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The Impact of Densification by Means of Informal Shacks in the Backyards of Low-Cost Houses on the Environment and Service Delivery in Cape Town, South Africa

The Impact of Densification by Means of Informal Shacks in the Backyards of Low-Cost Houses on... Environmental Health Insights Open Access Full open access to this and thousands of other papers at O RI G I NA L RE S E A RCH http://www.la-press.com. The Impact of Densification by Means of Informal Shacks in the Backyards of Low-Cost Houses on the Environment and Service Delivery in Cape Town, South Africa 1 2 2 Thashlin Govender , Jo M. Barnes and Clarissa H. Pieper Division of Community Health, Department of Interdisciplinary Health Sciences, Faculty of Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa. Division of Neonatal Medicine, School of Child and Adolescent Health, University of Cape Town and Groote Schuur Hospital, Observatory, Cape Town, South Africa. Corresponding author email: [email protected] Abstract: This paper investigates the state-sponsored low cost housing provided to previously disadvantaged communities in the City of Cape Town. The strain imposed on municipal services by informal densification of unofficial backyard shacks was found to create unintended public health risks. Four subsidized low-cost housing communities were selected within the City of Cape Town in this cross-sectional survey. Data was obtained from 1080 persons with a response rate of 100%. Illegal electrical connections to backyard shacks that are made of flimsy materials posed increased fire risks. A high proportion of main house owners did not pay for water but sold water to backyard dwellers. The design of state-subsidised houses and the unplanned housing in the backyard added enormous pressure on the existing municipal infrastructure and the environment. Municipal water and sewerage systems and solid waste disposal cannot cope with the increased population density and poor sanitation behaviour of the inhabitants of these settlements. The low-cost housing program in South Africa requires improved management and prudent policies to cope with the densification of state-funded low-cost housing settlements. Keywords: low-cost houses, backyard dwellings, service delivery, public health, environment, sanitation, diarrhoeal disease Environmental Health Insights 2011:5 23–52 doi: 10.4137/EHI.S7112 This article is available from http://www.la-press.com. © the author(s), publisher and licensee Libertas Academica Ltd. This is an open access article. Unrestricted non-commercial use is permitted provided the original work is properly cited. Environmental Health Insights 2011:5 23 Govender et al Introduction Housing and its relationship to health has long been one of the core areas of public health research. Housing affects health through a range of factors, acting directly or indirectly at different levels. The assump- tion that provision of improved housing to previously disadvantaged urban slum dwellers may improve their health is still being debated. This premise however forms one of the six principles of the state-funded low- cost housing scheme in South Africa, referred to as the Breaking New Ground initiative, formerly known as the Reconstruction and Development Programme. The exact association between housing and the Figure 2. An example of a low-cost house in Tafelsig. maintenance of health and well-being remain elusive. It is intuitively accepted that affordable housing that is in the deterioration of living conditions and the sur- appropriate for environmental and social conditions; 8–11 rounding environment. In theory, living in urban will protect people from hazards and will promote areas potentially offers improved access to health good health and wellbeing, but definitive proof has care, education, better housing and improved eco- not been published. Deficient housing on the other nomic opportunities. In reality however, the growth hand could compromise basic human needs such as of urban slum areas in developing countries brought water, sanitation, safe food preparation and storage as about an increase in poverty as many poor, often illit- well as assisting in the rapid spread of communicable erate and unskilled people leave rural areas to try and and food borne diseases. According to the World find employment in cities. Health Organisation (WHO), the developing world A consequence of the housing backlog in South records 98% of deaths resulting from unsafe water, Africa is that nearly one-fifth of households live in sanitation and hygiene. The WHO report identified informal dwellings and in response to this need, there infectious diarrhoea as the largest single contributor had been a large roll-out of government-sponsored to ill health associated with water, hygiene and sani- low-cost housing. The South African housing policy tation inadequacies. is centered around the provision of fully state-funded In South Africa, like in Mexico, the accelerated home-ownership for the poor and seeks to eradi- migration of indigent rural people into urban areas cate informal housing, including backyard shacks. caused informal settlements to grow beyond the coping capacity of city infrastructure. This resulted Figure 1. Adjoining shacks in the Greenfields settlement obscuring Figure 3. Dampness penetrating bedroom wall with infant sleeping on municipal reticulation systems. bed in a low-cost house in Greenfields. 24 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Figure 6. Flushing mechanism on this toilet is broken in a house in Masipumelela. Users flush toilet by manually manipulating the mecha- Figure 4. An example of structural damage: a seriously cracked wall of nism inside the system. Note that the toilet is dirty. main house in Tafelsig. The new owners of such subsidized houses acquired erecting informal or makeshift dwellings in their their houses for free, but the improvement in their backyard which were constructed from inadequate living conditions in most cases was not accompanied building materials (eg, corrugated iron sheets, wood by an improvement in their financial status. Most of and cardboard). Most of these informal dwellings these inhabitants remained unemployed or with inse- are used for rental by other poorly housed families. cure or intermittent employment. Backyard dwellings in such formal housing com- The new home owners soon exploited one of the munities caused the slum conditions of their for- 11,12 few resources at their disposal, namely space, by mer existence to follow them. These informal Figure 5. Tap against the wall on right is either lost or removed. Note the Figure 7. An example of a kitchen area in Greenfields. Note the rudi- broken pipe and cistern, as well as the broken window which has been mentary facilities and dirty wall. This is the only working tap in the main repaired with cardboard in Masipumelela. house. Environmental Health Insights 2011:5 25 Govender et al the facilities provided to previously disadvantages communities and the strain posed on municipal ser- vices by densified low cost housing communities in the City of Cape Town, thereby creating unintended public health risks. Methods This study was approved by the Committee for Human Research at the Faculty of Health Sciences of Stellenbosch University and was conducted accord- ing to the ethical guidelines and principles of the International Declaration of Helsinki, the South African Guidelines for Good Clinical Practice and Figure 8. Solid waste blocking the storm water inlet on street causing the Ethical Guidelines for Research of the Medical subsequent flooding during rain storms in Greenfields. Research Council of South Africa. All respondents were informed of the objective of the study in their dwellings (called shacks by the inhabitants) have home language (English, Afrikaans or isiXhosa) and no sanitation, water, electricity and waste disposal signed informed consent. A copy of the informed facilities. The subsequent overcrowding and failures consent was provided to all participating households. of the existing sanitation infrastructure causes severe The survey was conducted anonymously. All par- pressure on municipal services with accompanying ticipants could inspect the completed questionnaire environmental pollution. This paper investigates answer sheet for anonymity. They then posted the form into a sealed box with a postal slot. The box was only unsealed at the end of the study. Four subsidized housing communities were selected within the City of Cape Town Metropole (CCTM) to participate in this cross-sectional survey. The govern- ment subsidized low-cost housing communities iden- tie fi d as study sites were: Driftsands, Greene fi lds, Masipumelela and Tafelsig. These sites were selected to represent the best spatial coverage of all the subsi- dized housing settlements within the city. The settle- ments were selected regardless of the local or central authority under whose jurisdiction the housing schemes were originally erected. They had to be older than three years. This was important because in some of the newer settlements structural wear and tear of the houses had not yet become evident to the same extent as in the older settlements. The settlements selected had to have distinct boundaries that did not blend into informal set- tlement areas (so-called squatter settlements) in order to avoid infection pressure in the form of garbage and water pollution introduced from neighbouring areas. All four settlements had numerous low-cost houses (referred to as main house from this point forward) with informal dwellings made of temporary building Figure 9. Waste water running down the street in Greenfields. The materials in the back yard (referred to as shacks by the woman doing her washing on the side walk is adding to the polluted water stream. inhabitants and so called in this paper). 26 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements A legacy of the previous spatial disparities in the and these interviews were carried out under the same City resulted in communities with predominantly only conditions as the main study. The data from the dwell- one ethnic group. There were three settlements with ings in these pilot sites were therefore included in the predominantly black inhabitants and one settlement total group, ie, 1080 participants living in 336 dwell- with predominantly coloured (mixed ancestry) inhab- ings (173 main houses and 163 shacks). itants. This selection was representative of the overall The questionnaire was designed to record data demographic profile of the settlements in the city. No from all dwellings on a plot. These questionnaires questions or annotations on race were included in the were available in all three languages and adminis- questionnaire. tered in the language of preference during an on- The sampling strategy was based on a systematic site interview with the head of the household. The sampling technique with random starting points so as questionnaire comprised sections on demographic, to cover the entire community in a non-biased and health and home ownership as well as a section to representative sample. This sampling strategy is a note the condition of the dwelling and its surround- probabilistic sampling technique when spatial ran- ing yard. The inspection of the dwelling and yard domness is required. It comprises a selection of ele- concentrated on the sanitation infrastructure and ments from an ‘ordered list’ (such as a street plan) in condition of the premises. The toilet was classified a specific way. A random starting point (plot number) as non-operational when one of the following was is selected eg, along every street and pathway in the noted: toilet blocked, could not flush, had serious community and in the case of the present study every leaks or had a severely cracked cistern or bowl. The 10th dwelling after that was selected to participate in sanitary condition of the yard was classified as poor the study. when one or more of the following was noted: pres- Data were collected by means of structured inter- ence of broken glass, solid waste, excreta, puddles view questionnaires during home visits to all selected of dirty water, overflowing waste bins, overflowing dwellings by the senior author, assisted by a quali- or dirty drains. fied registered nurse who spoke all three languages Demographic and socio-economic variables prevalent in the area. All dwellings on a selected plot included age, gender, physical challenges, educational (main house and informal dwellings in the back yard) attainment, citizenship, social grant recipients, were included but recorded separately. Overall, 321 employment status and household monthly income. dwellings on 165 plots were selected for participation The household monthly income was arrived at by in the study. A systematic randomized sampling pro- adding the income of all employed members of the cedure was used to select the plots in the four study dwelling. Health variables included HIV and TB sites. Data were obtained from 1020 persons in total status, as well as ailments suffered in the preceding with a response rate of 100%. All households elegible two weeks of the survey. Respondents were given for inclusion into the study by the sampling strategy an option of disclosing their HIV and TB status. All participated and no one in any of the selected dwell- medication in the dwelling that was issued by the ings refused to provide data. The field work for this clinic was inspected and the reported diagnoses veri- study was conducted over a period of 16 days and fied from that. interviews took a median time of 40 minutes per A fully qualified community health nursing sister household. administered a questionnaire (available in three lan- The questionnaires were piloted in two different guages) regarding various aspects of health, including settlements (predominantly coloured and predomi- 20 questions on symptoms relating to sanitation and nantly black) in the CCTM. The pilot study sites were waterborne diseases. When respondents reported that situated in Mfuleni and Westbank and four plots were they were on medication (either acute or chronic), randomly selected from each of the sites. From these the nurse asked to see the medication and confirmed eight plots the survey was administered to 15 dwellings the illness by cross-checking the reported illness with with data obtained from 60 persons. The results from the prescribed medication. Only the illnesses con- the pilot sites met the same criteria as the study sites. firmed by prescription medication from the clinic No problems or confusing questions were encountered were entered into the study data base. This was done Environmental Health Insights 2011:5 27 Govender et al Results in order to enter only verifiable illnesses into the study. This was necessitated by inaccurate reporting Income and education status of illnesses by respondents due to the poor under- Significantly more of the occupants of the shacks were standing of disease in general and specific symptoms employed than the occupants of the main houses (χ in particular in these communities mainly as a result test, P = 0.0000). Almost 42% of households in the total of low levels of education. group had a combined household income per month of Data were recorded in a database created in less than R1200 (about US$160). The reported incomes Statistica version 9.0 (StatSoft Inc. 2009, USA). of the inhabitants of the main houses were statistically Descriptive statistics mainly means and standard signic fi antly lower than those of the occupants of the deviations for continuous variables and frequency shacks (Mann-Whitney U-test, P , 0.01). Approxi- distributions for categorical variables were com- mately 28% of main households and 20% backyard puted. Bivariate analysis testing for differences shack dwellers received a government social grant in proportions of low-cost housing and backyard (Table 1). The occupants of the shacks had a signifi- shacks were performed using the test for probability cantly higher education status that the occupants of the values. main houses (Mann-Whitney U-test, P = 0.01). Table 1. Sociodemographic characteristics of the study population. Characteristic Main house % % Total group % P-value Shack (n = 163 (n = 173 dwellings) (n = 336 dwellings) dwellings) Study population 710 66 370 34 1080 100 Gender Male 322 64 184 36 506 47 0.17 Female 388 68 186 32 574 53 Disabled individuals 18 90 2 10 20 2 ,0.01 Nationality South African 695 68 329 32 1024 95 ,0.01 Non-South African 18 32 38 68 56 5 Highest education level No schooling 103 59 73 41 176 16 0.01 Grade 0–4 152 83 32 17 184 17 Grade 5–7 154 70 65 30 219 20 Grade 8–10 138 61 90 39 228 21 Grade 9–12 158 61 100 39 258 24 Tertiary level 5 33 10 67 15 1 Employment status Full time employed 122 62 76 38 198 18 ,0.01 Part time employed 8 20 33 80 41 4 Irregular employed 50 61 32 39 82 8 Unemployed 210 65 112 35 322 30 Pensioner 14 52 13 48 27 3 Child at home 104 61 66 39 170 16 Scholar 202 84 38 16 240 