7
The Social Pillar of Sustainable Water: Health Research Gaps

Diarrheal diseases impact many people worldwide and are a barrier for achieving health goals as outlined by various organizations. Technology alone cannot provide access to clean water, as social factors such as behavior, health, and culture can work either in concert or against even the best designed implementation strategies. Some in the water field suggest that interventions and water services programs in the United States and abroad need to take these social factors into account and also need to include the communities in the design, implementation, and evaluation of these programs. This chapter looks at these social factors to consider how they work with technology and economic factors to ensure water services.

WATER AND HEALTH: THE GLOBAL PICTURE OF RISK OF WATER-BORNE DISEASE AND CHRONIC DISEASE

Paul Hunter, M.D., M.B.A., Professor

University of East Anglia


Water-associated diseases are described by the World Health Organization (WHO) in terms of four categories: water-borne, water-washed, water-based, and water-related. A fifth category—water-carried (water-travelled)—has been proposed to include diseases spread by people travelling to collect water (Santaniello-Newton and Hunter, 2000). The global burden of these diseases is staggering. Each year, there are 4–8 billion episodes of diarrheal disease. It is particularly tragic due to its preventable nature given that 80 percent of diarrheal disease is attributed to unsafe water supply, inadequate sanitation, and lack of hygiene. Including diarrheal disease, schistosomiasis, trachoma, ascariasis, trichariosis, and hookworm disease, the burden of disease from water, sanitation, and



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7 The Social Pillar of Sustainable Water: Health Research Gaps Diarrheal diseases impact many people worldwide and are a barrier for achieving health goals as outlined by various organizations. Technology alone cannot provide access to clean water, as social factors such as behavior, health, and culture can work either in concert or against even the best designed imple- mentation strategies. Some in the water field suggest that interventions and water services programs in the United States and abroad need to take these social factors into account and also need to include the communities in the design, implementation, and evaluation of these programs. This chapter looks at these social factors to consider how they work with technology and economic factors to ensure water services. WATER AND HEALTH: THE GLOBAL PICTURE OF RISK OF WATER-BORNE DISEASE AND CHRONIC DISEASE Paul Hunter, M.D., M.B.A., Professor University of East Anglia Water-associated diseases are described by the World Health Organiza- tion (WHO) in terms of four categories: water-borne, water-washed, water- based, and water-related. A fifth category—water-carried (water-travelled)—has been proposed to include diseases spread by people travelling to collect water (Santaniello-Newton and Hunter, 2000). The global burden of these diseases is staggering. Each year, there are 4–8 billion episodes of diarrheal disease. It is particularly tragic due to its preventable nature given that 80 percent of diarrheal disease is attributed to unsafe water supply, inadequate sanitation, and lack of hygiene. Including diarrheal disease, schistosomiasis, trachoma, ascariasis, trich - ariosis, and hookworm disease, the burden of disease from water, sanitation, and 

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 GLoBAL ENVIRoNMENTAL HEALTH hygiene accounts for 4 percent of worldwide deaths and 5.7 percent of worldwide disability-adjusted life years (DALYs) per year (Prüss et al., 2002). Rather than expensive technological solutions designed without local input, there is a need for low-tech, community-based interventions; these interventions have achieved excellent results in health and hygiene, as well as a potential for economic and social benefits. Water-Borne Disease: A Worldwide Epidemic Water-borne diseases are caused by ingestion of water contaminated with human or animal feces and urine containing pathogens, including cholera, typhoid, amoebic dysentery, campylobacter, salmonella, cryptosporidium, among others. The transmission of these diseases is almost exclusively through diarrhea. Although in healthy, adult patients of more developed countries, it is generally of limited severity and short duration; in vulnerable patients of developing nations, it can be devastating. Worldwide, 1.8 million people die annually from diarrheal disease, 90 percent of whom are children. A WHO analysis looked at relative risks of disease given six different water and sanitation paradigms, from the ideal situation to one without access to clean water or improved sanitation. WHO found that risk increased as fewer had access to services, without piped water, without sanitation services, and little management of the water supply. In the worst-case scenario, the relative risk was 11-fold for diarrheal disease, yet the highly pen - etrant, water-based systems of developed nations still carried a relative risk of 2.5 from the ideal scenario (Table 7-1). Room for Improvement: Simple Interventions in More Developed Settings In developed nations, problems with water distribution systems are sig- nificant sources of disease. One-third of outbreaks of gastrointestinal illness in Europe are related to problems with the distribution system (Risebro et al., 2007). Cryptosporidium was associated with many outbreaks because of the inadequate removal during water treatment. As a result, most systems have been improved or removed from service. Major problems in distribution leading to outbreaks include construction or repair complications, low pressure, and damaged or outdated water mains. In the United Kingdom, low water pressure was found to be the strongest association with self-reported diarrheal disease, which could represent 10–15 percent of cases (Hunter et al., 2005). In developing countries, the problem of distribution is more complex and severe, with many large outbreaks occurring as a result of distribution problems. The risks depend on the system. In the Sudan, for example, some communities use large community water pots into which individuals dip their hands, leading to very high fecal contamination. In Vietnam, some households are able to capture rainwater through roof guttering but many poorer households have roofs made

