Memorandum submitted by the Water, Sanitation
and Health Programme (WSH) of the World Health Organization (WHO)
On behalf of the Water, Sanitation and Health
Programme (WSH) of the World Health Organization (WHO), I should
like to express our appreciation for the opportunity to provide
inputs in support of the deliberations of the International Development
Committee. We consider the attention by the Committee appropriate,
given the importance of the issue for health and the limited success
in accelerating progress in the area.
These comments are formulated in light of the
functions of WHO as a specialized Organization of the United Nations,
with global responsibilities for health matters and as a long-term
international player in the field of water, sanitation and hygiene.
As such, we recognize the direct role of access to safe drinking-water
and basic sanitation, proper water management and hygiene promotion
in the protection and promotion of human health—and, through
this impact on health, on poverty reduction. We further recognize
that the impacts of water resources development on health can
be both positive and negative. Water resources development without
health impact assessment, and water supply and sanitation projects
oblivious of the socio-cultural setting in which they are implemented,
can have substantive adverse health effects. In areas where the
burden of water associated ill-health is high, WSH interventions
have a proved capacity to deliver a cost-effective and sustainable
positive impact on health and on meeting development goals and
targets.
Our concern relates to five consecutive issues.
In the attached note we will outline these and then turn to the
eight priority areas identified in the document circulated for
comment. Throughout the attached text we provide URL links to
documents providing additional information and substantiation,
should these be of interest for your deliberations.
FIVE ISSUES
THAT JUSTIFY
TREATING WATER
SANITATION AND
HEALTH AS
A PRIORITY
CONCERN
1. There is a high global burden of water
and sanitation related disease.
WHO presented the first scientifically substantiated
estimate of water, sanitation and hygiene-related disease in 2001
and since that time has further developed methods to improve the
scope and reliability of these estimates. Our most recent estimates
indicate that approaching 10% of the total global burden of disease
is associated with water (both water resources and water supply),
sanitation, hygiene (www.who.int/water_sanitation_health). This
is a significant under-estimate as the applied assessment methods
are less than adequate and for many countries reliable datasets
are not available to ensure sound estimates for several important
groups of diseases. The most significant disease groups include:
— Diarrhoeal diseases. Water-borne
infections causing diarrhoeal disease account for 1.5 million
deaths annually. The burden is overwhelmingly carried by children
under five years of age in the developing world (1.3 million deaths).
Morbidity is also high and has become proportionally more important
in the overall burden of disease over the past 15 years. Access
to safe drinking-water, basic sanitation and better hygiene potentially
can remedy up to 94% of the diarrhoeal disease burden.
— Malaria. This water-associated vector-borne
disease is responsible for over a million deaths per year. In
many parts of the world, transmission could be interrupted through
proper water resources development and management; elsewhere such
environmental management approaches could make a substantive contribution
in an overall integrated disease management approach.
— Intestinal nematode infections. These
soil-transmitted infections (roundworm, hookworm and whipworm)
affect a third of the world's population (i.e. 2 billion preventable
current infestations). The combination of access to adequate sanitation
and hygiene education has been shown to have a significant and
lasting impact on the reduction of the burden caused by these
infections.
— Lymphatic filariasis. This parasitic
infection is transmitted by mosquitoes breeding in organically
polluted water (urban settings in Asia) and irrigation schemes
(rural Africa) is presently associated with 25 million severely
incapacitated people.
— Trachoma. Fly-borne bacteria are
at the root of the present burden of 5 million preventable blind;
hygiene education and provision of sanitation are two of four
elements in a global strategy to eliminate this disease as a public
health problem.
— Schistosomiasis. This disease is
virtually synonymous with irrigation development in Africa. Globally,
200 million people are infected. Programmes aimed at case detection
and drug treatment have little lasting impact as long as the environmental
receptivity to this disease is not reduced through improved sanitation
and health education.
