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: 1912-2008

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

Ten Great Public Health Achievements, US, 1900-1999

• 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;21:47-71. .

Global Prevalence of Obesity in Adult Males

% Obese

0-9.9%

10-14.9%

15-19.9%

20-24.9%

25-29.9%

≥30%

Self Reported data

North AmericaUSA 31%Mexico 19%Canada (self report) 17%Guyana 14%Bahamas 14%

South Central AmericaPanama 28%Paraguay 23%Argentina (urban) 20%Uruguay (self report) 17%Dominican Republic 16%

AfricaSouth Africa 10% Seychelles 9%Cameroon (urban) 5% Ghana 5% Tanzania (urban) 5%

South East Asia & Pacific RegionNauru 80%Tonga 47%Cook Island 41%French Polynesia 36% Samoa 33%

Eastern Mediterranea

nLebanon 36%Qatar 35% Jordan 33%Kuwait 28%

Saudi Arabia 26%

European RegionCroatia 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

Example of Trends in Adult Obesity in Developed Countries

0

5

10

15

20

25

30

35

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Year

% P

erce

nt

BM

I =>

30kg

/m2

Australia

Canada

England

Finland

France (self report)

Iceland

Japan

Netherlands

New Zealand

Norway (Tromoso)

Sweden (Goteborg)

USA (NHANES)

Wales n(self report)

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)

www.cdc.gov

May 2002

March 2007

www.apha.org

Safe Water?

Thank You

Water,Sanitation, Hygiene(WSH)

and Health –Let’s Talk About DiarrheaJohn Borrazzo, Ph.D.

U.S. Agency for International Development

Presented atPhiladelphia 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, 1990-2006

Source: “Soap, Toilets, and Taps,” UNICEF, 2009

Changes in Drinking Water Supply, 1990-2006

Source: “Soap, Toilets, and Taps,” UNICEF, 2009

But…the world keeps growing!

Yearly population to gain access 2007-2015 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?

sub-Saharan

Africa

South Asia

East Asia

Middle East

LAC

11 countries account for over 70% of the annual deaths

globally from diarrhea

11 countries account for over 70% of the approximately 1.52 million global deaths from diarrhea annually

0

100,000

200,000

300,000

400,000

500,000

India

Nigeria

Pakist

anDRC

China

Bangla

desh

Ethiop

ia

Angola

Afgha

nistan

Indo

nesia

Tanza

nia

Dea

ths

fro

m d

iarr

hea

90% of deaths are in children

Source: Safer water, better health (WHO, 2008)

Deaths from Diarrhea have declined in all regions

DD deaths in '000s

0

200

400

600

800

1000

1200

ECA LAC MENA SA EAP SSA

1990

2001

DD deaths reduction 1990-2001 (%)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

ECA LAC MENA SA EAP SSA

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

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Sierra

Leo

ne

Angola

Somali

a

Liberia

Mali

Rwanda

DR Con

go

Burund

i

Zambia

Mala

wi

Niger

ia

Ethiopia

Benin

Guinea

Moz

ambiq

ue

Uganda

Seneg

al

Cambodia

Tanza

nia

Djibout

i

Mad

agasc

ar

Kenya

Median Age-specific Incidences for Diarrheal Episodes per Child per Year from Three Reviews

of Prospective Studies in Developing Areas, 1955-2000

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

42

23

39

33

24*

05

1015202530354045

Hygiene Sanitation Water supply Water quality Multiple

Intervention

% r

educ

tion

in d

iarr

hoea

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?”