POST GRADUATE DIPLOMA IN

WATER, HYGIENE

AND SANITATION

MODULE 1

INTRODUCTION TO WASH

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 List of Abbreviations

BMF Biomass Fuel

CBOs Community-based Organizations

CCS Ceramic Colloidal Silver

CHW Community Health Workers

DALY Disability Adjusted Life Year

FVC Forced Vital Capacity

GBD Global Burden of Disease

HH Household

LCA Life Cycle Analysis

NGO Non-governmental Organization

O&M Operations and Maintenance

PIDs Pelvic Inflammatory Diseases

SHGs Self Help Groups

SLWM Solid and Liquid Waste Management

WASH Water, Sanitation and Hygiene

YLD Years Lived with Disability

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 Executive Summary

Access to water and sanitation is one of the major challenges for the 21st century. According to

WHO (2004), 1.1 billion people across the world do not have access to safe water and 2.4 billion

people do not have access to basic sanitation facilities. As a consequence every year around 4

million people, the majority of who are children, die from water and sanitation related diseases.

Water is not only important for public health, but also for general livelihoods: crop production

(70 to 80% of all water used is for crop production), livestock production, industry, commerce

and daily life depend on access to water. Water-supply conditions therefore affect health,

hunger, and poverty and community development.

This disastrous access to water and sanitation is due partly to a lack of infrastructure but also to

poor management that creates waste, contamination and degradation of the environment. Water

shortages may lead to tensions between individuals, communities or countries, which can evolve

into conflicts. At the same time, the demand for water is increasing due to population growth,

urbanization (rural exodus) and industrialization. Urbanization has also created extremely poor

sanitary conditions.

Most of these problems can be solved through comprehensive management of water resources

and demand. Water is a finite resource that must be managed with a global vision that works at

three levels: international to define rules to protect water resources and to avoid international

conflicts; national to apply defined rules and to define national water-access policies; and local to

develop local initiatives to ensure communities’ water access.

The Post graduate Diploma in WASH which is a eight module course which starts with

introduction of the basic concepts in WASH, Then taking the students to other topics like Water

Supply, Communicable Diseases, Sanitation and Waste Management and finally embarking the

final two modules on urban Wash since currently more than half of world population live in

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urban area, and it’s in urban areas where the problem of poor sanitation and waste management

is severely felt.

Table of Contents

Introduction to Water Sanitation and Hygiene ……………………………………………Pg. 5

Role of Frontline WASH workers……………………………………………………………Pg. 15

Introduction to Principles and concepts of Hygiene and Environmental Health…........Pg. 28

Environmental Health Hazards ……………………………………………………………..Pg.46

Public Health ….........................................................................................................................Pg 63

Assessing Public Health interventions in Emergency and Development settings ……..Pg. 90

Assignment …………………………………………………………………………………….Pg. 107

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 Chapter 1
INTRODUCTION TO WASH
Definition of Concepts

WASH Management: Administration of processes involved in: -

1. Provision of safe water for drinking, washing and domestic activities;

2. Safe removal of wastes (toilets and waste disposal) and

3. Promotion environmental hygiene activities

4. Encourages protective healthy behavioral practices amongst

population (whether or not affected).

Public Health: Means 2 things, namely: -

1. Prevention i.e. Public health is the practice of preventing disease and

promoting good health within groups of people, from small communities to
entire countries.

2. Policy Development and Population Health Surveillance i.e. Public health

professionals rely on policy and research strategies to understand issues such
as infant mortality and chronic disease in particular populations.

Environmental Health:

- Branch of public health also called Sanitation.

Concerned with controlling environmental conditions to protect and maintain people’s health
and sense of well-being in terms of:
1. Water quality and supply

2. Waste disposal and sewage treatment

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 3. Public food safety etc

1. Promotion of good hygiene practices

2. Provision of safe drinking water and

3. Reduction of environmental health risks

All 3 above allow people to have i) good health ii) dignity iii) comfort and iv) security.

Inadequate provision of WASH

- Leads to increased risk of diseases including:

1. Diarrhea

2. Hepatitis A

3. Cholera

4. Typhoid and Shigella Dysentery

5. Intestinal helminthes

6. Malaria

7. Trachoma etc.

- Such infections can be transmitted through:

• Consumption of contaminated water or food (through environment, washing

or cooking).

• Hand to mouth transmission (when water for personal hygiene is reduced).

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 • Vectors (e.g. flies and mosquitoes which breed near waste sites and stagnant
water).

- WASH services help people return to their normal daily activities.

- While both water quantity and quality are important for health, it is quantity which
should be given priority.
Basic WASH Practices

Essentially 2 namely: -

1. Personal hygiene practices Include: -

i. Hand washing (Particularly with soap is the single most important hygiene
measure to prevent diseases)

- The three times when we should wash our hands are:

Before cooking or preparing food

Before eating or before feeding children

After defecating and after changing or cleaning babies

- The three steps to wash our hands are:

Wash both hands with water and soap/ash/detergent

Rub the front and back of your hands and in between your fingers at
least three times

Dry hands

ii. Hair washing

iii. Brushing teeth

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 iv. Bathing regularly

v. Washing and airing beddings regularly.

2. Environmental hygiene practices

Such as cleaning surrounding, food storage in covered containers, washing

and cooking food, water source protection.

In developing countries: -

WASH programs emphasize household water for:

- Hygiene Promotion
- Home Water Treatment and
- Sanitation Promotion
WASH in Schools and in emergencies very essential for children sake.
For WASH, sustainability is a key challenge:

i. Climate change

- develop adaptation strategies

- pay more attention to water resource sustainability
ii. Technology
Basis of Public Health

The basis for public health can be said to encompass:

1. Advocacy with governments to prioritize WASH investments.

2. Partnerships with private sector on social marketing of soap, chlorine tablets

etc.

3. Research.

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 4. Investments in water supply systems in communities and schools.

5. Behavior change communication.

6. Training and capacity building.

Why Public Health? Three

reasons: -

1. Public Health Saves Money and Improves Quality of Life

• A healthy public gets sick less frequently and spends less money on
health care; this means better economic productivity and an improved
quality of life for everyone.

2. Public Health Helps Children Thrive

• Healthy children become healthy adults

• Healthy kids attend school more often and perform better overall

• Public health professionals strive to ensure that all kids grow up in a healthy
environment with adequate resources, including health care

3. Public Health Reduces Human Suffering

• Public health prevention;

- Educates people about the effects of lifestyle choices on their

health
- develop techno-friendly solutions

iii. Governance and management

Capacity building is crucial

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 - Reduces the impact of disasters by preparing people for the
effects of catastrophes such as hurricanes, tornadoes and terrorist
attacks.
Public health approach important because it: -

a. Creates and implements health awareness (educational) campaigns

b. Drafts and recommends health policies and practice e.g.

i. Vaccination programs (for children and adults)

ii. Regulation of prescription drugs (for safety and effectiveness)

iii. Safety standards and practices (to protect worker health and safety)
iv. Ensuring access to clean water and air

v. Educational campaigns

vi. School nutrition programs (to safeguard kids’ nutrition)

c. Administers health services, and

d. Conducts research.

Public Health Clinical Health

More preventive More curative

People-centered i.e. focuses on Person-centered i.e. focuses on the

populations Individual

Collective responsibility Individual responsibility

Public health practice should, therefore, be:

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 i. Equitable

ii. Empowering

iii. Effective

iv. Evidence-based

v. Fair

4. Link between WASH and Public Health

Water and Sanitation =>primary drivers of public health or hygiene.
Link between WASH and Public Health connects:

Hygiene practices=>poor sanitation=>polluted water sources => disease.

WASH seals critical gaps that might lead to disease outbreaks.

The spread of diseases (which is a concern of public health) depends on

environmental conditions and people’s behavior in the household and community
level (both of which relate to aspects of WASH at those levels).

Individual community members play an important role in community hygiene, and have
a responsibility to their neighbors and to the community to promote good health and a
clean environment (for example, everyone in the village must keep their houses and
compounds clean, because one dirty house can affect many conscientious neighbors and
contribute to the spread of disease).

Community leaders can promote cleanliness in the home by regularly checking on

village households and by using by-laws to encourage household maintenance.

Topic 1.4: Role of Data in Public Health

Data is central to public health issues.

- Collection (right, quality data)

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 - Capture (From raw to electronic version)

- Analysis (Giving meaning to data)

- Presentation (Sharing research information)

Planning for each phase critical.

Public health data

- Mainly from hospitals, laboratories, and private providers.

- Resource to improve community and public health practices

- Used to target and position health program interventions ( for control

and prevention of disease)

- The more valid, the more realistic and effective the interventions.

Methods of collecting, analyzing and disseminating data

Collecting: -

i. Questionnaires
ii. Interviews

iii. Observation
iv. Tables

v. Pie charts

vi. Graphs etc

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Acquiring water, sanitation and hygiene related diseases are controllable and
preventable

Public health perspective:

i. Ill health is avoidable

ii. People want to keep well and take control of their own health.

iii. It is a matter of personal or collective choice to be unhealthy.

Religious perspective:

i. Nothing happens for nothing

ii. What happens is preordained

iii. What happens cannot be avoided

To reduce demand on conventional health and care services people can choose their own
health with:

i. Better information

ii. Expert advice and

iii. Infrastructural support

(Public health perspective)

Illness impacts on society and the economy (cost of days lost at work and
expenditure on avoidable care).
Best way of empowering people for their own health and well-being is to assess the major
risk factors that may affect their health.

Some health risk factors and their corresponding health complications

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 Risk Factor Associated Health Complication

1. Obesity Strokes

2. Smoking Cancers

3. Alcohol Misuse Liver complications

4. Social Exclusion Mental / Stress – related cases

Pelvic Inflammatory Diseases (PIDs), Ectopic

5. Unprotected Sex Pregnancies,
Infertility

Parental advice (for children) and occupational health services (for adults at work) –
critical in health care.

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 Chapter 2
ROLE OF FRONTLINE WASH WORKERS
Introduction
The various infrastructures and systems involved in provision of WASH services include water
supply and distribution systems, and latrine and waste management facilities. These are
planned, developed, installed and maintained through the active involvement of a number of
frontline WASH workers. This study session describes the roles of different types of key frontline
WASH worker in these practical aspects of WASH provision. It also explains why facilitation is
an important skill for WASH workers and provides guidance on how it should be done.

Who are frontline WASH workers?

There are many people involved in the provision of WASH services, from planning and
construction to operation and maintenance. For example, engineers, health workers, social
development and economic professionals, community leaders, community mobilisation experts,
builders, contractors, and many others are involved. They contribute from town level, to zonal or
regional level, and, depending on the scale of the project, to federal level. Even small projects
such as construction of public latrines involve many different stakeholders including user
communities, private contractors, town municipalities and utilities.

Frontline WASH workers are those who work closely with the beneficiaries of a scheme. Their
role focuses on WASH service provision and maintenance. They mobilise urban communities to
work towards improved personal hygiene and environmental sanitation, and promote proper
care and utilisation of WASH infrastructure. They include health workers and those who operate
WASH infrastructure and provide the necessary care and maintenance to WASH services, such
as trained technicians, operators and facility administrators. All are important, irreplaceable
contributors who improve and sustain basic services in urban areas.

Which of the following would be frontline WASH workers? Urban Health Extension Workers,
members of the Health Development Army, water experts, WASH facility operators, plumbers,
mechanics, technicians and sludge collection operators.
Which do you think would be the most crucial for improving and sustaining WASH services in
your locality?
All these are frontline WASH workers. The most crucial groups will vary from project to project,
but are likely to be the Urban Health Extension Workers, members of the Health Development
Army, water experts, and both public and private WASH facility operators.
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If these crucial groups of workers are absent, inadequately trained or not undertaking their daily
tasks effectively, access to urban WASH service facilities will be restricted or reduced. In extreme
cases, WASH facilities may break down altogether leading to total lack of WASH services.
The following sections outline the roles of the key groups of frontline workers.

Role of Health Extension Workers

Health Extension Workers (HEWs) are usually graduates of Technical and Vocational Education
and Training Colleges (TVETCs) or Health Science Colleges. They are trained to promote
preventative healthcare practices among communities, undertaking community outreach
activities and conducting house-to-house visits to provide important information, knowledge
and skills on important health-related topics.
HEWs undertake 16 essential health packages that can be grouped into three key areas:

 disease prevention and control

 family health

 Hygiene and environmental sanitation.

Promotion of safe and healthy practices in relation to infant care, nutrition, immunization,
growth monitoring for babies and family planning advice are among the many services in the
first two areas above that HEWs undertake. They provide these services during house-to-house
visits or at health posts or health centers. Here we focus on their hygiene and environmental
sanitation work.
The health packages that relate to major WASH issues are:

 Excreta disposal: Human faeces are a major health risk (Study Session 2). HEWs provide
information and guidance on how human excreta can be safely managed and disposed of
through the construction and use of appropriate latrines.

 Solid waste and domestic liquid waste disposal: HEWs discuss health and environmental issues
caused by solid and liquid waste produced at household level, their risk to community
health, and how they can be safely managed.

 Water supply and safety measures: Contaminated water is a major cause of transmission of
waterborne diseases that cause diarrhoea. HEWs explain how water can be handled safely to
avoid contamination during transport and storage and how contaminated water should be
boiled or treated using chemicals.

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 Food hygiene and safety measures: Food can transmit disease if proper hygiene and safety
measures are not practised. HEWs demonstrate safe practices for preparing and storing food.

 Healthy home and environment: HEWs demonstrate how family members can take care of their
home and its surroundings to ensure a clean and safe environment.

 Control of insects and rodents: These are not only a nuisance, but may also transmit diseases.
HEWs teach possible methods to control and prevent the breeding of these animals in and
around the household.

 Personal hygiene: Finally, HEWs promote the importance of keeping and maintaining good
personal hygiene, particularly emphasising handwashing before coming in contact with food
and after using the latrine, and the importance of washing faces to protect from eye
infections.
HEWs promote all these recommended practices in urban communities (Figure 2.1). They work
to ensure that all health extension packages are implemented at a household level, including the
seven listed, through training of model families. They may use youth associations and traditional
cooperative associations such to promote community involvement. They also work with students
in schools to promote proper sanitation and hygiene practices.

Fig. 2.1 A HEW giving advice to a mother

Role of the Health Development Army
The Health Development Army (HDA) is another key group with a significant role in WASH.
You may already be familiar with them as enormous numbers of people are involved. They are
organised groups of families who promote healthy activities and behaviour among other
families. More than 2.25 million HDA families have been mobilised in many districts in Ethiopia
for example Asmara and SNNP regions (Figure 2.2). Since 2010/11, the Ethiopian government
has invested a lot in establishing the HDA who have made a huge contribution to the major
achievements made in the health sector, including reduction of the number of deaths in children
under five. HDAs are regarded as the key players in the attempts to achieve government targets
in the Health Sector Development Programme (HSDP).

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Fig 2.2 HDA promotional banner
The smallest unit of the HDA consists of six households organised together and is referred to as a
one-to-five (1–5) network. One of the households is a model family who have mastered and
implemented some or all of the WASH packages such as access to an improved latrine,
handwashing and solid waste management. Usually it is mostly the women who are involved.
The family head of the model household leads the 1–5 networks. Five of these networks are
organised into a larger team comprising 30 households in the same neighbourhood. The leaders
of these teams undergo intensive training over seven to ten days to ensure that they fully
understand their tasks. The HEWs, described in Section 2.2, facilitate the establishment of these
teams and in collaboration with the health centres, provide training for the team leaders.
The main task of the HDAs is implementing the components of a Health Extension Package in
each household. These are first adopted in the model household and then cascaded to the other
families in the 1–5 networks. To achieve this, the 1–5 networks meet every week to:

 identify the major bottlenecks and gaps in implementing the WASH improvement
components of the Health Extension Package

 prioritise gaps and agree on strategies to address them

 Review progress.
This process has accelerated achievements in achieving HSDP targets, notably the use of health
facilities by mothers with newborn babies. It has also successfully increased knowledge and
practice of safe hygiene and sanitation practices among households, including construction of
basic or improved latrines at household level, improved personal hygiene, waste management,
and safe handling and storage of water.
In summary, HDAs work to change practice in communities through a participatory process of
learning and action-oriented meetings, working below HEWs at neighborhood and family levels.
They are the key players in the improved WASH situations that many households enjoy today and
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will continue to be an important part in future progress towards improved and sustainable WASH
services in communities.

