1
Global Problems, Local Solutions

OVERVIEW

In order to appreciate the complexity of the global water crisis, it must be viewed from multiple perspectives, and its effects considered on scales ranging from the individual to the planet. This chapter offers several opportunities for reflecting on the necessity of safe water and sanitation services, the consequences of their increasing scarcity, and the potential for addressing these consequences within communities, at the national level, and through international cooperation.

We begin, not with an essay or review, but with the 18-minute film Running Dry, on the DVD included with this volume and which opened the workshop. The film’s writer, producer, and director, James Thebaut, said that his work was inspired by the book Tapped Out (Simon, 1998), by the late Senator Paul Simon. The film examines the growing global water crisis and its staggering toll of some 14,000 “quiet preventable deaths” per day. Focusing on China, the Middle East, Africa, India, and the United States, Running Dry presents compelling arguments for international cooperation on water issues and highlights some promising grassroots programs to improve access to safe water.

Grassroots efforts to improve water access, sanitation, and health are also featured in the chapter’s second contribution, by Donald R. Hopkins of the Carter Center. In the course of recounting the histories of two programs supported by the Center and undertaken in Africa—the first to control trachoma in Ethiopia; the second to eliminate dracunculiasis (Guinea worm disease) in Ghana—Hopkins demonstrates the key role of behavioral change as a determinant of success for public health interventions.



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1 Global Problems, Local Solutions OVERVIEW In order to appreciate the complexity of the global water crisis, it must be viewed from multiple perspectives, and its effects considered on scales rang- ing from the individual to the planet. This chapter offers several opportunities for reflecting on the necessity of safe water and sanitation services, the conse- quences of their increasing scarcity, and the potential for addressing these con- sequences within communities, at the national level, and through international cooperation. We begin, not with an essay or review, but with the 18-minute film Running Dry, on the DVD included with this volume and which opened the workshop. The film’s writer, producer, and director, James Thebaut, said that his work was inspired by the book Tapped Out (Simon, 1998), by the late Senator Paul Simon. The film examines the growing global water crisis and its staggering toll of some 14,000 “quiet preventable deaths” per day. Focusing on China, the Middle East, Africa, India, and the United States, Running Dry presents compelling arguments for international cooperation on water issues and highlights some promising grassroots programs to improve access to safe water. Grassroots efforts to improve water access, sanitation, and health are also featured in the chapter’s second contribution, by Donald R. Hopkins of the Carter Center. In the course of recounting the histories of two programs supported by the Center and undertaken in Africa—the first to control trachoma in Ethiopia; the second to eliminate dracunculiasis (Guinea worm disease) in Ghana—Hopkins demonstrates the key role of behavioral change as a determinant of success for public health interventions. 0

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 GLOBAL PROBLEMS, LOCAL SOLUTIONS A detailed understanding of waterborne pathogen transmission pathways can inform the development and implementation of effective interventions to prevent and control diseases. Such analyses, characterized in the chapter’s third contribution by David Bradley of the London School of Hygiene and Tropical Medicine, highlight the importance of the household as a target for clean water interventions and the critical role of water access, as distinct from water quality, in preventing water-related diseases. In 1972, Bradley and coworkers published the first functional classification of water-related diseases according to their routes of transmission (White et al., 1972). This now widely used scheme struc- tures and clarifies information critical to interdisciplinary efforts to address the health effects of water and sanitation (see also Workshop Overview). Bradley revisits and critically reviews his original taxonomy of water-related disease, and suggests several modifications to incorporate recent research findings, such as the involvement of the respiratory tract in certain water-related diseases (e.g., Legionnaire’s disease; respiratory infections controlled by hand washing). Taking the same approach to the study of sanitation and disease, Bradley and coworkers identified six sanitation-related transmission categories to inform the choice of preventive measures for a given disease (see Table WO-3 in the Work- shop Overview). Bradley presents and explains this classification scheme and describes its possible integration with the functional taxonomy of water-related disease. To further advance the understanding of waterborne disease transmission processes provided by functional taxonomies, he also explores the systematiza- tion of hygiene behavior and the spatial structure of water and sanitation services. Finally, in order to assess the relevance of these concepts, Bradley applies them to a real-world system in southwest Uganda. In much of the developing world, “water is often collected from sources of dubious quality, hauled over a distance, and stored in the home before it is consumed,” observe workshop speaker Robert Tauxe, of the Centers for Disease Control and Prevention (CDC), and coworkers, who contributed this chapter’s final essay. Water gathered in this way is vulnerable to contamination between its source and its point of use, and thus requires the most local of interventions in order to ensure its safety: household water treatment and storage interventions (also known as “point-of-use” strategies). Tauxe and colleagues discuss the con- cept and practice of point-of-use water treatment and review findings of recent implementation trials of this strategy in diverse settings that demonstrate its impact on public health; some of these trials featured the effective integration of point-of-use interventions with hand washing and other public health strategies. The authors also explore the critical connection between water- and foodborne disease through a series of case studies, all of which illustrate the global effects of local water quality.

