Water and health interlinkages of the sustainable development goals in remote Indigenous Australia

The UN's 2030 Agenda for Sustainable Development comprises 17 interconnected SDGs, with health integral to sustainable development. SDGs 3 ('Good health and well-being') and 6 ('Clean water and sanitation') are particularly intertwined, as unsafe water is a major risk factor for infectious diseases and mortality. Globally, unsafe water contributes to a significant portion of diarrheal deaths. While Australia reports 100% access to safely managed water and sanitation, remote Indigenous communities experience substantial WASH challenges (poor water quality, limited access, inadequate hygiene infrastructure). This disparity underscores the 'leave no one behind' principle of Agenda 2030. This research uses a case study in remote Australia to examine the complex intersection of SDGs 3 and 6, aiming to inform policy and promote integrated progress towards both goals. Australia's commitment to the SDGs, although not legally binding, involves significant processes encouraging political action, including detailed goals, targets, indicators, and peer review. Improved water quality and access directly contribute to better health outcomes, particularly in areas with prevalent waterborne diseases. Poverty acts as a structural factor influencing this interaction. Indigenous Australians in remote communities serve as a critical case study for understanding how SDG commitments can improve the health and water status of disadvantaged populations. The social determinants of health—factors like poverty, inequality, and access to essential services—play a crucial role in understanding health inequalities between Indigenous and non-Indigenous Australians, especially in remote areas.

The literature review examined the existing research on the relationship between health and water and sanitation, focusing on the health impacts of poor water quality, inadequate sanitation, and hygiene practices in remote Indigenous communities. The review highlighted the existing data on diseases such as trachoma, scabies and other hygiene related diseases that disproportionately affect these communities. Studies on water contamination, inadequate sanitation infrastructure, and the impact of overcrowding on hygiene were also examined. The review also explored the existing policies and interventions aimed at improving WASH services and health outcomes in these communities. Furthermore, existing literature on the social determinants of health among Indigenous Australians in remote areas was examined to provide context to the observed water and health interlinkages.

The research employed a case study design using three methods. First, a literature and information review examined the interaction of health with water and sanitation. Second, relevant SDG targets and indicators for health (SDG 3) and WASH (SDG 6) were selected based on existing literature describing their relationship. Finally, an analytical process involving author dialogue and debate, supported by literature, connected review data to the SDG targets. The research team included two Aboriginal Australians to ensure culturally appropriate representation and communication of results.

Table 1 presents Australian and Indigenous Australian data against selected SDG 3 and 6 targets. Significant data gaps exist, even in national statistics. Concerning findings include: **SDG 3 (Health):** * **Under-5 mortality rate:** Significantly higher among Indigenous Australians (6.2 deaths per 1000 live births in 2016) compared to the national average (3.8). * **Neglected tropical diseases:** Several, including scabies, soil-transmitted helminthiases, and trachoma, are prevalent in remote Indigenous communities, often linked to WASH-related factors like overcrowding and lack of hygiene. * **Mortality from unsafe water, sanitation, and hygiene:** Higher rates of chronic and hygiene-related diseases among remote Indigenous Australians, potentially linked to water contamination (microbes, chemicals, and wastewater issues). **SDG 6 (Water and Sanitation):** * **Safely managed drinking water:** While 99% of urban Australians have access to improved water, data for remote areas is limited; however, studies show significant water contamination in some remote Indigenous communities (E. coli, Naegleria, nitrates, uranium). * **Safely managed sanitation:** Improvements with centralized wastewater treatment, but concerns remain about contamination and maintenance. Overcrowding exacerbates sanitation and hygiene challenges (lack of washing facilities, limited access to soap). * **Wastewater treatment:** While there have been improvements in wastewater services with the introduction of centralized wastewater treatment replacing onsite septic tanks in many communities, there are ongoing concerns regarding contamination and the effectiveness of the wastewater treatment facilities. * **Ambient water quality:** Inland water assessments show varying quality ('very poor' to 'good'), with limited data available to evaluate the indicator comprehensively.

The findings reveal strong links between personal and environmental health (SDG 3) and drinking water, sewage, and hygiene (SDG 6), understood best through the lens of social determinants of health. Beyond SDGs 3 and 6, other SDGs (poverty, decent work, equality, sustainable cities) provide important context. The study highlights the need for more granular data reflecting the true progress towards SDG targets, particularly for marginalized populations like Indigenous Australians. Focusing on the interrelationships between SDGs enables more effective progress towards goals and targets. Addressing the SDGs in combination can result in more sustainable and impactful solutions.

This research underscores the critical interlinkages between water, sanitation, hygiene, and health outcomes in remote Indigenous Australian communities. The findings highlight the need for integrated policy approaches targeting multiple SDGs to address these complex challenges effectively. Future research should prioritize collecting accurate, disaggregated data on these populations to accurately reflect progress toward the SDGs. Improved data collection would enable a better understanding of the specific challenges faced by these communities and inform more targeted interventions.

The study's case study design limits generalizability to other contexts. Data limitations, particularly at the sub-national level, hamper a comprehensive assessment of SDG progress. The reliance on existing data sources might limit capturing all the nuances of the problem. The interpretation of the results is also influenced by the potential biases present within the existing data.