The major pathway of waterborne diseases through drinking water in rural areas follows a well-worn route: inadequate sanitation leads to contaminated water sources. The traditional approach to address this problem has involved infrastructure projects such as digging wells, putting in piped water, and building latrines. The focus, in other words, has been on improving water sources and sanitation. And these are obviously important. They can also be relatively expensive for very poor areas. There’s a reason beyond ignorance that they are not already in place. And even where wells and latrines are in place, there still may be a high incidence of waterborne diseases.
In recent years, researchers have realized that their model of providing clean drinking water to poor households is incomplete in an important respect. Digging a deep well and building latrines away from the water source are all well and good. But if the water is carried home and stored in a dirty container—if it becomes contaminated during transport or storage—then all the previous protections were wasted efforts. Providing clean water to a village is not enough. It must be kept clean until it is drunk by individuals. As a result, there has been a great deal of work studying behavior at the water’s point of use (known as POU).
“POU interventions” is the fancy name for behaviors and technologies in the household to ensure safe drinking water just before consumption. They fall into three broad categories. The first is physically removing pathogens, usually through sedimentation (letting the water settle) or filtration. Filters run the gamut from simply passing water through a cloth rag or sand to more sophisticated membranes, ceramic filters, or even reverse osmosis technologies. The second approach is to disinfect by heat or exposure to ultraviolet radiation. The third approach relies on chemically treating the water with small amounts of iodine or chlorine.
Household chlorination, for example, has proven an effective POU strategy with widespread adoption. It is often dispensed by filling a chlorine container’s bottle cap and pouring it into a standard-sized bucket filled with water. Simply stir, wait, and drink. A popular chlorine-based product in Africa, WaterGuard, is available for sale at a reasonable price. Diarrhea can be reduced by 22 to 84 percent and the cost is low, from 0.01 to 0.05 cents per use. The main downside is the chlorine taste in the water and its inability to kill some common parasites.
Solar disinfection is easy to use in sunny climates. Clear water is placed in plastic bottles and left in the sun for six hours, two days if cloudy. The sun’s ultraviolet radiation kills common germs such as giardia and cryptosporidia. The technique has been disseminated in more than twenty developing countries and currently has more than one million users. While free (apart from the clear bottle) and easy to use, the range of effectiveness is broad, reducing diarrhea by anywhere from 9 to 86 percent.
Another promising POU approach has been developed by the consumer products giant Procter & Gamble. Called Pur, the powdered product is provided in a small sachet. The instructions are straightforward—add the packet to ten liters of water, stir, let the particles settle, strain, wait, and drink. The cost is one penny per liter of water. Procter & Gamble, in partnership with the Children’s Safe Drinking Water program, has distributed over 130 million sachets on a not-for-profit basis since 2004. The main ingredients are ferric sulfate, a compound that binds to particles in the water, and the disinfectant calcium hypochlorite. Procter & Gamble claims that studies conducted by the U.S. Centers for Disease Control and Johns Hopkins University found diarrhea incidences reduced by half. The major downsides are the multiple steps required to treat the water and the need for mixing equipment, which can be a challenging obstacle in communities where water collection itself can consume hours each day.
These are only a few of the wide range of POU interventions currently under development, but suffice it to say that this is a vibrant field of activity. These experiences and others suggest that POU treatments can produce major health benefits at a low cost. Indeed, the research on POU raises a fundamental challenge to drinking water strategies more broadly. As an article in the medical journal BMJ concluded:
Water quality interventions were effective in reducing diarrhea even in the absence of improved water supplies and sanitation. Effectiveness did not seem to be enhanced by combining the intervention with other common strategies for preventing diarrhea (instruction on basic hygiene, improved water storage, or improved water supplies and sanitation facilities). Although the evidence does not rule out additional benefit from combined interventions, it does raise questions about whether the additional cost of such integrated approaches as currently implemented is warranted on the basis of health gains alone.
In plain English, the authors suggest that POU may be more effective and less expensive than the more traditional strategies for assuring drinking water quality. A major review of POU field studies reached the same conclusion. Providing clean water, improving sanitation, and hand-washing with soap may not significantly reduce waterborne disease any more than the POU intervention on its own.
The policy implications of these findings are significant. Assume for a moment that you are the head of development for a funding agency. You have been tasked to reduce the incidence of waterborne disease in a desperately poor group of villages in East Africa with contaminated surface water sources and little or no sanitation. Human and animal waste flow into the local ponds and streams. Protecting the water source and improving sanitation are obviously important priorities for poor communities, but what to do if funds are limited? Your budget is tight, and your bosses want quick results. Where should you invest your resources?
In the past, the traditional approach would have focused on digging wells and building latrines, and these definitely can improve quality of life. But they also require construction, labor, and time. The research described above suggests that focusing on POU interventions can provide more immediate benefits, to more people, at lower cost. Over the long term, one can reasonably debate about the relative merits of investing in infrastructure versus short-term POU actions (and experts in the field do indeed debate about this), but the low uptake costs of POU make it very attractive to the donor community, where real results can be seen soon after adoption in poor communities suffering from intestinal diseases caused by dirty drinking water, particularly when the likelihood of funds for large-scale centralized treatment and distribution infrastructure is remote.
