At 3.30pm, Salma Hakofagamaro emerges from a bush carrying a hoe and walks towards her house. The resident of Makere Village in Tana River County, is not coming from her farm, but from reliving herself.
When nature calls, you can’t ignore it, and for 5.6 million Kenyans, answering the call of nature means going to the nearest bush.
In Makere Village open defecation is the order of the day, and one has to hop and jump to avoid stepping on human waste.
More than half (57 per cent) of Tana River residents do not have toilets, but this is an improvement. In 2013, only 36 per cent of residents had access to toilets in 2013, compared to the current 43 per cent, according to Odha Dae, the public health officer who coordinates water, sanitation and hygiene projects in the county. The rest still help themselves in the bush or in the river.
For some like Salma, their mud-walled latrines were swept away by the floods during the long rains mid this year, and they simply don’t have enough money or resources to build new ones.
“It is easier to go to the bush, than to request a neighbour to allow us to use their latrine all the time, plus the bush is closer to our home than the neighbour’s toilet,” the mother of five explains, adding that her children now know to use a hoe to cover their waste.
Although Tana River has less than half of its population having access to toilets, five counties – Samburu (74 per cent), Turkana (65 per cent), Marsabit (52 per cent), West Pokot (51 per cent) and Kwale (48 per cent) – fare worse, according to data from the Kenya Integrated Household Budget Survey.
This is despite an ambitious goal set in 2011 to free Kenya from open defecation, which happens mostly in rural areas, by 2013. By the end of the campaign only two per cent or just 1,273 out of 59,915 targeted villages had been certified open defecation free.
Before that, between 1990 and 2013, Kenya was only able to increase the number of people using proper toilets instead of thickets from 25 per cent to 29 per cent.
As of now, seven out of 10 Kenyans do not have access to improved sanitation facilities that separate waste from human contact, with 30 million Kenyans using unsafe sanitation methods, such as rudimentary latrines, and nearly six million going for long calls in the open.
Their faeces which are neither captured safely nor treated, contaminate water and soil and find their way back to food and drinking water, leading to outbreaks of diseases such as diarrhoea, amoeba, typhoid and cholera, intestinal worms and neglected tropical diseases such as trachoma, which is spread by flies that have been in contact with human waste.
Flooded latrines and untreated wastewater compound the problem, as faecal matter finds its way into environment and then to back to food and water sources.
Worldwide, an estimated 1.8 billion people use a source of water that is not protected from contamination with human faeces.
It is estimated that open defecation costs Kenya Sh8.8 billion per year – or nearly Sh2,000 per person per year – making it the most costly unimproved sanitation practice.
Eliminating the practice would require less than 1.2 million latrines to be built. And not just any latrine with a hole and walls, but an improved one that safely disposes waste, and preferably not shared by too many people.
Some of the greatest casualties of unimproved sanitation are children, especially those under the age of five, who are exposed to illnesses that could kill them.
Diarrhoea caused by contaminated water and poor sanitation kills more than 289,000 children under the age of five every year.
Moreover, frequent bouts of diarrhoea, which cause dehydration, make children more vulnerable to other infections and increase cases of malnourishment and stunting due to prolonged undernutrition. A quarter of all stunting is attributed to five or more episodes of diarrhoea during the first two years of life.
These children are also likely to suffer impaired emotional, social and cognitive development. Lives could be saved by a toilet and clean water and soap for handwashing, which is why the world set a goal of universal access to safely managed water and sanitation, as part of the Sustainable Development Goals, to be achieved by 2030.
This means universal access to safe drinking water at home, work or in public places; a private toilet to dispose faecal waste and soap and clean water to wash hands.
However, the goal to halve the number of people living without sanitation, is running behind schedule.
A 2017 Joint Monitoring Project update by the World Health Organisation and Unicef estimated that in 2015, 61 per cent of the global population (4.5 billion people) lacked safely managed sanitation services.
