Last September, Suzette Flores knew something was wrong when her toddler, Rob Ezequiel Garcia, vomited five times in a single day. It was the first time her 19-month-old son had ever been so sick, she said. When he developed a fever, she rushed him to the hospital.
"Five hours later he died," the 31-year-old said of her only born child. "In those last five hours he was having seizures."
Doctors told Suzette that her child most likely died of bacterial meningitis, an infection that swells and inflames the membranes covering the brain and spinal cord. Doctors said the boy likely contracted the infection by coming into contact with fecal material in his environment.
The disposal and treatment of human waste is a serious issue in the Philippines. The country's National Sewerage and Septage Management Program (NSSMP) says around 55 people die every day in the country of nearly 100 million because more than 90 percent of the country's sewage is not collected or treated properly. Only 10 percent of the country's population has access to piped sewage systems; and the NSSMP says that many Filipinos who have toilets "do not have septic tanks; many septic tanks have open bottoms; and most septic tanks are not regularly desludged and the septage removed is not treated and disposed of properly."
"Over 30 million people in the Philippines do not have access to improved sanitation facilities," says Katrina Arianne Ebora, who works on UNICEF's Water, Sanitation and Hygiene program in the Philippines.
"Out of this, 7.8 million people, or roughly 8 percent of the country's population don't have access to sanitation facilities at all - [thus they] resort to open defecation, meaning they have to defecate in the bushes, in the field, or at the seashore," she said.
Every day nearly 10 million (or 1 in 10) Filipinos defecate in open places or use a plastic bag that is then thrown out with the trash, according to the United Nations' Sustainable Development Fund, which is lower than the international average of 1 in 7 people.
Suzette is one of those who has no access to proper sanitation facilities. She lives in Tondo, a Manila neighborhood that is one of the world's most densely populated slums. On the walls of her home are framed pictures of her son and a bicycle that's the perfect size for a young boy learning to ride a bike.
Suzette is one of roughly 5 million Manila residents - around 37 percent of the capital region's population of 12 million - who live in slums. Like many families in Tondo, Suzette and her husband can't afford a toilet because it costs around 8,000 pesos (about $180). In Tondo, families who can't afford a toilets usually defecate in a plastic bag.
Suzette Flores says she would like to have access to a sanitary way to dispose of her and her family's waste, like a toilet, because it would be more comfortable and it would be healthier.
But it's a slightly different reality for toddlers like Zaldey Manlapaz, who are not yet potty-trained and whose families can't afford diapers.
Zaldey is only two years old. He was eating rice on a table in front of his house when he had to go to the bathroom. His mother, Issa, says that he usually poops on paper or plastic because diapers are too expensive.
When walking around Tondo, a Manila slum, it is not uncommon to see toddlers in shirts but without pants. Water costs about 3 pesos per container and it would take a lot of water to clean a cloth diaper. Zaldey pooped on the table where he was eating, bits of rice still on his face. Issa said she will collect the waste and place it in a plastic bag and add it the pile of plastic bags in her and her family's waste and garbage. Garbage trucks come into the neighborhood every morning around 9 or 10am and collect the bags of waste, according to residents. But the plastic bags are far from sanitary: bags break or are torn open by animals, thus spilling their contents and contaminating the area and leaving residents exposed to human waste.
Issa says she and her family often get ill, and have diarrhea all the time. Zaldey climbed off the table where he was eating and continued to use the bathroom while he was standing. This was not unusual for the community. When Zaldey was done pooping his mother put her cell phone away and followed her son to a basin where he was waiting to be washed. Issa said that if she would prefer to have a toilet, but the government has not provided one and she cannot afford one.
According to the nonprofit government research institution Philippine Institute of Development Studies (PIDS), about 32 percent of the slum population has incomes below the 2006 national poverty threshold of 20,000 pesos (US$400) annual per capita.
PIDS says Manila's slums are growing by the day with a population growth rate of nearly 8 percent. By 2050 the government predicts the slum population in Manila alone will reach over 9 million people.
The population growth rate is due in part to the large size of families: in Tondo, nearly every family has five to six members: two parents and three or four children. These families are living in overcrowded conditions: several warehouses modified to hold 88 families each now hold more than 200.
Many residents say the overpopulation of Manila's slums is due to families needing a source of income even if they don't earn much. Some families in Tondo have tried living in rural areas as part of the city's relocation program but they say they lasted less than a year and came back to Tondo to settle illegally because they couldn't find work outside of Manila and needed to feed their families.
In the slums of Manila, parents can earn a wage collecting garbage, segregating garbage, manual labor, working on the nearby port, or driving tricycles - a common form of transport in the Philippines.
Violi Okdeeman, 53, was part of the city's relocation program from Tondo to a more rural area. But Violi says that after less than a year she and her husband decided to move back to the city because they were worried about how they were going to feed their three children.
"In terms of facilities, there is much better than where we are now," said Violi. "It's a one room concrete house with a toilet in the same room and no faucet. But there was just nothing to eat [in the rural area], at least it is easier for my family to earn an income here."
Violi's husband is a welder but she is the main breadwinner in the family and all of her children are in school. Violi uses rain water that collects in a well near her home and for bathing, cooking and for her work. The water is free to the community. Other families from Tondo use the water from a pump that costs about three pesos per container. One family of five said they go through about ten containers of water for washing clothes and bathing, which costs them 30 pesos ($2.00) per day.
Violi uses the free water that she collects from the well to soak and peel garlic that she sells to her neighbors in the market a few buildings away from her home. Violi has a toilet, but it is broken, and even with her double income household she can't afford to fix it. So for now she and her family of five are also using plastic bags for their waste.
The Philippines is aiming to achieve universal access to safe and adequate toilets by 2028. While some villages have been declared Zero Open Defecation (ZOD) zones there is currently no national data available regarding ZOD villages.
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Sarah Jones is reporting on health and development from the Philippines as an International Reporting Project Fellow.