‘Hygiene, Sanitation and Water’(Environmental Health)
The Forgotten Foundations of HealthTIDI Research Seminar Series
Niall Roche, WaSH/Environmental Health Specialist and Adjunct Assistant Professor, Centre for Global Health, Trinity College Dublin.
27th February 2015
What we will cover today
1. What is HSW/WaSH as it is sometimes known and the wider discipline of Environmental Health.
2. Outline its historical and present importance to the achievement of health objectives
3. Articulate why it seems to be the forgotten foundation of health
HSW/WaSH
• What is WaSH and why say HSW instead?
• WaSH – Water, Sanitation and Hygiene
• HSW – Hygiene, Sanitation and Water
0 10 20
30
40
50
% red uct io n in d iarrho ea
W at er Quant it y
W at er Quali t y Ho useho ld
Hand washing
Water, sanitat io n, and hygiene intervent io ns to reduce diarrho ea in less develo ped co untries: a systemat ic review and meta-analysis, F ewtrell
et a l (2005)
Taken from Hygiene Promotion Briefing Paper prepared for the WASH clustermeeting in February 2008
Sanitation
Water Quality Source
Definition for Sanitation• Determined during the International Year of
Sanitation 2008 and defined by the Water Supply and Sanitation Collaborative Council and approved by the UN-Water Task Force on Sanitation.
• Sanitation is:• “the collection, treatment and disposal or reuse of
human excreta, domestic wastewater and solid waste, and associated hygiene”
Key Components of WaSH and wider Environmental Health for Developing Countries
WaSH• Water supply• Excreta Management• Liquid (grey water mainly) and Solid Waste Management (including dead
body management – Ebola!!)• Hygiene/Health Promotion
• Vector Control (malaria, dengue, leishmaniasis, chikungunya etc.)• Housing/Shelter and Settlement/Site Planning• Control of Pollution (Ambient and Household Air Quality in particular)• Tobacco Control
• Note: Frumkin et al describe climate change as ‘an environmental health hazard of unprecedented scale’ (Frumkin, Howard and McMichael Anthony, Climate Change and Public Health: Thinking, Communicating, Acting, American Journal of Preventive Medicine, 35 (5), p.403-410
Other aspects you could justifiably address
• Food Hygiene and Safety (think of Food Safety issues in Ireland) – not just microbiological safety anymore! – NCDs and Nutrition importance.
• Noise• Radiation (think of Radon)• Road Safety (1.3 million deaths globally every
year) – more than double from malaria!
Let’s not forget!
• Water and Sanitation
• One of the components of Primary Health Care as defined at Alma Ata in 1977
• It should be classified as a Health MDG but is lost under MDG7 on Environmental Sustainability.
Determinants of HealthDeterminants of Health
1.1. Genetic (Genetic (egeg sickle cell sickle cell anemiaanemia common common among Africans and cystic fibrosis common among Africans and cystic fibrosis common among north Europeans)among north Europeans)
2.2. Lifestyle (Lifestyle (egeg diet, smoking, alcohol)diet, smoking, alcohol)
3.3. Environment (Environment (egeg housing, water etc.)housing, water etc.)
4.4. Access to Health ServicesAccess to Health Services
History 10
Some History
• In 1854 John Snow and the Broad St. handpump
Slide from Dr. Miriam Owens, HSE, Dublin.
A wee lookInto our own history and acartoon publishedin December 1908
Decline in Infectious DiseasesDecline in Infectious Diseases
Deaths below 15 years attributed to scarlet fever, diptheria, whooping cough and measles, England and Wales
0
2000
4000
6000
1850 1875 1900 1925 1950 1985
Dea
ths p
er m
illio
n ch
ildre
n
No Effective medical care for children
Antibiotics immunisations
Source: Morley, D. and Lovel, H. My Name is Today, TALC, 1986
Decline in infectious diseasesDecline in infectious diseases
Reasons for the DeclineReasons for the Decline
1.1. Improved Nutrition Improved Nutrition 2.2. Improved HousingImproved Housing3.3. Improved Water and SanitationImproved Water and Sanitation
Note: 29% reduction in child mortality in 10 years between 1898 and 1908Note: 29% reduction in child mortality in 10 years between 1898 and 1908
BMJ Poll of 2007• In 2007 the British Medical Journal ran an online poll
asking people to vote on the Most Important Medical Advance since 1840:
• What advances topped the poll?
