An untapped resource: community based epidemiologists for environmental health

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1995 7: 219Environment and UrbanizationMay Yacoob and Linda M. Whiteford

An untapped resource: community based epidemiologists for environmental health

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Environment and Urbanization, Vol. 7, No. 1, April 1995 219

ENVIRONMENTAL HEALTH

An untapped resource:community basedepidemiologists forenvironmental health

May Yacoob and Linda M. Whiteford

SUMMARY: The following article promotes active communityparticipation whereby peri-urban neighbourhood residents moni-tor environmental health conditions. An effective and sustain-able community based environmental assessment and manage-ment programme relies on such participation. The authors sug-gest a combination of methodologies to incorporate communitymembers in the definition of their environment, the diagnosis oflocal health problems, the determination of appropriateremediation strategies, and the monitoring of environmentalhealth conditions in their community.

I. INTRODUCTION

ENVIRONMENTAL HEALTH CONDITIONS – and particularlythe health risks – of the peri-urban poor can be traced to thetransmission routes of pathogens in common, everyday activi-ties. Clues to disease transmission can be found by askingsuch simple questions as where do people sleep, what do theyeat and drink, and how do they dispose of their waste? Changesin these fundamental human behaviours can only be made atthe household and neighbourhood level as no national govern-ment or donor agency has sufficient resources to sustain theeffort required to change these conditions.

This article focuses on ways to develop effective and sustain-able community based environmental management to improvethe health status of peri-urban residents. The underlying as-sumptions are as follows:

• Disease is a biological condition. But it exists within a humanand social context.

• Community concerns and perceptions of disease risk are le-gitimate and should not be discounted.

• Members of the community and outside technical assistanceteams are committed to collaborative research and analysisto ensure that skills are developed locally at all levels.

Dr. May Yacoob is TechnicalDirector for Community Par-ticipation including social andbehavioural aspects of the En-vironmental Health Project,previously known as theWASH project. Dr. Yacoob hasworked with this project since1986. Dr. Linda Whiteford iscurrently an Associate Profes-sor of Anthropology at the Uni-versity of South Florida withover 15 years experience indealing with internationalhealth issues.

Address: EnvironmentalHealth Project, 1611 N KentStreet, Room 1001, ArlingtonVA 22209-2111, USA. Tel: (1)703 243 8200; fax: (1) 703 2439004.



220 Environment and Urbanization, Vol. 7, No. 1, April 1995

PARTICIPATORY APPROACHES

We will attempt to explain why local perceptions of the causesand prevention of disease are significant in any technical as-sistance programme aimed at reducing environmental healthrisks. (An example of local definition and treatment is given inBox 1). We believe that local residents are the best authoritieson local beliefs, behaviours and cultural practices; therefore,they should define, in collaboration with biomedically trainedpersonnel, environmental health problems and assist in thedevelopment of management plans. This article includes vari-ous methods available to incorporate local community mem-bers into the process. Drawing on field experiences, we will out-line the effectiveness of this approach and its contribution tosustainable programming at the community level.

Box 1: “La Diarrhée des Blancs” – “White People’sDiarrhoea”

A study conducted in Burkina Faso showed that mothersrecognized the term konobolí as “running stomach”, acondition they frequently saw in their children. Konobolíwas not regarded as an illness to be treated in itself butwas defined more often as a symptom from anotherillness. The classification of diseases with whichdiarrhoea was associated showed it to be related to theirlocally perceived causes. Some cases were attributed toa mother not giving her child proper care, or to a womanhaving sexual relations while pregnant, or other causessuch as cold weather during breast-feeding. Eachattributed cause produced a different type of diarrhoeaand, therefore, was treated differently. For instance,researchers found a new category of diarrhoea called ladiarrhée des blancs caused by worms or parasites. Itstreatment was always referred to the hospital.

Community knowledge is very useful in finding thelinkages between an illness and its causality, from thepoint of view of the person with the illness. Thosesuffering will feel they are understood, since localcommunity workers will recognize the attributed causes.In addition, the attribution of causality is frequentlyrelevant and can be used as an entry point for behaviourchange efforts.

SOURCE: Kanki B., V. Curtis and E. Traore (1991), “ From beliefto behaviour: diarrhoea and hygiene practices in Burkina Faso”,in draft, London School of Hygiene and Tropical Medicine, London.

