Open defecation: Trigger for polio, diarrhoea and high child mortality

Lekan Akinfenwa was surprised when he needed to answer nature’s call during his visit to Oke-Itoku, in Abeokuta, and was told to defecate in a nylon or paper, which then will end up in the nearest dump metres away.

For residents of this community, especially, the young ones, they have grown to see this act as the norm. The excuse residents often give for such open defecation is that they are sitting on a rocky environment, so, having a sewage tank to house their excreta might be difficult.

A similar excuse might be put up by residents of Otumara and Makoko areas of Lagos, where some of them, after defecating, throw their excreta into the overlooking mass of water, (Lagoon). And those who do not, build makeshift pit toilets, while excreta is passed into the water. Residents of these three communities are among the millions of Nigerians that engage in open defecation.

Therefore, when the Minister of Environment, Amina Mohammed, recently said Nigeria hopes to end open defecation by 2019, it was taken by many as a serious statement. This means that the over 50 million who openly defecate, either deliberately or as a result of not having access to toilets would, by then, have access to toilets and so, will have no reason to openly defecate.

If Nigeria, by 2019, eliminates open defecation, no doubt, it would be applauded, because of the huge benefits attached to it, as it would be six years to the deadline set by UNICEF for the elimination of open defecation around the world.

The World Health Organisation (WHO) recently linked 12.6m yearly deaths to unhealthy environments. Also, the health body said diarrhoea accounts for nine per cent of the death of children under five years worldwide, which is essentially as a result of faecal-oral disease, where germs are ingested due to contact with infected faeces. It is said that Nigeria loses over 150,000 children to diarrhoea yearly.

Studies have revealed that 80 per cent of diarrhoea cases in Nigeria are attributed to unsafe water and sanitation. These researches also stated that intestinal parasites, such as roundworm, whipworm and hookworm are transmitted through contaminated soil in areas, where open defecation is practiced, with hookworm, a major cause of anaemia in pregnant women, leading to malnourished and underweight babies, putting children at risk of stunted growth and even death.

The United Nations Children Education Fund (UNICEF) revealed that diarrhoea prevalence rate in Nigeria is 18.8 per cent and is one of the worst in sub-Sahara Africa, above the average of 16 per cent. The body also said that diarrhoea accounts for over 16 per cent of child deaths in Nigeria and an estimated 150,000 deaths, mainly among children under five occur yearly, which is mainly caused by poor sanitation and hygiene practices.

“We need to bring concrete and innovative solutions to the problem of where people go to the toilet, otherwise we are failing millions of our poorest and most vulnerable children,” said Sanjay Wijesekera, Head of UNICEF’s global water, sanitation and hygiene programmes. “The proven link with malnutrition is one more thread that reinforces how interconnected our responses to sanitation have to be, if we are to succeed.”  

Also speaking recently on sanitation issues, former UNICEF Representative in Nigeria, Dr. Robert Limlim, stated, “Diarrhoea is also closely linked to malnutrition, a condition that is associated with more than half of all under-five deaths. Undernourished children, in turn, have compromised immune systems and are higher risk for developing pneumonia – which also contribute to high children mortality in the country. This chain reaction illustrates that good hygiene practices, such as, hand washing are critical for child survival and development.”

A community health expert at the Lagos University Teaching Hospital (LUTH), Dr Abdul-Akeem Abiola, said to tackle open defecation requires provision of enough latrines, so that citizens could have somewhere to ease themselves, when they need to. He argued that it is, because the toilets are not enough, and those available are not properly maintained, that make people use any available space, when they need to pass out faeces.

Then, government should provide enough toilets and most of the toilets available when I was growing up are no more there. At the Idi-Araba Park, there used to be a public toilet, but it is no more there. So, instead of government phasing out the public toilets, they should build more. And this could be done through public-private partnership. Government can build the toilets; get people to manage it, who then make returns from the fees people, who use the toilet pay. Or get private persons to build and run them,” he said.

He also noted that some of those, who engage in the practice of open defecation, do so, because they are not properly educated about the consequences. He stated that if they know that most of the infectious diseases affecting children are from faeces, they would, probably, desist from such act. He added that legislation to punish those who engage in open defecation is also important, which could be effected after putting in place enough public toilets.

“If we do this, we could achieve the elimination of open defecation by 2019. It is possible, what we need is mass education and then all the places where public toilets used to be, should be rebuilt and more provision made for places like markets, fields, bus-stops.”In most rural villages across the country, houses are built with no toilet facilities. They believe in going into the bush or pass out faeces on community dumpsites.

On the strategy to tackle open defecation by rural people, Abiola maintained that health education is key. “For instance, polio is got from faeces, so, if people know that the consequences of open defecation is their children being paralysed; they will be cautious and not want to engage in such act. So, health education is important, mass enlightenment campaign on reasons for people not to engage in open defecation.”

Another public health expert, Prof Ekanem Enakem, also of LUTH, said when it comes to implementation of government policies, many of the officers often make statements without sincerity of purpose; they might mot be around to execute the programme. “By 2019, the person who made the utterance will not be in power and so, will not be held accountable. This is not the first time we are hearing such promises, but let us hope they mean well and are going to do something about it.”

He noted that there cannot be talk of ending open defecation, when a large proportion of Lagos residents, for example, do not have access to water. “About 17 million Lagosians do not have access to clean water, so, the building block is for the citizens to have access to clean water and sanitation, then government would begin to build public toilets. But in rural areas, the toilets in such areas should be different from the ones in urban areas.”

