or f r”

© 2014 International Consortium for Social Development
Terry A. Wolfer, PhD, MSW, is a professor in th e College of Social Work, University of South Carolina
([email protected]).
Calling it a “silent global crisis,” UNICEF (2008) asserted th at inadequate sanitation “constitutes an affront to hu m an dignity on a massive scale causing
widespread damage to hum an health and child survival prospects; social misery especially for women, the elderly and sick; depressed economic productivity
and hum an development; and pollution to the living environment and water
resources. Lack of sanitation is one of the single biggest challengesfacing the world today” (p. 1; italics added). Likewise, the World Health Organization (WHO, 2011)
describes lack of sanitation as “a serious health risk and an affront to hum an dignity” and notes th at it particularly affects the poor and disadvantaged (para. 1).
In 2008, an estimated 2.6 billion people— four of ten people in the world—
did not have access to adequate sanitation (UNICEF, 2008). Nearly half of those
people, especially those living in rural areas, practiced open defecation (i.e., defecation in fields, forests, bushes, plastic bags, streams, lakes, or other open spaces;
Sanitation Drive 2 0 1 5 ,2 0 1 3 ). The most recent data indicate th at there are still
2.5 billion people in the world— one in three— who lack adequate sanitation,
and the num ber of people practicing open defecation has decreased but remains
above 1 billion (UNICEF, 2013). The problem is most widespread and severe in
Southeast Asia and Sub-Saharan Africa (Sanitation Drive 2 0 1 5 ,2 0 1 3 ).
rural appraisal, sanitation
Keywords: CUTS, community-led total sanitation, extreme poverty, participatory
Currently, some 2.5 billion people lack adequate sanitation, including 1 billion who
practice open defecation. Because inadequate sanitation is both a cause and effect of extreme poverty, it deserves inclusion on the international social work agenda. This
article introduces community-led total sanitation (CUTS), a recent and highly effective
innovation for mobilizing whole communities to address their sanitation problems.
T erry A. W olfer
Community-Led Total Sanitation: A “New Frontier” for
International Social Work Practice
Social Development Issues 36 (1) 2014
Associated with extreme poverty, inadequate sanitation affects the lives of
individuals, families, and communities in various ways (UNICEF, 2008). Most
tragically, inadequate sanitation is the major cause of preventable diarrheal and
other diseases (e.g., cholera, dysentery, typhoid, hepatitis A, polio, cryptosporidiosis, ascariasis), which kill five thousand children and another one thousand adults per day (Sanitation Drive 2 0 1 5 ,2 0 1 3 ; UNICEF, 2008; WHO, 2011).
Worldwide, diarrheal diseases are the second leading cause of child death (Glausiusz, 2002). Even w hen diarrheal diseases do not kill, they leave hundreds of
millions more people seriously ill. Such diseases cause m any children and adults
to miss school and work. In addition, inadequate sanitation contributes to the
spread of other diseases, increases m alnutrition, and deters children (especially
girls) from attending school at all. In these and other ways, the lack of sanitation
both directly increases poverty and deters social development, and thus it poses
a major challenge to hum an well-being.
Although recognized as a root cause of extreme poverty (UnitedNations, 1995),
sanitation was not originally included in the UN Millennium Development Goals
(MDGs; UN General Assembly, 2000). However, it was subsequently added to the
MDGs, and 2008 was declared the International Year of Sanitation to rectify the
omission and to supplement other MDGs (UN General Assembly, 2005; UNICEF,
2008). Indeed, Robert Chambers (2008) first argued that providing adequate sanitation will substantially contribute to achieving all the MDGs by eradicating extreme poverty and hunger, improving maternal health, reducing young child mortality, reducing major diseases, increasing primary education, increasing gender
equality and female empowerment, and ensuring environmental sustainability.
