The Islamabad Declaration, the outcome of the Second South Asian Conference on Sanitation, held in the capital in 2006, commits Pakistan to accord high priority to sanitation; reach out to poor and disadvantaged communities; and promote active participation of women and children in sanitation.

The National Sanitation Policy of Pakistan, 2006, stresses on the safe disposal of excreta away from the dwellings, creation of an open defecation-free environment and, promotion of health and hygienic practices in the country.

Despite these commitments and policy guidelines, sanitation scenario continues to be poor in Pakistan. About 41million people in Pakistan, do not have access to a toilet and, as a result, they defecate out in the fields.

Ten years after committing to give high priority to sanitation, the government is still far from achieving the goal

Women and girls are disproportionately affected by poor sanitation, especially in rural areas. In the absence of toilets at home, women and girls have to wait till dark to defecate out in the open. In addition to the discomfort, caused by the long wait, this causes health complications. Walking to the defecation area in the dark puts women and girls at a greater risk of sexual assault. In rural schools, where there are no separate toilet facilities for girls, drop-out rate among adolescent girls is significantly high.

According to UN estimates, a child dies every 20 seconds due to poor sanitation. Sanitation, together with safe drinking water and proper hygiene, can reduce the occurrence of diarrhoea and other diseases. Authoritative studies estimate that more than 90pc of these deaths can be prevented by environmental intervention.

Diarrhoea, waterborne and water-washed diseases are directly related to poor sanitation. A study conducted by the World Health Organisation in 2004 revealed that the diarrhoeal disease burden, expressed in Disability Adjusted Life Year, is inversely related to improved sanitation; meaning in simpler terms that higher the percentage of population having improved sanitation, lesser the diarrhoeal diseases. A significant correlation between these two parameters indicates the importance of improved sanitation in reducing diarrhoeal diseases.

In a study published as recently as Jan 12, 2016, in mBio, an online journal of the American Society for Microbiology, the authors observed small intestine bacterial overgrowth in two-year-old Bangladeshi children, living in poor sanitation. Environmental enteropathy (also called tropical enteropathy) is a subclinical condition caused by constant faecal-oral contamination, resulting in blunting of intestinal villi (small, finger-like projections that protrude from the epithelial lining of the small intestine’s walls) and intestinal inflammation.

In 2007, over 11,300 readers of the British Medical Journal, voted sanitation as a top medical advance of the last 150 years, among the medical advances like invention of X-rays, research on bacteria and viruses, electrocardiogram, oral contraceptives, cardiac pacemaker, CT scan, diagnostic ultrasound, heart transplant, coronary bypass surgery, haemodialysis, MRI scans, endoscopy, and many other valuable and life-saving inventions.

The United Nations has declared that access to safe water and sanitation is a basic human right. In 2013, in his message on World Toilet Day, UN Secretary General Ban Ki-moon said: “Each year, more than 800,000 children under five die needlessly from diarrhoea — more than one child a minute. Countless others fall seriously ill, with many suffering long-term health and developmental consequences. Poor sanitation and hygiene are the primary cause. Worldwide, some 2.5bn people lack the benefits of adequate sanitation. More than one billion people practice open defecation. We must break the taboos and make sanitation for all a global development priority.”

UN’s, Deputy Secretary-General Jan Eliasson, in his keynote address at Stockholm World Water Week, Stockholm, Sweden on Sept 2, 2013, said, “Poor sanitation and hygiene is the primary cause of diarrhoea, which after pneumonia is the biggest killer of children under five in the world, responsible for 800,000 deaths each year — around 2,000 children every day. Even when diarrhoea does not kill, it drains nutrients from the body which in turn, after repeated occurrences, results in stunting, that is, stopping growth in children. Stunted children are not only shorter and thinner, they are also more vulnerable to disease and their brains do not develop as they should.”

The sustainable development goals, which became effective from Jan 1, 2016, have 17 goals and 169 targets. While goal-6 specifically pertains to ‘water and sanitation for all’, the rest of the 16 goals, more or less, are also connected with proper sanitation, safe drinking water and hygiene.

With the change in mindset and adoption of a strategic roadmap, Pakistan can achieve significant progress in sanitation. Roadmap for sanitation, suggested for Pakistan, should include components like: focus on ‘sanitation for all’; separate, well-functioning institutional set-up for sanitation at federal level and in all provinces; promotion of sanitation in schools; development of all the elements in the ‘sanitation chain’ (from containment and transport, to treatment and safe disposal and reuse); promotion of sanitation ‘hardware’ (toilets, pit-emptying equipment and durable water-closets), and sanitation ‘software’ (sanitation promotion, hygiene, women empowerment, behavioural change, creation of sanitation demand, sanitation marketing, and monitoring and evaluation).

No meaningful benefits can be accrued of improved sanitation, if it is not backed by provision of safe drinking water, and proper community and personal hygiene.

The writer has a master’s degree in water and wastewater engineering from the Asian Institute of Technology, Bangkok.

Published in Dawn, Sunday Magazine, April 10th, 2016