,” he says, “or else I would have been in big trouble.”
A scuffle over a place in line at a public bathroom may seem strange, but so many houses in this country of 23 million lack proper facilities that queuing to use a public toilet is routine, particularly in urban Ghana. Waiting for 20 minutes or more is standard, even for the most basic facilities. And most public bathrooms are unsanitary, poorly maintained, gender-insensitive and quite smelly. Beyond the personal humiliation, the toilet queues are a sign that something is terribly wrong in one of Africa’s most vibrant nations.
A River of Filth
Politically stable, rich in natural resources and endowed with twice the per capita output of its poorer neighbors, Ghana is, in many ways, an African success story. Corruption is relatively low, and the business sector is strong. In the World Bank Group’s 2010 “Ease of Doing Business Index,” which rates countries based on their citizens’ access to entrepreneurial opportunities, Ghana comes in 92nd in the world—above Russia, Kenya, Greece and India. On Barack Obama’s 2009 presidential visit to the country, he praised the nation as an example of African democracy and opportunity. It is, in part, because of its successes and rapid development that Ghana is mired, quite literally, in a sanitation crisis.
According to a report by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), Ghana ranks as Africa’s fourth-dirtiest—the official term is “least sanitary”—nation, and the second-worst of the 15 countries that make up the West African region. This means that Ghana has a severe shortage of what the WHO defines as “improved sanitation”—waste disposal systems that separate human excrement from human contact. Approximately 20 percent of Ghanaians are forced to relieve themselves in open spaces, and 80 percent of residential toilets are shared between more than one household. Of those facilities that are available, most have not been improved in accordance with WHOstandards, which means that the proportion of the population with access to safe sanitation facilities is only 10 percent. Anything approaching modern, Western bathroom facilities can only be found in Ghana’s four- and five-star hotels and the country’s wealthiest homes. But even “wealthy” sewage makes its way, untreated, into the country’s rivers, where it infects the populace. Diseases related to poor sanitation take eight lives an hour and account for 80 percent of all ailments reported to clinics and hospitals in Ghana. Diarrhea alone was responsible for 452,250 outpatient deaths in Ghana in 2007, making it the country’s fifth-leading killer. Intestinal worms killed 208,429. Upper respiratory tract infections—twice as likely for those regularly breathing the fumes of raw sewage—came second only to malaria as the country’s deadliest outpatient ailment, killing 920,806 Ghanaians in 2007.
Disease is not the only serious side effect of Ghana’s sanitation crisis. The country’s economy, education system, tourism industry and social structures all suffer from the impact of poor sanitation. Ghana’s beaches, for example, often serve as toilets, which hurts the tourism industry. In a country that wants to transform itself into a middle income economy by 2020, a river of waste is carrying away decades of progress.
The Roots of Failure
Ghana is significantly wealthier than many of its neighbors. It has the 16th-largest GDP in Africa (out of 52 nations) and, in 2007, a large oil field was discovered off the coast that is projected to bring Ghana an additional $1.8 billion annually, once drilling begins later this year. Ghana has the spending power to make a real difference in its sanitation structures, but first it must in- vest some $1.5 billion over the next five years if it is to reach the UN’s Millennium Development Goals for sanitation. There are few signs that Ghana’s leaders are willing to pay such a price tag, and some doubt whether real change is a possibility for the near future. “Perhaps the next generation will build our country,” Apoya says. “Our generation has failed.”
Despite his lament, Ghana’s sanitation crisis is deeper than the failure of a single generation; it is rooted in Ghana’s turbulent history. Shortly after midnight on March 6, 1957, Kwame Nkrumah proclaimed independence, marking the end of nearly a century of British rule and setting the stage for widespread anti-colonial movements throughout Africa. Nkrumah won support from Ghana’s trade unions and farmers and rose to power on demands for self-government. But soon after independence, Nkrumah turned on his supporters, banning workers’ strikes and imprisoning suspected opponents under the Preventive Detention Act. In 1964, Nkrumah announced a constitutional amendment that made his political movement the country’s only legal party. But Nkrumah’s authoritarian tendencies only stoked opposition and resentment. While on a state visit to China and North Vietnam in 1966, his government was overthrown by a military coup. In the 15 years that followed, Ghana was rocked by four successive coups, until Lt. Jerry Rawlings took power in 1981 and banned all political parties. In 1992, Rawlings ratified a new constitution and restored multi-party politics, paving the way for Ghana’s current democracy.
Ghana’s rocky beginnings had a profound effect on the nation’s infrastructure, particularly its sanitation system. From the colonial period until the 1980s, public sanitation—including public toilets and treatment sites—was overseen by municipal governments. “The early exit of Kwame Nkrumah gave way to successive generations of elite leaders who lacked the vision to set a national agenda,” Apoya explains. The high turnover rate of these local government officials, combined with the low priority given to sanitation, meant that the systems were often poorly built and sorely neglected.
