Sanitation in Developing Countries

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In 1999 the United Nations acknowledged that the development gap between rich and poor countries was widening: about three-fifths of the world's population lacked access to basic sanitation; and one-third did not have access to safe drinking water. Industrial development affects public health both favorably and unfavorably. Improved housing and social conditions and reductions in infectious diseases like gastroenteritis or pneumonia are often accompanied by increases in degenerative, noninfectious diseases like cancer and heart disease. In rapidly developing countries, such as Mexico, the People's Republic of China, and the Philippines, new public health problems often emerge before the old ones have been solved, and it is important to assess which problems pose the greatest risks to health, and which solutions are most cost-effective. Large funding organizations like the United Nations, the World Bank, and regional development banks now recognize that to solve priority health problems requires improvements in behaviors, attitudes, skills, services, products, and infrastructure that together yield lasting benefits long after external support is withdrawn.

In this global context, providing both safe drinking water and wastewater sanitation have long been recognized as priorities for the improvement of human health, especially in the prevention of infant and child mortality from diarrheas and dysenteries (e.g., Amoebiasis, caused by a protozoan; or E. coli diarrhea, caused by a bacterium). An estimated 4 billion cases of diarrheal disease occur worldwide every year, killing an estimated 3

Table 1

Major Water-Related Diseases and Sanitation Solutions
DiseaseInfection routeRangeCases 1Deaths per yearProblem

Sanitation Solution
Major Water-borne Diseases
1. Amoebic dysentryProtozoa (e.g. Giardiaor Cryptosporidium ) follow the fecaloral route; i.e., feces contaminate water and/or food that is ingested.Worldwide500 million per yearincluded in 3. belowUnsanitary excreta disposal, poor personal and domestic hygiene, unsafe drinking water.

Low-cost sanitation such as latrines, pour-flush toilets, and septic tanks. Education to promote basic hygiene (e.g., washing food, handwashing before eating and preparing meals). Provide safe drinking water sources.
2. Bacillary dysentryBacteria by fecal-oral routeWorldwideincluded in 3.included in 3.
3. Diarrheal disease (incl. Amoebic and Bacillary dysentry)Various bacteria, viruses, and protozoa by fecal-oral route.Worldwide4 billion in 19983-4 million
4. CholeraBacteria by fecal-oral route.S. America, Africa, Asia384,000 per year20,000
5. Hepatitis AVirus by fecal-oral route.Worldwide600,000 to 3 million per year2,400-12,000
6. Paratyphoid & TyphoidBacteria by fecal-oral route.Asia (80%), Africa, Latin America (20%)16 million in 1996600,000
7. PolioVirus by fecal-oral route.India (66%), Near East, Asia, Africa (34%)82,000 in 19969,000
Major Water-based Diseases
8. AscariasisEggs in human feceslarvae develop in soilsoil on foodfood eaten by humans and worm infects small intestine.Africa, Asia, Latin America250 million in 199660,000Unsanitary excreta disposal, poor personal and domestic hygiene.

Low-cost sanitation. Education to promote basic hygiene, especially in children.
9. ClonorchiasisWorms in snailssnails eaten by fishraw/undercooked fish eaten by humans.Southeast Asia28 million in 1994None reportedUnsanitary excreta disposal, poor personal and domestic hygiene

Low-cost sanitation. Education to promote basic hygiene.
10. Dracunculiasis (Guinea worm)Human host has blister, immersion in water causes larvae to release, larvae eaten by crustacean, in turn eaten by humans.Sudan (78%), sub-Saharan Africa153,000 per yearNone reportedUnsafe drinking water supply.

Provide safe drinking water supply.
11. Necatoriasis (Hookworm)Eggs in feces hatch to larvae in soil and on grass, pass into humans through skin to infect small intestine.Tropical and subtropical Africa and Asia900 million in 199060,000 per yearUnsanitary excreta disposal, poor personal and domestic hygiene.

