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Drinking Water and Sanitation

Michelle V Fanucchi, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
Ó 2017 Elsevier Inc. All rights reserved.
This article is an updated version of the previous edition article by Meghan Checkley, William Checkley, volume 2, pp. 234–244, Ó 2008, Elsevier Inc.

Introduction by Babylon, archeologists have identified exposed sewer lines

made of brick with household water-flush latrines directly con-
Few topics carry as great importance to public health as do nected to these sewer lines. Other cultures of the same era, such
water and sanitation. At the World Day for Water on 22 March as the Indus Valley Civilization, also appeared to have devel-
2005, then United Nations Secretary General Kofi Annan oped complex water and sanitation systems in their cities. At
stated, “We shall not finally defeat AIDS, tuberculosis, malaria, the ruins of Mohenjo-daro (2600–1700 BC), a city located in
or any of the other infectious diseases that plague the devel- southern Pakistan on the banks of the Indus River, archeolo-
oping world until we have also won the battle for safe drinking gists have identified bathrooms and latrines that were directly
water, sanitation and basic health care.” Although great strides connected to street drains or drained into the sewer system
have been made in improving the world’s access to safe via terra-cotta pipes with closely fitting spigot joints. Archeolo-
drinking water (2.6 billion people have gained access to an gists also identified what appeared to be independent lines for
improved drinking water source since 1990, World Health kitchen water and bath water. Another example is the Minoan
Organization, 2015), there is still much to be done. Currently, civilization (2700–1450 BC), on the island of Crete, which was
it is estimated that 1.8 billion people still drink water contam- found to have well-developed stone sewer drains and the
inated with fecal material and 2.4 billion people lack adequate ability to carry water in pipes under pressure. Archeologists
sanitation worldwide (World Health Organization, 2015). have also found pictorial evidence that the Egyptians
Disparities in coverage are far greater in developing countries (1450 BC) may have been one of the first civilizations to
than in developed countries, particularly in some regions of discover the importance of filtration and flocculation of water
Asia and in Africa. Human health is greatly affected by the (Figure 1).
lack of adequate water and sanitation. Indeed, contaminated More recent civilizations, including medieval Europe, were
water and poor hygiene practices are the main sources of trans- less successful at implementing adequate water and sanitation
mission for waterborne diseases and large-scale epidemics. The systems in large cities or had different priorities for water such
most important water- and sanitation-related illness is acute as its use for agricultural irrigation. The modern concept of
infectious diarrhea, which is responsible for 1.5 million deaths urban waste removal did not develop until the late eighteenth
per year (World Health Organization, 2016), with 1.25 million and early nineteenth centuries. Most cities removed excrement
deaths per year in children adolescents worldwide (Global and other wastes through street gutters or dumped ‘night soil’
Burden of Disease Pediatrics Collaboration, 2016). This on vacant land and into nearby watercourses. Individual
statistic equates to 3425 child/adolescent deaths each day or homes at best had cesspools. As populations in the cities
approximately 12 child/adolescent deaths every 5 min. The grew dramatically during the nineteenth century, the crisis of
adverse effects of water and sanitation extend to other aspects uncovered waste attracted increasing attention. Aesthetically,
of human health that include poor growth and development city side-streets and waterways declined rapidly to nearly
and that consequently translate into impaired physical and
cognitive capacities later in life. The goal of this article is to
summarize current knowledge of the effects of water and sani-
tation on human health and to provide a summary of current
international initiatives to improve water and sanitation and
common barriers to their progress. The first section provides
a brief historical perspective. The second section discusses the
diseases associated with inadequate water and sanitation, and
the third section summarizes potential health benefits. The
fourth section reviews recent international initiatives for the
improvement of water and sanitation. The last section summa-
rizes barriers and health policy challenges to the achievement
of these initiatives.

Historical Perspectives

There is good archeological evidence that early civilizations

recognized the importance of water and sanitation, especially
in large metropolises (Gray, 1940). One of the earliest excava- Figure 1 Egyptian hieroglyph illustrating water clarification tech-
tions to reveal an advanced sanitation system was found in niques. Tomb of Amenophis II at Thebes (1450 BC). Adapted from
Iraq, 50 miles northeast of present Baghdad. At the ruins of Wilkinson, 1879. Manners and Customs of the Ancient Egyptians.
Eshnunna (2500 BC), a Sumerian city that was later conquered William Clowes and Sons, London.

350 International Encyclopedia of Public Health, 2nd edition, Volume 2

Drinking Water and Sanitation 351

unlivable conditions: drainage ditches often overflowed, few solutions for sewer drainage should be implemented to
were built with any inclines, and even fewer connected to improve health (Mackenbach, 2007). Sir Chadwick began
each other in any organized system of sewerage. The social inquiries into public health as a means of reducing the costs
climate in the latter half of the nineteenth century for Europe of public relief. He was instrumental in establishing the first
was one of unrest. In the case of London, lime had to be British Public Health Act of 1848 and provided a framework
hung on the windows of the British Parliament, and the slogans for a comprehensive approach toward sanitation that included
such as “India is revolting and the Thames stinks” were the implementation of new technologies along with legal,
commonly voiced. Finally, health epidemics occurred, administrative, and governmental support.
touching the lives of rich and poor alike. For example, in During the same period, Dr John Snow made a seminal
1832, it is estimated that cholera claimed the lives of 5000 scientific discovery linking inadequate water and sanitation to
people in London and over 20 000 in Paris. In this environ- the spread of cholera. His observations in 1854 identified the
ment, the seeds of the urban hygiene movement flourished. Broad Street water pump in London as a likely source for the
Championing the hygiene campaign was Sir Edwin Chad- spread of cholera (Figure 2) and, despite general disbelief, he
wick, who believed that acute infectious diseases were caused convinced the Board of Guardians at Saint James Parish to
by air contaminated from poor drainage and argued that better remove the pump handle. The experiment of removing the

