2006: On September 11, 2001, along with several million other New Yorkers, I found myself on an island under attack. Several months later, I was approached to write a book that would capture a remarkable and untold story. The book, All Available Boats, described the largest maritime rescue since Dunkirk in World War II. It was the safe evacuation of 300,000 New York citizens in 24 hours under the expert guidance of the Coast Guard, arguable America’s most under appreciated armed force. They had sent out the call for “All Available Boats” on September 11, 2001, and coordinated the public/private flotilla’s efforts in New York Harbor.
Nearly two years later, I was invited to visit the Coast Guard Academy and address its leadership on the occasion of the launch of the All Available Boats exhibit in New London, Connecticut. During the discussion I asked the leadership how it was that the Coast Guard was prepared that day to simultaneously perform three very different functions. For, on that day, their leaders had made the call for help, closed the harbor to protect against possible additional attacks, and manned the piers to assure safe loading of passengers off the island.
In response, one of their leaders said that, to understand the success of that day’s response, you must understand three things about the Coast Guard. First, their mission defines them as a “humanitarian force”. Second, they are as prepared for peace as they are for war. And third, they honor judgment at least as much as decisiveness.
To understand these three things is to understand that when they sounded the alert on 9/11, the positive response of the boat captains in the region was assured by a legacy of trust that extended back many years. When they closed the port, all readily complied because there existed well established respect for the Coast Guards’ authority and legitimacy. And when they manned the piers to allow safe and secure evacuation of citizens from around the world, the people complied out of respect for the Coast Guard’s history of knowledge, skill and compassion in just these types of settings.
Some months later I was invited with members of the Coast Guard to recount this story to a group of water experts from the United Nations. In response to my remarks, one of the UN leaders shared the belief that the Coast Guard’s influence and effectiveness was the result, in part, of its good fortune in existing at the intersection of two most powerful metaphors: Water-symbolizing life, health, hope, revitalization, purification and goodness; and vessels-representing safety, security, opportunity, fairness and transport to a better place. She asked, “What do you really know about water?”
Her question was a natural one, considering the planned announcement to come in April of 2005 of the United Nation’s “Water for Life” Decade, a concentrated global focus on water as a health issue from 2005 to 2015. My embarrassed response to her question that day? “Not much”!
In exploring why this was the case, I had to admit to myself that physicians, nurses and other healthcare professionals (excepting the public health force) surprisingly have little connection to the policy side of water, its complexity and vast health implications. Perhaps this is because water has been positioned as an environmental issue and viewed in many quarters as ever present and everlasting. Or perhaps it is our training, often focused on intervention and reactivity, rather than assuring systems and environments that promote overall wellness and the capacity to reach ones full potential. Or perhaps it is the belief that access to water, for its many varied purposes, is the responsibility of government, not the responsibility of the people, or the people who care for the people.
Whatever the reason, in the wake of 9/11 and its water rescue epic; and in the wake of exposure to the Coast Guard’s broad humanistic message, so in touch with our caregiving ethic, and in the face of this UN leader’s very direct challenge “What do you know about water?”, I decided to take action.
The first step was to work with the World Medical Association, the World Ocean Observatory, and the Pfizer Medical Humanities Initiative to convene a unique gathering of water leaders and medical leaders in New York City, November 15 & 16, 2004 . For two days, I witnessed and benefited from the introduction and cross-education between renowned water scientists on the one hand, and highly respected leaders of the worlds national medical, nursing and pharmacy associations on the other; and was introduced to some basic facts about water.
The second step was to channel the energy and excitement flowing from this unique conversation into a more complete and personal exploration. This book, Healthy Waters, is the output of that activity. It represents an attempt to educate myself on this most important and critical health issue, and to share what I have learned with the people and the people who care for the people. It is my hope that in addressing this complex issue together, we will broaden the social context of health, engage health partners in water management and planning, and advance health as the leading edge of human development.
2016: It has been ten years since I launched the Healthy-Waters project. While there has been some progress and growth in awareness, there remains so much to be done. We still have global warming deniers. Fracking has raised a wide array of troubling environmental issues, from earthquakes in Oklahoma to methane leaks in California to water contamination from “sea to shining sea”. And then there is Flint, Michigan.
When I get discouraged, I think back on the original question from UN water expert, Kristen Leitner, in 2005. She asked, “What do you, or any health professionals, really know about water”? I can honestly reply now a decade plus later, “More than I knew before”.
I knew of course that water was essential to all life. But I was not conscious of the level of interconnectedness and interdependence of our water resources. I was surprised to learn that less than 1% of our water stores are both fresh and accessible, and how critical a challenge we face in keeping our surface and ground waters safe and pure. I was embarrassed to learn that a Masai tribesman survives on an average of less than 5 liters of water a day, while a Los Angelean routinely consumes 100 times this amount, and surprised as well to realize that where the water sources are does not necessarily match up with population concentrations.
