Water for the Displaced Population's Health: An Urban - Rural Dichotomy Revisited

Alpaslan 0zerdem & Sultan Barakat Abstract lations urbaines et rurales de lacking adequate supplies of safe water populations de'place'es de la re'gion de for their well-being and health. Besides This paper is a review andanalysis of the , Bosnie-Herze'govine. L'article the scope of these challenges with water health impacts of inadequate and unsafe conclut que la strate'gieglobale visant h quantity and quality in settlements af- water supplies on displaced populations. rkpondre aux besoins en eau potable des fected by armed conflicts, the influx of The investigation focuses on the overall populations dkplace'esdoit 2tre aussi at- refugees and internally displaced per- health implications of the curren t praxis sons (IDPs)further exacerbates the situ- tentiveet minutieuseenzoneruralequ'en ation. These influxes of displaced of watersupply recovey and reconstruc- zone urbaine. people, which increase the demand for tion, which is often biased towards urban Introduction water in a settlement sometimesby 10to areas, neglecting the waterneeds of those Water isnot only sigruficantfor our very 20 fold, put tremendous strain on dam- living in rural areas. Having explored a existence, but also for the continuation aged and already inadequate existing series of water quantity and quality is- of physical, social and economic as- supplies. Consequently, both host com- sues, and their inter-relationship to pub- pects of everyday life. Without adequate munities and those displaced from their lic health, by comparing urban and rural means of water, the development of so- homes and livelihoods often experience settlements in the Tuzla Region of ciety and satisfaction of human aspira- deadly health problems caused by wa- Bosnia-Herzegovina, this paper con- tions cannot be managed. Since there is ter-related infectious diseases cludes that the overall strategy of re- no substitute for water, humanity's ex- (0zerdem & Barakat, 1997). sponding to water needs of displaced istence totally depends on it. In fact, it is The literature in public health stud- water's indispensablemulti-functional ies and the health care for war-affected populations requires equal attention and character for life - health, habitat, carrier people usually state the classification of care to both urban and rural areas. and production functions - which is water-related infectious diseases ac- why water is often used as a weapon of cording to their transmission routes as war. (Feachem, et al., 1977; Dangerfield, Vulnerability of water supplies, par- 1983; WEDC, 1991; Mears & Cet article propose un re'capitulatifet une ticularly those in urban areas due to Chowdhury, 1994; Kolsky, 1993; analyse de l'impact sanitaire d'une dis- their complexity is often manipulated Thomson, 1995): tribution inadtquate et inse'curitaire de by warring parties in armed conflicts: 1. Water-borne route: The infection oc- l'eau chez les populations dkplace'es. La destruction inflicted on water supply curs by drinking water containing recherche concen tre son attention sur components by bombing and artillery; pathogens. cutting off or poisoning of water sources 2. Water-washed route: The infection in l'impact sanitaire global des pratiques when they are in the hands of opposing this group caused by the lack of water actuelles de distribution des eaux, qui side. Armed conflicts have also great for personal hygiene. privile'gie souvent les zones urbaines au indirect negative impacts on water sup- 3. Water-based route: Some pathogens de'triment des zones rurales, dont les plies, as the interdependence on elec- spend a certain part of their life cycle in besoins en eau potable sont sciemment tricity and fuel for their operationmakes an aquatic animal such as a water snail ne'glige's. Onexplore un certain nombre them very vulnerable to war conditions. and infection occurs by coming in con- dequestions relatives h la quantite'et h la The other indirect effect of war onurban tact with parasitic worms. qualitt de l'eau, et leur relation avec la water systems is the lack of personnel, 4. Insect vector route: Water in this route sante'publique, en comparant des instal- materials, equipment and chemicals for acts as a breeding ground for insects their operation and maintenance. Even which spread diseases. if they are obtained through great efforts, Table 1 shows these four water-re- Dr. Alpaslan tizerdem is a civil engineer from the lack of personnel may still pose a lated transmission routes with exam- Turkey. Dr. ozerdem is currently working as a great challenge for the improvement of ples of diseases and preventive research and teaching assistant at the Post- War supplies. Water board staff may be un- strategies. What canbe derived from the Reconstruction and Development Unit der conscription or they might be ethni- preceding table is that many infectious (PRDU), University of York, UK. cally cleansed and displaced, injured or diseases such as diarrhea, dysentery Dr. Sultan Barakat isanarchitectfrornfordan.Dr. dead (Ozerdem,1998). and cholera canbe prevented fromcaus- Barakat is the founding director of the PRDU As a result of these direct and indirect ing the deaths of thousands of war-af- and has extensive experience in conducting in- impacts of armed conflicts on water fected people by increasing and court y training, researchand publication in the supplies, war-affected communities go improving water quantity and quality. field of rebuilding war-torn societies. through the burden and hardship of According to Kolsky (Kolsky, 1993), the

