Csi Group 3b

CLINICAL SCIENCE AND HEALTHCARE INFORMATICS 26/11/2009

Sarah Murphy Triona Hussey Mehak Mahipal

Table of Contents 1

Farhana Kadir

1. Abstract (Choice of Topic)..……………………………………………………………. 03

2. History of Sanitation……………………………………………………………………. 04 3. Pathology of Inadequate Sanitation…………………………………………………….. 06

4. Benefits of Sanitation…………………………………………………………………… 00 5. Further Development of Sanitation……………………………………………………... 00 6. Conclusion……………………………………………………………………………… 00 7. Appendix 1(Group Work Process)……………………………………………………… 00 8. Appendix 2 (Bibliography)……………………………………………………………... 00

9. Appendix 4 (Word Counts)……………………………………………………………... 00

Abstract

2

Medicine finds solace in the age old adage “prevention is better than cure” and rightly so. As modern day health professionals, it is of paramount importance that we recognize that it may not necessarily be medicine, that is to say a certain medical procedure, medical drug or indeed any other medical advancement as such, which holds the key to solving a majority of underlying health problems. Within the realm of this very principle, it is imperative that we fathom the benefit of directing costs of traditional medicine into behavioural, environmental and even social change to promote prevention of illness and healthy living. The development of a proper sewage system or even the introduction of a basic toilet is one such change. In 1948, 14,137 Londoners lost their lives to recurring epidemics of cholera resulting from improper sanitation [Binghama P, et al pp . Provision of sanitation has more often than not been over looked and at times even been

387-394]

completely ignored despite such events.

Even in today’s magnanimously advanced world,

inadequate, or a complete lack thereof, sanitation results in approximately 1.87 million deaths from diarrhoea alone, 90% of which number are children under the age of 5

[Boschi-PintoI C et al (2008).

. In the words of Dr. Jong-wook Lee, the director general of the World Health

pp710-717]

Organisation, “once we can secure access to clean water and to adequate sanitation facilities for all people, irrespective of the difference in their living conditions, a huge battle against all kinds of diseases will be won

.” Development of sanitation facilities, a toilet in perhaps very

[WHO (2004)]

basic words, not only possesses the potential of preventing endemics but in turn, saving numerous lives and can therefore be deemed one of the most important medical advancements in the past 200 years. Hence the choice of this topic for the report.

History of Sanitation The etymology of the word hygiene itself creates a long standing association with health and medicine. The word finds its roots in the Greek word Hygeia, the Greek goddess of health 3

and the daughter of the Greek god of medicine Aesculapius

. Despite its ancient

[Miguel (2002) pp 122-23]

origins, defecation has never been a communal topic of discussion due mainly to the repugnance associated with it. Nevertheless, the toilet forms an indispensible part of the history of human civilization. In fact, sitting type toilets can be traced back to the Indus Valley Civilization of circa 2500 BC, India

. Over the years, however, adequate sanitation has proved to be a

[Pathak 1995]

tremendous challenge. Throughout the Middle Ages, Europeans, along with the rest of the world, lived amidst a terribly detrimental environment comprised of filth and absolutely insufficient sanitation. Bubonic plague, small pox, typhus and tuberculosis were unbridled and as such average life expectancy failed to exceed even teen years in such times [Miguel (2002) pp 122-23]. The 1780s marked the beginning of the Industrial Revolution in Britain followed by other parts of Europe

[Mackenbach J. (2007)]

. During this period, excreta was most commonly found in dung

heaps or within cess pools. The liquid components of excreta from the cess pools were meant to leach into the soil and the solid parts to be collected by manual labour and further used as fertilizers. However, fecal matter was, more often than not, left to overflow and cess pools were illegally dumped into water supplies. With the incessantly increasing population and in turn, excreta, the Parliament legalized dumping of waste into the Thames

[Mackenbach J. (2007)]

. Not only did

this result in the 1858 “Great Stink of London” but it also escalated bouts of cholera as 5 out of the 9 drinking water companies used the Thames as their main source [Mackenbach J. (2007)]. In the 1848 epidemic, 14,137 people lost their lives to cholera [Binghama P, et al pp 387-394]. These events propelled the motion of legislation to incorporate a proper sewage system in London

, which

[Mackenbach J. (2007)]

along with handwashing reduced child mortality by a fifth as compared to the death of 1 in every 2 children prior to such arrangements [Mackenbach J. (2007)].

