How did I arrive here today? It began in the days following 9/11. My family and I were direct witnesses to that event, and as a physician and public health professional on the ground, and as a medical journalist, I was directly involved in the immediate response. My direct contribution was the book you see before you – All Available Boats – which I was commissioned to write as part of a lasting exhibit to those events. The book told the story of the largest maritime evacuation since Dunkirk – 300,000 citizens safely evacuated from Manhattan Island, by a flotilla of boats commissioned by the Coast Guard on the spot that day, with a simple call for assistance to “All Available Boats’. The story is told through the voices of 10 boat captains and 10 passengers, and gives us a view of both the worst and the best of our human natures, as well as the remarkable leadership performation of our Coast Guard.

With the publication of that book, and an exhibit of the same name, I found myself some months later at the exhibits opening at the United Nations. After my speech, The UN’s expert on water who is now at the WHO, Kirsten Leitner, came up to me that day and said “What do you or any doctors really know about water?” My response, “Not much”. To which she replied, “Well, you ought to change that.” Two days later, there appeared in my office 7 boxes of UN materials which together piled 6 feet high. Two months later, I had condensed these down into a 125 page book and today I would like to share with you what I learned along the way

Those first days that I wandered thru the mounds of UN materials, I couldn’t help but wonder how it was that this beautiful planet, viewed here from space, so bountiful and blessed with water, could today be water scarce. I learned that this planet of ours is  4.3 billion years ago, with the first marine fossils appearing 1/2 a billion years later. This was a hostile planet bathed in a chemical soup of nitrogen and carbon dioxide. Add to this hydrogen and you have the four most important atoms of living organisms – nitogen, hydrogen, oxygen and carbon. Sprinkle in four others – sulphur, phosphorous, iron and calcium – and you have all you need to create 3 dozen or so amino acids, the building blocks for protein and DNA.

But I’m getting ahead of the story. In the  2 billion years between the appearance of the first priitive organisms and a new order that appeared some 1.8 billion years ago, , the, microscopic blue-green algae busied themselves with what science historians have labelled “Undoubtedly the most important and innovative metabolic reaction in the hx of the planet.” What these organisms did was to split oxygen from from H2O and in the process created largely the oxygenated atmosphere we still enjoy today.

And what a beautiful and mystical planet it. Yet the challenge that the UN placed before me was to see beyond the ideallic image, to go below the surface, face the force of the current, and understand in a sophisticated and integrated way that water is the critical health issue of our day. The cycles, their  integrated nature, and the predictable path we are on to unsustainablity.

Travel with me where I began, in those last days of 2001, to water’s chemistry. 2 small atoms tightly and stably bound to 1 large atom. But while an individual molecule is an intimate and private affair, it’s relationship with other water molecules is far more casual. In fact, were we to freeze frame a collection of these molecules we would find only 15% in contact with each other at any moment. They bind  and unbind billions of times a second. This reality helps define waters magic – solid enough for water bug to walk, for a stone to skip, but fluid enough to part for human dive.

The H2O molecule is the only one that exists in all three states–solid, liquid and gas–at the same time on our planet. 1/1000 of 1% exists as vapor in our atmosphere at any one time.  Evaporation occurs  mainly from our ocean surfaces with water molecules dropping back to earth on average in 12 hrs.  If to the ocean, the molecule may not reappear for another 100 yrs.; if to a lake perhaps 10 years ; if to non-fertile soil, they may move down thru stone to a storage point underground and be gone for a long long time: but if to fertile soil, absorbed by plants roots, it may reappear in the atmosphere in just a few hours.

Water covers 68% of our planet’s surface, most of it confined to our oceans and 5 rivers that carry 1/3 of all run off including 50 billion tons of sediment a year. Our oceans on average are  2.4 miles deep, and 7 miles at their deepest point. Thes waters possess only 2 teaspoons of  table salt per liter. But there are many other salts, in fact enough ocean salts to bury our entire earth 500 feet deep.  This salty water is toxic if we drink it, and yet very similar in composition to our own  sweat and tears. As for our land masses, 45% are in direct contact with coastal plains, and these areas support 60% of our current human population.

