Infrastructure, development and
health
Christopher Jones, MSII & Alexander Yu, MSII
Texas Tech University Health Sciences Center
Sanka and Araypallpa, Peru 2008
Research Question
Do infrastructural projects in developing areas
improve community health?
Infrastructure and health
Clean drinking water
Sanitation
Electricity
Hygiene
Roads
Buildings (Libraries, Schools, Health Posts, etc.)
TTUHSC
Lubbock, Texas (dust storm)
UCSB- Santa Barbara, CA
(picture taken from school
window)
EWB-UCSB Past Projects Peru
Solar powered lighting for the school
Community Library
Slow-Sand Water Filtration with Chlorination
Community Educational Workshops
Peru
Population
27,947,000
Capital and Population
Lima; 8,180,000
Area
1,285,216 square
kilometers
(496,224 square miles)
Language
Spanish, Quechua,
Aymara
Religion
Roman Catholic
Currency
nuevo sol
Life Expectancy
69
GDP Per Capita
U.S. $5,000
Literacy Percent
91
Araypallpa and
sanka
Cuzco at 11,600 feet
Our goals for working with
EWB
Research Interest: To measure health changes as
infrastructural projects are implemented
Research Model: Measure health changes in
Araypallpa and Sanka as EWB infrastructural projects
are implemented
EWB GOALS FOR WORKING WITH
TWO KNOW-NOTHING FIRST YEAR
MEDICAL STUDENTS
Health Assessment - Past Difficulties
Self-evaluation of project
Identify community health needs for design of
potential future EWB projects
Slow sand filtration goals
Reduce Diarrheal Burden
Community Desire
Millenium Development Goals
Diarrhea
Nearly 2 million children die from diarrhea every
year.
Despite the persistently high burden of disease,
research into childhood diarrhoea has been steadily
decreasing since the 1980s. (1)
(1) http://www.who.int/mediacentre/news/releases/2009/diarrhoea_research_20090310/en/index.html
WATER, SANITATION AND
INFANT MORTALITY IN RURAL
PERU
Rural population with sustainable access to
improved drinking water sources 63% (2006)
Rural population with sustainable access to
improved sanitation36% (2006)
Rural, Under-5 mortality rate - 85.3/1000 (2000)
(8.5%)
Millenium Development Goals
G7 T10: Halve by 2015 the proportion of people with
access to safe drinking-water and sanitation
Improving proportion of population with sustainable
water source, urban and rural
G4, T5: Reduce by two-thirds, between 1990 and
2015, the under-five mortality rate
http://www.who.int/mdg/goals/en/index.html
How to assess water filtration
efficacy
Test the water: Fecal E.Coliform
Ask questions about diarrheal frequency
the assumptions
Dirty Water = Increased Diarrheal Incidence
Clean Water = Decreased Diarrheal Incidence
The bigger picture :
Pathogenic entry
Water source
Pipes
Food Source
Harvest
Storage
House
House
Storage
Storage
Preparation
Consumption
1) Poor Sanitation
-Potential points of contamination
From poor sanitation
Water source
Food Source
Harvest
Pipes
Storage
Pathological
Organisms
House
House
(Bacteria, parasites)
Storage
Storage
Preparation
Consumption
2) Poor Hygiene
-Potential points of contamination
From poor hygiene
Water source
Food Source
Harvest
Pipes
Storage
Pathological
Organisms
House
House
(Bacteria, parasites)
Storage
Storage
Preparation
Consumption
What happens if a pathogen enters a person?
Consumption of Pathogen
Person
1. Normal Immune Sys.
Immune System
No problem
2. Weak Immune Sys.
Diarrhea
Death
Other symptoms
Recovery
23
3) Factors Predisposing a
Weak Immune System
Consumption
Person
1. Normal Immune Sys.
1. Poor Nutrition
Immune System
2. Poor Infant Health
No problem
2. Weak Immune Sys.
Diarrhea
Other symptoms
3. Poor General Health
Death
Recovery
Food Source
Water source
Points of Entry
Harvest
Pipes
Pathological
Organisms
(Bacteria, parasites)
Storage
House
House
Storage
(Direct contamination)
Storage
Preparation
Outcome Determinants
Consumption
1. Poor Nutrition
Person
1. Normal Immune Sys.
Immune System
2. Poor Infant Health
No problem
2. Weak Immune Sys.
Diarrhea
Other symptoms
3. Poor General Health
Death
Recovery
Assessment
1. Points of Entry
a.
i.
ii.
c.
c.