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 THE SoCIAL PILLAR oF SUSTAINABLE WATER TABLE 7-1 World Health Organization Analysis of Relative Risks of Disease Related to Water and Sanitation Access Scenario Description Min RR Realistic RR I Ideal situation, corresponding to the absence of 1 1 transmission of diarrheal disease through water, sanitation, and hygiene. II Population having access to piped water in- 2.5 2.5 house where more than 98% of the population is served by those services; generally corresponds to regulated water supply and full sanitation coverage, with partial treatment of sewage and is typical in developed countries. III Piped water in-house and improved sanitation 2.5 4.5 services in countries where less than 98% of the population is served by water supply and sanitation services, and where water supply is likely not to be routinely controlled. IV Population having access to improved water 3.8 6.9 supply and improved sanitation in countries where less than 98% of the population is served by water supply and sanitation services and where water supply is likely not to be routinely controlled. V Population having access to improved water 4.8 8.7 supply but not served with improved sanitation in countries which are not extensively covered by those services. VI Population not served with improved water 6.1 11.0 supply and no improved sanitation in countries which are not extensively cover by those services (less than 98% coverage), and where water supply is not likely to be routinely controlled. SOURCE: Prüss, A., D. Kay, L. Fewtrell, and J. Bartram. 2002. Estimating the burden of disease from water, sanitation, and hygiene at a global level. Environmental Health Perspectives 110:537-542. Reprinted with permission. of plastic sheets or branches, making collecting pristine rainwater impossible. Sometimes problems may be because of human action. In a recent visit to Africa, the speaker came across a women drinking directly from a stream in which cattle were also standing. A month earlier the village where she lived had a serviceable water supply, but workmen who were contracted to improve the supply started by destroying it and then left and had not returned to complete the work. People who have been accustomed to high-quality water are at much higher risk when suddenly exposed to unclean water because of lack of immunity or when their drinking water systems fail (Hunter et al., 2009). Some settings

