Water, Health and Social Inequality

Water, Health and Social Inequality Linda M Whiteford, University of South Florida, Tampa, FL, USA Cecilia Vindrola-Padros, London South Bank University, London, UK Ó 2015 Elsevier Ltd. All rights reserved.

Abstract This article reviews writings about water with a focus on health from the social and behavioral sciences. In addition, issues related to the equitable distribution of water resources such as potable water and their health consequences are discussed. A case study of one water-related disease (cholera) is used to exemplify the inexorable consequences of the failure to provide clean water and sanitation equitably. The reader also will be introduced to the magic triangle of water, health, and hygiene captured in the Global WASH (water, sanitation, and health) Campaign to include sanitation as a target of the Millennium Development Goals.

Introduction Throughout human prehistory and history, access to water has been a key concern and often contentious topic. Foraging peoples structure their annual migrations around access to water. Early agriculture that supported the increasingly large and concentrated populations in Mesopotamia was made possible by the construction of complex and massive irrigation canals. These early canal systems were themselves made possible and controlled by the development of a social structure reflecting a specialization of labor. The large-scale manipulation of water occurred conterminously with the growth of large-scale and densely populated settlements and their concurrent evolving cultures. This is but one small example of how water has always been a critical component of human activities from agriculture, industry, urban development, recreation, but most centrally, to life itself. Water has been channeled, dammed, transported, stored in giant reservoirs, dropped from helicopters, sprayed during riots and on forest fires, but most often it is used for the quotidian aspects of life such as cooking, cleaning, and bathing. And access to a clean and reliable supply of water is primary to good health outcomes (Cairncross, 2003; Cairncross and Valdmanis, 2006; Whiteford and Vindrola-Padros, 2011). While water has long been recognized as a central element in human health, its partner in reducing the spread of potentially deadly diseases, sanitation, has not shared in the same limelight. That is, however, in the process of changing. In 2001, The Global WASH (water, sanitation, and health) Campaign, initiated by The Water Supply and Sanitation Collaborative Council spearheaded a global advocacy movement around safe water, sanitation, and hygiene. In this article, we include the equitable distribution of sanitation, along with water and hygiene, as a critical component to improved global health outcomes. The recent and deadly epidemic of cholera in Haiti is a classic example of the consequences of failing to provide water and sanitation necessary to maintain the hygiene required to prevent the transmission of fecal/oral diseases. The cholera epidemic following the 2010 earthquake in Haiti demonstrates how water, sanitation, and health are connected and how their presence (or absence) reflects underlying social

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inequalities. In this article, we discuss the cholera epidemic in Haiti as one example of a devastating water-borne disease. Other water-borne diseases, such as diarrhea, are also killers. As Figure 1 suggests diarrhea, for instance, kills 1.5 million children every year; and is the leading cause of malnutrition in children under 5 years of age (WHO, 2012a). And the tragedy is

Figure 1 Poster created by the WSSCC as part of the WASH Hurry Up! campaign to raise awareness about the current water and sanitation crisis. Source: Water Supply and Sanitation Collaborative Council (WSSCC), 2012. Resources Hurry Up! http://www.wsscc.org/resources/ resource-advocacy-materials/hurry#10 (last accessed 12.08.12.).

International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 25

http://dx.doi.org/10.1016/B978-0-08-097086-8.64056-4

Water, Health and Social Inequality

that both cholera and diarrhea are preventable and treatable. What makes the Haiti cholera example so powerful is that at multiple times, and in multiple ways, it also could have been avoided. It is an exemplar of government failure to create and maintain water and sanitation infrastructure so necessary for the well-being of a population. Whether it is cholera in India in the third century, or again from 1817 to 1920 (Watts, 1997), the South American cholera pandemic in the 1990s (Whiteford and Vindrola-Padros, 2011), or the ongoing endemic epidemic of cholera in sub-Saharan Africa (WHO, 2012b), cholera kills needlessly. With clean water and sanitation, the cholera vibrio does not survive to sicken and kill. Clean water and sanitation must therefore be considered universal human rights, as the UN has argued: On 28 July 2010, the UN General Assembly recognized that safe and clean drinking water and sanitation are human rights, essential to the full enjoyment of life and all; other human rights. Subsequently, at its 15th session in September 2010, the UN Human Rights Council affirmed that the right to water and sanitation is derived from; the right to an adequate standard of living and inextricably related to the right to the highest attainable standard of physical and mental health, as well as to the right to; life and human dignity. The combined effect of the two resolutions was to anchor the; right to water and sanitation in the framework of the right to an adequate standard of living, making it legally binding like any other of the rights inscribed in UN treaties. Fundamental to the human rights framework is the concept of progressive realization: Governments cannot solve the drinking water and sanitation situation overnight, but; they must make tangible progress towards the realization of this right. Human rights; principles also define various characteristics against which the enjoyment of the right can be assessed, namely: availability, safety, acceptability, accessibility, affordability, participation, non-discrimination and accountability. A distinctive feature of the human rights framework is the principle of nondiscrimination. This; requires looking beyond average attainment and disaggregating data sets to determine whether any sort of discrimination is occurring. (UNICEF and WHO, 2012)

