In December 2006, the UN General Assembly declared 2008 as the International Year of Sanitation. The intention was to raise awareness of the importance of sanitation and encourage Governments, partners and communities to embrace the need for urgent action to reduce the number of people living without this basic service.


The declaration could not have been timelier or more welcome. At the midpoint in the time frame to achieve the internationally agreed Millennium Development Goals (MDGs), which include targets to halve the proportion of people living without sanitation and water by 2015, it is clear that investment to reach these targets is seriously insufficient. However, with seven years to go, there is still time to reverse the situation and reap the substantial potential rewards of taking action to meet the MDGs.
Current investment would need to be increased by $10 billion a year for the sanitation and water targets to be met1. But sanitation, perhaps the most off-track of all the Goals, is suffering acutely from under-investment. There are 2.6 billion people, or 42 per cent of the world's population, without improved sanitation2. If the present trend continues, the MDG target will be missed by half a billion people3. These people, who should have access to toilets, will continue to face the indignity of defecating in the open, with the risk of diseases, and even the abuse that it brings.
There is compelling evidence that sanitation brings the greatest public health returns of any policy intervention, but despite its importance it is rarely included in the development agenda. Simply put, no one wants to talk about toilets. The challenge is to raise awareness and prioritize the issue, so that sanitation stops being seen as an international taboo.
Globally, the water target is faring better and as a whole is currently on track to be met. However, the World Health Organization/United Nations Children's Fund Joint Monitoring Project (JMP) has warned that the trend appears to be deteriorating. The distribution of investment is far from equitable, with the world's poorest communities being disproportionately excluded from water services. Water coverage rates in sub-Saharan Africa are lowest. The JMP estimates 56 per cent coverage in 2004, but this figure masks large national differences; in Ethiopia, the official coverage is just 22 per cent. The poorest and most marginalized -- women, children, people living with HIV/AIDS and those with disabilities -- suffer the most.
The costs of not investing in sanitation and water provision for the developing world are huge and far outweigh the additional investment required. Infant deaths, lost workdays and missed school are estimated to have an economic cost of around $38 billion per year4, of which sanitation accounts for 92 per cent. The potential returns in terms of reducing poverty and disease, on the other hand, are huge, estimated at $9 for every $1 invested in sanitation. The returns are very high because the impact of water and sanitation cuts across so many aspects of people's lives. Water and sanitation are fundamental human needs that are vital prerequisites for health, livelihoods and education, and therefore underpin the achievement of all the MDGs.
Water, sanitation and hygiene education are essential in the fight against diarrhoeal diseases, such as cholera, typhoid and dysentery, because they put barriers in the "faecal-oral" transmission routes of these diseases. When latrines are safely used by people who wash their hands afterwards and uncontaminated drinking water is available, people are kept safe from the pathogens found in human excreta that are responsible for the spread of diarrhoeal diseases.
The scale of incidence of diarrhoeal diseases is shocking. People suffering with them occupy half of the developing world's hospital beds and tragically they often prove fatal for weaker members of society, such as children and the elderly5. Every day diarrhoeal diseases cause 4,900 deaths of the under-fives and they are the second biggest driver of infant mortality. Of these deaths, 90 per cent are attributed to poor hygiene, sanitation and unsafe drinking water6. With such a close link, the lack of improvements in child mortality (MDG 4) unsurprisingly mirrors the lack of improvements in water and sanitation.


Livelihoods and economic development are also being held back by the lack of water and sanitation, trapping communities, and especially women, in poverty. Poor families are paying money they can ill-afford for the treatment of water-related diseases, and women are being kept out of productive work by long hours of water collection and the care of family members sick with water-related diseases; not only diarrhoeal diseases, but also other serious diseases, such as trachoma, which can cause blindness, and skin infections like scabies. If the MDG targets for water and sanitation were met, an extra 320 million productive working days a year would be available, and this would put more money in the pockets of poor families, for food, school fees and other essentials. Estimates suggest that investing in water and sanitation could boost the annual growth rates by as much as 5 per cent in Africa, enough to put the rates over the poverty line needed to achieve the MDG of reducing poverty7. The psychological benefits, particularly for women, of lifting the burden of water collection and the threat of diseases are harder to quantify, but are also very crucial.
Education, especially for girls, suffers acutely in areas where there is no safe water and sanitation. Girls miss school because they must spend hours a day fetching water for their families. Both boys and girls are frequently too sick to attend school, with a total of 443 million school days lost each year due to water-related diseases. Children and teachers alike are reluctant to attend or work in schools without adequate latrines or safe drinking water, a problem particularly sensitive for teenage girls during menstruation.
The evidence so far points to how water, sanitation and hygiene education have the power to reduce dramatically the incidence of diseases, improve livelihoods and foster greater opportunity for girls and women. Investments in water and sanitation are essential not only for attaining these MDG targets, but also for the achievement of one of the most significant targets of the MDGs: the sustainable reduction of poverty in the developing world.

Notes 1. UNDP, Beyond Scarcity: Power, poverty and the global water crisis. Human Development Report 2006.
2. WHO and UNICEF, Meeting the MDG drinking water and sanitation target: The urban and rural challenge of the decade (Geneva: 2006).
3. G. Hutton, L. Haller, and J. Bertram, Economic and health effects of increasing coverage of low cost household drinking-water supply and sanitation interventions to countries off-track to meet MDG target 10. Background document to the Human Development Report 2006 (Geneva: WHO and UNDP, 2007).
4. Hutton and Haller, 2004; Rijsberman, 2004.
5. UNDP, The Costs of Attaining the Millennium Development Goals (2006), (www.worldbank.org/html/extdr/mdgassessment.pdf.
6. UNICEF, Children and Water, Sanitation and Hygiene: The Evidence, occasional paper for the Human Development Report (2006).
7. WHO, Health through safe drinking water and basic sanitation (2007), www.who.int/water_sanitation_health/mdg1/en/ index.html