50 0 50 100 150 200

Pump Deaths from cholera











































Figure 2 Location of death from cholera in central London for September 1854. The Broad Street pump is located at the center of the map. Repro-
duced from Gilbert, E.W., 1958. Pioneer maps of health and disease in England. Geogr. J. 124, 172–183. With permission from Blackwell Publishing.
352 Drinking Water and Sanitation

pump handle was an effective measure to curb the cholera Oceania

outbreak in that neighborhood, which had claimed more than 51
500 lives. The contribution of John Snow’s work, however, 52
was underrecognized until the republication of his work by Dr Sub-Saharan Africa 1990
Wade Hampton Frost in the 1930s (Vandenbrouke et al., 1991). 49 2002
Outbreaks of cholera continue into modern times despite 58
our advanced epidemiological knowledge and increased aware-
Eastern Asia
ness. Two events deserve special mention. The first is the 1991
cholera epidemic in Peru that resulted in 1.3 million cases of
cholera and approximately 13 000 deaths in South and Central
America between 1991 and 1995. The spread of cholera in this Southeastern Asia
region was probably multifactorial, including the lack of 73
proper disposal of human waste especially in rapidly growing 79
periurban communities, limited and poorly maintained water Southern Asia
treatment and distribution systems, poor hygiene practices, 71
and disposal of cholera-contaminated sewage into coastal 84
waters. A second notable occasion occurred in July of 1994, Western Asia
when an estimated 500 000 to 800 000 refugees fled from 83
Rwanda to the Democratic Republic of Congo over a 4-day 88
period. This large migration of refugees overwhelmed Congo’s
Latin America and the Caribbean
capacity to respond, creating a major humanitarian crisis. Over
a 1-month period, approximately 50 000 Rwandans died
mostly from cholera until proper public health measures
were implemented at refugee camps. Northern Africa
Diseases Associated with Inadequate Water and CIS
Sanitation 92
Current statistics describing the lack of improved water and Developing regions
sanitation services worldwide are alarming. Despite progress 71
made to increase the coverage of populations with water and 79
sanitation, approximately one-quarter of the world’s popula-
tion still remain without access to safe water (Figure 3) and 0 20 40 60 80 100
approximately half of the population lack adequate sanitation
(Figure 4). The health of populations is significantly affected by Figure 3 Proportion of population using improved sources of
the lack of improved services. Children in the developing world drinking water, 1990 and 2002 (percentage). Reproduced from United
are the main victims of this coverage deficit. Approximately Nations, 2005. Millennium Development Goals Report 2005. UN, New
60% of child mortality in developing countries is linked to York, with permission.
infectious diseases, most of them related to water and sanita-
tion and to hygiene practices. age of 5 (World Health Organization, 2015). In 2001,
Diseases related to inadequate water and sanitation are diarrhea was responsible for 59 million disability-adjusted
transmitted via contaminated water, poor fecal disposal, poor life years lost, approximately 4.2% of the global burden of
hygiene practices, and inadequate water collection and storage. disease (Lopez et al., 2006). In comparison, malaria was
Bradley described four main epidemiological categories of responsible for 40 million disability-adjusted life years lost
water-related infections which relate to the engineering tech- in 2001, and tuberculosis was responsible for 36 million
nologies needed to cope with them: waterborne, water- lost in 2001 (Lopez et al., 2006). Approximately 90% of the
washed, water-based, and water-related insect vectors (Bradley, burden associated with diarrhea is potentially attributable
1977). This classification system questioned the classic notion to inadequate water and sanitation. Therefore, diarrhea
that water quality was the prime driver of the relationship control via water and sanitation interventions is one of the
between water and health. highest priorities for disease control worldwide.
Acute infectious diarrhea is the most important water- and Another group of diseases related to contaminated water is
sanitation-related illness. Although cholera and typhoid fever that of diseases caused by parasites. Although parasitic infec-
are important diseases because of disease severity and rapid tions are widespread worldwide, exact numbers of infected
spread, acute infectious diarrhea in children is the most people are unknown because the majority of these infections
important cause of morbidity and mortality worldwide. are asymptomatic. Indeed, relatively few infected individuals
Diarrheal diseases are responsible for 1.5 million deaths and manifest with severe symptoms, and even fewer die as a result
between 2 and 4 billion cases of disease episodes globally of infection. However, these infections are associated with
(World Health Organization, 2016). Diarrheal diseases a high burden of chronic malnutrition, poor longitudinal
account for 18% of all-cause mortality in children under the growth, and iron-deficient anemia. Asymptomatic infections,
Drinking Water and Sanitation 353

Less than 50%




Insufficient data

Figure 4 Half the developing world lacks improved sanitation. Proportion of population using improved sanitation, 2002 (percentage). Reproduced
from United Nations, 2005. Millennium Development Goals Report 2005. UN, New York, with permission.

