Routledge Handbook of Water and Health

Jamie Bartram

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317436980
• Edition: 1
• Topic: Biological Sciences
• Subtopic: Environmental Science
• Index: Biological Sciences

This comprehensive handbook provides an authoritative source of information on global water and health, suitable for interdisciplinary teaching for advanced undergraduate and postgraduate students. It covers both developing and developed country concerns.

It is organized into sections covering: hazards (including disease, chemicals and other contaminants); exposure; interventions; intervention implementation; distal influences; policies and their implementation; investigative tools; and historic cases. It offers 71 analytical and engaging chapters, each representing a session of teaching or graduate seminar.

Written by a team of expert authors from around the world, many of whom are actively teaching the subject, the book provides a thorough and balanced overview of current knowledge, issues and relevant debates, integrating information from the environmental, health and social sciences.

1
Introduction^*

Jamie Bartram and Rachel Baum

THE WATER INSTITUTE, DEPARTMENT OF ENVIRONMENTAL SCIENCES AND ENGINEERING, GILLINGS SCHOOL OF GLOBAL PUBLIC HEALTH, UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL, NORTH CAROLINA, USA

There is worldwide recognition of the importance of water for health. Treatise after treatise states that human survival is impossible without it; that the human body comprises 60 per cent water; that civilization and civilizations depend on water; and that our contemporary health and quality of life are made possible and sustained through our management of this natural resource.

Archaeological and historical evidence convey the importance that water has had for the development of settlements and civilizations and for the health of their populations across the course of history. Excavations of ancient settlements suggest substantive investment in water management, dating back to at least 1000 BCE with the construction of aqueducts in Mesoamerica (Lucero and Fash, 2006). A common preference for wells and springs suggests that demand for ‘clean’ (clear) water is widespread.

Water figures prominently in religion and ritual, both historic and contemporary; and serves as a metaphor for cleanliness. It is used in the Christian baptism ritual, in Islamic ablutions for cleansing before prayer, in Judaic purification baths for certain rituals and in Shintoistic cleansing before prayer. In some Amazonian tribes a source of water used for drinking is abandoned if an animal is seen to drink from it – even if that requires moving the household; and in some parts of northern Pakistan, where fresh water comes from glacier melt, coldness of water is considered an indicator of drinkability.

Ancient written works indicate a belief in some relationship between water (cause) and health (effect). Hippocrates described at length the sources, qualities and health effects of water in Airs, Waters, Places (circa 400 BCE); and in the first century AD Pliny the Elder wrote extensively on the kinds of water and is attributed with the admirably succinct in aqua sanitas (i.e. in water there is health). This association of water with health extended to interventions intended to protect and improve health through water, with evidence for: bulk transport of cleaner water to human settlements such as the aqueducts of ancient Rome; bulk storage of water in underground tanks in the Mediterranean area; bathing facilities whether public or private; treatment of water to improve its quality through means such as settling, filtering and boiling; and drainage of both urban areas and marshlands – all known of through written sources and excavations (IWA, 2013).

There was debate in ancient Rome on the appropriateness of lead plumbing due to health concerns. While the credibility of there having been health effects has been questioned (Hodge, 1981), debate on the desirability of ceramic over lead pipes to resolve this health concern provides one of the first examples of response to a health problem introduced through water management itself.

Other water-related diseases were also important around the ancient Mediterranean area, including malaria and schistosomiasis, the latter which is thought to have been associated with flood irrigation from the Nile in ancient Egypt. It is unclear whether their water associations were perceived at the time, although association of marshes with ill health was, and the name mal aria (literally ‘bad air’) suggests appreciation of an external cause.

Construction of large water storage ‘tanks’ for water storage for irrigation in Sri Lanka, where rainfall is insufficient for rain-fed agriculture in the dry region (north and east), dates from around 400 BC. Parakrama Bahu the Great (AD 1153–1186) went as far as to say, ‘Let not even a drop of rain water go to the sea without benefiting man.’ He is credited with building or restoring 163 major and 2,617 minor tanks, including a 30 km² tank at Polonnaruwa, known as the Parakrama Samudra (Sea of Parakrama) which irrigated nearly 100 km² (Murphey, 1957). Over time these tanks were connected to form a network supporting sequential (‘cascading’) use. While the reasons for the decline of these systems are not known, one suggested factor has been malaria.

