Hello and welcome to week four, module three of the Household Water Treatment and Safe Storage MOOC. I'll be speaking today about household water treatment in the emergency context. My name is Daniele Lantagne and I'm a professor at Tufts University in the United States. First, I'll describe the three types of emergencies we'll discuss. The first type of emergency is natural disasters. These are earthquakes, eruptions, landslides, tsunamis, floods or droughts. They're unplanned for. The general health effects after emergencies come after flooding, or when populations are displaced and move away from their homes. These types of emergencies are increasing as population increases, as more people live in unplanned settlements, and as climate change exacerbates the type and severity of the natural disasters. The next type of emergency we'll discuss is outbreaks. Outbreaks of particular diseases, and in our case, where we're concerned about diarrheal diseases, we particularly are concerned with cholera. Cholera is on the rise, especially in Sub Saharan Africa. The last type of emergency is donor or United Nations defined and these are political emergencies, they are complex emergencies or fragile states. They're unlinked to particular health needs, but they are context in which the State cannot provide services to its population. After an emergency, we generally hear very bold statements about the health impact that we'll see at that emergency. An example statement is this, which was after the tsunami in Christmas of 2005. Which states, unless the necessary funds are urgently mobilized and coordinated in the field, we could see as many fatalities from diseases, as we have seen from the actual disaster, itself. Another quote, and this is from a paper that addresses some of the myths of responding in disasters, another common myth about disasters, is the affected local population is helplessly waiting for the western world to save it. In reality, there are health needs in emergencies and after disasters and outbreaks and in complex situations, and those health needs are linked to where the people are located. So, for example, we know that refugees, and these are displaced populations that move across an international border, they're protected by international law. And they often move into camp situations. And there is quite an extensive literature that establishes mechanisms to reduce the mortality rate within refugee camps. And the five intervention recommended to reduce the mortality rate are the provision of food, the provision of water, the provision of measles vaccination, adequate access to clinical care and providing health information to improve people's health. The second population of concern, that we work with in emergencies, is internally displaced persons. These are people that have moved away from their home, but not crossed an international border. These persons are not formally protected by international law. And their mortality tends to come from increased rate of background diseases. These people may move in to family members, they may be dispersed within the local population, they may move into camps. But the mortality we see in IDP situations is increased background diseases, whatever those initial diseases were. The last type of population in emergencies is entrapped populations, populations that are trapped and do not have access to services by the emergency around them, such as a war. Very little is known about the health needs of this particular population. So, when we talk about bringing household water treatment and safe storage to these types of populations, effected by emergencies, we generally talk about providing one of five options. These options have been discussed in previous sessions of this MOOC. The first option is providing a filter, such as a ceramic filter, where water flows through the porous media and is treated. Chlorination is often provided in emergencies. It's sometimes recommended that emergency-affected populations use SODIS and put bottles of water in the sun. Sand filters have also been provided in emergencies. And lastly, PuR, which is the Procter and Gamble product. It's a flocculant disinfectant product has been widely distributed in the emergency context. The two options most distributed in emergencies are PuR, which is often distributed when there's turbid water and various types of chlorine. Chlorine tablets, liquid chlorine, bucket chlorination, there's a number of ways to put chlorine in the water, in the emergency context. So, when we started working in household water treatment in emergencies, the first thing that we did was we reviewed the existing information on household water treatment in the emergency context. And what we found is actually there's not that much information out there. There's a total of 30 papers and that includes both peer-reviewed and gray literature documents. We also conducted a survey of implementers in our review. And the results of our review and survey really highlighted that there's a large data gap in knowing how and what products and if to implement household water treatment in the emergency context. What we did learn from our literature review is that household water treatment can be effective in some emergencies. That current products are targeted to high risk emergencies, emergencies with risk of diarrheal disease, such as cholera outbreaks, or emergencies where the