Infrastructure projects further deteriorated when Rawlings came to power. Rather than establish federal oversight for public sanitation, he shunted the duty off to even more localized collectives, which were often as small as a single neighborhood. New bathrooms were built, but officials charged fees to use them. At first, the new system worked, and the facilities were well run and maintained. The system broke down when politically motivated local collectives began spending maintenance money on reelections. The situation worsened until, eventually, Rawlings returned responsibility for the country’s sanitation facilities to municipal governments.
Today, human waste management in Ghana remains decentralized, run by metropolitan, municipal or district assemblies that either provide services directly or subcontract to private operators. With no central authority, sanitation standards are uneven and coverage is patchy. “There are no coherent national strategies,” says Lukman Salifu, chief executive officer of the sanitation consultancy WasteCare Associates. But the biggest factor in Ghana’s sanitation meltdown is the tidal wave of migrants moving into the country’s already overcrowded cities. Faced with bad schools and a farming industry struggling to compete with cheap imports, young Ghanaians have been flocking to urban areas for decades. In 1948, only 13 percent of Ghana’s population was considered urban. By 1984, it was 32 percent. Today, Ghana is estimated to be 52 percent city-dwellers. In the rest of West Africa, the average is 30 percent. As cities like Accra and Kumasi swelled with newcomers, new houses were built without access to public sewers or running water. A large proportion did not even include latrines. As a result of improper planning during a time of political unrest and hasty urban growth, the sanitation crisis took root. “For many years, we grew as a nation without social responsibility,” Apoya says.
Even today, modern building regulations are largely ignored. “Enforcement of building codes is abysmal,” says Salifu. “The Environmental Sanitation Policy banned the use of bucket and pan latrines, but there are still around 20,000 nationwide.” Part of the problem, according to Apoya, is that local government authorities do not enforce proper permits for new buildings. “Developers flatly ignore this requirement, with impunity,” he says. “In addition, the people who do obtain permits may eventually modify plans to exclude toilets in a bid to maximize the number of rooms they can rent out. And local building inspectors are weak and unable to enforce the rules.”
In a host of swelling Ghanaian cities, the influx of day laborers arriving from rural areas each morning has only compounded the problem. In Accra alone, at least a million people commute from the country each day. While people living in rural communities are still more likely to suffer from patchy sanitation infrastructure, the impact of poor sanitation is far more acute in areas of high population density. The WHO/UNICEF 2010 Joint Monitoring Report found that, although sanitation standards and water access are generally higher in urban areas of the world, progress toward improving sanitation is too often undermined by rapid population growth. The report found that the most rapidly growing cities saw the number of people benefiting from improved sanitation drop.
Sickness and Health,Wealth and Sewage
Open sewers run beside the streets throughout Ghana. With few drain covers, the gutters clog and overflow during heavy rainfall. Simply covering these vast networks would reduce the incidence of Ghana’s two biggest outpatient killers: malaria (stagnant water is a hotbed for mosquito larvae) and upper respiratory tract infections. The link between bad sanitation and disease is clear and direct. “When you think about sanitation, infectious diseases are the real problem,” says Dr. Yvonne Maldonado, a Stanford professor who specializes in pediatrics and infectious diseases. According to the 2006 United Nations Human Development Report, more than 1 billion people worldwide lack access to clean water, while 2.6 billion do not have access to adequate sanitation. Sanitation-related diseases kill more children worldwide than anything else—1.8 million a year die from diarrhea alone. In 2004, diarrhea was responsible for six times more deaths worldwide than the total casualties of all armed conflict in the 1990s.
Fatal diarrhea is far more common in cases where the individual either does not have access to an improved toilet or shares public facilities. In Ghana’s cities, shared facilities represent 70 percent of all bathrooms, nearly twice the level in rural Ghana. When five or six families are sharing one toilet, the risk of infection from communicable diseases rises dramatically, putting young children—who are especially susceptible—at risk. The UN Human Development Report notes that access to suitable sanitation is “one of the strongest determinants of child survival,” and that improving latrines could increase the number of children who live beyond the age of five by 30 percent. The report cites a study in Salvador, Brazil, where the incidence of infant diarrhea was twice as high in households without latrines, and three times as high in communities without any sanitation infrastructure.
Beyond providing significant health benefits, better sanitation leads to economic growth. According to the WHO, every dollar invested in sanitation returns, on average, between $5 and $11 in net gain. Improved sanitation lowers health care costs and mortality rates, slows the amount of labor lost to sickness and boosts education (fewer students miss class due to sickness). Currently, the World Bank estimates that poor sanitation costs Ghana around 5.2 percent of its annual GDP. If targets for United Nations Millennium Development Goals for water and sanitation are met (which would halve the number of people without access by 2015), the developing world could see gains of at least $15 per capita per year. Though this may not seem like a great deal of money, in Ghana, where the average daily income is around $4, it represents a significant boost to both long-term economic prospects and individual opportunity.
