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Zero-order working draft, November 2007

Wetlands and Human Health

Working Draft Report prepared for Ramsar Scientific & Technical Review Panel task 163

Co-ordinating authors:Philip Weinstein & Max Finlayson

Contributing Authors:Tony Cunningham, Lara O’Sullivan, [David Stroud], xxxxxxx

Zero-order draft, November 2007

For review at STRP intersessional technical workshop, Changwon, Republic of Korea, 12 November 2007

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Secretariat notes.The text sections on wetland types and distribution as under development and are not included in this zero-order draft. The structure and content of these wetland sections will be further discussed during the Changwon workshops.

Text on Highly Pathogenic Avian Influenza issues will be drafted by David Stroud and the Avian Influenza Working Group, with discussion on its content during day 1 of the Changwon workshops.

OUTLINE OF CONTENTS

Executive SummaryA brief summary will be provided that draws together the key points of background and the recommendations that follow from this.

ScopeThe STRP’s stated aim for this report is to “review and map out the relationships and issues concerning the wise use of wetland ecosystems and human health, including from information in the Millennium Ecosystem Assessment and its synthesis reports, and explore possible links between the Ramsar Convention and the World Health Organization.”

1. Introduction (2 pp.)Importance of the relationship between freshwater ecosystem health and human health

2. Types of Wetlands (10pp.)A description of the characteristics of the physical geography of wetlands that are directly relevant to 3. Ecology of Wetlands.

2.1 Freshwater wetlands: Aspects of the nature and occurrence of lakes and rivers, marshes, swamps, and bogs

2.2 Saltwater wetlands: Aspects of the nature and occurrence of mangrove, estuarine, coastal

2.3 Artificial: aspects of the nature and occurrence of reservoirs, urban

3. Ecology of Wetlands (10pp.)Common themes and differences relevant to 4. Ecosystem Services

3.1 Sources (primary production and food webs; productivity and overextraction)

3.2 Sinks (absorption and purification; stability and resilience)

4. Wetland Ecosystem Services and their disruption (10pp.)services that sustain the health of human populations; non-sustainable extraction and contamination

4.1 Provisioning: water supply; food; fuel; shelter; pharmaceuticals*4.2 Regulating: water quality; sanitation and sewage; biodiversity; climate4.3 Cultural: spiritual; recreational; educational4.4 Enhancement: agricultural production and support of industrial

development; disease elimination4.5 Deterioration: water purification, sanitation & sewage; loss of disease

regulation and increased disease contact; vulnerability to drought, flood, disasters and climate change; arable land, irrigation and famine; biodiversity

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5. Health Effects of disrupted Wetland ecosystems (15pp.)direct and indirect effects of non-sustainable extraction and contamination

5.1 By type of wetland5.1.1 Freshwater: water borne disease; vector borne disease; malnutrition5.1.2 Saltwater: malnutrition; vector borne disease5.1.3 Artificial: vector borne disease; displacement

5.2 By type of health effect5.2.1 Malnutrition*5.2.2 Sanitation-related infectious disease5.2.3 Toxic and mutagenic effects5.2.4 Sociocultural5.2.5 Indirect effects (inc. climate change)

6. Costs of Health consequences* (5pp.)Environmental resource and/or health economics

7. Interventions and recommendations (10pp.)7.1 Trade-offs:

Ecosystem maintenance vs human disease risk7.2 Approaches to intervention:

- Primary (conservation); Secondary (screening and treatment); Tertiary (arrest development of complications)- Local; Regional; Global

7.3 Surveillance:Human health as bioindicator of wetland ecosystem disruption

7.4 Improving ecosystem health and human health concurrently- Implications of the Millennium Development Goals on water and sanitation (inc. MA view that MDG delivery can run counter to maintaining ecosystem services).- Potential Ramsar-WHO collaborations

8. References

* These areas fall outside the expertise of the authors and will require additional input from other experts

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Executive Summary[A brief summary will be provided that draws together the key points of background and the recommendations that follow therefrom. The flow will be the same as that in the body of the report, starting with the types of ecosystem services provided by different types of wetlands. The potential for disrupting such services will then be examined, followed by potential human health consequences of disruption. We will conclude with a succinct summary of recommendations for interventions that would benefit ecosystem health and human health concurrently.]

1. Introduction: Healthy Wetlands – Healthy people

Human health is directly dependent on the ecosystem services provided by wetlands. Weather hunter-gatherers, agriculturalists or industrialised societies, humans have been dependent on healthy wetlands ecosystems for over 200,000 years. We drink their waters, eat their fauna, and depend on them to sustain the trees that we use for building shelters, cooking, and keeping warm in winter. Waters from healthy wetlands irrigate our crops and sustain our industries. Without healthy wetlands, we face poisoning, epidemics, starvation, and potentially catastrophic global environmental changes. It is only in the last couple of decades that the depth of this relationship has been realised, and as a result wetlands have not been well looked after. We now need to work towards management strategies that maintain wetland ecosystem health and human health concurrently.

