University of Pittsburgh

Vital Vessels

In remote villages in Honduras, simple ceramic pots are bringing better health to families and showing what's possible when Pitt people tackle global health problems.

Written by Cara J. Hayden

hondurasOn a day that falls between the beginning of the annual coffee harvest and the end of the rainy season, a group of Pitt medical students climbs into the bed of a pickup truck in Honduras.

From a health clinic in the village of San José del Negrito, they ride into the mountains, where coffee orchards are freckled with the mud-brick homes of families who tend to the coffee trees.

When mud on the road gets as mushy as brown bananas, the medical students abandon the truck and continue uphill on foot. After an hour, they reach an adobe house. A mother invites them inside. Student Amy Soni converses with her, using the Spanish words she can remember from high school and college classes. They talk about agua—water.

Every morning, women in this region emerge from their earthen homes and carry vessels to nearby springs or spigots. They fill them with water, repeating the same chore that their ancestors carried out in centuries past. But in the 21st century, many of them have added a new step to their daily routine. When they return to their kitchens, they don’t let the water sit in their vessels. Instead, they pour the water into ceramic bowls suspended over plastic buckets. The water seeps through tiny holes in the bowls and trickles into the buckets, rendering it clean for drinking or cooking. Many of the women learned about this filtering technique from a PowerPoint presentation shown on a computer at the health clinic in the village.

At the adobe house, the mother shows the medical students her filter and bucket, which cost $15, a significant investment for her family. Coffee farmers in this region earn only about $250 per year. Soni asks her questions from a scientific survey she prepared.

“¿Con qué frecuencia limpia usted el filtro?” How often do you clean the filter?

“¿En general, ha mejorado la salud de la familia despues de usar el filtro?” In general, has the health of the family improved since using the filter?

While Soni and the woman talk, the other students draw water from the filter with a syringe. Then they head outside and clamber down a ravine to find the well from which the woman draws her water each day. They fill up another syringe with water that’s swirling with bits of sediment and plant life. This is the kind of impure water that millions of people around the world drink every day.

Meanwhile, the mother tells Soni that she cleans her filter regularly. She says her family has been healthier since she began using it, but they’re still dealing with parásitos and diarrhea. Soni takes notes. Then she wishes the woman well, and the students hike to the next home to continue their study.

When she returns to the clinic, Soni sets up an experiment with the collected water samples. She adds a special liquid that detects E. coli and other bacteria and viruses. A few days later, some of the samples turn pink and purple, indicating that germs are present. The verdict is surprising: Water from the women who had been the most diligent at cleaning their filters was the pinkest and dirtiest. Soni wonders: Why?

water-filtrationDuring this same week, which falls between the beginning of autumn and the end of daylight savings time, engineering student Curtis Larimer is in the middle of a different kind of study on the water filters used by the women of San José del Negrito. He’s 2,000 miles north on Pitt’s campus, operating a digital optical microscope in a windowless laboratory in Benedum Hall. He places a piece of a water filter underneath the microscope’s eye and then zooms in on the surface. The filter suddenly looks like a rugged mountain range as seen from an airplane. Larimer, a PhD student, snaps photos with the microscope. Eventually, he will use these data to create topological maps of the water filters. The maps may contain some answers as to why Soni got surprising results from the samples she and her colleagues collected in their travels to remote Honduran households.

In recent years, students and faculty from across the University of Pittsburgh have been working toward a common goal—to help poor people clean their water. In many nations, water is a hazard. Even if it comes out of a pipe and looks clear and clean, it can contain invisible bacteria and viruses. For adults, a glass of water is a diarrhea cocktail. For children, it can be a fatal beverage. More than one million children die each year because of diseases they contracted from drinking contaminated water, according to the World Health Organization. Children are also more susceptible to diarrhea, the most common side effect of consuming contaminated water. Repeated bouts of the illness can lead to malnutrition and even stunted brain growth.

There are plenty of ways to clean water. You can add chlorine (but not too much), or boil it (without wasting precious heat resources), or pour it through a filter (if you can afford it). You can store it in a copper vessel, like people in India have done for centuries, and trust that the copper will destroy the invisible bacteria. But it might take a whole day for the copper to work its magic. And be wary of putting excessive amounts of copper in your water. It could give you, literally, blue diarrhea.

For every successful water-cleaning method, there’s a caveat of some kind. Too many chemicals, too much money, or too many miles between your house and the nearest store are all factors in the precarious balance between clean water and dirty water. For millions of people living in poor rural areas, like those of northern Honduras, there aren’t any easy solutions.