Role of woreda water experts

Woreda water experts in urban settings focus mainly on providing support to ensure continuous
water supply to communities. They regularly:

 provide technical support to facility managers and operators, such as utilities in medium and
large towns, WASH Committees (WASHCOs) in small towns

 provide training to facility managers and operators on operation, maintenance and tariff
setting

 provide supportive supervision to ensure utilities and WASHCOs are operating and
managing facilities properly

 conduct minor or major maintenance to water supply facilities, depending on their skills and
expertise

 Conduct water quality checks at different points in the water supply and distribution system
and on any alternative sources that the community is regularly using.
Woreda water experts are sometimes asked to address WASH facility management issues. This
usually calls for community meetings to identify issues and decide on appropriate actions. On
these occasions, the woreda water experts work closely with communities to develop and
implement participatory plans (Figure 2.3).

Role of private operators

Private operators and service providers are also frontline workers who play a key role in making
WASH services accessible to communities.
Private suppliers may supply WASH-related products such as soaps, sanitary pads and
household water treatment chemicals or sachets such as Bishan Gari and Wuha Agar.
Privately hired technicians may provide maintenance services for water distribution systems,
mainly in household connections and related plumbing tasks. In smaller towns, they also
provide minor operation and maintenance of the water supply system, for example they may be
called in to repair electromechanical components.
Micro- and small enterprises (MSEs) are increasingly participating in the WASH sector (see
Study Session 3). Many towns in Ethiopia use the services of MSEs to collect solid waste from
households and transport it to a centralized collection site or sometimes to final disposal sites.

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In some towns, the service by MSEs has grown to include septic sludge emptying using vacuum
trucks (Figure 2.4).

Fig 2.4: A tanker pumping out sludge from a septic tank.

Others are selling items for household use (Figure 2.5), or producing and selling pre-cast concrete
slabs for use in household latrines (Figure 2.6).

Figure 2.5 Selling jerry cans as a small Figure 2.6 Young men producing concrete
business enterprise. slabs for use in household latrines, as part
of a youth employment scheme in Gambela
Region.
The number of private operators is growing, although they currently provide only a small
proportion of WASH services. Organized groups are managing public WASH facilities, such as
public showers and latrines, which have been constructed by NGOs or other development
partners. Other private operators include water vendors (Figure 2.7) and informal waste
collectors like the cart.

Fig 2.7 Informal water vendors

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Private sector participation is still developing in Ethiopia and other developing countries. Urban
settings and their communities provide a number of opportunities for entrepreneurs. The
governments of developing countries should encourage private sector initiatives and provides
start-up support to promote improved service delivery. Government partners are also
investigating innovative approaches and best practices from other countries, to accelerate private
sector participation in the WASH sector.
With time, urban communities will benefit more from services provided by the private sector, as
the public sector shifts its focus to regulation of the services.

 Which frontline workers play the following roles?

 Work below HEWs at neighbourhood and family levels through a participatory process
including action-orientated meetings.

 Management of public WASH facilities.

 The answers are as follows:

 HDA members work below HEWs at neighbourhood and family levels.

 Private operators usually manage public WASH facilities.

Role of frontline workers in facilitation

The communities are the ultimate users of WASH services and they are the ones who probably
know more about their situation and understand their problems better than anyone else. The role
of frontline workers is to provide adequate information to the community and facilitate the
process for them to make informed decisions about their actions. You may find that, as an
additional frontline worker, part of your role is to facilitate the process that leads to a solution
that is acceptable by all.
Facilitation means helping groups of people to understand and agree on their objectives. It
involves engaging communities in a process.
Initiating sustainable change to improve WASH services requires full understanding of the
existing situation, the barriers to improvement and the available resources. The commitment for
change must come from within the communities themselves. Change should not be imposed
externally. Frontline workers, while working with communities, should avoid imposing a new
regime, otherwise the desired changes will not happen or will not be sustained. Mobilizing
communities for positive action and sustainable change without imposing solutions on them
requires specific skills in the processes of facilitation.

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What are facilitation skills?
Facilitation skills are skills used to direct and guide important processes with groups of people.
These processes can involve meetings, discussions and planning sessions or training events.
Somebody needs to guide these processes to make sure the objectives are met. This person is
called the facilitator.
The facilitator plays a key role in the success of a community meeting. He or she ensures that
ideas raised by participants are coherent with the main agenda of the meeting and works
towards finding an agreeable consensus solution to the problem at hand. A good facilitator also
ensures that all present are participating adequately in the process and their voices are heard
(Figure 2.8).

Fig.2.8 facilitating a meeting means listening and encouraging participation.

Facilitating is different from chairing a meeting. Neither is it teaching, giving orders or

prescribing solutions. It means encouraging of the flow of ideas and systematically drawing the
discussion to a conclusion that addresses the agenda.
A facilitator has three main roles:

1. To guide a group of people to move through a process together. A facilitator does not give
opinions, but encourages others in the group to voice theirs.

2. To focus on achieving solutions, but also on how people participate in the process.

3. To remain open and neutral throughout the process and not to take sides.

Key steps to facilitating a meeting

There is no specific formula for conducting effective facilitation. However, there are a series of
steps that should generally be included, though their order may vary depending on the context.

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Introduction
Always introduce yourself and anyone who has accompanied you by giving your name(s) and
explaining your role. This helps put participants at ease so that they are not meeting with
strangers. Explain the purpose of the meeting and what it seeks to achieve.

Set the agenda

Clearly state the problem that needs to be addressed and explain how it affects those present.
Everyone must understand what is at stake. List the discussion points and ask participants if
they would like to change or add any.

Ground rules
Sometimes it helps to set ground rules for the group process. This is especially important when
conflicting interests are expected. Setting and agreeing on ground rules is not mandatory but can
help you to have more control over the process. Try to start meetings on time as much as
possible. Waiting for latecomers is not fair on those who arrived promptly and encourages
people to be even later next time. If some key participants are late, explain firmly that you had to
start the meeting without them because of the need to finish on time.

Encourage participation
Remember that you are a facilitator, not a participant. Refrain from giving opinions, taking sides
or prescribing solutions. Instead, provide resources, information and strategies to guide
participants to give their views and reach a solution.
Some participants may be more vocal than others and some may try to dominate the discussion.
Be firm and encourage everyone to share ideas and observations to ensure that voices of all those
present are heard. Remember that those members of the community who are poor or
disadvantaged in some way may not willingly speak out. It is important to hear their views,
because the objective is to facilitate a community-wide commitment.
Rarely, some participants may ridicule or try to undermine opinions from vulnerable groups.
Your ground rules may be useful in such circumstances.

Stick to the agenda

Do not deviate from the agenda. Some participants may be focused on points that are not on the
agenda and may repeatedly raise them. Keep reminding them of the need to stick to the agenda.
If this does not work, ask the group to help you decide on the appropriate process and encourage
them to support you.

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Always build towards actions
Look out for any ideas from the participants that could lead to appropriate actions. Actions
should be practical and achievable with available resources. Remember that this is the aim of the
meeting and the reason why you got the groups together in the first place.
The actions must be accomplished by responsible bodies and a definite time should be set in
which to complete them. Your objective is to build a plan with clear actions, which specifies the
person, or group that is going to perform each action and the time by which it should be
completed. Make sure individuals or groups are willing to take responsibilities for the identified
actions and guide them to agree on the necessary time to complete them.

Reiterate solutions/agreements reached

Ensure that participants understand and agree to the identified actions. State a complete action
statement on each issue after agreement is reached and ensure all participants agree to it, before
proceeding to the next agenda item.

Propose follow-up meetings

Before concluding the process, summarize agreed actions and ask participants to agree on a
follow-up mechanism. This could be another meeting or a series of follow-up meetings at regular
intervals for the group to update each other on progress.

Conclude the meeting

Thank everyone for their participation and for the achievements of the process. Take a moment
to thank the people who assisted in setting up the meeting and those whose input required
preparation beforehand. Close the meeting on time. Members of urban communities normally
have a busy life and appreciate a meeting that keeps to schedule.
These are only guidelines and you may need to be flexible to accommodate variations. Case
Study 7.1 illustrates a slightly different facilitation approach.

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Case Study 1 Addressing school sanitation issues
As part of an urban sanitation project to address school sanitation issues, a planning session was
initiated in a small town in Welaita zone of SNNPR by the implementing NGO.
The participants for the session came from different government offices, including municipality,
water desk and health office, and also the parent teacher association (PTA), kebele administration
and the schools themselves. The facilitator introduced himself and the NGO he worked for. He
allowed enough time for participants to introduce themselves and the offices they represented.
Then he briefly introduced the urban sanitation project and explained why the planning session
was important.
Participants had been sent in groups to visit selected schools prior to the meeting and to record
their own assessment of the situation. They used observations and interviews with both students
and teachers.
First, the facilitator asked participants to share their findings and list the major issues they had
identified during their visit. The most pressing issues identified were lack of access to water,
open defecation and solid waste accumulation in the school premises.
The facilitator asked participants to identify the key stakeholders among the participants
themselves, who could act on these issues. After some discussion, the group identified the school
principals and members of the PTA, school WASH clubs, the woreda education office, health
office and the water desk.
Next, the facilitator asked all participants to link each of the identified issues to no more than one
responsible stakeholder as a primary contact to address each issue. For example maintaining
latrines was assigned to the PTA; providing access to water was assigned to the water desk in the
municipality. Ending open defecation and managing solid waste was assigned to WASH clubs,
with the support of the health and education offices.
The facilitator summarized the process so far, and reiterated which issues were assigned to
which stakeholders. He then asked the identified stakeholder for each issue to outline clear
actions to solve it, their resource requirement, and a reasonable time for completion for each
action. He encouraged them to priorities actions where necessary and present their plans to the
larger group.
The planning session was completed with clear action plans to improve the WASH situation in
the visited schools and a follow-up mechanism to track progress.

 What is different about the approach used in this case study, compared with the approach
outlined in Section above. In particular, how were the issues or problems identified? Do you
think that this different approach worked well?

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 The facilitator used the inputs from the participants to identify the key issues or problems,
instead of drawing up an agenda beforehand. However it worked well in this instance,
probably because the participants had been given responsibility for identifying the problems
from their own observations.
As a frontline WASH worker, much of your work may involve organizing communities and
conducting group meetings, planning sessions and discussions. If you manage to develop and
apply good facilitation skills, communities will:

 become increasingly comfortable about participating in your meetings

 take responsibility and ownership of the outcomes

 Develop sustainable solutions.

In the process, you will build a good reputation among the communities and get their trust,
which is crucial for your success in addressing more issues in the future.
Remember that facilitation skills – just like any other skills – are mastered with practice.

Summary of the chapter

In chapter 2, you have learned that:

1. Frontline WASH workers are people working closely with the users of WASH facilities. Their
role focuses mainly on mobilizing communities towards improved practices of WASH. They
also work with the community to provide adequate care and maintenance of the WASH
facilities for sustainable service.

2. The key frontline workers in WASH for urban areas include Urban Health Extension Workers
(HEWs), members of the Health Development Army, woreda water experts and both public
and private WASH facility operators.

3. The roles of HEWs are to promote the health extension programme among families and
communities and to ensure communities have adequate and proper understanding about
WASH issues.

4. HDAs are groups of families that plan, implement and review actions to improve WASH
situations in their neighborhood. They are led by model families under the guidance of the
HEWs, to construct and use improved latrines with hand washing facilities and adopt safe
sanitation and hygiene practices.

5. Woreda water experts provide technical support in maintaining water supply facilities for
utilities and WASHCOs provide training on operation and maintenance, conduct water
quality checks.

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6. Private operators or service providers play key roles in making WASH services accessible to
communities, supplying commodities, providing spare parts and equipment for construction
and maintenance. MSEs are one type of private operator and provide solid waste collection
service in most towns.

7. All frontline workers need to have good facilitation skills, so that they can effectively
encourage and promote change.

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 Chapter 3

INTRODUCTION TO THE PRINCIPLES AND CONCEPTS OF HYGIENE AND

ENVIRONMENTAL HEALTH
Historical perspectives on hygiene and environmental health

Hygiene and sanitation have a long history at various levels of human civilization. We can
roughly divide the historical events into two periods: the ancient and the modern.

Prehistoric and ancient civilization

Religious laws, such as Moses’ Law, writings in the Old and New Testaments and laws in the
Koran, played major roles in the lives of ancient peoples. These laws mainly concentrated on the
provision of personal hygiene. Dead bodies and contaminated surfaces were known to be
unclean or unhygienic to touch. The importance of burying human faeces was also strongly
indicated. The importance of body cleanliness before praying was a motive for maintaining the
integrity of hygiene with a religious practice.
The importance of hygiene and sanitation flourished at the times of Greek, Roman and Egyptian
civilization. The use of private and public baths and latrines, cleaning of the body, shaving the
head for protection from lice infestation, and the construction of water pipelines and sewage
ditches were widely observed. The transmission of schistosomiasis (bilharzia) was linked to
bathing and swimming in the Nile River. In these civilizations, the focus was on personal
hygiene (hygiene) and human waste management (sanitation).

Modern times
A number of discoveries in the 19th century were important events for the understanding of
communicable diseases. For example, the link between contaminated water and cholera was
discovered by John Snow in 1854; the importance of hygienic hand washing before attending
delivery of a baby was noted by Dr. Semmelweis in 1845; and the discovery that microorganisms
(very small organisms only visible under a microscope) cause disease was made by Louis Pasteur
around this time.

The period following the industrial revolution in Europe in the 19th century showed that
improvements in sanitation, water supply and housing significantly reduced the occurrence of
communicable diseases. The term ‘environmental health’ is used to describe human health in
relation to environmental factors such as these. Environmental health can be defined as the
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control of all the factors in a person’s physical environment that have, or can have, a damaging
effect on their physical, mental or social wellbeing. The issue of environmental health is now a
global matter under the guidance of the United Nations (UN) through the World Health
Organization.

Although hygiene and infection are vital factors in environmental health, it is also good to be
aware of emerging issues such as global warming and the links between medical conditions such
as cardio-vascular disease and our environment and lifestyles. Our environment is everything
that surrounds us. It includes all the external influences and conditions that can affect our health,
life and growth. These influences are constantly changing and the effects on our health may not
be easily foreseen.

A Case of Hygiene and environmental health development in Ethiopia

Historical information about hygiene practice among the Ethiopian population is sparse. We will
not only the organizational aspects, as follows.

(a) A formal health service was organized in the Ministry of the Interior in 1908. Hygiene and
sanitation in public health was a single service.

(b) The Ministry of the Interior had a Proclamation and Legal Notices to exercise sanitation
(urine handling, refuse and excreta management, street sweeping) in 1942–1943.

(c) The Ministry of Public Health was created in 1947. It organized Municipal and Provincial
Public Health services to run both curative and public health. Hygiene and sanitation were the
focus of these organizations.

(d) Late in the 1970s, safe water supply and sanitation became components of primary
healthcare.

(e) In the 1990s, the new Constitution in 1995 and a new Health Policy in 1993 were designed
to reflect the social and health needs of the Ethiopian population. Hygiene, sanitation and
environmental matters are stated aims.
(f) In early 2000 the Health Extension Programme was designed and integrated into the
Health Sector Development Programme as a tool to enhance hygiene and sanitation in rural and
urban areas.
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Definitions

Hygiene and sanitation

What do hygiene and sanitation mean to you from your brief reading of the historical
perspectives?

□ Hygiene is related to personal cleanliness, such as personal hygiene (body, clothing).

Sanitation refers to waste management, particularly management of human waste.

Hygiene generally refers to the set of practices associated with the preservation of health and
healthy living. The focus is mainly on personal hygiene that looks at cleanliness of the hair, body,
hands, fingers, feet and clothing, and menstrual hygiene.

Improvements in personal knowledge, skill and practice that modify an individual’s behavior
towards healthy practice are the focus of hygiene promotion. Safe hygiene practice includes a
broad range of healthy behaviors, such as hand washing before eating and after cleaning a child’s
bottom, and safe faeces disposal. When you carry out hygiene education and promotion the aim
is to transfer knowledge and understanding of hygiene and associated health risks in order to
help people change their behavior to use better hygiene practices.

Sanitation means the prevention of human contact with wastes, for hygienic purposes. It also
means promoting health through the prevention of human contact with the hazards associated
with the lack of healthy food, clean water and healthful housing, the control of vectors (living
organisms that transmit diseases), and a clean environment. It focuses on management of waste
produced by human activities.

