FOREWORD

WORLD WATER DAY

Long before the advent of modern medical care, industrialized countries decreased their levels of water-related disease through
good water management. Yet, even in these countries, outbreaks of water-borne disease continue to occur, sometimes with lethal
consequences. In developing countries, preventable water-related disease blights the lives of the poor. Diseases resulting from
bad hygiene rank among the leading causes of ill-health.
Much of this suffering is needless. Health provides an effective gateway for development and poverty alleviation.
Improving water management is a powerful tool that can be used by individuals, communities and households to protect
their own health.
3.4 million people, mostly children, die annually from water-related diseases. Most of these illnesses and deaths can be
prevented through simple, inexpensive measures. For instance, trachoma remains the leading cause of preventable blindness,
accounting for 146 million acute cases around the world. But the disease is almost unheard of in places where basic water
supply, sanitation and hygiene prevail.
Safe water supply and adequate sanitation to protect health are among the basic human rights. Ensuring their availability
would contribute immeasurably to health and productivity for development. "Business as usual" is no longer an option. We
don’t have enough time to just wait for large infrastructure investments to provide these basic services to all who need them.
Several simple interventions are available, such as improving the quality of water in the home as well as improving hygiene
education at the household level. Poor people can take charge of their own destinies and improve their lives by applying some
of these measures. But they need to know what works and how such interventions can be exploited.
World Water Day, celebrated on 22nd March, became an annual event after the 1992 Earth Summit in Rio de Janeiro, Brazil,
and brought home to millions of people the importance of cherishing a valuable resource which affects our very existence. The
theme for 2001, Water and Health, highlights the opportunities for promoting health and development through safe water.
People everywhere can use this day to raise awareness of the high level of disease and misery that results from bad and
inadequate water sources. People can learn that they need not be victims, but can take matters into their own hands to create
good, clean water for better health.
Gro Harlem Brundtland
Director-General
 TABLE OF CONTENTS

Chapter one: Water and health – two precious resources 5

Chapter two: Why we need to act 11

Chapter three: Where we need to act 15

Chapter four: Solutions most needed 21

Chapter five: It can be done 27

Epilogue: Opportunities for actors and stakeholders 31

Water is one of the earth’s most precious and threatened resources.
Health is one of each person’s most precious resources.
We need to enahnce and protect them both.
Water for Health
 Chapter One

WATER AND HEALTH:

Two precious resources linked to one another

F rom outer space, the earth looks like a "blue" planet because most of its
surface is covered by water. But only 2.5% of that water is fresh, and most
of that lies frozen and inaccessible in the icecaps and Greenland, leaving
less than 1% of fresh water accessible in lakes, river channels and underground.
Hydrologists estimate that the average annual flow of all the world’s fresh water
ranges from 35 000 Km3 to 50 000 Km3. Due to a mix of geographical, environmental
and financial factors, as well as to increased pollution from municipal and industrial
waste, the leaching of fertilizers and pesticides used in agriculture, only about one-
third of the world’s potential fresh water can be used for human needs. As pollution
increases, the amount of usable water decreases.
Water contributes much to health. Good health is the essence of development.
However water’s protective role is largely unseen and taken for granted in the
wealthier countries. More attention is paid to it’s role in disease transmission than
health protection. Water contributes to health directly within households through
food and nutrition, and indirectly as a means of maintaining a healthy, diverse
environment. These two precious resources — water and health — together could
enhance prospects for development.

5
 WATER & DEVELOPMENT: THE HEALTH CONNECTION
The poor are more susceptible to ill-health than are the well-off. They lack adequate
supplies of safe water and safe methods of disposing of their wastes.
WATER AND HEALTH LINKS
Lack of water and sanitation create ideal conditions under which faecal
oral diseases thrive.
Consumption: Most people The use of soap and water for
drink around 2 litres of water peronal hygiene helps prevent Study after study has shown that where a community improves its
each day. Contaminated water trachoma and scabies.
can transmit diseases such as water supply, hygiene and/or sanitation then health improves. For
typhoid, cholera and hepatitis.
Water-related insect vectors example, diarrhoea can be reduced by 26% when basic water, hygiene
cause one million deaths per
Water-based diseases like year through malaria alone. and sanitation are supplied. Yet statistics tell a terrible story. Forty
guinea-worm remain Basic water management helps
problematic. Improving water control malaria carrying percent of the world's 6 billion people have no acceptable means of
supply is a cornerstone of the mosquitoes and minimizes the
global effort to eradicate consequences of pesticide and sanitation, and more than 1 billion people draw their water from
guinea-worm. drug resistance.
unsafe sources.
Forty-five per cent of the
world's food production comes Food safety: Washing fruit and The World Health Organization says diarrhoeal diseases remain a
from irrigated agriculture. This vegetables with water is a
form of cultivation will have to recipe for good health. leading cause of illness and death in the developing world. Every year,
expand to keep pace with
population growth. Mismanagement of irrigation
about 2.2 million people die from diarrhoea; 90% of these deaths are
fosters schistosomiasis but can
be controlled through
among children, mostly in developing countries. A significant number
good water management.
of deaths are due to a single type of bacteria, Shigella, which causes
Water supports the ecosystems People worldwide enjoy water dysentery or bloody diarrhoea. It is readily controlled by improving
and biodiversity that contribute for rest, relaxation and exercise.
to drug development. hygiene, water supply and sanitation. Although no vaccine exists and
antibiotics may be inaccessible to many people, an effective intervention
Species harmful to humans
thrive where ecosystems are is available. The simple act of washing hands with soap and water
disrupted.
reduces Shigella and other types of diarrhoea by up to 35%.

