Access to water, sanitation, and hygiene (WaSH) services for involuntarily displaced populations is an important component of Sustainable Development Goal 6: achieving universal and equitable access to basic WaSH services by 2030. To date, households have been the main priority in the WaSH sector, and other settings have received less attention. Ensuring that involuntarily displaced persons have adequate WaSH and environmental health services is of critical importance for human rights and development outcomes. The Water Institute at the University of North Carolina (UNC) at Chapel Hill and World Vision organized a side event at the 2017 UNC Water and Health conference to discuss obstacles and opportunities related to improving environmental conditions in orphanages, prisons, and refugee and Internally Displaced Persons (IDP) settlements. Participants discussed the characteristics of each setting in breakout discussion groups, and then came together to discuss the similarities and differences between the three settings. Our goal was to allow common themes and lessons to emerge and to develop recommendations and shape future research. This side event provided an opportunity for participants from different professional backgrounds to share their experiences working with involuntarily displaced populations and discuss ways forward.
Universal access to water, sanitation and hygiene (WaSH) is essential for human health, well-being, and development outcomes, yet service levels are low in many low- and middle-income countries (LMICs). Sustainable Development Goal (SDG) 6 calls for universal and equitable access to basic WaSH services by 2030 and improvements in levels of service. Although the main focus of the WaSH sector has been on household access, ‘universal access’ also includes WaSH in populations that have been involuntarily displaced, or ‘dislocated populations’ as defined by Cronk Slaymaker & Bartram (2015). Settings where such populations reside, including orphanages, prisons, and refugee and Internally Displaced Persons (IDP) settlements, have received little attention in terms of the monitoring and improvement of WaSH services and environmental conditions.
There are an estimated 140 million orphans worldwide, and two to eight million children live in institutional care settings (Dunn et al. 2007; United Nations Children's Fund (UNICEF) 2016; Petrowski et al. 2017). An estimated ten million people are incarcerated worldwide (Walmsley 2013). Over 65 million people have been forcibly displaced (United Nations High Commissioner for Refugees (UNHCR) 2016). Adverse environmental exposures in these settings compromise human health, well-being, and development outcomes. These problems have received insufficient attention, and are likely to increase in severity due to population growth, climate change, and political instability. Effective policy and programmatic approaches to improving conditions in these settings are needed.
The Water Institute at UNC (University of North Carolina) and World Vision organized a side event on WaSH for involuntarily displaced populations, with an emphasis on orphanages, prisons, and refugee and IDP settlements, at the UNC Water and Health Conference on October 18th 2017. The objectives were to improve awareness and understanding of these populations, describe the challenges and knowledge gaps faced in each, in terms of WaSH and environmental conditions, to identify opportunities for improvement, and to begin to build a community of practice on this topic. This paper describes the findings that emerged from the presentations, breakout sessions, and group discussion at this event.
METHODS AND DESCRIPTION OF SIDE EVENT
The side event began with three brief presentations to introduce participants to the settings. Eric Stowe, Founder and Chief Executive Officer of Splash, provided an overview of WaSH in orphanages. David Clatworthy, Environmental Health and WaSH Technical Advisor at the International Rescue Committee, presented on WaSH in refugee and IDP settlements. Marielle Snel, Regional WaSH Advisor for World Vision Middle East, presented on WaSH in prisons on behalf of the International Committee of the Red Cross.
These presentations were followed by a discussion exercise where participants broke up into groups by setting. Participants were provided with a list of questions and discussion points (see supplementary material, S1, available with the online version of this paper). Experts on each setting were present to guide group discussions. After the breakout discussions, the groups came together to share and synthesize findings. Guiding principles for this larger group discussion were: identifying similarities across the three settings; noting setting-specific characteristics and differences between the settings; and developing possible steps forward.
Approximately 30 participants from academic institutions, international non-governmental organizations, and multilateral institutions attended the side event, providing insight from their work with displaced populations in Latin America and the Caribbean, sub-Saharan Africa, the Middle East and North Africa, and East, South, and Southeast Asia.
Many of the world's 140 million orphans live with family or community members or are integrated into a foster system, but an estimated two to eight million children live in orphanages (Dunn et al. 2007; UNICEF 2016; Petrowski et al. 2017). The definition of an ‘orphanage’ varies, ranging from large institutions housing several hundred children in Chinese cities to families in Kenya who open their homes to street children. For the purposes of this paper, we are defining ‘orphanages’ as institutions, which are separate from household hosts. Orphanages are increasingly controversial, as concerns grow over child trafficking and ‘orphanage tourism,’ where people from developed countries volunteer in orphanages as part of their personal travels (Guiney 2012). Due to neglect, poor environmental conditions, and deficiencies in medical care, institutional care is associated with severe delays in child development (MacLean 2003; Garcia Quiroga & Hamilton-Giachritsis 2016). Children living in orphanages are highly dependent on others for care, support, and advocacy, and many have physical or mental disabilities (Berens & Nelson 2015). Effective WaSH interventions can create immediate and long-term improvements to orphanage conditions.
