Health Implications of Poor Water Quality in the
Central Region of Ghana
Shannon Ronca ‘12
Department of Biological Sciences
Faculty Advisor: Alan B. Hale, Ph.D.
Thesis submitted in partial fulfillment of the requirements for the
Global Diseases minor.
Table of Contents
Acknowledgements
3
Abstract
4
Introduction
Overview
Cultural Experience: Global Water Brigades
6
7
Ghana
Geography, Economy, and Government
Health and Living Status
14
16
The Central Region
Overview
Economy
The People
Education
Health and Water
17
18
18
20
20
Water-related Diseases in Ghana
Causes of Water-related Diseases
Water-Borne
Sanitation Related
Vector-Borne
23
23
25
26
Recent Successes
Eradication of Dracunculiasis
Trachoma Control
29
29
Implemented Solutions
Community Solutions
Government Solutions
Nongovernment Solutions
30
30
31
A Personal Plan of Action to Mitigate the Impact of Disease in Ghana
32
Literature Cited
35
2
Acknowledgements
I would like to thank Dr. Alan Hale for providing the opportunity to pursue the Global
Diseases minor and for facilitating my trip to Ghana. I would like to thank Global Brigades for
the valuable learning experience that I had while in Ghana, specifically Orion Haas and Rebecca
Stebbins for their guidance and support during the water project and Penn State’s Global Water
Brigades Chapter for allowing me to join their Brigade. I would like to thank Dr. Jenny
Weatherford and the Office of Global Initiatives and International Programs at Cedar Crest
College for the scholarship that helped to fund my trip to Ghana.
3
Abstract
Clean water is a privilege often taken for granted in developed countries. Four percent of
the world’s global disease burden could be reduced by providing access to clean water. Clean
water is often inaccessible to rural communities, especially in the developing nations. Ghana, a
sub-Saharan African country, is one of many countries whose people suffer the negative effects
of unclean water. The Ghanaian disease burden due to unclean or stagnant water includes a
variety of diseases, such as water-borne diseases, sanitation related diseases, and vector-borne
diseases. This paper serves to discuss the three types of water related diseases and transmission
and prevention of these helminths, protozoa, bacteria, and viruses that cause the diseases.
Current solutions developed by the community, the government, and nongovernment
organizations are also discussed. Community solutions include the use of aluminum sulfate, a
compound that is used during the water treatment process, and the use of cloth to strain dirt from
the water. Some community members also boil their water, but this is not a common practice.
The government’s current solution is to provide public toilets and add more water treatment
facilities within the region, but these projects will take time. In addition, recommendations are
made to combine all of these solutions and provide a long-term goal to dramatically lessen or
eliminate the burden of these diseases in the country. The proposed solution requires three steps:
1) education about water-related diseases and sustainable, preventative solutions, 2) construction
of rain water harvesting systems, public toilets, and water treatment facilities with the help of the
community, and 3) form a committee within the community that will help to maintain the
construction projects that have been built to improve the community’s health. These three steps
require the cooperation of the community, the government, and nongovernment
4
organizations/volunteers to lead to a successful, sustainable solution that will benefit the
communities for future years.
5
Introduction
Overview
Four percent of the global disease burden is due to a lack of access to clean water (1). A
range of diseases caused by helminths (parasitic worms), protozoa, bacteria, and viruses are
spread directly through contact with contaminated water. Many of these diseases are related to
the gastrointestinal tract and can be propagated through the home. The disease burden from
contaminated water spreads beyond those transmitted directly through the water. Vector-borne
diseases, specifically those transmitted via the bite of an infected mosquito, have been shown to
be more prevalent in areas with stagnant water (2). Contaminated water can also account for
many hygiene related diseases, such as ringworm, since community members are not provided
with suitable sanitary conditions.
Ghana is one of many developing countries with communities that suffer from the effects
of contaminated water. Although the country has multiple water treatment plants, the plants do
not reach all communities and many Ghanaians are left with no access to clean water. The
Central Region, one of the more rural regions in Ghana, is one of the more problematic regions
in terms of water-related diseases due to its rural nature (3). Programs through the Ghanaian
government, the World Health Organization (WHO), and nongovernment organizations continue
to address these problems and create solutions to prevent these water-related diseases and they
have already succeeded in eradicating one water-borne helminth in Ghana. Current and future
development projects address the lack of sanitation through more water treatment plants and the
use of rain water harvesting systems.
6
Cultural Experience: Global Water Brigades
I was first exposed to these problems in the Central region of Ghana during a trip with
Global Water Brigades (GWB), a student-led nongovernment organization dedicated to
providing clean water to rural communities. Upon our arrival in Accra, Ghana, we were greeted
by program coordinators, mosquitoes, and a four hour bus ride to Weda Lodge in Anomabo,
where we would be staying for the next ten days. We were given very few details about the
project and were told that we would get to see the communities that GWB works with the next
day.