The definition of an epidemiologist is an individual interestedin the occurrence of disease and its distribution in time, placeand persons. An epidemiologist looks at whether there has beenan increase or decrease in disease over the years, whether onegeographical area has a higher frequency of a disease than an-other, and whether the characteristics of persons with a par-ticular disease or condition are distinguishable.





This article uses the term “native epidemiologists” to meanthose individuals who are trained in the community rather thanin formal educational or public health institutions, or in na-tional ministries of health. As such, they provide communitybased data and expertise and serve as a conduit between thelocal community and the national and international biomedicalcommunity. The use of native or indigenous epidemiologists isproposed for two important reasons:

• Field-level activities of data collection and reporting are doneby people within the community.

• Epidemiological data helps to define the disease by under-standing the nature of illness from the point of view of thoseaffected by it. Understanding how people think of illness, wherethey believe it comes from, what they do about it, who mighttake care of the different symptomatic manifestations of theillness, and why people treat the symptoms the way they doare all important factors. Community based health surveil-lance is more accurate (than surveillance by “outside experts”because it comes from a foundation of local knowledge, expe-rience, and traditions.

One may wonder if it is naive or optimistic to expect sociallyand economically disenfranchised peri-urban dwellers to moni-tor epidemiological trends. Epidemiology, as a science, is viewedas being value-free and immune to the influence of special in-terests. Therefore, involving the public would undo the scien-tific process.(1)

Separation of the social and biomedical aspects of disease hasprevented technicians from seeking information from those whohave contracted a disease. Biomedically, disease is a biologicalfact, identified through tests and the knowledge of the practi-tioner. Medical knowledge has unfolded in a linear fashion to-wards a comprehensive and accurate understanding of reality.(2)

To illustrate the importance of belief in present day medicine,one might examine the treatment of malaria by health workers.The disease category of “fever” tends to be a very common symp-tom frequently treated with prophylaxes believed to cure thesymptom. Generally, in the South, whenever people presentthemselves to clinics or health posts with “fever”, a presumptivetreatment is provided and a blood sample is taken for verifica-tion. Yet, by the time the symptom is verified,the time lag canbe two weeks to one month or, as is usually the case in South-ern countries, the results for the test never show up. Duringthat time, the symptom of “fever” may have either been tempo-rarily cured, may be showing additional symptoms, or the indi-vidual may have died. Health providers rarely discuss withpatients the subtleties of the various symptoms causing feverfrom malaria versus that from other possible diseases. Fever isnot the disease but, in practice, it is treated as such. Whilefever is no doubt a metabolic disorder which involves complexbiochemical parameters, it often takes on a symbolic meaning.Dispensing chloroquine is an act of faith rather than a purelyscientific decision.(3)

3. Ramakrishna, J., W.R. Briegerand J.D. Adeniyi (1988-1989),“Treatment of malaria and febrileconvulsions: an educationaldiagnosis of Yoruba beliefs”,International Quarterly ofCommunity Health Education,Vol.9, No.4, pages 305-319.

1. Capra, F. (1982), The TurningPoint: Science, Society and theRising Culture, Fontana, London.

2. Jones, Kelvyne and MoonGraham (1987), Health, Diseaseand Society, Routledge KeganPaul, New York.





Experience to date has proved that the poor and the disen-franchised can be trained to monitor environmental health con-ditions. Mothers’ groups have been used to identify and reportthe number of cases of a disease to district level health offices.Guinea worm surveillance in very remote areas of Nigeria wascarried out by local chiefs.(4) These experiences attest to thefact that local people have a vested interest in, and deep knowl-edge of, their surroundings, allowing them to be effective com-munity surveillance workers.

Box 2: The Multi-factorial Nature of Disease

Notes taken from a focus group discussion held in thevillage of Ajagusi, once known as the “grandmother” ofguinea worm in Asa, provide the following views:

“When a mother is neat, good-looking, wears goodclothes, eats good food, does everything expectedof her, she looks healthier and has enough time tocater to the child, therefore the child, too, lookshealthier than before. We believe that we arehealthier than before because there is no guineaworm in our community.”

The mothers claimed that since the introduction of theborehole and the elimination of guinea worm, the timetaken to perform essential domestic and child-care tasksduring the dry season, which coincides with the guineaworm season, had been reduced from seven to three hoursa day. This left them more time to spend with theirchildren and to engage in economic activities.