22 Household monthly income 25 48 27 52 52 15 ,R600 per month ,0.01 R600-R1200 29 33 59 67 88 26 per month R1200-R2500 58 53 52 47 110 33 per month .R2500 per month 23 28 60 72 83 25 Unsure 1 33 2 67 3 1 Households receiving 93 58 66 42 159 48 ,0.01 a social grant 28 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements by the seven houses for a month). A total of 66% of Housing infrastructure backyard dwellers pay the landlord between R20 and All of the main houses have been equipped with a R100 per month for water, in spite of the City provid- flush toilet, either inside or outside the house. In all ing the first 6000 litres of water for free each month to cases backyard dwellers were allowed to use the toilet all households. The 97 backyard shack dwellers paid on the property. If however the toilet inside the home R6080 (about US$811) in total per month to landlords was not available, then the neighbour’s toilet may be who themselves did not pay for this water. Backyard used or any receptacle that could act as a chamber pot inhabitants fetched water from the main house and was used. The contents of such receptacles were often stored the water in a bucket in the shack. disposed of in the storm water drain. On the day of the home visit, 58% of toilets were found to be non- operational (Table 2). Waste disposal The main houses were in a state of disrepair The disposal of household waste was unsatisfactory. (Table 2). The majority of the houses had cracked The sanitary state of the yard outside the dwelling was walls and/or visibly leaking roofs (walls streaked classified as poor in 76% of the premises inspected. with previous leak damage). About half of the houses In 68% of cases there was no waste bin inside the had unpainted walls, allowing wind-driven rain to dwelling. Household disposal of sewage from cham- seep through. A common occurrence was the use of ber pots and soiled baby diapers was inappropriate in softened bar soap to fill holes in leaking roofs. Some 21% of cases (mainly into the storm water drain and households had reported the structural problems in the street). In addition, 22% of households disposed (Table 2) to the City Council, but stated that they of their solid refuse on the street. Fifteen percent of eventually “fixed the problem themselves or learnt respondents said that nothing will happen if rubbish to live with it.” This was fruitless as Council does is thrown into the toilet. not own these structures and could not be expected to All of the respondents in the survey complained maintain them. of pests carrying potential health risks within their immediate home environment. The respondents from all four communities reported their most prominent Electricity and water services pest problem was rats by 50%, cockroaches by 30%, All of the main houses had an operational prepaid elec- fleas by 16% and flies by 4%. Flies were observed in tricity connection. Backyard dwellings created illegal all homes, indicating the presence of flies were under- connections from the main house, and paid between reported. R50 to R200 per month for electricity usage. Of the Only one of the four sites had access to a drain lead- main houses interviewed in the survey, only seven (4%) ing to the sewerage system for the disposal of grey water of the 173 houses timeously paid the local municipal- (Table 3). Storm water drains were mostly used by fam- ity for water usage (approximately R500 paid in total ilies who lived in close proximity to such an opening in the kerb, while others preferred to use the toilet or Table 2. Distribution of observations of poor condition of open ground as disposal points. The storm water vol- low-cost (main) houses. ume generated in built-up areas is related to the extent Observation Number % of the hardened surfaces in those areas. The total roof (n = 173) Outside walls not painted 82 47 Table 3. The percentage of dwellings who dispose of Inside walls not painted 88 51 household waste water inappropriately (n = 336). Cracked walls 117 68 Door not well fitted 103 60 Waste water Open Toilet Storm-water Broken windows 60 35 source land drain Toilet not operational 101 58 Toilet leaking 69 40 Bathing/washing 14.9 41.7 4.5 Tap leaking 63 36 Kitchen* 23.2 20.2 2.7 Roof leaking 136 79 Laundry 13.1 47.9 1.5 Structural damage 11 6 notes: *Includes waste water from food preparation, dishes and cleaning. Environmental Health Insights 2011:5 29 Govender et al area for main houses was 5550 m while for backyard Driftsands community used other healthcare facili- dwellings the total roof area was 1587 m . Therefore the ties in neighbouring communities. Of the 400 signs shacks added an extra 29% of roof area with resultant and symptoms of illness reported by the participants, increase in stormwater during rain events. The inhabit- only 35% (140 symptoms) were treated by visiting ants reported frequent flooding in the settlements. the local clinic (Table 6). Sixty percent of the participants walked to Health profile their primary health care clinic, while 39% used a Over the two weeks preceding the survey 38% of ‘communal taxi’ and one percent utilized private dwellings reported one or more persons suffering transport. The amount paid for a return trip per person from diarrhoea (Table 4). to a health care facility varied from R5.00 to R35.00 Five percent of the participants willingly disclosed (about US$1–$5). This was a significant amount of that they were HIV positive, while 11% reported that the total household earnings as the mean reported they were TB positive, one of whom reported being total monthly income per household was R1353 diagnosed with Multiple Drug Resistant (MDR) TB. (about US$180). The cost of transport mounted con- None of those who reported suffering from TB or who siderably for those on chronic medication who had were HIV positive had any medication for their condi- to visit the clinic regularly. Thirty-five percent of the tion in the dwelling. Furthermore, none of the TB or households reported that there had been one or more HIV infected individuals had visited the clinic in the pre- occasions during the preceding year when a family ceding two months. The use of chronic medication was member needed to visit a clinic, but did not have reported by 165 (15%) respondents. In many instances, money to pay for transport. A large percentage (71%) respondents did not know what disease the medication of the households were not satisfied with the services was intended for. The five most common diseases diag- provided by the clinic and 86% thought that private nosed at the clinic and reported by the respondents are health care facilities would offer better services than summarised in Table 5. Of the main houses, 51% had a state clinic. one or more inhabitants who smoked, while 49% of the shack dwellings had one or more smokers (Table 5). Discussion Despite commendable efforts, the housing backlog for Primary health care services South Africa’s urban poor has grown from 1.5 million Three of the four low cost housing communities units in 1994 to about 2.1 million in 2010, according had access to a state clinic in their community. The to the Minister of Human Settlements. Taking into account the pace of delivery and the resources avail- able, as well as continued economic and population Table 4. Gender and age group of reported cases of growth and the rapid pace of urbanisation, it could diarrhea. take decades to beat the backlog. Number of cases % (n = 153) Income and education status Dwelling type The economic implications of the creation of shacks Main house 70 40 for subletting can be seen not only in the direct rent Shack 38 23 charged but also the water that was sold to back- Gender Male 74 48 yard dwellers. Only 4% of formal home owners paid Female 79 52 the municipality for their water usage, but all sold Age water to the back yard dwellers. The amount of rent 50 33 ,10 charged was not exorbitant and constituted a basic 11–20 23 15 service rendered rather than an exploitative one. 21–30 38 25 Very few of the dwellers living in the shacks were 31–40 26 17 41–50 10 7 relatives of the dwellers in the main house. These 51–60 3 2 shacks are rented out for income and/or to relieve 3 2 the pressing housing need in the city. The situation 30 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Table 5. Five most frequent illnesses diagnosed at a clinic* and treated by medication as reported by participants, differentiated by housing type. Diagnoses Main house Shack dwellers P-value reported occupants (n = 710) (n = 370) (Chi-square test) Number % Number % Hypertension* 42 5.9 9 2.4 0.01 Asthma* 32 4.5 17 4.6 0.95 Diabetes* 28 3.9 7 1.9 0.07 Arthritis* 25 3.5 2 0.5 ,0.01 Epilepsy* 7 1.0 4 1.1 0.88 Substance use 89 53 80 47 0.66 Smoke cigarettes 106 49 110 51 0.23 Consume alcohol 23 56 18 44 0.03 Use drugs 89 53 80 47 0.66 notes: *These diagnoses were verified by inspecting the medication issued by the clinic in each home; The nature of the drugs were not explored. therefore represents predominantly a landlord-renter their new home. This lack of knowing how to keep relationship. their homes clean and how to fix broken infrastructure Contrary to common belief, the present survey were strongly verbally communicated by the respon- found that backyard dwellers were better educated dents. In addition, their acquisition of an improved and had a higher employment rate and income when home was not accompanied by an improvement in compared with the inhabitants of the main houses. employment status and that resulted in many being Backyard dwellers have to seek employment and unable to afford the repairs or the cleaning materials generate an income as they have to pay rent and water required to keep the home clean. Within a short space and electricity usage to the owner of the main house of time, the sanitation facilities in their new home or otherwise face eviction. There is an inherent con- fell into a state of disrepair and were left uncleaned tradiction in this situation as the persons better able because of lack of both awareness and resources. to pay (shack dwellers) are actually living in poorer housing conditions. When analysing the total dis- Housing infrastructure tribution of education categories as included in the The condition of the state-funded main houses in the survey, the educational level attained by the inhabit- present study was poor and a cause for concern. These ants of the main houses were significantly lower than houses are not ‘owned’ by the state or the local author- those of the shack dwellers. Of all the adults in the ity any longer and the present indigent owner does total group, 8% were illiterate or functionally illiter- not have the n fi ancial ability or skills to maintain the ate (defined as schooling only up to Grade 4 or four house. Few of the owners actually exhibit a realistic years of primary school education). The lack of edu- awareness of what home ownership actually entails. cation among adults in the study contributed to the Almost all of them wanted the “government” or the homeowners’ lack of knowledge on how to maintain “municipality” to repair their homes. The situation has Table 6. Reported ailments and treatment. Main house Shack Total P-value n % n % n % Ailments reported 249 35 151 41 400 37 0.06 Participants suffering from ailment 198 28 117 32 315 29 0.20 Treatment of ailment Visited clinic 89 12 51 14 140 13 0.79 Home treatment 170 24 90 24 260 24 Participants still suffering from ailment 158 22 96 82 254 24 0.62 Environmental Health Insights 2011:5 31 Govender et al now deteriorated to the point that the failing sanitation Improved technology can only be a partial solu- infrastructure is impacting on municipal service deliv- tion to this problem. Successful implementation ery as well as causing huge pollution risks to the inhab- of proper waste management strategies strongly itants and the environment. This looming crisis will depend on an enabling social and economic envi- need huge n fi ancial and other resources to redress. The ronment that supports the services rendered. In the improvements in living standards envisaged by the present study both the infrastructure enabling the low-cost housing schemes are fast being lost. There is inhabitants of these communities to follow safe dis- an urgent need for education of these home owners to posal practices and their level of knowledge of such improve their ability to maintain the infrastructure of practices fall far short of even the most lenient defi- their homes. In some cases small defects would have nition of user co-operation. No education programs cost little to remedy at the time, but left untended, the to redress this situation were encountered during cumulative cost for renovation in these settlements is the study. by now very large. The consequences of this disastrous lack of infra- structure and awareness can be seen from the worri- Electricity and water services some results in this study. The levels of environmental All the formal and informal houses in this study had pollution, the visible deterioration of the surroundings access to electricity. The shacks accessed electricity by of these houses and the disease profiles of the inhabit - means of illegal connections such as extension cords. ants all indicate a looming crisis. These settlements When these electrical wires, many of which are of the are creating favourable conditions for disease out- wrong technical specifications for building to build- breaks because of the easy transmission of particu- ing connections, come into contact with corrugated larly oral-faecal, water or food related pathogens. The metal roof material, sparks fly in windy conditions. lack of adequate and timely removal of solid waste In wet weather the ungrounded connections can cause causes seepage from bins and bulk rubbish containers severe electrical shocks. The high number of smokers and inappropriate rubbish disposal contributes to the and illegal electrical connections in the presence of environmental pollution. Improper waste disposal at flimsy building materials of the shacks (wood, cor - the household and community level led to problems rugated iron sheets and even cardboard) increased the such as fly and rodent infestation, as reported by all risk of structural fires considerably. four communities in the present study. These aspects An analysis of burn injuries in Cape Town showed of the re-housing of urban poor should receive atten- that shack fire burns were the second most frequent tion by disaster-risk planning authorities. reason for admission to a Burns Unit in a secondary Even though low-cost housing settlements pro- hospital in Cape Town. Thus the insecure nature vided access to an onsite toilet and water facilities of electricity supply to shacks in the backyard has for backyard shack dwellers to use, there are insuf- implications for health care and fire services in the ficient waste disposal facilities in those settlements. City. The damage to property and injuries caused by Direct discharges of untreated sewage from such these frequent settlement fires are potentially pre- settlements into the environment—notably the urban ventable if municipal bylaws are strictly followed. At rivers—greatly increased the risk of disease trans- present the majority of efforts are aimed at speedier mission and environmental degradation, adding to response to fires rather than prevention. It is however the pressures on the urban poor. With a reported 21% an extremely difficult situation for the municipal ser - of households admitting to the unsafe disposal of vices, because eviction of backyard dwellers are not a human excreta; waste water and raw sewage makes political option in South Africa at present. its way into yards, sidewalks and streets and into the storm water drains. The rationale behind the provi- Waste disposal sion of free improved housing and free basic water Managing waste disposal in developing countries is allocation, namely increased hygiene and improved one of the most costly services as it takes up to 1% living conditions are thus negated by the lack of pro- of the gross national product and typically absorbs vision for adequate disposal of sewage, solid waste between 20% and 40% of municipal revenues. and waste water. Armitage et al (2009) warned that 32 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements in settlements the waste streams of storm water, Primary health care services sanitation and refuse removal cannot be considered The reported HIV positivity of 5% was almost cer- separately as the contamination is so effectively inter- tainly an undercount. The prevalence of HIV for the mingled under these circumstances. Cape Town metropolitan area for 2008 was reported Armitage et al (2009) found that grey water man- by the National Department of Health (2008) as agement had a low priority amongst inhabitants of 16.1% (95% confidence interval 14.7%–17.5%). settlements. Without adequate waterborne sanita- The lack of any antiretroviral medication present in tion, the disposal of household