Clean, safe, and well-managed water is fundamental to public health.
Where water is unclean or sanitation poor, life-threatening diseases such as cholera and typhoid can take root. And where water is unregulated or enforcement is lax, contamination from chemicals, pathogens, or excreta is a persistent risk.
Poor hygiene, meanwhile, exacerbates each of these problems, amplifying one of humanity’s gravest health security threats: anti-microbial resistance.
Anti-microbial resistance (AMR) occurs when the effectiveness of anti-microbial drugs -- including anti-biotics -- is diminished due to mutations in infectious bacteria.
This happens when anti-biotics are ill-regulated and overused, or when they are used inappropriately or for non-human health.
Bacterial mutations and the superbugs they create make treating basic infections such as skin sores or diarrhea next to impossible. They also make surgery risky.
Around 700,000 people across the globe already die of AMR each year. If present trends persist, by mid-century, AMR will kill more people than cancer.
So where does water, sanitation, and hygiene come in?
To start with, poor sanitation and unsafe water cause a range of bacterial infections which heighten anti-biotic usage.
Though access across South-East Asia to improved water sources is now at 90%, poor operation and maintenance of water and sanitation systems continue to be a fact of life for many.
Millions of people region-wide remain susceptible to water-borne diseases, with high rates of infection compounded by self-medication and inappropriate anti-biotic use.
Next, poor water, sanitation, and hygiene (WASH) in health care facilities is a cause of hospital-acquired infections which accelerate bacterial mutations.
Just 38% of health-care facilities in low-and-middle-income countries have rudimentary WASH amenities, resulting in the incubation of a range of deadly pathogens.
It is no coincidence that some of the most vicious anti-biotic-resistant bacteria, including NDM1 and MRSA, have emerged from health-care settings.
And finally, ill-regulated waste-water is scattering anti-biotic residues and anti-biotic-resistant bacteria throughout the environment, including in drinking water and the food chain.
Across South-East Asia, contaminated waste-water from homes, hospitals, pharmaceutical industries, nursing homes, and livestock farms is finding its way into natural water sources, as well as soil and crops.
Though access across South-East Asia to improved water sources is now at 90%, poor operation and maintenance of water and sanitation systems continue to be a fact of life for many
This is hastening the spread of anti-biotic-resistant pathogens, and increasing human anti-biotic consumption.
As countries finalise national action plans to counter AMR, a return to core WASH principles is needed. By including WASH in multi-sectoral planning, and staying true to a “one health” approach, governments can neutralise one of AMR’s key accelerators and help reverse AMR’s growing reach.
And they can do so in a way that is cost-effective and has a range of other public health benefits.
There are three interventions which will have immediate impact:
First, governments can hasten efforts to achieve safe water and sanitation for all. Communities lacking clean water and effective sanitation should be identified in both rural and urban areas, and steps should be taken to ameliorate their situation.
This could mean treating water at its point of use or systematising the operation and maintenance of local water supply systems.
It could also mean investing in water supply systems to serve unreached populations.
At the same time, access to safely-managed toilets should be increased by investing in and building them, and by promoting behavioural change aimed at ending open defecation.
Second, WASH amenities and training can be enhanced at all health-care facilities.
This can be done by ensuring that each facility has a safe and adequate water supply, and that toilets and medical waste management facilities are in or near it. Hand-washing stations should be readily accessible at key points of care, and health-care workers should be trained in WASH procedures as part of wider infection prevention and control initiatives.
To this end, WHO’s Clean Care is Safer Care program is an essential resource, and can be integrated with national policies.
And third, regulation and treatment of waste-water can be vastly improved. To do so, investing in water management and treatment infrastructure is crucial, while creating public-private partnerships to extend service coverage may also be effective.
Key contaminators such as hospitals and pharmaceutical plants can, meanwhile, be encouraged -- or required -- to develop on-site treatment plants able to neutralise anti-biotics and resistant bacteria.
Waste-water used in aqua-culture and agriculture should also be better regulated to keep water and food systems free of potentially harmful residues and bacteria.
Though each of these interventions will have substantial impact, they must be supported by surveillance systems that can monitor the problems effectively and allow policy-makers in all sectors to respond as and where needed.
There is much that we still do not know about the quantity of anti-biotics and resistant bacteria in the environment, and the various ways they got there, meaning gathering actionable information is crucial.
Reversing AMR and safe-guarding the efficacy of our most precious drugs -- anti-biotics -- is a complex undertaking. It requires addressing how anti-biotics are produced and regulated, how they are prescribed and consumed, and how different sectors can work together to counter a range of AMR-related threats.
It is an undertaking for which WASH principles are well-suited, and for which WASH resources should be marshalled. In home and hospital, town and city, high-quality water, sanitation, and hygiene are vital and cost-effective means to beat back AMR’s rapid emergence. It is a means we must harness effectively.
Poonam Khetrapal Singh is Regional Director WHO South-East Asia.