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Int. J. Hyg. Environ.-Health 208 (2005) 101–107 www.elsevier.de/ijheh
Community environmental health assessment strengthens environmental public health services in the Peruvian Amazon Brian Hubbarda,, Richard Geltinga, Virginia Bafﬁgob, John Sariskya a Centers for Disease Control and Prevention, National Center for Environmental Health, 4770 Buford Highway, NE, Mail Stop F-28, Atlanta, GA 30341-3724, USA b CARE Peru´, Urban Environmental Health Project, Lima, Peru
Abstract In December 1999, the Centers for Disease Control and Prevention (CDC) and the Cooperative for Assistance and Relief Everywhere, Peru Country Ofﬁce (CARE Peru), initiated the Urban Environmental Health Project (SAU, in Spanish) to strengthen environmental public health services in urban and periurban settlements in Peru. The project received funding from the Woodruff Foundation as part of the CARE-CDC Health Initiative (CCHI). The ‘‘Protocol for Assessing Community Excellence in Environmental Health’’ (PACE EH) guided the development of a community environmental public health assessment (CEHA) process in Cardozo, a settlement in Iquitos, Peru. The project developed a three-phase process that merged scientiﬁc understanding and community perception about local environmental health problems. In phase 1, local environmental health technicians assisted the community in understanding environmental health conditions in Cardozo and selecting priorities. During phase 2, local technicians assessed the community-selected priorities: water and sanitation. Results from recent water quality assessments revealed that 82% (9 of 11) of samples from shallow dug wells, 18% (2 of 11) from deeper drilled wells, and 61% (11/ 18) from household drinking containers were positive for thermotolerant coliforms. Phase 3 activities produced an action plan and an intervention to mitigate health problems associated with inadequate water and sanitation services in the Cardozo community. As a result of the CEHA process, CARE Peru obtained funding from the United States Agency for International Development (USAID) to develop and implement an environmental health risk monitoring system and the proposed water and sewage intervention in the settlement. CDC continues to provide technical assistance to the local environmental health services groups in Iquitos through an agreement with CARE Peru as part of the USAID-funded Urban Environmental Health Models Project (MUSA). Technical assistance activities and the development of the environmental health risk monitoring system have helped to strengthen the local environmental public health services delivery system. Published by Elsevier GmbH. Keywords: International environmental health; Community environmental health assessment; Global health; Community participation; Water and sanitation
Introduction Corresponding author. Tel.: ++7704887098;
fax: ++7704887310. E-mail address: [email protected]
(B. Hubbard). 1438-4639/$ - see front matter Published by Elsevier GmbH. doi:10.1016/j.ijheh.2005.01.010
In December 1999, the Centers for Disease Control and Prevention (CDC) and Cooperative for Assistance and Relief Everywhere in Peru (CARE Peru) launched
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the Urban Environmental Health (Salud Ambiental Urbana [SAU], in Spanish) Project. The SAU Project was one of seven CARE-CDC Health Initiative (CCHI) projects funded by the Woodruff Foundation of the United States. The objective of the SAU Project was to strengthen the capacity of the municipal government and public and private organizations to understand and resolve local environmental public health problems in selected urban and periurban Peruvian communities. Additionally, as in other successful models, the SAU Project sought to improve local environmental health services by increasing community collaboration in the identiﬁcation, prioritization, and resolution of environmental public health issues (Spengler and Falk, 2002). CDC provided technical assistance on assessing community environmental health problems in Cardozo to CARE Peru, and the regional environmental health and health directorates (DESA and DISA, respectively, in Spanish). CDC and CARE Peru used the ‘‘Protocol for Assessing Community Excellence in Environmental Health’’ (PACE EH) to guide the community environmental health assessment process. The development of this 13-task protocol was a cooperative effort between CDC, local environmental health practitioners and the National Association of County and City Health Ofﬁcials (NACCHO) in the United States. The PACE EH process assists environmental health agencies and communities build collaborative methods needed to understand and resolve environmental health issues (NACCHO, 2000). The implementation of the PACE EH methodology in Cardozo, Peru, was the ﬁrst application of this community environmental health assessment (CEHA) process outside the United States (Bafﬁgo et al., 2001).