There are different types of sanitation relating to particular situations, such as:

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Basic sanitation: refers to the management of human faeces at the household level. It means
access to a toilet or latrine.

Onsite sanitation: the collection and treatment of waste at the place where it is deposited.

Food sanitation: refers to the hygienic measures for ensuring food safety.

Food hygiene is similar to food sanitation.

Housing sanitation: refers to safeguarding the home environment (the dwelling and its
immediate environment).

Environmental sanitation: the control of environmental factors that form links in disease
transmission. This category includes solid waste management, water and wastewater treatment,
industrial waste treatment and noise and pollution control.

Ecological sanitation: the concept of recycling the nutrients from human and animal wastes to the
environment.

Environmental health

Environmental health is broader than hygiene and sanitation; it encompasses hygiene, sanitation
and many other aspects of the environment that are not included in this Module such as global
warming, climate change, radiation, gene technology, flooding and natural disasters. It also
involves studying the environmental factors that affect health.

The World Health Organization’s definition is as follows:

Environmental health addresses all the physical, chemical, and biological factors external to a
person, and all the related factors impacting behaviors. It encompasses the assessment and
control of those environmental factors that can potentially affect health.

Key phrases in this definition are environmental factors and potentially affect health.
Components of environmental health
Table 3.1 describes the areas of environmental health and hygiene that will be of importance to
you as a health worker and that you will learn about in the rest of this Module.
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Table 3.1Components of Hygiene and Health

Description Concerns

Personal hygiene Hygiene of body and clothing

Adequacy, safety (chemical,

Water supply bacteriological,
physical) of water for domestic, drinking
and
recreational use

Human waste disposal Proper excreta disposal and liquid waste

management

Solid waste Proper application of storage, collection,

management disposal of
Waste. Waste production and recycling

Control of mammals (such as rats) and

Vector control arthropods
(insects such as flies and other creatures
such as
mites) that transmit disease

Food safety and wholesomeness in its

Food hygiene production,
storage, preparation, distribution and
sale, until
consumption

Physiological needs, protection against

Healthful housing disease and

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 accidents, psychological and social
comforts in
residential and recreational areas

Communal hygiene in schools, prisons,

Institutional hygiene health
facilities, refugee camps, detention homes
and
settlement areas

Sources, characteristics, impact and

Water pollution mitigation

Occupational hygiene Hygiene and safety in the workplace

Fig. 3 1 Components of hygiene and environmental health

■ Figure 3.1 illustrates the various aspects of hygiene and environmental health that are
described in Table 3.1. Look at the separate drawings within the figure and match each of them
to one of the descriptions.

□ Starting at top right, the drawing there illustrates solid waste disposal in a pit. Below that
is a woman cooking at a stove to show food hygiene in a cooking area. The hand pump illustrates
[33]
water supply. Personal hygiene is represented by the person washing themselves. The next
drawing shows a storage cupboard, again illustrating food hygiene. The drawing at top left is a
pit latrine to represent human waste disposal. The central drawing illustrates healthful housing.
(Vector control, institutional hygiene, occupational hygiene and water pollution are not shown.)

Figure 3.2(a) and (b) Pathways of diarrhoea transmission. (Source of 3.2(a): adapted from WHO, 1998,
PHAST step-by-step guide)

Concepts and principles in hygiene and environmental health

We will consider diarrhoea, which is a symptom of many common diseases, as a means to
understand the concept of disease transmission, the role of environmental health and the
framework for hygienic improvements.

Environmental health and disease transmission

The description of diarrhoea transmission represents a good way to understand the pathways of
disease through the environment and how environmental health and hygiene can help prevent

[34]
disease transmission. Figure 3.2 (on the next page) shows the factors that are essential for
diarrhoea transmission. (This diagram is widely used to represent these important links in
disease transmission. We have included two versions of it here to help you identify it if you see it
again. It is used in later sessions in this Module.)

Look first at Figure 3.2 (a). On the left is a person defecating, representing the source of
diarrhoea. The infectious agent or disease agent is actively discharged by a patient or carrier of
the disease. On the right is the host, who is the person that could be affected by the disease.
Between the two, there is the part of the environment that links the two; in other words, the
pathway that the disease travels between the source and the host. Now compare Figure 3.2(a)
with Figure 3.2(b); you will see they represent the same thing.

Figure 3.2(b) similarly shows the different pathways of transmission through the environment.
The source of diarrhoea is the agent or carrier who discharges infected faeces to the environment.
To remember the possible pathways we can use the six ‘F’s:

1 Faeces: resulting from defecation.

2 Fluids: through contaminated water and other contaminated liquids.

3 Fingers: contaminated fingers transmit diseases.

4 Flies: all sorts of animals such as flies can carry and transmit diseases.

5 Fomites or fields: fomites are inanimate objects that carry the infectious agent (e.g. dishes,
cups and other contaminated surfaces in contact with food or water).

6 Food: infected by fluids, flies, fingers or fomites and then eaten.

■ A mother had diarrhoea. She was making a meal for her child but did not wash her hands
before preparing the food and her child became sick with diarrhoea. Can you identify the source,
pathway of disease transmission and the host?

□ The source is the mother who had diarrhoea; the pathway in the environment is excreta →
fingers → food → mouth; and the host is the child.

[35]
If you understand the pathway of the disease, then you can design an intervention for the disease
that targets the source, environment or the host. An intervention is a way of stopping the disease
from being transmitted. The broken lines, in Figure 3.2, indicate the possible interventions for the
prevention and control of diarrhoea. Some of these interventions are described in Table 3.2.

Table 3.2 Possible environmental health interventions for diarrhoea.

The place of environmental health in your community

Our living environment is composed of home, work and recreational centers where people spend
their time. Water, air and food are our concern. The provision of environmental health services
extends to all these aspects of our lives.

■ List the locations in your kebele where environmental health is important.

 You may have thought of a list that includes the following, but the detail will depend on
your own areaworkplaces: health facilities, local workplaces, public offices, shops, mill
house, metal and wood works schools

 social places: church, mosque

 Homes: different types of home in your area.

It is important to know the different parts of your kebele so that you can promote better hygiene
in all areas. The interaction of the environment and possible environmental hazards are indicated
in Figure 3.3. These different types of hazard will be discussed in this chapter.

[36]
Figure 3.3 the system of environmental health. The human living environment consists of home,
work and recreational environments. The interaction between these environments and human
activities results in various types of hazards that may adversely affect human health. (Source:
adapted from Bassett, 2004)

Environmental intervention models

According to the Federal Ministry of Health, more than 80% of communicable diseases in
Ethiopia are believed to be preventable using environmental health interventions. Generally,
there are two intervention models: the clinical intervention model, which looks at treating the
sick person, and the public health model, including environmental health, which looks at how to
stop people getting sick in the first place by providing a healthy environment. This is indicated in
Figure 3.4.

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Figure 3.4 Health intervention models for the prevention and control of communicable diseases.
The clinical intervention model focuses on the treatment of patients, while the public health
intervention model concentrates on the maintenance of health through education and keeping
the environment safe. The red arrows indicate the points of intervention.
If we look at these two models in a wider context, then there are additional factors that must be
considered. These include having helpful local policies, appropriate community (kebele) level
organizations, sanitation legislation, developing sanitation technology options and poverty
alleviation efforts. Political will in policy development in health and environmental health,
designing the hygiene and sanitation legal frameworks and long-term socio-economic
developments, are aspects of the government’s responsibilities. As a Health Extension
Practitioner you have an important role in the prevention of environmental hazards that affect
the health of the public.

Environmental risk factors

You have learned in previous Modules that infectious agents play a part in the transmission of
disease. Infectious agents are pathogenic (disease-causing) bacteria, viruses, fungi, protozoa and
parasites. To cause a disease, they must be introduced into our bodies in sufficient quantities. The
environmental conditions and practices that facilitate the carrying of such infectious agents into
our bodies are termed environmental risk factors. A good example is drinking water, which can
be contaminated by human faecal matter that contains these infectious agents. When this water is
consumed, we are likely to get diarrhoeal diseases.

There are other ways that infectious agents can get into our bodies; for example, the air we
breathe can be contaminated by droplets that come out of a patient’s lungs when they breathe or
cough. TB and pneumonia are droplet-related infections that are transmitted in this way. There
are also diseases and conditions that are not caused by pathogenic organisms, but are caused by
other environmental risk factors, which may be due to chemicals or physical hazards such as
noise. Major environmental risks and examples of the diseases and conditions that are related to
these risks are indicated in Table 1.3. Further descriptions of these diseases can be found in the
Communicable Diseases and Non-Communicable Diseases, Emergency Care and Mental Health
Modules.
Table 3.3 Major environmental risk factors with related diseases and conditions.
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Environmental risk factors Related diseases and conditions

Contaminated water, lack of

latrines, Diarrhoeal diseases, trachoma,
poor hand washing, schistosomiasis, ascariasis,
inappropriate solid trichuriasis,
waste management, open hookworm, typhoid fever,
defecation, relapsing
vector infestation fever

Chronic obstructive pulmonary

Indoor air pollution disease,
lower respiratory infections,
lung cancer

Respiratory infections,
Outdoor/ambient air pollution cardiovascular
diseases, lung cancer

General environmental hazards Diarrhoeal diseases,

(climate, malnutrition,
malaria and other vector-borne
mosquitoes, nutrition) diseases;
heat exhaustion

Environmental hazards in Injuries, hearing loss, cancer,

workplaces asthma,
(excess noise, heat, dust,
chemicals) back pain, chronic obstructive
pulmonary disease

Human interaction with the environment

Urbanization and industrialization

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Urbanization and industrialization bring rural people into urban centers that may not be ready to
handle the additional sanitary needs. Ethiopia is at the stage of rapid development with priorities
in agriculture and industry.

Currently small-scale industries that bridge agriculture and industrialization are booming.
Large-scale industries, such as textiles, food and cement, are growing. The need to improve and
expand social infrastructures such as water supply, waste management and health services is
obvious in order to handle the needs of the growing urban centers. As a health worker you need
to understand that these developments have environmental health risks due to overcrowding,
inappropriate waste management and a shortage of safe drinking water.

Development as a means of interaction

Assume for a minute that a textile factory is planned to operate in your woreda. Now, think what
benefits and disadvantages may arise from the introduction of this factory.

Any development requires an interaction with the environment. The obvious advantages are in
terms of providing cloth, creating job opportunities and contributing to the growth of the
national economy. The disadvantage is when the factory produces environmental risks. The
factory uses energy, raw materials and human labor for its process of producing cloth. It
generates pollutants in the form of solid waste, liquid waste, air polluting substances and noise.
Such wastes can pollute the air we breathe, our food, water and soil. The poor management of
these wastes results in human exposure that may subsequently affect human health as well as the
environment.

Figure 3.5 Human–environment interaction model

[40]
Figure 3.5 shows diagrammatically the relationship between development and the environment.

In this diagram, the two arrows lying between ‘human activities’ and ‘ambient environment’
indicate the relationship between them, i.e. that development requires resources from the
environment (forward arrow) and, as a result, waste could be generated as a by-product
(backward arrow). In fact, there are three possible types of interaction: humans can affect the
environment, the environment can affect humans, and humans and the environment can co-exist
(where they sustain each other). The red arrows in Figure 1.5 indicate the negative effect if the
generated waste is not properly handled. This affects the environment in the form of pollution of
air, water, etc., and can have a negative influence on development.

Matters of development and health have been on the agenda in UN international conferences
and meetings. The issue of sustainable development is a key message for the friendly coexistence
between development and the environment. The World Commission on Environment and
Development defined sustainable development as:

Development which meets the needs of the present without compromising the ability of future
generations to meet their own needs.

- Referring to Figure 1.5, think of different examples of the three types of interaction
between human activities and the environment.

You may think of different examples; here are some that we thought of:

Humans affecting the environment: deforestation, polluting surface water, loss of wildlife.

The environment affecting humans: soil erosion, flooding.

Friendly coexistence (sustainable development): operating a factory so that it provides goods and
jobs that are needed now, without polluting the environment so that our children will have safe
water in the future.

1.5 The role of environmental health in public health

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Environmental health is a part of public health where the primary goal is preventing disease and
promoting people’s health. Environmental health is associated with recognizing, assessing,
understanding and controlling the impacts of people on their environment and the impacts of the
environment on the public. The role of the environmental health worker, therefore, includes the
following functions of public health:

(a) Improving human health and protecting it from environmental hazards.

(b) Developing liaison between the community and the local authority, and between the local
and higher levels of administration.

(c) Acting independently to provide advice on environmental health matters; designing and
developing plans of action for environmental health.

(d) Initiating and implementing health/hygiene, sanitation and environmental programmes

to promote understanding of environmental health principles.

(e) Enforcing environmental legislation.

(f) Monitoring and evaluating environmental health activities, programmes and projects.

You, as a health worker, are very much involved in all of the above except (e) and (f), which are
mainly carried out by the woreda environmental health worker. However, the kebele
administrator may ask you to help with the enforcement of environmental legislation, if deemed
appropriate.

Environmental health planning

Environmental health planning refers to a systematic process by which goals are established,
facts are gathered and analyzed, alternative proposals and programmes are considered and
compared, resources are measured, priorities are established, and strategies and activities are
designed to meet the established goals or objectives within a specified period of time. You, as
part of kebele cabinet, will be requested to prepare an environmental health plan. The approach
to planning is similar to that described in the Health Management, Ethics and Research Module.
However, the primary focus is what makes it different. The following planning steps are
suggested.
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1 Identifying the needs and gaps

This is essentially an inventory (or list) of problems related to environmental health in your local
context. You can use various tools in order to identify these problems.
 Environmental health survey: This is a systematic survey using a questionnaire. The
questionnaire contains basic indicators of environmental health such as latrine availability,
source of drinking water, waste disposal systems, cleanliness of the community, etc. You
will need to do some statistical analysis (proportions and averages) to refine basic
indicators of environmental health for your local context. You must be careful when
designing a survey as it requires time, expertise and resources. You can plan it in
coordination with the woreda environmental health worker.
 Rapid/quick assessment: This is the usual method that helps you gain a quick overview of
the range of problems. The usual data collection tools that you can use for this are focused
or group discussion, physical observation with checklists and interviewing people.

2 Priority setting
It is difficult to handle all identified problems due to resource limitations. You need to know in
advance the available resources in the kebele. Resources can be mobilized from government,
community, private organizations and NGOs.

Do not rely too much on governmental resources as there are always limitations. Mobilizing
community resources is the best option that could be sustained. Priorities are then made on the
basis of the depth and severity of the problem, the feasibility and the degree of community
concern and willingness to be involved in the resource mobilization.

3 Writing a planning report

This is a systematic description of the planning functions. The recommended sub-titles are:

- Title of the plan

- Introduction or background

- Objectives

- Strategies and activities

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- Indicators

- Resources (i.e. budget, human resource and materials)

- Plan of action (i.e. activities by time and responsible person)

You should prepare and present an annual plan of action for improvement of hygiene and
environmental health to the kebele head. The plan of action needs careful consideration of your
work in the kebele. The activities in the plan should include identifying problems, inspection
services (households, food establishments, public utilities such as water sources, health facilities),
hygiene promotion, monitoring selected indicators, sanitation promotion, training of local
partners, sanitation campaigns and commemorating sanitation and water days.

4 Implementing the plan

Once the plan has been approved by the kebele cabinet it can be implemented. Environmental
health activities are put into practice on the ground at this stage.

5 Monitoring and evaluating the planned performance

Daily, weekly or monthly monitoring will help you check the progress of the implementation,
while evaluating performance at the end of the year is useful to help you see the overall progress.
6 Learning by doing
You will be able to learn lessons from the experience of the previous year’s implementation and
the achievements and failures.

Summary of Study Session

In Study Session 1, you have learned that:

 The historical perspectives show us that hygiene and sanitation have a deep-rooted origin.
The practice of hygiene and sanitation is part of our daily life.

 There are differences between hygiene, sanitation and environmental health. While
hygiene focuses on individual personal hygiene/cleanliness, sanitation often refers to
waste management, and environmental health has a broader meaning beyond hygiene

[44]
 and sanitation, referring to where we live, work and play. The focus of environmental
health is on how environmental risk factors affect human health.

