Abstract
Diarrhea is the second leading cause of death and is the major cause of malnutrition in children under age 5 worldwide. More than 50 percent of the cases occur in developing countries, particularly in sub-Saharan Africa and Southeast Asia. Open defecation, substandard fecal disposal systems, and contaminated water supplies are the typical causes of diarrheal diseases. This public health crisis in low income countries mirrors the experiences of today's industrialized nations two centuries ago. The lessons learned from their sanitary evolution can be instructive in charting a sustainable path towards saving the lives of almost 2 million children annually. In this chapter a case study of Cuba's sanitary reformation is also presented to showcase successes, similar to those of developed countries, within a developing country and economically challenging context.
TopIntroduction
Diarrhea is the second leading cause of death and the major cause of malnutrition in children under age 5 (World Health Organization (WHO), 2013b). Of the more than 1.5 million childhood deaths due to diarrhea each year, over 50 percent of all cases occur in developing countries, particularly in sub-Saharan Africa and Southeast Asia (Walker et al., 2013). Diarrhea is usually a symptom of an infection of the intestinal tract and presents as the passage of three or more loose or watery stool at least three times per day or more frequently than normal for an individual (WHO, 2013b). The most common etiologic agents, namely bacteria, viruses and protozoa, are primarily transmitted via the fecal-oral route (Tinuade et al., 2006). This means that most diarrheal pathogens are transmitted from the feces of an individual to his/her and/or the mouth of another. The underlying assumption is: an individual must be exposed to or come in contact with the causative agent(s) to become infected and thus acquire the disease. This also implies that if the disease agents are removed or prevented from the environment of the at risk population, members will not become exposed and consequently develop the disease. Open defecation, substandard sanitation systems and subsequent pollution of nearby drinking water sources are usually implicated in disease causation (United Nations (UN), 2014). This is because fecal matter and its environmental repositories contain most common diarrheal etiologic agents. Thus, sanitation interventions such as latrines and, providing clean water and washing hands facilities, interrupt the fecal-oral transmission pathways. They are therefore effective in preventing and reducing diarrheal incidence, associated morbidity and mortality as wells as subsequent sequelae such as malnutrition. For example, research has shown that access to improved system of feces disposal may reduce the rate of childhood diarrhea by up to 43 percent (Cumming, 2009; WHO, 2013a).
In general diarrhea is, a very common, easily preventable and treatable disease, considered to be no more than a nuisance in most cases. In fact, there are about 1.7 billion incidence of diarrhea each year in both developed and developing countries (WHO, 2013b). However, developing countries are characterized by more adverse morbidity (persistent and reoccurring episodes) and higher mortality (death) health outcomes. For example, in developed countries the average disease incidence range from 1-3 episodes per person per year compared to 5-18 per person per year in developing countries (Guerrant, Hughes, Lima, & Crane, 1991). Rotavirus, which is a common cause of diarrhea in children under age 5 in the United States (US) causes about 300 deaths annually compared to over 220,000 actual hospitalizations (Pont, Grijalva, Griffin, Scott, & Cooper, 2009). In contrast, Rotavirus-induced diarrhea can be a death sentence for children in poor countries. For example, in 2008, the number of Rotavirus associated diarrheal deaths in some sub-Saharan African countries included, Angola (8,788), Uganda (10,637), Ethiopia (28,218), DR Congo (32, 653) and Nigeria (41,057) (Tate et al., 2012). The implication of this is, sadly, every 20 second a child, particularly in a low income country, dies of this relatively innocuous disease for which vaccine exits, is therefore preventable and for which treatment exists (Onda, Crocker, Kayser, & Bartram, 2014; UN, 2014). The World Health Organization (WHO) reports that children in sub-Saharan Africa are thus 16 times more likely to die before age 5 than children in developed regions and over half of these deaths could have been prevented by simple and affordable water and sanitation interventions (WHO, 2013a).
