Water for the Poor Act - 2008 Report to Congress available now

Water for the Poor Act - 2008 Report to Congress available now here.

More to follow shortly on this important document.

Water, Sanitation, Hygiene and HIV/AIDS

Thought I'd do a little research on the nexus of safe drinking water, sanitation, hygiene and HIV/AIDS tonight. I found a very interesting presentation given recently by USAID staffperson Merri Weinger at AfricaSan 2008 in Durban:

http://www.ehproject.org/PDF/ehkm/weinger-africasan2008_presentation.pdf
(PDF document)

It's a quick, introductory read. I'm not sure if you all will find anything new there but for me it does a good job of laying out the linkages between water, sanitation, hygiene and HIV/AIDS, and of quantifying the positive impact of WASH on HIV+ patients and to a certain extent the larger communities.

Note that Pepfar funds can be used for drinking water and hygiene improvements. Sanitation improvements (latrines) need outside sources of funding.

Page 14 discusses 'small doable actions' that need to be scaled up, out and over.

Then I thought of the ongoing debate (as seen in the recent LA Times article "Unintended victims of Gates Foundation generosity") between vertical (viz. disease-specific) and horizontal (viz. basic public health care) approaches to global public health challenges. The facts are, plenty of financial and political capital is flowing to one individual disease: HIV/AIDS. In my mind, it is premature to determine whether that is a good or bad idea (and there are others: malaria, TB). But how can the global watsan community work within the current situation of HIV getting a lot of attention and water getting relatively less?

Every water development organization (UNICEF, CARE, WaterPartners, WaterAid, Water For People, Living Water, and myriad others) that is working in a community where there are HIV positive people should approach Pepfar and ask for support for drinking water and hygiene promotion. Those water development organizations could make that more attractive to Pepfar by agreeing to provide sanitation facilities from their own funds. Essentially the water community should do a better job of grabbing onto the coattails of the HIV/AIDS juggernaut and get a bigger piece of the pie. The end game? - Every HIV clinic, and perhaps the surrounding families and communities could not only have ARVs and medical professionals trained in treating HIV, but also safe drinking water, sanitation and hygiene, and therefore significantly less diarrheal morbidity and mortality.

Water, Technology and the World Bank's 2008 "Global Economic Prospects" report

As interested as I am in basic and applied research, new technologies, and ways to get them to market, I am not particularly excited about new water-related technologies just for the sake of new technology. I am far more interested in the scale up, out and over of existing appropriate technologies, particularly in the developing world where people suffer not from a lack of solutions but a lack of diffusion of those solutions.










The World Bank has some very insightful things to say about all of this in its recent Global Economic Prospects report:

Page 12: One of the recurring themes in this report is that “even relatively simple technologies can have far-reaching development impacts…For example, the dissemination of the simple skills required to build rainwater collection systems can improve access to clean drinking water and reduce the incidence of disease.”

Page 55: “In developing countries, the diffusion of such technology as water and sanitation systems…(has) been tremendously important for improving household well-being, but such innovations will affect output (blogger’s italics) only over time as improved child health eventually pays off in terms of greater adult productivity (source: Alderman, Hoddinott, and Kinsey 2006; Behrman and Rosenzweig 2004; Glewwe, Jacoby, and King 2001). These technologies may also have important noneconomic societal benefits, such as improved gender equality, which are not recorded in GDP because women are more likely to engage in nonmarket production, or may appear only with a lag as improved health technologies facilitate women’s entry into the labor force over time (source: Bailey 2006; Miller 2005; Schultz 2007).”

Page 57: “A recent study of Rwanda identified simple technologies whose greater use could have a substantial impact on development. For example, the study identified a lack of qualified plumbers and water sanitation technicians as a major factor holding back the implementation of simple rainwater collection strategies that have helped improve the quality of drinking water supplies in neighboring countries.”

Examples of the diffusion (or more correctly, lack thereof) of watsan technologies appropriate for Rwanda include:

• Roof water harvesting: only on limited scale for households
• Boreholes: few and expensive
• Hand pumps: imported from region or India
• VIP and Ecosan latrines technology: available, limited uptake

To repeat, “even relatively simple technologies can have far-reaching development impacts.” And the World Bank, the U.S. government, other international donors, and most importantly the Rwandan government itself should see to it that those simple technologies get to where they are most needed.

What could happen if happen if more financial and technical resources were available to more broadly diffuse the known solutions to Rwanda’s water and sanitation challenge? Rwanda is not racing for the cure for its water and sanitation challenge – they have the cure in their hand – e.g. they and the rest of the world have been putting into practice rainwater harvesting for millennia. Rwanda needs to scale it out and over. Perfect segue to my closing remarks:

I shouldn’t be surprised by the accurateness and relevance of these ideas coming from the World Bank, considering its mission of “global poverty reduction and the improvement of living standards.”

