Water Stories__expanding Opportunities in Small Scale Water and Sanitation Projects _wics

8/2/2019 Water Stories__expanding Opportunities in Small Scale Water and Sanitation Projects _wics

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WATER STORIES: EXPANDING

OPPORTUNITIES IN SMALL-SCALE

WATER AND SANITATION PROJECTS

Report from the Navigating

Peace Initiative of the

Environmental Change

and Security Program


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PREFACE

By Ambassador John W. McDonald

INTRODUCTION

By Alicia Hope Herron and Geoffrey Dabelko

WATER STORIES PHOTO ESSAY

By J. Carl Ganter

HOUSEHOLD WATER TREATMENT AND SAFE STORAGE

OPTIONS IN DEVELOPING COUNTRIES: A REVIEW

OF CURRENT IMPLEMENTATION PRACTICES

By Daniele S. Lantagne, Robert Quick, and Eric D. Mintz

COMMUNITY-BASED APPROACHES TO WATER AND

SANITATION: A SURVEY OF BEST, WORST,

AND EMERGING PRACTICES

By John Oldfield

LOW-COST SANITATION: AN OVERVIEW

OF AVAILABLE METHODS

By Alicia Hope Herron

NAVIGATING THE MAINSTREAM: THE CHALLENGE

OF MAKING WATER ISSUES MATTER

By J. Carl Ganter

CLOSING THE GAPS: IMPROVING THE PROVISION

OF WATER AND SANITATION

By Charlotte Youngblood and Geoffrey Dabelko

Editors

Meaghan ParkerAlison WilliamsCharlotte Youngblood

Assistant EditorRachel Weisshaar

Photographs J. Carl Ganter/Circleofblue.org

iii

1

9

17

39

59

71

85

CONTENTS


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Report from the Navigating

Peace Initiative of the

Environmental Change

and Security Program

WATER STORIES: EXPANDING

OPPORTUNITIES IN SMALL-SCALE

WATER AND SANITATION PROJECTS


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The water in these rusting tanks must last for aweeks worth of cooking, washing, and bathingin Iztapalapa, Mexico City.2006 J. Carl Ganter/Circleofblue.org


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U nderstanding the relevance of this book,produced by the Navigating PeaceInitiative, requires relating a bit of per-sonal history. At the first inter-governmental worldconference on water at Mar del Plata, Argentina in1977, the represented governments adopted a Planof Action recommending a large number of nation-al and international actions on water. In 1978,after returning to the State Department after afour-year tour with the International LaborOrganization, I read the plan for the first time.Water had fascinated me since my service in theMiddle East and I was familiar with water-relatedproblems facing developing countries, especiallythose suffered by the rural poor.

One recommendation stood out: a call for theUnited Nations to designate a decade focused sole-

ly on the problems of drinking water and sanita-tion. I decided to make that recommendation areality. I drafted a UN resolution designed tolaunch the Water Decade, and over the next 18months, pushed it until it was adopted by four dif-ferent UN bodies and, on November 10, 1980, bythe entire General Assembly. By 1990, the end ofthe Decade, the World Health Organizationreported that 1.1 billion people received safe drink-ing water for the first time in their lives and 769

million people gained access to sanitary facilities.Unfortunately, these impressive figures did notprevent water from falling off government radarscreens at the end of the Decade. Little happened

for the next 10 years. But finally, in 2000, theUN established the Millennium DevelopmentGoals (MDGs). Goal 7 called for reducing by halfthe number of people in the world without safewater by 2015. At the third world conference onthe environment in Johannesburg in 2002, sani-tation was added to Goal 7.

But how would we reach these lofty goals? Ibegan promoting a second water decade at a meet-ing at the Wilson Center in early 2002, and draft-ed a UN Resolution calling for a second UN WaterDecade designed to achieve the water MDG by2015. Finally, with the government of Tajikistantaking the lead, the resolution was adopted by theUN General Assembly in 2003, and scheduled tolaunch on World Water Day, March 22, 2005.

The United States has now stepped up to the

plate. Thanks to the combined efforts ofCongressman Earl Blumenauer and Senator BillFrist, on December 1, 2005, President George W.Bush signed into law the Senator Paul SimonWater for the Poor Act, which directs the secre-tary of State to develop a detailed strategy forintegrating water and sanitation programs intoU.S. foreign policy. The law also calls upon theUnited States to fulfill its commitment to Goal7the first time that a MDG has been adopted

as part of U.S. law. This landmark bipartisan leg-islation puts the United States on the front linesof the fight to bring clean water and sanitation tothose without it. i

PREFACE

Ambassador John W. McDonald, ChairmanThe Institute for Multi-Track Diplomacy


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But high-level political attention alone will notbe enough to meet this goal. The Navigating PeaceInitiative, in the series of papers gathered here,

calls not only for global action at the highest lev-els, but also at the lowest: By reporting and evalu-ating small-scale opportunities to expand waterand sanitation, the authors show that we will not

win this fight without unglamorous but effectivesolutions like ceramic filters and pit latrines. All ofthese efforts demonstrate that the United States is

taking a globalas well as a localleadership rolein addressing one of the most critical issues theworld is currently facing.

WATERSTORIES:EXPANDINGOPPORTUNITIES

INSMALL-SCALEWATERANDSANITATIONPROJECTS

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Not surprisingly, the word wateris found in every language in theworld (UNESCO, 2006).1 But wateroften denotes more than the substance we drinkto survive. For example, the Setswana word forrainpula is also the name of Botswanan cur-rency; and significantly, it is invoked after every

tribal or political address (Turton, 2003;Hitchcock, 2000).It would take millions ofpulasto measure the

cost to human health from lack of access to cleanwater and sanitation, for waterwhile necessaryfor lifecan also be a vector for disease anddeath. Water sources contaminated by sewage cantransmit preventable waterborne diseases such ascholera, typhoid, diarrhea, and gastroenteritis.Ninety percent of the wastewater in the develop-ing world is released untreated into local water-

sheds, and more than 3 million people per yearmostly childrenare killed by such diseases(OECD, 2003a). In severely affected countries,water-related diseases kill 1 in 5 children beforethe age of five (WEHAB Working Group, 2002).

The link between clean water and proper sani-tation has been widely acknowledged at both thenational and international level. The provision offresh water is vital to meeting basic human needsand should be at the heart of any sustainable

development initiative. Unfortunately, efforts toprovide these basic services in the developing

world are blocked by large funding gaps and oftenmired in debates over governance, privatization,and large infrastructure projects. However, small-scale and community-based solutionsthe focusof this publicationcan help bridge these gapsand move beyond the debates.

The Woodrow Wilson Centers NavigatingPeace Initiative, funded by the CarnegieCorporation of New York, brings together expertsand practitioners to reframe stale debates and gen-erate fresh thinking on critical water problems.The papers collected here seek to shed light onthe challenges of improving access to safe waterand sanitation, as well as the possibilities affordedby innovation and cooperation. The initiativethus hopes to contribute to the ongoing discus-sion by examining alternatives to large-scale infra-structure projects in the water and sanitation sec-

tors, including NGO and community-based waterand sanitation efforts, and exploring how lessonslearned from small-scale projects can be effectivelycommunicated worldwide.

GROWING DIVIDE

The gravity of the threats posed by lack of accessto water and sanitation is revealed by the latestfigures of the Joint Monitoring Program of theWorld Health Organization (WHO) and

UNICEF: More than one billion people lackaccess to fresh water, equal to 17 percent of the

INTRODUCTION: WATER STORIES

By Alicia Hope Herron and Geoffrey Dabelko

1. For examples, see http://www.unesco.org/water/wwd2006/world_views/water_language.shtml


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global population (WHO/UNICEF, 2005).2 Evenmore people lack access to sanitation: 2.6 billionpeople, or 42 percent of the population. In sub-

Saharan Africa alone, 42 percent of the popula-tion lacks improved water sources and only 36percent have sanitation services.

This divide is set to drastically increase as theworlds water demand doubles every 20 years as the

population burgeons (Revenga, 2000). By 2025,48 percent of the worlds projected population willlive in water-stressed river basins. Water scarcity

and lack of sanitation loom not only as imminentchallenges for the countries that lack fresh water orthe infrastructure necessary to treat water andsewage, but also as potential sources of conflict.Recognizing these threats, the world community



2

FIGURE 1: TRENDS IN OFFICIAL DEVELOPMENT ASSISTANCEFOR WATER SUPPLY AND SANITATIONFIVE-YEAR MOVING AVERAGE FROM 19732004(Measured in constant 2003 prices)

3500

3000

2500

2000

1500

1000

500

0

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

DAC countries, annual figures

DAC countries, annual figures

DAC countries

Memo: Non-concessional flows

Multilateral donors

DAC countries

Memo: Non-concessional flows

Multilateral donors

Note:The Development Assistance Committee (DAC) is the principal body through which the OECD studies issues related to cooperationwith developing countries.

