pgwi conference april 4, 2009 highlights. water, public health problems, and public health...
TRANSCRIPT
PGWI CONFERENCE APRIL 4, 2009
Highlights
Water, Public Health Problems, and Public Health Solutions: Foreground, to Background, to Foreground
Shiriki Kumanyika, PhD, MPH
PGWI Conference April 2009
Standard Methods for the Examination of Water and Wastewater
Since 1905, Standard Methods for the Examination of Water and Wastewater has represented "the best current practice of American water analysts." This comprehensive reference covers all aspects of water and wastewater analysis techniques. Standard Methods is a joint publication of the American Public Health Association (APHA), the American Water Works Association (AWWA), and the Water Environment Federation (WEF).
Standard Methods for the Examination of Water and Wastewater
Since 1905, Standard Methods for the Examination of Water and Wastewater has represented "the best current practice of American water analysts." This comprehensive reference covers all aspects of water and wastewater analysis techniques. Standard Methods is a joint publication of the American Public Health Association (APHA), the American Water Works Association (AWWA), and the Water Environment Federation (WEF).
Among the best selling publications of the American Public Health Association; more than 100 years of publication
# of articles on water and size of the volume of AJPH: 1912-2008
# Articles in the AJPH that carried the label engineers or engineering in the title
Ten Great Public Health Achievements, US, 1900-1999
• Vaccination• Motor vehicle safety• Safer workplaces• Control of infectious
diseases• Decline in CHD and
stroke deaths
• Safer and healthier foods
• Healthier mothers and babies
• Family planning• Fluoridation of drinking
water• Recognition of tobacco
use as a health hazard
Water and Chronic Diseases: Current Issues
• Cancer prevention
• Obesity and diabetes
• Oral health
• Food and environmental sustainability
Cancer Prevention Recommendations
World Cancer Research Fund/American Institute for Cancer Research, 2009
Major health consequences of obesity
• Diabetes
• Cardiovascular diseases
• Some types of cancer
Source: Luke A. Nutritional consequences of the African diaspora. Annu Rev Nutr. 2001;21:47-71. .
Global Prevalence of Obesity in Adult Males
% Obese
0-9.9%
10-14.9%
15-19.9%
20-24.9%
25-29.9%
≥30%
Self Reported data
North AmericaUSA 31%Mexico 19%Canada (self report) 17%Guyana 14%Bahamas 14%
South Central AmericaPanama 28%Paraguay 23%Argentina (urban) 20%Uruguay (self report) 17%Dominican Republic 16%
AfricaSouth Africa 10% Seychelles 9%Cameroon (urban) 5% Ghana 5% Tanzania (urban) 5%
South East Asia & Pacific RegionNauru 80%Tonga 47%Cook Island 41%French Polynesia 36% Samoa 33%
Eastern Mediterranea
nLebanon 36%Qatar 35% Jordan 33%Kuwait 28%
Saudi Arabia 26%
European RegionCroatia 31%Cyprus 27%Czech Republic 25%Albania (urban) 23%England 23%
With examples of the top 5 Countries in each Region
With the limited data available, prevalence's are not age standardised. Self reported surveys may underestimate true prevalence. Sources and references are available from the IOTF. © International Obesity TaskForce, London –January 2007
Example of Trends in Adult Obesity in Developed Countries
0
5
10
15
20
25
30
35
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Year
% P
erce
nt
BM
I =>
30kg
/m2
Australia
Canada
England
Finland
France (self report)
Iceland
Japan
Netherlands
New Zealand
Norway (Tromoso)
Sweden (Goteborg)
USA (NHANES)
Wales n(self report)
Source: Kumanyika S, Rigby N, Lobstein T, Leach R, James WPT. Obesity: Global Pandemic, In: Kopelman P, Cateron I, Dietz W, eds. Clinical Obesity in Adults and Children, 3rd Edition (in press)
www.cdc.gov
May 2002
March 2007
www.apha.org
Safe Water?
Thank You
Water,Sanitation, Hygiene(WSH)
and Health –Let’s Talk About DiarrheaJohn Borrazzo, Ph.D.
U.S. Agency for International Development
Presented atPhiladelphia Global Water Initiative
April 4, 2009
Crude death rate for infectious diseases, United States, 1900 – 1996
(per 100,000 population per year)
[Source: National Center for Environmental Health, CDC, 1999]
• WSH and health- targeting
• Relevant programmatic strategies – focusing
• Outcomes and impact - measuring
Changes in Sanitation Practices, 1990-2006
Source: “Soap, Toilets, and Taps,” UNICEF, 2009
Changes in Drinking Water Supply, 1990-2006
Source: “Soap, Toilets, and Taps,” UNICEF, 2009
But…the world keeps growing!