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2 GLOBAL ISSUES IN WATER, SANITATION, AND HEALTH IMPROVING WATER, SANITATION, AND HEALTH AT THE GRASSROOTS Donald R. Hopkins, M.D., M.P.H.1 The Carter Center While others are reaching the moon, we are trying to reach the villages. Julius Nyerere The Carter Center’s motto is “Waging Peace, Fighting Disease, Building Hope.” Our divisional motto in the Health Programs of The Carter Center is “Fighting Disease and Building Hope at the Grassroots.” It is in the spirit of that motto that I shall review aspects of two programs we are assisting: illustrating the interaction of water and health in the fight against dracunculiasis (Guinea worm disease) in Ghana, and the interaction of sanitation and health in the fight to control trachoma in Ethiopia. The importance of behavioral change as well as biologic control measures is also greatly evident in both programs. Trachoma Control in Ethiopia Trachoma is a chronic bacterial infection of the eye that is caused by Chlamydia trachomatis (Figure 1-1). With an estimated 8 million blinded victims, comprising 16 percent of the global burden of blindness, trachoma is the leading cause of preventable blindness in the world, and an estimated three-quarters of its blind victims are women. About 500 million persons, or about 10 percent of the world’s population, are at risk of the disease, and some 63 million are estimated to have active trachoma in 56 countries. In its early stages, the disease is characterized by inflamed inner surfaces of the eyelids, which yield pus and related secretions around the eye, to which certain species of flies (Musca sorbens) are attracted. The bacteria are spread from one person to another by the flies, and by contaminated fingers, cloths, towels, sheets, or other fomites. After repeated infections, the inflamed inner surfaces of the eye- lids become scarred and contract, turning the eyelashes inward, causing them to scrape the eyeball, which is extremely painful. The subsequent scarring of the cornea of the eye itself causes blindness. Women are affected more than men because young children are the reservoirs of infection in the remote, poor, dusty, and unhygienic villages where this infection flourishes, and women suf- fer repeated reinfections because of their close association with their children (Mabey et al., 2003). 1Vice President, Health Programs.

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3 GLOBAL PROBLEMS, LOCAL SOLUTIONS FIGURE 1-1 Patients with early (left) and late (right) trachomatous infections. SOURCE: Reprinted from WHO (2009) with permission from the World Health Organization. The World Health Organization (WHO) has developed a four-pronged approach, called the “SAFE strategy,” which combines curative and preventive control measures for achieving sustained reductions in prevalence of the dis- ease (Emerson et al., 2006). The S stands for surgery to correct inward-turning eyelashes and thus prevent progression to blindness if the surgery is conducted early enough. The A is for mass distribution of antibiotics to cure active phases of the infection, although people do not develop immunity and are still subject to reinfection. The F stands for face (and hand) washing, which decreases attraction of the disease-bearing flies by removing secretions and dirt. The E denotes envi- ronmental improvement, especially measures to prevent humans from defecating on the ground, where such deposits are preferred breeding sites for M. sorbens (Emerson et al., 2001). Worldwide, Ethiopia2 is most affected by trachoma, and the Amhara Region (population ~19 million) of Ethiopia contains 31 percent of the active trachoma in the country (Emerson et al., 2006). In partnership with national and regional health authorities and local Lions Club members, and with support of the Lions Club International Foundation, Pfizer Inc. (which donates Zithromax® antibiotic via the International Trachoma Initiative), and other donors, in October 2000, The Carter Center began assisting efforts to eliminate blinding trachoma from the Amhara Region of Ethiopia by 2012. This elimination campaign emphasizes all four components of the SAFE strategy, but the E component is of particular relevance here. Since latrines are the main intervention to prevent people from defecating on the open ground and thus denying suitable breeding places for M. sorbens, the program in Amhara Region began encouraging villagers to construct and use latrines as part of the effort to prevent trachoma. With the support of local 2 Population estimated at 85.2 million as of June 2009 (CIA, 2009a).