waste water becomes the dwellings was an equally worrisome finding. This a problem. Although the main houses in the pres- indicates a need for better monitoring and evaluation ent study had waterborne sanitation, the design of along with a more incisive public health approach to the facilities and the low level of proper sanitation support HIV positive persons. This unmet need has behaviour of the inhabitants caused widespread dis- implications for the burgeoning HIV/AIDS epidemic posal of waste water in two inappropriate ways. The in South Africa. Improved housing can theoreti- City of Cape Town faces periodic water shortages cally improve the health of HIV positive persons, that are set to increase with the advancement of cli- but under the present state of sanitation failures and mate change. Using potable water on such a large polluted environments, these improvements will not scale to dispose of waste water and other solid waste materialize due to high infection pressure. by flushing down the toilet is a wasteful habit that In spite of the reported TB and HIV positivity in needs urgent educational remediation. Any commu- this survey, no form of public health support or pre- nity outreach to change this habit will ultimately fail, ventative programme regarding these diseases was however, if user-friendly alternatives to this way of visible in these communities. Education programmes disposal are not provided. Unfortunately, retrofitting need to be initiated and sustained over a long period, such user-friendly alternatives have cost and engi- otherwise the relapse into old and unhelpful ways neering implications for the City and this dilemma will simply overtake all progress made. Community should be avoided by amending the planning in health workers are needed to keep the programme future housing settlements. operational. Without community-based health care Storm water runoff in urban areas is increased by ‘advisors’ or community members who can keep an impermeable urban surfaces such roofs and as hard- eye on the situation regarding cleanliness and dis- topping of streets and driveways. Unfortunately ease status in the community, no lasting improve- settlements are often constructed with little consider- ments will be seen. These community workers should ation for storm water drainage. Even formal storm be recruited from the communities they serve. With water drains are ‘passive’ systems simply receiving rudimentary training they can fulfill a useful func- any water and solid matter discarded in or near them tion to bridge the gap between the health needs of the and are thus vulnerable to blocking-up or misuse. inhabitants and the City health services. Such a ser- Storm water systems in low-cost settlements are used vice will need some administrative support, but could for the disposal of unwanted waste water, solid waste be maintained at a relatively low cost. and even dead animals as was readily apparent in the TB or HIV positive persons or those who are mal- present study areas. Apart from the risk of flooding nourished need clean living environments because of because of blocked storm water systems, the other their lowered immunity. The present living conditions major impact of this unfortunate situation is the major in this study add significant infection pressure to the 22,23 contamination of rivers flowing past urban areas. already poor health suffered by these persons. This in The implications of this widespread pollution of sur- turn added to the patient load at the already overbur- face water in the City for future water resources and dened and underfunded local health clinics, as well environmental health should receive urgent attention as higher up the referral chain of health services. The by the City planners and engineers. Strategies that can public health measures to tackle TB in these com- be considered include: constructed wetlands, swales, munities were wholly inadequate. The self-reported passive infiltration systems and tactically placed prevalence of TB was a source of great concern, nota- impoundments. bly the existence of a case of MDR-TB. The fact that Environmental Health Insights 2011:5 33 Govender et al none of these patients, including the case of MDR-TB, Many of the inhabitants of low-cost housing was on any TB medication has serious implications communities preferred to treat their ailments using for the future management of this potentially prevent- home remedies or traditional medicines. South Africa able disease. None of the TB-positive persons visited has many tradition healers who dispense herbal medi- the clinic in the preceding two months either, which cines of various origins. Unfortunately the efficacy indicated a serious lack of involvement of the primary and safety of some of these medicines are unknown. health care services in the area. At worst, such treatment may delay the diagnosis or If one in 1080 dwellers of these low-cost hous- treatment of serious transmissible conditions such as ing communities are already MDR-TB positive, then HIV and TB. This necessitates a need for traditional the City can expect a substantial increase in these healers to work in synergy with Western medical treat- difficult-to-treat cases, with a serious knock-on effect ment to improve the safety and health of inhabitants on the already overburdened health care system. The from low-income areas in South Africa. Although development of MDR may be related to poor com- there have been sporadic programs to incorporate pliance with drug treatment, poor treatment drug traditional healers into the formal health services, no choices, poor access to primary health care facilities systematic policy for incorporating them into the for- along with patient factors such as poor absorption of mal health services exists. drugs and general poor health. Many of these factors Barriers to access to health information and sup- are at play in these communities and the meticulous port services include cost, geographic location, illit- execution of TB control programmes in such environ- eracy, disability and capacity to utilize information 27,28 ments should be a high priority. This need is clearly effectively. All of these restraints are present in unmet at present. the communities in the present survey and effec- Moraes et al (2005) showed that in three poor tive ways of bridging these gaps are not in place at communities in Salvador, Brazil the incidence of present. Deliberate delays in obtaining medications diarrhoea in children in neighbourhoods with drain- were reported to be one of the most common strate- age and sewerage was one-third of the incidence in gies among urban poor in Australia. There are indi- neighbourhoods with neither service. They also cations that this strategy was also prevalent among the found that improving community sanitation—even participants in the present study since most attempted in the absence of hygiene-promoting behaviour—can home remedies first. Many of those who should have have an impact on diarrhoeal disease. This is impor- been on treatment (TB and HIV positive persons) tant in the context of the high reporting of diarrhoeal were not. Although the local clinic is within reach- disease among the inhabitants of the low-cost commu- able distance for many, cost of transport remains a nities in the present study. Thus the effort and money significant factor for these communities. The barriers spent on improving the sanitation systems in these resulting in low utilization have not been addressed in communities should improve the diarrhoeal morbid- these communities, warranting further research into ity experienced by these communities. Unfortunately, such barriers in order to prioritize their removal. estimations of the possible impact of improvements The low opinion of the perceived quality of care seldom include the expected easing of disease bur- available at the clinics also contributed to the poor dens as well as the reduction in the patient loads of utilization of the primary health care available to the primary health services. these communities. Haddad et al (1998) studied the This survey only recorded conditions that were expectations and criteria that two rural communities diagnosed formally at the clinic and for which the in Guinea used to determine quality of service. He medication could be verified. A major factor influenc- found that the criteria depended inter alia on gen- ing the accessibility of primary health care was the der and the ability to access the services and that the inability of some persons needing medical attention communities placed considerable emphasis on out- to procure transport to the clinic. The cost of using a comes of treatment, but little emphasis on preventa- communal taxi, especially for those with chronic con- tive services. With such poor utilization as reported ditions who had to visit the clinic repeatedly, made in the present study and so many barriers to effec- significant inroads into their household budget. tive primary health care, the local clinics cannot play 34 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements any meaningful role in addressing the serious health The unfortunate separation of the fields of public needs of the urban poor in these four communities. health and urban planning has contributed to uncoordi- Preventative actions by the local clinics that are so nated efforts to address the health of urban populations sorely needed in these communities with their high and a general failure to recognize the links between HIV and TB burdens as well as the added complica- the built environment and health disparities facing tions of poverty, substance abuse and hunger will be low-income populations. A reconnection of these two largely fruitless under the present circumstances and responsibilities is a prerequisite for successful improve- needs to be addressed urgently. ment of the present unsafe and unhealthy conditions prevailing in low-cost housing areas in South Africa. Conclusion The irony is that these resettlement programs were insti- The overall conclusion is that the envisaged improve- tuted to improve the living conditions of the urban poor ments in health supposed to be associated by rehous- and it is imperative that this improvement be realized. ing impoverished urban shack dwellers in improved housing did not materialise due to unforeseen hous- Acknowledgements ing design aspects as well as social and behavioural We thank the Harry Crossley Foundation, the German aspects. The reasons are not straight-forward. The Academic Exchange Service (DAAD), the National lack of improvement in health resulted from com- Research Foundation and Stellenbosch University plex interactions of poor design (especially sanitation for the funding of this project. We are grateful to infrastructure of both the dwellings and the municipal Sister N. Lethuka for assisting in the administering of structures), low levels of education, poor sanitation the survey and Professor M. Kidd from the Centre for behaviour, poverty and overcrowding. The shacks in Statistical Consultation at Stellenbosch University the backyard contributed significantly to overcrowd- for statistical support. ing, sanitation failures and environmental pollution, but were not in all instances the main drivers of these Disclosure risk factors. They however added to the burdens This manuscript has been read and approved by all already present in the communities. The shacks did authors. This paper is unique and is not under con- contribute a moderate amount of income to the own- sideration by any other publication and has not been ers of the main houses, but whether this contribution published elsewhere. The authors and peer reviewers is offset by the extra burden of disease (for instance) of this paper report no coni fl cts of interest. The authors cannot be answered by the present study, nor was it confirm that they have permission to reproduce any designed to do so. copyrighted material. Given the design of these houses and the added pressure on the existing infrastructure by the inhab- References 1. Shaw M. Housing and Public Health. Annual Review of Public Health. itants of unplanned housing in the backyard, these 2004;25:397–418. results send a powerful message that the existence 2. Thomson H, Petticrew M, Morrison D. Health effects of housing improvement: systematic review of intervention studies. 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Water Science Technology. 2009;59:2341–50. 20. Carden K, Armitage N, Winter K, Sichone O, Rivett U. The management of greywater in the non-sewered areas of South Africa. Urban Water Journal. 2008;5:329–43. 36 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Appendicies Appendix A: Health evaluation questionnaire Good day Sir/Madam My name is Sister Lethuka. You are invited to take part in a research project carried out by the Medical Faculty of the University of Stellenbosch. We are going to be studying your health and home. Note that your participa- tion in the study is voluntary and you may opt to leave the interview at any time. All answers and comments will be kept highly confidential. We will not record your name and we promise that no information you give us will be attached to you or anyone living in your home. Please do not hesitate to ask any questions that you may have with this study. Section 1: Biographical details 1.1 Please provide us with the following information, so that we can learn more about your family. Is this sex Status of individual Educational status: person Male Female U—Unemployed A—No schooling disabled? F—Full time employed B—Pre-primary to grade 4 Yes no P—Part time employed C—Grade 5 to grade 7 IRR—Irregular employment D—Grade 8 to grade 10 S—Scholar E—Grade 9 to grade 12 C—Child at home F—Tertiary level A—Adult at home U—Unsure A1 A2 A3 A4 A5 A6 1.2 Are members of the household Mark the person’s choice () South African Citizens Yes No If no, what is your country of citizenship And for how long have you lived in South Africa Have there been any deaths among the persons living in the house in the past 6 months and if possible please specify the cause? Mark the person’s choice () Yes Specify: No Environmental Health Insights 2011:5 37 Code of person Role in household Age How long has the person lived in this house (years) Govender et al Section 2: Disease and health services 2.1 During the past two weeks, are there symptoms that affected you or persons living in your house? Symptom Code of person/ Home Visited clinic/ Is the person still suffering persons with treatment () Doctor () from the symptom (Y/N) symptom Diarrhoea Fever Nausea Vomiting Cramps/abdominal pain Blood in stools or vomit Worms in faeces Body/hand sores Eye infection Coughing Shortness of breath Tiredness and weakness of body Coughing blood Loss of appetite and weight Night sweats Headaches Nits/lice Yellow looking skin White of eyes are yellow Itchy skin Coughing for more than 1 week Other: 2.2 Have any members of your household visited the clinic and/or doctor in the past two months and been diagnosed with an illness/disease? Code of the Illness/disease Was medicine given Is the illness Have you or any member person for the illness? (Y/N) cured? (Y/N) in your household suffered from the illness before? (Y/N) 2.3 Are any members of the household on chronic medication? Mark the person’s choice () Yes No If yes, specify for what illness ***Note to interviewer: If the answer is yes, ask to see the medication. 38 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements 2.4 Do you think that people in your household suffer from the following diseases at the moment? (Optional) Mark the person’s choice () Yes No Unsure TB HIV/AIDS 2.5 What are some of the other health problems facing your household? 1. 2. 3. 4. 5. 6. 2.6 Do members of your household take part in using the following substances? Mark the person’s choice () Cigarettes Alcohol Drugs Yes No Unsure 2.7 What is the name of the clinic that members of your household visit when ill? –––––––––––––––––––––––– 2.8 How do you get to the clinic? Mark the person’s choice () Walk Taxi Bus Private transport Other, specify: 2.9 What does a return trip to the clinic cost (if you need to pay)? R _____, ___ 2.10 Has there ever been a time when you or a family member needed to visit the clinic, but did not have the money to pay for transport? Mark the person’s choice () Yes No Unsure 2.11 Are you satisfied with the services provided by the clinic? Mark the person’s choice () Yes No Unsure Environmental Health Insights 2011:5 39 Govender et al 2.12 Do you think that private health facilities provide better services than your clinic? Mark the person’s choice () Yes No Unsure 2.13 Have you or members of your household ever called for an ambulance? Mark the person’s choice () Yes No Unsure 2.14 Usually, how many meals does your family eat per day? Ring the person’s choice 1 2 3 4 5 6 7 8 Section 3: Hygiene and the environment 3.1 Do you think that you can get sick from the following? Mark the person’s choice () Using a dirty toilet Yes No Unsure An unclean home Yes No Unsure Dirt and rubbish in your yard or the street Yes No Unsure Drinking dirty water Yes No Unsure Drinking water from rivers and streams Yes No Unsure 3.2 Is it difficult to keep your home clean? Mark the person’s choice () Yes No Unsure 3.3 Do you find it expensive to purchase cleaning material for your home? Mark the person’s choice () Yes No Unsure 3.4 Have you or any member of your household been a victim of crime in the past six months? Mark the person’s choice () Yes No Unsure 3.5 Can you mention some of the crime committed in your community? 