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Absence of sanitation points to massive deprivation

Sanitation remains one of the most neglected issues both in the national policies of many countries and by the global community. Failure to increase the number of people with access to clean water and basic sanitation endangers progress towards other important development targets

Water and sanitation are among the basic requirements for a minimum quality of life, and are widely regarded as the most essential elements of public health. And yet, in recent months, development experts and global leaders have stressed that of all the Millennium Development Goals (MDGs) (link) it is the sanitation target (one of the three targets of Goal 7: ensuring environmental sustainability) that is most in danger of remaining unmet by 2015.

Sanitation remains one of the most neglected issues both in the national policies of many countries and by the global community. Failure to halve (from 1990 levels) the number of people with no access to clean water and basic sanitation will endanger progress towards other targets such as reducing infant mortality, achieving gender equity, boosting school enrolments and reducing severe poverty, thereby derailing the entire MDG endeavour.

Currently deprived of a decent place to relieve themselves, 2.6 billion people (1 in 3 of the global population) are at risk of contracting a variety of diseases and infections associated with bad public sanitation -- diarrhoea, cholera, typhoid, trachoma and parasitic worms. As a result, more than 1 billion people get water for drinking, washing and cooking from sources polluted by human and animal faeces.

The situation is worse in developing countries. At any given time almost 50% of people living in these countries suffer from one or more diseases linked to poor water and sanitation, or poor water resources management, according to the United Nations Development Programme's (UNDP's) Human Development Report 2006.

Increasingly worried by the magnitude of the problem and frustrated by the gross neglect of people's water and sanitation needs, experts are pushing for a global action plan, under G8 leadership, to resolve a growing crisis that is responsible for nearly 2 million child deaths every year. The action plan would act as a 'virtual mechanism,' says the HDR 2006, which cites the Global Fund to Fight AIDS, Tuberculosis and Malaria --run by a small secretariat with minimal bureaucracy -- as a useful reference point.

The water and sanitation taskforce for the UN Millennium Project recommends that rich countries give water and sanitation greater priority in their aid budgets. There are signs, however, that trends are going in the opposite direction and, more worryingly, that funds earmarked for water and sanitation projects are moving away from the poorest countries where they are most needed.

Since the mid-1990s, aid from wealthy nations for water and sanitation has declined in real terms, falling from 8% to 5% of overall development aid. "A marked contrast to education, where aid commitments doubled over the same period," said a United Nations press release issued shortly after the publication of the HDR 2006.

Japan is by far the leader in aid for water and sanitation, providing $ 850 million in 2003 and 2004, one-fifth of the total.

The UNDP estimates that it would cost US$ 10 billion to halve the percentage of people without access to safe drinking water and to provide them with simple pit latrines, thereby greatly reducing the risk of infection. This may sound like a lot of money to some, but it's less than half of what rich countries spend annually on bottled water.

Euphemisms for poverty

According to some development experts, 'lack of water and sanitation' are often euphemisms for 'massive deprivation'. People living in extreme conditions of poverty, normally peri-urban dwellers or rural inhabitants, are the ones with least access to improved toilet facilities.

Among the main problems responsible for this situation are: lack of priority given to the sector, lack of financial resources, lack of sustainable water supply and sanitation services, poor hygiene behaviour, and inadequate sanitation in public places including hospitals, health centres and schools. Providing access to sufficient quantities of clean water, provision of facilities for the sanitary disposal of excreta, and introducing sound hygiene behaviour are essential to reduce the burden of disease caused by these risk factors, says the World Health Organisation.

Sanitation and public health

Sanitation is the hygienic disposal or recycling of waste material, particularly human excrement and urine. Sanitation is particularly important is isolation of water supply systems from sewage discharge. The scope of public sanitation usually extends to solid waste disposal and street-cleaning.

The importance of sanitation as a public health measure essential for the prevention of disease gained widespread recognition after improvements in sanitary conditions in the big American and European cities, over a century ago, considerably reduced mortality rates from disease.

