VisiEAU 2018A Vision for Water in Haiti2018

PORT-AU-PRINCE, HAITI

Jocelyn WidmerCollege of Public Health & Health ProfessionsCollege of Design, Construction, and PlanningUniversity of Florida, Gainesville, FL, USA

Florence SergileEmerging Pathogens Institute University of Florida, Gainesville, FL, USA

Yvens CheremondCollege of EngineeringUniversité d’Etat d’Haïti, Port-au-Prince, Haïti

J. Glenn Morris, Jr.Emerging Pathogens InstituteCollege of MedicineUniversity of Florida, Gainesville, FL, USA

Emerging Pathogens InstituteWater InstituteSchool of Natural Resources & EnvironementCollege of Public Health & Health ProfessionsLevin College of LawCollege of Medicine

Faculté d’Agronomie et de Médecine VétérinaireFaculté de Droit et des Sciences EconomiquesFaculté de Médecine, de Pharmacie et Ecole de Biologie MédicaleFaculté des SciencesInstitut d’Etudes et de Recherches en Sciences SocialesRectorat de l’Université d’Etat d’Haïti

Contributors

VisiEAU 2018 A Vision for Water in Haiti, 2018

List of Acronyms...............................................................2Executive Summary..........................................................3Introduction........................................................................7Water Natural Resources............................................8 Who Owns Water? ........................................................11Environmental Impacts on Public Health..............15Water Management, Structures & Distribution...16One Health........................................................................20Key Messages.................................................................25Speakers and Themes..................................................26Suggested References................................................28

WorkshopsWater as a Natural Resource.....................................11Who Owns Water?.........................................................14WASH and Water Management.................................20Technology and Water Security................................24

BoxesDefinitions...........................................................................8Institutions Participating in Water Governance in Haiti....................................................................................12

FiguresVisiEAu 2018 Content Explored..................................5Drivers of Change for Water in Haiti..........................6Thirty Watersheds Across Haiti.....................................9Ideal Spatial Configuration of Human Development – Aquifer Recharge Nexus...........................................15 Schematic of Plaine du Cul-de-Sac Aquifer..........18

TablesPopulation of Haiti (1950 – 2040).............................9Percentage of the Population with Access to an Improved Water Source...............................................13Types of Quality Control..............................................16Access to Water & Sanitation in Haiti.....................21

Contents

Photographs taken by Jocelyn Widmer

VisiEAU 2018 A Vision for Water in Haiti, 2018

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AHDENCAEPACDCCNIGSDINEPAEAHEGHEPIFAMVFDSFDSEFMPGLAASIFASMARNDRMCIMDEMDGMENFPMICTMSPPMTPTCNGOODDODMOMSONGOREPASDGSFWMDSNRETEPACUEHUFUNICEFWASH

Haitian Association for Environmental LawCommittee for Potable Water Distribution and SanitationCenters for Disease Control and PreventionNational Center for Remote Sensing InformationNational Division for Potable Water and SanitationWater Sanitation and HygieneDepartment of Environmental and Global HealthEmerging Pathogens InstituteSchool of Agriculture and Veterinary MedicineSchool of EngineeringSchool of Law and Economics School of Medicine and PharmacyGlobal Analysis and Assessment of Sanitation and Drinking-WaterInstitute of Food and Agricultural SciencesMinistry of Agriculture, Natural Resources and Rural DevelopmentMinistry of Commerce and IndustryMinistry of EnvironmentUnited Nations Millennium Development GoalsMinistry of National Education and Professional TrainingMinistry of Interior and Communal DistrictsMinistry of Population and Public HealthMinistry of Public Works, Transportation and CommunicationNongovernmental OrganizationUnited Nations Sustainable Development GoalsUnited Nations Millennium Development GoalsWorld Health OrganizationNongovernmental OrganizationRegional Division for Potable Water and SanitationUnited Nations Sustainable Development GoalsSouth Florida Water Management DistrictSchool of Natural Resources and EnvironmentCommunal Technician for Potable Water and SanitationState University of HaitiUniversity of FloridaUnited Nations Children’s FundsWater Sanitation and Hygiene

LIST OF ACRONYMS

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Water is at the core of human existence, with availability and quality serving as a key driver for public health, agriculture, and development. As noted in the conference’s keynote address by UEH Professor Wilson Celestin, Haiti’s challenges with water span a range of issues: a lack of coordination among governmental and private institutions, at both the national and local level; infrastructural limitations to storage, treatment, and distribution systems; data deficiencies to support decision making; disjointed legislation dealing with rights to water; fragmented finance mechanisms for infrastructure enhancement; and education barriers at the community and household level which lead to pervasive health threats.

The issue with water in Haiti is not that the resource is insufficient, but that it is inadequately distributed and poorly managed. Water quality has been degraded because of social and demographic shifts over time, in conjunction with acute and chronic impacts from land use, infrastructure deterioration, and changes in climate. Sixty-two percent of urban and 34% of rural residents have access to distributed water;1 yet from 2000 to 2012, there was a smaller percentage of the population in both settings that used an improved water source.2 Water treatment practices are not yet widespread, with nearly three out of ten households (32%) drinking untreated water. Furthermore, saline contamination threatens significant urban aquifers such as the Plaine du Cul-de-Sac aquifer that provides water to 60% of the population living in the Port-au-Prince metropolitan area, due to over a century of pumping practices that are outpacing the aquifer’s ability to recharge.

With Haiti’s population currently in excess of 10 million and expected to rise to 14 million over the next twenty years, consumption rates and quality of water resources available to meet the growing demand place an increasing emphasis on the importance of water governance and management. The Framework Law of 2009 gave rise to Direction Nationale de l’Eau Potable et de l’Assainissement (DINEPA) under the Ministry of Public Works, dealing with regulation of potable water through a decentralized system of regional authorities. However, other aspects of water management fall under the jurisdiction of six national Ministries, each governed by its own rules and functioning within its own budget, making it difficult to develop a coordinated approach. This situation is further complicated by the over 50 non-governmental organizations (NGOs) which are actively participating in the water and sanitation sector.

While targets for water and sanitation have been included in the Sustainable Development Goals (SDG), the challenge lies in identifying effective interventions that respond to the diversity of water delivery in Haiti, which spans wells, community treatment centers, kiosks, water trucks, water sachets, and bottled water products; and each harbors consumer perception challenges. The presumption that groundwater in Haiti is potable and does not necessitate further treatment when derived from an engineered source is not necessarily true, and underscores the need for secondary treatment approaches at the community level that balance quantity, quality, and accessibility, with cost. Diarrheal diseases remain a significant public health challenge, with illness often caused by pathogens transmitted by contaminated water.

1 Water collected / distributed to people living within a radius of 500 m around a water point2 Defined as a source protected from exterior contamination.

EXECUTIVE SUMMARY

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Université d’Etat d’Haïti (UEH) in partnership with the University of Florida (UF) held a water summit – “VisiEAu 2018” - in Port-au-Prince, Haiti to: define natural resource characteristics specific to water in Haiti; explore water governance, rights, and legislation in Haiti and across Hispaniola; highlight systems of water management, infrastructure, and distribution; share examples of research activities that investigate the transmission of waterborne pathogens and the impact of effective interventions to date; and identify opportunities to integrate technology into water management for improved health outcomes and greater transparency of information in the decision-making process for water in Haiti.

