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Sustainable Control of -Related Infectious : A Review and Proposal for Interdisciplinary Health-Based Systems Research Stuart Batterman,1 Joseph Eisenberg,2 Rebecca Hardin,3 Margaret E. Kruk,4 Maria Carmen Lemos,3 Anna M. Michalak,5 Bhramar Mukherjee,6 Elisha Renne,7 Howard Stein,8 Cristy Watkins,9 and Mark L. Wilson2 1Department of Sciences, 2Department of , 3School of Natural Resources and the Environment, 4Department of Health Management and Policy, 5Department of Civil and Environmental Engineering, 6Department of , 7Department of Environmental Engineering, 8Center for African American Studies, and 9School of Natural Resources and Environment, University of Michigan, Ann Arbor, Michigan, USA

generally directed against proximal causes of Ob j e c t i v e : Even when initially successful, many interventions aimed at reducing the toll of water- , paying less (and often related infectious have not been sustainable over longer periods of time. Here we review his- insufficient) attention to the more distal causal torical practices in water-related infectious disease research and propose an interdisciplinary public factors. This proximal focus comes from an health‒oriented systems approach to research and intervention design. individual-based approach to etiology and Da t a sources: On the basis of the literature and the authors’ experiences, we summarize contribu- epidemiology that emphasizes the immedi- tions from key disciplines and identify common problems and trends. Practices in developing coun- ate and short-term risk factors. We suggest tries, where the is the most severe, are emphasized. that incorporating more distal processes into Da t a extraction: We define waterborne and water-associated vectorborne diseases and identify analyses and designs of interventions will result disciplinary themes and conceptual needs by drawing from ecologic, anthropologic, engineering, in more sustainable interventions. This new political/economic, and fields. A case study examines one of the classes of water- approach requires both systems-level thinking related infectious disease. and an interdisciplinary approach to research Da t a synthesis: The limited success in designing sustainable interventions is attributable to fac- and intervention design. tors that include the complexity and interactions among the social, ecologic, engineering, political/ Here we review the different disciplin- economic, and public health domains; incomplete data; a lack of relevant indicators; and most ary approaches to infectious disease research important, an inadequate understanding of the proximal and distal factors that cause water-related infectious disease. Fundamental change is needed for research on water-related infectious diseases, and interventions and argue for an expanded and we advocate a systems approach framework using an ongoing evidence-based health outcomes interdisciplinary approach. We focus on water- focus with an extended time horizon. The examples and case study in the review show many oppor- related diseases (such as waterborne and ­ tunities for interdisciplinary collaborations, data fusion techniques, and other advances. borne) and their more distal causes, which Co n c l u s i o n s : The proposed framework will facilitate research by addressing the complexity and involve both social and ecologic processes. We divergent scales of problems and by engaging scientists in the disciplines needed to tackle these dif- summarize traditional and recent approaches, ficult problems. Such research can enhance the prevention and control of water-related infectious identify the main disciplinary themes, and dis- diseases in a manner that is sustainable and focused on public health outcomes. cuss their strengths and weaknesses. We then Ke y w o r d s : infectious disease, interdisciplinary, , research, systems approach, water. Environ propose an interdisciplinary, public health– Health Perspect 117:1023–1032 (2009). doi:10.1289/ehp.0800423 available via http://dx.doi.org/ oriented systems approach to research aimed at [Online 17 April 2009] providing a comprehensive means to ­prioritize water-related health outcomes using evidence- based interventions (Ezzati et al. 2005). Finally, Why have interventions against infectious been associated with waterborne illnesses over the suggested approach is illustrated using a diseases often proven to be less successful the past few decades (Sharma et al. 2003). case study that focuses on diseases associated than anticipated? Even when initially suc- Thus, sustainability has become an important with water and management prac- cessful, many are not sustainable over lon- criterion for gauging the success of disease tices in developing countries where the disease ger periods of time. During the past 30 or reduction efforts. burden is the most severe. 40 years, we have observed many and diverse The nature and impact of water-related Background and motivation. Water- and examples where infectious disease reduc- infectious diseases are mediated by both eco- disease-related issues are major roadblocks to tion efforts have failed to meet expectations, logic and socioeconomic processes [Eisenberg sustainable development. As noted by Toepfer with diseases reemerging to preintervention et al. 2007; United Nations Environment (2004), disease statistics are stark and tragic: levels or worse. Dengue , for example, Programme (UNEP) 2007]. Although the 80% of illness and death in the developing was eliminated from the Americas for many complexity of these processes is being increas- world is water-related; half of the world’s hos- years only to reemerge with a more virulent ingly realized, current research and manage- pital beds are occupied by people with water- form of the disease, including dengue hem- ment approaches include only a subset of the related diseases; and malaria are by far orrhagic fever. and malaria considerations and interdisciplinary exchanges both have shown that they can quickly needed to approach and realize sustainable Address correspondence to S. Batterman, Environmental Health Sciences, University of reemerge after intervention efforts are loos- solutions. These issues represent major gaps Michigan, 1420 Washington Heights, Room 6075, ened. Waterborne zoonotic agents such as that cannot be resolved by simply boosting Ann Arbor, MI 48109 USA. Telephone: (734) O157:H7, Campylobacter funding for and sanitation facili- 763-2417. Fax: (734) 936-7283. E-mail: stuartb@ jejuni, and have ties. The need for new approaches to address umich.edu emerged in recent years (Cotruvo et al. the challenges of water-related infectious dis- The contribution of C.W. was supported by a 2004). Many other water-associated human ease research motivates this review and assess- grant from the Graham Environmental Sustainability Institute at the University of Michigan. , including cholerae O139, ment. In particular, we argue that one problem The authors declare they have no competing , cyclospora, , with interventions to reduce infectious disease ­financial interests. Yersinia enterocolitica, and environmental and emergence, particularly those Received 24 November 2008; accepted 17 April (e.g., pneumophila), have that are water-associated, is that efforts are 2009.