Guinea worm disease among young mothers affects theirhealth and ability to care for their children. Althoughthe burden of child-care is spread over the network offamily and friends, the disease ultimately impoverishesthe whole community. The value of qualitative study isthat it reveals these linkages and the multi-factorialnature of the problem of endemic disease in a community.

SOURCE: Brieger, W.R. (1991), A Farm Market Based System forDetecting Guinea Worm Endemic Villages, dissertation submittedto the Department of International Health, School of Hygiene andPublic Health, The Johns Hopkins University, Baltimore, USA.

II. HOW DISEASE ETIOLOGY ENSURESPROCESSES FOR SUSTAINABLE ACTION

THE DANGER IN knowledge, attitude, practice (KAP) surveys isthe expectation of a specific response to a specific named condi-tion. Such surveys gloss over differences and, as a result, in-formation is lost. The bland and often artificially skewed infor-mation that remains all too often is what is used as baseline

4. Brieger, W.R. (1991), A FarmMarket Based System forDetecting Guinea WormEndemic Villages, dissertationsubmitted to the Department ofInternational Health, School ofHygiene and Public Health, TheJohns Hopkins University,Baltimore, USA.





data. The following example illustrates why it is useful to askquestions about local perceptions of symptoms rather than torely on general information gathered on an illness.(5)

Local knowledge identifies the appropriate institutions andpersonnel for behaviour change programmes. Sustainableenvironmental risk management programmes must include com-munity-level institutions and personnel that the communitytrusts. These traditional organizations are vital to a culture, yetgovernments and ministries of health do not necessarily directimplementing organizations towards them. By studying localknowledge, creating cognitive maps and relying on native epi-demiologists, one can identify where people would go to treatspecific symptoms. The first step is to interview the individualsthat people turn to for treatment and to identify community basedresources.

Women’s societies associated with birthing and child care, forexample, are usually a source of support and information. Some-times such organizations are secret societies. Because sorceryis common in tightly-knit village communities, institutions ofthe elders responsible for mediating with the supernatural areanother source. Religious entities also provide a range of serv-ices and are another important resource to learn local etiologies.These are some examples of valuable local resources. Localperceptions can identify appropriate traditional gender rolesfor health care and resource management.

III. IDENTIFYING THE MOST APPROPRIATENATIVE EPIDEMIOLOGISTS

a. Men and Women

BECAUSE THE ROLES men and women have in health careand illness prevention change during the course of their lives,age, as well as gender, is a significant variable in understandingand identifying decision makers and their choices. Patternsalso vary to reflect the culture, so it is important to learn who isresponsible for the household water, what household measuresare taken to prevent diseases in each area, and what remediesare used for each disease category.

Not considering the importance of locally perceived gender rolescan render technical assistance useless. In a study addressingthe problem of trachoma, one donor agency chose to focus ex-clusively on the women of the household in a particular com-munity. Their efforts did not change the community’s concep-tion or behaviour because, although it was the women whowashed the children’s faces (an activity that prevents trachoma),it was the men who decided whether or not this was to be done.(6)

b. Community Standing / Respect

When identifying epidemiologists at the community level, oneshould choose those with the greatest interest in, and responsi-bility for, the area. They might be mothers or other family mem-

5. Early, E.A. (1982), “The logicof well being: therapeuticnarratives in Cairo, Egypt”,Social Science and MedicineVol.16.

6. McCauley, Ann P., MathewLynch, Moses Pounds and SheilaWest (1990), “Changing wateruse patterns in a water-poor area:lessons for trachoma interventionproject”, Social Science andMedicine Vol.31, No.11, pages1233-1238.





bers whose children have died, are at risk, or are sick due toexposure to adverse environmental conditions. Such peopleemerge from within communities. As one begins, by holdingfocus group meetings, individuals emerge who tend to have moreinterest in specific conditions. Subsequent to the focus groupmeetings, in-depth interviews and observations with such indi-viduals can provide the beginning of training in local epidemiol-ogy. To cite an example, it would be a waste of resources totrain young girls who are unemployed to be those with primaryresponsibility for surveillance because they do not, as yet, havethe same degree of vested interest and experience as older womendo; nor would they have the standing. On the other hand, if oneof the primary sources of contamination of food is the marketplace, then vendors might be the best choice for native epide-miologists.

c. Impact of Illness

Learning locally based models of risk and disease etiologiesmakes it possible to map out how to sequence disease treat-ments, who should be the primary conduit for new information,and what the culturally appropriate ways would be to remedythe situation. For instance, one might ask which symptoms aretreated in the home, which by pharmacists, by the local healthunit, by a religious person, or by a hospital physician. As anexample, because women have fewer monetary resources, theymay be likely to use home remedies more often and for longerperiods than men. One might also find that people use differentstrategies depending on who is sick, how severe the illness is,and how dependent the family is on the sick person.(7) The per-ception of the environmental risk also varies, not only by cul-ture but by gender and socio-economic status as well.