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0 GLoBAL ENVIRoNMENTAL HEALTH have multiple modes of transmission, such as a fish ponds being used both as a latrine and as a source of food. Extreme events are also catalysts for outbreaks of diarrheal disease, particularly cholera, which spikes during yearly flooding in Bangladesh. Water-Washed, Water-Borne, and Water-Related Disease: Infection by Contact or Vector Water-washed diseases are those that can be transmitted through poor per- sonal hygiene and skin or eye contact with contaminated water. Pathogens include trachoma, flea, lice, and tick-borne diseases. WHO includes scabies on this list, even though it does not meet the formal definition of water-washed but refers to the fact that many around the world use the term “scabies” in a general way to refer to itching disease. Water-borne diseases are contracted from parasites found in intermediate water organisms, such as schistosomiasis and helminth infections. An example is dracunculiasis, in which a parasitic worm enters the skin and grows to a meter’s length inside the body. The traditional treatment is to pull the worm out an inch or two per day to avoid breaking the worm internally which causes a painful inflammatory reaction. Water-related diseases are caused by insect vectors that breed in water. They include some lethal and highly morbid diseases, such as malaria, dengue fever, filariasis, onchocerciasis, trypanosomosis, and yellow fever. Parasitic intestinal disease often becomes chronic and impacts individuals for extended periods. Water traffic can also be the basis for spread of other infectious diseases; for example, in a refugee camp in Ethiopia, meningitis broke out and spread along the paths that individuals used to carry water. It was controlled only by a massive immunization campaign and ultimately sickened 291 and killed 43 (Santaniello- Newton and Hunter, 2000). Chronic Diseases and Water: Chemical Contamination Chronic disease caused by water with chemical toxicity from contamination and metabolic risk from lack of water-carried nutrients should be noted. Earlier presentations discussed the impact of arsenic filtration in Bangladesh and the impact of fluoride supplementation. Research on chemical contamination of water is a major need, as few correlations have been demonstrated other than chlorina - tion and bladder cancer. Examples of this kind of problem are fishermen wading in a stream filled with drainage from the local dump, an unprotected pile of trash washing unknown concentrations of dioxin and household wastes into the water that people drink and eat from. Again, the need to use these clearly sullied water sources is greater among the most disenfranchised and poor populations, leading to increasing health disparities.

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 THE SoCIAL PILLAR oF SUSTAINABLE WATER Musculoskeletal Disease: The Underestimated Weight of Water Musculoskeletal disease has a high and poorly recognized burden in devel - oping countries, falling within the top 15 of worldwide disease burdens and not including the significant burden of lower back pain. Lower back pain is poorly quantified in developed and developing countries alike, with no data available on the impact of carrying water on back pain and musculoskeletal disease. The effect of carrying heavy loads of water long distances on child development is unknown; although in developed countries there is a known correlation between heavy backpacks and low back pain in children. There is also the potential for a significant improvement in pregnancy and delivery in terms of reducing spinal problems. Conclusions: The Time Is Now for Improved, Not Perfect Water Standards should not be held too high and risk missing the benefits of simple interventions and education to reduce acute and chronic disease related to water. The most important step to take is the first one. The incremental benefits decrease with additional and complex interventions, especially those undertaken without the input of the community or addressing patterns of water use and needs. Examples are a shiny filtration unit being used for gardening and a water tap having been damaged by placing heavy water jugs on them prior to hoisting them onto women’s heads for carrying purposes. There is a need for sustain - able interventions, because short-term interventions that lapse back to previous exposures will be more likely to lead to disease (Hunter et al., 2009). It is clear that the benefits of improved water could be much more significant than just the reduction of diarrhea, with both productivity and social aspects. Drinking water is essential to health, and contaminated water has a myriad of harms other than diarrhea, which is a major source of worldwide disease alone. The rapid provision of high-quality drinking water will not miraculously appear in the near future, but this should not be a deterrent to using community-based, evidence-supported, simple interventions to achieve rapid improvements in health. PRELIMINARY OVERVIEW OF CURRENT RESEARCH AND POSSIBLE RESEARCH PRIORITIES: SMALL COMMUNITY DRINKING WATER SUPPLIES John Cooper, Ph.D., Director Water, Air and Climate Change Bureau, Health Canada Boil water advisories are an effective mechanism to reduce burden of illness as long as the people in the affected communities abide by them. In Canada, there are approximately 1,200 to 1,500 boil water advisories in place at any one time across the country, impacting approximately 200,000 to 300,000 people. With few