WATER MANAGEMENT TO REDUCE HEALTH RISKS

The transmission of disease is also rife among vulnerable communities because they live
in environments receptive to the breeding of insect vectors that carry parasites such as
malaria, filaria and trypanosomes. Most of these need water for part of their life-cycle.
300 million people suffer from malaria and in sub-Saharan Africa alone malaria kills an

6
estimated 1 million people per year, the large majority are children under five. Other
malaria hotspots are South and South-East Asia, and parts of South America.
Early diagnosis and treatment, as well as personal protection through the
use of low-cost insecticide-treated mosquito nets continue to spearhead WATER SUPPLY, GLOBAL COVERAGE 2000
malaria control programmes. However, the ability to treat the disease
effectively is being jeopardised as a result of growing problems of drug
resistance and counterfeit drugs, while the use of mosquito nets meets with
problems of affordability and social acceptability.
In many areas, particularly those with less intense transmission
patterns, environmental management as part of integrated vector
management can significantly reduce the spread of disease. Water
management, which is key to this approach, should be based on a proper
assessment and understanding of local vector ecology.
91%-100%
Many poor farmers in semi-arid areas may be dependent for their
76%-90%
agricultural water supply on a small number of rich land-owners who can
51%-75%
invest in the drilling of bore-holes. In the rice-growing areas of Tamil Nadu 26%-50%
in southern India, such situations are not uncommon. Dependency on 0%-25%
water provided by one rich farmer may create discrepancies between the no data

time water can be purchased and the cropping cycle. Rice fields may thus Source: WHO, UNICEF, WSSCC: 2000

be flooded for weeks and become important breeding places for Culex
mosquitoes which can transmit Japanese encephalitis. Outbreaks of the disease kill at
least 20% of people suffering clinical symptoms – mainly children. Twenty per cent of
survivors are left with permanent damage to their central nervous system.
Growing water shortages for irrigation may contribute to the alleviation of the
Japanese encephalitis problem. As farmers have to manage irrigation water as an
increasingly scarce resource, the promotion of alternate wetting and drying practices
of rice fields will contribute to a reduction in the vector population and, thus, in the
risk of outbreaks.

7
 SAVING SIGHT
Trachoma can be prevented by improving sanitation, reducing the breeding sites of flies
and teaching children to wash their faces with clean water. Trachoma
WHO ALLIANCE FOR THE GLOBAL ELIMINATION OF BLINDING TRACHOMA caused by microscopic Chlamydia trachomatis remains the leading
cause of preventable blindness — with an estimated 6 million people
suffering loss of sight and 146 million acute cases worldwide.

WATER & HEALTH: THE POVERTY CONNECTION

Poor health and illness are dreaded by almost everyone. Needy
people tend to live on what they earn on a daily basis and have no
cash reserves to pay for a sudden illness. The loss of income and the
inability to pay for the cost of treatment can push a family further into
poverty and debt, thereby perpetuating the cycle of poverty.
"If you don't have money today, your disease will take you to your grave."
– An old man in Ghana, 1995

Poor communities are often forced to over exploit their natural

First priority for intervention resources in order to survive. Water sources are particularly vulnera-
Other countries where interventions are needed
ble. In too many cases, they are abused to such an extent that they no
Source: World Health Organization
longer can provide for a community’s basic needs and end up posing
serious health risks. However, opportunities for reversing this situa-
tion exist. What is required is that priority is given to water management and develop-
In Bamako, the capital of Mali, poor people pay as
much as 45 times more per unit of water than do ment and that communities play a major role in solving their own problem. This will
the rich, who get water piped into their homes, entail the full involvement of communities in the planning and development of their
often at subsidized prices. In 1988, Cairncross and
own water systems.
Kinnear estimated that 25% of the population
living in cities in developing countries bought Gross inequities in the reliability and quality of water supply services create a
water from vendors, typically spending 10%-20% market for water-vendors and encourage use of unsafe local wells and springs in
of household income.
urban slums.
Similar inequities in access to safe water, especially in rural areas, force women in

8
developing countries to spend hours every day fetching water, causing an enormous
drain on their energy, productive potential and health. The lack of good quality, reliable
water puts people’s health at risk and may force them to extract water from alternative,
unsafe sources, exposing them to diseases such as diarrhoea or dysentery, cholera, Almost 70% of the 1.3 billion people living in extreme
poverty are women. Women – especially poor women–
typhoid and schistosomiasis. Traditional wells may become polluted with agrochemical
are often trapped in a cycle of ill-health exacerbated by
residues as irrigated agriculture intensifies. childbearing and hard physical labour.
The gap between rich and poor becomes all too apparent in regard to the lack of
water for drinking, irrigation and sanitation, and in their inability to maintain the
integrity of ecosystems on which people depend. Time and again, poor people Eliza Fenlas, a mother of three who lives in Inhambane,
one of Mozambique's driest provinces, spends five
everywhere – in Bangladesh, Viet Nam, Kyrgyzstan, Malawi, etc.– cite lack of safe hours a day trekking 24 kilometres to fetch 20 litres of
drinking-water as one of their most important problems. water. She looks forward with joy and anticipation to
Good water, good health and better living are worthy goals in and of themselves. the day when her area will benefit from a safe water
programme. She says a well nearby will make a big
But, basic services for the needy are also a moral and human-rights obligation. This difference in her life. She will have more time for
view is too often overlooked by those in control of the developmental purse-strings and household chores and farming. She will have more
by the poor themselves. Because deprived people are frequently unaware that they water available for washing. She is hopeful that the safe
water will put an end to her seven-year-old son's
have a right to properly functioning basic services – to good water and to good health – chronic diarrhoea.
they have been unable to obtain them. Source: UNICEF

LOST OPPORTUNITIES
The right to the highest attainable standard of health is
Where women and children spend hours each day walking to streams and other
a fundamental human right which embraces a wide
sources to collect water for their families, they have little time or energy left to pursue range of socio-economic factors that promote
an education and other gainful activities. The heavy loads they carry may cause conditions in which people can lead a healthy life, and
extends to the underlying determinants of health, such
skeletal deformation and accelerate the deterioration of joints.
as access to safe and potable water and adequate
Everyone benefits from good sanitation. But girls are among those who benefit sanitation, and a healthy environment.
the most. Girls often miss out on an education because they have to help with the
household chores and, when money is scarce, it’s usually the boys who get chosen to
go to school. An important reason why girls drop out of school in developing
countries – mainly in Africa and Asia – is because of lack of sanitation facilities.

9
 Studies show that school attendance by girls increases when separate latrines for
girls and boys are installed. In a school in Bangladesh, where UNICEF began
promoting separate facilities in 1992, girls’ school attendance has risen by an average
of 11% a year.

The unreliability of rural water supplies in parts of India stimulated people to store water
in their houses to bridge periods when the supply ran dry. This resulted in dengue out-
breaks, because the stored water provided breeding places for Aedes mosquitoes.

GOOD WATER SUPPLY, SANITATION, HYGIENE AND WATER MANAGEMENT

CONTRIBUTE TO PREVENTING:

Anaemia, Arsenicosis, Ascariasis, Campylobacteriosis, Cholera,

Cyanobacterial poisoning, Dengue, Diarrhoea, Dysentery,
Fluorosis, Guinea-worm disease, Japanese encephalitis,
Infectious hepatitis, Impetigo, Lead poisoning, Malaria,
Malnutrition, Methaemoglobinaemia, Ringworm (Tinea),
Scabies, Schistosomiasis, Trachoma and Typhoid Fever.

