WORLD “SILENT EMERGENCY”: BILLIONS STRUGGLE WITHOUT CLEAN WATER OR BASIC SANITATION

The vicious cycle of ill-health and poverty could defeat human development efforts, with children the first to suffer. More than 2.6 billion people - over 40 per cent of the world’s population - do not have access to basic sanitation, and more than one billion people still use unsafe sources of drinking water, warns a report by the World Health Organization (WHO) and UNICEF.
Entitled Meeting the Millennium Development Goals (MDG) drinking water and sanitation target - A mid-term assessment of progress, the report details the progress of individual countries, regions, and the world as a whole between the MDG baseline year of 1990 and the half-way mark of 2002. It makes two significant predictions on reaching the 2015 goals,1 based on progress to date:

• The global sanitation target will be missed by half a billion people - most of them in rural Africa and Asia - allowing waste and disease to spread, killing millions of children, and leaving millions more on the brink of survival.
• The world is on track to meet the drinking water target.

The severe human and economic toll of missing the sanitation target could be prevented by closing the gap between urban and rural populations and by providing simple hygiene education. A global trend towards urbanization is marginalizing the rural poor and putting huge strain on basic services in cities. As a result, families living in rural villages and urban slums are being trapped in a cycle of ill-health and poverty. Children are always the first to suffer from the burden of disease caused by dirty water and poor hygiene, while the wider impact of unhygienic environments drags back economic progress and erodes good governance.
“Around the world millions of children are being born into a silent emergency of simple needs, “says Carol Bellamy, UNICEF’s Executive Director. “The growing disparity between the haves and the have-nots in terms of access to basic services is killing around 4000 children every day and underlies many more of the 10 million child deaths each year. We have to act now to close this gap or the death toll will certainly rise,” and “Water and sanitation are among the most important determinants of public health. Wherever people achieve reliable access to safe drinking-water and adequate sanitation they have won a major battle against a wide range of diseases,” says WHO Director-General Dr Lee Jong-wook.
Developing regions of the world, such as sub-Saharan Africa, are most at risk. But the report also highlights some worrying trends in the industrialized regions, where coverage figures for clean water and basic sanitation facilities are estimated to have decreased by 2 per cent between 1990 and 2002. In the former Soviet Union, only 83 per cent of people had access to adequate sanitation facilities. With economic and population pressures growing, these percentages could decrease.
The consequences of inaction today are severe. Diarrhoeal disease currently takes the lives of 1.8 million people each year - most of them children under five - with millions more left permanently debilitated. Over 40 billion work hours are lost in Africa to the need to fetch drinking water. And many children, particularly girls, are prevented from going to school for want of latrines, squandering their intellectual and economic potential.
Reversing this trend and moving towards universal coverage for water and sanitation will take more than money. National policies based on the principle of “some for all” rather than “all for some” have been the key to improvements in many countries. And at the local level, resources have to be retargeted to include the poorest communities, with local government and the private sector co-operating to bring affordable solutions.
To meet the 2015 targets, countries need to create the political will and resources to serve a billion new urban dwellers, and reduce by almost 1 billion the number of rural dwellers without access to adequate sanitation facilities. Otherwise we risk leaving millions, if not billions, out of the development process.
The report, which is the first in a series looking at progress in water and sanitation coverage, should be a wake-up call to all global leaders. Every country still has work to do to eliminate disparities in basic services and the data show clearly how that can be done before the MDG deadline of 2015.
There are also some very encouraging signs. Great gains in water and sanitation coverage have been made against considerable odds in many countries. This progress came as a direct result of political prioritization and a drive to find locally effective solutions. This report is important because it proves that significant improvements are possible in a short space of time, even in the poorest countries. By identifying trends now, and committing to course corrections, we have real opportunity to ensure that by 2015 these basic essentials of life are available to all.

