Log in

When the Daughters of Charity of St. Vincent de Paul first arrived in Ondo State in Nigeria in 1988, they found fertile agriculture as well as fertile ground for disease and severely limited health care. In 1995, they made a giant health care leap. They opened St. Catherine's Hospital and Maternity. The initial site and building, which were donated, grew to accommodate the remote community's needs. They do not charge patients.

Over nearly 30 years, they've treated countless patients. But without an influx of needed funds, St. Catherine's health care story also became another story — a common one seldom told.

Tens of thousands of faith-based health care facilities around the world serve populations in impoverished areas where there might otherwise be no health care. But from maternal and newborn infections and deaths to dozens of illnesses and diseases, from malnutrition to the growing global crisis of antibiotic resistance, the root of health problems often returns to one thing, and it's the absence of WASH: water, sanitation and hygiene.

With small budgets stretched to the breaking point, stocking drugs and meeting basic treatment protocols become the priorities. The necessity of WASH goes unmet. The irony, of course, is that access to WASH is the foundation for preventing many of the infections that make these drugs and treatments necessary, and contaminated water can make already vulnerable patients sicker.

The lack of priority and budgets for sourcing safe water and WASH infrastructure means pipes, pumps, tanks and toilets don't exist. Or they age, break and don't get fixed. As an advocate for improved water, sanitation and hygiene measures throughout the world, I can't count the number of broken faucets I've encountered, or sinks used as bookshelves and trash bins (or even collapsed off the wall entirely). Toilets are germ-ridden; medical waste is openly burned, leading to dangerous environments; labor and delivery ward conditions are shocking. Staff, including cleaners, are left to work and live in sometimes terrible conditions. Most do the best they can, but safe and dignified care is impossible.

This crisis is by no means specific to faith-based health care. Across the 46 least developed countries, 47% of all health care facilities lack basic water services, 79% lack sanitation services, 68% lack basic hygiene services, such as hand-washing, and 66% lack basic waste management. The consequences ripple outward into a cavalcade of problems — the lack of infection prevention and control leads to health care-associated infections and antimicrobial resistance, with a massive economic impact on gross domestic product.¹

THE RIPPLE EFFECT
But there's another ripple effect underway. A very good one.

I first wrote about a Vatican pilot initiative to improve WASH services in Catholic-run health care facilities for the Health Progress Fall 2021 issue.² At that time, 150 Catholic health care facilities were wrapping up WASH assessments. In what now feels prescient, interest in this pilot project by the Vatican's Dicastery for Promoting Integral Human Development began in 2019, before the COVID-19 pandemic.³

When the Dicastery officially reached out to bishops in 2020 to see if any might be interested in voluntarily participating, the invitation provoked an outpouring across 23 countries and 65 dioceses. WASH assessments got underway in the first 150 health care facilities that requested help, with a symbolic"151st" representing the WASH needs across the Catholic health care system, the "Ecclesia Universalis."

Cardinal Michael F. Czerny, SJ, took over leadership of the Dicastery in 2022 and continues his strong support. "These facilities are invaluable, especially in deprived zones in which concerns for economic development and donor generosity go hand in hand. It is a matter of human dignity, solidarity and social justice," says Cardinal Czerny. "I may add that providing effective health care is a way of avoiding other social and economic burdens to the society, and it is also a way of contributing to the equality of opportunities for all of which the Holy Father speaks about in Laudate Deum."⁴

Thanks to the 150 WASH assessments, nearly all the facilities have identified needs and estimated costs. The price tag to improve all aspects of WASH, including maintenance and operations for sustainability, averages $80,000 per facility; of course, that varies per needs. The total budget for these 150 health care facilities to get, repair or upgrade WASH — and ensure sustainability — is $12 million. If that sounds like a lot of money, it's just $2.33 per person, considering these 150 facilities cover catchment areas totaling 28 million people.

So far, more than $3 million has been raised in private donations and spread across about half the facilities. These funds are being used to train staff in WASH management and focus on the most critical WASH needs as funding allows. Of course, it's not just about the money. For some projects, technical expertise and community labor contribute as much as 20% of the total project cost. And some WASH needs don't need funding; they just need to be identified and then prioritized.

The core teams leading the way include Catholic Relief Services and Caritas Internationalis, along with Daughters of Charity and their technical partner Water Engineers for the Americas and Africa. Other participants include (but are not limited to) the Camillian Sisters, Brothers Hospitallers of Saint John of God, also known as Fatebenefratelli, and Doctors with Africa. The Catholic Health Association and several CHA members have contributed to global WASH work.