However, considering the controversy over many of its policy and fiscal recommendations and requirements in the developing world, and the irrelevance or worse of some of those in many cases for its primary mission of alleviating poverty, I find the simple ideas in this report refreshing. The next step is to make those recommendations happen, and my hope is that the US government is taking a step toward making those happen with its recent funding of the Water for the Poor Act.

Water for the Poor Act - funded!

Happy 2008! We're off on the right foot:

As you know, the Senator Paul Simon Water for the Poor Act was signed into law in late 2005 by President Bush, making water and sanitation priorities of U.S. foreign policy. Unfortunately, Congress did not see fit at that point to fund the Act, making the Act basically the same as the President writing "Water is Important" on the back of a cocktail napkin and moving on. But it was a start - and water remains the only Millennium Development Goal that is officially a priority of U.S. foreign policy.

This lack of funding was rectified when the President signed into law the omnibus spending bill a few days ago, in which the following language was included:

"Provided further, That of the funds appropriated in this Act, not less than $300,000,000 shall be made available for safe drinking water and sanitation supply projects, including water management related to safe drinking water and sanitation, only to implement the Senator Paul Simon Water for the Poor Act of 2005 (Public Law 109-121), of which not less than $125,000,000 should be made available for such projects in Africa."

This is important for two reasons: it's give-or-take $100m more than last year, and more importantly the statutory language above makes it at least more likely that the taxpayer dollars will be invested in longterm safe drinking water and sanitation programming, and not sunk into Iraq, Afghanistan, or disaster response. The legislation essentially says "keep going with those other things, but re-emphasize the importance of longterm capacity-building for water and sanitation where the need is greatest." The most important word in the statutory may well be the "only."

Rep. Payne recently said, in support of precisely this sort of appropriation, that it's the "Water for the POOR Act, not the Water for the WAR Act." Although it is too early to tell how this will turn out, this is clearly a huge step in the right direction and I will be tracking progress closely.

Vaccinations vs. safe drinking water and sanitation

An interesting article in The Lancet late last year didn’t receive the attention that it – or at least one sentence in it – merits.

I’d like to change that with the help of my now six readers:In Vol. 368, Issue 9543 (Oct 7 – 13, 2006) The Lancet published an editorial to coincide approximately with the release of the UNDP 2006 Human Development Report “Beyond scarcity: Power, poverty and the global water crisis”.

The Lancet piece dealt with the primacy of water and sanitation in global development, and drew attention to the likelihood that the world will fail to meet the MDG on sanitation. It also highlighted the regional disparities which are masked by global progress on the water MDG (viz. progress in India and China masking a lack of such progress in subSaharan Africa). Also of note in the one page editorial was the continued/continuing lack of prioritization of water and sanitation in budgets throughout the developing world.

The sentence at the heart of the argument I want to make on this blog is:

"It is dangerously short sighted to pour immense time and resources into vaccinating children only for them to die a few years later from diarrhoeal illnesses."

I don’t care if the solution to the global safe drinking water and sanitation problem is not a “traditional” health intervention like passing out antiretrovirals or vaccinations. There is clearly not a silver bullet, or even a silver shotgun solution to the water challenge – each situation (unfortunately) requires its own unique solution. Those solutions involve fewer traditional health interventions, and more engineering and infrastructure projects, more behavioral change and education programs (think massive handwashing campaigns for women and kids like this one).

Public health officials in any country, state, province or elsewhere should support and lobby for these non-health initiatives to provide safe water and sanitation, as should the international donor community:

a) they save lives and livelihoods, and

b) less water-related mortality and morbidity frees up hospital beds, staff and other health care resources for those more traditional health interventions. A person sick from preventable waterborne diarrheal disease is occupying a hospital bed whose purpose would be better served by hosting an HIV or TB or malaria patient (plus that girl suffering from diarrhea would be better off in school thank you very much).

Health systems are burdened beyond capacity in many areas already – advocates for public health, water and sanitation throughout the developing and developed world should focus more cogently on preventing preventable illness.

And a belated Happy Birthday to the Great Soul

“A small body of determined spirits fired by an unquenchable faith in their mission can alter the course of history.”

Yes.

And to honor one of Mahatma Gandhi's greatest quotes (even if two days after his 138th birthday), I shall extol the virtues of two Indian organizations which seem to be living up to Gandhi's ideal. The leaders of these organizations are certainly determined, their work is vital to man and beast, their faith in their mission unalterable, and I can only hope they will change the course of history.

