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

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Christine Coussens, Rapporteur Roundtable on Environmental Health Sciences, Research, and Medicine Board on Population Health and Public Health Practice 

THE NATIONAL ACADEMIES PRESS • 500 FIFTH STREET, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Support for this project was provided by the American Chemistry Council (unnum- bered grant); ExxonMobil Corporation (unnumbered grant); Institute of Public Health and Water Research (unnumbered grant); National Center for Environmental Health and the Agency for Toxic Substances and Disease Registry, Centers for Disease Control and Prevention (Contract No. 200-2000-00629, TO#7); National Health and Environment Effects Research Laboratory and the National Center for Environmental Research, U.S. Environmental Protection Agency (Contract 282-99-0045, TO#5); National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention (Contract 0000166930); and National Institute of Environmental Health Sciences, National Institutes of Health (Contract N01-OD-4-2193, TO#43). The views presented in this book are those of the individual presenters and are not necessarily those of the funding agencies or the Institute of Medicine. International Standard Book Number-13:  978-0-309-13179-7 International Standard Book Number-10:  0-309-13179-0 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover credit: Select photos reprinted with permission from Matt Freeman (latrine), Michael Ritter (girls carrying water), and Caroline Voute (back cover) of The Center for Global Safe Water at Emory University. Suggested citation: IOM (Institute of Medicine). 2009. Global Environmental Health: Research Gaps and Barriers for Providing Sustainable Water, Sanitation, and Hygiene Services. Washington, DC: The National Academies Press. 

“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health. 

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a man- date that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examina- tion of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the ­National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org 

ROUNDTABLE ON ENVIRONMENTAL HEALTH SCIENCES, Research, and Medicine Paul Grant Rogers (Chair; deceased), Partner, Hogan & Hartson, Washington, DC Lynn Goldman (Vice Chair), Professor, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD John M. Balbus, Director of Health Program, Environmental Defense, Washington, DC Kenneth Chien, Scientific Director, Cardiovascular Research Center, Massachusetts General Hospital, Cambridge, MA Yank D. Coble, Immediate Past President, World Medical Association, Neptune Beach, FL Susan Dentzer, Health Correspondent and Head of the Health Policy Unit, The News Hour with Jim Lehrer, Public Broadcasting Service, Arlington, VA Henry Falk, Director, Coordinating Center for Environmental and Occupational Health and Injury Prevention, National Center for Environmental Health/Agency for Toxic Substances and Disease Registry, Centers for Disease Control and Prevention, Atlanta, GA Richard Fenske, Professor, Department of Environmental Health, University of Washington School of Public Health and Community Medicine, Seattle, WA Howard Frumkin, Director, National Center for Environmental Health/ Agency for Toxic Substances and Disease Registry, Centers for Disease Control and Prevention, Atlanta, GA Peggy Geimer, Corporate Medical Director, Arch Chemicals Inc., Greenwich, CT Paul Glover, Director General, Safe Environments Programme, Health Canada, Ottawa, Ontario Bernard Goldstein, Professor, Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA Myron Harrison, Senior Health Adviser, Exxon-Mobil, Inc., Irving, TX Carol Henry, Acting Vice President for Industry Performance Programs, American Chemistry Council, Arlington, VA John Howard, Director, National Institute of Occupational Safety and Health, Centers for Disease Control and Prevention, Washington, DC Sharon Hrynkow, Associate Director, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD Richard Jackson, Adjunct Professor, Environmental Health Services Division, University of California at Berkeley Floyd Malveaux, Executive Director, Merck Childhood Asthma Network, Inc., Washington, DC  

Michael McCally, Executive Director, Physicians for Social Responsibility, Washington, DC Mark Myers, Director, United States Geological Survey, Reston, VA Martin Philbert, Associate Dean for Research, School of Public Health, University of Michigan, Ann Arbor, MI Lawrence Reiter, Director, National Exposure Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, NC Leona Samson, Professor, Center for Environmental Health Sciences, Massachusetts Institute of Technology, Cambridge, MA Paul Sandifer, Senior Scientist for Coastal Ecology, National Ocean Service, National Oceanic and Atmospheric Administration, Charleston, SC Carlos Santos-Burgoa, General Director for Equity and Health, Secretaria de Salud de Mexico, Mexico D.F. John Spengler, Professor, Department of Environmental Health, Harvard School of Public Health, Cambridge, MA William Suk, Acting Deputy Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC Louis Sullivan, President Emeritus, Morehouse School of Medicine, Atlanta, GA William Sullivan, Associate Professor, Department of Natural Resources and Environmental Sciences, University of Illinois at Urbana-Champaign, Urbana, IL Jennie Ward-Robinson, Executive Director, Institute for Public Health and Water Research, Chicago, IL Samuel Wilson, Acting Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC Harold Zenick, Acting Director, Office of Research and Development, U.S. Environmental Protection Agency, National Health and Environmental Effects Research Laboratory, Research Triangle Park, NC David Tollerud (Roundtable Liaison), Professor and Associate Director, Institute of Public Health Research, University of Louisville, Louisville, KY Study Staff Christine M. Coussens, Study Director Nora Hennessy, Senior Program Associate (until January 2009) David Tollerud, Program Assistant (until November 2008) Louise Jordan, Senior Program Assistant (from February 2008–January 2009) Pamela Lighter, Program Assistant (from January 2009) Board Staff Rose Marie Martinez, Board Director Hope Hare, Administrative Assistant Christie Bell, Financial Associate vi 

Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evi- dence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Herman Ellis, Division of Public Health, State of Delaware Jonathan Hall, The Hall Water Report Roger Lewis, School of Public Health, Saint Louis University Although the reviewers listed above have provided many constructive com- ments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Melvin Worth, MD, who was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the rapporteur and the institution. vii 



Contents 1 WORKSHOP INTRODUCTION 1 Learning from the Past, 2 Workshop Objectives, 4 2 GLOBAL WATER SERVICES: SHORT- AND LONG-RANGE VIEWS 7 The Native American Approach to Sustainable Water: The Seventh Generation Concept, 7 Sustaining Progress for Clean and Safe Water, 8 Creating the Sanitary City: Water, Wastewater, and Health in American Cities, 12 3 THE TECHNOLOGY PILLAR OF SUSTAINABLE WATER: TECHNOLOGY, ECONOMICS, AND HEALTH 17 Moving Toward Megacities: Decentralized Systems, 17 Overview of the Water Sector: Policies, Institutional Roles, and Key Issues for Utility Services Delivered in Ghana, 20 Clean Drinking Water: Solving the Arsenic Crisis in Bangladesh Through a Sustainable Local Filtration Technology, 24 Small- to Medium-Sized Systems: Opportunities and Challenges, 29 The Use of Technologies: Exposure (Cross-Contamination), Risk Assessment, and Guidelines, 33 Approaches to Sustainablility: Global Water Partnerships, 40 4 PANEL DISCUSSION: COORDINATION AND PRIORITIZATION OF WATER NEEDS 43 Definition of Sustainable Water Services, 43 Priorities for Achieving Sustainable Water Services, 45 ix 

 contents Stakeholder Involvement, 45 An Integrated Approach, 46 Current Challenges for Water Services, 46 Effectiveness, Longevity, and Evaluation, 47 5 ACHIEVING WATER AND SANITATION SERVICES FOR HEALTH IN DEVELOPING COUNTRIES 51 Improving Water and Sanitation Access in Developing Countries: Progress and Challenges, 51 The Drinking Water Supply and Sanitation in Latin America: Moving Toward Sustainability Following Two Decades of Reforms, 59 6 THE ENVIRONMENTAL PILLAR OF SUSTAINABLE WATER: ECOLOGICAL SERVICES 65 Drinking Water Valuation: Challenges, Approaches, and Opportunities, 65 Impacts of Demographic Changes and Water Management Policies on Freshwater Resources, 68 The Sustainability of Drinking Water: Some Thoughts from a Midwestern Perspective, 72 7 THE SOCIAL PILLAR OF SUSTAINABLE WATER: HEALTH RESEARCH GAPS 77 Water and Health: The Global Picture of Risk of Water-Borne Disease and Chronic Disease, 77 Preliminary Overview of Current Research and Possible Research Priorities: Small Community Drinking Water Supplies, 81 Integrating Water, Sanitation, and Hygiene, 87 Water and Health: The Global Picture of Risk of Water-Borne and Chronic Disease, 90 8 PANEL DISCUSSION: MOVING FORWARD 93 Evaluation of Interventions, 94 Community-Based Evaluation and Participation, 96 9 THINKING ABOUT NEW VISIONS OF WATER SERVICES 99 Climate Change, 99 Regulatory Perspective, 100 10 Breakout Group: Meeting Goals for Water, Sanitation, and Hygiene 103 Standardization of Evaluation, 103 

contents xi Bridging the Gap Between Research and Policy, 104 An Absence of Leadership at the National Level, 104 An Interdisciplinary Approach, 105 The Community Agenda, 105 Building Community Involvement and Educational Capacity, 106 The Role of Donors, 107 REFERENCES 109 APPENDIXES A Workshop Agenda 113 B Speakers and Panelists 123 C Workshop Participants 125