A recent systematic review looking at short term water, sanitation and hygiene (WASH) interventions in emergency response found that ‘[d]espite regular use, emergency WASH strategies have a limited evidence-base’ and as delivering assistance has generally been
prioritised over research, much of the available literature is about ‘best practice’ rather than ‘evidence based’ programming (Yates et al, 2017, p. i). As a result ‘evidence remains low and lacking’ (Yates et al, 2017, p. iii). An analysis of emergency WASH looking for gaps and spaces for innovation found that ‘sanitation issues were identified as the major area with gaps and potential for innovation’ (Bastable & Russell, 2013, p. ii). Both solid waste and faecal sludge management fall under sanitation within WASH. Key gaps are around ‘excreta disposal issues such as latrines in areas where pits cannot be dug, desludging latrines, no-toilet options and the final treatment or disposal of the sewage’ (Bastable & Russell, 2013, p. iii).

Most of the available literature uncovered by this rapid review is grey literature, offering guidance on solid waste and faecal sludge management, rather than peer reviewed papers. It is not always clear what evidence the guidance papers used in this rapid review are based on. However, they have been written and produced by people and organisations who have worked extensively on WASH in emergencies.

A lot of available evidence focuses on water treatment plants, pre-assembled Mobile Water Treatment Equipment (MWTE), or modular water treatment kits (to be assembled in the field) which are used to clean water for drinking in emergency systems, which is not within the scope of this review. The WWTP findings listed are based on peer reviewed journals, global funding agency reports, as well as grey literature. Model information is taken from global manufacturers specialising in WWTP production, however, there is a paucity of information describing models used in specific settlements/refugee camps in low-income/slum areas.

Senior experts consulted for this review confirm that there are very little published evaluations on affordable wastewater treatment plants used in emergency settings. Although there are reports of camp areas specifically for women and children, most wastewater treatment plants are in settlements and sites to be used by both genders, therefore the data included in this review is gender-blind. No specific data searches were made for disabled WWTP users.

Wastewater treatment plants (WWTPs) remove contaminants from wastewater. The treatment to remove these contaminants includes physical, chemical, and biological processes to produce environmentally safe treated wastewater (Grange / HIF – Humanitarian Innovation Fund, 2016:10). Adequate sanitation provision is vital to promote health and prevent the spread of disease from wastewater in long-term temporary settlements such as refugee camps. As sites tend to be overcrowded, facilities can be far from adequate.

Introduction

Pollution currently poses one of the greatest public health and human rights challenges, disproportionately affecting the poor and the vulnerable. Pollution is not just an environmental issue, but affects the health and well-being of entire societies. Despite the huge impacts on human health and the global economy, and the opportunity to apply simple and affordable solutions, pollution has been undercounted and insufficiently addressed in national policies and international development agendas. Prioritising and increasing investment in pollution cleanup and control presents an extraordinary opportunity to save lives and grow economies.

The Lancet Commission Pollution and Health report

The Lancet Commission on Pollution and Health published its landmark report on 20 October 2017. This is the first global analysis of all forms of pollution and its impact on health, economic costs, and the environmental and social injustice of pollution. The aim of the Commission is to reduce air, soil and water pollution by communicating the extraordinary health and economic costs of pollution globally, providing actionable solutions to policymakers and dispelling the myth of pollution’s inevitability.

The Commission on Pollution and Health is an initiative of The Lancet, the Global Alliance on Health and Pollution (GAHP), and the Icahn School of Medicine at Mount Sinai. The Commission comprises many of the world’s most influential leaders, researchers and practitioners in the fields of pollution management, environmental health and sustainable development.

The findings of The Lancet Commission on Pollution and Health will be live streamed from the first two launch events to be held at the Icahn School of Medicine at Mount Sinai, in New York City and at Maastrict University, Brussels. Please refer to the bottom of this webpage for further details.

Pollution and poverty

Pollution is strongly linked to poverty. Nearly 92% of pollution-related deaths occur in low- and middle-income countries. Children face the highest risks and are the most vulnerable victims of pollution because small exposures to chemicals in utero and early childhood can result in lifelong disease, disability, premature death, as well as reduced learning and earning potential. The health impact of pollution is likely to be much larger than can accurately be quantified today because of insufficient data collection and scientific research from many pollutants.

Pollution is costly. Pollution-related illnesses result in direct medical costs, costs to healthcare systems and opportunity costs resulting from lost productivity and economic growth. Welfare losses due to pollution are estimated at $4.6 trillion per year, 6.2% of global economic output. The claim that pollution control stifles economic growth and that poor countries must pollute in order to grow is false.

