The sanitation gap:
Development's deadly menace
Akhtar Hameed Khan *
Adequate sanitation is the foundation of development—but
a decent toilet or latrine is an unknown luxury to half the people
on earth. The percentage of those with access to hygienic sanitation facilities
has declined slightly over the 1990s, as construction has fallen behind
population growth. The main result can be summed up in one deadly word:
diarrhoea. It kills 2.2 million children a year and consumes precious
funds in health care costs, preventing families and nations from climbing
the ladder of development.
the brink of the 21st century, half the world’s people are enduring a medieval
level of sanitation. Almost 3 billion individuals do not have access to
a decent toilet, and many of them are forced to defecate on the bare ground
or queue up to pay for the use of a filthy latrine. This unconscionable
degradation continues despite a fundamental truth: Access to safe water
and adequate sanitation is the foundation of development. For when you
have a medieval level of sanitation, you have a medieval level of disease,
and no country can advance without a healthy population.
In many developing countries, the plagues of old are revisiting, taking
their strength from teeming urban squatter settlements and shanty towns,
from streets and waterways awash in excrement and garbage. The recent cholera
epidemic in Peru and outbreaks of bubonic and pneumonic plague in India
are but three examples.
Plagues make headlines, but in human terms, the price of neglecting
sanitation is both more prosaic and more profound. It can be summed up
in one word: diarrhoea. It thrives in the absence of hygienic conditions
and is tied with pneumonia as the biggest child-killer on earth, taking
the lives of 2.2 million children each year. Diarrhoeal episodes leave
millions more children underweight, mentally and physically stunted, easy
prey for deadly diseases and so drained of energy that they are ill equipped
for the primary task of childhood: learning.
How can any nation hope to advance if its people—its main resource—are
so diminished from the beginning of their lives? How can leaders ignore
the fact that their citizens are diminished not by an implacable enemy
or an incurable disease but by something as mundane and easily preventable
as diarrhoea? And how can a civilized world tolerate the status quo when
it could be fixed with an investment equal to 1 per cent of yearly world
To deny people basic sanitation is not just inhumane—it also kicks the
first step out from a country’s ladder of development. History has taught
that a safe means to dispose of bodily wastes is not a luxury that can
wait for better economic times but a key element in creating them.
In the late 19th century, life expectancy in the industrial city
of Liverpool (UK) was about 35, lower than in any developing country today.
A key reason for the abbreviation of those lives was the lack of safe water
and sanitation, and providing these services was a decisive turning point
in reducing infant death rates. Epidemiologists studying historical records
realize that there has been a tendency to underestimate the impact of water
and sanitation on people’s health.
Considering the state of the infrastructure in the developing world,
it is no surprise that diarrhoea still holds sway in the 1990s. As population
has increased, so too has the number of people lacking access to sanitation.
Just since 1990, an additional 300 million individuals are making do without
decent sanitation, an ominous indication that the world community is failing
in its efforts to provide services where they are most needed.
Many large cities are still without central sewage systems for
their millions of residents. In New Delhi, for example, less than 40 per
cent of households are connected to sewers. In Ibadan (Nigeria), a city
of more than 1 million people, less than 1 per cent of households have
Though latrines are available to some city dwellers in developing countries,
more than a third lack adequate sanitation. In such conditions, many of
these residents, particularly the very poor, are forced to defecate in
open spaces or to dispose of their waste in nearby gullies and streams.
Have we become so inured to the disparity between rich and poor that we
fail to notice the dreadful irony of people defecating in vacant lots in
the shadows of high-tech office buildings?
Such de facto latrines become breeding grounds for bacteria, ripe to
contaminate the children who play in these open spaces and the families
who wash and fetch drinking water from streams near them. These sites also
encourage the growth of virulent strains of typhoid, typhus and dysentery
and infestation by disease-ridden carriers such as insects and vermin.
The water that collects in urban detritus, such as discarded vehicle tyres,
nurtures mosquitoes, which spread deadly malaria, yellow fever and dengue
fever—the latter a relatively modern disease. Rats, coexisting with people
in this fragile environment, thrive on the mountains of waste that accumulate
around squatter settlements and are the principal carriers of bubonic and