While we can not live off of ocean water, other life forms certainly can.   30 million species reside there and and create 50 billion tons of new life each year.
In addition the ocean waters are a great buffer and solvent. A 20 degree temperature change above the surface translates only to a 1 degree shift below the surface. And these waters are a remarkable carbon sink, of critical importance today.

So we are blessed with water, but the amount of fresh water we have available to us is a small percentage of the total. 97% of it is contained in our oceans.
Only 3% is fresh, and less than 1% is accessible as surface or ground water. As for us, we are 65% water. A loss of 1% results in thirst. 5% in a mild fever. Losing 10% leaves us immobilized. Lose 12% and you’re dead.  Ours is a delicate balance. And I must tell you, our draw to water is profound.

When I first viewed this photo of a  boy in a polluted reservoir in China, others with me were aghast. But I must admit to you, that having grown up on a small island, my draw to the water was so powerful that I too would swim through garbage to get to it. So it is critical that we understand not only our scientific need for this substance, but also our deep social and spirtual relationship with it as well.

Knowing and loving water as I do, I wa surprised how little I knew. For example, the fact that agriculture dominates its use – 70% worldwide. I had no idea. I was also unaware that these percentages vary widely from developed to developing economies where agriculture trumps daily personal need.

I was also surprsed to learn that water is food, and food is water. Indeed, food could be described as virtual water.And what we chose to eat affects how much water we consume.  For instance, 1 unit of water produces 1.5 units of cereal; but it takes 6 units of water to produce a unit of chicken, and 15 units to produce a unit of beef. Our dietary choices are in fact our water choices as well.  Consider this fact: Americans  require three liters of water a day to survive; yet  3000 liters a day are required to produce the average daily American diet. It made me wonder about our choices; their ties to heart disease,  diabetes, and  childhood obesity; and the food industries interest in marketing this diet  in the developing world.

Yet as I reviewed the piles of materials, I was justifiably proud of the progress that we have made using modern food technology. It iwas surprised to learn that, absent these advances,  we could feed only 600 million of the worlds 6 billion citizens today. Still its worth questioning our choices and appreciating other approaches and solutions . We don’t have a lock on ingenuity. For example here’s a Central  Indian farmer’s take on irrigation –  filling disposed Intravenous fluid bags with scarce water, to irrigate his plants.

The link between irrigation and poverty cannot be overstated. India I learned is a case in point: in irrigated areas, less than 30% of the population live in poverty;  but here in non-irrigated areas, 70% of these children grow up in poverty. Water scarity, poverty, and famine go hand in hand.  Even with modern agriculture, 711 million of our 6 billion global citizens are undernourished, 75% of which live in just ten nations, and 50% in just two nations.

In the developing world, as elsewhere, populations settle around water.Why? To transport people, product – and waste. 70% of the industrial waste and 90% of the human waste in the developing world is discharged directly into surface waterways.

It was a eye opener to me, but people do what they have to do. And they will
bath, and cleans themselves and their possessions in the shadow of sewage pipes. Here is the River Ganges in Varanasi, India – India’s most sacred and  most polluted river. Here each day  60,000 people bathe in the polluted waters, as part of a spiritual ritual. Such is the confounding mystery of humans relation to water – they are able to simultaneously revere it while at the same time fundamentally disrespecting its goodness.  This is not to judge. They are placed in an untenable situation because their society has failed to provide and sustain reliable infrastructure for water and sanitation. But the  net result  is that they contract and spread disease at alarming rates.

We should not be surprised if this Iraqi boy, near the Tuweith nuclear plant, regardless of the risk, has found his way to water; nor that his next stop is likely here. In impoverished and war torn areas, especially those with a lack of water resources, water scarcity leads to famine, malnutrition and dehydration; it also leads to malaria,TB, cholera and other diseases. And it complicates the HIV/AIDS situation.