Pollution control solutions and strategies

Pollution and health: six problems and six solutions

This global problem can be solved. Solutions to controlling pollution are feasible, cost-effective and replicable. Many of the pollution control strategies that have been widely used and have proven cost-effective in middle- and high-income countries are now ready to be exported and adapted for use by cities and countries at every level of income. The most effective strategies control pollution at its source. Their application in carefully planned and well-resourced campaigns can enable developing countries to avoid many of the harmful consequences of pollution and leapfrog over the worst of human and ecological disasters. Planning processes that prioritise interventions against pollution, that link pollution control to protection of public health, and that integrate pollution control into development strategies are critical first steps in fighting pollution. The Lancet Commission on pollution and health make six recommendations to raise global awareness of pollution, end neglect of pollution-related disease, and mobilise the resources and political influence that will be needed to effectively confront pollution.

A further 12 key strategies to reduce air, soil, water and occupational pollution are highlighted in the report.

Pure Earth is an organisation whose mission is to identify and clean up the poorest communities throughout the developing world where high concentrations of toxins have devastating health effects. Pure Earth devises clean-up strategies, empowers local champions and secures support from national and international partnerships.  This clip shows some of the solutions to the pollution crisis in action.

Controlling pollution to achieve the Sustainable Development Goals

Partnership and coordinated efforts to control pollution are key to achieving the Sustainable Development Goals (SDGs) due to the numerous ways that pollution affects communities around the globe. For example, severe pollution causes frequent illness, disability and inability to work (SDG 1: No poverty); the impacts of pollution are sources of instability (SDG 16: Peace, justice and strong institutions); highly toxic wastewater poisons soil and food supplies (SDG 2: Zero hunger) and toxic chemicals contaminate soil, migrate into crops and into our bodies (SDG 15: Life on land). More information on achieving the SDG’s through addressing pollution can be found here.

Research into pollution and pollution control

Research is needed to understand and control pollution and to support change to pollution-related policy. The Lancet Commission on Pollution and Health recommends the following research:

• Explore emerging causal links between pollution, disease, and sub-clinical impairment, for example between ambient air pollution and dysfunction of the central nervous system in children and the elderly
• Quantify the global burden of disease associated with chemical pollutants of known toxicity such as lead, mercury, chromium, arsenic, asbestos, and benzene
• Identify and characterise the adverse health outcomes caused by new and emerging chemical pollutants, such as developmental neurotoxicants, endocrine disruptors, novel insecticides, chemical herbicides, and pharmaceutical wastes
• Identify and map pollution exposures particularly in low- and middle-income countries
• Improve estimates of the economic costs of pollution and pollution-related disease
• Quantify the health and economic benefits of interventions against pollution and the costs of interventions.

Evidence of pollutants causing disease ranges from the well-established, to emerging effects and the unknown, where the effects of pollutants on human health are only beginning to be recognised and are not yet quantified. The Commission proposes a framework for organising scientific knowledge about pollution and its effects on human health, and to help focus pollution-related research through the concept of a pollutome.

Previous Launch Events

New York City

Icahn School of Medicine at Mount Sinai

23 October 10:00-12:00 EST

Live stream available: https://global.gotomeeting.com/join/785131213

Brussels

Maastrict University

26 October 10:00-12:00

Live stream available: https://www.youtube.com/user/maastrichtuniversity

Ottawa

CSIH Canadian Conference on Global Health

31 October 13:00-14:30

Qatar

7 November 09:00-10:00

More details.

Delhi

14 November 09:30-11:30

More details.

Philippines

30 November 08:00-17:00

More details.

Media coverage of The Lancet Commission Pollution and Health report

Global pollution kills 9m a year and threatens ‘survival of human societies’, The Guardian, Oct 19 2017

Pollution linked to one in six deaths, BBC News, Oct 19 2017

Pollution-related deaths exceed 9m per year, Financial Times, Oct 19 2017

Pollution is killing millions of people a year and the world is reaching ‘crisis point’, experts warn, The Independent, Oct 19 2017

Urbanisation
The world is urbanising. Globally, more people live in urban areas than in rural areas. By 2050, it is expected that 66% of the world’s population will be urbanites. Africa and Asia are urbanising the fastest. By 2050 56% will be urban in Africa and 64% in Asia. There are currently 28 mega-cities (i.e. with a population of 10 million or more). By 2030, the world is projected to have 41 mega-cities. However, the fastest growing urban areas are medium-sized cities and those with less than 1 million inhabitants located in Asia and Africa. UN-Habitat estimates the number of people living in slum conditions is now 863 million; growing from 760 million in 2000 and 650 million in 1990. Cities are at the forefront of ‘disease transition’ with malnutrition and obesity occurring simultaneously. Water and sanitation provision is grossly inadequate in urban slums. Tobacco consumption is a major concern among urban poor men, and increasingly women; a risk factor for both NCDs and TB. There are multi-sector influences on urban health.

