Running head: HEALTH IMPACT FRAMEWORK: CLEAN WATER

Health Impact Framework: Clean Water

Abstract

Worldwide, the importance of clean water and sanitation have been recognized as vital to

human health and well-being. The problems associated with lack of equitable access to clean

water and sanitation are factors in the life expectancies of populations worldwide. Explanations

and examples are given of mortality and morbidity related to lack of access in parts of the world,

and comparisons are made between the developed and developing world with specific examples

cited in the United States and the Democratic Republic of the Congo. Frieden's Health Pyramid

Model is used to describe the issue and evaluate courses of action that can improve conditions

for large portions of the developing world including changing the context to make individuals'

default decisions healthy, long-lasting protective interventions, clinical interventions, counseling

and education opportunities, and recommendations for future interventions. Finally,

opportunities in nursing for global health are evaluated with certifications, higher education, and

organizational affiliation.
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Access to clean water

factors in a country’s potential growth and ongoing health. Across the world there are millions of

individuals without basic assess to clean drinking water, simple sanitation, or water sources free

from parasites and disease. According to the World Health Organization, in 2015, only 71% of

the global population had safe and consistent access to a safely-managed drinking water service

(World Health Organization, 2018) and more than 35% of the world's population lacks access to

improved sanitation (Centers for Disease Control and Prevention, 2016). This leaves 844 million

people worldwide lacking safe drinking water, a vital and necessary human right (World Health

Organization, 2018).

When the Millennium Development Goals were written, the United Nations recognized

the disparity of access to clean water and sanitation as an indicator of health and prosperity, and

addressed these concerns within the framework of Goal 7: Ensure Environmental Stability, with

an intention to halve the number of individuals lacking access to clean water and

sanitation(United Nations, 2015). With the development of the Sustainable Development Goals,

Goal 6 was identified as ensuring availability and sustainable management of water and

sanitation for all (United Nations, 2018). This revised goal cites water scarcity, flooding, and

lack of wastewater management as hindrances to socioeconomic growth in developing regions.

Clean water and sanitation are multifaceted issues involving fair distribution of access,

overcoming the challenges of access, negotiating geographical disparity, mitigating natural and

man-made disasters, and overcoming potential health risks.

Access to clean water has a direct impact on the health and well-being of a country,

which can be demonstrated through a DALY indicator: disability-adjusted life year. The DALY
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is "the sum of years lost due to premature death...and years lived without disability" or the "years

of healthy life lost" (Skolnik, 2016, p.26). For the sake of comparison between developed and

developing countries the Democratic Republic of the Congo, part of sub-Saharan Africa, will be

evaluated against the United States. In the Democratic Republic of the Congo several leading

cause of DALYs were diarrheal diseases and infections related to WaSH (Institute for Health

Metrics and Evaluation, 2018). Water, sanitation, and hygiene, also known as WaSH, is an

indicator for health and a factor in several sanitation and hygiene related diseases (Centers for

Disease Control, 2016). In stark contrast, WaSH related concerns and diarrheal diseases don't

even register in the top ten causes of death or disability for the United States, because as a nation

the United States has wide-spread access to clean water and sanitation, as well as education

surrounding prevention of WaSH-associated infections (Institute for Health Metrics and

Evaluation, 2018).

Burden of disease on developed countries

Lack of clean water and sanitation isn't limited to the developing world. The struggles of

clean water security in sub-Saharan Africa parallel some of the access and distribution struggles

worldwide. Even the United States has pockets of inequality, such as Flint Michigan, where the

failing infrastructures lead to low-income residents lacking the funds to make repairs and the

resources necessary to ensure safe drinking water access. After decades of economic decline

prevented maintenance of pipes used to transport water from Lake Huron to the residents of Flint

further cost cutting efforts changed the source of Flint's drinking water to the Flint River (Fraser,

et al., 2011). This change rapidly advanced the corrosion of the pipes, which were made of lead,

causing lead exposure in the drinking water of an estimated 140,000 individuals (Ruckart, et al.,

2019). Changing climates, drought, and desertification exacerbate already dwindling water
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supplies creating water scarcity on every continent. The United Nations estimates that by 2050 at

least one in four people will suffer recurrent water shortages, including much of the developed

world (United Nations Development Programme, 2019).

