Keywords

1.1 Global Sanitation as a Long-Term Challenge

The establishment of appropriate sanitation has for long been presented as a challenge for global development by international organizations, at least half a century. The League of Nations Health Organization, which became the World Health Organization (WHO), had recognized the importance of sanitation as early as the 1930s, advocating appropriate sanitation in “rural” housing (Borowy 2007: 19–21). The origin of the recent global programs and discourses on sanitation can be traced back to the 1970s—it coincides with the change in the global discourse on international development. From the 1970s, the discourse shifted, from modernization emphasizing growth and industrialization to reducing poverty (Gubser 2012). With this transition from economic development to human development, sanitation became a growing concern (Rosenqvist et al. 2016: 301).

In the 1970s, sanitation became a part of the basic human rights and basic human needs, and the 1980s was designated as the International Drinking Water Supply and Sanitation Decade (1981–1990) (hereafter, “the Decade”). The United Nations Conference on the Human Environment in 1972, known as the Stockholm Conference, proclaimed that the “aspects of man’s environment, the natural and the man-made, are essential to his well-being and to the enjoyment of basic human rights” (UN 1973: 3). It also pointed out that people in low- and middle-income countries “continue to live far below the minimum levels required for a decent human existence, deprived of adequate food and clothing, shelter and education, health and sanitation” (UN 1973: 3, emphasis added). These perspectives have evolved over the years, and sanitation has become one of the key elements of development. In 1976, the United Nations Conference on Human Settlements—Habitat I recommended that governments consider water and sanitation in rural development planning (UN 1976: 162). To implement this recommendation, the United Nations Water Conference, in Mar Del Plata, in 1977 formulated the action plan for the Decade that “require[s] a concerted effort by countries and the international community to ensure a reliable drinking-water supply and provide[s] basic sanitary facilities to all urban and rural communities based on specific targets to be set up by each country, taking into account its sanitary, social and economic conditions” (UN 1977: 14). It also pointed out that “for providing safe drinking water and sanitation for all human settlements by 1990” (UN 1977: 66). The goal, however, was hardly achieved. The report on the Decade estimated that the global coverage of “urban sanitation” had increased from 69 to 72% and that of “rural sanitation” from 37 to 49% in that period (UN 1990: 20). After the end of the Decade, WHO and others pointed out the necessity to reinforce monitoring at the national level, and WHO and the United Nations Children’s Fund (UNICEF) launched the Joint Monitoring Programme (JMP) in 1990 (WHO/UNICEF Joint Monitoring Programme 1992: 1). In the same year, the first issue of the Human Development Report by the United Nations Development Programme (UNDP) was published—it explicitly mentioned that “poor sanitation” is a component of the “environment” that is created by poverty, and it thus reinforces poverty (UNDP 1990: 7).

From the 1990s, sanitation gained more attention in the realm of the discourse on global development. In 1992, the Earth Summit was held on the 20th anniversary of the first Human Environment Conference and resulted in “Agenda 21,” an action plan for sustainable development, which proclaimed to “provide the poor with access to fresh water and sanitation” (UN 1993: 30). The Millennium Development Goals (MDGs), established in 2000, set a more concrete target regarding sanitation—Target 11 of Goal 7 contains the indicator “proportion of people with access to improved sanitation” (UN 2001: 57). The report on the road map of the MDGs stated that “2.4 billion people lack access to basic sanitation,” and as “economic development and population growth increase demands, …sanitation facilities will become priority areas” (UN 2001: 20). In other words, discussion on sanitation as one of the essential factors for global development has been ongoing for almost half a century.

Yet, the issue of global sanitation still remains unresolved. The JMP for the assessment of the MDGs indicated that, over the MDGs period, the usage of improved sanitation facilities was estimated to have increased from 54 to 68% on a global level. Nearly 2.1 billion people have had access to improved sanitation since 1990. The MDGs target was aimed at reducing the proportion of people lacking sustainable access to basic sanitation by half between 1990 and 2015. Thus, the achieved proportion fell short of the global MDGs target of 77% by nine percentage points, and nearly 700 million people did not have access to basic sanitation facilities; in 2015, 2.4 billion people did not have access to improved sanitation (WHO/UNICEF Joint Monitoring Programme 2015: 12). The improvement has been uneven between urban and rural areas. On a global level, the estimated percentage of the urban population using improved sanitation facilities is 82%, while that of the rural population is 51% (WHO/UNICEF Joint Monitoring Programme 2015: 14).

