groundwater iron an important source for women in Bangladesh

Iron deficiency is the most common micronutrient deficiency in the world.  Although many believe that anemia and iron deficiency are synonymous (as I did until a few weeks ago), iron deficiency is but one  cause of anemia.   Iron deficiency and anemia are both associated with increased risk of morbidity and mortality and pose a real threat to women in the developing world.

Scientists have shown that iron-fortified water and cooking with cookware can both lead to improved iron status but few believed that natural sources of iron in groundwater could offer iron in the correct state, and in high enough concentrations, to have nutritional benefits.  That is, until researchers from a large nutrition study in Bangladesh, JiVita, noted that women in their target area had much lower prevalence of anemia, iron deficiency, and iron deficiency anemia than much of the country.  They started to ask themselves what makes this population different. They failed to attribute these discrepancies to demographics, differences in dietary intake of iron, and differences in the prevalence of other infections/diseases.  Next they turned to the women’s water source.

This population almost exclusively drinks from groundwater through tubewells. Despite the high variability of groundwater iron concentration in Bangladesh, they found a median total iron concentration of 16.7 mg/L -  greater than other parts of the country with higher iron deficiency prevalence. The team estimates that women in the study ingest ~42 mg/day of total iron and expects a 6% increase in ferritin concentration for every additional 10mg/day.

So in short, it seems that groundwater iron can offer nutritional benefits to women.  These nutritional benefits may in turn reduce mortality and morbidity associated with iron deficiency and anemia.

So why do I think this is interesting?

1. This may be important to consider when treating water in areas with high concentrations of iron in their groundwater.  In Bangladesh, what is the impact on nutrition of all the technologies that remove iron at the same time as arsenic?

2. Will iron concentration in groundwater now play an important role in nutrition studies?

If you want to learn more about this, here is a great presentation by Rebecca Merrill who did a large part of this research for her doctoral dissertation.

wash and phones

With all the buzz about using cell phones in the field of development I decided to do a quick review of the different ways people have attempted to use cell phone technology to improve water sanitation and/or hygiene related access.

When we talk about cell phones for water and sanitation we are talking about a broad range of uses and technologies.  On the simple end we can use basic cell phones to transmit data through sms (text messages) or voice.  We can get more fancy and utilize smart phones that run more serious operating systems and have powerful features like internet connectivity, gps, and cameras.  Here are some examples of how people have started using cell phones to improve WASH services in Africa and Asia:

1. Community Led Total Sanitation Tracking via SMS – In a World Bank WSP funded project in Indonesia, Health Officers and Sanitarians started using SMS to report on baseline conditions and progress on the path towards Open Defecation Free Communities.  The officers text in the number of latrines contructed and other key information to a SMS server which processes the information and puts it into some sort of database.  According to WSP they will plan to replicate this in 29 districts in the Province.

2. Q&A – IRC International Water and Sanitation Center piloted an SMS based Question and Answer service to link communities and individual users with information related to their water supply.  Questions submitted via SMS are (or were) answered by one of the members a Water and Sanitation Network.  Questions ranging from the costs of spare hand pump parts to inquiries about low pressure in a piped system in Dar es Salaam have been answered by this service.  This pilot project started back in 2005 and I have not received any response by the operators whether they are still in action.

3. Water from Cell Phones – Grundfos, the Danish pump company, launched a new business model called LifeLink.  LifeLink is a small water enterprise (see previous post on SWEs) that uses cell phones to transfer “water credits” from the user’s bank account to that of the pump operator.  Lifelink constructs a solar powered water kiosk in a community and when someone wants to buy water they add credits to their account thorugh a simple text message transaction.  The kiosk displays the users balance after they swipes some sort of pass.  After that they are free to have as much water as they can afford.

4.  Information Broadcasting – A number of programs throughout Africa and Asia have attempted to use SMS to broadcast information about everything from handwashing to water conservation.

These four cases are surely not comprehensive but give good examples of what people have used phones for in the WASH sector.  I think we can break these uses down to the following:

• Monitoring and evaluation – Cell phones can be used to collect information and relay data back to some central location.  This fucntionality can be extremly useful for tracking progress of work and maintaining transparency.
• Information Services (to end user) – People can get information by calling or texting a specified number (in addition to the example above check out google sms in Uganda).
• Gateway – The cell phone can act as a mechanism to enable a service (think about the Grundfos example above).