Tarun Bharat Sangh deals in community-based water systems in India. Those systems are based on millennia-old rainwater capture technologies. That captured monsoon water, which would otherwise flow directly into the sea for the most part adding little value along its way, now replenishes groundwater tables, provides drinking water for people and animals, and irrigates cropland.

TBS' founder Rajendra Singh is who I want to be when I grow up.

SCRIA does related work in arid and semi-arid regions of Rajasthan, northern India, led by their Director Sunder Lal. Their most interesting work is detailed here.

The work of both organizations is replete with best practices regarding community involvement and ownership, gender inclusiveness, decentralized planning, long term planning and budgetary cycles, and a holistic approach which incorporates the needs both of homo sapiens and the rest of the ecosphere simply by better utilizing the water resources already available to that part of India.

Give them many rupees.

Clinton Global Initiative Part 1: Water, water, nowhere

Sorry for the gap in posts – have been on the road a lot lately, including a couple of very interesting visits to water development groups in Guatemala – check out Agua del Pueblo here or google them to find out more about their work for those of you interested in Guatemala. They are primarily funded by a bilateral relationship with the Spanish government now, but looking to diversify and expand their work with water, sanitation and hygiene promotion.

I’m blogging today from right in the middle of the 2007 Clinton Global Initiative, waiting patiently for a direct mention of water, sanitation, hygiene, diarrhea, cholera, or anything… Throw me a bone people! There has been a great deal of optimistic, inspiring discussion in the plenary and breakouts so far from 52+ current and former heads of state and probably 1000 other people, representing 600+ commitments, tens of millions of lives impacted or saved, in over 100 countries.

Five significant commitments have been made public so far, the most interesting of which is the “Global Campaign to Reduce Maternal and Child Deaths in Poor Countries” launched by Norway’s Prime Minister Jens Stoltenberg with others.

Finally, a discussion early this afternoon in the Global Health session about Prime Minister Stoltenberg’s commitment elicited an interesting remark from CARE’s President and CEO Helene Gayle. She suggested that in order to meet the goals laid out by the Prime Minister, it is necessary to take a broader approach to child and maternal health, and focus on the causes of that mortality and morbidity – and she mentioned safe water and sanitation specifically.

More to come.

PS Off to question Jane Goodall about the nexus of biodiversity conservation (viz. great apes) and homo sapiens need for safe drinking water. See earlier related post here.

PPS Best quote ever: Development is about much more than safe water, but never about less.

I’ll be damned if I’m gonna pay to take a piss

Direct quote from a tourist during a recent trip to Paris: “I’ll be damned if I’m gonna pay half a euro to take a piss. I’m going to McDonald’s!”

So people have a difficult time paying to go to the bathroom in France. Not exactly a newsflash, and I think the same will be said once public toilets start becoming more prevalent in NYC. Tourists will still whistle nonchalantly through hotel lobbies to get away with doing their business for free.

In several woredas (districts) in Ethiopia, however, it’s now the hip thing to not only have your own pit latrine by your home, but to pay for the privilege. How did this happen, and in Ethiopia of all places, where the per capita GDP is $US1,000, and where only 6% (sic) of the population has access to improved sanitation facilities? What’s the secret?

Trachoma is the world’s leading cause of preventable blindness, and is caused by a lack of safe water and inadequate sanitation facilities. Transmission of trachoma can be decreased significantly by using improved sanitation facilities like pit latrines. The Carter Center’s Trachoma Control Program, in cooperation with the Ethiopian Ministry of Health, launched a program in 2002 to catalyze the building of 10,000 pit latrines to stem trachoma. If there is one global public health story over the past few years that deserves to be above the fold in every mainstream periodical, it is this one:

Pit Latrines for All Households: The experience of Hulet Eju Enessie Woreda, Amhara National Regional State, Northwest Ethiopia

The full report (in Amharic) is a bit of a read. The gist of this executive summary (in English) is this:

• 89,000 pit latrines were built (the actual number is now 225,000)
• Ethiopians have for the most part done this themselves
• Most households paid nothing for their latrines; of those who paid anything, the median amount was USD$2.80.
• The secret to success was not throwing money at the problem, or pushing some inappropriate top-down technology or infrastructure.

The secret to success is what the Carter Center calls "community mobilization, the presence of a strong political commitment among local leaders, and integration into the pre-existing community structures and practices." The latin taxonomic name for that is “Ethiopicae grandmae,” less technically “Ethiopian grandmothers,” or “informal village leaders.”

