The work is dirty, dangerous ... and thankless.

Sanitation workers in lower income countries often endure grueling conditions to perform a service that's vital to keeping their communities healthy. Yet their suffering has largely gone ignored — even by advocates for the poor.

"This has been a very neglected issue," says Andres Hueso, a senior policy analyst with the nonprofit aid group Water Aid. Now he's part of a group of researchers hoping to change that – with a new report jointly released by the World Health Organization, the World Bank Group and the International Labour Organization.

The report analyses a range of national-level studies in nine countries and interviewed 19 workers to provide what its authors say is the first global picture of the challenges that sanitation workers face.

"What surprised me was how widespread these problems were and how it was an issue in so many of the countries that we explored," says Hueso. "But the thing that really struck me were the stories that we have collected of the workers. Hearing their voices tell us what they are facing — that has been mind-blowing." (Many of the videos and photographs are available online.)

NPR spoke with Hueso to find out more.

(This conversation has been lightly edited for length and clarity.)

In lower income countries, sanitation workers keep sewers free of obstructions so waste can flow through to larger-scale containers – septic tanks or deep pits dug into the ground, sometimes with retaining walls or slabs inside. They also periodically empty those containers out. How is this work generally done?

You have two types of workers. In some countries – especially West Africa — there are a lot of vacuum tanks, meaning tanks that trucks can empty. But then there are some pits that are not easily emptied with those trucks. Many households are in slums where there are no roads, so the trucks can't reach them. So you then have the second category of work, which is what they call "manual empties." So these guys go in with very basic tools, shovels and buckets and empty the pits.

I can think of many reasons this work could be unpleasant and dangerous – it involves dealing with human waste, which is smelly and unsanitary! But did the workers describe any hazards that surprised you?

Yes, many. One worker in India described how he had to go into one of these big sewers because there was a carcass of a cow down there that was blocking it. So he had to go down and cut the carcass into pieces. And he was saying that the municipality gave him a gun – an actual gun – because there are rats and snakes in the sewers. That was all the protective equipment that he received.

Another worker in India told of a time he went with three co-workers to unblock a manhole. And it was quite a deep one. So at some point he went out for a break, to have a cigarette. And when he came back he realized that his co-workers – who were still inside the sewer – had lost consciousness because of toxic gases, likely ammonia or carbon monoxide or sulfur dioxide. He immediately went in to try to save them and he fainted as well. Ultimately they were taken out of the manhole by an ambulance crew. He survived, but it took him three weeks to recover. And his three co-workers, because they had been exposed to the gases for longer than him, all died.

Another problem is that it's quite common for people to smoke or use alcohol to numb their senses for going into the pits. And that can increase the risk of accidents. And of course it can lead to addiction over the longer term. Also, sometimes the latrine pits collapse. The worker will be inside the pit emptying it, and there's a separating wall that can cave in.

So this work is not just dangerous but potentially deadly?

The man who described encountering the toxic gas — he has been working, I think it was for 20 or 30 years as a sanitation worker. And he said most of the people he started out working with are now dead. He was saying, "I don't know if I will be alive either to reach retirement age."

Were there any hopeful accounts?

In Burkina Faso we talked to a guy who used to work in very, very poor conditions. Society has this habit of using toilets as a dustbin. So for sanitation workers it's often not just human waste that they have to empty. A lot of times there's broken glass or syringes, or other things that can cause injuries. And if you're immersed in s**t, getting a cut is really not the best combination.

So this worker saw how his co-workers were falling ill because of the contact they had with the excreta in the pits. And he decided not just to get vaccinated [against diseases such as tetanus] to protect himself, but to convince others to vaccinate themselves.

And from there he's gone on to create an association of manual emptiers – organizing them and making sure they have good working conditions. He's become a leader of these workers.

Similarly, in Tanzania, there was a person who had been working as a sanitation worker for a long time. And he described how when he started out he was doing the work informally. He didn't have any training. One time because he didn't know any better he stepped onto a slab that was weak and he fell into the pit and broke his leg.

But these days he is part of a small company where they have mechanical pumps to empty the sludge. They have uniforms and equipment – boots, gloves, a mask and helmet. And he is very, very vocal about how important it is to use that protection and how he doesn't do any of those crazy things he used to do anymore.

But he also sees other informal workers that are still working in such conditions.

So even though this man now works for a safer company, the informal – and presumably more dangerous – operators are still thriving?

Right. That man's company benefitted from a privately-driven small project that supported it. But with those sorts of projects you only have small islands of success. It's really important for the change to be driven by governments and municipalities and that it have an element of regulation and enforcement. Otherwise the contractors that are spending the money to take safety seriously won't be able to compete with the informal ones.

Are any governments doing a good job of that?

The strongest example has been South Africa – the city of Durban specifically. Durban has a history of being very progressive on urban sanitation, and there was a lot of collaboration between civil servants and the university to see how to improve all aspects. The result was that they've gone through a process of mechanization and formalization. They have lots of emptying trucks, and also they have machines to unblock sewers. So I think it's very rare that the workers have to enter the sewers.

You've noted that this issue has only recently started getting attention from anti-poverty and global health advocates. What's taken so long?

I think one issue is that across most countries, sanitation workers are seen as second-class citizens. So even if people [in those countries] knew that these workers had terrible working conditions or that they were dying from this job, there was not much outrage or pressure for authorities to do something about it.

And then, specifically for those of us in the water and sanitation sector, in the past there was a lot of focus on let's make sure everybody has a toilet. We were just building toilets mostly in rural areas. But we didn't talk about what happens after the toilet is flushed. If the waste ended up in the river or wherever, that was okay.

But over the past decade or so there's been more and more work going into urban sanitation. And with the Sustainable Development Goals — [a series of targets for ending global poverty adopted by the world's leaders at the United Nations in 2015] — the aim is to not just to make sure everybody has a toilet but that the waste from that toilet is properly managed. Now we need to make sure that the waste is treated.

And to make that happen, there are these workers unblocking the sewers, emptying the pits, transporting the waste to treatment plants. I think this critical mass of new projects, more money, more people focusing — I think that builds this uneasiness among people like myself.

We're thinking, "We are working on where the fecal sludge goes and how are we treating it. But there are all these workers that are unblocking sewers or doing it informally that are suffering these terrible conditions."

And even if we don't work with them in aid projects (because in our projects, the workers are well protected), now it's something that that is really central to the work that we are doing. Now it hits home much more.

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