If, as Charles Darwin postulated in his private correspondence, the origin of all life was “some warm little pond,” it’s one of the ultimate ironies of public health that this most basic and necessary element—water—also kills and sickens millions of people a year, whether through flood or infectious disease or contamination.
Take as evidence these scenes, witnessed by Emory public health students and researchers at the new Center for Global Safe Water:
Families displaced by the 2004 tsunami in Aceh, Indonesia, gather in temporary barracks—large wooden structures divided into smaller rooms, with five to twelve people living in each room. A lack of clean drinking water makes diarrheal and infectious diseases run rampant through the crowded camps. These survivors of the deadly wave are falling victim to the invisible microbe.
In Kenya, near the arid eastern district of Kitui, a woman walks hours to get to a dry riverbed. There, she digs deeper and deeper until she can fill her pails with tepid brown water. In Machakos, children of the Masai tribe walk five miles to dip their gourds in a muddy spring, strap them on their backs, and head home. The trip dehydrates them, starting a vicious cycle.
And in the western Nyanza province, around Lake Victoria, water is plentiful, but it is contaminated by waste from animals and people and by other pollution. This district has Kenya’s highest rate of diarrheal disease, the leading cause of death for children under five. Even when water is plentiful, it’s not necessarily safe.
A group of women serving as a community water board in Ecuador agree to ration the water from a modern but insufficient water system in town rather than supplement it with water from a nearby river—the old source for all their drinking, cooking, and bathing water. They knew the river water was bad, they say, but there was no other choice. Now, there will be less water, but it will not be dirty.
In January 2004, the Rollins School of Public Health established the Center for Global Safe Water in partnership with CARE USA, the Centers for Disease Control and Prevention (CDC), and Population Services International.
The center’s sole mission is to improve access to safe water in developing countries, and it has become the intersecting point for faculty from international health, environmental health, and infectious diseases. It also serves as a training ground for graduate students, who gain hands-on experience in water and sanitation.
“There’s only so much you can learn in a classroom. You have to go where the stakes are real,” says Robert Dreibelbis 05MPH, who has worked in the slums of Dhaka, Bangladesh, where water from the city’s municipal system was heavily contaminated. “The system had been designed about a hundred years ago, and was outdated and overtaxed, cross-contaminated with sewer lines . . . about everything you could think of. Samples we took from the tap were loaded with bacteria.”
Center researchers seek local, sustainable solutions that can serve as models for similar projects in other countries—bottles of diluted bleach to treat household water, deeper and more plentiful wells, ecologically sound latrines.
The neophyte center already has a pair of practiced pros in its lineup: adjunct Emory faculty members and CDC researchers Rob Quick and Eric Mintz, who designed a simple water purification system that lowers the incidence of diarrhea by nearly half. The Safe Water System is now used in nineteen countries on five continents.
The World Bank’s Development Marketplace selected two of the center’s programs—a latrine-use assessment in Bolivia and a network of rural women enlisted to sell water purification products in Kenya—as winners in its 2006 Global Competition, offering a portion of $5 million in grants to maintain and expand these efforts.
“Water is an area of great conflict,” says Stephanie Maurissen, a second-year student in global environmental health at the Rollins School of Public Health who worked with a CARE team in Ecuador to improve water and sanitation last summer. “There are wars and protests and uprisings all occurring over water right now. The poor are realizing that they are being denied a basic human right.”
Clear, pure water is a commodity that the richest portion of the population takes for granted. We swim in sparkling pools; take long, hot showers; brush our teeth with water from our bathroom faucet; and fill glasses with precooled water from our refrigerator dispensers. If harmful pathogens are found in a city’s water supply, or if contaminants turn up in a cluster of private wells, it makes front-page news.
But this is not the case worldwide.
“Water has to be one of the greatest social divides—the split between those who have to struggle every day to get the water they need to survive and those of us who simply turn on a faucet,” says Research Assistant Professor of Global Health Rick Rheingans, in an essay in Emory’s faculty newsletter, The Academic Exchange.
This divide, Rheingans says, is created by vagaries of rainfall and the “peculiar way it moves over and through the earth;” the financial inequities between countries, communities, and households; and gender and generational roles.
The best estimates are that 1.1 billion people do not have access to clean drinking water—fully one-sixth of the global population. The health problems that stem from unsuitable or scarce water read like a list of biblical plagues: infectious diseases, withered crops, sick livestock.
As is the case with so many social disparities, children are the main victims. About five thousand children ages five and under die each day from diarrheal diseases linked to contaminated surface water, poorly functioning municipal water systems, and inadequate sanitation, according to the World Health Organization.
Cholera, typhoid fever, and dysentery are water-borne diseases, and cruel parasites such as Guinea worm and Cryptosporidium invade their human hosts through drinking water.
Women and girls bear most of the burden of gathering water where it is not readily available. They rise early to collect it from rainwater buckets, metal roofs, rivers, lakes, dams, shallow wells, and puddles.
“If you see the water sources in a lot of developing countries, you can’t believe people drink out of them,” says Matt Freeman 05MPH, research program coordinator for the Center for Global Safe Water.