population is displaced or flooded. It generally, it's the product that dominates the option selection. So, for example, a responding organization, will have a product in its warehouse and they'll just simply distribute that household water treatment product in the context of the emergency. So, the users don't really have much say in what options they receive. We learn that training is crucial to uptake. And the more trainings that are provided, the more likely people are to use the product correctly, and that logistics are important. That products needed to be stocked before the emergency. The products needed to be registered in the country, so that they were able to be legally distributed before the emergency, and that products needed to be distributed with all the materials necessary to use them. For example, in the particular case of PuR, the PuR needs to be distributed with two buckets, a stirring rod, and a cloth, and a pair of scissors to open the sachet. Because it cannot be assumed that emergency affected populations have access to all those materials. And lastly, in our review, we saw that the, the dosage of chlorine is very varied across the context, and that establishing correct chlorine dosage is necessary to balance the issues of taste and odor if there's too high a dose with not having effective treatment if there's too low a dose. We definitely learned, in our review of the literature and survey of implementers, that more research is necessary in the emergency context. However, based on what we did learn, we were able to develop a document in collaboration with the International Federation of Red Cross and Red Crescent Societies entitled Household water treatment and safe storage in emergencies. This is a document, a booklet, that is downloadable from the web. The address for the English version of the document is included here on the PowerPoint presentation. And this document is in plain language, it's meant for the emergency responder who may not have much experience with wash, with water sanitation hygiene products, to learn how to respond with household water treatment and safe storage products in an emergency context. After we completed our literature review and survey of implementers we also worked with UNICEF and Oxfam to complete additional research. And the research questions that we asked in this research were, what role, if any, should household water treatment and safe storage play in the emergency response process? And what are the factors associated with feasible and potentially, sustained implementation of point of use water treatment, household water treatment, in response to emergencies? We conducted evaluations of four emergencies that happened within the time frame of our project. When we setup our project, we did not know what emergencies would occur. We had an open protocol to go to these four emergencies and evaluate all the different household water treatment products that were distributed by any NGO in the emergency. In these evaluations, we conducted household surveys, water quality testing. We conducted focus group discussions, key informant interviews. We collected GPS points and we also looked at cost analysis. The four emergencies that occurred during the time of our time to complete this evaluation, were first in Jajarkot Nepal, there's an image here of the hilly region of Nepal where this cholera outbreak occurred. We completed this evaluation in August of 2009. The second emergency that we evaluated was an earthquake in Pariaman, Indonesia. Then we completed our evaluation in October of 2009. The third emergency that we evaluated was a context where there was both flooding, as can be seen here in an area of Kenya in the northwest section of Kenya on the Sudan border, Turkana, where there was also an on-going cholera outbreak. We completed our evaluation of this response in January of 2010. To give you context, this is a home of a family that lives in Turkana, Kenya. And the last evaluation we completed, was actually in response to the Haiti earthquake. And we completed an evaluation of all household water treatment and storage safe storage products that were distributed in response to the Haiti earthquake from February to March 2010. And so, we were really looking at what happened in the acute emergency situations the first eight weeks after onset. Were household water treatment and safe storage products able to effectively reduce the risk to households of contracting diarrheal disease? Now, in these four emergencies, three of four actually have high diarrheal disease risk. And those are the places with cholera, in Jajarkot and Turkana, with flooding in Turkana. And in Haiti, because the earthquake led to very high internal displacement of a population. The one emergency we evaluated that would not have high diarrheal disease risk is in Indonesia, because the earthquake did not lead to displacement or flooding. So, we would not expect a high diarrheal disease burden post emergency in that context. This is our summary data table which I'll walk you through. And it tells the information about everything we learned in response, in our evaluations in these four contexts. So, in the first column, we have the country in which we responded. And in the second column, we have the household water treatment and safe storage products that were distributed by any NGO that we were able to find and evaluate. So, I