Dale’s Laws, the first laws in English-speaking North America, written in 1611 for the governing of ‘Virginea’, include provisions that explicitly link interventions to disease reduction. They also indicate knowledge of causes of disease, and include proportionate measures depending on perceived likelihood or severity of risk – several hundreds of years before the germ theory of disease:

There shall no man or woman, launderer or launderess, dare to wash any unclean linen, drive bucks or throw out the water or suds of foul clothes in the open street within the Pallizadoes or within forty feet of the same, nor rench and make clean any kettle, pot, or pan or such like vessel within twenty feet of the old well or new pump; Nor shall any one aforesaid, within less than a quarter of one mile from the Pallizadoes, dare to do the necessities of nature, since by these unmanly, slothful and loathsome immodesties, the whole Fort may be choked and poisoned with ill airs.

While an appreciation of the value of water for health can be recognized in these early accounts, contemporary understanding of water and health largely derives from the advances achieved since the mid-nineteenth century. This marked a period of major scientific advances, the industrial revolution, increasing urbanization in Western Europe, and the ‘sanitary revolution’.

Much of the health gains achieved during the nineteenth century sanitary revolution are credited to the progressive implementation of interventions in centralized drinking water treatment and supply, and urban drainage and sanitation (management of human excreta through latrine or water-borne sewerage). These health improvements were initially achieved before the era of immunization, antibiotics, and effective treatment of the associated diseases (McKinlay and McKinlay, 1977). Indeed growth in understanding of the mechanisms linking water and health provided key contributions to the development of the science of public health and the discipline of epidemiology (Chapters 66 and 67). The associated benefits accrued across society widely. However the motivation, as exemplified by the Public Health Act of 1848 in England, related largely to prevention of spread of disease from poor to wealthy populations and to the need for a healthy workforce to sustain industrial productivity, rather than any concern for equality and shared progress (Fee and Brown, 2005). Mirroring this situation, in many countries today, access to safe drinking water (and sanitation), as well as the associated health burden, is extremely inequitable (WHO/UNICEF JMP, 2014). Similarly, intervention in water today mirrors the same potential for socially progressive measures that would extend benefits to poor and otherwise disadvantaged as well as privileged populations. The importance of equity is deeply rooted in human rights (Chapter 51) and in public health practice.

Rapidly evolving understanding of water and health

This rich history may create the illusion of a domain that is ‘mature’. Indeed in the 1960s–1980s there was an often implicit, and sometimes explicit, assumption that we ‘knew’ all that was necessary to know about water and health, and that the remaining problems were problems of ‘development’. The solution to these problems would be to implement the well-known interventions for the residual, poverty-associated, problems of water to quietly go away under the influence of general development. Subsequent events have highlighted the over-optimism of those assumptions. This parallels the overly optimistic views regarding the suppression of infectious disease that prevailed soon after the eradication of smallpox.

In the early 1960s, the emerging environmental movement brought to light new health threats – from chemical agents of concern to both health and the environment – and made the case that these two were themselves intimately connected. Rachel Carson’s Silent Spring, published in 1962, and her research on the adverse effects of the chemical pesticide DDT, spearheaded this movement, demonstrating the connectedness of human and environmental systems, questioning the inherent goodness of technological advances, and led to a shift in the burden of proof of ‘safety’. However, research and interventions on water and health focused on infectious disease, so chemical agents causing chronic disease transmitted through water remained poorly understood; and a decade after Silent Spring, chemical hazards were still peripheral to, and poorly understood by, many of those working on drinking water and health. The then-prevailing view was that,

Conditions usually considered noninfective, such as cancer and artherosclerotic heart disease, also are believed to vary with water quality, but the relations are subtle and are poorly understood as yet. It is rarely possible by available technical means to control non-infective disease (apart from dental caries) by changing the quality of domestic water …