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 GLOBAL ISSUES IN WATER, SANITATION, AND HEALTH health and administrative leaders and Ethiopian Lions Club members, villagers in an initial area comprising parts of four districts built 1,333 simple latrines in 2002 at negligible cost beyond the labor for digging the individual pits, by taking advantage of favorable local geology and a plentiful supply of available wood, mud, and thatch (Figure 1-2). After other villagers in the area built 2,151 latrines in 2003, the program set an ambitious goal to build 10,000 latrines in 2004. What happened next astonished all who were concerned. FIGURE 1-2 Example of a latrine in Amhara Region of Ethiopia. SOURCE: Courtesy of The Carter Center/L. Rotondo.

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 GLOBAL PROBLEMS, LOCAL SOLUTIONS As villagers were mobilized to build latrines to prevent trachoma, women and girls began to take special interest for their own reasons, since local tradition allowed men to defecate in the open during the day, but forced women to wait until dark so no one could see them. One woman commented, “I am a prisoner of the daylight.” Women’s groups began pushing their husbands and other male relatives to dig latrines, which soon became status symbols and a focus for com- petition among families, villages, and officials. Villagers built not just 10,000, but more than 89,000 latrines in 2004 (O’Loughlin et al., 2006), and over 144,000 more latrines in 2005. Another woman was quoted as declaring, “Now we are equal to the men!” and another vowed, “We’ll never go back [to defecating in the field]!” After temporarily diminished output due to insecurity related to national elections, and program emphasis on distributing mosquito nets, over a quarter million latrines were constructed between January and August 2008 (Figure 1-3). This surprising feminist-led explosion in latrine building will not only help prevent trachoma but will undoubtedly reduce the spread of several intestinal parasites and diarrheal diseases as well. This experience also shows how quickly people will change their behavior when they perceive a rational reason for doing so. Dracunculiasis Elimination in Ghana Dracunculiasis (Guinea worm disease) is a parasitic infection caused by the nematode Dracunculus medinensis (Figure 1-4). The infection is manifest by one- meter-long thin white worms that emerge directly and slowly through the skin on any part of the body. The resulting pain incapacitates victims for periods aver- aging two to three months and severely constrains agricultural productivity and school attendance. People are infected by drinking water that contains tiny water fleas that have ingested immature forms of the parasite that have been spewed into stagnant ponds from emerging adult worms. This infection is only transmitted by contaminated drinking water, and there is a one-year lag between infection and emergence of the adult worm. Dracunculiasis also has no animal reservoir other than humans, no vaccine or cure, and infection confers no immunity to reinfec- tion. It can be prevented, however, by teaching villagers to filter their drinking water through a fine cloth and to not enter sources of drinking water when a worm is emerging; by treating unsafe sources monthly with a mild larvicide, ABATE®, which is safe for humans; and by providing safe sources of drinking water such as from borehole wells (Hopkins and Ruiz-Tiben, 1991). In 1986, dracunculiasis infected an estimated 3.5 million persons and some 120 million persons were at risk of the disease in impoverished rural areas of India, Pakistan, Yemen, and 17 affected African countries (Watts, 1987). Ghana 3 was the second-most highly endemic country for dracunculiasis, enumerating 3 Population estimated at 23.8 million as of June 2009 (CIA, 2009b).

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 700,000 611,997 600,000 Annual Output Cumulative Output 500,000 400,000 354,179 312,951 300,000 257,818 237,330 Number of Household Latrines 200,000 144,750 89,096 92,580 100,000 75,621 41,228 3,484 2,151 1,333 1,333 0 2002 2003 2004 2005 2006 2007 2008* Year FIGURE 1-3 Carter Center-supported household latrine construction in Ethiopia. *2008 data are provisional, January-August. SOURCE: Courtesy of The Carter Center.