Environmental Health Perspectives • v o l u m e 117 | n u m b e r 7 | July 2009 1023 Batterman et al. the largest causes of mortality in children < 5 agricultural irrigation, that lead to increased tree stumps) (Figure 1). Many water-related years of age (34%) in Africa; and the number of water-­associated disease (Patz infectious diseases have been referred to as the of deaths from water-related disease approaches et al. 2004). These factors can interact in ways “neglected diseases of neglected populations,” 5 million annually, most of them children. that adversely affect water quantity, quality, because they receive little attention and dis- These deaths, most of which are preventable, sanitation, and health. proportionately affect poor people in develop- largely occur among the estimated 1.2 billion We group water-related infectious dis- ing nations (Ehrenberg and Ault 2005). people worldwide without access to safe and eases into two categories. Waterborne infec- Sustainability and research. We adopt a reliable and the 2.5 billion with- tious diseases, such as diarrhea, are linked to definition of sustainable water use as the “use out access to sanitation services. Despite ongo- poor sanitation, inadequate , ingestion of water that supports the ability of human ing efforts, the 2002 Millennium Development of and contact with unsafe water, and lack society to endure and flourish into the indefi- Goal of halving the population without clean of access to adequate amounts of safe water nite future without undermining the integrity water or sanitation by 2015 is unlikely to be [World Health Organization (WHO) 2008]. of the hydrologic cycle of the ecologic sys- achieved (United Nations 2008). Water-associated vector-borne diseases, such tems that depend on it” (Gleick et al. 1995). Many stressors affect water hygiene and as malaria and , require water This broad definition is necessary to appro- sanitation. These include a) population to propagate vectors (e.g., mosqui- priately address the more distal factors associ- growth, , and increasing popula- toes, black ) that transmit pathogenic ated with disease burden, and it suggests a tion density that increases vulnerability to microbes when taking a meal from a research agenda for sustainable water manage- ; b) growing water demand human (WHO 2008). Another kind of water- ment that represents a profound change from by cities, industry, and agriculture, often cou- ­associated disease, schistosomiasis, is caused focusing on specific human uses—for exam- pled with limited opportunities for or by a worm or blood fluke whose life cycle ple, plants, , and aquifer development; c) climate variability and involves particular aquatic snails and human systems—to considering a more holistic sys- change that together erode food production contact with infected water. Habitat require- tem that encompasses both human and eco- capacity, diminish water availability and water ments of such insect and snail vectors are spe- logic systems and infrastructure components. quality, and increase flooding and drought cies-specific and can include large and small Furthermore, in this context, sustainability due to inadequate drainage and storage; and water bodies and channels (e.g., lakes, lagoons, must be approached using interdisciplinary d) “advancements” associated with develop- rivers, ditches, culverts, sewers), poorly drained tools that span social, physical, and ecologic ment, such as dams, roads, deforestation, and soils, and containers (e.g., pots, tires, leaves, sciences, including health sciences. In prac- tice, indicators of sustainability are context- or problem-specific, and programs that seek to advance sustainability must be flexible. To complete a cycle of planning, analysis, inter- vention, and evaluation, time frames must span one or preferably two decades, appropri- ate for economic discounting and forecasting, climate and other ecologic changes, and socio- cultural trends. As discussed below, many dis- ciplines have contributed to an understanding of water-related disease. We present these dis- ciplinary approaches, which help to motivate the need to move toward more integrated interdisciplinary approaches. Approaches to Water-Related Infectious Disease Research As early as the Hippocratic writings, scholars recognized the connection between food, water, and the environment, along with the direct and changeable influence of human behavior on disease prevalence (Franco and Williams 2000). The Egyptians, Romans, Greeks, and other ancients had perfected many water supply, hygiene, and sanitation practices (el Gamili et al. 2001; Koutsoyiannis et al. 2008). In modern times, (the “father of epidemiology”) and Henry Whitehead pio- neered the understanding of the causes of water-related disease transmission (Newsom 2006). Many disciplines have significant inter- ests in water management and disease control, including those concerned with natural and Figure 1. A drainage canal constructed by local efforts in Zaria City, Nigeria, a malaria region. Dr. Samaila U. Dakyes, of the Department of Industrial Design, Ahmadu Bello University–Zaria, is a local physical processes (e.g., ecology and engineer- chief who has organized people in his community to maintain sewers and waste control. Such efforts can ing), human dimensions (sociocultural and improve conditions, but the stagnant water shown in the photo indicates the need for additional work and economic/political); and health outcomes (e.g., infrastructure. Photo by S. Batterman. , ecology, epidemiology, parasitology).

1024 v o l u m e 117 | n u m b e r 7 | July 2009 • Environmental Health Perspectives Sustainable control of water-related infectious diseases

Such disciplines provide complementary frames for the design of safe (and adequate) water, sanitation that can lead to water ; that together can provide a comprehensive sanitation, hygiene, and drainage systems, as seasonal and annual variability of precipitation approach to understanding water-related infec- as the forecasting, operations, and man- and stream flow; climate change that exac- tious diseases. The following section highlights agement skills needed to maintain and opti- erbates water shortages and increases pollu- key themes from critical disciplines. mize systems for a suitably long period. For tion; financial and other resource limitations; Ecologic approaches. Water-related infec- millennia, scientific principles have been used and engineering and management expertise tious disease research has long used an eco- to engineer both the flow and quality of water (Liu et al. 2007; Medd and Chappells 2007). logic perspective to understand how best to for drinking, irrigation, recreation, and other Economic engineering and risk/cost-benefit control transmission (Eisenberg et al. 2007). purposes; to handle solid and liquid wastes; to analyses recognize the multiple values (e.g., Ecologic approaches to water-related diseases drain (and, more recently, restore) wetlands; monetary costs and benefits) of water proj- have drawn from biology, epidemiology, and and to provide control. Water-related ects, and systems approaches have been used genetics, among other fields, to focus on envi- infrastructure, including distribution systems to determine cost-effective designs and opera- ronmental determinants of disease via natural (e.g., , wells, treatment systems, tion (e.g., Lund et al. 2006). The natural and and increasingly anthropogenic changes to the pipelines) and drainage facilities (e.g., bridges, social sciences inherently overlap in this work. physical environment, which frequently result dams, channels, culverts, levees, storm sewers) Anthropological approaches. Anthropo­ from shifts in (human) population, consump- is designed to provide a sufficient supply of logical studies of water-related disease have tion, and technologic growth (UNEP 2007). healthy water and to remove physical, chemi- focused on several themes including local Often vectors, stressors, and disease can be cal, and biological () contaminants. understandings of water-associated diseases mechanistically linked to these changes from When any of these aspects is ignored, water- such as dengue fever (Kendall et al. 1991) and micro (e.g., , rivers, wells) to global related disease can emerge; thus, both design diarrheal diseases (Nichter 1988); conceptual- scales (e.g., effects of climate change on water and maintenance are crucial to the sustain- izations of water—as pure, unclean, scarce, or flow patterns and biomes). ability of water-related infrastructure. having healing properties (Arar 1998; Wellin Disease and microbial ecology research Much of the water-related infrastructure 1955); water use in treatments such as oral has identified multiple modes of transmis- in developed countries has been designed, rehydration therapy (ORT) for diarrheal dis- sion for both vectorborne and waterborne built, and operated according to prescriptive eases (Burghart 1996); the political economy pathogens that depend on environmental, cli- codes, standards, regulations, and practices of health care and access to proper sanitation matic, infrastructural, and sociocultural con- (Neumann et al. 2005). In contrast, infra- (Ecks 2004; Obrist 2004); community partici- ditions (Wright et al. 2004). Many pathogens structure in developing countries ranges from pation and (Yasumaro et al. move about the environment via human simple water catchment systems (containers of 1998); and gender, occupational, and cultural (Curtis et al. 2000), and both humans and any sort to harvest and store rain, river, run- inequalities in disease burden (Ramaiah et al. can act as hosts. Exposure to fecal off water, etc.) to those rivaling the complex- 2000; Vlassoff 1994). Many of these themes pathogens occurs in both private (e.g., domes- ity of those anywhere. Most often, however, are interconnected and overlapping. tic living spaces, private yards, and fields) and much of the water-related infrastructure and Local interpretations and use of water, public spaces (e.g., workplaces, transportation management systems in developing countries which appear independent of Western influ- hubs, markets; Kosek et al. 2003) and is most is grossly deficient because of unreliable