Urban Poverty and Environmental Risk:

A Quantitative Analysis of Environmental Equity in Accra,

Ghana

A thesis presented by

Heather Carmichael

to

The Committee on Degrees in Environmental Science and Public Policy

in partial fulfillment of the requirements

for a degree with honors
of Bachelor of Arts

Harvard College
Cambridge, Massachusetts

March 2009
Acknowledgements

I met Professor Majid Ezzati during my sophomore year at Harvard.

I thank the Harvard University Center for the Environment, which provided the
vast majority of funding for both my first and second trips to Accra. the Harvard College
Research Program for generous funding that made my

My research would not have been possible without the help of many Ghanaian I
have to thank my field assistants—Nana, Tete, Laye, Nazar, and Kilu—both for assisting
me around Nima and Jamestown, and for many lively discussions about local and world
politics. I particularly have to thank Adam Abdul Fatah and his wife, Hawa, for their
generosity and hospitality, as well as inviting me into their home on numerous occasions.
My second trip to Accra would not have been successful without the help of
Allison Hughes, Nana Primpeh, and Raphael and Comfort Arku,
Kathie/Ari/Michael Rooney /
Alison, Michael, Jay?

2
 Preface

While I was in Accra researching this thesis, I interviewed Ebenzer K. Garbrah,

an engineer at the Ghana Water Company, and Chief Manager of Planning and

Development. He described a recent incident in his office; pipes in one neighborhood of

Accra were in dire need of maintenance that would take ten days, and water supply would

be cut off. The engineer spent sleepless nights drafting plans to inform the public and

supply water to the neighborhood via tanker trucks. Finally, he completed the plans, only

to realize that due to existing rationing and shortages, most people in the area in question

received water through the pipes for only a few hours each week, with some waiting as

much as two weeks before receiving anything. He told me this story to highlight the

severity of the situation facing the developing city—population growth and demand for

resources that cannot be matched by city planners. These topics are the subject of this

thesis.

3
Table of Contents

Chapter 1 : Introduction...................................................................................................8
Chapter 2 : An Introduction to Accra and the Study Areas........................................18
Chapter 3 : Datasets and Methods of Data Collection.................................................27
Chapter 4 : Water, Hygiene and Sanitation in the Greater Accra Metropolitan Area
Census and Other Household Surveys...........................................................................37
Chapter 5 : The Spatial Distribution of Littered Solid Waste.....................................54
Chapter 6 .........................................................................................................................70
Chapter 7 : Liquid Waste and Roadside Drainage Gutters ........................................71
Chapter 8 : Household Drinking Water—Source versus Consumption.....................84
Chapter 9 : Discussion, Conclusions, and Suggestions for Future Policy.................101

4
List of Figures and Tables

Figure 2-1: Beach area (top) and residential street (bottom) in Jamestown..............23
Figure 2-2: Rooftop view (top) and public waste collection site (bottom) in Nima.. .24
Figure 2-3: Residential area (top) and the Ring Road (bottom) in Asylum Down... .25
Figure 2-4: Developing area along the walking path (top) and gated houses in East
Legon (bottom).................................................................................................................26
Figure 3-5: Water collected from a public tap in Jamestown, and stored outside the
house in a plastic barrel...................................................................................................31
Figure 3-6: Metal barrels used to store water in the courtyard of a household
compound in Nima...........................................................................................................31
Figure 3-7: An example of a highly polluted consumption sample collected from a
household in Jamestown. E. coli colonies appear blue or purple, while other
coliforms form pink colonies...........................................................................................32
Figure 3-8: Testing for E. coli and total coliforms using Coliscan® Easygel® system
—incubation at room temperature................................................................................32
Figure 3-9: Map of study areas and walking paths showing road type and surface,
as well their general location in the city (courtesy of Ari Friedman)..........................34
Figure 3-10: Partially covered cement gutter in East Legon with no trash and slow
flowing water (left) and clogged open gutter in Nima with stagnant water flow
(right). ..............................................................................................................................36
Figure 4-11: Population density in the Greater Accra Metropolitan Area. Boxes
show the approximate locations of the study areas......................................................39
Figure 4-12: Persons per bedroom for households in the Greater Accra Metropolitan
Area, aggregated by enumeration area..........................................................................39
Figure 4-13: Water sources by EA in the Greater Accra Metropolitan Area.............41
Figure 4-14: Water sources in the four neighborhoods using data from the 2000
census (left) and the 2007 household surveys (right)....................................................42
Figure 4-15: Household methods of solid waste disposal include (clockwise from top
left) disposal at public collection sites, private collection of solid waste, illegal
dumping (for example, into open drainage gutters) and burning of household trash.
...........................................................................................................................................46
Figure 4-16: Household methods of solid waste disposal by EA in the Greater Accra
Metropolitan Area............................................................................................................47
Figure 4-17: Methods of solid waste disposal in the four neighborhoods, according to
the 2000 census (left) and the 2007 household surveys (right).....................................48
Figure 4-18: Liquid waste disposal methods by EA in the Greater Accra
Metropolitan Area............................................................................................................50
Figure 4-19: Liquid waste disposal methods in the four neighborhoods, according to
the 2000 census (left) and the 2007 household surveys (right).....................................52
Figure 4-20: Toilet facilities in the four neighborhoods, according to the 2000 census
(left) and the 2007 household surveys (right)................................................................53
Figure 5-21: "Sachet" water is a common commercial source of drinking water in
Accra (left). The plastic sachet then becomes a common source of littered waste
(right)................................................................................................................................56

5
Figure 5-22: The spatial distribution of plastic waste in the four study areas. Only
Asylum Down and Jamestown show significant spatial autocorrelation....................59
Figure 5-23: The spatial distribution of food waste in the four study areas. Only
Nima shows significant spatial autocorrelation............................................................60
Figure 5-24: The spatial distribution of paper waste in the four study areas. No
neighborhoods showed significant spatial autocorrelation..........................................61
Figure 5-25: Map depicting the littered waste data collection points in Asylum
Down, along with the population density raster. The red circles represent buffer
zones (50 meter radius) for which an average population density was calculated....64
Figure 5-26: Histograms of this test statistic for replicate datasets sampled from the
model. Lines in red show the test statistics for the actual dataset..............................69
Figure 6-27: Level of trash in open gutters summarized for the four neighborhoods.
...........................................................................................................................................73
Figure 6-28: Level of littered waste in gutters along the walking paths for the four
study areas........................................................................................................................74
Figure 6-29: Stagnant waters provide breeding grounds for mosquitoes and other
pests (left). Shallow gutter with high flood risk in Jamestown (right).......................76
Figure 6-30: Classification of water flow in gutters along the walking paths for the
four study areas................................................................................................................79
Figure 6-31: Measure of flood risk for gutters along the walking paths for the four
study areas........................................................................................................................80
Figure 6-32: Comparison of trash level to water flow for all measured gutters
(pooled across neighborhoods).......................................................................................82
Figure 7-33: Classes of coliform bacteria used as indication of biological
contamination in water....................................................................................................86
Table 4-1: Mean population densities for EAs in each locality (standard deviations
shown in parentheses). ...................................................................................................38
Table 4-2: Mean number of persons per bedroom for households in each
neighborhood for the 10% household sample (standard deviations in parentheses).
...........................................................................................................................................38
Table 5-3: Mean level of different waste types by neighborhood (ranges shown in
parentheses)......................................................................................................................55
Table 5-4: Regression of log1plastic on neighborhood.................................................57
Table 5-5: Moran's I values for each neighborhood for different types of littered
waste. Data demonstrating high levels of spatial autocorrelation (unlikely to be
random) are marked by asterisks...................................................................................58
Table 5-6: Results for OLS regression of log1plastic on road capacity and surface..64
Table 5-7: OLS regressions of log1plastic on two measures of population density....65
Table 5-8: Results of the OLS regression of log1plastic on the percentage of the
population using a public dumpsite for solid waste collection.....................................66
Table 5-9: Summaries of posterior densities (mean and 95% confidence interval) for
important estimated parameters....................................................................................68
Table 6-10: Summary of important characteristics of gutter water in the four
neighborhoods..................................................................................................................78
Table 6-11: Flood risk of gutters with specified characteristics, namely, level of
littered waste (left) and water flow (right).....................................................................83

6
Table 7-12: Piped sources used by sampled households within each neighborhood. 89
Table 7-13: Comparisons of E. coli contamination in piped samples, at the source
and at the point of consumption. ...................................................................................90
Table 7-14: Comparisons of total coliforms in piped samples, at the source and at
the point of consumption.................................................................................................90
Table 7-15: Of households that store drinking water prior to consumption,
percentages using various containers for water storage. ............................................92
Table 7-16: Location of the storage container within the home in each neighborhood
(as a percentage of households that store drinking water prior to consumption). ...93
Table 7-17: Percentage of households demonstrating particular hygiene behaviors in
the household prior to consumption from piped sources. ..........................................94
Table 7-18: Difference in E. coli contamination between consumption samples and
source samples for all households with piped water sources, by source type.............96
Table 7-19: Difference in total coliform contamination between consumption
samples and source samples for all households with piped water sources, by source
type....................................................................................................................................97
7-20: Mean differences in E. coli and total coliform contamination between
consumption samples and source samples for all households with piped water
sources, by storage location. Numbers in parentheses include TNTC samples by
approximating TNTC counts at the minimum 200 cfus/5mL......................................99
7-21: Mean differences in E. coli and total coliform contamination between
consumption samples and source samples for all households with piped water
sources, by storage container type. Numbers in parentheses include TNTC samples
by approximating TNTC counts at the minimum 200 cfus/5mL..............................100

7
Chapter 1: Introduction

A Changing Global Demographic

In 2007 the world became predominantly urban for the first time in history.

Trends suggest that the world’s population growth in the next 30 years will occur almost

entirely in the urban areas of low- and middle-income countries (LMIC).1 Urban areas in

poor countries are experiencing rapid rates of growth, both due to high rates of rural to

urban migration and high birth rates in cities. As cities struggle to cope with such rapid

growth and development, infrastructure often lags far behind what is needed to prevent

situations of environmental strain. As a consequence, humanity must plan for an

increasingly urban future, quickly.

One outcome of rapid urbanization of the population in the developing world has

been the proliferation of urban slums. Nearly one sixth of the global population lives in

urban slums, defined as areas where the population lacks security of tenure, safe drinking

water and sanitation, and adequate housing.2 Almost four billion people are expected to

live in slums by 2030. In developing countries, the proportion of the urban population

who live in slums is 43%, and in the least-developed countries slum-dwellers comprise

78% of the population in urban areas.3

Urbanization is generally seen as a problem, and not as an opportunity. This leads

to attempts to accelerate rural development as the primary focus of poverty reduction. It

is thought that by creating better opportunities for rural populations, countries can

discourage the influx of rural migrants into urban centers, and thus solve the “problem”
1

2
3

8
of urbanization. Such a perspective on urbanization arguably has the most significant

ramifications for the urban poor. In fact, poverty in urban areas of the developing world

is largely underestimated, under-researched, and unacknowledged. This perspective also

fosters the misconception of the urban poor as being a transient population that is merely

a temporary problem, one that need not be recognized or rectified. Failing to

acknowledge the permanence of those living in urban poverty, government officials are

unwilling to formalize patterns of settlement for rural migrants as they flock to urban

areas. The urban poor are thus a marginalized population excluded from many aspects of

social development and welfare including health care, transportation, livelihood

opportunities, and political expression.4

Urbanization and the Environment: A Troubling Lack of Data

While research exists on the associations of environmental risks with poverty in

the developing world, there has been less focus on the urban setting. In the politics of

development, urban bias is a common and well-understood concept. Urban bias refers to

the tendency of city-dwellers, who live in centers of political, economic, and social

activity, to have greater access to policy-makers and government than their rural

counterparts. The corollary to this is the notion that urban poverty ought to be less of a

concern when facing poverty as a whole, and that the majority of the focus in

development should be on the seemingly greater problem of the rural poor. However, the

picture of poverty along this urban-rural divide is much more complicated, and needs to

be acknowledged as such.

9
 In addition to the urban bias described above, it is necessary also to consider the

potential for a rural bias in the context of development. Saumitra Jha has described this

in the following way:

If it is in fact the poorest migrants that gain from improved access to decision makers and
services by moving to the city, then urbanization, rather than being a strain on resources
that is to be discouraged, may in fact provide a means to better governance and poverty
alleviation. Unfortunately, due to an arguably strong “rural bias” in development data
and inquiry, little quantitative evidence is available either on the strategies of network
formation or on the actual political networks of the urban poor.5

Thus, it remains unclear whether the urban poor actually benefit from the urban bias in

development, and this lack of clarity is in part due to the lack of data and evidence that

comes from a rural bias whereby research and initiatives occur mainly in the rural setting.

There is a clear rural bias in the study of environmental risks. Environmental

risks and their health-related outcomes are generally studied at the household level, more

commonly in rural areas. However, the environmental risk and the physical deprivation

experienced by urban slum residents can be staggering, with many health risks at levels

substantially higher than those considered safe or seen in other areas of the city.

Inadequate access to safe water influences the spread of disease via water-borne

pathogens, and water scarcity also spreads disease due to poor hygiene. Inadequate

sanitation infrastructure contaminates the neighborhood and household environment, and

in turn can contaminate water sources. Inadequate waste removal exacerbates disease by

providing breeding grounds for flies and other pests, and littered waste also clogs

drainage systems, which then act as breeding grounds for mosquitoes that spread malaria

and dengue. Poor structural quality of housing leads to higher risk for physical injury and

overcrowding facilitates the rapid spread of infectious disease.6

5
6

10
 The environmental risks described previously indicate a need to move beyond the

study of the household environment and more broadly into the neighborhood effects that

occur in areas of concentrated poverty. Thus, one goal of this thesis is to examine both

neighborhood- and household-level environmental risks in the urban setting.

