GLOBAL ISSUES IN WATER, SANITATION & HEALTH

The Spectrum of
Water-Related Disease
Transmission Processes
David Bradley
London School of Hygiene & Tropical Medicine and
Department of Zoology, University of Oxford

DISEASE TRANSMISSION PROCESSES

1.
2.

3.

Revisit critically the classification of W

& S disease transmission processes.
Suggest unsystematized areas needing
attention, including behaviour, and
processes in space and time
Use a small area of SW Uganda to show
the inter-related complexities and
research issues.

A Waters-Eye View

Social Uses of Classifications

Bringing order & Clarity to thought
l Shining lights in dark corners
l To make explicit the assumed
l

[that may be less applicable elsewhere]

Eg health needs ACCESS to water
Water is not just for drinking
l

Analogy with research is that:

Draw attention to possible new data
Give validity and credibility to an area

What is the function of a

Classification?
Classification is a qualitative model of
distinctions that matter
l A means of (trans-sectoral) communication,
especially as water improvements are very
largely implemented outside the health sector
l A simplification to help public health
practitioners
l

WATER RELATED DISEASE CLASSIFICATION

1.

2.

3.

4.

WATER-BORNE

-Classical
-Other
WATER-WASHED -Diarrhoea
-Skin & Eyes
WATER-BASED
-Percutaneous
-Oral
WATER-RELATED -Breeding
INSECT VECTORS -Biting

WATER RELATED DISEASE CLASSIFICATION

5. WATER-AEROSOL
The Legionella pattern of transmission does
not fit well into any of the four existing
categories, which are defined by how the
diseases are contracted. None of the others
relates to intake via the respiratory tract

WATER RELATED DISEASE CLASSIFICATION

l WATER-BORNE

l WATER-WASHED

l WATER-BASED

l WATER-RELATED

INSECT VECTORS

-Classical
-Other
-Diarrhoea
-Skin & Eyes
-Percutaneous
-Oral
-Breeding
-Biting

COMPARATIVE FINDINGS OF THE TWO

Drawers of Water STUDIES
Water Use in Litres / Person / Day; 30 Years Apart

DOW I

DOW II

Piped Urban

128

66.0

Down, Halved

Unpiped Urban

15.4

23.7

Up, By Half

Unpiped Rural

9.7

18.3

Up, Doubled

WATER RELATED MODE OF DISEASE

TRANSMISSION CLASSIFICATION
l WATER-WASHED

Diarrhoea
Skin

Eyes: Trachoma
? Waterwashed Respiratory
Infections

WATER RELATED DISEASE CLASSIFICATION

l WATER-BORNE

-Classical
-Other
l WATER-WASHED -Diarrhoea
-Skin & Eyes
l WATER-BASED
-Percutaneous
-Oral
l WATER-RELATED -Breeding
INSECT VECTORS -Biting

CLASSIFICATION OF DISEASES
RELATED TO SANITATION

Excreted Load

LATENCY
PERSISTENCE
MULTIPLICATION

Infective Dose

Categories of Transmission by Excreta

DISEASE TRANSMISSION RELATED TO SANITATION

# Lat. Persist Mult.

Biology Focus

V,Pr,He Pers,Dom

II
III
IV
V
VI

No

Short

No

Examples

Rotavirus
Enterobius
No Longer Yes
Bact
P,D,W
Typhoid
Cholera
Yes Long
No
Helm Field,C
Ascaris
Hookworm
Yes [Long] Cow/Pig Helm Field
Taenia saginata
Taenia solium
Yes [Long] Aquatic Helm Water
Paragonimus
Schistosoma
Spread by excreta-related insects Some mosq.
Wuchereria
Flies. Cockroaches: several above

DISEASE TRANSMISSION RELATED TO SANITATION

l
l

The categories feed into sanitary barriers

Give a sense of where control best:

l
l

Personal hygiene behaviour

Domestic water supply
Provision of toilets
Treatment of Excreta
Specific measures (e.g. cooking fish)

