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Wise Water

The Center for Global Safe Water is helping make aid sustainable.

By Kay Torrance

Down a short dirt road on the outskirts of Accra, Ghana, sits an abandoned waste water treatment plant.

A few bricks have crumbled. Greenery has overtaken its sides; the metal location sign is long rusted.

Some years ago, this facility was the pride of local residents and the European government that paid to build it. But just three years after it was completed, the main pump broke down. It was fixed using foreign aid money but then broke down again. And was fixed again. And broke down again. Today, it sits as a reminder that aid agencies and nongovernmental organizations (NGOs), despite good intentions, may need more scientific information and guidance before rushing to complete the next big idea.

What agencies and NGOs need is a trusted adviser, and that's where the Center for Global Safe Water (CGSW) at Emory University comes in. Through its research, the CGSW helps governments and international donors make informed choices so their funding goes further and projects are sustainable. Recently, the center has helped focus attention on serious water and sanitation problems in urban areas in developing countries.

Its faculty and staff, which now number 45, want to take the lead in "figuring out which way to go," says Christine Moe, director of CGSW and the Eugene J. Gangarosa Professor of Safe Water and Sanitation. "It may not always be the obvious choice"—like the waste water treatment plant in Accra.

"I see us as adjudicators for what works or doesn't," says Matthew Freeman 05MPH, assistant professor of environmental health and the Rose Salamone Scholar in Sanitation and Safe Water. "Our role is to provide unbiased evidence on how water, sanitation, or hygiene improvements impact health and well-being. It's not science for science sake—we want to inform policy and practice at the global level."

To help determine what may work in Accra, Moe and Clair Null, assistant professor in global health and environmental health, are first identifying patterns in how residents are exposed to contamination in their environment. Their research team of Emory and Ghanaian collaborators is sampling water, surfaces, food, and soil around the city, including public latrines, schools, open drains, and the beach, all of which frequently are contaminated by excreta. Researchers also are studying people's behavior. Where and what do they use as toilets? What are they touching? With the results, the team hopes to characterize exposure and risk.

"We are breaking new ground in urban, low-income communities," Moe says. "Most NGOs have concentrated on bringing water access to rural areas. But the latest statistics from 2008 show that more people now live in cities. There are very few studies of water and sanitation problems in cities in the developing world."

Study findings in Accra will help local policy-makers and international donors determine how to make the most effective investments in sanitation for this rapidly growing city of 4 million people, Moe says. The study is funded by the Bill & Melinda Gates Foundation.

What do the girls say?

UNICEF's "Toilet Team" is among the groups that have sought to partner with the CGSW. The agency wanted to understand better the challenges that girls in developing countries face with managing menstrual hygiene in schools and how access to water, sanitation, and hygiene at schools impacts girls' education during menses.

This project is part of an ongoing collaboration with UNICEF, led by Freeman, to assess equity of access to water, sanitation, and hygiene (WASH) at schools in several countries.

"Most WASH research takes the environmental approach—change people's environment and their behavior will change," says Bethany Caruso 09 MPH, a PhD student in behavioral sciences who co-designed and manages the project. "We started at the societal level by looking at policies and cultural taboos and then looked to the facilities in the school environment and the girls themselves to gain insight on how they manage their period at school."

Caruso and four research fellows, including three Rollins alumnae, worked in the Philippines, Rwanda, Sierra Leone, and Bolivia. In the Philippines, the latrine was in the corner of the classroom. It had no ceiling and no running water. Girls didn't want to use it because of the lack of true privacy. A school in Rwanda had a washroom, but the teacher held the key, and girls were often too embarrassed to ask for it. In Bolivia, the researchers asked girls to draw the perfect setting for handling menstrual hygiene.

"A lot of them drew trees—private natural settings," Caruso says. "Many of them didn't know about latrines, or they didn't see sanitation facilities being for them."

The team is compiling information gleaned from interviews with girls, their mothers, teachers, and boys. "One main message we had is that each place is different, even within a country," says Caruso, who is working with the fellows to tailor recommendations for each location.