The Underestimation of Urban Poverty: Definitions and Discrepancies

Urban poverty is usually underestimated. This is in part because average urban

incomes exceed average rural incomes by a significant margin, which all too often cited

as a reason to divert focus away from the urban poor. The UN Millennium Project

Report on Improving the Lives of Slum Dwellers states: “The conventional wisdom is

that urban areas are better off than rural areas and that urban slum dwellers live better

lives than their rural counterparts.”7 This underestimation of poverty in the city is

partially due to a lack of adjustment for cost of living. Although the urban poor are on

average wealthier than the rural poor, their earnings often fail to cover even the most

basic necessities when living in the city. Definitions of lack of access to safe drinking

water, sanitation, and shelter are also inadequate and may misrepresent the experiences of

the urban poor. While many urban residents meet the definitions of having access to

“improved provision” of water and sanitation, these facilities may be shared by hundreds

of people, greatly increasing the risks of contamination and exposure. Similarly,

proximity to infrastructure such as hospitals or water sources does not ensure that poorer

residents will have access to these amenities.8

7
8

11
 Finally, there is also a problem of aggregate statistics when considering the urban

poor. By lumping data together from urban areas, one obscures the huge disparities that

often exist in these settings. Middle and upper class households are also concentrated in

urban areas, and can obscure the differences between rural and urban poverty. Under-five

mortality rates in informal settlements in Nairobi, for instance, are more than twice the

city’s average, while these informal settlements comprise nearly half the city’s

population.9 It is unclear whether the urban bias extends to the urban poor, who may be

just as distanced as the rural population from formal government and access to

policymakers who live just next door.

Although the meaning and scope of the term environmental equity remains vague,

it has been roughly defined by the Environmental Protection Agency as “the equal

protection from environmental hazards of individuals, groups, or communities regardless

of race, ethnicity, or economic status.”10 The study of environmental equity in developing

world cities has been limited, although marked differences exist in the living conditions

and health outcomes of urban dwellers. Another goal of this thesis is to explore

environmental differences and disparities in the urban setting of the developing world.

9
10

12
Environmental Risk Factors for Health

It has been demonstrated that environmental risks have substantial impacts on

human health, accounting for close to one-fifth of the burden of disease in developing

countries (a conservative estimate).11 Among the most important environmental risk

factors in the developing world are inadequate water, sanitation, and hygiene (WSH),

indoor air pollution from solid fuels, urban ambient air pollution, and vector borne

diseases such as malaria.12 In urban areas, overcrowding and widespread malnutrition

make populations even more vulnerable to the spread of infectious disease.

Reducing environmental risks also presents a valuable opportunity to improve

health outcomes for populations in developing countries. For example, it has been

estimated that 4.79 million children under the age of five years died in sub-Saharan

Africa in 2004, an estimated annual child mortality of 39.1 per 1000 children. Among

other things, the Millennium Development Goals (MDGs) seek to reduce child mortality

worldwide by two-thirds. However, it has been estimated that 50% of the gap towards

meeting this child mortality goal in sub Saharan Africa could be reached if the three

nutritional and environmental MDGs—improving child nutrition, provision of adequate

water and sanitation, and reduction in the use of solid fuels—were achieved for all

households with children.13 Thus, improving the condition of the household environment

is a potential strategy to make vast strides in improving human health.

However, exposure to environmental risks is determined by a complex web of

interactions between technological, environmental, and behavioral factors. For example,

the environmental risk factor of indoor air pollution can be influenced, among other

11

12
13

13
things, by the fuel or stove types used by a household, the location of vendors for a given

fuel type, the amount of time that the stove is on, or the amount of time spent near the

stove.14 This makes causality as well as the health effects of individual interventions

difficult to establish.

Water, Sanitation and Hygiene (WSH)

Adequate water, sanitation and hygiene (WSH) have been identified as the key

environmental risk factors for diarrheal diseases, which contribute heavily to the burden

of disease in developing countries. Diarrheal diseases are estimated to cause 3.3 million

deaths globally each year and are responsible for more than one-quarter of childhood

mortality every year.15 The majority of diarrheal disease is caused by infectious

pathogens such as viruses, bacteria, protozoa and parasitic worms that are transmitted via

fecal matter excreted by the human host. Thus, poor WSH contributes to the spread of

diarrheal disease by facilitating transmission between human hosts. In addition to

diarrhea, poor WSH can increase the risk of other diseases such as schistosomiasis,

trachoma, ascariasis, trichuriasis, and hookworm, and also contributes to the risk of

diseases such as typhoid, malaria, dengue, yellow fever, hepatitis A and hepatitis E.16

It should be noted that while a large portion of infectious diarrheal disease is

water-borne (transmitted via drinking water containing pathogens), water-washed disease

also plays a substantial role (transmitted via hands or food due to lack of water and

adequate sanitation).17 Thus, WSH can be defined broadly to encompass many factors

including ingestion of contaminated water, lack of water, poor hygiene practices in the
14
15

16
17

14
home and neighborhood, contact with unsafe water in agriculture and inadequate

management of water resources and water systems (such as drainage gutters).18 Chapter 7

of this study focuses on water-borne transmission, considering the effects of

environmental risk factors on the level of fecal-oral contamination in household drinking

water. Chapters 5 and 6 focus on neighborhood gutter systems and neighborhood solid

waste management, which can influence the risk of water-washed disease.

Risk can be influenced by factors at the household level or in the surrounding area

—household vicinity—in which case they are generally behavioral. Alternatively, WSH

can be influenced at the broader neighborhood level by infrastructure and technology. At

the infrastructural level, WSH can be affected by the availability and type of water

sources, the quantity of water available, and the sewage and waste disposal

infrastructures within the neighborhood. WSH can also be influenced by technological

and behavioral choices at the household level such as the household source of water and

storage method, type of latrine, and the household or community techniques for waste

disposal. Additional technological factors include point of use decontamination for water

(such as boiling or filtration), and food and hand washing techniques (such as soap).

Finally, WSH can be affected by behavioral factors such as hygiene, methods of water

transportation and storage, and waste disposal methods.19 This hierarchy is summarized

below.

18
19

15
 Household Vicinity Household
Neighborhood Effects Effects
Effects -population -type of water Drinking
-distribution density/crowding source
-solid/liquid waste
Water
infrastructure -storage
-solid/liquid waste disposal methods methods
Outcome
infrastructure -toilet facilities -purification
-water sources/distance methods

Outline of the Thesis

The interaction between urbanization, poverty and the environment requires

further inspection. I designed this study to assess some of the differences in the

distribution of neighborhood and household level environmental risk factors between

neighborhoods of varied socioeconomic status. In particular, this study considers water,

hygiene and sanitation, while deemphasizing the equally important problems of indoor

and outdoor air pollution.

The second chapter of this thesis describes some of the specifics of the Accra

metropolis, as well as the four neighborhoods chosen for the study. The third chapter

describes the methods used in data collection for this thesis. The fourth chapter uses data

available on these areas from the Accra census as well as a much smaller but more recent

set of household surveys done in the four neighborhoods to explore demographic trends

in the four neighborhoods as well as drinking water sources, methods of solid and liquid

waste disposal, and sanitation facilities. The fifth chapter focuses on the spatial

distribution of littered waste in the four neighborhoods. The sixth chapter analyzes the

distributions of open drainage gutters that line the streets of Accra, intended for storm

water runoff, but generally used for liquid waste disposal by many city residents. The

seventh chapter considers household drinking water quality, hygiene and sanitation,

16
including an analysis of samples that were tested for E. coli and other coliforms. The

final chapter will conclude and include suggestions for policy in the future.

17
Chapter 2: An Introduction to Accra and the Study Areas

Choice of Accra as a Study Location

Accra is in many ways an ideal location for the study of urbanization in the

developing world and its associated health risks. Similarities in urban structure and

development, poverty, and past colonial history make Accra fairly representative of other

cities in coastal West Africa.20 Accra is characterized by a sprawling urban area and

uneven infrastructure due to the incomplete implementation of development plans post-

independence, which has led to unplanned development and the proliferation of slum

communities. UN Habitat estimates that 66% of the city’s population lives in urban

slums.21

While the physical and demographic characteristics of Accra facilitate

generalization to other parts of sub-Saharan Africa, the city is made somewhat unique by

the quantity of data available on the environment, poverty, and health. The fourth

Population and Housing Census, completed in 2000, provides information on water and

sanitation in the household environment at a high level of spatial detail. The Stockholm

Environment Institute (SEI) conducted a study of household environments in three

developing world cities (Accra, Jakarta, and Sao Paulo) in 1991, including citywide

surveys of 1000 households in Accra. Professor Jacob Songsore of the University of

Ghana has published multiple works on the environmental health situation in Accra,

including a study of important environmental health indicators in all residential areas.

Water, sanitation, pests, sullage/drainage, food contamination, hygiene, solid waste,

20
21

18
housing problems, and indoor/outdoor air pollution were all assessed at the neighborhood

level in one of these studies.22

Demographic and Environmental Characteristics

In the 2000 census, the Accra Metropolitan Area had a total population of

1,658,937. With an estimated annual growth rate of 4.4% in the Greater Accra Region,

the expected population of the city in 2008 is approximately 2.3 million.23 This rapid

growth is largely due to rural-urban migration, as the total fertility rate in the

metropolitan area, at 2.2 children per woman per lifetime, is the lowest in the country.24

Indeed, the growth rate for this region far outpaces the national average of 2.7% per

annum.25 Other estimates indicate that the floating population in the city could be as high

as half a million daily, with nearly half this population remaining in the city overnight.26

Forty-eight percent of Accra’s population is below the poverty line and the city

experiences acute problems of sanitation, waste management and pollution coupled with

this rapid urban expansion.27 Data from the 2000 census indicate that 73.9% of

households in Accra do not have a toilet with a sewer connection, 56.3% have no piped

water in the house, and 47.8% have more than three people per room.28

The five most reported diseases at outpatient facilities in Accra indicate the

importance of environmental factors in determining health outcomes; according to

Songsore et. al. the health problems in the city are primarily “preventable and

22

23
24
25
26

27
28

19
communicable diseases, diseases attributable to poor environmental sanitation, ignorance,

and poverty.”29 Malaria is the most common, followed by upper respiratory tract

infections, diarrheal diseases, skin diseases, accidents, and intestinal worms. Five-fold

differences in mortality rates have been found between poor and wealthy neighborhoods

in the city.30 Household living conditions are clearly differentiated between

socioeconomic classes as well. A study by Songsore et. al. of 1000 households in Accra

found that while only 10% of households in the wealthiest quintile had to fetch water

from outside their household compound, nearly 80% of households in the poorest quintile

did. 71.7% of households in the poorest quintile used pit latrines, while 77.3% of

households in the wealthiest quintile had access to a flush toilet. Similarly, 68.8% of the

poorest households shared a toilet facility with more than ten other households, while

64.6% of the wealthiest households had a private toilet.31

In particular, my research focused on four neighborhoods within Accra of varying

socioeconomic status. Two of these communities, Jamestown and Nima, can be

classified as urban slums. Asylum Down is a mixed-income neighborhood in the heart of

Accra, while East Legon is an area of relative affluence on the outskirts of the city.

Jamestown and Usshertown

The study area in Jamestown and Usshertown is densely crowded with a

population of 13,617 in Jamestown and 22,140 in Usshertown, according to the census.

The study area includes both neighborhoods, but will henceforth in this thesis be referred

to as Jamestown only. Jamestown is located along the coastline in the old colonial area of

29

30
31

20
Accra, and many of the older colonial buildings have been preserved and now house

multiple households. The primary ethnicity in this study area is Ga, and the population is

for the most part poor and uneducated. The study area includes the main road that passes

from central Accra along the coast to the Korle-Bu area, as well as a large area along the

beach with a sizable squatting settlement and large boat yard. It is bordered on the south

by the ocean and on the west by the highly-polluted Korle Lagoon.

Nima

In Nima, the population according to the 2000 census was 69,044. Located in the

central part of the city, Nima has a large Muslim population of Hausa origins, and is

considered to be one of the most deprived slums in Accra. It is adjacent to the

neighboring slum areas of Mamobi (population 49,812) and New Town (population

45,130). The study area enjoys a mix of residential and commercial use, with a large

market place located to the east of the main road. The Al-Hamdu Gutter, one of the main

open drainage gutters for the city, passes along the western border of the study area, and

the land has a substantial gradient going down towards the drain.

21
Asylum Down

Asylum Down, with a population of 9,363 according to the census, is located in

the central part of the city and has a mix of residential and commercial areas, as well as a

mix of ethnicities and socioeconomic statuses. Poorer populations live in areas along the

main gutter that are prone to severe flooding during periods of heavy rain. The study area

also includes the Central Ring Road, one of the larger highways in the city, which is

bordered by a number of multi-story office buildings, hotels, and other businesses.

East Legon

The population of East Legon was 7,681 at the time of the census; however, the

area has grown substantially since then. East Legon is located near the University of

Ghana on the periphery of the city. The area is relatively affluent and largely residential,

with many single-family homes on fenced-off properties. However, it is also recently

developed, and many areas lack some of the infrastructure found in some parts of the city

such as paved roads and sewage systems. Finally, the community includes pockets of

poorer residents, many squatting on vacant lots or in unfinished houses.

22
Figure 2-1: Beach area (top) and residential street (bottom) in Jamestown.

23
Figure 2-2: Rooftop view (top) and public waste collection site (bottom) in Nima.

24
Figure 2-3: Residential area (top) and the Ring Road (bottom) in Asylum Down.

25
Figure 2-4: Developing area along the walking path (top) and gated houses in East Legon (bottom).

26
Chapter 3: Datasets and Methods of Data Collection

This chapter summarizes briefly the data used for analysis in this thesis, including

three original datasets that I collected in Accra during the summer of 2008 with the help

of a small team of research assistants.

