CLINICAL SCIENCE AND

HEALTHCARE INFORMATICS
26/11/2009

Sarah Murphy

Triona Hussey

Mehak
Mahipal
Table of Contents Farhana Kadir

1
1. Abstract (Choice of Topic)..……………………………………………………………. 03

2. History of Sanitation……………………………………………………………………. 04

3. Pathology of Inadequate Sanitation…………………………………………………….. 06

4. Benefits of Sanitation…………………………………………………………………… 00

5. Further Development of Sanitation……………………………………………………... 00

6. Conclusion……………………………………………………………………………… 00

7. Appendix 1(Group Work Process)……………………………………………………… 00

8. Appendix 2 (Bibliography)……………………………………………………………... 00

9. Appendix 4 (Word Counts)……………………………………………………………... 00

Abstract

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 Medicine finds solace in the age old adage “prevention is better than cure” and rightly so.

As modern day health professionals, it is of paramount importance that we recognize that it may

not necessarily be medicine, that is to say a certain medical procedure, medical drug or indeed

any other medical advancement as such, which holds the key to solving a majority of underlying

health problems. Within the realm of this very principle, it is imperative that we fathom the

benefit of directing costs of traditional medicine into behavioural, environmental and even social

change to promote prevention of illness and healthy living. The development of a proper sewage

system or even the introduction of a basic toilet is one such change. In 1948, 14,137 Londoners

lost their lives to recurring epidemics of cholera resulting from improper sanitation [Binghama P, et al pp

. Provision of sanitation has more often than not been over looked and at times even been
387-394]

completely ignored despite such events. Even in today’s magnanimously advanced world,

inadequate, or a complete lack thereof, sanitation results in approximately 1.87 million deaths

from diarrhoea alone, 90% of which number are children under the age of 5 [Boschi-PintoI C et al (2008).

pp710-717] . In the words of Dr. Jong-wook Lee, the director general of the World Health

Organisation, “once we can secure access to clean water and to adequate sanitation facilities for

all people, irrespective of the difference in their living conditions, a huge battle against all kinds

of diseases will be won .” Development of sanitation facilities, a toilet in perhaps very

[WHO (2004)]

basic words, not only possesses the potential of preventing endemics but in turn, saving

numerous lives and can therefore be deemed one of the most important medical advancements in

the past 200 years. Hence the choice of this topic for the report.

History of Sanitation

The etymology of the word hygiene itself creates a long standing association with health

and medicine. The word finds its roots in the Greek word Hygeia, the Greek goddess of health

3
and the daughter of the Greek god of medicine Aesculapius . Despite its ancient
[Miguel (2002) pp 122-23]

origins, defecation has never been a communal topic of discussion due mainly to the repugnance

associated with it. Nevertheless, the toilet forms an indispensible part of the history of human

civilization. In fact, sitting type toilets can be traced back to the Indus Valley Civilization of

circa 2500 BC, India [Pathak 1995]. Over the years, however, adequate sanitation has proved to be a

tremendous challenge.

Throughout the Middle Ages, Europeans, along with the rest of the world, lived amidst a

terribly detrimental environment comprised of filth and absolutely insufficient sanitation.

Bubonic plague, small pox, typhus and tuberculosis were unbridled and as such average life

expectancy failed to exceed even teen years in such times [Miguel (2002) pp 122-23].

The 1780s marked the beginning of the Industrial Revolution in Britain followed by other

parts of Europe [Mackenbach J. (2007)] . During this period, excreta was most commonly found in dung

heaps or within cess pools. The liquid components of excreta from the cess pools were meant to

leach into the soil and the solid parts to be collected by manual labour and further used as

fertilizers. However, fecal matter was, more often than not, left to overflow and cess pools were

illegally dumped into water supplies. With the incessantly increasing population and in turn,

excreta, the Parliament legalized dumping of waste into the Thames [Mackenbach J. (2007)] . Not only did

this result in the 1858 “Great Stink of London” but it also escalated bouts of cholera as 5 out of

the 9 drinking water companies used the Thames as their main source [Mackenbach J. (2007)]. In the 1848

epidemic, 14,137 people lost their lives to cholera [Binghama P, et al pp 387-394]. These events propelled the

motion of legislation to incorporate a proper sewage system in London [Mackenbach J. (2007)], which

along with handwashing reduced child mortality by a fifth as compared to the death of 1 in every

2 children prior to such arrangements [Mackenbach J. (2007)].