given their higher prevalence rates than symptomatic infec- addition, children from high-income families whose homes
tions, may have adverse health consequences such as subop- were supplied with municipal water were 12 times more
timal growth (Checkley et al., 1997). Of the parasites, the likely to be infected with H. pylori than children from high-
10% of individuals are infected with helminthic infections income families whose homes were supplied from
such as Ascaris lumbricoides and other nematodes. Protozoan community wells (Klein et al., 1991). More recently, several
infections are also highly prevalent in contaminated water. investigators have identified H. pylori in drinking water
Protozoan infections that are associated with diarrhea, such samples by using polymerase chain reaction–based methods.
as Cryptosporidium parvum, are particularly important because Water- and sanitation-related illnesses extend beyond the
they are resistant to interventions such as chlorination. This gastrointestinal tract. For example, trachoma is a preventable
resistance means that Cryptosporidium is of concern to high- eye disease that is perpetuated by the presence of inadequate
income countries, such as the United States, as well as to sanitation and poor hygiene practices. Trachoma is caused by
low-income countries. In 1993, a waterborne outbreak of infection with Chlamydia trachomatis. Transmission occurs
Cryptosporidium occurred in Milwaukee, Wisconsin. This through direct contact or is transmitted by flies from person
outbreak affected approximately 403 000 residents (out of to person. The flies that transmit this bacterium breed in
a population of 1.61 million) at a total estimated cost of human feces. Trachoma is endemic in 55 countries, and it
$96.2 million (Corso et al., 2003). The following year predominantly affects children. Currently, it is estimated that
(1994), another outbreak of Cryptosporidium occurred in Las over 150 million people have active disease and that
Vegas, Nevada, this time affecting immunocompromised 10 million are at immediate risk of blindness. Interventions
HIV-infected patients (Roefer et al., 1996). The Milwaukee for the prevention of trachoma include facial cleanliness and
outbreak was traced back to a large rain event and runoff hygiene, as well as environmental improvements, particularly
from a cattle farm. The Las Vegas incident occurred even in sanitation. A number of studies have found that families
though no breaches in water treatment were found, and the with latrines have less trachoma and that households that
outbreak ended abruptly without changes in water used more water for washing children also had less trachoma
treatment. Helicobacter pylori is a chronic bacterial infection (Cairncross, 1999).
that may be transmitted through contaminated water. Schistosomiasis is a water-based disease that is transmitted
Helicobacter pylori is the major cause of chronic gastric disease through the contamination of water sources with urine and
worldwide. In developing countries, approximately 75–90% fecal material. It is estimated that schistosomiasis affects
of individuals become infected with H. pylori during their approximately 200 million people in 74 countries around the
lifetime, compared to 25–50% in developed countries. world and that 20 million suffer severe consequences from
Recent epidemiological and microbiological evidence the infection. Interventions to reduce this disease include pre-
suggests that H. pylori may be transmitted through drinking venting disposal of urine and feces in surface water. Dracuncu-
water. In Lima, Peru, one study found that children from liasis is a debilitating disease that causes painful ulcers on the
low-income families were more likely to become infected lower limbs. It is transmitted exclusively through drinking
with H. pylori than children from higher-income families. In water. Successful campaigns that focus on safe water through
354 Drinking Water and Sanitation

filtration have reduced the burden of cases from 3.5 million in trihalomethanes (TTHMs – chlorine-disinfectant by-products)
1980 to approximately10 000 in 2005. The transmission of that exceed federal drinking water limits by January 2015.
vectorborne diseases such as malaria may be increased when The University of Michigan–Flint tests its water and finds
water sources are poorly protected and provide habitats for lead in drinking fountains. Because of their struggles with
mosquito breeding. drinking water quality, Flint is offered water services again
Hepatitis A virus is a liver pathogen that occurs worldwide from the Detroit Water and Sewerage Department, but the
but more commonly in countries with poor hygienic and sani- city rejects the offer. It is not until 25 September 2015 that
tary standards. It is estimated that 1.5 million clinical cases of a lead advisory is issued to the citizens of Flint (the advisory
hepatitis A occur worldwide, but seroprevalence data suggest instructed residents to only use cold tap water for drinking
that the population affected is 10 times that of acute clinical cooking and making baby formula) due to concerns of the local
cases. In young children, the majority of cases are asymptom- medical community. On 1 October 2015, the Genesee County
atic, but in older children and adults, hepatitis A can lead to Health Department declared a public health emergency due to
jaundice, fever, and life-threatening fulminant hepatitis. increased blood levels and concentrations of lead in the water,
Although a vaccine is currently available, it is not used in and residents are told not to drink the water. On 16 October
many developing countries given high rates of endemicity of 2015, Flint is reconnected to the Detroit Water and Sewerage
hepatitis A. Therefore, improved water sources and better sani- Department 18 months after the crisis begins, but it is too
tation would likely decrease the prevalence of this disease late. A State of Emergency is declared for Flint, and residents
worldwide. must use bottled water for all drinking, cooking, and bathing
Finally, chemical pollutants such as arsenic and nitrates also (Dixon, 2016). The most recent studies available indicate that
present major threats to public health. Arsenic is a common the percentage of children under the age of 5 years with
natural element and may be found in water that has flowed elevated blood lead levels increased from 2.4% in 2013 (before
through arsenic-rich rocks. Chronic exposure to arsenic via the water source switch) to 4.9% in 2015 (after the water source
drinking water leads to skin cancer, lung cancer, bladder cancer, switch) with socioeconomically disadvantaged neighborhoods
kidney cancer, and other skin lesions. The technology for affected the most (Hanna-Attisha et al., 2016).
arsenic removal from piped water supply, however, is moder- When several infectious diseases related to inadequate
ately costly and requires technical expertise. Control of arsenic water, sanitation, and hygiene were combined into one anal-
is more complex where drinking water is obtained from many ysis, it was estimated that they were responsible for more
individual sources, and it may be difficult to achieve in periur- than 82 million disability-adjusted life years lost in 2000
ban communities of developing countries and in most rural (Prüss et al., 2002). Indeed, unsafe water and sanitation
areas worldwide. accounted for 3.7–5.7% of the global burden of disease,
Of increasing concern is the contamination of lead in making it the leading environmental risk factor worldwide
drinking water. Lead was the material of choice in the United (Prüss et al., 2002; Ezzati et al., 2003).
States for municipal water service lines before 1930, with
a decrease in its use after that date. A national survey of
community water systems in the United States has found that
approximately 6.1 million partial or full lead service lines pres- Potential Health Benefits of Water and Sanitation
ently in use in the United States serving a population of Interventions
293 million people (Cornwell et al., 2016). The danger of
continuing to utilize lead service pipes has become apparent The effects of inadequate water and sanitation on human
following the community-wide lead exposure through munic- health in developing countries are difficult to measure
ipal drinking water in Flint, MI. In 2013, the city of Flint, Mich- because poverty is linked to poor nutrition, higher rates of
igan, decided to change water sources, from the Detroit Water disease, and to the lack of improved water and sanitation
and Sewerage Department (distributing water from Lake services. Nonetheless, there is a considerable body of litera-
Huron) to the newly established Karegnondi Water Authority ture that documents potential health benefits of water and
(KWA – also to distribute water from Lake Huron). However, sanitation interventions. A comprehensive review based on
KWA would not be ready to distribute water until 2016, leaving 67 studies investigated the relationship between diarrheal
Flint to find an alternative water source until KWA is ready. A disease and water quality, water availability, and fecal
political ‘water war’ followed, with the Detroit Water and disposal (Esrey et al., 1985). The results of this study sug-
Sewerage Department terminating Flint’s water contract in gested that median reductions in diarrheal disease from water
April 2014. The city of Flint began to use water from the Flint availability (25%) were higher than those recorded for water
River in April 2014; however, corrosion control was not used quality improvements (16%) and those recorded for improve-
nor required by state officials, even though Flint had aging ments in fecal disposal (22%). Many concluded that although
water infrastructure and the Flint River water was more corro- hygiene and water quality are important interventions,
sive than Lake Huron water. Residents complain about the adequate supply of water needs to be achieved before
water quality soon after the switch. By December 2014, the improvements in quality can yield health benefits. A subse-
automobile company General Motors switches to another quent review of 144 water and sanitation interventions (Esrey
water source due to rust spots appearing on newly machined et al., 1991) found that improved water supply and sanitation
engine parts. During this time period, there were boil water facilities resulted in substantial reductions in morbidity of
advisories due to bacteria in the system prompting increases diarrhea (26%), ascariasis (29%), guinea worm infection
of chlorine for disinfection. This leads to an increase in (78%), schistosomiasis (77%), and trachoma (27%).
Drinking Water and Sanitation 355