Household Data

Ghana National Census (Ghana Statistical Services, 2000)

The 2000 Population and Housing Census was the fourth population census

undertaken in Ghana since independence and the most recent since 1984. The census was

enumerated on a household-by-household basis in March and April, 2000, with special

arrangements made for the homeless and floating populations. The census was

enumerated at the level of the individual, but data are also collected for households. A

household is considered by the GSS to be “a person or group of persons who live

together, in the same house or compound, share the same housekeeping arrangements and

are catered for as one unit.”32

The smallest statistical unit of the census is the enumeration area (EA), a

geographic area with clear physical boundaries that is enumerated by one census official.

There were 26,710 enumeration areas in the country, and 1,724 in the Greater Accra

Metropolitan Area (GAMA). The average population of each EA was 750, making the

EA similar in size to U.S. census blocks.33 Another important geographic unit in the

census is the locality, which is defined by the Ghana Statistical Services as a “nucleated

32
33

27
and physically distinct population cluster in which the inhabitants live in neighboring

living quarters and which has a name or locally recognized status.”34 In the GAMA,

localities are what might be referred to more colloquially as neighborhoods or

communities.

I have access to a 10% random sample of the census for the entire Greater Accra

Metropolitan Area in 2000, courtesy of Professor Allan Hill. This sample includes

information on liquid and solid waste disposal methods, toilet and bathing facilities, and

water sources for a random sample of 10% of households in the GAMA. A rough

estimate of population density can also be obtained by dividing the total population in

each EA by its area.

Accra Household Air Pollution Surveys (Ezzati et. al., 2007)

The primary focus of these surveys was to gather information related to household

use of solid fuels, household exposure to indoor air pollution, and respiratory disease.

However, some survey questions were directed more generally towards the household

environment, and pertain to water, hygiene and sanitation. As in the National Census,

respondents were asked about their water sources, toilet facilities, and methods of

disposal for solid and liquid waste. Although the sampled households represent a much

smaller dataset than is available through the census, with only 18-20 households per

neighborhood, the dataset is more recent, and may provide clues to how the household

environment is changing in these areas of Accra. This survey was approved by the

Institutional Review Board (IRB) of the Harvard School of Public Health and the results

34

28
of the survey questionnaire were provided to me in anonymized form courtesy of

Professor Majid Ezzati.

Household Water Quality and Water Storage (Original Dataset, 2008)

I collected samples of water in a total of 61 households in the four neighborhoods

described. These households represent a subset of households surveyed in the air

pollution studies described above. Two 12 mL samples were taken in each household;

one is denoted the consumption sample, and was taken one at the point of consumption

(as it would be consumed by a household member) and was taken from the source (the

tap or location from which the household fetches water). If the household’s source was

commercial (i.e. bottled or sachet water) only one sample was taken. The household

head was asked to describe his or her household’s primary source of drinking water.

Drinking water is defined as water that is used for direct consumption, and not used for

bathing or cooking. Specifically, they were asked to provide a sample of water as they

would consume it.

The family’s primary source of drinking water was described as one of the

following:

1. Indoor pipe – Water flows into the household building by pipe.

2. Pipe in yard – Water flows from a pipe within the household
compound/yard.
3. Public tap – Water from a source outside the household compound.
4. Tanker Truck – Water bought from a tanker truck.
5. Bagged – Water bought in plastic bags from a vendor.
6. Sachet – Water bought in plastic sachets from a vendor (sealed).
7. Bottled – Water bought in plastic bottles from a vendor (sealed).
8. Rainwater – Water collected during precipitation

29
Additionally, the source was classified as being private (only for the household or

surrounding compound) or as shared (used by multiple compounds or sold to the public).

The household head was also asked to describe any alternative sources of drinking water

used by the household.

I then observed the following characteristics of the source and storage of the

consumption sample:

1. Storage Container Type: Described as plastic bin/barrel, metal

bin/barrel, polytank, or plastic bottle.
2. Storage Location: Described as indoor (inside building but not
refrigerated), outdoor (outside household building or in compound), or
refrigerator.
3. Storage Time: Number of days stored, if known.
4. Wash: Whether the subject washes or rinses hands prior to retrieving
water.
5. Filter: Whether the water is filtered prior to consumption.
6. Boil: Whether the water is boiled prior to consumption.
7. Brand: For bottled/sachet water only, the company providing the
water.

5 mL of each sample was tested in field conditions for E. coli and total coliforms,

indicators of fecal contamination, using the Coliscan® Easygel® system. These data are

right-censored, as E. coli and total coliform counts greater than 200 per 5 mL were

denoted too numerous to count (TNTC). A more detailed description of the testing

procedure can be found in Appendix X.

30
Figure 3-5: Water collected from a public tap in Jamestown, and stored outside the house in a plastic
barrel.

Figure 3-6: Metal barrels used to store water in the courtyard of a household compound in Nima.

31
Figure 3-7: An example of a highly polluted consumption sample collected from a household in
Jamestown. E. coli colonies appear blue or purple, while other coliforms form pink colonies.

Figure 3-8: Testing for E. coli and total coliforms using Coliscan® Easygel® system—incubation at
room temperature.

32
Neighborhood Data

Neighborhood Solid Waste Management (Original Dataset, 2008)

Within each neighborhood, measurements were taken along a predetermined 6-7

km “walking path” used in previous studies for urban air pollution research. Each path

traverses the neighborhood in a crisscrossed pattern and covers a representative variety of

road capacities and surfaces, which have been classified and recorded in previous studies

along the walking path. Along the walking paths, I took a survey of the level of litter and

trash, stopping approximately every 80 meters. This amounted to 100-120 points per

neighborhood over the course of two days measurement in each neighborhood.

Alternating points were sampled on each day. The following parameters were measured

within a radius of 5 meters, not including any trash or waste that was within a gutter, or

within a household/individual waste container. If the number of items in a given count

exceeded 100, the level of waste was estimated from a smaller area count.

1. Location: Spatial coordinates recorded using GPS, averaged over 30

seconds.
2. Time: Recorded GPS time.
3. Plastic: A count of all plastic waste. One unit is defined as approximately
the size of a plastic water sachet.
4. Food: A count of all food waste (e.g. corn cobs, orange peels, coconut
husks, pineapple husks, etc). One unit is defined as approximately the size
of a fist.
5. Metal: A count of all metal waste. One unit is defined as approximately the
size of a (flattened) can.
6. Plant/wood: A count of all plant and wood waste. One unit is defined as
the size of a palm frond/large branch.
7. Paper: Count all paper, cardboard, and newspaper waste. One unit is
defined as the size of a sheet of paper.
8. Other: Notes for any other significant trash or waste, or waste that is in
containers.

33
Figure 3-9: Map of study areas and walking paths showing road type and surface, as well their
general location in the city (courtesy of Ari Friedman).

34
Finally, I also located and marked all public toilets, bathing facilities, and public rubbish

dumpsites or collection points within each neighborhood area.

Classification of Open Gutters (Original Dataset, 2008)

I also classified and georeferenced all the gutters along the walking paths. Each

segment of gutter was classified according to its structure, size, and the amount of water

and trash in it. Each section of the walking path for each neighborhood was described

according to the following parameters, using a waypoint to mark its start:

1. ID: Recorded both with GPS waypoint and other attributes (below)
2. Location: Recorded using GPS waypoint
3. Altitude: Recorded using GPS waypoint
4. Time: Recorded GPS time
5. Approximate Location: A brief description of the waypoint location.
6. Type: Each segment of the walking path was classified as having no gutter
or as having a gutter
7. Side of road (L or R): When gutters are on both sides of the roadway used,
the right side was classified. If there was no gutter on the right side the left
side was classified.
8. Opposite: The opposite side of the path was classified as having no gutter
or as having a gutter.

Only gutters running parallel to the path were classified, unless the width of the

gutter crossed was greater than 1 meter. Isolated gutters less than 3 meters long were not

recorded. All gutters were also classified according to the following variables:

1. Cover: Open gutter or partially-covered gutter.

2. Construction: Cement, partially broken, or dirt (unstructured).
3. Width: Width of gutter in meters.
4. Depth: Depth of gutter in meters.
5. Water width: Width of water flow in meters (approximate).
6. Water depth: Water flow depth in meters (approximate).
7. Water flow: Speed of water flow was described as dry, stagnant, slow
flow, or fast flow.
8. Trash: The quantity of solid waste in the gutter was classified as none, low
(<10 % estimated coverage), medium (<40 % estimated coverage), high (<
70 % coverage), or clogged (>70 % coverage)

35
 9. Turbidity: Transparent or opaque.
10. Color

Figure 3-10: Partially covered cement gutter in East Legon with no trash and slow flowing water
(left) and clogged open gutter in Nima with stagnant water flow (right).

Other Research

I also visited important agencies within Accra to learn about sanitation and water

issues from a more qualitative perspective. I visited the National Water Research

Institute, as well as the Ghana Water Company (GWCL), which handles the distribution

of water throughout the city. I also met with an official at the Ministry of Local

Government (Sanitation Division). I attended meetings of some local organizations such

as the Federation of Youth Clubs (FYC) in Nima, which has been actively campaigning

for the construction and improvement of the major gutter that runs through the

neighborhood. In addition, I took every opportunity to discuss my research topic with

local field assistants in the neighborhoods.

36
Chapter 4: Water, Hygiene and Sanitation in the Greater
Accra Metropolitan Area Census and Other Household
Surveys

This chapter uses household-level data from the 2000 National Census and from

household surveys conducted in 2007 to examine disparities in environmental conditions

in the Accra Metropolitan Area. I first consider demographic indicators of household and

neighborhood crowding in the four neighborhoods, before turning to household indicators

of environmental risks. Importantly, I look at differences in household water sources,

methods of solid and liquid waste disposal, and toilet facilities.

Population Density and Persons per Bedroom

Population density is one potential demographic variable that could explain

neighborhood differences in environmental risks. Areas with high population density

may generate higher levels of littered waste, or may have more acute problems of sullage

and drainage. Crowding can also directly impact the spread of communicable disease by

increasing the probability of exposure to infectious pathogens.

The map of population density for the Greater Accra Metropolitan Area highlights

the fact that the majority of the urban population is concentrated in urban slums like

Nima and Jamestown. Relative population densities in each neighborhood studied were

compared using the mean population density of enumeration areas in that locality as

found in the 2000 census. The table below summarizes these results. In particular, the

EA-level population densities in Nima and Jamestown are more than five times greater

37
than those of Asylum Down, and are almost fifteen-fold the densities in East Legon.

While population densities in Jamestown and Nima are nearly identical, the variation

between EAs in Nima is much greater than in Jamestown; thus, Nima’s population is

spread more heterogeneously throughout the neighborhood.

Neighborhood Number of EAs Population per hectare

Jamestown 73 671.7 (395.8)
Nima 63 671.4 (665.4)
Asylum Down 32 94.4 (80.6)
East Legon 12 45.5 (73.9)
Table 4-1: Mean population densities for EAs in each locality (standard deviations shown in
parentheses).

While population density better approximates neighborhood concentrations of

populations, the number of persons per bedroom is an indicator of crowding at the

household level. Differences in persons per bedroom are less pronounced across the

Greater Accra Metropolitan area than are differences in population density. Similarly, the

differences between the study neighborhoods are not as dramatic for this measure; while

households in Nima and Jamestown, on average, have more persons per bedroom than do

households in Asylum Down or East Legon, the differences are relatively small. Notably,

while the population density in Asylum Down is twice that of East Legon, households in

Asylum Down are less crowded than those in East Legon.

Neighborhood Persons per bedroom

Jamestown 3.25 (2.49)
Nima 3.88 (2.58)
Asylum Down 2.81 (2.13)
East Legon 3.10 (2.46)
Table 4-2: Mean number of persons per bedroom for households in each neighborhood for the 10%
household sample (standard deviations in parentheses).

38
Figure 4-11: Population density in the Greater Accra Metropolitan Area. Boxes show the
approximate locations of the study areas.

Figure 4-12: Persons per bedroom for households in the Greater Accra Metropolitan Area,
aggregated by enumeration area.

Sources of Household Water

Accra experiences problems of acute water stress due to the rapid expansion of

the city with little complementary development in the piped water supply for developing

areas. Additionally, the piping distribution system in some parts of the city is more than

39
thirty years old and thus suffers from deteriorating quality. Almost without exception,

households that I visited in Accra described some inconsistency in their supply of water.

In wealthier areas, households generally have indoor piping and store water in large,

sealed “polytanks” for when there is water outage. In poorer areas, most households use

a communal source of water—either a public tap or a tap in the yard of the household

compound—and store water in open barrels inside or outside the home.

Songsore has shown that in general, households in Accra that rely on communal

sources outside the home have, on average, higher diarrheal prevalence for children under

the age of six than do households with an indoor pipe. Similarly, households that must

store water or have interrupted water supply have significantly increased risk (4.3 and 3.1

approximate relative risk, respectively) for diarrheal diseases in children under the age of

six.35

Both the 2000 census and the 2007 household surveys conducted by Harvard

researchers show clearly differentiated patterns of water sources for households across

neighborhoods. The results from the 2000 census show that the majority of households

in Nima (n = 1534) and Jamestown (n = 917) use pipes outside their home as their main

supply of water. Households in Asylum Down (n = 439), on the other hand, generally

had an inside pipe, with a smaller minority using outside pipes. In East Legon (n = 271),

the results were mixed, with relatively similar numbers of households using outdoor and

indoor pipes. Other sources of water, such as tanker trucks, wells, boreholes, and rivers

were only used by a small fraction of the population in each neighborhood.