Access to a clean and reliable supply of water is neither random nor equitably distributed globally. Geography, history, and politics shape the distribution of water across the globe, and even within countries social groups differ in their access to water (Whiteford and Vindrola-Padros, in press). Hygiene, the practice related to washing one’s hands and other body parts to reduce the transmission of fecal-oral diseases like cholera or other forms of diarrhea, is strongly connected to the availability and reliability of a source of clean water (Whiteford, 1999). Social and behavioral science research has repeatedly demonstrated how people’s attitudes and practices reflect not only cultural rules and expectations, but also the ability to regularly access clean water (Esrey, 1996). During the 1991 cholera pandemic that moved through South and Central America (in research funded through a bilateral agreement between USAID and the Ecuadorian government), researchers found that in areas of water scarcity, water was used and reused, stored, and parceled out. Clean water was first used in cooking, food preparation, and dishwashing, then for personal use like hand washing or bathing, and then as slops for the animals. As part of the Ecuadorian cholera intervention project, soap was introduced along with health education about the need to use soap. The assessment following the intervention showed many

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successes, but not in the use of soap (Whiteford, 1999; Whiteford and Laspina, 1996a; Whiteford et al., 1996b; Whiteford and Vindrola-Padros, in press). Ethnographic interviews with women in the households uncovered the reason for the failure to use soap in water that needed to be used multiple times and for multiple purposes. ‘The pigs do not like soap in their water’ women said, ‘so we stopped using soap’. If the pigs were less picky, or if the household had more water so the water did not need to be used so many times, the women would have used soap. The lesson is that in water-scarce settings, householders are particularly conscious of the many uses the water must serve, both inside and outside of the house and adapt their practices accordingly.

Water and Health According to the World Health Organization (WHO), one of the greatest global challenges to world health is the prevention of water-related disease (WHO, 2012c). Close to 1 billion people lack access to an improved water supply, and there is an estimated 2 million annual deaths attributable to unsafe water, sanitation, and hygiene worldwide. In addition, more than 50 countries report the continuing presence of cholera (WHO, 2012c). Schistosomiasis, another water-related disease, infects an estimated 260 million people globally (WHO). The list of water-related diseases and what parts of the globe people are most affected reflects the continuing inequality of access to clean water and sanitation. An estimated 4% of the global disease burden could be prevented by improving water supply, sanitation, and hygiene (WHO, 2012c). “Poor water quality continues to pose a major threat to human health. Diarrheal disease alone amounts to an estimated 4.1% of the total disability adjusted life years global burden of disease and is responsible for the deaths of 1.8 million people every year (WHO, 2004). It was estimated that 88% of that burden is attributable to unsafe water supply, sanitation, and hygiene and is mostly concentrated on children in developing countries” (WHO, 2012c). Water-related diseases (some of which can be seen in Table 1 above) are common worldwide and require environmental as well as infrastructural, educational, and behavior change interventions to control their spread. And as humans continuously modify their surroundings by building canals, transforming wetlands into agricultural areas, removing forests, irrigating arid lands, and by bringing new animals – including humans – into contact with the vectors, the type of threat changes, as do the responses. One classic example of this vector/environment/human health picture can be seen in the story of the Aswan High Dam in Egypt. “In 1971, with the completion of the great dam at Aswan and the filling of Lake Nasser behind it, the epidemiology of Schistosomiasism in Egypt changed radically” (Desowitz, 1987). Schistosomiasis (also known as bilharzia) is a waterrelated disease caused by parasitic worms that spend part of their life cycle in the water. More than 200 million people are infected globally and the disease is second only to malaria as the most devastating parasitic disease (CDC, 2012). The parasites that cause schistosomiasis live in types of freshwater snails and the infectious form of the parasite emerges from the