Nationality, ethnicity and occupation also affect the ways inwhich people define illness. In one example, women working invarious positions in the peri-urban areas around Quito, Ecua-

Box 3: “A las Casadas no nos dan Oportunidades” –Married Women are not given Job Oppoortunities

Women from el Comite del Pueblo who had worked inindustry before they were married told of how, once theywere married, they were asked to leave their jobs. Thisis because industries rarely want the additional expenseof pre-natal and obstetric care. Because marriage doesnot eliminate a woman’s need for income, she is oftenforced into the informal and unregulated job market. “Lacasada tiene necesidades.” Women sell cosmetics,stockings, flowers and food on the street. They areexposed to the constant assault of dust and wind, totraffic if they sell on the side (or medians) of the road,and to thieves. “La vida de las mujeres es muy dura”they said, (“Women’s lives are very hard”).

7. Whiteford, Linda (1980),“Mexican-American women asinnovators” in Melville, M. (editor)(1980), Twice a Minority:Mexican-American Women,Mosby Press, St. Louis, Mo.USA, pages 109-128.





dor, complained of frequent chronic bladder infections.(8) NorthAmerican male physicians and biomedical health workers at-tributed this problem to the possibility of multiple sexual part-ners because of the women’s socio-economic group. When thewomen were interviewed, they provided a different insight.

Following their pregnancies, these women were forced out oftheir jobs. Their only alternative was to work in the informalsector where they could bring their children to work.(9) Becausethe markets and roadsides have no toilet facilities for women,they went all day without urinating which made them more vul-nerable to bladder infections.(10) Other sources have verifiedthat urinals and public toilets in markets are for men only. Inthis case, the women could clearly articulate the factors sur-rounding their health problems but they did not have the meansto implement the remedy – a public latrine construction pro-gramme.(11) The biomedical community needed the personalaccounts of the women themselves – their social and economicconditions – to analyze and address the problem.

Once the symptoms are matched to a disease, the behaviourspeople describe as the cause then need to be investigated. Thisis best done through questioning and observation. Communi-ties in Bangladesh, for example, were surveyed regarding ill-nesses from “drinking water”. Most people responded that theyonly used hand pumped water for drinking. Observation, how-ever, showed that they used contaminated water for cooking,washing vegetables and filling baby bottles, activities techni-cally not considered as “drinking” the water.(12)

Box 4: “La Vida misma Nos va Ensenando” –“Life Teaches Us”

“Life teaches us” said a woman whose husband is disabledwith Parkinson’s disease. She, and other women in elComite Del Pueblo, recounted their efforts to safeguardtheir families from accidents, disease and disability.Those without piped water buy used metal drums fromindustries and paint them with an anti-corrosive. Theyuse these drums to store their water for drinking,cleaning and washing. However, storage is the least oftheir water problems; acquiring the water is moredifficult. If one is fortunate and does not live too far offthe main street, the water tanker that drives throughthe community may come by. But the water is expensiveand not necessarily uncontaminated.

IV. TYPES OF DATA TO BE COLLECTED ANDMETHODOLOGIES TO BE USED

THERE ARE A number of contexts within which donor andimplementing agencies can use local perceptions and be-liefs to evaluate health risks. Community and neighbour-hood risk assessment studies show that although the presence

8. Whiteford, Linda (1993),“Women’s voices heard inEcuador health risk assess-ment”, Voices from the City,Peri-Urban News Vol.3., WASHProject, Arlington, USA, Sep-tember.

9. See reference 8.

10. Arcia, Gustavo, EugeneBrantly, Robert Hetes, BarryLevy, Clydette Powell, JoseSuarez, and Linda Whiteford(1993), Environmental HealthAssessment: A Case StudyConducted in the City of Quitoand the County of PedroMoncayo, Pichincha Province,Ecuador, WASH Field ReportNo.301, WASH Project,Arlington, USA.

