Of the 1.1 billion people without access to improved water sources
worldwide, over 80% live in rural areas. Drinking-water quality is especially
difficult to control, and small community water supplies frequently fail on basic
microbiological quality. Rural communities have a different relationship to water
than do urban dwellers. Water dominates every aspect of their lives. People in the
countryside live off the land and depend on water to grow their crops. Scarce
water supplies are used sparingly for household needs. Water is the source of
their livelihood, and when water is unclean or mismanaged, it becomes a source of
ill-health and continued poverty, thus with negative bearing on development. To
achieve the international development target of halving the proportion of people
without access to improved water or sanitation by 2015, an additional 1.6 billion
people will require access to water supply and about 2.2 billion will require
access to sanitation facilities.
Water and Health for the Urban Poor
Competition for water in the world’s ever-growing cities is
fierce. Industry, urban agriculture and households all rely on and demand water to
meet their needs. But water is becoming scarce, and this often results in the
inequitable distribution of what is available. Municipal water regulations,
government subsidies, public and private investment all tend to favour traditional
water-supply services which provide piped .water directly into peoples’ homes, but
neglect the urban poor. Hygiene practice is closely linked to the availability of
water and sanitation facilities. In places where these may be lacking, communal
areas which offer facilities for hand-washing, bathing and laundry may effectively
encourage good hygiene. For instance, the health of communities can be enhanced if
they are able to protect their water sources, dispose of solid waste and excreta,
and provide wastewater drainage.
Urban habitats provide breeding grounds for diseases such as
dengue fever and filaria. Control methods for reducing breeding-sites for the
insect vector is a proven and effective means of cutting disease. Unfortunately,
they are difficult to implement in densely-populated shanty towns with inadequate
Trace elements and minerals in Water
Water contains many trace elements and minerals, which may be
benign, beneficial or toxic. Everything depends on how much. While some minerals
may be beneficial in low concentrations, most can be toxic in excess. Only a few
chemicals - for instance, arsenic and fluoride - are thought to be major public
health issues. The problems they and nitrate cause are most common in rural areas.
Arsenic in Drinking-Water
One of the worst examples of a do-good project gone wrong is
occurring in Bangladesh. About two decades ago, millions of small wells began to
be drilled in an effort to provide safe water to the population. At the time, all
attention was focused on preventing diarrhoeal disease which ravaged the
population. No one, until the 1980s, identified naturally-occurring arsenic as a
health hazard. A recent study published in the Bulletin of the World Health
Organization suggests that Bangladesh is grappling with the largest mass poisoning
in history, potentially affecting between 35 and 77 million of the country’s 125
million population, threatening them with potential epidemics of cancers and other
fatal diseases. Attacking the problem in Bangladesh is not easy. There are
millions of wells and those that are dangerous are mixed in with those that are
safe. There are several technical solutions but no single universal method.
Well-to-well testing is needed.
Fluoride is present in all waters. Low amounts of this element can
be good for teeth. But, excessive amounts of fluoride in drinking-water can be
toxic. People with teeth discolored by fluoride are found worldwide, and crippling
skeletal effects are prominent in at least eight countries. It is estimated that
30 million people suffer from chronic fluorosis in China where the custom of
burning fluoride-rich coal in the household may further aggravate the problem.
These issues can be solved and answers are available, but implementing projects,
especially in the rural areas where the disease is most prevalent, have often
found out to be difficult.
Of all the water-associated tropical diseases, schistosomiasis, a
water-based parasitic disease, which is commonly found in some parts of Africa,
the Middle East, some Caribbean islands and parts of South America best
illustrates the complexities of the various water issues with which mostly the
rural poor are faced. For part of their lifecycle, Schistosoma parasites depend on
aquatic snails. The disease is maintained through faecal and urine contamination
of open waters with parasite eggs, the presence of the snails and frequent water
contact for recreational, domestic or occupational purposes.
Water management can play an important role in reducing
transmission risks. But it must be combined with drug treatment, the provision of
safe drinking-water and adequate sanitation. Health education is also important.
Canal lining, regular rapid draw-down of reservoirs, and increased flow rates in
irrigation canals all favour snail elimination, but are only efficient if they
have a positive effect on agricultural production at the same time.
Contamination of traditional food sources is becoming an
increasing issue of concern among indigenous populations, many of whom derive most
of their drinking, irrigation and food from local lakes and rivers. In South
America for example, indigenous peoples in the Andes and Amazon regions are
exposed to high levels of arsenic and mercury in local water systems and fish.
This is creating health problems among children and breastfed infants. For many
tribal groups in Africa, unsafe drinking- water and unhygienic handling of food is
contributing to high levels of diarrhoeal diseases in infants and children.
