#  A Measure and Process for Improving Human Excreta Disposal Practice in Rural Alaska Villages 

# 2007 - 2008 

# Environmental Public Health Leadership Institute Fellow:

# Joe Sarcone; MSPH, RS

*Rural Sanitation Coordinator*

Alaska Operations Office

U.S. Environmental Protection Region 10

222 W 7^th^ Avenue, Room 537

Anchorage, AK 99513-7588

\(907\) 271-1316

sarcone.joseph@epa.gov

# 

**Mentor:**

# Robbin Rose; M.S., REHS 

*Supervisor, Food Protection Program*

Environmental Health Services Division

Washoe County District Health Department

Reno, Nevada

# Acknowledgements:

**Jeanine Oakland**

*Environmental Program Specialist*

*Alaska Department of Environmental Conservation*

**Lorinda Lhotka**

*Environmental Health Officer*

*Alaska Department of Environmental Conservation*

# EXECUTIVE SUMMARY:

A significant number of people in rural Alaska live without piped water
and sewer. "Honey buckets" (5 gallon plastic buckets) are used for human
excreta collection, transport and disposal. A wide gap exists in
villages through out Alaska between the highest and lowest levels of
sewage disposal practice and there are few resources for interim
improvements to address health threats at the lowest levels. The reasons
for this condition are complex, but two beliefs prevail. The resignation
of the water and sewer service providers that they are doing all they
can within existing constraints and the acceptance of the villages that
there is little they can do to change things. The challenge is to work
with service providers and villages to emphasize a shared vision for
improved sanitation with roles for both all along the continuum of
environmental public health protection. The ongoing goal is to reduce
human exposure to disease through improved excreta disposal practice.
Methodology included: develop a metric for human excreta disposal
practices, develop and implement a village practice questionnaire,
implement a participatory process with pilot villages to identify
improved practices, and work with service providers and villages to
commit resources for identified measures. The Sanitation Practice Index
is based on the fecal-oral route of transmission and the potential for
person contact with human waste associated with certain practices. The
Index is a tool to measure outcomes related to improvements in excreta
disposal practice. The questionnaire developed with the UAA, Institute
of Social & Economic Research establishes a baseline of practice and
elicits village identified improvements. In this process villages are
empowered and service providers find that support for measurable village
identified sanitation improvements meets their essential mission to
protect human health. The project provides a transferable measure and
process for instituting environmental public health solutions.

# INTRODUCTION/BACKGROUND:

Permanent settlements in rural Alaska were developed largely based on
the establishment of trading centers, churches and schools. As the
nomadic indigenous people became settled in permanent villages the need
to address sanitation issues related to population concentration became
evident. For decades, remoteness, geography, permafrost, and cost have
presented a challenge to villages and service providers in achieving
sanitation improvements. The state and federal government continue to
work to fulfill their responsibility to protect human health through the
provision of safe water and adequate sanitation to villages in rural
Alaska. At this time approximately 80 - 85% of rural Alaska households
have piped water and sewer or an "equivalent" system.

The following methods of human excreta collection, transport and
disposal continue to be used in villages that lack piped water and sewer
systems. The "honey bucket" is a five gallon plastic bucket used for
human excreta collection. The honey bucket may be lined with a plastic
bag for ease of transport and disposal. Please see Image 1, Honey
buckets awaiting transport and disposal. Honey bucket waste is disposed
of in a number of ways. The waste may be disposed to sloughs, beaches,
rivers, tundra ponds, out houses, or a designated dump site or lagoon.
Please see Image 2, Honey bucket disposal site. In addition, the honey
bucket waste may be commingled with solid waste at a village dump site
or indiscriminately disposed of to the environment.

![](media/image1.wmf){width="3.75in" height="4.097222222222222in"}In
some instances honey bucket bunkers are constructed in order to
discourage random dumping of honey bucket waste to the environment and
to provide separation of the waste from human contact. Depending on the
availability of materials and site conditions these structures have
plywood sides and covers and are partially buried with open bottoms.

Designated honey bucket dumpsites or "lagoons" are also used. The
effectiveness of a honey bucket "lagoon" as a wastewater treatment
lagoon is often compromised by the use of plastic bag liners in the
honey bucket. When the plastic bags containing waste are disposed of to
the lagoon the bags prevent the natural settling of the waste and
biological action of the lagoon. Although

*Image 1, Honey buckets awaiting disposal* individual households
typically self

![](media/image2.png){width="3.75in" height="2.625in"} haul their honey
buckets to a disposal

site some villages have initiated

> a honey bucket collection system.
>
> The next level of intervention to improve human excreta disposal in
> villages without piped water and sewer systems is the honey bucket
> haul system. This system was designed and introduced in rural Alaska
> by the Indian Health Service (IHS) in the early 1980s. The purpose of
> the system is to further separate the honey bucket user from contact
> with the waste in the transport of the waste to

*Image 2, Honey bucket disposal site* the disposal site.