 Environmental health plays a major role in the prevention and control of communicable
diseases caused by pathogens, such as diarrhoea, and other diseases and conditions, such
as chronic obstructive pulmonary disease caused through inhalation of air pollution.

 There are various environmental health risks that affect our health. These include water
and air pollution, food contamination and the disposal of wastes into our environment.

 The interaction between humans and the environment has various forms. Urbanization,
industrialization and development are the major forms of interaction. We should
remember and try to control the disadvantages of development and not focus only on the
benefits.

 Environmental health planning requires you to gain knowledge of problems in your area
and to identify needs and gaps, to set priorities and find resources to solve the problems.

[45]
 Chapter 4
ENVIRONMENTAL HEALTH HAZARDS
Introduction

There are a range of environmental health hazards that affect our wellbeing. Hazards can be
grouped together to improve understanding and action planning. The actions that you need to
carry out to protect the health of your community depend on knowing how these hazards can
affect us all. In this study session, you will learn about the types and categories of environmental
health hazards, the routes of exposure and the ways of preventing and controlling these hazards.

What is an environmental health hazard?

In the previous chapter, you learned that environmental health addresses the assessment and
control of environmental factors that can potentially affect health. It is targeted towards
preventing disease, creating health-supporting environments and encouraging positive human
behaviors. You have also learned about the general issues of environmental health risks. Our
environment generally consists of physical, chemical and biological factors and our relationship
with our environment is always interactive. This means that we affect our environment and our
environment affects us. These interactions may expose us to environmental health hazards; that
is any environmental factors or situations that can cause injury, disease or death.

It is worth pausing here to clarify the difference between hazard and risk. A hazard is something
which is known to cause harm, that is, a source of danger to health. Risk is the likelihood or
probability of the hazard occurring and the magnitude of the resulting effects. For example, if
you climb a ladder you know there is a chance you could fall off and be injured, although it is
unlikely. The ladder is the hazard and the chance of injury is the risk you take by climbing the
ladder.

We will illustrate an environmental health hazard with an example. The production of cow dung
cake to be used for fuel is a common practice in Ethiopia. Fresh dung supports the breeding of
flies. Dung cake is usually prepared near to the house (Figure 2.1 on the next page). Young flies
need food and move from the dung to the food that is found in the house.
The flies pick up pathogenic organisms from the dung and transfer them to fresh food that is
ready for consumption. A child eats the contaminated food and gets diarrhoea in a few days.

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Figure 4.1 Dung cake for fuel is drying on boulders near the house.
(Photo: Nicholas Watson)

The conditions or the situation of producing dung cake close to the house is hazardous (or
dangerous) because it facilitates the breeding of flies near to fresh food in the house. The infected
food is the hazard that damages the child’s health. In this example, the hazard arises because of
the infectious agent (the pathogenic organisms) and the process or condition (the preparation of
cow dung cake close to the house). The risk of getting an infection is very high if someone
consumes food that is contaminated with an infectious agent.

What causes environmental hazards? List some different types of natural and human-
produced hazards.

You may have listed a number of factors. Natural hazards include earthquakes, volcanic
eruptions and flooding. Human-produced hazards are mainly related to pollution of the air,
water and soil, and contamination of food.

Categories of environmental health hazards

Physical hazards

Physical hazards are those substances or conditions that threaten our physical safety. Fires,
explosive materials, temperature (hot or cold), noise, radiation, spills on floors and unguarded
machines are some examples of physical hazards.

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Physical hazards also include ergonomic hazards which occur when the type of work, body
position and working conditions put strain on your body. This happens when your capacity for
work is restricted by the type of work. These instances are hard to spot since you don’t always
immediately notice the strain on your body or the harm these hazards cause. Short-term
exposure in badly designed work may result in muscle fatigue or tiredness, but long-term
exposure can result in serious long-term injuries of the muscular-skeletal system. Injera baking is
one of the hardest tasks a woman faces routinely.
She spends one to two hours in a forced sitting and bending position which can be damaging to
her body. Ergonomic hazards also exist among farmers, for example while manually ploughing
and cleaning the weeds in farmland (Figure 2.2).

Figure 4.2 a farmer ploughing his land needs lots of physical effort. (Source:
Pam Furniss)

Biological hazards

Biological hazards are organisms, or by-products from an organism, that are harmful or
potentially harmful to human beings. They include pathogenic bacteria, viruses and parasites,
and also toxins (poisons) that are produced by organisms. Biological hazards are the cause of the
majority of human diseases. For example, bacteria cause cholera, tuberculosis, leprosy, relapsing
fever and many diarrhoeal diseases; viruses are responsible for hepatitis B and C, HIV, measles
and polio; and there are many diseases caused by parasites. A parasite is any organism that lives
on or in another organism, called the host, and causes damage, ill health or even death to the
host. Some human parasites are external and live on the skin and hair; for example, mites that
cause scabies. Internal parasites, living inside the body, include protozoa and helminths.

Protozoan parasites are single-celled organisms that enter the body either by ingestion or via the
bite of an infected insect. Malaria, sleeping sickness and leishmaniasis are examples of diseases
[48]
caused by protozoan parasites introduced by insect bites; amoebic dysentery and giardiasis
result from drinking or eating contaminated water or food.

Helminths are parasitic worms that live inside the body. Several helminths have complicated life
cycles involving humans and other animals as secondary hosts. They have different routes of
entry into the human body depending on the type of worm including ingestion with food or
water, the faeco-oral route, insect bites and penetration through the skin. ‘Helminth’ is the
general term used to describe several different types of parasitic worm. There are three main
groups: tapeworms, roundworms and flukes. Tapeworms may be ingested with food, especially
under-cooked meat, or with water or soil contaminated with faeces. Roundworms, also called
nematodes, are responsible for many different diseases including ascariasis, dracunculiasis
(guinea worm), filariasis, hookworm, onchocerciasis (river blindness), trichinosis and trichuriasis
(whipworm). A type of fluke is the cause of schistosomiasis, also known as bilharzia. People
become infected with schistosomiasis, not through food, but by standing or swimming in water
that contains the immature form of the fluke; these are released into the water from the snail
secondary host. The fluke gets into the water and the snail from the excreta of infected people.

Biological hazards arise from working with infected people animals, or handling infectious waste
and body fluids, as well as contact with unsafe water, food and waste. The hazards may occur in
the home, at school or at work. In particular, work in hospitals, hotel and hospital laundries,
laboratories, veterinary offices and nursing homes may expose someone to biological hazards.

Chemical hazards

Chemical hazards are present when a person is exposed to a harmful chemical at home or at
work. The chemicals can be in the form of gases, solids or liquids. Exposure to chemicals could
cause acute health effects (an immediate or rapid onset) if taken in large quantities in a single
dose; and chronic health effects (long-term effects on health) if taken in small doses over an
extended time. Detergents (powdered soap, bleaching powder), drugs (veterinary and human)
and pesticides (DDT, malathion, diazinon, zinc phosphide, warfarin) are chemical hazards that
are commonly found in rural households (Figure 2.3). Farmers, young children (under 5 years)
and household animals are vulnerable to chemical exposure, but it is always possible that anyone
might come into contact with the chemical during preparation, spraying, use or storage. A
person is exposed to chemicals through various ways: through inhaling the vapors, gases or
dusts; through skin contact with solvents, acids and alkalis; and through ingestion of unknown
chemicals with food and water.
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Figure 4.3 Household chemical hazard – insecticide.

Incomplete burning of fuel releases carbon monoxide (CO) which is a chemical hazard. When
breathed in, CO binds to the haemoglobin in our blood, reducing the uptake of oxygen; the cells
of the body then suffer because they are not getting enough oxygen. This can result in severe
sickness and even death.

Cultural/practice-related hazards

Culture is the knowledge, belief, art, law, morals, customs and habits that are acquired by people
as members of society. It is also the common ways of life and set of thoughts and feelings shared
by the members of a society. Just as there are cultural practices that are good for health, such as
breastfeeding a child, there are also cultural practices that adversely affect health and these can
be considered to be cultural hazards. There are practices that are widely accepted and found in
different areas of Ethiopia that can be hazards for health; for example, the belief that evil spirits
are the source of diseases, practices of storing drinking water uncovered, open defecation and
not hand washing before meals and after latrine use.
Hygiene and health promotion and community mobilization are critical interventions that help
improve practices that are not useful to the community. To change human behavior away from
undesired practices, you need to change knowledge and attitudes.

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 Let us assume you have observed that one of the households in your area has a clean
latrine but it has not been used for the last few months. What could be the explanation for
not using the latrine?

 You may have thought of some different reasons, but here are some we have thought of:

[51]
  The head of the household might not have taken the lead and guided others in using the
latrine.

 Children may be afraid of falling into the latrine hole.

 They may be afraid the bad odor will cause a disease.

 They have plenty of space for open defecation and don’t understand why this is not a
good practice.

Social hazards

Poverty and illiteracy are examples of social hazards. We know that poor and uneducated people
get sick more frequently, compared to wealthier and more educated people. Alcoholism, obesity,
smoking and drug abuse are also social hazards that affect our health. A person with such habits
is, over time, degraded, not respected by society, physically and mentally dissatisfied, and
ultimately is likely to suffer with chronic illnesses such as lung and cardio-vascular diseases.

Describing environmental exposure to hazards

To reduce the adverse impacts of environmental hazards on human health you need to
understand where the hazard comes from, identify it and the pathway it can take to affect
people.

The source of the hazard is the place of origin from proposed and existing activities. Patients and
carriers discharge infectious agents (biological hazards) that could infect healthy people.
Industrial processes in a factory release chemical hazards that may be found in sewage; the
sewage could reach drinking water, thereby creating the possibility of ingesting these chemicals.
Household activities could also be sources of hazards, for example, cooking with fuels such as
animal dung and charcoal produces toxic smoke that can cause lung diseases.

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The type of hazard is the particular chemical, infectious agent or other agent involved. The
pathway is the route by which the hazard gets from the source to the person.

The response or the effect is the health outcome (changes in body function or health) after the
hazard has affected the person. The amount and type of change (or response) depends on the
type of hazard and the effect it can have on different people. This would depend on the person’s
individual health and factors such as their age; for example, young children or people who are
already sick are often more harmed by diseases such as diarrhoea than healthy adults.
If you want to prevent a hazard, you need to understand the source of the hazard (where it
comes from), the type of hazard (for example the type and concentration of a chemical), the
pathway (the affected environment and how the exposure could take place), and the response
(the effect the hazard could have on people).

We will demonstrate this with an example. Sewage containing cadmium (a toxic chemical) is
produced by a hide-processing factory and flows into a river. People downstream of the point of
discharge drink the contaminated water and become sick. The hazard exposure is described as
follows:

 The source is sewage from a factory.

 The type of hazard is chemical, in this case cadmium.

 The pathway or affected environment is the river that is

used by the public as a source of drinking water and the
exposure took place by swallowing/ ingesting the
chemical with drinking water. In addition, any fish
contaminated with cadmium may have been eaten.

 The response is that people who consumed the

contaminated water and

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  fish had symptoms of pains, pains in the abdomen) and they complained to a
cadmium poisoning health centre.
(i.e. joint and spinal

Principles of hazard management

You may be asked to plan how to manage environmental hazards, say in a Health Post or mill
house that exists in your locality. Involvement in hazard management requires you to follow
certain steps, which are outlined below.

Establish the context and identify the hazard: These are the first steps. You have learned that a
hazard is something that is harmful to our health. A description of the categories of hazards is
given in Section above. You should identify the type of the hazard in as much detail as you can.
You should also describe the exposure conditions and try to answer the following questions:
What is the source of the hazard? Who is exposed? What are the pathways or activities that
expose a person? What part of the environment is involved in the transfer of the hazard to
humans?
Hazard/risk analysis and evaluation: Here you would analyze the risk and evaluate the potential
of the hazard to cause damage to health. This step needs a deeper appraisal in collaboration with
the woreda environmental health worker. The evaluation may require appropriate design,
sampling and laboratory investigation.

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  Communicate and consult: When the hazards and risks have been determined, advice can
be communicated on the interventions or control measures that are needed to control the
hazard. There can also be consultations with relevant people and organizations.

 Treat the hazard/risk: The interventions or control measures are carried out by the person
or people responsible for the hazard or risk.

 Monitoring and reviewing: The implementation of interventions or control measures for

the hazard must be followed up in order to determine whether they are successful.
Correction measures can be applied if there is any failure. Identifying appropriate
indicators for monitoring is critical and must be done formally.

 Record keeping: Keeping records and reports on hazard management is always important.
These records must contain the type of hazard, exposures and what control measures were
taken.

The process of hazard management is shown in Figure 4.4.

Figure 4.4 The hazard management process.

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Environmental pollution

What is pollution?

We have seen that hazards are things that endanger human health or life, but hazards can also be
harmful to our environment. Pollution is the introduction of contaminants into an environment
causing harm, instability or disorder to the ecosystem. (An ecosystem includes all the living
organisms (plants, animals, microorganisms) and their physical environment and the interactions
between them.) Pollution can be also defined as the presence of a substance in a medium or
environment that results in a change to its ‘natural’ state, potentially causing an adverse effect.
Pollution, however, is not simply the introduction of contaminants. There is always a response in
the form of modification or change in the environment. From this standpoint, pollution is the
harm that results because substances are present where they would not normally be found, or
because they are present in larger than normal quantities.

Contaminants are not necessarily pollutants. A contaminant is a minor substance, material or

agent that is unwanted in the environment and may or may not be harmful. A pollutant is a
contaminant which, due to its properties or amount or concentration, causes harm. Gases (carbon
monoxide, ozone, and nitrogen dioxides), chemical vapors, dust particles, fumes and liquid
chemicals (pesticides, solvents, drugs, acids, etc.) are examples of potential pollutants of air and
water ecosystems.

In nature, the environment has an inherent capacity to clean itself through self-cleaning
processes. Natural environmental processes have the ability to deal with many pollutants and
correct most imbalances if given enough time. For example, self-cleaning processes in a river
could involve:

 Dilution: this takes place when a small amount of a chemical in sewage enters a large
flowing river and the pollutant is diluted in the water.

 Oxygenation: this process occurs through mixing of air with water which introduces
oxygen that can then be used by aquatic (water-living) plants and animals.
Microorganisms consume oxygen when they break down organic matter.
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  Sedimentation: this takes place when larger particles settle out at the bottom of the river.

 Biodegradation: this takes place when organic matter is broken down by microorganisms.
Organic matter means everything that is derived from living organisms. In a river this
could be human and animal waste, decaying plant material, etc.

Pollution sources and categories

Pollutants can come from natural or man-made sources. Examples of natural sources of pollution
are volcanoes which give out ash and dust into the atmosphere and metals such as arsenic which
are naturally present in some rocks and soils. Man-made pollutants can come from industrial,
domestic (home), transport and agricultural sources.

Think of one example of a pollutant from industrial, domestic (home), transport and
agricultural sources.

□ There are lots of different examples that you could think of. Here are some that we came
up with:

. Industrial sources: sewage discharged into water bodies; air emission of smoke released to the
atmosphere (see Figure 2.5).

 . Domestic sources: cooking and heating that releases smoke to the atmosphere. Solid
waste and liquid waste are other forms of pollutants that can be released to water bodies
and soil.

 . Transport: discharge of air pollutants from various types of vehicles. Heavy trucks and
diesel engine vehicles are much more polluting than a petrol engine.

 . Agricultural sources: organic wastes such as agriculture residues, animal dung and
wastes from agriculture-based plants.

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Figure 4.5 Air pollution from an industrial source.
Pollution can take many forms. The air we breathe, the water we drink, the soil where we grow
our food, and even the increasing noise we hear every day all contribute to health problems and a
lower quality of life. Pollution can be classified as:
Pollution can take many forms. The air we breathe, the water we drink, the soil where we grow
our food, and even the increasing noise we hear every day all contribute to health problems and
Air pollution: the release of chemicals and particulates into the atmosphere.

 Water pollution: the release of wastes, chemicals and other contaminants into surface and
groundwater.

 Soil pollution: the release of wastes, chemicals and other contaminants into soil.

 Radioactive pollution: presence of radioactive substances in the environment.

 Noise pollution: unacceptable levels of noise in work, residential and recreational places.

 Thermal pollution: the release of heat into the environment; for example heated water into
a river.

Air pollution

This occurs with the release of chemicals in gaseous or dust form into the atmosphere. Household
cooking, industries, vehicles and incinerators are common sources of air pollution.