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 Hospital reform also ensued in terms of improvement in hygiene and sanitation. This was

a direct result of Florence Nightingale’s work in the Crimean War. This reform greatly reduced

maternal and infant mortality along with typhoid, tuberculosis and the likes, thereby increasing

life expectancy from 59.7 years in 1930 to 74.9 by 1987 [Miguel (2002) pp 122-23].

Over the years, developed countries seem to have adequately provided sanitation

facilities, but the challenge is yet to be met at such a scale in developing countries. Even so,

evaluation studies carried out in

developing countries provide

evidence of the considerable effect

of provision of sanitation [Mackenbach J.

(2007)] .

Pathology of Inadequate Sanitation

The history of sanitation clearly alerts one to the multiple medical conditions that arise

from inadequate sanitation. Safe sanitary excreta disposal involves the isolation and control of

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faeces from both adults and children so that it doesn’t come into contact with water sources, food

or people. Without access to a toilet or latrine, there exist no safe means of collection, storage,

treatment and disposal of excreta. Unsafe excreta disposal, therefore, leads to contamination of

ground and water sources, provides breeding sites for nuisance organisms, like flies and

mosquitoes, which operate as primary vectors of infection and transmission of fecal-oral disease.

A current estimated discharge of 200 million tons of untreated human waste enters watercourses

worldwide every year [UNICEF (2008), pp.1-2]. In some regions in India, where 800 million people are

thought to practice open defecation [Burki, 2009, pp.531], “60-70% of the groundwater is contaminated

with human faeces” according to Dara Johnston of UNICEF. He adds that “it is very worrying:

(because) 80% of the rural population relies on groundwater via hand-pumps.” This concern

stems from the estimation that 1 g of faeces qcontains approximately 10 million viruses, 1

million bacteria, 1000 parasite cysts, and 100 worm eggs [Burki, 2009, pp.531].

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 An estimated 50 diseases are known to be transmitted faecally [Burki (2009) pp.531] . These

include diarrhea, a symptom of poor water and sanitation along with cholera, typhoid and

dysentery (including shigellosis). 1.8 million people die of diarrhoeal diseases per annum [Boschi-

PintoI C et al

(2008) pp710-

717] , 88%

of which

are due to

poor

hygiene

and lack

of

sanitary

facilities

[Black, et al.,

(2003) pp.227] .

1.6

million, 90% of these diarrhoeal cases, are children under the age of 5 years [Burki (2009) pp.531] . This

implies that 1 child dies every 15 seconds from diarrhea (Burrows, et al. (2004) pp. 3], or more than 5000 die

each day which is 5 times the number dying from HIV/AIDS [UNICEF, (2008) pp.1-2]. Diarrhoea via the

faecal-oral route, the primary route of infectious agents associated with diarrhoeal disease [Clasen &

, accounts for 17% of all deaths of persons under 5

Haller (2008) pp.7] [Harvey (2007) pp.2] . Children of this

young age are most at risk because of their underdeveloped immune systems. People suffering

7
from malnutrition and the elderly are also at an increased risk owing to their lower prognosis for

full recovery.

Cholera, one of the leading infections causing severe diarrhoea, quickly accentuates to

acute dehydration and death as well. Over 120,000 people were affected by the disease in the

year 2002 alone [UNICEF (2005)] . Despite being asymptomatic in around 75% of cases , it is
[WHO (2008)]

considered a serious threat by all health organizations due to its virulent nature. The pathogens

stay in the faeces of the infected individual for 7-14 days [WHO (2008)] , and are then shed back into

the environment withholding high potential of infecting more individuals.

Direct or indirect contact with decaying faeces or polluted water systems also causes the

growth of intestinal worms. These infect an estimated 10% of the population in developing

countries . 400 million young children are infected by intestinal parasites such as
[UNICEF (2005)]

hookworms and roundworms at any given time . Domestic animals and vermin are
[UNICEF (2005)]

also attracted to faeces, thereby acting as additional means of spreading infection.