The next day we were taken to Mankessim, where we were given a tour of the
Mankessim and District Water Supply Water Treatment Plant. It had been built by a Swedish
company a few years earlier and serves the larger towns in the Central region, including the
lodge we were staying at in Anomabo. Although the plant seemed fairly large, it had one
laboratory for water testing. The lab used for testing water looked very similar to a traditional
American kitchen, with very little space for testing. Currently, they are not able to test for
specific types of bacterial growth as it is “not in their budget”. Even with the small lab, the
treatment plant is able to provide clean, safe water to households in the Mfantsiman District. It
made me wonder what caused this region’s water problems, but that question proved to be
irrelevant by the end of the day.
From the treatment facility, we went to visit three communities that GWB works with
throughout the Ekumfi area. Each community member greeted us with smiles, although most of
them lived in less than ideal conditions. The pipe-borne water does not make it to these
communities, and the community members are required to walk as far as five miles to retrieve
water for their families. Their water sources are unsanitary mud holes and rivers where
7
community members also swim, bathe, and defecate. While in each community, we took water
samples from their water sources to test the quality of the water.
The next day we were introduced to Egyankwa, the community that we would be
working in. Egyankwa is a community with about 400 people, where approximately 8 people
live per household. The majority of the households are single rooms, and few homes other than
the church in town have electricity. Upon our arrival, we were greeted about a mile away from
the community by a band of drummers and a large portion of the community. We were asked to
get off the bus and dance with them down to the community, where the opening ceremony would
then begin. We all danced with children attached to our hands, not realizing that the opening
ceremony would include even more dancing. Once we arrived in the community, we were
greeted by an open space and large speakers which were blaring Ghanaian hip life music, a genre
that is very similar to American hip hop and rap. Nana Asamoah, the country director for Global
Brigades, translated an opening speech by the community leaders, welcoming us to their
community and thanking us for the work that we would do. However, before we were allowed to
start any work, we had to judge and five of my peers had to take part in the dance competitions.
Dancing is an integral part of their community. The dance competitions are done within
different age groups of the young children, and the winner is rewarded with money that helps
pay for the child to go to school. Four or five children would line up, the music would start, and
they would dance for almost the entirety of a song. Various age groups performed, and then the
community informed us that it was our turn to participate. Although I did not take part in the
competition, I enjoyed watching five of my new friends try to imitate the dance moves that the
children and teens had done.
8
At the close of the ceremony we were paired with interpreters, Ghanaian high school and
college students, so that we could go door to door to determine the needs of the community
members and see the water source of this community (Figure 1). Although the official language
of Ghana is English, most of the smaller communities speak an Akan (Ah-kan) language. This
community, except for the well-educated and current school children, can speak only Fante
(Fahn-tea), which is one of the Akan languages. Through our door to door visits, we were able to
determine that some of the community members felt that their water made them sick, while
others weren’t sure if their illnesses were from the water or from something else. We also
determined that this was a very tight knit community and that they hoped to have a rain water
system like the local school had, but they wanted the system to be attached to a community
center for all members to share.
Figure 1: Egyankwa’s Water Source. Source: personal photo
taken December 28, 2011.
9
That evening back at Weda Lodge we discussed our options. Coming into the project, we
knew that we would be building a rain water harvesting system. However, we did not know how
much planning we would be doing. We determined that the community should receive their
community center, and a construction team was formed. This team was in charge of building the
community structure and the structure that would hold the polytanks, which are part of the rain
water harvesting system. Rain water harvesting systems are very basic; large tanks, called
polytanks, are hooked up to piping on a roof. When it rains, the first amount of rain water is
collected in a separate, small compartment to remove dirt and bird droppings from the roof, but
the rest of the rain water is filtered into the large polytanks. A water spigot is attached to the
polytanks, which is used to distribute the water.
It was clear to us that the community members needed more than just construction. The
rest of us split into three groups: sustainability, education, and water quality. Sustainability was
in charge of working with the Water Council, the group of community elders who would be in
charge of keeping the system running once we left. Education was dedicated to finding ways to
teach the community about the types of diseases that are found in water, the symptoms, and how
to prevent these diseases. These preventative measures included buying buckets with lids and
spigots to help keep clean water clean and selling the buckets to the community at a subsidized
price. The water quality group tested the water samples from the other communities and this
community to determine what kinds of things were in the water. Bacteria were present in all
water samples except for the pipe-borne water collected from the water treatment plant, but they
were unable to determine which type of bacteria were present. After finding this information, the
water quality group paired with the education group to help with the distribution of the buckets.