At St. Catherine's Hospital and Maternity in Nigeria, the hospital no longer drains much-needed funds on purchasing and transporting water. Sr. Mary Louise Stubbs, DC, who leads the Daughters of Charity International Project Services, raised funds to drill a new borehole for water and build new water tanks. They've also demolished unsafe infrastructure and built an incinerator to safely dispose of hazardous medical waste. There are new latrines accessible to those with disabilities and plenty of hand-washing stations.

These WASH improvements have met a laundry list of needs. Not only do staff and patients have enough clean running water, but the community also has access to this safe water, which reduces exposure to waterborne diseases the health care center might otherwise need to treat. Improved facility conditions mean more people will be willing to seek out care at St. Catherine's, especially prenatal, maternal and newborn care. Nigeria has the second highest maternal and newborn death rates in the world, with preventable infection among the leading causes.^{5, 6}

Despite its many health benefits, getting WASH into health care facilities has, until recently, largely remained under the global radar. Then, in 2018, UN Secretary-General António Guterres issued the first global call to action. The World Health Assembly followed with a resolution and WHO/UNICEF followed with eight practical steps as guidance.^7-9 These initial UN actions were important in generating much-needed attention. That the Catholic Church — which operates a quarter of the world's health care facilities and is the largest network of providers in the world — decided to take a look in its own backyard is admirable and influential.¹⁰

"Adequate WASH conditions in all health care facilities are a fundamental need and a priority. The assessment carried out through so many
partners over the past years has revealed that there is much to be done in Catholic facilities in poor areas," says Cardinal Czerny. "Moreover, the requests for assistance and training emanating even from health centers or congregations not involved in the initial assessment demonstrate a greater awareness of these issues."

Indeed, this Dicastery-driven project has garnered attention at the highest levels in Rome, across dioceses, at the UN, WHO and UNICEF, and has attracted funders including CHA members, new partner organizations and local government engagement. While it is impossible to know how many more Catholic, public and other faith-run health care facilities are starting to look at their own WASH needs, we know the ripple is widening.

Tony Castleman, director of agriculture, livelihoods, water and environment at Catholic Relief Services, sees the attention to this effort expanding. "The involvement of the Vatican's Dicastery has been critical to inspiring dioceses, congregations and other local partners to prioritize improving WASH in health care facilities," says Castleman, who also serves as director of monitoring, evaluation, accountability and learning for Catholic Relief Services ."The Dicastery's voice has helped bring attention to this critical issue." Sr. Stubbs agrees: "Being able to say we're working with the Vatican on WASH projects increases our advocacy and reach." She adds that the partnership has generated many more health facility water system projects for her organization, projects that also benefit communities.

It's so important to note that faith-based health care facilities are not just embedded in a community; they are the community. Sometimes lip service is paid to community-led efforts, but organizations like Catholic Relief Services and Daughters of Charity live it. "The community impact of any one of these WASH projects," says Sr. Stubbs, "is enormous." A WASH project creates jobs. The community gets access to the new water point. No longer having to spend time searching for water, girls get to go to school. The sisters actively engage community health workers, who spread health education — from hand-washing, to improving maternal and child health, starting with clean births, to emphasizing the importance of safe water for HIV/AIDS patients.

The Kenya Conference of Catholic Bishops has the largest number of health care facilities participating in this Vatican pilot. Kenya is also among the most water-scarce countries in the world, and the climate crisis only makes conditions worse. Assessments found most facilities had no access to safe drinking water because water came primarily from unprotected boreholes or vendors that transport water from rivers. Medical waste was burned in open pits, toilets were unhygienic and not accessible, and staff had limited WASH training. At one facility, when there was no water, the maternity ward would be shut down.

With 22 of 28 pilot facilities having received some private funding through this initiative, the Kenya Conference of Catholic Bishops and Catholic Relief Services began work on critical improvements, such as new water tanks with increased capacity for rainwater collection during dry seasons. In one facility, where the biggest challenge was replacing its borehole damaged by elephants, they've installed a solar pump and fenced the area in the hopes of keeping out animals. Data collection systems are also being set up to better measure impact, especially when it comes to reducing health care-associated infections.

But what isn't typical is what happened next.

The Kenya Conference of Catholic Bishops is going to try to tackle the Achilles' heel of WASH — sustainability — by hiring a point person whose sole purpose is to ensure it. WASH conditions inevitably deteriorate, and when there is no one with the focus, skills, tools and parts, and the funds to do preventive maintenance and fix problems, WASH falls apart. By hiring a dedicated person, the Kenyan conference will advance global understanding of how to systemically address this pervasive challenge. Starting with these 28 facilities, they hope to eventually cover all 497 of Kenya's Catholic facilities.

Then came another ripple effect. WASH construction attracted the attention of regional and local government officials. Catholic-run facilities are becoming models and training sites for public facilities, which have many similar WASH needs. In one diocese, the county government, in partnership with Catholic Relief Services and the diocese, is now mapping out water delivery options in a particularly arid area, sharing findings and connecting Catholic facilities to the public water utility system, where applicable.