Coordination
Local governments are key to coordinating inter-sectoral action. Donors are increasingly working with local government to strengthen capacity to plan, manage services, link with sector ministries, enforce public health legislation and establish local level governance structures.

There is a need to coordinate health services between local government and health ministries. The urban public health service is woefully inadequate. There has been underinvestment due to years of the perceived ‘urban advantage’. Responsibilities for staff, their training, equipment/drugs, and facilities often fall between the Ministry of Health (MOH) and the Municipality. The poor are left with little option but to use meagre resources on private facilities resulting in high levels of catastrophic health expenditure. There are poor referral mechanisms due to the plethora of NGO and private providers. There is a need for monitoring and enforcement of quality standards among providers and pharmacies. Secondary care is insufficient with maternity hospitals not open all hours and weak services. Tertiary hospitals are overloaded and not easy to access for the poor.

Public Private Partnerships (PPPs)
There are challenges with different forms of PPPs, private for-profit and not-for profit forms. For-profit PPPs have no incentive to reach out to the urban poor. They are not keen to partner for outreach care which is the key to preventative healthcare and the most crucial for urban deprived communities. Non-profit agencies tend to have few resources. Bangladesh’s Urban Primary Healthcare Programme uses partnerships with NGOs, private clinics and government health centres to expand services to slum and vulnerable communities. There are still challenges with monitoring, quality, and referrals between providers which covered in some detail by in the reading packs.

Health promotion
Helping people remain healthy and not in need of health services is a fundamental goal of any urban health strategy. There is a lack of evidence on which health promotion approaches are likely to be effective in changing ‘lifestyle behaviours’ such as tobacco use, diet, and exercise among the urban poor. Encouraging waist measurement, desired diet, physical activity and mental wellbeing at community level; peer education approaches to nutrition, physical activity, and promoting optimal behaviours in schools have shown some success. Community healthworkers (CHWs) have been effective at changing behaviours in Bangladesh, India, and Ethiopia. CHW and slum women’s groups promoting peer-to-peer health promotion shows promise. Mass media through mobile phones, print, radio and television have wide audience reach in urban centres, but it is hard to compete in the cluttered media environment. Instant messaging for skilled birth attendants is more effective in urban areas. There has been increases in zinc treatment awareness following TV, radio, and newspaper media campaign in urban areas.

Water, sanitation and hygiene (WASH)
WASH needs to be promoted in households and schools to improve, health, nutrition and education. The three interventions of the WASH sector (hand-washing, food storage, garbage disposal) – depend on one another for full realisation of their benefits. For example most sanitation systems cannot function without water. School WASH impacts education outcomes, especially for girls. Menstrual hygiene and girl friendly toilets in schools affect school attendance of girls and reproductive tract infections. Hand-washing with soap and water and other personal hygiene practices have the potential to substantially reduce within household transmission of diarrhoea and improve nutrition. Promoting practices such as hand-washing with soap and water, and safe disposal of child faeces benefit health and nutrition and can be incorporated in a wide range of public health strategies at low cost.

Participatory neighbourhood mapping
Participatory mapping has been used in India to expand the reach of urban services. Slum women’s groups use hand drawn maps to ensure that no family is left out from municipal/NGO lists used for housing, sewage systems, toilets, and entitlements. They are also used to track access to health services eg. immunisation, antenatal care,  and delivery. The maps help identify recent migrants for linkage to services and entitlements. Gentle negotiation is occurring through collective petitions. Inclusive urbanisation requires disadvantaged communities to actively participate in governance.

Healthy places
Pressure from real estate developers, poor governance and corruption undermines local government’s role in controlling urban development to keep healthy places within the city. Access to green spaces reduces mental illness and has been shown to reduce inequities in cardio vascular disease and all-cause mortality in high income countries. Green spaces are rarely considered in controlled and uncontrolled expansion of urban areas. Urban agriculture can make an important contribution to household food security, especially in times of food crisis or food shortages. This needs support and regulation so food is grown in healthy environments.

