Running head: UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 1

Unsafe Water and Sanitation: Global Effects

Cassandra Levchuk

Delaware Technical Community College

UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 2

Abstract

Goal 6 of the Sustainability Development Goals (SDGs) created by the United Nations in 2016

addresses the global issue of unclean water and sanitation. At least 1.8 billion people globally

use a source of drinking water that is fecally contaminated (UNDP, 2017, facts and figures, para.

2). This common occurrence has led to various diseases being consumed in contaminated water

such as diarrheal diseases, killing thousands of our worlds population. These diseases are both

treatable and preventable with the correct resources. This paper addresses current public health

interventions associated with the Health Impact Pyramid (HIP) and their levels of effectiveness.

Areas of the Health Impact Pyramid include socioeconomic factors, changing the context to

encourage healthy decisions, long-lasting protective interventions, clinical interventions, and

counseling and education interventions. Finally, there is information on careers in global health

and water sanitation. This sustainability development goal should be a major priority in global

health, addressing a basic right and dignity, clean water.

UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 3

Unsafe Water and Sanitation: Global Effects

Water is the most basic necessity for survival next to oxygen for the human population,

leaving humans only about three days without water to survive. Water scarcity affects more than

40 percent of people around the world (UNDP, 2017). With this need, water is consumed

worldwide on a daily basis unfortunately whether it is safe to drink or not. Over 900 million

people do not have clean drinking water available to them, and approximately 2.5 billion people

do not have proper sanitation practiced in their daily lifestyle (Frieden, 2010). In many countries

where clean water and sanitation is an issue there is no proper waste disposal system, therefore

feces is found in the drinking water. Contaminated water increases the transmission of diseases

such as cholera, diarrhoea, hepatitis A, typhoid, and polio (WHO, 2017b). Diarrhoeal disease is

the second leading cause of death in children under five years old, killing 525,000 children each

year. Unfortunately, this disease is preventable and treatable. With severe dehydration and fluid

loss being main causes of death, this disease also leads to septic bacterial infections killing

children as well. Children who are malnourished, immunosuppressed, or have HIV/AIDS are at

the most risk for contracting diarrhoeal disease and dying. On average, children under three years

of age experience three episodes of diarrhoea each year in low-income countries. With each

episode depriving the child of nutrients it needs to grow, diarrhea is a major cause of

malnutrition leaving this population in a constant cycle of risks for diarrheal diseases (WHO

2017a). Although water sanitation has improved for 2.1 billion people since 1990, clean water

and sanitation still remains Goal 6 of the Sustainability Development Goals created by the

United Nations for years 2016 to 2030 (UNDP 2017).

The Health Impact Pyramid is used for a framework for public health action in global

issues such as clean water and sanitation because it describes different types of public health
UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 4

interventions organized by level of impact. The bottom of the pyramid consists of addressing

socioeconomic factors, which reaches and impacts the largest amount of people and the top of

the pyramid is counseling and education, an intervention specific to an individual and their needs

and proved the least effective. Interventions to address clean water and sanitation can be

described and guided by the Health Impact Pyramid showing which ideas would affect the

largest amount of people and be the most effective (Frieden, 2010).

Socioeconomic factors or determinants of health describe why the people live the way

they do and what factors of their environment contribute to their current issues. A determinant of

health explaining why water-borne diseases are so prevalent in low-income countries is improper

sanitation. A study conducted in Ghanas Central Region showed 74% of households having E.

coli in their water source. Households with a water closet toilet showed significantly lower levels

of E. coli in their water compared to homes using pit latrines or no toilets at all. The lack of

proper disposal of human waste is the most significant factor on this issue. Other sources of

infection come from water that is not boiled for milk preparation and untreated rainwater stored

in a well and in close proximity to animals (McGarvery et al, 2008). Other socioeconomic

factors of the population include urban areas, less wealthy households, and low level of

education. On the contrast, available clean water sources would allow people to focus on other

hygiene practices such as hand washing and decrease long and risky trips to a clean water source,

improving health. Available clean water, decreasing diseases, would result in an increase in

school attendance for children providing the future generation with more education than their

parents.