![](media/image3.wmf){width="3.875in" height="3.0in"}Plastic honey
bucket hoppers (approximately 70 gallons) are placed throughout the
village for people to dispose of their honey bucket waste (Please see
Image 3). The hoppers are designed to attach to a trailer that is then
hauled by a four wheeler (all-terrain vehicle) or a snow machine to the
honey bucket dump site or sewage lagoon (Please see Image 4). The bin
can swivel on its carriage so that it can be easily dumped by hand by an
operator. Limitations include overfilling, spillage in transport, and
freezing in winter

*Images 3, Honey bucket hopper*

Indian Health Service support

![](media/image4.wmf){width="3.875in" height="3.0in"}for the honey
bucket haul system was discontinued in the mid 1990's

and although replacement equipment and parts can be difficult to procure
a number of villages continue to use this system. Honey bucket bunkers
and the honey bucket haul system represent a low level of sanitation
practice despite their obvious improvement over the indiscriminate
disposal of honey bucket waste to the open environment. Ultimately the
goal of local, state and federal government is to eliminate the use of
honey buckets in rural Alaska through the provision of piped water and
sewer or an "equivalent" system.

*Image 4, Trailer and all terrain vehicle (4-wheeler)*

The "equivalent" system referred to in this instance is the Flush Tank
and Haul System (FTHS) introduced to rural Alaska in the early 1990's.
In the FTHS each house is plumbed and has its own water storage tank and
waste water collection tank. The house is served on an as needed basis
with water delivery and waste water collection operated and managed by
the local government. Limitations of the FTHS are primarily related to
the way it is used. Users tend to limit water use in the interest of
saving money on water delivery and waste water pump out. Many users
collect their own water for the system in order to save the cost of
water delivery. These practices diminish the public health benefit of
the system. Please see Image 5, Flush Tank and Haul System (FTHS)
"pumper" unit, and Image 6, Flush Tank and Haul System (FTHS) household
waste water collection tank.

![](media/image5.wmf){width="4.25in" height="2.8194444444444446in"}The
process for funding, planning, design, and construction of an FTHS is
basically the same as for a piped system. In the final government
accounting of households served by piped water and sewer the Flush Tank
and Haul Systems are considered a sanitation improvement equal to piped
water and sewer despite use that suggests otherwise.

There are a number of variables

*Image 5, Flush Tank and Haul System (FTHS) "pumper" unit* that
influence the prevailing sanitation conditions in

Alaska villages. Included is![](media/image6.png){width="4.25in"
height="2.625in"} how villages are considered

and selected for water and sewer improvements. The process for water and
sewer project selection has evolved to include a consolidated project
solicitation and a multi-agency committee for project review and
selection. The funding for water and sewer projects comes from state and
federal government. An annual solicitation goes out to villages

Image 6, *FTHS household waste water collection tank* and the villages
complete and submit applications for water

and sewer projects. The funding agencies and water and sewer service
providers score the applications based on a standard set of criteria the
they have developed. Projects which score well are funded to the extent
funds are available.

The water and sewer service providers are the gate keepers for villages
to access improved systems. Scollon and Scollon[^1] in *Interethnic
Communication* define gatekeepers as, "individuals who have the
authority to make decisions that will affect the mobility of others.
They work in institutions deciding daily whether to open the gate and
let people through or keep them out." The water and sewer service
provider/gate keepers define the village capacity or capability required
to gain water and sewer improvements.

The question becomes, "What sanitation improvements can be funded and
who can receive the improvements?" Three significant variables have
increased in influence over time. One variable that has increased
steadily and has more recently shown signs of leveling off is the
funding available for capital construction of water and sewer
facilities. These funds can only be used for capital construction and
not operation and maintenance. A second variable is the requirement that
newly constructed and renovated water and sewer systems operate in full
compliance with state and federal regulatory requirements. The third
variable is associated with stricter government accounting measures for
grant funds. The stricter accounting has resulted in a definition for
village capacity based largely on economic indicators. Villages that can
not demonstrate technical, managerial and financial capacity as defined
by the service providers are unable to access funds for water and sewer
improvements.

The above variables result in a process in which the service providers
determine the entry point to water and sewer improvements as well as
what type of improvements can be funded. In this process there are few
resources for interim sanitation improvements that lay between the two
prevalent states of water and sewer practice in rural Alaska\...the
honey bucket and piped water and sewer. The Behavior Over Time graph,
Figure 1, illustrates the approximate relationship of these key
variables over time.

*Figure1, Behavior Over Time Graph*

*Problem Statement:*

Why are there limited resources to improve human excreta disposal in
rural Alaska villages in the interim between the use of honey buckets
and the delivery of piped water and sewer?

In addressing the identified problem it is important to consider the
assumptions which apply. Assumptions made by the water and sewer service
providers include: 1) newly constructed and renovated water and sewer
systems should operate in full compliance with state and federal
regulatory requirements; 2) villages that can not demonstrate "capacity"
as defined by the service providers can not access funds for sanitation
improvements; and, 3) water and sewer project funds can only be used for
capital construction and not operation and maintenance.