Excreta related diseases are mainly transmitted orally or through skin penetration.

According to studies [Fewtrell et al. (2005); Esrey (1996)] , there’s a 36% reduction in childhood diarrhoea by

safer excreta disposal and 35-42% reduction by handwashing alone. Good standards of personal

and domestic hygiene are essential to breaking the transmission chain of faecally related

diseases. In addition, waste needs to be treated in the correct manner, by eradicating or

inactivating pathogens before it can be used or disposed off safely.

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9
 Benefits of Sanitation

The history and resulting pathology of sanitation make it unquestionably apparent that the

implementation of proper sanitation is, first and foremost, essential for maintenance of human

health. Enhancing sanitation and access to it would lead to a definite decline in the number of

cases and deaths resultant of the various afore mentioned diseases. As such, it would lead to a

marked improvement in quality of life for people all over the world.

Secondly, access to sanitation would also prove to be a sound economic investment as it

would curb the onset of more fecal and water borne diseases greatly reducing direct medical

costs along with lost income, reduced productivity and even government health service costs. In

addition, it would conserve time and effort lost as a result of lack of sanitation resulting in an

additional economic value of $114 billion every year and increase tourist income of a country by

means of reducing risks of contamination and diseases [UN (2008)].

Upgrades in sanitation would also have a substantial effect on education. Current

estimates propose 200 million lost days of school and at least two thirds of African children in

schools being worm infested due to lack of or horrific sanitation . The introduction of
[UN (2008)]

appropriate latrines will lead to a massive increase in enrolment and retention rates of girls in

schools post the onset of menstruation [UN (2008)].

Some may argue that the provision of sanitation would require monetary support in the

first place. However, for every 10% increase in female literacy, a country’s economy grows by

atleast 0.3% [DDWS (2008)]. In addition, an investment of $1 in sanitation facilities results in a return

or profit of $7 [Hutton, Haller et al (2007) pp 481-502] . The environmental impacts of improper sanitation also

result in vast amounts of untreated human waste and pollution resulting from it. In South East

10
Asia alone, over US$ 2 billion are spent on clearing over 13 million tons of faeces dumped in

water sources [UN (2008)]. This is a huge financial burden that can avoided.

Lastly, sanitation also contributes to dignity and social development in terms of parents

bearing stigmas of the deaths of their young children, women being raped as they tend to their

sanitary needs in the open at night and the dishonor that results from having jobs of cleaning

faeces [UN (2008)].

Further Development of Sanitation

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 An estimated 2.6 billion people, constituting about 40% of the world population, still do

not have access to toilets today [UN (2008)].

In the past sewers were built to help such unfortunate people but these were not

adequately capable of disposal. Toilets were supplied as well but these, being more tangible than

people’s homes, began to be used as temples and storage houses. Having a proper toilet also

often meant that those sans running water had to fetch extra water each day in order to flush the

toilet.

The 7th Millenium Development Goal (MDG),

which looked to reduce the proportion of people lacking

access to sanitation by half till the year 2015 [UN (2008)] ,

did not beget as much attention as it should have

despite being a goal essential to achieve the other goals.

At the current rate of progress, the prognosis of MDG 7

being achieved by 2015 might not be completed till

2026 [DDWS (2008)].

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 There have been multiple programs, however, that are beginning to change this scenario.

By setting up the National Rural Environmental Sanitation Program, the Malaysian government

has provided 98% of its rural population with access to latrines [UN (2008)] . The Government of

Thailand runs a similar program as well resulting in massive health and development benefits for

the population . According to the UNICEF, a billion people received sanitation between
[UN (2008)]

1992 and 2002 as well [UNICEF (2004)].

