Sanitation in Developing Countries

In 1999 the United Nations acknowledged that the development gap between rich and poor countries was widening: about three-fifths of the world's population lacked access to basic sanitation; and one-third did not have access to safe drinking water. Industrial development affects public health both favorably and unfavorably. Improved housing and social conditions and reductions in infectious diseases like gastroenteritis or pneumonia are often accompanied by increases in degenerative, noninfectious diseases like cancer and heart disease. In rapidly developing countries, such as Mexico, the People's Republic of China, and the Philippines, new public health problems often emerge before the old ones have been solved, and it is important to assess which problems pose the greatest risks to health, and which solutions are most cost-effective. Large funding organizations like the United Nations, the World Bank, and regional development banks now recognize that to solve priority health problems requires improvements in behaviors, attitudes, skills, services, products, and infrastructure that together yield lasting benefits long after external support is withdrawn.

In this global context, providing both safe drinking water and wastewater sanitation have long been recognized as priorities for the improvement of human health, especially in the prevention of infant and child mortality from diarrheas and dysenteries (e.g., Amoebiasis, caused by a protozoan; or E. coli diarrhea, caused by a bacterium). An estimated 4 billion cases of diarrheal disease occur worldwide every year, killing an estimated 3

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to 4 million people per year, most of them children (see Table 1). While it can be readily argued that a safe water supply plus wastewater sanitation is the most cost-effective public health goal for any given population, in practice, many social, cultural, technical, and economic factors govern whether the design and implementation of these systems will provide the long-term benefits sought.

To measure development and health progress, public health agencies use indicators such as access to water supply, access to sanitation, the under-five-year-old child mortality rate (U5MR), and per capita income. In 2000, the UN reported that the U5MR varied from 4 per 1,000 live births for developed countries like Sweden, Japan, and Norway, to 280,292, and 316 per 1,000 for Niger, Angola, and Sierra Leone, respectively. Figure 1 shows the relationship between the U5MR and access to safe water. Figure 2 shows the relationship between the U5MR and access to sanitation. These figures clearly show that improved water supply and/or sanitation can reduce child mortality (see Table 2).

WATER AND HEALTH

The uncontrolled pollution of water supplies by chemical and pathogens is one of the most serious threats to public health and the natural environment in developing countries. Standing water is a

Figure 1

medium for vector-borne diseases, and caused by poor water management, especially poor drainage. Table 1 shows the main water-related diseases from pathogens (viruses, bacteria, and protozoa), their relative geographical extent, numbers of cases, mortality rate, and sanitation solutions. Although the focus for remediation varies by disease and local conditions, all solutions include attention to four basic factors: 1) basic infrastructure (water supply and waste disposal); 2) personal and domestic hygiene; 3) better housing; and 4) primary health care and health promotion. Where basic infrastructure is lacking, pathogens are the priority contaminants, although the comparative risks posed by chemical pollutants should also be considered, especially in industrial areas and areas using pesticides. In dealing with pathogens in these areas, it is important to consider the life cycle of pathogens, pathogen infection routes, and pathogen susceptibility to treatment.

Chemical pollution of water from agricultural and/or industrial practices may include organic substances such as polychlorinated biphenyls (PCBs), chlorinated pesticides and herbicides, polyaromatic hydrocarbons (PAHs), solvents and disinfection by-products (DBPs), as well as inorganic substances like metals and nitrates. The risks posed by such chemicals to human health depend on three parameters: their concentrations in the water; their specific toxicity for both cancer effects and noncancer effects (e.g., birth defects, reproductive effects, neurotoxicity); and dose rate (the amount of substance entering the body over time). Pollutants in water can enter the body by ingestion of the water in drinks and food, by bathing and skin contact with the water, and by inhalation of the water vapor while showering.

Sanitation solutions for chemical agents combine prevention and cure tactics. Prevention includes minimizing the sources of pollution by substituting nontoxic substances and using cleaner, more efficient technologies. Cure consists of treating water to appropriate quality standards according to use (domestic, industrial, or agricultural). Water supply and wastewater treatment systems in developing countries must be affordable, cost-effective, and able to be maintained by local people.

The monitoring and enforcement of appropriate water quality standards is a vital part of sanitation. Diverse chemical and microbial standards seek to regulate important known risk agents, and acceptable levels must be monitored. In the United States, the Primary ("legally enforceable") Drinking Water Standards cover 60 organic chemicals, 20 inorganics, and 8 microbes/indicator organisms. The World Health Organization's Guidelines for Drinking-Water Quality includes over 60 organic chemicals (31 of them pesticides), 19 inorganics, 17 disinfectants and their by-products, and pathogens. However, although water quality laws exist in many developing countries, their enforcement is either weak or nonexistent, most often due to a lack of resources and political will.

