Evidence-based research provides solutions that work. MacDonald and Schwab argue that we will need greater commitment to rigorous research programs to meet the challenges ahead.
The solutions to today’s water and sanitation development challenges are right in front of us, provided we look for them. We are quietly reminded of this each time our research team visits a field site to assess the newest water treatment system. Arriving at the site, we typically find the new system alongside an old, broken filter, or next to a partially dismantled bicycle-driven water pump that had been touted in the international press as an inexpensive work of genius that would save the world, or near a perfectly functioning pit latrine that no one uses. Few remember who put these devices in place, how to fix them, why to use them, or whether life got better while using them. Meanwhile, as the team begins to evaluate the latest technology to provide clean water, a child shyly eyes us from behind the broken filter. She runs home afterwards to drink pathogen-laden water collected and carried by hand from a stagnant stream, just yards from the village open defecation zone that is discretely concealed in the underbrush. We wonder whether the latest incarnation of water service will give her clean water and begin to collect the evidence.
Countless well-intentioned projects begin and end at enormous cost and effort globally, but they often leave stakeholders no better off, a grim reality those who work in the water sector know all too well. What works well in a North American or European lab can quickly fail in the humid tropics; when monsoons make dirt roads impassable, supply chain disruptions can cripple operation of small treatment plants. Too many organizations drill a well or distribute some point-of-use water treatment technologies and declare “mission accomplished” without any data collection to see if health has improved, which is the ultimate goal, and without any follow up support beyond the initial year or so.
For example, Small Water Enterprises (SWE) are community-based entrepreneurial water systems that provide the lion’s share of drinking water in many countries, and in a 2009 literature survey that scanned thousands of articles on SWEs, the Schwab research group did not find a single rigorous, evidence-based, peer-reviewed scientific study to show the efficacy of SWEs in providing potable water. Many of these SWEs have failed or will fail. But if we had evidence for approaches that work versus those that do not, we could break the cycle of neglect and failure that plagues the water and sanitation sector. With evidence, we can learn from our mistakes. With evidence, we might even learn how to take the next gizmo promising to save the world and actually save the world.
A major challenge for the next decade is to identify successful water and sanitation approaches through evidence-based research, which is a core philosophy underlying the mission of the JHU Global Water Program. Funding for research is scarce, however. Donors, both big and small, often say they are not interested in research, that they are interested in implementing solutions, that they want to their dollars to go to helping people directly, implying that research is a diversion. Nothing could be further from the truth. Evidence is what guides us and prevents our repeated follies.
In fact, building a toolbox of appropriate evidence-based solutions will save more in the long term. There are enormous financial and human costs associated with implementing an inappropriate technology or strategy that ultimately fails. The World Bank estimates that it will cost $9 billion per year to run the interventions just to provide basic water and sanitation coverage to meet the Millennium Development Goal targets, and up to $30 billion per year to provide universal coverage. But how many of these interventions have staying power? Research suggests that very few do, so we can expect to spend billions of dollars annually on solutions that are temporary at best.
At the very least, implementing the wrong approach represents a missed opportunity. At most it represents nearly criminal neglect, because the burden of lack of access to clean water is tragically high. Dr. Schwab often tells students that water is heavy, and asks them to try carrying 20 liters of water around for a while, just to see what it is like. Every day, millions of people spend hours carrying water on their heads over many kilometers, sometimes developing neck problems. Asking students to carry water teaches them that water is heavy in the literal sense, but the rest of the course teaches them that water is heavy in the figurative sense. The burden of disease from unsafe water far outweighs the physical heaviness of water. Lack of access to clean water causes health problems like malnourishment and diarrhea, the number two killer of children under 5, and has social consequences, like preventing girls from attending school because they need to fetch water. Sustaining this crushing burden on the poor is the true cost of choosing the wrong water intervention, and this choice is largely sustained by neglect to gather or learn from scientific evidence.
At the Johns Hopkins University Global Water Program we are making tools to gather the evidence that will ultimately guide us to approaches with positive impact. We discovered a data gap on SWEs, so we are currently working on a study in Ghana to fill that gap. We are also developing a portable, rapid-response, comprehensive water quality screening “toolkit” which can be used to quantitatively detect key microbial and chemical contaminants. This kit involves user-friendly tools and methods for the intermittent monitoring and evaluation of the quality of water systems. Using this toolkit, our goal is to determine the efficiencies of various water treatment technologies using the selected water quality assessment tools. On a related research thrust, we are developing ways to creatively make use in advances on information technology, including real-time data collection on cell phones with geospatial accuracy, and eventually through wireless sensing networks. And in collaboration with the Center for Communications Programs, we are undertaking research in social science and human behavior to learn how to get the best results from our hygiene, water, and sanitation programs.
The context in which we develop these tools is international, but they have immediate translation to needs at home, especially for disaster relief. In the aftermath of Hurricane Katrina, many Americans found themselves resorting to sources with dubious quality, and fecal contamination in the streets of New Orleans was high. The U.S. was largely unprepared for this scenario. But should another Katrina strike the Atlantic coast, or a major earthquake hit California, the rapid-response toolkit and cell phone technologies that we develop internationally will help us at home. To get to that point, however, to create an arsenal of effective water and sanitation solutions, we need a major commitment from all in the water sector, including donors and implementers, to gather the evidence. Through evidence-based research, we can find solutions that work.
Keywords: Evidence-based research, Drinking water, Sanitation, Small water enterprises, Water quality monitoring
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4 Comments on this article.
Thanks, Nicole, your points are well taken. A global database for sharing information on water interventions is a fantastic idea, and I agree that culture is a major component of interventions.
Rather than pigeonholing interventions, the toolbox approach should increase options to find the best meeting of technology, with local need, capacity and culture. The truth is that most organizations operate under a de facto technology-based toolbox, even if it is not called this, with only one or two tools. The idea in our article is to develop an approach-based toolbox that pairs technology with outreach, followup, and participation, with many more tools. This toolbox could take the form of a global database backed up by objective, peer-reviewed studies, and would provide the documentation that allows new interventions to learn from the technological and social failures of previous efforts.
I completely agree that this is a neglected area of published research - however, I believe you will find that the interest in approving publishings of this type is also neglected and can be improved. Additionally, many journals that accommodate this work being published do not have adequate reviewers with the necessary backgrounds to provide constructive commentary. I believe that this area of research is also lacking a global database where information can be shared rapidly and does not rely on scientific publication.
In terms of developing a “toolbox” approach, I caution you not to neglect the significant challenges that various cultures can present and may require different structures. I believe that the cause of much of this “criminal neglect” is the result of project planners focusing too much on the technology and not realizing that proper investigation, education, implementation and follow-up are 90% of the project focus and the technology is 10% or less with respect to time and economical resources.
Finally, I cannot express enough how important relationship building compliments project implementation and long-term success. Establishing trust with these communities reveals their true needs and challenges which otherwise would have been disguised by possible embarrassment, shame, pride and cultural differences.
You are so correct with the follow-up on these projects. Too often a great solution is presented and actually working but the follow-up is Zero and when a problem comes up like the filters it all was for nothing. A plan isn’t a plan unless it has a clear update schedule.
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