The summit explored a range of topics by Haiti and U.S.-based experts (Figure 1). The session on Water as a Natural Resource examined issues of water volume, inventory, and spatial mapping. Professor Pierre Adam of UEH characterized the aquifer systems and processes for recharge across the 30 watersheds in the Haiti context. Professor Lionel Rabel of UEH presented data underscoring future demands on water in Haiti by citing consumption rates in reference to available water from where distribution is sourced. Dr. Tom Fraser of UF focused on water volume across various systems and fluctuations to these system, broadening the scope of the discussion to consider how human, agricultural, and food security needs can be sustainably met if an integrated water management system takes all components and user groups into consideration. Boby Emmanuel Piard, Director of the National Center for Geospatial Information (CNIGS) described the national repository of geospatial information specific to water management that exists and which is providing a network of water-related geospatial data to DINEPA.

The session on Who Owns Water? questioned issues of water governance, rights, and legislation.

Dr. Jean André Victor of UEH highlighted the challenge with water as a shared resource spanning the border between Haiti and the Dominican Republic.

Dr. Mary Jane Angelo of UF discussed legal tools from the U.S. context as a potential framework for water management in Haiti. Astrel Joseph with the Ministry of the Environment presented the current situation of water governance in Haiti at the national level, outlining the different Ministries that intersect with water governance while recognizing the diverse group of relevant stakeholders falling between those which manage water resources and those with use water resources in Haiti. Jean-Marie Raymond Noel with UEH focused on the social and communal management of water access, and in doing so encouraged a re-thinking of the matrix of responsibility to include quality, quantity, and cost considerations in water access.

The second day of the summit investigated Environmental Impacts of Water on Public Health in systems where water and health converge. In the session on Water Management, Structures, and Distribution, Cinthia J-B Blaise of DINEPA described the function of the present-day laboratory and water quality control center in metropolitan Port au Prince that exists to guarantee the quality of water and to estimate the human health risks. James Adamson with Northwater International presented the recent evaluation of the Plaine de Cul-de-Sac aquifer and its potential to increase accessibility to potable water for metropolitan Port an Prince. Johnny François from Water Mission discussed the evolution of developing community drinking water systems where the communities themselves manage their water supply through these systems, and suggested that Water Mission’s experience has been that when water supply systems provide a high level of quantity, quality, and accessibility, communities are willing to pay a nominal fee for the service. Alexandre Laraque from the Caribbean Bottling Company presented the business case of water in Haiti, first cataloguing different sources of portable water and then addressing several consumer perception challenges with water delivery.

Key Objectives of the Summit

Content Explored during the Summit

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The session on One Health explored issues of waterborne pathogens that occur naturally and that are introduced into water systems in Haiti – and then these pathogens’ impacts on human health.

Richard Gelting with the U.S. Centers for Disease Control and Prevention discussed the coverage of access to water and sanitation (WASH) in Haiti, and then strategies to improve coverage of interventions that pair with long-term commitments by the national government and active NGOs. Dr. Jacques Blaise of UEH presented the zoonotic parasite transmission risk in drinking water in Haiti from animals that are naturally occurring in the water, and those that are introduced into water by various routes of transmission. Dr. Eric Nelson of UF showcased mobile technologies used in community and clinical settings to improve data reporting on waterborne disease outbreaks to a broad range of decision-makers. Dr. Glenn Morris, Director of the Emerging Pathogens Institute chronicled UF’s efforts since 2010 to investigate waterborne pathogens in Haiti out of the infectious disease laboratory UF supports in Gressier.

The summit facilitated four collaborative working sessions, with ample discussion ensuing after each session. In these opportunities for open dialogue by summit participants, three critical questions that could drive a theory of change for water in Haiti were posed and reflected upon (Figure 2).

Is there already traction to better support integrated water management in Haiti? The summit highlighted the institutions actively engaged in the governance and management of water in Haiti, which include nine national Ministries (MDE, MARNDR, MTPTC, DINEPA, MSPP, MPCE, MCI, MENFP, and MICT); and over fifty NGOs, many of which are receiving funds from bilateral and multilateral aid institutions – and even more which directly or indirectly support community-based organizations (CBOs) that directly manage water delivery at the community scale across Haiti.

With traction clearly identified through the individual efforts of national Ministries, NGOs and CBOs – funded by multi- and bilateral aid intuitions, a subsequent question emerged: What unique partnerships exist to support governing and management of water resources in Haiti? The partnership between UEH and UF served as the convening force bringing together researchers, policy makers, program practitioners, educators, and students. This partnership is buttressed by funding agencies, donors, and research collaborators of each respective university. Universities have played an important research role in integrated water management in Haiti in the past, yet the summit showcased the role bilateral university partnerships can play in the future.

And finally, the summit showcased several different scales of technology applications currently being used and adapted for the Haiti context. Summit participants were exposed to: How technology can integrate into water management, delivery, and financing – and then what role technology can play in impacting public health during times of disease outbreak? In answering these questions throughout the summit, the way these technology applications occur among individual users, at the community scale, and through existing hardware and software platforms was emphasized.

WATER AS A

NATURAL RESOURCE

WATER M

ANAGEMENT,

STRUCTURES AND DISTRIBUTION

WHO OW

NS WATER?

ONE HEALTH

Figure 1 VisiEAu 2018 Content Explored

Critical Questions Driving a Theory of Change for Water in Haiti

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The workshop also aimed to forge strategic partnerships among relevant ministries, non-governmental organizations, and university researchers to transition policy dialogue into action; and then for this action to inform a new era of best practices in teaching through the creation of UEH’s new Water Sanitation and Hygiene Institute, which will have implications for WASH throughout communities across Haiti.

The workshop produced several key messages around a call to action for improved water management in Haiti. Chief among these were that integrated water management is essential to understanding water, which includes access, quality, and pricing; and better coordination among

the 6 Ministries, 50 NGOs and others working in the water sector in Haiti. Information is needed to improve decision-making processes, which canonly occur through improved mechanisms for data sharing alongside innovative uses of emerging field-based technologies. WASH and water management is critical to overcome the enormous burden of disease in Haiti attributed to waterborne pathogens. Innovations are occurring in system design, technology deployment for monitoring and evaluation, and capacity building, yet there remains an educational imperative to train a new generation of professionals working in water management in Haiti while also training the consumers in rural and urban communities across the country. The opportunity for partnerships to be strengthened among policymakers, researchers, program implementers, and educators is central to achieving these key goals.

PARTNERSHIPS

TECHNOLOGYTRACTION

WATER AS A

NATURAL

RESOURCE

WATER M

ANAGEMENT,

STRUCTURES AND DISTRIBUTION

WHO OW

NS WATER?

ONE HEALTH

Unique PARTNERSHIPS are already in place to support governing and management of water resources in Haiti and represent a broad range of water-related content areas and stakeholders.

There is already significant TRACTION to better support integrated water management in Haiti across key content areas.

TECHNOLOGY is being integrated into water management, delivery, and financing; and also playing an important role in impacting public health during times of disease outbreak.

Figure 2 Drivers of Change for Water in Haiti

Key Messaging as a Way Forward with Water Management in Haiti

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Université d’Etat d’Haïti (UEH) in partnership with the University of Florida (UF) held a water summit VisiEAu 2018 in Port-au-Prince, Haiti to examine topics related to water resources, governance, integrated water management, and One Health specific to the Haiti context. The summit also included discussions on how data systems through the integration of technologies can better support water management in Haiti. Over the course of the two-day summit in November 2017, researchers, policy makers, program practitioners, educators, students, and other experts discussed how best to support policies, practice, and research initiatives across areas of water access, quality, and management throughout the unique geographic, hydrologic, social, cultural and political context of Haiti. More broadly, the summit sought to:

define natural resource characteristics specific to water in Haiti;

explore water governance, rights, and legislation in Haiti and across Hispaniola;

highlight systems of water management, infrastructure, and distribution;

share examples of research activities that investigate the transmission of waterborne pathogens and the impact of effective interventions to date; and

identify opportunities to integrate technology into water management for improved health outcomes and greater transparency of information in the decision-making process for water in Haiti.

