The sisters were buried in their favourite clothes: Patricia in a white dress and Mirana in plimsolls, a skirt and a blouse. Patricia was three and loved her Barbie. Not the Barbies that most girls in the village play with – dolls made from bamboo sticks, with grass “hair” tied in elastic bands – but a real one, with a pink plastic face. Her father, Augustin Randrianasolo, now 62, had bought it a few years earlier from the market for 200 Malagasy ariary (then worth 50p), a lot of money in the early 80s.
Mirana died seven years after her sister, in the early 90s; she was two and a half. “Not yet old enough to really speak,” says her older sister, Odile, who is now 35. “She was the most beautiful of all of us,” she continues. “She had the nicest hair, the most beautiful face. She looked like my dad.”
Patricia and Mirana were two of six girls born to Isabelle and Augustin. They married when Augustin was 20 and Isabelle was 16, and settled in Ambatoantrano, a remote village in the central highlands of Madagascar. Augustin was measured, thoughtful and could read and write. She was a talented seamstress and embroiderer.
The sisters died in the rainy season. The village is built on a slope and, when it rains, water streams down the pathways. Today, it is mainly red soil that gets swept into puddles. Back then, it was mixed with human faeces. There were hardly any toilets in the village; until three years ago, most people defecated in the maize fields at the edge of the village, or in the tall grass behind the school. The puddles the children splashed and jumped in were sources of life-threatening disease. Cases of diarrhoea always peaked with the rain, from November to April: children suffered most. Patricia’s death happened very quickly – three days from the onset of a persistent stomach ache and diarrhoea to death. “We didn’t pay too much attention at first. Diarrhoea is very common,” her father says. “But then it got worse.”
They tried to take Patricia to the health centre in the next village, but heavy rains cut off the road. They gave her an infusion made from ground guava leaves that she could not keep down, and bought some pills from the village shop. “But when it’s really bad diarrhoea, these pills don’t work,” he says. Patricia died in the night of profound dehydration. Her parents were stunned. “She had been there, and then, very suddenly, she went,” Augustin says. His face is full of pain.
When Mirana got ill, it took a long time for Odile to understand what was happening. “My mother wanted to take her to the hospital because she saw how dangerous it was, but my dad wanted to go to his father, a healer, in the village. He gave her some medicine, but my mum didn’t want it. She burnt it.” Finally, they got someone to drive them to the hospital in town, but it was too late. The parents blamed each other and separated a month later.
“She was disappointed about life, about us,” Augustin says of his wife. Isabelle left for a man who was improving the road to the village. She took the four girls and moved to a town 500km away.
Although he was only 35 when his wife left, Augustin never remarried. “I decided to live my life alone,” he says. For the past 30 years, he has focused on farming and village affairs; he is currently vice-president of the community, after serving as president for five years. “Sometimes when I think about my wife and my daughters I go to the shop and buy something to drink,” he says. Usually Malagasy rum.
Odile says all the pain in her family can be traced back to one thing. If there had been toilets in the village, everything would have been different. “My sisters wouldn’t have died and we would have had a better life.”
About 673 million people in the world don’t have sanitation, according to the most recent statistics, published in 2019 by the World Health Organisation and Unicef.
Not even a stinking, fly-invested box, or a rickety shack that empties over a ditch – this counts as sanitation, though of an unsafe variety. The people who have access to this – 701 million people – are relatively fortunate, compared with those without any latrine, who must defecate in street gutters, behind bushes or into rivers or plastic bags. The impact on health is huge. Diarrhoea caused by faecally contaminated food or water – nearly 58% of cases – kills 910,300 people a year: many of them are children. According to Unicef, it is the biggest hurdle that a young child in a developing country must overcome to survive – bigger than HIV, tuberculosis or malaria.
Good sanitation can reduce diarrhoea cases by nearly 35%. It means children are less likely to be off school with tummy ache and girls can attend when they get their periods – otherwise, what do you do if your school has no toilet? Where good sanitation exists, people are wealthier and healthier.
But inserting a good system into a developing country is not easy. “It is critical not only to have a functioning government but one that prioritises sanitation,” says Andrés Hueso, senior policy analyst for WaterAid. Brazil, for example, has increased its military spending over the past decade, but reduced its investment in water and sewage systems, despite having a sanitation ranking of 112 out of 200 countries in the most recent survey by the World Bank, in 2014. Treating the resulting diseases cost Brazil nearly $25m (£20m) in 2017 alone.
To make a lasting change requires more than a high-level political push, Hueso says. “You need real work at grassroots level, and behavioural change.” Defecating in the open is as old as humankind – and a practice that is still celebrated in countries such as Madagascar with startling fervour. “Men will say: ‘I like going in the fresh air. I like the walk in the morning. I like socialising with my friends when I go in the open,’” Hueso says. “But very rarely will women say they enjoy it.”
Going to the toilet outdoors is dangerous and embarrassing for women and girls. In many communities, modesty requires that they get up at 4am to do it under the cover of darkness, leaving them vulnerable to sexual assault and snakes. “In almost every developing country, you will hear women say: I go at night, so people don’t see me. I always go with a friend, so she can keep an eye on people prying,” he says.