The 1980s were designated the International Drinking Water Supply and Sanitation Decade by the United Nations. Despite the efforts of this campaign, however, in many countries more than half the rural populations are without adequate water supply access and sanitation. Many of the failures can be explained by weaknesses in the design and implementation of projects, as evidenced by many abandoned water and wastewater treatment plants. Such weaknesses often stem from a lack of maintenance caused by failures in equipment or training. A widespread lack of community participation in projects also helps explain failures. In most developing countries, the public sector provides facilities to central urban areas but

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leaves rural and marginal urban areas underserved. A 1990 evaluation of water-decade achievements in rural Bangladesh revealed that even when safe water supply and sanitary latrines were provided, people did not always use them, while only a third of the household water supplies had adequate usage. This demonstrates the need for joint improvements in education and economic conditions to accompany investments in infrastructure.

A useful reference for the visualization of health-risk sources, diseases, and solutions is the water-wastewater cycle (see Figure 3). The cycle ideally consists of water supply parts and sanitation counterparts, with each stage (or lack of it) affecting others. It should be remembered that this engineered cycle operates within the natural constraints of a dynamic hydrological cycle that supplies water to plants and animals as well as

Figure 2

people. Human beings have coevolved with other species in these ecosystems, while at the same time becoming super-modifiers of them. Logically, the health of people is influenced by the condition of these ecosystems.

ENVIRONMENTAL SANITATION

Holistic environmental sanitation has four main water-related aspects: water supply, rainwater drainage, solid waste disposal, and excreta disposal.

Water Supply. The major problem for poor people in most countries is access to safe water in adequate quantity, with reasonable convenience, and at an affordable cost. Solutions include local grants to install household gutters and rainwater capture tanks; local wells designed to resist pollution; and small networks of water points served by a local well, borehole, or spring. The supply problems of major cities require integrated approaches that combine demand management, leak repair, backflow prevention, wastewater reuse, and the efficient, sustainable exploitation of sources.

Rainwater Drainage. Without adequate control of rainwater to mitigate floods and soil erosion, other sanitation measures can be nullified. People safe from floods and mudslides are more willing to invest in sanitation for their homes; and those in poor tropical urban areas attach a high priority to rainwater drainage. While local communities can build local drainage, downstream obstructions can cause the backing-up of channels and rivers, requiring a watershed-wide strategy.

Solid Waste Disposal. The interdependence of sanitation aspects is illustrated by the need for adequate solid waste removal to prevent the blockage of rainwater drains. Collection of refuse in hot climates must be frequent since piles attract flies and rats, and it should rely more on local labor-intensive methods rather than on expensive trucks. For the operation to be successful requires close cooperation between the users and providers of the service, and financing must come either from municipal recurrent funds and/or user fees.

Excreta Disposal. Large sewerage infrastructure projects tend to be too expensive for the vast majority of urban and rural people in developing countries, and it may be impossible to build a sewage network infrastructure in congested, narrow streets. On-site options include latrines, pourflush toilets, and septic tanks. There should be evaluated at each location according to needs and priorities. As water use grows in villages and towns, wastewater from washing and bathing (sullage) can be cost-effectively handled by a separate drainage system coupled to on-site excreta disposal.

TOWARD LASTING SANITATION

Sanitation, including water supply, is a major part of the United Nation's 1992 Agenda 21, a "Blueprint for Sustainable Development." The paradigm of sustainable development focuses on how to satisfy the basic needs of the present human population, and also secure resources to satisfy the needs of future generations. Growing population pressure, persistent poverty, and ecological degradation call for new integrated solutions to sanitation problems that strengthen both socio-economic and technical elements, including the following:

1. Financial, political, and societal will to invest in public health and the environment.
2. Human resources and public awareness through education and training.
3. Information resourcesn health, water cycle, and ecological monitoringor informed planning and actions.
4. Regulatory frameworks, enforcement, and compliance.
5. Basic sanitation infrastructure suited to local priorities and conditions.
6. A market for public health and environmental support goods and services that provide economically viable, effective, and lasting sanitation strategies.

Figure 3

These elements are interdependent. For example, adequate training improves monitoring and the operation and maintenance of infrastructure; and effective, enforced regulations stimulate a market and long-term investment. In India, state water boards were established to prevent pollution under the 1974 Water Act, closely modeled on systems in Great Britain. However, despite good scientists and engineers on staff, the chronic shortage of funds means controls have a limited effect on sanitation.

Above all, the support and involvement of the local community are essential if sanitation is to work. Ideally, many social sectors should be involved, to varying degrees, in community-driven ("bottom-up") sanitation projects. Sanitation users, water and public health regulators and administrators, health professionals, sanitation engineers, ecologists, researchers and scientists, financing agencies and donors, nongovernmental organizations, and suppliers of health and sanitation products and services can all contribute to a successful project. These new approaches reflect the trend away from professionally centered, curative methods and towards multi-stakeholder preventive strategies. To face these challenges, public health professionals and institutions need to play an expanding role as facilitators and promoters of this trend, building new partnerships in developing and developed countries. Protecting public health and ecological integrity are ethical and practical imperatives to be viewed as opportunities for people from diverse cultures, social groups, and disciplines to work more closely together.

TIMOTHY J. DOWNS

I. H. SUFFET

(SEE ALSO: Chlorination; Drinking Water; E. Coli; International Development of Public Health; Rural Public Health, Sanitation; Sewage System; Wastewater Treatment; Waterborne Diseases; Water Quality; Water Treatment)