The mental models that ensue include: "Our job is to construct piped
water and sewer (or equivalent systems)," "Only villages that meet our
criteria can access water and sewer improvements," and "It's not our
role to support sanitation improvements in the interim between the use
of honey buckets and the delivery of a piped water and sewer system." As
noted, the service providers determine the entry point for villages to
access water and sewer improvements as well as the types of improvements
that can be implemented. The service providers acknowledge and accept
that poor sanitation conditions prevail in underserved villages, but
they are resigned that they have done all they can within the
constraints of the appropriations, regulations and policies which apply.

The desire to improve one's health is inherent. People in rural Alaska
living without proper sanitation want water and sewer improvements for a
number of reasons including improved health status and convenience.
There are, however, many cultural, social, and economic concerns that
strain the available human and financial resources of the villages. In
villages where poor sanitation conditions persist and resources are
limited it is possible for people to lose sight of the associated public
health threat and to perceive poor sanitation as part of the background.
The true costs of not changing may not be as evident to those living in
these conditions

In addition, villages often assume that if they can not meet the
government criteria for accessing water and sewer improvements there are
little or no other options for improving sanitation. The accompanying
"mental models" include: "What can we do? It will be years before we can
get a piped water and sewer system. So for now and for as long as we can
tell we live with honey buckets," and "We don't have the resources in
our village to improve sanitation on our own." The result can be a
vicious cycle of hopelessness and submission to government process.

> The recent impact of government on villages, while often beneficial in
> content, has been destructive in process. Laws, regulations,
> appropriations, and service agencies...intent on helping
> people...reached right through community networks of obligation to
> deal directly with each individual living there. Little time or money
> was spent on supporting the village's innate capacity to take care of
> it. Accordingly, local authority and responsibility for decisions had
> been usurped; Native people had lost control of their own communities
> and of their children's lives. The assumption that people cannot do
> for themselves, if continued long enough, becomes a self-fulfilling
> prophecy.
>
> *Alaska Commission on Rural Governance and Empowerment (ACRGE)
> 1999:22*[^2]

In Figure 2, Causal Loop Diagram, the dynamic system described is
presented in the language of systems thinking.[^3] The
interrelationships are presented as a "Shifting the Burden" systems
thinking archetype, with associated mental models, addressing the
focusing question: "Why are there limited resources to improve human
excreta disposal in rural Alaska villages in the interim between the use
of honey buckets and the delivery of piped water and sewer?"

*Figure 2, Causal Loop Diagram*

**Government Measures to**

**Improve Sanitation**

**Acceptance of,**

**Sanitation Conditions in Resignation to**

**Alaska Villages Poor**

**Sanitation**

**Village Identified**

**Measures to**

**Improve Sanitation**

How do the benefits of not changing and the costs of changing keep the
system the way it is? Tim O'Brien[^4] in his novel *Going After
Cacciato* explains that there is complacency in the acceptance of
conditions as they are. The service providers believe they are doing
their best. Villages believe there is little they can do.

People and organizations fear the consequences of parting from familiar
roles. We fear change because we fear failure. The service providers as
gate keepers are entrenched in a construction management approach in
delivering piped water and sewer systems or their "equivalent."
Deviating from this path would require a different set of skills
(socio-cultural versus engineering and finance) and a reexamination of
the appropriations, regulations, and policies within which they work.
Villages struggle with myriad cultural, social and economic challenges
that overwhelm local resources and can lead to a vicious cycle of
hopelessness. Moving beyond this would require villages to challenge
government processes and to acknowledge the true costs of not changing
by committing precious local resources to improve sanitation conditions.

What can be done to minimize the strength of these factors while
building up the benefits of change and costs of not changing? Every
service provider and every village has a deep sense of purpose that
expresses the organization's reason for existence. Building the benefits
of change follows on building a shared vision that reflects the deeper
sense of purpose of all involved. In this case a shared vision includes
the protection of human health and the environment.

Health is a dynamic continuum and not an end goal. A piped water and
sewer system is one goal for achieving environmental public health
improvement, but there are other opportunities for improvements in
health status between the use of honey buckets and the delivery of piped
water and sewer. In order to build up the benefits of change it is
important to reinforce a shared vision that emphasizes a role for both
service providers and villages at all points along the continuum of
health.

Cost Benefit Analysis, Figure 3, is an analysis of change versus no
change, addressing the focusing question: "Why are there limited
resources to improve human excreta disposal in rural Alaska villages in
the interim between the use of honey buckets and the delivery of piped
water and sewer?"

