WATER and SANITATION in Developing
Countries: Including
Health in the Equation
Millions suffer from preventable illnesses and die every year.
M AGGIE A. MONTGOMERY
MENACHEM ELIMELECH
YALE UNIV ERSIT Y

WORLD BANK

I

mproving global access to clean drinking ­water and safe sanitation is one of the least expensive and most effective means to improve public health and save lives. The concept of clean water and safe sanitation as essential to health is not a novel idea. In 350 B.C., Hippocrates recommended boiling water to inactivate “impurities”. The
U.S. and Central Europe, where water and sanitation services are nearly universal, significantly reduced water-, sanitation-, and hygiene-related diseases by the start of the 20th century by protecting water sources and installing sewage systems. However, in developing countries, water and sanitation services are still severely lacking. As a result, millions suffer from preventable illnesses and die every year
(1). Many obstacles must be overcome to improve these statistics. The integration of public health into engineering problem solving is critical, but current efforts are insufficient. Through partnerships with local communities to implement water and sanitation solutions that consider environmental, cultural, and economic conditions, progress toward achieving and sustaining global coverage of water and sanitation services will be greatly enhanced.
In this article, we discuss three main themes about water, sanitation, and health in developing regions. First, water and sanitation services have markedly improved health and engendered many secondary benefits. These benefits could be en-

© 2007 American Chemical Society

hanced and services expanded through greater collaboration between the fields of water and sanitation engineering and public health. Second, researchers should focus on the sustainability of water and sanitation services by developing strategies that holistically address the influence of the environment, culture, and economics on the implementation and long-term maintenance of treatment systems. Lowcost household technologies, as opposed to centralized systems, offer one means of addressing water and sanitation needs in a more integrated and sustainable manner. Third, the obstacles to improving water and sanitation services, such as lack of investment, lack of political will, and difficulty in maintaining services, must be overcome so that these services can be improved and global coverage ultimately achieved. This will require greater collaboration among the water, health, and education sectors in conducting community-based research and work, formulating evidence-based policies that allow for effective investments, and focusing on developing solutions that can be locally managed and maintained. Billions suffer without improved water and sanitation services
Global figures that describe the lack of water and sanitation services are alarming. More than 1.1 billion people do not have access to improved drinkJANUARY 1, 2007 / Environmental Science & Technology n 17

health standards, such as those set forth by World
Health Organization (WHO) Guidelines for Drinking Water Quality. Rather, the term “improved acComparison between lack of access cess” usually represents households that obtain to improved water and sanitation and water from sources that are superior to traditional, deaths attributable to diarrheal diseases unprotected ones. Sources that meet the definition
Adapted with permission from Ref. 1. of improved water include a household connection, borehole, protected dug well, protected spring, or rainwater collection (1). Connection to a public sew70
25
er or septic system or use of ventilated pit latrines
60
20 and some simple pit latrines qualify as improved
50
sanitation (1).
15
40
Figure 1 illustrates, by region, the percentage of
30
10 the population without access to improved water
20
and sanitation. To demonstrate how this impacts
5
10 health, the figure also shows number of deaths per
0
0
1000 children younger than 1 year of age that are attributable to diarrheal diseases (1). Conditions are most severe in sub-Saharan Africa, where 42% of the population is without improved water, 64% is without improved sanitation, and deaths due to diarrheal diseases are greater than in any other region.
In an effort to bring global attention and resources to the problem, international organizations have
% without access to improved sanitation created several water and sanitation initiatives. The
% without access to
UN, as part of its Millennium Development Goals improved water
(MDGs), has set a target of halving the proportion
Number of deaths/1000 of people without access to safe drinking water and children 7 log removal of bacteria and
>4 log removal of viruses (21). Chlorine bleach typically achieves only 2 log removal for both bacteria and viruses (25). Chlorine is particularly poor for treating turbid water (>1 nephelometric turbidity unit) or chlorine-resistant pathogens, including many types of protozoan cysts. However, the chlorine residual protects against recontamination; this is especially important in homes where hygiene is substandard. Health gains from POU techniques will only be realized if treatment is effective in the communities where such technologies are used. This is a greater challenge than achieving high removal rates of pathogens in the controlled laboratory environment. Recent studies in Kenya, Guatemala, and India have demonstrated that use of POU treatments leads to a reduction in diarrhea by 40% for PUR and solar disinfection and by up to 85% for chlorine (20, 26, 27).
These results suggest that although chlorine is less effective in removing bacteria and viruses, it may lead to a greater reduction in diarrhea because of economic and cultural advantages relating to low cost, ease of use, and its ability to be manufactured locally. Other studies, however, have not found such a large advantage for chlorine. A study in Guatemala that evaluated sodium hypochlorite (bleach) and PUR demonstrated no significant difference between the two technologies, both of which reduced diarrhea by ~25% (28).
Precise rankings of POU-based disease reduction are difficult to ascertain, as we describe in the following paragraph, but more qualitative conclusions are possible. The review on household technologies concluded that solar disinfection with clear plastic bottles and chlorination plus storage in an improved vessel led to significant reductions in diarrhea and other infectious diseases (24).