2. Types of Wetlands [to be added]

3. Ecology of Wetlands [to be added]

4. Wetland Ecosystem Services and their disruption

We have been dependent on wetlands since the first emergence of Homo sapiens. Hunter-gatherer communities, both then and now, are directly dependent on the availability of resources in their immediate environment, foremost of which is a reliable and clean source of drinking water. They use products from wetlands, like fish and shellfish, for food and tool manufacture. Water-dependent trees provide their construction materials for shelter, and fuel for heating and cooking. Agricultural and industrial societies are also dependent on the provision of these same ecosystem services from healthy wetlands in order to sustain their workforce, but in addition require water for their crops, and cooling water for their factories. The erosion of such ecosystem services through non-sustainable use has impacted adversely on human health, and will continue to do so until better management practices are developed.

Over-exploitation and modification of wetlands impede their ability to provide ecosystem services on a sustainable basis. Rapid population growth, agricultural expansion and industrialisation have all led to unprecedented rates of exploitation of wetland ecosystem services. If water is extracted more rapidly than it is naturally replenished, the wetland ecosystem will, in the most extreme case, collapse, with a complete loss of ecosystem services – the unfortunate scenario at Lake Baikal. If the ‘absorptive’ and ‘purifying’ capacities of the wetland are exceeded, chemical pollutants and microbial pathogens will accumulate, leading to the failure of provision of ‘safe’ water. More subtle hydrological changes can lead to unexpected

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alterations in ecosystem service provision, such as through vegetation cover, microclimate, and biodiversity maintenance. The deliberate removal of wetlands because of the diseases they may harbour (eg. malaria), can backfire through these latter, still poorly understood mechanisms.

5. Health Effects of disrupted Wetland ecosystems

When ecosystems services fail, human health suffers – and for no ecosystem is this link more direct than for wetlands. One third of the world’s population lacks sufficient clean water for drinking, personal hygiene and cooking, and about two million people die annually from water-borne diarrhoeal disease. These staggering health statistics are a direct result of human populations exceeding the carrying capacity of the wetlands that provide our basic water supplies. Even when water is available in abundance, ecosystem disruptions can carry a heavy disease burden: Over-irrigation results in standing water in which disease carrying mosquitoes breed, and water used by industry often allows toxins to enter the human food chain. Altered hydrologies and vegetation structures can lead to hardship, global environmental change, and, most recently, a host of new, ’emerging’ infectious disease epidemics.

6. Costs of Health consequences [to be added]

7. Interventions and recommendations

Poor wetland management leads to a deterioration of both wetland ecosystem health and human health. It is only in the last couple of decades that we have come to appreciate the strength of the fundamental relationship between wetland ecosystem health and human health, and therefore the importance of developing environmental management strategies that support the maintenance of both wetland ecosystem health and human health concurrently. One valuable strategy for doing so may lie in using human disease burden data as a bio-indicator to help target and prioritise wetland remediation. Human health data are generally collected more widely and more reliably than are ecosystem health data, and closer collaborations between wetland ecologists and health researchers could therefore help sure up the sustainable provision of wetland ecosystem services.

Recommendations

1. Identify and implement interventions that benefit both wetland ecosystem health and human health concurrently.

In support of this recommendation, it would be useful to:- pursue multidisciplinary research to provide an evidence base (a) to identify

appropriate interventions and (b) monitor the efficacy of those implemented (including human health outcomes).

- Apply the principles of conservation through sustainable use to wetlands where conservation needs and human needs are in apparent conflict (with particular emphasis on disease suppression).

- Engage with ecological economists and health economists to establish dollar values for the wetland ecosystem services conserved

- Engage with wetland ecosystem managers to demonstrate the value of best practise in terms of (a) economic gain from maintaining wetland ecosystem

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services (including human health) or (b) other paradigms that resonate with the particular communities concerned.

2. In the first instance target wetlands that are high on the priority list for both their conservation value and their human health benefit. Successful demonstration projects that include quantifiable environmental, societal and economic benefits should provide the necessary leverage to gain support for then expanding the type and number of wetlands involved.

One possible strategy for identifying target wetlands involves the use of human health surveillance data as bio-indicators of disrupted wetland ecosystem services.[add concrete examples from main text: cheaper food, safer drinking water].