Furthermore, the pace of improvement in sanitation is markedly slower compared with that of safe drinking water. Over the MDGs period, the global use of improved drinking water sources is estimated to have increased from 76 to 91%. The MDGs target of 88% was exceeded in 2010, and 6.6 billion people had access to an improved drinking water source by 2015 (WHO/UNICEF Joint Monitoring Programme 2015: 6). Although the domain of safe drinking water still faces a challenge, especially in Sub-Saharan Africa (WHO/UNICEF Joint Monitoring Programme 2015: 7), and careful reexamination of the details of its improvement is required (Satterthwaite 2016: 103–106), sanitation has lagged further behind, considering the failure to meet the MDG targets.

The Sustainable Development Goals (SDGs) present a new vision for improving global sanitation. In contrast to the MDGs, which aimed to halve the proportion of the population lacking access to basic sanitation, the SDGs are “sanitation for all” (UN 2015: 14). Though the MDGs emphasized the promotion of sanitation, its quality and effect upon marginalized people were either not mentioned adequately or omitted altogether (UN 2001: 20–21, 24). The SDG 6.2 (sanitation target) is not only “end open defecation” but also “achieve access to adequate and equitable sanitation and hygiene,” “paying special attention to the needs of women and girls and those in vulnerable situations” (UN 2015: 18). To match SDG 6.2, the indicator has also been modified as a “proportion of the population using safely managed sanitation services, including a hand-washing facility with soap and water” (UN 2017: 10). This change in the target on sanitation from the MDGs to the SDGs is fundamental. It is a transformation, so to speak, from building a latrine to establishing an adequate and equitable sanitation system that includes appropriate treatment and disposal of human waste, especially focusing on vulnerable people. Furthermore, for the first time, water, sanitation, and hygiene (WASH) have been targeted under the same global goal (SDG6); the MDG targets did not include hygiene (handwashing).

The transition from the MDGs to the SDGs requires more consideration based on the socio-cultural aspects of global sanitation. Those living in severe situations face structural violence, and vulnerability is a structural product of class-based economic exploitation as well as cultural, gender/sexual, and racialized discrimination (Quesada et al. 2011). In other words, equitable sanitation for those in vulnerable situations can only be based on socio-cultural considerations. Sanitation is a system that comprises not only a latrine but also the works for the treatment and disposal of human waste. Sanitation facilities do not function by themselves, but have significance only through social management. The process of decision-making also largely depends on socio-cultural conditions, and the importance of sanitation needs to be socially acknowledged. The health benefits of sanitation improvement—among the significant contributions of sanitation—also need to be considered in the socio-cultural milieu. In this context, a more holistic approach across disciplines is required.

This book presents a holistic approach to WASH, especially focused on the sanitation of human waste (i.e., human excreta, containing feces and urine), and an analysis of the case studies based on this approach. In this chapter, we present the concept of the Sanitation Triangle as a holistic approach and indicate its scope in comparison with previous research.

1.2 The Sanitation Triangle: An Interdisciplinary Research Field

Recently, several important studies have considered sanitation’s socio-cultural aspects. For example, van Vliet et al. (2010, 2011) discussed socio-technical change, multi-level governance, and the role of the citizen-consumer as the social scientific topics relevant to the sanitation challenge. These pioneering works concretely show how the social sciences are involved in sanitation issues. Subsequently, Hyun et al. (2019) reviewed the literature concerning global sanitation, which includes diverse disciplines—not only public health, sanitary engineering, and environmental science but also economics, planning, and social sciences; their review highlights the growing number of social sciences, humanities, and interdisciplinary studies on sanitation.

