Governance & rational management of water & WSS

One pillar of current policies aimed at enhancing good governance in the management of natural resources and essential public services is the Integrated Water Management approach. The IWM promotes the “coordinated development of water, land, and related resources in order to maximise the resultant economic and social welfare without compromising the sustainability of vital ecosystems (European Commission, 2002b), a programme that in the European Union has become embodied in the Water Framework Directive (WFD) (European Union, 2000). From our perspective, IWM presents two important facets: a) it is an experiment in good governance, potentially facilitating of people-centred policies, and b) its holistic approach provides an institutional framework for cross-sectoral policy design and implementation (e.g. bringing together water and health policy).

This is of the utmost relevance, as a large proportion of water-related risks and threats to human health are linked to or even caused by the way water resources are developed and managed. This is especially true of vector-borne water related diseases such as malaria and schistosomiasis, but it also applies to broader health concerns such as “nutritional status, exposure to agricultural pesticides and their residues and accidents/injuries”(WHO 2003e). In this regard, the link between water resources management and public health encompasses wider considerations encapsulated in the concept of environmental health, which refers to the impacts of chemical, physical, and biological agents on human life and health (Sims and Butter, 2000; WHO-Europe, 2003). It is estimated that between one fourth and one third of human morbi-mortality is directly attributable to environmental risk factors, among which water-related diseases are paramount. Moreover, the impact of these diseases is much greater in the poor areas of developing countries, and they have a disproportionate impact on young children and women. Moreover, these factors are known to have also an impact on many other diseases that are loosely connected with environmental conditions, such as genetic and sexually transmitted diseases such as HIV which compound the need for WSS by further reducing immunity and reducing the scope for breast feeding (to prevent HIV transmission). Consequently, the actual weight of household-related environmental risks derived from poor air, food, and water quality may be grossly underestimated (Sims and Butter, 2000; Smith et. al., 1999; UN et. al., 1998; UNCHS, 1996).

Most of the water-related environmental risks mentioned above are part of a traditional and relatively well-known pool of diseases that continues to be one of the main threats to human life and health. However, there is also an emerging group of water-related environmental threats that are much less understood, and have the potential to become widespread and have a far-reaching impact on environmental health in the near future. These diseases emerge “either because they are newly recognized or because their importance increases [which] may be due to the micro-organisms themselves evolving, to changes in the way we manage water resources and supplies; changes in the tools and methods used to study the organisms and the health effects they cause; or due to changes in the human population itself” (WHO-Europe, 2003).

These risks to human life and health derived from the poor management of the aquatic environment and lack of water supply and sanitation are wide ranging and multidimensional (NWCF, 2005). The qualitative association between water and health has been known for millennia. However, the quantitative relationship between the prevailing WSS regime and ill health may be situation specific and modulated by other physical, social and economic factors (e.g. girls education). For this reason the apparent lessons of the 19th century sanitary revolution in Europe and North America cannot be uncritically carried to all societies at all times.

The relationship between water, sanitation and disease can be clarified by using the classifications for water-related and excreta-related diseases developed by Cairncross and Feachem (Cairncross and Feachem, 1996). Taken in the round these classifications offer a guide to the plausible relationships between a given WSS scenario and the panoply of diseases and infective agents. For example, cholera may be associated with insufficient quantities of water, poor water quality (the cause of explosive outbreaks of the disease in the UK in the 19th century and Bangladesh today) or the irrigation of food crops with untreated wastewater (a major transmission route in the Middle East and South America). Cholera is a highly visible disease with serious economic and political consequences. Other more insidious diseases, such as ascariasis (roundworm) or hookworm are less well known, though they are probably the most prevalent infections in the world (O’Lorcain and Holland, 2000; Schuster and Chiodini, 2001). These infections rarely kill; instead they debilitate promoting malnutrition and lethargy. These diseases have a disproportionate impact on children and (in the case of hookworm) women, robbing them of productivity, vivacity, affecting their mental development (in children) and (with hookworm) promoting anaemia which is particularly prejudicial to pregnant women.

Increasingly, these infections are now being considered alongside diseases caused by chemical contaminants in water. These contaminants may be geochemical in origin, for example fluoride in the Rift Valley or Arsenic in Bengal or anthropogenic, perhaps being the result of pollution from poorly controlled industries or agriculture releasing heavy metals, pesticides and other contaminants into waters used for washing, drinking, fishing and irrigation. To recall one well-publicised example, in many developing countries water used for drinking purposes contains naturally-occurring substances that are a threat for human health, such as arsenic. Arsenic poisoning of water resources is particularly alarming in Asia, including Eastern India, Bangladesh, Cambodia, China, Pakistan, Taiwan, Thailand, Vietnam, and Latin America. Though these chemical hazards do not kill or debilitate on the scale of infectious disease they may have disastrous consequences where they do occur. Moreover, this form of pollution is often insidious in nature and may only be noted once pollution has reached catastrophic levels. Needless to say, both infectious disease and chemical contamination disproportionately affect the poor and the powerless.

In this connection, there is evidence that chemical pollution of the environment, especially water bodies, is associated with long-term health hazards whereby the actual manifestation of diseases caused by these agents may happen at a later stage, have lifelong effects, and compromise the health of future generations. Also, the particular implications of environmental degradation on the health, well-being and quality of life of women and children are firmly established, and the need for further research and practical action is recognized as a top priority (UN et. al., 1998). However, not only is the understanding of the complex interactions between these substances and the environment, including human and animal life, still rudimentary, but preventive action continues to be impaired by many factors, not least by the lack of consensus about the very need it. This is illustrated by the controversies surrounding the actual implementation of the precautionary principle in relation to environmental risks and threats (WHO-Europe, 2003; UNCHS, 1996).

Also, the fact that responsibility for the management of water resources is often fragmented across different sectors and levels of decision has been identified as a key obstacle in the design and implementation of effective preventive health policies in this field. On the positive side, the increasing adoption of IWRM policies is seen now as an opportunity for encouraging synergies and mainstreaming water-related public health as “a cross-cutting issue throughout the decision-making in different sectors and at different levels” (WHO 2003f). In this connection, the increased conflicting demands for water from agricultural, industrial, and domestic users and the tighter quality standards that have been developed and implemented in recent decades have led to the recognition of the need for IWRM at the basin level. In turn, the acknowledgement of the complex interactions between the water environment and human life and health have led, after years of debate, to the approval of the Protocol on Water and Health (UNECE-WHO/Europe, 1999), which was signed in 1999 by 36 countries and is waiting for ratification. The Protocol envisages the prevention, control, and reduction of water-related diseases through the integrated management of WSS and the protection of water resources operating at the basin level. Both the WFD and the Protocol are contributing to setting new international standards for the rational management of natural resources and environmental health protection.

These advances form part of a growing intellectual consensus that meeting the challenge posed by the UN goals requires “an integrated approach to water resources management that takes cognizance of the links between water, sanitation and health, between the economy and the environment, and between cities and their hinterland, and harmonizes land-use planning and housing policies with water sector policies and ensures a comprehensive and coherent approach to setting and enforcing realistic standards […] strong political commitment, cooperation across disciplines and sectors, and an active partnership of all interested parties is essential to integrated water resources management” (UNCHS, 1996).

In recognition of the validity of this approach, the European Water Initiative has set as a top development priority “within an overarching framework of integrated water resources management […] ensuring a supply to every human being, especially the poorest and with a clear focus on the needs of women and children, of sufficient drinking water of good quality, adequate sanitation and hygiene, with the general objective of reducing poverty, and improving people’s health and quality of life and livelihood opportunities” (our emphasis) (European Commission, 2002b).