and ences, may have important implications for often linked to , poor education, and unsustainable water supplies, contamination, public health. There are many examples: underdevelopment. Knowledge of the inter- inadequate distribution, the high cost of water Peruvians with little Western education actions between bacterial, viral, and parasitic in some areas, and numerous other reasons ignored instructions to boil water and instead enteric pathogens and the microbial system of (UNEP 2008). Obvious examples of deficient preferred “uncooked” water (Wellin 1955); in the human gut can shed light on population infrastructure include poor drainage or water contrast, many well-educated Sri Lankans also differences in susceptibility (Mathew et al. catchment, which may result in habitats suit- failed to follow boiling instructions (Nichter 1991), whereas vector ecology can inform able for certain mosquitoes, and inadequate 1988), whereas women in southern Nepal, the design of interventions—for example, or intermittent pressure/operation of potable when preparing ORT mixes, boiled water behavioral flexibility (Huang et al. water distribution networks, which permits according to their own understandings of the 2006), flight range, and spatial distribution the entry of pathogens and other contami- effects of heat on water, using traditional pro- (Pope et al. 2005; Sirot et al. 2008). Disease nants. Such factors unquestionably increase cedures for sterilizing milk (Burghart 1996). ecology, however, cannot be seen as indepen- the prevalence of infectious disease. From an In Tanzania, among women who accepted dent of social behavior and political economy. engineering perspective, innovative although public health messages about using clean Motivated by unsuitable and poorly tar- not necessarily complex infrastructure is essen- water, infrastructure deficiencies made it dif- geted programs, as well as dis- tial to reduce water-related diseases in poor ficult to obtain piped water and created emo- eases that are drug-resistant or for which there countries (Mara 2006), especially in urban tional stress on those who wanted but did not are no , the WHO has promoted areas where population density, financial, insti- have access to it (Obrist 2004); others knew integrated vector management (IVM) (WHO tutional, and other constraints can preclude the importance of boiling water, but could 2004), an ecologic approach that includes elaborate systems. In arid areas, technologies not afford the fuel. Thus, water-associated dis- both vector ecology (promoting minimal use such as dry or low-water-use can help to ease risk and prevention is not only economi- of ) and public health initiatives decouple water supplies from sanitation,­ thus cally and politically framed, but often is also (including community dialogue and partici- extending limited water supplies. socially and behaviorally constrained. pation). The need for increased community Multidisciplinary engineering perspectives In the absence of adequate and usually education, management integration, monitor- have long addressed environmental, economic, state-provided knowledge and resources, social ing, and evaluation in such programs has been social, and institutional elements inherent science approaches increasingly recog­nize recognized (Mukabana et al. 2006; Townson to large-scale water systems in developed adaptive capacity—that is, the ability to cope et al. 2005; Van den Berg et al. 2007). countries. Environmental engineering (for- with change—of individuals, institutions, and Engineering approaches. Engineering merly called sanitary engineering) addresses, even entire social systems. Adaptive capacity approaches offer the science and technology as examples, urbanization and inadequate considers resilience and, instead of devising

Environmental Health Perspectives • v o l u m e 117 | n u m b e r 7 | July 2009 1025 Batterman et al. interventions that replace old behavior and the response to the question “Do you have and the social sciences if they are to be techni- technology with novel behavior and technol- access to a ?” WHO (2000) statistics cally effective and culturally appropriate. ogy, explores the development of interven- report that 96% of Nairobi’s (Kenya) and 98% Public health approaches. From its begin- tions that incrementally alter existing systems of Dar Es Salaam’s (Tanzania) inhabitants have nings with Snow and Whitehead, public health (Yacoob and Whiteford 1994). This approach access to sanitation. However, in Nairobi, with research has shown the need to address all pos- has been offered as a means to improve half the population in informal settlements, sible points of water contamination, includ- integrative water management programs in there can be more than 200 people using a sin- ing sources and storage (Wright et al. 2004), UNESCO’s (United Nations Educational, gle open pit; in Dar, pits frequently overflow in sanitation systems (Cairncross 2003), and Scientific and Cultural Organization) the rainy season and flood the streets with raw hygiene processes (Curtis et al. 2000; Curtis Ecohydrology Program (Lemos et al. 2007). sewage (Satterthwaite 2003). and Cairncross 2003). Public health research Adaptive capacity integrates local knowledge, The concentration of poverty implied in areas most germane to water-related infec- skills, and traditions at all levels and illustrates the previous discussions of deficient water tious disease include surveillance/forecasting,­ that although “disease is a biological condition supply and sanitation infrastructure is a key environmental health, epidemiology, interven- … it exists within a human and social con- force behind the spread of water-related (and tions, and health education, and the meth- text” (Yacoob and Whiteford 1995). While other) diseases (Massey 2009). Poor people ods to strengthen the relevance and impact admittedly controversial in the sustainabil- often have greater exposure to pathogens of findings in each of these areas. These areas ity context, adaptation is also a response to (e.g., crowding may promote disease trans- themselves are multidisciplinary and overlap- ­climate change. mission and vector growth), higher preva- ping. Surveillance is critically important and The anthropological approach also encom- lence of underlying diseases, and less access sometimes quite poor, especially in developing passes a shift within to adequate health services (discussed later). countries. For example, although declines in from interpretive analyses of the cultural Such social determinants of health, which diarrheal mortality have been reported in some understandings of illness and local classifica- include both proximal factors (e.g., homeless- settings, true rates may be greater because of tion of diseases to ethnoecologic studies that ness, crowding, water supply, and ) reliance on verbal autopsy reports or con- examine environmental, biological, and social and distal factors (employment and develop- founding by other health conditions, such aspects of disease, as well as political/economic ment policy), are integrally linked to poverty as HIV/AIDS and malaria (Parashar et al. approaches in which public health is placed and act to increase susceptibility to disease. 2003). In addition to health indicators, sur- within a larger nexus of power and knowl- Another dominant theme for water-re- veillance can be of and quantity edge (Whiteford and Whiteford 2005). Using lated development projects is the influence parameters that provide fundamental data interdisciplinary approaches, anthropologists of donor agendas rather than priorities set by for predicting and possibly preventing dis- and public health practitioners have worked local governments. The structural adjustment ease outbreaks by anticipating, for example, together to formulate and evaluate appropri- policies of the World Bank have deemphasized impacts of seasonal changes and weather pat- ate interventions. At the same time, they have government-related social projects while pro- terns (Fisman 2007). examined distal factors, such as national and moting market-driven options, for example, Many public health interventions have international aid and loan schemes that con- privatization of water supply (Stein 2008). been conducted to evaluate insecticides and tribute to health inequalities, a theme exam- Donor project approaches were phased out in vector control techniques (Edman 2005), ined next. Rapid ethnographic analyses may the 1990s, and bilateral aid moved toward the vaccines (Tetteh and Polley 2007), immu- prove advantageous in these investigations. pooling of resources to aid economies through nizations, rehydration therapies, and ORT Economic/political approaches. An essen- sectorwide action programs. However, there supplements (Bhutta et al. 2000). Such inter- tial determinant of water availability and are rarely mechanisms (financial, institu- ventions do not always account for socio- quality is the extent to which political will tional, capacity-related) in place to continue cultural traditions and norms and pathogen and economic resources exist among water the project when donor contributions end and human ecology and behavior. Moreover, management agencies (Coit 2002). Further, (Rautanen et al. 2006). For example, the ter- interventions should be aimed at the incre- political approaches must overlap with socio- mination of the large Swedish International mental reduction of disease rather than eradi- cultural research to address issues of trust and Development Cooperation Agency (SIDA) cation (Koren and Crawford-Brown 2004). empowerment. For example, the neglect of Health, Sanitation and Water project around Another trend is a move beyond risk analy- sanitary conditions of India’s poor urban areas Lake Victoria was driven by the decision of sis and risk reduction strategies toward more has been tied to the mistrust of the govern- SIDA, not the central or local governments holistic health-impact assessments, which ment: The poor have little or no voice, pay of Tanzania, and without consideration of use ongoing community-oriented evalua- few taxes, and thus are excluded from state- the sustainability of the project (Weeks et al. tions and a broad set of techniques (Patz et al. provided resources and services, whereas mid- 2003) The continued donor-coordinated focus 2008; Veerman et al. 2005). Such approaches dle-class residents, who have little confidence on AIDS, tuberculosis, and malaria rather than promote the use of preventative measures in local municipalities to deal with problems, diarrhea, which is the second leading cause of and early warning systems and can help to create alternatives (albeit subpar) that do not morbidity and mortality in the country, may close the gap between research and policy rely on local governments (Chaplin 1999). also be seen as evidence of a donor-controlled (Eisenberg et al. 2002). Such mistrust is compounded by the cultur- health agenda. Policy spaces need to be gener- Health systems, which are responsible for ally sensitive nature of sanitation in India ated that empower the historically marginal- both curative and preventive care, offer many (Rosenquist 2005). ized and that change the nexus between water, public health opportunities for provision of The relevance and validity of indicators environment, and health. Recent and self- clean water and improved sanitation through and underlying data availability and quality are ­sustaining systems that can help to institution- surveillance, education, and interventions. Yet important concerns. For example, Target 11 alize clean water and sanitation habits include health posts, clinics, and of Millennium Development Goal 7 aims to microcredit schemes and health-related clubs even referral hospitals themselves suffer from a significantly improve lives of 100 million slum (Waterkeyn and Cairncross 2005). These range of water-related problems. Often, operat- dwellers by 2020 (United Nations 2008), as ­economics-driven plans depend on inter­ ing and delivery rooms in developing countries measured, in part, by access to sanitation and disciplinary insights from ecology, engineering, dispose of infectious waste in pits and open

1026 v o l u m e 117 | n u m b e r 7 | July 2009 • Environmental Health Perspectives Sustainable control of water-related infectious diseases sewers, and the water supply is neither clean highlight several common issues associated (Nunan and Satterthwaite 1999), as are com- nor reliable. For example, in Uganda, 77% with water-related research and suggest how plete transmission pathways for all but a few of primary care clinics and 46% of hospitals interdisciplinary approaches might be used to infectious diseases (Patz et al. 2004). Although lacked running water, and only 40% of all enhance understanding and improve the effec- remote sensing of water quality, water tem- facilities had a functioning latrine, an accept- tiveness of interventions. perature, and soil moisture, as examples, may able level of cleanliness, and a protected wait- Complexity and interactions. The social, complement sporadically sampled data, such ing area (Uganda Service Provision Assessment ecologic, engineering, economic/political, and measurements often are only indirectly related Survey 2008). Such deficiencies in water and public health domains that together deter- to the main parameters of interest (Brando and sanitation create opportunities for serious mine water and health outcomes are complex, Decker 2003; Lavery et al. 1993). Furthermore, breaches of hygiene that increase the rate of interactive, nonlinear, and dynamic. These the divergent temporal and spatial scales used postoperative and other iatrogenic . processes are difficult to represent using statis- in sampling may provide incompatible data Despite increasing cross-disciplinary tical or physically based simulation because of ( Network 2008). Innovative data fusion activities, an important disconnect remains their high-dimensionality, sample-size limita- techniques are needed to optimize the informa- between public health research and the social/ tions, which prohibit investigation of most tion that can be derived from existing measure- behavioral and economic/political approaches interactions, and unmeasured or unknown ments and to support the indicators needed or discussed earlier. Development goals often spatial and temporal variables (Fleming et al. desired for research, planning, and evaluation. only indirectly address public health goals 2007). Ideally, models should represent a bal- Sustainability. Last, the lack of sustainabil- (Satterthwaite 2003), while most public health ance between simplicity, which may increase ity of water management projects is a daunting programs notably exclude issues such as polit- robustness, and complexity, which should problem. Although many health outcomes ical will, economic livelihoods, and resource enhance realism (Soller and Eisenberg 2008). have been improved in some countries, few availability. Still, public health research has Multiple outcomes. Impacts of water-re- interventions in developing countries have led to many successful policies and interven- lated projects can be classified using nomen- had lasting improvements, and most operate tions. The literature shows some agreement clature from the environmental impact only with donor support. Research and policy about prioritizing interventions; for example, assessment literature: primary impacts directly must understand and appreciate the useful- safe and sanitary fecal disposal is of utmost associated with actions or projects (e.g., pres- ness of context, which provides information importance; routine and access ence of pathogens, displacement of communi- about historical practices and trends in cli- to potable drinking water are important, but ties, channelization) and secondary or indirect mate, economics, politics, social, and cultural secondary (Curtis et al. 2000). impacts (e.g., siltation, ecologic changes, para- conditions. Although sustainability implies Other interdisciplinary approaches. site infestation, , drought, and com- continuity, changes can be rapid and unex- There have been many earlier efforts to syn- munity restructuring) that often are much pected, and a surprise-rich future should be thesize and integrate disciplinary contribu- harder to predict yet ultimately more signifi­ anticipated. As expressed by Rammel et al. tions to water- and health-related research. cant. Impacts and causal factors may also be (2007), sustainability can be viewed through These include the renowned and ground- classified by distance as proximal or distal an evolutionary lens in which it is understood breaking science–community–policy nexus (Birley 1995; Birley and Lock 1999). Clearly, that while we may not know exactly what will (e.g., Brundtland 1997; Lemos et al. 2007), the focus on sustainability has increased the change or how, we can anticipate that change a largely conceptual model useful for recog- importance of the temporal dimension, for will happen. This demands novel and flexible nizing omissions in analyses and motivating example, short- and long-term (including solutions and systems that can meet evolv- interdisciplinarity, but not necessarily one that intergenerational) impacts. ing circumstances (applying to both environ­ provides a framework suitable for research and . Unintended mental and human systems). analysis. Another example is integrated water consequences are a corollary following from management (IWM), promoted by the World these complex interactions and multiple out- Looking Forward: An Approach Bank and United Nations and also guided by comes. Drastic differences may result between for Sustainability Research multidisciplinary (ecologic, institutional, and short- and long-term outcomes and between A research framework appropriate for creating economic) principles. However, IWM intends local and regional effects. History is rife with sustainable solutions to control water-related to provide a universal solution to very com- examples: flood-control programs that led to infectious disease must move beyond exist- plex problems, rather than a framework for flooding or greater prevalence of vector-borne ing approaches. We suggest four necessary understanding and controlling potential out- diseases (Saenz et al. 1995; Sur et al. 2000); attributes: comes. It also has been criticized for compart- improperly treated water that irrigated crops • Interdisciplinary approaches and teaming mentalized management and, in the case of and transmitted infectious disease (Liang et al. that account for the complexity, scale, and flood control, a focus on postdisaster responses 2007); and large-scale irrigation projects that dynamics of water-related infectious disease rather than predisaster prevention and pro- promoted mosquito breeding (Amerasinghe problems. tection (UNEP 2004). Additional examples and Indrajith 1994; Tyagi and Chaudhary • Ongoing surveillance and monitoring of interdisciplinary approaches, mentioned 1997). Additional examples are described in that include not only the traditional pub- earlier, include WHO’s IVM, UNESCO’s the case study below. lic health indicators (such as mortality and ecohydrology program, and many large-scale Data gaps, incompatible temporal and morbidity), but also indicators from other research projects emerging from public health. spatial scales of available data, and the cost of relevant disciplines. . These items repre- • Research agendas that use an extended time Common Problems and sent additional research challenges. Complete horizon on the order of decades—long Conceptual Needs information on all relevant parameters is never enough to provide continuity and meaning- Although the disciplinary approaches ­discussed available. Rather, information must be gleaned ful progress for data collection, policy devel- above have reached out to other disciplines from multiple and sparse data sets, and knowl- opment, implementation, and analysis, but and have provided valuable insight into edge and data gaps are common. As exam- short enough to allow system evolution and many aspects of water and health, a systems ples, linkages among environment, poverty, information updating. Five-year evaluations approach requires more integration. Here, we and health in urban areas are poorly known are suggested below.

Environmental Health Perspectives • v o l u m e 117 | n u m b e r 7 | July 2009 1027 Batterman et al.