One of the tragic hidden costs of Ghana’s sanitation crisis is childhood education, especially among girls. According to Ghana’s Ministry of Education, half the country’s schools lacked toilet facilities in 2008 and, where they did exist, the facilities were often gender-insensitive. “For many female students, insufficient bathrooms are a big problem, and many end up taking time off school during menstruation,” Apoya says. “Some girls drop out of school altogether.” While the completion rate of primary education for boys in Ghana is 91 percent, it is only 79 percent among girls, a figure that Kofi Asare, the program officer of the Ghana National Education Campaign Coalition, says is directly related to inadequate sanitation. “The absence of toilets for girls does not only affect school attendance, but also contributes to the denial of their right to dignity and quality education,”Asare wrote in an editorial for All-Africa.com last August.
The Wealth Gap
When it comes to symbols of health and prosperity, the toilet isn’t especially glamorous. In policy-making and public debate, sanitation suffers from the stigma that it primarily affects the poor. In Ghana, as in many other nations, sanitation can only be tackled when the government realizes that, if nothing is done, its impact will damage other, higher-profile priorities on the national agenda—such as economic development and education. “It’s all about money and political will,” Maldonado says.
On March 30, Kweku Quansah, the program officer of the Environmental Health and Sanitation Directorate of the Ministry of Local Government and Rural Development (his title alone points to Ghana’s fractured bureaucracy) announced that the country will require an extra $1.5 billion if it is to meet its sanitation goals, which will ensure 78 percent of the population access to clean water and improved sanitation by 2015. Quansah urged the private sector to support capital investment, since 80 percent of work in Ghanaian sanitation and water is con- trolled by private interests. Since 2006, Ghana’s urban water system has been managed by a private contractor, Aqua Vitens Rand Ltd (AVRL), on behalf of Ghana Water Company Ltd. AVRLhas come under fire in recent years from groups such as the National Coalition Against Water Privatization for its questionable service record, including accusations of large-scale leakages and poor water quality. AVRL’s contract followed a failed agreement with the U.S. company Azurix, which broke down after the firm was accused of corruption and bribery. Though Azurix denied allegations, the World Bank withdrew its support.
Sanitation in Ghana is managed by local authorities and organizations, and rural water is in the domain of local communities and their district assemblies. When a community has a population of less than 50,000, it manages its own water and sanitation. It is estimated that between 80 and 90 percent of Ghana’s water and sanitation funding comes from outside sources, such as the World Bank, the EU, and non-profit organizations such as Water Aid and World Vision International. A recent budget tracking report found that, of 31 million Ghana cedis ($21 million) allocated to the Ghana Water Company Limited and the Community Water and Sanitation Agency, only 10 percent ever found their way to local sanitation programs. Although it is not clear where the promised money ended up, it is likely to have been diverted to other, higher-profile sectors.
With little government transparency and rampant, irresponsible spending, not enough money in Ghana is reaching the projects that really need it. As part of a five-year plan to improve government accountability, the Integrated Social Development Centre found that the country’s poor were distinctly underrepresented in terms of government funding. According to the report, Ghana’s poor benefit from just 5 percent of government water expenditure, while most funds go to urban projects that serve a wealthier segment of the population. The lack of investment in Ghana’s poor is a sad and familiar pattern, repeated by inefficient and callous bureaucracies across sub-Saharan Africa. It is also remarkably shortsighted.
There is no doubt that a vast improvement in Ghanaian sanitation would be costly, but if the WHO’s 2004 report on the costs and benefits of sanitation and water improvements is anything to go by, the payout could be huge. “The WHOreport demonstrates that the economic savings can be 10 or 100 fold,” says Stanford’s Maldonado. According to the study, it would cost the sub-Saharan region some $11 billion to reach its sanitation and water goals—an effort that would yield $80 billion in long-term economic benefits. A significant financial gain from reaching these targets comes from “convenience savings,” which is simply the time won back from no longer having to wait in line to use a toilet.
Not the First, Nor the Last
If the situation in Ghana seems hopelessly dire, it is worth remembering the transformation that took place in London, Paris and New York. A visitor to London 135 years ago would have walked through streets lined with overflowing, open gutters carrying raw sewage into the Thames. Waterborne diseases such as typhoid, dysentery and diarrhea were rife, raising rates of child mortality and strangling economic and social development. But social reforms during the late nineteenth century brought widespread improvements in water and sanitation. Paris’s vast underground sewage system underwent a major overhaul in the late 1800s, when Baron Haussman engineered separate passages for clean water and sewage. Around the same time, London’s sewage system underwent a similar facelift to keep up with the rapid pace of the Industrial Revolution. The results were dramatic. With a safe sanitation system in place, infectious disease rates dropped. Forty years later, life expectancy in the U.K. had increased by 15 years. France’s new sewage system led to a vast drop in the rate of diseases such as typhoid and cholera, and by 1900 Paris was considered the cleanest city in the world. In New York in 1865, sweeping reforms brought improvements to the city’s infrastructure. Under the Croton Aqueduct Department, 39,000 feet of sewer line was built and the city’s overall health improved.
The past teaches a valuable lesson. Sanitation is a treatable problem, and while change doesn’t take long, money and unified support from those in power are required. In Ghana, a turnaround is within reach, as long as those who hold the purse strings are prepared to take charge. “At the moment, maintenance of Ghana’s sanitation standards falls to the people, not the government,” says Apoya. “If we are going to see real change, the effort needs to be centralized, backed by real government will.”•