Water pollution

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Water can be polluted by the release of liquid waste (human, animal or industrial) into rivers,
streams and lakes. A common type of water pollution is organic material such as human and
animal wastes and in waste water from food processing. These wastes can be removed from
rivers and lakes by the self-cleaning processes described above but, if present in large quantities,
the biodegradation process can reduce the level of dissolved oxygen in the water so much that
fish and other aquatic life cannot survive. As well as these environmental impacts, water
contaminated with human waste is a significant cause of many diseases that will be described in
more detail elsewhere in this Module. Some pollutants can be extremely harmful even if they are
taken in small quantities and may cause cancer, reproductive health effects (abortion, embryo
malformation, birth defects) or nerve damage when the contaminated water is consumed.

Land/soil pollution

This occurs when land is used as a site for accumulating wastes that are generated from various
sources (industry, agriculture, health facilities, and villages, private and public organizations).
These wastes may be biologically, chemically or physically hazardous to plants and animals. The
pollution by chemicals such as pesticides may have long-term consequences, such as
groundwater pollution.

Principles of pollution management

■ Explain the differences between a hazard, a contaminant and a pollutant.

A hazard is anything that harms our health. A contaminant is something introduced to the
environment (air and water) that may or may not pose a significant health risk. A pollutant is a
contaminant introduced into the environment that adversely affects animal and human life.
There are two main approaches to pollution management:

 Pollution prevention: focuses on stopping pollution being produced in the first place, or
reducing any waste generation at the source.

 Pollution control: those measures taken to control pollution and wastes after they have
been generated or produced.

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Principles of pollution prevention

There are a number of principles of pollution prevention; we will briefly discuss some of them.

Principle of waste optimization: The motto in this principle is ‘Do not produce any waste; if this is
not possible, reduce or minimize waste generation as much as possible’.

There are three ‘Rs’ that are applied in waste optimization: Reduce, Reuse and Recover. Figure
2.6 shows the hierarchy or the order in which the waste optimization options should be used.
Reduction refers to changing the process so that waste is not produced in the first place. Reuse
involves using an item more than once (for example you can reuse plastic bottles for collecting
water). Recovery involves recovery of materials or energy through recycling, composting and
incineration. An example of recycling is taking used aluminum cans (tin cans) and recycle the
metal to make it into something else. In composting we can take waste organic matter and make
it into useful compost for fertilizer. Through incineration (burning) we can recover the energy
contained in waste materials.
The concept of waste optimization is applied in industries through cleaner production. Cleaner
production implies appropriate environmental management, waste minimization, and
replacement of toxic chemicals, process and product modification, and the application of the
three ‘Rs’.

 Polluter pays principle: This principle identifies the people or organizations that generate
or produce waste or pollution as those who are accountable for any human or ecological
damage. They are responsible for paying the costs of any damage. The principle is an
economic tool to enforce accountability and responsibility. Strict standards for pollutant
discharge permissions and enforcing heavy taxation on products or waste handling are
ways of making the polluter pay.

 Principle of ‘Cradle to Grave’: This principle applies to the production of any object or to
any activity by an individual or institution and all the pollution that object or activity
might cause throughout its lifecycle; that is, from its ‘cradle’ to its ‘grave’. For example, if
you make a plastic bottle, pollution might be caused in the manufacturing process;
pollution is also caused by the lorries that transport the bottles around the country; and
pollution is caused when the bottle is thrown away. All these aspects should be taken into
account.

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  Precautionary principle: For any activity, there is an obligation not to cause harm even
when someone is uncertain about the effect of the activity on humans and the
environment. Under this principle, you take precautions to avoid environmental damage,
even if you are not certain that damage will result. The application of waste minimization
is an example
 Principle of duty of care: Any person or organization that produces waste, i.e. a waste
generator, has a citizenship and ethical obligation to handle their waste properly. They
have a duty to ensure that it does not harm other people or the environment.

 Principle of discharge/emission permit: A waste generator has an obligation to obtain

permission from the regulatory authority in order to discharge waste to surface water and
to the atmosphere.

 Principle of sustainable development:

What do you remember about the term ‘sustainable development’?

Sustainable development is ‘development which meets the needs of the present without
compromising the ability of future generations to meet their own needs’. You could think of this
as friendly coexistence where people and the environment sustain each other.

Sustainable development requires people to carry out environmental mitigation (lessening the
damaging effects) for newly developed factories, dams, irrigation schemes and other
undertakings as prescribed by law.

 Principle of the right to know: The public has the right to information about pollution from
a particular process. Public participation at various stages of project development avoids
mistrust and the consequences of conflicts of interest.

Pollution control

Pollution prevention through various applicable principles and methods is not always possible
and the consequence is that some pollution is produced. If pollution is produced, there should be
some measures to control it and minimize the effects on people and the environment. The
application of waste treatment before disposal, restricting contact between the waste and the
public, and monitoring and evaluating the effect of the waste on the immediate environment are
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some of the intervention options in waste control. Pollution control options will be explored later
in this Module.

Summary of the chapter

In this Chapter, you have learned that:

 An environmental health hazard is anything in the environment that endangers human

health and life; there are various types of environmental health hazard.

 Managing environmental health hazards requires knowledge of environmental health

hazard identification, exposure conditions including the pathways of the hazards and
hazard controls or interventions.

 The principle of hazard management involves hazard recognition, deeper analysis of the
risk of the hazard and the control or treatment and monitoring of the hazard.

 Contamination and pollution are different; uncertainty of damage is a characteristic of

contamination, while there is certainty of harm in the case of pollution.

 The environment has a natural self-cleaning process. Pollution occurs when the self-
cleaning process is defeated. The consequence of water, air and soil pollution is damage to
the environment and to humans.

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 Chapter 6

Public Health
Introduction
Public health refers to health care and health promotion that targets a population or particular
group within the population (Institute of Medicine, Division of Health Sciences Policy, 2001).
While public health does not directly involve the provision of medical care to individuals, the
important role of physicians in addressing public health issues. Physicians have the responsibility
to care for individual health while maintaining an awareness of public health issues and
promoting public health. Public health should not be seen in isolation, as it is intrinsically linked
to individual health, health care and medical care. The WHO has stressed the importance of
development of integrated health care systems in which both public health and individual health
can be addressed. High quality primary, secondary, and tertiary care is fundamental to an
effective health care system. A failure at any of these levels could result in serious threats to
public health. Air travel between regions and continents has made It easier for the outbreaks of
HIV/AIDS, the return of tuberculosis, the persistence of malaria, and the occurrence of SARS and
pandemic flu have illustrated that public health knowledge is more important than ever(William,
2014).
More importantly the current outbreak of Ebola has crippled public health systems especially in
West Africa countries where the pandemic has hit the most. The 2014 Ebola outbreak is the
largest Ebola outbreak in history and the first in West Africa. The current outbreak is affecting
multiple countries in West Africa. The World Health Organization (WHO), and other domestic
and international partners and has activated its Emergency Operations Center to help coordinate
technical assistance and control activities with partners. The current global air travel and
traditional practices especially in West African countries has made it difficult to control the
epidemics. The disease has not only caused several deaths but also caused economic stagnation in
affected countries.
In preview, Ebola virus disease (EVD) or Ebola hemorrhagic fever (EHF) is a disease of humans
and other primates caused by an ebolavirus. Symptoms start two days to three weeks after
contracting the virus, with a fever, sore throat, muscle pain and headaches. Typically, vomiting,
diarrhea and rash follow, along with decreased functioning of the liver and kidneys. Around this
time, affected people may begin to bleed both within the body and externally. The virus may be
acquired upon contact with blood or bodily fluids of an infected animal. Spreading through the
air has not been documented in the natural environment. Fruit bats are believed to carry and spread
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the virus without being affected. Once human infection occurs, the disease may spread between
people, as well. Male survivors may be able to transmit the disease via semen for nearly two
months. The International Health Regulations of the World Health Organization has installed a
mandatory system of mutual information and alertness to help fight and contain and control the
disease.

Statistical reasoning in Public Health

Evidence-based public health is defined as the development, implementation, and evaluation of

effective programs and policies in public health through application of principles of scientific
reasoning, including systematic uses of data and information systems, and appropriate use of
behavioral science theory and program planning models. Developing, implementing, and
evaluating public health programs or public health policies (in public health terms an
"intervention") that have 1) data demonstrating their effectiveness and 2) a grounding in a health
behavior theory or ecological model of health. It is the process of integrating science-based
interventions with community preferences to improve the health of populations Good public
health practice demands excellent statistical reasoning. Statistical concepts and methods are
essential for both biomedical and health services research and both health statistics and
epidemiology make abundant use of their analytic strategies. For population-based surveys, such
as those conducted by the National Center for Health Statistics, the methods used were pioneered
by social scientists--and social epidemiology is of increasing importance.
Counting is the “stock in trade” of these endeavors but investigators, clinicians, and managers of
all disciplines need to remember that not all that “counts” can be counted. Caring, compassion,
and hope--the foundation of therapy and healing--cannot be easily counted or measured.
Nevertheless, familiarity with health statistical, epidemiological, and survey applications and
methods is now a requirement for all public health graduates. Of far greater importance is the
internalization of the underlying concepts of statistical reasoning such as: bias (in its many
forms), randomization, probability, sensitivity and specificity--the distinction between efficacy
and effectiveness--and above all, the difference between statistical and clinical significance.
Counting the dead initially gave way in the 17th century to recording the “causes” of death, and
over the decades, to expanding and diversifying their “labels” based on notions of causality.
These too have changed frequently over time, thus giving us the 10th edition of the International
Classification of Diseases (ICD-10). To address the need for studying the natural history of initial
symptoms, their mutation into disease, and its early prevention, the International Classification of
Primary Care was created. Accurate and honest labeling is essential for the production of useful

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epidemiological and statistical information. However there still remains doubt about the
reliability and validity of some morbidity and mortality survey data.

Social and Behavioral Foundations of Primary Health Care

Social reform to improve health is rooted in the early work of advocates such as Virchow and
Chadwick. The late 19th century saw the rise of the Sanitary Movement, with organized efforts to
improve standards of hygiene, living and working conditions as strategies to improve the health
of people living in poverty. The growth of social and behavioral science applications in public
health was strengthened by the redefinition of health in 1948 within the newly formed World
Health Organization (WHO) as a state of complete physical, mental and social well-being, and not
merely the absence of disease or infirmity(Schneider, 2011)

Historical milestones:

There are important milestones in the development of social and behavioral sciences in public
health include the 19th century health reforms, WHO definition of health, 1964 surgeon general’s
report on smoking, formalization of subfields of medical anthropology, medical sociology, health
psychology and gerontology, and the introduction of SBS courses in public health professional
training. The seminal framework that emerged in the 1950s was the Health Belief Model.
Drawing upon cognitive and behavioral theories of human behavior, the model conceptualized
health practices as motivated by value expectancies, or subjective assessments of the personal
benefits of particular outcomes and the expectations that certain actions will achieve desired
goals. Over the course of the 20th century, the public health enterprise underwent significant
transformation as a result of a radical shift in the focus from infectious diseases to chronic
conditions as the major challenges to population health in industrialized societies. Tied to
demographic, environmental, and social change, this transformation required profound
alterations in how public health problems were addressed.

In the second half of the century, with the emergence of chronic diseases, injury, substance abuse
and other health problems as the focal public health challenges, the dominant paradigm shifted
toward social and behavioral approaches to disease prevention and health promotion. While the
more traditional activities of infection control and environmental protection remain important in
today's world, much attention and effort is now focused on changing the social conditions
underlying health, as well as the behavioral patterns which put people at risk for illness and
injury.

Social ecology of health model:

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A number of formulations of the social ecological model have been developed (Institute of
Medicine, Division of Health Promotion and Disease Prevention, 2011). They all have in common
the notion of multi-level systems of mutual influence and interaction, moving from the individual
level through linkages to larger social networks including the family, community, social
institutions, the state and global systems. Key concepts include system integration, change and
adaptation over time. The model used in the textbook organizes determinants of health according
to five hierarchical levels of influence: intrapersonal, interpersonal, organizational, community
and society. A visual depiction of the model uses an iceberg graphic, with the tip of the iceberg or
triangle representing behavior, and successive underlying levels representing social contextual
and structural factors. Students should be able to identify both factors influencing health at
different levels as well as interventions at different levels.

Population indicators:
Total fertility refers to the mean number of children born per woman in a particular population.
On average this figure ranges between 1 and 10. The crude birth rate, on the other hand, is based
on the number of children born in a given year per 1,000 populations. This indicator may range
from 10 to 50. Age-adjusted fertility rate is determined by the number of live births/1,000
women 15-44 years old, or some other defined age group. The crude death rate refers to the
number of deaths in a year per 1,000 people. Infant mortality rate (IMR) is one of the most widely
used demographic measures in public health because it has come to be recognized as the most
sensitive indicator for overall health and quality of life of a population. The IMR is determined by
the total number of deaths among infants in the first year of life, per 1,000 live births. Because
deaths among adults occur less frequently than among infants and children, the adult mortality
rate is calculated using a larger denominator than infant mortality; it is the number of deaths over
a year per 100,000 in a population.
Population growth is a function of fertility and mortality, and net migration. Population growth
rates can be slow, moderate, rapid or explosive. Overpopulation occurs when there are too many
people to meet basic needs, but having too few people, or under population, also can pose
problems. Maldistribution of the population can take a variety of forms, including geographic
and social dimensions. Overconsumption results when populations use excessive amounts of
nonrenewable energy and natural resources and exceed the carrying capacity of their ecological
niches.
Three important developmental transitions that have important ramifications for public health
include the demographic transition, the epidemiologic transition and the health transition:
(i)Demographic transition: As societies undergo the shift from rural agricultural economies to
urban industrialized ones, population processes follow a predictable course of change referred to

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as the demographic transition. The pretransition period is characterized by high rates of fertility
and mortality, particularly infant and child mortality, producing moderate rates of population
growth. During the period of transition, death rates first begin to decrease in response to
improvements in living conditions and health care, but there is a lag time during which fertility
remains high. This is because the factors favoring large family sizes, such as expectations for high
mortality among children, are slow to change. This results in elevated population growth rates,
characteristic of many developing countries today and the reason that population growth is
sometimes used to define underdevelopment. Over time, fertility decreases in response to falling
mortality, producing the low growth rates characteristic of industrialized nations.
(ii)Epidemiologic transition: Along with the demographic changes just described, corresponding
changes occur in the pattern of diseases which dominate the health profile of a society. The pre-
transition situation is characterized by high rates of infectious disease including diarrheal
diseases, respiratory infections, and parasitic diseases, which coupled with poor nutritional status
leads to excess deaths in the younger age groups. As infectious diseases decline, more children
survive to adulthood, life expectancy increases, and chronic diseases affecting the older
population become the major health problems of a society, as currently seen in industrialized
countries. These processes are referred to as the epidemiologic transition, and most developing
countries are currently in the early stages of this transformation.
(iii)Health transition: The concept of the health transition is a more recently defined area of
study which seeks to understand the cultural, social and behavioral determinants of health which
underlie the epidemiologic transition.