10
Over the course of the next eight days, we worked hard to implement our plans. As part
of the sustainability crew, I was able to help with the planning of maintaining the water system.
One problem we encountered was that rain water harvesting systems are only useful when it
rains. Since this part of the region can go for four months without rain, those tanks could be
empty for long periods of time, forcing the community members to go back to their unsanitary
water source. With the help of the Global Brigades coordinators, we were able to find a tanker
company that would be willing to drive to the community to deliver pipe-borne water into the
polytanks during the dry season. Our next problem: money. The community decided that they
would sell the water collected in the polytanks so that they could pay for the tanker that would
distribute the water. They also decided that, even when the tanks were filled with rain water, they
would sell the water for a reduced price agreed upon by the entire community to help build their
community development fund. Sustainability was a success.
Figure 2: Educating the Community. Right: Teaching the community how to properly store their water.
The poster displays a container with a lid to prevent mosquitoes away. Left: A sign explaining the
symptoms associated with water-related sieases. Source: personal photos taken January 2012.
11
Education was also a success. Over a course of three days they educated every household
about the symptoms of water-related diseases and how to prevent them (Figure 2). Over half the
members in the community purchased buckets to store the water that would come from the new
water system.
Of course, the project would not be complete without the success of the construction
team. The finished community center gave the community a new place to gather and celebrate,
and also contained a clean roof to collect the rain water from (Figure 3). The project was
rewarding, and the closing ceremony was even better than the opening ceremony.
Figure 3: Egyankwa Water System and Community Center. Left: Attaching the roof to the almost
complete community center. Top right: GWB posing with some of the community members in
front of the completed project. Bottom right: Rain water harvesting system polytanks after
completion. The ribbon is tied for the dedication ceremony to occur. Source: personal photos
from January 2012.
12
The closing ceremony consisted of the same dance competitions, and the dedication of
the water system was incredible. Regional government officials were there to help dedicate the
system, and promised to provide the community with public toilets in the next few years (Figure
4).
Figure 4: Closing Ceremony. Local government officials and community members gather to
dedicate the new water system. Source: personal photo taken January 2012.
Overall, the experience was as educational as it was rewarding, but the experience does
not start and end with the community. While there, I suffered from one of the diseases that are
common to the area. Exactly seven days after our arrival I experienced chills, a low fever, and
dizziness. After seeing the doctors associated with Global Medical Brigades, I was treated for
malaria. I was incredibly fortunate to have received the treatment that I did as early as I did, but
most Ghanaians are not as fortunate.
13
Ghana
Geography, Economy, Government
Located in Western, sub-Saharan Africa, Ghana is a former colony of the United
Kingdom that shares its borders with Togo, Cote d’ Ivoire, Burkina Faso, and the Atlantic
Ocean. Ghana gained its independence in 1957, after which the country suffered through
multiple coups before developing a stable constitutional democracy in 1992 (4). The country
maintained English as the official language, although many traditional dialects, such as Akan
languages, are still more widely spoken. With a population of approximately 24 million people,
Ghana is a peaceful country with a variety of religious and ethnic groups. According to United
State’s Failed State Index, Ghana is one of the least failed states in Africa (5). The Failed State
Index ranks countries based on social, economical, and political aspects. The more problems the
country faces with those aspects, the more of a “failed state” the country is considered.
The Ghanaian legal system is very similar to British Common Law, but with regional
tribunal elements. The country is considered a constitutional democracy that is governed by the
Chief of State/Head of Government, President John Evans Atta Mills, and Vice President John
Dramani Mahama. Like in the United States, Presidential elections are held every four years and
the president is only permitted to govern for two consecutive terms before he is required to step
down. However, unlike in America, the President and Vice President are elected through popular
vote and Ghana has seven political parties (3). The voting age in Ghana is the same as in the
U.S., so all persons 18 and older are eligible to vote (4).
Ghana has one of the highest Gross Domestic Product (GDP) per capita of the African
countries and ranks second in GDP growth for 2011. However, the country has a 5.4% budget
deficit and 28.5% of the population lives below the poverty line. There is an 11% unemployment
14
rate. The economy is mainly based on revenues from agriculture, gold, and oil (4). The majority
of the country’s electricity comes from the Akosombo Hydroelectric Dam on Lake Volta, the
world’s largest man-made lake. This power source is powerful enough that it is able to provide
power to neighboring countries.
There are ten administrative regions that comprise Ghana: Ashanti, Brong-Ahafo,
Central, Eastern, Greater Accra, Northern, Upper East, Upper West, Volta, and Western (Figure
5). These regions can be compared to the separate states that make up the United States, with
each region having its own smaller governmental branches. These regions can be divided into
smaller districts, which include many cities, towns, and villages, but the focus of this paper is on
the administrative regions and only those within the Central Region since that is where I visited
and learned of the water crisis.
