Achieving public health equity – start with sanitation and hygiene for all

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What was once unthinkable is now reality. An unknown disease has spread around the world with terrifying speed, and the global community was not prepared — not by a long shot.

There have been pandemics before: SARS in 2003, H1N1 in 2009, Middle East Respiratory Syndrome in 2012, Zika in 2016 and, perhaps most terrifying of all, Ebola in 2014, which made world headlines and touched many through the accounts of first responders. In each instance, sanitation and hygiene — or the lack thereof — played a key role. And in each of these outbreaks, it was the poorest and most vulnerable communities who were the most heavily impacted.

Each of these diseases caused immeasurable distress to those affected and killed thousands, but was contained. Unlike COVID-19, the outbreaks did not have worldwide economic impact or require global behaviour change. Communities adapted once the emergency was over and the wider world moved on. This pandemic is different in its pace and reach, already having a global economic effect and a profound impact on society. We are all in this one together, though some will certainly fare better than others.

Health for all

The people most at risk because of inadequate sanitation and hygiene are populations who are already vulnerable: those living in low-income countries, in remote rural areas, in overcrowded slums, in environments already damaged by climate change, and in refugee camps. It includes women and girls, the elderly, people living with disabilities hospital workers, sanitation workers, and frontline workers.

Securing health equity — where everyone can attain a high level of health — is dependent on families being able to take action, supported by affordable and accessible public health services. Yet sadly, for billions living in poverty, these services remain out of reach. Therefore, equitable public health needs to go hand-in-hand with poverty reduction, strong stewardship, and accountability.

As injections of government and international emergency aid to stop coronavirus come into Africa, India, and Asia, these funds must finally lay the foundations of public health for all, not just the few. The large volume of pledges and donations must translate to a commitment to tackle systemic problems preventing health for all, including creating safe and sustainable health systems and access to safe sanitation and hygiene.

Sanitation and hygiene crisis

The numbers alone reaffirm the urgency. Globally, more than 4 billion people do not have access to safely managed sanitation services and 3 billion lack access to basic hand-washing facilities. A 2019 report from the World Health Organization and UNICEF shows that one in three schools and one in five health care facilities do not have even basic sanitation and basic hygiene services — directly impacting more than 1.5 billion people — while 43% of health care facilities have no hand hygiene facilities at points of care.

At the current rate of investment, Sustainable Development Goal 6.2 on safely managed sanitation, will only be achieved in the 22nd century. This is unacceptable, particularly considering the current pandemic. If we are to ensure global health security and be prepared for the next pandemic, we must look to long-term systems change and focus on sanitation and hygiene.

Moving from emergency response to long-term solutions

That is why we are calling for a long-term perspective, one that also takes account of national and local absorption capacity, the need for coordination, equity-based planning, budgeting, and accountability. This should be a perspective that moves commitment to investment in sanitation and hygiene and finally moves beyond the rhetoric that sanitation and hygiene is a basic human right to action.

The Water Supply and Sanitation Collaborative Council has been investing in sanitation and hygiene for 30 years, providing grants and working closely with local communities to support effective and innovative solutions. Today, we recognize the need for a global approach, a transformative approach, and a long-term approach.

Investment in sanitation and hygiene is about defeating disease, strengthening public health systems, and preparing defences for everyone. Public health campaigns for COVID-19, regardless of language or geography, ask us all to do the same thing: to recognize the efficacy of safe sanitation and good personal hygiene. The message, like the behaviour, must now be sustained.

We call upon global leaders, business, and investors, to support the Sanitation and Hygiene Fund and put an end to a world where nearly three-quarters of the population of least developed countries lack hand-washing facilities with soap and water.

About the authors:

Hind Khatib-Othman is chair of the Water Supply and Sanitation Collaborative Council and brings extensive leadership capability and more than 20 years’ experience in global public health. Prior to assuming the role of chair in late 2018, Khatib-Othman served as managing director of the Gavi, the Vaccine Alliance from 2012 to 2019.

Elhadj As Sy is the chair of the Kofi Annan Foundation. Prior to that, Sy assumed the role of secretary-general of the International Federation of Red Cross and Red Crescent Societies. He has extensive experience in leadership roles in the humanitarian sector, having previously served at a senior level with UNICEF, UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other agencies for more than 25 years.

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