Remarkably, the International Federation of Social Workers (2012) does
not m ention sanitation as part of the social work profession’s agenda for global
poverty eradication, despite noting th at the Copenhagen Declaration defined
absolute poverty as “a condition characterized by severe deprivation of basic
hum an needs, including food, safe drinking water, sanitation facilities, health,
shelter, education and information” (United Nations, 1995, p. 41).
Nevertheless, there is growing public recognition of the m agnitude and severity of the problems posed by inadequate sanitation (e.g., Black, 2008; George,
2008; Sanitation Drive 2 0 1 5 ,2 0 1 3 ). Promoting sanitation may never have the
appeal of promoting clean water, but there is growing recognition that the two
are inextricably linked. Indeed, readers of British Medical Journal selected “clean
water and sewage disposal” as the most im portant medical advance since that
journal began publishing in 1840 (Ferriman, 2007).
Despite the consequences and prevalence of inadequate sanitation in impoverished communities, both government and nongovernment organization
(NGO) leaders have tended to ignore it. W hen the problem could not be avoided,
the conventional response was to build public latrines and then provide financial incentives to promote their use (Kar & Pasteur, 2005). Despite the commitm ent of significant resources and efforts, these approaches have not succeeded
in m any parts of the world (Chambers, 2008; Sanan & Moulik, 2007).
By evoking a collective sense of disgust, CLTS apparently taps into a universal
and visceral emotion th at is key for hum an survival (Glausiusz, 2002). Robert
Chambers (2009), the esteemed development scholar and practitioner, considers CLTS “a revolutionary participatory approach to rural sanitation” (p. 9).
Several basic principles distinguish CLTS (Chambers, 2009; Kar, 2005;
Sanan & Moulik, 2007): community self-help action (i.e., grassroots, or bottom
up rather th an top down), hands-off triggering, facilitation through questions
rather th an instruction, no standard latrine design (i.e., letting people choose
their own designs, and allowing private suppliers to meet local demand); promotion of community assistance to poorer and weaker community members, no provision of a household hardw are subsidy (focusing instead on community-level
outcomes). Of these, refusing to provide either overt instruction or financial
subsidy represents the most significant departures from conventional practice in
Chambers (2009) identified five benefits of CLTS over traditional approaches
to sanitation: the unusual speed of success; the community-wide scope of its
success; the resulting social solidarity, which may lead to other initiatives; the
development of local leadership, confidence, and livelihoods; and its application
in other contexts, such as schools and urban communities.
Recently, systematic research on CLTS outcomes has begun to confirm an ecdotal reports of its effectiveness. For example, a large, m ulticountry study in
West and Central Africa found im portant but fragile progress on sanitation goals
across eighteen countries (UNICEF, 2011). A multimethod study in Cambodia
compared CLTS and conventional subsidized sanitation approaches (Kunthy &
Catalla, 2009). In camps w ith CLTS, it found greater use of latrines, greater
equity across income levels, better cost-effectiveness (both short and long
term), and more attitudinal and behavioral change, but some problems with
sustainability. Mukherjee (2011) found th at communities that became open-
based on stimulating a collective sense of disgust and sham e among comm unity members as they confront the crude facts about mass open defecation and its negative impacts on the entire community. The basic assumption is th at no hum an being can stay unmoved once they have learned that
they are ingesting other people's faeces, (p. 3)
This article introduces community-led total sanitation (CLTS), a recent and
highly effective innovation for mobilizing whole communities to address sanitation problems (Kar, 2005, 2008; Kar & Pasteur, 2005). In sharp contrast to
previous efforts to build and incentivize the use of public latrines, CLTS “triggers
the com m unity’s desire for collective change, propels people into action and encourages innovation, m utual support and appropriate local solutions, thus leading to greater ownership and sustainability” (Institute of Development Studies,
2011, para. 3). KamalKar (2005), the originator of CLTS, explains th at it is
Community-Led Total Sanitation
Social Development Issues 36 (1) 2014
The CLTS usually begins with a transect walk— a tour of the community with
the assembled community members—to visit and discuss areas of open defecation and all types of latrines. At each location, facilitators pause to smell and
Transect Walk
The first step is gaining entrance to a community and building rapport with
community leaders and members (Kar, 2005). The approach to this varies
from informal to more formal. In some situations, CLTS facilitators simply visit
communities and begin asking people about sanitation issues while walking
through the community. In others, they contact community officials in advance
to request formal permission to conduct sanitation analysis. In either case, the
goal is to recruit as many community members as possible for the intervention
(e.g., ten to more than one hundred). At the outset, facilitators also determine
the crude local word for feces (i.e., the equivalent of shit in English) and proceed
to use that terminology throughout the intervention.