Public Health Practice

Public health activity, the public health workforce, and the entire public health system provide
the defining framework for public health practice (Rescher, 2003). Public health activities are
implemented to prevent disease and disability, and this further defines public health practice
.Public health practice focuses on the health of aggregates or groups, family, or community. A
key feature of public health practice is the acknowledgment that health is greater than the
biological determinants of individual health; public health practice also embraces a host of
behavioral, social, economic, and environmental factors that affect the health of a community.
Public health refers to all organized measures (whether public or private) to prevent disease,
promote health, and prolong life among the population as a whole. Its activities aim to provide
conditions in which people can be healthy and focus on entire populations, not on individual
patients or diseases. Thus, public health is concerned with the total system and not only the
eradication of a particular disease. The three main public health functions are:

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  The assessment and monitoring of the health of communities and populations at risk to
identify health problems and priorities.
 The formulation of public policies designed to solve identified local and national health
problems and priorities.
 To assure that all populations have access to appropriate and cost-effective care,
including health promotion and disease prevention services.
Public health professionals monitor and diagnose the health concerns of entire communities and
promote healthy practices and behaviors to ensure that populations stay healthy. One way to
illustrate the breadth of public health is to look at some notable public health campaigns:
 Vaccination and control of infectious diseases
 Motor-vehicle safety
 Safer workplaces
 Safer and healthier foods
 Safe drinking water
 Healthier mothers and babies and access to family planning
 Decline in deaths from coronary heart disease and stroke
 Recognition of tobacco use as a health hazard.
The term global public health recognizes that, as a result of globalization, forces that affect public
health can and do come from outside state boundaries and that responding to public health
issues now requires attention to cross-border health risks, including access to dangerous products
and environmental change.
What Public Health Does
In practice, public health interventions center on the following five strategies, which, though
partially overlapping, tend to target diverse beneficiaries and to engage distinct stakeholders
(Rescher, 2003). One of these, provision of care, is pretty much distinct to the United States. (The
Institute of Medicine provides a different list of “core functions” – namely assessment, policy
development, and assurance)
Protection; The first and foremost mission of public health is to protect the population against
exposure to illnesses that are contagious person-to-person or transmissible from environmental
sources (e.g., tainted food, polluted water, lead paint and asbestos in lodgings, air pollutants
associated with asthma and cardiovascular diseases, and, arguably, cigarette smoke). This basic
function, which protects the public against “enemies of the people” – in this case not foreign
militaries but rather foreign (or domestic) microbes, brings the formal power of the State to bear
against biological and/or environmental threats.
Prevention: Public health practitioners also work to identify and arrest threats to health (which
may or may not originate in contagions or environmental assaults) before they strike. The
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strategies deployed – vaccinations, screening for an ever-longer list of conditions (e.g., diabetes,
cancers of the breast and colon), and disease management (which aims to keep ailments such as
diabetes from worsening) – create an ambiguous partnership between public health and the
medical community in defining (sub) populations at risk and identifying and applying
procedures and treatments.
Promotion: In its quest to keep people well, public health increasingly adopts means that
transcend the conventional preventive agenda. Strategies conducive to “healthy living” – which
may extend from encouragement to eat more fresh fruits and vegetables and fewer fatty, salty
foods and to get more exercise, all the way “out” to engagement with a myriad social
determinants of health – thrust public health into unfamiliar preserves that tend to feature
complex and sometimes indecipherable interactions between the public and private sectors (e.g.,
the design of the built environment, the location of stores that sell fresh food, the distribution of
income and status).
Prognosis: Because public health professionals try to anticipate threats to the health of the public,
surveillance and monitoring of health conditions in communities are traditional tools in their
strategic kit. That these tools ought to be broadened and put in service of genuine planning that
would replace institutional fragmentation with the comprehensive, coherent, coordinated
arrangements communities deserve has long been a central tenet among public health
aficionados. Needless to say, these arguments have never found much of an audience b public
health community itself, and even the relatively powerless local Health Systems Agencies the US
federal government sponsored between 1974 and 1986 tended to treat public health agencies as
one constituent among many others. Some nations, and some US cities, however, now require
that Health Impact Assessments be crafted and presented to policymakers who thereby
presumably gain an accurate understanding of the implications of existing arrangements and
of proposed public and private decisions for the health of the public. 7 By envisioning and
estimating in advance as many potential threats to health as is feasible, such prognostic exercises
are essentially prospective syntheses of the familiar protective, preventive, and promotional
functions of public health. Beneficiaries are, in principle, the community as a whole, and by its
nature the strategy may implicate a virtually limitless range of public and private stakeholders.7
Provision: In many developed countries across the world, public health institutions – especially
city, county, and state health centers, clinics, and hospitals – deliver medical services to
disadvantaged citizens (particularly the uninsured and some of those covered by Medicaid) and
non-citizens, including illegal aliens. This public “safety net” cares for a distinct subset of the
community and in doing so, negotiates incessantly with the purchasers, payers, and
philanthropists about the resources from Medicare, Medicaid, the Children’s Health Insurance
Program, Dispro portionate Share funds, state appropriations, local tax levies, commercial
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payments, and foundation grants that allow them to stay in operation. This activity has been a
chronic sore point for a contingent of public health leaders who have hoped that the federal
government would one day create equitable and universal healthcare coverage and thus, by no
longer “draining vital resources away from population-wide services,”4(p.13) let them get on with
their proper roles and missions. Until 2010, the profession’s pleas for universal coverage fared
little better than those demanding health planning and the rationalization of community
healthcare systems; indeed, the safety net duties of public health personnel appeared to be
growing.
The national health reform will doubtless change the picture. The measure authorizes the
expansion of Medicare and the creation of income-related subsidies for most of the presently
uninsured, aiming to increase coverage to roughly 95 percent nationally. However, it does not
address the needs of illegal immigrants, who will presumably continue to get care from the safety
net, as will (presumably) insured Americans who cannot readily find “mainstream” providers to
treat them. In short, provision is likely to remain a not insubstantial function of public health
authorities for the indefinite future. How these duties are acquitted in the future will depend,
then as now, on a set of little-studied political variables that include: the legal status and strength
of state and local public health agencies; the power of local medical societies (which may resist
public health encroachments on any and all patients but the unprofitable and unappealing – e.g.,
substance abusers and those with sexually transmitted disease); and the entrepreneurial energies
of local public health leaders.
Provision enmeshes public health not only in debates about the financing of healthcare in federal
and state capitals but also in painful disputes about the role of the field in health affairs at home.
The public components of local safety nets are big business: city and county politicians control
sizable shares of their budgets, residents benefit from the jobs these institutions sustain, suppliers
of their goods and services make money. Not a few public professionals, however, view safety
nets dominated by large municipal hospitals as an anachronism and urge that such facilities, and
the money they now consume, be used to create accessible primary care centers, leaving inpatient
activities to increasingly under-occupied voluntary hospitals. Outcomes of these intra-
professional fights span a continuum from hard-won successes to bitterly-fought fiascos, and
rarely fail to consume sizable time, attention, and political capital.
Population based approach
The distinguishing attribute of community and public health practice when compared to medical
practice is public health’s central focus on the health of a population. The population-based
approach uses a defined population (community) as the organizing principle for preventive
action targeting the broad distribution of diseases and health determinants. Population-based
principles use population-based data as the scientific basis for community level interventions.
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Five principles that characterize the population-based approach are (a) a community perspective,
(b) a clinical epidemiology perspective (using population-based data), (c) evidence-based
practice, (d) an emphasis on effective outcomes, and (e) an emphasis on primary prevention.
Another term, population-focused care, refers to a process that uses the population-based approach.
Population-focused care is defined as interventions aimed at disease prevention and health
promotion that shape a community’s overall profile. Community level interventions that affect
the determinants of disease within an entire community rather than simply those of a single,
high-risk individual are considered population-based interventions. Population-based and
individual interventions are not exclusive but complementary strategies. The DHHS WHO
described population-based public health services as interventions aimed at disease prevention
and health promotion that shape a community’s overall health status profile. Clearly, the
population-based approach transcends the individual level. The population-based approach does
not limit itself to the biological, environmental, and agent determinants of illness but includes as
well lifestyle factors and health care organizations (as determinants), as well as other factors that
contribute to health determinants.

Sanitation

Sanitation is everything associated with excreta in relation to people. It includes the structures
used to deal with excreta (e.g. latrines), the materials needed to use these correctly (e.g. water),
and people‘s behaviors and attitudes in relation to both excreta and the sanitary structures (e.g.
acceptance of open defecation, washing hands after defecation).

This chapter looks at how excreta and excreta-related infections are linked, and how these
infections can be prevented by improved sanitation. Several sanitation-related issues are
considered in some detail, and we look at issues which are important to the planning, design, and
construction of sanitary structures.

In addition to health benefits, the installation of adequate sanitation may bring people increased
convenience and privacy. Improving sanitation can eliminate the unpleasant or unsightly living
or working conditions which often result from poor sanitation. Where excreta are reused, people
acquire a potential resource. And although this will not be the development worker‘s motivation,
nice sanitary structures often increase the prestige of the owner.

The uncontrolled discharge of excreta, sewage, or effluent into surface water may result in
environmental problems. The organic matter in excreta-related waste will use oxygen to oxidize,
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and it will draw its oxygen from the water. The amount of oxygen used is called the Biochemical
Oxygen Demand (BOD) of the excreta. If the waste is discharged into surface water without being
adequately treated, the natural aquatic life in the water may die from lack of oxygen.

The transmission of excreta-related infections

Infections are related to excreta in two ways: the pathogens leave the original host‘s body
through excreta, or one of the vectors of the disease benefits from the lack of adequate sanitary
structures or from accessible excreta.

Several disease-groups leave the body through excreta.

Faecal-oral infections are transmitted directly through faecally contaminated hands, food, water,
or soil. The pathogen must be ingested to cause infection (see Section 2.4.1.1, Figure 2.2).
Schistosomiasis needs to develop in a freshwater snail before it can infect people. The pathogen
infects people by penetrating skin which is in contact with infected surface water

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Water-based helminths with two intermediate hosts (e.g. fasciolopsiasis, clonorchiasis) need to
develop in two freshwater intermediate hosts before they become infectious to people.
Transmission occurs when the second intermediate host is eaten without being properly cooked

[73]
Soil-transmitted helminths (e.g. hookworm disease and roundworm infection) have to develop in
soil before they can infect people. Some of these helminths infect people by penetrating their skin
when they are in contact with contaminated soil; others infect people when ingested (see Beef
tapeworm and pork tapeworm have to be ingested by cattle or pigs and development in them.
People are infected by eating poorly cooked beef or pork.

Cysticercosis, a complication of pork tapeworm, is transmitted like a faecal-oral infection from

person to person
Leptospirosis is mainly transmitted through direct skin contact with water or material
contaminated with the urine of infected rats

Vectors which benefit from inadequate sanitation include domestic flies, cock-roaches, and Culex
mosquitoes.

Domestic flies, which can transmit several faecal-oral infections including conjunctivitis,
trachoma, and yaws, can breed in, and feed on, excreta Cockroaches, which have the potential to
transmit several faecal-oral infections, can feed on excreta and hide in sanitary structures.

The mosquito Culex quinquefasciatus, a vector of filariasis and several arboviral infections, can
breed in the polluted liquids in latrines and cesspits or septic tanks.

As there are many disease-groups related to excreta and sanitation, the following concept should
help to assess when these infections could pose a risk.

If pathogen transmission is to succeed, the excreta have to come in contact with certain elements.
For example, schistosomiasis can only be transmitted if the pathogen infects a freshwater snail, so
transmission can only occur if the excreta are released into fresh surface water.

Faecal and urinary transmission of infections

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Most excreta-related infections are only transmitted by faeces. The exceptions are urinary
schistosomiasis, which is common in Africa and which has no animal host; leptospirosis, which is
transmitted mainly through animal urine; and (para-) typhoid fever, which is occasionally
transmitted through urine (16).

The risk of children’s excreta

As many excreta-related infections occur mainly in children, it is more likely that children‘s
excreta will contain pathogens than adult‘s excreta, so special care must be taken in disposing
their faeces. Health and hygiene promotion to mothers will usually be needed to improve the
children‘s behavior and reduce the risks of open defecation by children. Sanitary structures will
have to be adapted and acceptable to children.

The risk of animal excreta

Many excreta-related pathogens can infect animals as well as people, and animals can be
important reservoirs of disease. Cattle, pigs, dogs and rats are all potential hosts for several
diarrheal infections, several water-based helminths, and leptospirosis. Chickens and wild birds
can be the reservoir of pathogens that cause diarrhoea. Where animals are believed to be playing
a role in the transmission of infections they will have to be controlled.

Risk-factors relating to excreta and sanitation

There are five major problems relating to excreta and sanitation which can result in a health risk:

There is open defecation as people do not use sanitary structures. People do

not wash their hands (properly) after defecation.
Sanitary structures are not used correctly, are poorly designed, or are poorly maintained.

Excreta are re-used as a fertilizer, fish food, building material, or for fuel. People
come in contact with excreta of infected animals.

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Several of these problems can be broken down further into specific risk-factors. These specific
risk-factors with their associated disease-groups are presented in Table 6.2.

The health impact of improving sanitation

Table 6.3 shows how different excreta-related infections can be reduced with improved
sanitation.

The survival of excreta-related pathogens in the environment

Outside the host, excreta-related pathogens will usually die off over time. Most pathogens can
remain viable in the environment for some time, however, and Table 6.4 shows the maximum
time of survival of some. As a general rule, pathogens survive longer when they are in lower
temperatures, in a moist environment, and protected from direct sunlight. Again as a general
rule, helminths and viruses will survive longer then bacteria and protozoa. Except for
roundworm, all the infections in Table 6.4 are faecal-oral. It is less useful to look at the survival
times of pathogens which need intermediate hosts, as these usually remain viable for as long as
the intermediate host survives.

The health risk of contaminated material (water, food, other objects) will usually decrease over
time if no multiplication or recontamination occurs. As the number of pathogens discharged is
often very large, the potential for transmission can remain high, even if most pathogens die off or
if the excreta is diluted in surface water. A person with cholera can defecate up to 1x1012 bacteria
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per liter of diarrhoea, for example, a person with urinary schistosomiasis can discharge 50,000
eggs per liter of urine, and people infected with hookworm disease can shed 1x106 eggs per day
(73).

Several bacteria and helminths can multiply outside the host. The bacteria Salmonella spp.
(causing salmonellosis and (para-) typhoid), Shigella spp. (causing bacillary dysentery) and E.coli
(causing bacterial enteritis) can all multiply in food. The food can be contaminated through
faeces, hands, utensils, domestic flies, or cockroaches. Meat and dairy products pose the greatest
risk. Thus food which is not initially harmful because it contains too little bacteria can become
infectious over time because the bacteria have multiplied.

Several water-based helminths (schistosomiasis, fasciolopsiasis, fascioliasis, clonorchiasis, and

opisthorchiasis) can multiply in freshwater snails, and strongyloidiasis can multiply in soil. Here
again, a light contamination of water or soil can become very infectious because the pathogen has
multiplied outside the host.
Excreta poses a large and prolonged health risk because of its potentially high load of pathogens,
the persistence of pathogens in the environment, and the potential for multiplication outside the
host, so excreta-related wastes must be dealt with carefully.

Practical issues on sanitation

This section looks at several of the risk factors mentioned in Table 6.2. It also presents several
aspects important to the planning, design, and construction of sanitary structures.

Open defecation
Open defecation allows the transmission of all excreta-related infections and is therefore a serious
health threat. Open defecation is not acceptable close to the household plot, or in urban
communities or other areas with high or medium population densities.

Each infected person usually has great potential to spread pathogens, so sanitary structures will
only be effective in preventing disease if they are used by everyone, all the time. Even if only

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some people in the population (e.g. children) defecate in the open, the health benefits of sanitary
structures will be limited. Some examples to illustrate this problem:

A person with bacillary dysentery excretes 1x109 bacteria in a small stream. Ingesting 10 to 100
bacteria can cause infection. The number of pathogens excreted in the water could in theory
pollute 10,000m3 of water with 100 bacteria per liter.

A person with a hookworm infection can easily release 1,000,000 eggs per day. If this person
does not always use a latrine, and we assume that 1 per cent of the eggs end up in favorable
soil, become infectious, and remain viable for six weeks, then this person will be responsible
for over 400,000 infectious larvae in the soil at any time for as long as the infection lasts.

Even though open defecation is a serious health threat, it should not be condemned categorically
in areas with low population densities. Open defecation might be preferable to using poorly
maintained latrines (57) which can become foci for the transmission of diarrhoea and hookworm
(9).

Poor hygiene of sanitary structures

Sanitary structures can play an important role in disease transmission if they are not kept clean
(28). Faecal-oral infections can be spread through direct contact with faeces, contaminated
material, or through flies or cockroaches. Latrines with floors contaminated with faeces can
transmit hookworm.

Sanitary structures must be kept clean to reduce health risks and to make them acceptable to
users. Installing a SanPlat, which is a smooth concrete latrine slab? makes it easier to clean the
latrine. A SanPlat can be built into a new latrine or an existing latrine can be upgraded. The slab
should slope towards the drop-hole so that spilled water, or water used for cleaning, flows into
the hole. Figure 6.1 shows an example of a SanPlat.

Water supply and the sanitary structure

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There should be a reliable source of water near the sanitary structure. Water is used for hand
washing and cleaning the structure, and possibly for flushing or anal cleansing. The water does
not have to be high quality as it is not used for drinking.

Table 6.5 gives approximate quantities of water needed. A communal pour-flush latrine used by
20 people who use water for anal cleansing may need around 200 liters of water per day to work

– and be used – correctly.

