PGWI CONFERENCE APRIL 4, 2009 Highlights

Water, Public Health Problems, and Public Health Solutions: Foreground, to Background, to Foreground Shiriki Kumanyika, PhD, MPH PGWI Conference April 2009

Standard Methods for the Examination of Water and Wastewater Since 1905, Standard Methods for the Examination of Water and Wastewater has represented "the best current practice of American water analysts." This comprehensive reference covers all aspects of water and wastewater analysis techniques. Standard Methods is a joint publication of the American Public Health Association (APHA), the American Water Works Association (AWWA), and the Water Environment Federation (WEF). Standard Methods for the Examination of Water and Wastewater Since 1905, Standard Methods for the Examination of Water and Wastewater has represented "the best current practice of American water analysts." This comprehensive reference covers all aspects of water and wastewater analysis techniques. Standard Methods is a joint publication of the American Public Health Association (APHA), the American Water Works Association (AWWA), and the Water Environment Federation (WEF). Among the best selling publications of the American Public Health Association; more than 100 years of publication

# of articles on water and size of the volume of AJPH:

# Articles in the AJPH that carried the label engineers or engineering in the title

Ten Great Public Health Achievements, US, Vaccination Motor vehicle safety Safer workplaces Control of infectious diseases Decline in CHD and stroke deaths Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as a health hazard

Water and Chronic Diseases: Current Issues Cancer prevention Obesity and diabetes Oral health Food and environmental sustainability

Cancer Prevention Recommendations World Cancer Research Fund/American Institute for Cancer Research, 2009

Major health consequences of obesity Diabetes Cardiovascular diseases Some types of cancer

Source: Luke A. Nutritional consequences of the African diaspora. Annu Rev Nutr. 2001;21:

Global Prevalence of Obesity in Adult Males % Obese 0-9.9% % % % % ≥30% Self Reported data North America USA 31% Mexico 19% Canada (self report) 17% Guyana 14% Bahamas 14% South Central America Panama 28% Paraguay 23% Argentina (urban) 20% Uruguay (self report) 17% Dominican Republic 16% Africa South Africa 10% Seychelles 9% Cameroon (urban) 5% Ghana 5% Tanzania (urban) 5% South East Asia & Pacific Region Nauru 80% Tonga 47% Cook Island 41% French Polynesia 36% Samoa 33% Eastern Mediterranean Lebanon 36% Qatar 35% Jordan 33% Kuwait 28% Saudi Arabia 26% European Region Croatia 31% Cyprus 27% Czech Republic 25% Albania (urban) 23% England 23% With examples of the top 5 Countries in each Region With the limited data available, prevalence's are not age standardised. Self reported surveys may underestimate true prevalence. Sources and references are available from the IOTF. © International Obesity TaskForce, London –January 2007

Source: Kumanyika S, Rigby N, Lobstein T, Leach R, James WPT. Obesity: Global Pandemic, In: Kopelman P, Cateron I, Dietz W, eds. Clinical Obesity in Adults and Children, 3rd Edition (in press)

May 2002

March 2007

Safe Water? Thank You

Water,Sanitation, Hygiene(WSH) and Health –Let’s Talk About Diarrhea John Borrazzo, Ph.D. U.S. Agency for International Development Presented at Philadelphia Global Water Initiative April 4, 2009

Crude death rate for infectious diseases, United States, 1900 – 1996 (per 100,000 population per year) [Source: National Center for Environmental Health, CDC, 1999]

WSH and health- targeting Relevant programmatic strategies – focusing Outcomes and impact - measuring

Changes in Sanitation Practices, Source: “Soap, Toilets, and Taps,” UNICEF, 2009

Changes in Drinking Water Supply, Source: “Soap, Toilets, and Taps,” UNICEF, 2009

But…the world keeps growing! Yearly population to gain access to meet the MDG target for improved drinking water supply Source: U.N. MDG Global Monitoring Data, 2007

90% preventable Undernutrition implicated in 50% of child deaths, and is also associated with diarrhea 9.2 million child (<5 yrs) deaths annually Source: State of the World’s Children, UNICEF 2008

Source: “Safer Water, Better Health”, WHO 2008

Diarrhea – Real Progress in Reducing Mortality 1990 World Summit for Children Goal met by 2000 (reduce under-five diarrheal deaths by half) Almost 3 million child deaths/year averted by 2005 Estimated 1.5 billion child diarrhea episodes/year (in developing countries) Still over 1.5 million child deaths/year

Where do child deaths from diarrhea occur?

11 countries account for over 70% of the annual deaths globally from diarrhea

Deaths from Diarrhea have declined in all regions Source: WHO, 2002; ECA=Europe and Central Asia, LAC=Latin America and the Caribbean, MENA=Middle East and North Africa, SA=South Asia, EAP=East Asia and the Pacific, SSA=sub-Saharan Africa

Under-five mortality rate from diarrhea (deaths per thousand live births) Source: The Lancet Child Survival Series, 2003

Median Age-specific Incidences for Diarrheal Episodes per Child per Year from Three Reviews of Prospective Studies in Developing Areas, Source: Disease Control Priorities in Developing Countries, Second Edition; 2006

So…Targeting is Important Geography – sub-Saharan Africa and South Asia Considerations of magnitude and severity Focus on high-risk groups – esp. young children 6 months to 2 years of age (and also neonates). Now let’s consider programmatic focus…

Focus on the evidence-based interventions with greatest potential for reducing morbidity and mortality POU water treatment & safe storage – approximately 30-50% reduction in DD prevalence (Cochrane Review, Clasen et al., 2006) Optimal handwashing (meta-analysis showed 43% reduction in diarrhea prevalence, April 2003, Lancet) Sanitation – basic, low-cost systems can reduce DD by 30% or more Increasing quantities of water used – impact on general hygiene and specifically facilitates handwashing

Household Water Treatment Options Chlorination- SWS PuR Ceramic Filtration Biosand Filtration Multiple barrier Solar/SODIS Boiling

So…Programmatic Focus is Important Focus on evidence-based interventions Consider the target population and how to reach them with cost-effective programmatic approaches Short-term, relatively low-cost options are available Now let’s consider what to measure…

Impact of Key Interventions on Diarrhea

What to Measure…Beyond access to improved services Use of sufficient quantities of water – surrogate: access to an improved source; ideal is reliable piped supply to the home Safe water quality at the point-of-use – surrogate: reported treatment and safe storage at household level Use of improved sanitation – surrogate: reduction of open defecation Optimal hygiene practices – surrogate: observed handwashing behavior (?)

TAKE-HOME MESSAGES TARGET - Countries with high DD burden (severity, magnitude), children ages 6-24 months, newborns (caregiver handwashing) FOCUS - On key behavioral outcomes – water use, water quality (at POU), feces disposal, and handwashing MEASURE - Behaviors, not diarrhea

A NEW Culture of Multi- displinary Collaboration? Handling wicked problems is hard work and may be dangerous to your career.

Behavior change in institutions and professions The silo system of institutional competition over collaboration. Building collaboration around the questionnaire. Acknowledgement by the boss for work done outside the specialty: publications and the “waste of time” working in the community. Does my working with outsiders count for my promotion and tenure. Are we becoming “Bad Samaritans?”