Water, sanitation and hygiene and the Millennium Development Goals (MDGs) Better hygiene and access to drinking water and sanitation will accelerate progress toward two MDGs: ���Reduce under- five child mortality rate by 2/3 between 1990 and 2015��� and ���By 2015 halve the proportion of people without sustainable access to safe drinking water and basic sanitation���. Meeting the latter goal will require infrastructure investments of about US$23 billion per year, to improve water services for 1.5 billion more people (292,000 people per day) and access to safe sanitation for 2.2 billion additional people (397,000 per day). Fewer than one in five countries are on track for meeting this target. How do water, sanitation and hygiene affect health? Water supply, sanitation, and hygiene and health are closely related. Inadequate quantities and quality of drinking water, lack of sanitation facilities, and poor hygiene cause millions of the world���s poorest people to die from preventable (primarily diarrheal) diseases each year. Women and children are the main victims. Water, sanitation and health are linked in many ways: ��� contaminated water that is consumed may result in water- borne diseases including viral hepatitis, typhoid, cholera, dysentery and other diseases that cause diarrhea ��� without adequate quantities of water for personal hygiene, skin and eye infections (trachoma) spread easily ��� water-based diseases and water-related vector-borne diseases can result from water supply projects (including dams and irrigation structures) that inadvertently provide habitats for mosquitoes and snails that are intermediate hosts of parasites that cause malaria, schistomsomisis, lymphatic filariasis, onchocerciasis and Japanese encephalitis ��� drinking water supplies that contain high amounts of certain chemicals (like arsenic and nitrates) can cause serious disease. Inadequate water, sanitation and hygiene account for a large part of the burden of illness and death in developing countries: ��� Approximately 4 billion cases of diarrhea per year cause 2.2 million deaths, most���1.7 million���children under the age of five, about 15% of all under 5 deaths in developing countries. ��� Diarrheal diseases account for 4.3% of the total global disease burden (62.5 million DALYs). An estimated 88% of this burden is attributable to unsafe drinking water supply, inadequate sanitation, and poor hygiene. These risk factors are second, after malnutrition, in contributing to the global burden of disease. ��� Intestinal worms infect about 10% of the population of the developing world, and can lead to malnutrition, anemia and retarded growth. ��� 6 million people are blind from trachoma and the population at risk is about 500 million. ��� 300 million people suffer from malaria. ��� 200 million people are infected with schistosomiasis, 20 million of whom suffer severe consequences. Water supply, sanitation and hygiene are about more than health. Saved time, particularly for women and children, is a major benefit. Beneficiaries of water and sanitation projects in India reported these benefits: less tension/conflict in homes and communities community unity, self-esteem, women���s empowerment (less harassment) and improved school attendance (WaterAid 2001). Effectiveness of water supply, sanitation and hygiene interventions Improved hygiene (hand washing) and sanitation (latrines) have more impact than drinking water quality on health outcomes, specifically reductions in diarrhea, parasitic infections, morbidity and mortality, and increases in child growth (Esrey et al 1991 Hutley et al 1997). Most endemic diarrhea is not water-borne, but transmitted from person to person by poor hygiene practices, so an increase in the quantity of water has a greater health impact than improved water quality because it makes it possible (or at least more feasible) for people to adopt safe hygiene behaviors (Esrey et al 1996). Experience shows that constructing water supply and November 2003 W ater, sanitation & hygiene at a glance Water and Health ��� two precious resources linked to one another. Water for Health, World Water Day, 2001

sanitation facilities is not enough to improve health sanitation and hygiene promotion must accompany the infrastructure investments to realize their full potential as a public health intervention. Changing hygiene behavior is complex. Hygiene promotion is most successful when it targets a few behaviors with the most potential for impact. Based on extensive research, WHO and UNICEF have identified hand washing with soap (or ash or other aid) after stool disposal and before preparing food safe disposal of feces and use of latrines and safe weaning food preparation, water handling and storage as the key hygiene behaviors. A recent review (Curtis) of all the available evidence suggests that handwashing with soap could reduce diarrhea incidence by 47% and save at least one million lives per year. This is consistent with other studies which found that 12 hand washing interventions in 9 countries achieved a median reduction in diarrhea incidence of 35% (Hill, Kirkwood and Edmond, 2001). Many of the most successful interventions provided soap to mothers, explained the oral-fecal route for disease transmission, and asked mothers to wash their hands before preparing food, and after defecation. There are fewer studies of results of interventions to improve feces disposal, but Hill et al. found a median reduction of diarrheal disease of 26% (9 studies, range 0���68%), a median reductions in all-cause child mortality of 55% (6 studies, range 20���80%) and a median reduction in mortality from diarrhea of 65% (3 studies, range 43���70%). What can the public health sector do? The public health sector can do several things, in collaboration with other sectors, to help ensure that investments in water supply and sanitation result in greater health impact. Public health promotion and education strategies are needed to change behaviors so as to realize the health benefits of improved water supplies. Programs to improve hand washing behavior appear to be feasible and sustainable especially when they incorporate traditional hygiene practices and beliefs. New, better approaches to behavior change are being developed, including a recent project that has shown excellent results through persuading the private sector (soap manufacturers and the media) to transmit health information by advertising soap and its appropriate use to prevent diarrhea (see The Story of a Successful Public-Private Partnership in Central America: Handwashing for Diarrheal Disease Prevention, 2001). School health programs School health programs offer a good entry point for improved water supply and sanitation facilities and for community hygiene promotion. It is a realistic goal in most countries to ensure that all schools have clean water and sanitation. This enables schools to reinforce health and hygiene messages, ensure they translate into action, and set an example to students and the community. This can lead to community demands for similar facilities. Handwashing is one of the most effective interventions for reducing diarrhea Based on research findings and lessons learned from the successful public-private partnership ���Handwashing for Diarrheal Disease Prevention Project��� in Central America, the World Bank, the Water and Sanitation Program, the London School of Hygiene and Tropical Medicine, the Academy for Educational Development and the private sector, in collaboration with USAID, UNICEF, and the Bank-Netherlands Water Partnership developed a global initiative in 2001 to promote handwashing with soap in developing countries. The first pilot project locations are Ghana, Kerala, India, Senegal, Peru, China and Nepal. Results are being monitored and lessons documented and disseminated. Global advocacy events promote handwashing. Access to Water and Sanitation More people have access to safe drinking water and sanita- tion than ten years ago but population growth has eclipsed these accomplishments. One sixth (1.1 billion) of the world population lacks access to improved water supply, two-fifth (2.4 billion) have no improved sanitation. Most of these people live in Asia and Africa. Rural services lag far behind urban services. 2% 7% 28% 83% 2% 5% 13% 80% Total unserved: 1.1 billion Total unserved: 2.4 billion Water supply Distribution of unserved population Sanitation Distribution of unserved population Europe Latin America/Caribbean Africa Asia Source:WHO/UNICEF 2000