Still I must tell you that when I learned that half of developing world hospital beds are occupied by victims of water-bourne disease, I was shocked. The link between water and health is staggering.  20% of deaths worldwide in children under 5 years old result from water-borne disease.

When you look at this image, imagine a water scarce African village of 1000. On average, each Africian woman will spend 3 hours of every day finding, hauling and distribing water to the fields and home. Of the 1000 villagers,  600 at any one time will have no access to a latrine; on any given day, 20 will suffer from diarrhea with 15 of those under the age of five.

Where water is scarce, those who can adapt. For example the average Masai warrior is able to survive on 4.2 liters of water a day to cover all needs. This is inspite of the fact that the UN and the WHO declare that  20 liters is marginal to family health, and 50 liters are required to properly manage the health and hygiene of a family. But in the developed world, we use 100-200 liters per person per day of water, subsidized and casually managed, and often treated as an unlimited resource. It was disturbing to learn that the average LA resident consumes a staggering 500 liters of water per day, enough to support 11 Masai warriors.

Survival in their world falls literally on the backs of women who haul the water and manage its use for cooking, cleaning ,  caring for children and elderly, and  manage crops and livestock to boot.  The hours they spend  impact other opportunities like education and enterprise. And for their daughters, like these 2  from Nairobi, the future is the same. They are stuck in a water trap.

Women become even more important to this conversation when you consider that they are the primary caregivers and the first line of defense against disease. And disease prevention and good hygiene start in school. But the lack of private latrines at schools is enough to keep many girls away once they hit puberty.

It’s not surprising that both private bathrooms and improved access to water have been shown to increase primary school attendance.

Absent these advantages, I marvelled at how hard they try to bridge the gap on their own. The deck is heavily stacked against them.  Here is our planet at night. And here is what that looks like in Zimbabwe on the ground. This is night, a battle for education and self advancement. Who will win out?

Little progress is made absent power.Think about what happens at night without access to power: nothing. No studying, no small-scale productivity, no opportunity for people to improve their positions in the dark half of the day.   Worldwide, 2 billion people have no domestic electricity. 1 billion more use batteries or candles. Combined, that’s half the world’s population. And this leads to burning of other fuels, which pose environmental and health risks .

I was surprised to learn how ofetn water and energy cross paths .  Hydropower is remarkably prevalent, producing the majority of power in 66 countries. Hydro currently powers about 20% of our global energy needs. It is projected to increase 77% between 1995 and 2010, with major projects in China, Latin America and Russia leading the way.
Some projects are giant like this one in Yunnan province, China. Others much smaller like this  water wheel driven by a stream, operating a pump to irrigate a garden in the interior of Brazil . I learned with water, there is almost always a trade off. Here an energy source that is comparatively clean,  local, and accessible;  but also one that can displace populations and species, and can contribute to  water disasters as here at the Dawal Dam in Pakistan.

If we are uncomfortable with the choices above ground, we can always go down below, to ground water. And increasingly people are doing just that. Groundwater today accounts for 30% of the global fresh water supply and provides 50% of drinkable, 40% of industrial, 20% of agricultural supply. And while it is relatively safe and secure compared to surface water,  pollution of groundwater supplies is increasing, and difficult to reverse.

Three cheers here for the people of San Antonio who live above the Edwards Aquifer in Texas, a remarkable 100 year ground water supply, if protected for the local population. The problem? It is covered with porous limestone, and could be easily foiled by standard development water run-off and seepage. The local response? Use local tax dollars to purchase land over the Aquifer to assure it would be protected and preserved.

Sadly I learned that this positive outcome is by no means typical. In most cases, when man and water collide, it is the water that suffers.  Whether aw sewage and deoxygenated water responsible for  fish kill in Rio de Janeiro; agricultural runoff  associated with Red Tide.; bleached coral reefs in Belize as temperatures change, or this unusual contraption downriver in Brazil, a defoamer to dampen the floating clouds created by direct discharge from chemical detergents and organic pollutants far upstram.