Getting Started
The CLTS intervention consists of several tools for promoting community members’ comprehensive analysis of sanitation in their community. Drawn from participatory rural appraisal (Bar-On & Prinsen, 1999; Chambers, 1994a, 1994b,
1994c), the tools are “simple, visual, and practical” (Kar, 2005, p. 5). The tools
are accompanied throughout by Socratic questioning to promote community
members’ analysis and reflection. Unless indicated otherwise, the following descriptions are drawn from several key sources (Kar, 2005,2008; Kar & Pasteur,
2005) and personal experience.
CLTS T ools
In summary, the emerging evidence demonstrates that CLTS is no panacea, but
it may be significantly more effective than previous approaches. In many parts
of the world, it has generated significant progress toward the MDGs.
Open Defecation Free (ODF) achievement and sustainability are hastened
by: (a) community’s social capital and the involvement of leadership in the
change process, (b) local availability and affordability of latrine attributes
desired by poor and non-poor consumers, (c) absence of externally provided subsidies to a few households, and (d) post-triggering monitoring and
follow-up by external agencies together with communities, (p. 1)
defecation-free (ODF) most quickly were also most likely to sustain those gains
and that sanitation behavior change was more difficult to initiate in riverbank
and waterfront communities. Given adequate triggering, according to Mukherjee(2011):
Social Development Issues 36 (1) 2014
The CLTS intervention climaxes with demonstrations designed to trigger strong
emotional responses (e.g., shame, disgust, fear). During the transect walk, facilitators surreptitiously collect a sample of fresh feces and a sample of freshly
cooked food. Without explanation, they put these items on separate plates and
place the plates in close proximity at a prominent spot during the preceding
exercises. The classic trigger involves (1) offering participants a drink of safe
water brought along for this purpose, (2) touching a single human hair to the
feces sample and dipping it in the drinking water, and (3) offering participants
another drink of water. When participants refuse (as they consistently and
strenuously do), facilitators ask, “How many legs does a fly have?” (because
flies could pick up more feces than the hair). At this point, a participant often
exclaims, “That means we’re eating each other’s shit!” and the facilitators sit
down and turn the meeting over to community leaders. These leaders often ask
the facilitators what they will do to assist the community with their problem of
Goo Calculation
After the mapping exercise, facilitators ask participants to estimate the amount
of feces an adult produces each day (about 0.5 pounds, or 0.25 kilograms).
On the basis of this estimate, facilitators ask participants to calculate the total
amount of feces an adult produces per week, per month, and per year. Subsequently, facilitators ask people to calculate the total amount of feces produced by
a typical family per day, week, month, and year. Finally, they ask about the size
of the entire local community and repeat the questions. In addition, facilitators
seek to help participants visualize the total amounts by selecting a locally familiar container and asking participants to calculate the number of containers
required for each amount. Sample questions may include the following: How
many basins (buckets, bags) would that be? How many wheelbarrows (wagons,
boats, trucks) would that fill? The goo calculation dramatizes the cumulative
volume of feces generated by a community and raises further questions about
its disposal.
Medical Expense Calculation
Even without understanding the health effects of inadequate sanitation, people
know the costs of medical care. Facilitators can ask about the local costs of
medical care, including medications, treatment, and hospitalizations. They can
also ask about the costs of transportation for medical care and of wages lost
because of illness (by patients and their caregivers). For people in poverty, these
costs always compound the hardship of illness and all too often block access to
medical care. These questions remind people of their vulnerability.
