Americans often take clean water for granted. But in Africa, as The Carter Center’s Craig Withers explains, clean water can be hard to find. (More)

This is Part 2 of my interview with Craig Withers, the Director of Program Support at The Carter Center. Last week in Part 1 we discussed political and cultural challenges The Carter Center faces in their efforts to eradicate Guinea worm disease. This week we discuss how The Carter Center helps people gain and maintain access to safer water as part of their Guinea worm eradication efforts. Next week our interview concludes with how The Carter Center responds to outbreaks of Guinea worm disease.

Craig Withers has more than 20 years experience in public health policy. He received a Master of Business Administration in international business and a Master of Health Administration in health planning from Georgia State University, and a Bachelor of Science from the University of Notre Dame. His honors include awards for work done as special assistant to the deputy director of the National Institute for Occupational Safety and Health program at the Centers for Disease Control and Prevention.


LT: Access to clean water is essential to the eradication to the disease. Some of the tools mentioned are creating new wells, chemical treatment and filtration. What other steps do you take to enhance access to clean water? What challenges do you face in that process?

CW: Well first, it’s useful I think to understand that there are four interventions that are available to the program.

One is health education to change behavior. For instance, if a person has a worm emerging, and that worm doesn’t touch any water, the life cycle is broken. This is because that worm will die. Its like a salmon run, it comes out only to lay its eggs, before it dies. The second is, if you filter the water before drinking it, that screens out the infection agent and you won’t get Guinea worm. Then you can treat the pond with ABATE®, a safe chemical larvicide that kills the infectious agent. And then you can drink the water and you won’t get Guinea worm. And then as you mentioned, if you will, the purest, and perhaps preferred intervention is access to clean water. And if you have access to clean water, then there’s no risk of transmission.

Of course, there are a couple of issues with that. Particularly if you are talking about bore holes. Number one: its capital intensive. And two: it takes a long time, sometimes, to get a bore hole in place. And those are a couple of issues that have to be factored in.

And the advantage that the Guinea worm eradication has is that while any one of these interventions if applied perfectly would break transmission. However, because we are dealing with human beings, who are unpredictable, none by themselves will completely get rid of Guinea worm. And so, what we try to do is we try to put in as many of those four interventions in a village as we possibly can. So, you just put in as many barriers to transmission as you can and that’s one of the advantages that Guinea worm has over other programs that might have a single intervention, let’s say a vaccine. So, water is a key component that, by itself, could eliminate or break transmission, but oftentimes it doesn’t work.

And there are several reasons for that. One is that within these countries, at least in our experience, there is no systematic, data driven approach to determining where you are going to site your water points. Governments rarely know what water agencies are in their country, where they are, and what they’re doing. They may know a lot of it anecdotally, but a comprehensive picture actually is very rare. One of the things we have done in several countries is – using our village based surveillance system – we have been able to establish, if you will, a database that ministries of water can use to at least monitor what the status of water points are in Guinea worm endemic villages.

And that’s not the whole country, but oftentimes, we will develop that and give that to the ministry of water and encourage them to expand throughout the country. And then, oftentimes, we will continue to update at least the Guinea worm part of that.

There are some challenges we have encountered in the Guinea worm eradication program. And I’ll just go through a few of them here.

One is we would like to see water agencies improve their community mobilization. The reality is that, in many cases, water agencies are primarily focused on providing bore hole wells. And that’s a very technical effort, it requires engineers, people if you will, who are very good with equipment. They know the hardware inside and out. But they don’t focus so much on the software. And in my estimation, that’s just human nature. If you get someone who’s really interested in the technical side, the human side sometimes doesn’t get the same level of attention.

And we have encouraged water agencies to improve community mobilization, so that communities understand the value of the water, why they’re getting the water, and that maintenance and being careful with how you treat a bore hole is very important to its longevity. And in this regard, we encouraged them to work with ministries of health or other, if you will, organizations that have experience with engaging with villages. So that they can be properly mobilized and can be part of the solution rather than the problem.

Another issue is the supply system. One challenge we have, particularly in many developing countries, is that you’ll have multiple water agencies who come in with different types of equipment, difference sizes of equipment. And when you need to find a spare part for, let’s say a bore hole that’s broken down, sometimes that spare part is not available in the country. And what is available in the country won’t fit. So we’ve been encouraging water agencies, and water agencies have recognized this as well, they’ve tried to rationalize and, if you will, establish some sort of standardization for particular types of pumps, so that spare parts are easily available, cheap and can be accessed fairly quickly.