More than clean water

In Bolivia, hundreds of children die each year from diarrhea, thousands are hospitalized, and tens of thousands seek outpatient care. These cases occur despite a vaccine that protects against rotavirus, the most common cause of severe diarrhea in infants and young children. That's far too many lives lost, says Juan Leon, a CGSW faculty member and author of a recent paper on the topic.

The Bolivian government blankets about 80% of the country with the vaccine, which has dramatically reduced  rotavirus cases and deaths. But Leon believes there may be another piece to the puzzle.

He regards diarrheal disease as a "supposedly simple condition that isn't." The disease may be linked to the lack of clean water in many rural areas in Bolivia. But the rotavirus also causes diarrhea in the United States, which has clean water.

"Having repeated bouts of the disease during a child's first two years can lead to stunted growth and cognitive impairment," says Leon. "It can affect a kid's entire life."

What may affect Bolivia's rotavirus rate is moderate to severe malnutrition. Leon is addressing the connection between malnutrition and diminishment of the vaccine's effectiveness. In April, his rotavirus research team, which includes eight RSPH students and Emory mentees, began a wide-scale study to collect blood samples from 350 to 400 vaccinated children and their mothers.

In the Mexican state of Nuevo León, just over the Texas border, Leon is working to reduce contaminants on farm crops. His team took samples from crop surfaces, soil, farmworkers' hands, and water used to irrigate crops. They found high levels of contamination from the workers' hands.

"Hands are a huge source of contamination because people pick up the harvested produce, sort it, and put it on a truck," Leon says. "The produce is handled repeatedly. The more contaminated the hands become, the more contamination occurs on the produce."

Now his team is testing "wash breaks." The Clean Greens study, a collaboration with North Carolina State University and the Universidad Autónoma de Nuevo León in Mexico, is looking to make hand washing a routine practice in Mexico. Changing hand-washing behavior, coupled with language barriers among migrant farmworkers, will be difficult.

"Some farms in Mexico have hand-washing stations, but they are often miles away from the field, so we are using jugs of water to take to the field to implement wash breaks," he says. "Other farms are interested in a gel-based hand sanitizer solution. We'd like to see which practice the workers like more and which is more effective."

Atlanta, the nucleus

Back in Atlanta, CGSW faculty member Clair Null recently worked with the Georgia Institute of Technology to develop a latrine training "mat" for children in developing countries.

"Latrine holes often are too large for children," she says. "They can't squat or spread their legs far enough to use the latrine, so we looked at how to help them use the latrine with safety and comfort in mind. Children also are scared or intimated to use the latrines, and moms often don't want them to use them because children don't have great aim."

The first design by Null's team was a square wooden mat with a small hole in the middle and a handle on each side for picking up and placing it over the latrine. It won a $100,000 Grand Challenges Explorations Grant from the Bill & Melinda Gates Foundation. "It was the only idea that dealt with children's sanitation needs," Null says.

Her team then contacted Jonathan Colton, a mechanical engineering expert at Georgia Tech, who asked his students to find a way to make the mats easy to manufacture and stack. They came up with two designs in plastic and put Null in contact with a plastics manufacturer in Nairobi.

Georgia Tech is one of a number of partners that make up the CGSW, along with the CDC, CARE, and the Carter Center. They were brought together nearly 10 years ago by professor emeritus Eugene Gangarosa, one of the school's founding fathers and a waterborne disease expert who advocated for greater collaboration among Atlanta organizations working on WASH issues. Now these partner institutions regularly collaborate on research, just as Gangarosa envisioned.

He continues to influence the center. He and his wife, Rose, have endowed two academic chairs—the Eugene J. Gangarosa Chair in Safe Water and Sanitation, held by Moe, and the Rose Salamone Gangarosa Chair in Environmental Health, soon to be filled by a sanitation expert.

The Gangarosas stay in close contact with faculty and students. "To have someone of Gene's stature tell you that he values your work and you are doing a good job is incredible," says Null.

As Gene says of the couple's gifts, "These two endowments will be drops of water in an ocean of need. Water and sanitation go hand in hand." The CGSW will continue to find ways to lessen that need.