Bindeshwar Pathak, founder

of the Sulabh Toilet Museum in

Delhi, India has invented a twin pit

toilet. This toilet only costs about

$15 to construct and needs a mere 1.5 litres of water to flush. As the name suggests, the toilet

consists of 2 latrines, each with a pit. The family uses one of the pit latrines till it is filled and

13
subsequently use the other. Whilst the second pit is in use, the excreta in the first pit dries up and

can then be used as fertilizer. Most importantly, these pits do not require cleaning which reduces

the need for manual scavengers. In 2002-2003 there were an estimated 676,000 manual

scavengers compared to a more recent estimate of 115,000 in India. Pathak’s ambition is to make

the country scavenger free in five years time. Pathak’s Twin pit toilet has created greater access

to sanitation. For instance, in rural India access to sanitation has increased from 27% to 59% in

the space of five years [Khullar M. (2009)]. An additional 5,500 public toilets have also been built across

Asia based on his design for the homeless and those devoid of access to a toilet [Khullar M. (2009)] .

Clearly, this toilet has already had a dramatic impact. It has the potential to bring sanitation to 4

out of every 10 people that lack access to toilets, helping control the spread of disease and

encouraging girls to remain in school and get their education [Khullar M. (2009)].

Evidently, universal sanitation is not an unachievable goal. It requires a culmination of

hard work, plenty of funding, an ability to discuss sanitation freely and a stimulating vision of

the future amongst other things but with everyone’s support and cooperation, it can be done.

Conclusion

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 The development of sanitation over the years has led to the evolution of the collective

consciousness where public health is concerned. As the predecessor of the Germ theory, this development

has not only taught us that successful intervention may not always result from correct causation but also

reiterated that universal measures may indeed reduce health inequalities. The provision of sanitation

would alone reduce the necessity of many of the major medical inventions of the past 200 years vastly.

The need for antibiotics, vaccinations and multiple medical procedures for example would decrease

greatly if sanitation borne diseases were not rampant in the first place. Billions of people have and will

continue to lead better lives, not only medically but also financially and socially in the wake of the

sanitary revolution.

Appendix 1

Group Work Process

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This report is the culmination of four group meetings and supplementary individual research. The first

meeting was utilized to concur on a topic. Subsequently, individual research on the chosen topic was

carried out by each group member. This research was employed in the next meeting to conjure an outline

for the report.

At this stage, the outline consisted of:

• Choice of topic

• Introduction

• Medical history of sanitation

• Medical, or other, conditions resulting from lack of sanitation

• Benefits of sanitation

• Current efforts of improving sanitation

• Conclusion

• Group work process

This served as the foundation for assigning further individual investigation and associated pieces of

writing. The various components were then collaborated into a single report and a final meeting ensued to

review the report and its ultimate presentation.

Appendix 2
Bibliography

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1849 outbreak of cholera that affected London: a reworking of the data highlights the
importance of the water supply. Journal of the Royal institute of Public Health. 118 (1),
387-394.
2. Black, R.E., Saul S.M., Bryce, J. (2003). Where and Why are 10 Million Children Dying
Each Year?. The Lancet. 361 (1), 2227.
3. Boschi-PintoI C, VelebitII L, ShibuyaIII k. (2008). Estimating child mortality due to
diarrhoea in developing countries. .Bulletin of the World Health Organization. 86 (9),
710-717.
4. Burki, T. (2009). Slow progress towards sanitation goal. The Lancet Infectious Diseases.
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5. Burrows G, Acton J, Maunder T. (2004). Water and sanitation: The education drain.
Education Media Report. 3 (1), 3.
6. Clasen T.F., Haller L. (2008). Water Quality Water Quality Interventions to Prevent
Diarrhoea: Cost and Cost-Effectiveness. World Health Organisation. 1 (1), 7.
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%2520Kit/Final%2520IYS%2520Advocacy%2520Kit
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sanitation interventions. Journal of water and health. 05.4 (1), 481-502.

12. Khullar M. (2009). Heroes of the environment 2009 scientists and innovators
Bindeshwar Pathak .Available:
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9,00.html. Last accessed 17 November 2009.
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Sentinel . 7 (4), 122-23.
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http://www.sulabhtoiletmuseum.org/pg02.htm. Last accessed 20 November 2009.
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%20points.pdf. Last accessed 19 November 2009.

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 17. UNICEF. (2004). Meeting the MDG water and sanitation target: a mid term assesment
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Appendix 3

Word Counts

Choice of Topic……………………………………………………………………………..292

18
Report……………………………………………………………………………………...1998

Group Work Process………………………………………………………………………..134

19