The silent emergency

Ajocular former paratrooper, Amadou Toumani Touré was once dubbed Mali's “soldier of democracy”, the man who ousted a dictator in a 1991 coup before organising elections and handing power to a civilian administration the following year.

He was elected president himself in 2002 and has since acquired a new title: he is, in the pantheon of world leaders, the biggest champion of clean water and functioning toilets. That is what development workers call him and he describes it as a compliment.

“Water is life, as we say here, and sanitation and a clean environment are the basis of human development,” says Mr Touré. “A poor man who is clean can become rich. But a rich man who is sick can easily become poor.”

!ADVERTISEMENT!

In Mali, a parched west African land dominated by the Sahara desert, he has made sanitation a focus of government policy and launched the first national version of a global charity campaign to “End Water Poverty”. If there were a contest to put the most political muscle into promoting safe water and lavatories, he would face little competition from other heads of state.

“We're in a sector that for many years has been marginalised and neglected, and that's especially true of sanitation,” says Barbara Frost, chief executive of WaterAid, a charity the Financial Times is supporting this year in its seasonal appeal.

Water, lavatories and hygiene consistently lose out to more telegenic development efforts, such as those in education or medicine, when it comes to political backing, public awareness, investment and bureaucratic support.

Yet dirty water, a lack of toilets and poor hygiene are together the cause of a public health crisis that recurs every day in the slums and villages of south Asia and sub-Saharan Africa. WaterAid calls it the “silent emergency”.

“The scale of the crisis is enormous,” says Ms Frost. “Nine hundred million people do not have access to safe water and 2.5bn don't have a safe place to go to the toilet. That's 40 per cent of the world's population.”

The result is that streets, homes, food and fingers are coated in germs that, when ingested, cause debilitating illnesses. Chief among them is diarrhoea, which takes the lives of 4,300 children under the age of five every day, according to Unicef. That places it second only to pneumonia as the biggest child killer, with more deaths than malaria, measles and HIV/Aids combined.

“If we had nine jumbo jets falling out of the sky every day, which is the equivalent, there'd be an immediate G8 summit,” says Henry Northover, head of policy at WaterAid.

The World Health Organisation, in a calculation that includes victims of malnutrition associated with diarrhoea and intestinal infections, estimated this year that better water and sanitation could prevent 6 per cent of all deaths – children and adults. The mortality figures are stark but, as Mr Touré contends, the influence of water and sanitation extends further. The link between reducing poverty and investing in water and hygiene is irrefutable, says Andrew Hudson, who heads water governance at the United Nations Development Programme (UNDP). “Our analyses show that no socio-economic driver, including health spending, education spending and energy access, explains more of the variance in the UN Human Development Index than access to safe water and basic sanitation,” he says.

The UN calculates that each dollar invested in water and sanitation yields an $8 benefit in productivity gained and costs averted.

In the Himalayan mountains of Nepal it is clear why. Women are denied income-earning opportunities when they cannot make handicrafts because they spend four hours a day collecting spring water, or when they have insufficient water to grow vegetables in their gardens.

The output of rice farmers in rural Bangladesh is strangled when they cannot irrigate their paddy fields or fight insect infestations because they are confined to bed by diarrhoea – or when they cannot buy higher-yielding seeds because so much of their income is spent on oral rehydration salts.

The education of Malian children is impaired when sickness or water collection duties make them miss classes, or when their school fees are spent on buying supplies from water sellers. Teenage girls suffer most when they choose to stay at home rather than endure the indignity of sharing unclean lavatories with boys.

These problems reinforce inequality, because the availability of clean water and safe toilets tends to match the distribution of wealth, which means the poorest and weakest members of society – women, children, people with HIV/Aids, the disabled, ethnic minorities, lower castes – suffer most from their absence. In addition, the burden of two trends that complicate efforts to improve water and sanitation – climate change and rapid urbanisation – falls most heavily on the same shoulders.

Yet while water and sanitation are receiving more western aid in absolute terms than previously, the proportion devoted to them has tumbled since the late 1990s, according to the Organisation for Economic Co-operation and Development, the rich nations' grouping. In the developing world, public spending on water and sanitation typically represents less than 0.5 per cent of gross domestic product – and has been as low as 0.1 per cent in Pakistan and Zambia, according to the UNDP.

