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Access & Health Impacts
Water and sanitation services are key considerations in the planning of cities. This encompasses water provision, waste-water treatment, and sewage infrastructure. These services are not only crucial for public health, but for survival – thus, planners must consider how to best provide these services to urban residents in effective and cost-sensitive ways.

However, within urban environments, there are a number of disparities with regards to access to these services. For example, as of 2006, among the poorest quartile of the urban population in India, over 80% lacked access to piped water at home and over half did not have sanitary flushes or pit toilets. Data collected in 2005-2006 revealed that under half of the urban poor could access adequate sanitation compared to about 95% of the urban non-poor. In India, slums compose a major part of the urban environment - one of the largest barriers to improving slum conditions is that many slums go undocumented. Because most slums are informal settlements with no tenure rights, their illegal status excludes them from official listings and thus excludes them from access to municipal water and sanitation services.

Thus economic status is highly correlated to water and sanitation service access in urban environments. But economic status is often tied to other demographic characteristics such as caste, ethnicity, and race. Therefore access to water and sanitation services is an equity issue that faces urban planners working for urban governments. In the absence of policy to address these infrastructural disparities, the urban poor and minorities suffer disproportionately. A study of the social determinants of children’s health in urban settings in India looked at data from India’s National Family Health Survey and found that even within poor urban areas, caste status, religion, and sex are major factors which determine family employment and education level, factors which in turn affect access to sanitation and water.

Water and sanitation issues relate directly to health outcomes due to the susceptibility to disease experienced by populations that lack adequate access. In the 19th and 20th centuries, diseases like cholera were particularly feared due to their devastating effects and due to their proliferation in areas with poor waste management practices. Today diseases such as dengue fever, Hepatitis A, and intestinal parasites, are all examples of water-borne illnesses that plague the urban poor. Diarrheal illnesses are perhaps today the leading type of waterborne disease with cities like Jakarta experiencing disease rates as high as 50 cases per 1000 people. In India, waterborne disease accounts for the loss of roughly 180 million person-workdays annually, the economic equivalent of approximately 12 billion rupees. Thus inadequate access to water and sanitation among the urban poor and socially disadvantaged leads to systematic vulnerability to disease, which has both public health and economic consequences.

In Uganda, in order to address some of these access issues, NGOs and community- based-organizations (CBOs) have stepped in. The government in Uganda has acknowledged the role of sanitation in reducing poverty, but as NGOs and CBOs have pointed out, the government has been unable to adequately address the need for these services in urban environments or the high cost of procuring these services from private service providers. NGOs and CBOs are inherently limited in their ability to provide sanitation services, however, due to the need to obtain permissions for undertaking infrastructure projects and due to the high costs of implementing them.

Latrines
See also main article: Toilets

One aspect of sanitation infrastructure that is a major determinant of environmental health in slums is the latrine. There are a number of variables surrounding latrines and sewage which can play a critical role in determining health out comes for urban families, including latrine location (in house versus out of house), latrine usage (family vs community), and latrine type (for example pit latrine versus toilet). Furthermore, the latrine is a critical aspect of urban household-level layouts and designs.

In slum areas, unlined pit latrines constructed in areas with a high water table are a very common option. Other methods include flying toilets (in which individuals will excrete waste into polythene bags, tie them up, then throw them into the surrounding environment) and open defecation, both of which have significant environmental health risks associated with them. Only a small percentage of slum residents have access to things like ventilated improved pit latrines and pour flush toilets. Flying toilets and open defecation are significant environmental health risks because they expose communities to many of the pathogens and illnesses carried by sewage. Unlined pit latrines are problematic due to their contamination of groundwater.

One solution to the infrastructural issues posed by sewage and wastewater management in urban areas is the development of community toilet blocks. In India, the Alliance (consisting the three NGOs: Mahila Milan, SPARC, and the National Slum Dwellers Federation) has implemented a multi-city community toilet block program in more than eight different cities. The goal of this program is to elicit community participation in designing, building, and maintaining toilet blocks for communities. Traditionally, community toilet blocks have been problematic: municipal corporations often fail to upkeep the toilets, the toilets often become very dirty and unsanitary areas of open defecation, and with these toilets rendered unusable, women often abstain from excreting waste until nightfall to preserve modesty, which can often lead to gastric issues and other disorders. To address these issues, the Alliance has worked with women’s groups to spearhead efforts to pressure municipal service providers into making “big pipe infrastructure” available to communities so that community groups could build their own “little pipe infrastructure” and community toilet blocks to connect to this infrastructure. In addition, these community groups create management plans for maintaining the toilets, which are designed according to common-usage practices. The improved designs used by community groups often take into account often overlooked factors such as separating male and female entrances and not having the entrances face each other to avoid harassment. Thus, in the case of the Alliance, the involvement of community groups helped determine the relevant areas of focus for the project.

Waste-Water
See main article: Sewage treatment

Waste-water collection and treatment has always been an important consideration in urban planning, but it is becoming increasingly critical as urban population levels rise and water conservation becomes a growing concern. Planners must now consider how to properly incorporate waste-water treatment into urban environments in effective, and equitable ways.

In the US, prior to the 19th century, cities often used a decentralized privy vault-cesspool model for waste management. Urban households had vaults or tubs beneath their latrines which would collect waste-water until the vaults needed to be emptied into a nearby cesspool. This model worked at the time due to relatively low urban populations. However, industrialization, urbanization, and population growth during the 19th century led to a dramatic increase in America’s city-dwelling population and thus increased the need for a centralized waste-water collection and processing system. With the introduction of piped water, such a centralized system became possible as larger quantities of water were necessary for water-carriage waste removal. Since the 19th century, water-carriage sewage management has been preferred by planners due to its scalability.

However, more recently, decentralized waste water management has made a resurgence among planners and researchers. While centralized water-carriage systems have more potential for scalability, decentralized systems are simply more efficient because the waste-water is managed closer to where it is generated, thus allowing for each management system to be adapted to the local community/household needs.