Improved sanitation revolutionises public health

At the time, infant mortality rates in Washington, DC, were twice what they are today in sub-Saharan Africa, says the United Nations Development Programme. Waterborne diseases like diarrhoea, dysentery and typhoid accounted for 1 in 10 deaths in US cities in the late 19th century, with children the main victims, says a recent article in The New York Times.

In the United Kingdom and elsewhere, people were getting wealthier through the industrial revolution, but not healthier. The poor moved from rural to urban areas to benefit from the boom, while overwhelmed cities turned into deadly open-air sewers, with epidemics of typhoid and cholera regularly sweeping through cities like New Orleans and New York. In the hot summer of 1858, the UK Parliament was forced to temporarily close during what became known as 'The Great Stink,' caused by sewage flowing into the river Thames. For the rich, it was a nuisance. For the poor, who got their drinking water from the river, it was a killer.

By the end of the 19th century, says the NYT article, governments recognised that this was no longer just a poor man's problem. Diseases associated with water and sanitation could not be contained in the cities' poor tenements; it was in the greater public's interest to take action. In the UK, US and elsewhere, massive investments were made in effective sewerage systems and the purification of water supply. To great effect. No other period in US history, for example, has witnessed such a rapid decline in mortality rates. This change reflected a rare instance in history where a major social problem was successfully resolved.

A hundred years on, the HDR 2006 says it is time to address the issue of poor sanitation in the developing world with similar urgency.

The human cost of the sanitation taboo

Every year, more than 2 million children under the age of 5 die of diarrhoea and other illnesses brought on by dirty water and lack of access to sanitation, according to Unicef. According to the HDR 2006, up to 60% of these deaths can be prevented by access to a flush toilet. Evidence shows that access to a flush toilet reduced the risk of infant death by 59% in Peru and 57% in Egypt.

This fact is especially pertinent to India where centuries-old taboos on toilets within living quarters still persist and have proved a major stumbling block, especially in rural areas, in efforts to improve access to sanitation.

While the cities of the ancient Indus Valley civilisation had sophisticated sewerage systems and perhaps the oldest known toilets -- brick models that date back 4,500 years -- the development of Hinduism and its caste system in later centuries changed attitudes and practices concerning the disposal of human waste.

Bindeshwar Pathak, whose organisation Sulabh International has built over 700,000 toilets over 25 years, was quoted in The Washington Post assaying that ancient Hindu texts gave "firm religious sanction" to unsanitary behaviour by forbidding defecation near dwellings. "It's very difficult to bring it (toilets) into the home," Pathak said. "It's a cultural problem in India."

In rural areas, where more than 70% of Indians live, fewer than 10% of homes have toilets. Government officials and aid workers say they find it difficult to persuade uneducated villagers to abandon ancient customs and use an enclosed toilet. In the northern state of Rajasthan, villagers have converted outdoor latrines into storage areas and have resisted the construction of indoor bathrooms, fearing they would make their homes smell bad.

Also, traditionally, efforts to improve sanitation in India have not been motivated by the desire to improve public health. Instead, the aim has been the liberation of low-caste workers, formerly called "untouchables", from the degrading occupation of cleaning waterless toilets and carrying away woven baskets of human waste on their heads, an inhuman practice known as 'manual scavenging'.

In another part of Rajasthan, a private aid group, the Indian Institute of Health Management and Research, has achieved more success with a decade-old programme combining health education and the installation of household toilets.

When Bhika Ram Sharma, a sanitation worker who lives in the village, built an enclosed toilet within the compound of his house, a decade ago, he became the object of scorn because he was a Brahman, the highest caste. "People ridiculed me. They laughed at me and said: 'That Brahman boy has built a latrine inside his house,'" he recalls.

But, after years of continuous health education, a desire to keep up with the Sharmas began to take hold in the village. Now, the Indian Institute of Health Management and Research has a waiting list for the installation of toilets under a programme that requires each village only to make enough bricks to line the pit and to erect walls.

The number of small children dying from diarrhoea has since decreased in the area, say aid workers.

South Asia leads in sanitation-related deaths...