4

Hospital reform also ensued in terms of improvement in hygiene and sanitation. This was a direct result of Florence Nightingale’s work in the Crimean War. This reform greatly reduced maternal and infant mortality along with typhoid, tuberculosis and the likes, thereby increasing life expectancy from 59.7 years in 1930 to 74.9 by 1987 [Miguel (2002) pp 122-23]. Over the years, developed countries seem to have adequately provided sanitation facilities, but the challenge is yet to be met at such a scale in developing countries. Even so, evaluation studies carried out in developing

countries

provide

evidence of the considerable effect of provision of sanitation (2007)]

[Mackenbach J.

.

Pathology of Inadequate Sanitation

The history of sanitation clearly alerts one to the multiple medical conditions that arise from inadequate sanitation. Safe sanitary excreta disposal involves the isolation and control of 5

faeces from both adults and children so that it doesn’t come into contact with water sources, food or people. Without access to a toilet or latrine, there exist no safe means of collection, storage, treatment and disposal of excreta. Unsafe excreta disposal, therefore, leads to contamination of ground and water sources, provides breeding sites for nuisance organisms, like flies and mosquitoes, which operate as primary vectors of infection and transmission of fecal-oral disease. A current estimated discharge of 200 million tons of untreated human waste enters watercourses worldwide every year

[UNICEF (2008), pp.1-2].

thought to practice open defecation

In some regions in India, where 800 million people are , “60-70% of the groundwater is contaminated

[Burki, 2009, pp.531]

with human faeces” according to Dara Johnston of UNICEF. He adds that “it is very worrying: (because) 80% of the rural population relies on groundwater via hand-pumps.” This concern stems from the estimation that 1 g of faeces qcontains approximately 10 million viruses, 1 million bacteria, 1000 parasite cysts, and 100 worm eggs [Burki, 2009, pp.531].

6

An estimated 50 diseases are known to be transmitted faecally

. These

[Burki (2009) pp.531]

include diarrhea, a symptom of poor water and sanitation along with cholera, typhoid and dysentery (including shigellosis). 1.8 million people die of diarrhoeal diseases per annum

[Boschi-

PintoI C et al

(2008)

pp710-

, 88%

717]

of which are due to poor hygiene and lack of sanitary facilities [Black,

et

al.,

.

(2003) pp.227]

1.6 million, 90% of these diarrhoeal cases, are children under the age of 5 years

. This

[Burki (2009) pp.531]

implies that 1 child dies every 15 seconds from diarrhea (Burrows, et al. (2004) pp. 3], or more than 5000 die each day which is 5 times the number dying from HIV/AIDS

. Diarrhoea via the

[UNICEF, (2008) pp.1-2]

faecal-oral route, the primary route of infectious agents associated with diarrhoeal disease [Clasen & , accounts for 17% of all deaths of persons under 5

Haller (2008) pp.7]

[Harvey (2007) pp.2]

. Children of this

young age are most at risk because of their underdeveloped immune systems. People suffering

7

from malnutrition and the elderly are also at an increased risk owing to their lower prognosis for full recovery. Cholera, one of the leading infections causing severe diarrhoea, quickly accentuates to acute dehydration and death as well. Over 120,000 people were affected by the disease in the year 2002 alone

. Despite being asymptomatic in around 75% of cases

[UNICEF (2005)]

, it is

[WHO (2008)]

considered a serious threat by all health organizations due to its virulent nature. The pathogens stay in the faeces of the infected individual for 7-14 days

[WHO (2008)]

, and are then shed back into

the environment withholding high potential of infecting more individuals. Direct or indirect contact with decaying faeces or polluted water systems also causes the growth of intestinal worms. These infect an estimated 10% of the population in developing countries

. 400 million young children are infected by intestinal parasites such as

[UNICEF (2005)]

hookworms and roundworms at any given time

. Domestic animals and vermin are

[UNICEF (2005)]

also attracted to faeces, thereby acting as additional means of spreading infection. Excreta related diseases are mainly transmitted orally or through skin penetration. According to studies

[Fewtrell et al. (2005); Esrey (1996)]

, there’s a 36% reduction in childhood diarrhoea by

safer excreta disposal and 35-42% reduction by handwashing alone. Good standards of personal and domestic hygiene are essential to breaking the transmission chain of faecally related diseases. In addition, waste needs to be treated in the correct manner, by eradicating or inactivating pathogens before it can be used or disposed off safely.