Master of Ceremony Professor Nicolas Carvil opened the summit acknowledging that there is enough available water in Haiti, yet the inefficient management of the resource gives rise to tensions in supply versus quality that were echoed throughout many of the presentations across the two-day summit – which have applications to policy, practice and research. Dr. Jacques Blaise, Vice-Chancellor of Research at UEH, emphasized that one of the aspirations of the summit was to help move forward strategic partnerships between relevant ministries, non-governmental organizations, and university researchers to transition policy dialogue into action; and then for this action to inform a new era of best practices in teaching through the creation of UEH’s WASH Institute, which will have implications for WASH throughout communities across Haiti.

UEH Professor Wilson Celestin’s keynote address highlighted the necessity of integrated water resource management in Haiti. He cited that 62% of urban residents and 34% of rural residents in Haiti have access to distributed water;1 while more broadly 77% of urban residents and 48% of rural residents have access to water.2

1 Water collected / distributed to people living within a radius of 500 m around a water point2 Defined as a source protected from exterior contamination.

Tributary of Momance River (Leogane, Haiti)

Introduction

VisiEAU 2018SUMMARY

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Beyond issues of access, Celestin explored the challenges with water in the Haiti context which span: institutions (in the lack of coordination and repetition of tasks); infrastructure (limitations to storage, treatment, and distribution systems); information (in the deficiency of data, indispensable supports for decision making); legislation (in questioning legal rights prescribed to water); finance (for investments in infrastructure); education (particularly at the community and household level). Celestin went on to explain how these sanitation problems and those of water resources protection, as the pollution of surface waters from solid and liquid waste (in addition to threats from saltwater intrusion), lead to the strong prevalence of waterborne diseases across Haiti.

Celestin proposed a series of solutions to address overwhelming challenges in institutions, infrastructure, information, legislation, finance, education, and sanitation, noting that the issue with water in Haiti is not that the resource is not sufficient, but that the resource is inadequately distributed and poorly managed. Among the recommendations, zoning, land management (including proper use of soils), and reforestation (along with control of deforestation) were proposed; along with an increase in the number of artificial lakes and potable water plants to increase storage capacity, in concert with an increase in the number of wastewater treatment centers to control contamination of the aquifer. Celestin concluded by emphasizing conservation practices be central to this integrated water management system.

Professor Pierre Adam of UEH emphasized that the practice of managing water resources be grounded in an understanding of aquifer systems and their recharge. He provided definitions of water table, groundwater, and aquifer to delineate the different components of the aquifer system specific to Haiti (Box 1) and stated that there are 30 watersheds across the country (Figure 3).

Water Natural Resources: Volume, Inventory and Mapping

Adam described the aquifer recharge process by way of characterizing continuous and discontinuous aquifers. Continuous aquifers are permeable that contain groundwater which runs through microscopic cavities of its sedimentary rock. This type of aquifer is widely distributed around the world. Discontinuous aquifers have very low permeability, yet do contain exploitable groundwater which circulates within voids in the limestone, granite, lava, or shale that develop locally by fracturing or cracking – and in the case of limestone, dissolution of the rock as a result of the groundwater flow. Haiti has both continuous and discontinuous aquifers. Adam went on to emphasize that in the face of increasing demand coupled with the continual deterioration of surface water quality, systematic use of underground water reserves has become a necessity – particularly in Haiti. If such resources are going to be used to meet the growing demand, it is important to understand if and at what rate these two types of aquifers can be renewed, determined chiefly by hydrological and environmental characteristics. Adam urged that alternative water sources to aquifers should not be pursued, given that groundwater within aquifers is much less vulnerable to contamination than surface water. Yet monitoring aquifers is critical to predict the risks for pollution based on the type of water table in the aquifer system.

BOX 1Definitions

Water table: All the water present in the saturated zone of an aquifer, which are hydraulically connected.

Groundwater: The layer of water reached and exploitable by an ordinary well; it designates a type of water table, rather than refer to groundwater in the general sense.

Aquitard: A layer of low permeability that restricts the flow of groundwater, but which can still transmit small water flows vertically from one aquifer to another.

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Professor Lionel Rabel continued the discussion of water as a renewable resource, emphasizing that just because water is a renewable resource does not mean it is not an inexhaustible resource. He cited population data from 1950 - 2040 to establish the case for growing demand on water that lies ahead for Haiti (Table 1).

With Haiti’s population currently in excess of 10 million and expected to rise to 14 million over the next twenty years, Rabel explored consumption rates and water resources available to meet the growing demand, which he listed as: rainfall, surface water, artificial reserves, and groundwater. Much of current surface water is used for irrigation, yet the quality reduces along the stream because of pressures from urbanization, with Rabel noting that the more urbanization that exists along a stream, the less the water is used for irrigation. For example, DINEPA has plans to use water from the Momance River, 29 kilometers west of Port-au-Prince to provide water to the capital city. Rabel went on to explain that surface water for the most part in Haiti is not stored. The Péligre Dam completed in 1956 is an important water reservoir for Haiti, yet today remains the only reservoir.

Figure 3 Map of Haiti’s 30 Watersheds

Table 1 Population of Haiti (1950 – 2040)

Population Year3,221,000 19505,692,000 198010,085,000 201010,911,000 201614,000,000 2040

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Groundwater resources are being equally depleted at rates exceeding their capacity to recharge, which has led to saline intrusion. Rabel acknowledged that while diverse water resources are currently available in Haiti, availabilities to provide water at an increasing demand across larger geographic regions coupled with insufficient storage capacity place an urgency on managing water resources. He noted that water is currently managed across several entities, which function largely without intra-ministerial coordination. He made a call for policy that responds to projected population growth trends exacerbated by the increasing frequency of threats brought on by changes in climate. Doing so will ensure that not only is water provisioning a priority, but the distribution of water meets WHO quality standards.

Dr. Tom Frazer suggested that much of what the summit explored with respect to water in Haiti is a microcosm of what is occurring globally. He provided continuity to the call to be forward-thinking by considering delivering water to a growing population in Haiti. To do so, Fraser provided a step-by step process initiated by inventorying water resources to better understand volume; how water moves between its various components (including surface-, ground-, and rainwater); and fluxes of water. This information allows for resources to be allocated in such a way that human, agricultural, and food security needs can all be met. Fraser encouraged that when integrated water management systems take all components and user groups into consideration, water can be delivered sustainability. Acknowledging with others that Haiti has a relatively significant supply of water, he warned that the quality has been degraded because of social and demographic shifts over time. Frazer concluded by urging that water management include provisions to return water to the environment that does not compromise its future ability to be used, insofar as water resources need to be treated for quality for consumption purposes and also be devoid of contaminants when the resource is returned back to the environment. Frazer suggested that a critical step moving forward in managing water in an integrated way is to identity information gaps that are currently prohibiting best management practices.

Bobby Emmanuel Piard, Director of the National Center for Geospatial Information (CNIGS) described the national repository of geospatial information specific to water management supported by the public institution. CNIGS stores and disseminates geospatial data, making the information accessible to different institutions upon request. The center has been able to digitize information from historical data to map and represent digitally the hydrographic surface network. In doing so, Piard noted this digitized geospatial data has led to better land management practices. The process started in 2002, when CNIGS classified the hydrographic surface network from data produced by the Ministry of Agriculture. Subsequently, in 2002 and then in 2010, CNIGS has mapped the water plans for Haiti, working off digitized locations of springs from 1978. Today, CNIGS is providing this network of water-related geospatial data available to DINEPA. Piard emphasized that such water-related geospatial data has now all been digitized and is available to decision makers through www.haitidata.org.