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Table 1

Partial listing of water-related diseases and their transmission routes

Transmission/route

Definition

Preventive strategies

Examples

Water borne

Person/animal ingests water with pathogen

Cholera; typhoid; infectious hepatitis; diarrhea; dysentery

Water washed

Due to inadequate quantity of water for personal hygiene

Water based

Pathogen that spends part of life cycle in water (all parasitic worms)

Insect vector

Transmitted by insects breeding or biting in or near water

1. Improve water quality 2. Prevent casual use of unprotected sources 1. Increase quantity 2. Improve accessibility 3. Improve reliability 4. Improve hygiene 1. Reduce need for contact with infected water 2. Control snail pop 3. Reduce contamination of surface water 1. Improve surface water management 2. Destroy breeding sites 3. Reduce need to visit breeding sites 4. Use mosquito bed nets

Cholera; bacillary dysentery; bacterial skin sepsis; scabies; fungal skin infection; typhus; trachoma Schistosomiasis guinea worm

Malaria, yellow fever, dengue, onchoceriasis

Source: Ryan Schweitzer adapted from Mihelcic, J.R., Fry, L.M., Myre, E.A., Phillips, L.D., Barkdoll, B.D., 2009. Field Guide in Environmental Engineering for Development Workers: Water, Sanitation, Indoor Air. American Society of Civil Engineers (ASCE) Press, Reston, Virginia.

Figure 2 Left: Biomphalaria sp., the intermediate host for Schistosoma mansoni. Right: Bulinus sp., the intermediate host for Schistosoma haematobium and Schistosoma intercalatum. Center: Adults of S. mansoni. The thin female resides in the gynecophoral canal of the thicker male. Source: Centers for Disease Control and Prevention (CDC), 2012. Parasites-Schistosomiasis. http://www.cdc.gov/parasites/schistosomiasis/ (last accessed 12.09.12.).

snail, contaminating the surrounding water (see Figure 2). People are infected when breaks in their skin come in contact with contaminated freshwater as, for instance, when women wade into contaminated water to wash clothes or engage in other household tasks. The parasites enter the body and become worms that can lodge in the urinary or intestinal tracks and are released back into the water through defecation (CDC, 2012). In the Egypt case, the Aswan High dam changed patterns of seasonal irrigation and the winter closing of the irrigation canals. Prior to building the dam the schistosome, while endemic to the area was primarily limited to the Delta, and annual relief was provided during the winter season when the canals were allowed to dry out and were dredged to clear them out. As the canals were annually dredged of the accumulated silt, the snails were also removed (Malek, 1975). But all that changed with the construction of the dam and with the year around activity it made possible. Concomitantly, human activity and fecal pollution (and the distribution of the parasite) increased. As the human population increased, so did its risk of superinfection. Without a doubt the electricity

provided by the dam enhanced Egypt’s ability to develop the area, but as more than one health advisor has observed: “The beneficiaries of the Aswan project were the snail and the schistosome: they flourish. Unfortunately, the (hydro) electric bill too often contains a high schistosomal surcharge” (Desowitz, 1987). While the snails may have been a beneficiary of the dam, household and traditional gender roles resulted in women being increasingly exposed to the parasites through increased contact with water contaminated with the snails (Watts, 2004). As the annual dredging of silt (and snail) removal no longer occurred, and as population increased, so did rates of infection, at least in the Delta area. Gender roles and economic status were both implicated in the increased levels of schistosomiasis because certain groups of people (women and people whose livelihoods were attached to the water) were unequally exposed to the contaminated water. This pattern is repeated globally as people in resource scarce countries are more exposed to water-related diseases, and women, poor people, and marginalized or disenfranchised groups are at higher risk of infection.

