Corinne J. Schuster-Wallace

An ecological quantification of the relationships between water, sanitation and infant, child, and maternal mortality

BackgroundWater and sanitation access are known to be related to newborn, child, and maternal health. Our study attempts to quantify these relationships globally using country-level data: How much does improving access to water and sanitation influence infant, child, and maternal mortality?MethodsData for 193 countries were abstracted from global databases (World Bank, WHO, and UNICEF). Linear regression was used for the outcomes of under-five mortality rate and infant mortality rate (IMR). These results are presented as events per 1000 live births. Ordinal logistic regression was used to compute odds ratios for the outcome of maternal mortality ratio (MMR).ResultsUnder-five mortality rate decreased by 1.17 (95%CI 1.08-1.26) deaths per 1000, p < 0.001, for every quartile increase in population water access after adjustments for confounders. There was a similar relationship between quartile increase of sanitation access and under-five mortality rate, with a decrease of 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. Improved water access was also related to IMR, with the IMR decreasing by 1.14 (95%CI 1.05-1.23) deaths per 1000, p < 0.001, with increasing quartile of access to improved water source. The significance of this relationship was retained with quartile improvement in sanitation access, where the decrease in IMR was 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. The estimated odds ratio that increased quartile of water access was significantly associated with increased quartile of MMR was 0.58 (95%CI 0.39-0.86), p = 0.008. The corresponding odds ratio for sanitation was 0.52 (95%CI 0.32-0.85), p = 0.009, both suggesting that better water and sanitation were associated with decreased MMR.ConclusionsOur analyses suggest that access to water and sanitation independently contribute to child and maternal mortality outcomes. If the world is to seriously address the Millennium Development Goals of reducing child and maternal mortality, then improved water and sanitation accesses are key strategies.

Social capital, collective action and access to water in rural Kenya.

Globally, an estimated 748 million people remain without access to improved sources of drinking water and close to 1 billion people practice open defecation (WHO/UNICEF, 2014). The lack of access to safe water and adequate sanitation presents significant health and development challenges to individuals and communities, especially in low and middle income countries. Recent research indicates that aside from financial challenges, the lack of social capital is a barrier to collective action for community based water and sanitation initiatives (Levison et al., 2011; Bisung and Elliott, 2014). This paper reports results of a case study on the relationships between elements of social capital and participation in collective action in the context of addressing water and sanitation issues in the lakeshore village of Usoma, Western Kenya. The paper uses household data (N=485, 91% response rate) collected using a modified version of the social capital assessment tool (Krishna and Shrader, 2000). Findings suggest that investment in building social capital may have some contextual benefits for collective action to address common environmental challenges. These findings can inform policy interventions and practice in water and sanitation delivery in low and middle income countries, environmental health promotion and community development.

Developing a Vulnerability Mapping Methodology: Applying the Water-Associated Disease Index to Dengue in Malaysia

The Water-associated Disease Index (WADI) was developed to identify and visualize vulnerability to different water-associated diseases by integrating a range of social and biophysical determinants in map format. In this study vulnerability is used to encompass conditions of exposure, susceptibility, and differential coping capacity to a water-associated health hazard. By assessing these conditions, the tool is designed to provide stakeholders with an integrated and long-term understanding of subnational vulnerabilities to water-associated disease and contribute to intervention strategies to reduce the burden of illness. The objective of this paper is to describe and validate the WADI tool by applying it to dengue. A systemic ecohealth framework that considers links between people, the environment and health was applied to identify secondary datasets, populating the index with components including climate conditions, land cover, education status and water use practices. Data were aggregated to create composite indicators of exposure and of susceptibility in a Geographic Information System (GIS). These indicators were weighted by their contribution to dengue vulnerability, and the output consisted of an overall index visualized in map format. The WADI was validated in this Malaysia case study, demonstrating a significant association with dengue rates at a sub-national level, and illustrating a range of factors that drive vulnerability to the disease within the country. The index output indicated high vulnerability to dengue in urban areas, especially in the capital Kuala Lumpur and surrounding region. However, in other regions, vulnerability to dengue varied throughout the year due to the influence of seasonal climate conditions, such as monsoon patterns. The WADI tool complements early warning models for water-associated disease by providing upstream information for planning prevention and control approaches, which increasingly require a comprehensive and geographically broad understanding of vulnerability for implementation.

The place of health and the health of place: Dengue fever and urban governance in Putrajaya, Malaysia

This case study investigates the connections among urban planning, governance and dengue fever in an emerging market context in the Global South. Key informant interviews were conducted with leading figures in public health, urban planning and governance in the planned city of Putrajaya, Malaysia. Drawing on theories of urban political ecology and ecosocial epidemiology, the qualitative study found the health of place - expressed as dengue-bearing mosquitoes and dengue fever in human bodies in the urban environment - was influenced by the place of health in a hierarchy of urban priorities.

Dreaming of toilets: using photovoice to explore knowledge, attitudes and practices around water-health linkages in rural Kenya.

As part of a knowledge, attitudes, practices and empowerment (KAPE) project implemented by the United Nations University Institute for Water, Environment and Health (UNU-INWEH) in the Lake Victoria Basin, this paper reports findings from a photovoice study with women in Usoma, a lakeshore community in Western Kenya. Drawing on ecosocial and political ecology theory, findings reveal that access to water, perceptions and practices were shaped by ecological and broader structural factors. Further, collective actions to improve access were constrained by institutional and economic structures, thus (re)enforcing inequalities.