Estuarine Waters (Gressier, Haiti)

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Me Fabrice Fièvre, a lawyer and professor, moderated the session on issues surrounding who owns water in Haiti. He acknowledged that while water is a source of energy in Haiti, it also is a source of power. While water itself is not necessarily the problem, how water is managed and governed can be a challenge. Fièvre went on to state that when water is poorly managed and governed, it can become scarce, at which point it becomes a source of conflict.

WORKSHOPWater as a Natural Resource

Dr. Wendy Graham, Director of the Water Institute at UF and Dr. Niangona Gonomy, Director of the Rural Engineering Department at FAMV facilitated a workshop with summit participants to address water as a natural resource. The discussion focused on existing impediments to water access under the current system in Haiti, and what must be done to remedy challenges surrounding the provision of potable water. Impediments discussed include: natural factors in the unequal distribution of water (dry versus wet areas of the country); social and economic inequities; neglect in investment in water resources and management strategies; waste of water by way of inadequate storage infrastructure; lack of legislation that coordinates the above-mentioned actions; and deficiencies in data on water resources which prohibit proper planning. The discussion then shifted to mechanisms to address water resource challenges. These include: definition and coordination of responsibilities; a system of taxation that accounts for implementation of infrastructure for water distribution and storage, as well as the management of this infrastructure; education programs that reinforce the significance of coordinated management water resources in Haiti; and identification of opportunities for job creation at the community level to sustain these mechanisms.

Who Owns Water? Governance, Rights and Legislation

Dr. Jean André Victor with the School of Law and Economics at UEH explored water as a shared resource that spans the border between Haiti and the Dominican Republic. There have been four border conventions established to govern the shared resource (1929, 1935, 1936, 1978); yet these border agreements have never been implemented by either State, in large part because there have not been the appropriate financing channels integrated into the budgets of either Haiti or the Dominican Republic. Currently, the two countries support equal populations of approximately 10 million each. Despite similar populations, Victor noted that the share of land and water is unequal, and contributes to the ongoing tension between the two countries. For Haiti, this imbalance is contributing to declining water resources and reduction in water availability, exacerbated by a growing population on both sides of the border. Furthermore, hydraulic and agricultural needs are particularly at risk on the Haiti side of the border, and Victor suggested that better management of protected areas is needed. To address the climate of tension evolving between Haiti and the Dominican Republic, Victor listed several actions, including to: improve the conditions of civil status in Haiti; regulate binational trade; expand management of natural resources (including the Libon and Arroyo Blanco basins and Haitian coast); reconsider the situation of statelessness for Haitians in the Dominican Republic; and encourage the development of cooperative activities between the two countries. Victor concluded by stating that the majority of the island’s water resources are on the Dominican side, despite Haiti’s population being slightly larger. He encouraged an update in thinking about the shared water resources to encourage positive and cooperative activities to bring an end to the war in progress.

Dr. Mary Jane Angelo, Professor and Director of the Environmental and Land Use Law Program at UF discussed legal tools from the U.S. context as a potential framework for water management in Haiti. In Florida, water jurisdictions are established by watershed boundaries rather than political boundaries.

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There are five water management districts in the state, and each works across research, data collection, planning, regulation, education, restoration, land acquisition, and land management. Using water use permitting as an example, Angelo described a process whereby the goal is to allocate the use of water resources for reasonable-beneficial purposes, while protecting the public interest. The program also creates a forum to resolve water use conflicts and gives users certainty about water rights. Significant water uses (including agricultural, public supply, commercial, and industrial) in the state of Florida require a permit. Environmental Resource Permitting is cross-cutting to include water quality, water quantity, and wetland/riparian zones. In the southern part of the state, where population growth is placing unprecedented pressures on the allocation of water resources, particularly with respect to the management of storm water runoff in urban areas from agricultural practices, wetlands are increasingly functioning to mitigate the impacts for the ecosystem services they provide.

Astrel Joseph with the Ministry of the Environment discussed the current situation of water governance in Haiti, specifically outlining the different Ministries that intersect with water governance to ensure the diverse stakeholders were appropriately represented at the summit. Joseph characterized the entities involved with water in Haiti falling between those which manage water resources and those which use water resources. There are several mechanisms of exchange and coordination between these different entities which manage and use water in Haiti. Currently, water is managed by several institutions and falls under the jurisdiction of six Ministries, and each is governed by its own laws, operates from its own five-year plan, and functions within its own national budget with external contributions in the form of loans and donation. In addition to the six Ministries, there are estimated to be more than 50 NGOs which are particularly active in the field of water and sanitation, many of which are receiving funds from bilateral and multilateral aid agencies. See Box 2 for a description of the institutions participating in the governance of water in Haiti.

BOX 2Institutions Participating in Water Governance in Haiti

Ministry of the Environment (MDE): Provides coordination, support, supervision, and legislation for quality control of water; also administers educational training programs

Ministry of Agriculture, Natural Resources, and Rural Development (MARNDR): Responsible for irrigation infrastructure, flood and drought-alert systems, weather forecasts, and management of hydrometeorological data

Ministry of Public Works (MTPTC): Generation of electricity for the Péligre hydroelectric facility

National Service for Potable Water and Sanitation (DINEPA): As the main entity responsible for potable water and sanitation, oversees implementation of regulation of public service providers

Ministry of Public Health and Population (MSPP): Administers the quality of water and health-related diseases caused by water; responsible for basic sanitation

Ministry of Planning and External Cooperation (MPCE): Responsible for development and implementation of a national planning policy, which includes the water sector

Ministry of Commerce (MCI): Regulates the quality of treated and packaged water for sale on the market to protect consumers

Ministry of National Education (MENFP): Responsible for promoting quality water for human consumption

Ministry of Interior and Territorial Communities (MICT): Provides guidance to mayors responsible for sanitation and road works

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Joseph acknowledged that demographic pressures; deficiencies in centralized water supply and sanitation services; and technical, socio-economic, and institutional difficulties in managing available water resources exacerbates challenges with water in Haiti. The Ministry of the Environment is working under its new strategy to prioritize and integrate the issue of water into its mandate. This includes aspects of planning, legislation, conservation, rehabilitation, sustainable use, and monitoring, with the Ministry of the Environment posed to take the lead coordinating the diverse set of actors involved in water in Haiti.

Professor Jean-Marie Raymond Noel, with the School of Engineering at UEH moved beyond the national entities that manage water in Haiti to focus on the social and communal management of water access. The Framework Law of 20093 gave rise to DINEPA to decentralize water management to local structures OREPAs4 and CAEPAs.5 Noel questioned the realism of the transference of the responsibility of water management to communities. He went on to say that this transference of management created the illusion that rural populations were going to have access to potable water now that municipalities had jurisdiction over water management. Panning out from the municipal scale, Noel reminded the global burden of those who use contaminated water to be 2 billion (Report Global Analysis and Assessment of Sanitation and Drinking Water, WHO 2017).

Year Urban Rural Haiti2000 89.8 54.8 67.82005 89.1 49.6 65.02012 87.2 49.2 64.5

This poses a challenge that is both public health and economic in nature, yet for every dollar invested in WASH,6 there has been proven to be a $4.30 return on investment.7 Noel urged not only for the mobilization of monetary investments in the water sector, but also for some concrete measures to demonstrate better decentralized management and improvements in health outcomes.