8

9

Benefits of Sanitation

The history and resulting pathology of sanitation make it unquestionably apparent that the implementation of proper sanitation is, first and foremost, essential for maintenance of human health. Enhancing sanitation and access to it would lead to a definite decline in the number of cases and deaths resultant of the various afore mentioned diseases. As such, it would lead to a marked improvement in quality of life for people all over the world. Secondly, access to sanitation would also prove to be a sound economic investment as it would curb the onset of more fecal and water borne diseases greatly reducing direct medical costs along with lost income, reduced productivity and even government health service costs. In addition, it would conserve time and effort lost as a result of lack of sanitation resulting in an additional economic value of $114 billion every year and increase tourist income of a country by means of reducing risks of contamination and diseases [UN (2008)]. Upgrades in sanitation would also have a substantial effect on education. Current estimates propose 200 million lost days of school and at least two thirds of African children in schools being worm infested due to lack of or horrific sanitation

. The introduction of

[UN (2008)]

appropriate latrines will lead to a massive increase in enrolment and retention rates of girls in schools post the onset of menstruation [UN (2008)]. Some may argue that the provision of sanitation would require monetary support in the first place. However, for every 10% increase in female literacy, a country’s economy grows by atleast 0.3% [DDWS (2008)]. In addition, an investment of $1 in sanitation facilities results in a return or profit of $7

[Hutton, Haller et al (2007) pp 481-502]

. The environmental impacts of improper sanitation also

result in vast amounts of untreated human waste and pollution resulting from it. In South East 10

Asia alone, over US$ 2 billion are spent on clearing over 13 million tons of faeces dumped in water sources [UN (2008)]. This is a huge financial burden that can avoided. Lastly, sanitation also contributes to dignity and social development in terms of parents bearing stigmas of the deaths of their young children, women being raped as they tend to their sanitary needs in the open at night and the dishonor that results from having jobs of cleaning faeces [UN (2008)].

Further Development of Sanitation

11

An estimated 2.6 billion people, constituting about 40% of the world population, still do not have access to toilets today [UN (2008)]. In the past sewers were built to help such unfortunate people but these were not adequately capable of disposal. Toilets were supplied as well but these, being more tangible than people’s homes, began to be used as temples and storage houses. Having a proper toilet also often meant that those sans running water had to fetch extra water each day in order to flush the toilet. The 7th Millenium Development Goal (MDG), which looked to reduce the proportion of people lacking access to sanitation by half till the year 2015

[UN (2008)]

,

did not beget as much attention as it should have despite being a goal essential to achieve the other goals. At the current rate of progress, the prognosis of MDG 7 being achieved by 2015 might not be completed till 2026 [DDWS (2008)].

12

There have been multiple programs, however, that are beginning to change this scenario. By setting up the National Rural Environmental Sanitation Program, the Malaysian government

has provided 98% of its rural population with access to latrines

[UN (2008)]

. The Government of

Thailand runs a similar program as well resulting in massive health and development benefits for the population

. According to the UNICEF, a billion people received sanitation between

[UN (2008)]

1992 and 2002 as well [UNICEF (2004)].

Bindeshwar Pathak, founder of the Sulabh Toilet Museum in Delhi, India has invented a twin pit toilet. This toilet only costs about $15 to construct and needs a mere 1.5 litres of water to flush. As the name suggests, the toilet consists of 2 latrines, each with a pit. The family uses one of the pit latrines till it is filled and 13

subsequently use the other. Whilst the second pit is in use, the excreta in the first pit dries up and can then be used as fertilizer. Most importantly, these pits do not require cleaning which reduces the need for manual scavengers.

In 2002-2003 there were an estimated 676,000 manual

scavengers compared to a more recent estimate of 115,000 in India. Pathak’s ambition is to make the country scavenger free in five years time. Pathak’s Twin pit toilet has created greater access to sanitation. For instance, in rural India access to sanitation has increased from 27% to 59% in the space of five years [Khullar M. (2009)]. An additional 5,500 public toilets have also been built across Asia based on his design for the homeless and those devoid of access to a toilet

[Khullar M. (2009)]

.

Clearly, this toilet has already had a dramatic impact. It has the potential to bring sanitation to 4 out of every 10 people that lack access to toilets, helping control the spread of disease and encouraging girls to remain in school and get their education [Khullar M. (2009)]. Evidently, universal sanitation is not an unachievable goal. It requires a culmination of hard work, plenty of funding, an ability to discuss sanitation freely and a stimulating vision of the future amongst other things but with everyone’s support and cooperation, it can be done.

Conclusion

14

The development of sanitation over the years has led to the evolution of the collective consciousness where public health is concerned. As the predecessor of the Germ theory, this development has not only taught us that successful intervention may not always result from correct causation but also reiterated that universal measures may indeed reduce health inequalities. The provision of sanitation would alone reduce the necessity of many of the major medical inventions of the past 200 years vastly. The need for antibiotics, vaccinations and multiple medical procedures for example would decrease greatly if sanitation borne diseases were not rampant in the first place. Billions of people have and will continue to lead better lives, not only medically but also financially and socially in the wake of the sanitary revolution.