35

40
Figure 4-13: Water sources by EA in the Greater Accra Metropolitan Area.36

36
Note: Drinking water sources are evaluated at the household level. The following options are listed:
outside pipe, indoor pipe, tanker supply, borehole, spring/rain water, river/stream, dugout, other. For clarity,
enumeration area boundaries are not shown. The bottom frame (alternative methods) includes households
that use a source that is not pipe-borne.

41
 The results of the 2007 household surveys are quite different; this can be

attributed to a number of factors. First, this survey represents a much smaller sample of

households in each neighborhood. Second, households were asked specifically about

sources of drinking water in this survey, which is often distinguished in source from

water for other purposes such as cooking, bathing, and cleaning. Also, households were

given a broader selection of response options on this survey that included commercial

sources of water such as water sachets and bottled water. Households were allowed to

list multiple water sources on the later survey, but only one on the census. Households

may also have different conceptions of the definitions of different water sources; a tap

that is in the yard of the family compound but is shared by several households in the

vicinity may be considered by the household to be an “indoor” pipe. Finally, and

importantly, sources of water could have changed significantly in the intervening years

between the census and the survey.

Figure 4-14: Water sources in the four neighborhoods using data from the 2000 census (left) and the
2007 household surveys (right).

42
 The 2007 survey gives insight into sources of drinking water in the four

neighborhoods in particular. In Nima, households with one water source (n = 14)

primarily listed a public tap as their water source (57%), followed by water piped into the

yard (21%), and lastly water piped into the dwelling (14%). Households with two

sources (n = 7) almost without exception used a combination of water piped into the yard

and water piped into the dwelling.

In Jamestown, public taps (43%) and water piped into the yard (43%) were the

most common sources of drinking water for households with one primary source (n =

14), with a minority using water piped into the dwelling (14%). Households with two

sources (n = 7) most frequently used both sachet water and water from a piped source,

usually a public tap.

In Asylum Down, the sources used were much more varied. Of those households

using one water source (n = 11), there was a more even distribution of sources: sachet

water (36%), piped into dwelling (27%), public tap (18%), bottled water (9%) and piped

into yard (9%). For households with two sources (n = 9), all households used a

combination of sachet water and a piped source. For most multi-source households, this

second source was either piped into the yard (66%) or piped into the dwelling (22%).

East Legon displayed a very different profile of drinking water sources.

Households with only one source (n = 8) used either water piped into the dwelling (38%),

bottled water (25%), sachet water (25%), or water piped into the yard (13%).

Households with more than one source (n = 10) used, almost without exception, a

combination of sachet water and an alternative source. This alternative source was most

often water piped into the dwelling (50%) or bottled water (30%).

43
 Importantly, it appears that in some neighborhoods, particularly in Asylum Down

and Jamestown, households may supplement an existing piped source with water from

commercial sources, primarily sachet water. This phenomenon is not reflected in the

census data, both because the census does not specify water from commercial sources on

their survey, and because households cannot list multiple water sources. Thus, it is

impossible to determine from these data if the relatively common use of commercial

sources is a recent development in Accra or to discern city-wide patterns in commercial

water usage.

Household Solid Waste Disposal

Household solid waste disposal methods in Accra are both diverse and spatially

clustered. Households strategies include depositing waste at public dumpsites (61.3 % of

all households), having trash collected (20.4 %), burning trash (6.6 %), burying trash (3.0

%), and dumping trash elsewhere (5.6 %). Mapping these strategies by EA highlights

that solid waste disposal methods vary by geographic location. The more central and

densely populated slum areas (including Nima and Jamestown) generally rely on public

containers to dispose of solid waste. Areas in the central part of the municipality that are

less densely populated (including Asylum Down) are serviced primarily by private waste

collection. Areas on the periphery of the urban metropolis (East Legon), regardless of

socioeconomic status, tend to use alternative methods such as burning or burying trash.

44
45
Figure 4-15: Household methods of solid waste disposal include (clockwise from top left) disposal at
public collection sites, private collection of solid waste, illegal dumping (for example, into open
drainage gutters) and burning of household trash.

The results of the 2007 Household Surveys (Ezzati) show similarly differentiated

patterns of solid waste disposal. The majority of households surveyed in Nima and

Jamestown used public dumpsites, while all households in Asylum Down reported that

their waste was collected. East Legon demonstrated a variety of waste disposal methods

in both surveys, with the majority of households using waste collection, but with

significant minorities using all four other methods of waste disposal.

46
Figure 4-16: Household methods of solid waste disposal by EA in the Greater Accra Metropolitan
Area.37

37
Note: Solid waste disposal methods are evaluated at the household level. The following options are
listed: public dumpsite, collected, burned by household, dumped elsewhere, buried by household, or other.
For clarity, enumeration area boundaries are not shown. The bottom frame (alternative methods) includes
households that bury or burn trash, or dump their trash elsewhere.

47
Figure 4-17: Methods of solid waste disposal in the four neighborhoods, according to the 2000 census
(left) and the 2007 household surveys (right).

Notably, the percentage of households serviced by waste collection appears to

have increased substantially in East Legon during the intervening years between the two

surveys, likely due to rapidly developing infrastructure in this relatively wealthy

neighborhood. Once again the survey shows that, particularly in East Legon, multiple

methods of waste disposal are used by some households; in particular, while waste

collection is used by many households, the same households also use alternative methods

such as burning or burying trash.

Household Liquid Waste Disposal and Toilet Facilities

Household methods of liquid waste that are assessed on the census in Accra

include disposal via sewage system (12.4% of households), waste thrown on street

(16.3%), waste thrown in gutter (51.9%), waste thrown in the household compound

(16.3%), and other (0.7%). Thus, a remarkably small number of houses were serviced by

a sewage system as of 2000, and the majority of households instead rely on open gutters

48
that run alongside most city streets. These gutter systems, intended to deal with rainwater

runoff during the rainy season, feed into larger “drains” across the city that eventually

deposit their contents directly into the Atlantic Ocean.

The toilet facilities used by households also reflect this lack of sewage systems in

most of the city. Only 22.1% of houses reported using a flush toilet located in their

house, while 9.1% of households said they used a flush toilet located in another house.

Meanwhile, 32.2% of households rely on public toilets. The remaining households use

traditional pit toilets (6.1%), Kumasi Ventilated Improved Pits (11.5%), a bucket/pan

(12.4%) or have no facilities (4.0%).

A useful comparison by which to consider the effects of a city-wide sanitation

project is the case of Salvador, Brazil, a city similar in size to Accra. In 1997, an

intervention was planned for the city which aimed to increase the sewerage coverage

from 26% to 80% of households. The effects of the intervention were assessed using two

longitudinal studies of diarrheal morbidity in children under three years of age, one prior

to the intervention and one after its completion. The researchers found that diarrheal

prevalence was reduced by 21% (95% CI 18-25%), and that after adjustment for baseline

sewerage coverage and confounding variables, an overall reduction of 22% (19-26%) was

found. In areas where initial prevalence was highest, declines of more than 40% (39-

46%) in prevalence were estimated after adjustment.38

38

49
Figure 4-18: Liquid waste disposal methods by EA in the Greater Accra Metropolitan Area.39

39
Note: Liquid waste disposal methods are evaluated at the household level. The following options are
listed: sewerage system, dumped in gutter, dumped in compound, dumped in street, or other. For clarity,
enumeration area boundaries are not shown. The bottom frame (alternative methods) includes households
that dump liquid waste in the street or in their compound.

50
 Analysis of the census data indicates that construction of sewage systems in Accra

has been limited to wealthier areas of the central city such as Cantonments, Airport

Residential, and, to an extent, Asylum Down. Within the city, and particularly in poorer

areas, most households dispose of waste into open drainage gutters. Alternative methods,

such as dumping in the compound or street, are used in the peripheral areas of the city

which lack infrastructural developments such as the construction of gutters or a sewage

system.

Both the census data and the survey results reflect the prominence of dumping in

gutters as a primary method of liquid waste disposal in Accra, particularly in poorer areas

such and Nima and Jamestown. The EAs in Asylum Down where households were

sampled in the 2007 survey do not include EAs with high levels of sewer coverage,

although parts of the area do, as the census indicates, have relatively high numbers of

households connected to sewer systems. Thus, the fact that none of the households

sampled in the 2007 survey use a sewer is likely due to the small sample size in this

survey as well as the heterogeneous nature of sewer coverage in Asylum Down.

Similarly, the apparent increase in the number of households with sewer systems in East

Legon and decrease in households dumping in their compound between the 2000 census

and the 2007 survey could reflect either the infrastructural development of this area in

these years or the fact that these households represent only a small sample from a few

EAs within the locality.

51
Figure 4-19: Liquid waste disposal methods in the four neighborhoods, according to the 2000 census
(left) and the 2007 household surveys (right).

Similar to the patterns for liquid waste disposal, data from the census indicates

that toilet facilities are highly differentiated by neighborhood, with the vast majority of

households in Nima and Jamestown relying on public facilities, and more households

having access to flush facilities in Asylum Down and East Legon. The surveys conducted

in 2007 show improvements in these two neighborhoods in the percentage of households

with access to a flush toilet, particularly in East Legon, although this may be due to

limited sampling. Notably, it does not appear that any improvements have been made in

either Jamestown or Nima, where all but a small portion of households continue to rely

on public toilets or alternative facilities such as traditional pit toilets, KVIPs, and

bucket/pan systems.

52
Figure 4-20: Toilet facilities in the four neighborhoods, according to the 2000 census (left) and the
2007 household surveys (right).

53
Chapter 5: The Spatial Distribution of Littered Solid Waste

The lack of capacity for solid waste management is a common problem in

developing cities. Waste is generated in smaller quantities in the developing world when

compared to the developed world, and within developing cities poorer residents produce

less waste. Despite lower waste generation, there is often more littered waste is

developing cities, especially in poorer neighborhoods, because the infrastructure for

waste removal is limited. Poor households may have to resort to less effective

alternatives, such as burning or burying waste, or illegal dumping in public areas.

Inadequate waste removal exacerbates disease by providing breeding grounds for flies

and other pests, and littered waste also clogs drainage systems, which then act as

breeding grounds for mosquitoes that spread malaria and dengue.40 This study examines

some of the spatial patterns of littered waste in Accra, using original data collected in July

and August of 2008, described in Chapter 3. In particular, spatial techniques and a

Bayesian hierarchical model are used to estimate effects at the EA and neighborhood

level.

Inter-Neighborhood Variation in Littered Waste

Plastic waste is by far the most common form of waste found in this study. The

levels of plastic waste found within a five meter radius ranged from 0 to 350 items. The

most common form of littered plastic waste was the plastic water sachet, a common

commercial source of drinking water throughout the city. Paper and food waste were also

common. The density of plastic waste was higher in the slum areas of Nima and
40

54
Jamestown, and higher in East Legon than in Asylum Down. Littered food waste was

most common in Nima, which has a large open market, and was more common in both

slum communities than in either East Legon or Asylum Down. Similarly, paper waste

was less common in the wealthier communities. Metal waste and wood/plant waste were

more evenly distributed between the four neighborhoods (see Table X).

Table 5-3: Mean level of different waste types by neighborhood (ranges shown in parentheses).

Because of the ubiquity of littered plastic waste, it is the primary form of waste

considered in the following analysis. An additional motivation to consider the case of

plastic litter in particular detail is because its life cycle dictates that it will remain in the

environment perpetually unless otherwise removed. Many other forms of littered waste,

such as food and paper products, also pose health risks to a community, but these

products will eventually biodegrade. The use of plastic products on a large scale is also

relatively new phenomenon within the city of Accra—at least in part due to the recent use

of plastic water sachets and black plastic bags used by many market vendors to sell their

products.

55
Figure 5-21: "Sachet" water is a common commercial source of drinking water in Accra (left). The
plastic sachet then becomes a common source of littered waste (right).

The distribution of plastic waste in these neighborhoods was roughly lognormal

(right skewed). Thus, in order to do regression analysis, the variable was first log-

transformed. Because a value of zero is possible for plastic waste, the variable was

transformed as follows:

This transformed variable was then regressed against a dummy variable for

neighborhood, yielding the results presented in Figure X. Because this is a log-linear

regression (regression of a log-transformed dependant variable on an untransformed

dummy independent variable) the coefficients can be roughly interpreted as percent

change in reference to the base category (Asylum Down). Thus, both slum areas of Nima

and Jamestown have, on average, 78% and 88% more littered plastic waste than Asylum

Down, and these differences are highly significant. East Legon, on the other hand, has

roughly 28% more littered plastic waste, but this difference was not significant at the 5%

level.

56
Table 5-4: Regression of log1plastic on neighborhood.

Intra-Neighborhood Variation in Littered Waste

There was also variance in the amount of plastic waste found at different points

within each neighborhood. In order to explore possible explanations for variations in

plastic waste within each neighborhood, the littered waste data was mapped in ArcMap.

The data were then analyzed for spatial clustering, to see if any notable patterns emerged.

In particular, Moran’s I—a statistical measure of spatial clustering, or autocorrelation—

was calculated for three types of waste (plastic, food, and paper) in each neighborhood.

Values close to zero indicate that the data is most likely random. Positive spatial

autocorrelation values indicate that data are clustered in patterns unlikely to be due to

random chance; that is, if a particular collection point has high levels of waste, points

nearby are also likely to have high levels of waste, and visa-versa. Negative spatial

autocorrelation values indicate that neighboring data points are different in patterns

unlikely to be due to random chance, or that a point with high levels of waste is likely to

be surrounded by points with low levels of waste.