To date none of these projects have really gone to scale.  As you could imagine there are some huge barriers to success including poor cell phone networks (including poor coverage and a lot of system downtime).  I have a few ideas of my own on how to enhance WASH service delivery with cell phones and hope to post them in the coming weeks.
Any other interesting cell phone based projects?  Post them in the comments section.

the safe water biz

What do PepsiCo, GE, Rotary Club, Harvard, Johns Hopkins, ARD, and Tata Trust all have in common?

An interesting group of academics, private sector representatives, and people from Governmental/International Organizations came together last week to discuss the Small Water Enterprises (SWEs). What is an SWE? SWE refers to the management of water as a business, for or non-profit, by non-state entities. SWEs provide opportunities for supplying safe water to many underserved populations throughout the world but also raise ethical challenges.

A small water entrepreneur at work

From a company in Ghana packaging and distributing drinking water sachets to a community owned high-tech membrane treatment plant kiosks in India, SWEs come in many forms. Small water enterprises illustrate one solution where governments fail in providing safe water to communities. Where do governments fail? We find examples everywhere, from far away hard to reach rural areas to urban slums…Who will supply water to an “illegal” squatter settlement? Will a government fulfill their duty of providing water while in the same action recognizing and investing in an illegal settlement ?

By definition, SWEs do not require economic viability on their own. Some models rely on subsidies while others are run for profit. The users of SWEs often pay more for their water than those served by public utilities (think economies of scale). While paying more for their water, these users may also receive an inferior product. Recent reviews of existing SWEs (see links below) cite the lack of regular water quality monitoring as a serious barrier to successful growth.

In thinking about what would happen if SWEs take off (some would argue they already have), my continually reverts back to two realities:

Reality #1: SWEs gain traction throughout the world through financing schemes and recognition by governments. They end up serving the majority of people in previously underserved in communities but the most vulnerable are left out (or they are taken care of in some communities with stronger cohesion and social mechanisms).

The people with any political capital in places served by SWEs are probably able to afford the water. Is it likely that they would continue to lobby for water if their needs are met? Will politicians really see the needs in these communities or will it be masked by the coverage of SWEs? Will the government have any real incentives to invest in water utilities in these areas after most of the people are covered by an SWE?

Reality #2: SWEs gain traction throughout the world and communities are slowly lifted out of poverty. This leads to a wealthier community with few people who cannot afford the water and stronger communities that will take care of their poor. (a bit too simplistic and reductive but it will work for this blog)

What concerns me the most is SWEs leaving the most vulnerable behind. Pro-poor policies within certain governments who choose to recognize the legitimacy of SWEs could help with this – but do you really think it could happen?

SWEs can provide some amazing opportunities to get safe (not just “improved”) water to people who need it, but in the long run will this come at a cost to these very same people? As SWE popularity increases with entrepreneurs, international organizations, and private companies , we will just have to wait and see (hopefully set up some useful studies too).

If you want to learn more about SWEs check out these resources:

• “Safe Water for All,” International Finance Corporation, 2009
• “Data gaps in evidence-based research on small water enterprises in developing countries,” Journal of Water and Health Vol 7, Number 4 , pg 609-622, 2009.

Also, check out some of the work of EcoTact Ltd. in Kenya who applies this model to sanitation…Pretty interesting and promising stuff!

the case for good coordination

I just went through some old photos of my time in Northern Uganda and found this great one.

a waste of 5000 USD in Otara, Northern Uganda

If you can’t tell, the borehole in the foreground had just been drilled despite the fact that there is one <50 m away in the background (and neither one was dry or had water quality issues)…This is what happens when people stop using their brain and forget to talk to one another!

zim cholera

The BBC posted a photo series on Cholera in Zimbabwe yesterday.  Check it out here.

myopia

The terms myopia and myopic (or the common terms short sightedness or short sighted) have also been used metaphorically to refer to cognitive thinking and decision making that is narrow sighted or lacking in concern for wider interests or longer-term consequences.” -Wikipedia (8/9/09)

I started to think about this term after reading a paper from Environmental Health Perspectives called Public Health Strategies for Western Bangladesh That Address Arsenic, Manganese, Uranium, and Other Toxic Elements in Drinking Water. The authors of this paper sampled a number of tube wells in Western Bangladesh to investigate the water quality, not only with respect to Arsenic but an array of other potential toxicants.   They found levels exceeding WHO health-based drinking water guidelines for Uranium, Manganese, Arsenic, Chromium, and Lead along with significant levels of other important elements like Antimony.  Why is this interesting one may ask?