White et al., 1972, pp 161–162

Notwithstanding the importance of the impact that attention to industrial chemicals had on risk management, it subsequently became clear that, globally, disease burdens associated with chemical contamination of water were primarily associated with the naturally occurring geogenic elements fluorine and arsenic where they occur in excess concentrations (Chapter 10). Indeed in Bangladesh, what has been described as the largest mass poisoning in history emerged, where insistence on pursuing the traditional (infectious disease prevention focused) agenda and well-established approaches (extending access to ‘improved’ water sources such as boreholes with hand pumps) delayed recognition of and response to such a chemical hazard (Chapter 68). While concern for industry-derived chemical contamination of water triggered concerns, other chemical hazards, ironically including some from water treatment and distribution, were progressively recognized. In an echo of the ancient Roman debate over lead in water distribution, disinfection by-products (DBPs) have attracted attention as unintended companions of water disinfection. Their regulation is complex, in part because of the implicit trade-off (chemical safety versus microbial safety), and also because the most studied compounds tend to be those regulated, encouraging the use of less-studied (but not necessarily more safe) alternatives. The difficulty in balancing these chemical risks with their infectious counterparts contributed to the cholera outbreak that began in Peru, following avoidance of chlorination, based on fears of DBPs, and swept through Latin America in the 2000s (Hanekamp, 2006). In the examples of arsenic in Bangladesh and DBP regulation, inadequate understanding of the relative risks arising from microbes versus that from chemicals complicated appropriate and effective decision making.

The discovery of Legionella bacteria as a cause of a life-threatening pneumonia (Legionnaires’ disease) in 1976 (Chapter 8) further expanded our understanding of the scope of disease exposure routes associated with water. The role of water as a vector of disease, through droplet inhalation, again reconfirmed that engineered water systems can introduce new health hazards as well as solve them – in this case through multiplication of Legionella bacteria in water systems.

Notwithstanding the breadth of water-related disease and the rapid evolution in our understanding of it, the global burden of water-related disease is still dominated by faecally transmitted infection: the combination of diarrhea (including the under-nutrition which diarrhea causes and the adverse health effects of that under-nutrition), soil-transmitted helminthes and environmental (tropical) enteropathy (Chambers and Medeazza, 2014). This is true despite the great reductions reported in diarrheal disease in recent decades.

The second half of the twentieth century saw growing concern about human population growth, urbanization and the carrying capacity of planet earth, including worries about the ability to feed the burgeoning population. In large part, this concern was addressed through the ‘Green Revolution’ and substantive increases in irrigated agriculture. By 2000, 70 per cent of water withdrawals globally were directed to agriculture with far higher rates in some areas (UN Water, 2008). Expansion of irrigation where there was inadequate design of schemes to account for health risks – notably in sub-Saharan Africa – brought in its wake a dramatic increase in some water-related diseases, especially schistosomiasis. More recently the impacts of demands on water for agriculture have been exacerbated by a combination of declining dependability of rainfall for rain-fed agriculture; increasing water scarcity; over-exploitation of (especially groundwater) resources; and escalating demands for agricultural foodstuffs (both for direct consumption and to satisfy the meat demand of an increasingly wealthy population). One response has been greater indirect and direct use of waste water in agriculture with associated health concerns for both infectious and chemical hazards (Chapter 47).

Unsurprisingly water in its various manifestations has appeared prominently in a series of innovations and developments, fads and fashions:

• International policy and development discourse brought water (as part of water, sanitation and hygiene (WaSH)) to the fore with the International Drinking Water Supply and Sanitation Decade (1981–1990) and the Millennium Development Goals (MDGs) and it seems likely to remain there in light of proposals for future Sustainable Development Goals (SDGs) (...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• List of figures
• List of tables
• Acknowledgements
• 1 Introduction
• PART I Water-related hazards
• PART II Sources of exposure
• PART III Interventions: what do we do to reduce exposure
• PART IV Implementing interventions
• PART V Distal influences
• PART VI Policies and their implementation
• PART VII Investigative tools
• PART VIII Learning from history
• Index