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

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 the house or yard from public distribution systems, protected wells and springs, public stand posts, rain water collection; 17% of world population 2.6 billion (42% of population) lack access to basic sanitation – sewerage, on-site septic waste treatment system, latrine 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

5. Lack of WSH = Disease and Poverty Inadequate water supply Unsafe water resources Inequitable access Time, financial cost Disease burden Health care costs POVERTY

6. WSH = An Engine for Development and Productivity Improved water supply Safe water resources Universal access Time, financial savings Averted disease costs Healthy populations Development

7. UN Millennium Declaration Overall Goal: Poverty Reduction

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: Five F’s of WSH Feces Fingers Flies Fields/Food Fluids Fomites Water Treatment

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

11. 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 Latrine VIP latrine

12. Inferior/No Community Wastewater Treatment Systems Untreated/poorly treated wastewater is discharged to land or natural waters

13. 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

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

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

16. Issues in Water and Health Quality Quantity Access Habitat and Ecology Resources and Management Economics Behavior and Beliefs

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

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

19. Handwashing Hygiene to Prevent Disease Handwashing with soap and water after contact with fecal material can reduce diarrheal diseases by 35% or more Source: Almedom et al. 1997

20. Piped and Non-Piped Water Supplies Most people lack piped water –They collect water or have it delivered Sources are often contaminated (UNSAFE!) Piped water is often contaminated –Classified as “improved” but UNSAFE! Collected, stored water often becomes contaminated in the home (UNSAFE!) Water is often not treated – used directly Boiling is widely practiced, but…… –Disadvantages: cost, inconvenience, no residual protection (gets recontaminated in use!), environmental degradation (deforestation), air pollution (health effects)

21. 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”)

22. 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

23. 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

24. 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

25. Celebrating Water for Life The International Decade for Action 2005 to 2015