Improvements in water supply alone, however, are unlikely water supply, sanitation, and hygiene interventions, as well
to accomplish full health benefits. One recent longitudinal as their combination, were effective at reducing diarrheal
study underscored the additional need to improve both sanita- illness (Figure 5). Hygiene interventions, and particularly
tion and water storage practices to attain better health handwashing (relative risk 0.56; 95% confidence interval
outcomes (Checkley et al., 2004). Using data from the Cebu 0.33 to 0.93), were as effective as water supply and sanitation
Longitudinal Health and Nutrition Survey, another study improvements. In this review, water quality interventions
found that improvements in water quality had large health were more effective than previously acknowledged. The
benefits where community sanitation was good, whereas authors, however, raised concern about the possibility of
improvements in water quality had small health benefits where publication bias among included studies of water quality. A
community sanitation was very poor (VanDerslice and Briscoe, recent meta-analysis of 33 reports from 21 countries docu-
1995). menting 42 comparisons found that water quality interven-
A follow-up analysis that used nationally representative tions were generally effective at reducing diarrheal disease
data from eight countries identified that an incremental even in the absence of improved water supply and sanitation
improvement in sanitation was associated with less diarrhea (Clasen et al., 2007). The heterogeneity in findings across
and better anthropometric indicators (Esrey, 1996). The health studies, however, reflects the difficulty in making policy deci-
benefits of improved water were less pronounced than those of sions on the health effects of a single intervention and high-
improved sanitation, and health benefits from improved water lights the interplay among water, sanitation, and hygiene at
occurred only when sanitation was improved. More recently, the community level. It therefore follows that, at the popula-
the implementation of a citywide sanitation program to tion level, there is not a necessary sequence to improvements
improve sewage coverage from 26% of households to 80% in in water and sanitation.
Salvador, Brazil, was accompanied by a reduction of 22% in Intervention studies of the health impacts achieved by
the longitudinal prevalence of diarrhea in the population of coverage gains have presented inconsistent results. A review
the city as a whole, and 43% in the areas where the baseline of these studies reported a wide range of results measured
prevalence of diarrhea was highest (Barreto et al., 2007). across settings. This range and the history of conflicting conclu-
A systematic review of 2120 publications and meta- sions from field studies have led many decision-makers to
analysis of 46 studies (Fewtrell et al., 2005) suggested that believe that large-scale investments required to improve water

Number Relative risk

of studies (95% Cl)
Hygiene 11 0.63 (0.52–0.77)
Excluding poor quality studies 8 0.55 (0.40–0.75)
Hand washing 5 0.56 (0.33–0.93)
Education 6 0.72 (0.63–0.83)

Sanitation 2 0.68 (0.53–0.87)

Water supply 6 0.75 (0.62–0.91)

Diarrhea only 4 1.03 (0.73–1.46)
Household connection 2 0.90 (0.43–1.93)
Standpipe or community connection 3 0.94 (0.65–1.35)

Water quality 15 0.69 (0.53–0.89)

Source treatment only 3 0.89 (0.42–1.90)
Household treatment only 12 0.65 (0.48–0.88)
Household treatment
• Excluding poor quality studies 8 0.61 (0.46–0.81)
• Rural location 6 0.61 (0.39–0.94)
• Urban/periurban locations 5 0.86 (0.57–1.28)
• Urban/periurban excluding sathe 4 0.74 (0.65–0.85)

Multiple 5 0.67 (0.59–0.76)

0.4 0.6 0.8 1.0

Pooled effect

Figure 5 Summary of a meta-analysis of water and sanitation interview. Reproduced from Fewtrell, L., Kaufmann, R.B., Kay, D., Enanoria, W.,
Haller, L., Colford Jr., J.M., 2005. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review
and meta-analysis. Lancet Infect. Dis. 5, 42–52. Elsevier, London, with permission.
356 Drinking Water and Sanitation