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 GLoBAL ENVIRoNMENTAL HEALTH exceptions, the vast majorities of these advisories in Canada and most developed countries are in small communities. Recognizing that fact, the question needs to be asked how we should approach the issue of addressing these challenges to the safety of drinking water in small communities. In Canada, we have set up a consortium involving industry, government regulators, nongovernmental organizations (NGOs) and academia to not only define the challenges faced by small systems, but to also identify solutions and develop strategies to address these. At the same time, it is important to build on and contribute to the work done internationally. The World Health Organization’s Network on Small Community Water Supply Management is actively engaged on developing tools and strategies for small systems, in both developed and developing countries. Clearly, it is important to identify where research efforts should focus to most effectively reduce the burden of illness from unsafe drinking water in both developed and developing countries, and how to successfully promote and sup- port this research and the transfer of knowledge. Context The burden of illness from water, sanitation, and hygiene total approximately four percent of world deaths (Prüss et al., 2002). Health care costs to treat these health-related effects on unsafe drinking water are approximately $7 billion per year, which results in $63 billion per year in time lost (Hutton and Haller, 2004). The advantage of improving the supply of drinking water can translate into sig- nificant economic benefits for a developing country. Sachs (2001) estimated a 3.7 percent annual average growth by developing countries with improved water and sanitation versus 0.1 percent for those without these improvements. The WHO Small Community Water Supply Management Network was established in 2003 as a coordinated global response for the safety of drinking water in developed and developing countries. Its target was to help meet the Mil - lennium Development Goal of reducing the number of people without access to safe drinking water by a half by 2015. The Network is focused on developing better management tools (e.g., water safety plans), and determining best manage- ment practices that are community driven and applied. Other central components include better communication and education, capacity building in the local com - munity, knowledge transfer (research and technology), and advocacy. As part of this work, the WHO Network has undertaken to identify research priorities as a basis for addressing research gaps and determining investment opportunities which could result in significant health benefits. As a first step, a preliminary assessment of the state of research on small water systems was conducted. This assessment must now move beyond catego- rizing the broad research needs to focus specifically on research that could most effectively reduce the burden of illness globally.

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 THE SoCIAL PILLAR oF SUSTAINABLE WATER The research agenda will also concentrate on promoting and supporting the transfer of research into real world settings. As noted many times during this workshop, transferring research knowledge is a pressing need globally to meet the Millennium Development Goals. One challenge, which at the same time reflects the need for a research network, is that we often follow the traditional but impractical approach of every jurisdiction or every country developing their own solution to a given problem. For example, there are currently 15 risk assessment tools to identify the risks in the drinking water system from source to tap. There is a need to evaluate the necessary components of research that can be transferred to other areas of the world, but at the same time communication of this research is essential, in order to prevent duplication and promote optimization of efforts. Overview of Research In a simplistic way, risks and barriers to improving small community drink - ing water supplies can be used to set research priorities. The risks range from the source water to the tap. Source water risks include availability, which has become more important with awareness of climate change; water usage; watershed vul - nerability; and pollutants from microbiological and chemical exposures. At the tap, these risks include the infrastructure vulnerabilities from the collection from the watershed, treatment technology, distribution, and operation and maintenance of the system. Barriers, including capacity (financial, people, and knowledge) and socioeconomic factors (culture, governance, and business models), can stop effec- tive action to address these risks in both developed and developing countries. The focus for the WHO Small Community Network is to identify areas where more research would contribute to the goal of safe drinking water by identifying gaps and priorities and strategically implementing mechanisms to direct and guide research, and deliver and/or fund projects. As a starting point, the research that has been done in the drinking water, defined broadly, can be used to identify the research needs for small community water supplies, while recognizing the unique challenges in the small community. This focus needs to be done in the appropriate context by recognizing that one size does not fit all—the importance of understanding and adapting to different cultures, and socioeco - nomic and political conditions. Thus, a range of solutions need to be identified as many factors will affect whether and how research can be applied to any one community. We can arbitrarily define the core components of a targeted research program as follows: • Health-based research • Treatment technology • Source water protection • Capacity and socioeconomic research