Water, Health and Social Inequality

Gender, economics, geography, and education are all characteristics that correlate to inequalities in access to clean water and sanitation, and thus, are directly tied to increased risk of exposure to water-related disease (Coles and Wallace, 2005; De Alburquerque, 2009; El Katsha and White, 1989; Roark, 2003). Women are particularly vulnerable as they may have to travel considerable distances to bring water from its source to their homes. Likewise, women who must use open defecation practices because of the lack of sanitation often seek secluded areas to protect themselves from being seen. However, that very seclusion may expose women and girls to predatory attacks. These examples show us how water and sanitation are directly tied to power and social inequality (Ahlersa and Zwarteveenb, 2009). According to a UNICEF and WHO report on the time used to collect water in water-poor areas: “An analysis of data from 25 countries in sub-Saharan Africa, representing 48% of the region’s population, reveals that women and girls bear primary responsibility for water collection, at considerable cost in terms of their time. Only a quarter of the population in these countries had water on their premises in 2010, meaning that in 75% of households, water had to be collected from a source some distance from the dwelling. In 71% of all households without water on the premises, women or girls are mainly responsible for water collection. In 29% of households, men or boys assume this task. Further analysis shows that the mean time of one round-trip to collect water is approximately 30 min for both women and men, and is only slightly lower for children (28 min). Each household requires at least one trip per day, but may, in fact, require several trips. The time and energy devoted to water collection is considerable, even based on a one trip per day minimum. In these 25 countries, it is estimated that women spend a combined total of at least 16 million hours each day collecting drinking water; men spend 6 million hours; and children, 4 million hours” (UNICEF and World Health Organization, 2012: p. 31). One response to the unequal distribution of water and sanitation and their health and well-being consequences is the 1999 Protocol generated by the United Nations Economic Council for Europe (UNECE), The Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes (UNECE, 2000). Article 1 of the Protocol states: “The objective of this Protocol is to promote at all appropriate levels, nationally as well as in transboundary and international contexts, the protection of human health and well-being, both individual and collective, within a framework of sustainable development, through improving water management, including the protection of water ecosystems, and through preventing, controlling and reducing water-related disease” (UNECE, 2000). According to the document: “. in the European part of the UNECE region alone, an estimated 120 million people, i.e., one person in seven, do not have access to safe drinking water and adequate sanitation, making them vulnerable to waterrelated diseases, such as cholera, bacillary dysentery, coli infections, viral hepatitis A, and typhoid. Cleaner water and better sanitation could prevent over 30 million cases of waterrelated disease each year in the region. The 1999 Protocol on Water and Health was negotiated with this in mind. The main aim of the Protocol is to protect human health and well-being by better water management, including the

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protection of water ecosystems, and by preventing, controlling, and reducing water-related diseases. The Protocol is the first international agreement of its kind adopted specifically to attain an adequate supply of safe drinking water and adequate sanitation for everyone (UNECE, 2000: p. 10, emphasis not in the original) and effectively protect water used as a source of drinking water. To meet these goals, its parties are required to establish national and local targets for the quality of drinking water and the quality of discharges, as well as for the performance of water supply and wastewater treatment. They are also required to reduce outbreaks and the incidence of water-related diseases. This Protocol introduces a social component into cooperation on water management. Water resources management should link social and economic development to the protection of natural ecosystems. Moreover, improving the water supply and sanitation is fundamental in breaking the ‘vicious cycle of poverty’ (UNECE, 2000). The relation between access to clean water and sanitation and good health is clear and has been well understood for decades. However, the global provision of an equitable supply of water and sanitation is elusive. But steps are being taken. Both the Millennium Development Goals (MDGs) and 1999 Protocol provide mechanisms by which to assess and measure improvements in access to clean water and sanitation, and simultaneously (at least the 1999 Protocol) the management of shared resources such as bodies of freshwater. As we will see in the next section, the case of the cholera epidemic in Haiti demonstrates how failed attempts to provide clean water and sanitation allowed the introduction of the cholera vibrio to spread rapidly with deadly results.