Low-cost sanitation such as
12. ParagonimiasisWorms in human lungs lay eggs, coughed up and swallowedeggs excreted in feces and break in freshwater. Larvae find snail host then move into crab or crayfishhumans eat raw seafoodworms move from stomach to lungs.Far East, Latin America5 million in 1994None reportedlatrines, pour-flush toilets, and septic tanks. Education to promote basic hygiene.
13. Schistosomiasis (Bilharzia)Eggs passed out in feces to water, releasing parasitespass into snail host to replicatepass into waterpass through human skin and become worms.Africa, Near East, Western Pacific, Southeast Asia200 million in 199620,000Unsanitary excreta disposal, unsafe bathing water.

Provide safe water. Low-cost sanitation such as latrines, pour-flush toilets, and septic tanks.

Table 1 continued

Major Water-Related Diseases and Sanitation Solutions
DiseaseInfection routeRangeCases 1Deaths per yearProblem Sanitation Solution
*cases given as number per year (incidence) or as number of cases in existence at a given time/in a given year (prevalence)
sources: Hinrichsen et al., 1998; World Health Organization at
Major Water-related Vector Diseases
14. DengueVirus passes to mosquito from infected person or animalreplicates and passes again into human by mosquito bite.Tropical areas, Asia, Central and South America50-100 million per year24,000Poor water management: poor operation of water sources, drainage and storage. Poor solid waste management.

Combination of improved water management (drainage, preventing stagnant water bodies), physical barriers to hosts (bednets, screens at night), biological methods (introduce natural enemies of hosts), and chemical (pesticides). Best methods emphasize sanitation to reduce dependence on chemicals like DDT.
15. Filariasis (includes Elephantiasis)Worm larvae pass to mosquito and replicatepass into humans by bite.Africa, Eastern Mediterranean, Asia, South America120 million in 1996None reported
16. MalariaProtozoa in mosquito gut pass to humans by bite.Africa, Southeast Asia, India, South America300-500 million per year (clinical)2 million
17. Onchocerciasis (river blindness)Worm embryos eaten by black flies and become larvaepass to humans by bite.sub-Saharan Africa, Latin America18 million in 1996None reported but 270,000 cases of blindness per year
18. Rift valley fever (RVF)Virus passes to mosquito/other blood-sucking insects from infected person or animalreplicates and passes again into human by bite.sub-Saharan AfricaNo dataNo data
Water-washed Diseases
19. TrachomaVirus infects eye and infection is contagious.Worldwide150 millionNone reported but 5.9 million cases of blindness or severe complications per yearLack of face washing, bathing and safe water.

Provide safe water. Personal hygiene and education.
20. Flea, mite (e.g. Scabies), lice, and tick-borne diseasesContagious skin infections caused by contact with fleas, mites, lice and ticks.WorldwideNo dataNo data

to 4 million people per year, most of them children (see Table 1). While it can be readily argued that a safe water supply plus wastewater sanitation is the most cost-effective public health goal for any given population, in practice, many social, cultural, technical, and economic factors govern whether the design and implementation of these systems will provide the long-term benefits sought.

To measure development and health progress, public health agencies use indicators such as access to water supply, access to sanitation, the under-five-year-old child mortality rate (U5MR), and per capita income. In 2000, the UN reported that the U5MR varied from 4 per 1,000 live births for developed countries like Sweden, Japan, and Norway, to 280,292, and 316 per 1,000 for Niger, Angola, and Sierra Leone, respectively. Figure 1 shows the relationship between the U5MR and access to safe water. Figure 2 shows the relationship between the U5MR and access to sanitation. These figures clearly show that improved water supply and/or sanitation can reduce child mortality (see Table 2).


