Global urban public health depends just as much on sanitation as it does on water - a critical assessment of the 2006 Hashimoto Action Plan for the United Nations

The disposal of human waste was solved for cities in Europe, North America, and parts of Southeast Asia and Latin America roughly 100 years ago. In January 2007, the British Medical Journal's poll of 11,000 readers and panel of experts rated sanitation as having been, since 1840, the most important medical advance in extending life expectancy and improving living conditions - ahead of antibiotics and anesthesia, and far ahead of immunology and oral contraceptives.

Two out of every five persons living on earth have no access to basic sanitation - twice the number without safe water. We are almost on target to meet the 2015 date for Millennium Development Goal (#7) for increasing access to safe water. However, we are years behind with the sanitation target. Because of this disparity, the UN General Assembly recently decreed 2008 to be "The International Year of Sanitation."

In March 2006, the United Nations Secretary-General's Advisory Board on Water and Sanitation published the "Hashimoto Action Plan - A Compendium of Actions" (named for the Board Chair). It contains a section on sanitation, calling for global advocacy, and recommends an International Year of Sanitation, establishing an annual sanitation prize, and a Global Sanitation Conference to be held in six or seven years. The Plan also recommends review of the MDG database on sanitation, moving "primary responsibility for providing assistance to the regional level" through workshops, and better distinguishing between sanitation and water in reports and policies of donors and governments. Finally, it calls for consideration of sustainable reuse-oriented sanitation, and some focus on small scale eco-sanitation, reed beds, and urine separation technologies.

The Action Plan, although welcome, comes quite late, after two generations of global effort on sanitation and water. It should be strengthened to include a series of smaller annual sanitation prizes, not just a single one. Sanitation efforts should be highlighted for a sustained five-year period, not just a single year. There should be an annual evaluation meeting during each of these five years, not just a large (and expensive) global conference years from now. Finally, the Plan is silent on the question of privatization and problems it can cause for accountability.