Water, Health, and Inequality in Haiti The 7.0 earthquake that struck Haiti on 12 January 2010 killed 316 000 people and displaced nearly 1.5 million to camps and temporary housing facilities (IOM, 2010). The country was devastated and the large influx of international humanitarian aid was not properly targeted, nor sufficient enough to compensate for the lack of medical resources, destroyed infrastructure, and an ill-functioning water and sanitation system. Internally displaced people (IDPs) were relocated to camps that were not always equipped to handle the large influx of people and many camps did not have water or toilets. The spread of disease was imminent in too many ways. Since the laboratory confirmation of the first cholera case was made on 21 October 2010 (Mendoza et al., 2011: p. 2177), 250 000 cases, about 125 000 hospitalizations, and 4000 deaths have been reported (Dowell and Braden, 2011; Tuite et al., 2011). The first Haitian cholera case was produced by the contamination of water sources by UN troops who had traveled from Nepal and were stationed near the town of Artibonite (Tuite et al., 2011). Haiti had not experienced cholera for more than a century (Mendoza et al., 2011: p. 1161) and suddenly it had to deal with one of the largest cholera epidemics in the world.

An Epidemic Waiting to Happen The sharp political, social, and economic inequalities in Haiti set the stage for the rapid spread of the disease, the inability to

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Water, Health and Social Inequality

contain the bacteria, the late treatment of patients, and the avoidable deaths of thousands of people. As Bell has argued, “problems that occur elsewhere are often more extreme in Haiti, the causes found in the age-old processes of domination and expropriation” (2001: p. 9). Haiti is located in the Greater Antillean Archipelago and shares the Island of Hispaniola with the Dominican Republic. It is divided into 10 departments and Port-au-Prince, the capital, is the largest city (WHO, 2011). Haitian political administration has been characterized by political instability with 32 coups and a series of brutal dictatorships (WHO, 2011). Pan American Health Organization summarized Haiti’s recent socioeconomic situation as follows: “one of the poorest and smallest countries in the world and the least developed in the American region; a high level of corruption and inequality; severe environmental deterioration and deforestation; lack of export industries and a large deficit; an on-going brain drain, primarily to the United States, Canada, and France; most services delivered by NGOs with token supervision and consultation from the Government” (2011: pp. 2–3). With regard to this last point, it is important to highlight the reliance on nongovernmental organizations (NGOs) for the management of the basic services required by the population in Haiti and its negative effect on the role of governmental institutions (Schuller, 2012). International donors and providers of aid have favored foundations and other forms of NGOs when depositing their funds, thus reproducing a privatized form of humanitarian assistance (Schuller, 2012). Two of the factors most intimately related to the spread of cholera, an inadequate water and sanitation system and poor access to health care, have been severely affected by the political and economic situation outlined before. The public health care system suffered so much deterioration that as of 2010, it delivered only a third of health services (Ivers et al., 2010: p. 2050). Medical care in Haiti has been described as ‘an obstacle course, one that places innumerable barriers before poor people seeking care’ (Farmer, 1999: p. 145). In 2009, there were three physicians per 10 000 people and 13 hospital beds per 10 000 people (PAHO, 2011). The people who could physically access public services paid for fees as the most basic services had hidden costs (Farmer, 2011). This situation certainly contributed to the low life expectancy (59 for males and 63 for females), high infant (80.3 per 1000) and maternal mortality (523 per 100 000) rates in the country, the highest incidence of tuberculosis in the Americas, and an ongoing HIV epidemic (PAHO, 2011; WHO, 2011). The water and sanitation system fared no better. Between 2000 and 2004, international aid to the Haitian public sector was significantly reduced, and donors and lending agencies preferred to direct funding to NGOs (Ivers et al., 2010: p. 2048). Water shortage was exacerbated by the earthquake, but it was certainly not a new phenomenon in Haiti. For instance, in 2002, Haiti was ranked last among 147 nations in a water poverty index produced by the World Resources Institute in Washington, DC (Webster, 2011: p. E83). In 2006, it was estimated that only 58% of the population had sustainable access to improved drinking water sources while 19% were able to use improved sanitation (WHO, 2011).

Table 2

The spread of cholera cases in Haiti, 2010

Date

Event

14 October 2010 17 October 2010 18 October 2010

First cholera case in Meille First death registered in Mirebalais hospital Increase in diarrhea cases reported by the Cuban medical brigades to the Ministry of Public Health and Population Haitian investigation team is sent to Meille Ten additional cholera cases found in Meille The first alert from Bocozel in the Lower Artibonite is received when three children die from diarrhea New alerts received from approximately 10 health centers along the lower course of the Artibonite river 3020 cases, 1766 hospitalizations, and 129 deaths were reported in the Lower Artibonite region Epidemiologic confirmation of first case in Meille Cholera cases notified in 14 communities in the regions around the Artibonite plain and Port-au-Prince Clusters of cases were identified in the North-West Department Clusters of cases were identified in the West Department Cases confirmed in the Dominican Republic and Florida (U.S.) Clusters of cases were identified in the North-East Department (Haiti)

