Aging Population and Lacking Sanitation Governance: Global Challenges in Alleviating Deaths from Unsafe Rural Sanitation.

With the rapid pace of global urbanization, health risks faced by rural communities are often overlooked. Deaths Attributable to Unsafe Sanitation in Rural areas (DAUSRs) are influenced by demographic factors, disease mortality rates, and environmental sanitation conditions. However, most studies have been limited in scope and scale and lack a comprehensive evaluation framework for global DAUSRs. Therefore, this study estimated the global DAUSRs from 2000 to 2030, using data from the Global Burden of Disease (GBD) and the World Health Organization (WHO). We employed methods such as comparable risk assessment, Bayesian age (period) models, and AutoRegressive Integrated Moving Average (ARIMA) models. Changes in the DAUSRs and their influencing factors were evaluated by applying a decomposition method to assess the impact of population dynamics, sanitation conditions, age structure, and disease mortality rates. The results indicated that despite improvements in rural sanitation, 12.2% of rural populations will still lack access to sanitary toilets in 2030, with an estimated 243,000 deaths (CI: 147,000-441,000) due to unsafe rural sanitation environments. This outcome highlights the need for better rural sanitation governance to provide for demographic shifts, such as aging and declining fertility rates, which are key drivers of DAUSRs. Regions such as Africa and Southeast Asia are at a higher risk with higher diarrhea-related mortality rates in rural areas. We suggest comprehensive measures, including enhancing rural medical facilities, improving sanitation infrastructure, and focusing on vulnerable groups, such as the elderly and children. These measures could inform global rural environmental and public health policies.