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 GLoBAL ENVIRoNMENTAL HEALTH Health-Based Research Health-based research related to burden of illness has made significant con - tributions to advancing technology and solutions to ensure safer water supplies. Health risk assessments are key drivers and need to be undertaken in addressing the safety of drinking water, including drinking water for small community water supplies. The research to better understand the health risks related to both patho - gens and chemicals in drinking water is not directly linked to the size of the water system. Significant advances in the understanding of the range of health effects have been made: There is a growing body of information on acute and chronic illnesses, an increased focus on disinfection byproducts, and risks to reproductive and developmental health effects, to name a few. Additional research will have benefits in helping to determine appropriate remediation strategies. Potential areas for more work in developing countries include having the capacity and support for better surveillance and monitoring of acute and chronic illnesses. In all countries, and especially in developing countries, it will be impor- tant to conduct comparative risk analysis before making new policy decisions. For example, in Bangladesh and Croatia, the surface water had microbial contamina - tion, which resulted in a decision to switch to ground water sources. The result is that 50–60 percent of the population is now exposed to very high levels of arsenic (WHO, 2000). In summary, health-based research is not a limiting factor in improving the safety of drinking water in small communities, or communities lacking resources and capacity. Infrastructure and Technology Most of the existing technology and research for water treatment is appli - cable to large community systems and for systems in developed countries; for example, the use of ozone, ultraviolet, membranes technology, remote monitor- ing (Supervised Control and Data Acquisition). While engineering solutions do exist for small community systems, the cost and infrastructure capacity prevent wide-scale application or adequate maintenance—sustainability of these systems continues to be a challenge. In recent years, there has been a movement toward distributed systems for small communities; however, this approach is probably useful in some contexts and not in others. Across the world, communities need reliable, robust, and resilient systems. We need additional research in many areas to reach this goal, including more affordable, operator-friendly treatment technologies for the full range of contami- nants. The traditional focus has been on microbiology, especially for small sys - tems, but technologies need to also address the inorganic contaminants, such as arsenic. In addition, communities have moved toward centralized drinking water systems, but in natural disasters, a distributed system provides a greater likelihood of continuity of service. However, governments have not been investing in under- standing how a distributed system can work for small community systems.

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 THE SoCIAL PILLAR oF SUSTAINABLE WATER Multi-barrier systems will be important, but the transfer of knowledge should include understanding of how the integrated system will function with other essential components, including energy. Especially in the small communities, energy solutions, whether it is a “turnkey” package, wind power, dams, waste, should ensure continuity of service. Finally, there is a need for affordable moni - toring and testing tools to more quickly assess the health impacts related to drinking water contamination. Source Water Protection Key to the multi-barrier approach is the need to protect source water. This is challenging because local and regional protection of watersheds needs to be a part of the planning. The extent of the protection will depend on the size of the watershed and other local factors. Local factors include capacity, knowledge, resources, and decision-making authority available to the community. In general, developed countries are doing more work on watershed management and source water protection; and knowledge transfer to the developing countries has been limited. Socio-Economics and Capacity Socio-economic factors in both developed and developing countries need to be considered in small community systems. As discussed earlier, there is sufficient evidence that safe drinking water protects health, reduces burden of illness, avoids boil water advisories; yet it’s very difficult to get communities to actually invest and value water as a resource. Additional work on cost-benefit analysis is, therefore, an important component of advancing safe drinking water in small communities. We must better understand the cultural challenges, and social and economic barriers to help guide investment which will lead to sustain - able improvements. In order for governments, NGOs, and researchers to help communities, they need to engage the community as a partner and focus on community-driven research. Furthermore, cultural and traditional issues can affect efforts in this area and they need to be understood and respected. One example of how culture can effect decision making is the painted pump story—a village with a blue pump. Originally, it was painted red, which indicated that the water was non-potable. However, there is a social stigma to having a red pump in your village which can, for example, affect the marriageability of your daughters and sons. The villagers went out at night and painted the red pump blue. While this was not a good solu- tion, scientists, policy makers, and NGOs need to recognize that socioeconomic issues need to be considered and addressed if the world is going to achieve safer drinking water.