Discharge of excreta or effluent in surface water

Discharging excreta-related waste into freshwater cause‘s different risks than discharging into
seawater.

Discharging excreta in freshwater

Discharging excreta, night‘s oil, or sewage into fresh surface water creates a serious health risk.
Faecal-oral infections can be transmitted to people who drink the contaminated water, and water-
based helminths (e.g. schistosomiasis, clonorchiasis) can infect their intermediate hosts. If cattle
and pigs drink contaminated water, they can be infected with beef and pork tapeworm. Domestic
flies, which transmit conjunctivitis and trachoma, and Culex mosquitoes, which transmit filariasis
and several arboviral infections, can breed in surface water polluted with faeces.

The discharge of excreta, night‘s oil, or raw sewage into fresh surface water should be limited as
much as possible. The practice would only be acceptable where the waste was diluted in a large
volume of moving water, where people are not in contact with the water (including people
downstream), and where the risk from food taken from the river is very small. This combination
is unlikely to occur in developing countries.
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As conventional sewage treatment plants do not usually reduce the number of pathogens to a
safe level (their main aim is generally to reduce the BOD to acceptable levels), their effluent is
normally still much polluted. Exceptions to this are properly designed and functioning waste
stabilization ponds, plants with maturation ponds, and adequate filtration systems

Discharging excreta into seawater

Only faecal-oral infections pose a health risk if excreta, night‘s oil or sewage are discharged into
seawater. The cysts of protozoa and the eggs of helminths will settle out rapidly, so only viruses
and bacteria will normally be a threat. It is unlikely that pathogens will travel more than a few
kilometers from a sewage outfall.
As seawater is not used for drinking, the main health risk comes from handling or eating
contaminated fish and shellfish. Fish can harbor pathogens in their body for weeks and can
therefore be a risk if they are caught close to a sewage outfall. As shellfish can accumulate
pathogens in their bodies, they are a larger health risk than fish. Fish and shellfish should always
be properly cooked before eating.

The additional health risks from contaminated seawater will normally be limited if people
already live in an environment with poor sanitation .

Groundwater pollution by sanitary structures

Polluted liquid seeping out of sanitary structures can sometimes percolate through the soil into
the groundwater. The groundwater can thus be polluted with pathogens and chemicals from the
excreta. Both types of pollution will be covered here, with the emphasis on pollution by
pathogens.
Only faecal-oral pathogens will be transmitted by polluted groundwater, and unless the soil
consists of fissured rock or coarse sands, only viruses and bacteria will pose a risk. Because of
their large size, the cysts of protozoa and eggs of helminths will easily be blocked by the soil and
will not seep down.
Groundwater pollution will only be a problem if the groundwater is used for drinking, or if water
mains with intermittent supply are piped through polluted soil.

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It is important to remember that the health risks from open defecation or from using inadequate
sanitary structures are usually greater than the health risk of polluting the groundwater by
sanitation.

If groundwater pollution is a serious risk, it is usually more appropriate to change to a piped

water supply than to install off-site sanitation (e.g. a sewerage system).

Although groundwater pollution is often used as an argument against on-site sanitation (e.g.
pit latrines), poorly constructed or maintained sewerage systems are just as likely to pollute the
groundwater

Pollution in the unsaturated zone

In the zone above the water table, polluted liquid from the sanitary structure will percolate
downwards under the influence of gravity. The removal of pathogens in the unsaturated zone is
very effective, and where groundwater pollution could be a problem, this distance should be
maximized (e.g. by raising the latrine, using a shallow pit) . If there is at least 2m of fine sand or
loam between the source of pollution (e.g. the base of the pit of the latrine) and the groundwater
table, most pathogens will be removed from the liquid. Within months of a latrine being used an
organic mat will form naturally in the soil. This mat is very effective in removing pathogens.

Pollution in the saturated zone

To understand the principles of pollution below the water table, the movement of groundwater in
the saturated zone must be understood.
Shallow groundwater tables usually follow roughly the form of the terrain . As water flows from
high to low areas, groundwater will normally move in the same direction that water on the
surface would flow. As a rough rule, the steeper the terrain and the coarser the soil particles (if
there are no small particles like silt and clay), the faster the groundwater will flow .

When the polluted liquid meets the groundwater, the liquid will be carried with the groundwater
flow. The liquid forms a ‗tongue‘which follows the flow of the groundwater, but the liquid and
the groundwater do not really mix. This is shown in Figure 6.2.

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Bacteria will not normally travel further than the distance the groundwater flows in 10 days (42).

Predicting the exact distance that pathogens will travel from a sanitary structure is difficult, as
this will depend strongly on the local situation. In terrain with a low gradient and medium to fine
sands, bacteria will probably not travel further than 10 meters. Viruses can travel further, as can
bacteria in coarse sands or fissured rocks (42). In fine soils a safety distance of 15 meters will
usually be adequate.

These values can be used for sanitary structures which have to deal with up to 50 liters of liquid
per horizontal m2 per day , and family structures will usually not exceed this.

Even though pathogens are removed from the flow, they are not necessarily killed, and if large
volumes of liquid are suddenly discharged, viable pathogens which were ‗stuck‘ may be flushed
out. Pathogens will not travel as far if the same amount of liquid is discharged continuously than
if it is discharged in gushes.

If groundwater is abstracted through a properly sealed borehole well below the polluted layer,
the water from the pump will be safe. This only works if water is abstracted in low volumes (e.g.
with a hand pump). Mechanized pumping can draw down the water table to such an extent that
the pollution of deeper groundwater is possible . A properly sealed borehole that pierces an
impermeable layer would be even safer. It might sometimes be possible to install latrines and
properly constructed tube-wells close together, but it is always better to have a minimum safe
distance between the two.

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Chemical pollution of groundwater through sanitation
The chemical pollution of groundwater is caused mainly by nitrogen (nitrate) and chloride. The
health risk of chloride in groundwater is limited (chloride is a component of kitchen salt), but a
high chloride content could make the water taste unacceptably salty. Nitrate can cause blue-baby
syndrome in infants, but this risk seems to be limited. Nitrate is possibly linked to gastric cancer
and congenital deformities, but here again, the risks seem to be limited.

Unless there is a high population density, or some other cause of chemical pollution (e.g. using
sanitary structures to discharge chemically polluted waste water), the health risk of chemical
polluting groundwater by sanitary structures will usually be small.

Re-use of excreta
Excreta can be a valuable resource. Excreta-related wastes can be used for:

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 fertilizing or irrigating crops: night‘s oil, sludge, sewage or composted wastes can be used to
fertilize plants, and sewage or effluent can be used for irrigation (and fertilization).

Aquaculture: Night‘s oil, sludge or sewage can be used to feed fish in ponds.

Gas production: Night‘s oil is used to produce biogas, a useful source of energy.
Fresh excreta, night‘s oil, sludge, sewage, or effluent can all contain large quantities of pathogens,
and thus pose a serious health risk to the people who handle the waste and those around them.
People who work directly with waste or who live or work close to where excreta-related wastes
can all be at risk from excreta-related infections. But excreta, effluents, and sludge can be treated
to make them relatively safe to handle and re-use.

Treatment of excreta-related wastes

There are several ways to make excreta-related wastes safer. The waste may not be totally free of
pathogens, but if one of the following techniques is used correctly, the risk of handling the
treated waste will normally be negligible.

Pass the waste through properly designed and working waste stabilization ponds .
Let the effluent from a sewage treatment plant sit for enough time in maturation ponds.
Filter sewage treatment plants effluent through a sand bed.
Compost excreta, night‘s oil or sludge under aerobic conditions, at temperatures of at least
62oC for over one hour, 50oC for over one day, or 46oC for over one week.

Treat nights oil or sludge with heat; temperatures and duration should be at least equivalent to
those mentioned above . The high financial and environ-mental costs of fuel will usually make
this method inappropriate.

Bury excreta, night‘s oil, or sludge for two years (e.g. use twin-pit latrines, bury nights oil or
sludge in trenches, or top with earth full latrines). In tropical climates most pathogens, except
for roundworm, will not survive longer than one year when buried.

Dry night‘s oil or excreta for at least one year .

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Fresh excreta, nights oil, and any type of excreta-related sludge or effluent that has not been
treated adequately can contain pathogens and should therefore be isolated as much as possible
from people, animals, insects, food, crops, vegetables, soil, and water. Conventional sewage
treatment plants usually do not reduce the number of pathogens to safe levels, and their effluent
can still contain high levels of pathogens.

Use of excreta-related waste for fertilization and irrigation

The main health risks of workers (and often of their families) that use excreta-related waste for
fertilization or irrigation are faecal-oral infections and soil-transmitted helminths (e.g.
roundworm and hookworm). Where workers come in contact with contaminated surface water
schistosomiasis could also be a problem.

Consumers of the crops are at risk of faecal-oral infections and ingested soil-transmitted
helminths (e.g. roundworm and whipworm).

The health risks of using excreta-related waste for fertilizer should be reduced by minimizing the
contact between crops and pollution as much as possible (e.g. through subsurface irrigation).
Excreta-related wastes should only be applied before the crops are planted or up to one month
before the crops are harvested. This will reduce, though not eliminate, the risks of faecal-oral
pathogens. The health risks of soil-transmitted helminths will not be reduced significantly.

The health threat to people can be reduced by feeding these crops to animals, though several
infections (e.g. salmonellosis and beef and pig tapeworm) will remain a health threat to people
through infections in the animals

Use of excreta-related waste for aquaculture

Using excreta-related waste to feed fish ponds creates several health risks. People who handle,
prepare, or eat undercooked fish from these ponds are at risk from the faecal-oral pathogens that
are on the fish‘s body or in its intestines .

In addition to faecal-oral infections, consumers are at risk from water-based helminths which use
fish as an intermediate host (e.g. clonorchiasis and opisthorchiasis). These pathogens can be

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transmitted to people or animals if the fish is not properly cooked. Other pathogens which have
to reach surface water to develop (e.g. schistosomiasis) could also potentially be transmitted.

Keeping the live fish in unpolluted water for two to three weeks before eating them will reduce
the health risks.

As the eggs of water-based helminths with two intermediate hosts settle out easily in water, the
risk of these pathogens can be reduced by putting ponds in series, and only harvesting fish from
ponds which have not been fed with excreta-related wastes

Production of biogas

Handling excreta and the sludge that has to be removed regularly from a biogas plant could be a
health risk. The sludge could be heavily contaminated with pathogens and should be handled
and disposed of with the same care as fresh excreta.

Some practical issues on the planning and construction of sanitation

While not all practical sanitation issues can be considered here, some important issues need to be
highlighted.
Assessment

To maximize the impact of improved sanitation, everyone must have access to adequate
structures, and these structures must be used correctly.

The structures have to be adapted to local behavior, traditional beliefs, and the population‘s
needs. In addition, sanitation has to be affordable to the users, and appropriate for local
institutional capabilities and restrictions. The structures also have to be adapted to the physical
situation in which they will have to operate. A thorough assessment will be needed, and it is
likely that different groups will identify different issues, needs, and preferences, and these must
be identified and considered. It is especially important to address the problems of marginalized
people to ensure that everyone has access to sanitation.
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Household versus communal latrines
Each household should normally have its own sanitary structure so that responsibility for
maintenance and cleanliness lies with the family.
In a stable situation, communal latrines should only be considered if it is impossible to install
structures at household level (e.g. because there is no space or installation is unaffordable), or in
public structures like schools or hospitals.
Where communal structures have to be installed, the issues of management, cleaning,
maintenance, and operation must be worked out before construction begins. Usually people have
to be employed to keep communal structures clean . The facilities for men and women should be
separated, and issues of privacy and safety for women using the structures, or walking to the
structures, have to be addressed in the planning phase.

Numbers and location of latrines

People will only use sanitary structures if they do not lose too much time at them. This is
achieved by having enough latrines available and setting them close to the users.

There should be no more than six cubicles per communicable latrine, with not more than 20 or at
most 25 users per cubicle . Structures should be sited less than 50 meters from people‘s houses,
and at most 250 meters .

If groundwater is the community‘s drinking-water source, latrines must be located and

constructed so that the risk of contaminating groundwater is minimal. As a general rule, if the
latrine is constructed in fine soils, there should be at least 15 meters between the water source and
the latrine. If possible, the water source should be installed on higher ground than the latrine.
Where the soil is coarse, or waste water is discharged in the structure, the distances between
water source and latrine may have to be more. Latrines should be located so that the risk of
flooding by storm water or floodwater is minimized. The top of the latrine slab should be raised a
minimum of 0.15 meters above surface level to prevent surface water or rainwater from entering
the structure . Pits should be dug some meters away from the foundations of buildings as this
could weaken the foundation or cause collapse; and pits must not be dug against a road carrying
heavy traffic as this can also collapse the pit.

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Sanitation in emergencies
In the early stages of an emergency it is not usually feasible to provide household latrines or even
enough communal latrines. It may be necessary to construct structures with 50 to 100 users per
cubicle or meter of trench (if trench latrines are used) to begin with. This must be upgraded as
soon as possible to communal latrines with 20 users per cubicle, or household latrines . As it is
not normally possible to provide adequate structures from the beginning, and the aim should be
to decrease the health risks and increase the convenience to the users as quickly as possible.

Start by discouraging people from defecating near any water source used by people and animals,
or in fields where crops for consumption are grown. As soon as possible defecation should be
confined to specific areas: open defecation fields or trench defecation fields. The next step could
be to install trench latrines, or communal borehole or pit latrines. Following that latrines could be
installed at household level if feasible. Provision should progress through these steps as soon as
possible, to use the best feasible structures at all times.

If communal latrines are installed people have to be employed to maintain and clean them. Anal
cleansing material, water and soap for hand washing, and soil to cover the excreta may have to be
provided. If insects can access the contents of the latrines, the excreta should be covered with 0.1
meter of soil every two to three days .

Some issues concerning construction

Structures are designed to last a certain period (the ‗design life‘). In a stable situation the pit of a
latrine may be expected to last for up to 30 years. The expected number of users at the end of the
design life should be used when designing structures. Annexed 5 have information on the
accumulation rates of solids in pit latrines, and how to estimate the infiltration capacity of the
soil.

Where soil stability, soil erosion, or rats could become a problem, the top 0.5 meters of a pit
should be protected with a closed lining. If the soil cannot carry much weight the superstructure
should be light. It may be necessary to make a foundation in the form of a concrete ring beam to
make the latrine structurally sound. The more complex a latrine becomes, the more expensive
and demanding its construction will be.

Latrines should be built so that insects cannot enter the pit. This can be achieved by installing a
tight-fitting lid (this is difficult in a communal structure), a water seal (this will only be adequate
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if water or soft paper is used for anal cleansing), or a VIP-latrine (this type of latrine is probably
less adapted to use at household level as they are expensive and rather complex; in addition, VIP
latrines usually do not stop mosquito breeding). If the latrine is ‗wet‘, polystyrene beads can be
used to create a floating layer which will prevent mosquitoes from breeding in the pit All other
openings which give access to the pit containing excreta should either be sealed or closed with fly
proof netting.

Vandalism and theft must be prevented by sealing the lids of access-holes with mortar or locking
them and by making structures as solid as possible; this is especially important in communal
structures.

This example of a pit latrine (Figure 6.3) shows some of most important points for proper use.

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 Chapter 7
Assessing Public Health Priorities in Emergency and Development Settings

Introduction

This topic discusses the importance of improving water, sanitation, vector control and hygiene in
emergency settings.

People affected by emergencies often suffer from:

1. Malnourishment
2. Stress
3. Fatigue and other ailments including injuries.
These conditions coupled with unsanitary living conditions such as:
1. substandard sanitation
2. inadequate water supplies and
3. Poor hygiene makes disaster-affected people especially vulnerable to disease.

Which is why improving water, sanitation and hygiene in emergency settings is so

important because few emergencies leave people displaced for only a short time.

In this topic:

1. Water means water for domestic purposes and not agricultural or industrial
purposes.

2. Sanitation is used in a broad sense and considers:

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 a. excreta disposal
b. vector control
c. solid and medical waste management and
d. drainage.

3. Hygiene includes practices related to:

a. water hygiene (e.g. keeping water supplies safe)
b. personal hygiene (e.g. washing hands)
c. domestic hygiene (e.g. food hygiene) and
d. environmental hygiene (e.g. keeping household environments free of excreta
and solid waste).

a. Survival and longer terms needs in an emergency

- At the onset of an emergency, the aim is to: protect life
and health through rapid assistance

Quickly put in place immediate measures to

protect human life and health.