According to him, it is important the present administration takes the minister’s statement serious, because over the years, diarrhoea has been killing children and it is among the leading causes of morbidity and mortality in children. “We have Sustainable Development Goals, access to water and sanitation is a key element of the SDGs.”

Enakem also argued that government could make a policy statement and work assiduously towards it, yet the efforts may not make the needed impact, because the people were not carried along. He said it is important government carried the people along in its drive to end open defecation because sometimes, government would build facilities and the people it is meant for, refuse to use such facilities.

The professor of community health also disclosed that all those, who channel their faeces to drainages and canal or bury their faeces untreated are engaging in open defecation. He maintained that such act is risky, because faeces that emanate from such facilities, go into drainages, which would filter into water sources, like well and borehole.

“And in such cases, people are likely to come down with different diseases. So, I still consider such actions, open defecation, as along as it is not controlled and not properly disposed. When it rains, it carries the faeces and waste matter, which sinks down and filter into the borehole and if the borehole is shallow, it gets contaminated from the underground water that is contaminated by faeces from open defecation.”

He noted that, at present, there is epidemic of typhoid; people do not even consider where it is coming from. He, however, said that diseases contacted as a result of open defecation, such as cholera, diarrhoea and typhoid are not directly linked to malnutrition, but indirectly, because children, who continuously have diarrhoea will not keep the nutrients in body, which means, the body does maintain the nutrients; so, continuous loss of water and fluid leads to malnutrition.

There were four public toilets around Mile 2 Motor Park, under Amuwo Odofin Local Council, but the only one that had not been pulled down, is not functional at present. However, there are toilet facilities provided by private individuals. In spite of these facilities, there are faeces dotting different parts of Mile 2. It is almost the same scenario in Oshodi, Lagos Island and some other parts of Lagos.

Interacting with some of the transporters, they claimed that those who defecate in the open do that in the dark or where they could not be easily seen.
According to Samsom Adebiyi, the private toilet facility providers close for the day once it is getting dark, and so, anybody who needs to defecate will be forced to do that in the open. For Badmus Adio, the area boys, most of whom sleep within the garages and parks, are the culprits who excrete in the open, especially, along the rail lines. “Most of these boys and girls have no homes where they rest their head, so they sleep in buses and under the bridge and when they need to defecate, they use any available spot,” he said. Adio said they do it not just in the night, but also during the day, because they are usually not willing to pay a fee for the toilet service.

However, a senior lecturer in the College of Medicine, University of Lagos, Dr. Folu Olatona, said that open defecation in sparsely populated areas or forests might not lead to grave consequences, but it becomes a significant public health issue, when it occurs in more densely populated areas, fields, urban parks, rivers and open trenches in close proximity to the living space of others or where other people could make contact with the faeces or soil contaminated with it.”

The consultant public health physician noted that in countries, where open defecation is common, there is a high level of under-nutrition, child deaths; especially, among children younger than five years of age and poverty. “The health and personal safety impacts due to open defecation are principally the same as those from lack of sanitation. There are three identified direct pathways through which poor sanitation and associated open defecation may adversely affect nutritional outcomes in children: diarrhoeal diseases, mal-absorption of nutrients, and worm infections,” Olatona said.

The public health expert noted that repeated infection with diarrhoeal diseases contributes to chronic under-nutrition by reducing appetite and inhibiting intestinal absorption of nutrients, because the little absorbed are also wasted in dealing with the infection, instead of contributing to body building.

“Apart from the chronic under-nutrition, which manifests as short stature, the children are likely to suffer lower intellectual capacity. Under-nutrition, in turn, increases susceptibility to infectious diseases, such as diarrhoea, thus perpetuating a somewhat vicious cycle. Another result of ingestion of faecal bacteria apart from diarrhoea is a condition, which causes mal-absorption of nutrients. When nutrients are not well absorbed, it leads to under-nutrition and if prolonged, stunting in children.

“Children and adults who walk barefooted can also step on the faeces, and thereby, get infected with hookworm or other worms, which are transmitted through the soil. These worms cause mal-absorption and compete with the person for nutrients that should have been used for blood formation and other functions in the body. This can also lead to under-nutrition and hence growth retardation in children.

A child’s height reflects his/her nutritional and health status within the first few years of life, including before birth. Children, who are well nourished within the first 1000 days of life, are likely to achieve their maximum height potential. Since height is an indicator of the development of the body, brain and skills, most children, who achieve their maximum height potential are likely to grow up to be more productive and live longer. Whereas those, who suffer under-nutrition in childhood, are likely to be less productive and more susceptible to diet related non-communicable diseases in adulthood.”

She stated that access to sanitation is critical for human development as there is enough evidence that connect open defecation to nutrition, health and development. Olatona maintained that construction of toilets should not be seen as government’s responsibility, but a priority that individual households should take responsibility for. “Each household should have at least one toilet. People should be motivated to see a toilet as fundamental to their social standing, status and well-being.”

She, however, pleaded with policymakers to invest in measures that would improve access to Water, Sanitation and Hygiene (WASH) so that people, who practice the habit, because of lack of facilities, can stop it. To tackle the practice of open defecation, she suggested having several public toilets in strategic places so that people can defecate safely, when they are not in their houses. Besides, there should be adequate water supply everywhere, just as the people should be well informed to inculcate good hygienic practices.

“Health education on the disadvantages, especially the health problems associated with open defecation should become popular. There is a need for behavioral change in addition to the provision of toilets, because even if toilets are available, people still need to be convinced to desist from open defecation and use the toilets,” Olatona said.