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Summary: “Healthy Wetlands, Healthy People”

The relationship between healthy humans and healthy wetland ecosystems goes back to over 200,000 years ago when modern humans first emerged. We were hunter-gatherers and directly dependent on the availability of resources in our immediate environment – foremost of which was a reliable and clean source of drinking water, but also fish and shellfish for both food and tools, and indirectly even construction materials for shelter, and fuel for heating and cooking from healthy water-dependent vegetation. Later we developed agriculture and industry, both of which are also dependent on the provision of these same ecosystem services from healthy wetlands. Unfortunately, the increasing rate of human exploitation and modification of the environment adversely affected the health of wetlands, some of which were then no longer able to provide the ecosystem services we were (and remain) dependent upon. Sources of drinking and irrigation water dried up, leading to thirst, starvation and population displacement; toxic pollutants poisoned waters, fish and people; altered hydrologies and vegetation structures led to hardship, epidemics, and global environmental change. It is only in the last couple of decades that we have come to appreciate the strength of the fundamental relationship between wetland ecosystems and human health, and therefore the importance of developing environmental management strategies that support the maintenance of both wetland ecosystem health and human health concurrently. One valuable strategy for doing so may lie in using the human disease burden as a bio-indicator to help target and prioritise wetland remediation.

Background and Scope of this report

The STRP’s stated aim for this report is to “review and map out the relationships and issues concerning the wise use of wetland ecosystems and human health, including from information in the Millennium Ecosystem Assessment and its synthesis reports, and explore possible links between the Ramsar Convention and the World Health Organization.” This forms priority task 163 of the STRP’s 2006-2008 work plan, as mandated by Contracting Parties at Ramsar COP9 in Resolution IX.2, Annex 1.

The Terms of Reference for this report includes a list of areas of particular interest, developed by the STRP, as follows:

- the ways in which wetlands can and do maintain or enhance human health and well-being through livelihood provision;

- relationships between wetlands and human sanitation;- how and which types wetlands negatively affect human health and well-

being;- how these can be ameliorated with minimized damage to wetland

ecological character (but also including trade-offs between ecosystem maintenance and human disease risks);

- declines in water quantity and quality;- water-related diseases;- waterborne pollutants (chemical and microbiological);- disease emergence related to small and large dams;- increased land-use in marginal landscapes leading to closer disease

contacts;- implications of climate change for human health issues associated with

wetlands (including drought and flood events);- economic costs of human health aspects associated with natural disasters

affecting wetlands;

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- human nutrition and wetlands; and- wetlands as sources of beneficial drugs (including for local communities);

All of the issues above have been incorporated and covered within the structure of the report below.

The broad purpose of this report is to review and map out the interactions and issues concerning the wise use of wetland ecosystems and human health, with reference to the information contained in the Millennium Ecosystem Assessment and its synthesis reports. The request for the report came from Resolution IX.2 from the 9th Conference of Parties to the Ramsar Convention on Wetlands. The resolution further requested the Convention’s Scientific and Technical Review Panel to explore possible links between the Convention and the World Health Organisation.

The specific scope of the report covers the following: the ways in which wetlands can and do maintain or enhance human health

and well-being through livelihood provision; relationships between wetlands and human sanitation how and which types of wetlands negatively affect human health and well-

being, and how these can be ameliorated with minimized damage to wetland ecological

character.

In addressing this scope the trade-offs between ecosystem maintenance and human disease risk have been considered. The following issues have also been addressed- declines in water quantity and quality, including waterborne pollutants; water-related diseases; disease emergence related to small and large dams; increased land use in marginal landscapes leading to closer disease contacts; implications of climate change for human health issues associated with wetlands; human nutrition and wetlands; and wetlands as sources of beneficial drugs.

The depth and detail of coverage has been defined by the time and resources available, but have benefited by the accessibility in global overviews such as the Millennium Ecosystem Assessment (2005), the World Water Development Report (2006), the Comprehensive Assessment of Water Management in Agriculture (2007), and the Global Environmental Outlook (2007). These assessment represent both a global consensus on key issues affecting wetland ecosystems, water and people, and up-todate widely reviewed compilations of science-based evidence. These are particularly important when considering the implication of the achievement of the Millennium Development Goals that may run counter to the maintenance of ecosystem services from wetlands.