The Vatican initiative is not limited to Africa. The Philippines has stronger government health care regulations, and medical staff are highly qualified. Still, facilities face structural problems and, not surprisingly, sustainability issues. WASH assessments found a lack of preventive maintenance, spare parts and funding for repairs. This systemic weakness led Catholic Relief Services to work with the Philippine pilot facilities to strengthen management to improve operations, maintenance and life cycle financing, and collect district-wide WASH data for better monitoring.

SMART INVESTMENT MADE SMARTER
These are some of the good tales to tell. Even so, Cardinal Czerny acknowledges broader support is needed. "A whole ecosystem is needed for the Church to effectively carry out this part of its diakonia ministry: the commitment of universities and other training centers, qualified experts, bishops, vigilant leaders in the health sector and well-trained staff. Procedures, maintenance routines and economic capacity are needed to support health care facilities."

When it comes to increasing economic capacity with sustained funding, doubters out there — whether public or private funders — would be wise to take a look at a recent eye-popping report from WaterAid.¹¹

Preventable infections acquired inside health care facilities, such as sepsis and pneumonia, are costing Sub-Saharan Africa a staggering $8.4 billion each year. Most health care-associated infections are caused by contaminated hands, surfaces or equipment. Infection prevention and control, like proper hand-washing, could prevent up to 70% of these infections. This $8.4 billion is also equivalent to the funds needed to provide universal, basic WASH services in all health care facilities across the 46 least developed countries where WASH remains desperately needed.^{12, 13}

Using World Bank economic assessments generated with new methodology (available to countries to do their own assessments), WaterAid focused its report on seven countries where it has a presence: Nigeria, Ethiopia, Zambia, Uganda, Mali, Ghana and Malawi.¹⁴ Just to give a taste of the extraordinary financial burden imposed by health care-associated infections, in Malawi, the impact on GDP is nearly 3% and consumes almost 11% of its annual health care budget. On average, health care-associated infections alone cost 4.5% of these health budgets every year. Investment in WASH more than pays for itself.

Of course, financial impact is not the only burden. One in 10 patients with a health care-associated infection will die.¹⁵ (I will never forget what a nurse sent from Scandinavia to install incubators in rural government health care facilities in East Africa once told me. Without reliable WASH, these incubators were, in his exact words, "killing machines.")

We talk about mass casualties in terms of war, but health care-associated infections are a war on the masses, causing mass death and suffering.

To stop the rapid spread of health care-associated infections where WASH is lacking, health care providers overuse antibiotics. This, of course, contributes to antibiotic resistance, which kills at least 1.27 million people worldwide annually.¹⁶ But what choice do they have? The WHO makes this frightening prediction, "In all countries, some routine surgical operations and cancer chemotherapy will become less safe without effective antibiotics to protect against infections." The World Bank estimates additional health care costs due to antibiotic resistance will top $1 trillion by 2050, and $1-$3.4 trillion in GDP losses per year by 2030.^{17, 18}

NEW TOOL FOR ADVOCATES
In one way or another, we are all affected by the lack of WASH in health care facilities. While there are many competing global needs, this needs to be one of them. The UN General Assembly's resolution to get water and sanitation, electricity, and a way to manage human and medical waste into every health care facility by 2030 is a new concrete tool for advocacy.¹⁹ It was unanimously adopted and secured government commitments at the highest levels to increase coordination, collaboration, funding and technical support, as well as to identify bottlenecks.

For advocates, it provides opportunities to remind leaders of this global commitment and its urgency. Advocates can invite policymakers to visit health care facilities to see conditions for themselves; engage health care facility staff to demand a safe and dignified working environment; highlight the value of WASH investments; hold leaders to account; and publicize progress to put good pressure on more decision-makers.

Since the worst days of COVID-19, when we faced a shortage of the health care many of us had come to expect, most of us better appreciate the tremendous pressures on health care facilities and staff. Among us is Pope Francis. "These past years of the pandemic have increased our sense of gratitude for those who work each day in the fields of health care and research," he said on World Day of the Sick in 2023."Yet it is not enough to emerge from such an immense collective tragedy simply by honoring heroes. COVID-19 … exposed the structural limits of existing public welfare systems. Gratitude, then, needs to be matched by actively seeking, in every country, strategies and resources in order to guarantee each person's fundamental right to basic and decent health care."²⁰

There is ample opportunity to actively seek ways to offer support for WASH. As one non-Catholic funder of this initiative told me, "I've been inspired by how Catholic sisters working in hospitals and clinics in the most remote areas of the world are faithfully responding to the medical needs of the poorest of the poor, and how devastatingly difficult it is for them to do so if their health facility lacks water, adequate toilets or a place to wash hands."