Background Iquitos, the capital of the province of the Maynas located in northeastern Peru, rests at the conﬂuence of the Itaya and Amazon rivers in the Amazonian forest. In the Loreto region of Peru, 79% (377,304 of 477,601 people) of the provincial population lives in the city. Rapid urbanization in Iquitos has led to the establishment of settlements on the periphery of the city. Growth of settlements has been particularly rapid along the Iquitos–Nauta highway in the southernmost zone of the city. The settlement of Manuel Cardozo Davila, which lies in the districts of San Juan and Bele´n, borders the banks of the Itaya River. The population of the settlement is approximately 4750. Settlement residents suffer from overcrowding, poverty, and poor environmental conditions that affect human health. Needed sanitary infrastructure (water supply, wastewater disposal, solid-waste management) has not kept pace with
the growth around the city. In fact, connections to the municipal water and sewer systems do not exist in the human settlements. Although the settlement formed 25 ago, many residents still do not have legal title to the land on which they live. Poor and nonexistent environmental public health services typify the Manuel Cardozo Davila settlement. The water supply system consists of community ground water wells with elevated storage tanks and an undetermined number of shallow dug wells and private groundwater wells. Sewage ﬂows freely in the settlement streets, which are prone to ﬂooding from the tropical rains. Solid-waste collection services are erratic because of the mud-clogged streets that are impassable by larger trucks. Participatory processes in urban and periurban areas in Peru focusing on environmental health issues require a great deal of creativity. Most residents and their elected authorities or representatives do not perceive environmental health issues as a vital concern. This is not unique to Peru; beneﬁts from environmental health improvements are more subtle than direct monetary beneﬁts and are spread out over a number of people. Therefore, they do not immediately affect a person’s economic well-being in the short run. This attitude is even more pronounced among residents of periurban areas where the main priorities involve satisfying basic subsistence and housing needs. However, once environmental health issues are placed into a larger perspective for local residents through a process such as the one described here, those perceptions often are modiﬁed and environmental health becomes a priority.
Materials and methods: PACE EH community assessment To address the environmental health issues in the settlement and to create awareness of those issues, CARE Peru and CDC developed an assessment process using PACE EH. The objectives of the process were to
identify environmental public health problems, select environmental public health priorities, develop and initiate plans of action, and monitor performance of the project activities.
The assessment process endeavored to apply the 13 tasks recommended in the PACE EH guidebook (Table 1). The PACE EH methodology is ﬂexible and adaptable to different communities, environmental situations, and cultural settings. Likewise, the Peruvian application of PACE EH proved an adaptable process. Sometimes the order of the recommended tasks in PACE EH changed, or tasks were omitted. However, the SAU Project used the most appropriate and important tasks recommended in PACE EH to drive
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Recommended tasks of the PACE EH guidebooka
Task 1: Determine community capacity to undertake assessment Task 2: Deﬁne and characterize the community Task 3: Assemble community environmental health assessment team Task 4: Deﬁne goals of the assessment Task 5: Generate the environmental health issues list Task 6: Analyze issues with a systems framework Task 7: Develop appropriate community environmental health indicators Task 8: Select standardsb Task 9: Create environmental health issue proﬁles Task 10: Rank environmental health issues Task 11: Set priorities for action Task 12: Develop an action plan Task 13: Evaluate progress and plan for the future a
Available at http://www.naccho.org/GENERAL261.cfm Task 8 was not addressed in the Cardozo assessment process.
the assessment process forward. To accomplish objectives, the SAU Project implemented the PACE EH process in three separate phases: 1. needs assessment to prioritize environmental health issues, 2. focused assessment of community priorities, and 3. development and implementation of interventions and action plans. Phase 1 of the Peruvian PACE EH experience focused on the initial ﬁve tasks recommended in the PACE EH guidebook. In addition, this phase included a ranking of environmental priorities, task 10 in the PACE EH guidebook. SAU Project staff implemented activities to address the PACE EH tasks and to begin building local community collaboration. CARE Peru staff met with directors from the DISA and DESA and with representatives from the municipality to learn about the region’s social, demographic, historical, environmental, and health situation. After several site visits to settlements, CARE Peru and community leaders agreed to initiate assessment activities in Manuel Cardozo Davila. Criteria for selecting Manuel Cardozo Davila included
presence of an organized health center serving the greater southern zone of Iquitos, commitment of organized community groups to improve local conditions, selection of a site that illustrated the southern zone’s urbanization process, and capacity of local community groups to participate in a CEHA team.
After choosing the site, CARE Peru organized the CEHA team, known as the Inter-institutional Committee to Improve Environmental Health (CIIMSA in Spanish).