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 GLOBAL PROBLEMS, LOCAL SOLUTIONS FIGURE 1-4 Guinea worm emerging. SOURCE: Courtesy of The Carter Center/L. Gubb. nearly 180,000 cases during its first nationwide village-by-village search for cases of the disease in 1989-1990. Ghana’s poor, arid, and long-neglected North- ern Region, which includes one-third of the land mass of the country and the lowest rates of literacy, school attendance, and access to safe drinking water and medical care, was found to contain 56 percent of all cases. With early external support from The Carter Center, the U.S. Centers for Disease Control and Prevention (CDC), the U.S. Agency for International Devel- opment (USAID), the Japan International Cooperation Agency (JICA), the United Nations Children’s Fund (UNICEF), the Danish Bilharziasis Laboratory, and enthusiastic support from then head of state Flight Lieutenant (retired) Jerry John Rawlings, Ghana’s Guinea Worm Eradication Program made impressive progress initially, reducing cases by 95 percent between 1989 and 1994, from 179,670 to 8,432. As a result of JICA’s targeted provision of 159 borehole wells in the North- ern Region’s agriculturally fertile Nanumba District in 1988-1989, for example, cases of dracunculiasis in the district plummeted by 77 percent in one year, from ~14,000 to ~3,000 between 1989 and 1990, with substantial associated increases in local yam production. A disastrous and ill-timed outbreak of ethnic fighting in the most highly endemic areas of the Northern Region in 1994-1995 inaugurated a 12-year-long

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 GLOBAL ISSUES IN WATER, SANITATION, AND HEALTH period of programmatic stagnation that has been overcome only in the past two years (Figure 1-5). Some of the long-standing historical enmities at play in the volatile region include memories of slave raiding during the Atlantic Slave Trade, and earlier twentieth century battles that preceded the “Guinea Fowl War” of 1994-1995 (Dawson, 2000; Skalník, 1987). These and other factors such as strongly held traditional beliefs about the disease were manifest over the past five years by the predominance of cases in one or another of the different ethnic groups. Addressing the latter challenges required targeting training, mobilization, and health education efforts to members of specific ethnic groups and their lead- ers, once their relatively low participation was belatedly recognized. Without a vaccine or curative drug, in Ghana and elsewhere the global Guinea Worm Eradication Program has had to rely on persuading large numbers of conservative villagers to change their behavior. The obvious horror and easy diagnosis of clinical dracunculiasis are advantages in that regard, but the one- year-long incubation period between infection by drinking contaminated water and appearance of the disease, and the strong traditional beliefs associated with the disease (Bierlich, 1995), are distinct disadvantages. Filtering water from the local source of drinking water, backwashing the filtered material into a clear jar or glass, and letting villagers see the numerous water fleas (and other microscopic organisms) swimming around in the water they were drinking is a very effective tool for convincing villagers to filter their water before drinking it. It also helps them understand how and why the infection comes from their drinking water. In Ghana and other dracunculiasis endemic countries, unfavorable geologic (Hunter, 1997) and sociologic factors, expense, political pressures, indifference, corruption, and managerial incompetence have often impeded attempts to bring the water supply sector to bear in endemic areas. The dramatic impact realized by the JICA project cited above has been much rarer than it ought to be in the Guinea worm eradication campaign. But advocacy by health workers in this eradication campaign for consideration to be given to distribution of disease in establishing priorities for providing and rehabilitating sources of drinking water has at least helped affirm that important principle for future decision makers. Meanwhile, the global Dracunculiasis Eradication Program has reduced cases of the disease from the estimated 3.5 million cases in 20 countries in 1986 to a projected total of less than 5,000 cases in 6 countries in 2008, with the over- whelming majority (98 percent) of remaining cases in Sudan, Ghana, and Mali, and falling fast (Hopkins et al., 2008a,b; Figure 1-6). The goal is to try to stop all transmission of dracunculiasis by the end of 2009. Acknowledgments I am grateful to Dr. Ernesto Ruiz-Tiben, director of The Carter Center’s Guinea Worm Eradication Program, and his staff; to Dr. Paul Emerson, director of The Carter Center’s Trachoma Control Program, and his staff; to the many