NUTRITION, FOOD SECURITY AND IRRIGATION

Malnutrition affects nearly 20% or almost 800 million people in the developing world
(WHO 2000). Malnutrition plays a major role in their ill-health, making them particularly
susceptible to infectious diseases carried by unsafe food and water, which results in further
malnutrition. Great progress has been made in feeding the world. Over the past 30 years,
food production and distribution have more or less kept up with the growing population.
The two factors responsible for this improvement are irrigation and high-yielding varieties
of crops. Food production needs to increase further to feed a growing world population;
while famine, owing in part to water shortage, is already affecting large parts of the world
(particularly Africa). 40% of the world’s food now comes from irrigated land and this
requires ample supplies of water. For example, 1 000 tons of water are needed to grow one
ton of wheat. Solutions include more efficient use of water, recycling and sustainable use of
Faecal contamination of water is an important cause of ill health. Improving dams and irrigation systems.
sanitation is a priority.

10
 Chapter Two

WHY WE NEED TO ACT

Water and heath – everyone stands to gain

T he treatment of wastewater often is a haphazard affair. In developing

regions of the world, treatment is applied in only a minority of systems.
Even in the industrialized countries of North America and Europe, for
example, sewage is not universally treated.
Problems of unsafe water and inadequate sanitation systems are most acute in
developing countries. Although in a smaller proportion, people in industrialized
countries also get sick from contaminated water and untreated sewage. Despite the fact
that developed countries normally have the means to deal with these problems, they
often don't for reasons of complacency, lack of political will, cost and so on. Public
pressure to remedy serious health and environmental problems may be instrumental in
initiating change.

PRESSURES ARE GETTING WORSE

Unsustainable approaches : Some of the technologies adopted in the wealthier
countries to make life easier and more comfortable for their inhabitants can cause
problems. The move from latrines and septic tanks to flush toilets in major cities
propels municipal sewage, often with limited treatment, into rivers and coastal areas.

11
 If all goes well, the waste may be diluted and treated by natural processes. But, it also
may accumulate in fish and shellfish which, if eaten, can make people sick.
Furthermore, the contaminated water may endanger the health of swimmers at beach-
MEDIAN PERCENTAGE OF WASTEWATER
TREATED BY EFFECTIVE TREATMENT PLANTS side resorts. Governments increasingly are forced to balance the costs of cleaning up
100% sewage-polluted water against the loss of revenue that may result from ill-health, lost

80 tourism and problems incurred by fisheries.

Urbanization: Cities are growing at an incredible rate worldwide. The current urban
60
population of 2.8 billion people will increase to 3.8 billion in 2015 and to 4.5 billion in
40
2025. Megacities create tremendous demand for water and act as dense sources of
20
pollution. This challenges the ability of those in charge of water management to provide
0 35% 14% 90% 66%
0 for the needs of all inhabitants.
Africa Asia Latin N. America Oceania Europe
America Population: With population growth, demand for the world’s finite supply of fresh
& the Caribbean
Source: WHO, UNICEF, WSSCC: 2000 water is rising, putting strains even on the industrialized countries. Global population
The lack of wastewater treatment is a health hazard. projections suggest that the world population of over 6 billion in 2000 will increase 20%
to over 7 billion by 2015, and to 7.8 billion by 2025, a 30% rise. Enormous strains will be
In Indonesia, the transmission of malaria was put on existing services, and substantial increases in the provision of water and
drastically reduced when farmers synchronized
sanitation will be needed to meet the needs of the swelling population. As populations
their rice-production system to allow rice paddies
to dry out completely during certain periods. Then grow and demands for water and other services expand, pollution levels will rise, while
again, in Sri Lanka, the breeding of malaria more water will be needed in agriculture to feed and nourish the large population.
mosquitos was suppressed in small rivers and
irrigation canals by regularly flushing them out.
Interdependence: Health is often not systematically considered by those who plan
water development projects. Consequently, local communities, many of whom do not
even stand to gain from the project, end up carrying the increased risk of illness from
newly introduced water-related diseases. There are far too many examples of poorly-
designed development schemes which have brought malaria or schistosomiasis into
areas where it previously did not exist. Health concerns are rarely included in
agricultural development policies. It has been shown that where health is taken into
account, the eventual efficiency of water projects is greatly enhanced.
Fresh water: The world's supply of fresh water is limited. Water sources are

12
vulnerable, too often ill-managed and inequitably distributed between the rich and the
poor. The poor are also disadvantaged in that too many of them live in water-deficient
countries, mostly in Asia, the Middle East and
sub-Saharan Africa. This creates particular
problems for people in rural parts of Africa where,
on average, less than 50% of people have access to
both improved drinking-water and sanitation.
Climate change: The 21st century could see a
rise in disease if predictions of climate change
come true. If nothing is done to reduce the
emissions of carbon dioxide and other greenhouse
gases which are believed to lead to global
warming, scientists warn that global temperatures
might increase by 1 to 3.5 degrees centigrade by
the year 2100. Scientists believe that the climate
changes would increase the number of deaths and
illnesses due to infectious diseases. For instance,
mosquitos may extend their range to new
geographical areas, leading to more cases of
malaria. Climate change also would threaten
hundreds of millions of people, who currently are
not at risk, with dengue (another mosquito-borne
disease), and floods and drought would impact on
Floods and drought are amongst the most frequent natural disasters that contribute to
food production.
ill-health and most frequently affect the poor.
Natural disasters : Floods are the second most frequent cause of natural disaster,
after windstorms. However, drought is the largest cause of death because it often leads
to famine. Floods affect more regions and more people than any other phenomenon.
The consequences of flooding, especially in poor communities, can be horrific. This