Figure 3. Cost Benefit Analysis

+-----------------------+-----------------------+-----------------------+
|                       | **Changing**          | **Not Changing**      |
+-----------------------+-----------------------+-----------------------+
| **Benefits**          | -   Realization of    | Maintenance of        |
|                       |     shared vision     | traditional roles     |
|                       |                       | (comfort level)       |
|                       | -   Actualization of  |                       |
|                       |     empowerment       |                       |
|                       |                       |                       |
|                       | -   Immediate         |                       |
|                       |     improvements in   |                       |
|                       |     environmental     |                       |
|                       |     public health     |                       |
+-----------------------+-----------------------+-----------------------+
| **Costs**             | -   Organizational    | -   Organizational    |
|                       |     change in the     |     stagnation        |
|                       |     delivery of       |                       |
|                       |     services          | -   Continuation of   |
|                       |                       |     poor sanitation   |
|                       | -   Redirection of    |     between the use   |
|                       |     limited resources |     of honey buckets  |
|                       |                       |     and the delivery  |
|                       |                       |     of piped water    |
|                       |                       |     sanitation        |
|                       |                       |     services          |
|                       |                       |                       |
|                       |                       | -   Continued         |
|                       |                       |     resignation to    |
|                       |                       |     poor sanitation   |
|                       |                       |     conditions        |
+-----------------------+-----------------------+-----------------------+

In the analysis it is important to note that the service providers
assume for the most part that in fulfilling the requirements of
applicable appropriations, regulations and policies they are also
fulfilling their mission. The following example illustrates the effect
of applying this assumption. In a Yupik village located on the coast of
western Alaska service providers have been working with the village for
the past ten years to plan design and construct a multi-million dollar
piped water and sewer system. It is estimated that it will be four more
years before the water and sewer system is completed.

The village is a self haul honey bucket village (each household is
responsible for transporting and disposing of their honey bucket waste).
People transport the honey buckets through the village by all terrain
vehicle (ATV) or snow machine to an uncontrolled, open dump site where
honey bucket waste is co-mingled with solid waste. This situation
presents many opportunities for exposure to pathogens due to direct
contact with human waste and persists despite the concurrent expenditure
of millions of dollars in the ongoing construction of the piped water
and sewer system.

In the case of the Yupik village service providers may satisfy
appropriations, regulations and policies but do not meet an immediate
over arching mission to protect human health and the environment. In the
same light a village's resignation to poor sanitation conditions does
not appear to meet an over arching dedication to the health and welfare
of future generations. The result is situations such as this where the
most significant environmental public health threats are the least
likely to be resolved.

When the over arching mission of service providers to protect human
health and the overarching dedication of villages to protect the welfare
of future generations meet, the result is a shared vision that makes
solution of the focusing question desirable and natural. Appropriate
interventions/recommendations for this scenario include: 1) villages
identify measures to improve sanitation in the interim between the use
of honey buckets and the delivery of a piped water and sewer system; 2)
village identified measures can include operations and maintenance as
well as construction alternatives; 3) service providers contribute
technical and financial assistance to implement village identified
interim measures to improve sanitation with villages; and 4) capacity
demonstrated by villages in the implementation of interim measures is
weighed in the process to select villages for piped water and sewer
projects.

> Self--governance is the most important single ingredient in solving
> the difficult problems faced by Alaska's Natives. This fact alone
> should command the interest not only of Native peoples but of other
> Alaskans and of both state and federal policy-makers as well. Native
> self-governance is not the whole answer to Native problems, but it is
> a necessary component in achieving sustained economic development, in
> overcoming virulent social problems, in reducing the financial burdens
> of social welfare programs, and in restoring health and dignity to
> Native communities.
>
> *Achieving Alaska Native Self-Governance: Toward Implementation of the
> Alaska Natives Commission Report, Stephen Cornell and others
> 1998:2*[^5]

An action plan for implementation of the interventions/recommendations
identified follows (For more detail see Figure 5, Project Logic Model):

-   Develop a metric for human excreta disposal practice between the use
    of honey buckets and the delivery of piped water and sewer systems.
    The "Sanitation Practice Index," will provide a way for villages and
    service providers to measure improvements in human excreta disposal
    practices.

-   Develop and implement a sanitation practice questionnaire with
    villages that are not served by piped water and sewer systems. The
    questionnaire will establish a baseline of sanitation practice for
    each village from which improvements can be measured using the
    Sanitation Practice Index.

-   Implement a participatory process with villages to identify measures
    to improve human excrement disposal. Work with the villages to
    prepare basic work plans and budgets for implementing the identified
    improvements. Identify the reduction in the Sanitation Practice
    Index expected with implementation of the sanitation improvements.

-   Introduce service providers to the Sanitation Practice Index as a
    valuable tool to measure environmental public health outcomes
    related to interim improvements in sanitation between the use of
    honey buckets and the delivery of piped water and sewer.

> "All villages in Alaska fall along a continuum of capability to
> manage, operate, and maintain services and infrastructure. Some
> villages have greater capability and some less capability. For most
> villages this is a dynamic continuum. Changes in variables such as
> leadership, personnel, and local economy can result in immediate and
> dramatic movement along the continuum in either direction.
>
> The O&M Project approach in working with villages acknowledges the
> dynamic described above. The approach is based on the following
> reasoning: 1) capability can be built starting at any point along the
> continuum; 2) the best place to start is at a point the village
> identifies; and, 3) a village identified starting point is more likely
> to lead to a sustainable outcome."
>
> *Sarcone and Miller, ANHB, O&M Demonstration Project Final Report,
> 2000*[^6]

*10 Essential Environmental Health Services:*

This project seeks to fulfill three of the 10 Essential Environmental
Health Services[^7] represented in Figure 4:

*Inform, educate and empower people about environmental health issues*
utilizing the Sanitation Index as a tool to create awareness of the
health threats associated with human excreta collection, transport and
disposal practices and to identify improved practices;

*Mobilize community partnerships to identify and solve environmental
health problems* by implementing a participatory process with villages
to identify measures to improve human excrement collection, transport
and disposal and to prepare basic work plans and budgets for
implementing the identified improvements; and

*Link people to needed environmental health services and assure the
provision of environmental health services when otherwise not available*
by partnering water and sewer service providers with villages that
primarily rely on honey buckets for human excreta collection, transport
and disposal to implement community based measures to improve sanitation
in the interim between the use of honey buckets and the completion of a
piped water and sewer project.

