Global Water Sanitation and Health: What this Course is about

1. Global Water Sanitation and Health: What this Course is about Mark D. Sobsey University of North Carolina Department of Environmental Sciences and Engineering Sobsey@email.unc.edu

2. Kofi Annan United Nations Secretary-General “We shall not finally defeat AIDS, tuberculosis, malaria, or any of the other infectious diseases that plague the developing world until we have also won the battle for safe drinking-water, sanitation and basic health care.”

3. Global Burden of Disease Attributable to Selected Major Risk Factors Underweight Tobacco Unsafe sex Alcohol Overweight Water, sanitation and hygiene (5.5%) 5% - Percent of total burden (within region) Indoor air (3.7 %) Physical inactivity Zinc deficiency Tobacco Alcohol Occupational risks 1% - Overweight Unsafe sex Ambient air Occupational injuries Lead Ambient air Water, sanitation and hygiene Climate change Lead Developed countries Developing countries(high mortality) More recent estimate even higher!

4. Global Burden of Poor Water, Sanitation and Hygiene (WSH) • 1.1 billion people (~17% of the population) lack access to improved water • tap water in house/yard from public distribution systems, • protected wells & springs • public stand posts • rain water collection • 2.6 billion (42% of population) lack access to basic sanitation • sewerage, on-site septic waste treatment system, latrine

5. Global Burden of Poor Water, Sanitation and Hygiene (WSH) • 1.8 million people die every year from diarrheal diseases (including cholera) • 90% are children under 5 • mostly in developing countries. • 80% of the population without access to drinking-water are rural dwellers, but future populations will be mainly urban • Peri-urban slums are among the most underserved and unsanitary places on earth!

6. The Older Conventional View: Lack of WSH = Disease and Poverty • Inadequate water supply • Unsafe water resources • Inequitable access • Time, financial cost • Disease burden • Health care costs POVERTY

7. The Newer Optimistic View! WSH = An Engine for Development and Productivity • Improved water supply • Safe water resources • Universal access • Time, financial savings • Averted disease costs • Healthy populations Development

8. Millennium Development Goals • Goal 1 Eradicate extreme poverty and hunger • Goal 2 Achieve universal primary education • Goal 3 Promote gender equality and empower women • Goal 4 Reduce child mortality • Goal 5 Improve maternal health • Goal 6 Combat HIV/AIDS, malaria, and other diseases • Goal 7 Ensure environmental sustainability • Target 9: Integrate the principles of sustainable development into country policies … reverse loss of environmental resources. • Target 10: Halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation • Target 11: improve the lives of at least 100 million slum dwellers • Goal 8 Develop a global partnership for development

9. What a lot of this course will be about:The “F”s of WSH • Feces • Fingers • Flies • Fields/Food • Fluids • Fomites Water Treatment

10. A Lot of What Else this Course is About • Air pollution • Solid waste management • Vectors & vector-borne diseases • Disasters and emergencies • Climate change health effects

11. Human Sanitation:Fundamental but Often Lacking • Excreta management and disposal • Hygiene behaviors • Handwashing • Safe water

12. Sanitation: Our Biggest Failure • Our sanitation systems don’t work well and result in pathogen release • Whether community or on-site, they all fail or have serious deficiencies • Sanitation is one of the biggest technological gaps we have globally • Pathogens go everywhere as a result Roman latrine VIP latrine Latrine

13. Inferior/Absent Community Wastewater Treatment Systems Rx. No Rx. Rx. Often Absent! Untreated/poorly treated wastewater is discharged to land or natural waters

14. Water, Disease and Health • Water-borne • Exposure mainly by ingestion of contaminated water • Primarily enteric diseases transmitted by the fecal-oral route • Water-washed • exposure is reduced by water use for personal and domestic hygiene: washing (clothes, floors, other household chores), bathing & other personal hygiene • Water contact and water vector-borne • Exposure by skin contact with infested water • Ex: schistosomiasis • Exposure to water habitat "insect vector" diseases

15. The Microbial World: Types and Sizes of Microbes SOME BAD ONES! Amebic dysentery Giardiasis Cholera Diarrhea Dysentery Typhoid fever Norovirus Hepatitis A&E Rotaviruses Polio-/enteroviruses BACTERIUM ~ 1 µM Helminth (Worm) (eggs shed in feces) >30microns (Ascaris lumbricoides)

16. Excreta from humans and animals Land Runoff Sewage Solid Waste Landfills Oceans and Estuaries Rivers and Lakes Groundwater Irrigation Shellfish Recreation Water Supply Crops Aerosols Human Waterborne Pathogens Come Primarily from Feces by Various Routes of Exposure E. coli from Spinach Lettuce & Tomatoes! Adapted from Charles P. Gerba et al. 1975

17. Issues in Water and Health • Quality • Quantity • Access • Habitat and Ecology • Resources and Management • Economics • Behavior and Beliefs • Enabling Environment and Policies

18. Analyzing the Role of WSH in Reducing Disease Recent meta-analysis shows major impacts by • Hygiene • Sanitation • Water quality • Water supply

19. Comparison of Impacts of WSH Interventions: Fewtrell et al. 2005 vs. Previous Studies Good Studies All Studies • Water quality interventions (POU water Rx) was more effective than previously thought • Multiple interventions (combined WSH) were not more effective than single interventions (?)

20. Piped and Non-Piped Water Supplies • Most people lack piped water • They collect water or have it delivered • Most wells in developing countries deliver NO or UNSAFE water! • Sources are often contaminated • Piped water is often contaminated • Classified as “improved”, but still unsafe

21. Piped and Non-Piped Water Supplies • Collected, stored water often becomes contaminated in the home • Water is often not treated, but used directly • Boiling is widely practiced • Disadvantages: • Cost • Inconvenience • no residual protection (gets recontaminated in use!) • environmental degradation (deforestation) • air pollution (health effects)

22. Barriers against Microbial Contamination and Waterborne Disease • Collect from a safe source • Store it with contamination safeguards: • Treat water to reduce microbial contamination • Physical treatments: • Heat, sunlight (heat + UV), UV lamp radiation & filtration • Chemical treatments (disinfection): • chlorine • Combined physical-chemical treatments: • coagulation-flocculation-chlorination (“conventional Rx”)

23. Behavioral and Educational Components of WSH Interventions Increase awareness of the link between the 5Fs and disease and the benefits of appropriate hygiene behaviors Behavior change techniques: • social marketing • community mobilization • motivational interviewing • communication • education

24. World Health Organization Health-Risk Based Framework • Risk-based framework • Source-to-consumer management approach • Establishes health based-targets for performance • Can set acceptable level of risk appropriate to setting and population • Establish and carry out Management Plans • Independent surveillance • Integrated. Consistent across, compatible with and applicable to all WSH measures These principles apply to all types of WSH measures!

25. WSH, Addressing the Global Burden of Disease by Working towards Meeting the MDGs: Still Plenty to Do • Research • Implementation/Dissemination • Communication • Advocacy • Finance • Policies • Diplomacy and Politics

26. Celebrating Water for LifeThe International Decade for Action2005 to 2015 2008: International Year of Sanitation