11. MacCormack, Carol P.(1988), “Health and the socialpower of women,” Social Scienceand Medicine Vol.26.

12. Zeityln, S. and F. Islam(1991), “The use of soap andwater in two Bangladeshicommunities: implications fortransmission of diarrhea”,Reviews of Infectious DiseasesSupplement 4: S259-264.





of an actual health hazard increases risk, perception of the riskdoes not arise inevitably through a rational cost-benefit analy-sis.(13) Local beliefs and understanding of risk are couched withincultural, political and economic contexts. Peoples’ perceptionsof the diseases associated with those risks are also shaped bythe media and other factors, such as population movements.

One approach used in development projects is to strengthenthe capabilities of service managers of municipalities who servethe peri-urban poor. Often, service agencies focus on solid wastecollection, testing of market food and market sanitation, etc.Unfortunately, staff are not trained to carry on a dialogue withneighbourhood residents or to identify data from neighbourhoodsto determine the types of services people need at a particularpoint in time. To have a beneficial health impact, the delivery ofany services to the peri-urban poor requires an ability to listento the perceptions of illnesses of community people themselves.

Some diseases, such as cholera in Latin American countries,have become endemic. Whilst the primary transmission routeshave been identified, the disease (in this case cholera) has per-sisted. This persistence has called for an understanding of high-risk behaviour, for a defining of interventions that are specificto a neighbourhood, and for a monitoring of any changes in theprevalence of the disease before it becomes widespread.

To monitor the disease and collect data from communities,the following activities have helped initiate a dialogue with neigh-bourhoods:

1. Begin by identifying the community’s environmentalconditions: developing a community map illustrates the majorcommunity resources (such as water, garbage collection pointsand hospitals or clinics). It is useful to have community mem-bers locate additional sources affecting the environment (suchas dumps, markets, public toilets and bath houses).

Mapping is most effective when carried out with different com-munity groups such as women caretakers of households withyoung children, men, elders (male and female) and youth. Eachgroup, depending on the length of time in the community and

Box 5: “Son los Ninos que Sufren” – “It is theChildren who Suffer”

“It is the children who suffer” when the women mustleave them when they go to work. Women in Carapungodescribed leaving their children for the entire day whilethey worked as maids, laundresses or took care of otherchildren. Wives must help their husbands provide moneyfor the family - “Una mano lava la otra” (“one handwashes the other”) - and often this means that thechildren are left alone. Sometimes nine-year olds areresponsible for one-year and two-year olds. “When thenine-year old is in school, I take the babies with mewhen I work selling in the street. When he is out ofschool, he watches them.”

13. See reference 10; alsoKottak C.P., and Costa A.C.“Ecological Awareness, Environ-mental Action, and InternationalConservation Strategy”, HumanOrganization Vol.52, No.4, pages335-343.





the resources it uses, will tend to identify various environmen-tal conditions. The creation of composite maps by various groupswill provide an inventory of all the resources. It will also providean opportunity for discussion across community groups.

2. Use government data on critical environmental risks,or epidemiological studies conducted by the technical team’smedical epidemiologist to describe the symptoms: commu-nity health providers can provide the local names for each ofthe symptoms identified. Although a biomedical term will beused to describe these symptoms, the local terms are more use-ful in discussions with community groups. Data collection inthe community to identify the prevalence rate should use thelocal names. The vernacular use of these terms will, in fact,facilitate the collection of data by community people. The com-munity or health workers can then locate where people withsuch symptoms live and work. This information is then verifiedby observation to determine the accuracy of symptoms to therelevant disease.

3. Cross-check the cause of the illness from the commu-nity’s point of view: the next step is to investigate the cause ofa disease by searching for associations between aspects of thephysical and social environment and the disease. This cross-check must include the community’s perceptions of the cause.Health workers can glean from community members’ views, whythe disease is occurring and under what conditions. The insightsgained from the community might lead to a different interven-tion than that determined by the biomedical community. Bothviews need to be understood, acknowledged and implementedin the process of defining and sequencing interventions.

4. Show a video of an illness to help elicit information:this method might be useful in cases resulting from industrialpollutants. For a number of reasons, it seems very hard forpeople to accept industrial pollutants as health risks. The pri-mary impact of industrial pollutants tends to be on the peri-urban poor who, in turn, depend for their livelihood on theseindustries. Because of this economic linkage, people frequentlydeny the impact of industrial pollutants. Furthermore, the dis-eases of industrial pollution are relatively new and unfamiliarto people. Identifying symptoms that people have not commonlymet before usually cannot be done through discussions alone.Videos can provide a better way of introducing the topic. Sincecommunities’ economic well-being is at stake (in addition tohealth), remedial/preventive actions need to be stressed, alongwith discussions with plant managers for the enforcement ofpreventive measures.