![](media/image7.png){width="3.75in" height="3.8125in"}

*Figure 4, 10 Essential Environmental Health Services*

####### *National Goals Supported*

This project focuses on promoting healthy people in healthy places which
is one of CDC's Health Protection Goals.[^8] Improving sanitation
practices in rural Alaska villages that rely on honey buckets for
collection, transport and disposal of human excreta protects and
promotes the health and safety of people in the places they live. The
project addresses those at greater risk of health disparities in a way
that recognizes the unique needs of their communities. In this way the
project approach not only captures an important CDC Health Protection
Goal but also meets the Healthy People 2010[^9] goals to increase
quality of life and to eliminate health disparities.

In applying broad goals it is important to consider that some where in
government between intent and mission rests the plight of the
under-served. It is in the gap of intent between the responsibilities of
law, regulation and policies and the obligation of mission that the
substantive work of government to serve the under-served largely
resides. This project encourages environmental health providers to push
the boundaries of established practice to better meet agency mission at
the interface of government and under-served populations.

In this way the project supports the National Strategy to Revitalize
Environmental Public Health Services[^10] by helping to shape a
workforce that is competent and effective in delivering contemporary
services. In addition the project approach builds the capacity of the
environmental public health practitioners involved to understand and
solve problems and to form partnerships. Both of these points are
recommended competencies included in the Environmental Health Competency
Project: Recommendation for Core Competencies for Local Environmental
Health Practitioners.[^11]

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

*Program Goal*

To reduce human exposure to disease through implementation of improved
sanitation in rural Alaska villages

*Health Problem*

In rural Alaska approximately 15-20% of households are not served by
piped water and sewer. Five gallon plastic buckets referred to as honey
buckets are used for human excreta collection, transport and disposal.
In households that lack piped water and sewer exposure to human excreta
increases the risk of infection from disease.

*Outcome Objective*

By December 31, 2010 villages that primarily use honey buckets for human
excreta collection, transport and disposal will reduce exposure to
disease associated with these practices by 50% of baseline.

*Determinant*

The number and frequency of person contact points with human excreta in
collection, transport and disposal resulting in exposure to disease.

*Impact Objective*

By December 31, 2010 villages that primarily rely on honey buckets for
human excreta collection, transport and disposal will cut in half the
number and frequency of person contact points with human excreta.

*Contributing Factor*s:

-   Remoteness, geography, and permafrost conditions which limit
    engineered sanitation improvements.

-   Cost of implementing sanitation improvements.

-   Limitations on the use of available state and federal funding.

-   Community capacity to manage, operate and maintain sanitation
    improvements.

-   Lack of a measure for sanitation practice in villages that primarily
    use honey buckets for human excreta collection, transport and
    disposal

-   Resignation or acceptance of poor sanitation conditions as part of
    "background."

-   Lack of clarity of responsibility on the part of water and sewer
    service providers as to who should implement interim measures to
    improve sanitation in honey bucket villages

-   Inconsistent participatory process for inclusion of villages in the
    identification and implementation of sanitation improvements.

-   Application of determinants of community capacity narrowly based on
    economic indicators

*Process Objectives*

1.  By June 1, 2008 work with 50% of villages that primarily use honey
    buckets for human excreta collection, transport and disposal to
    assign a sanitation practice index score. The index score will
    reflect the number and frequency of potential person contact points
    with human excreta in the collection, transport and disposal in each
    village.

2.  By August 1, 2008 complete sanitation practice questionnaires with
    50% of villages that primarily use honey buckets for human excreta
    collection, transport and disposal.

3.  By October 15, 2008 10% of villages that primarily use honey buckets
    for human excreta collection, transport and disposal identify
    community based measures to improve sanitation in the interim
    between the use of honey buckets and the completion of a piped water
    and sewer project and two pilot project villages will have begun to
    implement their measures.

4.  By February 15, 2009 partnerships between villages and service
    providers will fund implementation of community based measures to
    improve sanitation in the interim between the use of honey buckets
    and the completion of a piped water and sewer project in 10% of the
    villages that primarily use honey buckets for human excreta
    collection, transport and disposal.

5.  By December 31, 2010 villages that primarily rely on honey buckets
    for human excreta collection, transport and disposal will have
    identified community based measures to improve sanitation in the
    interim between the use of honey buckets and the completion of a
    piped water and sewer project. All of the villages will have begun
    to implement their measures with the assistance of service
    providers.