Burden of disease on developing countries

For the Democratic Republic of the Congo, access to clean water impacts several DALY

factors including WaSH (Water, Sanitation, Hygiene) which is the second leading risk factor that

drives death and disability, exceeded only by malnutrition. In consideration of this, there are

several diseases from waterborne sources that contribute to this, including Onchocerciasis (River

Blindness) which is the single leading cause of disability, and diarrheal diseases, such as cholera,

shigella, and dysentery, ranking fourth in cause of premature death and sixth leading cause of

death overall. Because of these factors, the life expectancies of females is about 64 years, while

males are about 60 years, which is an improvement in the past 10 years. However, the infant

mortality rate for children under 5 years old is about 8%, and about 5% of children under age one

die from various causes, many of which are communicable diseases or nutrition related (Institute

for Health Metrics and Evaluation, 2018).

One of communicable diseases, Onchocerciasis, has the potential to be eradicated in Sub-

Saharan Africa as it is already becoming in other parts of the world, including South America

(World Health Organization, 2018). The challenges for the country lie primarily in funding.

Vaccines, infrastructure, and access to adequate healthcare are financially out of reach for much

of the Democratic Republic of the Congo. Global access to safe water, adequate sanitation, and

proper hygiene education can reduce illness and death from disease, leading to improved health,

poverty reduction, and socio-economic development for the nation, hinting at a promise for
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potential economic growth and improved stability in the region (Centers for Disease Control,

2018).

Adrian Hopkins said, "Although river blindness is still endemic in many African

countries, it is still possible that it will be eliminated by 2025. Doing so will require political

stability and an unwavering focus on the goal." (Hopkins, 2017). Given the opportunities, there

are several organizations and outreach programs working to establish and maintain clean water

access and medical care to the population, however disease outbreaks and sabotage by warring

groups can stall or reverse progress in the areas most heavily impacted by outbreaks. The lack of

investment in the health system of the country is only further undermined by the political unrest,

so policies to improve the health and clean water access fall on the shoulders of the World

Health Organization (WHO) and several other non-governmental organizations (Fleck, 2009).

The size of the primarily unsecured area, migratory nature of many groups, and poorly

maintained roads further strain the efforts in the region.

Application of chosen topic on Frieden's Health Impact Pyramid

Utilizing Frieden's health impact pyramid is an effective framework for optimization of

global health. With it, effects on the DALY by diseases like Onchocerciasis and Cholera can be

reduced significantly. At the base of the health impact pyramid, the broad health determinants

such as basic access to clean water and sanitation, socioeconomic factors for the region including

the widespread poverty and migratory nature of the people, and the Sustainable Development

Goals are considered. Farther up the pyramid, reframing the decision-making process without

making major changes to the culture and efforts to make default decisions healthier work toward
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health improvement. Finally, toward the top individualized care and clinical interventions and

education reduce and in some cases eliminate the impacts of disease (Frieden, 2010).

Directly creating an example of this within the context of Onchocerciasis, recognizing the

at-risk population, redirecting efforts toward a managed basic water source in place of river

water usage, and embracing the Sustainable Development Goal of clean water and sanitation for

all creates an environment that minimizes the risk for the population. Ongoing education about

recognizing symptoms and proper response to infection can limit the life-cycle of the helminth.

Finally, clinical intervention such as rapid treatment of infection and vaccination of the

population move toward eradication of the disease for the people of sub-Saharan Africa, much

like has happened in Columbia (World Health Organization, 2018b).