Within these allocations, water absorbs most of the funds and only 12-15 per cent goes to toilets. Many countries lack ministries with specific responsibility for the issue, there are few detailed national plans and the needs usually get no mention in broader poverty-reduction strategies.

The results are evident in the Millennium Development Goals (MDGs), a set of development targets for 2015 that were agreed by world leaders at the start of this century to improve prosperity, education, health and the environment in the developing world. A target of halving the number of people without sustainable access to safe drinking water between 1990 and 2015 is on track, largely because of progress in China that conceals the poor performance of sub-Saharan Africa. But a twin aim, to halve the number without access to basic sanitation, is way off target and not due to be met for a century, says WaterAid.

Activists say that without drastic improvements in water and sanitation, many of the other MDGs will be put in jeopardy, too – such as halving the number of people who live on less than $1 a day, reducing child mortality by two-thirds and achieving universal primary education. One reason for the marginalisation, say development experts, is that many politicians do not know that water and sanitation are among the best disease-prevention measures available – a point widely recognised by doctors – and do not appreciate the links between them and other development issues.

“The aid system is not responding to evidence or the needs of the poor,” says Mr Northover. “You talk about water and sanitation and the knee-jerk response is, ‘Yes, but you'd be taking money away from health and education.' We don't make the case strongly enough that investments in health and education will reap diminishing returns if you don't have good water and sanitation.”

Another reason is poor governance. “The countries lagging furthest behind the MDG targets on water and sanitation are those where government is less transparent, less accountable and less responsive to its citizens,” Douglas Alexander, UK international development secretary, said last month.

In its 2006 Human Development Report, the UNDP urged governments to get serious about treating access to water – a clean, affordable supply of at least 20 litres a day – as a human right. It has not happened. (Europeans use a daily average of more than 200 litres and Americans over 400.)

An additional explanation for the blind spot is gender: water collection is seen as “women's work” and the absence of toilets is felt most acutely by women, in terms of dignity and exposure to sexual harassment. Yet because women in the developing world are often denied a political voice, their needs and priorities are ignored.

A final factor is squeamishness. Maggie Black and Ben Fawcett published a book this year on sanitation called The Last Taboo, and for many policymakers that is exactly what it is – not least because porcelain and plumbing enable elites in rich and poor countries alike to take a “flush and forget” attitude. “No minister is going to want to [declare] open a toilet or visit a zone that has been declared free of open defecation,” says Ms Frost of WaterAid. “It's not the same as saying, ‘I opened a health centre or a school.' ”

The UNDP report of 2006 was an attempt to pull the issues out of the development ghetto where they languished. It lamented the lack of “a concerted drive to extend access to water and sanitation for all through well-designed and properly financed national plans, backed by a global plan of action to galvanise political will and mobilise resources”.

The changes since then have been bitty. This year was declared the International Year of Sanitation by the UN. Last month, the UK's Department for International Development said it would spend £200m ($297m, €238m) a year on sanitation in Africa for the next five years. Last Wednesday was World Toilet Day.

Mr Hudson at the UNDP says the commitment of certain countries has improved. “But I can't say there's been a definable paradigm shift – at least from the donor side. A lot of attention has been raised, with events and publications and so forth, but whether the money has come to the table is a different question.”

An extra $10bn-$18bn a year would be needed to meet the relevant MDGs by 2015, the UN estimates. Most governments in developing countries that lack mineral wealth are strapped for cash, but Bangladesh and Madagascar have at least stood out for putting water and sanitation high on their agendas. Mr Touré's stance in Mali provides some hope that attitudes across the developing world can change.

He rejects the idea that investing political capital in taps and toilets cannot yield political rewards, and cites the evidence of his own experience. After his 1992 handover of power, he left the military and joined the Carter Center's campaign to eradicate guinea worms, which grow inside the human body from water-borne larvae to create agonising blisters.

The disease can only be prevented with hygienic toilets, a clean environment and safe water. “The people in the villages where we managed to curb the incidence of the disease told me that if I could solve their problems related to guinea worms, then maybe I could solve their other problems,” Mr Touré recalls. “I don't just believe that these villages all voted for me in 2002. I know they did. I checked the results.”