want to highlight that none of these products that we select or pre-select, we just evaluated what other people had already, independently, distributed. So in Nepal, a local NGO was living in the community and they rented houses in the community and they received chlorination products, tablets and two types of liquid. They received these chlorination products from UNICEF and they distributed them on a continuous basis, so for example, if you ran out of Aquatabs, you can go back and two weeks later then, you might get WaterGuard because that's what UNICEF had sent that week. They distributed this on a continuous basis, with training and ongoing training for the users. And this was in the context of cholera. Now, in Indonesia, the distribution was different. These products, which were AirRahmat, a liquid chlorine product and a tablet chlorine product were both distributed in NFI kits. These are non food item kits. They're a box that may have a stove, and a blanket, and a tent, and some pots and pans, and some crayons for your kids. And these NFI kits come with no training. They're just distributed as a box. Now, boiling was not promoted in Indonesia by any NGO, but was widely used by the population because of previous training. And so, we included it in our evaluation. In Turkana, it was the same type of situation. Aquatabs and PuR were included in an NFI kit distribution. And people received a 30 minute training the day the NFI kits were distributed, on how to use the products and that was all the training or follow-up they received. In Haiti, there were quite different, modes of distribution. Aquatabs were distributed in NFI kits within spontaneous settlements, places where, where internally displaced people settled. But they were also distributed in a separate program that had existed in Haiti before the emergency, through community health workers in a distributed network of 200 community health workers in a rural area. And those community health workers visited people's homes, and provided ongoing education and access to the Aquatabs. In both cases for the filters, and this is the first time we see filters, we saw ceramic filters distributed in Haiti. Those were flown in from the Dominican Republic, and they were distributed with one training to the household. And then Biosand filters were distributed over a wide area through a network of priests, and a few households in each of the priests' network areas received Biosand filters. What I'd like to point out here, of the products that were distributed in these emergencies, they're primarily chlorination products, and that has to do with the fact that chlorination products were warehoused in the country beforehand, and are quite small and easy to distribute in the emergency context. Additionally, the only products of any distributed in the emergencies, we saw, and this is within the first eight weeks of onset, that were not available in country warehouse before the emergency, were ceramic filters in Haiti and some of the Aquatabs in Haiti. Every other product was stored in a warehouse prior to the emergency when it was used, then, to respond to an acute emergency situation. So now, I'd like to walk you through the next three columns, to show you our data. So, in Nepal, essentially, what we see is 30% of people reported using the chlorination products in their stored household drinking water. And that's because we can't divide this up by product really because you might have received Aquatabs two weeks ago and WaterGuard yesterday. So, we're going to lump the stage together and show that about 30% of the households reported they were using the chlorine. Now, about 65% of those households actually had free chlorine residual in their drinking water, when we did an unannounced household survey. Which means, really, in total, about 65% of 30%, which is about eighteenish percent of the population, roughly a fifth, had free chlorine residual in their drinking water, from the products that were distributed. We weren't able to test microbiological indicators in this context because we didn't have access to any electricity at all. And so, we simply left free chlorine residual as the outcome of interest. And that's the confirmed use, as the presence of free chlorine residual, and effective use is improvement of water quality as measured by E. coli. So, to sum up the Nepal data, about one fifth of the population had free chlorine residual in their drinking water from the intervention. Now, in Indonesia, we have a very different story from chlorination. There was only 3% and 1% reported use of the products that were distributed that has to do with lack of training, as well as a lack of desire to use chlorine in that context. Additionally, the tablets were only provided with English written directions, so there were no appropriate directions on how to use the product. Because use was so low of these distributed products there was no ability to measure confirmed or effective use. However, 88% of the population reported boiling. Boiling was something they had done before the emergency and they continued to do afterward. We tested untreated water from households, from untreated storage household water. And we also tested reported boiled stored household water. And we found that 27%, about a quarter of the population, had safe drinking water from boiling. Their treated water was safe and their untreated water was