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200,000 179,556 150,000 123,793 100,000 Number of cases 66,697 50,000 Official Target Dates for GW Eradication in Ghana 33,464 17,918 8,432 8,894 4,877 8,921 5,473 9,027 7,402 4,739 5,611 8,290 7,275 3,981 4,132 3,358 464 0 1989^1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008*2009 Year FIGURE 1-5 Ghana Guinea Worm Eradication Program. Number of cases of dracunculiasis reported by year, 1989-2008 (1989 ^ national case search; 2008* number is provisional). SOURCE: Courtesy of The Carter Center. Figure 1-5  R01515 bitmapped base all type is reset

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0 GLOBAL ISSUES IN WATER, SANITATION, AND HEALTH FIGURE 1-6 Number of reported cases of dracunculiasis by year, 1989-2007. SOURCE: Courtesy of The Carter Center. village volunteers, health workers, local Lions Club members in Ethiopia; and to The Carter Center’s numerous donors for their support and participation in the work reported here. I also thank my executive assistant, Ms. Shandal Sullivan, for assisting me in preparing this manuscript. THE SPECTRUM OF WATER-RELATED DISEASE TRANSMISSION PROCESSES David J. Bradley4 London School of Hygiene and Tropical Medicine Introduction This paper seeks to do three things, all related to functional classification, or taxonomy, of water-related diseases. The first is to revisit the taxonomies of diseases related to water and to sanitation that I put forward more than 30 years 4 Ross Professor of Tropical Hygiene Emeritus.

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 GLOBAL PROBLEMS, LOCAL SOLUTIONS be contaminated with fecal coliforms (Henry et al., 1990). In Peru, cereals and purees prepared especially for infants were more contaminated than were the foods prepared for the rest of the family (Black et al., 1989). Household drink- ing water used in the preparation of weaning foods is one of several important sources of contamination (Motarjemi et al., 1993). It is likely that using safe water and washed hands to prepare these foods would reduce their contamina- tion. It is possible that some of the general reduction in diarrheal illness observed when household water disinfection is practiced is the result of safer foods and safer drinking water. An intervention study remains to be done that evaluates the microbial quality of weaning foods prepared in homes with and without point- of-use water disinfection. Safer Foods on the Street Street vendors provide fast, inexpensive, and convenient food and drink in much of the developing world, filling the same social niche that fast food restaurants do in the developed world. Street-vended foods can be safe if they are cooked hot and served fast (Abdussalam and Kaferstein, 1993). However, many are not, and unsafe water often appears to play a supporting role. High levels of contamination with fecal indicator bacteria have been demonstrated in surveys of street-vended food and beverages (Garin et al., 2002), and disease resulting from consuming them has been well documented. In the early 1980s, eating street- vended flavored ices was a risk factor for typhoid fever in children in Santiago, Chile (Black et al., 1985). In 1989, in Manila, Philippines, a cholera epidemic in an area not served by piped water was linked to consuming street-vended foods, particularly to a rice noodle dish, and to mussel soup (Lim-Quizon et al., 1994). In 1991, consuming street-vended foods and beverages was a risk factor for epidemic cholera in Piura, Peru, where the municipal water supply was not chlorinated, and the ice used in beverages may have been particularly risky (Ries et al., 1992). In 1993, a cholera epidemic in Guatemala City, where the munici- pal water supply was chlorinated, was linked to eating street-vended foods and flavored ices (Koo et al., 1996). From 2001 to 2003, endemic paratyphoid fever was linked to eating foods prepared outside the home, largely as street-vended foods, while typhoid fever was associated with lack of clean water and sanitation inside the home in Jakarta, Indonesia (Vollaard et al., 2004b). The street vendors of Jakarta often had fecally-contaminated hands, ice, and drinking water, and poor hand hygiene (Vollaard et al., 2004a). Even if street vendors understand the principles of safe food preparation, there is little that they can do without access to safe water for preparing food, washing their hands, and cleaning their utensils and dishes (Mahon et al., 1999). In 1994, we conducted a survey of the knowledge and practices of street vendors in two Guatemalan towns. Most vendors and their customers were aware of the importance of using clean water and hand washing, but none of the vendors did

