Without water, sanitation and hygiene, we neglect the most basic elements of healthcare

Yael Velleman, WaterAid’s Senior Policy Analyst – Health & Hygiene, highlights the vital importance of safe water, sanitation and hygiene in healthcare facilities in the world’s poorest communities.


20 Mar 2015

A few years ago, I spent the night at a maternity home in rural Nicaragua.

This happened by chance; at the time, I was travelling with a network of Nicaraguan women working to prevent gender-based violence in remote communities on the Atlantic coast. We had arrived earlier that day and checked into the only ‘hotel’ in town, only to leave almost immediately due to the number of drunk men on the premises and the unlockable door. The maternity home was the only other available option.

This was a new facility, built through the contribution of a large aid agency. It had many beds, a kitchen, a delivery room, even a young and enthusiastic female doctor – and it was absolutely filthy.

There was dust everywhere, the beds were dirty with no mattresses or sheets, and cockroaches were rushing around the floor. There was no running water, and so the flush toilet didn’t work either. We paid to have water carried over from a nearby well so that we could at least have a wash. But of course what we could see was just the visible dirt; we tried not to think of the invisible dirt – the multitude of bacteria probably spread around every surface of this ‘flagship’ facility.

I didn’t sleep that night – it could have been the hard floor, the cockroaches, or the drunk man who burst through the door in the middle of the night in search of accommodation. But the overall feeling of filth remained etched in my memory – as is the knowledge that this facility is the only option for thousands of women in surrounding communities, who often make the dangerous journey by canoe or horseback in hope of a safe delivery for them and their children.

The few hours I spent there weren’t enough to understand what has led to this situation in such a new facility. Perhaps a broken pipe? A dry water tank due to a lack of rain? Or perhaps, more likely, these are the symptoms of a deeper planning and management failure. Regardless of the cause, the consequence was clear. This facility was failing to provide the most basic of requirements for a safe birth – a clean environment, and the means for the doctor and midwives who attended births under these circumstances to keep their hands clean, in order to avoid life-threatening infections such as puerperal sepsis.

Daily life in Bilwi, Nicaragua, 2014.
Daily life in Bilwi, Nicaragua. Photo: WaterAid/Rodrigo Cruz

At the time of my visit, Nicaragua had already become a middle-income country. This had done nothing to change the circumstances in poor rural communities. The same situation still exists in most of the countries in which WaterAid works. The report published by the World Health Organization today makes for grim reading, with only 38% of health-care facilities described as having access to water. Sadly, the health-care facility I describe here would have counted as ‘having access’, since the well from which water was fetched was within 500m of the facility, and because it had a toilet, functional or not. Such ‘access’ is a far cry from the standards set by WHO for all health-care facilities, and leaves so many important questions unanswered – is water and soap available to health-care providers in the delivery room, where life-saving handwashing needs to be practised? Is the water itself safe to drink or to wash with? Who washes the sheets? Who does the cleaning and how well? What happens to medical waste? And as sepsis may take several days to develop, do we even know how many infections occurred as a result of the poor hygiene conditions in this facility?

Preventable infections such as sepsis at birth are not a new threat; they are not an unfamiliar pathogen awaiting further investigation or the development of a vaccine. Nor do they require prohibitively expensive interventions. They have been known to medical practice for generations, and the infection control measures implemented in high-income countries have saved countless lives.

The widespread existence of these conditions is an affront to health-care professionals, and a terrible and easily preventable injustice. Of course, the solution cannot be to discourage births from taking place in health-care facilities; home environments may be just as dirty, and lack skilled personnel and the ability to provide emergency obstetric care. The solution must be to ensure that any existing or new health-care facilities have the most basic requirement of all – keeping their patients and staff safe. And putting water and sanitation into every health-care facility must form the bedrock of safe, hygienic health care.

This article was original published in Thomson Reuters Foundation

Yael Velleman is WaterAid’s Senior Policy Analyst – Health & Hygiene. She tweets as @YaelVelleman and you can read more of her blog posts here.

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