13
 was seen in the disastrous floods that occurred in the aftermath of the powerful
cyclones that struck Madagascar and Mozambique in February 2000. Many people died,
hundreds of thousands of people were made homeless, epidemics of malaria and
MAJOR FLOODS AND STORMS cholera broke out, rich farmland was rendered useless and economic development
Floods devastate people and structures received a severe setback.
YEAR LOCATION DEATHS The after-effects of a major flood usually linger on for many years. Flood-stricken
1421 Holland 100,000
1530 Holland communities have to come to terms with the drownings and injuries sustained by their
400,000
1642 China 300,000 loved-ones, with the loss of their homes and belongings. The breakdown of water and
1887 Yellow river, China 900,000 sanitation services increases vulnerability to waterborne diseases. Flood damage
1900 Galveston, Texas, USA 5,000
1911 Yangtze River, China sustained by water supply, irrigation and other water infrastructure is a major setback to
100,000
1931 Yangtze River, China 145,000 health and economic development. Environmental pollution leads to more ill-health. For
1935 Yangtze River, China 142,000 instance, leptospirosis, a bacterial disease which affects both humans and animals, can
1938 Yellow river, China 870,000
1949 Yangtze River, China
reach epidemic proportions during severe flooding because of the widespread
5,700
1953 Holland 2,000 contamination of surface water, soil and plants.
1954 Yangtze River, China 30,000
1959 Japan 5,098
1960 Bangladesh 10,000
CONTAMINATED WATER CAUSES 54 DEATHS IN MILWAUKEE
1963 Vaiont, Italy 1,800
1979 Morvi, India 15,000 Cryptosporidium parvum was not recognized as a human pathogen until late in the
1991 Bangladesh 139,000 1970s. In the early spring of 1993, the residents of Milwaukee, Wisconsin, fell victim
1991 Philippines 6,000 to the largest documented outbreak of waterborne disease in the USA. More than 400
1991 Huai River, China 2,900 000 people fell ill with acute watery diarrhoea caused by Cryptosporidium infection.
1998 Central America 18,000 The infection, which causes abdominal cramping, nausea, vomiting and fever was
1998 Yangtze River, China 3,000 transmitted through the public water-supply system. Milwaukee
1998 India and Bangladesh 2,425 gets its water from Lake Michigan. Apparently, one of the city’s
Source: White 1999: World Water Vision: 2000
water treatment plants failed to filter out the dangerous parasite
in the untreated water. Two years after this outbreak,
investigators concluded that the infection, which can have fatal
consequences for immunodeficient people, had killed 54 —
most of whom had AIDS.
Cryptosporidium
Source: MacKenzie et. al., 1994

14
 Chapter Three

WHERE WE NEED TO ACT

I t is estimated that it would cost about US$ 23 billion per year to achieve the
international development target of halving the percentage of people
unserved with improved water sources globally (currently at 18%) and
improved sanitation services (currently at 40%) by the year 2015. But governments
presently spend US$ 16 billion a year in building new infrastructure. The additional
US$ 7 billion a year needed to supply good water and sanitation to some who lack it is
less than one tenth of what Europe spends on alcoholic drinks each year, about the
same as Europe spends on ice cream and half of what the United States spends each
year on pet food. Compared to what governments expend on military weapons, the
cost of providing people with the means to improve their health is small.

WATER AND HEALTH FOR THE RURAL POOR

Managing water supply can be difficult in rural areas. Of the 1.1 billion people without
access to improved water sources worldwide, around 84% live in rural areas. Drinking-
water quality is especially difficult to control and even in the most developed countries,
small community water supplies frequently fail on basic microbiological quality.
Rural communities have a different relationship to water than do urban dwellers.
Water dominates every aspect of their lives. People in the countryside live off the land

15
 and depend on water to grow their crops. Scarce water supplies are used sparingly for
household needs. Water is the source of their livelihood and, when unclean or
mismanaged, the source of ill-health and continued poverty.
To achieve the international development target of halving Water contains many trace elements and minerals, which may be benign, beneficial
the proportion of people without access to improved or toxic. Everything depends on how much. While some minerals may be beneficial in
water or sanitation by 2015, an additional 1.6 billion
people will require access to water supply and about 2.2 low concentrations, most can be toxic in excess. Only a few chemicals – for instance,
billion will require access to sanitation facilities. arsenic and fluoride – are thought to be major public health issues. The problems they
and nitrate cause are most common in rural areas.

ARSENIC CONTAMINATED DRINKING-WATER

– A PUBLIC HEALTH EMERGENCY ARSENIC IN DRINKING-WATER
One of the worst examples of a do-good project gone wrong is occurring in Bangladesh.
•Arsenic exposure in Bangladesh is widespread and
involves thousands of wells. About two decades ago, millions of small wells began to be drilled in an effort to
• Estimates indicate that at least 100 000 cases of skin provide safe water to the population. At the time, all attention was focused on
lesions caused by arsenic have occurred and there may
preventing diarrhoeal disease which ravaged the population. No one, until the 1980s,
be many more.
• If exposure continues, skin lesions will continue to identified naturally-occurring arsenic as a health hazard.
occur. A recent study published in the Bulletin of the World Health Organization suggests
• Skin lesions are unpleasant and may be debilitating.
that Bangladesh is grappling with the largest mass poisoning in history, potentially
• Skin lesions are occurring in children aged 10 years
and younger. affecting between 35 and 77 million of the country’s 125 million population, threatening
• Large numbers of cancers are predicted to occur in the them with potential epidemics of cancers and other fatal diseases.
future, including fatal internal cancers.
Attacking the problem in Bangladesh is not easy. There are millions of wells and
• The cause is known: each day of continued exposure
increases the risk of morbidity and death. those that are dangerous are mixed in with those that are safe. There are several
• Sustained drinking of water containing 500µ/l of technical solutions but no single universal method. Well-to-well testing is needed.
arsenic may result in 1 in 10 people dying from arsenic-
related cancers.
• Unlike other major health problems experienced in
FLUORIDE
Bangladesh, arsenic-caused diseases can be eradicated at Fluoride is present in all waters. Low amounts of this element can be good for teeth. But,
relatively low cost.
excessive amounts of fluoride in drinking-water can be toxic.
Source: Bulletin of the World Health Organization, People with teeth discolored by fluoride are found worldwide, and crippling skeletal
volume 78, (9): page 1097 (2000).
effects are prominent in at least eight countries. It is estimated that 30 million people

16
suffer from chronic fluorosis in China where the custom of
burning fluoride-rich coal in the household may further aggravate
the problem.
These issues can be solved and answers are available, but
implementing projects, especially in the rural areas where the disease is
most prevalent, is often difficult.