• Vaccinations?• Antibiotics?• Immunology?• Computers?• Others?
BMJ Poll 2007
• Topping the poll was:
• SANITATION – 15.8%• Antibiotics – 14.5%• Anaesthesia – 13.9%• Vaccines – 11.8%
CURRENT BURDEN OF DISEASEGLOBALLY
ONE KEY BASIS FOR PUBLIC HEALTH POLICY AND ACTION!
Global Deaths for 2010
• Globally 52.8 million people died in 2010
• Note: Source for the following slides is The Lancet Series of Articles published in December 2012 on the Global Disease Burden Study of 2010.
• Note: 235 causes listed
Global Deaths by cause - 2010
• Non-communicable diseases accounted for 65.5% of deaths or 34.5 million which is 8 million up on 1990
• Communicable, maternal, neonatal, and nutritional causes were 24.9% of deaths worldwide (down from 34.1% in 1990)
• Injuries accounted for 9.6% of deaths or 5.1 million which is marginally higher than 1990
Non-Communicable Diseases
• Total number of deaths = 34.4 million
• 12.9 deaths from ischaemic heart disease and stroke (one in 4 deaths worldwide)
• 8 million deaths from cancer (Neoplasms) (38% up on 1990)
• 1.3 million deaths from diabetes (double the 1990 figure)
Communicable diseases etc.
• HIV/AIDS – 1.5 million (up from 300,000 in 1990 but down from the peak of 1.7 million in 2006
• Tuberculosis (TB) – 1.2 million• Malaria – 1.17 million (up almost 20% on 1990
figures) Please note the World Malaria Report 2014 estimates malaria deaths at 584,000
• Note: MDG 6 and the Global Fund
Communicable Diseases etc.
• Diarrhoea – 1.4 million (down from 2.5 million in 1990) Currently WHO estimate 760,000 deaths per year and 1.7 billion cases.
• Lower Respiratory Infections – 2.8 million (down from 3.4 million in 1990)
• Neonatal disorders 2.2 millions (down from 3.1 million in 1990)
• Measles – 130,000 (down from 630,000 in 1990)
Injuries – Total 5.1 million
• Road Injuries – 1.3 million• Drowning – 349,000• Self Harm and interpersonal violence 1.3 m
– Self Harm – 883,000– Interpersonal violence – 456,000
• Forces of Nature, war and legal intervention –213,000– Collective violence and legal intervention – 17,700
GBD 2010
• “In 2010, the three leading risk factors for global disease burden were
• high blood pressure, • tobacco smoking including second-hand smoke and • alcohol use.
• “In 1990, the leading risks were • childhood underweight, • household air pollution from solid fuels and • tobacco smoking including second-hand smoke.
GBD 2010
• “Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0.9% of global DALYs in 2010.
• However, in most of sub-Saharan Africa childhood underweight, HAP (Household Air Pollution), and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia.
26
0 1% 2% 3% 4% 5% 6%
Environmental fraction Non-environmental
DiarrhoeaLower resp. infectionsOther unintentional inj.
MalariaRoad traffic injuries
COPDPerinatal conditionsIschaemic heart dis.