Socioeconomic Factors

Access to clean water is about more than availability of tap water on demand. For

millions of individuals worldwide, a portion of their day is occupied with activities surrounding

the gathering, storage, and conservation of water for their homes. Only about 89% of the world's

population has access to at least basic water services, also known as an improved drinking-water

source, which is within a 30 minute round trip from their home to collect water needed for their

activities of daily living (World Health Organization, 2018). For the remainder, long distances

are a reality of life, such as in sub-Saharan Africa where timely access to clean and safe water

sources directly impact the mortality and morbidity rates, especially in children (Skolnik, 2016).

For individuals in these areas with a low socioeconomic standing, the cycle of vulnerability

continues because so much potential productivity is lost on the daily tasks of mere survival.
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A lesser considered issue related to access to sanitation is the impact on the lives of

women and pubescent girls in developing countries. Travelling alone to the outskirts of a village

to defecate, particularly at night, makes them vulnerable to attack. Furthermore, lack of proper

sanitary facilities and materials for management of menstruation can force young girls to stop

pursuing their education. Typically, these girls end up with the responsibility of gathering water

for their family in place of going to school. Access to proper bathroom facilities have the

potential to protect girls and improve continued attendance in school, contributing to achieving

the sustainable development goals of quality education and gender equality (United Nations

Development Programme, 2019). This is an issue of particular concern in parts of Southern and

Eastern Asia, and sub-Saharan Africa (Centers for Disease Control and Prevention, 2016).

Further complicating matters, there is a potential for a multitude of diseases, particularly

for the approximately 159 million people who depend on untreated surface water (World Health

Organization, 2018). These diseases include diarrheal diseases, parasite and helminth infections

such as Guinea Worm Disease, and sanitation diseases such as Trachoma. Many of these

diseases are readily preventable with simple sanitation methods and basic hygiene practices

(Centers for Disease Control and Prevention, 2016).

Changing the context to make the individual default decisions healthy

Several opportunities exist to change default behaviors, and “interventions that change

the environmental context to make healthy options the default choice, regardless of education,

income, service provision, or other societal factors...the defining characteristic of this tier of

intervention is that individuals would have to expend significant effort not to benefit from them”

(Frieden, 2010). Much of these interventions require support of the government, as well as non-
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governmental organizations (NGOs) and outreach programs such as Water.org and The Water

Project (The Water Project, n.d.). Developing protected water sources in areas that are repeatedly

used by migratory groups, as well as in more permanent areas, reduce the occasion for

individuals to need to gather water from unprotected sources such as rivers. Additionally, by

creating a shorter round trip to supply the needs of a family, more time is spent on other

productive endeavors enabling improved socioeconomic opportunity and economic growth in

place of simple survival tasks (Sphere Association, 2019).

Next, the erection of latrines as basic sewage disposal and other simple waste facilities

such as composting bins improve the separation of waste and drinking water. Globally, at least 2

billion people use a drinking water source that has been contaminated with feces which

perpetuates transmission of diarrheal diseases such as Cholera (World Health Organization,

2019). Since water contamination-related diseases account for 1 out of every 5 deaths in children

under the age of 5, sanitation facilities available in poverty-stricken areas reframe the default

practices, which in some areas include open defecation on land and in water sources, and impose

and immediate and measurable effect on the DALY for the region (The Water Project, n.d.).

According to the World Health Organization, every dollar invested returns up to eight dollars in

benefits (World Health Organization, 2008a)

Long-lasting protective interventions

The next step up the Health Impact Pyramid is the development of long-lasting protective

interventions. These are interventions that aim to reach individual members of the target

population that last for a prolonged period. One such intervention would include vaccination

against diseases such as Onchocerciasis. Distribution of soap for basic face and hand-washing
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would further reduce the burden of disease with many diarrheal diseases, including hepatitis A,

being prevented more passively in the home. Clean water wells and piping, as well as sewer

systems and waste treatment facilities, would have a large up-front cost for the region, but the

return on investment for the area would be the reduction of loss-of-life, reduced healthcare costs

associated with treatment of preventable diseases, and reduced disability that is a direct result

from infection (Centers for Disease Control and Prevention, 2017). These would further

contribute to potential socioeconomic growth.