The uncontrolled pollution of water supplies by chemical and pathogens is one of the most serious threats to public health and the natural environment in developing countries. Standing water is a

Figure 1

medium for vector-borne diseases, and caused by poor water management, especially poor drainage. Table 1 shows the main water-related diseases from pathogens (viruses, bacteria, and protozoa), their relative geographical extent, numbers of cases, mortality rate, and sanitation solutions. Although the focus for remediation varies by disease and local conditions, all solutions include attention to four basic factors: 1) basic infrastructure (water supply and waste disposal); 2) personal and domestic hygiene; 3) better housing; and 4) primary health care and health promotion. Where basic infrastructure is lacking, pathogens are the priority contaminants, although the comparative risks posed by chemical pollutants should also be considered, especially in industrial areas and areas using pesticides. In dealing with pathogens in these areas, it is important to consider the life cycle of pathogens, pathogen infection routes, and pathogen susceptibility to treatment.

Chemical pollution of water from agricultural and/or industrial practices may include organic substances such as polychlorinated biphenyls (PCBs), chlorinated pesticides and herbicides, polyaromatic hydrocarbons (PAHs), solvents and disinfection by-products (DBPs), as well as inorganic substances like metals and nitrates. The risks posed by such chemicals to human health depend on three parameters: their concentrations in the water; their specific toxicity for both cancer effects and noncancer effects (e.g., birth defects, reproductive effects, neurotoxicity); and dose rate (the amount of substance entering the body over time). Pollutants in water can enter the body by ingestion of the water in drinks and food, by bathing and skin contact with the water, and by inhalation of the water vapor while showering.

Sanitation solutions for chemical agents combine prevention and cure tactics. Prevention includes minimizing the sources of pollution by substituting nontoxic substances and using cleaner, more efficient technologies. Cure consists of treating water to appropriate quality standards according to use (domestic, industrial, or agricultural). Water supply and wastewater treatment systems in developing countries must be affordable, cost-effective, and able to be maintained by local people.

The monitoring and enforcement of appropriate water quality standards is a vital part of sanitation. Diverse chemical and microbial standards seek to regulate important known risk agents, and acceptable levels must be monitored. In the United States, the Primary ("legally enforceable") Drinking Water Standards cover 60 organic chemicals, 20 inorganics, and 8 microbes/indicator organisms. The World Health Organization's Guidelines for Drinking-Water Quality includes over 60 organic chemicals (31 of them pesticides), 19 inorganics, 17 disinfectants and their by-products, and pathogens. However, although water quality laws exist in many developing countries, their enforcement is either weak or nonexistent, most often due to a lack of resources and political will.

The 1980s were designated the International Drinking Water Supply and Sanitation Decade by the United Nations. Despite the efforts of this campaign, however, in many countries more than half the rural populations are without adequate water supply access and sanitation. Many of the failures can be explained by weaknesses in the design and implementation of projects, as evidenced by many abandoned water and wastewater treatment plants. Such weaknesses often stem from a lack of maintenance caused by failures in equipment or training. A widespread lack of community participation in projects also helps explain failures. In most developing countries, the public sector provides facilities to central urban areas but

Table 2

World Sanitation Status
CountryW (%)S (%)U5MRPCountryW (%)S (%)U5MRPCountryW (%)S (%)U5MRP
source: UNICEF 2000, multiple data compilation
Bahrain949713320Haiti372536130Papua New Guinea418345112
Bhutan587041116Iraq817537125St. Kitts and Nevis1001009037
Bolivia80655785Jamaica868914911St. Vincent/Grenadines899812023
Botswana90557748Jordan97999336Sao Tome and Principe82356177
Brazil76708542Kazakhstan93998343Saudi Arabia958611326
Burkina Faso423722165Kenya448540117Senegal816538121
Burundi525117176Korea, Dem. People's Rep.1009910430Sierra Leone34111316
Cambodia301924163Korea, Rep. of931001755Somalia31438211
Cameroon548927153Kyrgyzstan791006966South Africa87875883
Cape Verde65276573Lao People's Dem. Rep.441841116Sri Lanka576313719
Central African Rep.382718173Lebanon94639435Sudan735143115
Congo, Dem. Rep.42189207Malaysia789415310Tonga959512023
Cook Islands959510430Maldives60445687Tunisia988010232
Costa Rica968414516Mali6665237Turkey49808542
Côte d'Ivoire423928150Mauritania375716183Turkmenistan74916672
Dominica968013320Micronesia223911724United Arab Emirates979215310
Dominican Rep.79857551Rep. of Moldova55509435United States1001001608
El Salvador66909734Mozambique463410206Venezuela795911525
Equatorial Guinea955420171Myanmar604344113Viet Nam45298542
W percentage of population with access to safe drinking water 1990-98
S percentage of population with access to adequate sanitation 1990-98
U5MR world ranking of under-five-year-old mortality (1998 data)
P 1998 under-five-year-old mortality: probability of dying between birth and 5 years old expressed per 1,000 live births

