rebecca dillingham & garrick e. louis university of...
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A MULTIDISCIPLINARY APPROACH TO IMPROVING WATER ACCESS AND HEALTH IN DEVELOPING
COMMUNITIES: A CASE STUDY OF LIMPOPO PROVINCE IN SOUTH AFRICA
Rebecca Dillingham & Garrick E. Louis University of Virginia
Service in Society Fall Series
October 7th, 2010
University of Virginia, Newcomb Hall
Overview
• Global access to water and sanitation services
• Some health effects of deficient wasan services
• Wasan and health status in Limpopo
• The multidisciplinary approach in Limpopo
• The WHIL project
• WHIL project health report
• Next Steps
• Q&A
Global access to improved water & sanitation (wasan) services
• 874 million people lacked access to improved drinking
water (UNDP, 2006)
• 2.5 billion people lacked access to improved sanitation
services (UNDP, 2006)
• Lack of access results in 2 million deaths from
diarrhoeal diseases each year, over 90% of which are
children (UNDP, 2006)
• Millennium Development Goals (MDG). Goal 7, Target
10: “to halve, by 2015, the proportion of people without
sustainable access to safe drinking water and basic
sanitation” (UNDP, 2006).
The Millennium Development Goals (By 2015)
• Goal 1: Eradicate extreme poverty and hunger
• Goal 2: Achieve universal primary education
• Goal 3: Promote gender equality and empower women
• Goal 4: Reduce child mortality
• Goal 5: Improve maternal health
• Goal 6: Combat HIV/AIDS, malaria and other diseases
• Goal 7: Ensure environmental sustainability
• Goal 8: Develop a Global Partnership for Development
http://www.undp.org/mdg/basics.shtml
Global access to improved wasan services
WHO/UNICEF 2008 Report
Access to improved sanitation
WHO/UNICEF 2008 Report
Consequences of inadequate access
• Increased disease & death – 2.0 million diarrhea deaths/yr
• 99% preventable by improved WASAN
– 6 million blind from trachoma • 25% reduction possible by improved WASAN
– Schistosomiasis affects 200 million people • 77% reduction possible by improved WASAN
The consequences - indirect
• Other dependent infectious diseases – HIV/AIDS
• 63%of all people living with HIV globally live in sub-Saharan Africa— (~ 24.7 million in 2006).
• ~ 2.8 million people became infected with HIV in 2006,
• more than in all other regions of the world combined.
• The 2.1 million AIDS-related deaths in sub-Saharan Africa represent 72% of global AIDS deaths.
• How does inadequate access to wasan services influence this disease?
The consequences
• Lost productivity
– Women/girls • Water, fuel wood
• Not in school
• 55% in Africa
• Not educated
– 62 million DALYs lost each year • WASAN related
• 40 billion work hours
Children Not in School
45.525.0 20.5
42.3
23.319.0
27.6
15.212.4
0
20
40
60
80
100
120
All Girls Boys
Million
s All Other Regions
South Asia
Sub Saharan Africa
2001 data. Source: UNICEF 2005
Women & girls in developing countries walk 6km/day carrying 20L of water
The vicious cycle of poverty
Economic & social opportunity loss
Unearned tax revenue No investment in infrastructure
Lack of infrastructure services
How can we break it?
Water & Health in Limpopo
• A collaborative research, education, and community project between the people of Venda, the University of Venda (Univen) and UVA.
• Goals 1. To characterize the causal relationship between
access to adequate water and sanitation and community health
2. To craft a model for effective intervention that provides sustained access to adequate services and related community health
Univen
• Established in 1982 in Venda region of SA
• 8 Schools
– Agriculture, Education, Health Sciences, Human & Social Sciences, Law, Management Sciences, Math & Natural Sciences
• Collaboration with UVA since 2002
– UVA Global Health Fellows
Where’s Limpopo?
Limpopo Map
Limpopo Profile*
• Population 5.4Million
– 5th largest in SA
• Density – 114/sq. mi
– 4th highest in SA
• People/language
– 97.3% black, 2.4% white, 0.3% Asian
• Economy
– PCA R45,000 • 2nd poorest in SA
• 65% poverty rate
• Water Access – 78%?
• Sanitation Access -53 %?