Lack of sanitation coverage is particularly acute in South Asia where 1.9 billion people who lack access to proper toilets live. Up to 36% of urban South Asians, and a massive 76% in rural areas, do not have access to proper toilets, according to the United Nations Environment Programme.

India, one of the world's fastest growing economies, accounts for 450,000 of the world total of 1.8 million infant diarrhoea deaths annually. For every 1,000 children in India, 90 die before their fifth birthday, mostly from preventable diseases like diarrhoea. Infected water causes an estimated 80% of diseases in India, according to the World Health Organisation, making poor sanitation and inadequate sewage disposal the nation's biggest public health problem.

Urban sanitation coverage in the country is just 30%, and in rural areas it is half that -- a mere 15%. The government has now joined private organisations in adding bathrooms to rural homes, but at the current rate of construction and population growth it would take 200 years for every Indian to have access to a toilet within the home.

According to the global aid agency, WaterAid, no more than 250 of the country's 4,000 cities and towns have sewerage systems, and many of those systems do not have treatment plants. The bulk of municipal sewage -- even from such major cities as Mumbai and Kolkata -- flows untreated into rivers, lakes and the sea.

...and innovative and simple solutions

However, some of the most innovative efforts to expand the availability of latrines and simple sewage systems have been initiated in South Asia, the HDR 2006 says. In the Pakistani port city of Karachi, a local group began organising slum-dwellers, lane by lane, in 1980, to build sewer channels to collect waste from their homes. Entire neighbourhoods then got together to construct larger channels and the city eventually agreed to finance a trunk sewer line. As a result, the infant mortality rate in the slum, Orangi, fell to 40 deaths per 1,000 births, from 130 in the early 1980s.

In Bangladesh, more than 600 private groups work with communities to map places where people defecate and the routes of disease transmission, helping fuel a demand for sanitation services. Over 3,000 small businesses have sprung up to produce, market and maintain cheap latrines.

'Latrinisation' vs 'total sanitation'

WaterAid expressed its concern at the recent South Asian Conference on Sanitation (SACOSAN) that the rush to meet national and international targets on sanitation was leading to a focus on 100% latrine coverage rather than emphasising and spreading hygiene and sanitation awareness -- so called 'latrinisation' and not 'total sanitation'. National monitoring programmes continue to count only the number of latrines; they do not provide information on the number of totally sanitised communities and the sustainability of sanitation facilities.

Officials involved in programmes to install household toilets in villages often neglect to conduct public education campaigns to establish the connection between sanitation and health. In rural schools, instruction in such basic hygiene as hand-washing is limited and cannot be reinforced in school buildings that lack running water and toilets.

Water as a human right

In recent years, two very different philosophies have emerged to bolster the flagging target-based approach of the MDGs for water and sanitation. Firstly, the concept of water as a basic human right is gaining ground, having been omitted from the original Universal Declaration of Human Rights. In 2002, the UN Committee on Economic, Cultural and Social Rights adopted a proposal to recognise water as a human right, thereby placing considerable obligation on countries to fulfil individuals' rights to safe drinking water and sanitation. In response to the dire predictions of the HDR 2006, the United Kingdom became the first country to officially recognise water as a human right. HDR 2006 calls for 20 litres of clean water a day for all to be considered as a human right. It calls for governments to commit to spending at least 1.8% of their GDP to improving access to safe water and sanitation.

The second boost comes from cold economics. A cost/benefit evaluation by the World Health Organisation concludes that the cost of achieving the MDG for safe drinking water is US$ 1.78 billion per year, and the cost of the safe sanitation target is US$ 1.3 billion per year. In both cases, the benefits in terms of economic output and health savings are demonstrated to outweigh the costs, a crucial consideration for international donors.

Nevertheless, the combined pressure of high-level UN support, favourable cost/benefit analysis and powerful rights-based advocacy has not yet generated the desired sense of urgency. The NGO community was particularly frustrated at the apparent neglect of water and sanitation issues at the 2005 global summit to review progress on the MDGs. There remains no clear global plan for achieving water and sanitation targets, nor sufficiently detailed national strategies.

InfoChange News and Features, November 2006