Noel went on to cite rates from 2000 to 2012 where there was a reduction in the percentage of the population in both urban and rural settings that use an improved water source,8 which creates a situation for concern, particularly for rural areas (Table 2). Furthermore, water treatment practices are not yet widespread in Haiti, with nearly three out of ten households (32%) that do not treat drinking water.

India Mark II Handpump Installed by NGOs (Leogane, Haiti)

Table 2 Percentage of the Population with Access to an Improved Water Source

3 Framework Law of 2009: Law on the organization of Drinking Water and Sanitation sector 4 OREPAs (Regional Office for Potable Water and Sanitation) are in charge of water and sanitation in Haiti.5 CAEPAs (Potable Water and Sanitation Committees) manage water and sanitation systems in rural and suburban areas in Haiti. 6 OMS February 2017 online at http://www.who.int/ water_sanitation_health/monitoring/economics/fr/7 http://www.who.int/water_sanitation_health/ monitoring/economics/fr/8 Defined as a source protected from exterior contamination.

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Noel urged that when discussing water access issues, quality, quantity and cost should be considered. Cost is especially important in a country such as Haiti where the purchasing power is low, because people consider water a basic social service. To this end, people do not always want to pay for water, which creates a difficult context in which to sustain potable water systems. Noel encouraged engaging communities in the planning and inventorying phase, in addition to the monitoring phase, so that by being involved throughout the process, individuals can understand associated costs to maintain water systems. Through this progression, implementing pricing policies would follow logically, which currently vary across the country. In Jacmel for example, there is a progressive payment system where individual users pay in installments, which encourages practices of community and social management of water.

Prior to the Framework Law of 2009, Noel acknowledged that there were too many actors involved in the water sector in Haiti. It has yet to solve the challenge of coordinating actions, particularly in transferring management to communities. Noel lamented that the current state of affairs is far from the hopes raised by the reform of 2009, principally because the national budget is fragile and approaches to experiment with social and community management have neither been fully embraced nor executed. He urged that in re-thinking the matrix of responsibility, the national government must still be present in the management of water systems. Ultimately for community and social management of water, Noel cited the article 20 of the Framework Law of 2009 and stated that there must be commitment by the national government to ensure especially rural populations do not get left out of management schemes, while including private operators and / or NGOs in the matrix of responsibility. He concluded by saying that such an approach would ensure that neither urban nor rural citizens would fall out by this divide in community management of water.

9 http://pole-eau.ueh.edu.ht/pole-eau/

WORKSHOPWho Owns Water?

Dr. Mary Jane Angelo along with Samantha Jacob, UF Law Student, and Professor Montes Charles, FAMV faculty and Director of Agricultural Infrastructure with Ministry of Agriculture, Natural Resources, and Rural Development facilitated a workshop with summit participants to address questions of who owns water in Haiti. The discussion focused on governance, rights, and legislation. The group identified existing impediments, which can be characterized as: technological constraints; educational deficiencies; institutional barriers; and transparency challenges in water management. To assuage these impediments, the group proposed improved coordination between Ministries, alongside a new government entity where this coordination would live. In addition, a focus on measurement (derived from the SDG framework) across all indicators of water management would provide opportunities for collaborative research activities. POLE-EAU9 is an innovative example of a research collaboration between DINEPA and EUH to improve water management in Haiti.

Permanent overflow of National #2 (Mariani, Haiti)

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The second day of the summit built off the definitions and context established in day one as a way of focusing in on the environmental impacts on public health related to waterborne diseases. Dr. Evans Emmanuel from the University of Quisqueya in Haiti provided keynote remarks, which focused on the nexus between water and health (Figure 4). He stated that with the growth of population alongside an increase in unregulated industrial activities, the natural water resources of Haiti have become polluted. He went on to say that such unmanaged water pollution will continue to be a health hazard for humans who consume the water. Referencing a 1980 – 1991 study between Haiti and the UN that inventoried water resources, including the physical and chemical characteristics of water in Haiti, the database created from this inventory is still largely used

Environmental Impacts of Water on Public Health

today, despite increases in population, shifts in urban and rural demographics, and the onset ofseveral catastrophic natural disasters which have all complicated water-related infrastructure in the country over the past three decades. This study identified six hydrologic regions, one of which is the Plaine de Cul de Sac, a fertile lowland that encompasses Port au Prince and provides water to 60% of the population living in the metropolitan area, yet that is increasingly contributing to saline contamination of the aquifer due to over a century of pumping practices that are outpacing the aquifer’s ability to recharge. Emmanuel noted because of high concentrations of fluoride in the water, there are significant health impacts (particularly cavities and in some cases skeletal fluorosis) that affect individuals who consume water from Plaine de Cul de Sac. Emmanuel stressed the need to continue to evaluate health risks associated with water. While there is an emphasis to address waterborne pathogens, he urged that there needs to be

Figure 4 Ideal Spatial Configuration of Human Development – Aquifer Recharge Nexus

15

complementary efforts to better understand water contaminants that occur naturally due to geology.

Engineer Cinthia J-B Blaise, Director of Laboratory and Water Quality Control for DINEPA began by addressing water in Haiti not as a matter of scarcity nor limitation of resources, but in the rational management of resources that necessitate different strategies in rural and urban contexts. The modern history of potable water distribution in Haiti began in 1962 when the Technical Center of Exploitation of the Metropolitan Region (CTE-RMPP) of Port-au-Prince was created and charged with supplying potable water to the municipal area (including Carrefour, Port au Prince, Petion-Ville, and Delmas). Then in 1971, the Laboratory Unit and Water Quality Control was created to provide self-monitoring of water distributed by the CTE-RMPP. In addition, the lab provides daily control of residual chlorine at the subscriber level and water quality control at sources (19), drilling (18) and reservoirs (18). Blaise characterized the main challenges with potable water across the CTE-RMPP as structural in terms of instability in the network of distribution, which give rise to challenges with contamination, brought on by deforestation, decreases of the flow of the source, reduction of groundwater recharge, increased urbanization in Plaine du Cul-de-Sac alongside the absence of urban planning strategies, and lack of maintenance to an over-burdened network of water delivery. These issues are compounded by the fact that the majority of municipalities in the metropolitan region lack septic tanks, and where they do exist (22% of solid waste is collected), they are not connected to a central system to manage the 600,000 tons of solid waste produced annually in the area. Given the lack of infrastructure to accommodate wastewater, still only 10% of households in the metropolitan area buy treated water, which Blaise argued contributes to the spread of many infectious diseases. In rural areas, the situation is worse, where only 37% of the population has access to drinking water, which comes from a variety of sources (rivers and spring, purchased bucket, tap, and public fountain). These

Source Type Test ConductedSprings, Drilling Residual chlorine, and Cistern microbiological and physicochemical analysis Distribution Network Residual chlorine, microbiological analysis

Water Management, Structures and Distribution

water sources are contaminated as a result of: feces or other microbial sources due to lack of a protective perimeter; infiltration of the groundwatertable; latrines; and industrial discharge. Despite these vast sources of contamination, human consumption still occurs, leading to diseases such as cholera, diarrhea, typhoid, and others.

Blaise stressed the importance of conducting water analysis from the source, at the point of distribution, and at the consumer’s tap as a way of detecting any changes in the quality of the water at the source while also testing the effectiveness of the treatment system. Water testing is conducted regularly to guarantee the quality of water and to estimate the human health risks related to the presence of bacteria in the water (Table 3).

Various Methods of Water Access (Leogane, Haiti)

Table 3 Types of Quality Control

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Blaise noted that the establishment of protection perimeters around catchment points has been an important tool contributing to improved quality of distributed water. When water presents a human health risk, the use of water is stopped and treatment measures are put in place. Blaise urged for better enforcement in laws that govern water quality in Haiti, along with more civic education to raise awareness around the health impacts of contaminated water.

