Our hospital in southwest Ethiopia serves an area of 2.5 million people —from farming villages and tribal areas to refugees from South Sudan. Health care activities here are below standard by any measure and we face what sometimes feel like insurmountable challenges to curb these problems. But the single biggest challenge of all is water.
In our hospital, because we only have clean tap water available approximately twice per week when water is trucked in, we must supplement with river water, which we know is unclean. But a hospital needs water daily and for many purposes: not only drinking but also meal preparation, delivery rooms, operation theaters, patient wards, sterilization of medical equipment, toilet utilities, laundry, gardening, personal hygiene and so on. The lack of water/sanitation/hygiene (WASH) services deeply compromises our ability to prevent and control infections and puts our staff – our doctors, nurses and midwives, pharmacists, administrators and cleaners — at risk.
We have tried to harvest rain and have talked to city administration to direct the town’s total water to the hospital for one hour to pump it into a holding tank. It’s not enough.
Our hospital is not unique. A global assessment of the extent to which health care facilities in low- and middle- income countries are able to provide essential water, sanitation and hygiene for their staff and patients proved dismal. Only 44 percent of healthcare facilities surveyed had both soap and piped water to wash hands and keep facilities clean. Fifty percent of healthcare facilities lacked piped water and 33 percent lacked basic toilets. It’s no surprise that nearly 1 in 6 patients contracts an infection during hospitalization in developing countries. This widespread problem poses a global risk when many of these facilities are the frontline defense against infectious diseases that can turn into pandemics.
Large disparities exist among different facilities within the same country. That’s certainly something we see here. For example, according to the Ethiopian Ministry of Water and Energy 99 percent of healthcare facilities in Ethiopia’s capital city of Addis Ababa have access to water while only 23 percent of healthcare facilities in the region near our hospital have water (2012).
Services that should be basic and routine, such as a safe and clean delivery, put mothers and fragile newborns in particular risk. Here’s a typical scenario we see in our hospital: A laboring mother comes where she will be triaged by a health professional without gloves as often they are not available. After that, a physician examines her with unwashed or inadequately washed hands. She will then be admitted to the delivery ward where she will sleep with no bed sheets on an inadequately disinfected mattress. The floor is splashed with amniotic fluid and blood. All because there is no adequate water.
When she is ready to give birth, she will be transferred to a delivery table, which is partially cleaned with two jugs of water and detergent. If everything goes well, she will be blessed with a child. When things go to the other way, she might have to go to the OR for delivery. The OR has no adequate supply of tap water, which increases risk of post-operative infections that are rampant in our institution.
Once the procedure is over, both the mother and the child will have to stay in a crowded post-operative ward for three to four days where 12 beds are packed into a small room without adequate, safe water for personal cleanliness. To make things worse, the mother could acquire water borne infections from a meal prepared using unsafe water or the baby may develop easily prevented infections like sepsis. Subsequently, the baby might be required to be taken to the NICU for further treatment, which is an additional economic burden for the family, as are additional medical, food and bottled water costs incurred during the stay.
We know the Ethiopian Ministry of Health is working to improve this dire problem. It has created a national policy and strategic plan to radically improve the provision of safe water and sanitation throughout the country and bring significant benefits to millions of people. The Ministry is also trying to link WASH with infection prevention through its flagship project called Clean and Safe Health facility (CASH). Still, disparities are so big among different locations and conditions remain very bad in our hospital.
With all our problems, our hospital is still doing its best to address the needs of the region and local community. Last year we performed 303 caesarian sections, 1522 major surgical procedures and 1500 minor procedures — all of which should be unthinkable without water. The most important cause for morbidity was infections and related sepsis, all due to inadequate and low-quality water. We do the best we can.
We need leaders, governments and donors to come together on this most fundamental healthcare need. We deeply appreciate the UN Secretary General’s Call-to-Action, calling for all healthcare facilities to have adequate WASH by 2030. Now it is time for coordination and action. This worthy goal will be accomplished only when health, development, water and finance sectors work together to achieve universal access to real healthcare. As professionals serving on the frontline of healthcare, it is with deep gratitude and urgency that we make this most fundamental request.
Tewodros W. Liyew, M.D., Chief Clinical Director, Mizan-Tepi University Teaching Hospital
Ephrem Alemayehu Kirub, M.D., Clinical governance & Quality Improvement unit head, Mizan-Tepi University Teaching Hospital
Biruk Ambaw Teshome, M.D., CRC ambassador and Clinical governance & Quality Improvement unit vice head, Mizan-Tepi University Teaching Hospital