1. Kay Mattson, MSW, MPH Engineers Without Borders OHSU – Center for Evidence-based Policy Grace Weatherford, MS, EIT Engineers Without Borders PBS Engineering + Environment

2. Overview World water situation and basic issues - Millennium Development Goals (MDGs) Link between water-sanitation-hygiene, health and poverty in development -Water Related Disease -Diarrhea -Gender/Children burden Drinking water development and sustainability Haiti EWB case example

3. Questions for Consideration Are drinking water and sanitation a basic right or a need? Why are water and sanitation global health issues? What are some of the developing country sustainability challenges in wat-san and how can they be addressed? How to bring about change in wat-san in the developing world?

4. Is Water a Basic Right? “the human right to water entitles everyone to sufficient, safe, acceptable and affordable water for personal & domestic uses” United Nations Committee on Economic, Social & Cultural Rights November 26, 2002

5. Is Water a Basic Right? Water was determined to be a “Need” World Water Forum in 2000 Consequence – “Water is subjected to the supply and demand forces of the global marketplace, where the distribution of resources is determined on the basis of the ability to pay.” Maude Barlow and Tony Clark Blue Gold

6. Millennium Development Goals (MDGs) Established by world leaders convened by the UN in 2000 Eight goals to address the overarching goal of reducing poverty by 50% by 2015 Goal 7 Ensure Environmental Stability - Wat-San Targets - to cut by half the portion of people without sustainable access to safe drinking water and basic sanitation

7. 1.1 Billion People in the World Lack Access to Improved Sources of Water 1 in 5 people in the developing world

8. Drinking Water and 2005 MDG’s and Case Study Conditions Les Anglais, Haiti

9.  Piped water into dwelling  Piped water to yard/plot  Public tap/standpipe  Tube well/borehole  Protected dug well  Bottled water (only when there is a secondary source of improved water for other uses such as personal hygiene)  Protected spring  Rainwater collection Improved Water SourcesUnimproved Water Sources  Unprotected spring  Unprotected dug well  Cart with small tank/drum  Tanker Truck  Surface water (river, dam, lake, pond, stream, canal, irrigation channels)  Other (specify) What is Improved Drinking Water Access

10. Improved or unimproved?

14. Could you do it?

15. 2.6 Billion People in the World Lack Access to Improved Sanitation 50% of the developing world

16. Sanitation and 2002 MDG’s and Case Study Conditions Les Anglais, Haiti

17.  Flush/pour flush to  Piped sewer system  Septic tank  Pit latrine  Unknown place/not known where  VIP latrine  Pit latrine w/ slab  Composting Toilet Improved SanitationUnimproved Sanitation  Flush/pour flush to:  Elsewhere  Pit latrine without slab/open pit  Bucket  Hanging toilet/hanging latrine  No facilities, bush or field What is Improved Sanitation

18. Improved or unimproved?

22. Improved or Unimproved?

25. Necessity and Disease Burden Water is a basic element required by all human beings for survival, without water we will die in a matter of days. -20 liters (abt 5.28 gallons) a day for basic water needs (washing/drinking) -The average European uses 200 liters of water every day. North Americans use 400 liters. -The average person in the developing world uses 10 liters a day for drinking, washing and cooking Without adequate and safe water and sanitation, transmission of water related disease mortality and morbidity increases. Of the 37 major disease in developing countries, 21 are water and sanitation related. Water borne disease (Diarrhea, Cholera, Arsenicosis) Water washed (Diarrhea, Trachoma) Water based/vector borne diseases (Schistosomiasis, Dengue, Malaria)

26. http://www.abc.net.au/science/news/img/arsenicosis.jpg Arsencosis 1000wells.com/why.html Trachoma Malaria & Dengue Cholera http://geotourweb.com/32-cholera.jpg Water borne disease Water Based & Vector Borne Water Washed www.abdn.ac.uk/.../integrative/vector.shtmlSchistosomiasis

27. Diarrhea Disease Burden 4 billion cases of diarrhea annually, 88% attributable to unsafe water. 1.8 million deaths each year, an estimated 6,000 people every day, almost twice the number of the estimated persons who die from malaria and approximately equal to the number of AIDS death each year. 90% of the deaths are children under the age of five; 3,900 children under the age of five every day. The integrated approach of providing sanitation, water and hygiene reduces the number of deaths caused by diarrheal disease by 65%. (WHO) The simple act of washing hands with soap and water can reduce diarrheal diseases by over 40%. (British Medical J)

28. Gender Inequality in wat-san Women and children, particularly girls, carry the primary burden. Water collection can take up two- three hours a day, physically demanding. Limits women’s available time for other activities (child care, productive time, rest). Impacts children, especially girls, ability to attend school. Places women at risk of violence and increased health risks as often have to defecate after dark, placing them at risk of harassment and assault, liver disease and acute constipation Dignity & Gender Inequality

29. Improved Drinking Water Impact on Health in the Developing World

30. What would it cost to achieve wat-san MDG’s by 2015? Halve by 2015 the proportion of urban/rural people without sustainable access to safe drinking water; Halve by 2015 the proportion of urban/rural people without access to basic sanitation; World Bank Estimates - Universal Coverage $30 USD Billion a year Basic Coverage $9 USD Billion a year US 2009 Stimulus Package $787 Billion