The development of the CIIMSA was a key element to promote project sustainability. Foundation of the CIIMSA provided for a synergistic process, where participants could share institutional strengths and place environmental health issues into their organization’s agendas. Early composition of the group included representatives from water committees (that manage community wells), the local school, sports clubs, community kitchens (that provide free meals to poor residents), and the local health center (CLAS Cardozo). Additionally, the CIIMSA included members from the greater community, such as the municipal government, DISA, DESA, the public water and sewer utility (SEDALORETO), and community leaders from adjacent settlements. As reported in other community participatory processes the effectiveness of the CIIMSA and internal unity increased through consensus building and shared work efforts (Borrazzo et al., 2003). Formation of the CIIMSA coincided with activities to deﬁne and characterize the community. The SAU Project conducted a broad-based needs assessment (Diagno´stico Amplio Participativo (DAP) in Spanish). Information from 12 key informant interviews, three focus group discussions, and disease data routinely collected and maintained by CLAS Cardozo provided an understanding of the environmental health situation from the local perspective. CARE Peru chose a project kick-off workshop as the forum to present local environmental health information to the community. Local ofﬁcials used the workshop to describe the urbanization process in the southern zone of the city. CARE Peru project staff presented qualitative information from DAP. Additionally, committee members learned about demographic, social, health, and economic factors from the CARE Peru staff (Rojas and Rojas, 2000). Presentations provided community members sufﬁcient information to generate an environmental health issues list. Discussion groups, consisting principally of community residents, deﬁned the scope of their environmental assessment. The result of the workshop was community consensus on the top three environmental health priorities for Manuel Cardozo Davila:
lack of safe water, lack of sewage system, and unpaved and poorly maintained streets, resulting in air quality impacts caused by the large amounts of dust generated.
Efforts to organize the community and assist in identifying priorities increased demand for environmental health services. The community organized around environmental health issues that municipal representatives, as well as community residents, agreed to resolve. Phase 2 project activities addressed PACE EH tasks 6–11. This phase focused on assessing the prioritized
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environmental health risks, the perceived needs of the residents, and the feasibility of technical solutions. The CDC technical assistance team utilized World Health Organization guidance documents to design instruments to assess sanitary procedures, water storage practices, and water system conditions that could adversely affect water quality and health (World Health Organization, 1997). CARE Peru and CDC staff worked closely with technicians in Cardozo to assess water supply and sewage disposal systems. This comprehensive systemsbased approach identiﬁed construction and operation and maintenance factors affecting water quality. These assessments addressed the question, ‘‘What are the contaminants of concern and how are residents being exposed?’’ The instruments focused on collecting information about the factors leading to exposure and identifying sources of contamination. The CIIMSA approved the SAU Project work proposals and began developing indicators of risk related to the local water supply and sewer systems. In October 2000, August 2001, and September 2003, DISA, DESA, and municipal technicians assessed the water systems used by the community and collected samples for microbiological analysis. Before these assessment activities, no water quality information existed about the settlement’s water supply systems, even though the settlement had existed for more than 20 years. Assessment activities focused on obtaining water quality data, promoting interaction among key environmental health service groups, and training on environmental health problem solving. Information collected at this stage of the assessment was a crucial ﬁrst step for the development of locally Table 2.
1. strengthen sustainability of the CIIMSA, 2. build capacity to implement successful environmental health projects, 3. promote environmental health awareness, 4. implement a water and sewage intervention, and 5. develop a monitoring and evaluation system to track environmental priorities and advances in their operational plans. The CIIMSA immediately sought activities to address goal 3 by raising environmental consciousness in the community. CIIMSA members worked with CARE Peru to organize an environmental health conference that addressed municipal environmental management and evaluation of environmental risks and effects on public health. Conference attendees included representatives from the provincial ministries of health and education, local municipality, and students from the local university. A second workshop, sponsored by the
Water quality results provided by Iquitos referential laboratory from Cardozo
Positive results for thermotolerant coliforms
Dug wells Drilled wells Water samples collected from household drinking water containers
appropriate indicators of risk for the water supply systems used by community members. Furthermore, information gathering proved to be the initial building block for developing a local environmental health risk monitoring system (Tables 2 and 3). Galvanizing the focus and vision of the CIIMSA group was the second major goal of phase 2 activities. CARE Peru worked with CIIMSA members to develop a strategic planning workshop. The aim of the workshop was to develop vision and mission statements. Moreover, the Manuel Cardozo Davila CIIMSA also developed ﬁve strategic objectives:
9/13 (69%) 1/11 (9%) 11/17 (65%)
9/11 (82%) 0/12 (0%) 11/18 (61%)
— 2/11 (18%) —
Locally appropriate indicators of the Cardozo water supply and distribution system
Conditions—April 2002 (n ¼ 1023)
Water cost Coverage
$1.25 per household per month 0% of households connected to the municipal system 67% of households located less than 200 m from a water source with potable water 23% of households have access to a water source that is available 24 h a day, 7 days a week; however, the quality is dubious 77% of households have access to an intermittent potable drinking water source 74% of households use water sources that comply with Iquitos Laboratory microbiologic standards 25% of households at or above the per capita quantity of water recommended by the World Health Organization
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National General Executive Directorate of Environmental Health (DIGESA in Spanish) provided training in food handling and hygiene to workers from local markets, community kitchens, and the municipality. In phase 3 of the CEHA process, CARE Peru constructed project proﬁles, which led to the development of intervention plans. Phase 3 efforts also focused on locating funding to implement interventions. The development of project interventions and the search for funding started earlier in the process, when CARE Peru addressed task 9 of the PACE EH guidebook (Task 9: Create environmental health issue proﬁles). However, as the SAU Project addressed later tasks in the PACE EH process, project intervention plans received increased attention. To develop intervention plans, CARE Peru reviewed the successful experiences of implementing condominial water and sewer systems in Brazil and Bolivia. Information on these World Bank supported water and sanitation project may be found at: http:// www.worldbank.org/watsan/waterweek2003/posters/ Poster15-ExpandingtheCondominialWSModelinLA. pdf. The condominial system offers an alternative to more expensive conventional systems by connecting homes in a series along branch lines rather than connecting each home individually to a main line. This not only reduces the length of needed pipelines, but also makes residents dependent on each other to monitor and care for the system. The primary connection point to the water main serves an entire block of houses instead of for each house individually. Maintenance of each block water supply line becomes the responsibility of the block residents rather than a centralized entity. Development of the proposed, ‘‘Condominial System for Water and Sewage in Manuel Cardozo Davila’’, relied on lessons learned from Brazil and Bolivia and from environmental health information from project proﬁles. The intervention plan addressed the CIIMSA’s fourth strategic goal by providing a comprehensive solution to the lack of safe water and sewer systems in the settlement. CARE Peru, acting as a consultant to the CIIMSA, presented the condominial plan to the Cardozo CIIMSA for approval. CARE Peru submitted a successful proposal in response to a request for application from the United States Agency for International Development (USAID) Peruvian Urban Environmental Health and Hygiene Behavior Activity. Based on lessons learned from the PACE EH process, CARE Peru proposed to replicate CEHA activities in other periurban areas of Peru. In addition, CARE Peru proposed to implement the ‘‘Condominial System for Water and Sewage in Manuel Cardozo Davila’’ intervention as a model pilot project. Since September 2001, CARE Peru’s USAID-funded Urban Environmental Health Models Project (MUSA in Spanish) has continued to work with the Cardozo CIIMSA implementing their strategic goals. In this
process, CARE Peru and other MUSA consortium members have served primarily as facilitators rather than as implementers.
Results: beneﬁts of community collaboration The PACE EH process is an iterative assessment activity. When necessary, communities may need to revisit tasks to build new coalitions, collect more data, or develop new action plans for remaining issues. Receiving the USAID Environmental Health Activity grant catalyzed efforts of CARE Peru and the Cardozo CIIMSA to strengthen local environmental health services in Iquitos, strategic objective two of the CIIMSA. Strengthening environmental health services included facilitating interaction among various disciplines to implement the chosen intervention. SEDALORETO, the municipality, DISA, and DESA assumed prominent roles as CIIMSA members to facilitate implementation of the ‘‘Condominial Water and Sewer Intervention’’. Focusing the efforts of organizations with responsibility to implement the intervention on the prioritized problems was signiﬁcant in moving the intervention forward. Additionally, building a wider coalition of groups to ﬁnance the intervention was necessary. Funders include the Peru–Ecuador Bi-national Commission, Loreto regional government, Maynas municipality, SEDALORETO, the government work program sponsored by the Ministry of Labor, and the Manuel Cardozo Davila residents. Local residents agreed to pay for the new services. Moreover, residents’ contributions included participation in the construction of the intervention, attending CIIMSA meetings, and volunteering to work on environmental health activities organized by the local health clinic. The collaborative process also improved measurement of actual local environmental health conditions. Because environmental health data for periurban areas rarely are disaggregated from urban data, improvements in health and environmental conditions are difﬁcult to monitor effectively in periurban areas, where circumstances are usually worse than the prescribed urban area (Moore et al., 2003). As part of the MUSA consortium, CDC scientists provided technical assistance to DISA and DESA technicians and the CIIMSA members to assess environmental concerns on the basis of community perceptions. Ongoing assessment activities yielded the information needed to build locally appropriate indicators that communicate the condition of the water supply systems (strategic objective 5 of the CIIMSA). The lack of a sewage system was the second environmental public health issue prioritized by the Cardozo CIIMSA. Assessment of the community system revealed 75% of households used latrines; 22%