and sanitation in the community are not cost-effective in terms for more than a few hours a day. Certain international initia-
of health benefits alone. As a result, ministries of health with tives were notable in this period, including:
limited resources have assigned a low priority to water and
l United Nations Development Programme event in 1990 in
sanitation. This issue has subsequently initiated much dialogue
New Delhi, India, which drew attention to inequities in
among international agencies and developing country govern-
coverage: “Some for all rather than more for some.”
ment officials. Time and again, measurement of the success of
l 1992 Dublin International Conference on Water and the
a capital investment in piped water supply or sewerage by the
Environment, which emphasized the need to manage water
interruption in fecal–oral disease transmission alone has
in an integrated fashion and treat it as an economic good,
proven to be fraught with sanitation is undervalued by
the role of women in the management and security of water
measuring short-term impacts alone and by failing to consider
systems, and the need to be participatory in development
nonhealth benefits (Briscoe, 1987). In fact, the long-term bene-
fits on childhood survival are likely to be substantial. Better
l First World Water Forum in 1997, which not only
information is needed to support available evidence that
continued to prioritize gender equality and shared water
improvements in water supply and sanitation are necessary if
management, but also recognized the danger inherent in
not sufficient keystones to public health progress, particularly
water being viewed as an economic good alone.
among the urban poor.
In particular, improvements in water, sanitation, and During the 1990s, data collected from household surveys
hygiene are likely to play an important role in breaking the demonstrated that although the gross number of people with
vicious cycle between diarrhea and malnutrition in children access to improved water increased – a total of 5.3 billion
of poor communities. Education about better practices of water people in 2004 compared with 4.1 billion in 1990 – so did
storage, improved water pressure, and more reliable water sour- the world’s population. Uneven investment in sanitation
ces is likely to discourage storage of contaminated water, remained a trend in all regions of the world. Rural regions
improve hygiene practices, and decrease the frequency of diar- were even less likely to have access to basic water supply and
rhea. Additional improvements in sanitation facilities, namely sanitation than they were just 10 years before. Hence gains in
access to flush toilets, are likely to result in better health coverage were modest at best.
outcomes in developing countries. In 2002, the consensus reached at the World Summit for
Sustainable Development, in Johannesburg, South Africa, was
that very little gain in coverage of water and sanitation has
International Initiatives been achieved in the last decade. Nonetheless, poor popula-
tions in developing countries continue to grow, further
In 1977 at the United Nations Conference on Water in Mar de widening the gap of those in need of water and sanitation.
Plata, Argentina, water was defined as a common good and One of the clear successes of the Summit was to affirm a goal
a human right. Three years later, the United Nations General for water and to add a new goal for sanitation since the Water
Assembly urged governments of developing countries to ‘adopt and Sanitation Decade.
national targets for drinking water supply and sanitation At the turn of the twenty-first century, the United Nations
services, commensurate with resource availability, absorptive dedicated several Millennium Development Goals (MDGs) to
capacity and ability’ and proclaimed 1981–90 as the Interna- target poverty reduction and ensure sustainable development,
tional Drinking Water Supply and Sanitation Decade. Although including Goal 7: “Halve, by 2015, the proportion of people
the quantitative goals were not reached, the Decade was a success without sustainable access to safe water and basic sanitation.”
in many ways. From a policy perspective, the Decade saw The MDG target for drinking water was met in 2010, with
increasing coordination of activities at the national and local 58% of the world’s population enjoying improved drinking
level and recognition of water as a finite resource. Governments water quality. In addition, 2.1 billion people (or 68% of the
and international agencies invested more than $US134 billion. world’s population) also gained access to improved sanitation
Water supplies reached an estimated additional 1.2 billion since 1990, but this number did not meet the MDG of 77%.
people, and sanitation services reached an additional Progress is still needed: 663 million people still lack access to
770 million (World Health Organization, 1992). In 1990, the improved drinking water sources, and 2.4 billion people do
United Nations reemphasized the importance of the goals iden- not have access to improved sanitation facilities. The majority
tified in the International Drinking Water Supply and Sanitation of people without access to improved drinking water live in
Decade and extended the deadline to the end of the century. sub-Saharan Africa (319 million) and southern Asia
Despite this momentum, international interest again began (134 million). Of those without improved sanitation facilities,
to wane during the 1990s particularly in donor nations whose 953 million live in southern Asia, 695 million in sub-Saharan
focus moved toward agricultural use of water, chemical Africa, and 337 million in eastern Asia.
contamination, and global climate change. Meanwhile, events The magnitude of the crisis is much greater than what is
such as the Cryptosporidium outbreak in Milwaukee in 1993 and implied by coverage shortcomings alone, however. Beyond
Las Vegas in 1994 rekindled interest in water quality and the achieving basic access, communities at all levels of develop-
need to monitor the safety of municipal water systems. ment are faced with the need to sustain the systems that they
However, it also highlighted the difference between options already have in place. For instance, the majority of cities in
available in industrialized nations, where sophisticated water Eastern Europe and Central Asia already have infrastructure
treatment processes could be considered, versus the continued but are facing extensive repairs and serious financial invest-
struggle in transition economies to provide basic piped water ments in order to arrest system deterioration.
Drinking Water and Sanitation 357