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 GLOBAL ISSUES IN WATER, SANITATION, AND HEALTH so, perhaps because none had treated water available. In 1996, we provided a cohort of street vendors in Guatemala City with Safe Water® system containers and chorine-based disinfectant (Sobel et al., 1998). Vendors were given soap and encouraged to wash their hands with the clean water, as well as use it to prepare the drinks they sold, made from fruits and cereals. We tested the stored water, beverages, and hands of the 41 intervention vendors and 42 similar but unequipped control vendors for evidence of fecal contamination before and during the six- week intervention period. The intervention was associated with a significant decrease in fecal coliforms in the stored water, and in the beverages that they were selling, though there was little change in the contamination of their hands. The intervention was well accepted. The vendors thought it increased their sales by increasing customer confidence. In a spontaneous innovation, some vendors offered the hand washing platform to their customers, so they could wash their hands before eating. Five months later, the original intervention group of vendors was still using the water disinfection system. Though no assessment of health impact was attempted, the intervention trial showed that making clean water and soap available at the street vendors’ point of use resulted in a less contaminated product. This intervention can be easily adopted as a public health policy and incorporated into ongoing efforts to educate and license street vendors. Safer Food Processing Water is used in many stages of food production and processing. For fresh produce that is eaten without further cooking, the quality of the water that is used to spray, wash, and chill the food is linked directly to its safety. This means that the microbiological quality of the water in the developing world is of immedi- ate consequence to consumers in the industrialized world, as well as affecting the health of consumers in the country where the produce is grown. In 2001, 17 percent of fresh and frozen vegetables and 23 percent of the fresh and frozen fruit consumed in the United States was imported, largely from Latin America (Jerardo, 2003). In Europe, a growing fraction of fresh produce is imported from Africa. Outbreaks of foodborne diseases have been associated with important lapses in maintaining the safety of water used to process foods before they were imported. Investigating these outbreaks and tracing them back to their sources is difficult and requires effort, luck, and the cooperation of many parties, so it is likely that the identified outbreaks represent only the tip of the metaphorical iceberg (Tauxe et al., 2008). Shigellosis and Parsley In 1998 in Minnesota, two outbreaks occurred of a febrile bloody diarrheal illness caused by the fecal bacterium Shigella sonnei. In one outbreak, an epide- miological investigation linked illness with eating foods made with parsley, while

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 GLOBAL PROBLEMS, LOCAL SOLUTIONS in the other, parsley was strongly suspected though not proven; the parsley source for both events was the same (Naimi et al., 2003). The state health department used molecular methods to fingerprint the Shigella bacteria and showed that the Shigella strains from the two outbreaks were indistinguishable. Public health authorities around the continent were alerted and quickly reported six more out- breaks caused by Shigella sonnei with the same DNA fingerprint as the first two. In each outbreak, parsley was implicated or was strongly suspected. In addition, two other outbreaks of gastroenteritis in Minnesota caused by a second microbe, enterotoxigenic Escherichia coli, also appeared to be linked to parsley. In all, 486 persons were ill with shigellosis and 77 with enterotoxigenic E. coli diarrhea. The combination of two different enteric diseases linked to the same food item across multiple states and countries suggested that contamination by raw sewage had somehow occurred near the point of production. The parsley in these outbreaks was traced to the likely source, a farm in Mexico. Investigators from the Food and Drug Administration (FDA), Mexico, and CDC visited that farm. The farm used local municipal water to rinse and chill the parsley, though the chlorination of the municipal system was inadequate and intermittent. The farm also placed ice made from apparently unchlorinated water on the parsley to ship it chilled to the United States. It is likely that the local water and/or ice contaminated the parsley. Pre- venting such contamination would require a guaranteed potable water supply for washing and chilling the produce. It seems self-evident that water used to process fresh foods that are eaten without further cooking must be safe to drink. Jaundice and Green Onions In 2003, large outbreaks of hepatitis A infections affected customers of restaurants in Tennessee, Georgia, North Carolina, and Pennsylvania (Amon et al., 2005; Wheeler et al., 2005). A total of 1,023 cases were reported. In Pennsylvania, at least 124 of the 601 identified patients were hospitalized, and 3 died. Symptoms were jaundice, abdominal pain, fever, and the prolonged malaise characteristic of this infection in adults. In each location, illness was linked to eating green onions, which were traced back through the supply chain to likely source farms in northern Mexico. In rural Mexico, hepatitis A is a common infection in young children, acquired as a result of poor sanitation and unsafe drinking water, and usually causes relatively mild diarrhea. Investiga- tion of the farms by the FDA, Mexican authorities, and CDC revealed dubious quality of water used in packing sheds and ice machines, poor sanitation and hand washing facilities, and the possibility that young children in diapers were sitting on harvested produce (FDA, 2003). Prevention strategies include ensuring that water used for washing and icing the produce is potable, improving local sanitation and health conditions of farm worker families, and separating young children from harvested food.

