Global Environmental Health: Research Gaps and Barriers for Providing Sustainable Water, Sanitation, and Hygiene Services: Workshop Summary (2009)

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1 Workshop Introduction The Roundtable on Environmental Health Sciences, Research, and Medi- cine of the Institute of Medicine (IOM) focuses on building partnerships and facilitating scientific discussions of ongoing and emerging issues in the field of environmental health. The roundtable illuminates scientific discussions to foster understanding among the public, academia, government, nongovernmental orga- nizations, industry, and policy makers, but it does not make recommendations. A cornerstone of the approach is to air divergent views on sensitive and difficult issues in an atmosphere of respect and neutrality, in order to foster dialogue and strategic solutions. This workshop summary was prepared for the roundtable membership in the name of the rapporteur and includes a collection of individually authored com- mentaries. The contents of the unattributed sections are based on the presentations and discussions that took place during the workshop. The workshop summary is organized in chapters as a topic-by-topic description of the presentations and discussions. The workshop agenda, as well as speaker information and a list of attendees, appears in the appendixes at the end of the summary. The reader should be aware that the material presented here expresses the views and opinions of the individuals participating in the workshop and not the deliberations of a formally constituted IOM consensus study committee. These proceedings summarize only what participants stated in the workshop and are not intended to be an exhaustive exploration of the subject matter and should not be perceived as a consensus of the participants, nor the views of the roundtable, the Institute of Medicine, or its sponsors.  

 GLOBAL ENVIRONMENTAL HEALTH Learning from the Past Paul G. Rogers, J.D., Chair Roundtable on Environmental Health Sciences, Research, and Medicine The nation has made tremendous progress in the past 35 years in addressing its watersheds. Individuals, such as Rachel Carson, and meetings, such as the one in Rio de Janeiro in 1992, spurred individuals and organizations worldwide into action. Many people will remember when the Cuyahoga River caught fire in 1969. As Time Magazine reported the incident, “Some river. Chocolate Brown. Oily. Bubbling with subsurface gases. It oozes rather than flows. Anyone who falls into the river does not drown, he decays.” At the same time, the Federal Water Pollution Control Administration dryly noticed, “The lower Cuyahoga has no visible sign of life, not even low forms such as leeches, or sludge worms that usually thrive on wastes. It is also literally a fire hazard.” The Cuyahoga River fire and other environmental decays of the water sys- tems in the United States led to some of the landmark congressional legislation of the 1970s, such as the Clean Water Act, which helped to clean up the watersheds, and the Safe Drinking Water Act, which ensures that the drinking water is of high quality. These acts ensured that people in the United States will have water for recreation, drinking, and other activities. The world that we live in is changing. In 1999, the world population sur- passed 6 billion people. By the end of the last century, there was a shift in the demographics as more people were living in urban areas than rural areas, which stressed the world’s natural resources. Climate change is no longer an academic debate, but a growing public concern as the impacts of climate change on health are categorized. These effects may include water scarcity, heat waves, and other extreme weather events. The need for water is vital not only to the United States, but also to all regions of the world. Many regions worldwide are water stressed, particularly those located near large megacities (Figure 1-1) but especially in Brazil, China, India, Mexico, Nigeria, the Philippines, Turkey, and the United States. The South- west region of the United States, including fast-growing desert cities like Phoenix and Los Angeles, is already experiencing high levels of water stress. However, other regions, such as the South, with its extensive web of rivers, are not immune. For example, metropolitan Atlanta’s rapid transformation to a sprawling city of 4 million people and other rapidly growing areas are starting to tax the region’s water availability. Current United Nations estimates suggest that there are about 300 potential conflicts over water around the world, arising from disagreements over river bor- ders and the drawing of water from shared lakes and aquifers (Oatridge, 1998). Avoiding these conflicts means using limited resources smarter and looking at new ways to manage and protect water. This is a daunting task, and the solutions will not come from a single sector of the water community but will require differ- 

WORKSHOP INTRODUCTION  FIGURE 1‑1  In 2000, the majority of the sixteen megacities were found along the coasts, within regions experiencing mild to severe water stress; this is particularly true for the cit- ies located on the Asian continent. “Water stress” is a measure of the amount of pressure Figure 1.1.eps put on water resources and aquatic ecosystems by the users of these resources, includ- ing the various municipalities, industries, power plants and agricultural users that line the high-resolution bitmap world’s rivers. The map uses a conventional measure of water stress, the ratio of total legend boxes enhanced availability. This map is annual water withdrawals divided by the estimated total water based on estimated water withdrawals for 1995, and water availability during the “climate normal” period (1961–1990). SOURCE: Map prepared for the World Water Assessment Programme (WWAP) by the Center for Environmental Research, University of Kassel, 2002. For the water stress calcu- lation: data from WaterGAP Version 2.1.D; Cosgrove and Rijsberman, 2000; Raskin et al., 1997. For the megacities: UN, 2002. Reprinted with permission. ent expertise from engineers, health research and offices, economists, ecologists, and policy makers. This two-day workshop held on October 17–18, 2007, in Washington, DC, follows up on previous workshops in 2003 and discusses how to provide people with access to drinking water in the context of sanitation and hygiene. The leg- islation of the 1970s started to show the value of water by providing protection. This workshop brings together people from various sectors of water services and from various countries to consider how to do this in a sustainable way. 

