Public Health Current Issue


	n 1981, the United Nations launched its first decade of safe water with a lofty goal of “safe water and sanitation for all by 1990.” And indeed for each day from 1981–1990, some 200,000 people gained access to safe drinking water and another 80,000 access to better sanitation. By the decade’s end, more than 1.2 billion people had been added to the population with improved water sources and approximately 770 million had benefited from improved sanitation. But while water and sanitation quality were improving for some people, other forces intervened to hinder progress. Population growth and rapid urbanization exceeded the capacity and infrastructure of developing countries to keep up with demand for water. Armed conflict and natural disasters presented their own logistical problems in providing water and sanitation to large numbers of displaced people. By the end of the 1990s, despite the expenditure of $100 billion, the number of people without safe water and sanitation was the same as at the beginning of the decade. Today that number remains a staggering 1.1 billion people who are without this basic human right, or one-sixth of humanity. In addition, at least 2.4 billion people lack adequate sanitation services. The public health consequences of unsafe drinking water and sanitation are severe, particularly for children. WHO estimates that 6,000 children under the age of 5 die each day of diarrhea, totaling 2 to 3 million every year. That doesn’t even include the more than 1 billion cases of respiratory infections and gastroenteritis that are possibly linked with drinking unsafe water. The UN recently declared another initiative to increase access to safe water. The Millennium Development Goal for Water is to cut in half the proportion of people unable to reach or afford safe drinking water by 2015. To reach that goal, agencies working on the problem will have to reach nearly 300,000 people every day until 2015. And, according to faculty at Emory and CDC, they’re already behind. If the challenge of providing safe water for everyone who lacks it now were easy to solve, we’d have solved it already, says Jeffrey Koplan, vice president for academic health affairs at Emory’s Woodruff Health Sciences Center. But the problem is a complicated one with myriad causes. In some parts of the world, geography is the culprit. Water resources may be far away from the largest concentrations of people. Hot, arid climates bring little rainfall to some regions. In other areas of the world abundant with streams, rivers, and lakes, people have access to water, but these sources may be contaminated. Even if the source is clear, the water can easily become contaminated when transported in dirty containers, or once it is in the home, when it comes in contact with unclean hands. Transporting water from the source to where it is needed is another element of the challenge, particularly for women and children, who may travel several hours a day to haul water home. They get dehydrated coming and going, caught in a circular pattern. They expend energy and time that could have been used for education and training. In addressing the problems that lead to unsafe water and sanitation, “one size doesn’t fit all,” says Koplan. “One way to think of the challenge is to think of lots of different sized feet.” Recently, Emory has launched a multi-focal effort to improve safe water, relying on the expertise of faculty and partners. Or as Koplan says, “Emory has a good-sized warehouse of high-quality shoes.” In January, the Rollins School of Public Health established a Center for Global Safe Water in partnership with CARE USA, CDC, and Population Services International. With a mission to improve access to safe drinking water globally, the center is the focal point for faculty experts in international health, environmental health, and infectious diseases and the umbrella for collaborative projects under way around the world. Its three-part approach is to train graduate and postgraduate students to deal with the water crisis, to engage in applied public health research and evaluation, and to strengthen local, in-country partners working on specific water and sanitation problems and solutions. The center’s efforts are bolstered by pledges from Eugene J. Gangarosa, professor emeritus of International Health, and his wife, Rose Gangarosa, to establish endowments for two academic chairs: the Eugene J. Gangarosa Chair in Safe Water and the Rose Salamone Gangarosa Chair in Environmental Health. Once completed, these endowments, which grow out of Gangarosa’s lifelong passion for safe water, will help support new faculty in the center. The center’s acting director, Richard Rheingans, sees it as a catalyst for new activities, courses, and outside collaborations. With support from the Gangarosa Scholarship Fund, students have a chance to participate in summer fellowships abroad to strengthen local NGO efforts. Center faculty are pursuing research on a number of fronts, from stunted growth in Guatemala to sanitation improvements in El Salvador to an evaluation of safe and fresh water in Florida. The center’s partnership with the Atlanta Rotary Club will result in new wells for Kenya along with support for water treatment and storage. “As you build a network, you multiply the efforts for safe water and sanitation,” Rheingans says. James Hughes believes that, too. Director of the National Center for Infectious Diseases at CDC, Hughes will capitalize on the momentum building at the Center for Global Safe Water when he joins Emory this spring with joint appointments in public health and medicine and as director of the Center for Global Safe Water. (See article on page 5.) His plan for taking the center’s work forward begins with strategic thinking about how to strengthen existing partnerships across disciplines and countries. “Microbes don’t respect geographic boundaries. Therefore, neither does water safety or quality. It is incumbent on national governments to collaborate,” he says, echoing the words of Kofi Annan. Hughes’s priorities include nurturing innovative ideas from the scientific evidence base and then communicating those findings to governments and funders for translation into effective public health action. Communication becomes a tool for not only changing human behavior but also mobilizing political will.