For plastic waste, there was significant clustering in Jamestown and Asylum

Down. Possible explanations for spatial clustering in Jamestown include high levels of

plastic waste found in the southernmost part of the neighborhood, which is along a beach

57
with an illegal dumpsite. In Asylum Down, very low levels of waste are found in the

commercial area along the Central Ring Road, where cleanup of littered waste occurs on

a daily basis. Conversely, high levels are found in the poorer central part of the area,

along the main drainage gutter. This could explain the spatial autocorrelation found in

Asylum Down. Finally, in Nima, spatial autocorrelation was detected for littered food

waste. From the map, it appears that most food waste was found either in the market area

along the main road or alongside the gutter that borders the western edge of the study

area. No neighborhoods demonstrated negative spatial autocorrelation for any waste

type. However, aside from the aforementioned exceptions, no waste types demonstrated

spatial autocorrelation in any of the other neighborhoods.

Plastic Food Paper

Jamestown 0.32*** 0.06 -0.04
Nima 0.02 0.14** 0.06
Asylum Down 0.26*** 0.06 0.05
East Legon 0.02 0.12 -0.06
Table 5-5: Moran's I values for each neighborhood for different types of littered waste. Data
demonstrating high levels of spatial autocorrelation (unlikely to be random) are marked by asterisks.

58
Figure 5-22: The spatial distribution of plastic waste in the four study areas. Only Asylum Down and
Jamestown show significant spatial autocorrelation.

59
Figure 5-23: The spatial distribution of food waste in the four study areas. Only Nima shows
significant spatial autocorrelation.

60
Figure 5-24: The spatial distribution of paper waste in the four study areas. No neighborhoods
showed significant spatial autocorrelation.

61
Analyzing Patterns of Littered Waste

It is possible that both inter- and intra- neighborhood variation in plastic waste can

be associated with demographic or other characteristics of the surrounding area, such

road surface and capacity, methods used by households for solid waste disposal or

population density. The littered waste measurements were conducted along walking

paths constructed to cover each neighborhood spatially and also to traverse a variety of

road capacities (i.e. alley, secondary and primary roads) and road surfaces (paved or dirt).

While less likely to explain differences between neighborhoods, it was hypothesized that

road capacity could possibly explain within-neighborhood variations in levels of littered

waste. Methods used for household solid waste disposal, which vary both within and

between neighborhoods (see Chapter 4), represent another mechanism that could explain

variation in littered waste, as some methods may lead to more effective collection of

waste from the neighborhoods. Another possible explanation for the differences in

littered waste within and between neighborhoods is population density. The population

density in the slum areas of Nima and Jamestown is much higher than the density in East

Legon, while Asylum Down has a medium level of population density.

GIS Analysis

In order to analyze the spatial relationships between the littered waste data and

other demographic and environmental variables such as population density, road type,

and solid waste disposal methods, an overlay of relevant datasets was created in ArcMap.

A shape file of all EAs in the Greater Accra Metropolitan Area41 was joined with a table

of relevant census data (solid waste disposal, population density) summarized by

41
Provided courtesy of Allan Hill, Harvard School of Public Health

62
enumeration area. A shape file of the road classifications along the walking path42 and

the original trash data set were also added to the same data frame.

A spatial join was then used to associate each trash data collection point with the

relevant census tract data. Thus, each point of littered waste data was associated with the

population density and the proportion of the population using a public dumpsite for solid

waste disposal for the EA in which it was located. Additionally, a spatial join was used to

associate each littered waste data point with the road type and surface at that location.

The table created from these spatial joins contains information on geographic location,

quantities of littered waste recorded, road type and surface, population density, and solid

waste disposal methods. This table was then exported for further analysis using the R

statistical computing program.43

As the littered waste data points were taken along roadsides, the data points are

often found at the intersection of multiple EAs with different population densities.

Accordingly, the census shape file was converted to a raster, with population density as

the variable. A 50 meter buffer zone was defined around each littered waste data point.

In these buffers, zonal statistics were computed to find the mean population density

within the buffer. Thus, this represents a more “smoothed” measure of population density

at the data collection point, and should address the discontinuities in the census shape

file. These smoothed population densities were then joined with the littered waste dataset

based on their location.

42
Provided courtesy of Majid Ezzati and Ari Friedman, Harvard Initiative for Global Health
43
R Development Core Team (2008). R: A language and environment for statistical computing. R
Foundation for Statistical Computing, Vienna, Austria. ISBN 3-900051-07-0, URL http://www.R-
project.org.

63
Figure 5-25: Map depicting the littered waste data collection points in Asylum Down, along with the
population density raster. The red circles represent buffer zones (50 meter radius) for which an
average population density was calculated.

Correlation with Demographic and Infrastructural Variables

In general, it appears that the proposed neighborhood characteristics do little to

explain variations in littered waste within neighborhoods. For road capacity and surface,

only the coefficient for Divided Multi-Lane was significant. However, the only road with

this classification was the Central Ring Road in Asylum Down, which had demonstrably

low quantities of trash, as explained above. Thus, the quantity of trash does not appear to

vary significantly by road type.

Table 5-6: Results for OLS regression of log1plastic on road capacity and surface.

64
 While the coefficient on population density is very small in this regression, it can

be roughly interpreted as a 23% increase in the amount of waste between the 25% and the

75% percentiles (roughly 1 person per hectare and 430 persons per hectare, respectively)

for the dataset. While the effect of population density is statistically significant,

substantial unexplained variation in plastic littered waste remains (R2 = 0.03). The

smoothed population density created little change in the results for this regression. The

coefficient can be roughly interpreted as a 32% increase in the amount of waste between

the 25% quartile (roughly 3 persons per hectare) and the 75% quartile (roughly 463

persons per hectare).

Table 5-7: OLS regressions of log1plastic on two measures of population density.

Results for the regression on the percent households using a public dumpsite as

their method of solid waste disposal showed that the amount of waste increases when a

higher percentage of the population uses public dumpsites for waste collection. The

coefficient can be roughly interpreted as a 57% increase in the amount of waste between

the 25% quartile (13% of the population using public dumpsite) and the 75% quartile

(92% using a public dumpsite). The R2 for this regression was also low (0.06). When

population density was included in this regression (results not shown), the coefficient for

public dump decreased slightly, but remained significant, while the coefficient on

65
population density was not significant. This makes sense, as these variables are highly

collinear (r = 0.67, p < 2.2e-16).

Table 5-8: Results of the OLS regression of log1plastic on the percentage of the population using a
public dumpsite for solid waste collection.

Bayesian Hierarchical Regression

There was significant variance in the amount of plastic waste found at different

points within each neighborhood. However, the hypothesized explanatory variables

occur at different levels of analysis—road surface and capacity are unique to a specific

data collection point, while the collection points are clustered within different EAs. Each

EA, in turn, has a population density and percentage using public waste collection, which

could also explain the level of plastic waste. Finally, the data collection points are

clustered within four neighborhoods.

Thus, I chose to model the data using a hierarchical (multi-level) model. This

allows for gains in efficiency (because we are pooling across a larger dataset), but less

concern for bias if the variation between clusters (in this case EAs) is large. Bayesian

methods are ideal for this analysis, because they allow for the estimation of a relatively

large set of parameters with a relatively small dataset, without any computational

shortcuts or approximations. Thus, we can completely characterize the joint distribution

of all model parameters for the hierarchical model.

The model assumes that the dependent variable is distributed normal with linear

mean:

66
Thus, there are two independent categorical variables here, road surface and road

capacity, for a total of 10 parameters to be estimated. Here, βj is the EA-level effect. We

assume further that:

There are two additional parameters to be estimated at the EA level: the

population density and the percentage of households using public waste collection. I

assumed vague normal priors on the slopes and gamma priors on precisions. Parameters

in this model were estimated using the JAGS program in conjunction with the R

statistical program. This program uses a Gibbs Sampler approach to create Markov chain

Monte Carlo (MCMC) simulations that approximate the posterior densities. The chains

were run for 50,000 iterations and traceplots were used to diagnose convergence (all

chains converged).

67
Table 5-9: Summaries of posterior densities (mean and 95% confidence interval) for important
estimated parameters.

With the exception of public collection of waste, all estimated parameters have

confidence bounds that include zero. The mean of the posterior distribution for public

collection is approximately 0.50. Because this is a log-linear regression (regression of a

log-transformed dependant variable on an untransformed dummy independent variable)

the coefficients can be roughly interpreted as percent change. Thus, the coefficient can

be roughly interpreted as a 40 % increase in the amount of waste between the 25%

quartile (13% of the population using public dumpsite) and the 75% quartile (92% using

a public dumpsite). However, all of the coefficients at the lowest level of the hierarchy,

which include road surface and capacity, have much smaller means and confidence

intervals that contain zero.

A test statistic approach was used to determine if the model adequately

characterizes the differences between the four neighborhoods. This involves estimating

replicate datasets using the posteriors of the estimated parameters. If there are additional

differences at the neighborhood level that are not explained by the model estimated, we

68
would expect that the neighborhood means for the dataset would differ substantially from

the replicate datasets. Thus, the test statistics used were the mean of the independent

variable for each of the four neighborhoods. As can be seen below, the sample means do

not differ substantially from the distributions of the test statistics for the replicate

datasets. Thus, we can conclude that there is not a need for an additional level of

hierarchy (“neighborhood effect”) in the model.

Figure 5-26: Histograms of this test statistic for replicate datasets sampled from the model. Lines in
red show the test statistics for the actual dataset.

69
Conclusions

It appears that patterns of littered plastic waste are not easily explained at a high

level of spatial resolution. While significant differences exist between the four study

areas, with much higher levels of waste in the two slum areas, patterns within each

neighborhood are harder to explain. A higher percentage of households using public

collection for solid waste management is predictive of higher levels of littered plastic

waste. This variable seems to adequately model differences between the four

neighborhoods, without the need for an additional “neighborhood effect”.

Within neighborhoods, however, these demographic variables do not adequately

explain the spatial patterns of littered waste. Road capacity and surface are also unable to

explain within-neighborhood variation. An alternative explanation is that larger

neighborhood features such as market places, drainage gutters, and major roadways can

explain clustering and variation within neighborhoods.

Chapter 6

70
Chapter 7: Liquid Waste and Roadside Drainage Gutters

This chapter includes a spatial analysis of an original dataset that considers the

characteristics of roadside drainage gutters in Accra, used indiscriminately by many

residents for the disposal of liquid wastes and other refuse.

Spatial Methods and Data Analysis

Each unit of data in this survey represents the beginning of a segment of the path

and the associated information pertaining to the gutter characteristics along that segment.

The walking paths were recorded using a GPS with sub-meter accuracy; the data were

then processed and smoothed to remove error associated with poor satellite signal when

the path was measured. The GPS coordinates collected in the gutter data have an error of

up to a few meters, and thus while the locations recorded fall quite close to the path, there

is not an exact spatial match between the gutter data and the pre-recorded path. The goal

of the data processing procedure was to associate each gutter data point with the closest

point along the path, and then to calculate the length of the path segment between gutter

data points. Because the walking paths have points of overlap and intersection, it was

also important to ensure that each point of data collection was associated with the correct

segment of the path in the correct order. To accomplish this, each walking path was

divided into two to three “analytic segments”, designed so that each segment did not

overlap itself or have any crossings. The gutter data was divided into these analytic

segments as well, so that the closest point on the path by distance could be associated

with the appropriate point on the walking path. ArcMap was then used to spatially join

71
the datasets by associating the closest point along the path with the gutter data. Thus, the

gutter data points were effectively “snapped” to the closest location along the path.

These path segments were then used to calculate the lengths of the gutters and to create

maps displaying the various gutter characteristics along the path.

Statistics in this chapter, unless otherwise noted, are expressed as the total length

of gutter displaying a given characteristic, or set of characteristics, as a percentage of the

total path length covered by gutters. Thus, if it is stated that 62.3% of gutters in

Jamestown had stagnant water, this would indicated that of the total length of path in

Jamestown with gutters, which measures approximately 4.1 km, about 2.6 km of these

classified gutters had stagnant water. It is important to note that gutter sampling was

neither random nor complete in each neighborhood, as the walking path represents only a

small subset of all roads and alleys within each neighborhood. However, the walking

paths are representative of all areas within the neighborhood—each path covers a variety

of road types within the neighborhood and traverses the entire study area.

Prevalence of Littered Waste in Open Gutters

The amount of littered waste found in the drainage gutters was estimated as a

percent coverage of the gutter, and classified in five categories: none, low (less than 10%

estimated coverage), medium (10-40% coverage), high (40-70% coverage), and clogged

(greater than 70% coverage). Overall, most gutters along the paths had low (38.5%) or

medium (28.2%) trash coverage. Fewer gutters were clogged (12.9%) or demonstrated

high levels of waste (11.8%). Only a small portion of gutters had no trash (7.5%).

72
 Stratified by neighborhood, there appears to be an association between the levels

of littered waste in open drainage gutters and the socioeconomic status of that

neighborhood. The data shows that the slum communities of Nima and Jamestown have

more gutters which are clogged or have high levels of waste (42.6% and 36.3%,

respectively). The clogged gutters in Nima were concentrated along the main road

through the market place, which is highly clogged with trash and comprises a large

portion of the walking path. Overall, East Legon had the lowest levels of waste in open

drainage gutters, with the majority (65.5%) of gutters in this neighborhood having low

levels of trash or no trash at all. Asylum Down also had a majority of gutters with low or

no trash (54.0%), but a slightly higher proportion of gutters had medium levels of trash in

this neighborhood. The results are summarized in Figure X.

Figure 6-27: Level of trash in open gutters summarized for the four neighborhoods.

73
Figure 6-28: Level of littered waste in gutters along the walking paths for the four study areas.

74
Water Quality and Flood Risk

Stagnant waters can act as a proxy measure for mosquito and other vector

breeding sites, which in turn increase the risk of diseases like malaria. It is not unusual to

find visible larvae in these stagnant gutters (see Figure X). Thus, malaria is another risk

associated with water, sanitation and hygiene, although through pathways independent

from fecal-oral contamination.