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reported having bathrooms inside their dwellings’, and 3% used open ﬁelds. However, most latrines rested over abandoned dug wells and open sewage canals. Many of the household bathrooms discharged directly to the open sewer canals running through the settlement streets. Only 44% of households disposed of human waste appropriately. The Cardozo CIIMSA set as an original goal building capacity to track improvements in environmental health conditions. Community collaboration helped remove barriers, which previously hindered efforts of public health ofﬁcials to monitor improvements. Data collected on the water supply and sewage systems helped environmental technicians better understand problems and develop interventions. Environmental health services providers (Iquitos Laboratory, DESA, EPS Loreto, CLAS Cardozo, and DISA) who were overwhelmed now collaborate with stakeholders and community residents on demand-driven environmental public health issues. Public health ofﬁcials assumed a new leadership role that required development of new skills to work with the communities they serve. Redeﬁning the role of environmental leadership in Cardozo required environmental health services to increase focus on skills (such as community collaboration), training and environmental education.
Discussion: challenges The PACE EH process in Manuel Cardozo Davila followed a realistic and practical implementation period. The process moved at a tempo appropriate to the stakeholders’ commitment and relied on available resources. During assessment activities, political changes ushered in several new periods of public health leadership. Maintaining political support and awareness of the environmental assessment and accompanying intervention was vital to advancing the process. Despite these political changes, the CIIMSA and its members stayed focused on their chosen priorities, an outcome that probably would not have occurred without the CEHA process. This maintenance of focus kept the intervention moving forward despite transitions of political leadership. Nonetheless, the political instability in the region impeded the inclusion of the PACE EH process by the environmental health sector, a necessary condition for local sustainability. Replication of the PACE EH process in other areas in the southern zone of Iquitos will require ownership of the methodology by the DESA and the new coalition emerging from the current process. In addition, the current facilitator, CARE Peru, will have to focus on transferring the facilitator role to the local environmental health authorities.
Although the condominial system chosen for a water and sewer intervention was a less costly alternative, the technical aspects are complicated. Implementation of the intervention required the groups who provide environmental health services in the community to take a more prominent role. Thus, process ownership has shifted from local residents, raising fears the intervention is occurring without local control. In a new leadership role, the groups providing environmental health services must continue to work in partnership with community residents. To maintain trust and communication with local residents, environmental health service providers plan to work with voluntary promoters to implement the environmental health risk monitoring system. Working with community residents to develop monitoring activities will require new efforts to restructure the delivery of environmental health services. The CEHA process resulted in prioritization of community environmental health issues and demand for environmental health services to alleviate problems associated with those priorities. CEHA activities and goals set by the Cardozo CIIMSA caused environmental health leadership to seek new ways of interacting with the community. Increased participation by environmental health leadership brought more science-based information to the community in the form of sanitary survey results, microbiologic water analysis and reliable locally appropriate indicators to monitor progress. An essential outcome of the assessment process was the development of an environmental health planning process to drive decision-making about the Cardozo environmental health risk monitoring system. For the ﬁrst time, environmental health leaders from laboratory services, water and sewage utilities, health-care organizations, volunteer groups, and environmental health services met to operationalize an environmental health risk monitoring system. This system promotes the sharing of information so that responsible authorities will take appropriate corrective action. Increased community collaboration when identifying, prioritizing, and resolving environmental health issues have accelerated the provision of environmental health services in the Cardozo. Local environmental leadership and political authorities have emphasized that without the assessment process, the Cardozo settlement would not have received municipal water and sanitation services until at least 2020.
Acknowledgments The R.W. Woodruff Foundation through the CARECDC Health Initiative (CCHI) supported initial activities associated with the SAU Project. CCHI was a collaborative effort between the CDC and CARE International to improve global health. The USAID
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supports the continuation of activities through the MUSA project. The authors thank Jonathan Drewry, Association of Schools of Public Health Fellow, for his help with research and editing.
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