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Water: elixir of life or harbinger of disease?

Professor Ron TrentDr Jamie Bartram, WHO

12 September 2008

Water is a vital ingredient for every living thing on earth. But how do we stop that same water from bringing disease, even causing death?

A leading expert on water quality from the World Health Organization, Dr Jamie Bartram, explains to Marilyn Chalkley that it can take more than just the first-world water and sanitation infrastructure we enjoy in Australia. In developing countries that don’t yet have that infrastructure, it also takes awareness and education programs.

These programs teach communities simple ways of treating water at home to reduce water-borne disease. It’s an approach that worked extremely well in Peru, Dr Bartram explains, where not one community that used the techniques was affected by a cholera epidemic that devastated the surrounding region a few years ago.

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Transcript of podcast

Voice-over: Welcome to this National Health and Medical Research Council podcast. Our podcasts aim to keep you in touch with major health and medical research issues and the people who shape them.

Introduction: Hello, I’m Marilyn Chalkley. In most parts of Australia when you turn on a tap clean, clear water comes out, water that’s safe to drink. That’s not the case in many parts of the world where poor water quality can lead to death and disease, and even in Australia water quality is becoming an issue. In the last 7 years the NHMRC has spent over two million dollars on funding research into water quality. A leading expert on the issue from the World Health Organisation, Dr Jamie Bartram, is currently in Australia. As co-ordinator of the water sanitation and health program at WHO in Geneva, Dr Bartram leads WHO’s work on cholera and epidemic diarrhoeal diseases.

Interviewer: Dr Bartram, there are at least one billion people who have no safe water supply and another two billion who have to collect their water. It doesn’t come out of a tap. WHO has a huge problem hasn’t it?

Dr Bartram: The health systems of the world have a huge problem. What we see is, because of our collective failure to manage optimally drinking water, sanitation, water resources and hygiene as well, we have an enormous health burden. The preventable disease is a significant proportion of all disease. We estimate it’s something approaching 10 per cent of all ill health on the planet could be prevented by better management of those resources. What in there are the big news items? Well certainly the biggest proportion of that disease burden comes from simple diarrhoeal disease and the consequences of malnutrition which itself is a consequence of that diarrhoeal disease, that’s the biggest single hit. And do we know how to prevent them? Certainly, in countries such as Australia a progressive sanitary revolution over a 100 years has brought those diseases under control. They’ve not been brought under control by medical interventions or treatment, they’ve been brought under control by prevention. Access to reasonable basic water and reasonable basic sanitation and practice of reasonable hygiene are the three core principals in preventing that unnecessary disease.

Interviewer: You’ve talked in your seminar today about some of the areas that have actually made a difference, perhaps you could enlarge on those.

Dr Bartram: Sure, what we’ve seen in recent years is an understanding that while we do need to move towards the long term goal of getting infrastructure so everyone actually has access to basic services, that the great majority of that disease is concentrated on the people that don’t have them and you can’t simply ask people to wait in line — it’s not a queue for another three generations, that doesn’t work, so what we’ve tried to do, or what we’ve seen countries try to do, is to combine the long, slow haul of gradually getting infrastructure in place to provide basic services and alongside that deploying interventions that can help reduce disease burden in the most disadvantaged populations in the short term. Now just to give one example of that that’s relevant to water safety — that’s the issue you’re discussing, only around 5 to 10 years ago it started to become clear that there are a number of very simple ways that ordinary households could treat their water at home and therefore improve its quality and therefore reduce risk. Now that doesn’t solve all the problems. They still have problems of access to water but it can interrupt the water-borne transmission component. Now is that effective? There have been a lot of studies in many different countries which suggested very significant disease reductions when households adopt those kinds of simple treatments. Now the percentages are quite impressive. Individual studies have gone in perhaps the 20 to 40 per cent range very much affected by the sustainability of the intervention. So does the household do it once because they’ve been frightened by the news of cholera or do they keep doing it day in day out over many years? That’s a very different issue but what we do see is these very high rates of reduction. That’s not a substitute for getting the infrastructure in place, for getting the services in place and the long haul is still needed. But we need strategies to target the most disadvantaged populations because that’s where all the disease occurs.

Interviewer: So you’re talking about awareness and education as much as infrastructure in a way.

Dr Bartram: Absolutely. Infrastructure’s important but infrastructure is not sustainable and it doesn’t exist unless there is demand. One of the lessons I think that’s been learned only in the last 10 to 20 years is that in increasing infrastructure provision, especially in the developing world a demand-responsive approach is absolutely critical. If you offer a service which is either not affordable or doesn’t respond to the cultural norms of an area it simply won’t be taken up and it won’t be maintained so demand responsiveness is critical and that means allowing a far greater voice to households in saying what works for them and giving a genuine platform of choices not the one that’s being offered and some others which really aren’t going to work.

Interviewer: You also gave an example of Peru where cholera swept through a few years ago and how cholera was basically prevented. Could you talk a bit about that?

Dr Bartram: I think it’s a very interesting story at three levels. First of all we should recall that cholera, a real dread disease and one of the ultimately preventable diseases, hadn’t occurred in Latin America for nearly a hundred years and it got a foothold and swept in effect through a continent with enormous effect. So first of all we shouldn’t be complacent that’s the first point. Second point is it’s really expensive to get water and sanitation wrong. Now if we look at that country Peru it has been estimated that the cost to the economy of that country in one year was more than had been invested in water and sanitation in that country in the previous decade. So the cost of inaction — or the cost of inadequate action — is very high. Now the third lesson which I think is the one you’re referring to, is that there is a group there supported by CARE, the International NGO that for many years had been running a very careful, long term water sanitation hygiene program in rural areas in some of the northern villages in Peru. Now that is an interesting program because it was long term — they didn’t just go into a community do something and leave — a long term commitment, very responsive to community needs, very, very strong educational awareness raising components so quite unusual if we’re honest and they were always very proud of it. What’s very interesting in a recent write-up not one of the communities that were participating in that program was affected by cholera as the epidemic swept through the region. Now if you want a measure of success it seems to me that’s about as good a measure as you can get.

Interviewer: Thank you Dr Jamie Bartram, co-ordinator of the Water, Sanitation and Health Program from WHO in Geneva.

Voice-over: This podcast was brought to you by the National Health and Medical Research Council working to build a healthy Australia. You’ll find more information about this and other health and medical research issues on our website at

Page reviewed: 8 April, 2011