A large portion of gutters in all neighborhoods (43.0%) were characterized by

stagnant waters, with roughly equal portions having slow flow (19.4%), fast flow (17.4%)

and no water (20.1%). The proportion of gutters with stagnant waters differed across the

four neighborhoods, and was notably high in Jamestown (62.3%). Aslyum Down had the

lowest proportion of gutters with stagnant water flow (35.0%), and East Legon and Nima

had intermediate levels (39.6% and 42.6% respectively). One explanation for why Nima

had relatively few gutters with stagnant waters is due to the steep gradient on the western

side of the neighborhood; while gutters on the flat, eastern portion of the neighborhood

near the market place tended to have stagnant waters, the gutters on the steep hill near the

main drainage gutter all had relatively fast flow.

Turbidity of water is a second important characteristic. While not a direct

indicator of a health effect, turbidity provides some indication of the use of open gutters

for functions other than their intended purpose rainwater drainage from road surfaces.

Gutters with opaque waters in Accra are most frequently filled with grey, greenish, or

white waters. Thus the opacity of water in gutters can often be inferred as a sign of

households disposing of sullied water used for washing and cleaning in the gutter system.

Indeed, it is frequently possible to see women disposing of wash water directly into

75
gutters, or to see opaque waters flowing out of a household pipe directly into the gutter.

The percentage of gutters with opaque waters was considerably higher in both Jamestown

and Nima (80.9% and 87.6%, respectively) than in the wealthier communities of Asylum

Down (56.7%) or East Legon (25.9%).

Figure 6-29: Stagnant waters provide breeding grounds for mosquitoes and other pests (left).
Shallow gutter with high flood risk in Jamestown (right).

76
 Another measure considered was what I have deemed the “flood risk” for a

particular gutter. This was measured by taking the depth of water in the gutter and

normalizing by the depth of the gutter itself. This measure was intended to approximate

the risk that water in the gutter will overflow the bounds of the constructed gutter.

Because many gutters contain fecal waste due to defecation, as well as other sewage and

waste products, flooding can spread this contamination in the neighborhood and lead to

poor neighborhood hygiene.

77
 Most gutters had very low flood risk according to this measurement; however,

some gutters, particularly those found in Jamestown, were shallow and less able to

capacitate their usual water flow. The “flood risk” for a neighborhood was measured by

taking the mean of flood risks for all gutters along the walking path, weighted by the

length of each gutter. According to this simple metric, the flood risk in Jamestown is

highest (0.146), making it more than twice the flood risk calculated in Asylum Down

(0.062) and three times that in East Legon (0.048). The flood risk calculated for Nima is

also high, and is nearly twice that found in East Legon (0.084). This is perhaps due to the

shallow construction of gutters in Jamestown and Nima in comparison to the gutters of

Asylum Down and East Legon, which are more able to meet the quantities of water

deposited. However, the statistics on gutter depth in Nima and Asylum Down are skewed

by the presence of the large drainage gutters that flow through these communities, so it is

difficult to quantify and compare the overall “depth” of gutters across the communities.

Additionally, it is possible that residents of Nima and Jamestown utilize the drainage

gutters more frequently for the disposal of household liquid wastes, resulting in higher

water levels, which would exacerbate the flood risk in these communities.

Table 6-10: Summary of important characteristics of gutter water in the four neighborhoods.

78
Figure 6-30: Classification of water flow in gutters along the walking paths for the four study areas.

79
Figure 6-31: Measure of flood risk for gutters along the walking paths for the four study areas.

80
Multiple Characteristics and Comparisons

The unit of analysis thus far has been the neighborhood; however, it is useful to

consider comparisons between the different characteristics described above. Correlations

between these characteristics may be suggestive of causal relationships which, if explored

further, could lead to helpful policy suggestions. For example, if the accumulation of

trash in gutters is associated with stagnant water flow, this could indicate that the removal

of trash might act as a means of improving water flow in street side gutters. There could

be causality in the other direction as well—fast water flow may act to remove trash that

would otherwise accumulate. Ideally, comparisons would be made by estimating these

characteristics for many neighborhoods, instead of just the four considered in this study,

and then considering relationships between these characteristics for this large sampling of

neighborhoods. However, with such a limited sampling, it makes more sense to pool all

the gutter data, and consider some relationships between variables for this pooled dataset.

One obvious comparison is to consider the relationship between the level of

littered waste and water flow in the gutter; as previously discussed, stagnant water could

be caused by high levels of solid waste that clog gutters and prevent water flow. Gutters

with no water flow were excluded from this portion of the analysis. For gutters with no

trash, the proportion of fast flowing gutters is slightly higher than the proportion with

slow or stagnant flow. For low levels of waste, on the other hand, differences in water

flow were small, with a slightly higher proportion of slow and stagnant gutters. Gutters

classified as having medium trash levels had a slightly higher portion of stagnant gutters.

Notably, however, clogged gutters and gutters with high levels of trash were much more

likely to have stagnant waters than another water type; the proportion of clogged gutters

81
with stagnant waters exceeded the proportion clogged gutters with fast flow more than

ten-fold. Thus it appears that there is a correlation between higher levels of waste and

decreased water flow (stagnant and slow-flowing gutters).

Figure 6-32: Comparison of trash level to water flow for all measured gutters (pooled across
neighborhoods).

Higher levels of waste were associated with higher flood risk in gutters, measured

as the depth of water in the gutter divided by the total depth of the gutter. The flood risks

in gutters with high and clogged levels of waste (0.128 and 0.122, respectively) were

nearly three times flood risks for gutters with both no waste and low levels of waste

82
(0.045 and 0.037, respectively). Thus, there appears to be a correlation of higher trash

levels with increased flood risk. Also, increased flood risk was associated with stagnant

waters; the risk in gutters with stagnant waters was more than twice that of gutters with

fast flowing water.

Table 6-11: Flood risk of gutters with specified characteristics, namely, level of littered waste (left)
and water flow (right).

83
Chapter 8: Household Drinking Water—Source versus
Consumption

This chapter focuses on biological contamination of drinking water, that is, the

presence of organisms such as bacteria, protozoa, viruses and worms in water that is used

for direct human consumption. This biological contamination can be separated into two

categories. First, contamination can occur prior to the household water source—the tap

—as water travels from a treatment facility to the neighborhood or home. Alternatively,

contamination can occur after water is obtained from the source tap during the time when

water is transported and stored prior to consumption.

What follows is an analysis of a very limited sampling of drinking water from

households in the four study neighborhoods. It is not possible to draw rigorous

conclusions from such a small dataset, as the sampling of households was by no means

statistically random. However, the analysis does indicate differences between

neighborhoods in source type, methods of storage and hygiene behaviors, and provides

evidence that these differences can affect the quality of water consumed.

Total Coliforms and E. coli as Indicators of Biological Contamination

Total coliforms and E. coli are frequently used as indicators to compare biological

contamination of drinking water samples. Coliforms are bacteria found in soils, surface

waters, and, importantly, in the guts and feces of endothermic species, including humans.

While coliforms are generally harmless, they are an indicator of the presence of enteric

pathogens in water. As disease-causing pathogens are difficult to culture in vitro, total

coliforms can be used to more easily measure the potential risk for contracting water-

84
borne disease.44 Coliforms are also generally more resistant to disinfectants and other

water treatments such as boiling, and thus the absence of coliforms from water indicates

that that water is safe for consumption.45

Total coliform counts measure a complete count of all coliform bacteria present in

the sample, including bacteria of the genera Citrobacter, Enterobacter, Escherichia, and

Klebsiella.46 The presence of total coliforms is considered to be an indicator of potential

bacterial contamination from soils, plants or fecal matter. Water that tests positive for

total coliforms alone is not necessarily contaminated specifically by fecal sources;

however, total coliforms are a standard test for water safety, as pathogens from all of

these sources are considered unsafe for consumption. In the United States, standards for

drinking water are based on total coliform counts, and require a measure of zero total

coliforms per 100 mL water in more than 95% of samples.47

Fecal coliforms—coliforms that persist at higher temperatures, such as those

found in the human gut—and the subset Escherichia coli are more specific to fecal

contamination. Thus, presence of E. coli in water can be used as a specific indicator of

contamination from contact with human or animal wastes. The WHO standards for water

quality require no detection of E.coli in a 100mL sample.48 As noted above, most

coliforms are harmless if ingested by humans. The 0157:H7 strain of E. coli is a notable

exception and has been the subject of recent media coverage. Cases of 0157:H7 infection

are usually due to the consumption of undercooked meat, and are rarely attributed to

44
45

46

47
48

85
contaminated drinking water.49 The different classes of coliform bacteria used in water

testing are summarized in Figure X.

Figure 7-33: Classes of coliform bacteria used as indication of biological contamination in water.50

In this study, both E. coli and total coliforms are used to compare the quality and

potential health risk of drinking water samples. E. coli is used specifically to compare

the likelihood of fecal contamination. It is important to note that the absolute quantities of

these indicators do not necessarily indicate absolute differences in health risks, but are

rather a general indicator of the presence and rough magnitude of biological

contamination. Also, as mentioned in Chapter 3, the testing equipment used does not

yield reliable results when coliforms in the sample are in excess of 200 cfus. Thus,

coliform concentrations greater than 200 cfus/5mL are considered too numerous to count

(TNTC) and have been approximated in this analysis.

Commercial Sources

Overall, 16 households (27%) sampled used a commercial source of water. This

included households using either bottled or sachet water as a primary source of drinking

water. In these households, only one sample was taken, as individuals typically drink

49
50

86
water directly from the container used for sale, and thus the source sample and the

consumption sample are indistinguishable. East Legon had the highest proportion of

households using commercial sources (45%), followed by Asylum Down (36%), Nima

(36%) and Jamestown (17%).

Only two households, both in East Legon, used bottled water as a primary source

of drinking water, and both of these samples tested negative for total coliforms and E.

coli. While the precision on these tests is not enough to determine if this water passes

WHO drinking standards, it is possible to conclude that this water is less contaminated

than most other samples, and is unlikely to suffer from the large problems of

contamination that occur during storage within the home, as discussed in the next section.

The most common form of commercial water available in Accra is the plastic

sachet, discussed briefly in Chapter 5. Sachet water is a cheap alternative to bottled

water that is sold by vendors throughout the city, usually costing only US$0.04-0.05, but

is considered by urban residents to be of varied quality. Some wealthier residents told me

that they did not trust the quality of drinking water sachets because some companies will

fill sachets indiscriminately from piped sources without any tests for quality. In general,

however, the level of contamination found in sachet water samples, while it varied

considerably, was low.

Importantly, no samples of sachet water tested positive for E. coli contamination;

thus, there is no evidence of fecal contamination in these commercial sources of drinking

water. Total coliforms detected in the 5mL samples ranged from 0 to 154 cfus, with a

mean level of 12.7 cfus/5mL. Out of the 14 samples of sachet water, 6 had no total

coliforms detected, and all samples but two had less than 10 cfus/5mL. There was only

87
one sample with relatively high levels of total coliform contamination (154 cfus/5mL),

which was collected from a household in Jamestown. Thus, bottled and sachet water,

while they may not pass government standards for drinking water, are sources with

relatively little environmental or fecal contamination at the point of consumption.

Piped Water Sources

Previous studies in Accra have focused on the quality of piped water at the source,

considering only contamination that occurs in pipes between the water treatment facility

and community taps due to leaks or the presence of biofilms within the piping

infrastructure. An independent assessment of microbial contamination in taps across the

city conducted by the Public Utilities Regulatory Commission in 2006 indicated that

quality varies substantially, with total coliform counts ranging between 0 and 220

cfus/100mL, and fecal coliform counts ranging from 0 to 96 cfus/100mL.51 On the

whole, fecal contamination, while in excess of the WHO standards for drinking water,

was relatively low in comparison to the levels of contamination found in my study both at

the source and the point of consumption.

A total of 43 households sampled described their primary source of water as a

piped source. These sources included taps inside the home, pipes in the yard that are

shared by a number of households within the compound, and public taps used by many

households in the neighborhood. Although these samples were not adequately

randomized to make rigorous comparisons between neighborhoods, the sampled

households do make up a rough estimate of the types of piped sources used within each

neighborhood. Notably, the majority of residents in Jamestown and Nima use public
51

88
standpipes as their primary water source, while households in Asylum Down were more

likely to use water that was piped into the yard or compound. Most households with

piped water in East Legon had an indoor tap.

Neighborhood Total households Pipe indoors Pipe in yard Public standpipe

with piped sources
East Legon 6 3 (50%) 2 (33%) 1 (17%)
Aslyum Down 11 4 (36%) 6 (55%) 1 (9%)
Nima 11 0 (0%) 4 (36%) 7 (64%)
Jamestown 15 1 (7%) 4 (27%) 10 (67%)
Table 7-12: Piped sources used by sampled households within each neighborhood.

The level of contamination in these piped source samples was relatively low (see

Table X). Of these samples, 33 source samples detected no E. coli contamination, 8

samples had a measured contamination of 1 cfu/5mL, and 2 samples had contamination

greater than 1 cfu/5mL. The mean number of E. coli detected for all piped source

samples was 1.88 cfus/5mL. It should be noted, however, that these counts were much

higher than those found in the previous Public Utilities Regulatory Commission studies

(approximately equivalent to 0-1320 cfus/100mL).

In contrast, only 25 consumption samples from piped sources had no detected E.

coli contamination (four of these sampled households with no contamination boiled their

water prior to consumption). While 11 samples had between 1-10 cfus/5mL, 6

households had greater than 10 cfus/5mL, with one sample being denoted too numerous

to count (TNTC). The mean level of contamination for the piped consumption samples

was 6.21 cfus/5mL, but this estimate excluded the TNTC sample and is therefore an

underestimate.