• A systems approach that provides an overall goals, objectives, and evaluative criteria, and environmental and public health and can framework to facilitate analysis, understand it allows continuous assessment and updat- include standard measures, such as mortal- interactions/feedbacks, and promote col- ing as new information becomes available. ity, morbidity, and infection rates, and those laboration among researchers with diverse Another strength is its ability to facilitate tailored to local circumstances. backgrounds. As discussed below, this problem mitigation and active planning by • Policy, infrastructure and interventions rep- framework is well suited to the complex and identifying the processes and parameters resent actions designed to influence human interdisciplinary nature of the problem. that influence key outcomes (called sensitiv- behavior in a positive manner, reduce risks Overall, the envisioned approach will ity analysis) (Bender and Simonovic 2000; of transmission, and otherwise lessen the not only foster responsive cross-disciplinary Simonovic 2000). Many water management disease burden, for example, improved research collaborations, but will be amenable problems have applied a systems approach hygiene and water safety. to on-the-ground implementation, monitor- using computer models to simulate physi- • All decisions and interventions are made ing, and evaluation, as well as the training of cal processes (Jeppsson and Hellstrom 2002; within the context and constraints of physi- a cadre of water and disease specialists and Lund et al. 2006) and institutional factors, cal, political, economic, and social environ- researchers. Note that we propose only a such as the capacity for interagency and orga- ments, for example, cultural views of water framework for research, not specific programs. nizational collaboration (Cassady et al. 2008; and hygiene, and the available economic Systems approach. The systems approach Temel 2005). resources. increasingly is considered a useful problem- The proposed research framework In Figure 2, we highlight the interdisci- solving framework to deal with large and acknowledges the dynamics of infectious dis- plinary teaming within a systems framework, complex issues. A system is defined by its ease transmission and integrates the disciplin- specifically the five frames reviewed above interrelated components that function ary approaches. Figure 2 depicts linkages of (outer circles), designed to capture the com- together within a defined and explicit bound- key processes within the water-related infec- plex dynamics and multiple temporal and ary, often to advance a common purpose. tious disease cycle. The four key interrelated spatial scales of water-related infectious disease Many systems are hierarchical in nature, and components that constitute the water-related problems. Rather than reducing the validity of some are amenable to computer simulation. infectious disease transmission cycle are repre- traditional approaches, the proposed frame- Generally, systems methods encompasses iter- sented near the center of the figure: work is intended to be integrative and prob- ative steps of defining the problem, gathering • Pathogen prevalence and transmission cor- lem oriented, incorporating these and other data, developing evaluative criteria, formulat- respond to vector ecology and proximal fac- relevant and helpful disciplines or techniques. ing and evaluating alternatives, and select- tors that affect vector breeding and pathogen Although a systems approach is, by definition, ing, designing, and implementing the plan transmission, for example, the presence of multidisciplinary, we are calling for a deeper (Jewell 1986). Many disciplines contribute standing water. integration and collaboration between scien- to these steps. By acknowledging the rela- • Relevant health indicators and disease bur- tists in which constituent disciplines inform tionships among system components, specifi- den represent results from surveillance and investigations of others and where hypotheses cally the feedback and reversibility of many monitoring that show the status and trends might even be jointly formed (Wear 1999). interactions, the approach allows evaluation of both ecologic and human health. Such The proposed approach is driven by the of alternative courses of action or scenarios. indicators are selected and developed using need to better address the burden of water- The systems approach strives for straight- knowledge of disease ecology within the associated diseases, with improved human forward problem definition, assumptions, context of existing surveillance systems for health being the principal objective. It could be argued that providing adequate access to water and proper sanitation and possibly fulfilling the needs and/or desires of com- Ecology munities are sufficient and more appropri- ate goals. As described above, however, most characteristics of the water-related infectious disease cycle (e.g., complexity, unintended consequences, data incompatibility, long Pathogen time horizon, and interplay within the social/ prevalence and cultural/economic and other frames) suggest transmission that health indicators are more relevant and more consistent than economic, political, or Water- Public Engineering Physical, Health infrastructural indicators, which tend to be related health political, infectious indicators less stable, more susceptible to change, and social, and disease and disease sometimes irrelevant under changed circum- economic cycle burden environments stances. Furthermore, many health indica- tors are becoming increasingly standardized Policy, infrastructure, in terms of their definitions and data collec- and interventions tion methods (Centers for Disease Control and Prevention 2006). For example, in the context of sanitary and water supply improve- Political/ Social/ ments, the focus would not be on the level of economic cultural expenditures on new sewage systems, but on levels and trends of pathogens in the water supply, incidence trends of diarrhea, the Figure 2. Conceptual framework of multidisciplinary health-based systems approach for understanding the numbers of outpatient visits to clinics for dys- water-related infectious disease cycle. entery and intestinal worms, and the like. The

1028 v o l u m e 117 | n u m b e r 7 | July 2009 • Environmental Health Perspectives Sustainable control of water-related infectious diseases proposed framework explicitly shifts the focus dynamics and interactions among environ- ecology of the region (Sierra 1999). Although to health-based goals rather than economic mental, ecologic, social, and pathogen factors there is evidence that road construction affects targets and thus represents a radical reorienta- that affect disease transmission (Eisenberg the incidence of vector-borne and sexually tion for most development programs. Some et al. 2007; Remais et al. 2008). transmitted diseases (Birley 1995), impacts on movement in this direction is evidenced by a Given the complexity of water-associated diarrheal disease remain poorly understood. U.S. Environmental Protection Agency grant infectious disease, statistical data and Further, although transmission of enteric opportunity (Pongsiri and Roman 2007), a variable selection techniques using tree-based pathogens has been linked to proximal factors World Bank (2008) review that emphasized searches through the model space (Breiman of water quality, sanitation and hygiene prac- collaborative research (especially in exploring 2001) may be useful. Latent variable models tices, the relationship between distal social linkages between environmental sustainabil- under a structural equation framework may and ecologic factors (e.g., increased popula- ity and poverty), and recent discussions in provide an option for understanding causal tion density and regional scale water patterns) the National Science Foundation/National pathways and interacting factors that lead and diarrheal disease remains poorly under- Institutes of Health collaborative program to disease transmission. The study of water- stood (Curriero et al. 2001). on the ecology of infectious disease (National related diseases inevitably involves various To help understand road construction‒ Institutes of Health 1999). spatiotemporal covariates, with the spatial related diarrheal disease, Eisenberg et al. We also suggest that the research frame- variables themselves often measured at differ- (2007) mapped a suite of distal environmental work can be embedded in the policy process, ent scales and with a nested interface. Such changes that can affect proximal environmen- following the approach taken in health impact problems can be analyzed using wavelet-based tal characteristics, which in turn can affect assessment, discussed earlier—a structure that methods, spatial process models, hierarchi- the transmission of enteric pathogens. Their might help provide continuity of support. cal or multilevel modeling frameworks, and framework incorporates processes at multiple This may also be valuable for young and inter- Bayesian inferential methods (Banerjee et al. spatial and temporal scales using regional, vil- disciplinary research investigators, as officially 2004), although the application of these lagewide, individual, and molecular-level data. sanctioned projects might help surmount methods to date has been limited. There are These data can be integrated using systems some of the challenges of establishing trust many opportunities to use these tools to great approach. To demonstrate the system’s com- and understanding among members of the advantage in the evidence-based decision- plexity, multiple outcomes, and the potential research team, as well as help in funding and making public health paradigm. for unanticipated consequences, consider how publishing interdisciplinary research (Turner road construction can affect diarrheal disease and Carpenter 1999). Case Study prevalence: Roads can lead to deforestation, Ongoing evaluation is a critical component A case study of water-associated disease in which subsequently affects watershed hydrol- of the proposed approach. At the project level, Ecuador illustrates the need for and applica- ogy, local climate, and pathogen transmission evaluations must address environmental qual- tion of the proposed approach. With the goal (Figure 3) (Curriero et al. 2001). Roads also ity, impacts on livelihoods, health, household of providing transportation faster and cheaper increase flows of consumer products, material economies, and the overall cost and acceptabil- than river boats, the Ecuadorian government goods, and medicine and potentially improve ity of the action. Distributional effects need to built a 100-km road between the southern access to health care facilities and health infor- be carefully assessed to ensure equity of bene­ Colombian border and the Ecuadorian coast mation. At the same time, short-term travel fits. At a programmatic level, interventions from 1996 to 2001. After completion of patterns are intensified, introducing pathogen and policy experiments should be evaluated the main road, secondary roads continued strains into the communities. The population for their intellectual contributions, repeatabil- to be built that linked multiple villages to density in both existing and new communi- ity, fostering of effective collaboration, and the main road. This roadway network led to ties created along the new roads can rapidly training opportunities, among others. Given major changes in both the social structure and increase, but water supply and sanitation the 20-year time horizon we argue for, formal evaluations might be conducted every 5 years Political/ by interdisciplinary researchers, a schedule Collection, economic including storage, drinking allowing for evolution and the opportunity to aid and loan dirty water Diarrhea modify components within the entire program Social/cultural conditions as well as promoting the training of new inves- traditions, practices, tigators. Up-front structuring of data collec- knowledge tion activities and indicators obviously would Excrete pathogens into environment facilitate evaluation. Complementary research tools. The pro- Pathogens posed research framework needs to incorporate into water Increased the latest research tools, including geographic Inadequate population sanitation density information systems (GIS), process and simu- Insufficient lation models, and statistical techniques. GIS excreta Runoff has been used for many purposes, including control designing early-warning systems (Fleming et al. 2007) and tracking disease outbreaks Road Decreased construction (Sarkar et al. 2007). Combined with forest Deforestation resources surveillance, it has been used to map vector Raise livestock breeding sites and other disease sources (Jacob et al. 2003; Njemanze et al. 1999; Polack Short-term/small scale (proximal) Medium-term scale Long-term/large scale (distal) et al. 2005). A wide range of models are used to study environmental changes and impacts Figure 3. Example of distal, medium-term, and proximal components in the water-related infectious on health and sometimes combined to study ­disease cycle in the Ecuadorian case study.