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 GLoBAL ENVIRoNMENTAL HEALTH Knowledge Transfer There is strong pressure in the academic community to conduct and publish research, but less on ensuring that the results of the research are picked up and applied broadly. Transfer of research directly or indirectly to the end-user is obvi- ously essential to improving safety in small community water supplies. And yet, in a global context, there is not a good mechanism for the community of research- ers to share their information and work together more collaboratively. There are a number of opportunities to break down these barriers through optimizing the application of research results to stakeholders, end users, and communities. By building broad-based networks to share information, researchers can build col - laboration and be involved in setting priorities. Policy Most countries have regulations, guidelines, and policies to guide the provi - sion of safe drinking water; however, there are significant variations in design, application, and enforceability. Regulations and policies that are valued indicate a level of commitment by government and communities to take action and try to meet the requirements. Once again, these policies and regulations are not neces - sarily tailored for small systems. Even if the regulations are for small systems, they cannot be met because of the following: • The treatment is inadequate or lacking • Operation and maintenance are not supported • onitoring and testing can be particularly onerous for small communities M • nadequate laboratory access affects ability to receive timely sampling I results Recognizing this inherent problem in small systems, there is a need for evaluation of best approaches to ensuring safe drinking water in small water systems that is country or regionally based. Conclusion This has been a very preliminary and limited overview of research priori- ties related to improving the safety of small community water supplies. Clearly, the focus needs to be on helping to support developing countries, and tailoring research to meet their needs. It is suggested that one of the first priorities for the community of scientists and policy makers is the identification of research gaps and research priorities for small community water supplies, which reflects the need for a better understanding of the social, economic, and governance factors that must be addressed in supporting wise investment and sustainable solutions. At the same time, the research community should be able to take advantage of

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 THE SoCIAL PILLAR oF SUSTAINABLE WATER the wealth of existing research, and find opportunities to transfer this knowledge through better evaluation of current systems or refocusing research results for the end users. It will not be a “one-size-fits-all approach,” and we need to focus on incremental improvement and steps toward reaching the Millennium Develop- ment Goals. INTEGRATING WATER, SANITATION, AND HYGIENE Richard Gelting, Ph.D., P.E. National Center for Environmental Health, Centers for Disease Control and Prevention The challenge of meetings that focus on water is that the meeting is not just about water. In fact, it is a meeting about water, sanitation, and hygiene. These areas are intertwined and dependent on each other, so that any program needs to consider all three aspects in order to have a successful health intervention. How- ever, researchers do not know if there is a hierarchical approach to providing safe drinking water. They do not know how water, sanitation, and hygiene are related, or if there is a hierarchy for improving health. In other words, they do not know if emphasizing drinking water is more important than sanitation to ensuring health outcomes, or vice versa. Learning from Hurricane Mitch Hurricane Mitch made landfall in Central America in October 1988 and affected four countries: Nicaragua, Honduras, El Salvador, and Guatemala. It was a category 5 storm with sustained winds over 200 mph—the fourth strongest Atlantic hurricane in history to that point. Due to the fact that the storm was slow moving, Hurricane Mitch dropped historic amounts of rainfall in Nicaragua and Honduras. Some estimates suggest that Tegucigalpa, the capital of Honduras, experienced at least 20 inches of rain in one day, but the actual number may be as high as 36 inches. In Honduras alone, approximately 10,000 people were killed and 90 percent of the infrastructure was destroyed, including the majority of the bridges in the country (USAID, 1999). The landscape changes that were brought about by Hurricane Mitch were estimated to be the equivalent of 50,000 years of change in normal geological time. As part of the response, the American Red Cross started a water and sanita- tion and hygiene intervention program in 110 communities in all 4 countries. The interventions benefited approximately 75,765 people and were individually tailored to the conditions in each country. As part of the evaluation process to determine needs of each region, the Centers for Disease Control and Prevention (CDC) assisted the Red Cross by looking at environmental health inputs—access to water, access to sanitation, and hygiene (hand washing) education—in 800

