What does a COVID-19 response look like with limited water?

NAIROBI — As the World Health Organization echoes some of its key advice around preventing the spread of COVID-19 — washing hands regularly or using an alcohol-based rub — many are wondering what this means for people around the world with limited access to water.

In the past week, the virus has spread exponentially, beginning to take root in countries with weaker health systems — and where populations have limited access to water. Globally, 3 billion people lack access to basic hand-washing facilities.  

The COVID-19 pandemic presents a particular challenge for those working in the water, sanitation, and hygiene sector. While much of what is needed in the response includes programming the sector already has in place, there is also a need for WASH professionals to re-envision their strategies — and to do it quickly.

Dense populations, limited water

People living in densely populated settings — including urban areas, refugee, and internally displaced people camps, and prisons — are especially vulnerable, say WASH experts. According to Anjali Mahendra, director of research at the World Resources Institute Ross Center For Sustainable Cities, in many of these places, people rely on community facilities, such as shared water points and communal toilets, and are dependent on private vendors and tanker trucks rather than water piped in from a water utility.

Even when there is access to water, it is often intermittent and only available a few hours per day, Mahendra said.

“How does the hand-washing standard, with the need this pandemic requires, get fulfilled in a context like this?” she asked.

Organizations, companies, and donors are already working to help fill these gaps. In response to a growing number of COVID-19 cases in Kenya, Shining Hope for Communities recently set up hand-washing stations in the informal settlement of Kibera.

The Kenya Red Cross Society is educating communities on hand-washing in rural areas, prisons, and those using ferries. Living Water International is giving pastors and other community leaders in East Africa toolkits to educate their congregations and communities on hand-washing.

Alight is setting up hand-washing stations around refugee camps and offering soap to households. It is also using children as “change agents” — including teaching them songs on handwashing.

U.K. aid and Unilever launched a £100 million ($122 million) campaign Thursday to target 1 billion people globally in hand-washing campaigns and distribution of hygiene products, including soap. 

According to WASH experts, in settings like these, there is also a need for a mindset shift on what is necessary to practice safe hygiene.

“The research shows that we can have hand-washing with a limited amount of water,” said Laure Anquez, WASH specialist for emergencies at UNICEF. “It's encouraged to have more regular hand-washing, rather than long hand-washing, throughout the day.”

In many places, there is also limited access to soap. According to Bruce Gordon, head of WASH at WHO, in these cases, solutions that are not regularly recommended, are possible. This includes chlorinated water, which WHO does not typically recommend because it can lead to dermatitis after many hand-washes, as well as washing hands with ash and clay in lieu of soap. Even washing hands with water and no soap is better than nothing, Gordon explained.

“Water also doesn't need to be a perfect quality to wash your hands,” he said. “I think the message is, unless [contamination is] extreme, to go ahead and use it to wash your hands,” he said, adding that rainwater harvesting can help supplement water stocks.

Speed and water access in public places

Given the rate the disease is spreading, there is a need to act quickly, which means not implementing new programming that could cause delays, Anquez said.

“Speed is very important for this response,” she said.

Because of this, UNICEF is encouraging partners to tweak existing programming, activities, and partnerships to work for the COVID-19 response.

Many African countries have shown positive examples of scaling up this type of programming quickly, Gordon said.

“I have been pleasantly surprised in the past to see how quickly things can change on the hygiene front,” he said.

While often WASH works separately from the health sector, there is now a need for these activities to be considered an essential public health intervention, Gordon said. This includes putting hand-washing stations outside of public buildings.

Controlling the virus in health care facilities is key, Anquez said, where around one in six facilities lack access to hygiene services. Health care workers should follow existing infection, prevention, and control standards, and governments and organizations must work to increase access to hygiene services in such facilities, she said. It is also important to ensure there is access to handwashing in schools.

In March, WHO and UNICEF published a technical brief with detailed advice for those in the WASH sector — in areas such as management of health care waste, managing wastewater, and keeping water supplies safe.  

Technical capacity and health of WASH workers

There are also questions around technical capacity. Travel restrictions limit the ability of organizations to send experts to countries struggling to control the virus, Anquez said.

“There's clearly a question of capacity that is worrying,” she said. “We need to use expertise that's already on the ground and to use them as much as possible.”

In terms of the health of WASH workers, some of the most vulnerable will include cleaners in health care facilities, staff supporting vulnerable communities, as well as those removing bodies after death, Anquez said.

“We can't afford to have WASH professionals sick in large numbers — that would really have a direct impact on access to WASH services,” Anquez said.

Avoiding community meetings, going digital

Existing ways of accessing communities may not be feasible during the COVID-19 pandemic because of the emphasis on social distancing to prevent the spread of the virus.

WaterAid, for example, previously held community events on hygiene behavior change. In Niger, it promoted hygiene messaging during the opening ceremonies of wrestling matches.

"We need to emphasize the importance of not conducting any community events to promote hygiene so that we are not increasing the likelihood of exposure," said Helen Hamilton, senior policy analyst of health and hygiene at WaterAid UK.

Reaching more communities through digital and other social media platforms will be necessary, according to WASH experts.

“Because people are quarantined and in lockdown in their homes, we are seeing digital engagement, more than ever, as not just a communication strategy, but also part of the response itself to help support behavior change,” said Kelly Ann Naylor, associate director of WASH at UNICEF.

WHO is trying to tap into this through the “safe hand challenge” where it encourages people to upload videos of themselves properly washing their hands on social media. Celebrities such as Selena Gomez have participated.

Radio messaging can also be a powerful tool, Hamilton said.

“People need multiple opportunities to be reached by this messaging,” she said, adding that messages around safe hygiene need to be accessible through local languages and in different mediums — for people who might have trouble reading or hearing.

Long-term pressure on water utilities

Organizations like UNICEF are also concerned about how secondary effects of the crisis — such as disruptions to supply chains, fuel shortages, and a financial crisis — could hinder the availability of WASH services, Naylor said.

There are already concerns about supplies, such as soap, stocking out at local markets, Naylor said. But there are also other potential, longer-term issues.  

“What we see as a growing concern, especially with the duration of the crisis, is that we will start to see pressure on the ability of water utilities to provide water and sanitation services,” she said. Water utilities could become strapped for cash if they are not able to recover costs through tariffs, making them unable to pay for water treatment chemicals or water quality testing.

There could also be fuel shortages, which could interrupt water pumping, causing taps to run dry or create a need for water rationing, Naylor said.

According to Anquez, UNICEF is talking with local governments and the private sector about strategies for continuing access to water throughout the crisis, including connecting households to water supplies and subsidizing services.