Our Water Future: Not just less water, the pipes will fail too

This post originally appeared at Healthy Democracy.

Shifts in spatial patterns of relative human water security threat after accounting for water technology benefits. Source: doi:10.1038/nature09440

The BBC has an interesting report that highlights that it's not just global warming-related changes to rainfall that threaten global water supplies, it the water infrastructure too. The areas of vulnerability for managed water supplies, as distinct from natural vulnerability, are surprising and include large parts of Eastern Europe and North America, as well as Asia.

The BBC report is based on an article in Nature that's worth reading.The article goes further than the report in making the link between underinvestment in water infrastructure and threats to freshwater biodiversity.

Prevailing patterns of threat to human water security and biodiversity.
Source: doi:10.1038/nature09440

As the figure above shows, the regions with the most threatened human water supplies and biodiversity loss are in Asia and Africa, a region that faces numerous water and biodiversity challenges.

The Article

Vorosmarty, C. J., McIntyre, P. B., Gessner, M. O., Dudgeon, D., Prusevich, A., Green, P., et al. (2010). Global threats to human water security and river biodiversity. Nature, 467(7315), 555-561. doi:10.1038/nature09440

Researchers' Pages

Charles Vorosmarty

Peter McIntyre

Mark Gessner

David Dudgeon

Alex Prusevich

Pamela Green

Water and health: where science meets policy conference

This conference will bring together individuals and experts from academia, industry, NGOs, government and foundations to provide an inter-disciplinary perspective spanning science, policy, practice, financing and economics on drinking water sanitation, hygiene and water resources with a strong public health emphasis. The conference will deal with critical concerns relevant to both the developing and developed worlds.

The UN-Water Global Annual Assessment of Sanitation and Drinking-Water (GLAAS) will be presented at the conference. “This will be the first public event at which such discussion is encouraged and organized and provides a means to both present the report to an expert audience and to secure feedback and comment on it.”

Organised by: Water Institute and Institute for the Environment at the University of North Carolina at Chapel Hill

Alongwith having Pete Kolsky, Senior Water and Sanitation Specialist, World Bank (with whom I did my medical school elective looking at surface water drainage in low-income countries when he was at the London School of Hygiene and Tropical Medicine) there is also a Networking Weekend Event on Health Impact Assessment - Principles and Practice.

Click here to go to the conference website.

For those interested in Water Management and HIA check out the book below:

Health Impact Assessment for Sustainable Water Management 

"It is a pioneering international text, exploring and developing this emerging discipline. It is the first to take an international perspective seeking to draw generic lessons from both the developed and developing nations' experience in this new area of activity. The approach is being applied in policy development to strengthen the 'evidence-base' and across a wide spectrum of resource developments, industrial and urban infrastructure projects and in 'aid' projects in developing countries. 

This book illustrates the importance of considering health in water management developments and demonstrates the role of health impact assessment (HIA) in this process. Case-studies illustrate a range of management approaches to different system implementation issues and scale factors, ranging from domestic rainwater harvesting for the supply of non-potable water to a large-scale hydroelectric project. The concept, objectives, terminology and challenges of HIA are introduced and illustrated by case studies including rainwater harvesting, greywater reuse, sustainable drainage and evaluations of the health impacts of flooding.Developing country case studies include a small-scale irrigation project in Zimbabwe, a large hydro-electric scheme in Lao (Peoples Democratic Republic) and the implementation issues surrounding the use of domestic wastewater as a resource in demand by agricultural enterprises in Pakistan. 

The case studies illustrate different HIA approaches, including the use of quantitative and qualitative information and provide benchmarks of current practice for practitioners seeking to apply HIA in the emerging agendas in both developed and developing nations. The critical appraisals within each chapter offer both best practice exemplars as well as explanations of problems and mistakes of past project implementation, and define the requirements for the policy communities who will be increasingly required to accommodate HIA information in resource allocation decisions. As a result, this book will be of interest to planners, developers, policy makers, public health, environmental and water utility scientists and practitioners."

The original SDOH rainbow; policies and strategies to promote social equity in health

To celebrate 5 years of the HIA blog I thought I would share something exclusive that you won't find anywhere on the internet.

How many of you have seen the original social determinants of health (SDOH) diagram?

How many of you have read the original document? Probably one of the two most quoted documents in HIA literature, the other being the Gothenburg HIA Consensus Paper.

This is an amazing historical document that was written on a typewriter! Yes, before the ubiquity of computers in our lives. The SDOH rainbow is similarly hand-drawn and very twee!