1. Introduction

In recent decades it has become apparent that many 'traditional' environmental health problems cannot be solved by 'traditional' approaches alone. Rather, we need broader approaches to analyse interactions between humans and biotic and abiotic factors, often drawing on the science of ecology. Nowhere is this more obviously so than in vector and water-borne disease, which are influenced by many factors in the physical, social and biological environments. A fundamental and underlying contributor to this complexity is the health of freshwater ecosystems: Because ecosystem health and human health are inextricably linked (McMichael, Parkes et al.), it should be no surprise that the incidence of many diseases varies with short- and long-term changes in freshwater ecosystem health

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For a variety of vector-borne, water-borne and other 'environmental' diseases, appropriate, scientifically based public health interventions can only be devised with an understanding of the ecology of the disease. By extension, effective adaptation to the potential effects of disrupted freshwater ecosystem services is more likely to occur if based on a sound understanding of the relationship between ecosystem health and human health.

[Insert BOXED CASE STUDY]

A Historical Case-Study: Rome, Wetlands and Malaria

Prepared by Dr Lara O’Sullivan

Although mistress of an empire that stretched across the Mediterranean, Rome never wielded successful control over her natural environment, nor was she able to master the disease burden of her urban population. Draped over her famed ‘seven hills’, the city is built around the basin of the Tiber, on land prone to marshiness and subject to the intermittent floodings of the river itself. In antiquity, such low altitude, warm and well-watered sites were favoured for city foundation; indeed, it was these very enviromental conditions that made possible the intensive farming of staple crops — notably of grain, olive and grapes among the Greco-Romans — upon which the growth of urban populations was predicated. With the fertile land, however, came high risks of disease; the malaria-bearing anopheles mosquito, for one, thrives in such conditions. This nexus between disease and land fertility was to be found in antiquity on Sardinia, an island whose agricultural surpluses afforded a major supply of grain for the Roman population; Sardinia’s agricultural regions were a malarial deathtrap (see Strabo 5.2.7.225c = Jones (1923) 360, Tacitus Annals 2.85.3 = Grant (1977) 118, with Sallares (2002) 90-93).

Rome itself seems to have suffered similarly; Sallares (2002) and Scheidel (2003) have argued that malarial infection may have been hyperendemic there. The claims of ancient writers certainly attests to widespread familiarity with the disease in the metropolis: among them, the first-century B.C.E. doctor, Asclepiades of Bithynia, regarded the quotidian fevers of early P.falciparum infection as commonplace (see Caelius Aurelianus 2.63-64 ed. Drabkin, quoted by Sallares (2002) 220 n42), and the situation was no better in the second century C.E., when the medical writer Galen (7.435 = Kühn (1965) 435) would note that semi-tertian fevers were a ubiqitous presence on the streets of the capital. This picture fits neatly with the marked variation in the seasonality of death in Rome that Sheidel (1994) and Shaw (1996) have identified, in which the concentration of deaths occurred in late summer / early autumn. The presence of malaria, contributing to mortality both in its own right and exacerbating the impacts of other conditions (gastro-intestinal infections, respiratory infections), would explain the significantly high levels of death charted for ancient Rome during this phase of the year (so Sallares 2002; Sheidel 1994 & 2003).

The connection between such disease and low-lying wetlands was recognised, although its agency misunderstood, by the Romans themselves. Agricultural writers, most notably Varro (R.R. 1.12.3 = Heurgon (1978) 35) and Vitruvius (1.4.1 = Granger (1931) 34), repeatedly urged against the building of farmhouses on low ground near swamps or slow-moving rivers, on the basis that these locations were pestilential in summer. Within the city itself, the higher ground of the hills was prized for its greater healthiness. In the first century B.C.E., Cicero (de Re Pub. 2.6.11 = Keyes (1951) 120) praises Rome’s mythical founder, Romulus, for locating Rome on a site that ‘both has adundant sources of water and is healthy, in a pestilential region, for there are hills,’ and his near contemporary, Livy, similarly speaks of the ‘healthy hills’ of Rome (Ann. 5.54.4 = Foster (1924) 184). The protection of the hills was not sufficient, however, to safeguard the Roman political elite, whose business brought them down to the Roman Forum, sited in one of the lowest valleys of the city; public business was all but suspended during the summer months, allowing those affluent enough to do so to quit the pestilential capital for their safer country retreats and thereby avoid the death that, quips the

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poet Horace (Ep. 1.7.8-9 = Fairclough (1926) 294), one was likely to suffer if pressing a lawsuit through summer.1

Attempts to modify the drainage of the land around the capital began very early. The development of the urban centre, the Forum, was predicated on the reclamation of marsh-prone land by drainage tunnels (Cornell 1995: 164-65); still in existence today, the greatest of these — the Cloaca Maxima — is reputed to have been constructed first in the sixth century B.C.E. (so Pliny, N.H. 36.24.104-8 = Eichholz (1962) 82-4). Roman drainage interventions, however, may have done little to alleviate the problems associated with the marshiness of the low-lying areas of the city. Indeed, there is reason to believe that the Romans’ impact on the Tiber river system overall may have been a negative one, in both ecological and health terms, although precise changes in both realms are — given the paucity of evidence — impossible to quantify.