Only one road connects Ambatoantrano to the nearest town of Ts’didy. The drive takes two hours, snaking over mountainous terrain. The village is home to about 2,000 people, none of whom own a car. Only three have a motorbike. Augustin, like most people in the village, gets around on a bicycle; it takes him three hours to cycle to Ts’didy – longer when the rains turn the road into a quagmire.
It is a pre-industrial life. People depend on the land, with dozens heading off to work in the fields as morning breaks, having been woken by cockerels. The women, young and old, are always working – pulling weeds from the ground, crouching in the red dust to pound rice, hanging washing out to dry on bushes and trees. With no toy shops or TV, children make up their own games. Boys play marbles with rounded pebbles or guava stones; girls plait skipping ropes from the long grass at the edge of the village.
There are cattle-drawn carts and guinea pigs are food, not pets. Getting mobile coverage is a laborious process, as the sole hotspot is by a tree in the centre of the village. There are more churches (five) than shops (three) and the congregations gather for Sunday morning services that last for three hours. Raymond Razafiarison, 63, the pastor of the Lutheran church, is one of only a few people in the village to have solar power.
And yet Ambatoantrano bucks a trend in Madagascar. In the country as a whole, fewer than 10% of households have a private toilet – among the lowest rates of sanitation in the world. In rural areas, these numbers are even lower; people are more likely to use a mobile phone than a loo. But here, nearly 98% of households have their own toilet. Despite having no electricity or sewage works, it has higher sanitation levels than Bulgaria, thanks to the efforts of NGOs and charities over the past two years.
Aurelie Ranoeliarimanana, 56, was one of the first in the village to get a latrine. She is now the head of a church’s women’s association and is wearing her church finery (black patent shoes with buckles) when we meet one Sunday morning. Her childhood ambition was to be a midwife, although a lack of money held her back. “I had an aunt who was a doctor in a hospital and she allowed me to do a kind of internship. Because I wanted to work in the health sector, I knew that a latrine and a bathroom were really important.”
She remembers the early 80s, when many young villagers died after having diarrhoea. “We kept on burying children, maybe 10 a year at that time,” she says. They included her own nieces, who were aged one and three. In 1997, pastor Razafiarison led the funeral service for his granddaughter, who died when she was barely four weeks old. “She had diarrhoea, continuous diarrhoea,” he says. Her name was Tafita. “It means succeed,” he says.
Ranoeliarimanana’s first latrine dates from when she was newly married, in 1979. It was similar to the pit or long-drop toilets built in the village today. These have three components – a deep hole in the ground; a concrete slab or mud floor with a small hole (sometimes laid with two bricks squatting distance apart); and a shelter – and are built close to the house (but not too close, because of the stench).
A pit toilet is ideal for places without water or sewers, because the faeces compost in the deep hole. When it is full, after four years or so, the owner digs another one and starts again.
Ranoeliarimanana talks with pride of her many latrines and how, even 10 years ago, they were a rarity. In 2016, only about 5% of families had a latrine. The turning point was the arrival of water in early 2017, from a source seven miles away, thanks to a gravity flow system and £70,000 from WaterAid. This meant women no longer had to make the long walk to collect water from the river. It meant fundraising photographs could be taken of water gushing from the village’s tap stands. “NGOs like WaterAid like to talk about water much more than sanitation, because it gets more traction – from supporters, academia, media, celebrities, the government,” Hueso says. “Sanitation is not sexy.”
The ready supply of water undoubtedly makes handwashing easier. But long-drop toilets don’t require water to work, only ashes to neutralise the smell. Nevertheless, the effect was dramatic. Latrines appeared, not gradually, but all at once. Mialy Randriamampianina, the head of policy, communications and campaign for WaterAid Madagascar, puts it down to the “integrated message of water, sanitation and hygiene”. Others say it was peer pressure, and the fact that the community imposed fines on refusers that were enforced by the gendarmes.
The latrines were funded and designed by the villagers – an approach, say sanitation experts, that helps to make people feel more invested. Augustin’s is pared-down, like his bachelor home, which is dark and basic even by local standards: no floor covering, only earth; no bed, only a wooden couch hidden behind a rag curtain. He shares his latrine with a neighbour who has a family of nine and who helped build it. It cost about Ar10,000 (£2.20) and has mud walls and a straw roof. Augustin tends to visit early in the morning. “One person always takes a long time, but I am not going to say who,” he says.
Ranoeliarimanana’s daughter, Saholy, in her early 30s, has one of the smartest latrines in Ambatoantrano. She and her husband run the shop-cum-cafe, which sells coffee and noodle soup as well as packs of spaghetti, biscuits, dried fish and plastic bottles of paraffin. They live in an aspirational part of the village, near the money lender’s house, which is bigger and grander than the rest. Her husband gave up his job as a maintenance engineer for the mobile phone company Orange three years ago.
“We were always moving and our two boys were suffering,” she says. The cement floor of her latrine is inlaid with beautiful ceramic tiles, inspired by the more upmarket toilets she saw on her travels.