Environmental Health Perspectives • v o l u m e 117 | n u m b e r 7 | July 2009 1029 Batterman et al. infrastructure frequently lags, thus increasing how these affect behaviors, services, and infra- economic, anthropological, and public health the likelihood of transmission of enteric patho- structures needed for disease prevention. In spheres; the need to integrate data and meth- gens. Similar changes can also be produced an analogous fashion, ecologic sciences and ods used in the relevant disciplines, including by dams, urbanization, agricultural practices, engineering describe impacts of the larger- surveillance activities tracking public health deforestation, and climate change. scale processes on the environment in general and other short-term and long-term indicators; Interventions at multiple points in the and ultimately on water quality, and they also and the multiple and often unanticipated out- cycle and at different temporal and spa- offer input into the assessment and design comes as well as the long time frame needed tial scales can break the pathogen transmis- of actions to mitigate adverse environmen- to consider the sustainability of interventions sion cycle. For example, Figure 3 shows that tal (and health) impacts. Public health has addressing water-related diseases, all of which although road construction and the resulting the role of both measuring the occurrence motivate an adaptable research framework. deforestation are linked to disease transmis- of disease through surveillance activities and A research agenda using an interdisciplinary sion, these medium-scale drivers are ultimately evaluating the effectiveness of possible inter- systems framework with an evidence-informed linked to distal drivers, such as country-level ventions. The challenge in such studies is health outcomes focus and extended time economic conditions and the agendas of devel- to make these activities truly integrated and horizon is responsive to these issues and builds opment aid/loan programs. Deforestation interdisciplinary. Barriers include differences on recent trends, although it may diverge can then lead to proximal drivers—such as in terminology and theoretical frameworks, from goals of the (economic) development soil runoff that increases pathogen transmis- which require working together to create pro- paradigm. We used many short examples and sion into water sources, and decreased forest tocols for collecting and analyzing data, and a case study to illustrate the dynamics and resources—potentially leading to more inten- the need for sustained financial and institu- complexity inherent in these problems. These sive livestock husbandry to compensate for lost tional support, which can develop local capac- show the ripe opportunities for interdisciplin- forest resources, which then may increase the ity, understand the complex relationships, ary collaboration in data collection, analysis, risk of pathogen transmission via inadequate and ideally move beyond observational stud- and evaluation. The suggested systems-based control of waste. An interdisciplinary systems ies into intervention research. Ecuador could research framework is amenable to methods approach can account for the varying tem- become a test case that both demonstrates and data culled from the ecologic, anthropo- poral and spatial scales depicted in the figure the value of the proposed research approach logical, and engineering fields, among others, and will foster collaboration in the collection and leads to improved health. Although many and it facilitates knowledge sharing across the and evaluation of data. Table 1 outlines sev- of the linkages between road construction diverse disciplines involved. It can be embed- eral measurable indicators relevant to health and disease may be case-specific, such studies ded, we believe, in new initiatives in educa- and sustainability within the water-related would show the utility of an interdisciplinary tional curriculum, research programs, policies, infectious disease cycle appropriate for the systems approach framework that incorporates and intervention programs designed to control Ecuadorian example and identifies key con- the dynamics of infectious disease transmis- water-related infectious disease. This review is tributing disciplines. The table highlights the sion within the social, ecologic, engineering, an initial step toward these goals. need for interdisciplinary collaboration start- economic/political, and public health spheres Many challenges remain. More time and ing with conceptualization of the approach discussed in this review. flexibility may be needed than is customary in and continuing throughout. disciplinary research. Interdisciplinary train- This case study demonstrates the signifi- Conclusions ing at theoretical, methodologic, and ana- cant and intersecting roles played by multiple We have argued that fundamental changes lytical levels is needed. Program priorities and disciplines in understanding the causal link- are needed in the structure and organization funding opportunities must be shifted. There ages between road construction and disease. of research on water-related infectious dis- has never been a more pressing yet more pro- As examples, the political/economic disci- ease and specifically for a systems- and health- pitious time for such changes in approach, plines shed light on why the road was built based approach that can lead to sustainable shifts in paradigms, and development of new and its impact on the local economy of the strategies. After reviewing contributions of interdisciplinary collaborations. region, whereas anthropology/ethnoecology the key disciplines, we highlighted important studies describe the relationships between themes and conceptual needs that include the Re f e r e n c e s these larger-scale political/economic factors complexity of and linkages (both proximal and and the community’s social structures and distal) across ecologic, engineering, political, Amerasinghe F, Indrajith N. 1994. Postirrigation breeding patterns of surface water mosquitoes in the Mahaweli Project, Sri Lanka, and comparisons with preceding Table 1. Examples of indicators for water-related disease and control and the primary disciplines needed develop­mental phases. J Med Entomol 4:516–523. to contribute in the formulation and evaluation of each indicator. Arar NH. 1998. Cultural responses to water shortage among Palestinians in Jordan: the water crisis and its impact on Social/ Political/ child health. Human Org 57(3):284–291. Indicator cultural economic Ecology Health Engineering Banerjee S, Carlin BP, Gelfand AE. 2004. Hierarchical Modeling and Analysis for Spatial Data. :Chapman & Hall. Changes in water quality and conditions X X X Bender M, Simonovic S. 2000. A systems approach for collab- (flow frequency, intensity, path; orative decision support in water resources planning. Int J pollution and pathogen levels) Tech Pol Manag 19(3–5):314–325. Ecologic and infrastructural capacity X X Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, to withstand climatic changes (temperature Hidayat A, et al. 2000. Therapeutic effects of oral zinc in fluctuations, rainfall variability) and persistent diarrhea in children in developing Household- and community-level motivation for X X countries: pooled analysis of randomized controlled trials. Am J Clin Nutr 72(6):1516–1522. changes in water-seeking and water-using Birley M. 1995. The of Development behaviors; intervention acceptability Projects. London: Publication Centre. Human migration, settlement, and X X X Birley M, Lock K. 1999. The Health Impacts of Peri-urban water-use patterns Natural Resource Development. Liverpool, UK:Liverpool Economic conditions, access to potable water X X School of Tropical Medicine. and health care providers Brando V, Decker A. 2003. Satellite hyperspectral remote sens- ing for estimating estuarine and coastal water quality. Multiple disciplines contribute to most indicators. IEEE Trans Geosci Rem Sens 41(6):1378–1387.