I got a photocopy of this a few years back and then misplaced it. I've now scanned my photocopy so that anyone can read it and this is the perfect time to share it.

For the next few days and weeks you can only download it exclusively from here.

Click here to download Policies and Strategies to Promote Social Equity in Health.

Click here to download the jpeg image of the Original SDOH Rainbow.

Things to check out:
The Strategy Matrix on page 53
The Checklists for Action on pages 62-65


Courtesy of: Hannah Zackrisson, Librarian, Institute of Future Studies. Click here to go their website.

Why alcohol is good for you - looking for holistic explanations

A tech blog Gizmodo has a really good discussion of the reasons why alcohol is good for you from a social wellbeing perspective rather than the more usual chemical composition perspective.

Click here to go to the full article.

A recent study has found that moderate and heavy drinkers were both likely to live longer than abstainers. Rather than looking at the chemical composition of various alcoholic drinks the author suggests a less reductionist hypothesis. Its worth quoting the article here:

"...Let's think, for a moment, about the cultural history of drinking. The first reason people consume booze is to relax, taking advantage of its anxiolytic properties. This is the proverbial drink after work – after a eight hours of toil, there's something deeply soothing about a dose of alcohol, which quiets the brain by up-regulating our GABA receptors. (But don't get carried away: While the moderate consumption of alcohol might reduce the stress response, blood alcohol levels above 0.1 percent - most states consider 0.08 the legal limit for driving - trigger a large release of stress hormones. Although you might feel drunkenly relaxed, your body is convinced it's in a state of mortal danger.) And so the stresses of the day seem to fade away – we are given a temporary respite from the recursive complaints of self-consciousness. Since chronic stress is really, really bad for us, finding a substance that can reliably interrupt the stress loop might have medical benefits.


But drinking isn't just about de-stressing. In fact, the cultural traditions surrounding alcohol tend to emphasize a second, and perhaps even more important, function: socializing. For as long people have been fermenting things, they've been transforming the yeasty run-off into excuses for big parties. From Babylonian harvest festivals to the bacchanalias of Ancient Greece, alcohol has always been entangled with our get togethers. This is for obvious reasons: Alcohol is a delightful social lubricant, a liquid drug that is particularly good at erasing our inter-personal anxieties. And this might help explain why, according to the new study, moderate drinkers have more friends and higher quality "friend support" than abstainers. They're also more likely to be married..."


Hence the health benefits of alcohol are as much or more to do with the social relationship building and interactions around alcohol than its chemical properties. As the author states at the end of his article this of course does not mean that alcohol does not have " negative, frequently devastating, consequences" and there are other ways of gaining the health benefits but without drinking alcohol.

Source: Why Alcohol Is Good For You, Jonah Lehrer, Gizmodo 8th Sep 2010

Increased risk of malaria infections living near Koka Dam, Ethiopia

An International Water Management Institute (IWMI) study has found that communities living within 1km of the Koka Dam in Central Ethiopia are 3x more likely to get malaria than those living 1-2km away and 20x more likely than those living over 5km away. The increased risk is due to the reservoir being a standing body of water which is a better breeding ground than the free flowing river.

However, these risks may be mitigated by better management of water releases from the reservoir. The study found that changes in reservoir water levels influenced mosquito larvae prevalence in shoreline puddles.

The study authors concluding remarks are:

"By creating numerous mosquito vector breeding sites close to the reservoir shore, the Koka Dam in Ethiopia has substantially increased the frequency of diagnosed cases of malaria. As a result, communities closest to the reservoir are at increased malaria risk.

Although not conclusive, evidence from this study suggests that increased rates of drawdown could play a role in reducing larval habitat with a consequent impact on malaria transmission in the area.

In light of the likely increase in dam building in sub-Saharan Africa in the near future, methods to control malaria need to be prioritized. In conjunction with historic experiences from elsewhere in the world, results from the current study indicate that manipulation of water levels to control Anopheles larvae has the potential to suppress malaria and could be a useful supplement to control measures targeting adult mosquitoes. More research is required to gain insight into the processes and mechanisms operating and to be able to predict under exactly what conditions such control measures are likely to be both successful and cost-effective."


Source: Circle of Blue Waternews

Download Report: IWMI Research Report 132 Malaria transmission in the vicinity of impounded water: evidence from the Koka Reservoir, Ethiopia

The Texas Sharpshooter Fallacy

There is a lovely exposition of the Texas Sharpshooter Fallacy on the You Are Not So Smart blog.