Pit latrines do not sell themselves in most cases, particularly in rural and peri-urban areas where the need to find an unspoiled place to leave a #2 is less urgent because there is simply more real estate. Latrines are frequently expensive to build and maintain, even if the local demand exists. It is often very difficult even to create that demand though, particularly in more rural communities, and difficult to ensure that those latrines are used for their intended purposes, not as homes or as cow-dung storage sheds.

This particular Carter Center program did not have the resources to build latrines themselves, but only to do the community mobilization and training. I spent several years in the late 1990s working for USAID and U.S. Department of State contractors on democracy and governance initiatives throughout Africa. Not infrequently I found that the fewer financial resources we had available for a project, the more successful it turned out to be. This was because less money led to non-financial commitment(s) being provided by local leaders, and by women’s groups in particular. Once those local commitments were made available, the sustainability of our work increased dramatically.

This Carter Center report indicates similar results from a similar approach. If Patty Stonesifer would come to me today with the “How would you spend $5b” question, my answer would be “Scale the sanitation work of both the Carter Center and Sulabh International by customizing their approaches for every country/community in the world, and blow the sanitation MDG out of the water.”

It is not cost-effective to vaccinate a newborn against polio or mumps if that child will die at three years old from a preventable waterborne disease like diarrhea or malaria or be forced into a life of leading a trachoma-blinded adult around for the rest of his/her life.

“Using a pit latrine is freedom, comfort, and honour!” — Villager from Hulet Eju Enessie Woreda

Hearts and Minds

Rear Admiral William McRaven had an intriguing quote in The Economist on June 14, 2007:

American officials insist that AFRICOM will not be all about building bases and airstrips but will co-operate with development agencies, NGOs and diplomats to win African hearts and minds and so deny terrorists havens from which to operate. Rear Admiral William McRaven, head of the special forces now operating in the Sahara, says his men are much more likely to drill boreholes and build houses than to shoot at anyone. “I don't want a fragile state collapsing any more than Greenpeace or USAID does,” he says.

Rear Admiral McRaven is Special Operations component, SOCEUR (Special Operations Command, Europe). His comment comes in the broader context of The Economist article called Policing the undergoverned spaces.

This post is not to suggest that the U.S. will win the long war by drilling boreholes, nor is it to suggest that U.S. military forces, much less the Special Forces, should be taking care of the water needs of the developing world (in fact I argue against this). There is, however, a growing recognition that along with traditional military operations we should be pursuing less militaristic methods of winning hearts of minds, particularly in countries deemed most likely to become breeding grounds for terrorists. The provision of water and sanitation becomes a particularly salient intervention in this equation. The U.S. intelligence community has realized for some time that overlaying the map of water scarce countries with the map of countries deemed the biggest threats to U.S. national security gets an almost perfect match. Plus the USG gets the biggest bang for its development dollar (in both direct and indirect returns) by investing that dollar in relatively simple water and sanitation initiatives.

One good recent example where this all comes together is CSIS's recent post on Below the Surface: U.S. International Water Policy. Erik Peterson notes:

Targeting water would also yield other geopolitical dividends—including removing what is a serious obstacle to stability and security within states and reducing the possibility for conflict or tension between countries with shared water resources. Finally, water represents an avenue for the United States to demonstrate leadership in the world at a time when its image has eroded so considerably. In short, a water-centered set of policies could represent a remarkable opportunity for the United States to “do good” while “doing well” when it comes to pursuing its own interests in the world.

So maybe this post is about how to win the long war after all.

Bush/Cheney and Global Public Health Challenges

Let's consider for a moment the article currently front and center on WaPo:

Bush Appointee Blocked Surgeon General's Draft

I don't yet have a copy of the report, but its draft includes the following:

"we cannot overstate . . . that problems in remote parts of the globe can no longer be ignored. Diseases that Americans once read about as affecting people in regions . . . most of us would never visit are now capable of reaching us directly. The hunger, disease, and death resulting from poor food and nutrition create social and political instability . . . and that instability may spread to other nations as people migrate to survive."

Yes. And without provoking a flame war by getting involved in the partisan debate associated with the release (or non-release) of this report, let me tie this article to the world's largest public challenge: unsafe water and inadequate sanitation. They are not only the world's largest public health challenges but also the most solvable.

Safe water is not gun control or abortion or Iraq. It is noncontroversial, and supported by all save a few rabid isolationists. So let's ask this White House to fully fund 2005's Senator Paul Simon Water for the Poor Act and include this request in their FY09 budget to Congress this fall. Further updates shortly on how the FY08 process is going, btw.