Conclusive results about which POU technologies are the most effective in improving health are still lacking. Because of heterogeneities between communities and in the methodology of epidemiological studies, comparing outcomes is difficult. The performance of POU treatments is highly dependent on source water quality and the degree to which households adhere to the operation and maintenance requirements. A review of the promotion of chlorine disinfection in Malawi found that incorrect dosage (8–100% of the appropriate concentration was used) resulted in a chlorine residual that was far less than suggested (29). An additional challenge is determining whether health outcomes are primarily due to POU treatment or confounding factors, such as hand washing, education, economic wellbeing, and culture. For example, a drinking-water and hand-washing study in squatter settlements in
Karachi, Pakistan, found no significant difference in reduction of daily longitudinal prevalence of diarrhea among households that used POU technologies alone (64%), hand washing alone (51%), and a combination of POU treatments and hand washing with soap (55%) (30). Therefore, additional comparative and longitudinal health studies are required to determine which technologies are most effective.
Understanding the primary motivators that drive households to use POU technologies is important for sustaining use and achieving long-term health gains. Some of the main factors are affordability, aesthetic and taste preferences, and the ability to manufacture POU technologies locally. The cost of
POU treatments is a serious hurdle to adoption, especially in developing countries such as Tanzania, where for decades a “free water for all” policy existed (31). Placing a price on POU units is important to recover production costs and increase sense of ownership. However, water is viewed as a fundamental human right, and denying access because of inability to pay creates a serious ethical dilemma (19,
32). POU technologies that can be generated locally—such as chlorine which has been manufactured, packaged, and distributed by local microenterprises under brands such as WaterGuard in Tanzania and Safe Water (Sûr’Eau) in Madagascar—are more likely to be sustained after initial funding ceases. In contrast, PUR currently cannot be manufactured locally, thus preventing its widespread adoption and distribution. Long-term, sustained use of POU technologies may be reinforced as individuals experience the benefits of improved water and sanitation.
Furthermore, reductions in water-, sanitation-, and hygiene-related diseases allow individuals to engage in more productive work and attend school, both of which may lead to economic development, improved standards of living, and more hygienic conditions.
Household sanitation. A simple pit latrine, one of the most basic forms of household sanitation, offers an inexpensive alternative to expensive and environmentally intensive sewage systems. Although sanitation is important for the safe disposal of excreta—the source of pathogens that cause the majority of water-, sanitation-, and hygiene-related diseases—it has not received the same attention as
JANUARY 1, 2007 / Environmental Science & Technology n 21

water treatment (33). One of the major challenges with sanitation is developing and implementing innovative, user-friendly, low-cost systems (34).
Current efforts focus on overcoming some of the limitations of the simple pit latrine and expanding sanitation coverage. Some evidence has linked the standard latrine to contamination of groundwater by bacteria and nutrients (35). In addition, traditional latrines may harbor offensive odors and flies. The ventilated improved pit latrine improves on the standard design by allowing odors to escape, preventing flies from entering, and in many cases sealing the pit to prevent groundwater contamination (33).
Ecological sanitation, although practiced in China for centuries, has only recently been gaining acceptance throughout the world as an effective means to recycle the nutrients in excreta for use in agriculture.
This improves crop production and, ultimately, the nutritional health of the population (36).
A typical latrine design consists of a superstructure that sits above a raised, sealed vault. The toilet, either of the sitting or standing variety, usually diverts urine and excreta into two separate chambers within the vault. Urine, which is nearly pathogen-free and contains high amounts of nitrogen and phosphorus, can be diluted with water and used immediately for crop fertilization. Excreta must remain in the vault for a period of several months to allow for pathogen removal through die-off, desiccation, and predation by microorganisms (36). Once pathogen removal is nearly complete and excreta can be safely handled, it can be applied to crops. Advantages of ecological sanitation include the ability to empty and reuse storage vaults, production of an organic and free source of fertilizer, and prevention of groundwater pollution that can occur when pits are unsealed and located near the aquifer.
The promotion and large-scale implementation of latrines are at least as important as, if not more important than, improvements in sanitation design.
Latrine marketing does not focus on extolling the virtues of improved health but rather on other benefits such as reduced smell, cleaner surroundings, privacy, and less embarrassment when visitors need to use facilities (37). Combining low-cost technology with marketing efforts to secure community participation and management has been a successful way of expanding sanitation coverage. One notable example is in India, where 1 million pit latrines, which can be modified to suit different incomes and preferences, have been built since 1970 under the auspices of the nongovernmental organization Sulabh International Social Service Organization (3).
Further efforts are required in the marketing and implementation of household latrines before similar success can be realized throughout the globe.

Obstacles to achieving water and sanitation f ­or all
In many developing countries, a lack of financial resources and a low prioritization of water and sanitation constrain both the maintenance and expansion of services. In addition, lack of accountability, corruption, and inefficient management all plague
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efforts to improve water and sanitation. The lack of water quality standards and the difficulty in enforcing standards also limit the ability to improve health outcomes. Even countries where such standards exist frequently lack the personnel, monitoring equipment, and political will to ensure that quality and health guidelines are enforced (38).
Decentralization has not solved perhaps the largest problem facing water and sanitation projects—sustaining long-term use and operation. For example, at the conclusion of the 5-year, $135 million Indonesian Rural Water Supply and Sanitation
Sector Project, fewer than half of the ~3 million intended beneficiaries had received any services (39).
In addition, only 30–40% of the water and sanitation facilities constructed were still functioning or in use
4 years after the project was completed (39). This demonstrates both an initial lack of capacity and/or political will to implement services and a lack of local incentive to operate and maintain facilities. Efforts in rural Africa had similar outcomes. Throughout the continent, of the ~250,000 hand pumps currently
installed,