Source:OECD (2006) 3

2. Coverage rate figures were obtained by the Joint Monitoring Programme using an assessment questionnaire, which defined access to water

supply and sanitation in terms of the types of technology and levels of service provided. Summary statistics can be found online at

http://www.unesco.org/water/wwap/facts_figures/basic_needs. shtml

3. Figure available online at https://reader009.{domain}/reader009/html5/0503/5aea12197f20d/5aea121dce944.jpg; statistics available at http

dataoecd/50/17/5037721.htm

US$

million


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has agreed on three different occasions to set andmeet goals to improve water and sanitation: duringthe first International Drinking Water Supply and

Sanitation Decade (19801990); the MonterreyConsensus (2002); and the Water for LifeDecade (20052015). This consensus offers anunprecedented opportunity to hold governmentsaccountable to meeting these goals.

The effort to recognize access to fresh water as abasic human right has also gained significant trac-tion. The NGO IUCN notes that there have beenboth expressed and implied references to a right towater in public international law, despite the factthat there is no formal recognition of such a right(Scanlon et al., 2000). The International Covenanton Economic, Social and Cultural Rights declaredwater not only an economic good but also a socialand cultural one (ECOSOC, 2002).

Water plays an important role in poverty allevi-ation and gender equality. According to a reportreleased by Stockholm International WaterInstitute and the WHO (2005), access toimproved water and sanitation increased develop-ing countries average annual GDP growth rates to

3.7 percent, compared to 0.1 percent for countrieswithout such access. Gender equality has also beendirectly linked to the availability of adequate sup-ply of fresh water. In many communities, womenare the central users or gatherers of water, and alsocare for children sickened by water-related illness.

CURRENT FUNDING FLOWS

= MISSED TARGETS

There are several disturbing trends in aid flows,

despite the high level of attention that water andsanitation have received at the international leveland an apparent increase in Official DevelopmentAssistance (ODA) to the sector (see Figure 1).

After declining in the 1990s, ODA rose torecord levels in 2004. However, the increase since2002 is largely due to debt reduction and resched-

uling, and the large jump from 20032004 isprincipally U.S. aid to water projects in Iraq(Clermont, 2006). On the other hand, the 2002Monterrey commitment by the international com-munity to contribute 0.7 percent of GNP toODA, and the 2005 Gleneagles Summit commit-ment to double ODA, offer hope that giving willcontinue to rise.

Two other disturbing trends in aid flows mustbe considered: First, most of the aid is going to ahandful of middle-income countries; and second,the bulk of the funding is allocated to major infra-structure projects.

Of the total aid in 20002001, only 12 percentwas given to countries where less than 60 percentof the population had access to an improved watersource (OECD, 2003b). Figure 2 illustrates a fur-ther concentration in aid: 53 percent of the total isreceived by 10 countries. According to the WorldWater Council, allocation is dependent on thedemographic weight of the countrythe economic

and political stability of the country [and]itsgeostrategic visibility (Clermont, 2006, page 7).Areas with some of the greatest need, such as sub-Saharan Africa, remain on the losing end.

Figure 3 demonstrates the second trend. Thevast majority of aid for water and sanitation fundslarge infrastructure projects, which exacerbates therural-urban divide: 80 percent of people withoutaccess to sanitation live in rural areas, and roughlyone-third of rural residents lack access to improved

drinking water sources (UNESCO-WWAP, 2003).Estimates of the investment necessary toachieve the Millennium Development Goal(MDG) to reduce by half the proportion of


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FIGURE 2: MAIN DONORS AND RECIPIENTS OF BILATERAL OFFICIAL DEVELOPMENTASSISTANCE (ODA) TO WATER SUPPLY AND SANITATION, 20002004(Annual Average Commitments in US$ Million, Constant 2003 Prices)

FIGURE 3: BREAKDOWN OF ODA FOR WATER BY PROJECT TYPE, 19902004

Japan GermanyUnitedStates

France NetherlandsOther DAC

DonorsTotal DACCountries

China 222 5 1 6 4 37 275

Iraq 0 1 170 - 0 10 181

Vietnam 52 10 0 17 7 30 117

Palestinian Adm. Areas 2 23 72 5 1 9 113

India 39 8 2 3 18 32 102

Jordan 6 24 45 - 0 12 87

Malaysia 90 - - - - 1 81

Morocco 24 26 2 16 0 7 75

Peru 55 11 0 1 6 74

Tunisia 28 12 - 26 - 1 68

Other recipients 326 254 52 100 93 420 1245

Total 835 376 344 173 124 567 2417



0.2%

19%

3%

50%

18%

7%

3%

I Education and training:water supply & sanitation

I Water resource protection

I Waste management anddisposal

I River development

I Basic drinking water supplyand sanitation

I Water resources policy andadministration management

I Water supply and sanitation:large systems

5. Figure available online at https://reader009.{domain}/reader009/html5/0503/5aea12197f20d/5aea121f4b676.jpg6. Data available online at http://www.oecd.org/dataoecd/3/29/36253954.xls


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people without sustainable access to safe waterand sanitation vary from US$9 billion to US$30billion (Toubkiss, 2006). A comparative analysis

prepared by the World Water Council in prepara-tion for the 4th World Water Forum found thatthe estimates are actually quite similar if analyzedon comparable bases,4 and that current invest-ment must be roughly doubled to reach theMDG target (Toubkiss, 2006). Reaching thesanitation target will require 25 times theexpenditure necessary to meet the water targets(Toubkiss, 2006). In addition, 48 percent of theworlds projected population growth is expectedto occur in areas already experiencing, or expect-ed to experience, water stress, raising the stakeseven higher (Revenga, 2000). Within the last fewyears, donors and NGOs have begun to exploreoptions that will stretch their funding further,and many argue that low-cost, community-basedapproaches should play a larger role in efforts tomeet the MDG.

EXPANDING OPPORTUNITIES FOR SMALL-

SCALE WATER AND SANITATION

Given the magnitude of the problem and the dis-turbing aid trends, we must re-evaluate traditionalapproaches. Financing Water and EnvironmentalInfrastructure for All, a background paper pre-pared for the Commission on SustainableDevelopment, states that the most successful pro-grams are those that respond to local demand,with heavy local participation, using low-cost localtechnology, and without any public subsidy(OECD Global Forum on Sustainable

Development, 2004, page 16).

Water Stories: Expanding Opportunities in Small-Scale Water and Sanitation Projectsseeks to move pasttechnical hardware evaluations by incorporating

software issues. To ensure the effectiveness and sus-tainability of water and sanitation projects, the usersmust support them. Project designers thus mustunderstand how culture and gender issues affectdemand and acceptance by the community. As JohnOldfield notes in his chapter, breakthrough prac-tices in [the water and sanitation sector] are rarelynew technological solutions, but are instead thosethat innovatively and cooperatively apply currenttechnology to meet local needs. Beginning with J.Carl Ganters photo essay, this publication focuseson this nexus of hardware choices and softwareunderstanding, along with a look at the mediachannels that frame the larger debate.

In Household Water Treatment and SafeStorage Options in Developing Countries: AReview of Current Implementation Practices,Daniele S. Lantagne, Robert Quick, and Eric D.Mintz summarize five of the most common house-hold water treatment and safe storage (HWTS)options chlorination, filtration (biosand and

ceramic), solar disinfection, combinedfiltration/chlorination, and combined floccula-tion/chlorinationand describe implementationstrategies for each. They identify implementingorganizations and the successes, challenges, andobstacles projects have encountered. They also con-sider sources of funding and the potential for large-scale distribution and sustainability of each option,and propose future research and implementationgoals. They find that HWTS systems are proven,

low-cost interventions that have the potential to

4. Reasons include different assessment scopes, understandings of infrastructure and level of service, and calculation methods

(Toubkis, 2006).


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provide safe water to those who will not haveaccess to safe water sources in the near term, andthus significantly reduce morbidity due to water-

borne diseases and improve the quality of life.John Oldfield provides a ground-level review of

small-scale and rural projects in his chapter,Community-Based Approaches to Water andSanitation: A Survey of Best, Worst, and EmergingPractices. Through a combination of research andinterviews with leaders from selected NGOs in thewater sectorincluding WaterPartners Inter-national, Water For People, WaterAid, LivingWater International, CARE, and the HiltonFoundationOldfield finds that while communi-ty-based small-scale solutions can work well, themost successful projects focus not just on supplyingwater, but also on sanitation and hygiene, whichoften are more immediate causes of death or ill-ness. He concludes that water projects are rarelysimple. They are, however, eminentlydoable.