Breakout group findings
The breakout group discussed how challenges related to child trafficking and orphanage tourism have made orphanages a sensitive subject for governments and donors, whose focus is often on alternatives to institutionalization, such as foster care. The group discussed how this shift away from orphanages has made fundraising a challenge. A lack of monitoring data is also a significant barrier to addressing WaSH in orphanages. Orphanages often exist without formal regulation or recognition by governments, and, in some instances, even nearby communities are unaware of their existence. Because many children in orphanages have mental or physical disabilities or delayed development requiring specialized care and rehabilitation, WaSH infrastructure and services need to be appropriate and accessible for them.
The group discussed how orphanages present opportunities for effective WaSH interventions. In countries such as China, where the majority of orphanages are in cities, implementers often rehabilitate or retrofit water supply systems, building on the existing urban infrastructure rather than starting new projects that would require large capital investments. Children's long-term residency in orphanages can be an opportunity for behavior change interventions. Caregivers are also affected by poor WaSH conditions and services in orphanages and benefit from improvements in environmental conditions. The group discussed experiences with caregivers, who often care deeply about the children they work with and are highly motivated to prevent the spread of illness in orphanages.
Looking ahead, the group agreed that additional information and monitoring is needed to assess the scope of WaSH challenges in orphanages. The World Health Organization (WHO)/United Nations Children's Fund (UNICEF) Joint Monitoring Programme (JMP) for WaSH does not report on this setting, and few national data are available, yet such data could play a major role in bringing this WaSH setting to the international arena. Governments are the primary players in creating change in this setting through policy, regulatory frameworks, and incentivizing WaSH infrastructure interventions. Private sector and non-governmental organizations may also function as entry points for successful WaSH interventions. Advocating for appropriate and accessible infrastructure for disabled children, training caregivers, and strengthening regulation could result in effective and sustainable WaSH solutions for children in orphanages.
The definition of ‘prisons’ is broad. It includes short-term immigration and juvenile detention centers as well as long-term correctional facilities; people detained in immigration detention centers may experience different environmental conditions than those who are incarcerated for decades (Nembrini 2013). People may be detained for an indefinite period of time, or have a clear end date to their imprisonment. Although few data are available, WaSH conditions in prisons are often poor, and such conditions have a detrimental impact on the health of incarcerated people (Baillargeon et al. 2004; Cheruiyot Rop et al. 2016).
Breakout group findings
One challenge the group identified was political tension surrounding domestic financing and foreign aid for prisons. Incarcerated people rarely attract the sympathy of the general population and are often socially ostracized. Improving environmental conditions in prisons is thought to be a low priority for governments, particularly in countries where WaSH access is low and WaSH services are poor among the general population. Another challenge is coordination, as multiple government ministries can be responsible for providing services in prisons. The diversity in prison type complicates regulation that could sustain and improve environmental conditions. Prison managers, whether governmental or private, may not have incentives to provide adequate services if they are not well regulated. Advocacy for improved WaSH conditions in prisons is also encumbered by a lack of data. While there are institutions responsible for inspections and regulation of WaSH conditions in households in many countries, group members were aware of no country where such regulators exist for prisons. The group noted human rights concerns related to WaSH in prisons. For example, some jurisdictions charge detainees for hygiene products such as toilet paper and toothbrushes. In other cases, toilets and shower facilities can be seen as unsafe spaces for detainees.
The group discussed the possibility of using WaSH education for prisoners; for example, providing training on subjects such as plumbing or masonry may be transferrable to a WaSH-related career after leaving the facility. If provided with WaSH education while incarcerated, prisoners may be able to seek employment and work to contribute to improving WaSH in their own communities after serving their sentences. However, due to high turnover rates among prisoners, monitoring and follow-up on any such interventions may be difficult.
The conditions in which people are incarcerated are often poor. The group concluded that governments must uphold basic human rights in these settings, as it is a violation of human rights to accept the poor environmental conditions of prisons as justified punishment for incarcerated people (United Nations General Assembly 1990).
Refugee and IDP settlements
There are more than 65 million forcibly displaced persons globally, nearly half of whom are children (UNHCR 2017). The contexts in which displaced persons live vary, as do the WaSH services available to them. Most refugees flee to nations that have not fully met the basic needs of their own citizens, and more than 60% live in urban host communities rather than camps. Host governments anticipate that displaced populations will eventually return to their country of origin, but the average refugee spends 17 years displaced, and some never return to their country of origin (UNHCR 2017). UNHCR monitors and evaluates WaSH conditions for all recognized settlements. During the emergency stage, this monitoring is based on minimum standards for survival according to the Sphere handbook, which establishes standards for humanitarian response (The Sphere Project 2011; UNHCR 2017). Monitoring and regulation of conditions in protracted crises – those that last longer than two years – is less standardized. Since settlements are frequently assumed to be temporary, they are sometimes built on the least desirable land that may be prone to flooding (Hoerz 1995; Thomas 2012). Poor WaSH infrastructure and drainage in these population-dense areas can facilitate the spread of WaSH-related diseases such as cholera, which affect both the displaced population and the host community (Tota-Maharaj 2016; Vivar et al. 2016). There are also adverse environmental impacts to consider; large influxes of refugees often result in the depletion of natural resources such as firewood and groundwater supplies, and conflict can arise between host communities and the displaced over water rights (Martin 2005).