• Most rural province
• Health
– Diarrhea 2nd leading cause of death in children under 5 and increasing.
• Education
– Adult literacy rate 63%
* Statistics South Africa, 2002 Report
Water Collection and Quality in Limpopo Province
Quantitative Testing for fecal coliform and diarrheagenic pathogens reveals unacceptable levels in surface water, stored water, and in prepared weaning foods. Similar pathogens found in patients with diarrhea both in the community and in the hospital.
•Obi et al. Water Sci Tech 2003 •Potgieter et al. J Health Pop Nut 2005
•Samie et al. JASTMH.2006
Diarrhea and Death in Limpopo Rank Cause of death YLLs %
1 HIV/AIDS 384,989 33.4
2 Diarrheal diseases 82,746 7.2
3 Homicide/Violence 65,490 5.7
4 Lower respiratory
infections
59,020 5.1
5 Tuberculosis 39,890 3.5
http://www.sahealthinfo.org/bod/limpopo.pdf
A Multidisciplinary Approach in Limpopo
RESEARCH
UVA
Univen
Funding Sources
EDUCATION
UVA
Univen
Villagers
ENGAGEMENT
UVA, Univen
Villagers, Municipality,
Traditional Leaders
Schools
Project phases 1 Engage community: ‘08-’13
2 Assess community: ‘09-’10
3 Evaluate & prioritize options: ‘10-’11
4 Select & implement solutions: ‘11-’12
5 Manage system, Monitor Health Outcomes, E1T2: ‘12-’13
6 Validate model, disseminate: 2013+
Emphasize local capacity
Ngudo Nga Zwinepe :
Learning through Photos
“Photovoice blends a grassroots approach to photography and social action. It provides cameras not to health specialists, policy makers, or professionals, but to people with least access to those who make decisions affecting their lives.”
Caroline Wang (2005). http://photovoice.com/background/index.html
Ngudo Nga Zwinepe: Learning through Photos
Ngudo Nga Zwinepe
Photo Taking
Ngudo Nga Zwinepe
Group Interviews/Debrief
Tchibvumo & Tshapasha
Tchibvumo & Tshapasha - Houses
WASAN Progress Report • Selected villages – 2008
• Community engagement – 2008 to present • Photovoice
• Water committees and volunteers
• Tshapasha water supply – 75% done
• Tchibvumo water supply planned for 2011
• Sanitation still to be addressed in both villages
In-flow pipe
Out-flow
pipe
In-flow pipe
Out-flow pipe
Water Quality
Only 22% of water samples collected from municipal taps in June-July 2009 had levels of coliform bacteria below the cutoff levels defined by the WHO.
Evidence for lasting disability effects from early childhood diarrhea (ECD):
1. Growth shortfalls (esp. HAZ-2; 8.2cm by 7yo)
2. Fitness impairment (=17% decr. work prod.) 3. Cognitive impairment (c. 10 IQ points) 4. School performance (c. 1 yr)
(increased age at starting school and age-for-grade)
Moore et al. Int J Epi 30: 1457, 2001. Guerrant DI et al. Am J Trop Med Hyg 61: 707, 1999. Niehaus et al Am J Trop Med Hyg 66: 590, 2002. Guerrant et al Tr Parasitol 18: 191, 2002. Lorntz et al PIDJ 2006.
These effects >DOUBLE the global diarrhea DALYs.
Diarrhea-Associated Mortality in HIV+ Patients on Therapy for HIV
Diarrhea at Start of HAART
No Diarrhea at Start of HAART
Log rank;
p =0.01
26.4%
18.7%
Dillingham et al. Am Jour Trop Med and Hyg. 2009
Field Test Results
Group Days of Diarrhea/Week
Control O.44
Intervention 0.1 p = 0.003, Kruskal-Wallis Test
Diarrhea Rates with and without Ceramic Water Filters
Abebe et al. 2010
Ceramic Filters in storage
Planning Clean Water Health and Hygiene Education
Water Awareness Focus Groups –
Children are a major focus
Next Steps: June-August 2011 …
•Clean Water Supply –filter construction in Tchibvumo (part 1 of 3) •Ceramic Filter Factory •Agent Based Model Testing & Calibration •Continued health & hygiene education
Summary
• Large need for access to safe wasan services
• Sub-Saharan Africa is worst affected region
• No systematic approaches to solve this problem
• Developing multidisciplinary model in Limpopo
• WHIL project is midway
• WHIL wants you!