Alicia Hope Herron also stresses the need for aholistic approach to water and sanitation in Low-Cost Sanitation: An Overview of AvailableMethods, which presents several optionspit

latrines, dehydration systems, pour flush latrines,aquaprivies, and septic tanksand examineswhether these methods are cost-effective, sustain-able, and likely to be accepted by users. With sani-tationeven more so than water supplydeter-mining which option will be most effectiverequires weighing a complex set of variables rang-ing from culture and cost to geology and climate.Not only are these considerations important forefficacy and sustainability, but the lack of consid-

eration of one variable in sanitation planning hasthe potential to cause serious damage to commu-nity health, exacerbating rather than amelioratingan already dangerous situation.

Given the centrality of water to the human con-dition, why does water fail to rally a forceful, sus-tained response by the collective global conscious-

ness? It is not the absence of solutions, or even thelack of opportunitiesit is a lack of political will.J. Carl Ganter argues that the political will to recog-nize and address the expanding global freshwatercrisis cannot come from random efforts to increaseawareness, but from transcending moments thatcreate movements. Navigating the Mainstream:The Challenge of Making Water Issues Matterargues for a new paradigm for social changeonethat recognizes the needs and unites the strengths ofcitizens, leaders, NGOs, and especially the newsmedia. This approach requires emphasizing rele-vance, creating or identifying major events, involv-ing varied talents and disciplines, developing newuses of proven techniques, and pioneering commu-nications and information tools.

One old-fashioned but proven way to makewater issues meaningful to people is by tellinggood stories, ones that make the issues personaland relevant, and connect humanity through thesimple dramas of life, faith, and culture. The

Water Stories multimedia website (http://www.wilsoncenter.org/waterstories), also developedby the Navigating Peace Initiative, tells those sto-ries through audio and video presentations of thepeople living and working in water-stressed com-munities in Mexico.

Providing clean water and sanitation is a trulymonumental challenge and must be addressedfrom a multitude of angles. Water Storiesfocuses oninnovative ways to incorporate a communitys

needs and demandsthe software issuesandargues that these opportunities have the bestchance of success. However, as Barbara Schreiner(2001), chief director of the Department of Water



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Affairs and Forestry of South Africa, observes, it isan unfortunate aspect of the nature of water that itflows toward power, and therefore the power to

make decisions about water and sanitation rarelytrickles down to those most in need. This publica-tion hopes to redirect this flow by demonstratingthat decisions made by the least powerful can bethe most effective. The spectrum of water and sani-tation projects is broad enough to allow innovativetechniques and collaboration to flourish. Byexpanding the opportunities for small-scale projectsto reach communities in need, we could potentiallysave some of the 3 million people lost each year towaterborne disease, and help restore water to itsrightful place as the givernot takerof life.

REFERENCES

Clermont, Florence. (2006). Official Development

Assistance for water from 1990 to 2004. Paris: World

Water Council & World Water Forum. Available

online at http://www.world watercouncil.org/file

admin/wwc/Library/Publications_and_reports/Full

Text_Cover_ODA.pdf

Hitchcock, Robert K. (2000). The Kavango basin: A case

study. Available online from The Water Page athttp://www.africanwater.org/okavango_case_study.htm

OECD. (2003a). Improving water management: Recent

OECD experience. Paris: OECD.

OECD. (2003b). Supporting the development of water and

sanitation services in developing countries. Paris: OECD.

Available online at http://www.oecd.org/dataoecd/

27/22/2955840.pdf

OECD. (2006). Creditor reporter system on aid activities.

Available online at http://www.oecd.org/document/

0/0,2340,en_2649_34447_37679488_1_1_1_1,00.html

OECD Global Forum on Sustainable Development.

(2004). Financing water and environmental infrastruc-

ture for all: Some key issues. Paris: OECD. Available

online at http://www.un.org/esa/sustdev/csd/csd12/

Background6.pdf

Revenga, Carmen. (2000). Will there be enough water?Washington, DC: World Resources Institute. Available

online at http://earthtrends.wri.org/features/view_

feature.php?theme=2&fid=17

Scanlon, John, Angela Cassar, & Noemi Nemes. (2004).

Water as a human right? (IUCN Environmental

Law and Policy Paper No. 51). Cambridge, UK:

International Union for Conservation of Nature and

Natural Resources (IUCN). Available online at

http://www.iucn.org/themes/law/pdfdocuments/

EPLP51EN.pdf

Schreiner, Barbara. (2001, December 6). [Keynote Speech

to the International Conference on Freshwater]. Bonn,

Germany.

Stockholm International Water Institute (SIWI), & World

Health Organization (WHO). (2005). Driving devel-

opment by investing in water and sanitation: Five facts

support the argument. Geneva, Switzerland, &

Stockholm, Sweden: SIWI & WHO. Available online

at http://www.siwi.org/downloads/Reports/Driving_

Development.pdf

Toubkiss, Jrmie (2006). Costing MDG Target 10 onwater supply and sanitation: Comparative analysis,

obstacles and recommendations. Paris: World Water

Council & World Water Forum. Available online at

http://www.worldwatercouncil.org/index.php?id=3

Turton, Anthony R. (2003). A Southern African

perspective on transboundary water resource manage-

ment. Environmental Change and Security Project

Report 9, 7587.

United Nations Economic and Social Council

(ECOSOC). (2002, November). Substantive issuesarising in the implementation of the international

covenant on economic, social and cultural rights:

The right to water (Articles 11 and 12 of the


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International Covenant on Economic, Social and

Cultural Rights)(E/C.12/2002/11). Available online

at http://www.citizen.org/documents/ ACF2B4B.pdf

United Nations Educational, Scientific and CulturalOrganization (UNESCO). (2006). Water and world

views: The water language.Available online at

http://www.unesco.org/water/wwd2006/world

_views/water_language.shtml

UNESCO-World Water Assessment Program

(UNESCO-WWAP). (2003). Water for people, water

for life: The UN world water development report.

Barcelona: UNESCO & Berghahn Books. Available

online at http://unesdoc.unesco.org/images/0012/

001295/129556e.pdf

Water Energy Health and Biodiversity (WEHAB)

Working Group. (2002, August).A framework for

action on water and sanitation(United Nations prepa-

ration for the World Summit on SustainableDevelopment). Available online at http://www.un.org/

esa/sustdev/publications/wehab_water_sanitation.pdf

WHO/UNICEF Joint Monitoring Programme

for Water Supply and Sanitation. (2005). Water for life:

Making it happen. Geneva, Switzerland: WHO &

UNICEF. Available online at http://www.unicef.org/

wes/files/ JMP_2005.pdf



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Water StoriesPhoto EssayReal people exist behind every statistic andchart. What does the global freshwater crisislook like? There are families like the Silvas, wholive without access to an adequate supply offreshwater in a Mexico City barrio, and are justone family among the one-third of the worldspopulation for whom safe water is scarce. Andthere are people like Ron Sawyer, faces ofchange and hopepeople who provide basic,

sustainable technology home by home, personby person, school by school.Presented here are photo essays by journalist

J. Carl Ganter, a member of the NavigatingPeace working group, that chronicle water andsanitation endeavors in three resource-strappedregions of Mexico: Tepoztln, Valle de Bravo,and Mexico City. The images provide a vividglimpse of the lives behind the columns of numb-ing statistics. They remind us of the real families

worldwide who can benefit so profoundly fromthe simple, available, and effective solutionsdiscussed in Water Stories.

photo credits:2006 J. Carl Ganter/Circleofblue.org


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Tepoztln, MexicoStunning sunrises, pic-

turesque mountains, and bustling markets beliethe underlying water and sanitation challengesin this popular tourist destination south ofMexico City. In the small villages like San JuanTlacotenco that tuck into the surrounding moun-tains, disposal of human waste is a serious prob-lem: outhouses and leaking sewer pipes contam-inate the regions groundwater through theporous rock.

Ron Sawyer, the matter-of-fact director of the

Mexican nonprofit Sarar Transformacin, is work-ing to clean up the sanitation problem inTepoztln, by promoting nontraditional optionsthat do not require significant flows of water tooperate. Dry, water-less ecological toilets separatewaste streams into useable byproducts, capturingurine for fertilizer while directing solid waste intoa separate container for compost treatment.

The dream, Sawyer says, is that we canhave a town where there are mixed systems that

will include the water-based sewage system for thedowntown area, but will have a set of concentriccircles with different levels of services for differentparts of the population, depending on the physicalareas, and depending on their social and culturalpreferences, and their economic possibilities.

Dry Sanitation

PHOTOS (clockwise from top):

A dry sanitation building near the village of San Juan

Tlacotenco with separate urine and solid wastecollection systems.

Ron Sawyer, director of Sarar Transformacin, a non-profit organization in Tepoztln, Mexico, that focuseson affordable dry sanitation options.

Morning on the streets of Tepoztln, a popular touristdestination outside Mexico City.



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Valle de Bravo

PHOTOS (clockwise from top):

Feeding hand-tended irrigation trenches, water flowsplentifully from the ground, often from clear springs thatare eventually captured by the Cutzamala system to sateMexico Citys thirst.