— Drowning. This important water-associated
disease burden is associated with 280,000 preventable deaths annually—largely
concentrated in the developing world.
— significant water-associated disease
burdens, for which water interventions can contribute to the solution
include dengue/dengue haemorrhagic fever, Japanese encephalitis,
onchocerciasis and other tropical diseases.
For dengue fever no other control method exists
but vector control through chemical, biological or water management
practices. For several of the other diseases listed, medical solutions
are under pressure, either because of rapidly developing drug
resistance or because the most vulnerable communities cannot afford
effective treatment. And for most of the above diseases WSH interventions
are the most sustainable and resilient solutions, especially in
areas of conflict or humanitarian disaster where regular health
services may break down rapidly.
Diseases for which estimates are not yet available
but for which the disease burden associated with water is likely
to be significant include:
— infectious diseases such as legionellosis,
leptospirosis, conjunctivitis and otitis, respiratory infections
related to hygiene.
— water-associated injuries such as
spinal injury related to recreational water use or skeletal damage
caused by a lifelong practice of carrying domestic water over
large distances.
— the health impacts of hazardous chemicals
such as fluoride, arsenic, lead and nitrate, which may occur naturally
in ground water.
— the lack of essential micro-nutrients
for which water provides a small but possibly significant increment
over food, such as calcium (bone health) and of magnesium (cardiovascular
health).
Whilst the connection between water-related
ill-health (especially diarrhoea) and malnutrition is suspected,
until recently it has not been possible to quantify the fraction
of malnutrition and in turn malnutrition-associated disease that
would be prevented by improvements in water sanitation and hygiene.
With new research efforts under way, rapid progress in this area
is expected to occur in the coming years.
2. There is extensive evidence to show
that that this disease burden can be effectively reduced through
water, sanitation and hygiene measures
Our most recent estimates suggest that achievable
environmental interventions (including behavioural change) can
eliminate around 24% the global burden of disease. (www.who.int/quantifying—ehimpacts/publications/preventingdisease/en/indxex.html).
A further breakdown of these figures gives the following picture:
— Among children of the 0-14 age group,
an estimated 36% of deaths can be attributed to factors that are
modifiable through environmental management or improved hygiene
behaviour.
— There are great regional differences
in the burden of environment-related ill-health: an estimated
25% of all deaths in developing regions are attributable to environmental
causes, while in developed regions such causes only account for
an estimated 17% of all deaths.
— Diseases for which environmental
management approaches can achieve the greatest health improvements
include diarrhoeal diseases (tackling environmental risks factors
through improved access to safe drinking-water, basic sanitation
and better hygiene potentially addresses 94% of the disease burden);
malaria (42% of the global burden can be relieved through environmental
management, with improved water management as a major component);
intestinal worm infections and schistosomiasis (these infections
can be controlled for a full 100% through improved sanitation
and better hygiene).
3. WSH Interventions are cost-effective
and yield benefits that can be valued at many times their costs
In 2004, WHO reported to the 12th session of
the Commission on Sustainable Development the findings of its
work on the costs and impacts of water and sanitation policies
and programmes (www.who.int/water—sanitation—health/wsh0404/en/index.html).
The principal conclusions of that work were that interventions
in water and sanitation yielded benefits that could be valued
using standard economic methods at between 3 and 34USD per dollar
invested. Taking account of health impacts alone water and sanitation
interventions were judged to be cost-effective or even very cost-effective
(depending on the specific intervention and the region in which
it is applied) using the criteria of the WHO Commission on macroeconomics
and health. Achieving the MDG drinking-water target was, in 2004,
estimated to require an annual additional investment of of an
estimated US$11.3 billion; the benefits would include a reduction
of 10% in the global burden of diarrhoeal diseases, and an annual
economic benefit of US$84 billion. These benefits consists of
the value of the actual reduction in DALYs, lost, in reduced costs
for health care at the national and household levels, to reduced
absenteeism due to ill-health from productive activities and from
school attendance, and to new opportunities for productive activities,
child care and other household activities because of time freed
up from not having to collect water from large distances.