A Review of Health Risks and Pathways for Exposure to Wastewater Use in Agriculture

Background: Wastewater is increasingly being used in the agricultural sector to cope with the depletion of freshwater resources as well as water stress linked to changing climate conditions. As wastewater irrigation expands, research focusing on the human health risks is critical because exposure to a range of contaminants must be weighed with the benefits to food security, nutrition and livelihoods. Objectives: The goal of this paper was to review research examining health risks and exposure pathways associated with wastewater irrigation to identify research trends and gaps. Methods: We conducted a review of the literature and identified a total of 126 studies published from 1995 to 2013. Findings were summarized based on several themes including types of exposure pathways, wastewater contaminants, methodological approaches and the geographical distribution of research. Results: Only 23 studies used epidemiological methods, while most research applied alternative methods to estimate risk, such as quantitative risk assessment models or comparisons of crop contamination to established guidelines for wastewater reuse. A geographic breakdown demonstrated a focus on microbiological contaminants in specific regions such as sub-Saharan Africa and Southeast Asia, despite growing chemical risks associated with rapid urbanization and industrialization that may change the types and distribution of wastewater contaminants. Conclusions: To provide a more comprehensive understanding of the health risks of wastewater use in agriculture, future research should consider multiple exposure routes, long-term health implications, and increase the range of contaminants studied, particularly in regions heavily dependent on wastewater irrigation. Citation: Dickin SK, Schuster-Wallace CJ, Qadir M, Pizzacalla K. 2016. A review of health risks and pathways for exposure to wastewater use in agriculture. Environ Health Perspect 124:900–909; http://dx.doi.org/10.1289/ehp.1509995

Water Security Assessment Indicators: The Rural Context

An increasing number of factors pose challenges to the development and management of water resources in rural, remote, or otherwise marginalized (RRM) communities. Indicators and indices have been developed for evaluation, prioritization, and decision-making at local and supra-local scales. Indicators and indices are useful assessment tools as they simplify the modeling process and provide results in an accessible format. The purpose of this paper is to consolidate a list of indicators (n = 176) from a review of community- and basin- level indices and a selection of other literature within a water security framework for RRM communities. A detailed discussion of each of the six dimensions within the framework is provided. This paper concludes with some general remarks on the standards used for evaluation, the reliance upon historical and field data, suggestions for improving the descriptive clarity where it is lacking, and the prospect of these indicators getting used by community members.

Improving Aboriginal health data capture: evidence from a health registry evaluation

The lack of high-quality health information for accurately estimating burdens of disease in some Aboriginal populations is a challenge for developing effective and relevant public health programmes and for health research. We evaluated data from a health registry system that captured patient consultations, provided by Labrador Grenfell Health (Labrador, Canada). The goal was to evaluate the registrys utility and attributes using modified CDC guidelines for evaluating surveillance systems. Infectious gastrointestinal illness data were used as a reference syndrome to determine various aspects of data collection and quality. Key-informant interviews were conducted to provide information about system utility. The study uncovered limitations in data quality and accessibility, resulting in region-specific recommendations including conversion to an electronic system. More generally, this study emphasized how a systematic and standardized evaluation of health registry systems can help address challenges to obtaining quality health data in often remote areas where many Aboriginal communities are found.

Global public health policy transfer and dengue fever in Putrajaya, Malaysia: a critical discourse analysis

This study critically analyzed the operationalization and materialization of globally hegemonic dengue fever discourse at the local level in the city of Putrajaya, Malaysia. Textual analysis of the World Health Organizations First report on neglected tropical diseases (NTDs) (2010) identified three discursive strategies in the WHOs effort to set the agenda for research and action on neglected diseases: the nomination of dengue fever as a disease of the impoverished and voiceless other; the predication of neglected disease status on environmental and behavioural uncleanliness; and the framing of so-called ‘pro-poor’ neglected tropical disease discourse as a new paradigm under which targeting these othered people, behaviours and environments is a key strategy for NTD management and control. Further analysis of the transcripts of 14 key informant interviews conducted with experts in public health, governance and urban development in Putrajaya found that discursive links between dengue and poverty contributed to the inappropriate transfer of globally dominant dengue control strategies to Putrajayas non-poor local environment. These findings indicate that endemic dengue emerged in Putrajaya in part because planners, health officials and residents reproduced in their plans, policies and behaviours the construction of the disease as one of the other. The findings call into question the characterization of dengue fever as a disease of poor people, unclean spaces and unsanitary behaviours, and raise new questions about the appropriateness of targeting NTD initiatives to the poor. The findings also highlight the need for locally appropriate public health policies for infectious disease control in non-poor environments.

One community’s journey to lobby for water in an environment of privatized water: is Usoma too poor for the pro-poor program?

Achieving the proposed water, sanitation, and hygiene (WASH) post-MDG goals will require targeted measures if the human right to water and sanitation is ever to be realized. Particularly in rural areas, among urban poor populations and marginalized communities where access remains low, the human right to water and sanitation is an important vehicle to raise attention to inequalities in access. In this paper, we explore the journey of Usoma, a small community in Western Kenya, as they move toward the realization of a human right to water and sanitation. In the face of international pressure for increasingly privatized water and sanitation services that emphasize efficiency and financial sustainability, we conclude that translating the human right to water and sanitation requires adequate commitment to ‘pro-poor’ policies, innovative financing models, monitoring of water service providers, and stakeholder engagement at all levels of government. Only in this way will access to water and sanitation be realized as a human right.