31. Breakdown Of Global Aid For Water (2002-2004) $ Million Average Water Aid Areas 2002- 2004 $ million average Water supply & san – large systems4983.5 Basic drinking water supply and basic san.*1887.8 Agricultural water resources1420.9 Water transport1398.2 Water resources policy/admin. mgmt1331.4 River development677.5 Waste management/disposal337.9 Water resources protection200.2 Education/training: water supply & san*65.7 Grand Total12303.3 Source: Organisation for Economic Co-operation and Development (Retrieved on 9/8/06)

32. Small Scale Community Solutions Haiti – EWB Case Study

37. EWB Portland Haiti Drinking Water Project Professional chapter comprised of engineers and public health professionals in partnership with Our Savior Lutheran Church (OSLC), which has been assisting the community of Les Anglais since 1988 and Tu. OSLC free medical clinics identified low grade fevers, diarrhea and dehydration among clinic patients, particularly in children. The community piped water distribution system is comprised of two concrete reservoirs each fed by a spring. When operable these reservoirs served approximately 15,000 people 20,000 people. During the winter of 2008 hurricanes destroyed a main water line across the river Les Anglais and other lines cutting ½ the community off of a water supply. EWB initial site visit in 2008 tested drinking water spring sources and 15/18 tests were found to have high coliform counts (indicating presence of e- coli). The only water treatment currently in use is a small dose of chlorine per reservoir every few months. Two wells were constructed in the Spring of 2008. Majority y of HH surveyed in February 2009 get their drinking water from the river and an irrigation canal.

38. Les Anglais, Haiti Population Les Anglais District est 27,000+, Town 20,000 Main Drinking Water Sources Surface Water (Les Anglais River, Irrigation Canal) Two Public Wells, One Private Well (both installed w/in last year) Spring water from two reservoirs w/ gravity fed pipes to community taps (one system inoperable) Projects tested for e- coli/coliforms At Spring Box (2008 and 2009) Results16 /19 tests were positive Water TreatmentSome households report treating water w/ bleach and lemon, but few had bleach in the home when surveyed LatrinesScattered Pit Latrines throughout area, majority use fields or ocean Drinking Water Source and Quality

39. Determinants of Disease and Health – Three Potential EWB Approaches to Les Anglais Microbial Model (Infectious Agent) Behavioral Model (Host) Ecological Model (Environment) Increase access to soap and handwashing behaviors, improved “well behavior “ and “well knowledge” Increased water treatment Increased/improved water access & protection of water sources

40. February 2009 Household Surveys 50 HH Five “neighborhoods” Water (where, who, how much, storage, whether or not they treat) Sanitation (what/where) Hygiene (access to soap/critical times behavior) Under five malnutrition

44. Les Anglais, Engineering Challenges

45. Engineering Solutions/Challenges Increased/Improved Water Access and Protection of Water Sources Increased Water Treatment System map/inventory System repairs Access to tools and supplies to make repairs Access to/improved skills to make repairs Inventory/Check-out systems Education (e.g. plumbing skills and water shed protection) Central vs. Point-of-Use Chlorination Management of Treatment Cost of Treatment/Implementation

48. Potential Treatment Solutions Clean Water For Haiti

49. Conclusions Implementing new infrastructure that improves water and sanitation conditions is the relatively easy part. Changing behaviors and maintaining the infrastructure is difficult and takes sustained interventions that are supported by the community. Improved health is not always the motivation for change; diarrhea is not always considered an illness or related to water purity or poor hygiene. Importance of a multi-pronged approach - In highly fecal contaminated settings improved water quality may affect morbidity only when other variables related to fecal-oral agent transmission are ameliorated at the same time (kirchhoff et. all 1985). Measuring impact is a challenge – controlling for other variables is difficult, if not impossible, to determine cause-effect, but its essential. What works in one community will not necessarily work in another!

50. 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. Kofi Annan

51. Be the Change… Learn More MDG’s - http://www.un.org/millenniumgoals/http://www.un.org/millenniumgoals/ Water Supply and Sanitation Collaboration Council http://www.wsscc.org/ http://www.wsscc.org/ Cost of Wat-San MDG’s http://www.financingwaterforall.org/index.php?id=1099 http://www.financingwaterforall.org/index.php?id=1099 Water Aid http://www.wateraidamerica.org/http://www.wateraidamerica.org/ Oxfam http://www.oxfam.org/http://www.oxfam.org/ Global Citizen Corps - http://www.globalcitizencorps.org/http://www.globalcitizencorps.org/ WHO Statistics - http://www.who.int/whosis/en/http://www.who.int/whosis/en/ Get Involved March 22 World Water Day http://worldwaterday09.info/http://worldwaterday09.info/ World Toilet Day November 19 http://www.worldtoilet.orghttp://www.worldtoilet.org Engineers Without Borders - http://www.ewb-usa.org/http://www.ewb-usa.org/ Mercy Corps http://www.mercycorps.org/getinvolved/eventshttp://www.mercycorps.org/getinvolved/events