We have since then further developed these analyses
at regional level and for modified projection scenarios, leading
to similar general conclusions. We consider that such economic
arguments are critical in making the case for investments on W&S
at all levels and for this reason are presently making significant
efforts towards developing methods to a form that is suitable
for application at country and sub-national levels. We anticipate
the availability of the resulting tools during 2007 and believe
that they will make a substantial contribution to advancing the
capacities of WHO Member States to make decisions based on both
technical and economic evidence.
Earlier work on the cost-effectiveness of water
management interventions for the control of malaria and vector-borne
diseases has shown that their comparative economic benefits lie
in the fact that they can often be included into the planning
and design of dams or irrigation schemes at zero extra costs,
or they can be deployed for dual benefits. Examples of the latter
include environmental management measures that ensure both irrigation
water savings in water-scarce areas as well as a reduction of
environmental receptivity to disease vector breeding. The major
obstacle in this connection remains that of planning procedures
for such projects, which are confined by sectoral boundaries,
and the lack of capacity in the health sector to functionally
participate in the negotiations and decision-making over water
resources development. This is a generic problem that could be
remedied by establishing or strengthening environmental health
programmes within ministries of health with a remit for intersectoral
action.
4. Acting on WSH has significant impacts
on poor and disadvantaged households and can serve to improve
household economy
Less well known than the numbers of people without
access, yet equally disturbing, is the drinking water quality
situation for the a significant portion of the remaining 5.2 billion
who are assumed to have safe water. Many of these are, in fact,
drinking water with different levels of contamination.
Hazardous microbes may enter a water supply
through seepage of contaminated run-off water or within the piped
distribution system. Moreover, unhygienic handling of water during
transport or within the home can lead to contamination of initially
safe water. Considering these factors, additional water safety
measures are needed.
Recent research suggests that household water
treatment offers a reliable option and is among the most effective
water, sanitation and health interventions. Studies suggest that
diarrhoeal episodes can be reduced between 35-39% through household
water treatment and safe storage. Moreover, household approaches
are cost-effective; WHO estimates that benefits may be up to US$
60 for every dollar invested. Finally, household approaches are
rapidly deployable and are particularly effective in poor communities.
They allow families to take charge of their own water quality,
resulting in immediate improvements for the health status of family
members.
More information at http://www.who.int/household_water/en/
5. Acting on WSH for health also benefits
national economies
The above mentioned information with regard
to, for example, cost offsets and time savings would suggest that
interventions on WSH would have a beneficial impact on national
as well as household economies. Whilst less evidence for this
is available, whatever evidence there is does support this conclusion.
Thus amongst sub-Saharan African countries the burden of malaria
is reported to account for an annual cost of US$12 billion very
year in lost GDP. Analyses over the past 30 years have also shown
a significantly smaller annual GDP growth in high malaria as opposed
to low malaria countries. In reviewing countries at similar levels
of GDP, the difference in GDP growth for those that have made
Water, Sanitation and Health their priority as opposed to those
that have not, is reported to be 3.6 percentage points (an average
of 3.7% versus 0.1%, respectively).
A WHO analysis of Poverty Reduction Strategy
Papers from a number of countries indicates that investment in
water and sanitation features low in their overall scope. Investments
in the context of PRSPs seem to go, by priority, to "productive"
sectors. Within the social sectors, like health and education,
the investments focus on infrastructure development and capacity
building for delivery of improved health and education services.
Areas of a more cross-cutting or sub-sectoral nature appear to
receive relatively little attention in this context.
PRIORITY AREAS
Water Service Delivery
Through their `Joint Monitoring Programme',
WHO and UNICEF report periodically on global progress in communities'
access to improved drinking water sources and basic sanitation,
and the installation of piped water supplies (www.wssinfo.org).