These people either used basic toilets or latrine (2.1 billion people), shared toilets among several households (600 million people), used poorly constructed latrines or buckets (856 million people), or defecated in the open (892 million).
For Kenya, the failed attempt at being declared 100 per cent open-defecation free by 2013, led to the Community Led Total Sanitation campaign to end open defecation in many parts by 2020, and the rest by 2030.
Counties such as Vihiga, Nyeri, Nyamira, Kisii and Kiambu, with less than one per cent of their residents without toilets, hope to achieve open defecation free status by 2020, as do counties with higher rates such as Uasin Gishu (two per cent), Trans Nzoia (three per cent), Tharaka Nithi (four per cent), Siaya (20 per cent), Migori (33 per cent), Machakos (three per cent), Kitui (31 per cent), Kwale (51 per cent), Kilifi (34 per cent), Homa Bay (39 per cent), Kakamega (two per cent), Busia (eight per cent), and Bomet (five per cent).
Counties with with higher rates of open defecation are expected to meet the 2030 goals, with increased latrine coverage, expected to prevent faecal oral diseases and reduce death and disability.
However, a report by the Ministry of Health and Unicef notes that despite the efforts towards an open defecation free Kenya; only 27 per cent (16,227 villages) of targeted villages have partnerships for community level engagement and have operational problems including partial involvement with Community Led Total Sanitation elements.
Most of the parts of Kenya affected by open defecation, are sparsely populated and inhabited by pastoralists, but even in counties with lower rates of open defecation, children’s faeces are often not properly disposed due to fear that they might fall in latrines, and the perception that children’s faeces are harmless.
For this reason, 30 per cent of child faeces are unsafely disposed of in the open, rinsed into an open drain, buried or thrown out with the normal garbage. Moreover, some adults routinely defecate in the open at night and during the rainy season.
Although the problem of poor sanitation largely affects rural parts of Kenya, poor urban settlements are not spared, with less than 20 per cent of the population having access to improved sanitation.
Moreover, 80 per cent of latrines are shallow pits which pollute the environment, and especially the rivers and sources of drinking water near the settlements.
The consequences of poor sanitation are felt through waterborne diseases. When Tana River county flooded mid this year, the county hospital treated 250 cases of cholera, something the county executive for health and sanitation Mwanajuma Hiribae attributes to lack of toilets.
“There were no toilets in most of the villages. Many people got sick due to contaminated water from rivers or from drinking contaminated water from collected pools,” she explained.
In Kirindon, Trans Mara Sub-county, despite an intervention that has lasted close to 10 years, none of the eight villages with almost 8,000 inhabitants, have been declared open defecation free. Only 30 per cent of the population have latrines, and some of the villages have just three pit latrines.
“It’s an issue of culture and poverty. Men cannot share a latrine with their daughters, so they go to the bush instead. And for those without latrines, there are thickets for women, men and children to help themselves,” notes Duncan Sungu, a nursing officer at Kimintent Dispensary.
Community members do not seem to understand the link between going to the bush, and getting sick. And given that the main sources of water are water pans and streams, which are often contaminated with faecal matter, health practitioners say typhoid cases are a problem.
“For every 20 patients who come to Kimintet Dispensary, two or three are diagnosed with typhoid. We have held public barazas and used community health volunteers to spread the message about the importance of building a latrine, but we haven’t made much headway, though we are not giving up,” Sungu explains.
Open defecation costs Kenya Sh8.8 billion a year, yet Kenya allocates less than one per cent of its gross domestic product (0.2 per cent) to sanitation, against a global target of 0.9 per cent. The money is channelled through the Ministry of Health, and other ministries.
According to World Vision Kenya West Pokot Project Manager Titus Kaprom, sanitation conditions have to be addressed if livelihoods are to improve.
He explains that communities are triggered to start using latrines by evoking feelings of shame and disgust about open defecation, and then encouraged to construct latrines using locally-available, materials.