Appendix 1

Group Work Process 15

This report is the culmination of four group meetings and supplementary individual research. The first meeting was utilized to concur on a topic. Subsequently, individual research on the chosen topic was carried out by each group member. This research was employed in the next meeting to conjure an outline for the report. At this stage, the outline consisted of: •

Choice of topic

•

Introduction

•

Medical history of sanitation

•

Medical, or other, conditions resulting from lack of sanitation

•

Benefits of sanitation

•

Current efforts of improving sanitation

•

Conclusion

•

Group work process

This served as the foundation for assigning further individual investigation and associated pieces of writing. The various components were then collaborated into a single report and a final meeting ensued to review the report and its ultimate presentation.

Appendix 2 Bibliography

16

1. Binghama P, Verlanderb N.Q, Cheala M.J.. (2004). John Snow, William Farr and the

1849 outbreak of cholera that affected London: a reworking of the data highlights the importance of the water supply. Journal of the Royal institute of Public Health. 118 (1), 387-394. 2. Black, R.E., Saul S.M., Bryce, J. (2003). Where and Why are 10 Million Children Dying Each Year?. The Lancet. 361 (1), 2227. 3. Boschi-PintoI C, VelebitII L, ShibuyaIII k. (2008). Estimating child mortality due to diarrhoea in developing countries. .Bulletin of the World Health Organization. 86 (9), 710-717. 4. Burki, T. (2009). Slow progress towards sanitation goal. The Lancet Infectious Diseases. 9 (9), 531. 5. Burrows G, Acton J, Maunder T. (2004). Water and sanitation: The education drain. Education Media Report. 3 (1), 3. 6. Clasen T.F., Haller L. (2008). Water Quality Water Quality Interventions to Prevent Diarrhoea: Cost and Cost-Effectiveness. World Health Organisation. 1 (1), 7. 7. DDWS. (2008). International Year of Sanition 2008 - Information Package. Available: http://209.85.229.132/search?q=cache:Dz91MlmXKWYJ:ddws.gov.in/handwash/Media %2520Kit/Final%2520IYS%2520Advocacy%2520Kit %2520.doc+The+toilet+is+the+biggest+medical+advance+of+the+past+200+years&cd= 25&h. Last accessed 19 November 2009. 8. Esrey, S.A. (1996). Water, Waste, and Well-Being: A Multicountry StudyAmerican Journal of Epidemiology. Pubmed. 143 (1), 608 – 623. 9. Fewtrell, L., Kaufmann, R.B., Kay, D., Enanoria, W., Haller, L., Colford, J.M. (2005). Water, sanitation and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infectious Diseases. 5 (1), 4252. 10. Harvey, P.A (2007). Excreta disposal in emergencies: A field manual. UNICEF. 1 (1.2), 2. 11. Hutton G, Haller L, Jamie B. (2007). Global cost benefit analysis of water supply and sanitation interventions. Journal of water and health. 05.4 (1), 481-502. 12. Khullar M. (2009). Heroes of the environment 2009 scientists and innovators Bindeshwar Pathak .Available: http://www.time.com/time/specials/packages/article/0,28804,1924149_1924154_192442 9,00.html. Last accessed 17 November 2009. 13. Mackenbach J. (2007). Sanitation Pragmatism Works.British Medical Journal. 334 (1),

17. 14. Miguel A. Faria, Jr., MD. (2002). Medical History --- Hygiene and Sanitation. Medical Sentinel . 7 (4), 122-23. 15. Pathak, Bindeswar Dr., Ph.D., D.Litt. (1995). History of Toilets. Available: http://www.sulabhtoiletmuseum.org/pg02.htm. Last accessed 20 November 2009. 16. UN. (2008). Talking Points for the International Year of Sanitation. Available: http://esa.un.org/iys/docs/IYS%20Advocacy%20kit%20ENGLISH/Talking %20points.pdf. Last accessed 19 November 2009. 17

17. UNICEF. (2004). Meeting the MDG water and sanitation target: a mid term assesment

of progress. Available: http://www.unicef.org/publications/files/who_unicef_watsan_midterm_rev.pdf. Last accessed 17 November 2009. 18. UNICEF. (2005). Common water and sanitation-related diseases. UNICEF. 1 (1), 1. 19. UNICEF. (2008). International year of sanitation 2008: overview. UNICEF. 1 (1), 1-2. 20. WHO. (2004). Water, sanitation and hygiene links to health. Available: http://www.who.int/water_sanitation_health/publications/facts2004/en/. Last accessed 20 November 2009. 21. WHO. (2008). Cholera. World Health Organisation (Fact Sheet). 7 (1), 1.

Appendix 3

Word Counts

Choice of Topic……………………………………………………………………………..292

18

Report……………………………………………………………………………………...1998 Group Work Process………………………………………………………………………..134

19