The momentum due to the successes and improvements a 1988 survey of water charges in 122 developing countries,
gained by the MDGs is being transferred to the new 2030 researchers revealed that no-cost recovery occurred in 28%
Agenda for Sustainable Development adopted by world of the projects, and partial return on operation and mainte-
leaders in 2015. The 2030 Agenda outlines 17 goals, and nance costs were recovered in only 30% (Briscoe and de
Sustainable Development Goal (SDG) 6 is specifically written Ferranti, 1988). Full-cost recovery was achieved in only 6%
to ensure access to water and sanitation for all by the year of the countries.
2030. The goals set forth by the Agenda for Sustainable Devel- The shift toward cost recovery is necessary but difficult to
opment much more far-reaching and lofty than the MDGs achieve even for large-scale, urban projects. It requires multiple
because clean and accessible water is essential for life. In addi- advancements, including raised consumer awareness, encour-
tion, it is estimated that by 2050, one in four people is likely to agement of community participation, and confidence in those
live in a country affected by chronic or recurring shortages of delivering the services. Government officials are often
fresh water. To this end, the targets for SDG 6 include unwilling to raise the price of a public good, such as water or
achieving universal and equitable access to safe and affordable sanitation. Much of the water delivered to public water taps
drinking water and sanitation and hygiene for all; halving the is still delivered at less than full cost, and collection rates for
portion of untreated wastewater and increasing recycling household connections are notoriously low, particularly in
and safe reuse globally; implementing water resource manage- poor regions. Low revenues develop into limited system main-
ment and protecting/restoring water-related ecosystems; and tenance, in turn leading to leakage and further decline in
improving local participation and building capacity for water system efficiency. The challenge to finance water supply and
and sanitation management. Any successful strategy must sanitation systems thus requires innovations in local financing
rely not only on scaling-up available funds and using effective as well as less tangible social and legal reforms to create an
and appropriate technologies but also on the capacity of the enabling environment for potential investors.
unserved population to respond to international efforts. In In response to the poor performance of public providers,
Zimbabwe, for example, creating demand for sanitation and many governments have considered various management
hygiene at the community level was not only shown to be reforms. The 1990s saw the introduction of public–private
cost-effective but also resulted in significant gains in sanitation partnerships into the operations of water supply and sanitation
coverage over a short period of time (Waterkeyn and Cairn- systems. From South America to Southeast Asia, traditionally
cross, 2005). state-owned providers contracted out to private companies
(Mwanza, 2005). Various relationships developed from
concessions for water supply in Jakarta, Indonesia, to service
Health Policy Challenges contracts for leakage repairs and revenue collection in Manila.
Reviews of the performance of these private ventures are mixed,
Multiple health policy challenges lie ahead, both at the however. Experience thus far has shown that healthy public–
national level and multinational level. Recognizing that private partnerships require solid institutional arrangements
enumerating service coverage alone is not enough to achieve and well-defined regulatory frameworks, which often do not
health and economic development goals, the focus of current exist prior to the privatization efforts. For this reason, only
public health campaigns needs to be more expansive. Access some privately managed water agencies offer success stories.
to water and sanitation is considered basic human rights Several other governments under pressure to perform have
and is essential for economic development and human kept management of the water supply and sanitation public,
dignity. Nonetheless, although water is a human right, it but have adopted reform strategies and management principles
does not mean that it should be provided for free by associated with the private sector. This second type of reform
governments. comes in many colors but collectively is referred to as the
The following section highlights a few of the challenges New Public Management (NPM) (Lane, 2000). Key principles
facing local and national governments as they face the coming of NPM include the decentralization of authority, separation
decades of urbanization, water scarcity, and population of regulatory tasks from service provision, achievement of
growth. cost recovery, stimulation of competition in the water sector,
and development of customer-oriented, accountable services.
Some examples of such efforts include Uganda’s performance
Innovative Financing contracts, Zambia’s water watch groups, tariff increases to cover
operations and management costs in Mexico, and Vietnam’s
The argument is often made that water is a basic human benchmarking and local management offices (Schwartz,
right and therefore should be free. ‘Free’ water and sanita- 2007). No one solution works alone. In their attention to the
tion services, however, are not sustainable. They in fact local level and performance indicators, these practices may
advance coverage minimally and often fail to change the foster more progress toward the MDGs than previously failed
service levels of the poor at all. Retrospective evaluation of attempts.
failed schemes has taught us that the sustainability of a water
and sanitation project depends in part on the recovery of
capital and operational costs (Brikké and Rojas, 2001). Reaching the Poor
This emphasis is relatively new, particularly in developing
countries whose water and sanitation schemes were histori- Service inequities exist universally in cities, where the poorest
cally financed through donor agencies and loans. In live with the worst levels of coverage. Traditionally,
358 Drinking Water and Sanitation

