Adequate drinking water, sanitation, and hygiene are all essential ingredients to ensure human health. The same is true for proper wastewater management, which is a basic prerequisite for environmental health. Improving upon these services will bring economic gains while also helping to build resilience given increasing climate variability.
Many developing countries are already today struggling to cope with chronic water shortages and the inadequacies of their existing water infrastructure. They are also facing unprecedented population growth, rapid urbanization, and increased economic activity. Basic needs remain unmet, and the human right to water and sanitation remains unrealized for billions of people worldwide. Against this background, global water security has risen on the international agenda. In fact, in 2012, a US Intelligence Community Assessment identified water-related problems in developing countries, such as increased risk of disease from unsafe drinking water and poor sanitation, as a threat to American interests. Just last year, the World Economic Forum identified water crises as the global systemic risk of third highest concern. Policies, institutions and infrastructure to improve drinking water sanitation, hygiene and wastewater management must be put in place today. Such actions will also build resilience to cope with the future impacts of climate change.
The world’s drinking water situation is improving. However, there is still cause for concern. In 2012, it was reported that the international community had reached the Millennium Development Goal (MDG) target, to halve the proportion of people lacking access to safe drinking water, three years before the 2015 deadline. While this is a welcome achievement, there is an important caveat. The proxy indicator used to measure progress towards this target is “access to an ‘improved’ drinking water source.” This indicator has limited meaning, since it does not represent a reliable measure of drinking water safety. In fact, a recent study commissioned by the World Health Organization (WHO) and UNICEF estimates that at minimum 1.8 billion people around the globe use fecally-contaminated drinking water. This is more than twice the official figure from the WHO/UNICEF Joint Monitoring Programme of 748 million lacking access to an improved drinking water source.
The global sanitation problem requires urgent attention. The MDG sanitation target, to halve the proportion of people lacking access to improved sanitation by 2015, is seriously off-track. Today, 2.5 billion people still lack access to basic sanitation. In many parts of sub-Saharan Africa, less than half of the population uses a toilet fit for human beings. One billion people do not use a toilet at all. In South-East Asia almost 40% of the population defecates in the open. In cases where toilets exist, it is important that they hygienically separate human excreta from human contact. But this step by itself is not sufficient to protect health. There are other key factors. For example, excreta are often captured in unlined latrine pits from where excreta freely leach into the ground water. Also, when latrines are emptied, the fecal sludge is frequently dumped into surrounding water bodies. Both features cause major negative health impacts on communities and the environment at large. Approximately ninety percent of wastewater in developing countries is discharged directly into rivers, lakes, and seas. To realize sanitation’s health benefits, the full sanitation chain, including wastewater management, must be considered. Currently, there is no global monitoring to track progress in wastewater management.
Hygiene poses another global health challenge. However, thus far, hygiene has not been prioritized on the international development agenda, despite the fact that hand washing with soap could save 300,000 people annually. Safe drinking water and sanitation in the absence of hygienic behavior will not prevent feco-oral infections. Many households, for example, have no other option than to store water before use. Even if the original source of the water is safe, the water is frequently contaminated by unhygienic conditions and practices in the home. Across the developing world, hand washing and menstrual hygiene facilities along with toilets are often not available in schools, thereby deterring attendance, particularly for adolescent girls. A recent study by Freeman et al., published in the Journal of Epidemiology and Infection, estimates that inadequate hand hygiene practices affects 80% of the global population. Even though hygiene’s health benefits are well documented, there is no global development target or monitoring framework to track the uptake of improved hygiene practices.
There are tremendous economic gains that can be realized with improved drinking water, sanitation and hygiene. The WHO estimates that for every US dollar invested in improved drinking water and sanitation there is an economic return of four US dollars resulting from health and productivity gains. It is estimated that the benefits of achieving universal access to improved sanitation would outweigh costs at least five-fold, and for improved drinking water at least two-fold, with a minimum combined economic benefit of over 220 billion US Dollars annually.
The WHO estimates the total global economic loss per annum resulting from poor water supply and sanitation at 260 billion US Dollars. Per World Bank studies, countries in sub-Saharan Africa, as well as Bangladesh and India, on average lose more than 4% and 6% of their Gross Domestic Product (GDP), respectively, due to inadequate sanitation. The evidence is clear: poor sanitation and inadequate water supply play a role in keeping countries poor.
The burden of water-related diseases curtails efforts to improve public health in the developing world. Diarrhea – most often related to unsafe drinking water, poor sanitation and inadequate hygiene – is one of the leading causes of death among children under the age of five. It kills more children than Malaria or HIV/AIDS. The WHO estimates that exposure to inadequate drinking water, sanitation and hand hygiene was responsible for 58% of deaths from diarrhea, adding up to 840,000 deaths in low and middle-income countries, in 2012. This translates into 1.5% of the global disease burden, even 5.5% for children under five. There is growing evidence that repeated exposure to unsafe drinking water, poor sanitation and inadequate hygiene have a significant impact on stunting. This comes about as a result of intestinal worm infections, diarrheal diseases and environmental enteropathy which lead to a poor nutritional status. Cholera is also transmitted via contaminated water. The cholera epidemic in Haiti has killed more than 8,500 people since 2010.
Taking all of the above into account, water, sanitation (including wastewater) and hygiene must be given greater priority in the health community, which presently puts too much focus on curative approaches. In their paper “Hygiene, Sanitation and Water: Forgotten Foundations of Health,” published in 2010, Bartram and Cairncross conclude that the “active involvement of health professionals in hygiene, sanitation and water supply is crucial to accelerating and consolidating progress for health”. To translate this recommendation into practice, the WHO along with other key actors in the health sector, should streamline drinking water, sanitation and hygiene as preventative medicine. Through a push for more funding allocation and better policy design, tangible health benefits could be realized. And, most importantly, improvements will be made in the lives of billions of people.