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 GLOBAL ISSUES IN WATER, SANITATION, AND HEALTH Salmonella Newport Infections and Mangoes One outbreak is a cautionary tale showing how phytosanitary food regula- tions intended to prevent one problem created another. In 1999, a large outbreak of Salmonella Newport infections sickened at least 78 persons in 13 states and was linked to imported mangoes (Sivapalasingam et al., 2003). The mangoes came from one large orchard in Brazil that also exported mangoes to Europe, where no cases were identified by public health authorities. Investigation of the orchard by Brazilian authorities, FDA, and CDC revealed a difference in how the mangoes were handled that depended on their destination. To prevent the introduction of Mediterranean fruitflies, U.S. regulations mandated that the man- goes be disinfested. However, mangoes destined for Europe were not disinfested, because Mediterranean fruit flies are native to Europe. In the past, the mangoes were fumigated with ethylene dioxide gas, which has toxic effects on workers and the ozone layer, as well as on fruit flies. In the 1990s, the United States began to require dipping mangoes in a hot water bath instead. At the Brazilian orchard, the hot water dip was followed by a cold water dip to cool the mangoes. The sudden transfer of a hot mango into a cold water bath makes the interior of the fruit contract slightly, pulling water inside along with any bacteria that are present (Penteado et al., 2004). Although the quality of the water is critical to the safety of the fruit, treatment specifications did not mandate reliably safe water. The hot water was not chlorinated, and the cold water was only chlorinated once a week, though the tank was open to the tropical environment and was used daily. A point-of-use system that continuously disinfects and protects the water is needed to prevent the contamination of the fruit. One hopes that this is required wherever disinfestation via a hot water dip is mandated. As these outbreaks demonstrate, the safety of the water used to process foods is related to the health of the consumer. These scenarios offer a window into the safety of food production, whether the food is then consumed locally or exported. Using potable water for processing and chilling is a fundamental good food manufacturing practice. The health of the workers is also likely to be important, so providing clean drinking water, hand washing, and sanitation for workers and their families is not only humanitarian but also a prudent business practice. Summary and Conclusions The experiences outlined above show that substantial progress is possible with low-cost, sustainable, and effective interventions. They provide broad health benefits including fewer diarrheal illnesses and respiratory and skin infections, in both children and adults, and they decrease school absenteeism in students and teachers. Hand washing promotion can be easily added to a program that provides safe water at the point of use. Clinics and schools are good venues for introducing these interventions, to educate the public in their use, to target persons at high

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 GLOBAL PROBLEMS, LOCAL SOLUTIONS risk, and to improve institutional hygiene. Social entrepreneurs can distribute and sell safe water treatment products and soap along with other point-of-use health products. Safe water and hand washing is likely to make weaning foods and street-vended foods safer. In addition to local health benefits, safer water for drinking and food processing in the developing world makes fresh produce safer when exported to the developed world. These interventions are also likely to stimulate social development. Local production and sale of containers and disinfectants can create micro-economies. Successful interventions help people recognize the value of making their drinking water safe and keeping it safe, building a constituency for reliably safer water. Treating household drinking water can be a daily reminder of the desirability of a long-term solution. Rather than slowing demand for treated piped water, the practice of point-of-use disinfection may be an impetus for small community water systems and micro-utilities of increasing social and technical complexity. However, implementation to date has been limited, and few programs have been scaled up to the national level. Considering all the point-of-use interventions together, only about 1 percent of the billion persons lacking access to safe water have been reached to date (Clasen, 2008). Progress will accelerate if the health- care providers can engage and partner with the water department authorities, bridging the two bureaucracies that are often separate realms. One important step is to introduce water interventions in health clinics, which would likely reduce the risk of disease transmission, model healthy behavior for patients and their families, and bring the medical community into immediate contact with water issues. Progress will also accelerate if household water treatment can be coupled with other major health intervention programs, and promoted as an investment for community health. It can be a low-cost addition to programs for childhood vaccination, malaria control, and for programs to improve the quality of life in persons with AIDS. It can be integrated with maternal and child health programs, preventing illness in the youngest and most vulnerable children. Beyond the clinic, water treatment strategies can be promoted by pharmacists, traditional healers, and birth attendants. Progress in reaching the benchmarks of the Millennium Development Goals will also be faster if safe drinking water at point of use and handwashing are recognized and promoted as useful strategies. These interventions can reduce a substantial fraction of the childhood morbidity and probably can reduce the mortality that is targeted by Goal #4.9 Goal #710 aims to increase access to safe drinking water, but even if the water comes from “improved” sources there is a 9 Reduce by two-thirds the mortality rate among children under five (UNDP, 2009a). 10Target 7a: Integrate the principles of sustainable development into country policies and pro- grammes; reverse loss of environmental resources; Target 7b: Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss; Target 7c: Reduce by half the proportion of people without sustainable access to safe drinking water and basic sanitation; Target 7d: Achieve significant improvement in lives of at least 100 million slum dwellers, by 2020 (UNDP, 2009b).