But the latrines have brought new problems. Jeanne Ramanandraisoa, 58, has lost five ducks down the hole over four months. “They follow the flies,” she says. “We got three out with a stick, but two died. We need to make the hole smaller.” Her crops, at least, are no longer infected. “Now I can eat what I grow. Before, I could not. There were lots of flies on the sweetcorn, because there were so many people shitting just next to the field.”
It is not easy to duplicate the success of Ambatoantrano. Take Morondava, a city in south-west Madagascar. Andry Rajoelina, the country’s president, who is 45 and once worked as a DJ, proposes making Morondava a new “Côte d’Azur”, with its beautiful beaches facing the Mozambique channel. But just around the corner from the city’s five-star Palissandre Côte Ouest hotel is a community of Vezo – traditional fishermen. The warren of closely packed houses and chaotic alleyways that borders the beach is home to about 5,000 people. Roughly 1% to 2% have a latrine. The rest use the beach.
“It is the habit of the Vezo to come to the beach early in the morning to see the fishermen set off for the day,” says Angeline. She is married to a fisherman and has five children, aged 12 to 28. Dawn is also the time when people relieve themselves. “That is one of the places,” she says, pointing to some rocks.
The toilet seems to span the entire length of the beach. The contrast between the beauty of the surroundings – the beach in the golden light; pirogues, boats made from a hollowed-out log, each powered by a hand-stitched sail, being manoeuvred into the sea – and the sight of people squatting down is surreal.
“It does annoy us,” Angeline says. “Sometimes when we are catching shrimp [with small nets] there is poo in there, too.” Patrice Paul Tiandrainy, 25, a fisherman and health agent for a local NGO, says human faeces is also a problem further out to sea, where it is carried by the waves into fishing nets. He says he catches faeces along with the crabs, lobsters and tuna fish, about once a week.
Arguments against building latrines include lack of space and traditional beliefs. It is “fady [taboo] to store your shit”, Tiandrainy explains. “It’s like you are considering it as wealth, and you should only save money.” There is also the cost. The Morondava area is too cramped for pit latrines. Private companies sell latrines with a proper cistern and cement floor, but the cost is upwards of Ar200,000. Tiandrainy used to go to a public toilet in the centre of town. “But nobody maintained it and it got broken.”
Kolo Fritjob, the mayor of Morondava, agrees a “sanitary block” on the beach front is an answer, but he has the budget to build only one latrine a year. He receives no money from central government for sanitation. “It is not their priority,” he explains. “Pensions, education, health – they have money for those things, but not for water, sanitation and hygiene.” Fritjob says the council has funded a team of 12 “poo policemen” who prohibit people from defecating on the beach. But that is only in “touristy areas”.
Florette Raharinirina, 16, who has bleached hair and a mobile phone, tells me that young people are angry about the lack of sanitation. Is she hopeful that latrines will get built? “No. It’s too hard. It’s always about money and people don’t have money.” I ask if there are any benefits to pooing outdoors. She sighs. “There is nothing good about it,” she says. She and her friend Shella Nomenjanahary, 15, use the isolated side of the beach, where they crouch side by side. “People can see us, every time we go.”
As she prepares to leave, I ask her to describe her fantasy toilet. She has given this subject some thought. It would be “really big with rose walls and white tiles”, she says, “with a flush; soft toilet paper”. And a lockable door.
It is the middle of the rainy season in Ambatoantrano. The maize and cassava plants are bushy and green; squash vines loop over the trees. One woman’s front garden is filled with geraniums. This has been a shift since water arrived; people grow plants for decoration, not just to eat.
There is change, too, in Augustin’s family. Odile’s son, 10-year-old Nantenaina, has moved in with Augustin. “I really love my grandfather and worried he was a bit lonely,” Nantenaina explains. His favourite time of the days is after school, when he and Augustin work together in the fields. “We weed the cassava, or go fishing,” he says. Odile, who lives next door, is happy with this arrangement.
The village latrines have survived their third year. The worry with self-designed toilets is they will collapse in the rainy season if not built in a “technically sound way”, Hueso says. But aside from a few grumbles about leaks, the outlook in the village is optimistic.
There is still malaria, of course, and most recently plague. But Stella Vaonirina, 38, the village community health worker, says she used to treat about 30 cases of diarrhoea a month when she arrived in the village in 1999. Now it is about four. “Some people still have diarrhoea, but they don’t die from it,” she says. “That’s the difference.”
• Sally Williams travelled to Madagascar with WaterAid. For more information on its work supported by players of the People’s Postcode Lottery, go to wateraid.org/uk/ppl
• This article was amended on 13 August 2019 because updates to the statistics given for the number of people worldwide without access to sanitation went astray during the editing process. An earlier version included data from 2015 and said 2.3 billion people had access to makeshift toilets. That figure included not just people who use unsafe toilets, but also those who defecate in the open. This has been updated to refer to figures published this year by WHO and Unicef, which covered 2017 and showed 701 million people used unsafe sanitation.
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