And then the other part of that is we think they need to approach in a more systematic way the availability of spare parts. An example might be that each village ought to have a supply of inexpensive parts that are most likely to break. And if you’ve done proper community mobilization, there’s probably someone there who could make that repair if they had ready access to the part. You can keep the water point functioning. Then sometimes you may have, if you will, slightly more expensive items that don’t break down as much, and those can be kept at the regional level. So that when it breaks down, they can send word out, and get that part fairly easily. And those things that are expensive and might breakdown infrequently, could be supplied at the national level.

The next item is rehabilitation. We oftentimes track the status of water supply in each of the endemic villages that receive water points. And what we have found is that a lot of pumps break down on a regular basis, oftentimes within six months of being put in. And the system for identifying those that have broken down and repairing or rehabilitating them just doesn’t function very well. And oftentimes you’ll find water points that will go a long period of time without being repaired.

And in some cases what the the Guinea worm eradication program has done is we have established teams, we did this in Ghana for instance, that would visit every well in a Guinea worm village that broke down, do an assessment, and if it could be repaired with locally available spare parts, we would go ahead and have the team repair the well. Just so we can keep the water flowing in a Guinea worm endemic village.

Another issue that we’d like to see water agencies approach water supply problems a little more creatively. You’ll notice I mentioned in my comments up to now, I’ve focused exclusively on bore holes. In our experience, water agencies really are sort of geared up for bore holes. They make huge investments in these drilling machines, that can cost half a million, upwards, depending upon the level of sophistication for drilling bore holes.

And some realities are that: number one, the geology won’t allow for a bore hole. Number two, there are some areas in which the water table is actually quite high and very close to the surface, and a hand dug well might be a sufficient, cheaper, very quick option for providing clean water to a village. And we actually worked with UNICEF to put out a document in 1994 that provided a whole host of alternative solutions to providing clean water to villages that did not include bore holes. And these would be obviously hand dug wells, but also water catchments or, one thing that we worked on a lot in Ghana is what we would call mechanized water towers, in which we would find a source of water, and with a pump, pump it up to a tower, and then the water pressure would flow out through tubing to multiple households.

Also, particularly in northern Ghana, and northern Sudan where water is scarce, a lot of villages individually or as a group will actually hand dig a reservoir, they’re usually very shallow, to collect rainwater. And then they will all access that reservoir during the dry season. And because of the size of the pond, oftentimes these are very, very big ponds, we cannot treat with ABATE. And there are two strategies we would follow.

First, we would try fence off the reservoir so that there were specific entry points and at those entry points, we would build something like a pier, so people would walk into the reservoir and without any part of their skin touching the water, lean over and get water. Another option is we would actually build what we would call sand filters, in which you would pump water out into these filters, and using gravity would strain out all the contaminants and then at the bottom of the filter, you would catch the water. Those are things we encouraged, but a lot of water agencies don’t follow that, or pursue that very often.

Another issue is that we would just like them to monitor their water points more carefully. As I mentioned, we collect data on water points in the villages in which there’s Guinea worm, and we track whether there are pumps or water points and if so, what’s their status. And there’s no systematic monitoring system that we’re aware of – and which actually loops back to my first comment – that if were a centralized database for collecting information on the status of water throughout the country, you could do a pretty good job of keeping these water points up and running.

LT: I was just curious about those wells. It sounds to me like they’re mechanically powered. Are they powered by a diesel engine then? How are they powered?

CW: Most pumps are actually hand pumps. What they’ll do is drill down to the water table and then they’ll put a hand pump on top of it. And then people will use the hand pump to get the water. One of the problems you have though is that the demand for water is so high that oftentimes the parts break down easily.

LT: Okay. Because when you first described it, I was thinking these must be pretty heavy duty machines to have all sorts of failures. But I guess they can be simple machines then?

CW: They really have done a good job with coming up with these well heads that use very simple technology to try to minimize the number of moving parts. But despite that, things do break down. And there needs to be a system for maintaining those. Monitoring whether they break down and then having a system to repair them quickly. And that’s actually where community mobilization can come in very handy in that if you have somebody in the village that’s trained in the community, they can probably do a lot of the repairs in the village without any outside assistance and keep it functioning. But you would need parts and you would need somebody trained to do it, and you would need a community that’s sensitive to that need so that they will maintain the pump.


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