**METHODOLOGY**

*Event:*

Develop and apply sanitation practice index

*Activities:*

-   Establish a core workgroup of environmental health professionals
    that work with villages in rural Alaska to provide review and
    comment on a draft sanitation practice index

-   Prepare draft of a sanitation practice index

-   Seek review and comment from core work group

-   Incorporate comments and finalize sanitation practice index

-   Work with the villages and core work group to identify villages that
    primarily use honey buckets for human waste collection, transport
    and disposal

-   Work with the villages and core work group to identify the honey
    bucket practices currently in place

-   Estimate projected number of years before identified villages will
    obtain piped water and sewer

-   Work with the villages to apply the sanitation practice index

*Event:*

Develop and implement a questionnaire to elicit information from the
villages regarding sanitation practice, general level of concern
regarding sanitation practice, perceived barriers to improving
sanitation practice, and possible solutions to improve sanitation
practice in the interim between the use of the honey buckets and a
completed water and sewer project.

*Activities:*

-   Seek advice and direction from the University of Alaska Anchorage
    (UAA), Institute of Social and Economic Research (ISER) for
    developing a sanitation practice questionnaire

-   Draft sanitation practice questionnaire

-   Seek review and comment from UAA, ISER and the core workgroup on the
    draft questionnaire

-   Incorporate comments and finalize sanitation practice questionnaire

-   Identify EPA, Indian General Assistance Program (IGAP) grant
    recipients that are also villages that primarily use honey buckets
    for human waste collection, transport and disposal

-   Participate in quarterly conference calls organized by EPA Tribal
    Coordinators with IGAP grantees to introduce the questionnaire and
    establish a point of contact in each village

-   Implement the questionnaire with IGAP grantee contacts in the
    villages that primarily use honey buckets for human waste collection
    and disposal

-   Revise, where needed, the sanitation practice index based upon
    information collected in the sanitation practice questionnaire

-   Evaluate the information collected in the sanitation practice
    questionnaire

-   Target village specific sanitation health education

*Event:*

Implement a participatory process with villages that self select into
the process to

identify community based measures to improve sanitation in the interim
between the use of honey buckets and the completion of a piped water and
sewer project.

*Activities:*

-   Invite villages to participate in the process

-   Identify the entity specific to each village that would participate
    in the process to identify measures to improve sanitation
    (environmental committee, village council, etc.)

-   Facilitate in person or via teleconference a process to identify
    community based measures to improve sanitation

-   Work with the village contact to prepare a two page work plan and
    budget for the identified measure(s) (including the projected
    improvement in sanitation practice index associated with
    implementation of each measure)

-   Identify funding and technical resources to implement pilot projects
    in two villages

*Event:*

Establish a broad coalition of service providers to identify and make
available resources for the implementation of community based measures
to improve sanitation in the interim between the use of honey buckets
and the completion of a piped water and sewer project.

*Activities:*

-   Work with the core work group to identify partners and invite them
    into a larger workgroup

-   Schedule four working group sessions to be held through out 2009

-   Conduct sessions to clarify responsibilities of service providers,
    identify barriers, seek solutions, coordinate the delivery of
    targeted resources, and provide consistent support to villages over
    time

-   Establish a precedent for service providers to engage in
    participatory process with villages that leads to more sustainable
    outcomes

  --------------- ----------- ----- ------ ------------ --------------- ------------ ---------------- --------- -------------- ------------- ----------- -------
                  *Figure 6*                                            *Draft                        Metric:                                            
                                                                        Sanitation                    Person                                             
                                                                        Index*                        Contact                                            
                                                                                                      with                                               
                                                                                                      Human                                              
                                                                                                      Waste                                              

                                                                                                                                                         

                  **HOUSE**                             **TRANSPORT**                                           **DISPOSAL**                             
                                                                                                                \*\*\*                                   

                                                                                                                                                         

  **10**          Honey                    **10**       Honey bucket                                  **10**    Sewage Lagoon                            
                  bucket\*                              bins with                                               more than .25                            
                                                                                                                miles                                    

  ** **           and easily                            with vacuum                                             from nearest                             
                  cleanable                             pumper                                                  house                                    
                  surfaces                                                                                                                               

  ** **           ( smooth                              unit service (                                                                                   
                  walls and                             when                                                                                             
                  floors;                               temperatures                                                                                     
                                                        permit )                                                                                         

  ** **           for example                                                                                                                            
                  vinyl                                                                                                                                  
                  flooring )                                                                                                                             

  **9**                                    **9**                                                      **9**                                              

  ** **                                                                                                                                                  

  **8**                                    **8**                                                      **8**                                              

  ** **                                                                                                                                                  

  **7**                                    **7**        Honey bucket                                  **7**                                              
                                                        hoppers with                                                                                     
                                                        honey                                                                                            

  ** **                                                 bucket haul                                                                                      
                                                        trailer service                                                                                  

  ** **                                                                                                         Sewage Lagoon                            
                                                                                                                Less                                     