SCHISTOSOMIASIS
Of all the water-associated tropical diseases, schistosomiasis, a water-
based parasitic disease, best illustrates the complexities of the various
water issues with which mostly the rural poor are faced. For part of
their lifecycle, Schistosoma parasites depend on aquatic snails. The
disease is maintained through faecal/urine contamination of open
waters with parasite eggs, the presence of the snails and frequent
water contact for recreational, domestic or occupational purposes.
Water management can play an important role in reducing
transmission risks. But it must be combined with drug treatment, the
provision of safe drinking-water and adequate sanitation. Health
Dental fluorosis occurs worldwide – particularly in rural areas.
education is also important. Canal lining, regular rapid draw-down of reservoirs, and
increased flow rates in irrigation canals all favour snail elimination, but are only
The farmer with the black teeth seemed fine the first time I saw
efficient if they have a positive effect on agricultural production at the same time. him - out all day working. I know that he carried on drinking the
same fluoride-rich water he had drunk since he was born. Five
WATER, HEALTH AND THE URBAN POOR years later when I returned to the village his legs had buckled
under him. He was practically a cripple. I don't know what he
Competition for water in the world’s ever-growing cities is fierce. Industry, urban did for a living any more.
agriculture and households all rely on and demand water to meet their needs. But Source: Eli Dahi: researcher
water is becoming scarce, and this often results in the inequitable distribution of what
is available. Municipal water regulations, government subsidies, public and private
investment all tend to favour traditional water-supply services which provide piped

17
 water directly into peoples’ homes, but neglect the urban poor.
Hygiene practice is closely linked to the availability of water and sanitation facilities. In
places where these may be lacking, communal areas which offer facilities for hand-
200 million people in the world are infected with
washing, bathing and laundry may effectively encourage good hygiene. Education is
schistosomiasis, of whom 20 million suffer severe
consequences. also important. For instance, the health of communities can be enhanced if they are able
to protect their water sources, dispose of solid waste and excreta, and provide
wastewater drainage.
25% of all community water systems are currently posing
a health and safety risk to the community. Of the 425 Urban habitats provide breeding grounds for diseases such as dengue fever and
community sewage-treatment systems, 9% are urban malaria. Control methods for reducing breeding-sites for the insect vector is a
experiencing problems that could affect the health and
proven and effective means of cutting disease. Unfortunately, they are difficult to
safety of the community.
—"Water Quality Monitoring in Canadian Aboriginal implement in densely-populated shanty towns with inadequate waste disposal.
Communities" by Jeff Moore

INDIGENOUS PEOPLE
Contamination of traditional food sources is becoming an increasing issue of concern
In Ethiopia, unsafe water, unhygienic handling of food, among indigenous populations, many of whom derive most of their drinking, irrigation
storage of food at ambient temperature for a long time,
poor domestic and personal hygiene may have contributed and food from local lakes and rivers. In South America for example, indigenous peoples
to the gross contamination of weaning foods. The in the Andes and Amazon regions are exposed to high levels of arsenic and mercury in
contamination of food may lead to increased diarrhoeal local water systems and fish. This is creating health problems among children and
diseases in infants and children.
breastfed infants. For many tribal groups in Africa, unsafe drinking-water and
unhygienic handling of food is contributing to high levels of diarrhoeal diseases in
infants and children.
Indigenous peoples in rich countries may also live in abject poverty and suffer from
the kind of ill-health and economic deprivation that are commonly found in developing
countries. However, the outlook for disadvantaged communities in these societies is
usually better because of active social support networks.
Canada is a wealthy country with a large indigenous population which, according to
statistics, has a lower life expectancy, higher infant mortality and greater disease burden
than the rest of society. A study of water and sewage facilities conducted by Health Canada

18
and the Department of Indian Affairs examined 863 First Nations community water-
treatment systems and 425 community sewage-treatment systems. It found that vast
improvements in health, leading to economic development and poverty
reduction, could be achieved by providing native communities with a
good water supply and sanitation.

Fish collected in the Beni river, food source for indigenous

Amazonian populations, were contaminated and contained almost
four times the amount of mercury considered safe by WHO. High
levels of mercury in fish lead to an increase in contamination in
indigenous children, and young children still being breast-fed.

Indigenous Atacamena people in

Chile who live on the banks of
pre-Andes river are exposed to very
high concentrations of arsenic —
over 50 times the national
standard. This has a large impact
on the Atacamena, who derive
most of their drinking and irrigation
water source from the water.

Contaminated water contributes to poor

health among indigenous people.

19
Everyone needs basic water and sanitation. Long-term solutions should be
complemented by interim measures to promote health.

20
 Chapter Four

SOLUTIONS MOST NEEDED

T he United Nations Millennium Declaration aims to promote development

and eliminate poverty nationally and globally. A major goal is to halve, by
the year 2015, the number of people who earn less than a dollar a day, who
suffer from hunger and have no access to affordable, safe drinking-water.
Providing access to better water for more than 1 billion people cannot be done
overnight. Waiting for the "big solution" while ignoring the immediate priorities of
the most needy makes no sense. There are many small-scale, cost-effective
intermediate actions which can be taken to great effect. Easy, low-cost methods for
improving health do exist and can be applied collectively or individually. Water can
be purified by means of chlorination and solar-thermal techniques. People can stay
healthy by simply washing their hands with soap and water. Government policies
can support local initiatives.

CHLORINATED WATER
Chlorination is a proven means of ridding water of disease causing micro-organisms in
piped water supply. But the prevailing wisdom is that chlorinated water should be
dealt with after basic water supply and sanitation are in place.
Research carried out by scientists at the Centers for Disease Control and Prevention
in Atlanta, Georgia, in the United States of America and the Pan American Health

21
 Organization looked at how chlorinated water can be provided to poor households
through a simple, low-cost treatment and secure storage method.
"One of the findings we’ve made is that improving water quality alone does work
RAIN HARVESTING IN THE MALDIVES
and we can do this without improving sanitation," says Mark Sobsey, Professor of
The Maldives adopted a national control programme using
Environmental Microbiology at the University of North Carolina, Chapel Hill, USA.
chlorination in wells and oral rehydration salts for the
treatment of diarrhoea, as well as use of rainwater for "What we now know is that even in conditions of very poor sanitation and hygiene
drinking. 20 years later all the islands in the country are self- where people are collecting whatever water is available to use as household water
sufficient with their own community rainwater collection
supply, if the water is chlorinated, the water is improved microbiologically and you can
system tanks. Deaths due to diarrhoea are now a thing of
the past. find statistically significant decreases in diarrhoeal disease."

SODIS: SOLAR WATER DISINFECTION

"SODIS is a nearly cost-free system because sunlight is free of charge. Nobody has to pay for it."

– Martin Wegelin, Swiss Researcher.