1. 2. 3. 4. 5. 6. 40 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements 3.6 Are there safe places to play for the children in your household? Mark the person’s choice () Yes No Unsure Notes: Thank you for taking the time to answer our questions. Again, any information provided by yourself during the interview will be kept confidential. Your participation in the study is highly appreciated. Date of interview: Time of interview: Street Name and House number (This information will be kept strictly confidential) Classify: Main House or Shack Suburb: 1 2 3 4 Environmental Health Insights 2011:5 41 Govender et al Appendix B: Housing Evaluation Questionnaire My name is Thashlin Govender. You are invited to take part in a research project carried out by the Medical Faculty of the University of Stellenbosch. We are studying your health and home. Please note that your par- ticipation in the study is voluntary. All answers and comments will be kept highly confidential. We would appreciate it if you could allow us to ask you some questions about your home and have a look at the structure of your house. We will not need your name and we promise that no information you give us will be attached to you or anyone living in your home. Please do not hesitate to ask any questions that you may have regarding this study. Section 1: Household information 1.1 What is the total income of the household living in the dwelling per month? Mark the correct one () Less than R600 per month R600 to R1 200 per month R1200 to R2500 per month More than R2500 per month Unsure 1.2 What is the dwelling used for? Mark the correct one () Main household accommodation Additional household accommodation Rented out accommodation Business premises Storage room Garage Other: Other: 1.3 Who owns this home? ––––––––––––––––––––––––– 1.4 Does he/she stay here? Mark the correct one () Yes No Unsure 1.5 If you rent the home, how much do you pay per month? R _____, ___ 1.6 Where did you stay prior to moving to this settlement? 42 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements 1.7 Backyard dwellers only: Have you applied to join the housing list? If yes, how long have you been waiting for a house? Mark the correct one () On waiting list for: Yes –––––––––––– years No –––––––––––– months Unsure 1.8 RDP house only: Did you get this home by joining the housing list? If yes, how long ago did you receive this home? Mark the correct one () When did you receive the home? Yes –––––––––––– years No –––––––––––– months Unsure 1.9 Who pays for the repairs of this home? ––––––––––––––––––––––––– 1.10 Can you afford the repairs of the home? Mark the correct one () Yes No Unsure 1.11 Do you pay for water to drink and clean your home and if yes, who do you pay? Mark the correct one () Yes no Unsure Recipient of payment: Drink Clean your home 1.12 Do you pay for electricity and if yes, who do you pay? Mark the correct one () Yes Recipient of payment: No Unsure 1.13 Do you (or somebody in your home) receive a social grant? Mark the correct one () Yes No Unsure Environmental Health Insights 2011:5 43 Govender et al Section 2: Toilet facilities 2.1 Where is the toilet for the persons living in this house? Primary Secondary Mark the correct one () Toilet inside the house Toilet outside the house, but on the same property Communal toilet away from the dwelling No toilet available within easy walking distance If no toilet is available, what do the inhabitants use? 2.2 What sort of toilet is it? Mark the correct one () Flush toilet Longdrop (pit latrine) Bucket system Other, specify: 1.3 Does your toilet break or is it blocked often? Mark the correct one () Yes No Unsure Not applicable 2.4 Where do the members of the household dispose of soiled products, eg, sewage, soiled nappies? Please mark   = Yes, X = No In the street Outside bin Into the storm water drain If other, specify: Rubbish skip 2.5 If the toilet is away from the dwelling, how far do the inhabitants have to walk to get to the toilet Distance: paces 2.6 Do you know who to contact if there is a drain blocked or overflowing? If yes, specify Mark the correct one () Yes No Unsure 2.7 Who would you tell if there is a drain blocked and overflowing? 1. 2. 44 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements 2.8 What will happen if rubbish is thrown into the toilet? Mark the correct one () Nothing It will block the toilet and the pipes Don’t know 2.9 Can you get sick from not washing your hands after you used the toilet? Mark the correct one () Yes No Unsure 2.10 How often is your toilet cleaned? Mark the correct one () Once a day Twice a week Once a week Sometimes Unsure 2.11 What are the cleaning materials used to clean the toilet? Please mark   = Yes, X = No Disinfectant Soap Detergent Toilet brush Cloth 2.12 Do you pay to use the toilet? Mark the correct one () Yes No Unsure Section 3: Washing and other water use 3.1 Is there a working tap available? Mark the correct one () Inside the house On the property Nearby (not on property) Environmental Health Insights 2011:5 45 Govender et al 3.2 Are there facilities nearby to wash your hands after using the toilet? Mark the correct one () Yes No Unsure 3.3 Where are your clothes washed? –––––––––––––––––––––––––––––––––––––––––––––––––––– 3.4 What happens to the water used to wash your clothes? 3.5 When water is used to wash and prepare food, what happens to that water? 3.6 Where do the persons living in the house wash themselves? 3.7 What happens to the wash water? Section 4: Solid waste 4.1 Where does the household dispose of its rubbish? Please mark   = Yes, X = No In a rubbish bin inside the house At the skip outside on the street Throw it on the street Other If “Other”, please specify: ............................................................................. ...................................................................................................................... ...................................................................................................................... 46 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Section 5: Vector identification 5.1 Have you found any rats, mice or cockroaches in your home? Mark the correct one () Yes No Unsure If yes, specify the type of animal a) b) c) Thank you for taking the time to answer our questions. Again, any information provided by yourself during the interview will be kept confidential. Your participation in the study is highly appreciated. Date of interview: Time of interview: Street Name and House number (This information will be kept strictly confidential) Classify: Main House or Shack Suburb: 1 2 3 4 Survey Number: Environmental Health Insights 2011:5 47 Govender et al Appendix C: Dwelling Checklist Survey Number: Ring the appropriate answer comments 1 Type of dwelling Main Shack in Other dwelling backyard 2 Is the house neatly maintained? Poor Fair Good 3 Are the outside walls of the home painted? Yes No 4 Are the inside walls of the home painted? 5 Are there cracks on the wall? Yes No 6 Does the house have electricity? Yes No 7 Is the roof of the house leaking? 8 Is the door well fitted? Yes No 9 Does the house have any broken windows? Yes No 10 Is the bathroom clean? Poor Fair Good 11 Is the toilet in working order? Yes No 12 Is the toilet leaking? Yes No 13 Is the tap leaking? Yes No 14 Is there toilet paper in the bathroom? Yes No 15 Is there soap available in the bathroom to wash hands? Yes No 16 Is there a clean towel or paper towels available in the bathroom? Yes No 17 Is the drain clean? Poor Fair Good 18 Is the roof leaking? Yes No 19 Are there any structural damages to the home? Yes No 20 Are there any structural alterations or extensions to the home? Yes No 21 What is the state of the yard outside the home? Poor Fair Good 22 Is there a bin inside the home? Yes No 23 Is there a bin outside the home? Yes No 24 Is there a garden outside the home? Yes No 25 Is rubbish evident outside the home? Yes No 26 Are there pools of water outside the home? Yes No 27 Is there broken glass evident outside the home? Yes No 28 Does the family own pets/animals? Yes No 29 Does the home have electricity? And if yes, is it legal or illegal? Yes No Legal Illegal 30 Is there evidence of other forms of heating/lighting? Yes No 31 Does the home have an operational refrigerator? Yes No 32 Does the home have an operational stove? Yes No 48 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Appendix D: Participant Information Leaflet and Consent Form TITLE OF THE RESEARCH PROJECT: An epidemiological study on the health and sanitation status of specific low cost housing communities as contrasted with those occupying ‘backyard dwellings’ in the City of Cape Town, South Africa. REFERENCE NUMBER: N09-08-214/215/216. PRINCIPAL INVESTIGATOR: Thashlin Govender, PhD Candidate, Division of Community Health, Department of Interdisciplinary Health Sciences, Faculty of Health Science, Tygerberg Campus, Stellenbosch University. ADDRESS: 55 Carnie Road, Rylands Estate, Cape Town, 7764. CONTACT NUMBER: 083 730 2846. You are being invited to take part in a research project. Please take some time to read the information presented here, which will explain the details of this project. Please ask the study staff or doctor any questions about any part of this project that you do not fully understand. It is very important that you are fully satisfied that you clearly understand what this research entails and how you could be involved. Also, your participation is entirely voluntary and you are free to decline to participate. If you say no, this will not affect you negatively in any way whatsoever. You are also free to withdraw from the study at any point, even if you do agree to take part. This study has been approved by the Committee for Human Research at Stellenbosch University and will be conducted according to the ethical guidelines and principles of the international Declaration of Helsinki, South African Guidelines for Good Clinical Practice and the Medical Research Council (MRC) Ethical Guidelines for Research. What is this research study all about? A total of 50 homes with a plot number will be randomly selected to take part in the study. The reason for us doing the study is to investigate the health of the people in your community and the water use and sanitation in your home. There are two parts to the study that we need your assistance with. Firstly, we will ask you questions about your home and your water use and sanitation. For this part of the survey we will also take a look around your home. You may accompany us during this part of the survey. Secondly, a nurse will ask you some questions about the health of your family. These surveys will be done for your home alone. We will be taking down your address, but we will not be taking down any names of you and your family in the interview. This is done so that no one will be able to identify from whom the information was obtained and who is sick or who became ill in your home. This consent form will not be attached to your answer sheet, so that again no one will be able to n fi d out that this information was provided by you. Once you have completed this consent form, this form will be placed in a sealed box together with all the other forms from your community, for safety purposes. A report of the n fi dings from the study will be sent to your ward councilor, and we will try to make the information available in a community news- paper. We will also send a report to the City of Cape Town ofc fi es, so that they know about the living conditions in your community and the problems that you and your community are faced with. You can contact Dr J.M Barnes at 021-9389480 if you have any questions or problems or would like to know the results of this study. You may also contact the Committee for Human Research at Stellenbosch University at 021-938 9207 if you have any concerns or complaints. You will receive a copy of this information and consent form for your own records. Why have you been invited to participate? You have been selected by chance so that the information we gather is a fair representation of your community. We want to investigate the health status of you and your family and the living conditions in and around your environment. Environmental Health Insights 2011:5 49 Govender et al What will your responsibilities be? To please answer the questions as best as you can. Will you benefit from taking part in this research? The results from this study will be summarised and provided to the local, provincial and national government in order to improve planning for housing and health. The results will help us understand the needs of your com- munity and environment. Are there any risks involved in your taking part in this research? There are no risks involved in taking part in the study. And we assure you of your anonymity. If you do not agree to take part, what alternatives do you have? YOU HAVE A RIGHT TO NOT TAKE PART OR STOP THE INTERVIEW; AND THERE WILL BE NO IMPLICATIONS IF THIS IS YOUR DECISION. DECLARATION BY PARTICIPANT By signing below, I …………………………………..…………. agree to take part in a research study entitled, An epidemiological study on the health and sanitation status of specific low cost housing communities as contrasted with those occupying ‘backyard dwellings’ in the City of Cape Town, South Africa. I declare that: • I have read or had read to me this information and consent form and it is written in a language with which I am fluent and comfortable. • I have had a chance to ask questions and all my questions have been adequately answered. • I understand that taking part in this study is voluntary and I have not been pressurised to take part. • I may choose to leave the study at any time and will not be penalised or prejudiced in any way. • I may be asked to leave the study before it has finished, if the study doctor or researcher feels it is in my best interests, or if I do not follow the study plan, as agreed to. • I have given permission to take and use pictures of my home and family members for publication purposes. Signed at (place) ......................…........…………….. on (date) …………....……….. 2009. ........................................................... ........................................................... Signature of participant Signature of witness 50 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements DECLARATION BY INVESTIGATOR I (name) ......................…........……………..…………..………….. declare that: • I explained the information in this document to ......................…........…………… • I encouraged him/her to ask questions and took adequate time to answer them. • I am satisfied that he/she adequately understands all aspects of the research, as discussed above. • I did/did not use a interpreter. (If an interpreter is used then the interpreter must sign the declaration below). Signed at (place) ......................…........…………….. on (date) …………....……….. 2009. ........................................................... ........................................................... Signature of investigator Signature of witness Declaration by interpreter I (name) ......................…........……………..…………..………….. declare that: • I assisted the investigator (name) ......................…...... to explain the information in this document to (name of participant) ......................…........ using the language medium of Afrikaans/Xhosa. • We encouraged him/her to ask questions and took adequate time to answer them. • I conveyed a factually correct version of what was related to me. • I am satisfied that the participant fully understands the content of this informed consent document and has had all his/her question satisfactorily answered. Signed at (place) ......................…........…………….. on (date) …………....……….. ........................................................... ........................................................... 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The Impact of Densification by Means of Informal Shacks in the Backyards of Low-Cost Houses on the Environment and Service Delivery in Cape Town, South Africa

Environmental Health Insights , Volume 5 – May 16, 2011