The giant pumping towers of the Cutzamala system forcewater from Valle de Bravos manmade Lake Avndaro upand over the mountains toward Mexico City.

Hundreds of years old, a small fish farm providesprotein for villagers using the cold headwaters aboveValle de Bravo.


Valle de Bravo, MexicoLike giant sentries,

white pumping towers dot the horizon betweenValle de Bravo and Mexico City. The Cutzamalawater system, a complex web of massive concreteand steel pipes, stretches for miles to connectdams and spring water to the worlds secondlargest metropolis, Mexico City. Indigenous com-munities in the Valle de Bravo region are con-cerned about the large amounts of water beingdiverted to meet the citys demands.

Valle de Bravo is a popular weekend retreat

for Mexico Citys upper class and home to theworld-renowned winter nesting grounds formonarch butterflies.


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Mexico CityAs the sky brightens over the

Batallones Rojos apartments in the Iztapalapadistrict of Mexico City, Rogelio Gonzalez turnsa giant blue valve, releasing a rush of water tothe apartment buildings across the street, hometo 1,500 working-class people.

The residents have to hurry their morning wash-ing and cooking tasks, though. Gonzalez will turnoff the water two hours later, just before the giantreservoir tank above him runs dry. Engineers saythere isnt enough water in the Iztapalapa system

to supply this and many other Mexico City neigh-borhoods with enough water.

Batallones Rojos

PHOTOS (near right, top to bottom):

Water tankers proliferate throughout Mexico City,especially in Iztapalapa, where water demand exceedsthe supply provided by the municipal undergroundinfrastructure.

Rogelio Gonzalez manages this pumping and reservoirstation that supplies waterfor only two hours each

dayto the 1,500 residents of the Batallones Rojosapartment complex.

Children play in the parking lot of the Batallones Rojosapartment buildings.



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Iztapalapa, Mexico CityIn Colonia SanMiguel, water trickles from the small plasticpipe for only an hour each week in the Silvafamilys austere home. This is enough water tofill three rusting tanks with about 200 gallonsfor bathing, washing clothes, and flushing thetoilet. But the water is not safe to drink andthe family, like many here, buys water fromvendors who travel daily throughout theneighborhoods yelling, Water for sale!

San Miguel

PHOTOS (near left, top to bottom):

The familys makeshift kitchen overlooks the sprawlingmetropolis of Mexico City.

The Silva family stands outside their makeshift home inthe Iztapalapa district of Mexico City.

A young boy plays soccer in the streets outside the Silvafamilys house in Colonia San Miguel.



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Jemima Odo of Nyanza, Kenya,demonstrates Pu--R sachet(courtesy of Greg Allgood)


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The United Nations International DrinkingWater Supply and Sanitation Decade(19811990) failed to achieve its goal ofuniversal access to safe drinking water and sanitationby 1990 (World Health Organization [WHO],2003). Even though service levels rose by more than10 percent during the decade, 1.1 billion people stilllacked access to improved water supplies, and 2.4billion people were without adequate sanitation, in1990 (WHO/UNICEF, 2000). Reasons cited forthe decades failure include population growth, fund-ing limitations, inadequate operation and mainte-nance, and continuation of a traditional business asusual approach (WHO/UNICEF, 1992).

The world is on schedule to meet the

Millennium Development Goal (MDG), adoptedby the UN General Assembly in 2000 and revisedafter the World Summit on Sustainable Develop-ment in Johannesburg, to halve, by 2015, the pro-portion of people without sustainable access to safedrinking water and basic sanitation (World BankGroup, 2004; WHO/ UNICEF, 2004). However,success still leaves more than 600 million peoplewithout access to safe water in 2015 (WHO/UNICEF, 2000). In addition, although the MDG

target specifically states the provision of safe drink-ing water, the metric used to assess the MDG targetis the provision of water from improved sources,such as boreholes or household connections, as it isdifficult to assess whether water is safe at the house-

hold level (WHO/UNICEF, 2004). Thus, manymore people than estimated may drink unsafe waterfrom improved sources.

HOUSEHOLD WATER TREATMENT

AND SAFE STORAGE

To overcome the difficulties in providing safe waterand sanitation to those who lack it, we need tomove away from business as usual and researchnovel interventions and effective implementation

strategies that can increase the adoption of tech-nologies and improve prospects for sustainability.Despite general support for water supply and sani-tation, the most appropriate and effective interven-tions in developing countries are subject to signifi-cant debate. The weak links among the water,health, and financial sectors could be improved bycommunication programs emphasizing health1as

well as micro- and macroeconomicbenefits thatcould be gained.

STORAGEOPTIONSINDEVELOPINGC

OUNTRIES

1

HOUSEHOLD WATER TREATMENT AND SAFE:STORAGE OPTIONS IN DEVELOPING COUNTRIES:

A REVIEW OF CURRENT IMPLEMENTATION PRACTICES:

By Daniele S. Lantagne, Robert Quick, and Eric D. Mintz:

1. The health consequences of inadequate water and sanitation services include an estimated 4 billion cases of diarrhea and 2.2million deaths each year, mostly among young children in developing countries (WHO/UNICEF, 2000). In addition, water-

borne diarrheal diseases lead to decreased food intake and nutrient absorption, malnutrition, reduced resistance to infection

(Baqui et al., 1993), and impaired physical growth and cognitive development (Guerrant et al., 1999).


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The new focus on novel interventions has ledresearchers to re-evaluate the dominant paradigmthat has guided water and sanitation activities

since the 1980s. A literature review of 144 studiesby Esrey et al. (1991) represents the old paradigm,concluding that sanitation and hygiene educationyield greater reductions in diarrheal disease (36percent and 33 percent, respectively) than watersupply or water quality interventions.2 However, amore recent meta-analysis commissioned by theWorld Bank contradicted these findings, showingthat hygiene education and water quality improve-ments are more effective at reducing the incidenceof diarrheal disease (42 percent and 39 percent,respectively) than sanitation provision and watersupply (24 percent and 23 percent, respectively)(Fewtrell & Colford, 2004).

The discrepancy between these findings can beattributed in part to a difference in interventionmethodology. Esrey et al. (1991) reviewed studiesthat largely measured the impact of water qualityimprovements at the source (i.e., the wellhead orcommunity tap). Since 1996, a large body of pub-lished work has examined the health impact of

interventions that improve water quality at thepoint of use through household water treatmentand safe storage (HWTS; Fewtrell & Colford,2004). These recent studiesmany of them ran-domized controlled intervention trialshavehighlighted the role of drinking water contamina-tion during collection, transport, and storage(Clasen & Bastable, 2003), and the health value ofeffective HWTS (Clasen et al., 2004; Quick et al.,

1999, 2002; Conroy et al., 1999, 2001; Reller etal., 2003).

In 2003, as the evidence for the health benefits

of HWTS methods grew, institutions from acade-mia, government, NGOs, and the private sectorformed the International Network to PromoteHousehold Water Treatment and Safe Storage,housed at the World Health Organization inGeneva, Switzerland. Its stated goal is to contributeto a significant reduction in waterborne disease,especially among vulnerable populations, by pro-moting household water treatment and safe storageas a key component of water, sanitation, andhygiene programmes (WHO, 2005).

HWTS OPTIONS

This article summarizes five of the most commonHWTS optionschlorination, filtration (biosandand ceramic), solar disinfection, combined filtra-tion/chlorination, and combined flocculation/chlo-rinationand describes implementation strategiesfor each option.3We identify implementing organi-zations and the successes, challenges, and obstaclesthey have encountered in their projects. We consid-

er sources of funding and the potential to distributeand sustain each option on a large scale, and pro-pose goals for future research and implementation.

This article focuses on point-of-use drinkingwater treatment and safe storage options, which canaccelerate the health gains associated with improvedwater until the longer-term goal of universal accessto piped, treated water is achieved. By preventingdisease, HWTS practices can contribute to poverty



18

2. This study reinforced previous work (Esrey, 1985) that led the water and sanitation sector to de-emphasize improving water quality as a

way to reduce diarrheal disease incidence.3. Space precludes exhaustive consideration of all HWTS options, and thus we have chosen those that are most widely used. For a thor-

ough technical review of all HWTS options, see Managing Water in the Home: Accelerated Health Gains From Improved Water Supply

(Sobsey, 2002). For reviews of safe storage options, see Mintz et al. (1995, 2001).


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alleviation and development. Their widespread use,in conjunction with hygiene education and sanita-tion, could save millions of lives until the infra-

structure to reliably deliver safe water to the entireworld population has been created.