Figure 5. Map of the Regions of Ghana. Source:
http://www.ezilon.com/maps/africa/ghanamaps.html
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Health and Living Status
The mean life expectancy of Ghanaians is about 63 years of age, which is ten years
higher than the life expectancy of the rest of the African region. However, the healthy life
expectancy of Ghanaians is only 49 years of age, which means that Ghanaians will spend at least
14 years of life suffering from disease or injury (6). The infant mortality rate is 51.3/1000 births
(3). According to the World Health Organization (WHO), approximately 260,000-300,000
people are infected with HIV and there have been 24,000 deaths related to HIV/AIDS (7). The
rate of immunization of children is 80%, which is 15% more than the other African nations. This
information on the Central Region will be addressed in more detail below.
16
The Central Region
Overview
The Central Region is comprised of seventeen districts: Abura/Asebu/Kwamankese,
Agona East, Agona West Municipal, Asikuma/Odoben/Brakwa, Assin North Municipal, Assin
South, Awutu-Senya, Cape Coast Metropolitan, Effutu Municipal, Gomoa East, Gomoa West,
Komenda/Edina/Eguafo/Abirem Municipal, Mfantsiman Municipal, Twifo/Heman/Lower
Denkyira, Upper Denkyira East, and Upper Denkyira West (3) (Figure 6). The Central Region is
primarily rural, although Cape Coast, Awutu, and Agona, are becoming more urbanized. This
region lies on the equator and has a tropical climate. Rainfall is common from May-June and
September-October, but droughts can occur for months at a time between December-February.
Figure 6: Map of the Districts of the Central Region. Source:
http://en.wikipedia.org/wiki/File:Central_Ghana_districts.png
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Economy
For the entire region, the unemployment rate is 8%, which is lower than the national
average. However, in the Mfantsiman district, where Egyankwa is located, the unemployment
rate is 14.6%, which is higher than the national average. Agriculture, which includes fishing, is
the predominant form of income for the population in this district, with manufacturing being the
second form. Pineapple and grain production are the most common products in the Mfanstiman
district. Sales workers are often found in the Mfanstiman district, with more females than males
being involved in sales (8).
The People
The population of the region is 1.6 million people, making it the most densely populated
region in Ghana. There are more females than males. The region is predominantly made of Akan
(pronounced “ah-kahn”) people, with the most prominent Akan group being the Fantes. Akans
speak a dialect of the Akan language, two of which are Fante (pronounced “fahn-tea” and Twi
(pronounced “tree”). The people name their children based on the day of the week that they were
born, with seven traditional male names and seven traditional female names. The traditional male
names (Monday-Sunday) are Komnan, Kweben, Kweku, Yaw, Kofi, Kwame, and Kwesi. The
traditional female names (Monday-Sunday) are Adwoa, Abena, Ekua, Yaa, Efua, Ama and Esi.
However, many of the Akan women adopt English names, with the most common being Alberta.
Akan people trace their lineage through the maternal side and live in extended family
households, especially in the rural districts of the Central Region. Although the Akan have
maintained many traditional aspects, religion is not one. Most of the population in the region is
Christian/Catholic, or Muslim (8).
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Most houses in the region have only one room which serves as both a living area and a
bedroom. This design is considered overcrowding by international standpoints and contribute to
the spread of disease in the household. Most house walls are made from mud, brick, and wood,
whereas floors are of concrete, and roofs are made from corrugated metal sheets (8).
Dancing is a common form of entertainment, celebration, and ceremony for the Akan
people. There are traditional dances based upon the myth of the man who was kidnapped by
gnomes, where the dancers are ducking and jumping to escape. These types of dances are done to
traditional Ghanaian music played only with drums and vocals. Dances are done in a ring and the
movement represents the story that is being told. There is a lot of freedom in the movement and
there is no set dance leader. The movement is dependent on the people and more interesting
movements are seen in smaller dance rings (9).
There are two main styles of music popular in the region today; Ghanaian highlife and
hip life. Highlife was developed during World War II and is derived from American jazz and
swing. Hip life started in the 1990s and is hip hop with background elements of highlife. Hip life
is predominately produced by the Akan people. Traditional music is related to traditional naming
practices and other cultural aspects of the Akan people (10).
Traditional foods include those made from cassava and plantains, with a popular dish of
pounded cassava and plantains called fufu. Rice and beans is another common dish. Fish and
goat are the main meat staples in the region. Traditionally, all households have a specific area
designated for cooking and the creation of meals is a family affair (8).