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Breiman L. 2001. Statistical modeling: the two cultures. Stat Sci sites in urban Kisumu and urban Malindi, Kenya. J Med on comparative risk assessment approaches for policy 16(3):199–231. Entomol 40(6):777–784. making. Annu Rev Public Health 29:27–39. Brundtland G. 1997. The scientific underpinning of policy. Jewell TK. 1986. A Systems Approach to Civil Engineering Patz J, Daszak P, Tabor G, Aguirre A, Pearl M, Epstein J, et al. Science 277(5235):457. Planning and Design. New York:Harper and Row. 2004. Unhealthy landscapes: policy recommendations Burghart R. 1996. The purity of water at hospital and at home as Jeppsson U, Hellstrom D. 2002. Systems analysis for envi- on land use change and infectious disease emergence. a problem of intercultural understanding. Med Anthropol Q ronmental assessment of urban water and wastewater Environ Health Perspect 112:1092–1098. 10(1):63–74. systems. Water Sci Technol 46(6–7):121–129. Polack S, Solomon A, Alexander N, Massae P, Safari S, Shao J, Cairncross S. 2003. Sanitation in the developing world: cur- Kendall C, Hudelson P, Leontsini E, Winch P, Lloyd L, Cruz F. et al. 2005. The household distribution of trachoma in a rent status and future solutions. Int J Environ Health Res 1991. Urbanization, dengue, and the health transition: Tanzanian village: an application of GIS to the study of 13:S123–S131. anthropological contributions to international health. Med trachoma. Trans R Soc Trop Med Hyg 99(3):218–225. Cassady J, Higgins C, Mainzer H, Seys S, Sarisky J, Callahan M, Anthropol Q (NS) 5(3):257–268. Pongsiri MJ, Roman J. 2007. Examining the links between bio- et al. 2008. Beyond compliance: environmental health Koren H, Crawford-Brown D. 2004. A framework for the inte- diversity and human health: an interdisciplinary research problem solving, interagency collaboration, and risk gration of ecosystem and human health in public policy: initiative at the US Environmental Protection Agency. assessment to prevent waterborne disease outbreaks. two case studies with infectious agents. Environ Res Ecohealth 4(1):82–85. J Epidemiol 60:672–674. 95(1):92–105. Pope K, Masuoka P, Rejmankova E, Grieco J, Johnson S, Centers for Disease Control and Prevention. 2006. Introduction to Kosek M, Bern C, Guerrant R. 2003. The global burden of Roberts D. 2005. Mosquito habitats, land use, and malaria risk the Environmental Public Health Indicators Project. Available: diarrhoeal disease as estimated from studies published in Belize from satellite imagery. Ecol Appl 15(4):1223–1232. http://www.cdc.gov/nceh/indicators/pdfs/​introduction.​pdf between 1992 and 2000. Bull WHO 81(3):197–204. Ramaiah K, Radhamani M, John K, Evans D, Guyatt H, [accessed 10 October 2008]. Koutsoyiannis D, Zarkadoulas N, Angelakis A, Tchobanoglous G. Joseph A, et al. 2000. The impact of lymphatic filariasis Chaplin S. 1999. Cities, sewers and poverty: India’s politics of 2008. Urban water management in ancient Greece: legacies on labour inputs in southern India: results of a multi-site sanitation. Environ Urban 11(1):145–158. and lessons. J Water Resource Plan Manage 134(1):45–54. study. Ann Trop Med Parasitol 94:353–364. Coit K. 2002. The mismatch between politics, aid and environ­ Lavery P, Pattiaratchi C, Wyllie A, Hick P. 1993. Water-quality Rammel C, Stagl S, Wilfing H. 2007. Managing complex adap- with particular reference to in monitoring in estuarine waters using the Landsat thematic tive systems—a co-evolutionary perspective on natural Madagascar. Environ Urban 14(1):247–259. mapper. Remote Sens Environ 46(3):268–280. resource management. Ecol Econ 63:9–21. Cotruvo JA, Dufour A, Rees G, Bartram J, Carr R, Cliver DO, Lemos MC, Recharte J, Chang C. 2007. Integration of Social Rautanen S, Seppäla O, Skyttä T. 2006. Health through et al., eds. 2004. Waterborne Zoonoses: Identification, Science in the UNESCO’s Ecohydrology Programme. Sanitation and Water Programme (HESAWA), Tanzania. Causes, and Control. Geneva:World Health Organization. Report submitted by the UNESCO’s Ecohydrology Ex-post (Retrospective) Evaluation Study Report No. Curriero FC, Patz JA, Rose JB, Lele S. 2001. The association Programme Social Science Task Force, April 2007. Ann 06/36, Department of Natural Resources and Environment. between extreme precipitation and waterborne disease Arbor:University of Michigan. Stockholm:Swedish International Development outbreaks in the United States, 1948–1994. Am J Public Liang S, Seto E, Remais J, Zhong B, Yang C, Hubbard A, et al. Cooperation Agency (SIDA). Health 91(8):1195–1199. 2007. Environmental effects on transmis- Remais J, Liang S, Spear R. 2008. Coupling hydrologic and Curtis V, Cairncross S. 2003. Effect of washing hands with soap sion exemplified by schistosomiasis in western China. infectious disease models to explain regional differences on diarrhoea risk in the community: a systematic review. Proc Natl Acad Sci USA 104(17):7110–7115. in schistosomiasis transmission in southwestern China. Lancet Infect Dis 3(5):275–281. Liu Y, Guo H, Zhang Z, Wang L, Dai Y. 2007. An optimization Environ Sci Technol 42(7):2643–2649. Curtis V, Cairncross S, Yonli R. 2000. Domestic hygiene and method based on scenario analysis for watershed manage­ Rosenquist L. 2005. A psychosocial analysis of the human- diarrhoea – pinpointing the problem. Trop Med Int Health ment under uncertainty. Environ Manag 39:678–690. sanitation nexus. J Environ Psychcol 25(3):335–346. 5(1):22–32. Lund JR, Cai XM, Characklis GW. 2006. Economic engineer- Saenz R, Bissal R, Paniagua F. 1995. Post-disaster malaria in Ecks S. 2004. Bodily sovereignty as political sovereignty: “self- ing and water resource systems. J Water Resource Plan Costa Rica. Prehosp Disaster Med 10:154–160. care” in Kolkata, India. Anthropol Med 11(1):75–89. Manage 1323(6):399–402. Sarkar R, Prabhakar A, Manickam S, Selvapandian D, Edman J. 2005. Emerging vector-borne diseases and their Mara DD. 2006. Modern engineering interventions to reduce Raghava M, Kang G, et al. 2007. Epidemiological investi- control. In: New Discoveries in Agrochemicals (Clark the transmission of diseases caused by inadequate gation of an outbreak of acute diarrhoeal disease using JM, Ohkawa H, eds). Oxford, UK:Oxford University Press, domestic water supplies and sanitation in developing geographic information systems. Trans R Soc Trop Med 314–325. countries. Building Serv Eng Res Technol 279(2):75–83. Hyg 101(6):587–593. Ehrenberg JP, Ault SK. 2005. Neglected diseases of neglected Massey DS. 2009. The age of extremes: concentration afflu- Satterthwaite D. 2003. The Millennium Development Goals and populations: thinking to reshape the determinants of ence and poverty in the twenty-first century. In: Urban urban poverty reduction: great expectations and nonsense healthcare in Latin America and the Caribbean. BMC Health (Hynes HP, Lopez R, eds). Boston, MA:Jones and statistics. Environ Urban 15(2):179–190. Public Health 5:119. Bartlett Publishers. Sharma S, Sachdeva P, Virdi JS. 2003. Emerging water-borne Eisenberg J, Brookhart M, Rice G, Brown M, Colford J. 2002. Mathew M, Mathan MM, Mani K, George R, Jebakumar K, pathogens. Appl Microbiol Biotechnol 61:424–428; doi: Disease transmission models for public health deci- Dharamsi R. 1991. The relationship of microbial pathogens 10.1007/s00253-003-1302-y [Online 9 April 2003]. sion making: analysis of and condi- to acute infectious diarrhea of childhood. J Trop Med Hyg Sierra R. 1999. Traditional resource-use systems and tropi- tions caused by waterborne pathogens. Environ Health 94(4):253–260. cal deforestation in a multi-ethnic region in North-west Perspect 110:783–790. Medd W, Chappells H. 2007. Drought, demand, and the scale Ecuador. Environ Conserv 26(2):136–145. Eisenberg J, Desai M, Levy K, Bates SJ, Liang S, Naumoff K, et al. of resilience: challenges for interdisciplinarity in practice. Simonovic S. 2000. Tools for water management—one view of 2007. Environmental determinants of infectious disease: Interdiscip Sci Rev 32(3):233–248. the future. Water Int 25(1):76–88. a framework for tracking causal links and guiding public Mukabana W, Kannady K, Kiama G, Ijumba J, Mathenge E, Sirot L, Poulson R, McKenna M, Girnary H, Wolfner M, health research. Environ Health Perspect 115:1216–1223. Kiche I, et al. 2006. Ecologists can enable communities to Harrington L. 2008. Identity and transfer of male reproduc- El Gamili M, Ibrahim H, Hassaneen A, Abdalla M, Ismael A. implement malaria vector control in Africa. Malar J 5:9; tive gland proteins of the dengue vector mosquito, Aedes 2001. Defunct Nile branches inferred from a geoelectric doi: 10.1186/1475-2875-5-9 [Online 3 February 2006]. aegypti: potential tools for control of female feeding and resistivity survey on Samannud area, Nile Delta, Egypt. National Institutes of Health. 