The second tier of the Health Impact Pyramid addresses changing the environment or

context of the population so they have no choice but to default to a healthy option. One example
UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 5

of this solution took place in China in 2011 called the Hai Basin Integrated Water and

Environment Management Project. This project improved the water supply of the Hai Basin

reaching 16 counties in northern China and benefitting 20 million people. Improved water and

decreased pollution in the Basin improved local health and living conditions, eliminated odors,

improved crops through irrigation, improved household incomes, and enhanced life of the

connecting Bohai Sea for both animals and fisherman (The World Bank, 2014). With the Hai

Basin being this areas primary water source, it would be difficult and not wise for the local

population to get an unclean water source from farther away. Therefore, this intervention worked

by forcing the people to default to a healthy option.

The next level of the Health Impact Pyramid includes long-lasting protective

interventions that do not require much maintenance to implement and be effective. An example

of this can be immunizations because most you deliver just once or twice and it is not required

again, another example is male circumcision to prevent HIV, which only needs to be performed

once (Frieden, 2010). An example of a long-lasting protective intervention related to a clean

water source is the introduction of using a sari cloth to filter water. This intervention was

implemented in Bangladesh and is still used today. A study was done showing the prevalence of

cholera, another common diarrheal disease found in contaminated water, was reduced by 48% in

the population using the sari cloth to filter. Going back five years later, it was found 31% of the

respondents were still using a filter for their water, the majority using the sari cloth. This

intervention proves to be under this category because it required the introduction of the cloth and

that's it. It did not need to be kept up with and the people really used this method, which was

their choice. It was tested in the study that using four layers of sari cloth to filter was optimal

because it actually filtered out 99% of bacteria (Huq et al., 2010). Another way of prevention of
UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 6

diarrheal diseases being worked on today is a rotavirus immunization. Rotavirus is the most

common cause of severe diarrhea in young children around the world and causes continuous

hospital visits and deaths. There are currently two rotavirus vaccines available both given orally.

The first African country to use the rotavirus vaccines was Sudan, in July 2011. Now more than

20 African counties have introduced the rotavirus vaccine in their immunization programs

(PATH, 2014). This intervention again only needs to be administered once and requires little

follow up, making it easy for the population.

The next tier of the Health Impact Pyramid includes clinical interventions and acute care.

This area is fairly individualized and specific to the patients that need it. It is also one of the least

effective interventions on public health because we are treating the problems we are trying to get

rid of because it is necessary but not helping the prevalence of the disease (Frieden, 2010). The

most common clinical interventions for diarrheal disease due to contaminated water are oral

rehydration solutions and zinc supplementation. With populations having severe diarrhea, the

treatment is all about replacing fluids and electrolytes. The United Nations Childrens Fund

(UNICEF) and the World Health Organization (WHO) have recommended a glucose-based oral

rehydration solution as treatment for more than 25 years now. Recent efforts to improve the oral

rehydration solution have reduced sodium and glucose due to evidenced based studies showing

this new solution has decreased the fecal volume and the duration of diarrhea. WHO now

recommends an oral rehydration solution with 75 mEq of sodium and 75 millimoles of glucose

per liter to treat diarrheal diseases everywhere. Some examples of this are Pedialyte, Pediatric

Electrolyte, and Enfalyte. Zinc supplements are also recommended to children with acute

diarrhea to be given for 10 to 14 days during and after diarrhea, showing increased outcomes

when combined with the oral rehydration solution. Other diseases passed in contaminated water
UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 7

such as shigellosis, causing bloody diarrhea, are treated with antibiotics. Above all, the reduced

osmolality oral rehydration solution is the number one recommended treatment of acute diarrheal

disease by WHO (Keusch et al, 2006).