After drilling millions of tube wells to save people from the morbidity and mortality related to gastrointestinal illnesses, UN agencies and the Bangladesh Government realized that they had exposed millions of people to arsenic.  This arsenic shifted the causes of illness and death related to water to other ailments like cancer (lung/bladder/skin).  Most of you know how this happened but in case you don’t…They simply didn’t test the water for Arsenic!!!

With so much focus on dealing with the arsenic problem, are we forgetting about other potential toxicants in the water?  This study seems to suggest we may be – at least in some parts of Bangladesh.  The government of Bangledesh is focused on testing each and every well for As but does not look at many of these other elements mentioned in the article (it should be noted that Arsenic probably poses the biggest threat to the population but the possible effects of the others are by no means negligible).   The authors note that in wells exceeding limits for As Uranium was not often found in quantities above the limit. However, the household treatment technology that many use to remove arsenic could actually increase the dissolved Uranium concentration (by making otherwise insoluble form soluble)….

This type of myopia happens all the time the water and sanitation sector.  We want to focus only on provision of clean water but don’t want to think about the multiple other pathways for enteric pathogen transmission.   We focus on toilets but forget that there is no readily accessible water to wash hands….Hopefully it won’t take another mass poisoning for us to wake up and look at the big picture.

Check out the article it is pretty interesting (oh and try to estimate the carbon footprint of the samples that made their way from India to Dubai to France to Vermont,USA)

Scaling Household Water Treatment

Tom Clasen from LSHTM recently prepared a paper for the WHO entitled “Scaling Up Household Water Treatment Among Low-Income Populations”.  In this paper he reviews research and interventions (scale and effectiveness) related to Household Water Treatment (HWT).  Boiling, Chlorine Disinfection (NaClO and NaDCC), SODIS, and filters are the main technology focuses of this insightful document.

Clasen comes up with some interesting stats on global use of HWT technologies.

HWT Method	2007 Use/Scale
NaClO (SWS)*	7.6 billion litres [60% of sales in 3 countries!!]
NaDCC*	2.86 billion litres [majority of sales in Kenya]
Ceramic Filters	2.6 billion litres
Biosand Filters	1.3 billion litres
SODIS	2.1 million users (estimate litres as you wish..5 l/p/d? 10? 20? 40?)

*does not include emergency use, (2007 statistics)

Although these numbers seem huge (well, they are quite impressive), it is important to keep them in perspective. More than 350 million people rely on boiling (not including much of China and other Asian communities who boil) and the UN Joint Monitoring Program estimates that nearly 900 million people still rely on unimproved sources of drinking water.  How are we going to bridge this HUGE gap?

We have all heard the buzz phrase  “SCALING UP, ” and many have asked ourselves what that means with respect to water and sanitation interventions.  No it is not just a word UN and development agencies toss around for kicks (well may be it is…I once heard people talking about scaling up scale up activities!).  Fortunately, Clasen talks a lot about what it means to scale up water interventions and suggests that “coverage” is an important metric but not the ultimate one.  It may be necessary but NOT sufficient for true health benefits of household treatment to impact the target populations.  What we are concerned with in “Scaling Up” is not only coverage but uptake.   Uptake is really the challenge for all of us and we don’t like to measure it too often (it is much harder than figuring out presumed coverage)…We can come up with great technologies but can we make them affordable, desirable, and usable?  Think about all of the great ideas out there like the Lifestraw and Lifefilter (and other technologies reviewed in the Clasen Paper)….what is going wrong?

