During the 2014-16 Ebola outbreak in West Africa, healthcare workers were contracting Ebola at an alarming rate. The World Health Organization (WHO) found that those fighting Ebola at the frontlines–in clinics and hospitals–were up to 32 times more likely to contract the disease than the rest of the population. Among the principal reasons why was the lack of water, sanitation, and hygiene (WASH) services in healthcare facilities, which rendered healthcare workers unable to wash their hands and disinfect surfaces. At the time, UNICEF reported that the demand for running water in Sierra Leonean healthcare facilities outstripped supply, as safely treating patients with Ebola requires 140 liters per day per patient. The most recent data from 2021 show that a staggering 80% of healthcare facilities in the West African country are without basic water services and less than 1% of its population has piped water at home. Globally, a quarter of all healthcare facilities are without basic water services and in the Least Developed Countries (LDCs), which includes Sierra Leone and the Democratic Republic of the Congo–the latest country to fight an Ebola outbreak–this number grows to half of all healthcare facilities. Without access to WASH services in healthcare settings and in communities at-large, global health security cannot be achieved.
Moreover, as the current COVID-19 pandemic has shown, global health insecurity can contribute to increasing fragility in countries, as outbreaks can easily deteriorate already fraught political and socio-economic conditions. To make matters worse, countries must not only contend with the risk of contagion, but also climate change. Water security serves as the connective tissue for these threats. When water resources are jeopardized by climate change, infection prevention and control efforts are compromised, fragility intensifies, economic development is threatened, and the risk of violent conflict heightens.
Climate Impacts on Health Systems
These last few years have provided a glimpse of what could come as climate variability increases and healthcare systems are pushed to their breaking point. During the summer of 2019, for example, the Indian city of Chennai declared a “Day Zero” event following the worst drought in 150 years. In one city hospital, piped water ran out and even supplies trucked in by water tankers became increasingly scarce. According to one medical provider, these conditions left surgery patients at “God’s mercy” as to whether they would end up with a hospital-acquired infection. Just recently in April 2022, India also reeled from an unusually early heatwave, which resulted in record scorching heat not seen in the last 120 years. Many worry that this event foreshadows an exceptionally dry and hot summer in which, yet again, WASH services could be interrupted in healthcare facilities still fighting a global pandemic. This does not bode well for a nation of nearly 1.4 billion people and one that is ranked the world’s 13th most water-stressed country.
Droughts are not the only climate-related disaster that affect WASH and health service delivery. Cyclones, including Cyclone Pam in 2015 in the Pacific and Cyclone Idai in 2019 in Southern Africa, have wreaked havoc on WASH infrastructure in hospitals and clinics. Across Vanuatu, Cyclone Pam destroyed 68% of the country’s rainwater harvesting catchment and sanitation structures, and harmed the water quality of 70% of its wells. In a post-cyclone evaluation of 64 healthcare facilities in Vanuatu, it was found that nearly half lacked adequate water supply as a result. In Malawi and Zimbabwe, groups like Medecins Sans Frontieres worked to rehabilitate water and sanitation services in healthcare facilities ravaged by Cyclone Idai, including in cholera treatment centers. In addition to being one of the hottest years on record, 2022 is also expected to be an above-average hurricane season, posing a threat to WASH infrastructure in Africa, Latin America, and the Caribbean and to global health security everywhere.