Progress overview

Progress towards the drinking water goal
The world appears on target to reach the MDG drinking water goal of reducing the number of people without access to an improved drinking water source to 800 million by 2015. Over the past 12 years, WHO and UNICEF estimate that an additional 1.1 billion people have gained access to an improved source of drinking water - bringing global coverage rates up to 83 per cent, from 77 per cent in 1990. Good news.
South Asia shows the greatest gains in drinking water coverage, increasing from 71 per cent to 84 per cent. Great progress has been made in India and China. But Asia still accounts for two-thirds (675 million) of the people worldwide whose drinking water still comes from unsafe sources like rivers, ponds, and vendors.
Sub-Saharan Africa has shown patchier progress. While countries such as Angola, Central African Republic, Chad, Malawi, and Tanzania have all increased drinking water coverage by over 50 per cent, the region’s overall drinking water coverage has increased by only nine percentage points since 1990 - to 58 per cent - leaving 288 million people still with no choice but to rely on water that could leave them sick or dead.
In addition to the encouraging progress made by individual countries across the globe, much of the new coverage in developing countries has come from water piped directly into homes. Roughly half of the world’s population now drinks piped water. Substantive economic benefits will result from this increase: piped water into the home is associated with the greatest improvements in household health, and frees women and girl from the burden of water carrying, giving them greater time for work, family, and school.

Progress toward the sanitation goal

While more than 1 billion people have gained access to basic sanitation services, population growth has outstripped our efforts, translating the numerical gains into much smaller gains in proportional terms. In 1990, 49 per cent of world had access to basic sanitation facilities. Today, that figure has increased by only nine percentage points, leaving us way behind schedule for the 2015 MDG target (75 per cent coverage). If this trend continues, the world will miss its sanitation pledge by over 500 million people. Bad news.
Eastern Asia shows the greatest increase in coverage, from 24 to 45 per cent, fuelled primarily by gains in China. But Asia is still home to three out of the four people worldwide who don’t have use of even a simple improved latrine. Over half of all people living without improved sanitation live in India (735 million) and China (725 million).
Sub-Saharan Africa, meanwhile, has the lowest percentage of people with access to basic sanitation facilities - 36 per cent, an increase of just four per cent since 1990. In the developing world as a whole, only 49% of people had access to adeguate sanitation facilities, while in the world’s developed regions, 98% of people did.
Worldwide, Benin, India, Madagascar, and Myanmar made especially rapid progress towards the sanitation target. But only two out of the world’s nine developing regions - Eastern Asia and Southeastern Asia - are on track to meet the sanitation goal, with north Africa and Latin America very close behind.
For more information contact Gregory Hartl, WHO, Geneva, Tel.: +41 22791 4458, e-mail: hartlg@who.int

WHO/58/2004

CUSTODIAL PSYCHIATRIC HOSPITALS IN EMERGENCIES AND CONFLICTS

Background

Custodial psychiatric hospitals (often referred to as mental asylums) - which often hold people with mental disorders for a life-time - exist throughout the world and are of human rights concern during war and peace.
It has been firmly established that large custodial psychiatric hospitals tend to be repressive and regressive, and hinder rather than facilitate recovery from mental illness.
The failures of custodial psychiatric hospitals have been evidenced by inadequate treatment services, repeated ill-treatment to patients, inadequate inspection and quality assurance procedures, and absorption of limited financial resources for mental health care.
As described in detail in the World Health Report 2001, Mental Health: New Understanding, New Hope, many countries across the world are in the process of addressing this health and human rights issue and are gradually phasing out existing custodial psychiatric hospitals while strengthening community mental health care.

Conflict situations

During emergencies - such as wars - children, women, the elderly, the disabled, and persons with severe physical or mental disorders are all rightly considered as belonging to vulnerable groups.
Persons in custodial psychiatric hospitals may be among the most vulnerable for at least three reasons. First, they tend to live in physical isolation from their families. Second, they are less likely to receive help from community members because of misplaced public fear of people with mental disorders and because of social stigmas. Third, some persons in custodial psychiatric hospitals may have become too dependent on custodial care to feasibly move and settle elsewhere if necessary during conflict.