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0 GLOBAL ISSUES IN WATER, SANITATION, AND HEALTH demonstrated risk for contamination as it is collected, transported, and stored in the home. Therefore, this goal would have even more health impact if it were amended to focus on increasing access to water that is safe at the moment that it is consumed. Finally, progress will be faster if decision makers find that interim point-of- use water disinfection is a logical step along the path towards safe piped water in every home. OVERVIEW REFERENCES Simon, P. 1998. Tapped out: the coming world crisis in water and what we can do about it. New York: Welcome Rain Publishers. White, G. F., D. J. Bradley, and A. U. White. 1972. Drawers of water: domestic water use in East Africa. Chicago: University of Chicago Press. HOPKINS REFEFERENCES Bierlich, B. 1995. Notions and treatment of Guinea worm in northern Ghana. Social Science and Medicine 41(4):501-509. CIA (Central Intelligence Agency). 2009a. The World Factbook: Ethiopia, https://www.cia.gov/ library/publications/the-world-factbook/geos/et.html (accessed July 14, 2009). ———. 2009b. T he World Factbook: Ghana, https://www.cia.gov/library/publications/ the-world-factbook/geos/gh.html (accessed July 14, 2009). Dawson, C. A. 2000. Becoming Konkomba: recent transformations in a Gur Society of Northern Ghana. Thesis submitted to the Department of Anthropology, University of Calgary, Alberta Canada. Emerson, P. M., R. L. Bailey, G. E. Walraven, and S. W. Lindsay. 2001. Human and other feces as breeding media of the trachoma vector Musca sorbens. Medical and Veterinary Entomology 15(3):314-320. Emerson, P. M., M. Burton, A. W. Solomon, R. Bailey, and D. Mabey. 2006. The SAFE strategy for trachoma control: using operational research for policy, planning and implementation. Bulletin of the World Health Organization 84(8):613-619. Hopkins, D. R., and E. Ruiz-Tiben. 1991. Strategies for dracunculiasis eradication. Bulletin of the World Health Organization 69(5):533-540. Hopkins, D. R., E. Ruiz-Tiben, P. Downs, P. C. Withers, Jr., and S. Roy. 2008a. Dracunculiasis eradication: neglected no longer. American Journal of Tropical Medicine and Hygiene 79(4):474-479. Hopkins, D. R., E. Ruiz-Tiben, M. L. Eberhard, and S. Roy. 2008b. Update: progress toward global eradication of dracunculiasis, January 2007-June 2008. Morbidity and Mortality Weekly Report 57(43):1173-1176. Hunter, J. M. 1997. Geographical patterns of Guinea worm infestation in Ghana: an historical contri- bution. Social Science and Medicine 44(1):103-122. Mabey, D. C., A. W. Solomon, and A. Foster. 2003. Trachoma. Lancet 362(9379):223-229. O’Loughlin, R., G. Fentie, B. Flannery, and P. M. Emerson. 2006. Follow-up of a low cost latrine promotion programme in one district of Amhara, Ethiopia: characteristics of early adopters and non-adopters. Tropical Medicine and International Health 11(9):1406-1415. Skalník, P. 1987. On the inadequacy of the concept of the traditional state-illustrated with ethno- graphic material on Nanun, Ghana. Journal of Legal Pluralism 25 and 26:301-325.

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