In the diagramming phase of the intervention, facilitators ask what happens
to all the feces and then invite participants who respond to draw a picture or
write the word on a card (Government of Uganda, Ministry of Health, n.d.).
Without ever lecturing or instructing, facilitators ask questions that lead participants to identify fecal-oral transmission routes. Basic questions include the
following: How do feces get from open-defecation areas to water sources? How
do feces get into the mouth? Participants typically volunteer that domesticated
animals (e.g., pigs, dogs, chickens) eat feces or carry it away on their feet, that
vehicles (e.g., bicycles, cars) carry it on their wheels, and that people also carry
it on their feet and hands. But the sheer volume of feces leads to the realization
that animals and people cannot dispose of it all, and that rain washes much of
it into their water supply (e.g., wells, streams, lakes). After gathering responses
to these questions, facilitators ask a community member to organize the cards
to demonstrate fecal-oral transmission routes. The process leads participants to
realize that they often and inevitably ingest human feces.
Diagramming Fecal-Oral Contamination
In the next step, facilitators encourage participants to draw a map of their community on the ground at a central location. The mapping often begins by n o tin g
landmarks in the immediate vicinity. After participants have drawn their own
homes and key sites on the map, facilitators offer flour, bonemeal, or a simila r
powdery substance for marking open-defecation areas on the map. Again, facilitators use questions to guide the exercise (e.g., Where are the open-defecation
sites that we visited? Where else do people defecate in the open? Where is the
rubbish site? Do people ever go there? Where is the dirtiest neighborhood? Who
lives there? Why is it the dirtiest neighborhood? Do people from other neighborhoods go there?). Building on the transect walk, the community-mapping exercise helps people visualize the scope of the sanitation problem in their community and provokes reflection about its uneven distribution.
Community Mapping
view the effects of open defecation and poor latrine maintenance. Although
community members find it embarrassing to have visitors view these parts of
their community, they often gain a fresh perspective on conditions to which they
have grown accustomed. The sight of a large group visiting open-defecation
sites often attracts additional participants. Facilitators take time to ask questions at each stop (e.g., Which families use this area? Do people come at night?
Do women and children feel safe here? Do people come here when it’s raining?
When they are sick? What are the flies doing here? Do these flies stay here or
go to the camp? How long have people been using this area?). The transect
walk and questions are intended to stimulate frank conversation and reflection
about open defecation among community members and to provoke visceral
Social Development Issues 36 (1) 2014
Social workers with experience in participatory rural appraisal, community organizing, and Socratic questioning may be well suited for learning to facilitate
CLTS interventions. Facilitator training is offered through multiday workshops,
and num erous training resources are available at the Community-Led Total
Sanitation website (http://www.com m unityledtotalsanitation.org), hosted by
the Institute of Development Studies at the University of Sussex and funded by
the Bill and Melinda Gates Foundation.
Follow-Up with Livelihood and Community Development Initiatives
Of significant interest for social workers, CLTS interventions often stimulate
community-wide collaboration and successes that create opportunity for and
interest in other poverty alleviation initiatives (Deak, 2008; Kar & Pasteur,
2005). In short, they serve to empower and build solidarity in communities.
Implications for Social Work
It appears that the problem of inadequate sanitation deserves greater attention
on the international social work agenda and that CLTS is a potentially useful
approach for social workers who work in communities where people practice
open defecation.
Potential Role as Trainer or Facilitator
In general, attention to sanitation is an essential component of a holistic focus on
poverty, and including it in the social work agenda will likely contribute to greater
success in addressing poverty. More specifically, sanitation is an especially significant problem for the disadvantaged members of impoverished communities who
social workers often champion (e.g., women, children, older adults, people who
are ill, people with disabilities, rural residents). Inadequate sanitation is both a
significant source and a consequence of health and economic disparities, and
thus it should represent a significant concern for social workers.