19
Education
Only 57% of the population in the region is literate, and includes more males than
females (70% males versus 46% female). Of those literate, 37% are literate in English and a
Ghanaian language, while the rest are literate in English only (8).
The region has 1,207 primary schools, 856 junior secondary schools, and 49 senior
secondary schools, but one-third of the region’s population has never been to school, with more
females than males being left uneducated. Half of the region’s population has completed primary
or middle school education. Individuals making up less than 6% of the population have received
a secondary school education, with only 3% of the population having attended one of the two
colleges in the region (8). Due to the low number of senior secondary schools, students are
required to travel far distances and sometimes live in other districts to attend school. This often
requires funds that the families are not able to provide.
Health and Water
The region has 17 hospitals, 54 clinics, and 57 health posts. There are 76 doctors in the
region, which represents only 4% of the total number of doctors in the entire country. The
traditional healer, an individual who uses herbs and local traditions to try and improve the lives
of the community members, is very important in the areas where hospitals and doctors are not
easily accessible (8).
Most households do not have a private toilet. Instead, a water closet, a pit latrine, or a
bucket are used in the household for collecting bodily excretions. Some communities have a
public toilet, which is a concrete structure with a hole. One fifth of the communities do not have
any toilet facilities and thus people use the bushes, fields, beach, or water source. Bathing
20
facilities are also scarce and require the use of a bucket filled with the local water source. Waste
is usually disposed of in a public dumpsite, which may be very close to a water source (8).
There are four main sources of water for Ghanaians in this district; boreholes, hand dug
wells, rivers and lakes, and pipe borne water. Slightly fewer than half of the households in the
region have access to pipe borne water. Although there are water supply systems in the area, few
of the systems have pipes that run through the rural communities (8). Boreholes are wells with a
pump attached. They are usually dug to reach an underground water source. This water source
can run dry and the pumps are prone to breaking, but they are the next cleanest source of water
after pipe borne water. A hand dug well is an open hole in the ground that range in size. Some
hand dug wells appear to be the size of lakes. These hand dug wells, as well as the rivers and
lakes, can also dry up in the heat and during the dry season, forcing people to travel miles to
retrieve water for their families. Hand dug wells and rivers and lakes are commonly
contaminated. The water sources in the Mfantsiman District can be seen in Figure 7 (11).
21
22
Figure 7: Distribution of Water Facilities. Source: Mfanstiman
District Water and Sanitation Board
Ghanaian Water-related Diseases
Causes of Water-related Diseases
Helminths (parasitic worms), protozoa (parasitic single-celled eukaryotic organisms),
bacteria, and viruses are the main causes of water related diseases. These types of organisms do
not always cause disease and there are species in each type that can actually be beneficial to
human health. These organisms that cause water-related diseases are not unique to developing
countries and many of them cause the same water-related diseases in well developed countries
throughout the world. However, these diseases are more common in the developing nations, as
these nations do not have access to the clean water required to prevent the diseases. There are
three main types of water related diseases that will be the focus of this review: water-borne
diseases, sanitation related, and vector-borne diseases. Each type of disease is equally important.
Water-borne Diseases
Water-borne diseases are diseases that are transmitted directly through drinking, bathing,
or swimming in the contaminated water. Some pathogens require ingestion of the water, while
others can enter through the skin. These diseases can be caused by helminths, protozoa, bacteria,
and viruses and the entrance of these organisms into the body could be prevented with access to
clean water. Many of these diseases affect the gastrointestinal tract and can lead to diarrhea, but
there is a broad range of bodily systems affected by infection with these agents.
Diarrheal diseases are the seventh most common overall cause of death in Ghana and the
sixth most common cause of death in Ghanaian children under the age of five (12). Diarrhea can
lead to dehydration and death in many cases, especially in the parts of the region where clean
water and medical attention are not readily available. The most common diarrheal diseases in
Ghana are giardiasis and cholera, but other bacteria and protozoa have also been responsible for
23
diarrheal diseases. Giardia lamblia, the cause of giardiasis, can survive for months outside of the
body due to its outer protective shell and 1-10 billion cysts are released when an infected human
or animal defecates in or near a water source. The infection can last one to two weeks, causing
chronic diarrhea, dehydration, and death (13). Cholera, which is caused by the bacterium Vibrio
cholerae, causes watery diarrhea, nausea, and vomiting, and the onset is sudden. If untreated,
50% of infected people will die, but less than 1% of infected people die if treatment is sought
(14). Since adequate treatment is not readily available in many of the rural areas of Ghana, a
cholera outbreak can result in numerous fatalities.
Typhoid fever is another high-risk bacterial infection for Ghanaians. Typhoid fever,
caused by Salmonella tyhpii, leads to fever, malaise, anorexia, headache, constipation or
diarrhea, red spots on the chest, and an enlarged spleen and liver. Symptoms typically take one to
three weeks to show and the bacteria can be spread person-to-person and through foods while a
person is symptomless (15).