Connections Between Health Crises and Conflict Risks
The inability to contain disease outbreaks can have deleterious security consequences both within and between states. One example is the most recent 2018-2020 Ebola outbreak in the Democratic Republic of the Congo (DRC). When Ebola struck the DRC, the country was already in the throes of a long-standing conflict with armed rebel groups. However, research suggests the outbreak contributed to further conflict. One study found that in the Ituri and North Kivu provinces, the number of conflict events per month was higher by a factor of 0.7 in Ebola-affected health zones than where there was no disease transmission (2.75 versus 2.04). The researchers concluded that the Ebola outbreak destabilized already fragile regions, increasing conflict in those provinces. The Government’s Ebola response effort, Riposte, contributed to conflict, too, as it paid money to government security forces and armed groups, was characterized at times by its brutality to patients and families, and led to misplaced suspicion of healthcare workers and Ebola Treatment Centers, which became targets for attacks. At the same time, conflict hindered the delivery of public health services fueling the spread of Ebola, leading to a cyclical relationship between conflict and disease. While the World Health Organization declared the Ebola outbreak over in June 2020, new cases were reported in the DRC in April 2022. In a country where half of all healthcare facilities are without basic water and sanitation services and communities are similarly water poor, as well as one that ranks 5th least ready and 12th most vulnerable to climate change, climate change can influence the spread of diseases including and beyond Ebola.
Opportunities to Address the Health, Climate, and Security Nexus
There are opportunities to get ahead of these intertwined threats of WASH, climate, and health insecurity. Recognizing the need for climate-resilient healthcare facilities, the WHO produced a 92-page guidance report that includes specific WASH interventions (among others) to support monitoring and assessment, risk management, and health and safety regulation efforts. This guidance provides a foundation for programs to mainstream climate change into public health projects, especially those focused on increasing WASH coverage in healthcare facilities.
The U.S. Government is uniquely positioned to provide thought leadership and meaningful, concrete action on the nexus of climate change, WASH, global health security, and conflict, which has largely been unexplored. In April 2022, the government launched its USAID Climate Strategy and began implementation of its U.S. Strategy to Prevent Conflict and Promote Stability. It is also in the process of finalizing the next iteration of the whole-of-U.S. Government Global Water Strategy and, just recently on June 1, Vice President Kamala Harris announced a historic White House Action Plan on Global Water Security. The action plan recognizes the need to advance global water security to achieve other U.S. national security priorities, including those relating to climate change, conflict prevention, and public health. At the center of this White House initiative are three pillars: 1) advancing U.S. leadership in the global effort to achieve universal and equitable access to sustainable, climate-resilient, safe, and effectively managed WASH services without increasing greenhouse gas emissions; 2) promoting sustainable management and protection of water resources and associated ecosystems to support economic growth, build resilience, mitigate the risk of instability or conflict, and increase cooperation; and 3) ensuring that multilateral action mobilizes cooperation and promotes water security.
In the development and implementation of these various policies, the U.S. Government has an opportunity to look past siloes that have historically blocked meaningful integration, and promote sector-inclusive policies, funding streams, research, and programs that strive to get ahead of these complex threats. For example, USAID’s WASH and health teams could work more closely with the Centers for Disease Control and Prevention on WASH in health settings; the Inter-Agency Water Working Group could launch an ad hoc whole-of-government sub-group on solutions to the WASH in Healthcare Facilities challenge; the Department of State could bring together their internal water and health teams to consider and act on ways in which WASH interventions could better prepare countries across the globe for the next pandemic; the White House could support the WHO in its campaign to establish a Financial Intermediary Fund at the World Bank to finance global health security, wherein WASH gaps should be considered; and so on.
We know what we need to do to get ahead of the next global public health threat. Now is precisely the right time to put into place concrete WASH, climate, health, and peacebuilding interventions focused on prevention rather than simply response.
Kelly Bridges is a consultant on WASH and global health policy. Previously, she served as Senior Associate at Global Water 2020, where she led efforts to integrate WASH and health investments, policies and programs, as well as advocate for water security for conflict prevention, stability and resilience. In addition to these roles, Kelly is the Young Professional Director on the Board of Directors of the Environmental Peacebuilding Association and serves on the Board of Directors of the Global Water Alliance. She has an MSc in Water Science, Policy, and Management from the University of Oxford, and a BA from the University of Pennsylvania in Science, Technology, and Society with a concentration in Energy, Environment, and Technology.