Breakout group findings
The group discussed the challenges related to management of WaSH and environmental health conditions in refugee and IDP settlements, particularly the sustainability of services beyond the emergency response stage. United Nations agencies, such as UNICEF and UNHCR, usually coordinate the WaSH response throughout the emergency phase. This coordination is complicated since foreign actors must work within host government processes; and many organizations only provide WaSH services during the emergency phase. The primary goal of aid organizations is the protection of refugees, including provision of essential services such as adequate water and sanitation. This includes latrine design and safety; all latrines should have locks and be well lit to deter sexual violence. Monitoring should be a priority, but it is challenging to track conditions over time since the population is often transient; at the height of an emergency, data collection is not a high priority.
The group discussed how the transition from humanitarian relief to sustainable development can be complex; since refugee and IDP settlements are intended to be temporary arrangements, it is difficult to convince host governments to invest in infrastructure improvements that would improve the quality of life for displaced persons long-term. However, WaSH infrastructure could also have health benefits for the host community, which may create a more compelling argument from the government perspective. These is usually more flexible funding available during the emergency stage, which could be more strategically oriented toward transitional and longer-term provision of sustainable WaSH services. WaSH professionals already working within refugee and IDP settlements could be better mobilized and coordinated for the purpose of providing more appropriate and sustainable services. There may also be opportunities for WaSH-related income-generating activities or waste reuse programs, which could make a substantial impact in refugee and IDP settlements. Hygiene promotion programs introduced in refugee or IDP settlements may result in lifestyle changes that persist beyond beneficiaries' displaced status. The most successful responses to displaced person situations are the result of strategic pre-planning; prepositioning superstructures, plastic slabs, jerry cans, and soap can save lives.
One similarity across orphanages, prisons, and refugee and IDP settlements is their unclear and often taboo political and social status, which can jeopardize effective interventions and fundraising. Each of these settings has undefined stakeholders and challenging sociopolitical dynamics, which often result in diminished agency for their respective populations. Advocacy is therefore particularly important in order to combat associated negative social constructs. Children are particularly vulnerable in all three setting types: in refugee settings and orphanages they often lag in educational development, and children born in incarceration often face disrupted care. All settings also feature communal areas where WaSH infrastructure is fundamental – hand washing stations with soap and functional toilets that can accommodate different ages, genders, and abilities are needed to meet basic health needs of these populations and prevent the spread of disease. Despite their perceived temporary nature, each of these settings features transient, contained, and longer-term populations, which may introduce opportunities for WaSH behavioral interventions.
Differences between settings
In contrast, the compositions of populations vary tremendously between setting types. In each case, caregivers/authority figures and dependent populations must be targeted specifically in order to positively affect WaSH behavior and systems. The functionality and availability of WaSH infrastructure also vary within and between setting types. For example, the group described how, in orphanages, toilets are often present but are often non-functional. Refugee and IDP settlements have distinct challenges, including the fact that WaSH facilities constructed during the initial emergency response phase may be inappropriate for long-term use. In prisons, there is a particularly wide variety in quality of WaSH facilities. There is a substantial difference in information available on WaSH in each of these settings. While there is evidence of effective WaSH interventions in refugee and IDP settlements, little information is available on WaSH in orphanages and prisons. Collecting data is an important first step to understanding and improving conditions.
Involuntarily displaced populations, including those living in orphanages, prisons, and refugee and IDP settlements, share dependency on others for their health and well-being and often have heightened vulnerability. Furthermore, their unclear political and social status can exacerbate existing social sentiments that cause displaced persons to be undervalued and neglected in national and international development policy. This can translate to insufficient monitoring, ineffective or poorly targeted programming, and a lack of stakeholder coordination. Combined with poor environmental conditions, these factors can lead to inadequate WaSH services and behaviors and adverse health outcomes for some of the world's most marginalized populations. Further research is needed in order to better identify environmental health conditions, challenges, and opportunities within each setting. This is particularly true for orphanages and prisons, which have weak evidence bases with regard to environmental health. Advocacy regarding this topic is of paramount importance, as each setting's population has diminished agency and is politically, socially, and physically vulnerable. Finally, orphanages, prisons, and refugee and IDP populations should be included in the conversation surrounding SDG 6 from practical, policy, and human rights perspectives. Future conference events and working groups related to WaSH and environmental health should include involuntarily displaced populations in their agendas.
The authors thank World Vision for co-hosting this side event, as well as the participants who led rich discussions in breakout groups. The authors would also like to thank Wilson Guo, Christie Chatterley, Jeremy Guest, John Brogan, David Clatworthy, Diana Byrne, and Elizabeth Campa for their helpful comments and revisions on a draft of this article.
This paper was made possible with support from the Wallace Genetic Foundation, the Morehead-Cain Foundation, and the Royster Society of Fellows at the University of North Carolina at Chapel Hill. Nikki Behnke was supported by a Foreign Language and Area Studies grant from the US Department of Education, which was awarded and administered by the Carolina Center for the Study of the Middle East and Muslim Civilizations.