It starts off by looking at the coincidences between John F Kennedy and Abraham Lincoln and takes in Nostradamus before moving onto the way we can get fooled into thinking vague and general statements about someone's personality capture who we are and finally ending with a discussion about cancer clusters.

http://youarenotsosmart.com/2010/09/11/the-texas-sharpshooter-fallacy/

The post is so good I'll leave you with only there main point and a short quote to entice you to read the whole post at You Are Not So Smart blog itself and check out some of the other intriguing posts there as well.

The Misconception: We take randomness into account when determining cause and effect.

The Truth: We tend to ignore random chance when the results seem meaningful or when you want a random event to have a meaningful cause.

“A community that is afflicted with an unusual number of cancers quite naturally looks for a cause in the environment – in the ground, the water, the air. And the correlations are sometimes found: the cluster may arise after, say, contamination of the water supply by a possible carcinogen. The problem is that when scientists have tried to confirm such causes, they haven’t been able to. Raymond Richard Neutra, California’s chief environmental health investigator and an expert on cancer clusters, points out that among hundreds of exhaustive, published investigations of residential clusters in the United States, not one has convincingly identified an underlying environmental cause. Abroad, in only a handful of cases has a neighborhood cancer cluster been shown to arise from an environmental cause. And only one of these cases ended with the discovery of an unrecognized carcinogen.”

The Cancer Cluster Myth, The New Yorker, Feb. 1999

NB: Though I generally agree with the quote above on cancer clusters (where exposure and onset of the health effect is delayed) it is important to remember as the John Snow cholera oubreak cluster mapping image above shows clusters, particularly for acute health impacts, can be very real. In addition, community concerns about cancers and physical health impacts can be a manisfestation of the worry and anxiety communities have about a technology/industrial, the operator of that technology/ industrial facility and the effectiveness of regulatory bodies. And therefore we have a duty to address those concerns.

Image Source: Wikipedia http://en.wikipedia.org/wiki/File:Snow-cholera-map.jpg

Call for Papers: enhancing positive impacts lessons from SEA, EIA, SIA and HIA

The Impact Assessment and Project Appraisal (IAPA) is developing a special issue on the above topic.

The guest editors are:

• Elsa João, David Livingstone Centre for Sustainability, University of Strathclyde, Scotland
• Frank Vanclay, Department of Cultural Geography, University of Groningen , The Netherlands
• Lea den Broeder, National Institute for Public Health and the Environment, The Netherlands

Papers are sought on enhancement of positive impacts that will be published in 2011. The special issue will bring together for the first time ideas on accentuating the positive from different angles, including SEA, EIA, SIA and HIA.

Enhancement can be associated with a wide range of issues such as biodiversity, social development, ecosystems (as well as soils, water or air), health, green spaces, landscape character, and cultural or historical heritage.

The two key dates are:

• 7 October 2010 - Authors to inform elsa (dot) joao (at) strath.ac.uk of intention to submit paper (specifying author(s), affiliation, email, draft title and one hundred and fifty word summary of the paper).
• 14 January 2011 - Deadline for authors to submit full paper to elsa (dot) joao (at) strath.ac.uk

For full details go to: http://www.strath.ac.uk/civeng/enhancement/

HIA'11 Health Impact Assessment Conference, Granada

First announcement for the 11th International HIA conference being held in Granada, Spain from 14-14 April 2011.


More information on the conference website.

Quantifying the health impacts of policies - principles, methods, and models

Over the last few years, the attempt to quantify health impacts of new policies, plans and programs has gained in importance. Different approaches, models, and tools have been, or are being, developed internationally for this purpose.

A European workshop was held on this issue between 16-17 March this year in Dusseldorf organised by our kind colleagues - Rainer Fehr and Odile Mekel - at the North Rhineland and Westphalia Institute for Health and Work.

This was a really great workshop that brought together leading researchers that are developing health impact quantification methods in Europe (mostly).

The hope is to follow this workshop with one next year and over subsequent years in order to create a wider international forum and network of researchers and practitioners that are actively developing approaches to quantifying health and wellbeing impacts. The aim of this forum and network would be to analyse and synthesise these different methods to - among other things -  a) identify which quantitative methods work best in which contexts and b) how these methods can work with each other.