  **6**                                    **6**                                                      **6**     than .25 mile                            
                                                                                                                from nearest                             
                                                                                                                house                                    

  ** **                                                                                                                                                  

  ** **                                                 Honey buckets                                                                                    
                                                        with vacuum                                                                                      
                                                        pumper                                                                                           

  **5**                                    **5**        unit collection                               **5**     Honey bucket                             
                                                        at each                                                 bunker                                   
                                                        house\'s honey                                                                                   
                                                        bucket                                                                                           

  ** **                                                                                                         ( well                                   
                                                                                                                maintained )                             

  ** **                                                 Honey buckets                                                                                    
                                                        with household                                                                                   
                                                        collection                                                                                       

  **4**                                    **4**        service by                                    **4**     Honey bucket                             
                                                        honey bucket                                            waste and                                
                                                        worker using                                            solid waste                              

  ** **                                                 4 wheeler with                                          dumped                                   
                                                        a trailer or a                                          together more                            
                                                                                                                than .25 miles                           

  ** **                                                 snow machine                                            from village                             
                                                        with a sled.                                                                                     

  ** **                                                                                                                                                  

  **3**                                    **3**                                                      **3**                                              

  ** **                                                                                                                                                  

  **2**                                    **2**                                                      **2**                                              

  ** **                                                                                                         Honey bucket                             
                                                                                                                waste and                                
                                                                                                                solid waste                              

  ** **           Honey                                                                                         dumped                                   
                  bucket and                                                                                    together less                            
                  not                                                                                           than .25 miles                           

  **1**           easy to                  **1**        Self haul honey                               **1**     of village                               
                  clean                                 bucket using a                                                                                   
                  surfaces                              4 wheeler or                                                                                     

  ** **           (porous                               snow machine,                                                                                    
                  floors,                               this includes                                                                                    
                  walls,                                **\*\***                                                                                         
                  e.g.,                                                                                                                                  

  ** **           unpainted                                                                                     Dumping all                              
                  plywood )                                                                                     around (beach                            
                                                                                                                and slough )                             
                                                                                                                or                                       

  **0**                                    **0**                                                      **0**     poorly                                   
                                                                                                                maintained                               
                                                                                                                honey bucket                             
                                                                                                                bunkers                                  

  \* Honey bucket                          \*\* Honey                                \*\*\* Subtract                                                      
  liners and                               bucket                                    2 points                                                            
  disinfectants                            disposal to                                                                                                   
                                           35 - 50 gal                                                                                                   

  (e.g., Pine Sol                          containers                                for poor                                  **House                    
  ) are often                              at each                                   drainage in and                           Points**                  
  used.                                    household                                                                                                     
                                           with self                                                                                                     

  There are                                haul using a                              around disposal                           **Transport                
  advantages and                           4 wheeler                                 site and                                  Points**                  
  disadvantages                            with a                                                                                                        
                                           trailer or                                                                                                    

  to these                                 a snow                                    transportation                            **Disposal                 
  practices.                               machine with                              route                                     Points**                  
  Based on this,                           a sled                                                                                                        

  the index does                                                                                                                             **TOTAL**    
  not assign a                                                                                                                                           
  value to them.                                                                                                                                         
  --------------- ----------- ----- ------ ------------ --------------- ------------ ---------------- --------- -------------- ------------- ----------- -------

**PROGRESS TO DATE:**

The following activities have been completed to date:

-   Established a core workgroup of environmental public health
    professionals that work with rural Alaska villages to advise on the
    project

-   Drafted a sanitation practice index (see Figure 6, Draft Sanitation
    Index)

-   Solicited workgroup review/comment of the draft sanitation index

-   Revised the sanitation index based on workgroup input

-   Drafted a list of villages that primarily use honey buckets for
    human waste collection, transport and disposal

-   Drafted a sanitation practice questionnaire

-   Worked with UAA Institute of Social and Economic Research to further
    develop the questionnaire

-   Work with the U.S. EPA, Tribal Program to contact Indian General
    Assistance Program

> (IGAP) grantees living in villages that primarily use honey buckets

-   Began to implement questionnaire with IGAP honey bucket villages
    that expressed interest in participating

In carrying out the activities several points required clarification.
For instance, would the sanitation index be applied to the village
overall or to individual households? There is potential to use the index
in both instances although the original intent was to use the index to
score or measure the honey bucket collection, transport and disposal
practices of the village as a whole.

Another point that came up was whether additional practices identified
by villages or environmental health service providers could be included
in the index? The format of the sanitation index allows for any practice
with potential to prevent person contact with human waste to be assigned
a value relative to the other practices listed

In discussions with a village environmental coordinator the question was
asked if public education and a local ordinance for honey bucket
practice could also be included in the sanitation index. Based upon this
input the variable "community" will be added to the other index
variables (house, transport, and disposal). Under the "community"
variable higher points will be assigned to activities such as safe
sanitation practices education and local honey bucket ordinances.