Responsibilities of health officials

During conflict, all health facilities, staff, and patients should receive special protection. The public health official must ensure that custodial psychiatric hospitals are not excluded from such protection.
Hospitals should have in place a crisis contingency plan. Such a plan should outline assignment of responsibility and mechanisms to carry out care during emergencies and evacuation if needed. If the institution contains locked facilities or cells, contingency plans should describe a hierarchy of responsibility for keys to ensure that doors can be unlocked at any given time.
The public health official must ensure that the basic physical needs of patients are met. These basic needs include potable water, adequate food, shelter and sanitation, and access to treatment for physical diseases.
During emergencies the public health official should implement or strengthen human rights surveillance in institutions. Custodial psychiatric hospitals are places where human rights often are violated, even during times of peace. During emergencies, when resources are low and staff may be fewer in numbers, patients are at further increased risk of human rights violations, such as general neglect, punishment, and physical and sexual abuse. Enhanced surveillance, especially by senior staff, can reduce the risk of such violations.
The public health official should ensure at least basic mental health care to patients throughout the emergency. In other words, the public health worker should be vigilant to ensure that sufficient essential psychotropic drugs and psychosocial support are available throughout the emergency and that drugs are rationally prescribed. Sudden discontinuation of psychotropic medication can be harmful - sometimes even dangerous - and should be avoided.

After the emergency

In the aftermath of an acute emergency, there is frequently impetus to develop and implement new mental health programmes. This may be an opportune time to make a paradigm shift towards gradually phasing out existing custodial psychiatric hospitals and developing community services for people with severe mental disorders.
WHO Backgrounder/14/03

HEALTH NEEDS OF A RAPIDLY AGEING POPULATION - WHO LAUNCHES NEW INITIATIVE

More than one billion people will be over 60 years old by 2025 and, as populations age, the burden of chronic diseases will increase. To help tackle the public health implications of ageing, the World Health Organization (WHO) launched Towards Age-Friendly Primary Health Care, new general principles that will serve as guidelines for community-based Primary Health Care (PHC) centres.
The principles are based on qualitative research in five countries, both developing and developed, and address three critical areas where more leadership, training, and better information are needed if the PHC centres are to meet the challenge of older people’s needs. These are:

• Information, education, communication, and training for PHC providers
• PHC management systems
• The physical environment of PHC centres

Today, there are 600 million people in the world aged 60 years and over. This figure in expected to double by 2025 and to reach 2 billion by 2050, the vast majority in the developing world. Population ageing is characteristically accompanied by an increase in the burden of chronic noncommunicable diseases (NCDs) such as cardiovascular diseases, diabetes, Alzheimer’s disease and other ageing-associated mental health conditions, cancers, chronic obstructive pulmonary disease, and musculoskeletal problems. As a consequence, pressure on health systems worldwide will increase.
Early detection, appropriate intervention, management, and follow-up of chronic conditions take place mainly at the PHC level. Older people already account for a sizeable proportion of PHC centre patients and as populations age and chronic disease rates climb, that proportion is expected to increase. PHC centres are ideally positioned to provide the regular and extended contacts and on-going care that older persons need at community-based level. WHO has recognized the critical role PHC centres play in the health of older people worldwide and the need for these centres to be accessible and adapted to the needs of the older population. Supporting older people to remain healthy and ensure a good quality of life in their later years is one of the greatest challenges of the health sector in all countries.
Opportunities missed by health systems to deal with or manage age-related chronic NCDs will lead to increases in the incidence, prevalence, and complications of these diseases and may take resources away from other priorities, such as child and maternal health. “An age-friendly health care centre does not favour older people, but instead benefits all patients, in line with the slogan of the United Nations to create ‘A Society for All Ages’,” says Dr Alexandre Kalache, who co-ordinates WHO’s activities on ageing. In the first instance, Age-Friendly Principles will serve as a tool for awareness-raising among older people and their health care practitioners. A second step will include the testing of a tool-kit with information and training materials to support the implementation of the Age-Friendly Principles. The project is expected to culminate with the establishment of minimum standards to determine the age-friendliness of PHC centres.

Press Release WHO 60/04

Editors’ Note: See also the leading article in this issue by Dr Xavier Emmanuelli on the heat wave disaster of 2003 that killed some 25,000 people, mostly the aged, in Western Europe.