Mass deforestation is one key factor.2 Driven not only by the need for agricultural clearing but also by an intensive demand for timbers (for building, and for supporting extensive metal smelting concerns), the clearing of land brought about the destruction of the large forests that Theophrastus (HP 5.8.3 = Hort (1916) 464) attests to have been standing, in the late fourth century B.C.E, in the area of Latium around Rome, and such widespread deforestation was scarcely confined to the immediate surrounds of Rome itself. The results were increased run-off into the river systems, a rising water-table, and substantial deposition of eroded soil into alluvial plains. These phenomena occurred at Rome. Tiber flooding is frequently observed in the first centuries B.C.E. and C.E., with major crises recorded for 54 B.C.E., 23 B.C.E. and C.E 15; lower level inundation was commonplace. In the first century C.E., Pliny the Elder affirms that it was the capital itself that the flooding was most concentrated; his nephew, the younger Pliny, confirms the existence of a high water table, noting that one soon struck water wherever one dug on his Laurentum estate on the coast not far from Rome (Pliny, Ep. 2.17.25 = Melmoth & Hutchinson (1957) 162). Archaeological investigations confirm the existence of significant alluviation: the Roman Form of the imperial period, in recent times buried beneath six to seven metres of alluvial deposits, itself lies several metres above the strata from the archaic period (so Quilici 1979: 69-70, cited by Sallares 2002: 109).

There are obvious implications here for a multitude of diseases. The flooding alone had significant health ramifications for a city whose sewerage and drainage systems were one and the same: instances of sewerage backwash may have been common.3 Receding flood waters create an ideal habitat too for the proliferation of insect-borne disease; the attractions to insects of water-bodies that dried over summer is, indeed, a fact of which the ancients were already apprised, for Palladius (Op. ag. 1.7.4 = Martin (1976) 14) warns particularly against marshes that dry out because of the ‘hostile animals’ and ‘pestilence’ thereby generated. From a malarial perspective again, a high water table, alluvial plains and frequent flooding encourage marshiness and thus have the potential to expand the available breeding sites for the anopheles mosquito. Sallares 2003: 104-5 argues for just such a situation at Metapontum, a Greek settlement in southern Italy, where archaeology has revealed not only a rise of over a metre in the water-table between the sixth and fourth centuries B.C.E, but also the likely presence of malaria (indicated by the thalassaemia-related lesions on ancient skeletal remains in the neraby necropolis4).

The silting up of river mouths created conditions more favourable to mosquito breeding in another way, by reducing the influx of seawater and thereby reducing the salinity of coastal marshlands. Several instances of such silting, with a probable increase in malarial infestation in consequence, can be traced in antiquity. On the coast of Asia Minor, the city of Mysus had to be abandoned when a nearby channel silted up, and the resulting inland marsh fostered an insect infestation (thus Pausanias 7.2.11 = Jones (1933) 178; cf Strabo 14.1.10.636c = Jones (1970) 210 for the collapse of the city). Similar patterns seem to have occurred close to

1 For discussion of the recess in public business in relation to malaria, see Sheidel 2003: 166.2 Evidence is treated in summary by Sallares 2002:105ff, with references to the relevant literature.3 Scobie 1986: 407- 22 provides discussion of Roman sanitation; see esp. 421-22 on the disease implications.4 For further on the evidence of malaria and thalassaemia (a condition which bestows some protection against malaria) in antiquity, see Grmek 1989: 245-83.

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Rome. Certainly, soil erosion up-stream brought about the deposition of alluvial plains at Ostia, on the mouth of the Tiber; the silting was severe enough for Ostia to be abandoned as Rome’s main port in the first century C.E., and the adjacent coastal lagoons were gradually replaced with stagnant marshes. The presence of malaria at Ostia, a location whose early salinity may have afforded some former protection, is documented in the anecdotal tradition from late antiquity onwards; by the eleventh century, the area was deemed so unhealthy that the bishop of Ostia relinquished his see. (On Ostia and malaria, see in particular Sallares 2002: 86-87).