16 Refige, Vol. 18, No. 5 (January 2000) Table 1: Water-related Infection routes with examples and control measures (Source: WEDC, 1991:70 and Dangerfield, 1983:27-28)

Transmission route

trolled sources

W ater-washed

Water-related insect vector

I preceding categorisation of water-re- mission route for diarrhoea1diseases as 3. water-based lated infectious diseaseswas es~eciallv both water-borne and water-washed 4. water-related insect vector appreciatedbyengineers, as it &utlin

Refuge, Vol. 18, No. 5 (January 2000) 17 -- 21.

such as being able to eradicate all water- seen on the map on p.17. In each mu- in Srednjehercegovacki Canton related diseases by only improving water nicipality of the region, there is a centre (Number 7), which means a further con- quality, or focusing on urban areas at the town which is the main settlement for centration of administrative and insti- expense of those living in settlements administrative, economic and social tutional structures in its boundaries. which are not covered by an umbrella of a activities and gives its name to the The Tuzla Region preserved its multi- water supply system complicate the whole municipality such as , cultural and multi-ethnic characteristics situation. Therefore this paper will review Tuzla and Zivinice towns in their re- for centuries under the rules of different a series of water quantity and quality spective municipalities. Besides these empires from the Ottomans to the issues, and their inter-relationship to public centre towns in each municipality, Austria-Hungary Empire. Although it health through an urban-rural injustice there are also a number of smaller was mainly a Muslim region - 65% of the discourse in the context of the Tuzla towns and villages, and it is in con- population in 1991- the and the Region of Bosnia-Herzegovina in order to junction with this administrative formed a considerable proportion derive a set of lessons to be utilised in structuring that the first layer of urban - of the population in municipalities such responding to water needs of people in rural dichotomy appears atthe intra- as Brcko and Tuzla. There is no doubt other war-affected areas . . municipality level. However it should that the war changed the demographic be noted that there are also distinctive composition in the municipalities, both in differences in economic development terms of population and ethnicity, The Tuzla Region Context The Tuzla Region of Bosnia- levels at the inter-municipality level. through its severe impacts such as ethnic Herzegovina is located approximately 90 For example, Tuzla, Srebrenik and cleansing and mass population km north of , and includes the Gradacac municipalities have much movements. According to the United municipalities of Banovic, Brcko, Celic, better physical, economic and institu- Nations High Commissioner for East, Gracanica, Gradacac, , tional resources than in Aelic, Kalesija Refugees (UNHCR 1997), there are , Lukavac, , Srebrenik, and Teocak. In addition to this, as a 200,000 Muslim IDPs living in the Tuzla Teocak, Tuzla and Zivinice. The Dayton result of the Cantonal System in the Region. However, apart from estimating Line separates the Tuzla Region from the Federation of , some approximate numbers and Serbian regions number 2, 3 and 4 along its Tuzla town also has the role of being percentages, it is not an easy task to west, north and east sides, while in the regional capital city, as is the status for estimate the current ethnic breakdown for south, it borders with the Muslim Canton in Zenickodobonjski Canton each municipality. number 4, as can be (Number 6) and Table 2 shows that the municipalities of Gradacac and experienced a considerable level of displacement in Table 2:The pre-war and post-war population and ethnicity terms of receiving refugees and IDPs, as in four sample municipalities well as having people displaced from their boundaries, due to their geographic GradaCac I Lopare Lukavac Tuzla positions between the Federation ofBosnia - Herzegovina, and Republica I cis a I cis alcl s Sirpska. On the other hand, the main Pre-war POP. Total 56,581 32,537 57,070 131,618 displacement experienced by Lukavacand 1991 % 60 15 20 37 4 57 66 3 21 47 15 15 Tuzlahad been in terms of receiving Current Fed 38,600 19,500 51,200 159,718 mainly Muslim IDPs from other parts of ,~~. --«<->- Bosnia-Herzegovina. For example, IDPs Major form 25 % of the current population in Population ethnicity the Tuzla Municipality. More _____ ••• -_' •••••• __ •••••• _.-_- ___ •••• v ••••• _ ••.•••••••• ______fr<' ••• - ••• ·,· .•• ______-f ...••• « ••• ~--- ______importantly, it can be seen that, as a & Major RS consequence of Muslim IDPs, the pro- Major portion of ethnic groups has changed Ethnicity considerably. Even assuming that the ethnicity population of Croats and Serbs remained the same during this period, the ratio of Refugees Fed I min250 I --- I min660 I min2.3oo the Muslims in the Tuzla Municipality From Major increased from 48% to 65% ______ethnicityethnicity (Ozerdem,1998). Displaced ------m--i=;;d--m Rs-l--~~4 ~--1----~----+------41.200------Persons Major The Provision of Drinking-Water ethnicity in the Tuzla Region I RS - - A survey carried out by Jusupovic and n T2~600 Beslagic (1998) from the Tuzlanski- Major ethnicity podrinjski Cantonal Ministry of Health and the Cantonal Public Health Institute ------SerbsB: Mainly Bosniacs, C: Mainly Croats, S: Mainly Bosnian min: minirrum respectively, presented the current Fed: Federation of Bosnia-Herzeqovina AS: Reolblica SilPska situation of water supply and drinking-