Again, in gathering data, surveys need to obtain from viewersthe local name for the illness and its perceived cause. Individu-als can note any cases they have seen and identify where thepeople live. It is particularly important to find out where peoplewould go to treat such illnesses, what they pay for treatments,and if the illness varies with the seasons.

5. Define environmental conditions and have the commu-nity describe the symptoms associated with each of theseconditions: the definition of environmental conditions associ-





ated with specific symptoms is not an easy or straightforwardtask. It is a complex step that requires negotiation between thescientific community and governments on the one side andneighbourhoods and communities on the other. The best casescenario is one in which varying peoples’ outrage at specifichigh-risk health conditions coincide. This scenario, however,does not always occur.

In a case in Ecuador, community people were able to providethe behavioural explanation for high faecal contamination ofmarket food which, in turn, explained high rates of enteric dis-eases. In this example, the scientific community and marketwomen agreed on interventions that would reduce the incidenceof the disease. In other cases, the perceptions of environmentalrisk differ; the use of particular pottery for cooking, for exam-ple, is often not considered an environmental condition tied tohealth symptoms. A dialogue between health assessors andcommunity residents would bring about a better understand-ing of the relationship between practices and health status orrisk. In another example, two different methods for reducingthe incidence of diarrhoeal disease were used. The staff fromthe Ministry of Health and the ministry responsible for waterand sanitation determined that hand-washing was an impor-tant behaviour to promote. When ministry staff observed dailyhousehold activities, they were appalled to find out that peopleused rainwater for drinking and, as part of routine hygiene be-haviour, emptied the rainwater containers every month andpainted them with lead based paint. The issue of lead-poison-ing was much more urgent than hand-washing. As a result ofthis information, teams from both ministries worked together tochange this behaviour, providing explanations for some of theneurological diseases found in the communities.

6. Outline the various symptoms; then ask individuals todescribe modes of transmission and associate the symptomswith its conditions: these two steps help to explain the areasof environmental conditions that people might attribute to thedisease. Most important here is that project staff and the com-munity learn from one another. Such a relationship is vital inestablishing that people’s knowledge and experiences are valid.

7. Track impacts: the traditional biomedical approach sug-gests that when causality is determined and interventions areimplemented, the result must be an improvement in health orenvironmental conditions. In reality, it rarely works this way.One possible reason is that people living in poverty are rarelyinterested in government statistics related to environmentalhealth conditions. The best indicators to use for health track-ing are those identified by community people themselves. Whatimpacts are tracked and how these indicators are used are twoimportant and inter-related issues.

As Box 2 shows, women care about contracting a disease thataffects their ability to make money in the marketplace and theirability to care for their children. Allowing people to define whatimpacts them the most will serve as a better motivator for change,first, because people are more likely to take action when thesituation is one they want to change, and second, because peo-





ple will be more willing to track monitoring indicators and willfeel responsible for achieving the anticipated results.

Behavioural indicators have also been used very effectively bycommunity people. In a rural water and sanitation project inGuatemala, high-risk behaviours were identified and pictorialrepresentation of those behaviours was agreed upon.(14) Com-munity representatives were appointed who used a checklist tomonitor households regarding these behaviours. These indica-tors were reviewed on a monthly basis by district/provincialstaff who, in turn, were able to focus their attention on the spe-cific households where healthy behaviours were not practised.This approach sought to address the specific reasons for cer-tain households’ inability to practice specific behaviours.