Key Terms in this Chapter
Disease Incidence: Incidence is the rate of new (or newly diagnosed) cases of the disease in a defined population (e.g., children under 5 years old) during a specific time period (e.g., a calendar year). It is generally reported as the number of new cases occurring within a period of time (e.g., 20 new cases of HIV infection occurred in village A during 2013. The defined population refers to the population at risk. This means that for the defined population, children under 5 years old, they are all at risk of getting diarrhea but do not have the disease at the beginning of 2013.
Oral Rehydration Therapy (ORT): A mixture of clean water and electrolyte solution typically given in response to a diarrheal episode.
Sustainable Development: The conceptual framework for organizing plans and activities to achieve sustainability. Where a community’s developmental activities is considered sustainable if it produces resources faster than they used, those resources are mostly renewable and/or infinite and, works in harmony with ecological systems to eliminate its wastes.
Life Expectancy: The mean number of years an individual is expected to live if born and/or exposed to specific environmental conditions in a country or geographical location.
Diarrhea: Usually a symptom of an infection of the intestinal tract and presents as the passage of three or more loose or watery stool at least three times per day or more frequently than normal for an individual. It is a very common disease and affect individuals in every country and from every socio-economic background. In healthy individuals there is usually little cause for concern as episodes tend to be self-limiting. However, for undernourished and disease weakened patients, especially children, persistently reoccurring episodes are typically life-threatening. The interaction between diarrhea and malnutrition is bidirectional and synergistic. During a diarrheal episode, the increased rate of the passage of food through the intestines reduces the digestion and absorption of macro and micro nutrients. In addition, patients with persistent diarrhea may have poor appetite and thus have a reduction in food intake. With limited nutrients, the immune system becomes impaired and is unable to respond to attacks from enteric pathogens. Therefore both diarrhea and malnutrition work in synergy to predispose affected individuals to reoccurring episodes, more severe symptoms and higher rates of mortality. Children are particularly susceptible because their immune systems are underdeveloped.
Infant and Child Mortality Rates: Infant mortality rate is the number of children that die before their first birthday per 1000 live births in a country or geographical location. While child mortality is the number of children that dies under age five per 1000 live births in a country or geographical location.
Disease Prevalence: Prevalence is the actual number of cases alive, with the disease in a defined population either during a period of time (period prevalence) or at a particular date in time (point prevalence). While incidence deals with entirely new cases, prevalence counts what exists. It is typically reported as a prevalence rate which is the proportion of ad defined population that has specific disease or attribute at a specific time.
Open Defecation: The practice of depositing human stool outside particularly in areas where there is no access to improved feces disposal systems. It is typically a rural activity and about 1 billion persons practice it around the world. It is one of the main cause of diarrhea in developing countries.
Enteric Infections: Infectious disease of the intestines. Typical bacterial enteric infections include E. coli and cholera. These infections are accompanied by diarrhea, nausea and sometimes vomiting.
Environmental Justice: Requires that no one group should disproportionately bear the burden of adverse health outcomes from environmental hazards simply on the basis of ethnic and racial background, geography and income. Each cohort and/or people group must be fairly represented in all environmental related decision-making processes – so as to prevent environmental discrimination. Environmental discrimination occurs when certain communities, because of their minority or disadvantage status, bear a higher burden of risk from environmental hazards without enjoying the benefits that are easily accessible to other groups.
Health Outcomes: Simply put, are symptoms or result of health-related activities. They are measured on a continuum from morbidity (illness) to mortality (death).
Systems Approach: A problem solving approach that views the problem (s) as part of an overall system. The component parts of the overall system are view in context to each other rather than in isolation. Therefore, rather than reducing a problem into the properties of its parts or causative components (as in the case of reductionist approach), this approach focuses on the arrangement of and the relations between the parts which connect them into a whole – based on the principle that the whole is greater than the sum of its parts. Instead of simply looking at problems through a linear cause and effects model, the systems framework recognizes the inherent nonlinearity of the synergistic interactions among systems components that can produce unintended consequences through emergence.
Sanitation: Generally speaking, sanitation encompasses fecal disposal systems, water treatment and delivery systems, personal and environmental hygiene education and practices as well as solid waste (garbage) disposal systems. In this work, sanitation typically refer to fecal disposal systems such as latrines in order to differentiate from water treatment interventions.