Schistosomiasis is the second most important parasitic infection after malaria and the
most common helminthic infection in Ghana. It is caused by infection with the flatworm species
Schistosoma. The Schistosoma larvae develop in fresh-water snails and humans become infected
by swimming, bathing, or wading in infected water. People who fish or work in irrigation are at
an increased risk of being exposed to the Schistosoma larvae. Once inside the body, the larvae
are transported through the blood to the bladder or intestines, where the larvae mature into
flatworms. The flatworms then mate and produce more eggs, which are released to repeat the
cycle when the human host urinates or defecates into water. Initial symptoms are a rash and itchy
skin, but untreated infections can lead to fever, chills, cough, muscle aches, bloody urine and
stools, and enlarged liver and spleen as the parasite matures. Infected children have stunted
24
growth and lessened cognitive development. Although disfigurement can occur, death is not a
common outcome (16).
Ascariasis, trichuriasis, and hookworm are infections caused by helminths that are found
in the soil. Infection occurs when the host ingests eggs from contaminated soil. This can happen
if the soil is mixed in with a water source, as is the case in many boreholes and hand-dug wells in
small Ghanaian communities. Similar to schistosomiasis, the eggs mature in the body and the
mature worms produce more eggs which are released in the feces. The manifestations of these
intestinal worms are diarrhea, abdominal pain, weakness, impaired physical growth, and anemia
(17). These infections rarely lead to death, but severe complications can occur in children.
Hepatitis A and E are viral infections that can be propagated through contaminated water
or food or person-to-person and causes inflammation of the liver. The symptoms are abrupt and
include fever, weakness, loss of appetite, nausea, abdominal pain, and jaundice and can last one
week to several months. The mortality rate for these hepatitis infections are low (18).
Sanitation Related Diseases
Sanitation related diseases are those diseases that are not spread directly through the
water, but are problematic if clean water is not available. The diseases can be contracted through
unsanitary conditions and without access to clean water; infected persons cannot clean
themselves to prevent transmission of the infection to others and cannot rid themselves of the
infection. These diseases include ringworm and trachoma.
Contrary to its name, ringworm is not caused by a parasitic worm. Ringworm is a
contagious fungal infection that can affect the scalp, nails, feet, or whole body. The infection
first appears as a small sore, which becomes large and the center clears to leave a ring of infected
25
body tissue. Since this disease can be spread person-to-person, access to clean water is
imperative to preventing the spread of the infection because clean water is needed to support the
proper hygiene practices required to further prevent the spread of the infection (19). This
infection does not have a high mortality rate, but its contagious nature prevents many children
from being able to attend school while they are infected.
Although problematic mainly in the Northern and Upper West Regions, trachoma, an
infection in the eyes, is caused by the bacterium Chlamydia trachomatis and repeated exposure
can lead to blindness in adulthood. The infection is easily spread from person-to-person and
causes scarring on the inside of the eyelids, turning in of the eyelashes, and scarring of the
cornea. This disease can also be spread by flies that land on the face of the infected, which makes
this disease overlap with the vector-borne diseases (19).
Vector-borne Diseases
Vector-borne diseases are diseases that are transmitted through the bite of an infected
vector, usually an insect like a mosquito, a fly, or a tick. Vector-borne diseases are related to
water in that stagnant water is part of a mosquito’s life cycle and certain types of flies breed in
water. These diseases could be prevented if stagnant water were removed and if water in the
home were stored properly in closed containers. Common vector-borne diseases that are a
problem in Ghana are malaria, yellow fever, Dengue, lymphatic filariasis, and onchocerciasis.
Malaria has the largest burden of disease in Ghana as of 2004, beating HIV/AIDS by
4.7%. The most common cause of death among children under the age of five is malaria (6). The
second most common cause of death in Ghana is due to malaria (12). Malaria, caused mainly by
Plasmodium falciparum in Ghana, is transmitted via the bite of an infected Anopheles mosquito.
26
This mosquito breeds near stagnant water sources. A study published in 2011 (2) showed the
relationship between precipitation and malaria incidence in children in the Ashanti Region of
Ghana, stating that the amount of rainfall can actually predict the prevalence of malaria for that
given season (2). This information could help the country to properly handle malaria outbreaks
in the future by predicting how many mosquitoes may be present to transmit the disease.
Manifestations of a malaria infection include fever, chills, headache, muscle aches, weakness,
nausea, vomiting, anemia, jaundice, and dizziness and can take 7-30 days to develop. The initial
symptoms of fever, chills, and dizziness can occur in cycles every few days. The chance of
further complications can be lessened if treatment is received during the first cycle. In many
Ghanaian communities, repeated infection with Plasmodium falciparum has lead to a protective
immunity in those individuals (21).