“Cattle are in them, people bathe and wash clothes in them. Girls often don’t go to school during the dry season because they need to go miles at a time to get water from faraway sources. They collect it in ten- or twenty-liter cooking oil cans, plastic cans, jerrycans, and store it at home in clay pots with wide necks, which they scoop the water out of. They might even wash their hands in their drinking water. There’s a lot of contamination.”
While preparing to take a deep swallow from a murky glass of water offered to him at a home in Kenya, Freeman was forced to confront the reality of “safe” versus “drinkable.”
“I knew the water had been treated, and I’ve read the efficacy studies of chlorine. But it’s a hard thing to shift your mind around when you’re drinking water that is cloudy and doesn’t smell very good,” says Freeman.
Freeman has worked at a clinic in Guatemala, with CARE in Bolivia, and with the CDC in Kenya on water projects. “Improving water access and sanitation,” he says, “is key to almost every other social justice issue.”
Safe water has climbed to the top of most public health priority lists, but attracting enough resources—from funding to field workers—has proven more difficult. At the United Nations Millennium Summit, members adopted a goal to halve the number of people without sustainable access to safe drinking water and basic sanitation by 2015. By last year, some progress had been made, but not nearly enough to reach the goal.
In response, the United Nations launched the “International Decade for Action: Water for Life” in 2005.
“We shall not finally defeat AIDS, tuberculosis, malaria, or any of the other infectious diseases that plague the developing world,” Secretary General of the United Nations Kofi Annan asserted, “until we have also won the battle for safe drinking water, sanitation, and basic health care.”
There is no lack of knowledge about how to keep water from sickening and killing so many people, and the immediate solutions aren’t high-tech or overly expensive. Many water-related illnesses could be eliminated with a bit of chlorination, safe water storage, clean water and soap for hand and face washing, and basic latrines.
Efforts are complicated, however, by political instability, inadequate transportation, cultural norms, and a lack of support from government agencies both here and abroad.
“If the challenge of providing safe water for everyone who lacks it were easy to solve, we’d have solved it already,” says Jeff Koplan, former director of the CDC and now vice president for academic health affairs at Emory’s Woodruff Health Sciences Center.
|Center for Global Safe Water Director James Hughes.
“Our biggest challenges are poverty and a lack of political will,” adds James Hughes, former director of the National Center for Infectious Diseases at the CDC, who came to Emory last spring to direct the Center for Global Safe Water.
The center is designed to be interdisciplinary and inclusive, and its staff works closely with faculty and researchers across Emory and at other universities, such as the Georgia Institute of Technology. It relies on the support of corporate partners, such as The Coca-Cola Company and Proctor and Gamble, as well as organizations like Rotary Atlanta.
The center and its collaborative approach, says Hughes, is the brainchild of Professor Emeritus of International Health Eugene Gangarosa, his mentor and a CDC colleague with whom he has worked closely for more than three decades.
Gangarosa, an international expert in waterborne diseases who has done extensive research into methods of disinfecting water, was a professor in preventive medicine at Emory’s School of Medicine and director of the community health program, the program that evolved into the Rollins School of Public Health. Two of the Gangarosa’s four children—Ray Gangarosa 90MPH and Paul Gangarosa 94MPH—are Rollins alumni.
Faculty at the center have been supported by endowments in safe water and environmental health through chairs established by Gangarosa and his wife, Rose.
By concentrating on clean water, the Gangarosas have chosen the one area they believe can have the largest impact. From vaccination drives to hand-washing stations, global health programs “presume access to clean water,” Eugene Gangarosa says, “but that isn’t always the reality.
“Every public health intervention is affected by whether or not a mother has safe water.”
|CDC researchers Rob Quick (left) and Eric Mintz, adjunct associate professors at Rollins.
One of the simplest, most adaptable methods for improving water quality in remote areas is the Safe Water System, developed by CDC scientists Quick and Mintz, both adjunct associate professors in Emory’s Hubert Department of Global Health.
They developed the Safe Water System in response to an epidemic of cholera in Latin American countries in the early 1990s. The only prevention strategy being offered to people in affected areas was to boil the water, which wasn’t possible without great time and effort in poor households without electricity.
After reviewing techniques used around the world, Mintz and Quick decided to recommend point-of-use decontamination with sodium hypochlorite, a diluted chlorine bleach that can be produced cheaply with electricity, salt, and water, and to encourage safe storage of water in containers with narrow mouths, lids, and spigots.
The Safe Water System was first tested in Bolivia in 1993, and the scientists found that it lowered the incidence of diarrhea by nearly half. They found similarly encouraging results in Uzbekistan, Zambia, Guatemala, Kenya, and Pakistan.
More problematic, says Quick, was convincing people to make the Safe Water System a financial priority. Purchasing a steady supply of the bleaching solution, inexpensive as it was, proved to be a hardship for families who live on less than a dollar a day.
“We want to provide this for the people at greatest risk for diarrheal diseases from poor quality water. But they have very little disposable income, if any,” he says. “If the choice is between food and anything else, most people choose food.”
