Facing NTDs requires both WASH and health perspectives
Liang Qu is a medical student from Monash University, with an interest in global health.
Globally, it is estimated that more than a billion people are affected by NTDs. In addition, one-third of the world’s population does not have access to adequate sanitation, and over a billion people still practice open defecation. Poor hygiene and sanitation practices can lead to the transmission and development of NTDs, from soil-transmitted helminthiases to water-borne schistosomiasis. Efforts to combat the long list of diseases with a combined tremendous burden must involve improving access to WASH – one of the five key strategies for reducing NTDs outlined in the WHO NTDs roadmap.
On Nov 23, the International Society for Neglected Tropical Diseases (ISNTD) Water 2017 meeting reiterated the importance of investing in WASH for facing NTDs. The meeting highlighted the huge potential benefits attainable through WASH innovations and interventions. Every dollar invested in water and sanitation has been estimated to result in a return of more than five dollars in health alone. However, WASH interventions must be done effectively, and the meeting served to remind us of the challenges faced. In particular, there is room for better integration of efforts between WASH and health sectors.
Every programme must refer back to the upstream causes of the disease’s impact. Public health engineers need to account for the transmission routes or the various phases of a parasite’s life cycle, where applicable. In the case of human schistosomiasis – a disease that can result in severe health issues affecting the urinary and the gastrointestinal systems – the Schistosoma species transition through various stages in their life cycles, including being free-swimming in water reservoirs, to being transmitted by various aquatic (Biomphalaria, Bulinus) and amphibious (Oncomelania) snail species. Interventions therefore need to bear in mind these specific life cycle phases. This exact trap was observed in the 1980s, when a dam was constructed at Diama, Senegal, in the Senegal River Basin. The sudden addition of a new water reservoir led to a surge in S mansoni prevalence, as well as the development of a new S haematobium focus. Freshwater snails also multiplied, leading to greater transmission of the parasite. Overall, this failure to collaborate with the parasitology community resulted in an outbreak of human schistosomiasis.
Interventions should also not neglect the importance of community education and initiating behavioural change. Reducing water contact for tackling schistosomiasis requires a deeper understanding of the reasons why the community affected engages in water contact. From performing domestic duties (washing), to hygiene requirements (bathing) to occupation (rice farming), or even recreation (swimming) – each of these areas must be addressed to ensure each person understands the risks of contaminated water exposure. To take another disease as an example of misunderstood requirements, leprosy – a disease that affects the skin and immune system – requires far greater thought for programme implementation beyond the construction of medical care and WASH facilities. Exploring the deeper cultural effects that result from leprosy infections is essential. In the northeastern Myanmar state of Shan, infected individuals are marginalised and even expelled from the village community, meaning that there would be no access to clean washing facilities, even if they were constructed with these individuals in mind. Educating the community is vital to ensuring disease prevalence is reduced, along with disability and medication use, while time for productivity and children’s education is increased. Achieving behavioural change goes beyond constructing fresh water sources or new hygiene facilities; the key is through clear communication and thorough mutual understanding.
Health professionals involved with NTDs can similarly be aided by the broadening of perspectives from WASH sector colleagues. So often there is a focus on the linear framework of diagnosing and treating disease, that attention is focused purely on aspects such as mass drug administration, as an effort to curb the growing prevalence of a NTD. However, far greater heights can be achieved through understanding the role that WASH innovations have in addressing underlying sanitation problems like as faecal contamination of water sources.
It is easy to dismiss WASH interventions as being outdated and lacking innovation, due to their stable and seemingly slow-growing presence since the 1980s. Quiet and steady innovations have embraced the advances of technology and led to novel ideas that can have effects that spread beyond just its impacts on health. Container-based systems have been developed that are portable and ideal for sanitation in high-density/low-income settings. These systems cover the entire service chain, from containment to emptying, collection of waste, transportation of waste, waste treatment, as well as waste disposal. The embracement of mobile technology has led to mobile phone apps that can efficiently track borehole servicing and maintenance, as part of an initiative for the provision of clean water. Microwave technology has also been utilised for safely processing and disposing of faecal sludge, in a self-contained system. These examples highlight how better health can be achieved through original solutions that have been developed for addressing the conditions that enable NTDs to persist.
Looking beyond the technological advancements, there can even be social benefits when WASH interventions are implemented in a sustainable manner. The move away from providing ‘handouts’ and empowering local communities through production packs and education, has resulted in longer lasting and more impactful solutions. The support for local manufacturing has been completed for sanitary and hygiene products such as composting toilets, sanitary towels, soaps, as well as shoes (made from waste tyres). Programmes that encourage products to be manufactured locally, enable the communities to engage in a sustainable enterprise that can benefit both their health, as well as their economy. In addition, these solutions benefit from maximising the ability to add value as close to the consumers as possible; build local capacity through training and resources; attain local ownership of the project; and are able to gain direct feedback from the users locally. Supporting local enterprises therefore ensure communities gain greater control over their own health, as well as improvements in productivity.
Challenges do however exist in the implementation of WASH interventions. A general awareness of the limitations of these programmes reminds us of the need to continue improving our methods for tackling NTDs. For example, newly constructed pit latrines have been found to be incorrectly utilised. In Uganda, pit latrines – which are meant to be covered, and new ones built after they are filled – are instead commonly emptied for reuse through manual labour, as there is often little space for new latrines to be dug. In addition, truck access for machine-operated emptying of these filled latrines is not possible due to poor road infrastructure and limited access to these sites. There is a need for better sustainability through alternatives to pit latrines, as well as stronger infrastructure development to enable improved transportation of waste. The difficulty for achieving these long-term goals is further compounded by the short-term tenure of governments who place these interventions low on their list of priorities. Neglect on a systemic level leads to slow-moving improvements in water, sanitation, and hygiene, affecting health, as well as social aspects of communities.
There is a requirement for mutual understanding between the WASH and health sectors. Greater integration will ensure that interventions are implemented with a disease in focus, as well as allow health professionals to better encourage the behavioural changes that can benefit not only health, but the productivity of the community as well. A holistic and collaborative approach is essential if we are to bring about significant improvement to the burden of NTDs.