Before work on this project, I had little understanding of the concept of “virtual water”, nor the relative amounts of water required to produce quantities of vegetables, grains, and meat. That the average global citizen’s daily diet represents the consumption of 3000 liters of water was an eye opener. I knew, of course, that farms consume water, but did not understand that 70% of our supplies are so dedicated, and did not appreciate how successful and critical high tech irrigation has become. With irrigated fields producing 400% greater food yields than rain-fed fields, with high-tech seeds, and advanced agricultural planning, it is no wonder that the worlds’ food supply, except for pockets around the globe, is now relatively secure. And by 2030, 70% of our grain crops are projected to come from irrigated lands; more cause to closely follow land use issues, pesticide runoff, and overall agricultural consumption of water.
The information on aquaculture was fascinating, that today 25% of all the fish we eat is “grown” and that consumption of fish continues to increase rapidly. What is less visible is the potential impact on marine and inland waters from the outputs of “fish farms”, and the large amount of marine fish stores that must be caught to feed the fish we “grow”. Three pounds of fish food to grow one pound of farmed salmon certainly attracted my attention; as did the power of consumers, to drive the agricultural and aquacultural “crop” selections through informed choices of what they eat. When it comes to “growing”, countries like China are clearly on the rise, managing to feed their enormous population and weave together a multi-tasked approach like growing rice and fish in the same fields. But at the same time, water availability clearly does not match up with population growth. So China is already in a water scarcity environment, and over the next 20 years many of us will join their citizens with a projected 3.4 billion or 43% of our global population projected to be water scarce by 2025.
I am much more aware today of the health linkages between water, sanitation and hygiene. It’s amazing that 1/6th of us lack improved water and 2/5th of us lack improved sanitation. And it is understandable that if it’s a choice between good water and good sanitation, water wins out, at least in the short term. Clearly our future potential is tied to geography and to gender. If was fascinating to learn that we are just beginning to listen more carefully to women’s advice on water policy. The burden that they have carried in the water arena has been heavy indeed. Not surprisingly, when it comes to water, women get it. They understand that without sanitary systems, the water they do have is comprised. They understand that water proximity impacts their productivity. They understand that sanitation facilities at schools that do not secure privacy, especially for girls, ensure lost primary education and lost opportunity. They understand that schools provide a dual service in educating and promoting health. And they understand that poor water and disease have made an unholy alliance through history, taking target at women and the young and the vulnerable. To accept that 25% of all deaths worldwide and 50% of all hospitalized patients are the result of water borne diseases is a painful admission.
Through this work, I have gained a better understanding of where we are going as a global family. Clearly we are heading to the cities, and our fate remains to be determined. What we do know is that by 2025, 60% of us will live in cities. Many of these cities still exist on coastal waterways, and along major river catch basins. The number and size of these cities are growing. With proper investment, rural people flooding in may benefit from more secure water and sanitation. But without sustained investment and wise policy, they may encounter squalor and disease; centers of death and despair rather than hope and progress.
As we centralize, urbanize and industrialize, I now can see that energy will be a critical lever. And it seems that hydroenergy, well planned, executed and maintained could help break the cycle of carbonization of our atmosphere, and give us some breathing room from global warming. But this would require a much more aggressive cross sector commitment to clean, non-fossil fuels. I was impressed that 20% of the worlds energy now comes from hydropower and that by 2010 the contribution is expected to reach 32% of all energy production.
I now have a different vision of our planet and our “planetary patient”. Earth, covered in vast oceans of water, is actually a quiet fragile planet, requiring care and wise policy. The watershed catch-basins that cover 45% of our land and sustain 60% of our global population are surprisingly complex and vulnerable. I suspected that these waterways in developing nations would be at risk, but was surprised to learn that 70% of industrial waste and 90% of raw sewage is discharged untreated into local surface waterways. And in developed nations, zoning and planning vagaries that allow sanitary systems and ground water to cross paths; lack of attention to runoff, deforestation, and hog plant manure gone wild; and lackadaisical attention to water quality monitoring, safe food preparation and even proper hand washing in hospitals; all suggest that when it comes to water and health, we all have plenty of room for improvement.
I have a clearer picture in my mind of surface water and ground water. Most impressive are the many river catch-basins that 145 nations now share, and that the fate of those downstream is largely determined by the behavior of those upstream. Equally intriguing are the vast stores of ground water which will likely be more accurately imaged, managed and efficiently accessed in the future thanks to advanced technology. Once again, these aquifers are shared, sometimes unknowingly, across geographic borders and from the surface appear safe from spoilage or rapid evaporation. But once foiled by pollutants, as I have learned, they may be out of commission for a lifetime, since clean-up can be impossible. And I was surprised to learn that some aquifers in fossil rock are never rechargeable. I didn’t know that.