James Adamson with Northwater International presented the recent evaluation of the Plaine du Cul-de-Sac aquifer and its potential to increase accessibility of potable water to metropolitan Port au Prince. He prefaced his evaluation by stating that currently in Haiti there is an information and knowledge gap to support informed and cost-effective decisions around water delivery. He urged a culture of open and accessible data sharing among those working across policy, research, and practice in Haiti to improve the collective decision-making capacity.

Adamson conducted geophysical and hydrogeological analysis to characterize the aquifer and determine the best locations to consider drilling new wells. His team also identified abandoned agricultural wells throughout Plaine du Cul-de-Sac that have the potential to be rehabilitated. Through the analysis, Adamson

estimates that 80% of the recharge of the Plaine du Cul-de-Sac aquifer may originate from river seepage from Riviere Grise and Riviere Blanche (Figure 5). He also found that there is not necessarily salt water intrusion occurring in the area of some DINEPA production wells, as had been previously speculated. The phenomenon is rather a dynamic interaction between several aquifer layers of various ages, pressures, and varying concentrations of minerals. Yet he did note that salt water intrusion is a concern for the aquifer due to overexploitation, and if wells are drilled too deep, they may intersect rock formations that produce ancient brackish groundwater that can have elevated arsenic concentrations. His analysis revealed that the water table has recovered in some instances as much as three meters since the Haitian-American Sugar Company ceased operation of their 60+ wells in Plaine du Cul-de-Sac in the late 1980s. Saltwater intrusion that was detected during this period in the Sibert area has also appeared to have recovered.The synthesis of Adamson’s data indicates that the Plaine du Cul-de-Sac can supply first phases of Canaan’s water demands, largely due to the inactivity of the agricultural sector. Yet there are several aspects to consider in managing groundwater development to serve Canaan.

Housing Density (Port-au-Prince, Haiti)

Urban Density (Port-au-Prince, Haiti) 17

These include: considering dynamics related to recharge from area rivers (understand impacts of proposed dams, and diversions); accounting for variations in water quality associated with the deepest layers at the northern limit of the aquifer in addition to potential saltwater intrusion; and conducting additional hydrogeological assessments and modeling to better characterize the aquifer as a whole. Adamson’s analysis points to locally-occurring over-exploitation of the aquifer in some areas, whereas other areas of the aquifer hold future development potential. He urged for ongoing exploration of the characteristics of the aquifer based on current demand and future projections, while also encouraging the practice of monitoring and integrated management across sectors to drive policy and assure the sustainability of what is considered Haiti’s most important aquifer.

Johnny François from Water Mission discussed the evolution of developing community drinking water systems and supporting communities to manage water supply in Haiti. Water Mission began in 2004, and early efforts were focused on responding to technical shocks brought about by natural disasters and outbreaks to community water supply systems. Since 2004, community water supply needs in Haiti have grown, and Water Mission now employs 60 full-time staff to support 500 safe water treatments and distribution systems across Haiti.

Water Mission has found that water supply system design should utilize advanced yet appropriate technologies so that these systems can be sustained to provide quality water.

Figure 5 Schematic of the Plaine du Cul-de-Sac Aquifer

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The NGO works to customize solutions that include mechanized pumps designed to create the proper flow; reliable power sources, including solar, so that the system has the capacity for greater access while minimizing operational and maintenance demands over the long-term; transportation and storage of water; along with water treatment options that combine chlorination with other appropriate treatments depending on the source.

Through this process, Water Mission has found that when water supply systems provide a high level of quantity, quality, and accessibility, communities are willing to pay a nominal fee for the service (HTG 5 / 5 gallon). To establish transparency, Water Mission builds capacity through community water committees that become responsible for technical, institutional, environmental, financial, and social challenges associated with maintaining a water delivery system in Haiti. This process encourages a spirit of innovation and entrepreneurship that is not only shared among water committee members, but becomes pervasive across communities that support such systems. François cited that over the past three years, 100 communities now cover the day-to-day operating responsibilities and maintenance of their water system, which each generate a revenue in excess of costs necessary to sustain the operation. Water Mission utilizes a mobile dashboard to remotely monitor water systems across the country, while empowering communities. François acknowledged that integrating technology into capacity building ensures a level of commitment among communities. Water Mission’s approach is creating a culture where individuals are committed to paying for water services that they are confident are of good quality, accessible, and reliable.

Alexandre Laraque from the Caribbean Bottling Company continued with the business case of water, from the value chain perspective. Laraque catalogued different sources of potable water in Haiti to include wells, community treatment centers, kiosks, water trucks, water sachets, and bottled water products. He went on to address several consumer perception challenges with water delivery. For kiosks, while they are ubiquitous across Haiti, there is a distrust in the water because individuals do not know the original source of the water.

Water trucks that fill cisterns have challenges with not only contamination of the water from the original source, but also cross-contamination from the truck’s storage or the container. Water quality in sachets varies due to temperature fluctuations.

Among these different channels for delivering potable water, Laraque noted that there are criteria to ensure quality, and treatment systems require on-going maintenance and daily monitoring. Because groundwater is mostly used for the provision of potable water in Haiti, it has to be captured, stored in a reservoir, chlorinated, filtered through a treatment center (first to remove waste, and then through a charcoal system to remove odor), softened, and finally undergo processes of reverse osmosis and UV lights. The control points in this process reveal that providing potable water to consumers is a business where the invested capital is important. The Caribbean Bottling Company (CBC), the parent company of Culligan Water, has been working in Haiti for forty years, creating 380 direct jobs and 25,000 indirect jobs.

Footpump for Water Access (Leogane, Haiti)

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With a national population over 10 million and human consumption needs at two liters a day, Laraque calculated that 7.9 billion liters of water are needed per year in Haiti. While CBC is one of the leading companies in the beverage sector in Haiti, with one of the largest market shares in water, Laraque estimated that CBC only meets 1.3% of the annual national demand for drinking water. He noted several risks and challenges that need to be overcome to increase future water supplies. Chief among these risks is the unregulated water market which favors unfair competition creating a scenario where the product becomes too expensive for the consumer. In addition, it is difficult to penetrate this market due to the lack of infrastructure. Finally, there are economic challenges associated with sustaining a fair market for water, whereby the consumer does not have the economic means to support the market. Despite these challenges, Laraque noted the opportunities that exist. Principally, there is a large portion of the market which is currently underserved in terms of its water needs. With large reservoirs and comparatively few sources of contamination (aside from cholera), Laraque suggested that there are increasing opportunities to participate in large-scale water treatment plant projects.

One Health

WORKSHOPWASH and Water Management

Jean Allain Darius, a WASH Specialist for Centers for Disease Control and Prevention (CDC) Haiti and Reginald Claveus, a WASH Officer for UNICEF Haiti facilitated a workshop with summit participants to address WASH and water management. The discussion focused on: rapid urbanization in the absence of proper urban planning; deficiencies in water delivery in rural areas of the country; water quality and its normative aspect to put in place; and a crowded institutional space among water-related actors that lack coordination mechanisms, including intra-ministerial coordination. The group proposed reorganizing the water sector to distribute responsibilities across areas of quality, storage, allocation, and education – with there being a data imperative to manage water resources both today and in the future.