Childhood clusterLead-caused MMR
DrowningsHIV/AIDS
Diseases with largest environmental contributions (I)
Diseases with largest environmental contributions (I)
% of global disease burden in DALYs
Source: WHO, Disease Control Priorities, 2006
Lindi, TanzaniaPhotos: Richard Evans
11% of the global population still do not have access to safe water. Most are in sub-Saharan Africa and in rural areas. 700 million people
Muzzafarabad, AJ+K, Pakistan – Jan 2006 Photo: Niall Roche
36% of the global population or 2.5 billion people do not have access to adequate “sanitation” and of that 1 billion people defecate in the open. MDG not met!!!!
Maimu IDP camp, Liberia, 2004 Photo: Niall Roche
It is estimated that only 19% of people wash their hands with soap after going to the toilet. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wold J, Pruss-Ustun A, Bonjour S, Hunter PR, Fewtrell L, Curtis V. 2014. Hygiene and health: Systematic review of handwashing practices worldwide and update of health effects.
Over 40% of diarrhoea cases could be avoided by handwashing with soap.
Rawalpindi, Pakistan 2004 Photo: Niall Roche
Thermal Fogging – Khmer refugee camps, Thailand 1992
Leishmaniasis – Photo courtesy of Richard Allan, Mentor
Maimu IDP camp, Liberia, 2004Photo: Niall Roche
Eritrea, 2009Photo: Niall Roche
WHO estimated for 2012, 7 million deaths (1 in every 8 globally as a result of exposure to air pollution, 3.7 million from ambient air pollution and 4.3 million from household air pollution. In Africa alone there were 581,000 deaths from Household Air Pollution.
Women and Children are exposed the most from HAP.
Mozambique, March 2000Photo: Niall Roche
10.4 million refugees (UNHCR)28.8 million IDPs(UNHCR)863 million slum dwellers (UN-Habitat)
Over 60% of Africa’s urban population live in slums
By 2030 it is estimated there with be over 8 million tobacco related deaths. The majority (80%) will be in low and middle income countries. Already over 6 million deaths per year
Non-Communicable Diseases• A key burden of disease globally and an increasing burden in poor
countries.
• WHO 25 by 25 goal – a 25% reduction in premature deaths from non-communicable diseases by 2025
• Nine targets include halting the rise in diabetes and obesity, reducing salt intake, reduction in the harmful use of alcohol and a reduction in tobacco use.
• Many of these issues are lifestyle or health behaviour issues.
• How many development agencies in Ireland have a focus on these issues? Look at the Dochas Wednesdays News for the issues that come up.
Source: WHO infographic
Traditional areas of focus for the overseas development community in Ireland?Are the poorest of the poor affected by these issues?
Evidence to suggest WaSH and wider Env. Health is either
forgotten about or ignored!
EYD2015• MEPS’ VISIONS
• 11 MEPS outlined their vision on Sustainable Development for the European Year of Development.
• Go look and see how much reference is made to Public Health and within that WaSH and Env. Health.
• Great deal of reference to social determinants of health such as global security, environmental protection, food security, inequality and even climate change.
Bilateral ODA by Sector1% allocated to WaSH
22% allocated to Health, HIV and AIDS
Water and Sanitation
Health, HIV and AIDS
Quote from Lancet EditorialQuote from Lancet Editorial
'The shamefully weak presence of the health sector in 'The shamefully weak presence of the health sector in advocating for improved access to water and sanitation is advocating for improved access to water and sanitation is incomprehensible and completely shortincomprehensible and completely short--sighted.sighted.
Sanitation has languished at the bottom of the international Sanitation has languished at the bottom of the international agenda for far too long and the global health community has agenda for far too long and the global health community has been complicit in letting it stay there. This unacceptable been complicit in letting it stay there. This unacceptable situation must change now'.situation must change now'.
Source: The Lancet Editorial 2008; 371:1045Source: The Lancet Editorial 2008; 371:1045
WE NEED A CULTURE OF PREVENTIONIn the words of Depeche Mode: GET THE BALANCE RIGHT!
There is a Health Systems Failure in relation to Environmental Health