 GLOBAL ENVIRONMENTAL HEALTH Workshop Objectives Jennie Ward Robinson, Ph.D., Executive Director Institute for Public Health and Water Research The issues surrounding water services are some of the most critical chal- lenges facing not only the United States, but also the global community today. In September 2000, the United Nations developed the Millennium Declaration in order to accelerate democratization and securing peace, scale up development and poverty reduction, ensure environmental sustainability, and promote global partnerships. The eight identified goals provided a road map to reduce poverty and hunger, and to tackle ill-health, gender inequality, lack of education, lack of access to clean water, and environmental degradation by 2015. While these are challenging goals, various organizations have identified targets as steps to meet each goal. Targets, such as those identified by the Asian Bank, have been identi- fied under all eight of these goals (see Box 1-1), and if water services around the globe are going to meet the Millennium Development Goals, then organizations cannot discuss water without considering the impact or the interrelationship of sanitation and hygiene. It is the convergence of these strategies that promotes healthy outcomes for both individuals and the environment. A holistic approach is needed. People need to step outside their traditional way of thinking to under- stand what happens beyond their sphere of experience to ensure water services and environmental health. One of the objectives of this workshop is to think about the interdependence of environmental health and human health as connected through water. The World Health Organization (WHO) defines human health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO, 1948). The roundtable has built on this definition by looking at broad-reaching goals for environmental health, including establishing and maintaining a healthy, livable environment for humans and other species; promoting an environment that improves well-being and a high quality of men- tal health; and pleasing for a sustainable the environment to be sustainable for the future. At the same time, these health goals need to create a setting that can address population growth and permits manufacturing and agriculture to thrive. The timing is right, as the world is under more stresses because of globaliza- tion, urbanization, population growth, and climate change. All of these factors have resulted in a stress on many natural resources—in particular water, not only for drinking water, but also for water services being used in agriculture, industry, and recreation. These different uses can be at odds with each other and may be a driving factor in water scarcities today. A second challenge in addressing needs is that many organizations and agen- cies are trying to forge a path toward sustainable practices in water, but the vari- ous sectors utilizing and governing water services are not interconnected. More integration and a greater understanding of holistic approaches are needed. The current disparate action represents why it is important to find a solution and to 

WORKSHOP INTRODUCTION  Box 1-1 Millennium Development Goals: Asian Bank Water Supply and Sanitation Targets MDG 1: Eradicate extreme poverty and hunger •  roviding more water for agriculture and irrigation will increase food production P and will help alleviate the world’s hunger. • mproving water infrastructures and services will not only increase water provi- I sion but will also provide jobs to local communities and build capacities. •  asy access to water will halve the proportion of people who suffer from hunger E and whose income is less than $1 a day. MDG 2: Achieve universal primary education MDG 3: Promote gender equality and empower women •  ccess to water supply will reduce the multiple burdens on women and girls, A as they are the primary collectors, providers, users, and managers of water in the household. • Easy access to water will give girls and boys more time to attend school. • Better sanitation services will improve women’s health. •  ith their hands free from collecting water, women will have more time to W participate in community decision making and have greater opportunities for livelihood improvement. MDG 4: Reduce child mortality MDG 5: Improve maternal health MDG 6: Combat HIV/AIDS, malaria, and other diseases •  etter water quality and sanitation services will reduce children’s and expectant B mothers’ susceptibility to diseases and generally improve health. •  he provision of safe water for drinking and medical purposes will prevent T pregnancy and birth complications, and increase people’s ability to combat HIV/AIDS, malaria, and other diseases. • Better water management will reduce the incidence of waterborne diseases. MDG 7: Ensure environmental sustainability Better management of water resources will • Lessen pollution and improve water conservation •  nsure access to adequate and safe water and improved sanitation ser- E vices for poor and poorly-serviced communities in rural and urban areas • Improve the lives of people in slum areas •  uild capacity among communities organized around water supply B provision MDG 8: Develop a global partnership for development •  here water problems serve as a constraint to development (e.g., water scarcity, W salinity, disasters, etc.), improved water resources management and water sup- ply and sanitation services can facilitate partnerships for global development. SOURCE: Asian Development Bank. Water, Sanitation, and the Millennium Development Goals. Available at: http://www.adb.org/Water/Knowledge-Center/statistics/water-sanitation- mdgs.asp. Reprinted with permission. 

 GLOBAL ENVIRONMENTAL HEALTH plan a way forward. A second objective of the workshop is thus to consider how planning, management, and interdisciplinary approaches—including technology, social behavioral issues, gender, health, environment, economic, and political aspects—can be integrated to arrive at sustainable solutions.