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Sustainable Control of Water-Related Infectious Diseases: a Review And Review Sustainable Control of Water-Related Infectious Diseases: 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 Environmental Health Sciences, 2Department of Epidemiology, 3School of Natural Resources and the Environment, 4Department of Health Management and Policy, 5Department of Civil and Environmental Engineering, 6Department of Biostatistics, 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 JECTIVE : Even when initially successful, many interventions aimed at reducing the toll of water- infection transmission, paying less (and often related infectious disease 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 DATA 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 disease burden is the most severe, are emphasized. that incorporating more distal processes into DATA 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 public health 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 DATA 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 vector- tunities for interdisciplinary collaborations, data fusion techniques, and other advances. borne) and their more distal causes, which CONCLUSIONS : 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 KEY WORDS : infectious disease, interdisciplinary, malaria, 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 sanitation 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 fever, 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; diarrhea and malaria are by far orrhagic fever. Schistosomiasis 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) Escherichia coli O157:H7, Campylobacter funding for water supply and sanitation facili- 763-2417. Fax: (734) 936-7283. E-mail: stuartb@ jejuni, and Cryptosporidium parvum 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. pathogens, including Vibrio cholerae O139, ment. In particular, we argue that one problem The authors declare they have no competing hepatitis viruses, cyclospora, microsporidia, with interventions to reduce infectious disease financial interests. Yersinia enterocolitica, and environmental incidence and emergence, particularly those Received 24 November 2008; accepted 17 April bacteria (e.g., Legionella pneumophila), have that are water-associated, is that efforts are 2009. Environmental Health Perspectives • VOLUME 117 | NUMBER 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 prevalence 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 drinking water 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 hygiene, 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 dengue fever, require water This broad definition is necessary to appro- sanitation. These include a) population to propagate insect
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