We use a consistent evaluation scheme for eachof the HWTS options discussed (see Table 1):

1. Does the HWTS option remove or inactivateviral, bacterial, and parasitic pathogens inwater in a laboratory setting?;

2. In the field, is the HWTS option acceptable,can it be used correctly, and does it reducedisease among users?; and

3. Is the HWTS option feasible at a large scale?

OPTION 1: CHLORINATION

Chlorination was first used to disinfect publicwater supplies in the early 1900s, and helped dras-

tically reduce waterborne disease in cities in Europeand the United States (Gordon et al., 1987).Although there had been small trials of point-of-use chlorination (Mintz et al., 1995), larger-scaletrials began in the 1990s as part of the PanAmerican Health Organization (PAHO) and theU.S. Centers for Disease Control and Prevention(CDC) response to epidemic cholera in LatinAmerica (Tauxe, 1995). The Safe Water System(SWS) strategy devised by CDC and PAHOincludes three elements:


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Criterion

HWTS Option

Lab Studies Field StudiesCan intervention bebrought to scale?

Virus Bacteria ProtozoaResidual

Protection?Acceptable to

users?Health impact?

Chlorination Medium High Low Chlorine YesYes

(4 studies)

Yes(operates at villageand national scale)

BioSand Filtration UnknownMedium-

HighHigh No Yes Unknown

Unknown(operates at villageand regional scale)

Ceramic Filtration UnknownMedium-

HighHigh No Yes

Yes(1 study with

imported filters)


Solar Disinfection High High High Safe Storage YesYes

(4 studies)


Filtration andChlorination

Medium High Unknown Chlorine Yes

Yes(1 unpublishedcross-sectional

study)


Flocculation andChlorination

High High High Chlorine YesYes

(5 studies)

Yes(operates at villageand national scale)

TABLE 1: SUMMARY OF HWTS OPTION PERFORMANCE CRITERIA


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Treating water with dilute sodium hypochlorite4

at the point of use; Storing water in a safe container; and

Educating users to improve hygiene, as well aswater- and food-handling practices.

The sodium hypochlorite solution is packaged ina bottle with directions instructing users to addone full bottle cap of the solution to clear water(or two caps to turbid water) in a standard-sizedstorage container, agitate, and wait 30 minutesbefore drinking. In four randomized controlledtrials, the SWS reduced the risk of diarrheal dis-ease by 4484 percent (Luby et al., 2004; Quicket al., 1999, 2002; Semenza et al., 1998). At con-centrations used in HWTS programs, chlorineeffectively inactivates bacteria and some viruses(American Water Works Association, 1999); how-ever, it is not effective at inactivating some proto-zoa, such as cryptosporidium.5 Initial researchshows water treated with the SWS does not exceedWHO guidelines for disinfection by-products,which are potentially cancer-causing agents (CDC,unpublished data). Because the concentration of

the chlorine solution used in SWS programs islow, the environmental impacts of the solutionare minimal.

Chlorination: Implementation StrategiesSWS implementation has varied according to localpartnerships and underlying social and economicconditions. The disinfectant solution has been dis-tributed at national and subnational levels in 13

countries through social marketing campaigns, inpartnership with the NGO Population ServicesInternational (PSI). In Indonesia, the solution is

distributed primarily by private sector efforts, ledby a local manufacturing company. In severalcountriesincluding Ecuador, Laos, Haiti, andNepalthe ministries of health or local NGOsrun the SWS programs at the community level. InKabul, Afghanistan, the SWS is provided at nocharge to pregnant women receiving antenatalcare. The SWS has also been distributed free ofcharge in a number of disaster areas, includingIndonesia, India, and Myanmar following the2004 tsunami, and also in Kenya, Bolivia, Haiti,Indonesia, and Madagascar after other natural dis-asters. When SWS programs are in place, theproducts ready availability greatly facilitates emer-gency response. The CDC has developed animplementation manual and provides technicalassistance to organizations implementing SWSprojects (CDC, 2001).

PSIs Social Marketing of the SWS in ZambiaPSI is the largest social marketing NGO in the

world, with offices in more than 70 countries. PSIdesigns a brand name and logo for health prod-ucts; sells them at low prices; distributes themthrough wholesale and retail commercial net-works; and generates demand for the productsthrough behavior change communications such asradio and TV spots, mobile video units, point-of-sale materials, theater performances, and person-to-person communications.



20

4. Sodium hypochlorite (NaOCI) is a slightly yellow, transparent liquid. As a chlorine donor, it serves as a strong oxidizer, bleaching

agent, and sterilizer.

5. Microscopic parasites of the genus Cryptosporidium cause a diarrheal disease called cryptosporidiosis. Once an animal or person is

infected, the parasite lives in the intestine and passes in the stool. The parasite is protected by an outer shell that allows it to sur-

vive outside the body for long periods of time and makes it very resistant to chlorine-based disinfectants.


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Safe Water System resellerin Jolivert, Haiti(courtesy of Daniele Lantagne)


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In October 1998, PSI launched its ZambianSWS product, a bottle of sodium hypochloritesolution branded as Clorin. This program is one

of the oldest PSI/CDC collaborations. Sales steadi-ly increased from 732 bottles per month inOctober 1998 to 132,000 bottles per month inNovember 2003. A cholera epidemic in 1999increased demand for Clorin; sustained social mar-keting and promotion in health centers and door-to-door visits stimulated further sales (Olembo etal., 2004). A population-based, cross-sectionalstudy conducted by an independent agency report-ed that 42 percent of households said they werecurrently using Clorin, and 22 percent reportedusing it in the past (Olembo et al., 2004).However, only 13 percent of households had resid-ual chlorine in their water at the time of the unan-nounced visit, indicating a discrepancy betweenreported and actual use. The study did not find alower rate of reported diarrhea among users ofClorin as compared to non-users. However, usinglarge cross-sectional studies to assess the efficacy ofhousehold water treatment options requires fur-ther refinement. The limitations of this study,

which was the first large cross-sectional populationstudy (as opposed to a randomized study with acontrolled population), impacted the results.

The Clorin product is subsidized by USAID; thefull cost of the 250-milliliter bottleincluding pro-duction, marketing, distribution, and overheadisUS$0.34, and the retail price is set at US$0.12. Thetotal program cost per person-month of protectionfrom diarrhea is US$0.045 (CDC, unpublisheddata). Increasing the price to recover full costs could

have a negative impact on demand, particularly in acountry like Zambia, which ranks 164th out of 177on the Human Development Index (UN Develo-pment Programme, 2004). The program needs

studies of the price elasticity of demand for thisproduct, and is currently implementing options tosignificantly lower costs.

PSIs Zambia project is an example of asuccessful social marketing intervention thatcreates demand for a product and makes it wide-ly available through the commercial sector.Interested NGOs can readily incorporate Clorininto their own programming. The two majorchallenges this program faces are achieving finan-cial self-sufficiency while maintaining access tothe product, and increasing demand among thehighest-risk populations. With its wide Clorinuse and distribution, Zambia is an ideal locationfor future research on program effectiveness indisease prevention, cost-effectiveness, and inter-ventions to reduce economic and behavioralbarriers to utilization.

Community-Based NGO Programin Northern HaitiIn contrast to PSIs national-scale approach, the

Jolivert Safe Water for Families Project(JSWF)produces its own disinfectant, Dlo Pwp, at the

Missions of Love Clinic in Jolivert, Haiti, for dis-tribution in nearby communities. The JSWFProject installed a hypochlorite generatora sim-ple device that passes electric current throughwater and salt to generate hypochloriteandtrained two Haitian technicians to produce thedisinfectant, sell it to families, provide educationalsupport, and test for residual chlorine in usershousehold water. Small-scale local production anddistribution has ensured a continuous supply of

disinfectant to families in spite of natural disastersand political upheavals.JSWF spends about US$7 to provide a bucket

with a lid and spigot for safe storage, as well as



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educational materials, for a family in the program.After that initial investment, disinfectant salesalmost meet operating expenses. One months sup-

ply of the disinfectant sells for US$0.09, which iswithin the budget of most Haitian families. Theproject uses refillable bottles to reduce the cost ofthe disinfectant. JSWF began in September 2002with 200 families; an independent evaluation fourmonths later documented a reduction in diarrhealdisease incidence of 55 percent (Brin, 2003).However, the data were from a cross-sectional sur-vey, which is not as reliable for determining diar-rheal disease outcomes as randomized, controlled,cohort studies. JSWF has expanded to moreremote areas by transporting bulk disinfectant anddistributing it through satellite refilling stations.Currently, the program distributes about 1,000bottles of solution per month to approximately1,200 participating families (7,200 people).

This type of program reaches rural populationsin ways that are culturally appropriate and morecost-effective than many other programs. In addi-tion, this program has created demand in sur-rounding communities via word-of-mouth adver-

tising. The main drawbacks are the dependence onthe hypochlorite generator and on outside pro-grammatic support to enroll new families.

Chlorination: Benefits and Drawbacksof the SWSThe benefits of point-of-use chlorination include:

Proven reduction of bacteria and most viruses; Residual protection against contamination; Ease of use and thus acceptability to users;

Proven health impact in multiple randomized,controlled studies;

Scalability; and Low cost.