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 GLoBAL ENVIRoNMENTAL HEALTH households. The output measure was the number of cases of diarrheal disease in children under age 13, with a goal of a 25 percent decrease in childhood diarrhea. The water interventions varied from shallow groundwater wells to deep-drilled wells, and the sanitation interventions varied from simple pit latrines to compost - ing desiccation latrines (Figure 7-1). In order to evaluate whether a composting latrine is working, it needs to be individually inspected. The hygiene test was a rigorous evaluation of hand washing by scoring people as they wash their hands. As discussed many times during the workshop, there was a significant community involvement, such as input of community labor and input into the type of system (intervention) for each community. From these results, the Red Cross and the CDC evaluated the combination of these inputs. A qualitative evaluation of the Chiquimula area in Guatemala found that the community met the goals for access to water, access to sanitation, and hygiene education, and there was a corresponding decrease in childhood diarrhea. Con - versely, in Las Pozas, El Salvador, there was a good water intervention with a drilled well that used gravity to provide water to the community. However, the installed composting latrines were not used properly, and hygiene was ineffec - tive. So, although the community had a good-quality water intervention, they did not meet the health outcome goal. Interestingly, in Segovia, Nicaragua, they met FIGUREFigure 7-1a.eps latrines and composting desiccating toilets from various 7-1 Examples of pit Figure 7-1b.eps water interventions. Left figure: Side of double vault composting latrine in Guatemala not bitmap image bitmap image in use, sealed with concrete cap. Right figure: Side of double vault composting in Guate- mala in use, with toilet seat installed. SOURCE: Photos by R. Gelting.

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 THE SoCIAL PILLAR oF SUSTAINABLE WATER the sanitation and hygiene goals, but the community did not meet the water goal owing to local politics. In contrast to the El Salvador program, the community met the health output goal even without a successful water intervention. From a qualitative analysis, it appeared that hygiene practice had the largest impact in these projects, followed by sanitation, and then water interventions. With further data acquisition, quantitative and univariate analysis was possible. None of these interventions by itself had a statistically significant impact on health; however, a multivariate analysis of all three interventions resulted in a statistically significant effect of the interaction of water intervention, sanitation intervention, and hygiene practice. It is interesting that single interventions did not have a measurable statistical impact, but the combination of the three inter- ventions had an impact on childhood diarrhea. The intervention interaction is in direct contrast to some of the research literature. The impact of the integrated approach did not have a greater effect than the single intervention, including several meta-analyses (Esrey et al., 1990). It is unclear from the Hurricane Mitch work, why there is a disparity between these interventions and the research literature. From my experience in the Peace Corps, often there was a disparity in the field with what was occurring and what was reported. For much of the work in rural communities, the program was called an integrated intervention, but the focus was very heavily on water. Water systems were designed and constructed, but the sanitation varied from community to com- munity. Similarly, hygiene education would vary because the water intervention was the focus. This problem is not unique to low-income countries. Building water sys - tems is an objective toward the goal of improving health, and equal time needs to be devoted for sanitation and hygiene measures. The Red Cross program was designed as an integrated program from the ground up: water, sanitation, and hygiene. Secondly, there is more data about water interventions than about sanitation, and even less information is available about hygiene and health edu- cation interventions. Incidentally, the funding follows a similar pattern. Most of the funding is allocated for water intervention, less for sanitation, and even less for hygiene and health education. The funding may also be a factor in some of these analyses. One other difference about the Red Cross project is noteworthy. It was evalu- ated as an integrated program from the beginning, and the data availability was designed so that all three interventions were measured. This approach raises the question of whether incremental interventions versus integrated interventions are more effective. There is some evidence in the literature (Fewtrell, 2005) that incremental interventions focused on one element of water, sanitation, or hygiene, are more effective—or not less effective—than integrated interventions, but researchers do not have an understanding of why. More work is therefore needed to understand the effectiveness of the three interventions separately and together. If water interventions are not as effective, then further analyses may