Yellow fever is a viral disease transmitted through the bite of an infected Aedes aegypti
mosquito. Aedes aegypti also breeds near stagnant water. Ghana is considered a hot-spot for
Yellow Fever transmission by the Centers for Disease Control and Prevention in Atlanta,
Georgia. Symptoms of yellow fever include fever, muscle pain, backache, headache, shivers, loss
of appetite, nausea, vomiting, and in cases where the body does not clear the infection within
three to four days, jaundice and high fever occur during the second wave. Initially diagnosis can
be difficult, as it is easy to confuse the symptoms with those of malaria. The incidence of yellow
fever has been increasing in recent years and there is no treatment available. A vaccine is
available, but due to the cost of the vaccine, it is not widely available to Ghanaians (22).
Dengue Hemorrhagic Fever is another viral disease spread by Aedes aegypti. Dengue is a
flu-like illness that affects all age groups, but does not usually result in death. Although it is
more common in the urbanized areas of Ghana, it has been found in the rural communities (23).
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Lymphatic filariasis, another mosquito borne disease, is caused by a roundworm and can
lead to elephantitis. The mosquito vector can be Anopholes, Aedes, Culex, or Mansonia. This
disease can lead to disability, which prevents the infected person from working and supporting
their family (24).
Onchocerciasis, also called river blindness, is caused by the worm Onchocerca volvulus,
which can survive in the human body for up to 14 years. This worm is transmitted through the
bite of a blackfly, which lays its eggs in water. A mature worm can be more than 0.5 meters in
length and can produce millions of microscopic immature worms. These microscopic worms can
move through the skin and cause itching and depigmentation when they die. Blindness occurs
when the worms reach the eyes. Symptoms do not usually show until one to three years after
infection (25).
28
Recent Successes
Dracunculiasis Eradication
Ghana has already succeeded in eradicating one water-borne disease from its boundaries
with the help from The Carter Center (http://www.cartercenter.org/index.html). Dracunculiasis,
also known as guinea worm disease, was successfully eradicated from Ghana in May 2010. Due
to The Carter Center’s program, there are only four African countries left still transmitting the
worm; South Sudan, Mali, Ethiopia, and Chad.
The worm is contracted through contaminated water and is removed from the body
through a painful blister in the skin after approximately one year of infection. The eradication
was accomplished by educating people to filter their water with cloth or other material that can
catch the eggs and worms and by preventing persons with an emerging worm from entering
water sources. After ranking second in the most number of cases of the disease in 1989, Ghana is
now free of the disease (26).
Trachoma Control
In 2001, Ghana implemented the SAFE program to eliminate trachoma in the Northern
and Upper West Regions. SAFE stands for surgery, antibiotics, facial and hand cleanliness, and
environmental improvements. Currently, the use of antibiotics has been discontinued and
emphasis has been put on education and environmental improvements. As of 2009, less than 5%
of children were infected and the disease is expected to be eradicated before the WHO’s 2020
global deadline (20).
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Implemented Solutions
Community Solutions
The community members in Egyankwa had multiple solutions for dealing with their
contaminated water: boiling, aluminum sulfate, or filtering. Some community members take time
to boil the water they are going to use for drinking, cooking, and bathing, but the majority of the
community do not want to spend the extra time. To save time, those community members would
add aluminum sulfate to their water. They believed that this would rid the water of all
contaminants since the compound is commonly used for the flocculation step in water
purification. However, they used unmeasured amounts and did not take the time to stir and wait
for flocculation to occur. Most of the community members would filter their water with a cloth
to remove most of the visible dirt from the water. In addition, many of the community members
purchased large bucket containers with spigots and lids so that they could keep their drinking
water from being exposed to mosquitoes. Although these procedures may lessen the spread of
certain diseases, other measures are required.
Government Solutions
Currently, there are water treatments plants throughout the Central Region. These plants
were built by Spaans Babcock (http://www.accra-properties.com/spaans-babcock.html,
http://www.spaansbabcock.com/), and there are plans to build more treatment plants in the
future, but these plans are not yet in the construction phase. However, construction to put in
more pipelines to bring pipe-borne water from existing water treatment plants to more
communities is occurring. Since President Mills is from the community of Otuam, which is off
of the same local road as Egyankwa, that road is one of the first to have the new pipelines put in.
30
During the ceremony to celebrate the opening of the rain water harvesting system in Egyankwa,
the government representatives promised to provide the communities on that road with public
toilets in the next two years. The Ghanaian government is taking the initiative to create positive
change, and the results are showing. According to the WHO, 82% of the population has access to
improved drinking water sources, which is 28% higher than the estimate from 1990 (6).