The reports are based on rigorous analysis of a large number of
household surveys, each assessing actual water use in large samples
of representative clusters. As a result, the datasets collected
have a high level of reliability, although they do not provide
the desired depth of insight that could be achieved were more
extensive data gathering be economically feasible. These reports
have described progress towards the MDG7 target of halving the
population without sustainable access to safe drinking-water by
2015 as `on track in (www.wssinfo.org/en/40—mdg2006.html).
However, we would argue that this assessment is at present optimistic
for the following reasons:
— Firstly it is noteworthy that the
UN system accepted definition of `on track' is to be within 5%
of the target. Against this criterion, it is correct to say that
progress towards the water target remains on track. Consecutive
reports indicate, however, that the perspective is deteriorating,
that there is an incremental increase in the deviation from the
target and that a continuation of this trend will lead to the
target being missed.
— Secondly, the moderate ambition of
the target arises from the adoption of a relatively low benchmark.
In effect a household is considered `served' with drinking water
if a protected source (such as a protected dug well, a tube well
or a standpipe) is within a moderate walk of the dwelling—for
example, within 20 minutes walk. It is doubtful whether such a
level of service brings a significant proportion of potential
benefits to households.
— Thirdly, whilst the MDG goal refers
to sustainable access to safe drinking-water, the available indicators
presently assess use of protected drinking-water sources. Evidence
derived from the monitoring suggests that only a fraction of either
improved sources or piped supplies are in fact `safe'. With UNICEF
and with the support of DFID we have been investigating approaches
to assessing safety. The preliminary outcome of our work suggests
that it is possible to make cost-effective improvements to drinking-water
safety, that also reinforce good system and asset management practices.
The approach adopted has been coded in WHO's Global Drinking Water
Quality Guidelines (GDWQ) as `Water Safety Plans'. Widespread
roll out WSPs, which can be applied at different levels, provides
the perspective of a significant improvement.
— Fourthly, even if the MDG target
is reached there will remain a large unnerved population of approximately
700 million people. In fact, the limited decline in the absolute
number of people without access to an improved drinking-water
source is the resultant of progress made in extending coverage
and the impact of population growth. As a function of this, the
actual burden of water-borne disease will also have only declined
slightly.
It is therefore imperative that measures to
address the water-related disease of unserved populations are
treated as a parallel priority to the efforts of increasing access.
It is for these reasons that since 2003 WHO has been advocating
household water treatment and safe storage alongside other household
measures such as hygiene as a means to directly address WSH in
poor, unserved households. This approach was mentioned above.
The recommended interventions have a proven impact and cost-effectiveness.
Sanitation: hygiene promotion, household sanitary
arrangements and sewage treatment
There is strong evidence for the high impact
on health status of improved hygiene at the household level. This
evidence also suggests, however, provision of basic drinking-water
and sanitation infrastructure is a major incentive for improvements
in hygiene conditions and behaviour. and in some cases a prerequisite
to the adoption for health protecting behaviours.
In your letter you refer to sewage treatment
as the third core aspect of sanitation. Successive JMP reports
have described progress in piped sewerage infrastructure and have
noted the low levels of treatment of sewerage globally. Work with
UNEP GPA in this context has brought up evidence to suggest that
the disease burden and environmental impact of inadequate treatment
of sewage before discharge into the environment is significant.
Population growth, rapid urbanization, increasing affluence and
therefore per capita water demand, aggravated by the effects of
global climate change and increasing demand for foodstuffs overall
and animal protein in particular all combine to create significant
water scarcity in countries at all levels of development. For
these reasons (as well as because of the continuing demand for
water-borne sewerage, especially in urban areas) drivers will
increase in intensity towards use of wastewater in agricultural
production. WHO therefore considers work on the safe and productive
use of wastewater as a higher strategic priority than wastewater
pretreatment per se. It should also be noted that much
established treatment technology is not appropriate to dealing
with health concerns. The recently released third edition of the
WHO Guidelines on Safe Use of Wastewater, Excreta and Greywater
in Agriculture and Aquaculture (in cooperation with FAO and UNEP)
was significantly supported by DFID. DFID support was vital in
the timely delivery of these Guidelines, whose comprehensive risk
assessment and management approach in our perspective will prove
of great value in the coming decade or two (www.who.int/water—sanitation—health/wastewater/gsuww/en/index/html).