Questions/ Comments
• Ro Livuha!
• Garrick E. Louis
• Rebecca A. Dillingham
Acknowledgements
• The community members and students whose commitment to WHIL makes it move!
• WHIL is supported by grants to the SID Center and the Center for Global Health from:
• The Jefferson Trust
• The Kelly Family of Los Angeles, CA
• The May and Stanley Smith Charitable Trust
• The Fogarty International Center of the NIH
• The presentation was prepared with invaluable assistance from graduate students of the SID Center:
• Rana Akdogan and Justin Henriques
Definitions
• Poverty • The incapacity to achieve one’s human potential
• Developing community • A community that lacks the capacity to provide
adequate access to one or more basic human services to its constituents using its local resources
• Basic human services • Services that meet human needs for:
• Clean air (indoor), water, food, shelter, sanitation, household energy, personal security
Diarrheal incidence & pathogen identification (both diarrhea and normal stool)
From a total of 53 participants, 4 cases of diarrhea have been documented.
Pathogens Total tested No positive (%)
Rotavirus 158 5 (3.2%)
Adenovirus 158 4 (2.5%)
Astrovirus 158 4 (2.5%)
E. coli Just started
Aeromonas 250 1 confirmed
Campy 193 18 (9%)
Vibrio/Yesinia 250 0
E. histolytica 187 0
Giardia 187 0
Crypto 250 1
Helminths 250 0
• Internal QC according to MOP
• External QC conducted
• QA once every week by lab supervisor
Anthropometry results & growth curves to date
-3.5
-3
-2.5
-2
-1.5
-1
-0.5
0
0.5
1
1.5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
WAZ
WAZ scores for 18 children with all
data at 5 months of age
-2.5
-2
-1.5
-1
-0.5
0
0.5
1
1.5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Length for age
HAZ scores for 18 Kids with all
data at 5 months of age
Root Causes = Capacity Factors
Factor Definition Institutional Laws, Regulations, Administration, Processes
Human Resources Professional (Type 1), Skilled Labor (Type 2),
Unskilled Labor: Literate (Type 3), Illiterate (Type 4)
Technical Supply chain: Spare parts, Supplies, Services
Economic/Financial Private Sector, Markets, Mechanisms, Taxes, Fees
Environmental/
Natural Resources
Carrying capacity of media
Stock of resources: land, water, soil type, precipitation
Energy Sources, access, intensity, utilization (efficiency)
Social/Cultural Participation, Health, Demographics
Service Supply (quantity, quality), demand, delivery, type, growth
Preliminary CFA of Limpopo Province
Factor Definition Institutional South African Water Law of 1998
Human Resources Professional (Low), Skilled Labor (Low),
Unskilled Labor: Literate (Low), Illiterate (High)
Technical Supply chain: Spare parts, Supplies, Services (Unknown)
Economic/Financial Private Sector, Markets, Mechanisms, Taxes, Fees –( Low)
Environmental/
Natural Resources
Carrying capacity of media
Stock of resources: land, water, soil type, precipitation (Medium)
Energy Sources, access, intensity, utilization (efficiency) (Low)
Social/Cultural Participation, Health, Demographics (Medium)
Service Supply (quantity, quality), demand, delivery, type, growth (Low)
Urban v. Rural Access to Water (2006)
WHO/UNICEF, 2008.
Urban v. Rural Access to Sanitation (2006)
WHO/UNICEF, 2008.
The shocking electrification problem
OECD/IEA, 2007. World Energy Outlook 2006.
Implications of electrification status
• Centralized wasan infrastructure needs the grid
• Electrification rate is lowest in SSA • 58.3 % urban areas
• 8.0% rural areas
• This does not account for the reliability factor • Standard wasan equipment designed for continuous
operation
• Back-up petrol generators are costly to operate
• Power generation not included in cost estimates
WHIL Project Issues - Water
• Water policy
– National government vs. Traditional leaders
• Water rights
• Land tenure and land use
– Federal water law and the courts
• Water allowance per capita
• WHO standard
• What is an appropriate intervention
– What can the community do with aid?
• $ is not the driver at this stage