leaves rural and marginal urban areas underserved. A 1990 evaluation of water-decade achievements in rural Bangladesh revealed that even when safe water supply and sanitary latrines were provided, people did not always use them, while only a third of the household water supplies had adequate usage. This demonstrates the need for joint improvements in education and economic conditions to accompany investments in infrastructure.

A useful reference for the visualization of health-risk sources, diseases, and solutions is the water-wastewater cycle (see Figure 3). The cycle ideally consists of water supply parts and sanitation counterparts, with each stage (or lack of it) affecting others. It should be remembered that this engineered cycle operates within the natural constraints of a dynamic hydrological cycle that supplies water to plants and animals as well as

Figure 2

people. Human beings have coevolved with other species in these ecosystems, while at the same time becoming super-modifiers of them. Logically, the health of people is influenced by the condition of these ecosystems.


Holistic environmental sanitation has four main water-related aspects: water supply, rainwater drainage, solid waste disposal, and excreta disposal.

Water Supply. The major problem for poor people in most countries is access to safe water in adequate quantity, with reasonable convenience, and at an affordable cost. Solutions include local grants to install household gutters and rainwater capture tanks; local wells designed to resist pollution; and small networks of water points served by a local well, borehole, or spring. The supply problems of major cities require integrated approaches that combine demand management, leak repair, backflow prevention, wastewater reuse, and the efficient, sustainable exploitation of sources.

Rainwater Drainage. Without adequate control of rainwater to mitigate floods and soil erosion, other sanitation measures can be nullified. People safe from floods and mudslides are more willing to invest in sanitation for their homes; and those in poor tropical urban areas attach a high priority to rainwater drainage. While local communities can build local drainage, downstream obstructions can cause the backing-up of channels and rivers, requiring a watershed-wide strategy.

Solid Waste Disposal. The interdependence of sanitation aspects is illustrated by the need for adequate solid waste removal to prevent the blockage of rainwater drains. Collection of refuse in hot climates must be frequent since piles attract flies and rats, and it should rely more on local labor-intensive methods rather than on expensive trucks. For the operation to be successful requires close cooperation between the users and providers of the service, and financing must come either from municipal recurrent funds and/or user fees.

Excreta Disposal. Large sewerage infrastructure projects tend to be too expensive for the vast majority of urban and rural people in developing countries, and it may be impossible to build a sewage network infrastructure in congested, narrow streets. On-site options include latrines, pourflush toilets, and septic tanks. There should be evaluated at each location according to needs and priorities. As water use grows in villages and towns, wastewater from washing and bathing (sullage) can be cost-effectively handled by a separate drainage system coupled to on-site excreta disposal.


Sanitation, including water supply, is a major part of the United Nation's 1992 Agenda 21, a "Blueprint for Sustainable Development." The paradigm of sustainable development focuses on how to satisfy the basic needs of the present human population, and also secure resources to satisfy the needs of future generations. Growing population pressure, persistent poverty, and ecological degradation call for new integrated solutions to sanitation problems that strengthen both socio-economic and technical elements, including the following:

  1. Financial, political, and societal will to invest in public health and the environment.
  2. Human resources and public awareness through education and training.
  3. Information resourceson health, water cycle, and ecological monitoringfor informed planning and actions.
  4. Regulatory frameworks, enforcement, and compliance.
  5. Basic sanitation infrastructure suited to local priorities and conditions.
  6. A market for public health and environmental support goods and services that provide economically viable, effective, and lasting sanitation strategies.