The drawbacks include: Relatively low protection against some viruses

and parasites; Lower effectiveness in water contaminatedwith organic and certain inorganic com-pounds;

Potential objections to taste and odor; and Concerns about the potential long-term car-

cinogenic effects of chlorinationby-products.

OPTION 2: FILTRATION

Porous stones and a variety of other natural mate-rials have been used to filter visible contaminantsfrom water for hundreds of years. These mechani-cal filters are an attractive option for householdtreatment because:

There are many locally available and inex-pensive options for filtering water;

They are simple and easy to use; and Such filter media are potentially

long-lived.

However, filtration is the least-studied HWTSintervention; and pathogen removal, filter mainte-nance, and the lack of residual protection pose chal-lenges to implementation.

A recent health impact study in Bolivia docu-mented a 64 percent reduction in diarrhea inusers of 0.2 micron ceramic candle-shaped filtersmanufactured in Switzerland (Clasen et al.,

2004).6

Users prevented recontamination by usinga tight-fitting lid over the receptacle, a tight seal


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26. Most currently used filtration options are locally manufactured.


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to prevent leaking around the filters into thereceptacle, and a spigot to access the water. Inaddition, users can clean the filters without

removing them and potentially exposing the waterin the receptacle to contaminants.

OPTION 2A: BIOSAND FILTRATION

The BioSand Filter (BSF) is a slow-sand filteradapted for use in the home. The most widely usedversion of the BSF is a concrete container approxi-mately 0.9 meters tall and 0.3 meters square, filledwith sand. The water level is maintained at 56centimeters above the sand layer by setting theheight of the outlet pipe. This shallow water layerallows a bioactive layer to grow on top of the sand,which helps reduce disease-causing organisms. Aplate with holes in it is placed on the top of thesand to prevent disruption of the bioactive layerwhen water is added to the system. To use the sys-tem, users simply pour water into the BSF, and col-lect finished water from the outlet pipe in a bucket.In laboratory and field testing, the BSF consistentlyreduces bacteria, on average, by 81100 percent(Kaiser et al., 2002) and protozoa by 99.98100

percent (Palmateer et al., 1999). Initial research hasshown that the BSF removes less than 90 percent ofindicator viruses (Mark Sobsey, personal communi-cation, March 20, 2005).

BioSand Filtration: Implementation StrategiesThe BSF has been implemented through twomain strategies. In the NGO model, employed inCambodia and other countries, the cost of the fil-ters is subsidized, and a NGO promotes the use

of the BSF in the community and provides thefilters. In the micro-entrepreneur model, used inKenya and the Dominican Republic, local entre-preneurs construct the BSF, receive training and

start-up materials, and then develop micro-enter-prises to sell filters within their communities.

Regional-Scale NGO Project in CambodiaSamaritans Purse, an international faith-basedNGO, is one of the principal implementers of theBSF, responsible for the installation of approxi-mately 30,000 of the 100,000 BSF filters in useworldwide. Samaritans Purse has developed animplementation manual and employs a staff waterexpert to provide technical support to BSF proj-ects across the world.

Samaritans Purse has installed 15,000 filters inCambodia, where it works with local partners tohold informational meetings for potential BSFusers. Attendees interested in receiving a BSF areinvited to a second training meeting to sign up forthe program. This self-selected group is then askedto contribute a small amount of the cost of the BSF(about US$3), attend focus group trainings onhygiene and use of the BSF, and send one familymember to assist with the construction and trans-portation of the BSF. The full cost of installing aBSF in a home in Cambodia is US$67; funding for

this project primarily comes from the CanadianInternational Development Agency.

The success of this project is directly related tothe strength of the cooperating staff in Cambodia(Kaida Liang, personal communication,December 24, 2004). Implementation challengesinclude human errors and the weight of the BSF(350 pounds), which makes transportation diffi-cult and complicates installation in homes onstilts. Currently, 75,000 families are waiting to

receive a filter, and lack of funding has limitedexpansion. As the project has grown, economiesof scale and lessons learned have made installationmore efficient and less costly.



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BioSand Filtration: Benefits and DrawbacksThe benefits of the BSF include:

Proven removal of protozoa and approximate-

ly 90 percent of bacteria; High user acceptability due to ease of use,

and improved look and taste of water; Produced from locally available materials; One-time installation with few maintenance

requirements; and Long life.

The drawbacks of the BSF include: Low rate of virus inactivation;

Lack of residual protection and removal ofless than 100 percent of the bacteria, whichleads to recontamination;

The current lack of studies proving healthimpact; and

Difficulty in transport and high initial cost,which make scalability more challenging.

OPTION 2B: CERAMIC FILTRATION

Ceramic filters have traditionally been used for watertreatment throughout the world. Currently, the

most widely distributed ceramic filter is the Pottersfor Peace (PFP) filter, which is shaped like a flower-pot and impregnated with colloidal silver.7 Holding8.2 liters of water, it sits inside a 20- to 30-liter plas-tic or ceramic receptacle with a spigot. Laboratorytesting has shown that although the majority of thebacteria are removed mechanically through the fil-ters small (0.63.0 microns) pores, colloidal silver isnecessary to inactivate 100 percent of the bacteria(Lantagne, 2001a). The filter removes 99.99 percent

of protozoa by mechanical processes (Lantagne,2001a); however, the effectiveness of the filter ininactivating or removing viruses is unknown.

Ceramic Filtration: Implementation StrategiesPFP is a U.S.-based NGO whose mission is tobuild an international network of potters con-cerned with peace and justice issues. PFP helpspotters learn appropriate technologies and mar-keting skills that improve their livelihoods andsustain their environment and cultural traditions.After staff members were introduced to theceramic filter design, PFP established a filter-mak-ing factory in Managua, Nicaragua. Funding forthe project initially came from private donations.The filter factory is now a self-financed micro-enterprise in Nicaragua. NGOs pay US$10 perfilter, and transport the filters themselves to proj-ect locations. From 19992004, PFP made andsold a total of 23,000 filters in Nicaragua. PFPhas also established filter-making factories in 12other countries, contracted by organizations thatprovide funding for technical assistance and facto-ry construction.

In the current model, the factory sells filters toNGOs, who then implement a water program.This model is attractive to NGOs because they donot have to produce the filters, but it suffers froma lack of consistent training and education forboth the NGO implementers and the users. Poorcleaning and maintenance of the filter often leadsto recontamination of finished water (Lantagne,2001b). To address this issue, PFP is workingwith cooperating NGOs to develop, implement,


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7. Colloidal silvertiny silver particles suspended in liquidis a disinfectant, preventing bacterial growth in the ceramic filter

and assisting in inactivating the bacteria in the filter. The use of colloidal silver in the PFP filter does not leave a residual in the

drinking water.


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and evaluate an educational program that includessafe storage, proper procedures for cleaning thefilter, and follow-up visits to ensure proper use

continues and broken filters are replaced. Thiseducational component is critical for the real-world performance of the filter to match itseffectiveness in the laboratory, and to test whetherfilters made with locally produced materials willprevent diarrhea.

Ceramic Filtration: Benefits and DrawbacksThe benefits of the PFP ceramic filter include:

Proven reduction of bacteria and protozoa inthe laboratory;

Ease of use; Long life, if the filter remains unbroken; and Relatively low cost due to local production of

the filter.

The drawbacks include: Unknown effectiveness against viruses; Lack of residual protection, leading to reconta-

mination; Lack of health impact studies of this particular

filter design; The need to educate the user to keep the filter

and receptacle clean; andA low flow rate of 12 liters per hour.

OPTION 3: SOLAR DISINFECTION

Solar disinfection (SODIS) was initially developedto inexpensively disinfect water used for oral rehy-dration solutions (Acra et al., 1984). In 1991, theSwiss Federal Institute for Environmental Science

and Technology began to investigate and implementsolar disinfection as a HWTS option. Users ofSODIS fill 0.32.0 liter plastic soda bottles withlow-turbidity water, shake them to oxygenate the

water, and place the bottles on a roof or rack for sixhours (if sunny) or two days (if cloudy). SODIS hasbeen proven to inactivate bacteria and viruses

(Wegelin et al., 1994; Sommer et al., 1997); theprotozoa cryptosporidium and giardia are also sensi-tive to solar irradiation (Mndez-Hermida et al.,2005; Martin Wegelin & Regula Meierhofe, person-al communication, March 8, 2005). Randomizedcontrolled studies have shown SODIS to reducediarrheal disease incidence by 986 percent (Conroyet al., 1996, 1999, 2001; Hobbins, 2003).

