Jean-Hervé Bradol, Francisco Diaz, Jérome Léglise, and Marc le Pape

SITUATIONS WHERE MSF PROVIDES WATER

MSF first became involved with supplying water in a displaced persons camp during the Ethiopian civil war in the 1980s. Sanitation and health conditions were catastrophic, people had no food or water, and providing healthcare had lost all meaning. At that time, MSF had gained most of its technical experience, both medical and non-medical, in camps for refugees or people displaced within their own country (IDPs). Although intervention in such camps has become less common with the end of the Cold War and evolutions in refugee policies, barely a year goes by without at least one large operation of this type.

Healthcare facilities, medico-social institutions, prisons and the like (such as juvenile detention centres) are other types of setting where MSF takes charge of supplying water. Natural disasters – including epidemics – are yet another setting where MSF public health technicians and engineers operate. Techniques developed specifically for camps are inappropriate in these cases where there are smaller groups scattered over large areas. Yet the number of interventions in situations of “natural” disaster, especially floods, which inevitably lead to the pollution of water sources, is increasing. MSF’s epidemic response operations have also increased significantly in both number and size since the mid-1990s, as evidenced by the current operation in Haiti where 250,000 victims of a cholera epidemic have already received treatment.

And, since the early 2000s, we have stepped up our activity and our analysis of situations where infant and child mortality are acutely or chronically high and water quality-related diarrhoeas are a major cause of death in young children.

TECHNIQUES

The standards and the professional culture of public health technicians and engineers recommend using ground water whenever possible, in the hope that it is less polluted than surface water. To prevent users from polluting ground water, the preference is for drilled wells as these are better protected than dug wells. However, the risk of unfavourable geological conditions, the relative technical complexity, the socio-economic impacts, and the time required, all explain why the drilling option is rarely the first choice.

In reality, surface water is more commonly selected. The two techniques used to reduce health risks related to surface water consumption are clarification and chlorination. The main indicators to monitor these techniques are clarity, taste, human intestinal bacteria levels, residual chlorine, and quantity. Most distribution systems are gravity-fed. Using a pumping and community-level treatment system, users access water via lines of taps installed in a residential area. Diesel-powered electric generators supply the energy required for pumping. MSF does not use street fountains equipped with a water treatment device. Public health technicians distribute jerry cans so that families can fetch water at the water points and store it at home. Families are not given home water treatment devices.

When there are no accessible resources in the vicinity of the potential site, water is drawn from other sites and transported by tanker trucks. In some cases (healthcare facilities, in particular) rainwater is used.

THE SAFETY OF WATER DISTRIBUTED BY AID ORGANIZATIONS

A series of failures was the starting point for our analysis. Several outbreaks of hepatitis E, transmitted via the water supply, occurred in refugee and IDP sites in the Sahel (Sudan in 2004, and Chad in 2007) and in central Africa (Central African Republic in 2002, and Uganda in 2007). MSF was responsible for all or part of the water supply, as well as medical care. These outbreaks are a reminder that significant infectious risk persists even after we implement our usual procedures. In particular, the hepatitis E virus survives our water treatment process (i.e., surface water collection, clarification, chlorination, and distribution), as shown both by the data in the literature and by our own experience with four hepatitis E outbreaks at our intervention sites in less than ten years. Granted, hepatitis E is not like cholera, which can rapidly kill a large number of people within a population. But we must not let the disease’s low case fatality rate mislead us regarding its gravity. Because when one in four individuals is infected, a small percentage of deaths can still in absolute terms add up to a fairly large number of deaths. Moreover, these deaths occur in vulnerable groups (pregnant women, and perhaps children too), the main target of public health.

Hepatitis E outbreaks sometimes spread via the water supply put in place by aid organizations, causing deaths in two vulnerable social groups. The crisis is then amplified by the lack of any possible response once the epidemic becomes full-blown. Because hepatitis E has a long incubation period (several weeks), by the time the first case appears, it is too late to stop the outbreak. When the first symptomatic cases start to be seen, a large percentage of the population is already carrying the virus, for the most part asymptomatically. Even if aid organisations knew in advance that a hepatitis E outbreak was likely, they still wouldn’t know how to prevent it. The technologies we use do not eliminate the virus from water. There are no antiviral drugs for the disease, and the only treatment is symptomatic. Once the epidemic is full-blown, it is impossible to prevent the growth in the number of infected people – or death in the most serious of cases. The only way of preventing an outbreak is to take action upstream – provided we are capable of doing a better job of treating water than we do now. For the time being, our professional environment lacks both the will and the right equipment. Is it even worth it? If the number of deaths alone is taken into account, then the answer is no. But if an epidemic spread via the public water supply causing the deaths of numerous pregnant women – and perhaps young children – is viewed as being unacceptable, then the answer is yes.