Catholic health systems will continue to catalyze growing global commitments to safer and more dignified health care for all. If you're not yet part of these efforts, know that your help would be welcome.

SUSAN K. BARNETT is founder of Faiths for Safe Water and was part of the four-year Global Water 2020 initiative, which focused on underrepresented issues of global water health and security. A former journalist with the network newsmagazines PrimeTime Live, 20/20 (ABC News) and Dateline NBC, she now leads Cause Communications.

NOTES

1. "Half of Health Care Facilities Globally Lack Basic Hygiene Services – WHO, UNICEF," World Health Organization, August 30, 2022, https://www.who.int/news/item/30-08-2022-half-of-health-care-facilities-globally-lack-basic-hygiene-services---who--unicef.
2. Susan K. Barnett, "Water, Sanitation and Hygiene: Vatican, Catholic Health Care Take Leadership Roles in ‘WASH' Work," Health Progress 102, no. 4 (Fall 2021): 38-44.
3. "WASH–Water Sanitation Hygiene," Dicastery for Promoting Integral Human Development, January 17, 2024, https://www.humandevelopment.va/en/progetti/wash-water-sanitation-hygiene.html.
4. Pope Francis, Laudate Deum, The Holy See, https://www.vatican.va/content/francesco/en/apost_exhortations/documents/20231004-laudate-deum.html.
5. Nike Adebowale-Tambe, "Nigeria Is World's Second Nation with High Maternal, Child Deaths — Report," Premium Times, May 10, 2023, https://www.premiumtimesng.com/news/top-news/597814-nigeria-is-worlds-second-nation-with-high-maternal-child-deaths-report.html?tztc=1.
6. Patricia Tonbra Osunu, Charles C. Ofili, and Ezekiel Uba Nwose, "Maternal Mortality in Nigeria: A Consideration of Infection Control Factor," Preventive Medicine and Community Health 4 (2021): https://doi.org/10.15761/PMCH.1000158.
7. "UN Secretary-General's Call to Action on WASH in Healthcare Facilities," Children's Environmental Health Collaborative, March 2018, https://ceh.unicef.org/events-and-resources/knowledge-library/un-secretary-generals-call-action-wash-healthcare-facilities.
8. "Water, Sanitation and Hygiene in Health Care Facilities," WHO, January 30, 2019, https://apps.who.int/gb/ebwha/pdf_files/EB144/B144_R5-en.pdf.
9. "Eight Practical Steps to Achieve Universal Access to Quality Care," WASH in Health Care Facilities, https://www.washinhcf.org/practical-steps/.
10. "Catholic Health WASH Hub," GoodLands, https://catholic-healthcare-facilities-wash-cgisc.hub.arcgis.com/.
11. "Sub-Saharan Africa Left to Pick Up $8.4 Billion Cost of Healthcare Infections," WaterAid, April 5, 2024, https://www.wateraid.org/uk/media/sub-saharan-africa-left-to-pick-up-84-billion-cost-of-healthcare-infections.
12. "WHO Launches First Ever Global Report on Infection Prevention and Control," WHO, May 6, 2022, https://www.who.int/news/item/06-05-2022-who-launches-first-ever-global-report-on-infection-prevention-and-control.
13. Michael Chaitkin et al., "Estimating the Cost of Achieving Basic Water, Sanitation, Hygiene, and Waste Management Services in Public Health-Care Facilities in the 46 UN Designated Least-Developed Countries: A Modelling Study," The Lancet 10, no. 6 (April 2022): 840-849, https://doi.org/10.1016/S2214-109X(22)00099-7.
14. "Costs of Health Care Associated Infections from Inadequate Water and Sanitation in Health Care Facilities in Eastern and Southern Africa (English)," World Bank Group, https://documents.worldbank.org/en/publication/documents-reports/documentdetail/099428002212438578.
15. "WHO Launches First Ever Global Report on Infection Prevention and Control."
16. "Antimicrobial Resistance," WHO, November 21, 2023, https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance.
17. "Global Action Plan on Antimicrobial Resistance," WHO, 2015, https://www.amcra.be/swfiles/files/WHO%20actieplan_90.pdf.
18. "Drug-Resistant Infections: A Threat to Our Economic Future," World Bank Group,  https://www.worldbank.org/en/topic/health/publication/drug-resistant-infections-a-threat-to-our-economic-future; "Antimicrobial Resistance."
19. "Global Action Plan on Antimicrobial Resistance."
20. Pope Francis, "Message of His Holiness Pope Francis XXXI World Day of the Sick," The Holy See, February 11, 2023, https://www.vatican.va/content/francesco/en/messages/sick/documents/20230110-giornata-malato.html.