	ltimately, construction of deep wells or piped water systems is the way to ensure safe water for populations, but that will take time and resources. Meanwhile, hundreds of millions of people in developing countries need a solution now. To bridge that gap, CDC and the Pan American Health Organization developed the Safe Water System (SWS), a simple and sustainable intervention that uses low-cost technologies appropriate for distribution in developing nations. The Center for Global Safe Water is joining other partners to take that intervention to Kenya. At the core of the SWS is a health focus, which CDC believes is the most critical water issue. Eric Mintz and Rob Quick, scientists in CDC’s National Center for Infectious Diseases who have worked on the project since its inception, are quick to distinguish themselves as “the diarrhea guys, not the water guys.” In other words, their approach to water is health-focused rather than a focus on infrastructure. They began developing the system in 1991 in response to the seventh pandemic of cholera that swept across Latin America and continues unabated to this day. As a first response, Ministries of Health in Latin America recommended boiling water to treat it and thus kill the deadly cholera bacteria. However, boiling proved too expensive, time-consuming, and detrimental to the environment. Mintz’s and Quick’s idea was to deliver a point-of-use intervention. It wasn’t a new idea. For example, at the American University of Beirut (AUB) in the late 1970s and early 1980s, Gangarosa’s colleague, Aftim Acra, pioneered a method that used sunlight to purify water. Research showed the solar technique worked, but people in the developing world didn’t embrace storing their drinking water in the hot sunshine, preferring instead the cool places where bacteria breed. “It was hard for the homemaker to understand that something invisible in the water was causing the death of a child,” says Gangarosa.

	Rather than sunlight, Mintz and Quick settled on the use of dilute chlorine bleach (sodium hypochlorite), which can be produced cheaply with electricity, salt, and water as the decontamination strategy. Synthesizing research in Lebanon, India, Brazil, and Egypt, they assembled an intervention that followed treatment with safe storage. The storage component required keeping human hands away from the water, so they held a design competition, which Gangarosa helped judge, for an appropriate vessel. Although the storage containers proved too expensive to manufacture, the competition did help them focus their choice on containers already on the market that had narrow mouths, lids, and spigots—all of which kept hands out of the water. While the chlorine solution and the storage vessel served as the hardware of the SWS, the more critical element is what Quick calls the “software.” He means the messages and methods on which the intervention relies to change behavior. “We refer to our vessel as the Trojan Horse,” he says. “Once it’s in the home, it can lead to other changes in behavior, such as washing hands, washing fruits and vegetables, and cleaning eating surfaces.” In Bolivia, where they first tested the Safe Water System in 1994, the scientists found that it lowered incidence of diarrhea by 48%. They took the intervention to other countries, finding a reduction in diarrhea in Uzbekistan by 85%, in Zambia by 48%, in Guatemala by 25%, in Kenya by 55% in children under five years old, in Pakistan by 49%, and most recently in Uganda by 30% in people infected with HIV. Another valuable finding was that the intervention is sustainable, a crucial component for long-term success. By having local people inexpensively produce the chlorine solution and then having other locals sell the product, the intervention uses a grass roots approach to reach the community. Social marketing through events, commercials, and parades—in collaboration with Center for Global Safe Water partner Population Services International—raises awareness and interest in the SWS in local communities and involves the private sector in distributing the products. In Kenya, the idea is taken even further as CARE has trained women to sell the hypochlorite solution and to teach people how to use the intervention. In the process, the effort is providing a source of badly needed income. Summer research fellows from the Center for Global Safe Water are further refining the effort there. (see related story, Where Health and the Environment Meet) Since the SWS worked and was sustainable, Mintz and Quick thought every country would be lining up to sign on for the intervention. “We thought everyone would want it,” Mintz says. But, it has taken a decade for the SWS to be implemented in 19 countries on three continents, and only in the past few years have the CDC scientists begun to perceive more general acceptance of point-of-use treatment approaches from the water community as a whole. With a combined total of 26 years of their careers devoted to the SWS, Mintz and Quick want to insure that the Safe Water System continues to reach the people who need it most. The collaboration with the Center for Global Safe Water gives them that guarantee. “The center will take the work into perpetuity,” Quick says.