Adoption, though, is the key word. Developing effective POU interventions is one thing; ensuring they are used, and used appropriately, is quite another. Changing people’s behavior is no easy matter, particularly when trying to persuade them to adopt new ways to handle something as basic and commonplace as water. Are they affordable? Are they easy to use and reliable? Are they scalable? There are too many examples of treatments that work in pilot projects with hands-on education and follow-up. The test is what happens when the support has been withdrawn. Will people return to their traditional practices? Barriers to adoption include timeworn habits, local norms, the smell and taste of treated water, and the lack of disposable income.
One of the more interesting debates concerns this last challenge of poverty. Is it more effective to provide POU treatments for free or to sell at a low price? One might assume that providing chlorine bottles for free, for example, would increase use since poverty will not prevent their purchase. Some research, though, suggests that those who purchase the kits are more likely to use them than those to whom the kits were simply given. When we get something for free, we tend to value it at the cost we paid—zero. Paying for the POU kits, by contrast, requires sacrifice and can create a sense of obligation to use them.
We know that the very poor are willing to pay for water, so it would seem reasonable to assume they would be willing to pay for POU treatments, as well, but this is not always the case. Paying for water is not the same as paying for chemicals or materials to treat the water. As one researcher observed, “Some people are willing to pay for water quantity and for convenience, but in low-in
come countries many households will not pay for quality.”
There are some success stories that give reason for optimism, though. To take one example, the nongovernmental group PSI launched a product in Zambia called Clorin, basically a bottle of the disinfectant sodium hypochlorite. PSI developed a brand identity for Clorin, advertised on radio and TV spots, and distributed bottles for sale through traditional retail networks, health centers, and door-to-door vendors. A survey found impressive penetration—42 percent of households reported using Clorin. Thanks to aid from the U.S. Agency for International Development, the $0.34 cost of the bottle is subsidized and sold to the public for $0.12. In a country that ranks at the bottom of the United Nations Human Development Index, 164 out of 177, this level of use is no small achievement. It bears keeping in mind, however, that the typical adoption rate for chlorination POUs is much lower, closer to 5 to 10 percent. PSI’s initiative in Zambia is the greatest success story to date and offers important guidance for program design in other places.
Experts in development can argue about the relative merits of POU versus wells versus piped systems, but regardless of their approach, they all agree there is not enough money available to satisfy the demand for clean water in developing countries. Just as research on POU is challenging how we think about providing clean water, so, too, is the savvy creativity of one man challenging how we think about raising money to pay for clean water.
SCOTT HARRISON STANDS ALONE AT THE BACK OF THE ROOM AS THE students start to enter. With average height, close-cut hair, and a cropped beard, he’s well-dressed—a clean white textured shirt, designer blue jeans, leather shoes. The posters at Duke’s Nicholas School of the Environment say he’ll be talking about something called Charity: Water. Spotting the oldest person in the room, Harrison walks up to me and shakes my hand. “You’re a professor? Great. Tell me about the crowd.” As I describe the students’ back-grounds, he gives me his full attention and keeps saying, “Cool, cool.” A few minutes later, he walks to the front of the classroom, sits cross-legged on a desk, and in even tones starts talking.
Scott Harrison, the founder of Charity: Water, speaking at an event in 2010
The room gets quiet as he shows photo after photo on the screen of Africans with enormous, grotesque tumors on their faces, most sticking out of their mouths. Harrison says he cried the first time he saw someone like this. The photos were taken by him in Liberia, when he was working aboard a hospital ship. He pauses, then starts to tell how he got there.
In 2004, Scott Harrison was one of the top event planners in New York City. He lived the high life, clubbing with the A-list crowd in Manhattan, drinking $350 bottles of vodka, dating a model, taking vacations all over the world. He had grown up in a religious family but he left for New York City and did everything his family had told him not to: “From eighteen to twenty-eight, I partied and did drugs.” He was successful by any measure, had a remarkable talent for organization and for engaging with people, but he felt empty.
On a whim he still doesn’t completely understand, he walked away from it all and volunteered to work on the Mercy Ship Anastasis, heading to Liberia to provide badly needed medical services for free. He bluffed about his experience as a photojournalist to the organizers, reading the Nikon camera manual as the ship steamed east. Arriving in Liberia, he found a capital ravaged by war and literally hundreds of people with facial deformities waiting to be treated by doctors on the Anastasis. As Harrison recounted, “I fell in love with Liberia—a country with no public electricity, running water, or sewage. Spending time in a leper colony and many remote villages, I put a face to the world’s 1.2 billion living in poverty. Those living on less than $365 a year—money I used to blow on a bottle of Grey Goose vodka at a fancy club. Before tip.”
Harrison pauses in the story. He’s a powerful speaker and knows it. The slide show is slick. Naked words appear on the screen and fade out, a graphic photo taking its place. The audience is following his every word.