The Tsunami of 2004 had already alerted me to the magnitude and power of water disasters. But I was surprised to learn that a half a million people had died from water related disasters in the last decade of the 20th century. This work helped me better understand how man-made and natural disasters are tied to water, climate, pollution, and poor preparedness. I also have learned that people will respond to need, especially if the need is caused by an act of nature, is publicized, and is urgent and unexpected. But we are less likely to be there if the disaster is the result of human ignorance or malice. It was reassuring to see that throughout history water has generally brought people and nations together. We have made treaties and made peace most of the time. Humans seem better able to cooperate around water than most anything else, suggesting that our world, so in need of common vision and purpose, so fearful and in turmoil, might ride the wave of healthy waters to a better and more secure place.
Finally, I have learned what IWRM means. When I first read the term, Integrated Water Resource Management, my mind wanted to dissect it. Integrated, I learned, has multiple meanings. Water is remarkably connected to everything else – to our environment and ecology, to agriculture and famine, to industry and urbanization, to energy production of all sorts, to weather and weather events, and to the health and advancement of all life, including ourselves. Integrated also reflects a system of competing demands and needs that must be harmonized and prioritized if our fixed supply of water is to be able to keep pace with the growing demands of an expanding human population. After all, in the past 100 years our population has tripled, and our water consumption has increased six-fold.
IWRM also positions water as the resource it truly is; valuable, critical, essential to life. If we fail to assign this resource a value, we encourage waste and destruction of this scarce asset. On the other hand, if it is viewed simply as a commodity, we risk further victimizing our most vulnerable brothers and sisters. I have learned that investment in water as a resource has a 34 fold return on investment. But I now understand that the accessible delivery of clean, pure water, and the safe discharge of waste require investment of time, energy, and money, in a sustained manner. So the challenge is to bridge the gap between a foolish level of waste and incompetence on the one hand, and an unenlightened and inequitable commodity driven system on the other.
To address this challenge IWRM preaches Management, not just the ordinary type, but a form of management that challenges governments, industry, academics, and non-governmental organizations to lend their best talent on behalf of water. In short, we must work together. Beyond a common understanding of the strengths and capabilities of each sector, and the desire for collaboration reflected in a willingness to mutually plan, to align goals and objectives, and to share risk, there remains the issue of readiness for IWRM. What are the factors that must be in place to ensure success?
First, if it is true that all politics are local, so too are all successful cross-sector partnerships in so far as they acknowledge in their planning, design and management the realities of time, place, people, culture and institutions in the target geography.
Second, in any cross-sector initiative in health, there should be some level of representation from each of the four sectors. Water is certainly a well-defined common need and public purpose that unites us.
Third, the proposed project or solution must be right sized to the problem or challenge at hand. Too small and the effort will lack resources to ensure measurability and sustainability. Too large and the effort will create structure without solution.
Fourth, human conditions must be right. This includes identifiable optimistic leaders with the time and willingness to commit and a reservoir of good will among the players to support both innovation and implementation of the common vision, the structural integration, the joint governance, and ongoing civic engagement.
Fifth, there needs to be accurate information and baseline data that clearly define the challenges and serve as a grounding for future reasonable outcomes. It is not enough to marshal human resources. There must be an established organizational capacity, processes, and oversight to ensure that the human effort translates into a highly coordinate and effective service result. All of which is to say, that success in IWRM involves harmonization of diverse needs and interests.
What I have learned is the IWRM has social, political and economic dimensions that directly impact human health, poverty levels, and gender equality. IWRM requires reliable data and careful valuation of water as a resource. Identifying the true cost of safe water and sanitation is essential for financing and creating sustainable and reliable infrastructure.
I have learned a lot, certainly more than I knew before. But I continue to be somewhat plagued by my initial admission to the question “How much do you really know about water?” After 30 years in Health Care, shouldn’t I have known more? Perhaps. But for physicians, nurses and other health professionals in developed nations (excluding those directly involved in public health careers) water has been largely an environmental rather that a health issue, and someone else’s responsibility.
Yet today, health for an individual is about having the opportunity to reach one’s full human potential, and for a nation, it is the leading edge of development. Health is about wellness and prevention, growth and stability, peace and security. It is about individuals, families, communities and societies looking after each other, caring for and about each other, and securing each other’s future. What I have learned in this process is that we, as caregivers, need to ride water’s wave, because its destination is health, and patients worldwide have the right to expect our active involvement and participation in this critical health issue.
Here are 25 facts you should know about water. Your voice is critical. Please raise it in defense of our human race and our fragile planet.
Mike Magee MD
When you drink the water, remember the spring.