History of water and health
3.8 LESSONS LEARNED OR NOT
It is the interplay between the building of knowledge in science, medicine and engineering that has lead us into the 21st century where safe water sits within its current definition. We can test water for almost any contaminant known, we have new tools such as genomics that provides us with insight into the biological nature of a“healthy”system and we have toxogenomics and physiological models which help us to understand better the human system as it is exposed to contaminants. The World Health Organization, the European Union and the United States Environmental Protection Agency have all lead the way to provide criteria and standards to protect, restore and treat water for ensuring safety. All are supporting quantitative microbial risk assessment (QMRA) (Haas et al. 1999) as a framework to integrate science, medicine and engineering toward meeting the goals of safe water. The latest WHO Guidelines for Drinking Water Quality recommend QMRA for health based target setting (WHO, 2011c). This has also been used for the establishment of water regulations, within the US Safe Drinking Water Act (SDWA), via institutions like the USEPA, and it has been shown that it is possible to address water safety (Public Law, 1974) using science-based approaches. New issues will always emerge which will need to be addressed such as the emergence ofCryptosporidiumand other important issues such as the removal of lead from plumbing which in the US was enacted in the 1986 amendments, and solidified in the lead and copper rule (McGill, 1993). A substantial investment is needed in the field of risk analysis for water to lead to appropriate decision analysis tools (Kammen & Hassenzah, 1999). Overall the quality of drinking water in developed countries has been improved through the various regulations and standards evidenced through the reduction of drinking water outbreaks of disease in countries with strong regulations. Since the focus is to reduce or eliminate water-related disease, energy and effort are
focused to continuously improve water systems to attain these goals. A major focus of late is the ability to predict potential outbreaks and prevent them through engineering systems. QMRA is a multidisciplinary tool which gives decision makers and engineers a means of assessing current or potential health impacts from contaminated drinking water. This field of risk assessment is an iterative set of modelling frameworks developing a continually evolving field. The power of decision support tools is that they allow for a perspective into how hazards can affect the health of populations of various sizes.
Exploring the past demonstrates that there are several issues which remain the key to understanding the risk.
(a) Potency of the organism (or chemical): The dose-response function provides the yard stick that helps us to measure the level of risk associated with the level of the exposure (level of the contamination).
(b) The consequences of the outcome (type of morbidity and mortality) which are influenced by the genetic characteristics of the pathogen, the host’s specific make up in regard to susceptibility and immune status.
(c) The excretion of the pathogen into the environment and its survival. And
(d) The environmental conditions, particularly the climate which influences the transport and ultimately the temporal and spatial nature of the exposure.
The historical evidence on waterborne disease shows that schistosomiasis, typhoid, dysentery and cholera which have a faecal-water pathway caused widespread and serious disease, dramatic attack rates and high mortality. In a modern day society these diseases can be eradicated. Yet these diseases have global staying power as the science, medical and engineering knowledge has not been used. Sanitation has never received as much attention as drinking water and has been more difficult to tackle. Even with sophisticated water systems in ancient civilizations, waste was still handled with cess pits or with pots until sewers were brought into play. Even then wastewater treatment has not advanced to address nutrient recovery, energy recovery and safe water recovery globally and has only recently been getting the attention deserved.
We live in a world where in an instant we can watch and see what is happening around the globe. We see droughts, floods, famine, disasters and wars. The one thing all of these have in common is the need to provide water and sanitation to the people. The massive cholera outbreak in Haiti need not have happened, if the lessons from the past were heeded.
Bill Gates in 2011 (http://www.nytimes.com/2011/02/01/health/01polio.html) restated his continued support for eradication of polio via vaccination programs (funded largely by the Bill and Melinda Gates Foundation). The disease caused by poliovirus is transmitted via faecally-contaminated hands, food and water. Poliovirus belongs to the Picornaviridae family which includes many enteric viruses spread by the faecal-oral route and can be classified as a waterborne disease causing agent. While the vaccination program for this disease has been successful globally, at the same time the developed world was investing in water treatment for both sewage and drinking water. It is no accident that poliovirus remains a threat in areas where there is no sanitation and inadequate water treatment. Waterborne disease caused by faecal pollution will continue to have an important impact on communities until water treatment is in place which would not only help to eradicate polio but hundreds of other diseases.
It should be remembered that cholera and typhoid, two important faecal-oral waterborne pathogens, were eradicated in the developed world not through vaccinations but through water treatment. These ancient diseases still plague developing countries due to polluted water. Water quality diagnostics and targeted programs for corrective measures are needed.
Those of us who are microbiologists, environmental engineers and public health epidemiologists have received an integrated education. This broad overview is needed to address global health problems such
as the fight against waterborne diseases. Only then will strategies and investments be maximised so that the precious dollars spent really do decrease the global burden of disease.
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