Richard Gelting with the U.S. Centers for Disease Control and Prevention discussed the role the organization has played in WASH since the 2010 earthquake. He linked the importance of WASH by citing numbers that capture the burden of waterborne diseases in Haiti. Diarrhea is the leading cause of infant and child mortality, with 88% of deaths from diarrheal diseases attributable to unsafe WASH conditions. Poor WASH also contributes to respiratory diseases and neglected tropical diseases (e.g. trachoma). He referenced the relationship being established between malnutrition, diarrheal diseases, and poor conditions, which contribute to stunting of children. Lastly, vector-borne diseases are attributed to mosquito habitats which are created from areas of poor drainage. He then went on to acknowledge that while the lowest level of drinking water coverage occurs in sub-Saharan Africa, Haiti has the lowest coverage of access to water and sanitation in the Western Hemisphere, with

Stand Pipe (Gressier, Haiti)20

only 50 – 70% of the population using an improve drinking water source (2012) (Table 4).

Targets for water and sanitation have been included in both the Millennium Development Goals (MDG) and the Sustainable Development Goals (SDG), particularly given the overwhelming evidence that shows WASH is effective. Examples cited by Gelting include: improved water sources can lead to 21% reduction in diarrhea illness; improved sanitation can lead to a 37% reduction in diarrhea illness; handwashing can reduce the number of diarrhea cases by 35%; and improved drinking water quality can lead to a 45% reduction in diarrheal episodes. The challenge lies in identifying effective interventions that work in context-specific ways, which respond to the reality of water delivery, such as exists in Haiti.

At least basic access to Drinking Water Sources11

Urban 81%Rural 40%Overall 64%

Access to Improved Sanitation Facilities12

Urban 37%Rural 22%Overall 31%

To tailor interventions for specific environments, Gelting suggested to increase coverage of sustainable WASH facilities and services, and including these in healthcare facilities, schools and markets as important community nodes. He also urged measurement be a standard practice alongside the implementation of WASH interventions. In addition, Gelting also encouraged strengthening technical and administrative capacity, which he acknowledged DINEPA was already doing with the TPACs in rural areas of the country. Gelting concluded by stating WASH is a long-term effort, which requires an immense amount of time to increase coverage (particularly for sanitation infrastructure) alongside long-term commitments from different institutions involved.

Dr. Jacques Blaise, Vice-Chancellor of Research at UEH presented on the zoonotic parasites transmission risks in drinking water in Haiti. Blaise focused on two groups of parasites: the first being parasites that are transmitted by other animals that are naturally occurring in the water; and the second as parasites that are introduced into water by a number of different routes which include pollution, washing of certain vegetables, water where animals eat vegetation out of the water, and water where people wash their clothes. Blaise listed ten parasites that are known in Haiti,13 which have been identified either directly in water or indirectly from coproscopic or necropsic tests. Dogs have been found to transmit the most parasitic diseases to humans via water in Haiti, followed by cats, rats, oxen, pigs, sheep, goats, mice, horses, and guinea pigs. Blaise suggested that the obstacle in fighting against these diseases is to address these vector animals that are found in environments close to reservoirs and springs. He made a call for greater regulation, particularly in rural areas, to control free-range animals in the environment, which represent a threat to human health.

Dr. Eric Nelson with the Emerging Pathogens Institute at UF showcased technologies being used to improve data reporting on waterbornedisease outbreaks to decision-makers. Nelson characterized the importance of these

Table 4 Access to Water & Sanitation in Haiti10

10 (WHO/UNICEF Joint Monitoring Program, 2015)11 Either safely managed source or improved drinking water source within 30 min (improved = piped water into dwelling or yard, public standpipe, tubewell or borehole, protected spring, rainwater)12 Either safely managed facility or improved sanitation facility not shared (improved = facility that hygienically separates human excreta from human contact)13 Angiostrongylus cantonensis, Dracunculus medinensis, Echinostoma sp., Gnathostoma spinigerum, Paragonimus westermanni, Plagiorchis muris, Polymorphus sphaerocephalus, Sparganum or Spirometra sp.

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technologies as a unified tool that empowers the community to identify and report urgent health needs while equipping healthcare professionals with guidance to make better decisions and deploy limited resources to meet these needs. The decision-making framework includes both community members and healthcare professionals to generate a faster response-time and improved health outcomes by producing enhanced decisions and more efficient resource deployment. For community members to better assess a family-member’s needs and seek help, the technology can connect households to basic resources, including information on potential health threats. With reporting features, the technology also empowers community members to track conditions of critical infrastructural systems in the community, including water and sanitation infrastructure that may fall into disrepair.

For healthcare professionals in a clinical setting, the technology allows healthcare providers to assess patient needs and seek the appropriate help. Clinical decision-support applications can efficiently train teams on WHO guidelines for disease management while at the same time generating epidemiologic reports from data that can be easily collect, aggregated, and visualized in real-time, with spatial and temporal capabilitiesthat ground the data back into the context from where outbreaks may be occurring for better rapid

diagnostics and response times. Nelson stressed the importance of partnerships that are necessary to maximize the technology applications both in communities and in a clinical setting.

Dr. Glenn Morris, Director of the Emerging Pathogens Institute chronicled the University of Florida’s commitment to investigating waterborne pathogens in Haiti. An infectious disease laboratory in Gressier supports the university’s research agenda, and represents a collaboration between the U.S. National Institutes of Health, a local NGO, the UEH School of Medicine, and the University of Florida. Research on waterborne diseases began with the cholera outbreak in 2010, where UF researchers tracked the spread of the infection from urban road systems into the countryside. The cholera investigation then expanded into sampling locations along the rivers in the Leogane and Gressier region, where toxigenic Vibrio cholerae was identified particularly during months with heavy rains. Full genome sequencing isolated from both cholera patients and environmental samples revealed the spread of Vibrio from rivers and then back into clinical cases. Upon further investigation, each river appeared to have its own set of strains, consistent with spread of the bacteria from clinical cases, to the river, and then to subsequent clinical cases.

Internal Medicine Unit (Petite Rivière, Haiti)

Cholera Rehydration Center (Gressier, Haiti)

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The cholera research also highlighted significant levels of fecal contamination of surface water in Haiti. From here, the research began to explore contamination of water sources, eventually sampling over 300 water points which found that 37% were contaminated with fecal coliforms. The majority of these water points were wells, often dug by NGOs following the 2010 earthquake. However, there was little evidence of these NGOs providing ongoing monitoring or maintenance of the wells after construction was complete. This investigation was able to capture fecal contamination levels pre- and post- storm event associated with Hurricane Sandy in 2012, with over half of wells showing evidence of fecal contamination after passage of the storm. Morris suggested that hotspots of fecal contamination raise questions about the contamination of the aquifer, yet in the absence of data on the depth of individual wells, further investigation is needed to better understand the impacts that these hotspots of fecal contamination may have on the aquifer. Morris emphasized that the presumption that groundwater is Haiti is potable and does not necessitate further treatment when derived from an engineered source is not necessarily true, and underscores the need for secondary treatment approaches at the community level, such as those described by Water Mission.

Morris also described research conducted out of a local school in Gressier that catalogued

the ten most common disease syndromes presenting at the school’s clinic (2012 – 2013). Respiratory complaints (including acute respiratory infections [ARI] and asthma) accounted for 27% of clinic visits, with 362 cases and an incidence rate of 290.7 cases per 1,000 child years of observation. Among all children with respiratory complaints, lower respiratory infections accounted for 65% of cases and upper respiratory 35% of cases. Interestingly, asthma accounted for only 2% of the total respiratory cases seen at the clinic, a much lower percentage than seen in the United States. Gastrointestinal complaints accounted for 19% of all clinic visits, with febrile illnesses without an obvious source of infection constituting the third most common complaint, accounting for 16% of all patients seen.

