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Journal of Pioneering Medical Sciences
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Objectives: Exposures and WASH service performance are interconnected determinant factors of avoidable mortality and health. A secondary analysis has been carried out in the context of a national-level indicator-based assessment of the situation with exposure/WASH in Saudi Arabia, based on the long-term national level exposure time-series data of urban air pollution PM2.5, household environment and WASH behavior profile, wastewater treatment regional benchmarks, attributable mortality, and SDGs-aligned service indicators. Methods: A secondary, retrospective ecological analysis using the national-level indicators of Saudi Arabia in three independent, analyzed datasets has been conducted. The key outcomes included World Health Organization age-standardized modeled mortality per 100,000 attributable to household and ambient air pollution (SDG 3.9.1), mortality per 100,000 attributable to unsafe WASH (SDG 3.9.2, 2019 only), safely managed sanitation (%), safely treated domestic wastewater flows (%), primary reliance on clean fuels (%), and urban population-weighted PM2.5 (SDG 11.6.2, µg/m³). Variables used additionally were: (i) 1990-2020 time-series of urban PM2.5 exposure in Saudi Arabia with summations per decade, annual change, smoothening and OLS regression models, (ii) national household environment and WASH-related practices including drinking water source, water saving devices, waste sorting, e-waste management and perceived pollution in one cross-section in 2022 reported by GASTAT Household Environment Survey, and (iii) GCC benchmarking of household-only percentage share of safely treated domestic wastewater flow using SDG 6.3.1 indicator report year. Results: The air pollution-attributable mortality in Saudi Arabia went down from 113.3 to 91.2 per 100,000 between 2010 and 2019 (-22.1, -19.51%, AAPC -2.38 %/year), whereas the endpoint PM2.5 values showed almost no difference in 2010-2019 (from 56.6 to 57.2 µg/m³, +1.06%, AAPC +0.12%/year). Meanwhile, the 1990-2020 PM2.5 exposures in Saudi Arabia reached its peak value in 2012 at 65.81 µg/m³ and went down to 53.15 µg/m³ in 2020 with the OLS regression slope +0.517 µg/m³/year (95% CI 0.351-0.683), while the slopes in 2000-2020 and 2010-2020 periods were not statistically significant. The safely managed sanitation improved slightly from 79% to 80% (2000-2022, +1.27%, AAPC +0.06 %/year). The safely treated domestic wastewater went up from 80% to 85% (2020-2022, +6.25%, AAPC +3.08 %/year). Primary reliance on clean fuels is at 100% for 2000-2022. Cross-section in 2022 of household practices showed that 49.06% of households use bottled water as the source for drinking water and the presence of water-saving devices is quite uncommon (34.34%), but there is a high level of e-waste disposal to public bins (73.11%) and low percentage of proper recycling (11.07%). In terms of SDG 6.3.1 benchmarking of safely treated domestic wastewater percentage among peers using the different years of last available reports (2022-2024), Saudi Arabia demonstrates higher coverage (87.65%) than the global average (55.78%), but still lower than some GCC members and lower domestic coverage (58.43%). Conclusion: There was a reduction in air pollution-attributable mortality in Saudi Arabia in 2010-2019 despite low reduction of PM2.5 levels, while there are high and volatile levels with an increasing slope observed in the 1990-2020 exposure time-series. No correlation between them was found. Some slight improvement has occurred in the WASH indicators, although their baseline is high. Maximum differences are observed for safely treated domestic wastewater in a short period 2020-2022. Household profiling and wastewater benchmarking show priority aspects of monitoring and policymaking beyond mere WASH service coverage.
Exposures and WASH services remain major determinants of diseases and mortality that can be prevented [1]. Particulate matter (PM2.5) is consistently linked with cardiopulmonary morbidity and mortality, and updates to the World Health Organization guidelines highlight that a significant health burden exists for a wide range of exposure, necessitating monitoring and measures even in environments of rapid infrastructural development [2]. Global comparative risk assessments identify air pollution as the leading cause of the attributable mortality reflecting intensity and characteristics of the underlying populations [1-3].
In parallel, WASH services affect the infectiousness and safety of water, sanitation and hygiene by providing safe containment and processing of the human waste products. Modern monitoring emphasizes safely managed sanitation and safely treated domestic wastewater over the mere existence of service access [4-5]. While the indicators cannot substitute for each other, the first captures the households' access to sanitation whose excreta are safely managed, and the second measures the domestic wastewater flow treated to the standard (alongside other sources of wastewater) [4-7]. The issues of PM2.5 pollutions and its management are relevant for Saudi Arabia because of rapid urbanization, demographic transformation and continuing infrastructure growth. The dust pollution is a dominant factor behind ambient PM2.5 pollutions in the Arab Peninsula, PM2.5 levels vary depending on the climate region and the city [9-11]. The urban annual mean PM2.5 indicators is standardized and therefore can be compared over time and across countries, although longer term time-series structure, volatility and presence of any non-monotone trends can benefit the assessment [12].
Mortality attributable to household and ambient air pollution takes into account both the exposure and the baseline risk and clinical services available, therefore divergence between the exposure metrics – e.g., PM2.5-and the attributable mortality metric might reflect the shifts in the population vulnerabilities, risk distribution, access to care, or estimation methods rather than exposure levels alone [8]. These factors cannot be disentangled using aggregate indicators. The mortality indicator encompasses both household and ambient air pollution [3,13], while the PM2.5 series describe only the ambient exposure. In the same manner WASH services captured by the safely managed sanitation and safely treated domestic wastewater measures include complementary aspects of service coverage and performance of the downstream system. At the same time, such coverage indicators might hide the problems with quality and the pathways of exposure such as drinking water access patterns, water saving practices and household waste handling. The latter factors can be better assessed by the means of national statistical surveys [4,14]. Some Saudi studies examined PM2.5 burden, sources or spatiotemporal pattern, but, to the best of authors' knowledge, none of those studies combined the long-term exposure trend with SDG-aligned WASH indicators, national household environment and wastewater benchmarks. Therefore, the aim was to estimate the absolute, relative and annualized changes in standardized air pollution and WASH indicators during their available reporting periods, including an exposure series of PM2.5 from 1990 to 2020. The additional aims were to characterize the 2022 national household environment and WASH practices and to compare domestically treated safely domestic wastewater to regional peers.
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