1. Jamie Bartram With adaptations by Mark Sobsey, UNC- Chapel Hill Water, Sanitation and Health: the Millennium Development Goals and Reducing the Global Burden of Disease

2. Overview Water, poverty and prosperity Water, poverty and prosperity Water: a health concern? Water: a health concern? Disability adjusted life years (DALYs)Disability adjusted life years (DALYs) Who and where are the disadvantaged? Who and where are the disadvantaged? Perspectives / trends Perspectives / trends Why invest in water and sanitation? Why invest in water and sanitation?

3. Water, poverty and prosperity

4. WSH = disease and poverty ? Inadequate water supply Unsafe water resources Inequitable access Time, financial cost Disease burden Health care costs POVERTY

5. WSH = a motor for development Improved water supply Safe water resources Universal access Time, financial savings Averted disease costs Healthy populations Development

6. Water: A health concern?

7. Leading Causes of Deaths from Infectious Diseases 2004 World Health Report

8. Non-fatal health effects  Mortality numbers can dominate conversations about health  Also concerned about non-fatal health conditions  A metric was needed to quantify non-fatal health outcomes, make informed policy decisions and allocate health resources  WHO introduced Disability Adjusted Life Years (DALYs) in 1994  Used to assess risks and benefits associated with various diseases, threats to health and interventions

9. Disability Adjusted Life Years DALY = YLL + YLD DALY = YLL + YLD YLL – years of life lost due to early deathYLL – years of life lost due to early death YLD – years of life lost to disabilityYLD – years of life lost to disability YLL = N x L YLL = N x L N = number of deathsN = number of deaths L = standard life expectancy at age of death in yearsL = standard life expectancy at age of death in years YLD = I x DW x L YLD = I x DW x L I = number of incident casesI = number of incident cases DW = disability weightDW = disability weight L = average duration of the case until remission or death (years)L = average duration of the case until remission or death (years)

10. DALY – Example Disability Weights

11. DALY – Graphical Example

12. Prüss-Ustün and Corvalán (2007) How Much Disease Burden can be Prevented by Environmental Interventions?, Epidemiology, 18:1, p. 167-178.. How much disease could be prevented by modifying the environment?

13. Diarrhoeal disease reduction from drinking water and sanitation improvements Reduction (%) Intervention Source: Fewtrell L et al. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis.Lancet Infectious Diseases, 2005

14. Diarrhoea: 1.8 million people, mostly children, die of diarrhoea every year Malaria: 1 million people, mostly children, die of malaria every year Better management of water resources reduces transmission Schistosomiasis: 200 million are infected, 20 million suffer severe consequences Basic sanitation reduces the diseases by up to 77% Trachoma 6 million visually impaired, 146 million threatened by blindness Improved sanitary conditions and hygiene practices prevents trachoma GBD – Selected water-related diseases

16. The more we know, the more environment matters ? 2002 WSH caused diarrhoea and parasitic diseases 2005 Also WSH-caused malnutrition In addition (2010?) Water hardness and heart disease, hepatitis A and E, fluorosis, arsenicosis, typhoid fever etc. 3% 4% 5% Total disease

17. Who and where are the disadvantaged?

18. WHO/OMS WHO/OMS Improved Drinking Water: Status in 2002 Meeting the MDG Drinking Water and Sanitation Target: Mid-term Assessment of Progress WHO and UNICEF, 2004

20. WHO/OMS WHO/OMS Improved Sanitation: Status in 2002 Meeting the MDG Drinking Water and Sanitation Target: Mid-term Assessment of Progress WHO and UNICEF, 2004

21. Improved Sanitation: Unserved population by region, 2002 (millions) Meeting the MDG Drinking Water and Sanitation Target: Mid-term Assessment of Progress WHO and UNICEF, 2004

22. Disparities Masked by National Averages: Rural versus urban sanitation (2002) Meeting the MDG Drinking Water and Sanitation Target: Mid-term Assessment of Progress WHO and UNICEF, 2004

23. Perspectives / trends

24. Reaching the MD Goals from 2002: What does it mean for Goal 7 Target 10? To halve, between 1990 and 2015, the proportion of the population without improved drinking water and sanitation now means means: Enabling an additional 260,000 people a day up to 2015 to use improved drinking water sources Enabling an additional 370,000 people a day up to 2015 to use improved sanitation Ensuring continuation of services to an unprecedented population and maintenance and renewal of infrastructure

25. Reaching the MD Goals from 2002: Focusing G7 T10 on the wider goals Reaching the target would: Reduce disease and death Reduce disease and death Improve nutrition and food securityImprove nutrition and food security Reduce poverty (avert health care costs, time savings) Reduce poverty (avert health care costs, time savings) Unserved, children and women likely to benefit most (health and education) Studies show WS&S to be cost effective

26. Improved Drinking Water: Trends in service levels Un-served Other 'improved drinking water source' Piped water at home Meeting the MDG Drinking Water and Sanitation Target: Mid-term Assessment of Progress WHO and UNICEF, 2004

27. Improved Sanitation: Perspectives Meeting the MDG Drinking Water and Sanitation Target: Mid-term Assessment of Progress WHO and UNICEF, 2004

28. Change 1990-2002 Global: 18% Urban: 31% Rural: 8% Change 1990-2015 Global: 37% Urban: 70% Rural: 12%

29. Reaching the MD Goals from 2002: Focusing G7 T10 on the wider goals Reaching the target would: Reduce disease and death Reduce disease and death Improve nutrition and food securityImprove nutrition and food security Reduce poverty (avert health care costs, time savings) Reduce poverty (avert health care costs, time savings) 1 billion urban dwellers to keep up with urban population growth – targetting slums 900 million rural dwellers to start to deal with the rural backlog Unserved, children and women likely to benefit most (health and education) Studies show WS&S to be cost effective

30. Why invest in water and sanitation?

31. Introduction of Municipal Water Treatment in the United States

33. Annual cost of not dealing with water and sanitation Lives lost 1.8 million annually due to diarrhoea alone 1.8 million annually due to diarrhoea alone Health care costs: USD7 billion per year to health agencies USD7 billion per year to health agencies USD340 million to individuals USD340 million to individuals Value of time lost USD 63 billion per year USD 63 billion per year

34. Cost-benefit analysis (CBA) The aim of the study was to estimate: the costs (capital and recurrent) the health benefits (diarrhoea cases and deaths) the additional benefits (costs averted, time saved) Results presented as US$ per year, per capita, per intervention. Note that these methods are highly dependent upon assumptions and that there are numerous data gaps

35. Interventions 5 interventions were modelled: Halving population w/o improved WS by 2015 (through low-tech services). Halving population w/o improved WS&S by 2015 (through low-tech services) (MDG 7). Increasing access to improved WS&S services (low- tech) for all by 2015. Increasing access to improved WS&S services (low- tech) plus disinfection at point of use, for all by 2015. Increasing access to in-house piped water and sewer connection for all by 2015.

36. Cost-effectiveness ratios (US$ per DALY averted)

37. Macro relevance? High malaria versus low malaria countries: 1% difference in annual GDP growth High malaria versus low malaria countries: 1% difference in annual GDP growth Cholera in Latin America in 1990’s Cholera in Latin America in 1990’s 3.7% average annual growth by poor countries with improved W&S (as opposed to 0.1% for those without) 3.7% average annual growth by poor countries with improved W&S (as opposed to 0.1% for those without)

38. Further Topic Details at: www.who.int/water_sanitation_health/ Suggested Reading: Pruss-Ustun, A. and C. Corvalan (2007) How much disease burden can be prevented by environmental interventions? Epidemiology. 18(1):167-78.