Pitt doctors, nurses, students, and other volunteers began providing medical care in San José del Negrito back in 2000. Three doctors—N. Randall Kolb (MED ’82), William Markle, and Mark Meyer—set up a permanent clinic there after their interests converged. Kolb, a Pitt alumnus and faculty member in Pitt’s Department of Family Medicine, had treated people in Honduras two years before, just after Hurricane Mitch devastated the country. He was eager to return and continue helping the sick. Markle, an assistant professor and a global internship coordinator in Pitt’s School of Medicine at the time, was serving on the national board of the Global Health Education Consortium. He knew colleagues in the consortium who were looking for help with another clinic they were already running in Honduras. Meyer, a Pittsburgh physician, was eager to work at a permanent clinic abroad, in a village where he could build and maintain relationships with patients over time.

Together, the doctors founded a nonprofit organization named Shoulder to Shoulder Pittsburgh-San José, a branch of the Shoulder to Shoulder organization that Markle’s colleagues had already founded in Honduras. His colleagues had helped them to identify San José del Negrito as a remote village that would benefit from access to medical care. The doctors set up a schedule. Every six months, they’d lead a brigade of fellow doctors, nurses, medical students, and volunteers—many of them with Pitt connections—to the village. They’d also work with a health committee of local residents who could make decisions about what medical and public health projects would be the most practical and important to them.

When the Shoulder to Shoulder brigades began in San José del Negrito, people lined up at the clinic by the hundreds. Most of them, especially children, were malnourished. The doctors’ first line of business was to work with the health committee to set up school-based feeding programs and milk distribution programs. Then they began to think of other ways to combat the problem of malnourishment.

Many of the patients who came to the clinic also had frequent cases of diarrhea, which excretes important nutrients from the body. The rate of diarrhea indicated to the doctors that the local water supply was probably not clean. Figuring out how to get clean water to the 1,600 residents in the village, plus the 4,000 coffee farmers living in the surrounding mountains, would be a challenge for a number of reasons.

To the people of San José, a case of diarrhea indicated that it was just another normal day. After all, it was common for kids to have four to six bouts a year. Most of the residents didn’t think diarrhea had anything to do with their water. When one Shoulder to Shoulder brigade conducted a survey asking people what likely caused the diarrhea, most said it was mal de ojo, a mythic evil eye that influences life and death.

Some residents had been cleaning their water by adding chlorine, but most hadn’t, either because they didn’t like the taste, they couldn’t afford it, or they didn’t think it needed to be cleaned. For a while, Kolb, Markle, and Meyer weren’t sure what to do.

Then an unexpected solution appeared in the form of an art professor. Markle was browsing a newspaper in his doctor’s office when he read about a man named Richard Wukich who had been traveling all over the world on a quest to train pottery artists to create cheap but effective water filters and sell them in their communities. Wukich is an art professor at Slippery Rock University north of Pittsburgh.

Markle invited Wukich to the next Shoulder to Shoulder board meeting, where he showed up wearing overalls. Wukich explained the steps to making the filters: First you knead clay and sawdust or straw together, materials that are available almost anywhere. Then you shape the “dough” into a bowl form. You fire it in a kiln, where the sawdust burns up, leaving a tiny capillary system in the bowl. This allows water to seep through but traps large bacteria and other microbes. Finally, you paint the bowl with a liquid containing water and silver. The silver kills other germs in the water that would make a human sick. You only need a pinch of silver per bowl, which keeps the cost of the filters low.

“They seemed too fruity and cheap to be real,” Meyer recalls thinking at the meeting. Yet, studies at the Massachusetts Institute of Technology and other universities had shown that these water filters were 99 percent effective in removing germs. The filters, known as ceramic water filters, were designed in 1981 by a chemist in Guatemala and have since been cited by the United Nations as an appropriate technology for cleaning water in developing countries. They’re used in Latin America, Asia, and Africa.

Then the next Shoulder to Shoulder brigade went to Honduras in April 2006, Wukich arranged for a ceramic water filter expert from Nicaragua to visit the clinic and give a presentation. He also invited a potter from the region of Tegucigalpa, the capital of Honduras, to come. Nearly 100 women walked to the clinic to see the presentation. The clinic was the only building in San José with electricity, run intermittently by a generator. That day, they used it for a PowerPoint presentation that showed pictures of the filters and how they work. The women asked numerous questions about how long it took for the water to filter (answer: one hour) and whether the filters really would reduce diarrhea (the doctors said yes). In the end, the consensus was that it was worth a try.

After the meeting, the potter began making the filters. By the summer of 2007, the clinic in San José had distributed dozens of filters and buckets.