The project received an unexpected boost from a CARE program that has trained a network of women in Africa to sell the bleach solution and to teach people how to use the system, resulting in a source of income for the women.
Although they’ve been called the “Avon ladies of Kenya,” their product line consists not of beauty items but of public health staples—safe water supplies, protein-fortified flour, mosquito netting and repellent, and condoms.
“These were mostly AIDS widows, living with a death sentence and shunned by others in the community,” Quick says. “Jemimah, when we first started working with her, weighed about seventy pounds. She and her husband both had AIDS, and she was taking care of twenty-two people—children, grandchildren, and other AIDS orphans. When we approached her and the other women about selling Water Guard [the Safe Water System], they just grabbed onto it, and also started using it themselves. Jemimah gained about forty pounds and is on retroviral therapy, although her husband has since died of AIDS. She and the other women are now valued members of the community.”
Alumni of the Global Environmental Health program at Rollins have helped to evaluate the Safe Water System in Kenya—Shelly Bratton MPH03 traveled to Lake Victoria to compare different strategies in changing behaviors about water use and storage, and Freeman and Dan Abbott MPH05 returned to the area a few years later to build upon Bratton’s research.
“We like having a home at Emory,” says Quick. “We are epidemiologists, but by joining with the Center for Global Safe Water, we have access to economists, behavioral scientists, business expertise, all these eager MPH students. You open up a university of possibilities for collaboration.”
Not a dirty word: Better sanitation is vital to global health
Associate Professor Christine Moe, who teaches a class on “Water and Sanitation in Developing Countries,” is passionate—and optimistic—about improving access to safe water in developing countries.
But what she really loves to talk about are outhouses, dual-flush toilets, fiberglass latrines, and waste treatment facilities.
“Just this morning, I took my students on a field trip to the DeKalb County water treatment plant and the Gwinnett County water reclamation plant,” she says. “They love this field trip. It’s one of the highlights of the course for them. I even took my nine-year-old son out of school so he could go too.”
Such modern facilities are out of the question for the 2.4 billion people—more than 40 percent of the world’s population—who lack adequate sanitation. Raw sewage still flows through shallow trenches or is dumped into rivers in many parts of the world, spreading infectious diseases and contaminating water supplies.
“There’s a reason we’re not called the Center for Global Sanitation,” says Matt Freeman 05MPH, a researcher at the Center for Global Safe Water. “As little as people like to talk about water, because they don’t know how, they talk about sanitation even less, because it grosses them out. Latrines never show up on the cover of magazines. No one wants their corporate logo put on toilets.”
But attention must be paid to proper methods for the disposal of human waste, says Moe. “It’s a matter of health, but also a matter of human dignity.”
Moe has worked on water and wastewater issues since she was a VISTA volunteer in southern West Virginia.
“It was a county of about fifty thousand people, and their drinking water came from abandoned coal mines,” she says. “Basically, it was undrinkable. Residents would drive to the next county with milk jugs in their cars, fill them, and drive back again.”
Moe’s doctoral research was on drinking water and diarrhea in the Philippines. She came to Emory in 2000, drawn by its strong global water efforts, and became one of the founders of the Center for Global Safe Water, along with Rick Rheingans and Eugene Gangarosa.
“Between Emory, CARE, the CDC, The Carter Center, and Georgia Tech, we already had a brain trust on water and sanitation,” she says. “A bunch of us would gather informally to discuss the problem, and what could be done about it. [Dean] Jim Curran finally said, ‘Let’s give this center a name.’ ”
In the last decade, the push for safe water has gained support, Moe says, but sanitation has been “relatively ignored.”
“One of the main reasons girls drop out of school in developing countries is because of a lack of private, appropriate bathrooms,” she says. “Water sanitation issues affect women and children in countless ways.”
Recently, Moe worked on a sanitation project in El Salvador, building new latrines. “The people are very proud of them. They aren’t outhouses the way we think of them, but are very modern structures of fiberglass,” she says. “We tend to look down on dry sanitation, using outhouses only when camping in a state park, but it’s not feasible for the whole world to have waterborne sewage. When I think of all the drinking water we flush down the toilet every day it boggles my mind. It’s just not sustainable.”
Moe remembers an elderly woman and community leader in a slum community who had become a champion of the dry toilets UNICEF was building in the area. “These are very economical,” Moe says. “Excreta goes into one chamber, and when that one gets full, you switch to the other side, in contrast to a pit latrine, which has to be moved when it gets full.”
Homeowners saved money by not paying for water for flushing. Instead, they used handfuls of wood ash or lime after each use to control the odor. “I think about that little old lady, who proudly had her picture taken holding a handful of ash beside her toilet, and I think, that’s progress,” says Moe. “I saw Jimmy Carter giving a talk at Emory the other day, talking about building toilets in Ethiopia, and I shook his hand and said, ‘Thank you for talking about latrines.’ He told me, ‘Oh, it’s one of my favorite subjects.’
“More presidents need to be talking about sanitation. It’s a basic, fundamental human need.”