“You do not have to use expensive materials like bricks and iron sheets to construct a toilet, one can use the locally available materials,” said Trans Mara West medical officer in charge of health Dr Timothy Lumarai, during an event to celebrate four villages that had been certified open defecation free earlier this year, after a six-month community-led effort.
Safe human waste disposal is crucial because it reduces the spread of disease-causing germs.
Human waste disposal facilities that are considered improved or adequate include those that have a connection to a main sewer line or septic tanks; ventilated improved pit latrine, pit latrine with slab and composting toilets.
Unimproved human waste disposal methods include flushing to other areas, using uncovered pit latrines or bucket toilets and open defecation.
The Joint Monitoring Programme found that for the few who have latrines, 72 per cent of the toilets are simple pit latrines that might not meet the recommended safety, hygiene and privacy standards.
According to Moses Mulomi, Deputy Governor for Busia County, whose villages have been declared open defecation free, whereas many communities stopped practising open defecation, they are stuck at using unimproved sanitation facilities and smelly toilets yet it is the improved toilets that can protect humans from their waste.
Ibrahim Kabole, the managing director for Water Aid, an organisation that helps communities implement water and sanitation projects in Tanzania, concurs, noting that rudimentary toilets affect the state of water bodies and groundwater in the region, leading to cholera outbreaks.
In Kenya alone, nearly 20,000 Kenyans, including more than 17,000 children under the age of five, die every year from diarrhoeal diseases directly attributed to poor water, sanitation and hygiene.
Mr Mulomi also emphasises that beyond getting all Kenyans to use toilets, there is need for complementary behaviour of hand-washing with soap and water, for proper sanitation to be achieved.
Somewhere to learn, but nowhere to relieve themselves
School-going children suffer from lack of adequate sanitation facilities. Toilets are particularly a problem in public schools, and where they are inadequate or lacking, pupils may either have to relive themselves in the bush.
The World Health Organisation recommends a toilet for every 25 girls and one for every 35 boys. The national school health policy estimates that that there is need for new toilets in 10,000 schools across the country, as well as need to renovate toilets in 10,000 schools across the country.
Further, a Unicef survey of 343 schools, found that 87 per cent had separate latrines for girls, boys and staff, but only 20 per cent met the standards for latrines for boys and only 19 per cent met the standards for latrines for girls.
The latrines were also assessed for child-friendliness, and the survey found that 62 per cent met the criteria for spacious cubicles, 51 per cent for appropriate aperture and 76 per cent for privacy.
Only 32 per cent of schools met the minimum hygiene criteria and just over one in four schools maintained their latrines correctly.
Another report on school toilets released by Water Aid this year, found that one in three schools around the world do not have decent toilets, and one in five primary schools and one in eight secondary schools do not have toilets at all.
The report noted that when children do not have decent school toilets, they have to run home at breaktime to relive themselves, or use the bushes on school grounds.
Some pupils miss school altogether when they are sick or when they are on their periods, when there are not enough or decent toilets in school.
Toilets are not just a matter of convenience, as diarrhoea and intestinal worms together kill nearly 140,000 school age children around the world.
The report shows that only 66 per cent of schools have basic sanitation (flush or pour-flush toilets, ventilated improved latrines, composting toilets and pit latrines with a slab or platform that are single-sex and usable – available, functional and private).
Twelve per cent of schools have limited sanitation, meaning that they have basic toilets that are either not single-sex or not usable.
Twenty-three per cent of schools have no sanitation, meaning toilets that don’t hygienically separate human waste from contact with people, such as latrines over an open pit or water, or no school toilets at all.
“Investing in good toilets, in workplaces and schools, to ensure that women and girls have clean, separate facilities to maintain their dignity, manage menstruation or pregnancy safely, can boost what is often referred to as the ‘girl effect’, which is maximising the involvement of half the population in society,” says Mr Kaprom, the World Vision project coordinator in West Pokot.