89
 Source samples Consumption samples
Total 43 43
No contamination (0 cfus/5mL) 33 25
Low contamination (1 cfu/5mL) 8 3
Intermediate contamination (2-10 cfus/5mL) 1 8
High contamination (>10 cfus/5mL) 1 6
TNTC (>200 cfus/5mL) 0 1
Mean level of contamination (cfus/5mL) 1.88 6.21
Table 7-13: Comparisons of E. coli contamination in piped samples, at the source and at the point of
consumption.

Environmental contamination in consumption samples, as measured by the total

coliform count, also greatly exceeded the contamination in found in source samples (see

Table X). While the vast majority of source samples had no more than 10 cfus/5mL

(76.7%), the majority of consumption samples had counts exceeding 10 cfus/5mL

(74.4%), and a large portion of consumption samples had total coliforms exceeding 200

cfus/5mL (39.5%).

Source samples Consumption samples

Total 43 43
No contamination (0 cfus/5mL) 15 7
Low contamination (1 cfu/5mL) 7 1
Intermediate contamination (2-10 cfus/5mL) 11 4
High contamination (>10 cfus/5mL) 9 14
TNTC (>200 cfus/5mL) 1 17
Mean level of contamination (cfus/5mL) 7.50 42
Table 7-14: Comparisons of total coliforms in piped samples, at the source and at the point of
consumption.

The mean number of total coliforms in consumption samples was more than five

times greater than that found in the original source samples, but even this is a strict

underestimate of the difference in contamination. This mean does not include censored

samples denoted TNTC, and is therefore much lower than the true mean. If the total

coliform count of these TNTC samples is set to 200 cfus/5mL, which would be the

90
minimum possible number of coliforms present in the sample, the mean of total coliforms

in the consumption samples is 108.6 coliforms (nearly fifteen times greater than that

found in source samples). This is still a very biased underestimate, as many TNTC

samples have coliforms well in excess of 200 cfus/5mL.

Differences in Household Storage and Hygiene Practices

Importantly, this evidence indicates that transportation, storage, and hygiene

practices that occur after water leaves the source pipe play an in important role in the

quality of the drinking water consumed by households in Accra. When water is obtained

outside the home at a public standpipe, that water must be transported back to the

household compound and stored prior to use; contamination can occur if water is carried

in unclean or unsealed containers. Once the water reaches the household, it must be

stored until it is used, and if not properly sealed, may be contaminated by the surrounding

environment. Existing pathogens may also proliferate during storage, increasing

contamination. Alternatively, households may employ some method, such as boiling or

filtering water, that improves the quality of water before consumption. Previous studies

have demonstrated that this is the case; one study of 93 households in Lima, Peru

indicated that transportation and initial storage played the largest role in fecal

contamination of water. While all water sources used by the households tested negative

for E. coli, more than 30% of households had positive tests for E. coli at the point of

consumption.52

In Accra, existing water shortages and lack of infrastructure make water storage a

necessity for most households. Shortages in water supply do not originate from a lack of
52

91
water resources or from drought—water demand for 2020 is estimated at only 12% of

total surface waters—but rather from deficits in coverage. It is estimated that adequate

water supply exists for only 55% of the population urban areas and 51.6% in rural areas

and smaller towns (2004).53 When collecting samples for this study, households were

often visited multiple times in order to obtain a source sample, as the pipes would only

have flowing water two or three times per week. Storage time for household samples

ranged between 0-7 days, with an average storage time of 1.6 days for piped sources.

While not every household visited was storing water at the time when samples were

taken, every household described some means of storing water when pipes were not

flowing.

Storage and hygiene practices differed noticeably between neighborhoods. I

observed both the type of storage container and location of the storage container in each

household where water from a piped source was stored. Types of containers observed

included sealed bottles, polytanks (large, sealed, storage tanks), plastic barrels and metal

barrels. In all four neighborhoods, plastic barrels were the most common storage

containers, although Nima had a high percentage of households using metal barrels as

well. Use of bottles and polytanks was more common in the wealthier neighborhoods of

Asylum Down and East Legon.

Neighborhood Total households Bottle Polytank Plastic Metal

with stored water barrel barrel
East Legon 6 33% 17% 50% 0%
Aslyum Down 10 20% 10% 70% 0%
Nima 8 0% 0% 57% 43%
Jamestown 14 0% 0% 86% 14%
Table 7-15: Of households that store drinking water prior to consumption, percentages using various
containers for water storage.

53

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 There was also evidence that households of different socioeconomic status stored

drinking water in different parts of the home or compound. Once again, in the wealthier

neighborhoods, more households refrigerated their stored drinking water (these

households often separated smaller quantities of water used for drinking from water used

for bathing and other purposes). In the poorer communities, none of the sampled

households stored water in a refrigerator. The proportion of households storing water

indoors (not refrigerated) versus outdoors does not appear to be as affected by changes in

socioeconomic status.

Neighborhood Total households Stored in Stored indoors Stored outdoors

with stored water refrigerator
East Legon 6 50% 17% 33%
Aslyum Down 10 30% 60% 10%
Nima 8 0% 50% 50%
Jamestown 14 0% 43% 57%
Table 7-16: Location of the storage container within the home in each neighborhood (as a percentage
of households that store drinking water prior to consumption).

Household hygiene behaviors also differed by neighborhood. The wealthier

neighborhoods had a higher percentage of households that boiled or filtered water prior to

use, although these practices were generally uncommon in all four neighborhoods.

Washing hands prior to fetching water from the storage location was also a practice

utilized by a small number of households in the poorer neighborhoods, particularly in

households where water was stored in a barrel or bucket and retrieved with a dipping cup.

However, only a very small minority of households utilized any of these methods to

prevent or reduce contamination of drinking water.

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Neighborhood Total households with Boil water prior Filter water prior Hands
piped sources to use to use washed
East Legon 6 33% 17% 0
Aslyum Down 11 18% 0% 9%
Nima 11 0% 0% 18%
Jamestown 15 0% 0% 13%
Table 7-17: Percentage of households demonstrating particular hygiene behaviors in the household
prior to consumption from piped sources.

Differences in Contamination by Source Types

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 In this study, I use the difference between contamination in the consumption

sample and contamination in the source sample to determine any patterns in water quality

improvement (when source contamination is greater than consumption contamination)

and deterioration (when consumption contamination is greater than source

contamination) that can be attributed to household storage and hygiene practices. One

possible corollary with these differences in contamination is the source type. As

mentioned previously, transportation and storage prior to consumption play a large role in

determining the overall quality of water at the point of use. In particular, one hypothesis

is that the further the source is from the home, the greater the likelihood of contamination

prior to consumption. Insert something from the literature about the importance of

distance to the source/transportation?

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 Overall, seven households showed improvements in E. coli contamination at the

point of consumption relative to the source, that is to say, E. coli in the consumption

sample were less than E. coli found in the source sample. On average, households with

pipes found in the yard actually showed an improvement in contamination of -2.38

cfus/5mL, and only 31.3% of samples showed any deterioration in water quality. Water

piped indoors, on average, showed some further fecal contamination occurred, with a

mean increase in E. coli counts of 3.88 cfus/5mL. However, only 25% of sampled

households in this category had any increases in contamination, and 75% of households

showed no change or improvements in quality. Thus, it appears that for both water that is

piped indoors and water that is piped into the yard, further fecal contamination during

storage and transport is less of a concern. Households that bought water from a public

standpipe, however, showed, on average, an increase of 7.5 cfus/5mL, with more than

half of samples showing increases in E. coli counts between source and consumption.

Once again, this is an underestimate due to one sample being TNTC; the mean increase is

likely in excess of 17.6 cfus/5mL if this is taken into account.

Pipe indoors Pipe in yard Public standpipe

Total samples 8 16 19
Large improvement (>4 cfus/5mL) 0 (0%) 1 (6.3%) 0 (0%)
Small improvement (1-4 cfus/5mL) 2 (25%) 3 (18.8%) 1 (5.3%)
No change (0 cfus/5mL) 4 (50%) 7 (43.8%) 7 (36.8%)
Small deterioration (1-4 cfus/5mL) 1 (12.5%) 4 (25%) 4 (21.1%)
Large deterioration (>4 cfus/5mL) 1 (12.5%) 1 (6.3%) 6 (31.6%)
TNTC deterioration 0 (0%) 0 (0%) 1 (5.3%)
Mean level of contamination (cfus/5mL) 3.88 -2.38 7.5 (17.6)
Table 7-18: Difference in E. coli contamination between consumption samples and source samples for
all households with piped water sources, by source type.

Only five samples showed any decrease in the number of total coliforms between

the source and the consumption sample. Most samples (72.1%) showed a large or TNTC

96
increase in total coliforms. The total coliform increase in this study is consistent with the

hypothesis that contamination is related to distance from the source, as shown in Table X.

The overwhelming majority of samples from public standpipes (89.5%) showed increases

in excess of 10 cfus/5mL for total coliforms between source and consumption, and more

than half showed increases that were TNTC (in excess of 200 cfus/5mL). These

differences are augmented when the TNTC samples are incorporated into the average. At

minimum, water from a source in the yard had approximately twice the contamination

found in water piped into the house, and water from a standpipe contained, on average,

more than three times the number of total coliforms found in indoor piped samples.

Pipe indoors Pipe in yard Public standpipe

Total samples 8 16 19
TNTC improvement 0 (0%) 1 (6.3%) 0 (0%)
Large improvement (>10 cfus/5mL) 1 (12.5%) 1 (6.3%) 0 (0%)
Small improvement (1-10 cfus/5mL) 1 (12.5%) 1 (6.3%) 0 (0%)
No change (0 cfus/5mL) 3 (37.5%) 3 (18.8%) 2 (10.5%)
Small deterioration (1-10 cfus/5mL) 0 (0%) 0 (0%) 0 (0%)
Large deterioration (>10 cfus/5mL) 2 (25%) 5 (31.3%) 6 (31.6%)
TNTC deterioration 1 (12.5%) 5 (31.3%) 11 (57.9%)
Mean level of contamination (cfus/5mL) 19.9 (42.4) 29.5 (68.4) 56.0 (139.4)
Table 7-19: Difference in total coliform contamination between consumption samples and source
samples for all households with piped water sources, by source type.

Differences in Contamination by Storage and Hygiene Practices

It is also interesting to consider differences in contamination that might be

attributable to the specific storage and hygiene practices of the household. One example

of such practices is the location of the household’s water storage. In 6 of the 38

households that stored water, drinking water was stored in a refrigerator. Only one of

these households demonstrated any increase in E. coli between the source and the

consumption sample, and even this change was small (2 cfus/5mL). Similarly, only one

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sample had any increases in total coliform counts, although the change was large

(TNTC). Outdoor storage and indoor storage were less distinguishable in quality. While

both indoor and outdoor storage had roughly the same proportion of households that

demonstrated a deterioration in quality from source to consumption sample (52.9% and

56.7%, respectively), outdoor storage had a slightly higher mean difference in E. coli

counts.

Similarly, when considering total coliforms, households that refrigerated drinking

water had substantially lower deterioration of water quality from source to consumption

when compared with samples that were stored indoors or outdoors. Only one household

with refrigerated storage showed any increase in total coliforms, although this change

was large (TNTC). When this sample is taken into account (estimated at 200 cfus/5mL),

the mean level of contamination can be approximated at 29.6 cfus/5mL. Similar to E.

coli counts, the differences between indoor and outdoor storage were small, with an

approximate contamination of 128.3 cfus/5mL for indoor storage as compared to 124.1

cfus/5mL for outdoor storage. The vast majority of samples in both categories (88.2%

and 86.7%, respectively) had increases in total coliforms between source and

consumption that were in excess of 10 cfus/5mL.

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 Total Mean level E. coli Mean level total
Samples contamination coliform contamination
Refrigerator 6 -10.3 -4.5 (29.6)
Indoor storage (not refrigerated) 17 8.1 47.6 (128.3)
Outdoor storage (not refrigerated) 15 4.1 (17.2) 57.8 (124.1)
7-20: Mean differences in E. coli and total coliform contamination between consumption samples and
source samples for all households with piped water sources, by storage location. Numbers in
parentheses include TNTC samples by approximating TNTC counts at the minimum 200 cfus/5mL.

Similarly, the contamination that occurs between source and consumption could

vary by the type of storage container. While the large majority of samples use plastic

barrels for water storage, six households, concentrated in Asylum Down and East Legon,

use sealed plastic storage tanks—known as polytanks—or plastic bottles to store water.

These sealed containers were associated with much lower levels of deterioration during

household storage; in fact, no households that used bottles or polytanks as a storage

container had increases in E. coli counts between the source and consumption sample.

On the other hand, households using metal barrels and plastic barrels had large increases

in E. coli counts, with 80% of all households using metal barrels experiencing

deterioration in quality, and 58% of households using plastic barrels having deterioration

in quality. The mean differences between consumption and source samples are shown in

Table X.

The results for changes in total coliforms between source and consumption

samples also demonstrate that contamination varies by storage type. Once again, no

households that used plastic bottles for water storage had increases in total coliform

counts, and only one sample from a household that used a polytank had an increase in

contamination (12 cfus/5mL). Once again, households that used metal or plastic barrels

for storage had much larger increases in total coliform contamination, with all households

99
with metal barrels showing increases in excess of 10 cfus/5mL, and the majority of

households with storage in plastic barrels showing increases in total coliforms that were

TNTC.

Total Mean level E. coli Mean level total coliform

Samples contamination contamination
Plastic bottle 4 -16.5 -5.7
Polytank 2 -0.5 6.0
Metal barrel 5 4.6 121.3 (156.0)
Plastic barrel 26 6.8 (14.3) 38.8 (135.7
7-21: Mean differences in E. coli and total coliform contamination between consumption samples and
source samples for all households with piped water sources, by storage container type. Numbers in
parentheses include TNTC samples by approximating TNTC counts at the minimum 200 cfus/5mL.