While Epicentre’s 2004 epidemiological study in Darfur’s Mornay camp was unable to stop the outbreak or reduce the case fatality rate, it did raise awareness of its gravity and the importance of preventive measures. And other epidemic risks finally convinced everyone of the need to improve the treatment of water supplied by aid organizations.

Cholera epidemics are a major cause for concern because of the large number of deaths they can cause in the absence of an appropriate response. Typhoid fever and, of course, hepatitis E are some other reasons for improving community- and family-based water treatment systems. But the biggest danger from consuming poor quality water is the most banal. Ordinary infectious watery diarrhoea is still a major cause of early childhood death in the places where we operate.

«HUMANITARIAN WATER» STANDARDS

The first challenge is to produce large amounts of high quality water, often no small task in the settings where humanitarian organizations operate. Whatever the obstacles, however, incremental improvement in water quality is always possible, even if it is not always feasible to meet current standards. In practice, the humanitarian standard,Minimum Standards in Water Supply, Sanitation and Hygiene Promotion. Sphere Handbook. Chapter 2. http://www.sphereproject.org/component/option,com_docman/task,cat_view/gid,70/Itemid,26/ which recommends using unpolluted, protected groundwater whenever possible, is often difficult to meet. When it is, the water quality is not always as good as we would like, and sometimes there is faecal contamination (especially in karstic zones or with poorly protected dug or drilled wells) or physicochemical (natural or man-made) pollution.

According to this same standard, once an unpolluted water source is selected, chlorine is supposed to prevent secondary proliferation of pathogens both in the distribution network and during home storage. But with the frequent lack of access to ground water, the role of chlorine is changing. No longer used just to protect already-safe drinking water from subsequent contamination, chlorine is now being used for preliminary disinfection of an already-contaminated resource – surface water. Yet chlorine’s limitations in disinfecting water contaminated by faecal matter are well-known. High turbidity, high levels of metals (iron, for example) or ammonia and alkaline pH render chlorine disinfection relatively ineffective. Clarification prior to chlorine disinfection can certainly improve performance. But while bacteria are sensitive to this type of chemical disinfection, some parasites (Giardia and cryptosporidium) and viruses (hepatitis E, for example) are not. And increasing the chlorine concentration does not solve the problem. In fact, increasing the chlorine level reduces the acidity of the water – in other words, raises its pH. The chlorine then becomes less effective, because the higher pH partially neutralizes hypochlorous acid (HClO), the by-product most active in disinfection.

The second challenge arises from the fact that there is no correlation between the main quality indicators (faecal coliform levels and residual chlorine) and public health assessments. Even when the indicators are good, people are not necessarily protected from all water-borne pathogens. In the tropics, we would be better off looking for enterococci than for E. coli, but in any case, neither of these two indicators guarantees that there are no toxins, viruses or parasites. Moreover, testing is done at a given point in time, but contamination may be intermittent. In this case, there is no guarantee that water that meets the standards at the moment it is sampled is not contaminated at other times. Another flaw in the system is that tests for physicochemical contamination are rarely conducted, despite the technologies being available. True, physicochemical contamination only has a health impact after prolonged exposure, but refugee or IDP camps – though considered temporary – often become permanent, lasting several decades. A lack of knowledge of the indicators’ low negative predictive value explains why good results create a false sense of security ill-suited to maintaining the vigilance needed to quickly detect and respond to ongoing threats of epidemic. Solving this problem requires a change in professional culture, from a quality/standards-based culture to a risk-management culture based on the design and execution of a strategy to reduce water-related health risks (Water Safety Plan), a change that is already underway within institutions that manage water in non-humanitarian contexts.