Health and safe places for children
Urban poor women are more likely to work outside the home than other women in urban or rural settings. Working outside the home provides opportunities to improve income and increase self-esteem and gender equity. However, there is a lack of childcare and supervision for children. This could be solved with early childhood development opportunities. An NGO mobile crèche run day care centres in partnership with government’s National Creche scheme and with support funding agencies in India. Day care centres operate in coordination with builders and contractors near construction sites.

Transport and communications
10 billion trips are made every day in urban centres around the world. An increasing proportion of urban trips are using high carbon and energy-intensive private motorised vehicles. The urban poorest are disproportionately affected by key negative externalities generated by transport, including road accidents, air pollution and displacement when transport developments are occuring. Regulation to improve road safety can make a substantial difference to accidents. For example regulation of ‘matatus’ (mini-buses) in Kenya was introduced where drivers had to increase their driving and safety skills. This legislation resulted in a 73% reduction in accidents. Keeping cities compact, with opportunities for walking, cycling and public transport reduces emissions and support public health.

All of these issues and more are covered in the reading packs which point out key resources.

This document may be accessible through your organisation or institution. If not, you may have to purchase access. Alternatively, the British Library for Development Studies provide a document delivery service.

• The Johns Hopkins and Red Cross Red Crescent public health guide outlines essential tasks for prioritising health services and shows a simple technique for ranking health problems in emergencies.
• The Humanitarian Practice Network (HPN) guide proposes questions for identifying health problems for prioritisation and a framework for answering these.
• The UNICEF Emergency Field Handbook gives a priority action checklist.
• The WHO Health and Nutrition Tracking Service (HNTS) highlights priority indicators for assessing the nutritional and general health situation in complex emergencies.
• Medecins Sans Frontieres list intervention priorities for refugee health for the emergency and post-emergency phase of a situation.

Further resources, section 3, include papers on distributive justice and resource allocation, a paper examining how evidence is used to assess needs in Southern Sudan, an opinion paper and two systematic reviews.

Section 4 describes some priorities outlined for different countries. The case studies in Section 5 offer some experience which may help to prioritise health intervention in future crises.

Data collection and measurement are key to determining priorities in humanitarian crises. Section 6 includes guidelines, comments and advice for data collection and evaluations.

This systematic review examined peer-reviewed and grey literature in order to document global best practices for effective public health emergency response by EOCs; to identify indicators to monitor EOC performance; to describe risk communication in EOC settings; to outline research needs; and to identify standardised terminology.

The review makes recommendations in the following areas:

• Best practices for building new EOCs and improving existing ones
• Components and characteristics of an emergency operations plan
• Risk communication and information sharing
• Needs assessments and baseline data
• Organisational training and exercises

• A synthesis of food assistance programme evaluations finds unacceptably high numbers of refugees were food-insecure, women more so than men.
• A review of nutrition indicators evaluating performance of nutrition programmes in more than 90 camps in 18 countries found supplementary and therapeutic feeding programmes exceeded nearly all standards.
• A feeding programme in Thailand used funds to subcontract the Burmese Border Consortium to organise food and fuel needs for Burmese refugees.
• Evaluation of managing health in a protracted refugee situation in Kakuma, Kenya, shows the advantages of specialisation in delivering healthcare.
• A district in Uganda used a planning mechanism called ‘Quality Design’ to bring user expectations together with technical standards for service integration.
• Long-term support for protracted refugees fits uneasily with conventional donor funding modalities.

Findings on psychosocial impacts of displacement include:

• Experience of conflict and displacement inherently involves exposure to a range of stressors and has the potential to negatively impact the mental health and well-being of everyone affected.
• Although protracted displacement increases the risk of mental health disorders, it is striking that more people do not develop them. Factors preventing adverse mental health outcomes are likely to be individualised and include an individual’s natural response to stress, and social support networks available.
• UNHCR have recommendations and guidelines to operationalise mental health and psychosocial support (MHPSS) interventions in those experiencing protracted displacement.
• Experience of gender based violence (GBV) has been significantly associated with increased risk of poor mental health outcomes.
• Children experience stressors associated with displacement differently to adults.

Claims to have achieved Open Defecation Free (ODF) status have often been exaggerated and estimates of numbers of ODF communities inflated. Verification systems need to be improved. Another problem is that ODF is an absolute condition, important as a community objective but unlikely to be strictly achieved. This does not mean that significant progress has not been made. Most studies identified for this report were observational.

There is debate around the use of the term ‘shame’. An independent CLTS trainer notes that whether good or bad shame is provoked, a good and sensitive facilitator is most important. Experts comment that the shame element is overemphasised and is not the key emotion that CLTS is meant to evoke. It is disgust rather than shame which is the motivator.