Poor Sanitation Causes Disease and Death Globally. Climate Change Will Only Make It Worse.

Colin McFarlane

From dilapidated sewer systems in the US and Europe to a shortage of toilets and clean water in Global South cities, poor sanitation is breeding disease and death around the world. The climate crisis will only make its impacts more severe.

A woman crosses a sewage canal in the slum district of Freetown, Sierra Leone, on April 15, 2022. (John Wessels / AFP via Getty Images)

Interview by
Sara Van Horn
Cal Turner

Across the globe, more than half of the urban population lacks access to safe sanitation. Yet this crisis is often shunted to the political sidelines or thought of as a narrow engineering problem, rather than seen for what it is: a crisis of social provisioning at the center of urban politics.

In his recent book, Waste and the City: The Crisis of Sanitation and the Right to Citylife, Colin McFarlane shows how sanitation infrastructure is failing around the world, from urbanizing neighborhoods at the outskirts of cities in South Asia to aging infrastructure in the UK, and discusses how sanitation is intertwined with broader dynamics of city life and social relations.

Sara Van Horn and Cal Turner spoke with McFarlane for Jacobin about the gendered and racialized impacts of the sanitation crisis, the failures of “eco-sanitation,” and how we can build a political movement for sanitation for all.

Cal Turner

What is the sanitation crisis? Where is it happening, and how did it start?

Colin McFarlane

As long as we’ve had cities, we’ve had problems with sanitation. What’s new is the extent of urbanization globally.

Over half of the global population lives in cities — the future of humanity is urban, in many respects. Predominantly poorer neighborhoods, typically on the edges of cities, are urbanizing fastest. In cities with sewer systems, these neighborhoods are often beyond the sewer network. Residents have to improvise and form relationships with all kinds of state and nonstate actors to deliver the basics of sanitation: toilets and septic tanks and waste removal.

About half of the global urban population doesn’t have reliable, safe access to sanitation day to day. About a billion people regularly use open spaces to answer the call of nature. In the city, this means under bridges, by railway tracks, in tunnels, or in peripheral fields at the edge of the city, which are often not very safe places to be — especially for women and girls, who frequently encounter harassment and assault. The human dimensions of this are vast, and the ways in which it manifests in different cities, from Mumbai to Lagos to London, are very different.

The infrastructures we have in cities are also very dated. In the UK, we have media stories every other week about sewage flowing out into rivers or into the sea untreated, because the sewer networks were built for a much smaller population and haven’t been expanded or maintained. They’ve been privatized, which means water companies are making huge profits but not investing those profits back in the systems.

Shareholders have made a lot of money, but the systems themselves haven’t been cared for. As a result, there isn’t a single river in Britain that meets chemical health standards, according to a report released in 2021.

Sara Van Horn

Waste and the City discusses the unequal impacts of the sanitation crisis. How does this crisis of sanitation affect different groups?

Colin McFarlane

There is a global sanitation crisis, but it is particularly poorer neighborhoods urbanizing in the Global South where we see the extremities of this crisis. You’ll have tens of thousands of people crammed into tiny slivers of peripheral urban land, often by a polluted waterway, maybe by or on industrial land.

But across and within cities, all of this is deeply mediated by social relations, especially income, race, and gender. There’s critical research on predominantly black working-class neighborhoods in the United States and Europe, where you’re seeing situations where water and sanitation haven’t been upgraded or extended for generations — where whenever it floods, sewage runs into the streets or people’s homes.

There’s also a story in the book about refugees and their experience around arriving in cities and ending up in peripheral neighborhoods that lack sanitation systems for the same reasons, because of social stigma around race and class. Then there’s a story about how women and girls experience sanitation day to day, trying to access a public toilet in cities like Mumbai, where hundreds of people are also trying to access it, and then giving up and going somewhere else in the neighborhood and being at risk of getting attacked or harassed, often by groups of men, who target women in vulnerable situations like that.