Indigenous peoples in rich countries may also live in abject
poverty and suffer from the kind of ill-health and economic deprivation that are
commonly found in developing countries. For example in Canada where a large
indigenous population live, the statistics show that they have a lower life
expectancy, higher infant mortality and greater disease burden than the rest of
society. However, the outlook for disadvantaged communities in these societies is
usually better because of active social support networks.
Dams and Health
The development potential of dams includes irrigation, power
generation, drinking-water supply, flood control, navigation, fisheries and
recreation. Dam construction has a chequered past because of adverse environmental
and health impacts.
The impacts of dams on environmental and social determinants often
worsen the health status of vulnerable communities; they transfer hidden costs to
the health sector and they undermine the project’s sustainability. For example, in
Ethiopia the cumulative effect of microdams translated into a seven-fold increase
of malaria transmission in the nearby communities.
Health impact assessment (HIA) provides a well-tested method and
procedure for minimizing health risks and maximizing the health benefits of
development projects. HIA fits in with prospective environmental and economic
assessments. It is an effective decision-support tool, provided recommended
mitigating health measures are included in the resulting environmental management
and resettlement plans.
Scaling up HIA will ensure improved equity of health benefits of
dams and other water-resource projects. It will prevent the transfer of hidden
costs to the health sector and it will contribute a great deal to its
Solutions most needed
The United Nations Millennium Goals aims to promote development
and eliminate poverty nationally and globally. A major goal is to halve, by the
year 2015, the number of people who earn less than a dollar a day, who suffer from
hunger and have no access to affordable, safe drinking-water.
Providing access to better water for more than 1 billion people
cannot be done overnight. Waiting for the ‘big solution’ while ignoring the
immediate priorities of the most needy makes no sense. There are many small-scale,
cost-effective intermediate actions which can be taken to great effect. Easy,
low-cost methods for improving health do exist and can be applied collectively or
individually. Water can be purified by means of chlorination and solar-thermal
techniques. People can stay healthy by simply washing their hands with soap and
water. Government policies can support local initiatives.
Chlorination is a proven means of ridding water of disease causing
micro-organisms in piped water supply. But the prevailing wisdom is that
chlorinated water should be dealt with after basic water supply and sanitation are
Research carried out by scientists at the Centers for Disease
Control and Prevention in Atlanta, Georgia, in the United States of America and
the Pan American Health Organization looked at how chlorinated water can be
provided to poor households through a simple, low-cost treatment and secure
storage method. "One of the findings we’ve made is that improving water quality
alone does work and we can do this without improving sanitation," says Mark Sobsey,
Professor of Environmental Microbiology at the University of North Carolina,
Chapel Hill, USA. "What we now know is that even in conditions of very poor
sanitation and hygiene where people are collecting whatever water is available to
use as household water supply, if the water is chlorinated, the water is improved
microbiologically and you can find statistically significant decreases in
"Our research shows that washing hands with soap would probably
save half of the deaths from diarrhoeal diseases," suggests Valerie Curtis,
Lecturer in Hygiene Promotion at the London School of Hygiene and Tropical
Medicine. "All it requires is soap and motivation." But that’s more easily said
than done. Curtis participated in a major three-year study in India, the
Netherlands, the United Kingdom and West Africa to learn what motivates good
hygiene practices. The results are interesting and in many ways unexpected. The
research finds that hygiene is a common value around the world. Nobody likes dirt.
But, people’s hygienic practices have less to do with health than with social and
aesthetic considerations. Mothers want to keep their babies clean because they
believe it is a loving, caring thing to do and will make their babies socially
acceptable. One Indian mother explains "If my child is dirty, no one will hold him
in their arms, no one will love him. And, so I keep my child clean."
There has to be a rethinking of the traditional ‘scolding,
moralistic’ approach to hygiene, which hasn’t worked. A number of studies show
that people are turned off by dire warnings that they will face disease and death
if they don’t change, "their filthy ways". For example, people in Brazil refused
to collaborate in a cholera prevention program because they felt they were being
accused of being ‘filthy dogs’.
Evidence is growing that positive messages are more successful
than negative ones in producing behaviour change. A three-year study in
Bobo-Dioulasso (Burkina Faso) used positive messages to change old entrenched
habits. At the end of that period, the people in the study had tripled their use
of soap. Curtis says an evaluation of the intervention shows that the money spent
on the programme and buying extra soap was less than what families and health
agencies had been spending on treating childhood disease. "There was actually a
net saving on the overall programme."
Studies show that cases of diarrhoea were cut an average of 35% by
the simple act of washing hands with soap and water. Getting people to change
their habits represents a big task for health promoters.
These women and children may get infected with Schistosomiasis through
contaminated water. The provision of piped water supply to the villages can
drastically reduce the infection.