18 Refuge, Vol. 18, No.5 (January 2000) Table 3: State of Water Supply in Tuzla Region 1998 (source: Jusupovic and Be&lagic, 1998:116)

l unicipaiity % ot inhabitants with Water consumption %of deteriorated connections to city (litresl inhabitant1 day) water supply network water networks Banovici 10 50 - 230 25 Brcko I I I I Belic 3 0 16 G racanica 3 2 150 57 - G radacac- I 22 I 150 I 8 0 Kalesija 25 20 I Kladani I I I I Lukavac I 28 I 250 I 20 Sapna I Srebrenik I 14 I 140 I I -- - -- Teocak I I Tuzia I 67 200 I water quality control in the Tuzla Re- gion.' The following data obtained from data. 4dto 50 per cent. this survey are presented in table 3. This Table 3 also shows that the technical Apart from Tuzla and Zivinice, table shows the percentage of munici- state of water supply and its distribu- which use sedimentation, filtration and tion networks are rather alarming. The disinfection facilities, the main type of palities with service connections to city water treatment for other municipali- waterworks, their water consumption, level of deterioration in Gradacac, for example, is as high as 80 per cent. There- ties in only chlorination (disinfection). and the percentage of deteriorated city fore it is not surprisingto see that almost Furthermore, the treatment facilities watersupply networks. all water distribution networks in the only supply water to the towncentres in This table shows that the level of serv- - ice connection to existing urban water Table 4: Four major diseases registered at the Cantonal Public Health supplies is very low in the Tuzla Re- Institute in four municipalities of the Tuzla Region gion. The Tuzla municipality has the (Source: The Cantonal Public Health institute, 1995) highest proportion of its population, Year I Tuzla I Srebrenik I Lukavac I Zivinice I connected with the water supply net- work, while it is as low as 10% in the municipality of Banovici. However, the percentagesprovided show the ratio for the number of inhabitants with connec- tions to city water networks bymunici- pality. However, it is known from the field work that the percentages for the population living in town centres are much higher than those in rural areas. For example in Gradacac, Gracanica, Tuzla and Zivinice town centres, almost all populations are served with water by town water supply networks. The variation of water consumption from one municipality to another is large: over 150 litres per capita per day (L/p/ d) in major municipalities, to between 20-50 L/p/d in the smallermunicipali- ties, which from field experienceis sirni-

-- Refuge, Vol. 18, No. 5 (January 2000) 19 Table 5: Results of bacteriological survey of water supplied to rural areas, according to type of facilities, in the Municipality of Tuzla (Source: ~ehinovib,1998:96)