And in the red corner - our next 2008 contender

Senator Sam Brownback, a longstanding friend of Africa and water, continued his committed leadership by speaking at a group of national water leaders organized by Water Advocates on World Water Day March 22, 2007. In a speech given at that meeting, Sen. Brownback stated that "[t]he global water crisis is currently one of the greatest public health issues, condemning billions of people to a perpetual struggle to survive at the subsistence level. It is unconscionable that in 2007 so many people are dying from waterborne diseases." Talk to me Senator - I need a subscription to that sort of thinking.

He continued with "the crisis is most prevalent in developing countries, especially in Sub-Saharan Africa and South Asia. Many women and young girls in rural areas in Sub-Saharan African and other parts of the world must walk miles every day to retrieve water for their families."

That's two 2008 contenders on board, 7 Democrats and 9 Republicans to go, I think.

Where to Start in Africa?

William Easterly had an insightful piece "What Bono doesn't say about Africa" in the LA Times on July 6 which included:

...the typical African is a long way from being a starving, AIDS-stricken refugee at the mercy of child soldiers. The reality is that many more Africans need latrines than need Western peacekeepers — but that doesn't play so well on TV.

Couldn't agree more. The opportunities for education, health, poverty alleviation and real economic development which accrue to an individual who has a place to go to the bathroom are worth contemplating. Also worth contemplating, considering the overall pessimism regarding the potential of sub-Saharan Africa to reach the Millennium Development Goals, is the contribution that the provision of safe drinking water and improved sanitation (viz. latrines) makes to each of the other Millennium Development Goals. Much research exists to quantify the positive impact that safe drinking water and improved sanitation have on the MDGs on maternal and child health, education, poverty alleviation, gender equality and environmental sustainability. Some of the most clear findings on this are here.

John Edwards first of 2008 U.S. field to tackle safe drinking water

Democrat John Edwards recently became the first (of many - stay tuned for reports on Brownback, Obama and others) of the 2008 U.S. presidential contenders to thoughtfully tackle the global safe drinking water and sanitation issue.

His campaign website includes the following commitment:

"Invest in Clean Water: The World Health Organization has found that every $1 invested in clean water yields an economic return of $8. Edwards will double the U.S. investment in clean water. He will also convene an international summit of government, businesses, and non-profits to agree on necessary investments to make water safe worldwide by 2015."

The return on that one dollar investment may be even higher in many instances as reported here. These are both direct financial returns to individuals, families and communities, as well as significant time savings and healthcare cost savings.

For a broader look at the 2008 field and what the candidates are doing to prioritize solutions to global health challenges and extreme poverty, check out One Vote '08.

Diarrhea: the unloved red-headed stepchild of the global health debate

We all know that 1.1 billion people do not have access to safe drinking water around the world, primarily in rural communities. We all know that 2.6 billion people do not have adequate sanitation facilities. So let’s jump right into this discussion of issues related to the global safe drinking water crisis with a shout out to what is arguably the world’s largest, most solvable but least compelling public health challenge: diarrhea. For reasons which remain obscure to me, diarrhea remains under-discussed at dinner parties and cocktail hours. But so was HIV/AIDS until a few years ago, and diarrhea also kills millions of people (mostly children) in a very unappetizing fashion.

2008 is the International Year of Sanitation. Will this accomplish anything other than give me the opportunity to say the “S” word in public at the Blue Salon last weekend? Will it result in anything consequential being done by developing or developed countries to tackle this issue?

I am humbled and inspired by Dr. Larry Brilliant’s recent words about diarrhea. In February 2007 he stated “We need to reduce population growth…And the best way to control population is through increasing child survival (and) educating girls…” He continued: “It is counter-intuitive, but eradicating smallpox and vaccine-preventable disease, stopping diarrheal diseases and malaria are the best family planning programs yet devised. With fewer childhood deaths, you get lower fertility rates.” Diarrhea kills five times as many children as does HIV/AIDS, twice as many as malaria, four times as many as measles. And those are just mortality statistics.

How about diarrhea-related morbidity? You can’t compete with the negative health, social and economic impacts of 4 billion cases of diarrhea each year. This isn’t the sort of diarrhea where you spend the evening on the couch getting caught up on Netflix and eating Pedialyte ice pops to rehydrate – all within paces of a bathroom with a nice flushing john. This is the sort of diarrhea which keeps children from school, which keeps adults from working or farming, which prohibits communities and nations from pulling themselves up to the next rung of the economic development ladder. And kills two million kids each year.

Diarrhea is not just treatable, it is preventable. It is preventable through the provision of safe drinking water, adequate sanitation and hygiene education throughout the developing world. So what’s the best way for the international community to invest its limited donor financial commitments? Where’s the best return for governments in the developing world to invest their healthcare resources?