There’s a tendency to look at sanitation as an engineering problem — beginning with the toilets, the pipes, and the sewers — and to believe that once we’ve addressed those, these problems will disappear. What we actually find, time and time again, is that governments will selectively provide sanitation in accordance with social relations of inequality.

That’s the crucial mistake made by liberal international development approaches to sanitation. Bill Gates’s approach to sanitation, which is that we just have to innovate our way through it, risks denying the realities of class, race, and gender in the unfolding of infrastructures and services across urban environments.

When we look at the global sanitation crisis through an urban lens, what we see are the messy materialities, political economies, and cultural inequalities within cities that shape who gets what, where, and when across different neighborhoods.

Cal Turner

Could you talk a little bit about how climate change has intensified the sanitation crisis?

Colin McFarlane

The most important element is flooding. If you don’t have sewers, if you have septic tanks or other rudimentary waste collection systems near the surface that are often at capacity, then rain will spill those wastes into the surrounding neighborhood and downstream into rural areas. Even in areas where there are sewers, capacity has been stretched because of intense rainfalls. At the other extreme, there’s not enough water due to heat, and sewer systems can’t function.

One response to these problems is eco-sanitation. Eco-sanitation efforts include on-site sanitation systems that treat waste within the confines of the system. You might have a rudimentary toilet system where the wastes are used to produce compost that might grow, for example, a fruit tree or vegetables. This works very well in many places, especially rural areas. But in an urban area with high density, the evidence is often that these systems do not cope very well.

There’s a risk of imposing a Global North fantasy of a low-carbon, climate-friendly city, which doesn’t function in dense neighborhoods, because the systems struggle to cope with the levels of waste, and also doesn’t function socially, because residents often don’t want a toilet where you have to throw sawdust over the waste — they want to flush the toilet. There’s a politics around imposing these alternative systems coming out of predominantly wealthier groups and areas in places where they themselves would not use them. This is another part of the liberal international development approach to sanitation.

There is also evidence emerging that sanitation systems can be a major part of a city’s carbon output. In Kampala, Uganda, for example, recent research showed that the sanitation systems are responsible for almost half of the city’s greenhouse emissions. They’re exploring this in other cities now, and if that statistic is true at scale, the relationship between the urban sanitation crisis and the climate emergency is much more significant than we previously thought.

Sara Van Horn

Could you say more about the health impacts of the sanitation crisis?

Colin McFarlane

There are some staggering statistics around the health impacts of the sanitation crisis. In 2016, diarrhea led to 1.5 million deaths, and a quarter of them were of children under five. When you don’t have a system of safely disposing of human waste, the chance for pathogens to circulate in neighborhoods massively increases.

It’s entirely preventable. This is a straightforward thing to deal with if you’ve got the right systems in place and invest in neighborhoods and communities, regardless of social differences like race, ethnicity, gender, or refugee status.

With climate change and the increase in urban flooding from intense rainfalls, urban wastes circulate around neighborhoods, and the capacity for people and animals and soils and water to mix together in ways that may exacerbate the urban microbiome is increasing all the time. So we’re seeing the spread of illness. Cholera, for example, has had a comeback in recent years.

This is partly because of cities growing and sanitation systems not keeping pace with the growth of cities. It’s also partly due to climate change; and it’s partly due to the global refugee crisis, where we’re seeing more and more people displaced.

There are ongoing problems with sanitation-related diseases in Palestine. In the wake of the bombardment, stoppages to water and electricity supplies, and displacement, you can bet there will be big outbreaks.

Cal Turner

What measures are being taken to prevent these health impacts, and where might they fall short?

Colin McFarlane

There’s more and more research going on to try to map the reasons that pathogens emerge in urban environments. We’re seeing increasingly sophisticated technologies to map where wastes might appear, to understand where pathogens are more likely to crop up, and to intervene in those supply chains.

That’s given us a better picture of where waste flows. There’s been a big investment push since COVID-19, which originated in a peripheral part of a city, which is often where a lot of sanitation-related illnesses take root.

But fundamentally, the shortfall is in the political attention and spending that’s been given to urban sanitation. If you want to address the urban sanitation crisis, that has to be a priority at city hall and at the national level — recognizing that it requires prioritization and money to follow it.