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Environmental Health Insights Open Access Full open access to this and thousands of other papers at O RI G I NA L RE S E A RCH http://www.la-press.com. The Impact of Densification by Means of Informal Shacks in the Backyards of Low-Cost Houses on the Environment and Service Delivery in Cape Town, South Africa 1 2 2 Thashlin Govender , Jo M. Barnes and Clarissa H. Pieper Division of Community Health, Department of Interdisciplinary Health Sciences, Faculty of Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa. Division of Neonatal Medicine, School of Child and Adolescent Health, University of Cape Town and Groote Schuur Hospital, Observatory, Cape Town, South Africa. Corresponding author email: [email protected] Abstract: This paper investigates the state-sponsored low cost housing provided to previously disadvantaged communities in the City of Cape Town. The strain imposed on municipal services by informal densification of unofficial backyard shacks was found to create unintended public health risks. Four subsidized low-cost housing communities were selected within the City of Cape Town in this cross-sectional survey. Data was obtained from 1080 persons with a response rate of 100%. Illegal electrical connections to backyard shacks that are made of flimsy materials posed increased fire risks. A high proportion of main house owners did not pay for water but sold water to backyard dwellers. The design of state-subsidised houses and the unplanned housing in the backyard added enormous pressure on the existing municipal infrastructure and the environment. Municipal water and sewerage systems and solid waste disposal cannot cope with the increased population density and poor sanitation behaviour of the inhabitants of these settlements. The low-cost housing program in South Africa requires improved management and prudent policies to cope with the densification of state-funded low-cost housing settlements. Keywords: low-cost houses, backyard dwellings, service delivery, public health, environment, sanitation, diarrhoeal disease Environmental Health Insights 2011:5 23–52 doi: 10.4137/EHI.S7112 This article is available from http://www.la-press.com. © the author(s), publisher and licensee Libertas Academica Ltd. This is an open access article. Unrestricted non-commercial use is permitted provided the original work is properly cited. Environmental Health Insights 2011:5 23 Govender et al Introduction Housing and its relationship to health has long been one of the core areas of public health research. Housing affects health through a range of factors, acting directly or indirectly at different levels. The assump- tion that provision of improved housing to previously disadvantaged urban slum dwellers may improve their health is still being debated. This premise however forms one of the six principles of the state-funded low- cost housing scheme in South Africa, referred to as the Breaking New Ground initiative, formerly known as the Reconstruction and Development Programme. The exact association between housing and the Figure 2. An example of a low-cost house in Tafelsig. maintenance of health and well-being remain elusive. It is intuitively accepted that affordable housing that is in the deterioration of living conditions and the sur- appropriate for environmental and social conditions; 8–11 rounding environment. In theory, living in urban will protect people from hazards and will promote areas potentially offers improved access to health good health and wellbeing, but definitive proof has care, education, better housing and improved eco- not been published. Deficient housing on the other nomic opportunities. In reality however, the growth hand could compromise basic human needs such as of urban slum areas in developing countries brought water, sanitation, safe food preparation and storage as about an increase in poverty as many poor, often illit- well as assisting in the rapid spread of communicable erate and unskilled people leave rural areas to try and and food borne diseases. According to the World find employment in cities. Health Organisation (WHO), the developing world A consequence of the housing backlog in South records 98% of deaths resulting from unsafe water, Africa is that nearly one-fifth of households live in sanitation and hygiene. The WHO report identified informal dwellings and in response to this need, there infectious diarrhoea as the largest single contributor had been a large roll-out of government-sponsored to ill health associated with water, hygiene and sani- low-cost housing. The South African housing policy tation inadequacies. is centered around the provision of fully state-funded In South Africa, like in Mexico, the accelerated home-ownership for the poor and seeks to eradi- migration of indigent rural people into urban areas cate informal housing, including backyard shacks. caused informal settlements to grow beyond the coping capacity of city infrastructure. This resulted Figure 1. Adjoining shacks in the Greenfields settlement obscuring Figure 3. Dampness penetrating bedroom wall with infant sleeping on municipal reticulation systems. bed in a low-cost house in Greenfields. 24 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Figure 6. Flushing mechanism on this toilet is broken in a house in Masipumelela. Users flush toilet by manually manipulating the mecha- Figure 4. An example of structural damage: a seriously cracked wall of nism inside the system. Note that the toilet is dirty. main house in Tafelsig. The new owners of such subsidized houses acquired erecting informal or makeshift dwellings in their their houses for free, but the improvement in their backyard which were constructed from inadequate living conditions in most cases was not accompanied building materials (eg, corrugated iron sheets, wood by an improvement in their financial status. Most of and cardboard). Most of these informal dwellings these inhabitants remained unemployed or with inse- are used for rental by other poorly housed families. cure or intermittent employment. Backyard dwellings in such formal housing com- The new home owners soon exploited one of the munities caused the slum conditions of their for- 11,12 few resources at their disposal, namely space, by mer existence to follow them. These informal Figure 5. Tap against the wall on right is either lost or removed. Note the Figure 7. An example of a kitchen area in Greenfields. Note the rudi- broken pipe and cistern, as well as the broken window which has been mentary facilities and dirty wall. This is the only working tap in the main repaired with cardboard in Masipumelela. house. Environmental Health Insights 2011:5 25 Govender et al the facilities provided to previously disadvantages communities and the strain posed on municipal ser- vices by densified low cost housing communities in the City of Cape Town, thereby creating unintended public health risks. Methods This study was approved by the Committee for Human Research at the Faculty of Health Sciences of Stellenbosch University and was conducted accord- ing to the ethical guidelines and principles of the International Declaration of Helsinki, the South African Guidelines for Good Clinical Practice and Figure 8. Solid waste blocking the storm water inlet on street causing the Ethical Guidelines for Research of the Medical subsequent flooding during rain storms in Greenfields. Research Council of South Africa. All respondents were informed of the objective of the study in their dwellings (called shacks by the inhabitants) have home language (English, Afrikaans or isiXhosa) and no sanitation, water, electricity and waste disposal signed informed consent. A copy of the informed facilities. The subsequent overcrowding and failures consent was provided to all participating households. of the existing sanitation infrastructure causes severe The survey was conducted anonymously. All par- pressure on municipal services with accompanying ticipants could inspect the completed questionnaire environmental pollution. This paper investigates answer sheet for anonymity. They then posted the form into a sealed box with a postal slot. The box was only unsealed at the end of the study. Four subsidized housing communities were selected within the City of Cape Town Metropole (CCTM) to participate in this cross-sectional survey. The govern- ment subsidized low-cost housing communities iden- tie fi d as study sites were: Driftsands, Greene fi lds, Masipumelela and Tafelsig. These sites were selected to represent the best spatial coverage of all the subsi- dized housing settlements within the city. The settle- ments were selected regardless of the local or central authority under whose jurisdiction the housing schemes were originally erected. They had to be older than three years. This was important because in some of the newer settlements structural wear and tear of the houses had not yet become evident to the same extent as in the older settlements. The settlements selected had to have distinct boundaries that did not blend into informal set- tlement areas (so-called squatter settlements) in order to avoid infection pressure in the form of garbage and water pollution introduced from neighbouring areas. All four settlements had numerous low-cost houses (referred to as main house from this point forward) with informal dwellings made of temporary building Figure 9. Waste water running down the street in Greenfields. The materials in the back yard (referred to as shacks by the woman doing her washing on the side walk is adding to the polluted water stream. inhabitants and so called in this paper). 26 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements A legacy of the previous spatial disparities in the and these interviews were carried out under the same City resulted in communities with predominantly only conditions as the main study. The data from the dwell- one ethnic group. There were three settlements with ings in these pilot sites were therefore included in the predominantly black inhabitants and one settlement total group, ie, 1080 participants living in 336 dwell- with predominantly coloured (mixed ancestry) inhab- ings (173 main houses and 163 shacks). itants. This selection was representative of the overall The questionnaire was designed to record data demographic profile of the settlements in the city. No from all dwellings on a plot. These questionnaires questions or annotations on race were included in the were available in all three languages and adminis- questionnaire. tered in the language of preference during an on- The sampling strategy was based on a systematic site interview with the head of the household. The sampling technique with random starting points so as questionnaire comprised sections on demographic, to cover the entire community in a non-biased and health and home ownership as well as a section to representative sample. This sampling strategy is a note the condition of the dwelling and its surround- probabilistic sampling technique when spatial ran- ing yard. The inspection of the dwelling and yard domness is required. It comprises a selection of ele- concentrated on the sanitation infrastructure and ments from an ‘ordered list’ (such as a street plan) in condition of the premises. The toilet was classified a specific way. A random starting point (plot number) as non-operational when one of the following was is selected eg, along every street and pathway in the noted: toilet blocked, could not flush, had serious community and in the case of the present study every leaks or had a severely cracked cistern or bowl. The 10th dwelling after that was selected to participate in sanitary condition of the yard was classified as poor the study. when one or more of the following was noted: pres- Data were collected by means of structured inter- ence of broken glass, solid waste, excreta, puddles view questionnaires during home visits to all selected of dirty water, overflowing waste bins, overflowing dwellings by the senior author, assisted by a quali- or dirty drains. fied registered nurse who spoke all three languages Demographic and socio-economic variables prevalent in the area. All dwellings on a selected plot included age, gender, physical challenges, educational (main house and informal dwellings in the back yard) attainment, citizenship, social grant recipients, were included but recorded separately. Overall, 321 employment status and household monthly income. dwellings on 165 plots were selected for participation The household monthly income was arrived at by in the study. A systematic randomized sampling pro- adding the income of all employed members of the cedure was used to select the plots in the four study dwelling. Health variables included HIV and TB sites. Data were obtained from 1020 persons in total status, as well as ailments suffered in the preceding with a response rate of 100%. All households elegible two weeks of the survey. Respondents were given for inclusion into the study by the sampling strategy an option of disclosing their HIV and TB status. All participated and no one in any of the selected dwell- medication in the dwelling that was issued by the ings refused to provide data. The field work for this clinic was inspected and the reported diagnoses veri- study was conducted over a period of 16 days and fied from that. interviews took a median time of 40 minutes per A fully qualified community health nursing sister household. administered a questionnaire (available in three lan- The questionnaires were piloted in two different guages) regarding various aspects of health, including settlements (predominantly coloured and predomi- 20 questions on symptoms relating to sanitation and nantly black) in the CCTM. The pilot study sites were waterborne diseases. When respondents reported that situated in Mfuleni and Westbank and four plots were they were on medication (either acute or chronic), randomly selected from each of the sites. From these the nurse asked to see the medication and confirmed eight plots the survey was administered to 15 dwellings the illness by cross-checking the reported illness with with data obtained from 60 persons. The results from the prescribed medication. Only the illnesses con- the pilot sites met the same criteria as the study sites. firmed by prescription medication from the clinic No problems or confusing questions were encountered were entered into the study data base. This was done Environmental Health Insights 2011:5 27 Govender et al Results in order to enter only verifiable illnesses into the study. This was necessitated by inaccurate reporting Income and education status of illnesses by respondents due to the poor under- Significantly more of the occupants of the shacks were standing of disease in general and specific symptoms employed than the occupants of the main houses (χ in particular in these communities mainly as a result test, P = 0.0000). Almost 42% of households in the total of low levels of education. group had a combined household income per month of Data were recorded in a database created in less than R1200 (about US$160). The reported incomes Statistica version 9.0 (StatSoft Inc. 2009, USA). of the inhabitants of the main houses were statistically Descriptive statistics mainly means and standard signic fi antly lower than those of the occupants of the deviations for continuous variables and frequency shacks (Mann-Whitney U-test, P , 0.01). Approxi- distributions for categorical variables were com- mately 28% of main households and 20% backyard puted. Bivariate analysis testing for differences shack dwellers received a government social grant in proportions of low-cost housing and backyard (Table 1). The occupants of the shacks had a signifi- shacks were performed using the test for probability cantly higher education status that the occupants of the values. main houses (Mann-Whitney U-test, P = 0.01). Table 1. Sociodemographic characteristics of the study population. Characteristic Main house % % Total group % P-value Shack (n = 163 (n = 173 dwellings) (n = 336 dwellings) dwellings) Study population 710 66 370 34 1080 100 Gender Male 322 64 184 36 506 47 0.17 Female 388 68 186 32 574 53 Disabled individuals 18 90 2 10 20 2 ,0.01 Nationality South African 695 68 329 32 1024 95 ,0.01 Non-South African 18 32 38 68 56 5 Highest education level No schooling 103 59 73 41 176 16 0.01 Grade 0–4 152 83 32 17 184 17 Grade 5–7 154 70 65 30 219 20 Grade 8–10 138 61 90 39 228 21 Grade 9–12 158 61 100 39 258 24 Tertiary level 5 33 10 67 15 1 Employment status Full time employed 122 62 76 38 198 18 ,0.01 Part time employed 8 20 33 80 41 4 Irregular employed 50 61 32 39 82 8 Unemployed 210 65 112 35 322 30 Pensioner 14 52 13 48 27 3 Child at home 104 61 66 39 170 16 Scholar 202 84 38 16 240 22 Household monthly income 25 48 27 52 52 15 ,R600 per month ,0.01 R600-R1200 29 33 59 67 88 26 per month R1200-R2500 58 53 52 47 110 33 per month .R2500 per month 23 28 60 72 83 25 Unsure 1 33 2 67 3 1 Households receiving 93 58 66 42 159 48 ,0.01 a social grant 28 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements by the seven houses for a month). A total of 66% of Housing infrastructure backyard dwellers pay the landlord between R20 and All of the main houses have been equipped with a R100 per month for water, in