The idea of the sanitation index as a tool to measure basic sanitation
conditions has been applied in two other areas. A water haul index has
been drafted and uses as a measure the potential for pathogen
introduction to water transported and stored in homes in villages. The
scoring is based on four variables: water source, method of transport,
in house storage, and in house disinfection. In addition, a waste
burning index has been developed. The waste burning index uses the
measure of potential for inhalation exposure associated with various
solid waste burning practices in villages. The four variables that are
scored include: separation of waste, type of burn unit, distance of
burning from homes, and operation of burn unit. The waste burning index
is currently being adapted for use by the U.S. Environmental Protection
Agency Region 10, Tribal Air Program and Tribal Solid Waste Program.

# 

# NEXT STEPS:

In implementing the project the question that continues to present
itself is, "How do we arrive at sanitation improvements that are: 1)
desirable and attainable by the village, and 2) acceptable and fundable
by the water and sewer service providers?" In addressing this question
the project continues to focus on two key points: 1) rethink the
**measure** of progress, and 2) initiate a participatory **process**.

Rethinking a measure of progress can mean choosing the most basic
measure. In the case of the sanitation index it means continuing to look
at sanitation practices relative to one another using a most basic
metric: potential for person contact with human excreta. Simply applied
there are more opportunities for contact with human excreta by a greater
number of individuals in a self-haul honey bucket scenario with disposal
to a combined honey bucket/solid waste dump site versus an operator
maintained honey bucket haul system with disposal to a sewage lagoon.
Fundamentally the index relates to the fecal-oral route of disease
transmission and to people getting sick or not.

Initiating participatory process can mean choosing change. Introducing
participatory process into the relationship between the water and sewer
service providers and the villages continues to be significant
challenge. In the face of this challenge the project approach remains
the same, engage the village in positive change at a point they identify
and invite the service providers to be partners in change starting at
the point identified by the village. The project will continue to
reinforce a shared vision for the protection of human health that
emphasizes a role for both service providers and villages.

# EXPECTED OUTCOMES

It is hoped that this project will 1) raise awareness of the sanitation
conditions in rural Alaska villages that lack piped water and sewer and
that in a number of villages these conditions are likely to prevail for
some time; and, 2) provide a way for villages to find support for
village identified solutions to improve human excreta collection,
transport and disposal in the interim between the use of honey buckets
and the provision of a piped water and sewer system. It is also hoped
that the idea of the sanitation index as a tool to measure basic
sanitation conditions will be transferable to other environmental health
scenarios.

# 

# 

# 

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### *Joe Sarcone*

The opportunity to participate in EPHLI comes at a critical time in my
twenty-five (25) year career in government working with underserved
populations. Work on environmental public health issues at this
interface can be overwhelming and presents a continuous challenge in
maintaining the energy needed to be effective. The EPHLI experience has
restored my energy for the work and increased my effectiveness in
carrying out the responsibilities of my position. The skills learned
through participation in the Institute will help me to create and
promote a vision for improved environmental health status for the Alaska
Native villages I now serve and for others I will serve in the future.

# ABOUT THE EPHLI FELLOW

Joe Sarcone has worked at the interface of government with the
indigenous people of the Pacific, Africa and Alaska on environmental
public health programs over the course of more than twenty years. He
currently works with tribes in Alaska to identify and implement
sustainable solutions to environmental health challenges as the Rural
Sanitation Coordinator for the U.S. Environmental Protection Agency,
Alaska Operations Office. He holds an MSPH from the University of North
Carolina at Chapel Hill, School of Public Health and is a Registered
Environmental Health Specialist with the National Environmental Health
Association.

# REFERENCES

1 Scollon R, Scollon S, *Interethnic Communication*. Alaska Native
Language Center. 1980

^2^ Alaska Commission on Rural Governance and Empowerment, Final Report
to Governor. State of Alaska. 1999:22

^3^ Senge PM, Kleiner A, Roberts C, Ross RB, Smith BJ, *The Fifth
Discipline Fieldbook*. Doubleday. 1994: 87-189

^4^ O'Brien T, *Going After Cacciatto*. Broadway Books. 1999

^5^ Cornell S and others, Achieving Alaska Native Self-Governance:
Toward Implementation of the Alaska Natives Commission Report. The
Economic Resource Group Inc.1998:2

^6^ Sarcone J, Miller N, Rural Sanitation Facilities Operation and
Maintenance Demonstration Project Final Report. Alaska Native Health
Board. 2000

^7^ Osaki, C, *Essential Services of Environmental Health*. Northwest
Center for Public Health Practice, University of Washington School of
Public Health and Medicine. 2004

^8^ Centers for Disease Control, Health Protection Goals
<http://www.cdc.gov/about/goals/default.htm>

^9^ U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion Health People 2010.
<http://www.cdc.gov/nchs/about/otheract/hpdata2010/about.htm>

10 Centers for Disease Control, National Strategy to Revitalize
Environmental Public Health Services.
<http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf>

11 American Public Health Association, Environmental Health Competency
Project.

<http://www.apha.org/programs/standards/healthcompproject/corenontechnicalcompetencies.htm>

Images courtesy of Simone Sebalo and Lynn Zender, Zender Environmental
Health and Research Group.

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