That same summer, Ian Nettleship, a Pitt engineering professor, took his 8-year-old daughter to an exhibition of Pulitzer Prize-winning photographs at the Heinz History Center in Pittsburgh. One photo in particular stood out—a starved girl in Sudan, hunched over an empty bowl. A few yards behind her, a buzzard waited.

Nettleship felt acute sympathy for this girl who happened to have been born in a place where food and water weren’t taken for granted, unlike his daughter, who was born in the United States and had happily joined him on that father-daughter outing. In thinking about those dual realities, Nettleship felt inspired “to get into the business of saving lives,” but what could he, as a ceramics engineer and professor, possibly offer? He started by printing a copy of the Pulitzer Prize-winning photo from a Web site and tucking it into his wallet.

Not long afterward, he too read an article about Wukich, the art professor. Nettleship was delighted by the simplicity of the ceramic water filters. He also was excited to learn about a project that combined ceramics and humanitarian aid. Ceramics are what Nettleship knows best. As a materials science professor, he’s written and published dozens of scientific papers about the internal properties of ceramics. He was sure there would be plenty of interesting ways to improve the water filters, which were designed to help needy people like the Sudanese girl. Through materials studies, he could, for example, modify the strength of the ceramic filters or experiment with the water-flow rate through the filters. He called Wukich and offered to help.

Soon, a portion of Nettleship’s laboratory was dedicated to the water filters. He began advising student Curtis Larimer, who had become interested in the worldwide problem of water contamination after participating in an undergraduate research program in Sao Paulo, Brazil, with Pitt’s Mascaro Center for Sustainable Innovation in the Swanson School of Engineering. The pair began visiting a pottery studio that Wukich had founded in the basement of the Carnegie Library in nearby Braddock, Pa. There, they got their fingernails dirty with clay as artists taught them how to make water filters. They also made small tiles of the same material as the water filters and painted them with the same silver-and-water liquid that potters put on the filters. The square tiles would be much easier to fit under microscopes than the large, bowl-like filters.

Under Nettleship’s supervision, Larimer began conducting various experiments, mainly to see how the silver was interacting with the ceramic material of the filters. He earned his bachelor’s degree in the spring of 2008, then decided to continue his research by enrolling as a PhD student in mechanical engineering and materials science. In the fall of 2008, he regularly examined the tiles under a digital optical microscope.

By that time, the women in San José del Negrito were using the filters with great success. Once mothers saw that their children were having fewer cases of diarrhea, they told their neighbors, who told their friends. Everybody wanted one. When Soni went on the brigade as part of her rotation in family medicine, they’d become very popular. Even though some of the water samples she tested turned pink and purple, the filters were working well overall. Families were experiencing dramatic drops in the rate of diarrhea. Still, the filters weren’t perfect. After some pondering, she suspected that women who were cleaning their filters too much were scrubbing off the silver that was vital to killing bacteria.

Larimer’s tests later confirmed her data. By using the topological maps, as well as other techniques, he found that the silver was not staying inside the filters for very long. When he painted the silver-and-water liquid onto his tiles, it seemed like the solution permeated the material because it was wet. When the solution dried, the water evaporated out of the material, and pulled the silver to the surface. Because the silver was only on the surface, it could chip off easily or be rubbed off by cleaning.

These days, the doctors with Shoulder to Shoulder are encouraging people to get their filters repainted with the silver liquid at least once a year. The doctors are also staying in contact with the Pitt engineers, Wukich, and other ceramic filter experts worldwide who are continually improving and creating new ways to clean water. Markle and Meyer have received calls from nonprofit organizations all over Honduras, including the first Shoulder to Shoulder clinic that helped them to get started, to ask how they can distribute water filters, too. More than 400 filters have been distributed from the clinic in San José del Negrito. Soni (MED ’09) is now a resident in women’s health in the Internal Medicine Residency Program at Pitt.

In January, Larimer published his first academic paper, “The segregation of silver nanoparticles in low-cost ceramic water filters,” in Materials Characterization. His advisor, Nettleship, has been encouraging members of Pitt’s Engineers Without Borders undergraduate student organization to get involved. They’re now building a laboratory at the pottery studio in Braddock, where they’ll be working on improving the ceramic filters with an engineering mindset—increasing production, developing quality-control methods. Nettleship envisions generations of undergrads learning the techniques there, then fanning across the world to share them with potters.

Most importantly, hundreds of children in San José del Negrito aren’t getting sick from a basic need—water. They’re going to school, playing soccer, and learning how to care for the coffee trees.