Refocus on Basic Needs of the Most Vulnerable Community Members
Over the past two decades, an emphasis on safe water has gradually given way
to a more comprehensive emphasis on water, sanitation, and hygiene (WASH).
Safe water and adequate sanitation are essential for hum an well-being, and the
two are inextricably linked and related to hygiene. Furthermore, unsafe water
and inadequate sanitation both contribute to extreme poverty. While governm ent and NGO leaders have traditionally preferred to address water and have
downplayed or even ignored sanitation, it is increasingly clear th at sanitation
plays a critical role in integrated water, sanitation, and health (WASH) efforts.
Addressing inadequate sanitation goes a long way toward addressing water
problems, especially when inadequate sanitation involves open defecation. As
UN Secretary General Ban Ki-moon asserted recently, ‘Adequate sanitation is
crucial for poverty reduction, crucial for sustainable development, and crucial
for achieving any and every one of the Millennium Development Goals" (Sanitation Drive 2015, 2013).
Critical Role of Sanitation in Water, Sanitation, and Hygiene Efforts
The ultimate goal of CLTS is declaration and celebration of ODF status. Although success and timing vary by community, in many cases communities
achieve ODF status within weeks or months of the initial intervention. Whenever it occurs, success is great cause for celebration and community pride. Often,
the sense of empowerment and solidarity that results from CLTS may inspire
communities to tackle other problems together. Facilitators sometimes recruit
natural leaders from successful communities to assist with CLTS interventions
in neighboring communities.
ODF Declaration and Celebration
At the conclusion of the intervention, facilitators schedule return visits to
observe the community’s progress toward ODF. It appears that early and repeated visits to the community (e.g., monthly) serve to stimulate and reinforce
follow-through on action plans and increase the likelihood that communities
will achieve ODF (Government of Uganda, Ministry of Health, n.d.).
Once community members and/or leaders have decided to address the problem
themselves, facilitators may provide general guidance and encouragement for the
development of a sanitation committee and an action plan. The goal is to establish and reinforce community ownership of the solution, and their initiative must
be respected. Possible activities may include listing or mapping households and
their current sanitation status, digging pits or makeshift latrines, m aking plans
and acquiring resources to build permanent latrines, planning outreach to other
members of the community, establishing penalties to enforce community-wide
participation, and establishing ODF goals. In short, facilitators encourage natural
leaders to plan for mobilizing their communities to take collective action.
Open-Defecation-Free Planning
open defection, and facilitators remind community leaders and members that
they came only to ask question, not to provide subsidies or other assistance.
This moment often stimulates the emergence of natural leaders eager to address
the problem of open defecation, typically by volunteering to immediately build
latrines for their own families.
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Despite the early precedent set by Jane Addams (Nobel Foundation, n.d.), the
social work profession has generally overlooked sanitation. But inadequate sanitation remains a significant contributor to poverty in many parts of the world,
and thus it is an appropriate target for professional concern and intervention.
Beyond the direct, immediate, and severe health consequences of inadequate
sanitation, there are significant consequences for education and employment.
As with many other problems, these consequences disproportionately affect
women, children, older adults, and people with disabilities. For these and other
reasons, it seems appropriate that the social work profession begin to address
inadequate sanitation. As a potential approach, CLTS appears to be highly effective and largely consistent with social work values, knowledge, and skills.
Finally, it seems clear that work in sanitation fits with social work's emerging
environmental agenda. Inadequate sanitation has grave consequences for
humans and for the environment more broadly. With continuing global population growth, adequate sanitation is increasingly critical for sustainability. Addressing inadequate sanitation as a matter of environmental degradation and
social justice constitutes another linkage for social workers.
Part of Social Work’s Environmental Agenda
The community development and livelihood initiatives that emerge in the wake
of CLTS interventions provide a more familiar role for social workers in poverty
alleviation. It is necessary only that social workers be alert for these opportunities or seek to actively partner with CLTS facilitators.
Social Development Issues 36 (1) 2014
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