Water Resource Management
In 2004 WHO commissioned systematic literature
reviews to elucidate the fraction of the burden of four water-associated
vector-borne diseases that can be attributed to water resources
development. The reports are available on the WHO web site (www.who.int/water—sanitation—health/resources/stiliteraturerev/en/index.html).
Of the four diseases (malaria, schistosomiasis, lymphatic filariasis,
Japanese encephalitis), the strongest evidence base exists for
the association between the burden of schistosomiasis and irrigation
development in Africa, China and the Philippines. There is an
extensive literature on effective engineering measures and other
environmental interventions for the prevention and control of
the transmission of this disease. For Japanese encephalitis, regionally
distributed in Asia and linked to irrigated rice production systems,
a vaccine exists, but its application is cumbersome (one initial
vaccination and two booster vaccinations are required to achieve
protection) and the most vulnerable groups (poor rural communities)
are often out of reach of the health services. Water management
in rice ecosystems can reduce risks of outbreaks and can be integrated
into agricultural practices aimed at saving water and at reducing
agricultural pests (IPM). With respect to malaria the picture
is more complex. In Africa, the burden of malaria is the highest
(80-90% of the global burden) but the scale of water resources
development is the most limited—malaria is well-entrenched
in the natural ecosystem. Nevertheless, development of the water
resources potential in Africa holds a serious threat for the further
exacerbation of the disease burden, particularly in the areas
where malaria now is seasonal/meso-endemic. Research on the development
of small dams in Ethiopia showed a seven-fold increase in malaria
transmission after the dams became operational. In Asia and Latin
America, the attributable fraction of the malaria burden to water
resources development is clear; also, the mosquito vector species
tend to be distributed by clearly defined ecological niches and
are therefore more prone to environmental management interventions.
For lymphatic filariasis there is insufficient evidence to make
a statement on the nature and magnitude of its association with
water resources development.
The reduction of reliance on insecticides for
disease vector control is an important international policy goal,
championed by the WHO (World Health Resolution 50.13) and promoted
by the international legally binding Stockholm Convention on Persistent
Organic Pollutants. Under this Convention, signatory countries
have committed themselves to develop alternatives to pesticides
used for public health purposes. There is ample scope to assist
countries in the development and testing of water management interventions
as part of integrated vector management strategies.
Health impact assessment (www.who.int/water—sanitation—health/resources/hia/en/index.html
and www.iaia.org/Members/Publications/Special—Pubs/Bi1.pdf)
is a critical tool in development planning, including water resources
development. Through HIA, health safeguards can be made part of
the project design and health opportunities can be identified
and seized at an early stage. WHO has developed a comprehensive
HIA capacity building programme, which is currently implemented
in the countries of the Mekong Region, focusing on water resources
development. Plans exist for its implementation in a number of
African countries, as well.
Urbanisation and water
The most recent WHO/UNICEF Joint Monitoring
Programme report takes as its theme the twin rural and urban challenges.
Whilst the present population without access to drinking water
and basic sanitation is overwhelmingly found in rural areas (6
of every 7 `unserved'), population growth is overwhelmingly concentrated
in urban areas. Separate application of the MDG goal to rural
and urban populations would suggest that the challenge is almost
evenly distributed, requiring 900 million rural dwellers and 1
billion urban dwellers to attain access by 2015.
It is widely recognized that sanitation `lags
behind' and that the MDG goal of halving the proportion of the
population without access to basic sanitation is unlikely to be
met. Therefore, the limitations of present approaches are noteworthy.