Type of Water Facility No. of No. of Positive Percentage of Positive Sam~les Results Results ( %I City waterworks - survey 1 9 1 11 - survey 2 4 2 5 0 Local waterworks - survey 1 3 8 2 5 66 Tapped source - survey 2 4 5 3 1 6 9 Public fountain 14 5 3 6 Well (above 5 households) 153 129 8 5 Artesian well 1 1 100 Cisterns 2 2 100 TOTAL: I 266 I 196 I 7 4 each municipality. Therefore the real tion during the war; the Institute re- ral water supply in the municipality of state of treatment facilities for those who ceived its figures only from the Tuzla Tuzla posed a high level of danger to do not live in rural areas is much worse, General Hospital, while those cases public health for possible epidemics of as they are supplied with water directly treated in the clinics may not have been infectious diseases. from local sources, such as garden sent to them. Therefore it canbe assumed Using UNICEF's threshold, which wells. that the real state of these four major identlfy water with more than 10 E-coli Health Consequences of diseases were in fact much worse in the colonies per 100 ml as polluted, the de- Inadequate Water Supplies in the four municipalitiesduring the period of gree of contamination of water in these Tuzla Region war. Due to unreliable population esti- positive test results is in excess of ac- The war in Bosnia and Herzegovina had mates, incidence rates of diseases could ceptable levels. Of the positive test re- serious impacts on the health of the not be calculated. sults, 52% had between 1-50 colonies population due to the deterioration of The decrease in the number of the per 100 ml of water, 17% had 51-200 environmental and living conditions, given diseases in the Tuzla region for colonies, and 31% had too many colo- malnutrition and destruction of health the year 1994inTable4 can be explained nies to count. Considering the high facilities. Communicable diseases, es- by the improved response to basic needs percentage of E-coli of faecal origin in pecially among refugees and IDPs, have by the international community which the water, it is not surprising to see that shown a large increase throughout the was effective fromearly 1994 onwards. there was a high incidence of intestinal country. For example, the result of a The paper willnow present the result infectious diseases registered in the medical survey upon the arrival of 4,200 of a survey on the bacteriological safety municipality of Tuzla during the period displaced people from , in of water in the rural areas of the munici- when this survey was carried out. the Tuzla Region, showed that 72 % of pality of Tuzla which are not covered by The presence of the above mentioned childrenhad malnutrition,42 %of them the Tuzla Town Water Supply.The sur- faecal-oral diseases (water borne and suffered from anaemia, 40 % had an vey was carried out using the Oxfam's water washed) in the territory of the upper respiratory tract infection, 31 % E-coli counting method by the Tuzla Tuzla municipality show that water in had a skin disease, 17 % suffered from Health Centre in 1997. It was particu- settlements which are not covered by diarrhoea, and 17 % had bronchitis larly important to show the scale of the the town water supply is exposed to a (Ministry of Health, 1996).2 health problem for approximately 30 high risk of faecal contamination. Con- The Cantonal Public Health Institute per cent of the rural population who are sequently, water in these settlements is in Tuzla (1995) prepared a report on the not connected to a town water supply in not safe for drinking purposes because hea1.th situation in several municipali- the Tuzla municipality. Mehinovic of bacteriological contamination. ties in the region. The data provided in (1998: 95) ~tated:~ Discussion this report covers the period from 1991 "The control of quality of water from The health impacts of inadequate water to 1994, where 1991and early 1992 fig- water supply facilitieswhich are out- supplies on the population of the Tuzla ures represent the pre-war situation side of the city waterworks system is Region of Bosnia - Herzegovina have while mid-late 1923,1993and 1994 fig- performed mostly by no one, except been evaluated in this paper. It high- ures are for war time.3This data is pre- in epidemiologically indicated situa- lights a series of challenges in terms of sented in Table 4, which shows cases tions". responding to water quantity and qual- registered at the CantonalPublicHealth ity needs, but also to the existence of an Institute. The figuresprovided are arti- From the data in Table 5,74 % of all overall bias in the current praxis of ficially low for the following reasons: facilitiestested were positive forbade- water supply improvements for the difficulties of compiling informa- riological contamination. Thus the ru- populations in urban areas at the ex-