Morris noted that 13% of children without diarrhea had a potential pathogen identified, versus 54% of children with diarrhea. The most common pathogen was enteroaggregative E. coli (EAgEC), which was also a common isolate from normal stool samples, although its isolation was significantly associated with diarrhea. Morris concluded by stating that diarrheal diseases remain a significant public health challenge in Haiti, with illness often caused by pathogens which can be transmitted by contaminated water.

Various Strengths of AquaTabs (Gressier, Haiti)

River Crossing (Gressier, Haiti)23

WORKSHOPTechnology and Water Security

Dr. Eric Nelson along with Stace Maples, Geospatial Manager at The Stanford Geospatial Center, and Josh Wyrtzen from SeeClickFix facilitated a workshop with summit participants to address community-based technology innovations in data collection. The discussion focused on innovative platforms, which transform paper data collection methodologies into digital forms that can be easily deployed in communities with simply an Andoid phone and a Gmail account. Such a system allows for the collection of high quality field data with built-in mechanisms for control. Integrating technology into larger rhythms of community engagement and empowerment in Haiti will allow for proactive rather than reactive approaches to minimizing health risks. The session ended by emphasizing that decisions informed by data lead to better actions, while also creating a layer of accountability among those who make community-based decisions.

SMS Message about Importance of Hand Washing

Community Health Workers Use Tablets (Gressier, Haiti)

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The two-day summit produced several key messages around a call to action for improved water management in Haiti. The opportunity for partnerships to be strengthened among policymakers, researchers, program implementers, and educators is central to the following key messages.

Integrated water management is essential to understanding water, which includes access, quality, and pricing Principally among the integration needs to be better coordination among the six Ministries, 50 NGOs and others working in water in Haiti.

Information is needed to improve decision-making processes, which can only occur through improved mechanisms for data sharing alongside innovative use of emerging field-based technologies.

WASH and water management is critical to overcome enormous burden of disease in Haiti attributed to waterborne pathogens.

Innovations are occurring in systems design, technology deployment for monitoring and evaluation, and capacity building, yet there remains an educational imperative to train a new generation of professionals working in water management in Haiti while also training the consumers in rural and urban communities across the country.

Key Messages as a Way Forward with Water Management in Haiti

Natural Waterfall (Port Salut, Haiti)

Water Collection (Gressier, Haiti)

1

2

3

4

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SPEAKERS &THEMES

SpeakerWilson Celestin

Bobby Emmanuel PiardPierre AdamLionel RabelTom FrazerWendy Graham and Niangona GonomyJean-André VictorMarie Jane AngeloAstrel JosephJean-Marie Raymond NoëlMontes Charles and Samantha JacobEvans Emmanuel

Cinthia J-B. Blaise

James K. Adamson

Johnny François

Alexandre LaraqueRichard GeltingJacques Blaise

Eric Nelson and Molly KlamanJ. Glenn Morris

ThemeIntegrated water management: an absolute need for HaitiMapping waterRecharge of the water tableWater resources in HaitiWater, ecology and environmentWorkshop A. Water as a Natural Resource workshop

Water war between Haiti and the Dominican RepublicWater Law and Management. Perspective from the U.S.Current state of water governance in HaitiAccess, social and communal water managementWorkshop B. Who owns water? Governance, rights, and legislationEnvironmental impacts on public health: medical geology contribution to understanding chemical risks associated with waterWater quality, human and environmental health in Greater Port-au-PrinceA Recent Evaluation of the Plaine du Cul-de-Sac Aquifer, and its potential to serve CanaanDeveloping community drinking water system: Perspective of a non-governmental organizationWater value chain and businessWASH and waterborne diseases in HaitiZoonotic parasites transmission risks in drinking water in HaitiHow might we best train first responders to water-borne infectious disease outbreaks?Research on transmission of waterborne pathogens in Haiti

AffiliationUEH

CNIGSUEHUEHUFUF and UEH

UEH and AHDENUFMDEUEHUEH, MARNDR, and UFQuisqueya University

DINEPA

Northwater InternationalWater Mission

CBCCDCUEH

UF

UF

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SPEAKERS &THEMES

SpeakerJean Allain Darius and Réginald ClavéusElda Déronette and Eric NelsonStace Maples

Joshua Wyrtzen

ThemeWorkshop C. WASH and water management

Workshop D. Technology and Water Security: How might we...?How might we better rapidly map water-borne infectious disease outbreaks?How might poor communities be empowered to report water infrastructure problems?

AffiliationUF

CDC and UNICEF

UEH and UF

Stanford University

SeeClickFix

AcknowlegmentsThe conference and speakers had been sponsored by Université d’Etat d’Haiti, University of Florida, Water Mission and Charles Féquière S.A. We also thank Séjourné, La Couronne, Caribbean Bottling Company, DINASA, and each of the speakers, facilitators, moderators and their institutions for their generous contributions.

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SUGGESTEDREFERENCES

Alam MT, Weppelmann TA, Longini I, De Rochars VMB, Morris JG Jr, Ali A (2015) Increased Isolation Frequency of Toxigenic Vibrio cholerae O1 from Environmental Monitoring Sites in Haiti. PLoS ONE 10(4): e0124098. https://doi.org/10.1371/journal.pone.0124098

Cayemittes, Michel, Michelle Fatuma Busangu, Jean de Dieu Bizimana, Bernard Barrère, Blaise Sévère, Viviane Cayemittes et Emmanuel Charles (2013) Enquête Mortalité, Morbidité et Utilisation des Services, Haïti (2012) Calverton, Maryland, USA : MSPP, IHE et ICF International. https://dhsprogram.com/pubs/pdf/FR273/FR273.pdf

Office Internationale de l’eau (2016) Evaluation de la mise en œuvre de la réforme du secteur eau potable et assainissement en Haiti et préparation du plan d’action. Direction Nationale de l’Eau Potable et de l’Assainissement. https://www.dinepa.gouv.ht/wp-content/uploads/2016/09/verylastversionbidnov2015revisen2-160728111216.pdf

Gelting, Richard & Bliss, Katherine & Patrick, Molly & Lockhart, Gabriella & Handzel, Thomas (2013) Water, Sanitation and Hygiene in Haiti: Past, Present, and Future. The American journal of tropical medicine and hygiene. 89. 665-670. 10.4269/ajtmh.13-0217. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3795096/

Institut Haïtien de l’Enfance (IHE) [Haïti] et ICF (2017) Enquête Mortalité, Morbidité et Utilisation des Services, Haïti, 2016-2017 : Indicateurs Clés. Rockville, Maryland, et PétionVille, Haïti : IHE et ICF. https://mspp.gouv.ht/site/downloads/rapport%20preliminaire%20emmus%20VI.pdf

Organisation Mondiale de la Santé (2017) Investir dans le secteur de l’eau et de l’assainissement génère d’importants bénéfices économiques. http://www.who.int/water_sanitation_health/monitoring/economics/fr/

WHO 2017. UN-Water GLAAS (2017) Financing universal water, sanitation and hygiene under the Sustainable Development Goals. http://apps.who.int/iris/bitstream/handle/10665/254999/9789241512190-eng.pdf;jsessionid=078764D05EDF11E636CB0C893149D7EF?sequence=1

WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation Progress on Drinking Water and Sanitation: 2012 Update (2012). https://washdata.org/sites/default/files/documents/reports/2017-06/JMP-2012-Report.pdf

Widmer, J. M., Weppelmann, T. A., Alam, M. T., Morrissey, B. D., Redden, E., Rashid, M. H., Morris, J. G. (2014). Water-Related Infrastructure in a Region of Post-Earthquake Haiti: High Levels of Fecal Contamination and Need for Ongoing Monitoring. The American Journal of Tropical Medicine and Hygiene, 91(4), 790–797. http://doi.org/10.4269/ajtmh.14-0165

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