The workshop programme and the presentations have now been placed online and can be downloaded and viewed at:

http://www.liga.nrw.de/service/downloads/pub-gesundheit/pub-tagng/100316_quanitying_health_impacts/index.html


Programme Outline

Programme of the workshop

Welcome
Eleftheria Lehmann, Director General of LIGA.NRW


Session 1: Principles of quantification of health impacts
Vision and promise of quantification in health-related Impact Assessments
Rainer Fehr (LIGA.NRW, Germany)
Summary Measures of Population Health (SMPH) in health-related Impact Assessments
Annette Prüss-Üstün (WHO Geneva, Switzerland)
Critical comment on the use of Summary Measures of Population Health (SMPH) in health-related Impact Assessments
Michael Schümann (BSG, Germany)
Equity and quantification in health-related Impact Assessments
Fiona Haigh (IMPACT+, United Kingdom)


Session 2: Models / projects
PREVENT
Esther de Vries (Erasmus MC, the Netherlands)
DYNAMO HIA
Wilma Nusselder (Erasmus MC, the Netherlands), Hendriek Boshuizen (RIVM, the Netherlands)
BoD in NRW
Claudia Terschüren (LIGA.NRW, Germany), Claudia Hornberg (University of Bielefeld, Germany)
HEIMTSA / INTARESE Toolbox
Introduction about the projects / integrated environmental HIA
Hilary Cowie (IOM, Scotland)
INTARESE-based Guidebook / Resource Centre
Volker Klotz (University of Stuttgart, Germany)
HEIMTSA-based computational Toolbox
Alberto Gotti (JRC, Italy)
Current area of application: major case study
Volker Klotz (University of Stuttgart, Germany)
Impact Calculation Tool
Anne Knol (RIVM, the Netherlands), Virpi Kollanus (THL, Finland)
Health Forecasting
Jeroen van Meijgaard (UCLA, United States of America)

Assessing Equity in Systematic Reviews: Anything new?

There's a discussion piece in this week's British Medical Journal on Assessing equity in systematic reviews: realising the recommendations of the Commission on Social Determinants of Health. Systematic reviews seek to identify and synthesise all high quality studies on a particular topic. The studies that are included in systematic reviews vary, though often they're limited to randomised controlled trials.

The article sets out seven guidance points for assessing equity in systematic reviews

1. developing a logic model,
2. defining disadvantage and for whom interventions are intended,
3. deciding on appropriate study design(s),
4. identifying outcomes of interest,
5. process evaluation and understanding context,
   
6. analysing and presenting data, and
   
7. judging applicability of result.

This guidance seems sound but my question is does this represent anything new?

I feel like I've heard or read variations of these "should" points for over a decade with very few concrete examples of it being done. It's probably not an accident that few analyses of equity are done within systematic reviews. It adds several levels of nuance and complexity to what is already a time-consuming and demanding task.

We desperately need high quality evidence on differential impacts, that evaluates process and describes context (a need the authors did well to identify) to inform our HIAs. I hope it's forthcoming.

Approaches to urban slums: adaptive and proactive strategies

A really useful and interesting website from The World Bank - presentations, video interviews, aerial imagery and animations.

http://info.worldbank.org/etools/urbanslums

"Approaches to Urban Slums brings together the growing and rich body of knowledge on the vital issue of improving the lives of existing slum dwellers, while simultaneously planning for new urban growth in a way which ensures future urban residents are not forced to live in slums. The sourcebook comprises 14 self-running audiovisual presentations and 18 video interviews. 


It is organized into four broad sections: Adaptive Approaches, Proactive Approaches, Case Profiles, and Thematic Interviews and contains more than 9 viewing hours of content. 


Approaches to Urban Slums builds on an extensive body of knowledge accumulated over 35 years from a wide range of sources. The 14 self-running audiovisual presentations include photographs, illustrations, maps, graphic animations, and aerial imagery, along with voice-over narration. The 18 video interviews provide access to the knowledge and opinions of urban stakeholder and experts on specific issues, and from various development perspectives, including development organizations, governments, nongovernmental organizations (NGOs), community organizations, academia, and professional urban consulting."

Using Twitter for Health Impact Assessment?

I've contributed to a post over on Croakey about using Twitter for public health advocacy. Its emphasis is on the use of Twitter for general health/public health but it made me wonder if Twitter could have some specific applications in relation to HIA?

Twitter might help to make information more accessible to stakeholders, or to elicit additional views as part of consultation. But could it have additional uses?

I'd be interested in hearing your thoughts.

Five Years of the HIA Blog

This month marks five years since Salim and I started the HIA Blog. In that time we've published 219 posts on more HIA-related topics than I could name.

In that time I think we've had a dozen comments! Please consider leaving a comment. We want to know what we're getting right, and what you'd like to see us doing more of.

Thanks for reading.

