WHO:Clean water - a basic human right
Regional priority goal I: We aim to prevent and significantly reduce the morbidity and mortality arising from gastrointestinal disorders and other health effects, by ensuring that adequate measures are taken to improve access to safe and affordable water and sanitation for all children
Contents
Key messages
- Population access to improved water sources, sanitation and wastewater treatment has increased over the past two decades in most Member States. Progress in many countries in the east of the Region is, however slow, giving rise to important health inequalities.
- Water-related diseases remain a burden for people throughout the Region, including in the most economically developed countries. To reduce these diseases, a change is required from the present system of controlling drinking-water solely at the tap towards quality management along the production and distribution continuum from capture to tap. Thus there needs to be a shift in policy approach from penalties to active support.
- Gaps remain in our understanding of the distribution and causes of water-related diseases. Harmonized surveillance systems for waterborne diseases and outbreaks are needed throughout the Region, as are systems for monitoring health risks related to bathing water. It is particularly important to maintain a core of expertise to advise on and conduct outbreak investigation; testing, implementing and revising procedures in cooperation with other actors; and updating regulations
and policy.
- Legislation adopted in the framework of the EU acquis communautaire is an important policy driver throughout the Region. The United Nations Economic Commission for Europe (UNECE)/ WHO Protocol on Water and Health offers the Region-wide legal framework for the reduction of water-related diseases, integrated water resource management, a sustainable water supply compliant with WHO’s Guidelines for drinking-water quality and adequate sanitation for all.
- Climate change is adding to the challenge of providing sustainable water and sanitation services. Urgent action is required to assess systematically the climate change resilience of water supply and sanitation utilities, and to include the effects of climate change in water safety plans.
Public health importance
Safe drinking- and bathing water are vital for health. Illnesses arise from exposure to water contaminated by pathogenic viruses, bacteria or protozoa or by chemical substances which may enter water sources naturally or through human activity.
In the Region, diarrhoea arising from poor water quality, sanitation and hygiene is estimated to cause 33 000 deaths and 1 182 000 disability-adjusted life years (DALYs) every year, with over 90% of both occurring in low- and middle-income countries. These deaths are largely preventable: the risk of water-related disease decreases where standards of water, sanitation and personal hygiene are high.
When action is taken to prevent water-related diseases, lives are saved. Mortality from diarrhoeal disease in children aged 0–4 years has fallen in the Region since the mid-1990s, with particularly dramatic reductions in the newly independent states. Figure shows the standardized death rates (SDR)4 for diarrhoeal disease in this age group in EU and newly independent states. It is both necessary and feasible to make further reductions by improving water and sanitation.
The pattern of outbreaks5 of waterborne disease across nations can give considerable insights into the quality of drinking- and bathing water. Between 2000 and 2007, 350 outbreaks of waterborne disease related to drinking-water were recorded in the country surveillance systems and reported by 14 Member States, resulting in over 47 000 episodes of illness (5). Owing to wide variations in countries’ systems, their lack of sensitivity and underreporting, the differences between countries are more likely to reflect the efficiency of surveillance rather than the water-related public health situation. Even though only 14 countries submitted the key public health indicator and the limitations in the current health surveillance practices, this information show that outbreaks are not restricted to developing countries. Infants and young children are at disproportionately high risk of waterborne diseases, yet no country was able to submit child-specific information.
Region-wide, harmonized and effective surveillance systems for waterborne diseases and outbreaks thereof would greatly enhance understanding of the causal agents and the ability to prevent and eliminate the health risks. This requires urgent action related to public health.
Access to improved water supply: disparities within and between countries
Sustainable access to safe drinking-water lies at the core of public health. It indicates the extent to which essential needs are met, and is defined by the United Nations as a fundamental human right.
The United Nations Millennium Development Goals aim to halve, by 2015, the proportion of people without sustainable access to an “improved” drinking-water supply and basic sanitation. In Europe, there is an east-west gradient for access to an improved supply of safe drinking-water, defined as permanent access to an adequate amount of safe drinking-water preferably within, or at least near to, the household. In western Europe (EurG-A), virtually the whole population has had access to a public water supply since the 1990s. In the east of the Region (EurG-D), access remains low (although improving), ranging from 58% to 80%. Rural populations have less access to an improved water supply, and this disparity also increases towards the east of the Region. In more extreme cases, there are four to five rural dwellers without improved drinking-water for every one person lacking an improved supply in urban centres.
Access to improved water supplies across the Region has generally improved. Between 1990 and 2006, people in central and eastern Europe in particular experienced a marked improvement in water supplies, particularly in rural areas (8). There was however, some deterioration in access to a water supply in Bosnia and Herzegovina, Kazakhstan, Serbia and Montenegro, Slovakia, Tajikistan and Uzbekistan.
Wastewater collection, treatment and sanitation: pronounced country differences
Access to safe drinking-water does not eliminate water-related diseases. Hand-to-mouth transmission of diseases present in faeces will occur if hygienic practices are poor. Moreover, industrial and agricultural processes also contaminate water sources in various ways that require the water to receive significant treatment if it is subsequently used for human consumption. Especially in coastal areas, the discharge of untreated sewage may result in the contamination of the bathing waters and present a major human risk. Taken together, these points emphasize that sanitation and wastewater treatment are essential for public health.
Approximately three quarters of the European population live in urban environments, where the collection and treatment of urban wastewater is especially important. The proportion of the population connected to wastewater treatment facilities grew steadily in most countries between 1995 and 2005, with a connection average of approximately 69% in 2005. Nevertheless, many eastern European countries still require substantial investment to reach the 80% or higher coverage typical of most western countries.
There is a conspicuous disparity between urban and rural areas in the percentage of the population living in homes connected to improved sanitation facilities. In almost all European countries, at least 60% of the urban population is connected, whereas in rural areas, mainly in the eastern part of the Region, this is often around 20% or lower. The situation is improving in some countries: Albania, Belarus, Hungary, Lithuania and Turkey all reported considerable progress in coverage in rural areas between 1995 and 2004. More needs to be done: it is estimated that providing access to a regulated water supply and full sanitation coverage, with partial treatment for sewage for the entire population of children in countries with low mortality in both children and adults, would save about 3700 lives and 140 000 DALYs annually. In the northern Mediterranean countries, and in particular in the coastal areas where the population doubles in summer, 24% of the coastal cities with populations of more than 2000 inhabitants have no access to wastewater treatment plants, affecting 2.7 million of the permanent population.
Good sanitary practices are also necessary. Even when the infrastructure has been improved, an estimated 30% of the water-related environmental burden of disease may remain unless hygiene is also improved. Better hygiene need not be complex or expensive: Promoting hand-washing with soap has been shown to be the single most cost-effective health intervention.
Safe bathing water: faltering progress
The safety of bathing water is tightly linked to sanitation and wastewater treatment: allowing contaminants to enter fresh water or the sea increases exposure by bathers and causes disease outbreaks. Children are at higher risk than adults, because they play for longer periods in recreational waters, are more likely to swallow water and may lack immunity to endemic diseases.
The global burden of disease attributable to gastroenteric infections arising from unsafe recreational water was recently estimated at 66 000 DALYs. Data on the public health impact of contaminated bathing water in the European Region are scarce: only nine countries have monitoring systems that record outbreaks from bathing water. Data from these countries indicate that outbreaks from bathing water are rare, causing a total of 4 to14 outbreaks annually between them. The low disease burden from recreational water may be related to the known improvements in EU bathing water quality, as well as to the significant limitations of routine country surveillance. Furthermore, it is still difficult to attribute illnesses to exposure in recreational water owing to the large number of other transmission routes of the pathogens.