Everywhere Harrison traveled in Africa, unsafe water seemed to be at the root of so many of the hardships he saw. “I saw school after school with no clean water. There were no iPods. Just yellow jerry cans as their accessories.” Most communities don’t have enough money to boil water before drinking. Charcoal is too expensive. It’s illegal to cut down trees, and cow dung, the regular fuel source, doesn’t burn hot enough to boil for long enough. Instead, he saw people relying on crude filters, usually just pouring water though a dress or some other fabric. He shows slides of a small water hole, puddles in trampled mud beside cows and children. “This is a common sight at drinking holes. Kids and cows. The cows are bigger, so they go first.”
Returning to the States, Harrison was a changed man. He decided to get involved, raise money, and make a difference. The problem was that he didn’t think much of organized charity. He had been remarkably effective in getting people to go to club parties and spend money there. Why not do the same raising money for clean water in developing countries? The key, he realized, was clever marketing. And he knew he could do that.
So he founded the group Charity: Water. To raise money, he started selling twenty-dollar bottles of water. All of the money raised went to water projects in Africa. “It was a context-shifting bottle of water. We put on a black label with facts of death and disease. Putting them in hotels was great. They already cost ten or eleven dollars, and business people could expense them to the room.” He got others excited and they started selling water bottles, too. Seven-year-old Max Schmidhauser sold seven thousand dollars’ worth. Steve Sabba, a small-time accountant in New York working in a cramped office, got in touch. “He said he could sell five thousand of water. We said, ‘OK, that’s a lot of water.’ He set up a credit card terminal in his office.” Sabba raised hundreds of thousands of dollars, got his first passport at fifty years old, and went to Liberia to see the wells he had funded
Using his A-list of contacts, Harrison raised fifteen thousand dollars at his thirty-first birthday party. With the money, he fixed three wells and built three more. He took photos and sent emails back to everyone who had contributed—“Some couldn’t even remember the party.” For the one-year anniversary of Charity: Water and his thirty-second birthday, he decided to invite people not to attend a party: “Instead, I gave up my birthday and asked people to give thirty-two dollars instead.” Ninety-two people joined him for their September birthdays, giving up their birthdays for gifts. He shows a montage on the screen of ninety-two faces, including a monkey. “I don’t know about that one,” he deadpans. He eventually raised a hundred fifty thousand dollars, enough for three hospitals and one school.
Harrison is now getting into it. Energetic, hands moving, eyes sparkling, he is fully engaged. You can see why he was so successful on the club scene. You’d love to party with this guy. His birthday giving concept is scalable. He wants to make it ten times bigger, so he created the website borninseptember.org. His goal was to raise $1.2 million. And that’s just the beginning. “So you open it up to every month. You can give up your wedding, your anniversary. We already have a hundred fifty schools signed up. Micropayments can really scale, and not just in the U.S.” You can see his mind clicking. This is social entrepreneurship in real time.
Harrison went to the management of Saks Fifth Avenue and put his sales skills to the test. As he described, “So I went to them and said, ‘Hey, like we’re a year old and just got our 501(c)(3), and you should do this with us.’ And they got the message.” One expects that the discussions were a bit more involved, and Harrison can surely tell a good story. Saks became a strong supporter. The store sold Charity: Water bracelets and dedicated its Fifth Avenue windows for a week to displays of the jerry cans used to collect water. This directly followed their Giorgio Armani display. Quite a contrast. Saks’ efforts raised $540,000 in two months.
Using fashion photographers for publicity shots, Harrison re-created photos of gathering water in Africa, but now set in the Upper East Side. Kids
dressed for the most expensive schools in the city were carrying forty-pound jerry cans on their backs. “It’s not OK for our kids to carry forty pounds of water on their backs to school, so why is it OK in Uganda when the kids don’t go to school?” A crew of forty-five filmed a public service announcement. Well-dressed people walk out of their luxury apartment buildings and line up to fill their jerry cans from a dirty pond in Central Park. The entire production was done on a shoestring budget of five thousand dollars, yet it managed to attract big-name talent such as actress Jennifer Connelly. Using Harrison’s club connections, the spot was aired for free on the hit show American Idol, and seen by twenty-five million people in an ad slot that normally cost one million dollars per minute.
Harrison lists example after example of creative, clever ways to raise money and spread the message. He wanted Charity: Water to be the first charity to use Twitter for fund-raising so he helped come up with the idea for the “Twestival.” Through tweeted micropayments, more than two hundred cities around the globe hosted events that more than ten thousand people attended, raising $250,000. The drilling of his first “tweet well” was posted online.
Actor Hugh Jackman tweeted, “I will donate 100K to one individual’s favorite nonprofit organization. Of course, you must convince me why by using 140 characters or less.” Harrison was in Uganda and immediately went to a local school for his tweet. He also urged Charity: Water’s more than 140,000 followers on Twitter to encourage Jackman to give them money. Choosing among thousands of suggestions, Jackman contributed fifty thousand dollars to the group and one other. Harrison says that Charity: Water received three hundred media mentions in its first three years with no marketing budget. In its first two and a half years, the group raised $9.5 million from more than forty thousand donors.
Drinking Water Page 22