Although there is a difference in terms and expressions, these studies share the understanding that sanitation systems are embedded in each society—these systems do not automatically operate by technology and economic interests, but rather, they are “the highly complex interfaces between sanitation technologies, consumers, and providers” (van Vliet et al. 2010: 3). Decentralized sanitation, also known as on-site or off-grid sanitation, commonly employed in low- and middle-income countries barring in the very center of large cities as well as rural areas in high-income countries, also requires the decision-making on sanitation, opened up by actors at multiple levels (van Vliet et al. 2010: 3). More generally, sanitation not only disposes of human waste but also affects the environment and includes the social functions and flows where stakeholders engage in each process (Hyun et al. 2019: 306–307). As discussed in this book, we add the socio-cultural configuration to the sanitation service chain. Cultural cognition on the “pure” and “impure” (Douglas 1966) provides the basis of the practices of sanitary and hygienic activities, creating the stigma and leading to the marginalization of specific groups such as sanitation workers in some cases. In sum, sanitation is a “total social phenomenon,” as the eminent French anthropologist Marcel Mauss defined, which is an ensemble of the religious, legal, moral, political, economic, and esthetic matters (Mauss 1923: 32).

Besides these diverse aspects, the difficulties of global sanitation especially in low- and middle-income countries have emerged in the interconnection between health, materials, and socio-culture. In terms of materials, sanitation is a system to transfer human waste and relevant substances and/or transform their state. One of the major difficulties from the viewpoint of materials is that open defecation, use of unsanitary latrines, and unsafe disposal of human waste discharge pollutants and deteriorate the environment, resulting in increased health risks for the people in that neighborhood, but such poor sanitation does not necessarily mean discomfort for those who practice it. This is explained as a negative externality of environmental pollution. Furthermore, sanitation is essentially not a large “income-generating” affair, and is located between economic reasoning and health benefits. Although the economic loss due to poor sanitation has been calculated (e.g., Hutton 2008; Hutton and Haller 2004), it is difficult for low- and middle-income countries or donor countries to direct public investment toward the full implementation of sanitation facilities. Sanitation is a public matter, but sanitation facilities are often private property. Therefore, partial public funding on household sanitation (e.g., Trémolet et al. 2010) and small-scale “income-generating” on-site sanitation (e.g., Ushijima et al. 2015, 2019) are pursued by several groups. These solutions are not operated through the way of “laissez-faire,” but they require the social framework for managing the sanitation system. Thus, the interconnection between health, materials, and socio-culture is the key to resolving sanitation affairs.

In terms of health, the problem of sanitation emerges in a misconnection involving the three components. Sanitation reduces health risks, but these are measured at the mass level, and even at this level, the health impact of sanitation is not shown precisely (e.g., Clasen et al. 2014). In contrast to water supply, sanitation’s health benefits can only be understood in terms of the health indicators of the population in each area over a long time. These figures are meaningful for central and local governments, but not for individuals who cannot directly perceive the health benefits. In fact, some reports show that individuals do not place much importance on toilet use for health-related reasons (Jenkins and Curtis 2005; Jenkins and Scott 2007). On the other hand, individuals, rather than governments, are the central actor in the sanitation issues in the rural areas of low- and middle-income countries where on-site sanitation plays a major role; this has made them both users and maintainers of the sanitation service. It is a paradoxical situation that while sanitation’s health benefits can be perceived at the public level, the public sector covers only a part of its introduction and maintenance. In other words, the problem emerges in the misconnection involving the three components—health, materials, and socio-culture—derived from the attributes of sanitation itself.

Sanitation is composed of these components. It is intricately linked with the health domain—inadequate sanitation causes excreta-related infections and, in certain contexts, mental suffering. Sanitation is a material flow in terms of the storage of human excreta and their conversion into harmless substances. Material flows are inevitably related to economic activity in that they include the costs of storing and converting human waste and, under certain socio-economic conditions, the benefits of producing compost from that waste. In the Edo era (1600–1867) in Japan, before the introduction of the modern sewerage system, human waste used to be the commodity for economic exchange (e.g., Aratake 2015). Human waste has potential economic value in its materiality. When it comes to socio-culture as a basis for sanitation, norms on defecation, its places, etc. are shaped by cultures, and the technologies and sanitation workers are socially organized. Finally, sanitation does not operate well in the case of misconnection—it is a complex issue encompassing the three components and requires their seamless interconnection. In that regard, sanitation studies are essentially an interdisciplinary research field requiring this interconnection.