1999. Ecology of Infectious reproduction. Insect Biochem Mol Biol 38(2):176–189. J Archaeol Sci 28(12):1339–1348. Diseases. Available: http://grants.nih.gov/grants/guide/ Soller J, Eisenberg J. 2008. An evaluation of parsimony for micro- Ezzati M, Utzinger J, Cairncross S, Cohen A, Singer B. 2005. rfa‑files/RFA-TW-00-002.html [accessed 1 November 2008]. bial risk assessment models. Environmetrics 19:61–78. Environmental risks in the developing world: exposure Neumann N, Smith D, Belosevic M. 2005. Waterborne disease: Stein H. 2008. Beyond the World Bank Agenda: An Institutional indicators for evaluating interventions, programmes, and an old foe re-emerging? J Environ Eng Sci 4(3):155–171. Approach to Development. Chicago:University of Chicago policies. J Epidemiol Community Health 59:15–22. Newsom S. 2006. Pioneers in infection control: John Snow, Press. Fisman DN. 2007. Seasonality of infectious diseases. Annu Rev Henry Whitehead, the Broad Street pump, and the Sur D, Dutta P, Nair G, Bhattacharya S. 2000. Severe cholera Public Health 28:127–143. beginnings of geographical epidemiology. J Hosp Infect outbreak following floods in a northern district of West Franco D, Williams C. 2000. “Airs, waters, and places” and 64(3):210–216. Bengal. Indian J Med Res 112:178–182. other Hippocratic writings: inferences for control of food- Nichter M. 1988. From Aralu to ORS: Sinhalese perceptions Temel T. 2005. A systems approach to malaria control: an insti- borne and waterborne diseases. Environ Health 62:9–14. of digestion, diarrhea, and . Soc Sci Med tutional perspective. 71:161–180. Fleming G, van der Merwe M, McFerren G. 2007. Fuzzy expert 27(1):39–52. Tetteh K, Polley S. 2007. Progress and challenges towards the systems and GIS for cholera health risk prediction in Njemanze P, Ihenacho J, Russell M, Uwaeziozi A. 1999. development of malaria vaccines. BioDrugs 21(6):357–373. southern Africa. Environ Model Software 22(4):442–448. Application of risk analysis and geographic information Toepfer K. 2004. Water and sustainable development. In: Water Gleick P, Loh P, Gomez S, Morrison J. 1995. California Water system technologies to the prevention of diarrheal dis- for a Sustainable and Secure Future (Schiffries C, Brewster 2020: A Sustainable Vision. Pacific Institute Report. eases in Nigeria. Am J Trop Med Hyg 61(3):356–360. A, eds). A Report of the 4th National Conference on Science, Oakland, CA:Pacific Institute for Studies in Development, Nunan F, Satterthwaite D. 1999. The Urban Environment. Policy and the Environment, 29–30 January, Washington, Environment and Security. Birmingham, UK:University of Birmingham, School of DC:National Council for Science and the Environment. Huang J, Walker E, Otienoburu P, Amimo F, Vulule J, Miller J. Public Policy. Townson H, Nathan M, Zaim M, Guillet P, Manga L, Bos R, et al. 2006. Laboratory tests of oviposition by the African malaria Obrist B. 2004. Medicalization and morality in a weak state: 2005. Exploiting the potential of vector control for disease mosquito, gambiae, on dark soil as influenced health, hygiene and water in Dar es Salaam, Tanzania. prevention. Bull World Health Organ 83(12):942–947. by presence or absence of vegetation. Malar J 5:88; doi: Anthropol Med 11(1):43–57. Turner MG, Carpenter SR. 1999. Tips and traps in interdisciplin- 10.1186/1475-2875-5-88 [Online 12 October 2006]. Parashar U, Bresee J, Glass R. 2003. The global burden of diar- ary research. Ecosystems 2(4):275–276. Jacob B, Regens J, Mbogo C, Githeko A, Keating J, Swalm C, rhoeal disease in children [Editorial]. Bull WHO 81(4):236. Tyagi B, Chaudhary R. 1997. Outbreak of falciparum malaria et al. 2003. Occurrence and distribution of Anopheles Patz J, Campbell-Lendrum D, Gibbs H, Woodruff R. 2008. Health in the Thar Desert (India), with particular emphasis on (Diptera : Culicidae) larval habitats on land cover change impact assessment of global climate change: expanding physiographic changes brought about by extensive

Environmental Health Perspectives • v o l u m e 117 | n u m b e r 7 | July 2009 1031 Batterman et al.

canalization and their impact on vector density and dis- Waterkeyn J, Cairncross S. 2005. Creating demand for sanita- WHO (World Health Organization). 2004. Global Strategic semination. J Arid Environ 36:541–555. tion and hygiene through community health clubs: a cost- Framework for Integrated Vector Management. Available: Uganda Service Provision Assessment Survey. 2008. Uganda effective intervention in two districts in Zimbabwe. Soc http://whqlibdoc.who.int/hq/2004/WHO_CDS_CPE_ Service Provision Assessment Survey Kampala:Uganda Sci Med 61:1958–1970. PVC_2004_10.pdf [accessed 10 October 2008]. Ministry of Health and Macro International Inc. Waters Network. 2008. Science, education and design strat- WHO (World Health Organization). 2008. Water-related UNEP (United Nations Environment Programme). 2004. egy for the WATer and environmental research systems Diseases. Available: http://www.who.int/water_­sanitation_ Guidelines for Reducing Flood Losses (Pilon PJ, ed). New network. Available: http://www.watersnet.org/docs/SEDS- health/diseases/en/ [accessed 1 November 2008]. York:United Nations. 20080227-draft.pdf [accessed 2 November 2008]. World Bank. 2008. Environmental Sustainability. An UNEP (United Nations Environment Programme). 2007. Global Wear D. 1999. Challenges to interdisciplinary discourse. Evaluation of World Bank Group Support. Available: Environmental Outlook (GEO-4) Available: http://www. Ecosystems 2(4):299–301. http://siteresources.worldbank.org/EXTENVIRONMENT/­ unep.org/geo/geo4/media/ [accessed 15 October 2008]. Weeks J, Anderson D, Cramer C, Geda A, Hailu D, Muhereza G, Resources/environ_eval.pdf [accessed 1 November 2008]. UNEP (United Nations Environment Programme). 2008. UNEP et al. 2003. Supporting Ownership: Swedish Development Wright J, Gundry S, Conroy R. 2004. Household drinking water Environment for Development: Water. Available: http:// Cooperation with Kenya, Tanzania and Uganda. Vol 2. in developing countries: a systematic review of microbio- new.unep.org/civil_society/GCSF8/water_env.asp Stockholm:Swedish Development Cooperation Agency logical contamination between source and point-of-use. [accessed 18 November 2008]. (SIDA). Trop Med Int Health 9(1):106–117. United Nations. 2008. Millennium Development Goals Report. Wellin E. 1955. Water boiling in a Peruvian town. In: Health, Yacoob M, Whiteford L. 1994. Behavior in water supply and New York:United Nations Department of Economic and Culture, and Community: Case Studies of Public Reactions sanitation. Hum Organ 53(4):330–335. Social Affairs. to Health Programs (Paul B, ed). New York:Russell Sage Yacoob M, Whiteford L. 1995. An untapped resource: com- Van den Berg H, von Hildebrand A, Ragunathan A, Das P. 2007. Foundation, 71–103. munity-based epidemiologists for environmental health. Reducing vector-borne disease by empowering farmers in Whiteford L, Whiteford S, eds. 2005. Globalization, Water, Environ Urban 7:219–230. integrated vector management. Bull WHO 85(7):561–566. and Health: Resource Management in Times of Scarcity. Yasumaro, S, Silva M, Andrighetti M, Macoris M, Mazine C, Veerman J, Barendregt J, Mackenbach J. 2005. Quantitative School of American Research Advanced Seminar Series. Winch P. 1998. Community involvement in a dengue pre- health impact assessment: current practice and future Santa Fe, NM:School of American Research Press. vention projection in Marilia, Sao Paulo, Brazil. Hum Organ directions. J Epidemiol Community Health 59(5):361–370. WHO (World Health Organization). 2000. Global Water Supply 7(2):209–214. Vlassoff C. 1994. Gender inequalities in health in the Third and Sanitation Assessment Report. Geneva:WHO/UNICEF/ World: uncharted ground. Soc Sci Med 39:1249–1259. Water Supply and Sanitation Collaborative Council.

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