Sodis was pioneered in Lebanon in the 1980s. It is a simple water-treatment method

which uses the sun, throw-away plastic soft-drink bottles and a black surface. Further
research was carried out and promoted by the Swiss Federal Institute for Environmental
Science and technology on Sodis.
Transparent bottles are filled with water and placed horizontally on a flat surface in
sunlight for about five hours. The illness causing micro-organisms (pathogens) in the
polluted water succumb to the killing effect of the ultraviolet light in the solar radiation.
The process is enhanced when the solar water disinfection is combined with a "solar
thermal water treatment" which makes use of the fact that the colour black absorbs light.
This is accomplished by painting the bottom half of the bottle black or placing it on
black-painted corrugated iron or plastic sheets.
Field studies have been conducted in Bolivia, Burkina Faso, China, Colombia,
Indonesia, Lebanon, Morocco, Thailand and Togo. Testing shows the process works.

Water quality can be improved through simple measures

Anecdotal evidence has been gathered indicating that people have less diarrhoea.
source: www.sodis.ch Supporters say SODIS even has advantages for conventional supply schemes where

22
people collect water from public sources. Under this system, secondary pollution by
consumers may occur which can be eliminated by the solar water-disinfection method
which takes place in a closed bottle.

CHANGING BEHAVIOUR
"Our research shows that washing hands with soap would
probably save half of the deaths from diarrhoeal diseases,"
suggests Valerie Curtis, Lecturer in Hygiene Promotion at the
London School of Hygiene and Tropical Medicine. “All it requires
is soap and motivation.”
But that's more easily said than done. Curtis participated in a
major three-year study in India, the Netherlands, the United Kingdom
and West Africa to learn what motivates good hygiene practices. The
results are interesting and in many ways unexpected.
The research finds that hygiene is a common value around the
world. Nobody likes dirt. But, people’s hygienic practices have less to
do with health than with social and aesthetic considerations. Mothers
want to keep their babies clean because they believe it is a loving,
caring thing to do and will make their babies socially acceptable. One
Indian mother explains "If my child is dirty, no one will hold him in
their arms, no one will love him. And, so I keep my child clean."
There has to be a rethinking of the traditional "scolding,
moralistic" approach to hygiene, which hasn't worked. A number of
studies show that people are turned off by dire warnings that they
will face disease and death if they don't change, "their filthy ways".
For example, people in Brazil refused to collaborate in a cholera
prevention program because they felt they were being accused of Using even small quantities of water effectively can improve hygiene and health.
being "filthy dogs".

23
 Evidence is growing that positive messages are more successful than negative ones in
producing behaviour change. A three-year study in Bobo-Dioulasso (Burkina Faso) used
positive messages to change old entrenched habits. At the end of that
period, the people in the study had tripled their use of soap. Curtis says
an evaluation of the intervention shows that the money spent on the
programme and buying extra soap was less than what families and
health agencies had been spending on treating childhood disease. "There
was actually a net saving on the overall programme."
Studies show that cases of diarrhoea were cut an average of 35% by
the simple act of washing hands with soap and water. Getting people to
change their habits represents a big task for health promoters.

COMMUNITIES ORGANIZING AROUND WATER

Water which collects in and around houses can pose a serious risk of
dengue outbreaks, the virus transmitted by Aedes mosquitos. These
mosquitos, which breed in small, man-made water places such as tires
and cans, can be eliminated through environmental management and
organized community clean-ups. In certain settings, regulations and
possibly fines can be used to rid the environment of these breeding-sites,
Communities can be effective managers of their own water.
although this may not apply to the poorest communities.
Farming communities can be encouraged to adopt new cropping practices which take
water management into account. This will help reduce the spread of vector-borne disease.
Through education and information, local governments can help communities better
understand that their water-management practices have a direct impact on their health.
Once this link is made, farmers are more likely to change their methods for the better.
Huge sums of money are invested in water-supply systems around the world. Yet
many of these systems — especially in rural areas — fail because local communities are
not involved in their planning, construction and management.

24
 There is ample evidence to suggest that communities can manage their water
supplies effectively if they are given the technological and financial support they need.
Financing institutions are often unwilling to make the long-term commitments
Total annual investment in water supply compared to total
necessary to sustain community water systems. And if national and local governments, annual investment in sanitation in Africa, Asia, Latin America
and the Carribean: 1990-2000
as well as domestic NGOs are unable to take up the slack, the systems fall into disuse.
US billions
18
COMMUNITY ORGANIZATION AND PEOPLE POWER 16 National Investment External support
14
6.409
Telling poor people what to do, telling them "what's good for them", does not work. 12
People caught in the vicious cycle of poverty and ill-health know best "what’s good for 10
9.213
8
them" and what motivates them to do what they do. Water projects would have a 2.396
6
better chance of succeeding with minimum risk to health if nearby communities were 4
3.103 4.771 0.040
brought into the decision-making process from the start. If local people are well 2
0 1.470 2.973
informed about a water project, they will be able to weigh the benefits of development
Africa Asia Latin Total
against the cost of increased risk from certain diseases. America &
the Caribbean
Women are more likely than men to be motivated to do whatever is necessary to Source: WHO, UNICEF, WSSCC: 2000

obtain and keep a more convenient and reliable water supply functioning. A project in
Kwale (Kenya) shows that community management of water supplies works,
HAND-WASHING
especially when women are involved. Other studies from South Asia also have shown
Hand-washing with soap after toilet Mother hand-washing with soap
that it is essential to involve women in the design and selection of sanitation facilities. after cleaning up after a child
Involving women in sanitation programmes has resulted in higher coverage, better Kyrgystan 18% Kyrgystan 0%

maintenance of the facilities, increased hygiene awareness, and lower incidence of Burkina Faso 1% Burkina Faso 13%
Lucknow 46% Lucknow 21%
faecal-oral disease in the community.
United Kingdom 30-75% United Kingdom 47%

AN INTERNATIONAL EFFORT: GUINEA WORM DISEASE Source: London school of Hygiene and Tropical Medicine (unpublished)

The World Health Organization and its partner agencies are well on their way to
eradicating guinea worm disease, a horribly disfiguring, disabling disease caused by
a large nematode (roundworm) which breeds in open water sources such as ponds
and shallow wells. People who drink this contaminated water become infected. As

25
 the disease develops, they become progressively weakened and incapacitated. This
has a profound effect on their ability to work, to farm and to go to school. It takes
about a year for the 1 metre long worm to mature and start to release eggs, a painful
PROTOCOL ON WATER AND HEALTH and deforming process.
Not every country in the WHO European region has In the middle of the 20th century, about 50 million people in Africa and Asia were
met UN targets for safe water. Over 120 million infected with guinea-worm disease. By 1999, that number had been reduced to an
inhabitants lack safe drinking-water. Water-related
estimated 96 000. Guinea-worm disease has been eliminated in Asia and is now
diseases, such as cholera, typhoid fever and hepatitis A
are reappearing. In response, 36 countries signed a prevalent in only 13 African countries. Through measures including the provision of
unique Protocol on Water and Health committing safe drinking-water in rural and isolated areas in these countries, the campaign to
themselves to achieve:
eradicate this terrible disease is moving ever closer to its goal.
• adequate supplies of wholesome drinking-water;
• adequate sanitation, protecting human health and
the environment;
• effective protection of water resources;
• adequate protection from water-related diseases;
• effective monitoring systems and response capability.