The third challenge is even more banal. The water supplied by aid organizations is not always the water people actually drink. Distances people have to travel, long queues at water points, the chlorine taste some find repellent, and many other economic and socio-cultural factors explain why people do not always use the water from a community system. Users then turn to alternative, often poorer-quality sources, without the benefit of a home water treatment system.

CURRENT STATE OF KNOWLEDGE REGARDING THE IMPACT OF UNSAFE WATER ON HEALTH

Providing access to sufficient quantities of high quality water is certainly an essential part of public health. Preventing deadly epidemics – of cholera and watery childhood diarrhoeas, in particular – is reason enough to pay attention to water quality. And the list is not exhaustive. Available epidemiological data are very clear. Water contaminated by faecal matter is deadly for people with weak immune systems. Children are the first to die in large numbers as, not having been exposed to many microorganisms, they do not have good immunity; they are also susceptible to dehydration from diarrhoea. Pregnant women, the elderly and patients with any kind of immunodeficiency are also in danger.

To start off, the epidemiological data suggest a primary and major requirement for water quality-related interventions: the system must be extremely reliable. The data presented today by Professor Hunter show that consuming unsafe water just one day a month negates the health benefit of consuming good quality water the other twenty-nine days. The public health engineer’s work maintaining the community system must be faultless, and the consumer must be disciplined enough to almost never drink unsafe water from another source. Keeping in mind the priority target – young children – has two main consequences. For the intervention to be meaningful, it must be implemented immediately before consumption, at the point of use. So, action can no longer be limited to efficient management of a community water system. The different home water treatment processes give varied results. Two of these, ceramic filters and home sanitation, stand out for their relative long-term effectiveness. In an emergency, other processes that can be used in the home can be effective for a few weeks – chlorine and solar disinfection and sand filtration. But none is as effective as ceramic filters, the effectiveness of which lasts well beyond a few weeks.

For the past ten years or so, MSF has put considerable effort into more effective paediatric treatment protocols, particularly in the areas of malaria and malnutrition. In contrast, the tools for fighting diarrhoea-related morbidity and mortality have advanced very little. The burden of diarrheal illness, in terms of child mortality, justifies an in-depth examination of every aspect of what has been done in the water domain. Simple oral rehydration and nutritional rehabilitation are still our best weapons in reducing the severity of diarrhoeas and preventing deaths and, while vaccination might be another, new vaccine research and development are not oriented toward addressing the needs of people with little buying power. In the case of hepatitis E, vaccination may soon become an option. But obviously, the vaccines currently in development have not been tested on the most susceptible groups – pregnant women and children.

The consequences on health arising from water access issues go beyond morbidity and mortality caused by epidemics affecting whole populations and infant diarrhoeas. Bone and joint trauma from carrying water is just one example. More indirectly, long waits in crowds around water points with insufficient output contribute to the spread of person-to-person transmitted diseases such as meningitis.

WATER AND THE SOCIAL, ECONOMIC AND POLITICAL ISSUES

On the face of it, the problems associated with supplying water in the situations where MSF operates appear very different from those seen in other settings. However, the tension that researchers describe between two economic models – family management versus corporate management (private or public, using more complex technologies) also occurs in humanitarian settings. The IDP camp (Ethiopia, 1985) afforded MSF’s Watsan department the opportunity to acquire its know-how. The model used by aid organizations in the camps was that of a private, non-profit organisation acting on the government’s authority.

Water sharing regularly led to conflict with camp residents. While the camp itself was well demarcated, the area from which the water supply for residents was drawn was much larger, and taking that water had social, economic and political impacts. Inside the camp, the system for supplying water to families was paternalistic and authoritarian. Yet the need to reduce water-related morbidity and mortality demanded intervention at the household level, and that families take ownership of the available technologies. This is even truer for non-camp interventions, in «open settings,» when responding to natural disasters or epidemics.

The almost total lack of technologies adapted to family-scale action illustrates MSF’s implicit adhesion to the corporate model. This explains, in part, the lack of interest in the sociological aspects of water consumption. Little effort is made to inform users of any problems with the origin and quality of the resource. Similarly, little attention is paid to social disparities and inequalities, even though these are critical to water access. MSF pays little heed to local water institutions. Yet it is with these we have to negotiate sharing the available water and improving its quality. Such discussions could be used to share knowledge, define the roles of the different parties, establish common rules, and provide mechanisms for conflict resolution. The nature of these tasks underscores the extent to which the work of the humanitarian public health technician and engineer is evolving from technical responsibility to social responsibility.