The top of the pyramid consists of counseling and education. This is considered the least

effective on public health because it is only followed by some people and does not force

behavioral change, which is difficult to initiate (Frieden, 2010). Some of the most common

topics in counseling and education done in the Sub-Saharan area due to contaminated water are

exclusive breastfeeding and hand washing. Exclusive breast-feeding is recommended for the first

six months of life, meaning no other food or drink (even water). This intervention is effective for

preventing diarrheal diseases from unclean water by eliminating the chance of consuming

contaminated food or water and giving antibodies via breast milk. This education has been

increased in hospitals where women are delivering, peers and heath workers elsewhere, mass

media, and mothers support groups. HIV infection is a problem with this intervention because

only known HIV negative mothers would be able to exclusively breastfeed safely. Some options

have become available for HIV positive mothers in these areas such a heat-treated breast milk,

HIV negative wet nurses, uncontaminated donor milk, or exclusive breastfeeding for six months

and immediately stopping afterwards. Mothers treated with antiretroviral therapy should have a

safe period for breastfeeding as well. Currently with the prevalence of HIV being high in this

area, exclusive breastfeeding, even if HIV status is unknown, remains the best option of health.

Another form of education that is being initiated in this area is hand washing. Promotion of hand

washing has reduced diarrhea incidence by an average of 33 percent. Antibacterial soaps are

costly and dont show much advantage. Ash or mud can also be used in place of soap, where

soap is not available. Washing hands after using the bathroom and before food handling is
UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 8

recommended, but it averages about 32 hand washes, consuming 20 liters of water per day

(Keusch et al, 2006). This is an issue for places with water scarcity or clean water limitations,

therefore may be an unrealistic method for the average person. The role of the nurse in

counseling and education matters because it requires a behavioral change by the population. It

requires the nurse to assess the patient holistically including the patients views and opinions and

selecting realistic options and resources. The client will not benefit from the education if they are

not able to perform it due to financial or lifestyle issues or if they simply dont believe in it. For

example, many people in the Sub-Saharan area do not believe in breast-feeding because of their

religion. These prevention methods and education are also more effective when adopted by entire

communities and not just single households. An extreme effort needs to be taken in order to

educate the population and usually requires changing their direct living environment, addressing

a different category of the health pyramid.

This topic, Water, Sanitation, and Hygiene (WASH), needs new ideas implemented in the

overall public in order to decrease the disease from unclean water. One idea I have constructed is

possible public toilets or area of waste. Many people in low-income countries have nowhere to

dispose of solid waste and defecate outside, in public areas. This is the number one reason why

the water is contaminated as discussed previously. If people did not have the money to create a

toilet or latrine in their home, they could use the various designated areas used by the public.

These areas would have to be placed strategically close and common enough to be used by

everyone but not near areas of clean water. It is likely that funding would need to be given for

this project as well.

Career options associated with clean water and sanitation are abundant because of the

amount of organizations involved in this movement, some being the United Nations, WHO,
UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 9

UNICEF, and USAID. A public health nurse would also be a contributing member in this

movement. Some other high in demand jobs are health educators to educate the people on safe

and clean practices, public health officers, and infection control officers. These jobs all relate

back to the SDGs being their overall focus. The Sustainability Development Goals have created

proposed targets such as by 2025, no one practices open defecation and by 2030, all school and

healthcare facilities provide all users with clean basic drinking water and adequate sanitation.

They plan to not only focus on households, but focus on communities, with a primary focus on

schools for the growing population (Trevett, 2013). These goals were created post 2015 when the

Millennium Development Goals (MDGs) were not met. This goal matters to our global

population because it is estimated 1,000 children die each day due to preventable and treatable

water and sanitation related diarrheal disease (UNDP, 2017). Unclean water is killing the current

population, the growing population, and is striping people of a basic need and right: clean water.
UNSAFE WATER AND SANITATION: GLOBAL EFFECTS 10

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