While medical anthropology has contributed to a significant and recognized portion of the literature on behaviors and beliefs associated with water-borne diseases, anthropologists have also begun to study the relationship between water scarcity and water insecurity and the intransigence of certain water-borne diseases such as endemic cholera. Following the 1991 cholera epidemic that swept across northern South America, massive public health aid controlled the epidemic in most of the urban areas. However, outbreaks continued to occur in the rural areas where cholera was endemic. Caused in part by lack of access to a constant source of clean water, water insecurity caused people to use their limited water for multiple uses—some of which were counter-indicated in the elimination of the Vibrio cholerae pathogen. Anthropological studies demonstrated that families who raised pigs, for instance, were reluctant to use soap (an intervention recommended by public health authorities) to wash their hands because the wastewater was used as slop for the pigs, and the pigs refused the slops with soap in the water. Traditional cultural practices and land tenure patterns were also identified through anthropological research as implicated in the spread or re-introduction of cholera in indigenous communities. Land use and ownership practices caused thousands of people to migrate to urban and often coastal cities to find employment. During peak periods in the calendar of traditional obligations when urban migrants returned to their rural communities and shared festival drinks from common bowls and water sources, cholera was spread. The same anthropological techniques applied to an analysis of the behavioral consequences of water insecurity provide some unexpected insights into water-washed and water-borne disease transmission.
Water insecurity, like food insecurity, results when people do not have access to a reliable water supply. While the underlying causes for the lack of a reliable water supply may be due to a wide variety of factors, it results in behaviors to conserve water through multiple means, such as water storage, re-use, and a hierarchy of use often placing personal hygiene activities such as hand-washing at the bottom of the scale (Cairncross & Kinnear, 1992; Esrey & Habicht, 1986; Whiteford, 1999). Patterns of water storage in the Dominican Republic due to water insecurity have been implicated in the increased rates of dengue fever (Whiteford, 1999), while Starkloff (1998) showed that in a village in Sri Lanka families were dependent on river water polluted with feces and pesticides during extended dry periods. Trachoma, another water-borne disease (sometimes referred to as "river blindness"), is also associated with water scarcity. When people must conserve water or travel considerable distances to obtain water they are less likely to use it for activities that are not economically productive—such as face or hand washing. And yet, according to public health officials, the easiest and most effective intervention against trachoma is to wash away the larvae deposited on the skin around the eyes (West et al., 1989).
The relationship between personal hygiene and enteric diseases such as diarrhea have long been noted by public health officials. However, in a 1998 study on cultural responses to water shortage among Palestinians in Jordan, Arar (1998) documented that as the availability of water was reduced and with it the frequency of personal hygiene behaviors (such as hand-washing and bathing), increased levels of diarrhea were noted. Lack of access to a reliable source of water impacts what people eat and may also affect the amount they eat, since water is a basic component for cooking many foods such as rice or beans. The cost of water, either in the formal or informal economy, can also influence patterns of water usage. In marginalized peri-urban neighborhoods in Guayaquil, Ecuador, where the public infrastructure to provide water did not extend, people paid an informal network of water trucks to deliver their water. The cost for one month of water delivery exceeded the government minimum wage covering the same period of time. Just paying for water could consume a wage-earner's entire monthly salary—and that's assuming that he or she was paid the minimum wage and not less (Whiteford et al., 1993). When people pay more than they earn for water, they learn to conserve it in as many ways as they can, often at the expense of their health.
Water insecurity and its associated water-borne diseases are not equally distributed. As was mentioned above, the poor, living outside of the city services, are disproportionately affected, as are women and girls (Ahmed, Hoque, & Mahmud, 1998; Cairncross & Cliff,
1987; Starkloff, 1998; West et al., 1989). In many societies, women are the prime users of water. They cook and clean with water, as well as treat the sick or the infirm. They may also be responsible for the collection and storage of water (Whiteford & Coreil, 1997). Women in many parts of the world spend between 10 minutes and 2 hours daily collecting water; this translates into less time to spend on other household-related activities.
Water scarcity is implicated in the diminution of health status through a reduction in consumption of water, the energy expended in its collection and storage, the loss of time from other health-related and family hygiene activities, the reliance on contaminated water sources, the multiple household use of a single water source, and the sharing of water-borne diseases through that source.
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