Agency and Structure in Health Inequalities Research

New Trends in Health Inequalities Research: Now it's personal
Mackenbach in The Lancet

This is an interesting article that highlights recent research on the role that individual as well as structural factors may play in causing health inequalities.

Mackenbach suggests that this may be due to genetics (seems unlikely to me), childhood environments, or a kind of selection that influences social mobility. The latter two factors seem inextricably linked to me, even if one were to believe that upwards social mobility occurs solely due to personal ability and merit. One's childhood environment plays a big role in determining a huge range of personal attributes.

I guess it only took public health forty years to discover agency as well as structure.

Income beyond $75,000 continues to improve life evaluation but not emotional wellbeing

Kahneman and Deaton investigated whether money buys happiness, separately for two aspects of wellbeing - emotional wellbeing and life evaluation.

Emotional wellbeing refers to the emotional quality of an individual’s everyday experience—the frequency and intensity of experiences of joy, stress, sadness, anger, and affection that make one’s life pleasant or unpleasant.

Life evaluation refers to the thoughts that people have about their life when they think about it.

They analysed more than 450,000 responses to the Gallup-Healthways Well-Being Index, a daily survey of 1,000 US residents conducted by the Gallup Organization. They found that emotional well-being (measured by questions about emotional experiences yesterday) and life evaluation (measured by Cantril’s Self-Anchoring Scale) have different correlates. Income and education are more closely related to life evaluation, but health, care giving, loneliness, and smoking are relatively stronger predictors of daily emotions.

When plotted against log income, life evaluation rises steadily. Emotional well-being also rises with log income, but there is no further progress beyond an annual income of  approximately $75,000.

Low income exacerbates the emotional pain associated with such misfortunes as divorce, ill health, and being alone. High income buys life satisfaction but not happiness while low income is associated with both low life evaluation and low emotional well-being.

Click here to go to the full article.

Citation: Kahneman D and Deaton A. 2010. High income improves evaluation of life but not emotional well-being. proceedings of the national Academy of Sciences. Published ahead of print September 7, 2010, doi:10.1073/pnas.1011492107

Social Relationships Are Key to Health, and to Health Policy

“Social relationships, or the relative lack thereof, constitute a major risk factor for health - rivaling the effect of well established health risk factors such as cigarette smoking, blood pressure, blood lipids, obesity and physical activity”

House, Landis, and Umberson; Science 1988 (Quoted in full article below)  [1]

A systematic review, published in PLoS Medicine in July 2010, reviewed 148 studies involving 308,849 participants. The researchers examined studies carried out in both community populations and patient samples, and examined only the “hardest” endpoint—mortality (excluding studies in which only suicide or injury-related mortality was reported).

The researchers report that stronger social relationships were associated with a 50% increased chance of survival over the course of the studies, on average. The effect was similar for both “functional” (e.g., the receipt or perception of receipt of support within a social relationship) and “structural” measures of relationships (e.g., being married, living alone, size of social networks).

The random effects weighted average effect size was OR = 1.50 (95% CI 1.42 to 1.59), indicating a 50% increased likelihood of survival for participants with stronger social relationships. This finding remained consistent across age, sex, initial health status, cause of death, and follow-up period. Significant differences were found across the type of social measurement evaluated (p<0.001); the association was strongest for complex measures of social integration (OR = 1.91; 95% CI 1.63 to 2.23) and lowest for binary indicators of residential status (living alone versus with others) (OR = 1.19; 95% CI 0.99 to 1.44).

The authors state that the degree of mortality risk associated with lack of social relationships is similar to that which exists for more widely publicized risk factors, such as smoking.

Click here to read the editorial.
Citation: The PLoS Medicine Editors (2010) Social Relationships Are Key to Health, and to Health Policy. PLoS Med 7(8): e1000334. doi:10.1371/journal.pmed.1000334

Click here to read the full article. 
Citation: Holt-Lunstad J, Smith TB, Layton JB (2010) Social relationships and mortality risk: A meta-analytic review. PLoS Med 7: e316. doi:10.1371/journal.pmed.1000316.

Microsoft Columbia Data Center Expansion Air Quality Health Impact Assessment

An intriguing news release that invites comments on the decision to permit the expansion of this data centre in Quincy, USA and involves a health assessment.

The key health concern identified is the potential for diesel exhaust particulates generated by the backup generators that are powered by diesel engines. The "third-tier review of the health impact assessment" was undertaken by the Department of Ecology for the State of Washington.

Click here to go to the news release.

Click here to go to the air quality health impact assessment report.