Expansion of sewerage is both costly and—in the absence
of treatment—normally results in significant adverse health
and environmental impacts. Nevertheless, sustainable solutions
for large water-scarce urban areas are not presently available
and there is a need for significant innovation and testing to
respond to the associated challenge.
Improving health and education through water and
sanitation interventions
We have addressed the health dimensions of water
and sanitation at some length above. We would note here, however,
two dimensions of this that have attracted insufficient recognition
from the WSH community: health care waste and WSH in health care
facilities.
Gender aspects of water and sanitation issues
There is extensive information available describing
the gender specific aspects of water and sanitation. The themes
that recur most often principally concern the time involved in
fetching water and the opportunity costs of doing so; to a lesser
extent, the physical burden of carrying water and resultant musculoskeletal
disorders and additional BOD in terms of fractures, sprains, falls
(and which cannot be separated from women's other weight-bearing
responsibilities in terms of fuel and fodder transportation);
women's caring role and links to availability of water and sanitation
facilities; women's relative lack of education and decision-making
ability in less advanced societies, and their resulting inability
to bring about change for the better to benefit themselves and
their families. Some literature is available underlining differential
health outcomes for men and women respectively in relation to
water-related disease, based on social roles and biological differences,
but this is restricted.
A number of factors contribute to the "chronic"
nature of gender issues in water and sanitation. These include
a lack of generalizable, reliable data, including epidemiological
data. The reasons for this are many, but may be summed up as the
lack of real political will to change the present situation, manifested
in inadequate funding to generate a meaningful body of evidence.
Many studies are too small, too methodologically flawed, make
too many generalizations, or are too context-specific to inform
wider work or policy decisions. The currently available evidence
succeeds in highlighting major problems, but meaningful solutions
remain elusive. The "toolkit" or "toolbox"
solution has been attempted, which again can bring benefit at
small scale, but does not lead to work at scale. Progress was
made in the acknowledgement that behaviour, particularly at household
level, is a key to many advances, but again there is inadequate
recognition of the funding and political support required to maximize
the gains to be made in pursuing this route. Many countries recognize
these problems, but fall back on creating gender policies and
gender bureaux which are not empowered to overcome the problems
they face, and which are not supported by, or may be in direct
conflict with, the provisions of policy in other sectors.
It is partially true that the required action
to achieve real change in this difficult area was identified decades
ago. The roots are certainly in the tradition and cultural practices
which generate differential gender roles and division of labour,
which often but not inevitably disadvantage women, and which express
and sanction these differentials through lack of political drive
to achieve change. However, it has to be recognized that many
inequities, or vestiges of them, remain in more advanced societies,
although the health consequences they generate where conditions
of life are very basic no longer manifest. Hence efforts to "impose"
equity can only be partially successful.
Ways forward in the case of other chronic and
intractable problems have been found in generating a systematic,
reliable, and accepted body of evidence. It may be helpful to
carry out a sufficient number of methodologically rigorous multi-country
studies on a number of broad gender, water and sanitation issues
to acquire a critical mass of information, and to build from this
towards stronger and more effective policy and institutional responses.
In doing so, it would be important to ensure that the issues chosen
lend themselves to the gender disaggregation of data. For example,
the provision of water at household level can be studied from
a gender perspective. The use of water at household level cannot.
If the current trend towards water shortage
increases, then existing patterns whereby vulnerable groups are
disadvantaged will increase. With women overrepresented among
most vulnerable groups, it is very likely that they will pay the
greatest price for further shortfalls in the provision of water
and sanitation services.
Other issues not identified as priorities
We were somewhat surprised not to see water
and sanitation in relation to emergencies and disasters not appear
as a priority issue. Available evidence indicates an increasing
high vulnerability of the population world-wide and an increasing
frequency of events either with WSH related causation or in which
effects on or through WSH are a significant factor.
We would also like to note that with increasing
international attention to deliberate (whether terrorist or malicious)
acts, water supplies themselves are a vulnerable target.
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