dirty. Which meant they'd used boiling to move from dirty water to clean water and safe to drink. So, about a quarter of the population effectively used boiling to treat their drinking water. In Turkana, which was a NFI kit distribution, we also saw fairly low use. And 13% of households reported using Aquatabs, 6% reported using PuR, because of the small amount of training and the complexity of using PuR, less than 1% of respondents knew how to use PuR correctly. We confirmed these with free chlorine residual in less than half of the households that reported use actually had free chlorine residual in the drinking water. And when we take it out to improving the quality of their stored household water from dirty to clean, only 5% of the surveyed households used Aquatabs to improve the quality of their water and 2% used PuR, which means 7% of the households, targeted households, used one of the products to improve the quality of their water. In Haiti, we have a more complex story. The tablets, the Aquatabs that were distributed in the NFI context in the spontaneous settlements 24% reported use of that 62%, about little over half had free chlorine residual, but only 15% improved the quality of their water from dirty to clean. And so, we see a similar number, it's a low use when there is NFI distribution and no training and follow up. Now, we see much different numbers when we move to the community health worker program, where we see 75% in urban areas and 92% of people in rural areas reported using the the household water, the Aquatabs that were distributed. And of those families, 75% had free chlorine residual in their drinking water and 54% improved the quality of their water with those Aquatabs in urban areas and 66%, 2/3rd's of households use those Aquatabs to improve the quality of their water in rural areas. And the reason for this increased effective use, in rural areas, is that the water, the untreated water in rural areas, was dirtier. So, more households had dirty water in the rural areas unless we're able to use the Aquatabs to make it clean. Now the ceramic and Biosand filter storage are slightly different. People really liked those filters and they reported, even with very little training or one training, 72% of households reported using the ceramic filter, 53% reported using the biosand filter. However, the ceramic filters were distributed in an area next to an airstrip. They were flown in, and then they were distributed right around that airstrip. And those households actually already had clean water. So, the households were not able to take dirty, untreated water and make it clean, so the effective use was quite low at 20%. And the Biosand filters were installed by local technicians who made errors in installation, so that the Biosand filters were not installed correctly. And so, they were not able to treat the water effectively. And so, the effective use was also quite low at 8%. So, as you can see here, the use is much lower than one might expect, and the effective use was much lower. The programs with the highest effective use, Aquatabs with community health workers in Haiti, and boiling in Indonesia. Both of those had existed before the emergency, and people were familiar and comfortable using those products before the emergency. And thus, were able to translate that knowledge into using the products after the emergency. And then we have some issues with knowledge and training and also correct installation and use. So, to summarize up all this data in a graphic. We found that effective use happened when people used an option that treated the water. And was effective at treating the water. When people actually had unsafe water, that's an assumption in emergencies, that everyone has dirty water and that's not always true. And when there was user demand, familiarity and use. People who knew the program before the emergency were more likely to use it after. And when those three things came together, we saw effective use in household water treatment products in the emergency context. In summarizing up this presentation, I'd like to offer a few thought questions about conducting research in emergencies, such as, thinking about, what research is ethical to conduct in emergencies? What products or projects would you donate to in an emergency? What is success in the emergency context? Should it be distribution? Should it be reported use? Should it be effective use? And how do we find out what the differences are between those metrics? How should money be tracked in an emergency? How should we spend our money? How do you balance the ethic of humanitarianism, which is reaching out to those most affected, with the desire to scale project up, and meet the, and reach the most people? How do we better apply lessons learned in the development context into our emergency response projects with household water treatment? And how do we link emergencies with development projects, so that we really offer a holistic household water treatment strategy to the population of the country? I'd like to thank you for listening to this presentation and end with a quote from a journal article by Slim. And say: "The notion that being humanitarian and doing good are somehow inevitably the same is a hard one to shake off. And I think that research can assist us in aligning being humanitarian with always doing good." I'm happy to take questions, thank you for listening today.