government schemes assumed that coverage extension to the Organization estimates that access to improved sanitation
poor would operate at a loss unless subsidized. Across facilities increased from 54% to 68% globally, missing the
cultures, however, the poor pay more per unit for their water global target by about 700 million people. In 2015, there
than their wealthier counterparts (Adrianzen and Graham, are still 47 counties or territories in which less than half of
1974; Gilman et al., 1993). Household data also reveal that the population uses improved sanitation facilities. As there
people, even poor people, are willing to spend considerable are disparities among countries, there are also disparities
amounts for improved sanitation. Previous propoor measures between urban and rural areas. While only 7% of urban
such as low tariffs and subsidies are now recognized as pro- dwellers use unimproved sanitation or open defecation,
rich, benefiting those already connected to a system dispro- 42% of rural dwellers do so (World Health Organization,
portionately and failing to secure funds sufficient to achieve 2015). This is a result, in part, of the lack of political commit-
cost recovery. Using this information creatively to expand ment, which has traditionally lagged behind water supply
services to the poor is clearly one of the present-day policy development. Sanitation appropriated only 20% of the
challenges. US$16 billion invested between 1990 and 2000 by national
governments and external support agencies (World Health
Organization/UNICEF, 2000).
Water Quality This gap in coverage promises to grow, as current sanitation
schemes are largely unsustainable. The operation of most off-site
Contaminants in water used at the household level play an sanitation systems requires significant financial commitment, as
important adverse effect on health. Households may store well as stable political environments to ensure proper mainte-
water for use in containers when availability is unreliable or nance of public components. Moreover, most urban sewerage
may obtain the water from a pipe far from the water treatment systems require an enormous quantity of water input in order
site. Such water is subject to poor pipe conditions and illegal to transport waste away from the household and into a waste
siphoning, which in turn leads to a loss of water from the treatment facility. According to sanitation engineers, wastewater
system and permits unforeseen changes in pressure. Once these is produced at rates of nearly 50 m3 per person per year in devel-
dynamics occur, cross-contamination between wastewater and oping cities. This translates into sufficient water being produced
drinking water can increase significantly. Less than a handful of from a city of 1 million people to irrigate 1500–3500 ha (World
developing countries achieve the international benchmark of Health Organization, 2006). It also translates into large quanti-
20% water leakage. Even fewer operate with functional water- ties of wastewater polluting surface and groundwater sources.
quality monitoring systems. As highlighted from the experi- Clearly, the challenge for the future will be to implement low-
ences of Mexico (Jiménez et al., 1999), analysis of water quality cost, appropriate sanitation and to consider the selective reuse
cannot simply transfer standards developed in the United of treated effluents.
States or Canada. Rather, standards should be based on criteria Although future projects in sanitation may still be less
that are affordable to measure and appropriate to the water use. successful than their water counterparts, an emphasis on
Government restructuring may also be necessary, as the respon- community-driven demand, not top-heavy supply, will be
sibility for water-quality monitoring usually resides within likely to produce more sustainable results. Projects in Pakistan
a department whose enforcement powers lie far from the and Mexico demonstrate that reorganization of sewage and
parties responsible for maintaining water supply and sanitation waste removal into community clusters improves flexibility to
infrastructure. In summary, in most cases, achieving water population growth, reduces water demand and unit price for
quality standards at the household level will require attention purchase as well as operations and maintenance, and enhances
to water continuity, delivery system leakage, wastewater treat- accountability. This, in turn, helps identify the parties respon-
ment, and monitoring enforcement. sible for repair and maintenance of system components
Discussion of water quality from a policy perspective must (United Nations Development Programme, 2006; Domínguez
also address the downside of increased water access: the ever- et al., 2007).
growing water pollution from industry, agriculture, and urban-
ization. No country can ignore the impacts of wastewater on
groundwater resources. Dr Perry McCarty, winner of the 2007 Managing Water Resources
Stockholm Water Prize, summarized it well when he stated:
“Attempting to remediate groundwater is extremely expensive, Water scarcity, related to either overextraction of groundwater
so we need to make a great effort in prevention before contam- reserves or pollution of existing surface water resources, prom-
ination happens. This is very important especially for the devel- ises only to increase as a problem. Currently, agriculture
oping world to understand, because once groundwater is accounts for over 70% of water use. In most countries,
contaminated, it is contaminated for centuries” (Environment production-linked support policies still dominate. This frame-
News Service, 2007). work encourages overuse and inefficiency and fails to address
the environmental damage that results from polluted runoff.
As populations increase, competition between uses of water
Sanitation and regulation of wastewater will develop into significant
policy concerns. Already, India and China have been faced on
The MDG target called for halving the proportion of the pop- numerous occasions with the decisions between providing
ulation that did not have sustainable access to basic sanitation for water-heavy crops or population settlements. Judicial policy
between 1990 and 2105 (REF). The World Health to address multicountry ownership of surface and groundwater
Drinking Water and Sanitation 359