8. Negotiate an environmental health agenda: this processis not without risks. As communities become more involved inthe decision-making, the likelihood for conflicting views andpolitical agendas increases. People who manage donor projectshave to be not only technically competent but politically realis-tic because they deal in such grey areas. Decisions need to bebased on the interests and values of the people rather than dic-tated by politics.(15)

V. METHODOLOGICAL CONSIDERATIONS FORDEVELOPING COMMUNITY LEVEL CAPABILITIES

AS THE STEPS outlined above show, the public health commu-nity is recognizing the value of anthropological methods in study-ing behaviour related to communicable diseases. While suchmethods frequently have been used to describe disease relatedbeliefs and treatments, they have not been directly applied toepidemiological investigations.(16)

The study of the behavioural aspects of the transmission ofcommunicable diseases requires that the analytic and the de-scriptive units of behaviour be directly commensurate with thoseof epidemiology. At the very least, anthropological and epide-miological descriptions must refer to the same individuals atthe same time, period and place.(17)

Understanding local conceptions of disease etiology is an im-portant building-block in the development of behaviour changeprogrammes. To empower communities to make the changesneeded to improve their health, implementing agencies need tohave a clear understanding of the culture and how it defineshealth and illness, as well as identify those who traditionallyhave been responsible for this aspect of life.

Programmes to reduce the incidence of diarrhoea - the majorenvironmental health issue of the peri-urban poor - require thatpeople alter the way they do things, at times changing centu-ries-old ways of interacting with their environment.(18) Behav-iour change programmes encourage people to change some oftheir fundamental daily activities - the ways they sleep, eat,defecate or use and store common resources such as water.(19)

Unfortunately, hygiene education programmes often assumea point of view of narrow scientific cause and effect. For exam-

14. Brown L.D. and E. Hurtado(1992), Development of aBehavior-based MonitoringSystem for the Health EducationComponent of the Rural Waterand Health Project, CARE-Guatemala, WASH Field ReportNo.364, WASH Project,Arlington, Va., USA; also BrownL.D., E. Hurtado and S. Esrey(1993), Follow-on Assessment ofa Behavior-based MonitoringSystem for the Health EducationComponent of the Rural Waterand Health Project, WASH FieldReport No.385, WASH Project,Arlington, VA, USA.

15. Priscoli, Jerome D. (1993),“Public involvement: conflictmanagement and disputeresolution in water resources andenvironmental decision making”,Water Nepal Vol.3, No.2-3, pages43-57.

16. Zeitlyn, S. and F. Islam(1991), “The use of soap andwater in two Bangladeshcommunities: implications for thetransmission of diarrhea” inReviews of Infectious DiseasesSupplement 4: S259-64; see alsoBoot, M. and S. Cairncross(1993), Action Speaks ,International Reference Center,The Hague.

17. Jenkins C. (1990),Methodological Issues in theMeasurement of Hygiene andSanitation Related Behavior,Institute of Medical Research,Papua New Guinea.

18. Hardoy, J.E., D. Mitlin, andD. Satterthwaite (1992),Environmental Problems in ThirdWorld Cities, EarthscanPublications Ltd., London.

19. Whiteford, Linda (1994), “Theethnoecology of dengue fever”,Medical Anthropology Quarterly(in press).





ple, sanitation improvement programmes frequently advocatelatrine construction and handwashing. Thus, hygiene behav-iour programmes have often prescribed pre-determined prac-tices within predetermined structures.(20) Such practices proveineffective because they don’t reflect local knowledge. Rarely dobaseline studies focus on what people already practice or be-lieve. By taking this approach, implementing agencies misslearning why people are reluctant to adopt certain behaviours.

VI. CONCLUSION

ENVIRONMENTAL HEALTH CONDITIONS of the peri-urbanpoor can be traced to the transmission routes of pathogens deeplyembedded in such fundamental areas as where people sleepand what they eat and drink. No donor agency has sufficientresources to sustain the effort required to change these condi-tions. Therefore, community based actions, supported by re-sponsible public sector institutions, are critical in this process.This is especially true since behaviours vary from one city toanother and from one culture to another. Furthermore, aschanges in the patterns of epidemics have shown, the patho-gens, the host and its environment are constantly changing.The ultimate objective of developing the capability of commu-nity based epidemiologists is to build the capability at the locallevel to monitor these changes and seek the appropriate actionsin a timely manner.

In conclusion, native epidemiology has an important role incommunity based health risk assessment and management. Toincrease the participation and ownership of the community inmonitoring environmental health conditions, a community basedmethodology incorporates traditional epidemiological techniquesthat the local community practices. In other words, the knowl-edge and experience of community people are woven into thesurveillance of environmental health conditions.

20. Yacoob, M., B. Braddy, andL. Edwards (1992), RethinkingSanitation: Adding BehavioralChange to the Project Mix,WASH Technical Report No.72,WASH Project, Arlington, VA,USA.



An untapped resource: community based epidemiologists for environmental health

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