spite of the City provid- flush toilet, either inside or outside the house. In all ing the first 6000 litres of water for free each month to cases backyard dwellers were allowed to use the toilet all households. The 97 backyard shack dwellers paid on the property. If however the toilet inside the home R6080 (about US$811) in total per month to landlords was not available, then the neighbour’s toilet may be who themselves did not pay for this water. Backyard used or any receptacle that could act as a chamber pot inhabitants fetched water from the main house and was used. The contents of such receptacles were often stored the water in a bucket in the shack. disposed of in the storm water drain. On the day of the home visit, 58% of toilets were found to be non- operational (Table 2). Waste disposal The main houses were in a state of disrepair The disposal of household waste was unsatisfactory. (Table 2). The majority of the houses had cracked The sanitary state of the yard outside the dwelling was walls and/or visibly leaking roofs (walls streaked classified as poor in 76% of the premises inspected. with previous leak damage). About half of the houses In 68% of cases there was no waste bin inside the had unpainted walls, allowing wind-driven rain to dwelling. Household disposal of sewage from cham- seep through. A common occurrence was the use of ber pots and soiled baby diapers was inappropriate in softened bar soap to fill holes in leaking roofs. Some 21% of cases (mainly into the storm water drain and households had reported the structural problems in the street). In addition, 22% of households disposed (Table 2) to the City Council, but stated that they of their solid refuse on the street. Fifteen percent of eventually “fixed the problem themselves or learnt respondents said that nothing will happen if rubbish to live with it.” This was fruitless as Council does is thrown into the toilet. not own these structures and could not be expected to All of the respondents in the survey complained maintain them. of pests carrying potential health risks within their immediate home environment. The respondents from all four communities reported their most prominent Electricity and water services pest problem was rats by 50%, cockroaches by 30%, All of the main houses had an operational prepaid elec- fleas by 16% and flies by 4%. Flies were observed in tricity connection. Backyard dwellings created illegal all homes, indicating the presence of flies were under- connections from the main house, and paid between reported. R50 to R200 per month for electricity usage. Of the Only one of the four sites had access to a drain lead- main houses interviewed in the survey, only seven (4%) ing to the sewerage system for the disposal of grey water of the 173 houses timeously paid the local municipal- (Table 3). Storm water drains were mostly used by fam- ity for water usage (approximately R500 paid in total ilies who lived in close proximity to such an opening in the kerb, while others preferred to use the toilet or Table 2. Distribution of observations of poor condition of open ground as disposal points. The storm water vol- low-cost (main) houses. ume generated in built-up areas is related to the extent Observation Number % of the hardened surfaces in those areas. The total roof (n = 173) Outside walls not painted 82 47 Table 3. The percentage of dwellings who dispose of Inside walls not painted 88 51 household waste water inappropriately (n = 336). Cracked walls 117 68 Door not well fitted 103 60 Waste water Open Toilet Storm-water Broken windows 60 35 source land drain Toilet not operational 101 58 Toilet leaking 69 40 Bathing/washing 14.9 41.7 4.5 Tap leaking 63 36 Kitchen* 23.2 20.2 2.7 Roof leaking 136 79 Laundry 13.1 47.9 1.5 Structural damage 11 6 notes: *Includes waste water from food preparation, dishes and cleaning. Environmental Health Insights 2011:5 29 Govender et al area for main houses was 5550 m while for backyard Driftsands community used other healthcare facili- dwellings the total roof area was 1587 m . Therefore the ties in neighbouring communities. Of the 400 signs shacks added an extra 29% of roof area with resultant and symptoms of illness reported by the participants, increase in stormwater during rain events. The inhabit- only 35% (140 symptoms) were treated by visiting ants reported frequent flooding in the settlements. the local clinic (Table 6). Sixty percent of the participants walked to Health profile their primary health care clinic, while 39% used a Over the two weeks preceding the survey 38% of ‘communal taxi’ and one percent utilized private dwellings reported one or more persons suffering transport. The amount paid for a return trip per person from diarrhoea (Table 4). to a health care facility varied from R5.00 to R35.00 Five percent of the participants willingly disclosed (about US$1–$5). This was a significant amount of that they were HIV positive, while 11% reported that the total household earnings as the mean reported they were TB positive, one of whom reported being total monthly income per household was R1353 diagnosed with Multiple Drug Resistant (MDR) TB. (about US$180). The cost of transport mounted con- None of those who reported suffering from TB or who siderably for those on chronic medication who had were HIV positive had any medication for their condi- to visit the clinic regularly. Thirty-five percent of the tion in the dwelling. Furthermore, none of the TB or households reported that there had been one or more HIV infected individuals had visited the clinic in the pre- occasions during the preceding year when a family ceding two months. The use of chronic medication was member needed to visit a clinic, but did not have reported by 165 (15%) respondents. In many instances, money to pay for transport. A large percentage (71%) respondents did not know what disease the medication of the households were not satisfied with the services was intended for. The five most common diseases diag- provided by the clinic and 86% thought that private nosed at the clinic and reported by the respondents are health care facilities would offer better services than summarised in Table 5. Of the main houses, 51% had a state clinic. one or more inhabitants who smoked, while 49% of the shack dwellings had one or more smokers (Table 5). Discussion Despite commendable efforts, the housing backlog for Primary health care services South Africa’s urban poor has grown from 1.5 million Three of the four low cost housing communities units in 1994 to about 2.1 million in 2010, according had access to a state clinic in their community. The to the Minister of Human Settlements. Taking into account the pace of delivery and the resources avail- able, as well as continued economic and population Table 4. Gender and age group of reported cases of growth and the rapid pace of urbanisation, it could diarrhea. take decades to beat the backlog. Number of cases % (n = 153) Income and education status Dwelling type The economic implications of the creation of shacks Main house 70 40 for subletting can be seen not only in the direct rent Shack 38 23 charged but also the water that was sold to back- Gender Male 74 48 yard dwellers. Only 4% of formal home owners paid Female 79 52 the municipality for their water usage, but all sold Age water to the back yard dwellers. The amount of rent 50 33 ,10 charged was not exorbitant and constituted a basic 11–20 23 15 service rendered rather than an exploitative one. 21–30 38 25 Very few of the dwellers living in the shacks were 31–40 26 17 41–50 10 7 relatives of the dwellers in the main house. These 51–60 3 2 shacks are rented out for income and/or to relieve 3 2 the pressing housing need in the city. The situation 30 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Table 5. Five most frequent illnesses diagnosed at a clinic* and treated by medication as reported by participants, differentiated by housing type. Diagnoses Main house Shack dwellers P-value reported occupants (n = 710) (n = 370) (Chi-square test) Number % Number % Hypertension* 42 5.9 9 2.4 0.01 Asthma* 32 4.5 17 4.6 0.95 Diabetes* 28 3.9 7 1.9 0.07 Arthritis* 25 3.5 2 0.5 ,0.01 Epilepsy* 7 1.0 4 1.1 0.88 Substance use 89 53 80 47 0.66 Smoke cigarettes 106 49 110 51 0.23 Consume alcohol 23 56 18 44 0.03 Use drugs 89 53 80 47 0.66 notes: *These diagnoses were verified by inspecting the medication issued by the clinic in each home; The nature of the drugs were not explored. therefore represents predominantly a landlord-renter their new home. This lack of knowing how to keep relationship. their homes clean and how to fix broken infrastructure Contrary to common belief, the present survey were strongly verbally communicated by the respon- found that backyard dwellers were better educated dents. In addition, their acquisition of an improved and had a higher employment rate and income when home was not accompanied by an improvement in compared with the inhabitants of the main houses. employment status and that resulted in many being Backyard dwellers have to seek employment and unable to afford the repairs or the cleaning materials generate an income as they have to pay rent and water required to keep the home clean. Within a short space and electricity usage to the owner of the main house of time, the sanitation facilities in their new home or otherwise face eviction. There is an inherent con- fell into a state of disrepair and were left uncleaned tradiction in this situation as the persons better able because of lack of both awareness and resources. to pay (shack dwellers) are actually living in poorer housing conditions. When analysing the total dis- Housing infrastructure tribution of education categories as included in the The condition of the state-funded main houses in the survey, the educational level attained by the inhabit- present study was poor and a cause for concern. These ants of the main houses were significantly lower than houses are not ‘owned’ by the state or the local author- those of the shack dwellers. Of all the adults in the ity any longer and the present indigent owner does total group, 8% were illiterate or functionally illiter- not have the n fi ancial ability or skills to maintain the ate (defined as schooling only up to Grade 4 or four house. Few of the owners actually exhibit a realistic years of primary school education). The lack of edu- awareness of what home ownership actually entails. cation among adults in the study contributed to the Almost all of them wanted the “government” or the homeowners’ lack of knowledge on how to maintain “municipality” to repair their homes. The situation has Table 6. Reported ailments and treatment. Main house Shack Total P-value n % n % n % Ailments reported 249 35 151 41 400 37 0.06 Participants suffering from ailment 198 28 117 32 315 29 0.20 Treatment of ailment Visited clinic 89 12 51 14 140 13 0.79 Home treatment 170 24 90 24 260 24 Participants still suffering from ailment 158 22 96 82 254 24 0.62 Environmental Health Insights 2011:5 31 Govender et al now deteriorated to the point that the failing sanitation Improved technology can only be a partial solu- infrastructure is impacting on municipal service deliv- tion to this problem. Successful implementation ery as well as causing huge pollution risks to the inhab- of proper waste management strategies strongly itants and the environment. This looming crisis will depend on an enabling social and economic envi- need huge n fi ancial and other resources to redress. The ronment that supports the services rendered. In the improvements in living standards envisaged by the present study both the infrastructure enabling the low-cost housing schemes are fast being lost. There is inhabitants of these communities to follow safe dis- an urgent need for education of these home owners to posal practices and their level of knowledge of such improve their ability to maintain the infrastructure of practices fall far short of even the most lenient defi- their homes. In some cases small defects would have nition of user co-operation. No education programs cost little to remedy at the time, but left untended, the to redress this situation were encountered during cumulative cost for renovation in these settlements is the study. by now very large. The consequences of this disastrous lack of infra- structure and awareness can be seen from the worri- Electricity and water services some results in this study. The levels of environmental All the formal and informal houses in this study had pollution, the visible deterioration of the surroundings access to electricity. The shacks accessed electricity by of these houses and the disease profiles of the inhabit - means of illegal connections such as extension cords. ants all indicate a looming crisis. These settlements When these electrical wires, many of which are of the are creating favourable conditions for disease out- wrong technical specifications for building to build- breaks because of the easy transmission of particu- ing connections, come into contact with corrugated larly oral-faecal, water or food related pathogens. The metal roof material, sparks fly in windy conditions. lack of adequate and timely removal of solid waste In wet weather the ungrounded connections can cause causes seepage from bins and bulk rubbish containers severe electrical shocks. The high number of smokers and inappropriate rubbish disposal contributes to the and illegal electrical connections in the presence of environmental pollution. Improper waste disposal at flimsy building materials of the shacks (wood, cor - the household and community level led to problems rugated iron sheets and even cardboard) increased the such as fly and rodent infestation, as reported by all risk of structural fires considerably. four communities in the present study. These aspects An analysis of burn injuries in Cape Town showed of the re-housing of urban poor should receive atten- that shack fire burns were the second most frequent tion by disaster-risk planning authorities. reason for admission to a Burns Unit in a secondary Even though low-cost housing settlements pro- hospital in Cape Town. Thus the insecure nature vided access to an onsite toilet and water facilities of electricity supply to shacks in the backyard has for backyard shack dwellers to use, there are insuf- implications for health care and fire services in the ficient waste disposal facilities in those settlements. City. The damage to property and injuries caused by Direct discharges of untreated sewage from such these frequent settlement fires are potentially pre- settlements into the environment—notably the urban ventable if municipal bylaws are strictly followed. At rivers—greatly increased the risk of disease trans- present the majority of efforts are aimed at speedier mission and environmental degradation, adding to response to fires rather than prevention. It is however the pressures on the urban poor. With a reported 21% an extremely difficult situation for the municipal ser - of households admitting to the unsafe disposal of vices, because eviction of backyard dwellers are not a human excreta; waste water and raw sewage makes political option in South Africa at present. its way into yards, sidewalks and streets and into the storm water drains. The rationale behind the provi- Waste disposal sion of free improved housing and free basic water Managing waste disposal in developing countries is allocation, namely increased hygiene and improved one of the most costly services as it takes up to 1% living conditions are thus negated by the lack of pro- of the gross national product and typically absorbs vision for adequate disposal of sewage, solid waste between 20% and 40% of municipal revenues. and waste water. Armitage et al (2009) warned that 32 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements in settlements the waste streams of storm water, Primary health care services sanitation and refuse removal cannot be considered The reported HIV positivity of 5% was almost cer- separately as the contamination is so effectively inter- tainly an undercount. The prevalence of HIV for the mingled under these circumstances. Cape Town metropolitan area for 2008 was reported Armitage et al (2009) found that grey water man- by the National Department of Health (2008) as agement had a low priority amongst inhabitants of 16.1% (95% confidence interval 14.7%–17.5%). settlements. Without adequate waterborne sanita- The lack of any antiretroviral medication present in tion, the disposal of household waste water becomes the dwellings was an equally worrisome finding. This a problem. Although the main houses in the pres- indicates a need for better monitoring and evaluation ent study had waterborne sanitation, the design of along with a more incisive public health approach to the facilities and the low level of proper sanitation support HIV positive persons. This unmet need has behaviour of the inhabitants caused widespread dis- implications for the burgeoning HIV/AIDS epidemic posal of waste water in two inappropriate