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0 GLoBAL ENVIRoNMENTAL HEALTH have funding implications to determine if more emphasis should be put on these other interventions as well. WATER AND HEALTH: THE GLOBAL PICTURE OF RISK OF WATER-BORNE AND CHRONIC DISEASE Peggye Dilworth Anderson, Ph.D., Professor, University of North Carolina at Chapel Hill Culture through shared-beliefs, religion, and myths influences the accep - tance of new ideas and influences how people address chronic diseases, chang - ing environmental conditions, and other aspects of their lives. World Water Day 2006 (UNESCO, 2006) recognized this issue by focusing on water and culture interdependence, noting The importance of water in our everyday lives cannot be overestimated. Al- though it is ever-present, it is also ever-changing. Indeed, the ways in which water is perceived and managed are determined by cultural traditions, which are themselves determined by factors as diverse as geographical location, access to water and economic history. . . . Water is not perceived the same way in Africa as it is in Asia or in Australia as it is in the Amazon. The role that water plays in shaping the lives of people can be seen in the huge variety of water-related religious practices, spiritual beliefs, myths, legends, and management practices throughout the world. Understanding these factors as part of public health and from a sociological perspective should be a part of the strategies for intervention by public health practitioners. What Is Culture? From a sociological perspective, one can define culture a number of ways, and each definition helps to define various borders for what can appear to be a borderless discipline. Culture is shared among an identifiable segment of a popu - lation (Rohner, 1984) and is often influenced by individual characteristics, such as gender and age (Goodenough, 1981). However, culture can be most precisely defined as a set of shared symbols, beliefs, and customs that shape individual and group behavior (Goodenough, 1999). Furthermore, it provides guidelines for speaking, doing, and evaluating one’s actions and reactions in life (Goodenough, 1999). In 2002, the Institute of Medicine further modified this definition, stating that culture is socially constructed and learned, not genetically transmitted. In essence culture is not static, but rather dynamic. Culture is not an end point; it is a process. Culture can change and become socially reconstructed on

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 THE SoCIAL PILLAR oF SUSTAINABLE WATER the basis of the political, economic, and religious factors that are impinging on the cultural group or individual within the culture. In other words, culture includes values and beliefs, customs, norms, and symbols, and the influence of these fac - tors can change over time and in intensity among individuals and groups. The influence of culture is multifaceted by • shaping how people perceive and interpret their environment, • influencing how people structure their community and social life, • determining what is perceived as a priority in the community, and • erving as both an enabler and a barrier to acceptance of new ideas and s interventions. What is occurring locally can shape what the scientific community can do in influencing and impacting people in a particular society. Culture and Public Health Interventions Often culture can be seen as a barrier in the process of implementing public health interventions; however, culture does not have to be a barrier. Individuals in the community do not see themselves as a barrier. These barriers are often labeled as such by the investigators or donor community because they are not able to implement their plans as designed. The indigenous people perceive their actions as practices, traditions, norms, and values and not barriers. Investigators need to recognize, respect, and work within the cultural framework when designing the collection and use of water in the family household. Central to this process is the dialogue with the local community. Culture involves more than understanding the spoken language, as one has to understand the nuances of the language—colloquialisms. Words are symbolic of behaviors that a person from outside the culture may easily miss, but they can have a profound impact on the acceptance or the rejection of the interven - tion. Community values may be moral, ideological, or social and may influence what the community deems a priority. Furthermore, components of culture, such as community values, the construction of health, stigma and taboo, patterns of authority, trusted sources of information, religion and spirituality, gender norms and roles, social structures, daily activities, and language and communication, can influence the acceptance of a new idea or intervention. Cultures understand and define the concept of health differently. For exam - ple, a community may define health as the absence of disease or as a state of well-being. Stigma and taboo may influence whether an affected group may be wiling to discuss a topic or participate in an intervention. Furthermore, religion and spirituality can influence health beliefs and practices. This is especially true for water, as it plays a key role in many religions. It is considered symbolic in most religions, considered a cleanser and purifier, and used in spiritual rituals.

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 GLoBAL ENVIRoNMENTAL HEALTH Trust is an important part of this process. Who is regarded as a credible source of information varies across cultures and may include medical provid - ers, traditional healers, family members, friends, religious leaders, and political leaders. In many communities there is often the blending of folk wisdom and experience with formal education, which together provide a stronger sense of the culture. Finally, there is often a trust barrier with outsiders that needs to be overcome. As a first step, researchers need to understand the patterns of authorities—the first contact in a community. This first contact may not be the person with the greatest amount of measurable power, but it may be the person with the greatest level of influence and authority in the system. Understanding the patterns of authority can help to determine who the community gatekeepers are, so that community members may be more likely to accept interventions when promoted by people in authoritative roles. In conclusion, successful interventions will not only recognize but also understand the local culture. Researchers should not see culture as a barrier, but rather as an opportunity to ensure the sustainability of their interventions. Recognizing the importance of water and culture and their intersection opens opportunities to begin to address the Millennium Development Goals.