Thousands of households in coastal Madagascar rely on locally manufactured pitcher-pump systems to provide water for drinking, cooking, and household use. These pumps typically include components made from lead (Pb). In this study, concentrations of Pb in water were monitored at 18 household pitcher pumps in the city of Tamatave over three sampling campaigns. Concentrations of Pb frequently exceeded the World Health Organization's provisional guideline for drinking water of 10 μg/L. Under first-draw conditions (i.e., after a pump had been inactive for 1 h), 67% of samples analyzed were in excess of 10 μg/L Pb, with a median concentration of 13 μg/L. However, flushing the pump systems before collecting water resulted in a statistically significant (p < 0.0001) decrease in Pb concentrations: 35% of samples collected after flushing exceeded 10 μg/L, with a median concentration of 9 μg/L. Based on measured Pb concentrations, a biokinetic model estimates that anywhere from 15% to 70% of children living in households with pitcher pumps may be at risk for elevated blood lead levels (>5 μg/dL). Measured Pb concentrations in water were not correlated at statistically significant levels with pump-system age, well depth, system manufacturer, or season of sample collection; only the contact time (i.e., flushed or first-draw condition) was observed to correlate significantly with Pb concentrations. In two of the 18 systems, Pb valve weights were replaced with iron, which decreased the observed Pb concentrations in the water by 57-89% in one pump and by 89-96% in the other. Both systems produced samples exclusively below 10 μg/L after substitution. Therefore, relatively straightforward operational changes on the part of the pump-system manufacturers and pump users might reduce Pb exposure, thereby helping to ensure the continued sustainability of pitcher pumps in Madagascar.

Environmental health risks such as household air pollution due to burning solid fuels, inadequate water, sanitation, and hygiene, and chemical pollution disproportionately affect the poorest and most marginalized populations. While billions of dollars and countless hours of research have been applied toward addressing these issues in both development and humanitarian contexts, many interventions fail to achieve or sustain desired outcomes over time. This pattern points to the perpetuation of linear thinking, despite the complex nature of environmental health within these contexts. There is a need and an opportunity to engage in critical reflection of the dominant paradigms in the global environmental health community, including how they affect decision-making and collective learning. These paradigms should be adapted as needed toward the integration of diverse perspectives and the uptake of systems thinking. Participatory modeling, complexity-aware monitoring, and virtual simulation modeling can help achieve this. Additionally, virtual simulation modeling is relatively inexpensive and can provide a low-stakes environment for testing interventions before implementation.

We evaluated the effectiveness of a sand barrier around latrine pits in reducing fecal indicator bacteria (FIB) leaching into shallow groundwater. We constructed 68 new offset single pit pour flush latrines in the Galachipa subdistrict of coastal Bangladesh. We randomly assigned 34 latrines to include a 50 cm thick sand barrier under and around the pit and 34 received no sand barrier. Four monitoring wells were constructed around each pit to collect water samples at baseline and subsequent nine follow-up visits over 24 months. Samples were tested using the IDEXX Colilert method to enumerate E. coli and thermotolerant coliforms most probable number (MPN). We determined the difference in mean log 10 MPN FIB counts/100 mL in monitoring well samples between latrines with and without a sand barrier using multilevel linear models and reported cluster robust standard error. The sand barrier latrine monitoring well samples had 0.38 mean log 10 MPN fewer E. coli (95% CI: 0.16, 0.59; p = 0.001) and 0.38 mean log 10 MPN fewer thermotolerant coliforms (95% CI: 0.14, 0.62; p = 0.002), compared to latrines without sand barriers, a reduction of 27% E. coli and 24% thermotolerant coliforms mean counts. A sand barrier can modestly reduce the risk presented by pit leaching.

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