We’re not spending enough; we’re not focused enough on this crisis. Too often not enough of the investment flows to the areas and people most in need. Sanitation needs to be seen as a right across the entirety of the urban realm, regardless of who is living where and what their legal status might be.

Sara Van Horn

Can you explain the distinction you make between “affirmative” and “destructive” sanitation?

Colin McFarlane

Governments have multiple ways to respond to urban sanitation crises. One is to ignore them completely.

Another option is to try to invest in sanitation. Affirmative sanitation is a way of recognizing that people’s lives in the city are significantly stymied by inadequate sanitation, to the point where it becomes very difficult to survive, let alone thrive, in the city. Examples of this approach include countries like Brazil, which had a massive program of investing in low-cost sewer systems to provide basic toilet facilities in poorer communities.

Destructive sanitation is a violent response to the sanitation crisis. It attempts to solve the sanitation crisis by displacing the urban poor and demolishing their homes. Abandonment — by allowing infrastructures to deteriorate to the point where they are barely functional — is also a destructive form of sanitation.

One of the examples that I talk about in the book is the remaking of rivers and streams in Karachi, Pakistani. Large World Bank–funded projects, also supported by the Pakistani government, are clearing rivers and streams into which poorer communities located on riverbanks have been disposing of their bodily wastes.

The idea [of these projects] is to address this, but the language of cleaning up the river morphs into the logic of “cleaning up” the city by removing urban, poor communities from those areas. Blame is attributed to the poorest people who have no alternative, who have been systematically denied these infrastructures, and sanitation becomes associated not with the provision of resources to the poorest communities in the city but with the removal of those communities.

This is a story writ large across urban Asia. You see versions of it in Europe and North America too. The abandonment of the black working class in the United States is folded into this idea of social-spatial discrimination.

Cal Turner

How are people responding to the sanitation crisis right now?

Colin McFarlane

When we think about resistance to urban services and urban inequalities, it’s often in relation to areas like housing or water, which are obviously closely related to sanitation. There’s a tendency among critical urbanists, and maybe even activists, to privilege those areas over sanitation.

Sanitation is often seen as a taboo issue. It’s partly because it’s been seen as a technical engineering problem, and partly due to the discomfort around it, that seems to act against political campaigning. A lot of the activism comes from residents who are living this and who have had enough.

Some people, when forced into desperate conditions, and who feel there’s nowhere to turn, in order to improve sanitation conditions, use their own bodies as political weapons. The Cape Town “poo politics” movement was a movement where a group of activists and residents linked to the African National Congress Youth League started emptying uncollected buckets of wastes onto streets, in the airport, and so on in this spectacular, visceral politics to try and dramatize the inequalities around sanitation in a highly visible way. Even people on the Left said, “We’re super supportive. But can you keep it clean?” It’s a risky politics of spectacle.

But it’s also connected to a much more mundane politics of the body. I recall a case in Mumbai, where a company that ran a small private toilet block in a poorer neighborhood threatened to close the block unless residents paid double what they were currently paying. Residents couldn’t afford it, so one afternoon, a group of the women residents told the caretaker: “We’re not leaving here until the company agrees to keep the prices as they are. Otherwise, we’re going to use the space as our own toilet in full public view.”

It was incredibly brave, but also extremely desperate politics. Sometimes residents are left feeling that this is all that’s left as a political option, if there aren’t any alliances and movements marching down the streets for better toilets or politicians making that difference.

There’s a second set of much more conventional politics that’s less about the body, less about the spectacle, less about desperation. In Mumbai, there’s a group called the Right to Pee, which is an umbrella group of NGOs that was started when women in one of the NGOs pointed out that whenever they go to protests on whatever issue, there are never toilets for the women in the movement. The right to pee is an audit-based movement. They inspect public toilets all across the city, asking whether they were in decent condition and whether they have provisions for girls as well.

Those are two forms of resistance. It feels like it’s becoming a more active area of concern.