Women’s involvement is a key to successful water management.

26
 Chapter Five

IT CAN BE DONE
What we need to do differently

P eople who are in good health are better able to take advantage of
economic opportunities. It is also true that an improvement in
standards of living contributes to better health. Society is generally
accustomed to look at the contribution of development to health; whereas the
contribution of health to development has been largely ignored. It is time to reverse
this formula. Putting health at the centre of economic and human development
instead of viewing it as a by-product of development could create new possibilities
for poverty alleviation.

GETTING HEALTH BACK INTO THE WATER AGENDA

In the second half of the 20th century there was a greater emphasis on medical
interventions which tended to push safe water supply, adequate sanitation and
environmental management to the back-seat. After years of reliance on strictly medical
interventions, the health sector is now increasingly faced with the limitations of this
approach. For several of the water-associated diseases, resistance to standard drugs is
increasing. Bacterial resistance to antibiotics, parasite resistance, and resistance to

27
 insecticides by insects that carry diseases (vectors) all follow this trend.

BETTER PLANNING FOR WATER AND HEALTH

POVERTY AND ILL HEALTH: THE VICIOUS CIRCLE The environmental movement has made enormous progress in highlighting the impact
• Diminished quality of life • Increased personal of development projects on people and their surroundings. Most countries now have
and environmental risks
POVERTY legislation that requires an environmental impact assessment before a project can go
• Reduced productivity
•Increased malnutrition ahead. Awareness is growing that health, like the environment, needs to be addressed at
• Lowered learning ability
• Less access to the early stages of planning to ensure that proper safeguards to protect health,
• Diminished household knowledge, information
savings (debt) particularly in water projects, are taken into account. For maximum benefit and
ILL-HEALTH • Diminished household
savings (debt) durability, developers must not transfer hidden costs to the health sector and they must
give priority consideration to the health and well-being of people affected by
Source: The Department for International Development (U.K.)
development projects, especially large-scale water management schemes.

WHAT SCIENCE HAS TO OFFER – THE ROLE OF RESEARCH

Less than 10% of the world's health research budget is spent on conditions that account
for 90% of global disease. In 2000, the Global Forum for Health Research called for a
reallocation of the estimated US$ 56 billion spent annually on health research by the
public and private sectors. While pneumonia and diarrhoea represent around 11% of
worldwide illness, only around one fifth of 1% of research funding is spent on them.
Although major new funds are unlikely to appear for water and health research
much can be learned by integrating what is already known in different areas of concern.
That agricultural productivity is reduced when farmers fall ill may appear to be obvious,
but the connections are not always made between agriculture and health because they
are treated as separate issues. Were health and agriculture researchers to work together,
they could enlarge their knowledge of the environmental and social conditions which
determine health. An example of this is work carried out on surveying insect ecology in
rice ecosystems.
Pressures on diminishing water resources are acting as a spur to technological

28
innovation. Faced by absolute freshwater shortages, the sea has stirred the inventive
spirit of many in the direction of modern desalination technologies. Although
dropping, their cost still remains too high to provide a viable solution to the world’s
DAMS AND HEALTH
inadequate supply of drinking-water.
The health sector could benefit from better use of advances made in information The development potential of dams includes irrigation,
power generation, drinking-water supply, flood control,
collection and management. It has been slow to embrace new devices such as remote
navigation, fisheries and recreation. Dam construction has
sensing and geographic information systems which could, for instance, detect and a chequered past because of adverse environmental and
analyse links between water resources and the distribution and intensity of water- health impacts.
The impacts of dams on environmental and social
associated diseases.
determinants often worsen the health status of vulnerable
communities; they transfer hidden costs to the health
LIVING IN ONE WORLD sector and they undermine the project’s sustainability. For
example, in Ethiopia the cumulative effect of microdams
Globalization has taken root, doing away with the old-fashioned notion that countries
translated into a seven-fold increase of malaria
can live in "splendid isolation." The rich cannot ignore the poor. Even if moral and transmission in the nearby communities.
human rights considerations play no part in their thinking, for purely selfish reasons, Health impact assessment (HIA) provides a well-tested
method and procedure for minimizing health risks and
rich countries must assist the poor in obtaining a better life. High-speed travel, instant
maximizing the health benefits of development projects.
information through the wonders of satellite technology and the internet have brought HIA fits in with prospective environmental and economic
every corner of the earth closer together. The ramifications of this more integrated assessments. It is an effective decision-support tool,
provided recommended mitigating health measures are
world are both good and bad.
included in the resulting environmental management and
Infectious diseases know no borders. Travellers vacationing in exotic places may be resettlement plans.
stricken with illnesses such as malaria, schistosomiasis and cholera. Malaria-bearing Scaling up HIA will ensure improved equity of health
benefits of dams and other water-resource projects. It will
mosquitos have been known to hitch rides on airplanes departing from Africa or Asia
prevent the transfer of hidden costs to the health sector
and unwittingly infecting an individual from a non-endemic country. Since the wild and it will contribute a great deal to its sustainability.
polio-virus can travel from one country to another, the global campaign to eradicate
this crippling disease will not succeed until polio has been eliminated in every country
of the world. These are some of the grim realities of a more integrated world. But,
pressures created by forces such as the multibillion dollar tourist industry for a safer
and cleaner environment could, if effectively channeled, contribute also to
development for the benefit of the poor.

29
 While the internet is still mainly the purview of the rich, access is rapidly
accelerating worldwide. The digital divide between the haves and have-nots is
enormous and will not be easily bridged. But, slowly, more opportunities for
development through the global information network are becoming available. An
example of this in the water and health field is Sanitation Connection, an internet-based
information clearing-house led by WHO with the United Nations Environment
Programme, the Water and Sanitation Programme, International Water Association and
Water Supply and Sanitation Collaborative Council
(http://www.sanitationconnection.net)

VECTOR CONTROL

Vector control can render whole areas of productive land habitable. While insect
populations important for plant protection are well studied, agricultural entomologists simply
throw out species of medical interest because they don’t fit into their field of study. By
pooling these surveys with medical entomologists, data vital for good health can be
collected at little extra cost.