resources needs to become a priority before water becomes like Clasen, T., Schmidt, W.P., Rabie, T., Roberts, I., Cairncross, S., 2007. Interventions to
oil as a commodity. Improved pricing structures, tradable improve water quality for preventing diarrhoea: systematic review and meta-
analysis. Br. Med. J. 334, 782.
permits, enforceable government regulations, and more
Cornwell, D.A., Brown, R.A., Via, S.H., 2016. National survey of lead service line
sustainable agricultural water management are necessary to occurrence. J. Am. Water Works Assoc. 108 (4), E182–E191.
address the crisis of water scarcity. Such initiatives also need Corso, P.S., Kramer, M.H., Blair, K.A., Addiss, D.G., Davis, J.P., Haddix, A.C., 2003.
to take place on local as well as national levels. Cost of illness in the 1993 waterborne Cryptosporidium outbreak, Milwaukee. Wis.
Emerg. Infect. Dis. 9 (4), 426–431.
Dixon, J., 2016. How Flint’s Water Crisis Unfolded. Detroit Free Press. Online:
Summary (accessed May 2016).
Domínguez Aguilar, M., García De Fuentes, A., 2007. Barriers to achieving the water,
Better water and sanitation are two of the most important sanitation-related Millennium Development Goals in Cancún, Mexico at the
beginning of the twenty-first century. Environ. Urban. 19, 243–260.
public health priorities worldwide. Although improvements
Environment News Service, March 22, 2007. U.S. Water Quality Expert Awarded 2007
in water supply and sanitation are part of an international Stockholm Water Prize.
agenda to reduce poverty, the necessary political commitment (access February 2008).
at the national and local levels must still increase. Although Esrey, S.A., 1996. Water, waste, well-being: a multicountry study. Am. J. Epidemiol.
many strides have been made in the last decade, the gross 143, 608–623.
Esrey, S.A., Feachem, R.G., Hughes, J.M., 1985. Interventions for the control of
numbers of people who lack water and sanitation services diarrhoeal diseases among young children: improving water supplies, excreta
have remained high. A more effective strategy must identify disposal facilities. Bull. World Health Organ. 63, 757–772.
and combine programs and policies that are likely to have Esrey, S.A., Potash, J.B., Roberts, L., Shiff, C., 1991. Effects of improved water supply
the greatest sustained effect. Conventional approaches – such and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection,
schistosomiasis, and trachoma. Bull. World Health Organ. 69, 609–621.
as education about hygiene and sanitation, or installation of
Ezzati, M., Hoorn, S.V., Rodgers, A., Lopez, A.D., Mathers, C.D., Murray, C.J., 2003.
sanitation facilities – have proven unsuccessful. It is clear that Comparative Risk Assessment Collaborating Group. Estimates of global and
people will not practice adequate hygiene or install and use regional potential health gains from reducing multiple major risk factors. Lancet
sanitation facilities unless they clearly see the need to do so. 362, 271–280.
It follows that any effective strategy must take into account Fewtrell, L., Kaufmann, R.B., Kay, D., Enanoria, W., Haller, L., Colford Jr., J.M., 2005.
Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed
the need to create demand for services. A multidisciplinary countries: a systematic review and meta-analysis. Lancet Infect. Dis. 5, 42–52.
approach is particularly important as poverty, with its associ- Gilman, R.H., Marquis, G.S., Ventura, G., et al., 1993. Water cost and availability: key
ated unsanitary living conditions and lack of access to water, determinants of family hygiene in a Peruvian shantytown. Am. J. Public Health 83,
proper nutrition, health care, and education, is the over- 1554–1558.
Global Burden of Disease Pediatrics Collaboration, 2016. Global and national burden of
whelming determinant of infection and malnutrition. The
diseases and injuries among children and adolescents between 1990 and 2013:
results of such efforts will better help us achieve the goals iden- findings from the Global Burden of Disease 2013 Study. J. Am. Med. Assoc. 1730
tified in the new SDGs: 17 Goals to Transform our World and (3), 267–287.
consequently serve the billions of people who currently live Gray, F.H., 1940. Sewerage in ancient and medieval times. Sew. Works J. 12,
without improved water or sanitation. 939–946.
Hanna-Attisha, M., LaChance, J., Sadler, R.C., Schnepp, A.C., 2016. Elevated blood
lead levels in children associated with the Flint drinking water crisis: analysis of risk
See also: Cholera and Other Vibrioses; Contaminants and public health response. Am. J. Public Health Res. 106 (2), 283–290.
Jiménez, B., Ramos, J., Quezada, L., 1999. Analysis of water quality criteria in Mexico.
Associated with Drinking Water; Intestinal Infections: Overview; Water Sci. Technol. 40, 169–175.
Parasitic Diseases, an Overview. Klein, P.D., Graham, D.Y., Gaillour, A., Opekun, A.R., Smith, E.O., 1991. Water source
as risk factor for Helicobacter pylori infection in Peruvian children. Gastrointestinal
Physiology Working Group. Lancet 337, 1503–1506.
Lane, J., 2000. New Public Management. Routledge, London.
Lopez, A.D., Mathers, C.D., Ezzati, M., Jamison, D.T., Murray, C.J., 2006. Global and
References regional burden of disease and risk factors, 2001: systematic analysis of pop-
ulation health data. Lancet 367, 1747–1757.
Adrianzen, B., Graham, G.G., 1974. The high cost of being poor: water. Arch. Environ. Mackenbach, J.P., 2007. Sanitation: pragmatism works. Br. Med. J. 334, S17.
Health 28, 312–315. Mwanza, D.D., 2005. Promoting good governance through regulatory frameworks in
Barreto, M.L., Genser, B., Strina, A., et al., 2007. Effect of city-wide sanitation pro- African water utilities. Water Sci. Technol. 51, 71–79.
gramme on reduction in rate of childhood diarrhea in northeast Brazil: assessment Prüss, A., Kay, D., Fewtrell, L., Bartram, J., 2002. Estimating the burden of disease from
by two cohort studies. Lancet 370, 1622–1628. water, sanitation and hygiene at a global level. Environ. Health Perspect. 110, 537–542.
Bradley, D.J., 1977. Improvements of rural domestic water supplies. Proc. R. Soc. Roefer, P.A., Monscvitz, J.T., Rexing, D.J., 1996. The Las Vegas cryptosporidiosis
Lond. Ser. B Biol. Sci. 1199, 37–47. outbreak. Am. Water Works Assoc. 88 (9), 95–106.
Brikké, F., Rojas, J., 2001. Key Factors for Sustainable Cost Recovery in the Context of Schwartz, K., 2007. Management reforms in the water supply and sanitation sector:
Community-Managed Water Supply. Occasional Paper Series 32-E. IRC Interna- the potential of the New Public Management for improving services. In: Paper
tional Water and Sanitation Centre, The Hague, the Netherlands. Presented at the 2007 World Water Week in Stockholm, Sweden.
Briscoe, J., 1987. A role for water supply and sanitation in the child survival revolution. United Nations Development Programme, 2006. Human Development Report 2006.
Bull. Pan Am. Health Organ. 21, 93–105. Beyond Scarcity: Power, Poverty and the Global Water Crisis. Palgrave Macmillan,
Briscoe, J., de Ferranti, D., 1988. Water for Rural Communities: Helping People Help New York.
Themselves. World Bank, Washington, DC. VanDerslice, J., Briscoe, J., 1995. Environmental interventions in developing countries:
Cairncross, S., 1999. Trachoma and water. Community Eye Health 12, 58–59. interactions and their implications. Am. J. Epidemiol. 141, 135–144.
Checkley, W., Gilman, R.H., Epstein, L.D., et al., 1997. Asymptomatic and symp- Vandenbroucke, J.P., Eelkman Rooda, H.M., Beukers, H., 1991. Who made John
tomatic cryptosporidiosis: their acute effect on weight gain in Peruvian children. Snow a hero? Am. J. Epidemiol. 133, 967–973.
Am. J. Epidemiol. 145, 156–163. Waterkeyn, J., Cairncross, S., 2005. Creating demand for sanitation, hygiene through
Checkley, W., Gilman, R.H., Black, R.E., et al., 2004. Effect of water and sanitation on Community Health Clubs: a cost-effective intervention in two districts in Zimbabwe.
childhood health in a poor Peruvian peri-urban community. Lancet 363, 112–118. Soc. Sci. Med. 61, 1958–1970.
360 Drinking Water and Sanitation

World Health Organization, 2015. Progress on Sanitation and Drinking Water – Further Reading
2015 Update and MDG Assessment. WHO Press, World Health Organization,
Geneva, Switzerland.
World Health Organization, 2016. World Health Statistics 2016: Monitoring Health for Esrey, S.A., Habicht, J.P., 1986. Epidemiologic evidence for health benefits from
the SDGs, Sustainable Developmental Goals. WHO Press, World Health Organi- improved water and sanitation in developing countries. Epidemiol. Rev. 8,
zation, Geneva, Switzerland.
World Health Organization, 1992. The International Drinking Water Supply and Sani- United Nations, 2016. Sustainable Development Goals.
tation Decade: End of Decade Review. (WHO/CWS/92.12). World Health Organi- sustainabledevelopment/.
zation, Geneva, Switzerland.
World Health Organization, 2006. Center for Environmental Health Activities. Overview
of Greywater Management Health Considerations. World Health Organization,
Geneva, Switzerland.