19 October 2010

20 October 2010

21 October 2010

22 October 2010

11 November 2010 14 November 2010 16 November 2010 21 November 2010

Source: Centers for Disease Control and Prevention (CDC), 2010. Update on cholera-Haiti, Dominican Republic, and Florida, 2010. Morbidity and Mortality Weekly Report 59 (50), 1637–1641; Piarroux, Renaud, Barrais, Robert, Faucher, Benoit, Haus, Rachel, Piarroux, Martine, Gaudart, Jean, Magloire, Roc, Raoult, Didier, 2011. Understanding the cholera epidemic, Haiti. Emerging Infectious Diseases 17 (7), 1161–1168.

In addition, the 2010 earthquake left about 1.5 million people without homes, forcing them to move to temporary settlements, where for many, living conditions worsened (IOM, 2010; PDNA, 2010). In these internally displaced camps, 40% of the camps had drinking water and 30% did not have toilets (Kaussen, 2011: p. 6). As a result of this situation, the cholera bacteria spread at a rapid pace, first in Mirebalais and then in each of the Haitian departments. Trauma victims, those with poor preexisting health status, and nutritionally compromised people could not fight it off and instead became its fatalities. In Table 2, we have summarized the different stages of the spread of cholera as outlined by Piarroux et al., 2011, the team of French and Haitian epidemiologists who tracked the dispersion of cholera.

Dealing with the Epidemic The earthquake that struck the country led to an unprecedented immersion of foreign humanitarian assistance. Foreign assistance took different forms, from the influx of monetary donations to the settlement of medical and assistance personnel in IDPs and Cholera Treatment Centers (CTCs) all over the country. It is estimated that the international community pledged to provide $10 billion in aid to Haiti, but only 2% of

Water, Health and Social Inequality

this money had been spent by 2010 (Kaussen, 2011: p. 6). Even though portions of this fund were eventually made available to the country’s officials, cases of government corruption were documented, the money was not used effectively, and there was no guarantee that the funds would be used to deal with Haiti’s most pressing problems (Farmer, 2011: p. 210). The coordination of the large number of local and international NGOs working in Haiti after the earthquake and during the cholera epidemic was not without complications. The lack of public oversight of NGOs led to the creation of gaps in services; the distribution of aid was unequal in that a large portion of the aid was focused on the areas that were most affected by the earthquake and not enough attention was paid to the rural areas where the epidemic ultimately emerged; and the overreliance on NGOs for the management of basic services demeaned the role of governmental institutions (Ivers et al., 2010: p. 2048; Schuller, 2010). By the end of 2011, most public health reports indicated that the cholera epidemic in Haiti had moved toward containment as fewer cases were being reported and treatment was provided to those already suffering from the disease. Several publications, however, cautioned that the improvement of the cholera scenario could be the product of the end of the rainy season in the region and they predicted the disease would probably reemerge once the rain returned (MSF, 2012). That prognosis was also supported by reports that proclaimed that water and sanitation infrastructure had not undergone significant transformations and the living conditions in settlement camps had actually deteriorated (Webster, 2011). During the first half of 2012, many of these predictions became realities. The rainy season began and the disease continued to spread. Medecins sans Frontieres (MSF) reported in less than 1 month into the rainy season, that the cases of cholera patients in their CTCs nearly tripled. From 16 to 23 April 2012, 134 cholera patients were admitted into MSF’s center in Martissant and another 400 patients were admitted to the other MSF centers in Port-au-Prince and Leogane. This organization even had to reopen a CTC in Carrefour to prevent the overburdening of other operating centers in nearby cities (MSF, 2012). The cholera epidemic in Haiti points to the fact that in areas of the world where water, sanitation, and access to health care cannot be guaranteed for society as a whole, the spread of infectious diseases (like cholera but not limited to it) will remain a latent possibility. The fragile condition of Haitian public services posed a threat to people’s lives even before the earthquake struck the country. A natural disaster of this magnitude certainly complicated matters, but Haiti’s cholera epidemic was mainly produced by deeper political, economic, and social factors that led to its long-term economic and material impoverishment, dependence on international humanitarian assistance, and lack of coordination of public services.