Figure 3

These elements are interdependent. For example, adequate training improves monitoring and the operation and maintenance of infrastructure; and effective, enforced regulations stimulate a market and long-term investment. In India, state water boards were established to prevent pollution under the 1974 Water Act, closely modeled on systems in Great Britain. However, despite good scientists and engineers on staff, the chronic shortage of funds means controls have a limited effect on sanitation.

Above all, the support and involvement of the local community are essential if sanitation is to work. Ideally, many social sectors should be involved, to varying degrees, in community-driven ("bottom-up") sanitation projects. Sanitation users, water and public health regulators and administrators, health professionals, sanitation engineers, ecologists, researchers and scientists, financing agencies and donors, nongovernmental organizations, and suppliers of health and sanitation products and services can all contribute to a successful project. These new approaches reflect the trend away from professionally centered, curative methods and towards multi-stakeholder preventive strategies. To face these challenges, public health professionals and institutions need to play an expanding role as facilitators and promoters of this trend, building new partnerships in developing and developed countries. Protecting public health and ecological integrity are ethical and practical imperatives to be viewed as opportunities for people from diverse cultures, social groups, and disciplines to work more closely together.

Timothy J. Downs

I. H. Suffet

(see also: Chlorination; Drinking Water; E. Coli; International Development of Public Health; Rural Public Health, Sanitation; Sewage System; Wastewater Treatment; Waterborne Diseases; Water Quality; Water Treatment )


Bell, M.; Franceys, R.; and Liao, M. (1995). "The International Water Decade and Beyond: New Public Health Interventions." In Health Interventions in Less Developed Nations, ed. S. J. Ulijaszek. Oxford: Oxford University Press.

Carter, R. C.; Tyrrel, S. F.; and Howsam, P. (1999). "The Impact and Sustainability of Community Water Supply and Sanitation Programmes in Developing Countries." Journal of the Chartered Institution of Water and Environmental Management 13(4):292296.

Downs, T. J. (2000). "Changing the Culture of Underdevelopment and Unsustainability." Journal of Environmental Planning and Management 43(5): 601621.

Downs, T. J.; Mazari-Hiriart, M.; Dominguez-Mora, R.; and Suffet, I. H. (2000). "Sustainability of Least Cost Policies for Meeting Mexico City's Future Water Demand." Water Resources Research 36(8):23212339.

Feachem, R. G.; McGarry, M.; and Mara, D., eds. (1977). Water, Wastes, and Health in Hot Climates. Chichester, Sussex: John Wiley.

Harpham, T.; Lusty, T.; and Vaughan, P., eds. (1988). In the Shadow of the City: Community Health and the Urban Poor. Oxford: Oxford University Press.

Hinrichsen, D.; Robey, B.; and Upadhyay, U. D. (1998). "Solutions for a Water-Short World." Population Reports Series M, No. 14.

Lewis, W. J.; Foster, S. S. D.; Read, G. H.; and Schertenleib, R. (1981). "The Need for an Integrated Approach to Water Supply and Sanitation in Developing Countries." Science of the Total Environment 21:5359.

Listorti, J. A. (1993) Environmental Health Components for Water Supply, Sanitation and Urban Projects (World Bank Technical Paper 121). Washington, DC: The World Bank.

Muyibi, S. A. (1992). "Planning Water Supply and Sanitation Projects in Developing Countries." Journal of Water Resources Planning and Management 118(4): 351355.

Phillips, D. R. (1990). Health and Health Care in the Third World. New York: John Wiley.

UNICEF. The State of the World's Children 2000. Available at

World Health Organization. Water-Related Diseases Bibliography. Available at

Yusuf, M., and Hussain, A. M. Z. (1990). "Sanitation in Rural Communities in Bangladesh." Bulletin of the World Health Organization 68(5):619624.