Close to biology (closer than for Water-related)

Levels of Action:
Person Personal Handwashing
Household. Toilet Provision
Community Sewage Treatment

Where to next?
l

Limitations of Strengths
Speak to engineers; but they cannot provide the whole
solution
Show needs for behaviour change
Greater complexity of Rural and Periurban Sites

AGENDA ITEM:
l

Systematization of Hygiene Behaviour

Handwashing with soap

Mechanisms for respiratory disease benefits ?
Handling childrens excreta
Behavioural aspect of the plateau, etc. etc.

Spatial Processes
In Control and in Service Provision
Periurban complications for interventions.
l Private Space & Public Space (Cairncross)
e.g. Who constructs & who maintains?
l Successive circles of Space (Kolsky)
l

In Disease Persistence and Emergence

l

The 4 tsetse and 75% sleeping sickness

GLOBAL ISSUES IN WATER, SANITATION & HEALTH

l

Global has several components

Affects whole world together (e.g. global warming)
Universal, affecting everyone in same way.
Affects many people: small scale but relicated very
many times but there are local variations; one size
in practice does NOT fit all.
A local happening whose consequences affect
many; e.g. a human transmissible avian flu emerges

Back to Global Threats; cf Global Endemics

Spatial Processes
In Disease Persistence and Emergence
l
l
l
l
l
l
l

Small populations sharing polluted water sources

Untidy species-rich neglected water sites
Recurrent motifs in water morphology
Consequential reservations
Ecotones
Shared spaces between species: People, Livestock,
Wildlife
Chronotones: Periods of massive change that can be
an opportunity

Spatial Processes
In Disease Persistence and Emergence
l
l
l
l
l
l
l

Small populations sharing polluted water sources

Untidy species-rich neglected water sites
Recurrent motifs in water morphology
Consequential reservations
Ecotones
Shared spaces between species: People, Livestock,
Wildlife
Chronotones: Periods of massive change that can be
an opportunity

Map of Nyabushozi County showing the study area

Rwetamo

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Map of nyabushozi villages.shp

Map sima.shp

N
W

E
S

To bring alive the integrated nature of water problems:

l

Consider settling nomadic pastoralists in SW Uganda

On settling, water problems and malaria got worse
?deviation of An. Arabiensis to children as less available cattle? No

Privatized land without water planning first

Cut people off from usual water bodies
Need more reliable sources if no migration
Everyone digs own farm ponds: more An. gambiae
People share the water sources of the cows
National Park lake is water source of last resort for them
Ugandas good water policy & poverty policy not designed
to cope with this.

Water, Sanitation & Health Agendas

l

Blue Agenda of water availability for

domestic and agricultural needs.

Brown Agenda with sanitary goal.

Green Agenda of environmental

sustainability, biodiversity.

Red Agenda of less vector-borne

disease.

Purple Agenda of less non-biological

pollution.

Some Research Implications

l

Need for analytical classification of

Behavioural aspects of W & S, including work on
perception of water as a basis for both changes towards
healthy behaviour and to multisectoral policies.
Water interactions in both conceptual and actual space
in relation to both disease emergence and disease
control
Need for Long-Term Longitudinal Field Studies
Biological as well as Mathematical Process Modelling
Both in Laboratory and by field studies
Build up integrated bodies of locally relevant
interdisciplinary knowledge

Acknowledgements
Ross Institute, LSHTM
Sandy Cairncross
Richard Feachem
Pete Kolsky
Tom Clasen
Valerie Curtis
Sylvia Struck
Sanga Project, Uganda
Joseph Okello- Onen
Charles Muchunguzi
and many others

Drawers of Water I & II

Gilbert F White
Anne U White
John Thompson
Mark Mujwahuzi
Munguti Katui-Katua
James Tumwine
Also
Hemda Garelick
Duncan Mara