I did take time to understand the link between carbonization, global warming and our waters. But we do not have time for that story today. We will just say that the numbers are the numbers and move on to a byproduct – water disasters with their floods, drought and remarkable distruction of human property and human life.

What surprised the most about these disasters was how democratic they were. Every continent suffered.  665,000 deaths in water disasters between 1991 and 2000. And for so long we felt immune. An image like this drew dispassionate sympathy for this less fortunate in places far away.  But as they camera rolled, the images drew closer, and became more familar, until we found ourselves face to face with a new reality. And it is this. That when confronted by an ever hostile environment, with aging or absent infrastucture, weak communications and warning sytems, and an inability to move large populations through tiny bottlenecks to safe ground, disasters happen. And it matters little whether it is a hurricane in New Orleans or a tsunami in Indonesia. Bad policy is simply bad policy.

Let us turn then to human populations that place themselves at risk. The world’s population today is 6.3 billion people. 57% rural and 43% urban, with our cities concentrated in coastal plains. By 2030, there will be about 8 billion of us but now 63% will be in cities, and only 37% will be rural. Under ideal circumstances, this urban migration could serve our human population – with jobs, clean air and water, transportation, housing and education, safety and security. Without investment however, this could be a death trap.

Here are all the cities with populations that exceed 1 million, 389 of them  beginning with Hong Kong 25 million. Most are in coastal regions. Many lack adequate infrastructure to support their needy populations which grow each and every day. Here is what that looks like. 1.1 million currently lack access to clean, safe water. Here is what that looks like. 25,000 die every day, mostly children for lack of water and food. Here is what that looks like. 6000 die each day from water born disease. Here is how they become infected.

So here is what I have learned, and what I have been sharing with doctors and nurses and hospitals who will listen. Here is where we are heading. Global Population: up 280 % between 1900 and 2020.  Water Consumption: up 840 % between 1900 and 2020. Urban Population: up 2180% between 1900 and 2020. Number of citizens in water scarce areas: up 500 % between 2000 and 2025. This is the truth.

To solve this crisis, we need cooperation, integration, and innovation.145 nations share 268 trans-boundary water basins. You might suspect this has lead to countless disputes, but water is more often a platform for peace than war. While there have been significant numbers of disputes, 1831 in the past 40 years, only 2% have been associated with violence. Most are resolved peacefully. For example, Israel and its Arab neighbors have stable water treaties and during the Vietnam War, the regional Mekong Water Committee, established in 1957, functioned peacefully throughout the entire Vietnam War. The Danube alone passes through 18 nations, and there has seldom been a dispute involving violence. The same goes for the Nile, which crosses 9 borders. Our own Mississippi crosses 38 state boundaries.

A  second positive is the increasing willingness to invlve women in integrated resource water management. Those who use it, who sacrifice for it, know it best.

Third, we have seen a convergence of venture philanthropy and social entrepreneurs with an eye toward innovation and sustainability. Here is just one example: a play well and water pump at once, with water tower doing double duty as well as it advertises clean hands and hygiene. We see shifts toward local foods, as in this hydroponic farm on a former Super Fund sight outside of Philadelphia.  And as we begin to struggle with the difficult issues of water pricing and water sharing, we’ve begun to consider personal responsibility, and how many of you will help us better manage grey water and green water.

Where will the money come from? Measured in dollars, the investment is reasonable. A seven fold return on investment. By the way, 11 billion is about what Americans spend each year on bottled water. But a important are the human returns on investment in school and work days.

So perhaps if you the next time you met Dr. Leitner in Geneva or elsewhere, you will tell her I am trying. I have learned a lot. That water flows. That water is integrated with the land, and the air, and the oceans, and with our hopes and dreams. Tell her that I understand now that the obstacles are real, but that they are by no means unsurmountable were we to combine the enormous knowledge, skill and committment of all of you with the people and the people caring for the people.

Finally, tell her that, in this journey, which she began with the question, “What do you or any doctors really know about water?”, I discovered that we Americans have a unique resource from which we can draw encouragement and guidance. It is our native origins, a spirit that values resources, and is well described in this Chinook Indian blessing.