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Characterizing the nature and extent of access to unsafely managed sanitation in the United States


Global development goals, including Sustainable Development Goal (SDG) 6.2 for sanitation access, purport to be applicable to countries at all levels of income and development. However, when applied to high-income countries, both the monitoring (which is reliant on in-country surveys and censuses that have deprioritized sanitation) and targets (that consider >99% access to have met the goal for SDG 6.2) may not be fit for purpose. The data used to evaluate progress towards the SDGs indicate that nearly 99.7% of US residents have access to at least basic sanitation, but emerging evidence from rural communities and populations experiencing homelessness reveals that this is certainly an overestimate. We identify the confluence of factors that leads to unsafely managed sanitation in the United States, a high-income country with diverse geology, climate and population density. We describe the specific ‘unsafely managed sanitation’ approaches in use across the United States, including over 330 million people in permanent housing, the roughly 370,000 people in shelters or transitional housing, and the approximately 230,000 people unsheltered. We also describe the challenges to understanding the extent of unsafely managed sanitation, factors that limit access and obstacles to addressing the problem. Finally, we propose a suite of approaches that can be leveraged to address these gaps in safely managed sanitation in the current funding and regulatory context of the United States, and possible alternative approaches to sanitation monitoring and targets for high-income countries.

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Fig. 1: The WHO and UNICEF JMP sanitation service level ladder.
Fig. 2: Simplified diagram of how most of the US population accesses Safely Managed Sanitation.
Fig. 3: Estimates of population lacking access to flush toilet or experiencing homelessness by state.

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The literature review was conducted as part of J.M.-B.’s consultancy with Global Communities, where she was supervised by K. Selchau and E. Perez. We acknowledge key technical advisors and consultants who contributed guidance and feedback: D. Hallahan, S. Gasteyer, C. Bessenecker, J. Schooley and A. Penrose. J.M.-B. was funded by Project Concern International (now merged with Global Communities) research funds, EPA Gulf of Mexico Program Cooperative Agreement MX-00D87019, Aqualateral, and a fellowship from the University of Alabama Council for Community-Based Partnerships. M.A.E. also received funding from USDA TAT-RWTS 00-69526, The Richard Lounsbery Foundation and Columbia World Projects ‘Transforming Wastewater Infrastructure in the United States’.

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M.A.E. and J.M.-B. planned and conceptualized the paper. J.M.-B. and D.C. analysed the data. J.M.-B. conceptualized and generated the figures and tables. J.M.-B. wrote the draft paper. J.M.-B., D.C. and M.A.E. provided conceptual input and edited and revised the paper.

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Correspondence to Mark A. Elliott.

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Maxcy-Brown, J., Capone, D. & Elliott, M.A. Characterizing the nature and extent of access to unsafely managed sanitation in the United States. Nat Water 1, 915–928 (2023).

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