In light of the current situation Clasen highlights some key constraints the must be overcome to scale up any HWT intervention:

…These [constaints] include 1) the persistent belief that diarrhoea is not a disease; 2) scepticism about the effectiveness of water quality interventions; 3) special challenges associated with uptake, including low aesthetic appeal for consumables, high up-front cost, the need to replace components for durables and the need to continuously use the product, even in the face of disease through other transmission pathways; 4) public health suspicion of the agenda of commercial products and strategies; 5) the orphan status of HWTS at the public sector level, with neither the water sector nor the health sector willing and able to assume ownership of the intervention; 6) minimal public sector participation in the promotion of HWTS; 7) a lack of focused international effort and commitment to advance HWTS; and 8)perceived policy conflict with efforts to promote piped-in water supplies.

In learning how to overcome some of these issues the paper looks at other interventions that have been successfully implemented at a large scale including Oral Rehydration Salts, Treated Bednets, and Guinea Worm Filters.  How did people start to accept these technologies, recognize their inherent value, and begin to use them correctly? Can these experiences translate to the challenge of providing clean water?  There are a lot of differences but Clasen suggests we can learn from their failures and successes.

Clasen goes on to argue that we will not meet the needs of the global poor with current technologies combined with current intervention strategies.

The gap between where we are and where we need to be is too great, given the urgency of the need. What is needed is a breakthrough. The largely public health orientation that has brought HWTS to its present point now needs to enlist the help of other experts: consumer researchers, product designers, educators, social entrepreneurs, micro-financiers, business strategists and policy advocates. The private sector is one obvious partner; it possesses not only much of this expertise but also the incentive and resources to develop the products, campaigns and delivery models for creating and meeting demand on a large scale. At the same time, market-driven, cost-recovery models are not likely to reach vast populations at the bottom of the economic pyramid where the disease burden associated with unsafe drinking-water is heaviest. As WHO ultimately concluded in the case of insecticide-treated mosquito nets, mass coverage among the most vulnerable populations may be impossible without free or heavily subsidized distribution. For this population segment, the public sector, UN organizations and NGOs that have special access to these population segments must engage donors to provide the necessary funding and then demonstrate their capacity to achieve both scale and uptake. Governments and international organizations can also help encourage responsible action by the private sector by implementing performance and safety standards and certification for HWTS products; reducing barriers to importation, production and distribution of proven products; and providing incentives for reaching marginalized populations.

He finishes with a number of suggestions on how we can accelerate the scale up of HWT approaches.

1. Focus on the users.
2. Develop and use partners.
3. Improve and expand on boiling.
4. Continue to pursue non-commercial strategies.
5. Continue to pursue market-driven strategies.
6. Leverage existing local strengths.
7. Initiate and use relevant, practical research.
8. Overcome public policy barriers to advancing HWTS. The Joint Monitoring Programme for Water Supply and Sanitation (JMP) of WHO and the United Nations Children’s Fund should clarify the contribution that safe and effective HWTS can make towards advancing health, even though, for policy and methodological reasons, it should not count towards the MDG water target. National governments should embrace the intervention while they work to extend piped-in supplies of treated water.
9. Engage national and regional governments.
10. Engage international leadership to support HWTS.

Hopefully some of this paper will be read by enough people in positions of power to change course….There are so many opportunities and many examples in other sectors to learn from.

Short Roundup

A quick post for the week:

1. USAID has launched a website about Water Financing.  The focus of this portal is to help partners of USAID comply with the 2005 Water for the Poor Act but they hope others can also learn how to incorporate notions of financial sustainability into their water projects…I have not had too much time to play around inside this site but it seems like an interesting idea.  (One other thing I learned when doing a little research on the 2005 WftP Act is that there is a 2009 bill under consideration that would establish an office of water within USAID!)

2. London School of Hygiene and Tropical Medicine got “hooked up” with an announcement of a 4.8 million dollar grant from the Gates Foundation to look into low-tech solutions for on-site sanitation.  From the little detail I have seen, it seems like their funding will be used to research techniques for speeding up microbial processes in pit latrines…I look forward to seeing the results of this research!

3.  The World Bank’s Water and Sanitation Program came out with Guidance Notes on Services for the Urban Poor: A practical guide for improving water and sanitation services. I haven’t had a chance to read this in detail but wanted to send a link out for anyone interested….