1. Global Water Sanitation and Health: What this Course is about
Mark D. Sobsey
University of North Carolina
Department of Environmental Sciences and Engineering

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

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

5. Global Burden of Poor Water, Sanitation and Hygiene (WSH)
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!

6. The Older Conventional View:
Lack of WSH = Disease and Poverty
Inadequate water supply
Unsafe water resources
Inequitable access
Time, financial cost
Disease burden
Health care costs
POVERTY

7. The Newer Optimistic View!
WSH = An Engine for Development and Productivity
Improved water supply
Safe water resources
Universal access
Time, financial savings
Averted disease costs
Healthy populations
Development

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: The “F”s of WSH
Feces
Fingers
Flies
Fields/Food
Fluids
Fomites
Water Treatment

10. A Lot of What Else this Course is About
Air pollution
Solid waste management
Vectors & vector-borne diseases
Disasters and emergencies
Climate change health effects

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

12. 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
VIP latrine
Latrine

13. Inferior/Absent Community Wastewater Treatment Systems
Rx.
No Rx.
Rx. Often Absent!
Untreated/poorly treated wastewater is discharged to land or natural waters

14. 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

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

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

17. Issues in Water and Health
Quality
Quantity
Access
Habitat and Ecology
Resources and Management
Economics
Behavior and Beliefs
Enabling Environment and Policies

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

19. Comparison of Impacts of WSH Interventions: Fewtrell et al. 2005 vs
Comparison of Impacts of WSH Interventions: Fewtrell et al 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 (?)

20. Piped and Non-Piped Water Supplies
Most people lack piped water
They collect water or have it delivered
Most wells in developing countries deliver NO or UNSAFE water!
Sources are often contaminated
Piped water is often contaminated
Classified as “improved”, but still unsafe

21. Piped and Non-Piped Water Supplies
Collected, stored water often becomes contaminated in the home
Water is often not treated, but used directly
Boiling is widely practiced
Disadvantages:
Cost
Inconvenience
no residual protection (gets recontaminated in use!)
environmental degradation (deforestation)
air pollution (health effects)

22. 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”)

23. 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

24. World Health Organization Health-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!

25. Implementation/Dissemination Communication Advocacy Finance Policies
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

26. 2008: International Year of Sanitation
Celebrating Water for Life The International Decade for Action 2005 to 2015
2008: International Year of Sanitation