Perhaps the most telling interaction between wetlands and human health arises in the so-called Pontine territory, a broad flat well-watered plain to the south of Rome. It was in early times an abundantly fertile region: if the Roman historical tradition is to be relied upon, the area once supported numerous settlements (Pliny N.H. 3.5.59 = Rackham (1947) 44 writes of 24 towns), and its early capacity to support crops and animal husbandry made it a key target of Roman acquisitiveness into the fourth century B.C.E. In the following centuries, the nature of the Pontine region altered radically, although the changes are, frustratingly, traceable only through later incidental references and anecdotes.5 What is clear is that, by the first century B.C.E. and perhaps even earlier, the area had become dominated by stagnant swamps and marshes — a change that, argues Traina 1988:113, may perhaps be reflected in a re-designation by the Romans of the ager Pomptinus, or Pontine field, as the Pomptinae paludes, or Pontine marshes. A number of factors may have contributed to the changes. Deforestation may well have played a part. Sallares 2002: 181- 85 points too to the possible impact of the construction of a Roman road, the Via Appia, across the Pontine plain in the late fourth century. The road may have interfered with the natural drainage pattern of the area; subsquent Roman attempts to drain the marshes — such as that by Marcus Cornelius Cethegus in 160 B.C.E. — may also have exacerbated, rather than alleviated, the problems, for the flatness of the land impedes effective removal of water. The Pontine marshes became, it seems, both too marshy to farm and too pestilential, for with this ecological change had come a pronounced infestation of malaria.6 Literary and archaeological evidence combine to indicate that the population of the region collapsed. Not until Mussolini’s bonifactions of the twentieth century could the Pontine marshes once more become widely inhabitated and cultivated.

Roma ferax febrium— Rome, fruitful with fevers: thus was a bishop of Osia in the mid-eleventh century moved to hail the city. The Tiber system had an important part to play in earning for the city this rather unsalubrious title. Scheidel 2001: 15 argues compellingly that, prior to modern understandings of hygiene and before the benefits of modern medicine, ‘location used to have a greater impact on longevity than access to material resources.’7 This may be especially true of ancient Rome and her surrounds, where the combination of high urban population density with the ecological setting of the city proved fatal for many.

Works Cited

Braund, S. M. 2004. Juvenal and Persius. London & Cambridge Mass. Cornell, T. J. 1995. The Beginnings of Rome. Italy and Rome from the Bronze Age to the Punic

Wars (c. 1000—264 BC). London & New York.

Duff, J. D. 1934. Silius Italicus Punica vol. 1. London & Cambridge Mass. Eichholz, D. E. 1962. Pliny Natural History vol. 10. London & Cambridge Mass. Fairclough, H. R. 1926. Horace Satires, Epistles, Ars Poetica. London & New York.Foster, B. O. 1924. Livy vol. 3. London & New York. Granger, F. 1931. Vitruvius On Architecture vol. 1. London & New York.

5 Koot 1991 catalogues the ancient testimonia on the ecology of the Pontine area.6 The pestilential — and deserted — aspects of the Pontine marshes are remarked upon repeatedly: compare Horace Sat. 1. 5.14-15 = Fairclough (1926) 64; Cicero de Orat. 2.290 = Rackham (1958) 418; Pliny N.H. 26.9.19 = Jones (1956) 278; Juvenal Sat. 3.305-8 = Braund (2004) 190-92; Silius Italicus Punica 8.3.79-82 = Duff (1934) 420. Proposals to drain them and thus to reclaim the arable land (as, for example, from Julius Caesar — Suetonius DJ 54.3 = Rolfe (1920) 60; Plut. Caes. 58.9 = Warner & Seager (1972) 298) came to nothing.7 See too Scheidel 1999 for an analysis of mortality among the Roman elite, in which he argues that life expectancy among the aristocracy may not have been significantly better than for the lower orders.

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Grant, M. 1977. Tacitus The Annals of Imperial Rome. London. Heurgon, J. 1978. Varron Economie Rurale vol. 1. Paris.Hort, A. 1916. Theophrastus Enquiry into Plants vol. 1. London & Cambridge Mass. Jones, H. L. 1923. The Geography of Strabo vol. 2. London & New York.——1970. The Geography of Strabo vol. 6. London & New York. Jones, W. H. S. 1933. Pausanias Description of Greece vol. 3. London & New York. ——1956. Pliny Natural History vol. 7. London & Cambridge Mass. Keyes, C. W. 1951. Cicero De Re Publica De Legibus. London & Cambridge Mass. Koot, C. J. 1991. ‘Marching through the marshes: an historical survey of the Agro Pontino.’ In

A. Voorips, S. H. Loving & H. Kamermans (edd.) The Agro Pontino Survey Project. Universiteit van Amsterdam Studies in Prae- en Protohistorie 6. Amsterdam: 9-20.