Address longer-term health interventions (focusing

on most crucial aspects of environmental health)

- Provide facilities for people to excrete safely and

hygienically

- Protect water supplies from contamination

- Provide enough safe water for drinking, cooking and
essential personal and domestic hygiene

- Ensure that people have enough water containers to collect

and store water cleanly

- Ensure that people have the knowledge and

understanding they need to avoid disease
- Ensure that people have soap for washing their hands

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 - As early as possible in the emergency, it is critical to;

Consult with the disaster affected populations to

get a good understanding of their needs

Identify key community leaders who can help

organize the community’s involvement in WASH
projects

Begin planning for and start implementing longer-

term interventions in consultation and cooperation
with the community

Vulnerable groups

Vulnerable groups – Individuals at greatest risk of disease or injury

Reasons for vulnerability vary:

1. Getting less priority for limited resources

2. Belonging to an ethnic, social, religious or political minority
3. Showing greater difficulty accessing treatment and care

Poverty and vulnerability strongly co-relate.

Vulnerable groups can include:

1. Women (ratio higher for pregnant women)

2. Children (ratio higher for children living in child-headed households)

3. older people (ratio higher for the infirm)
4. physically and mentally disabled people
5. people living with HIV/AIDS

6. infants and
7. weak and sick children living
8. People either separated from or without access to the main focus of relief
assistance
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 9. Refugees or displaced people scattered among the host community (might not
receive the same assistance as those who are living in camps or settlements).

The link between disease and environment

- Diarrheal diseases, acute respiratory infection, measles, malaria and

malnutrition are the most common causes of death in emergencies (see
Figure below).
Causes of Death, Kohistan District, Afghanistan

- All the above causes of death are preventable.

- Measures used to prevent common diseases in emergencies are shown
in the below table

Source: The Johns Hopkins and the International Federation of Red Cross and Red Crescent
Societies
Diseases targeted by preventive measures
Preventive measure Impact on spread of
Shelter, Site planning Diarrheal diseases, Clean water Diarrheal diseases, typhoid

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acute respiratory fever, guinea
infections worm
Good sanitation Diarrheal diseases, vector- Adequate nutrition Tuberculosis, measles,
borne diseases, acute
scabies respiratory infections
Vaccination Measles, meningitis, yellow
fever, Japanese diphtheria
encephalitis,
Vector control Malaria, leishmaniasis,
plague, Dengue, yellow fever, other viral hemorrhagic fevers
Japanese encephalitis,
Personal protection (insecticide-treated nets)
Personal hygiene Louse-borne diseases:
Malaria, leishmaniasis typhus, relapsing
fever, trench fever
Health promotion Sexually transmitted
infections, and Infections during and after deliveries
HIV/AIDS, diarrheal diseases,
Case-management Cholera, shigellosis, malaria, Dengue, hemorrhagic fever,
tuberculosis, acute meningitis, relapsing
respiratory infections, fever
Shelter, Site planning Diarrheal diseases, Clean water Diarrheal diseases, typhoid
acute respiratory fever, guinea
infections worm
Good sanitation Diarrheal diseases, vector- Adequate nutrition Tuberculosis, measles,
borne diseases, acute
scabies respiratory infections

The majority of these preventive measures are related to environmental

conditions i.e.:

- appropriate shelter and site planning

- clean water

- good sanitation

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 - vector control
- personal protection such as (insecticide-treated nets, personal hygiene and
health promotion).

These conditions relate to ‘risk factors’ that cause disease (interventions must target
risk factors properly).

Diseases affecting displaced populations in disasters

Environmental risk
Disease Symptoms factors Health hazards
All symptoms of the Influenza and
Acute upper common Crowding, poor pneumonia
cold, fever and
respiratory heavy hygiene may cause severe
coughing. Chest pain complications,
tract and pain especially in
infections between shoulder groups at risk
blades in pneumonia
Watery stools at least Dehydration,
Diarrhea three Contaminated especially in
times a day, with or children, shown by
without drinking water or dark
blood or slime. coloration of urine,
Might be food, or poor dry tongue
accompanied by
fever, nausea sanitation or leathery skin
or vomiting
Modest fever, severe,
Cholera but As for diarrhea As for diarrhea
liquid diarrhea (rice
water
stools), abdominal
spasms,
vomiting, rapid

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 weight loss
and dehydration,
rapid
deterioration of
condition
Measles A disease of early Crowding, poor Severe constitutional
childhood, symptoms, high case
characterized by hygiene fatality
fever and catarrhal Very contagious rate
symptoms, followed
by
maculopapular rash
in mouth
Painful muscles and
Malaria joints, Breeding of Disease may rapidly
high fever with become fatal, unless
chills, Anopheles medical
care is provided
headache, possibly mosquitoes in within the first
diarrhea and
vomiting stagnant water 48 hour
bodies
High fever, Dengue usually runs
Dengue and headaches, pain Breeding of Aedes a mild
in muscles and course. DHF,
Dengue joints, red mosquitoes in however, is
often accompanied
Hemorrhagic spots on skin natural or artificial by heavy
hemorrhages, which
Fever (DHF) containers, filled may
with water be fatal
Infected persons may Often fatal if
Meningococcal show no Crowding untreated at an
meningitis symptoms for a early stage;
considerable time. neurological

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 When an problems in
epidemic is in
progress, survivors
headache, fever and
general
malaise will suggest
the
diagnosis, which
must be
confirmed by lumbar
puncture
Diarrhea with blood Case fatality rate
Shigella in the Contaminated may be high
stools, fever,
dysentery vomiting and drinking water or
abdominal cramps food, or poor

sanitation, poor
hygiene
Without appropriate
Typhoid fever Starts like malaria, As for diarrhea, medical
sometimes with
diarrhea, and care, including
antibiotics and
prolonged fever, contaminated surgery, may
occasionally with lead to fatal
delirium foods complications in a
few
weeks
Long-term disabling
Viral hepatitis A Nausea, slight fever, Poor hygiene, effects
contaminated foods
palecoloured and water
stools, dark colored
urine,

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 jaundiced eye whites
and skin
after several days
Prolonged fever, May be fatal without
Louse-borne headache, Unhygienic treatment
typhus body pains conditions
leading to lice
infestations
Inflamed and painful A secretion is
Diphtheria throat, Crowding, poor deposited in the
respiratory tract,
coughing hygiene which can
lead to asphyxiation
Muscle spasms,
Tetanus starting in the Poor hygiene, injury Fatal
jaws and extending
to
the rest of the body
over
several days
Rabies Fatigue, headache, Bit from infected Fatal if untreated
disorientation,
paralysis, animal host
hyperactivity
Relapsing fever Unhygienic Often fatal in
(louse borne Acute high fever at conditions untreated
persons, depending
or tick borne) intervals leading to lice or on
tick infestations immunity levels
Heat stress Elevated body Excessive Risk of coma
temperatures,
nausea, temperatures
vomiting, headache

Collaboration between public health and water and sanitation sectors: -

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 • Critical in emergencies i.e. surveillance data from health sector steer
water-sanitation interventions.
• Gives highest priority to most vulnerable to disease in terms of
- provision of water supply
- sanitation and hygiene assistance.

• Disease surveillance maps disease ‘hot spots’ (where outbreaks are likely
to occur or are starting).

• Public health sector communicates disease hot spots to the water-

sanitation sector and crucial first steps for disease prevention begins i.e.

- rapid assessments of key environmental risk factors that need

immediate action.

(conducted in partnership between health sector personnel, water-

sanitation professionals and community representatives)
Disease transmission in Emergencies
Illnesses related to water, sanitation and hygiene include the following:

1. Water-borne diseases occur when a disease-causing agent enters the body

through drinking water;

2. Water-washed diseases occur because of inadequate hygiene conditions

and practices;

3. Water-based diseases include those illnesses that are spread through a

disease vector that lives in water;

4. Food-borne illnesses result when disease-causing agents enter the body

through food;

5. Vector-borne diseases are spread by means of insect or rodent vectors.

Types of diseases in emergencies include:

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 1. Diarrheal diseases: -
- major risk factor in emergency settings
- cause sickness and death among children.
- mostly spread by faecal-oral means (i.e. occurs when faeces, which
contain disease causing pathogens, from one person enters the mouth
and is ingested by another person).
- easily spread in overcrowded unsanitary conditions (typical of
camps and settlements in emergencies).

- Predisposing factors include: -

i. drinking water contaminated with faecal material (either at the
source, during transport or in the household)

ii. poor personal hygiene (due to a lack of water)

iii. poor food hygiene (e.g. contamination of food by dirty or
unwashed hands or flies).

Vectors: - Any animal capable of transmitting disease germs from one host to another
by its bite or bodily functions.

- Pathogens transmitted either:

i. mechanically (e.g. trachoma which is transmitted by non-biting flies)

ii. through biological transformation (e.g. malaria parasites by

mosquitoes).

Each emergency can be characterized by different types of vectors and vector-borne

diseases. Examples of outbreaks in emergencies include:

1. Malaria (transmitted by Anopheles mosquitoes) (Endemic

malaria major cause of death in emergencies)
2. Dengue fever (transmitted by Aedes mosquitoes) and
3. Epidemic typhus (transmitted by lice).

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 Vectors and diseases likely to be present in emergency settlements
(Adapted from Wisner and Adams, 2002)

Vector Disease Transmitted

Mosquitoes (Anopheles) Malaria, filariasis.
Mosquitoes (Aedes) Yellow fever, Dengue fever,
Chikungunya, filariasis, other viral
diseases.
Mosquitoes (Culex) Japanese encephalitis, filariasis, other viral
diseases.
Houseflies Diarrhea, dysentery, conjunctivitis,
typhoid fever, trachoma.
Cockroaches Diarrhea, dysentery, salmonellosis,
cholera.
Lice Epidemic typhus, pediculosis, relapsing
fever, trench fever, skin irritation.
Bedbugs Severe skin inflammation.
Triatomid bugs Chagas’ disease.
Ticks Rickettsial fever, tularaemia, relapsing
fever, viral encephalitis, borreliosis.
Rodent (Mites) Rickettsial pox, scrub typhus.
Rodent (Fleas) Bubonic plague, endemic typhus.
Rodents (Rats) Rat-bite fever, leptospirosis,
salmonellosis, melioidosis.
Sand fly Leishmaniasis

Community involvement in disease prevention

Happens through:

i. Community volunteers
ii. Community Health Workers (CHWs)

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Community involvement (Participatory Approach): Giving host population (both men
and women) opportunity to play an active role in initiating water and sanitation

Ultimate goal: To quickly address substandard environmental health conditions (reduce

sickness and death).

Community role:

i. constructing facilities
ii. creating awareness of hazards, disease prevention and detection

iii. contributing ideas and decision-making

Vulnerable groups to cope and survive in a disaster might be seriously

compromised.

- Identification of vulnerable groups critical

- Give vulnerable groups opportunity to participate and influence water and
sanitation projects.
Host populations also affected in emergencies (understand their needs)
Impact of Emergencies

i. Strain on local economy (added demand upon it from refugees, displaced

people and the host population alike).

ii. Unequal access to basic services and survival needs

- Food
- water
- health care.
iii. As emergencies progress, camps and settlements for the displaced stabilize
and become permanent

- Stretching needs of host population could be as great as or even greater

than the needs of the displaced population.

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 - Response efforts include the disaster-affected host community. a.
Importance of Community Involvement:

- Gives community members opportunity to identify their needs

- Builds and strengthens community problem-solving skills

- Empowers them to take action

- Promotes sense of process ownership
- Ensures quick recovery
- Encourages teamwork and bonding
- Identifies existing but hidden talent
- Encourages leadership

- Promotes project sustainability

b. Principles of participatory approaches:
The following are the basic principles of participatory approaches:
i. Communities can and should determine their own priorities in dealing
with the problems that they face;

ii. The enormous depth and breadth of collective experience and knowledge in
a community can be built on to bring about change and improvements;

iii. When people understand a problem, they will more readily act to solve it;

iv. People solve their own problems best in a participatory group process.

The community plays an important role in helping agencies formulate change strategies
for effective behavior.

- Effective hygiene programs use community knowledge to understand what will

motivate people to change their behavior toward using and cleaning toilet
facilities, toward washing hands after using toilet facilities, etc.

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 - In fact, disease prevention and good health might not be a strong factor to make
people want to change. It might instead be convenience, social status, the esteem of
others and financial gains that are the driving forces behind change.

- Engaging and getting input from community members is the best way to fully
understand these driving forces.

Safe water supply and adequate sanitation is to prevent disease rather than treat disease
(preventive rather than curative).

- Disease prevention should be a concern of the entire community (when disease is

not prevented, entire community suffers; when disease is prevented, the entire
community benefits)
• Benefits (both health and non-health) may include: -

a) Money saved on health services by the patient and the heath care
system

b) Availability of more time for the patient and family members

to

i. work (tend to crops, seek firewood, haul water etc)and earn

wages (to augment household finances, food supply and
hygiene)
ii. go to school
Community management in water, sanitation and hygiene projects: -

- Points to consider
i. Do people in the community consider that the project responds to a
priority felt need?

ii. Consensus building i.e. Have all sections of the community been consulted?
Has a baseline data survey (which identifies different groups in the
community, their views about water, sanitation, health and their
perceptions of the proposed project) been done?

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iii. Have women been involved as far as possible in the initial discussions on
the proposed project? Women are often the main water carriers and users.

iv. Does the project have the support of the local government and community
leaders? (Legal standing – i.e. let community leaders lead the discussions)
v. Have all stakeholders been involved?
- If not, organize a short workshop to discuss the importance of this and to
formulate strategies for inclusion.

- Try to ensure open and ongoing dialogue about the project. (Always
remain flexible and encourage suggestions from community members
about how the project should proceed).

- If people do not attend meetings, try to find out why as soon as possible

- Ensure that the issue of long-term project sustenance is raised as soon as

possible with community groups

a. Involve the community early in the crisis

Emergency response activities typically start by assessing needs
(immediately collect and analyze information).

Example: excreta disposal facilities; valuable information may include

- Design
- Access
- cleaning and

- cultural appropriateness etc (for their maintenance). b.

Improve environmental conditions i.e

- Overcrowding or Damage of traditional environmental health

facilities in a village become, lead to unhygienic living conditions
Large-scale outbreaks of diarrhea and other environment-related
diseases frequently reported during the acute emergency phase.

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 - Environmental health control then becomes top priority. c.
Assessing environmental health conditions

Requires understanding of the relationship between human and socioeconomic factors

and the physical landscape.

Environmental control measures with rapid impact and long-term view should be
selected.

- Minimum environmental health standards in emergency response should be

achieved within three to six months.

- Involve community representatives in planning and implementing

interventions

- Community representative groups should be gender sensitive and include a

cross-section of people from various socioeconomic levels.

An assessment of the physical environment should be carried out as soon as possible

after the disaster has occurred.

- Assessment results should identify environmental health priorities and provide

enough information to design a program quickly.

- Environmental health assessments should involve multiple sectors, water and

sanitation, food, shelter, health services, local authorities, representatives from the
disaster-affect population and local non-governmental organizations.
- Assessment teams must include individuals with local knowledge as well as
previous experience of disasters in the country or region.

- Appropriately qualified personnel such as the environmental health

technician or sanitation inspector should lead the assessment.

- Assessment checklists are useful for ensuring all the key questions have been
examined, but they must be adapted to the particular disaster situation.

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 ASSIGNMENT 1
1. Suppose you work with a community radio station, describe what your radio station
would do to address water, sanitation and hygiene issues with regard to your i) audience,
and ii) WASH messages?

2. In your own words, what is your understanding of public health and what are its key
elements?

3. Public health is about partnership between the different players. Explain how the role of
international non-profit/NGO in terms of

i) recruitment ii) training iii) funding and iv) monitoring for public health projects
contribute to the success or failure of those projects in the developing countries

4. In your capacity as the environmental health officer you have been tasked to lead the
assessment of a disaster situation. Come up with two key questions under each of the
following five headings in your assessment list , namely i) General overview of the situation
ii)Water supply iii) Solid-waste disposal iv) Excreta disposal and v) Vector-borne diseases for
purposes of assessing local conditions, health needs and identifying local resources in the
disaster situation that you are addressing.
NB: All questions carry 10 marks each

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