To promote and analyze the interconnection, we propose the Sanitation Triangle as an interdisciplinary framework for global sanitation (Fig. 1.1). The triangle represents the three components—health, materials, and socio-culture—and their interconnection, with all three having equal importance vis-à-vis sanitation. The triangle also indicates the connection between each pair of components: A (materials and health), C (health and socio-culture), and B (materials and socio-culture). Conventionally, A has been studied as the calculation of costs and benefits of the (dis)improvement in sanitation-related diseases (Hutton 2008; Hutton and Haller 2004; World Bank 2008). However, despite their importance, few studies have looked into the B and C connections—hence, these are what we focus on in this book.

Fig. 1.1
figure 1

The Sanitation Triangle model

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1.3 Organization of the Book

This book is divided into three parts based on the Sanitation Triangle and authors’ disciplines. The first part, contributed by the humanities and social sciences, focuses on the connections between health and socio-culture (C) and materials and socio-culture (B). Cultural anthropologists and developmental economists reveal the socio-cultural dimensions of health and material matters. The second part by health sciences, environmental sciences, and science communication focuses on the connection between health and socio-culture (C), highlighting how health issues are fundamentally affected by socio-cultural factors. The third part by sanitary and environmental engineering discusses the connection between materials and socio-culture (B), presenting the relationship between sanitation technology and each society. While the case studies are based on each discipline, their discussions go beyond the disciplines via the focus on the interconnection between the three components.

1.3.1 Part I

In Chap. 2, Nakao presents the outline and scope of the component socio-culture of sanitation, especially indicating its interconnection with health and materials. In Chap. 3, Masuki highlights the injustice and uneven social allocation of sanitation work, and the struggle for remediation of the hygienic, economic, and social working conditions in colonial and post-colonial India. Based on a close reading of Gandhi’s works, Masuki reveals the so-called ethics of sanitation; sanitation is at the core of self-rule (swaraj) and the social responsibility for human-waste management. In Chap. 4, Ikemi provides the social context of the implementation of new technology in the case of water supply management in rural Senegal. Each technology requires the social management system and brings forth the people’s perception of technology, such as the preference for the type of water. In Chap. 5, Sugita examines the global discourse on and local practices of Menstrual Hygiene Management (MHM). Considering the situation of girls in Uganda’s rural areas, Sugita reveals that the actual conditions of “safe” MHM are different from those mentioned in the global discourse. “Safe” MHM requires not only the proper items and facilities but also appropriate treatment of menstrual bleeding to avoid of using it for sorcery.

1.3.2 Part II

In Chap. 6, Yamauchi presents the connection between socio-culture and health in WASH by tracing the studies on the social determinants of health. In Chap. 7, Yamauchi et al. focus on environmental health in school and family in the densely populated area of Bandung, Indonesia, and show that age and gender affect fecal contamination on the hands of children as well as their nutritional and health status. In Chap. 8, Harada depicts the transfer of health risks in sanitation and its allocation in society by citing examples from Vietnam, and offers a perspective on such risks being a social problem in sanitation. In Chap. 9, Nyambe et al. describe a Participatory Action Research (PAR) involving members of youth club in Lusaka, Zambia, and present a case of collaborative examination and intervention through the tools of visualization with the club members, highlighting the health and socio-cultural aspects linked to WASH in their communities.

1.3.3 Part III

In Chap. 10, Harada first describes how sanitation is a system that transforms the quality of materials and generates material flow, and then outlines the connection between materials and socio-culture in sanitation. In Chap. 11, Fujiwara describes the development and implementation process of a new sanitation technology as public infrastructure in Japan, and discusses its diversity of actors and socialization process. In Chap. 12, Harada focuses on a resources-oriented sanitation for the rural areas of Vietnam, Malawi, and Bangladesh, which intend to utilize excreta for agriculture. Three cases of ecological sanitation are compared, and fertilizer values and acceptability of such sanitation discussed. In Chap. 13, Ushijima et al. describe the challenge in creating a sanitation system based on material flow and social network as a case in an urban slum of Indonesia. It depicts an attempt at co-creation of a sanitation system with local actors based on material flows and value flow networks, focusing on the actors’ motivation.

The conclusions by Nakao, Harada, and Yamauchi build on the overriding themes appearing in each chapter: the socio-cultural effects of health status and risks, social embeddedness of technology, and practical implications for interventions in WASH. The chapters are interlinked, providing a vision for the future of interdisciplinary studies and practices of global sanitation through a socio-cultural perspective based on the Sanitation Triangle.