Social and Behavioral Sciences on Water/Health/ Sanitation The use of water by human populations has been a topic of interest to researchers because of its importance in everyday life. Water is a social commodity in that it ‘connects different

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domains of social life to each other in ways that are not haphazard or accidental because they depend on each other’ (Orlove and Caton, 2010: p. 402). In other words, water is not only vital for human existence; it is engrained in all aspects of our society, from gender relations within the household that determine who collects and uses water, to complex economic and political systems that organize distribution at macro levels. Water has had multiple representations: a quantifiable good that can be commoditized, a scarce resource, a productive tool, and a universal resource (Aiyer, 2007; Derman and Ferguson, 2003). Its connection with all aspects of human life renders water studies varied in approaches; they have focused on the political nature of water, the power relations involved in its control and the inequalities in its distribution (Boelens and Doornbos, 2001; Johnston, 2005). These inequalities are often organized in relation to gender and social class. In relation to gender, “rights and entitlements may shape the ways in which women feel able to participate in particular mechanisms of water access, such as water-point committees or farmers’ organizations, how their voices are heard, and how their rights of access are shaped and asserted at the local level” (Cleaver and Hamada, 2010: p. 30). In some societies, gender influences access and use of water in ways that are detrimental to women, excluding them from local property rights and governance bodies, and prohibiting their access to water sources due to religious norms or taboos around menstruation, pregnancy, and childbirth (Cleaver and Hamada, 2010: p. 30). In other cases, women are the ones in charge of the hard labor surrounding water collection, investing energy and time in the collection of a resource that is fundamental for the survival of the household. The distribution of water is a process involving multiple actors, each with its own needs and interests. Allen et al. have proposed to look at water provision through a ‘water supply wheel’ (Figure 3) where the public, private, and community sectors negotiate different arrangements for water distribution based on policy and needs driven interests. In the developing world, water access is often generated by individual needs and informal mechanisms, rather than by governmental policies, thus leaving specific sectors of the population, usually the resource-poor social classes, without reliable access to potable water (Allen et al., 2006a). Inequalities in access to safe and potable water have been of particular interest to health researchers as water access, reliability, and quality are strong determinants of health and wellbeing (Whiteford and Cortez-Lara, 2005; Whiteford and Whiteford, 2005). Systems of water management directly affect the spread of disease and when guided by the principle of water as a commodity, tend to leave marginalized and underprivileged sectors of the population more vulnerable to waterborne, water-based, and water-related infections. Water-borne diseases are caused by ingesting water that is contaminated by human or animal excreta or urine containing pathogenic bacteria or viruses, while water-based diseases are caused by parasites located on intermediate organisms living in water (Montgomery and Eimelech, 2007). These diseases are usually prevalent in areas where people do not have access to running potable water and most frequent other, usually contaminated, sources of water. Water-related diseases are caused by microorganisms with life cycles associated with insects that live or

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Needs-driven

Pub

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Pu bli c

Communitybased provision Public community Water partnerships as a gift Rainwater Fully public harvesting Clandestine Passive private connections investment Public provision distorted by bribery Service contract Informal sector vendors BOT and (e.g., pushcarts) concession Water sold from privately Joint Fully venture private owned wells

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Figure 3 “Water supply wheel” developed to highlight the different types of water distribution. Source Allen, A., Davila, J.D., Hofmann, P., 2006a. The peri-urban water poor: citizens or consumers? Environment and Urbanization 18 (2), 333–351.