Solar Disinfection: Implementation StrategiesAs a virtually zero-cost technology, SODIS facesmarketing constraints. Since 2001, local NGOs inseven countries in Latin America as well as inUzbekistan, Pakistan, India, Nepal, Sri Lanka,Indonesia, and Kenyaare disseminating SODISby training and educating users at the grassrootslevel, providing technical assistance to partnerorganizations, lobbying key players, and establish-ing information networks. The program has beenfunded by the AVINA and Solaqua Foundations,private and corporate sponsors, and official devel-

opment assistance. The program has shown thatSODIS is best promoted and disseminated by localinstitutions with experience in community healtheducation. Creating awareness of the importance oftreating drinking water and establishing correspon-ding changes in behavior requires a long-termtraining approach and repeated contact with thecommunity. The Swiss Federal Institute for Enviro-nmental Science and Technology has developed animplementation manual, and provides technical

assistance to NGOs implementing SODIS. Themethod, which has been disseminated in morethan 20 developing countries, is regularly appliedby more than one million users.



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A NGO Project in East Lombok, IndonesiaAfter a successful pilot project, two local NGOsworked closely with the district health department

in East Lombok, Indonesia, to promote SODIS(Meierhofer, 2005). This large-scale disseminationproject worked through community health cen-ters to train health officials, sanitarians, teachers,and community representatives in improvedhygiene practices and use of SODIS. These train-ers, in turn, trained 144 villages and 70 elemen-tary schools in the use of SODIS, reaching130,000 people in 14 months.

The project ensured sustainability by working

closely with government partners. Integratinghygiene education and SODIS into the commu-nity health center structure provided long-termcontinuity for the project, which reduced bacterialcontamination of household drinking water by 97percent. Acquiring enough plastic bottles for eachfamily was a challenge, so the project established amechanism to transport and sell bottles. GeorgFischer AG, a German corporation, providedfunding at a cost of US$0.80 per capita.

Solar Disinfection: Benefits and DrawbacksThe benefits of SODIS include:

Proven reduction of bacteria, viruses, andprotozoa;

Proven health impact;Acceptability to users because of the minimal

cost to treat water, ease of use, and minimalchange in water taste; and

Unlikely recontamination because water isconsumed directly from the small, narrow-

necked bottles (with caps) in which itis treated.

The drawbacks include: Need to pretreat water that appears slightly

dirty;8

Low user acceptability because of the limitedvolume of water that can be treated at one timeand the length of time required to treat it; and

Requires a large supply of intact, clean, andproperly sized plastic bottles.

OPTION 4: FILTRATION AND CHLORINATION

Several systems incorporate both a physical filtra-tion step for particle removal and a chlorinationstep (or steps) for disinfection. This dual approachproduces high-quality finished water. The Gift of

Water, Inc., (GWI) purifier is a two-bucket sys-tem with a polypropylene string-wound filter inthe top bucket and a granulated activated-carbonfilter in the bottom bucket. Users collect water in

the top bucket, add chlorine (purchased locallyeach month), wait 30 minutes, and then place the


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28. Turbidities higher than 30 Nephelometric Turbidity Units.

Using solar disinfection (SODIS) in Nepal(courtesy of EAWAG/Water and Sanitation in Developing

Countries [SANDEC])


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top bucket on the bottom bucket, which activatesa check-valve allowing water to flow through thetwo filters into the bottom bucket. Water is

removed from the system via a tap in the bottombucket, and a small amount of chlorine is addedmanually to the bottom bucket as residual protec-tion. This system has been proven to reduce bacte-ria sufficiently to meet WHO guidelines(Varghese, 2002). Studies of protozoal removalhave been inconclusive (Borucke, 2002); viralremoval has not yet been studied.

Filtration and Chlorination: ImplementationStrategiesGWI is a faith-based organization headquartered inFlorida that assembles, distributes, and implementsvillage-based programs with the GWI purifier.Church groups in the United States sponsor com-munities in Haiti, many through the CatholicParish Twinning Program of the Americas.

Once a village is sponsored, Haitian GWI staffwork with the community to establish a watercommittee and install purifiers in 200400homes. In addition, two local community health

technicians are trained by master technicians tovisit the users homes weekly and perform mainte-nance and residual chlorine spot-checks. Thepurifier has garnered high levels of communityacceptance, and an independent cross-sectionalstudy found a 56 percent reduction in diarrhealdisease incidence in users, with a 35 percentreduction when controlling for socio-economicstatus and hygiene practice (Varghese, 2002). Asnoted earlier, however, cross-sectional studies are

not a reliable method for evaluating diarrheal dis-ease. There are currently 70 sponsorships, cover-ing 120 villages, and more than 16,000 purifiers,with 200 paid Haitian staff in the GWI program.

The program is expanding at a rate of8,00010,000 new families per year.

The program offers a successful product

(water treatment for a village) to consumers(churches) who have resources and good inten-tions, but lack the technical capacity to imple-ment a water intervention in a needy community.In July 2004, a church in Atlanta, Georgia, pro-vided GWI with US$5,600 to install 400 puri-fiers, train the community members and healthtechnicians, and pay annual salaries for two ofthe technicians (Molly Brady, personal communi-cation, December 29, 2004). By September2004, the program had conducted the trainingand installed 200 filters; the church was verypleased with the programs progress, but was con-cerned about its ability to provide the techni-cians salaries indefinitely. The drawbacks thusinclude the uncertainty of consistent supportfrom community health technicians.

Filtration and Chlorination: Benefitsand DrawbacksThe benefits of the GWI purifier are:

High removal rates of bacteria, even in turbidwaters;

Residual protection; High acceptability among users due to the

ease of use and visual improvement of thewater; and

Health impact, as measured by a cross-sec-tional study. (Internal GWI studies attributetheir success to the programs communityhealth technicians [Phil Warwick, personal

communication, March 8, 2005].)

The drawbacks of the GWI purifier are: Unknown viral and protozoa removal; and



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The need for regular filter replacement, ongo-ing technical support, and continuing educa-tion, in addition to concurrent ongoing costs.

OPTION 5: FLOCCULATION AND

CHLORINATION

Several systems incorporate both a chemicalcoagulation step for particle removal (floc-culation9) and a chlorination step (or steps) fordisinfection. This dual approach produces high-quality finished water. The Procter & GambleCompany(P&G) has developed a HWTSoption for sale at no profit to users and NGOs,called PuR Purifier of Water. This small sachetcontains powdered ferrous sulfate (a flocculant)and calcium hypochlorite (a disinfectant). To usePuR, users open the sachet, add the contents toan open bucket containing 10 liters of water, stirfor five minutes, let the solids settle to the bot-tom of the bucket, strain the water through acotton cloth into a second container, and wait 20minutes for the hypochlorite to inactivate themicroorganisms.

PuR incorporates both the removal of particles

and disinfection. Because of this dual processtreatment, PuR has high removal rates of bacteria,viruses, and protozoa, even in highly turbid waters(Souter et al., 2003; Le et al., 2003). Use of PuRreduced diarrheal disease incidence by 16 percentto more than 90 percent in five randomized con-trolled health intervention studies (Reller et al.,2003; Chiller et al., 2003; Crump et al., 2004;Agboatwalla 2004; Doocey, 2005). It also canremove heavy metals, such as arsenic. PuR is pro-

vided to global emergency relief groups forUS$0.035 per sachet, plus shipping.

Flocculation and Chlorination:Implementation StrategiesP&G has recently moved from research anddevelopment of the PuR product to research intoeffective implementation strategies. P&G is inves-

tigating social marketingin partnership withPSIin Haiti, Pakistan, and Uganda, and distri-bution during emergency responses.

Emergency Response Using Pu--RThree hundred thousand PuR sachets were distrib-uted in response to the flooding after HurricaneJeanne struck Gonaives, Haiti, in September 2004.PSI and CARE staff were trained in the use of theproduct and, within weeks of the flooding, distrib-

uted PuR and educational materials to affectedcommunities.


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29. In flocculation, fine particles in water are gathered together (aggregated) into larger particles by mixing water with coagulant chemicals.

Using solar disinfection (SODIS) in Nepal(courtesy of EAWAG/Water and Sanitation in DevelopingCountries [SANDEC])


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As correct use of PuR requires several steps, theprograms success in Haiti was due to well-trainedstaff who understood the product, trained the

trainers (local community members), and providedthem with the skills, knowledge, and materials toteach others through community demonstrations(Bowen et al., 2005). Adequate supplies of instruc-tional and promotional materials in the local lan-guage were also very useful.

The lessons learned in Haiti helped informemergency response procedures elsewhere. Inrefugee camps in Liberia, Johns Hopkins Universityresearchers provided trainings, demonstrations, and

the two buckets necessary to use the product. Theydocumented a 93.6 percent reduction in diarrhealdisease incidence among PuR users compared to acontrol group of safe storage users (Doocey, 2005).Before the South Asia tsunami in December 2004,5 million sachets of PuR had been procured foremergency response (Greg Allgood, personal com-munication, February 3, 2005). Since then morethan 16 million sachets have been purchased andtransported to tsunami-affected areas in Indonesia,Sri Lanka, and the Maldives by Samaritans Purse,

AmeriCares, and PSI. Samaritans Purse, UNICEF,World Vision, the International Rescue Committee,and the International Federation of the Red Crosshave all mobilized and trained communities to usePuR, following an initial model established bySamaritans Purse, which provides affected people acloth, a spoon, soap, an instruction card, and 72sachets of PuR packaged in two buckets.