•
•
•
Water- Water Purity Tests
Source
Points of Consumption
Food
I. Survey and Observation @
Point of Preparation:
b. Hygiene
I. Hand Washing
ii. Preparation Tools/ Area
c. Preparation Technique
I. Cooking Technique (raw, etc.)
Direct Contamination
Survey and Observation
General Hygiene
General Sanitation
Food Source
Water source
Harvest
Pipes
Storage
House
House
Storage
Storage
Preparation
Consumption
Person
1. Normal Immune Sys.
Immune System
No problem
2. Weak Immune Sys.
Diarrhea
Other symptoms
ii. Microscopic evaluation
a. Stool Eval to determine POE
Death
Recovery
Assessment
Food Source
Water source
Harvest
2. Outcome Determinants
a. Nutrition
I. Evaluate Foods Survey/Obsevation
a. types available
b. Diet Consumed
ii. Physical Exam
a. Nutritional State
a. General Health
• Infant Health
Pipes
Storage
House
House
Storage
Storage
Preparation
Consumption
Person
1. Normal Immune Sys.
Immune System
No problem
2. Weak Immune Sys.
Diarrhea
Death
Other symptoms
Recovery
Other General health foci
Respiratory Health
Maternal Health
Cardiovascular Health
Assessment
method
1) Household health surveys (diarrheal prevalence,
•
causes, respiratory health, general health)
2) Focus group surveys (impact, causes, respiratory
health, general health)
•
3) Household observations (causes)
•
4) Microscopic analysis of stool samples (causes,
impact)
•
5) Child nutritional assessment (causes, impact)
•
6) Regional data (diarrheal prevalence, impact,
respiratory health, general health)
•
Araypallpa
Results
Reported health diarrhea, stomach pain
Growth Charts - nutrition
Bathing, trash,hygiene, sanitation
Stool Samples
Basic statistics
Sanka:
42 of 65 households were visited by the team. 141 of 250 villagers were
respondents.
The genders were equally represented (70/71). The average age of respondents
was 33 years old.
Araypallpa
13 of 90 households were visited by the team. 52 of 420 villagers were
represented.
42% of the respondents were male and 58% were female. The average age of
respondents was 27.7 years old.
Sanka GI symptoms
Low reported incidence of diarrhea, but high reports of stomach pain.
• However, village leaders reported that for children, 40-90% are suspected to have diarrhea
at least once per year
46
Poor or No Ventilation in cooking
area: 55% of households
“Ok” (fair) Ventilation: 30% of
households
Good Ventilation: 15% of households
86% had visible soot lining the walls in
the cooking area.
Sanka Respiratory Symptoms
-Self Reported Respiratory Health:
Good - 37.2% of households rated their respiratory health as good
Fair- 55.8% of households rated their respiratory health as fair
Poor- 7% of households rated their respiratory health as poor
-The overall prevalence of smoking tobacco was 1.7%.
48
Beautiful Unspoiled Mountains
Sanitation
Pig
piggies
Trash
Sanitation and sewage
Trash Disposal:
Taken to ravine or the fields
Burning of trash, including plastics, either in the house yard or in the fields
Sewage:
Water taps without catch basins were observed spilling water throughout the
yard and into the public streets, carrying with it animal waste
Water in the streets generally muddied entire sections of the street, meaning
that villagers walking by necessarily walk through fecal matter dissolved in
water
Runoff
Hygiene
Self reported hygiene was good, but evidence was found
to the contrary:
Hand washing: 95% reported having had washed their hands the same day as the
interview.
Soap: 73% reported always using soap when washing their hands
However, only 55% of households were observed to have soap (mostly detergent)
Toothbrushing: 61% of houses were observed to have at least one toothbrush. The
village leaders report that almost none of the older adults brush their teeth.
Animals and Insects: Easy access of insects, animals and the elements to inside of
house.
-83% of houses had animals living indoors, in the kitchen area. (81% had guinea
pigs; 39% had cats; and 22% had chickens living indoors)
Kitchens: On a 3-rank score, 41% of kitchens were observer-ranked as “clean,”
with no noticeable food, trash or fecal matter on the floor. 9% of floors were
considered “very dirty.”
Latrines
LATRINES
Had a Latrine: 60%
Percent of Latrines that were functional: 55% -The most commonly cited reason
for non-functioning latrine was the lack of drainage or blockage of drainage
Percent of people with latrines that reported using them : 38%
Animals getting into latrines
Food stored in latrines
Bathing in latrines
Bathing
Means of Bathing:
With a Bucket - 40%
With a Hose - 40%
Location of Bathing:
Outdoors in their yards - 53%
In their latrine facilities - 33%
Frequency of Bathing:
More than 3-4 times a week - 0%
Once or Twice a Week - 64%
Barriers to bathing
Why not more bathing? (self-reported reasons)
Cold water
Lack of appropriate bathing facilities
Village leaders reported that soap was an expensive
commodity
Focus Group Data
Notable Health Concerns Raised during the Focus
Groups:
• 1) Fungus - Approximately 30% are estimated to be afflicted with a
fungus that primarily infects the skin of the face
• 2) TB - Tuberculosis has been reported in Sanka in the past.