Clinical interventions

For the individuals who do fall victim to the many potential diseases from exposure to

unsafe or contaminated water sources, rapid clinical recognition and treatment protect larger

portions of the community. Expansion of the healthcare system can be costly, but in many of the

diseases, the treatments are basic and affordable, such as fluid and electrolyte replacement for

diarrheal diseases. The initial cost of establishing clinics may be high, but some of the cost can

be mitigated by reduced incidents of disease through efforts in previous tiers of the Health

Impact Pyramid.

Counseling and Education

According to Frieden's model, counseling and education are the least effective

interventions. However, with repetition and consistency they can have an impact on the health of

a region (Frieden, 2010). In the cases of clean water and sanitation, basic WaSH techniques have

been shown to greatly impact the disease burden of an area (Centers for Disease Control and

Prevention, 2015). According to the CDC, 50% fewer diarrheal and respiratory infections were

shown in children receiving weekly hand-washing promotion and soap when compared with
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children not receiving those interventions. Further public education surrounding the

identification and response to several infections, including Guinea Worm Disease, can

significantly reduce the rates of infection and the spread of the diseases. The Health Belief

Model can be an effective tool through ongoing education, especially as clinics and healthcare

workers teach the community about diseases and infections that impact the regions. Addressing

and reframing cultural beliefs surrounding specific illnesses, such as diarrhea and Guinea Worm

Disease, will help break the disease cycles by changing the behaviors that allow the infections to

continue and spread (Skolnik, 2016).

Recommended future interventions

The World Health Organization and United Nations are focused on equitable access to

clean water and sanitation on a global scale. As a part of the Sustainable Development Goals,

water and sanitation have been recognized as vital to health and well-being, and therefore

assistance to developing countries is a part of ongoing development models. Support and

guidance, as well as some funding, are being offered globally to establish water access in regions

where it is currently lacking. Additionally, NGOs are actively contributing resources because

they recognize a return on investment and the impact on the DALY figures. Water treatment and

decontamination efforts will likely become vital in the coming years as climate change further

strains access to water in already water-insecure areas.

Professional opportunities available in the global health nursing field

For those seeking opportunities in the area of global health there are an abundance of

opportunities. Global health nursing can be small or large scale, ranging from advocating on a

local level to being at the forefront of stopping the next epidemic. Nurses seeking a certification
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may choose a Certificate in Public Health (CPH) or a Certificate in Global Health Nursing

(GHN) depending on the scale at which they intend to work. Furthermore, groups such as the

Peace Corps, Doctors without Borders, and the Red Cross offer opportunities to nurses who wish

to be at the forefront of global health concerns. Finally, there is the opportunity for Advance

Practice Nursing, with higher degrees in Public Health or Global Health available for Bachelor's

and Master's level degree programs.

Regardless of what path is chosen, nurses have the opportunity to make impacts both at

home and abroad for patients in many areas of global health issues, especially surrounding

WaSH practices and breaking the cycle of disease associated with poor hygiene or water

contamination. With a career path centered on patient advocacy and care, nurses are the eyes and

ears of the community and a vocal supporter of human rights in policy-making world wide.
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Resources
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(2019). The Flint Water Crisis. Journal of Public Health Management and Practice, 25.

doi:10.1097/phh.0000000000000871

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Sphere Association. (2019). The Sphere Handbook. Retrieved from

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The Water Project. (n.d.). The water crisis: The importance of clean water to health. Retrieved

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World Health Organization. (2008, March 20). Poor sanitation threatens public health.

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World Health Organization. (2018, February 7). Drinking-water. Retrieved from

https://www.who.int/news-room/fact-sheets/detail/drinking-water

World Health Organization. (2018, November 23). Onchocerciasis (river blindness). Retrieved

from https://www.who.int/news-room/fact-sheets/detail/onchocerciasis