Flocculation and Chlorination:

Benefits and DrawbacksThe benefits of PuR are:

Removal or inactivation of viruses, bacteria,parasites, heavy metals, and pesticides, even

in highly turbid waters; Residual protection; Proven health impact;

User acceptability due to waters visualimprovement;

Ease of scalability or use in an emergencybecause the sachets are centrally produced,and easily transported (due to their smallsize, long shelf life, and classification as anon-hazardous material for air shipment);and

Reduced concern about carcinogenic effectsof chlorination because organic material isremoved in the treatment process.

The drawbacks of PuR are: Mulit-step process requiring demonstrations

for new users and a time commitment forwater treatment from the users;

Requires two buckets, a cloth, and a stirringdevice; and

High relative cost per liter of water treated.

DISCUSSION

Many researchers, private companies, faith-basedorganizations, international and local NGOs,donors, ministries of health, and end users areinterested in HWTS options and in mechanismsfor their implementation. The evidence base forthese interventions is well-established and grow-ing, and an active program of further technicaland operations research is being pursued onmultiple fronts.

HWTS implementation has enjoyed numerous

successes. First and foremost, field-based programshave documented reductions of diarrheal diseasesin end users. Factors that contributed to successfulprograms include:



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The ability to obtain quality HWTS optioncomponents (and any replacement parts)locally;

Behavior change communications includingperson-to-person communications and/orsocial marketing; and

Availability of implementation materials andtechnical assistance to support on-the-groundimplementers.

HWTS implementation projects have also encoun-tered significant challenges, including:

Questions regarding the health impact ofthese interventions in large-scale real-worldsituations;

Long-term sustainability of the projects, espe-cially long-term access to supplies; and

Scaling up to efficiently reach people withoutaccess to improved water sources.

Larger studies will demonstrate the health impactof HWTS in real-world settings, and more timewill tell us whether these programs are sustain-able. Expanding efficiently to global scale will

require a creative combination of market, micro-enterprise, and community-based approaches.The long-term goal of water infrastructure for all,however, should not be delayed by efforts tomeet the short-term goal of health benefits fromhousehold water treatment. Research could helpensure that these two strategies can be imple-mented together to achieve both goals.

An additional challenge for implementers ischoosing the best HWTS option in a given area.

Important criteria to consider when selecting anHWTS option include:Community specific needs and preferences:For

example, if the turbidity of the source water is

high, users should pretreat water with filtrationor coagulation before disinfection and safe stor-ageor, if users prefer a current practice, such

as storing water in ceramic pots, incorporatethat practice into the project;

The mechanism to prevent recontamination of thetreated water: A number of HWTS optionsincorporate some form of residual protection(SWS, SODIS, GWI, PuR); safe storage orother mechanisms to prevent post-treatmentcontamination should be a part of everyHWTS project; and

The mechanisms (financial and otherwise) to pro-vide sustained availability:Long-term access tothe HWTS option requires not only activatingsome type of supply chain, but also ensuringthat once activated, access is uninterrupted.

Unfortunately, these criteria may not be systemati-cally considered when HWTS interventions areimplemented. We studied a BioSand Filter instal-lation in a peri-urban slum with access to piped,processed, municipal waterlikely not the mostcost-appropriate or effective intervention for this

setting. An investigation of source water qualitybefore implementation would have discovered this,and potentially a more appropriate interventionsuch as improving the local water supply, educat-ing users about safe water storage to preventrecontamination, or using chlorination alonecould have been implemented.

In some situations, there may not be an appro-priate HWTS option. While accompanying a U.S.school group on a trip to Mexico to plan a joint

Mexico-U.S. student-run SWS project, an investi-gation showed the project communities existingpiped, treated water was of good quality, thoughwith sub-optimal residual chlorine (Lantagne,


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2004). Although the SWS project was well-inten-tioned, it was not an appropriate intervention forthese communities. Instead, investigators recom-

mended improving the existing water treatment anddistribution infrastructure.

A critical piece of every development programis cost (see Table 2). Costs are highly program-spe-

cific; they vary with location, implementationstrategy, and desired endpoint, and cannot be gen-eralized. For example, in comparing the GWI and

JSWF projects, both of which operate in ruralHaiti, we find that the JSWF project requires asmaller subsidy and thus appears the better option.However, the GWI project incorporates a filtra-



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TABLE 2: COST OF HWTS OPTIONS

HWTS OptionProject Location

and ImplementerCost of Product

to UserFull Cost of Product*

Initial equipment Ongoing Cost

Chlorination Zambia, PSI1 bottle of chlorine

solution at US$0.12per family per month

Accounted for incost of bottle

US$0.37 per bottleof chlorine

solution (US$0.25per bottle subsidized

by donor)

Chlorination Haiti, JSWF1 bottle of chlorine

solution at US$0.09per family per month

US$7 start-up feeper family paid

by NGO

US$0.09 perfamily per month for

chlorine solution(no subsidy)

BioSand

Filtration

Cambodia,

Samaritans Purse

One-time cost of US$3 to

family for BSF

US$67 per BSFpaid by NGO covers all

expensesNone

CeramicFiltration

Nicaragua, Pottersfor Peace

ZeroUS$10 for filter paid byNGO covers all factory

expensesUnknown

SolarDisinfection

Indonesia, local NGOs Zero Zero

US$0.80 paidby NGO per person

reached in14-month project

Filtration andChlorination

Haiti, GWI

US$1.71 per familyfor filter

US$0.120.34 per

family per monthfor chlorine

US$12-15 paidby NGO per family

for filter

US$4 paid byNGO per family

per year

for education andreplacement filters

Flocculation andChlorination

South Asia tsunamiemergency response

Zero UnknownUS$0.07 per day

per familyfor sachets

*Including delivery, installation, distribution, education, marketing, overhead, and other costs.Source:Costs reported in this table are self-reported by program coordinators.


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tion step that the JSWF project does not, and thustreats turbid water more effectively. Program plan-ners must evaluate both the costs and the treat-

ment needs in a community to determine themost cost-effective and appropriate intervention.

When reviewing cost data, it is important tocompare them to the costs of other water and san-itation improvements. A recent cost-benefit evalu-ation found that all water and sanitation improve-ments analyzed were cost-beneficial in all regionsof the world, with returns of US$1.92$15.02on each US$1 invested, depending on region andtype of improvement (Hutton & Haller, 2004).However, disinfection at the point of use (theonly HWTS option considered in the analysis)had the lowest cost per person when comparedwith all non-HWTS interventions to provideimproved water supply or sanitation. This initialwork indicates that HWTS options are cost-effec-tive mechanisms for providing improved waterto households.

FUTURE WORK

Although much research has been completed on

HWTS options, more is needed, including: Health impact studies:

Of the HWTS options that are widely dis-tributed but have not yet been proven effec-tive at reducing disease;

Of a large-scale real-world project, such asone of the national or sub-national PSISWS projects; and

With longer-term endpoints in children,including growth, cognitive development,

and mortality. Development of real-term, practical parametersand performance measures to predict safety ofdrinking water in developing countries;

Investigations of the economics of moving tolarge-scale projects, including cost analysis,economic demand assessment, and sustainabil-

ity; and Determination of the relative and absolute

impact of HWTS options and other water, san-itation, and hygiene (WASH) interventions,and research investigating optimal combina-tions of HWTS and WASH interventions.

In addition, important operational research ques-tions remain, including:

What motivates users to purchase and use aHWTS option?;

What are current purchase (use) and re-purchase (sustained use) rates in differentdemographic, socio-economic, and culturalgroups; and how do these correlate with water-borne disease prevalence rates?;

What is the health impact of routine versussporadic use of HWTS options in the home?;

What are optimal behavior-change strategies forhygiene and sanitation practices; and how dowe best incorporate these into different HWTS

implementation strategies?; andWhat are the most sustainable and cost-

effective ways to reach rural and remote areas?

To address these research questions, the HWTScommunity should continue to work with aca-demic institutions that provide technical knowl-edge and student labor. The University of NorthCarolina, Emory University, MIT, Johns HopkinsUniversity, and the London School of Hygiene

and Tropical Medicine, among others, have exist-ing programs in public health or engineeringdepartments that research HWTS options. Thispath has resulted in numerous successes, such as


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34

the development of a computer model to ascertainSODIS appropriateness for any area of the worldusing NASA data (Oates et al., 2002).

One question to ponder: are students beingtrained for job opportunities that do not yet exist?The interest in HWTS options is very high at thestudent level. The HWTS community should seekto identify and coordinate future human resourceswith the growing number of graduates with relevantfield ex

Water Stories__expanding Opportunities in Small Scale Water and Sanitation Projects _wics

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