According to the village leaders, there have been five reported cases of
tuberculosis.
• 3) Dental - Dental pain is reported to be a major problem
• 4) Urogenital- 90% of the women in the village suffer from urinary
and/or vaginal infections. To seek treatment, the women have to go to
Paruro, which means these problems are rarely treated.
• 5) Musculoskeletal
• 6) Headaches
59
Infant/maternal Health
Generally good pre- and post-partum/natal care:
Breastfeeding : 100% reported breastfeeding, with 81% reporting breastfeeding for
>12 months. Most breastfed for 2+ years.
Vaccinations are available for tuberculosis, hepatitis, influenza, tetanus, polio,
diphtheria, and rubella.
Late maternal age? Several instances of women having children over the age of
35. One case of cleft palate was noticed in a baby, born to an older woman
Alcohol and Pregnancy? Nurse reported two cases of babies being born with
alcohol-related birth defects
Pet Guinea Pigs
Guineasaurus Rex
Cuy- Nutrition
Nutrition
• Few meats were reported as being a typical part of the diet.
• Primary foods grown in the fields:
–Corn
–Potatoes
–Wheat
–Beans
• Anemia problem?
• Protein/ Other Vitamin deficiencies?
63
Sanka Girl’s Height Charts vs.
WHO standard
64
Sanka Girl’s Weight Charts vs.
WHO standard
65
Sanka Boy’s Height Charts vs.
WHO standard
66
Sanka Boy’s Weight Charts vs.
WHO standard
67
Water Filters
Filtered water in araypallpa
Comparison of:
Araypallpa Filtered side of Village vs. Unfiltered
side of Village
Araypallpa Filtered and Unfiltered vs. Sanka
Unfiltered
- Caveat -- Potential mixing of water via a valve,
however, bacterial coliform tests for filtered water
was negative
Diarrhea in Sanka vs.
araypallpa
Diarrhea rate in Sanka (unfiltered water) - 5.8%
Diarrhea rate in Araypallpa (combined unfiltered and filtered) 5.7%.
Diarrhea rate in Araypallpa (Filtered water) - 2.9%
Filtered Araypallpa was not significantly different vs. Unfiltered
Sanka (chi-square, p=.494))
Araypallpa Filtered vs.
unfiltered
Diarrhea in part of Araypallpa receiving Unfiltered water- 11.8% (n=2/17)
Diarrhea in part of Araypallpa receiving Filtered water - 2.8% (n=1/35)
This difference was not statistically significant (chi-square, p=0.196)
Stomach pain As indicator
Stomach Pain in part of Araypallpa receiving Filtered water- 42% (n=13/31)
Stomach Pain in part of Araypallpa receiving Unfiltered water - 18% (n=3/17)
Higher rate of reported stomach pain in the filtered households?
This correlation approached statistical significance (chi-square, p=0.088), but has
no obvious logical basis.
Parasites as Indicator
Parasite Prevalence in Araypallpa (Filtered and Unfiltered)
children - 91%
Parasite Prevalence in Sanka (Unfiltered) children - 90%
On average, the stool samples in Araypallpa (Filtered and
Unfiltered) contained higher loads of parasites than Sanka
(Unfiltered)
Parasites Found in Stool
Iodamoeba butschlii
Entamoeba coli
Chilomastix mesnili
Giardia Lamblia
Hymenolepis nana
Endolimax nana
Blastocystis hominis
Balantidium coli
-Non-Fresh samples,
Anti-Helminthic medication use
Conclusion
Cleaning the water did not appear to significantly
reduce diarrhea, stomach pain or parasite
prevalence. This is likely due to the existence of
other potential routes of pathogenic entry combined
with impaired villager immunity due to poor
nutrition.
It is possible that water filtration as a solitary
intervention is insufficient.
Future
Longitudinal surveillance
Solar showers planned for 2009
Cooperation with Baylor Medical Students
Importance of Collaboration
Our ability to contribute to EWB’s mission goals
What we can learn from the Engineers about
sustainable growth and engineering/infrastructural
solutions to health problems
Collaboration with other disciplines, ie. Agriculture
and Nutrition, Economics and Socioeconomics