Safe drinking water for the most vulnerable

Abstract

Dr Greg Allgood with orphans in Orongo. More children die from diarrheal illness − about 1.8 million each year − than from HIV/AIDS and malaria combined. The vast majority of these needless deaths in the developing world can be eliminated by improved water quality, hygiene, and sanitation. Water quality, in particular, has been largely ignored in public health efforts during the last two decades, yet research has shown that water purification technologies used at the household level can save a huge number of lives. Nurses are providing a critical role in the education and training needed for community acceptance of the new technologies. A policy shift towards household water treatment can provide a rapid and cost effective approach that can be scaled up to prevent the 4000 deaths of children that occur every day. The majority of efforts in the water and sanitation sector during the last several decades were focused on providing water access to reduce the burden of collecting water; building latrines to prevent the contamination of water sources by human feces; and promotion of hand washing and other hygiene measures to prevent the spread of infectious diarrhea such as following defecation. A review by Esrey et al. (1985) showed that interventions of improved water quality provided less diarrhea reduction than improved water access, sanitation, and hygiene. However, the Esrey review examined improved water quality based on the point of collection, such as provision of standpipes, and did not examine the impact of improving water quality at the point that it is used, such as in the home. During the last decade, more than 30 randomized controlled studies involving more than 53 000 people have been conducted with a variety of interventions that improve water quality at the point-of-use or household level. A recent review of these studies by Clasen et al. (2006) demonstrated conclusively that improving water quality at the household level dramatically reduces diarrheal illness and, therefore, can save lives. The four types of proven interventions include: (1) solar disinfection or SODIS, (2) chlorination through a product typically named Waterguard or Sur L'Eau, (3) ceramic or biosand filtration, and (4) combined coagulation-disinfection through a Procter & Gamble (P&G) product called PUR Purifier of Water. A variety of technologies are needed, given the different needs of more than a billion people without safe drinking water. The technologies are all relatively low cost and are being provided inclusive of education, training, and the technology at a cost of less than US$0.01 per liter. In 2004, a number of organizations joined together under the leadership of the World Health Organization to create the International Network to Promote Household Water Treatment and Safe Storage (WHO 2007). This Network focuses on research, implementation, communication, and advocacy for household water treatment. The International Council of Nurses (ICN) was a founding member of the Network and has played a leading role in advocating these new technologies to nurses. P&G and ICN created a strategic alliance in 2002 to improve health with safe drinking water. P&G provides PUR Purifier of Water as a not-for-profit program called the Children's Safe Drinking Water Program, the signature program of P&G's global cause – Live, Learn and Thrive – aimed at improving the lives of children in need. P&G has committed to provide 3.5 billion liters of safe drinking water via the Children's Safe Drinking Water Program by 2012. As part of the P&G and ICN alliance, ICN developed a fact sheet entitled, ‘Safe Household Water: Prevents Disease, Saves Lives’, and has held scientific sessions at each of its Congresses since 2003 (International Council of Nurses 2003). In addition, ICN has partnered with P&G to provide safe drinking water in Guatemala, Malawi, Uganda, and Kenya. Together, we have learned that successful implementation of household water treatment requires credible sustained communication on proper use as well as reinforcing the benefits of improved water quality. Similar to the way that engineers have been on the front lines of providing water access through digging wells, nurses have been effective on the front lines of the effort to educate people on household water treatment. Importantly, we have discovered some of the most effective communication venues both for enabling sustained habit change as well as serving the most vulnerable. Specifically, the most effective strategies include the education of mothers on safe drinking water at health clinics such as during immunization days; provision of safe drinking water to people living with AIDS; the education of children as positive catalysts for community change; the provision of safe drinking water to malnourished children; and the use of household water treatment for cholera prevention. While each of these strategies involves nurses, some of the greatest successes targeting safe drinking water to the most vulnerable has involved health clinics, schools, and HIV/AIDS programs. Infant children are particularly vulnerable to the pathogens in contaminated drinking water. The time from weaning to development of a full immune system is the time that providing safe drinking water provides the greatest benefit. Because of this, reaching the caregivers of children at health clinics during immunization days and well-baby visits is one of the most effective strategies for the adoption of household water treatment. Anyone who has visited a health clinic in Africa knows that a mother who brings her child typically has a long day of travel and waiting. The mothers are usually nervous about their child receiving the vaccination but they understand that this bit of pain provides long-term protection. Through the work of nurses, we have learned that a visit to the health clinic can also provide mothers with education on the use of household water treatment. The mothers enjoy seeing the lively demonstrations conducted by nurses in which dirty and contaminated water is turned to clear and clean water. In addition, the demonstrations relieve the mothers' tension caused by the immunizations their babies are receiving. Research by the Centers for Disease Control (CDC) (Parker et al. 2006) showed that one year following a nurse recommendation, 71% of mothers reached in a Kenyan health clinic were still using household water treatment. School children can be catalysts for change in communities and we have found that they can be very effective in leading the adoption of household water treatment. P&G and our partners will have reached more than one million school children in the developing world by the end of 2009 with safe drinking water. These classroom sessions are demonstrated by nurses in programs with World Vision, Save the Children, PSI, CARE, and others. One of these programs in Malawi with World Vision and PSI measured a 57% decrease in school absenteeism, a 53% decrease in diarrheal disease among the community, and a 75% increase in pit latrine coverage in schools (World Vision 2008). In addition, through a partnership with ICN, safe drinking water is being provided to orphans, many of whom were orphaned from HIV/AIDS, in Kenya, Malawi, and Uganda. We found that safe drinking water and hygiene education not only reduced diarrheal illness, but led to improved social status of the orphanages in the communities because of the availability of purified water. Similar to infants, people with HIV/AIDS are particularly vulnerable to pathogens in drinking water and frequently have severe and persistent diarrhea. Water-borne parasitic infections caused by Cryptosporidium and Giardia are a particular problem, and while these infections are generally self-limiting in healthy individuals, they are frequently fatal in people with AIDS. Nurses in western Kenya started providing household water treatment products of chlorination (Waterguard) or coagulation/disinfection (PUR) to people with AIDS in 2003. The nurses began reporting anecdotally, the Lazarus type of recovery that occurs following administration of antiretroviral drugs. Based on these reports and more careful documentation of the quality of life improvement by the CDC (Lule et al. 2005), we began scaling up provision of safe drinking water to people with AIDS and have seen dramatic impacts on health through implementation programs with a dozen partners. Provision of safe drinking water for people with AIDS is a critical intervention since the absorption of antiretroviral drugs will be impaired if there is persistent diarrhea. The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is helping to provide more than 100 million liters of safe drinking water to people with HIV/AIDS in Ethiopia and Cote d'Ivoire through collaboration with CARE, Population Services International, P&G, and a number of other partners. Because safe drinking water for a person with AIDS can be provided at only US$0.02 per day, it is essential that this effort be scaled up in areas where people drink contaminated water. Due largely to the efforts of nurses in the developing world, and important new public private partnerships, household water treatment is being scaled up to save thousands of lives. There is great urgency to do more so that children do not die needlessly from lack of something as simple as clean water. Greg Allgood, PhD. is the Director of the Children's Safe Drinking Water Program at Procter and Gamble (P&G). He has a PhD in toxicology and Master of Science in Public Health. He is chair of the Communication and Advocacy Working Group of WHO's International Network to Promote Household Water Treatment and Safe Storage, and is also on the Advisory Board of the Clinton Global Initiative Health Track.