The World Health Organization and Nongovernment Organization Solutions
Organizations like the World Health Organization, The Carter Center, Global Brigades,
along with other organizations are dedicated to providing healthy, sanitary conditions for
communities. The WHO and the Carter Center have already dedicated funds and resources for
eradicating and controlling diseases in Ghana. Global Brigades has brigades outside of Water
Brigades and rain water harvesting that help to provide improved health conditions. One such
Brigade is Medical Brigades, a group of medical students and doctors who visit the communities
and provide them with healthcare screening and medications that the community’s members may
not have access to otherwise. Continued combined efforts between the Ghanaian government,
nongovernment organizations, and the communities will ultimately be required to see further
improvements in water sanitation and health.
31
A Personal Plan of Action to Mitigate the Impact of Diseases in Ghana
Throughout this review, the need for clean water in the Central Region of Ghana is
evident. To achieve this in the Central Region, the problem must be dealt with one community at
a time. Although this approach is time consuming, my experience with GWB has exemplified
that a close relationship with the community is an integral part of any successful project. This
proposed plan of action is based upon my GWB trip to Ghana and encompasses similar ideas and
steps to a successful project. Education, construction, and sustainable action are the focus of this
plan. All of the following steps are dependent upon government and nongovernment
organization teamwork and cooperation, as well as dedicated volunteers and funding.
The first step is to provide educational opportunities for the communities. This would
require educating the community about the infection process of water-related diseases more so
than the actual disease itself so that they will understand that their illnesses are due to waterrelated diseases and not due to the heat or other sources. Once they are aware that their water is
harming them, the next step would be to educate them on how they can prevent this from
happening with their currently contaminated water source. Methods such as boiling the water for
ten minutes or using life straws can make their free, contaminated water safe for drinking,
cooking, and bathing. If life straws will be used, additional education will be required to ensure
that the community members understand that life straws only last a small number of years and
need to be replaced. Additional education should be done to inform the community members
how to properly store clean water (Figure 2).
The educational aspect can be strengthened by visiting the communities over a period of
time. It is important to let the community educate the volunteers as much as the volunteers
educate the community. This solution is based significantly on community relationships and
32
trust, and can only be built by listening and learning about the culture and its people. If education
is successful up to this point, the community can be educated about rain water harvesting.
Important things to address are the function of the system, how the system works, and why it will
help them in the long run. If education is unsuccessful, the project will not be sustainable.
The next step is construction. With the help of the community members and outside
volunteers, rain water harvesting systems should first be constructed for all of the schools that do
not have access to piped-borne water. This would allow children to access clean water from a
young age and allow these children to educate their families that may not yet have access to or
education about clean water. Once all schools have been equipped with a rain water harvesting
system, systems should be built in the surrounding communities that have been educated about
and understand the importance of clean water. Providing these systems prevents community
members from relying on the dirty water sources until the government constructs new water
treatment facilities and provides pipe-born access to all communities.
Public bathrooms should also be constructed within each community. In Ghana, the
public restroom is usually a concrete slab where urination takes place. This allows them to keep
human waste isolated from food and drinking sources and may help lower the occurrence of
certain water-related diseases. Public restrooms should be a second stage in construction and
should be done in conjunction government plans and government workers.
The construction phase will require the most funding, man-power, and community
cooperation, which is why it should only be pursued if education is successful. To ensure the
success of the construction projects, sustainable solutions should be discussed with the
community.
33
Sustainability is crucial to the success of the projects. A committee within the community
should be formed to help maintain the water system. If they choose, they can set up a community
development fund by selling the water like they chose to do in Egyankwa. It is important to
establish a designated plumber for the community to contact in case repairs are needed for the
rain water harvesting system. It is also important to establish a contact with either the
government, NGO, or both to come back and check on the success of the projects.
To address the problems in the communities that would not immediately receive a rain
water harvesting system, a tanker filled with pipe-born water could drive through these
communities and sell the clean water. While in Egyankwa, the community members told us
about a tanker truck that would drive through the community and sell dirty river water to the
community members during the dry season. If the government created legislation to prevent this
activity and established a system where tankers could distribute pipe-borne water from the
treatment plants during the dry season, communities would at least have access to clean water for
drinking until their rain water harvesting system could be built.
My solutions are heavily based on community involvement, government cooperation, and
volunteer power from nongovernment organizations. To implement this strategy one community
at a time will take years, but no solution to the water problem can provide instant satisfaction.
My solution will help to provide for the small, rural communities that will not have access to
pipe-borne water in the next few years and provides water to all school-aged children. Rain water
harvesting also provides a back-up in the event that the pipe-born water systems fail.
34
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