Kühn, C. G. 1965. Claudii Galeni Opera Omnia vol. 7. Hildesheim. Martin, R. 1976. Palladius Traité d’agriculture vol. 1. Paris.Melmoth, W. & Hutchinson, W. M. L. 1957. Pliny Letters vol. 1. London & Cambridge Mass. Quilici, L. 1979. Roma primitiva e le origini della civiltà laziale. Rome. Rackham, H. 1947. Pliny Natural History vol. 2. London & Cambridge Mass. ——1958. Cicero De Oratore vol. 1. London & Cambridge Mass. Rolfe, J. C. 1920. Suetonius vol. 1. London & New York.Sallares, R. 2002. Malaria and Rome. A History of Malaria in Ancient Italy. Oxford.Scheidel, W. 1994. ‘Libitina’s bitter grains: seasonal mortality and endemic disease in the

ancient city of Rome.’ Ancient Society 25: 151-75.——1999. ‘Emperors, aristocrats and the Grim Reaper: towards a demographic profile of the

Roman élite.’ Classical Quarterly 46: 222-38.——2001. ‘Roman age structure: evidence and models.’ Journal of Roman Studies 91: 1-26.——2003. ‘Germs for Rome.’ In C. Edwards & G. Woolf (edd.) Rome the Cosmopolis.

Cambridge: 158-76.Scobie, A. 1986. ‘Slums, sanitation and mortality in the Roman world.’ Klio 68: 399-433.Shaw, B. D. 1996. ‘Seasons of death: aspects of mortality in imperial Rome.’ Journal of Roman

Studies 86: 100-138.Traina, G. 1988. Paludi e bonifiche del mondo antico. Rome. Warner, R., & Seager, R. 1972. Plutarch Fall of the Roman

[BOXED CASE STUDY ends]

2. Types of Wetlands (10pp.) [to be added]

A description of the characteristics of the physical geography of wetlands that are directly relevant to 3. Ecology of Wetlands.2.1 Freshwater wetlands: Aspects of the nature and occurrence of lakes and rivers, marshes, swamps, and bogs2.2 Saltwater wetlands: Aspects of the nature and occurrence of mangrove, estuarine, coastal2.3 Artificial: : aspects of the nature and occurrence of reservoirs, urban

- Coastal river deltas – Mediterranean (Rhone); S & E Asia (Mekong, Ganges, Indus, Yangtze, Yellow); Gulf of Mexico (Mississippi, Orinoco)

- Inland river deltas – Europe (Danube, Volga, Baltic sea coast); N America (Great Lakes); S America (Pantanal, Llanos)

- Great riverine forests – Amazon; Mississippi basin

- Salt Marshes – Europe (Wadden Sea); N America (Bay of Fundy, NE USA marshes Maine-NewJersey, Coastal plain marshes New Jersey-Texas); Asia (china salt marshes)

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- Northern peatlands

- Inland freshwater marshes and swamps (this includes vegetated wetland communities around the edge of lakes*)

– African lakes; Indian freshwater marshes; China marshes; N American incl Everglades and Prairie Potholes; arid climate including parts of Aust, USA/Mex and Central Asia

- Constructed wetlands – Paddy (Asian v Aust, Eur & S/N Amer); reservoirs; waste treatment ponds

3. Ecology of Wetlands (10pp.) [to be added](common themes and differences relevant to 3. Ecosystem Services)

3.1 Sources (primary production and food webs; productivity and overextraction)3.2 Sinks (absorption and purification; stability and resilience)

4. Wetland Ecosystem Services and their disruption (10pp.)(services that sustain the health of human populations) (non-sustainable extraction and contamination)

4.1 Provisioning: water supply; food; fuel; shelter; pharmaceuticals

Such is the importance of access to freshwater, that in November 2002, water for the first time was explicitly recognised as a fundamental human right when the United Nations Committee on Economic, Social and Cultural Rights adopted General Comment No.15 (ECOSOC 2002) to the International Covenant on Economic, Social and Cultural Rights. Although not legally binding, the 146 States that ratified the Covenant aim to progressively ensure that everyone has access to safe and secure drinking water, equitably without discrimination. Presently, 1.1 billion people lack access to improved water supply and 2.4 billion to improved sanitation (UNESCO 2003). Both inadequate water supply and sanitation are the underlying cause and outcome of the poverty/ill-health cycle.

Within the next 20 years, the amount of water available per capita worldwide is expected to drop by a third (UNESCO 2003). This will be driven by continued global anthropogenic ecosystem disruption (e.g., deforestation, urbanisation), resulting in the degradation and loss of freshwater. The increasing pressures on freshwaters and the expected reduction in availability has led water to be called “the next oil”, where scarcity and demand will fuel conflict and increase the global burden of disease. In 2000, waterborne (e.g., giardiasis) and water-washed (Disease caused by lack of water, poor personal hygiene and lack of proper human waste disposal; e.g., trachoma) diseases killed 2.2 million people and affected more than 2 billion, the majority being children under the age of 5 (UNESCO 2003).