breed in water and water collection and storage diseases are caused by contamination that occurs during or after the collection of water (Montgomery and Eimelech, 2007). When access to water is unreliable, people are forced to store water in containers for future use, thus creating breeding grounds for insects that act as disease vectors. Sanitation has been a relatively unexplored topic by social scientists (Singer, 2012; Whiteford and Whiteford, 2005). Most studies have stemmed from other disciplines such as environmental engineering and public health (O’Loughlin et al., 2006; Rodgers et al., 2007; Wakeman, 1995; McConville and Mihelcic, 2007). This situation is complicated by the fact that policy discussions on the need to consider access to water as a universal human right do not always explicitly include sanitation (Allen et al., 2006a). When examining practices of waste management, studies have found that this is an aspect of human behavior heavily influenced by social and cultural factors (Kendall, 2005). The management of human waste is influenced by religious beliefs and ideas regarding purity and danger (Alley, 2002). It is not surprising then that latrine programs that have failed to take these beliefs into consideration have been unsuccessful, such as the latrine program directed by the Swedish Army in Somalia during the 1980s where Muslim refugees refused to defecate facing Mecca (Waldman and Williams, 2001) or proposals for latrine programs in Bolivia where participants would not engage in the digging of their waste because it would be considered disrespectful of the Pachamama (deity of mother Earth) (Aruquipa, 2008). Where defecation takes place, when, and how are all issues inextricably linked to social categories such as gender, class, and ethnicity (Wakeman, 1995). Previous research

found that women and young children are the groups that benefit the most from sanitation programs as they are the ones at greatest risk of violence (attacked in ‘defecation zones’, victims of rape, etc.) when these facilities are lacking (Schuller, 2010; Wakeman, 1995). The distribution, availability, and quality of latrines and/or toilets mirror the distribution of economic resources in the larger society where disadvantaged groups and the lower social classes are often left without sanitation infrastructure or with subpar services (Allen et al., 2006a,b). In many areas of the world, disadvantaged groups are often indigenous groups because they live in marginalized areas without access to basic services such as potable water and sanitation (Whiteford and Vindrola-Padros, in press). This leads to a higher incidence of water-borne and excreta-borne diseases in particular ethnic groups as evidenced by the cholera epidemics of 1992–93 in the Orinoco Delta of Venezuela (Briggs and Mantini-Briggs, 2003) and 1991–93 in Peru and Ecuador (Whiteford and Vindrola-Padros, in press). When attempts have been made to change or improve sanitation, these interventions have been influenced by community-level behaviors (Yacoob and Whiteford, 1994) and individual preferences (Kendall, 2005; O’Loughlin et al., 2006; Rodgers et al., 2007). Even in cases where latrine programs have been developed in relation to local customs and practices, many times community members misuse or discontinue latrine use due to bad smell, flies, lack of privacy, or the perception that latrines are dangerous (O’Loughlin et al., 2006; Rodgers et al., 2007). Many studies have, therefore, concluded that technological innovation in the form of transforming sanitation infrastructure needs to be adapted to the local context, in sustainable form, and engaging the participation of community members (McConville and Mihelcic, 2007).

Conclusion Perhaps no other elements are as central to global health and well-being as water and sanitation. And while the relationship between access to a clean and reliable supply of water and health has long been understood, only recently have people involved in development, and global health begun to include sanitation as the twin urgent need. In this article, we used the case of the cholera epidemic in Haiti to demonstrate how the failure to create an equitable system for a water and sanitation infrastructure resulted in avoidably high levels of loss of life. Political turmoil over the control of water is perhaps as old as civilization itself. Shaped by power relations and reflected in the inequitable distribution of risk that women, the elderly, children, and the poor suffer from water-related diseases, increasingly attention is now being paid to the combination of water and sanitation. The social and behavioral science research clearly identifies the complex relationships among water, health, and inequality; less clear, however, is how to respond to the complex emergency of increased levels of water-related disease globally. Practitioners say that global health is sexy – curing people from exotic diseases like Ebola, saving babies and young

Water, Health and Social Inequality

children from untimely death due to malnutrition, or providing women with safe childbirth. But sanitation is not sexy. It is dirty, smells foul, and makes people uncomfortable. And yet, everyone engages in it. Some people are forced to defecate in the open; others defecate in streams or rivers or back alleys. At the level of the individual, defecation and other sanitation practices reflect personal, cultural, and religious constraints. At the level of the community, they are questions of political will and infrastructure – and in addition, creating and maintaining a system of waste management are expensive. The problems that beset improving water, health, and social equality are not, however, intractable. Improvements in water and sanitation are occurring and increasingly occurring with attention to equity. The MDGs, like the 1999 Protocol, have focused attention to the need to rectify the global inequities in levels of health, access to water, and now increasingly, access to sanitation. And, while the future itself may not be clear, the road to improved global health is.

See also: Ecology and Health; Hazards and Disaster Research in Contemporary Anthropology; Health Politics and Policy; Health: Anthropological Aspects; Inequality: Comparative Aspects.

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