Effects Go Beyond Better Health, Experts Say
It is safe to say that a world without safe, abundant and easily accessible water is hard for most Americans to imagine -- and one they would find hard to tolerate. The same goes for life without private, relatively clean places in which to go to the toilet.
Around the world, however, 1.1 billion people get their water from rivers and ponds, or from springs and wells open to the air and subject to contamination. More than twice as many -- 2.5 billion people in all -- use public latrines or the whole outdoors as their bathroom.
Access to safe water and basic sanitation were among the "Millennium Development Goals" that 189 heads of state from around the world adopted in 2000. Specifically, they pledged that by 2015 they would reduce by at least half the proportion of people living without those two essential comforts of civilization. The year 1990 was taken as the baseline against which progress would be measured.
Reaching those goals would have profound effects on the world's poorest people -- effects far beyond better health, the most obvious one. The World Health Organization and UNICEF recently issued a report on the progress achieved as of 2002, the midpoint in that 25-year period.
In 1990, 77 percent of the globe's population had access to indoor running water, piped public taps, protected wells and rainwater. In 2002, 83 percent of people had those "improved" drinking water sources. Progress is on track to meet the target of 89 percent by 2015.
Equally impressive is the fact that 52 percent of people have the best of the "improvements": household running water.
"More than half the population of the planet uses piped water at home. That is a stunning achievement," said Jamie Bartram, coordinator of WHO's water, sanitation and health program.
The sanitation news is less encouraging.
"Improved" forms of sanitation include not only flush toilets, but also latrines that are used by only one household, and are ventilated and designed to isolate waste from the surrounding environment. In 1990, 49 percent of people used such facilities. By 2002, that had increased to just 58 percent.
Unless progress accelerates, the target of 75 percent coverage will not be met, with the effort falling short by about half a billion people.
"The gap between the haves and the have-nots is widening," said Vanessa Tobin, UNICEF's chief of sanitation. "We need to have local solutions that are sustainable and affordable."
China and India together have the most people without safe water or improved sanitation. In the case of sanitation, 1.5 billion people in those two countries do without. Among regions, though, Africa is worst off. The entire sub-Saharan part of that continent today is only somewhat ahead of the United States of 1900.
In that year, 42 percent of Americans had access to public water and 29 percent to sewage systems. Among Africans in 2002, 58 percent had access to improved water (only 16 percent with household connections), and 36 percent had improved sanitation.
Although clean water and toilets have many benefits, some are not entirely obvious.
Both improvements lead to better health, although how much each contributes has been hard to measure. That is because people's health is also affected by personal habits, methods of storing and cooking food, as well as by education and income.
Piped water reduces the incidence of typhoid fever -- an outcome seen both in contemporary studies and in historical analysis. In Philadelphia, for example, a study showed that as water filtration was brought to the city's six water districts between 1902 and 1909, typhoid mortality in each district fell. Between 1888 and 1912, deaths in German cities from that disease fell by 80 percent, with half of the decrease attributed to piped water.
But clean water by itself has relatively little effect on rates of other water-borne infections, such as childhood diarrhea. Those illnesses are mostly transmitted by the fecal contamination of food, dishes and hands. They reflect the amount of water a household has for washing and hygiene, not the quality of the water.
For that reason, bringing the source of water to the house or yard reduces the diarrhea rate by 44 percent, while water delivered to a public "standpipe" -- where someone must go with a water container -- reduces the rate only by 6 percent.
Improved sanitation cuts diarrhea incidence by a quarter to a third. Interventions that promote personal hygiene, such as hand washing, decrease it by 42 percent, according to a recent analysis of studies by Lorna Fewtrell of the University of Wales and Jack M. Colford of the University of California at Berkeley.
Traditional water-borne diseases, however, are not the only ones reduced by clean water and toilets.
Trachoma is a bacterial infection of the eyelid responsible for about 6 million cases of blindness worldwide. Better water and sanitation reduces trachoma rates by an average of 27 percent. Once-a-day face washing with a handful of water is one of the four chief interventions being pushed in an international effort to eliminate trachoma.
Curiously, health benefits are far down the list of reasons that people in poor countries give for wanting better water and sanitation services. Relief from the drudgery of carrying water long distances -- a chore borne almost entirely by women and girls -- is the chief benefit that people mention.
A 2002 UNICEF study of rural households in 23 sub-Saharan countries found that a quarter of them spent 30 minutes to an hour each day collecting and carrying water, and 19 percent spent an hour or more. With closer water comes greater self-esteem, less harassment of women, and better school attendance by girls -- three things spontaneously mentioned by people in Ethiopia, Ghana, Tanzania and India in a different study.
Toilets are similarly liberating. In many cultures, rural women venture out to urinate and defecate only at night.
In a study of 320 households in the West African nation of Benin, people were asked to rank the benefits of owning a latrine on a scale of 1 to 4. "Avoid discomforts of the bush" came in at 3.98. "Gain prestige from visitors" was 3.96. "Avoid snakes" was 3.85.
By David Brown
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