ways. The in South Africa. Improved housing can theoreti- City of Cape Town faces periodic water shortages cally improve the health of HIV positive persons, that are set to increase with the advancement of cli- but under the present state of sanitation failures and mate change. Using potable water on such a large polluted environments, these improvements will not scale to dispose of waste water and other solid waste materialize due to high infection pressure. by flushing down the toilet is a wasteful habit that In spite of the reported TB and HIV positivity in needs urgent educational remediation. Any commu- this survey, no form of public health support or pre- nity outreach to change this habit will ultimately fail, ventative programme regarding these diseases was however, if user-friendly alternatives to this way of visible in these communities. Education programmes disposal are not provided. Unfortunately, retrofitting need to be initiated and sustained over a long period, such user-friendly alternatives have cost and engi- otherwise the relapse into old and unhelpful ways neering implications for the City and this dilemma will simply overtake all progress made. Community should be avoided by amending the planning in health workers are needed to keep the programme future housing settlements. operational. Without community-based health care Storm water runoff in urban areas is increased by ‘advisors’ or community members who can keep an impermeable urban surfaces such roofs and as hard- eye on the situation regarding cleanliness and dis- topping of streets and driveways. Unfortunately ease status in the community, no lasting improve- settlements are often constructed with little consider- ments will be seen. These community workers should ation for storm water drainage. Even formal storm be recruited from the communities they serve. With water drains are ‘passive’ systems simply receiving rudimentary training they can fulfill a useful func- any water and solid matter discarded in or near them tion to bridge the gap between the health needs of the and are thus vulnerable to blocking-up or misuse. inhabitants and the City health services. Such a ser- Storm water systems in low-cost settlements are used vice will need some administrative support, but could for the disposal of unwanted waste water, solid waste be maintained at a relatively low cost. and even dead animals as was readily apparent in the TB or HIV positive persons or those who are mal- present study areas. Apart from the risk of flooding nourished need clean living environments because of because of blocked storm water systems, the other their lowered immunity. The present living conditions major impact of this unfortunate situation is the major in this study add significant infection pressure to the 22,23 contamination of rivers flowing past urban areas. already poor health suffered by these persons. This in The implications of this widespread pollution of sur- turn added to the patient load at the already overbur- face water in the City for future water resources and dened and underfunded local health clinics, as well environmental health should receive urgent attention as higher up the referral chain of health services. The by the City planners and engineers. Strategies that can public health measures to tackle TB in these com- be considered include: constructed wetlands, swales, munities were wholly inadequate. The self-reported passive infiltration systems and tactically placed prevalence of TB was a source of great concern, nota- impoundments. bly the existence of a case of MDR-TB. The fact that Environmental Health Insights 2011:5 33 Govender et al none of these patients, including the case of MDR-TB, Many of the inhabitants of low-cost housing was on any TB medication has serious implications communities preferred to treat their ailments using for the future management of this potentially prevent- home remedies or traditional medicines. South Africa able disease. None of the TB-positive persons visited has many tradition healers who dispense herbal medi- the clinic in the preceding two months either, which cines of various origins. Unfortunately the efficacy indicated a serious lack of involvement of the primary and safety of some of these medicines are unknown. health care services in the area. At worst, such treatment may delay the diagnosis or If one in 1080 dwellers of these low-cost hous- treatment of serious transmissible conditions such as ing communities are already MDR-TB positive, then HIV and TB. This necessitates a need for traditional the City can expect a substantial increase in these healers to work in synergy with Western medical treat- difficult-to-treat cases, with a serious knock-on effect ment to improve the safety and health of inhabitants on the already overburdened health care system. The from low-income areas in South Africa. Although development of MDR may be related to poor com- there have been sporadic programs to incorporate pliance with drug treatment, poor treatment drug traditional healers into the formal health services, no choices, poor access to primary health care facilities systematic policy for incorporating them into the for- along with patient factors such as poor absorption of mal health services exists. drugs and general poor health. Many of these factors Barriers to access to health information and sup- are at play in these communities and the meticulous port services include cost, geographic location, illit- execution of TB control programmes in such environ- eracy, disability and capacity to utilize information 27,28 ments should be a high priority. This need is clearly effectively. All of these restraints are present in unmet at present. the communities in the present survey and effec- Moraes et al (2005) showed that in three poor tive ways of bridging these gaps are not in place at communities in Salvador, Brazil the incidence of present. Deliberate delays in obtaining medications diarrhoea in children in neighbourhoods with drain- were reported to be one of the most common strate- age and sewerage was one-third of the incidence in gies among urban poor in Australia. There are indi- neighbourhoods with neither service. They also cations that this strategy was also prevalent among the found that improving community sanitation—even participants in the present study since most attempted in the absence of hygiene-promoting behaviour—can home remedies first. Many of those who should have have an impact on diarrhoeal disease. This is impor- been on treatment (TB and HIV positive persons) tant in the context of the high reporting of diarrhoeal were not. Although the local clinic is within reach- disease among the inhabitants of the low-cost commu- able distance for many, cost of transport remains a nities in the present study. Thus the effort and money significant factor for these communities. The barriers spent on improving the sanitation systems in these resulting in low utilization have not been addressed in communities should improve the diarrhoeal morbid- these communities, warranting further research into ity experienced by these communities. Unfortunately, such barriers in order to prioritize their removal. estimations of the possible impact of improvements The low opinion of the perceived quality of care seldom include the expected easing of disease bur- available at the clinics also contributed to the poor dens as well as the reduction in the patient loads of utilization of the primary health care available to the primary health services. these communities. Haddad et al (1998) studied the This survey only recorded conditions that were expectations and criteria that two rural communities diagnosed formally at the clinic and for which the in Guinea used to determine quality of service. He medication could be verified. A major factor influenc- found that the criteria depended inter alia on gen- ing the accessibility of primary health care was the der and the ability to access the services and that the inability of some persons needing medical attention communities placed considerable emphasis on out- to procure transport to the clinic. The cost of using a comes of treatment, but little emphasis on preventa- communal taxi, especially for those with chronic con- tive services. With such poor utilization as reported ditions who had to visit the clinic repeatedly, made in the present study and so many barriers to effec- significant inroads into their household budget. tive primary health care, the local clinics cannot play 34 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements any meaningful role in addressing the serious health The unfortunate separation of the fields of public needs of the urban poor in these four communities. health and urban planning has contributed to uncoordi- Preventative actions by the local clinics that are so nated efforts to address the health of urban populations sorely needed in these communities with their high and a general failure to recognize the links between HIV and TB burdens as well as the added complica- the built environment and health disparities facing tions of poverty, substance abuse and hunger will be low-income populations. A reconnection of these two largely fruitless under the present circumstances and responsibilities is a prerequisite for successful improve- needs to be addressed urgently. ment of the present unsafe and unhealthy conditions prevailing in low-cost housing areas in South Africa. Conclusion The irony is that these resettlement programs were insti- The overall conclusion is that the envisaged improve- tuted to improve the living conditions of the urban poor ments in health supposed to be associated by rehous- and it is imperative that this improvement be realized. ing impoverished urban shack dwellers in improved housing did not materialise due to unforeseen hous- Acknowledgements ing design aspects as well as social and behavioural We thank the Harry Crossley Foundation, the German aspects. The reasons are not straight-forward. The Academic Exchange Service (DAAD), the National lack of improvement in health resulted from com- Research Foundation and Stellenbosch University plex interactions of poor design (especially sanitation for the funding of this project. We are grateful to infrastructure of both the dwellings and the municipal Sister N. Lethuka for assisting in the administering of structures), low levels of education, poor sanitation the survey and Professor M. Kidd from the Centre for behaviour, poverty and overcrowding. The shacks in Statistical Consultation at Stellenbosch University the backyard contributed significantly to overcrowd- for statistical support. ing, sanitation failures and environmental pollution, but were not in all instances the main drivers of these Disclosure risk factors. They however added to the burdens This manuscript has been read and approved by all already present in the communities. The shacks did authors. This paper is unique and is not under con- contribute a moderate amount of income to the own- sideration by any other publication and has not been ers of the main houses, but whether this contribution published elsewhere. The authors and peer reviewers is offset by the extra burden of disease (for instance) of this paper report no coni fl cts of interest. The authors cannot be answered by the present study, nor was it confirm that they have permission to reproduce any designed to do so. copyrighted material. Given the design of these houses and the added pressure on the existing infrastructure by the inhab- References 1. Shaw M. Housing and Public Health. Annual Review of Public Health. itants of unplanned housing in the backyard, these 2004;25:397–418. results send a powerful message that the existence 2. Thomson H, Petticrew M, Morrison D. Health effects of housing improvement: systematic review of intervention studies. 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Water Science Technology. 2009;59:2341–50. 20. Carden K, Armitage N, Winter K, Sichone O, Rivett U. The management of greywater in the non-sewered areas of South Africa. Urban Water Journal. 2008;5:329–43. 36 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Appendicies Appendix A: Health evaluation questionnaire Good day Sir/Madam My name is Sister Lethuka. You are invited to take part in a research project carried out by the Medical Faculty of the University of Stellenbosch. We are going to be studying your health and home. Note that your participa- tion in the study is voluntary and you may opt to leave the interview at any time. All answers and comments will be kept highly confidential. We will not record your name and we promise that no information you give us will be attached to you or anyone living in your home. Please do not hesitate to ask any questions that you may have with this study. Section 1: Biographical details 1.1 Please provide us with the following information, so that we can learn more about your family. Is this sex Status of individual Educational status: person Male Female U—Unemployed A—No schooling disabled? F—Full time employed B—Pre-primary to grade 4 Yes no P—Part time employed C—Grade 5 to grade 7 IRR—Irregular employment D—Grade 8 to grade 10 S—Scholar E—Grade 9 to grade 12 C—Child at home F—Tertiary level A—Adult at home U—Unsure A1 A2 A3 A4 A5 A6 1.2 Are members of the household Mark the person’s choice () South African Citizens Yes No If no, what is your country of citizenship And for how long have you lived in South Africa Have there been any deaths among the persons living in the house in the past 6 months and if possible please specify the cause? Mark the person’s choice () Yes Specify: No Environmental Health Insights 2011:5 37 Code of person Role in household Age How long has the person lived in this house (years) Govender et al Section 2: Disease and health services 2.1 During the past two weeks, are there symptoms that affected you or persons living in your house? Symptom Code of person/ Home Visited clinic/ Is the person still suffering persons with treatment () Doctor () from the symptom (Y/N) symptom Diarrhoea Fever Nausea Vomiting Cramps/abdominal pain Blood in stools or vomit Worms in faeces Body/hand sores Eye infection Coughing Shortness of breath Tiredness and weakness of body Coughing blood Loss of appetite and weight Night sweats Headaches Nits/lice Yellow looking skin White of eyes are yellow Itchy skin Coughing for more than 1 week Other: 2.2 Have any members of your household visited the clinic and/or doctor in the past two months and been diagnosed with an illness/disease? Code of the Illness/disease Was medicine given Is the illness Have you or any member person for the illness? (Y/N) cured? (Y/N) in your household suffered from the illness before? (Y/N) 2.3 Are any members of the household on chronic medication? Mark the person’s choice () Yes No If yes, specify for what illness ***Note to interviewer: If the answer is yes, ask to see the medication. 38 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements 2.4 Do you think that people in your household suffer from the following diseases at the moment? (Optional) Mark the person’s choice () Yes No Unsure TB HIV/AIDS 2.5 What are some of the other health problems facing your household? 1. 2. 3. 4. 5. 6. 2.6 Do members of your household take part in using the following substances? Mark the person’s choice () Cigarettes Alcohol Drugs Yes No Unsure 2.7 What is the name of the clinic that members of your household visit when ill? –––––––––––––––––––––––– 2.8 How do you get to the clinic? Mark the person’s choice () Walk Taxi Bus Private transport Other, specify: 2.9 What does a return trip to the clinic cost (if you need to pay)? R _____, ___ 2.10 Has there ever been a time when you or a family member needed to visit the clinic, but did not have the money to pay for transport? Mark the person’s choice () Yes No Unsure 2.11 Are you satisfied with the services provided by the clinic? Mark the person’s choice () Yes No Unsure Environmental Health Insights 2011:5 39 Govender et al 2.12 Do you think that private health facilities provide better services than your clinic? Mark the person’s choice () Yes No Unsure 2.13 Have you or members of your household ever called for an ambulance? Mark the person’s choice () Yes No Unsure 2.14 Usually, how many meals does your family eat per day? Ring the person’s choice 1 2 3 4 5 6 7 8 Section 3: Hygiene and the environment 3.1 Do you think that you can get sick from the following? Mark the person’s choice () Using a dirty toilet Yes No Unsure An unclean home Yes No Unsure Dirt and rubbish in your yard or the street Yes No Unsure Drinking dirty water Yes No Unsure Drinking water from rivers and streams Yes No Unsure 3.2 Is it difficult to keep your home clean? Mark the person’s choice () Yes No Unsure 3.3 Do you find it expensive to purchase cleaning material for your home? Mark the person’s choice () Yes No Unsure 3.4 Have you or any member of your household been a victim of crime in the past six months? Mark the person’s choice () Yes No Unsure 3.5 Can you mention some of the crime committed in your community? 