Beyond the local level, discussions at the national or even transnational level seem far from the concerns of a medical organization such as MSF. The large private water companies promote their own interests, never missing an opportunity to point out that they are performing a public service. The power of those who support this particular economic model does not bode well for water resource management and sharing, available technologies, or their cost. Regulation by the market and regulation by negotiation between social partners have very different consequences for the most vulnerable populations.

AVAILABLE TECHNOLOGIES FOR IMPROVING WATER QUALITY

There are three technologies used little, if at all, by humanitarian workers that could improve water quality: UV-C radiation, ultrafiltration, and ceramic microfiltration (home use only). UV-C radiation has been tested in the camp context in response to hepatitis E outbreaks. Our experience has shown that it is possible to install this type of device in an unstable situation. Whether it is effective against hepatitis E is still unknown. Testing to detect the virus is not feasible in humanitarian settings, due to the relative turbidity of the water.

Household-scale ultrafiltration has been tested at MSF-Logistics, in Bordeaux, France. The specifications of this equipment – a jerry can fitted with an ultrafiltration membrane and hand pump, costing 160 euro per unit – warrant evaluation in a real-life situation. The price alone is a significant obstacle, although we know from experience that the cost of new devices can come down quickly. MSF has no experience with ultrafiltration in community systems. It is worth exploring, however, because the water industry’s charitable foundations and the military are already using it in emergency settings. Moreover, ultrafiltration membranes filter out the pathogens that give cause for concern – in particular, the hepatitis E virus. This technology would bring aid organisation practices closer to the standards used in high-income countries. Aside from the expected effect of each technique, combining several of them in the same system increases the system’s safety. With this in mind, MSF has added UV radiation to clarification and chlorination in some of its interventions. This is the «multi-barrier» concept. Another mechanism may provide additional safety: stopping the flow when sensors reveal deterioration in the conditions required for the proper functioning of a chemical or physical disinfection technique. UV radiation lends itself well to such a mechanism. This is also a characteristic of membranes. When they deteriorate, the pores clog up and the flow slows or stops. This is a useful feature, as it must be remembered that accidental contamination has to be very rare if an impact on health is to be anticipated.

Simplicity, standardized equipment and high quality maintenance are essential criteria. Radiation, ultrafiltration and pumping all use energy, but the amounts needed are consistent with a renewable source – solar energy.

WHY AND HOW SHOULD WE REDUCE THE BURDEN
OF WATER SUPPLY-RELATED INFECTIOUS DISEASES?

There are four reasons for moving forward:

- non-potable water has an impact on health;

- MSF water supply systems are less and less suited to the settings where we operate;

- there are technologies that can complement or replace the ones already in use;

- our immediate responsibility as a humanitarian medical organisation supplying unsafe water.

There need to be a number of changes in the professional culture of supplying water in unstable situations:

- making use of the social sciences to study the social, economic and political issues in order to better surmount them;

- shifting our focus from monitoring quality (Sphere standards), which has little correlation with the health risks, to managing those risks (the Water Safety Plan);

- taking into account that there are several possible levels of intervention (community, household, and individual), whereas priority is currently given to community-based systems;

- adding filtration and radiation to the range of tools available to humanitarian public health technicians and engineers;

- conducting epidemiological studies on the relationship between water and health in humanitarian situations;

- increasing funding.

The role of the humanitarian public health technician and engineer is evolving and several aspects of this evolution are worthy of note. Now, the watsan technician or engineer is – whenever possible – part of a multidisciplinary group (comprising a clinician, epidemiologist, sociologist, public officials, user representatives, etc.) charged with organising how water is shared and managing water-related health risks. Given that no standard can ensure complete safety, public health technicians have to be constantly on the alert, mindful of the results from clinical surveillance and epidemiological surveillance, in addition to quantitative and qualitative watsan indicators. They also have to have a foot in each of two professional worlds – one in high-income countries, and the other in unstable situations – in the hope of being able to access new technologies and develop new water supply protocols that will help reduce morbidity and mortality.