Understanding behaviour is a key to disease control.

30
 Epilogue

OPPORTUNITIES FOR ACTORS

& STAKEHOLDERS

W hile clear linkages between poverty and ill-health are evident, rarely
do governments and aid agencies consider the improvement of health
as a potential strategy for reducing poverty. Economic development
remains the favoured option for poverty reduction. While the health sector is
expected to deliver good care and provide an acceptable level of community health,
resources to effectively fulfil these two essential tasks are often lacking. Water may
provide an entry point to support health and development.

HEALTH MINISTRIES AND ADMINISTRATIONS

A major structural adjustment of the health sector with regard to water is needed in
many countries to ensure that:
• it can function as an equal partner with other agencies in the planning, development,
and management of water resources and basic services;
• it can provide other sectors with reliable data on water-associated diseases and
effectiveness of interventions to facilitate decision-making on water projects;
• it can provide leadership for action in health and water-related issues;
• it can assimilate the concept of human rights and equity in health into development

31
 with the support of political leaders;
• it can promote health-efficient water interventions not supported by other sectors.

LOCAL COMMUNITIES AND CIVIL SOCIETY

• Communities can manage water supply for households or irrigation
effectively if backed-up by government and private aid agencies.
• International NGOs are well-positioned to support their local counterparts
and to engage in international advocacy.
• NGOs working on water projects (e.g. irrigation and water supply schemes)
can assist local communities in overcoming health problems.
• Epidemiological networks can bring water-health problems to the attention of
other professionals.

THE RESEARCH COMMUNITY

Priority research areas depend greatly on specific circumstances. Nevertheless,
there are a number of general trends that are of special importance:
• recognizing the importance of water for health and encouraging
Informed decision making depends on reliable data.
interdisciplinary research;
• ensuring that research targets the poor as they bear the burden of water-related
BASIC DEVELOPMENT NEEDS disease and stand to gain from improved water management;
Community and intersectoral participation are recognized as • bringing expertise and data together to provide new insights to existing information;
important for socioeconomic development. Approaches such
• fostering innovation and technical development in priority areas;
as basic development needs (BDN), which address all
determinants of health, give a wider perspective than can be • collecting high quality data on the impact of water interventions on disease prevention
achieved by health services alone. BDN was successful in to support or assist informed decisions.
Somalia in 1987 and is being implemented in other areas.

THE PRIVATE SECTOR

• Deregulation of the water sector offers opportunity for improved delivery of safe
water to needy customers.

32
• Private-sector initiatives of smallholder farmers can potentially decrease water use
for crop production and improve irrigation techniques for better health and economy.
• Goods and services supportive of health targeted at poor households can boost
private-sector enterprise in areas such as soap manufacture, emptying of latrines, septic
tanks and water vending.
• Public/private partnerships should be established with due consideration to the
health needs of the poor.

GOVERNMENT – LOCAL AND NATIONAL

• Water development policy-makers should be responsible for the health impact of
their actions.
• Decentralization creates new opportunities for productive alliances among diverse
groups involved in local water projects for health.
• Health must be included in environment impact assessment studies.
• The special water and health problems of the urban and rural poor which restrict
their access to safe water and sanitation or increase their exposure to unsafe
environments must be recognized.

INTERNATIONAL AND BILATERAL ORGANIZATIONS

• International partnerships can strengthen the position of health as a cross cutting
issue in the initiatives of water for people, water for food security and water for the
environment.
• Support to interventions for short-term health gains for destitute people.
• Increasing momentum for universal access to safe water and sanitation.
• Enhance access to relevant information through direct initiatives and information
collation and synthesis. Water sources serve multiple purposes.

33
Undertstanding the special needs of the poor is vital to protecting their health.

34
ACKNOWLEDGMENTS
Project coordinator: Jamie Bartram
Project manager: Nada Osseiran
Writer and editor: Lisa Schlein
Cover design, illustration and layout: Pat Leidl
Advisors & reviewers: Martin Wegelin, Val Curtis, Mark Sobsey, John Martin
Editorial support: Mary Vallanjon
Technical inputs and review: Water, Sanitation and Health Unit (WSH), Water
Supply and Sanitation Collaborative Council and WHO Regional Offices.
Photographs: WHO photo library

Water, Sanitation and Health at WHO

The Water, Sanitation and Health activities at the World Health Organization aim to
reduce water-related disease and optimize the health benefits of sustainable water and
waste management. Our objectives are to support the health sector in effectively
addressing water and waste-related disease burden and in engaging others in its
reduction. WSH also assists non-health sectors in understanding and acting on the
health impacts of their actions.
Activities carried out include :
• Articulating consistent ethical and evidence-based policy.
• Providing technical and policy support for sustainable capacity building.
• Setting, validating, monitoring and guiding the implementation of norms and
standards.
• Assessing status and trends.
• Developing tools and guidelines for disease control and risk reduction.
• Stimulating research and development, testing new technologies and comparing
performance.

35
 For more information please contact
World Health Organization
20 avenue Appia, CH 1211 Geneva 27, Switzerland
http://www.who.int/water_sanitation_health/ and http://www.worldwaterday.org

Addresses of WHO Regional Offices

Africa Eastern Mediterranean
WHO WHO Post Office
Parirenyatwa Hospital Abdul Razzak Al Sanhouri Street
P.O.Box BE 773 (opposite Children’s Library)
Harare Nasr City
Zimbabwe Cairo 11371
Tel : (+263) 4076951 Egypt
Fax: (+263) 4790146 Tel: (+202) 6702535
Fax: (+202) 6702492
Americas
WHO South East Asia
525, 23rd Street, N.W. WHO
Washington DC 20037 Indraprastha Estate
USA Manhatma Gandhi Road
Tel : (+1-202) 9743000 New Delhi 110002
Fax : (+1-202) 9743663 India
Tel: (+ 91-11) 3317804
Europe Fax: (+ 91-11) 3318607
WHO
Scherfigsvej West Pacific
DK-2100 Copenhagen 0 WHO
Denmark P.O.Box 2932
Tel: (+45-39) 171717 1000 Manila
Fax: (+45-39) 171818 Philippines
Tel: (+632) 5288001
Fax: (+632) 5211036

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