When Water Doesn’t Flow


I thought it was appendicitis and feared for the worst. The car hit a few potholes and a small crater in the road. My eyes flew open and I dry heaved. ‘You’ve really done it this time, Marisa. This is it. This is where you die.’ My body was sore from several hours of vomiting. I raised my head from my lap and looked out into the pitch black night. The dirt road was lit by the moon and a single functioning headlight.

I quietly calculated the distance it would take for a life flight ambulance to come get me. Limited cell phone service and the need for immediate assistance meant that if I wanted to get better, the closest district hospital— with three doctors serving 122,000 people— was my only choice.

I was scared—scared that I might need surgery and even more scared of getting an infection after the surgery. My fears were rooted in what I had observed after three years of collecting primary data on water, sanitation, and hygiene (WASH) in healthcare facilities throughout the developing world. I had worked in the Ghanaian district hospital that I was headed to and was painfully aware of what to expect when I arrived.

In my experience, hospitals in the developing world rarely have a reliable uninterrupted source of power and a guarantee of sufficient fuel for the generator, and without power, water cannot be pumped from a water source into the hospital. Power outages are not the only thing affecting water supply. Climate change and seasonal water scarcity also impact water access and quantity within healthcare facilities in Ghana.

Why Lack of Water Matters in Healthcare Facilities

Water, as well as the availability of sanitation and hygiene infrastructure, are essential to providing safe, quality healthcare. Without water, surfaces remain unclean and medical equipment cannot be sterilized. Water shortages within healthcare facilities are particularly concerning when thinking about the water needed for surgery or in maternity units. According to the World Health Organization’s Essential Environmental Health Standards in Health Care, 100 liters of water are needed per medical intervention preformed in healthcare facilities. As an example, if one hospital in Ghana reported that 138 babies were born in one month then 13,800 liters of water would be needed to ensure safe delivery of all babies. Based on my experiences as a researcher and a patient in a rural Ghana hospital, meeting this requirement would be virtually impossible.

During my hospitalization, water did not flow through the pipes within the hospital and the donated water treatment system was not operating due to water scarcity and intermittent power in the region. The lack of water sparked a series of managerial decisions, which in turn affected patients’ access to toilets and handwashing facilities, which led to clinical staffing shortages. Without adequate water in the hospital, management locked the bathrooms within the wards and rationed water for staff handwashing.

My infirmed neighboring bedmates were told to use an open area behind the ward to relieve themselves. In a few cases, these sick patients were too weak to do so, and the floor next to their beds quickly became soiled contributing to environmental contamination. The hospital would then dispatch valuable nursing staff to a lake –located half a mile away to get water in order to clean floors. This water-fetching activity further exacerbated clinical staff shortages. Although in rural settings, open defecation or urination is the norm, in hospital settings this is not common practice. In this situation, the lack of water and locked facilities triggered an uncustomary practice that also exacerbated environmental contamination.

When water does not flow from the piped water supply within the hospital, jerry cans (the yellow containers shown) are used to collect water from a nearby lake

Managing Healthcare Facilities in Crisis through Innovation

During water shortages, hospital staff adjust their expectations of patient care and have to make choices, which often compromise health outcomes. In the US, these kinds of managerial decisions occur mostly in times of crisis, but in Ghana, they are part of the daily reality in delivering healthcare.

The development and global health community is beginning to understand WASH conditions in healthcare facilities around the world as we collect more data in these settings. However, there is still much to learn and understand. How can we as development practitioners and researchers best design interventions and advocate for healthcare facilities with water scarcity? What are the best ways for healthcare facilities to manage water when water scarcity is part of their everyday life?

Prior to my hospitalization, the Center for Global Safe WASH created WASHCon, a real-time mobile monitoring tool that evaluates WASH conditions within healthcare facilities globally. One of the many features of this tool is that it reports water supply and water quality as well as WASH infrastructure. My experience as a patient at the district hospital helped my colleagues expand the WASHCon Tool, to track the availability and utility of functioning toilets, who has access to them, and whether the facilities are locked. This new tool has now collected data from 170 facilities in four countries.

Lindsay Denny trains staff in Zambia on data collection for the WASHCon Tool

Constance Bwire collects water quality samples for the WASHCon evaluation in Uganda

James Michiel (center), with colleagues Alien Mathews Mnyimbiri (left) and Daniel Nyirenda (right) of The Church of Central Africa Presbyterian, show off a WASHCon data dashboard in Lilongwe, Malawi.

As the WASH community works in partnership with development practitioners, global health researchers, and the private sector to reach Sustainable Development Goal 6 (SDG 6), “achieve[ing] access to adequate and equitable sanitation and hygiene for all and end open defecation” by 2030, it is imperative that more data be collected on WASH conditions in hospitals. Unsanitary conditions as well as locked toilets and handwashing facilities caused by the lack of water present is a threat to health, as disease can easily spread in unclean environments. As we strive to achieve SDG 6, it remains critical to continue collecting data to shed light on the problem and to drive advocacy for improved environmental conditions in healthcare facilities (HCF) with the ultimate goal of affecting national policy change.

My diagnosis was typhoid fever, not appendicitis. While the electricity remained intermittent and the water did not always flow from the pipes, the staff at the district hospital went above and beyond to provide excellent care that resulted in a full recovery. I was lucky, but many with my diagnosis treated in similar conditions are not so fortunate. The risk of substandard care and acquiring a secondary infection due to poor WASH conditions is very high. As a WASH and global health community, we must recognize and act on the reality that we cannot provide excellent health care without improving WASH conditions.

Marisa Gallegos receiving treatment in a Ghanaian hospital

Marisa Gallegos is a Senior Public Health Program Manager at Emory University’s Center for Global Safe Water, Sanitation, and Hygiene (CGSW). Researchers from the CGSW have been investigating the conditions of healthcare facilities in resource-limited countries and collecting primary data to inform interventions to improve access to safe drinking water. Marisa and her colleagues have spent the last four years testing water quality and assessing the sustainability of donated water treatment systems in healthcare facilities in five countries. Hospitalized in a health facility in Ghana for suspected appendicitis, she learned that while clean water is the gold standard in delivering patient care, limited access to an improved water source and seasonal water scarcity dictates water usage and availability for vulnerable populations within healthcare settings.

For more information, Marisa can be reached at marisa.n.gallegos@emory.edu.

This article was originally posted a PLOS.org.