1. 2. 3. 4. 5. 6. 40 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements 3.6 Are there safe places to play for the children in your household? Mark the person’s choice () Yes No Unsure Notes: Thank you for taking the time to answer our questions. Again, any information provided by yourself during the interview will be kept confidential. Your participation in the study is highly appreciated. Date of interview: Time of interview: Street Name and House number (This information will be kept strictly confidential) Classify: Main House or Shack Suburb: 1 2 3 4 Environmental Health Insights 2011:5 41 Govender et al Appendix B: Housing Evaluation Questionnaire My name is Thashlin Govender. You are invited to take part in a research project carried out by the Medical Faculty of the University of Stellenbosch. We are studying your health and home. Please note that your par- ticipation in the study is voluntary. All answers and comments will be kept highly confidential. We would appreciate it if you could allow us to ask you some questions about your home and have a look at the structure of your house. We will not need your name and we promise that no information you give us will be attached to you or anyone living in your home. Please do not hesitate to ask any questions that you may have regarding this study. Section 1: Household information 1.1 What is the total income of the household living in the dwelling per month? Mark the correct one () Less than R600 per month R600 to R1 200 per month R1200 to R2500 per month More than R2500 per month Unsure 1.2 What is the dwelling used for? Mark the correct one () Main household accommodation Additional household accommodation Rented out accommodation Business premises Storage room Garage Other: Other: 1.3 Who owns this home? ––––––––––––––––––––––––– 1.4 Does he/she stay here? Mark the correct one () Yes No Unsure 1.5 If you rent the home, how much do you pay per month? R _____, ___ 1.6 Where did you stay prior to moving to this settlement? 42 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements 1.7 Backyard dwellers only: Have you applied to join the housing list? If yes, how long have you been waiting for a house? Mark the correct one () On waiting list for: Yes –––––––––––– years No –––––––––––– months Unsure 1.8 RDP house only: Did you get this home by joining the housing list? If yes, how long ago did you receive this home? Mark the correct one () When did you receive the home? Yes –––––––––––– years No –––––––––––– months Unsure 1.9 Who pays for the repairs of this home? ––––––––––––––––––––––––– 1.10 Can you afford the repairs of the home? Mark the correct one () Yes No Unsure 1.11 Do you pay for water to drink and clean your home and if yes, who do you pay? Mark the correct one () Yes no Unsure Recipient of payment: Drink Clean your home 1.12 Do you pay for electricity and if yes, who do you pay? Mark the correct one () Yes Recipient of payment: No Unsure 1.13 Do you (or somebody in your home) receive a social grant? Mark the correct one () Yes No Unsure Environmental Health Insights 2011:5 43 Govender et al Section 2: Toilet facilities 2.1 Where is the toilet for the persons living in this house? Primary Secondary Mark the correct one () Toilet inside the house Toilet outside the house, but on the same property Communal toilet away from the dwelling No toilet available within easy walking distance If no toilet is available, what do the inhabitants use? 2.2 What sort of toilet is it? Mark the correct one () Flush toilet Longdrop (pit latrine) Bucket system Other, specify: 1.3 Does your toilet break or is it blocked often? Mark the correct one () Yes No Unsure Not applicable 2.4 Where do the members of the household dispose of soiled products, eg, sewage, soiled nappies? Please mark   = Yes, X = No In the street Outside bin Into the storm water drain If other, specify: Rubbish skip 2.5 If the toilet is away from the dwelling, how far do the inhabitants have to walk to get to the toilet Distance: paces 2.6 Do you know who to contact if there is a drain blocked or overflowing? If yes, specify Mark the correct one () Yes No Unsure 2.7 Who would you tell if there is a drain blocked and overflowing? 1. 2. 44 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements 2.8 What will happen if rubbish is thrown into the toilet? Mark the correct one () Nothing It will block the toilet and the pipes Don’t know 2.9 Can you get sick from not washing your hands after you used the toilet? Mark the correct one () Yes No Unsure 2.10 How often is your toilet cleaned? Mark the correct one () Once a day Twice a week Once a week Sometimes Unsure 2.11 What are the cleaning materials used to clean the toilet? Please mark   = Yes, X = No Disinfectant Soap Detergent Toilet brush Cloth 2.12 Do you pay to use the toilet? Mark the correct one () Yes No Unsure Section 3: Washing and other water use 3.1 Is there a working tap available? Mark the correct one () Inside the house On the property Nearby (not on property) Environmental Health Insights 2011:5 45 Govender et al 3.2 Are there facilities nearby to wash your hands after using the toilet? Mark the correct one () Yes No Unsure 3.3 Where are your clothes washed? –––––––––––––––––––––––––––––––––––––––––––––––––––– 3.4 What happens to the water used to wash your clothes? 3.5 When water is used to wash and prepare food, what happens to that water? 3.6 Where do the persons living in the house wash themselves? 3.7 What happens to the wash water? Section 4: Solid waste 4.1 Where does the household dispose of its rubbish? Please mark   = Yes, X = No In a rubbish bin inside the house At the skip outside on the street Throw it on the street Other If “Other”, please specify: ............................................................................. ...................................................................................................................... ...................................................................................................................... 46 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Section 5: Vector identification 5.1 Have you found any rats, mice or cockroaches in your home? Mark the correct one () Yes No Unsure If yes, specify the type of animal a) b) c) Thank you for taking the time to answer our questions. Again, any information provided by yourself during the interview will be kept confidential. Your participation in the study is highly appreciated. Date of interview: Time of interview: Street Name and House number (This information will be kept strictly confidential) Classify: Main House or Shack Suburb: 1 2 3 4 Survey Number: Environmental Health Insights 2011:5 47 Govender et al Appendix C: Dwelling Checklist Survey Number: Ring the appropriate answer comments 1 Type of dwelling Main Shack in Other dwelling backyard 2 Is the house neatly maintained? Poor Fair Good 3 Are the outside walls of the home painted? Yes No 4 Are the inside walls of the home painted? 5 Are there cracks on the wall? Yes No 6 Does the house have electricity? Yes No 7 Is the roof of the house leaking? 8 Is the door well fitted? Yes No 9 Does the house have any broken windows? Yes No 10 Is the bathroom clean? Poor Fair Good 11 Is the toilet in working order? Yes No 12 Is the toilet leaking? Yes No 13 Is the tap leaking? Yes No 14 Is there toilet paper in the bathroom? Yes No 15 Is there soap available in the bathroom to wash hands? Yes No 16 Is there a clean towel or paper towels available in the bathroom? Yes No 17 Is the drain clean? Poor Fair Good 18 Is the roof leaking? Yes No 19 Are there any structural damages to the home? Yes No 20 Are there any structural alterations or extensions to the home? Yes No 21 What is the state of the yard outside the home? Poor Fair Good 22 Is there a bin inside the home? Yes No 23 Is there a bin outside the home? Yes No 24 Is there a garden outside the home? Yes No 25 Is rubbish evident outside the home? Yes No 26 Are there pools of water outside the home? Yes No 27 Is there broken glass evident outside the home? Yes No 28 Does the family own pets/animals? Yes No 29 Does the home have electricity? And if yes, is it legal or illegal? Yes No Legal Illegal 30 Is there evidence of other forms of heating/lighting? Yes No 31 Does the home have an operational refrigerator? Yes No 32 Does the home have an operational stove? Yes No 48 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements Appendix D: Participant Information Leaflet and Consent Form TITLE OF THE RESEARCH PROJECT: An epidemiological study on the health and sanitation status of specific low cost housing communities as contrasted with those occupying ‘backyard dwellings’ in the City of Cape Town, South Africa. REFERENCE NUMBER: N09-08-214/215/216. PRINCIPAL INVESTIGATOR: Thashlin Govender, PhD Candidate, Division of Community Health, Department of Interdisciplinary Health Sciences, Faculty of Health Science, Tygerberg Campus, Stellenbosch University. ADDRESS: 55 Carnie Road, Rylands Estate, Cape Town, 7764. CONTACT NUMBER: 083 730 2846. You are being invited to take part in a research project. Please take some time to read the information presented here, which will explain the details of this project. Please ask the study staff or doctor any questions about any part of this project that you do not fully understand. It is very important that you are fully satisfied that you clearly understand what this research entails and how you could be involved. Also, your participation is entirely voluntary and you are free to decline to participate. If you say no, this will not affect you negatively in any way whatsoever. You are also free to withdraw from the study at any point, even if you do agree to take part. This study has been approved by the Committee for Human Research at Stellenbosch University and will be conducted according to the ethical guidelines and principles of the international Declaration of Helsinki, South African Guidelines for Good Clinical Practice and the Medical Research Council (MRC) Ethical Guidelines for Research. What is this research study all about? A total of 50 homes with a plot number will be randomly selected to take part in the study. The reason for us doing the study is to investigate the health of the people in your community and the water use and sanitation in your home. There are two parts to the study that we need your assistance with. Firstly, we will ask you questions about your home and your water use and sanitation. For this part of the survey we will also take a look around your home. You may accompany us during this part of the survey. Secondly, a nurse will ask you some questions about the health of your family. These surveys will be done for your home alone. We will be taking down your address, but we will not be taking down any names of you and your family in the interview. This is done so that no one will be able to identify from whom the information was obtained and who is sick or who became ill in your home. This consent form will not be attached to your answer sheet, so that again no one will be able to n fi d out that this information was provided by you. Once you have completed this consent form, this form will be placed in a sealed box together with all the other forms from your community, for safety purposes. A report of the n fi dings from the study will be sent to your ward councilor, and we will try to make the information available in a community news- paper. We will also send a report to the City of Cape Town ofc fi es, so that they know about the living conditions in your community and the problems that you and your community are faced with. You can contact Dr J.M Barnes at 021-9389480 if you have any questions or problems or would like to know the results of this study. You may also contact the Committee for Human Research at Stellenbosch University at 021-938 9207 if you have any concerns or complaints. You will receive a copy of this information and consent form for your own records. Why have you been invited to participate? You have been selected by chance so that the information we gather is a fair representation of your community. We want to investigate the health status of you and your family and the living conditions in and around your environment. Environmental Health Insights 2011:5 49 Govender et al What will your responsibilities be? To please answer the questions as best as you can. Will you benefit from taking part in this research? The results from this study will be summarised and provided to the local, provincial and national government in order to improve planning for housing and health. The results will help us understand the needs of your com- munity and environment. Are there any risks involved in your taking part in this research? There are no risks involved in taking part in the study. And we assure you of your anonymity. If you do not agree to take part, what alternatives do you have? YOU HAVE A RIGHT TO NOT TAKE PART OR STOP THE INTERVIEW; AND THERE WILL BE NO IMPLICATIONS IF THIS IS YOUR DECISION. DECLARATION BY PARTICIPANT By signing below, I …………………………………..…………. agree to take part in a research study entitled, An epidemiological study on the health and sanitation status of specific low cost housing communities as contrasted with those occupying ‘backyard dwellings’ in the City of Cape Town, South Africa. I declare that: • I have read or had read to me this information and consent form and it is written in a language with which I am fluent and comfortable. • I have had a chance to ask questions and all my questions have been adequately answered. • I understand that taking part in this study is voluntary and I have not been pressurised to take part. • I may choose to leave the study at any time and will not be penalised or prejudiced in any way. • I may be asked to leave the study before it has finished, if the study doctor or researcher feels it is in my best interests, or if I do not follow the study plan, as agreed to. • I have given permission to take and use pictures of my home and family members for publication purposes. Signed at (place) ......................…........…………….. on (date) …………....……….. 2009. ........................................................... ........................................................... Signature of participant Signature of witness 50 Environmental Health Insights 2011:5 The impact of densification in low-cost housing settlements DECLARATION BY INVESTIGATOR I (name) ......................…........……………..…………..………….. declare that: • I explained the information in this document to ......................…........…………… • I encouraged him/her to ask questions and took adequate time to answer them. • I am satisfied that he/she adequately understands all aspects of the research, as discussed above. • I did/did not use a interpreter. (If an interpreter is used then the interpreter must sign the declaration below). Signed at (place) ......................…........…………….. on (date) …………....……….. 2009. ........................................................... ........................................................... Signature of investigator Signature of witness Declaration by interpreter I (name) ......................…........……………..…………..………….. declare that: • I assisted the investigator (name) ......................…...... to explain the information in this document to (name of participant) ......................…........ using the language medium of Afrikaans/Xhosa. • We encouraged him/her to ask questions and took adequate time to answer them. • I conveyed a factually correct version of what was related to me. • I am satisfied that the participant fully understands the content of this informed consent document and has had all his/her question satisfactorily answered. Signed at (place) ......................…........…………….. on (date) …………....……….. ........................................................... ........................................................... Signature of interpreter Signature of witness Environmental Health Insights 2011:5 51 Govender et al Publish with Libertas Academica and every scientist working in your field can read your article “I would like to say that this is the most author-friendly editing process I have experienced in over 150 publications. Thank you most sincerely.” “The communication between your staff and me has been terrific. Whenever progress is made with the manuscript, I receive notice. Quite honestly, I’ve never had such complete communication with a journal.” “LA is different, and hopefully represents a kind of scientific publication machinery that removes the hurdles from free flow of scientific thought.” Your paper will be: • Available to your entire community free of charge • Fairly and quickly peer reviewed • Yours! You retain copyright http://www.la-press.com 52 Environmental Health Insights 2011:5

Journal

Environmental Health InsightsPubmed Central

Published: May 16, 2011

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