To the Editor, Despite sustained global commitments under Sustainable Development Goal 6 (SDG 6), inadequate sanitation remains a significant yet under-integrated determinant of health. According to the World Health Organization (WHO)/United Nations Children’s Fund Joint Monitoring Program, billions of people worldwide continue to lack access to safely managed sanitation services.1 Concurrently, diarrheal diseases remain a leading cause of preventable mortality, with recent Global Burden of Disease estimates attributing over one million deaths annually to diarrheal conditions, disproportionately affecting children under 5 years.2 These figures underscore that sanitation gaps persist as drivers of avoidable morbidity and mortality. Sanitation is frequently addressed as an infrastructure target; however, its implications are fundamentally clinical and epidemiological. Inadequate waste disposal facilitates fecal oral transmission of pathogens, contaminates drinking water sources, and sustains community-level disease transmission. Beyond acute infections, untreated wastewater contributes to environmental pathogen persistence and may facilitate the environmental spread of antimicrobial resistance.3,4 Such dynamics extend the health consequences of sanitation failure beyond immediate gastrointestinal illness. The marine and coastal dimensions of sanitation inadequacy warrant particular attention. Discharge of untreated or insufficiently treated sewage into coastal and freshwater ecosystems introduces pathogenic organisms into marine environments, increasing exposure risks for coastal populations, fishing communities, and individuals dependent on these waters for livelihood and recreation. The sanitation–marine health interface therefore represents an important but often underemphasized public health concern.5 In India, large-scale initiatives such as the Swachh Bharat Mission have substantially improved toilet coverage and reduced open defecation. While these achievements represent measurable progress, infrastructure expansion alone does not ensure sustained health gains. Long-term effectiveness depends on consistent usage, behavioral adoption, safe fecal sludge management, and maintenance systems. Framing sanitation primarily as a construction objective risk overlooking its integration within preventive health frameworks.6 Sanitation inequities also intersect with gender and social vulnerability. Limited access to safe facilities disproportionately affects women and girls, compromising safety, dignity, and educational participation in the resource-constrained settings.7 These inequities reinforce sanitation as both a health and equity issue. Given its cross-sectorial impact, sanitation should be embedded within primary healthcare and community health systems rather than addressed as a parallel development program. The WHO has highlighted persistent gaps in water, sanitation, and hygiene (WASH) within healthcare facilities themselves, underscoring the need for system-level integration.8 Incorporating WASH indicators into maternal and child health services, surveillance systems, and local public health monitoring may strengthen accountability and sustainability. Sanitation should therefore be recognized not solely as an SDG commitment but as a measurable and financed component of preventive medicine and environmental health. Aligning WASH strategies with primary healthcare delivery and marine environmental protection offers a pragmatic pathway toward translating global commitments into durable health outcomes. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Marulkar et al. (Fri,) studied this question.