20 Refwe.Vol. 18. No. 5 (Tanuarv 2000) pense of those living in rural settle- "those who are far from the sightwill FutureChallenges, Transactions of the Royal ments. also be far from heart.'j5 Society of Tropical Medicine and Hygiene, Our data clearly show large varia- the needs of rural settlements become Volume 87,3. tions in the number of inhabitants in further neglected as towns become the Mears, C. and S. Chowdhury. 1994. Health different municipalities connected to centres for many international relief Care for Refugees and Displaced People, water networks, highlighting the issue and development agencies. This con- Oxfam Practical Health Guide No. 9,Oxfam of unequal access to adequate and safe centration of organisations further bi- (Oxford). water supplies. Those towns inmunici- ases the building of infrastructure and Mehinovic, N. 1998. 'Control of Bacteriological palities with more commercial and in- projects towards the towns, consolidat- Safety of Waters from Water Supply Fa- stitutionalimportancearebetter served ing their already well-rooted presence cilitiesin the Territory of Tuzla Municipal- with water supplies than those which in the political and institutional arena. ity whicharenotCoveredbytheCityWater are smaller and poorer. It is in fact, ironic Therefore, it is crucial that those practi- Supply System', Institutional Strengthen- that most of those smaller municipali- tioners involved in the recovery of water ing of Public Utility Enterprises Workshop ties are now worse off after the war, as supplies in war-affected areas adopt an Report, 21-23 March 1998, Organized by they were either divided by the Dayton egalitarian strategytowards rural areas Vodoprivreda BiH (Tuzla, Bosnia and Line, creating the phenomenon of 'dis- in their approachfor water quantity and Herzegovina): 95-101. placed' municipalities, or they were quality improvements.After all, caring Ozerdem, A. 1998. An Approach to Sustain- badly affectedbythe influx of IDPs. The for human life without discrimination, able Recovery of Urban Water Supplies in issue of unequal access to adequate and whether it is South or North, far or close, War-Affected Areas with specific refer- safe water supplies also has a second or in urban or rural areas, is one of the ence to the Tuzla Region of Bosnia and dimension, as those in town centres of basic principles of humanitarianism. Herzegovina, an unpublished DPhil The- each municipality are more likely to sis, PRDU, University of York. have access to safer water supplies than Conclusion Ozerdem, A. and S. Barakat. 1997. (eds.) those living in rural settlements.In other It is evident from the preceding review of Water under Fire - The Challenge of Post- words, the inhabitants who obtain their displacement and public health issues war Reconstruction of Water Supplies water from private sources such as pri- in the context of the Tuzla region case Workshop Report, PRDU, University of vate garden and artesian wells or from study that the existence of pre-war bias York (UK). local waterworks, which are often lack- in the provision of an adequate amount The Cantonal Public Health Institute. 1995. ing atreatrnent facility or consistent test- of safe water for populations in urban 'State of the Health in several Municipali- ing of water quality, are the most likely areas at the expense of those living in ties', unpublished report (Tuzla, Bosnia tobe affected by water-related infectious rural settlements is often passed over to and Herzegovina). diseases. Though inequalities between the post-conflict period. It is often the Thomson, M. C. 1995. Disease Prevention urban and rural areas in accessing ad- case that rehabilitationand reconstruc- Through Vector Control: Guidelines for equate and safe water supplies (both tionprogrammesirnplementedbyinter- Relief Organisations, Oxfam Practical inter and intra municipality) has long national humanitarian organisations Health Guide No. 10, Oxfam (Oxford). been a challenge in the context of re- to improve water supplies in war-af- UNHCR, 1997. UNHCR Repatriation Team sponding to %asicneeds'in developing fected areas also concentrate on urban areas. As a consequence of this biased Reports, UNHCR (Bosnia and countries, this paper shows that the Herzegovina). scope of these problems are further ex- approach, the populations in rural ar- acerbated by the impact of armed con- eas are the most likely to be affected by WEDC, 1991. The Worth of Water: Technical flict. water-related infectious diseases. w Briefs on Health, Water &Sanitation with Furthermore, the framework of plan- an Introduction by John Pickford, IT Pub- ning and implementation of water sup- References lications (London). plies in war-affected areas is often Dangerfield, B. J. (ed.) 1983. Water Practice Notes designated by a series of biases. The Manuals 3 - Water Supply and Sanitation in 1. Fatima Jusupovic (M.D., Msc) and Zijad field research experience in the Tuzla Developing Countries, The Institute of Wa- BeSlagic (Prof., PhD) are working for the Region shows that spatial, institutional ter Engineers and Scientists (London). Tuzlanski-podrinjski Canton Ministry of and political biases have been very de- Feachem, R., M. McGarry, and D. Mara 1977. Health and the Public Health Institute in cisive in favouring urban groups in Water, Wastes and Health in Hot Climates, Tuzla, respectively. water supply construction and recon- John Wiley & Sons (Chichester). 2. This document wasprepared by the Federa- struction projects carried out by inter- Jusupovic, F. and Z. BeSlagic. 1998. 'Hygiene tion of Bosnia and Herzegovina Ministry of national NGOs and local authorities and Sanitary Situation in regard to Water Health with assistance of WHO. during and after the war. It appears that Supply and Drinking-Water Safety Con- 3. The war affected the Tuzla Region starting the pre-war era custom of neglecting the trol', Institutional Strengthening of Public from April/ May 1992. needs of rural settlements is often Utility Enterprises Workshop Report, 21- 4. Dr. NerminaMehinovic works for the Tuzla passed over to the post-conflict period, 23 March 1998, Organized by Health Centre and she led the team who during which those communities living Vodoprivreda BiH (Tuzla, Bosnia and carried out the survey on the bacteriologi- in rural areas become even more Herzegovina):115-123. cal safety of waters in rural parts of the marginalised, both politically and eco- Kolsky, P. J. 1993. 'Water, Sanitation and Di- Municipality of Tuzla. nomically. As it is said in a Turkish arrhoea: The Limits of Understanding', 5. TheTurkish proverb mentioned is "Gozden proverb: Diarrhoeal Disease: Current Concepts & Uzak Olan Gonulden de Uzak Olur". o

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