Finally, household hygiene practices could explain differences in contamination

between source and consumption; however, very few households sampled used these

methods. It is notable, however, that of households that boiled or filtered water prior to

use, none had any increase in E. coli or total coliform concentration between source and

consumption. On average, households that boiled water (n = 4) showed a mean decrease

in E. coli of -16.5 cfus/5mL, and a mean decrease in total coliforms of -54.0 cfus/5mL.

Thus, boiling water seems to be an effective means of reducing coliform contamination

prior to consumption. Hand washing had no notable effect on reducing E. coli or total

coliform contamination between the source and consumption.

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Chapter 9: Discussion, Conclusions, and Suggestions for
Future Policy

Previous studies have demonstrated that environmental risks have profound

impacts on human health, particularly in the developing world. The World Health

Organization estimates that 12.2% of the burden of disease in Ghana can be attributed to

unsafe water, sanitation and hygiene.54 Thus, improving access to adequate WSH can

greatly reduce the burden of common diseases such as diarrhea and malaria. The focus of

research in this field has generally been rural areas and at the household level. However,

with rapid urbanization occurring in the developing world, it is important to consider the

particulars of these environmental risks in urban communities and to account for

neighborhood effects as well. It is also important to consider the magnitude of

discrepancies in environmental risks among subpopulations in the urban community, and

to work to rectify the disparities in access to services.

While economic and political factors are constraints to providing better

environmental conditions for the urban poor, the efforts to improve environmental

conditions are also affected by limited evidence on the intervention need. This thesis has

first and foremost shown that it is possible to systematically quantify environmental

stressors that exist in urban communities of the developing world. In particular, these

risks can be researched and assessed in resource-poor settings at relatively little cost and

without the need for an on-site research laboratory or sophisticated technology. This

thesis also serves as a body of empirical evidence that can be used to promote policies to

improve the situation in the urban slums of Accra and other cities in sub-Saharan Africa.
54

101
Summary of Specific Findings

Specifically, this thesis has considered several dimensions of environmental

inequity in Accra by focusing on four study areas in the urban metropolis of varying

socioeconomic status. I have focused primarily on the environmental risk factor of water,

sanitation, and hygiene. In Chapter 4, I presented some important contrasts in household

water supply, liquid and solid waste management, and sanitation facilities using data from

the 2000 National Census and household surveys conducted in 2007. This analysis

showed that the slum communities of Jamestown and Nima had markedly different

profiles for these different household attributes than did the wealthier communities of

Asylum Down and East Legon.

In my consideration of solid waste management in Chapter 5, I focused on plastic

waste because it is the predominant form of littered waste found in my research, and a

visible part of the neighborhood environment in many parts of Accra. Additionally,

unlike organic waste products, littered plastic waste will remain perpetually unless

collected and removed. This longer life cycle makes plastic waste a particularly good

indicator of cumulative public solid waste disposal.

The level of plastic waste found in the different neighborhoods differed

significantly between the four neighborhoods, with the slum areas of Jamestown and

Nima having higher levels of plastic waste. The percentage of households using a public

dumpsite was as a good predictor to explain intra-neighborhood differences in littered

waste. However, further analysis, either observational or experimental, would be needed

102
to determine if this predictor is relevant causally; that is, to establish that public

dumpsters are a less effective means of removing waste from these neighborhoods.

Similarly, distinct patterns among the four communities emerge when one

considers the characteristics of open drainage systems (Chapter 6). The level of littered

waste in the gutters, classified by percent coverage, is higher in Nima and Jamestown,

with the lowest levels of waste in East Legon. Nima and Jamestown also have a higher

percentage of gutters that are characterized by stagnant water flow, which is an indicator

of malaria risk. A much higher percentage of gutters in these slum communities had

turbid waters, which indicates disposal of household waste water used for cooking and

cleaning into the gutter system. Finally, these communities, particularly Jamestown, had

higher levels of “flood risk”—a measurement of the capacity of the gutter system to deal

with existing levels of water flowing through them.

While the gutter data has primarily served to explore differences between the

study areas, it is also possible to pool the data and consider patterns and correlations

between the characteristics observed. In particular, there appears to be a correlation

between the level of littered waste in gutters and water flow; gutters with high levels of

waste and clogged gutters were most often characterized by stagnant water flow.

Likewise, gutters with higher levels of waste were also characterized by higher flood risk.

Finally, gutters with stagnant waters were associated with higher flood risk when

compared to gutters with slow or fast flowing waters.

Chapter 7 considered household drinking water quality, and focused in particular

on microbial contamination that occurred between the source—the tap—and the point of

consumption. These changes demonstrate the importance of household and

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neighborhood sanitation and hygiene behaviors in determining the quality of water

consumed by residents of Accra. In particular, the magnitude of changes in

contamination that occurred during household storage greatly exceeds contamination in

the source pipes, and while contamination in the source pipes is thus relatively low, most

piped water in Accra does not meet WHO standards for drinking water.

Use of commercial sources such as water bottles and sachets appears to be one

means of reducing the risk of fecal contamination in drinking water, as none of the

commercial sources tested positive for E. coli contamination. However, this strategy

comes with its own environmental concerns relating back to solid waste management;

plastic sachets are one of the most common littered items in Accra. Similarly, households

using public taps had, on average, higher levels of E. coli and total coliform

contamination at the point of consumption, which would indicate that access to taps

closer to the household improves the quality of water consumed. Households that used

sealed storage containers such as plastic water bottles or polytanks, particularly when the

storage container was located in a refrigerator during storage, demonstrated lower levels

of contamination during storage and thus these storage practices appear to be more

effective. Finally, there is evidence that boiling water is an effective means of reducing

coliform contamination prior to consumption. Notably, the storage and hygiene practices

that led to lower levels of household contamination were most common in the wealthier

communities of East Legon and Asylum Down. There is no evidence that the hygiene

practices found in the poor communities of Nima and Jamestown, such as hand washing,

are successful in improving water quality.

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Quantifying Environmental Equity

This thesis has attempted to quantitatively compare the quality of water,

sanitation, and hygiene at the neighborhood level. Similar empirical studies on

comparative environmental risks and burden of disease in the different localities of the

Greater Accra Metropolitan Area were undertaken by the Stockholm Environment

Institute (SEI) and the University of Ghana in the 1990s. While these studies were much

more comprehensive, taking into consideration all neighborhoods within the city, my

methodology has attempted to make these comparisons more quantitative and rigorous.

Previous studies have rested on qualitative comparisons of environmental risks,

where different characteristics—proxy indicators—are rated on a point-scale for each

neighborhood. For example, “pools of stagnant water in drains”, “mounds of uncollected

waste within a community” and “frequent water supply interruptions within the

community” were among the 81 proxy indicators assessed in studies by Songsore et. al.

Each proxy indicator was considered by a panel of experts and given a maximum point

value based on their assessment of its relationship to disease burden (more important

risks were assigned higher point values). Each study community was then scored for

each proxy indicator, and relative environmental risk was calculated from the total score

of all proxy indicator values.55 According to this scale, Nima was determined to be the

most environmentally deprived residential area of Accra, and was calculated to have

approximately 4.75 times the level of environmental risk as the least deprived quintile of

residential areas.56 On this aggregate scale of environmental deprivation, Jamestown was

55
56

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classified in the second most deprived quintile, Asylum Down in the third, and East

Legon in the fourth.57

My results are consistent with these previous findings. However, I have

attempted to be more rigorous, quantitative, and specific in my approach to the study of

environmental risks. In general, the magnitude of the disparities between neighborhoods

in these measured variables (levels of littered waste, qualities of open drainage gutters,

etc) are smaller than those approximated in the methods of previous studies. None of the

environmental indicators examined demonstrated four- or five-fold differences between

the study neighborhoods. While the magnitudes of environmental inequity I have

calculated are not as staggering as those estimated previously, they clearly articulate the

need for action to rectify disparities within the urban context, and specify the targets of

such actions. Furthermore, my attempt to quantify environmental inequities has led to

the observation of differences that cannot be as easily ascribed to the subjectivity of

chosen proxy indicators and measures.

Limitations of the Study

My research was limited by both time and resource constraints in the data

collection process. It was not possible to extend the analysis beyond the four study areas

of Jamestown, Nima, Aslyum Down, and East Legon. While these neighborhoods do

vary in socioeconomic status, and thus allow for some conclusions about environmental

inequity in Accra, the conclusions of this study would be much more robust with a larger

selection of research areas. In particular, it is impossible to determine the extent to which

the patterns observed are socioeconomic, particularly when the neighborhoods also differ
57

106
in other, potentially related, characteristics (such as population density, location within

the city, and types of land use). Given that I collected this data with only a small team of

field assistants over a period of less than eight weeks, I limited myself to the four

neighborhoods with which I was most familiar.

In the case of the neighborhood-level data on littered waste and drainage gutter

quality, it would also be helpful to have data collection methods that incorporated

temporal variability. It is possible that the levels of waste and the characteristics of

gutters change over time—either short term (by day) or long term (seasonally). The data

that I have collected are thus limited to a snapshot of conditions in the neighborhood.

Also, because data were only collected in one neighborhood each day and neighborhoods

were sampled over multiple days, temporal variation could be a concern when comparing

the data at hand. However, measures were taken to limit potential temporal variation; for

example, measurements were not taken on days with unusual weather, such as days

following rainstorms, which occur only occasionally in the summer. Similarly, data

collection was undertaken at a consistently in the early morning to limit any diurnal

variation that might exist. Also, the littered waste data collection was structured so that it

was possible to check for variations between measurement days; indeed, there were no

significant differences for neighborhood-level averages for these measurement days.

Another concern was the uncertainty due to changes in the study neighborhoods

—be they demographic, environmental, or spatial—during the time between the National

Census (2000) and my own data collection (2007-2008). While both the census data and

previous environmental research in Accra indicate that conditions in the slum community

of Nima are on par, or even worse, than those in Jamestown, both the 2007 household

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surveys and my own experience on the ground indicate that environmental conditions in

Nima are superior. This is perhaps explained by the presence of community

organizations, such as the Federation of Youth Clubs, that have partnered with lawyers,

community members, and political leaders to actively campaign for improved conditions

in this neighborhood. Similarly, rapid infrastructural development and population growth

have occurred in East Legon over the past decade, which could make the data of the 2000

census less representative of the present context.

In the case of the analysis of household water quality, an obvious difficulty was

limited testing equipment and the lack of access to a laboratory in Accra. Because of this,

field testing kits were used as a substitute. However, these techniques are highly

imprecise, and as used in this study, could not detect the presence of coliforms below a

level of 20 cfus/100 mL. It was not possible to do multiple dilutions to quantify the level

of contamination in highly polluted samples. In samples where coliforms exceeded 200

cfus/5mL, and were thus denoted too numerous to count (TNTC), it would have been

preferable to run another sample to test a smaller quantity of water.

For analysis, it would have also been helpful to have a more comprehensive set of

variables at the EA-level. The census provides information on population density,

household water sources, methods of solid and liquid waste disposal, and sanitation.

However, other spatial information, such as land use and density of commercial versus

residential use might have been helpful in considering patterns of littered waste. For

example, one qualitative observation I made while conducting the survey was that areas

in front of store shops and houses tended to have lower levels of waste, perhaps due to

the fact that these areas are actively maintained by private owners who want to attract

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customers. Similarly, areas where there was no clear private ownership of the land—

such as market places, back alleys, and abandoned lands—were characterized by high

levels of littered waste. However, because no information was available on land use, it

was not possible to analyze these observations quantitatively. It might be possible to do

so in a future study, perhaps with the use of satellite data and remote sensing, which

could be used to infer land use in the study areas.

A final concern in the neighborhood sampling is the measurement error inherent

in much of the data. Although efforts were made to measure and classify characteristics

as accurately as possible, there was often room for error in classifications. Many

quantities, such as the level of littered waste in gutters or in the surrounding five-meter

radius, were estimated by eyeball. However, efforts were made in the design of the

research protocol to minimize this measurement error by specifying both methods for

performing these estimations and making classifications as specific as possible.

Lessons and Implications for Future Environmental Policy

One reaction to the numerous problems of urbanization and poverty has been to

focus on rural development; accelerating economic development in rural areas, it is

hypothesized, will raise living standards and discourage rural-to-urban migration, thus

“solving” the growing problems of the urban poor.58 What is often ignored is that

urbanization simultaneously represents a great opportunity for developing countries.

While denser populations can mean concentrated wastes and environmental risks, it is

possible, with good governance, to provide services to residents of cities at lower costs.

Concentrations of people provide economies of scale in providing clean water, disposing

58

109
solid and liquid waste, and constructing adequate storm drainage systems.59 In turn, cities

often provide a source of remittances to rural areas, and thus simultaneously improve

rural conditions.60

However, the lack of quantitative evidence on environmental risks in urban areas

impedes both advocacy and programmatic progress towards this ideal. Residents in

urban slum communities experience the reality of environmental risks every day of their

lives. Many slum residents in Nima and Jamestown expressed awareness of the

detrimental effects of poor water quality and neighborhood sanitation on their health. As

has been stated by Chidi Anselm Odinkalu: “People are acutely aware of the injustices

inflicted upon them…What they need is a movement that channels these frustrations into

articulate demands that evoke responses from the political process.”61 While any

inhabitant of Nima or Jamestown could probably describe some of the problems of water,

sanitation and hygiene in his or her community, documentation of these concerns serves

as a means to promote public policy and the implementation of projects to improve

conditions in these deprived areas. These quantifications can act as a foundation for

community organizers to elicit government funding, or for local NGOs to press for

resources from international donors. In particular, if community workers could be trained

to carry out this analysis in multiple communities, it is possible that the results could

place political pressure on governing bodies to put resources into developing

infrastructure in poor communities.

59

60
61

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 This study has also emphasized the fact that environmental inequities in the

developing world are primarily a problem of delivery, not technology. TO BE

CONTINUED.

111
Works Cited

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