Yearly population to gain access 2007-2015 to meet the MDG target for improved drinking water supply
Source: U.N. MDG Global Monitoring Data, 2007
90% preventable
Undernutrition implicated in 50% of child deaths, and is also associated with diarrhea
9.2 million child (<5 yrs) deaths annually
Source: State of the World’s Children, UNICEF 2008
Source: “Safer Water, Better Health”, WHO 2008
Diarrhea – Real Progress in Reducing Mortality
• 1990 World Summit for Children Goal met by 2000 (reduce under-five diarrheal deaths by half)
Almost 3 million child deaths/year averted by 2005
Estimated 1.5 billion child diarrhea episodes/year (in developing countries)
• Still over 1.5 million child deaths/year
Where do child deaths from diarrhea occur?
sub-Saharan
Africa
South Asia
East Asia
Middle East
LAC
11 countries account for over 70% of the annual deaths
globally from diarrhea
11 countries account for over 70% of the approximately 1.52 million global deaths from diarrhea annually
0
100,000
200,000
300,000
400,000
500,000
India
Nigeria
Pakist
anDRC
China
Bangla
desh
Ethiop
ia
Angola
Afgha
nistan
Indo
nesia
Tanza
nia
Dea
ths
fro
m d
iarr
hea
90% of deaths are in children
Source: Safer water, better health (WHO, 2008)
Deaths from Diarrhea have declined in all regions
DD deaths in '000s
0
200
400
600
800
1000
1200
ECA LAC MENA SA EAP SSA
1990
2001
DD deaths reduction 1990-2001 (%)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
ECA LAC MENA SA EAP SSA
Source: WHO, 2002; ECA=Europe and Central Asia, LAC=Latin America and the Caribbean, MENA=Middle East and North Africa, SA=South Asia, EAP=East Asia and the Pacific, SSA=sub-Saharan Africa
Under-five mortality rate from diarrhea (deaths per thousand live births)
Source: The Lancet Child Survival Series, 2003
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Sierra
Leo
ne
Angola
Somali
a
Liberia
Mali
Rwanda
DR Con
go
Burund
i
Zambia
Mala
wi
Niger
ia
Ethiopia
Benin
Guinea
Moz
ambiq
ue
Uganda
Seneg
al
Cambodia
Tanza
nia
Djibout
i
Mad
agasc
ar
Kenya
Median Age-specific Incidences for Diarrheal Episodes per Child per Year from Three Reviews
of Prospective Studies in Developing Areas, 1955-2000
Source: Disease Control Priorities in Developing Countries, Second Edition; 2006
So…Targeting is Important
• Geography – sub-Saharan Africa and South Asia
• Considerations of magnitude and severity• Focus on high-risk groups – esp. young
children 6 months to 2 years of age (and also neonates).
Now let’s consider programmatic focus…
Focus on the evidence-based interventions with greatest potential for
reducing morbidity and mortality
• POU water treatment & safe storage – approximately 30-50% reduction in DD prevalence (Cochrane Review, Clasen et al., 2006)
• Optimal handwashing (meta-analysis showed 43% reduction in diarrhea prevalence, April 2003, Lancet)
• Sanitation – basic, low-cost systems can reduce DD by 30% or more
• Increasing quantities of water used – impact on general hygiene and specifically facilitates handwashing
Household Water Treatment Options
• Chlorination- SWS• PuR• Ceramic Filtration• Biosand Filtration• Multiple barrier• Solar/SODIS• Boiling
So…Programmatic Focus is Important
• Focus on evidence-based interventions
• Consider the target population and how to reach them with cost-effective programmatic approaches
• Short-term, relatively low-cost options are available
Now let’s consider what to measure…
Impact of Key Interventions on Diarrhea
42
23
39
33
24*
05
1015202530354045
Hygiene Sanitation Water supply Water quality Multiple
Intervention
% r
educ
tion
in d
iarr
hoea
What to Measure…Beyond access to improved services
• Use of sufficient quantities of water – surrogate: access to an improved source; ideal is reliable piped supply to the home
• Safe water quality at the point-of-use – surrogate: reported treatment and safe storage at household level
• Use of improved sanitation – surrogate: reduction of open defecation
• Optimal hygiene practices – surrogate: observed handwashing behavior (?)
• TAKE-HOME MESSAGES
• TARGET - Countries with high DD burden (severity, magnitude), children ages 6-24 months, newborns (caregiver handwashing)
• FOCUS - On key behavioral outcomes – water use, water quality (at POU), feces disposal, and handwashing
• MEASURE - Behaviors, not diarrhea
A NEW Culture of Multi-displinary Collaboration?
Handling wicked problems is hard work and may be dangerous to
your career .
Behavior change in institutions and professions
• The silo system of institutional competition over collaboration.
• Building collaboration around the questionnaire.
• Acknowledgement by the boss for work done outside the specialty: publications and the “waste of time” working in the community.
• Does my working with outsiders count for my promotion and tenure.
• Are we becoming “Bad Samaritans?”