[text from Tony Cunningham follows below here]

4.1 People’s wellbeing: basic needs, poverty alleviation and food security8

8 Phil Weinstein, Note: The title used above reflects terminology of the useful Figure 1 (from MDA, 2005). An alternative title would be “Wetland products and people’s livelihoods”. Both are, I think preferable to the original draft title: “Provisioning: water supply; food; fuel; shelter;

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4.1.1 IntroductionIt is well known that wetlands provide diverse and valuable goods and services for human wellbeing910. Despite this, wetland values are widely ignored and wetland destruction and degradation are widespread. The reason for our behaving this way is widely recognized. The direct and indirect values of wetlands are not taken into account, property rights are weak and wetlands can be affected by degradation elsewhere in the watershed1112. Although the wetlands represent a capital asset providing important ecosystem services, these assets are generally not reflected in conventional economic indicators. Instead, wetland goods and services are often considered a “subsidy from nature”, just as is the case with forests13. Integrating economic14 and socio-ecological approaches15 in policy and practice for continued provision of those wetland goods and services is therefore essential. Valuation estimates can be controversial16. In addition, non-market values, such as cultural or religious values of wetlands (or other ecosystems such as forests17) are extremely difficult to determine and can be location specific, so are that even if economic vaues were determined, that would not apply in other locations. Despite controversies and gaps, valuation studies commonly indicate the great economic importance of wetlands. What is needed is more effective communication by scientists to policymakers on the importance of wetlands to people’s wellbeing. Links between direct and indirect drivers of wetland change and opportunities for Ramsar to provide guidance on how these link to human wellbeing are clear (Figure

pharmaceuticals” from your early outline. The final choice, however, is up to you.

9 Covich, A. P., Ewel, K. C., Hall, R. O., Giller, P. E., Goedkoop, W and Merritt, D. M. 2004). Ecosystem services provided by freshwater benthos. In Sustaining Biodiversity and Ecosystem Services in Soil and Sediments (ed. D. H. Wall), pp. 45–72. Island Press, Washington D.C., U.S.A.

10 “well-being”, in the sense used by Amatya Sen is used here deliberately as it goes beyond income based benchmarks (such as people living on less than 1US$ per day). See Berenger, V and A. Verdier-Chouchane. 2007. Multidimensional Measures of Well-Being: Standard of Living and Quality of Life Across Countries. World Development 35:1259–1276

11 Dudgeon, D, H. Arthington, M O. Gessner, Z-I Kawabata, D J. Knowler, C Leveque, R J. Naiman, A-H Prieur-Richard, D Soto, M L. J. Stiassny and C A. Sullivan. 2006. Freshwater biodiversity: importance, threats, status and conservation challenges. Biological Review 81: 163–182.

12 Turner, R.K. and Jones, T. (eds.) 1991. Wetlands, Market and Intervention Failures. Earthscan, London.

13 Wunder, S. 2007. The efficiency of payments for environmental services in tropical conservation. Conservation Biology 21(1):48–58

14 Barbier, E., Acreman, M. & Knowler, D. 1997. Economic Valuation of Wetlands – A Guide for Policy Makers. Ramsar Convention Bureau/IUCN, Gand, Switzerland. http://www.biodiversityeconomics.org/valuation/topics-02-00.htm

15 Berkes, F., and C. Folke, editors. 1998. Linking social and ecological systems: management practices and social mechanisms for building resilience. Cambridge University Press, Cambridge, UK.

16 Balmford, A., Bruner, A., Cooper, P., Constanza, R., Farber, S., Green, R. E., Jenkins, M., Jefferiss, P., Jessamy, V., Madden, J., Munro, K., Myers, N., Naeem, S., Paavola, J., Rayment, M., Rosendo, S., Roughgarden, J., Trumoer, K. & Turner, R. K. 2002. Economic reasons for conserving wild nature. Science 297, 950–953

17 Adamowicz, W., T. Beckley, D. Hatton Macdonald, L. Just, M. Luckert, E. Murray, and W. Phillips. 1998. In Search of Forest Resource Values of Indigenous Peoples: Are Non-Market Valuation Techniques Applicable? Society and Natural Resources. 11: 51-66.

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1).

[insert Figure 1. Links between ecosystem services, drivers of change, human wellbeing and poverty reduction (from Millenium Ecosystem Assessment, and Ramsar Wise Use Handbook 1, 3rd edition 2007]

This chapter describes the contributions wetlands make to peoples wellbeing (Figure 2). These range from wetland ecosystem services (such as clean water), economic productivity and poverty alleviation (wetlands and fisheries) to food security (such as the genetic diversity of wild relatives of rice (Oryza), one the world’s major crops or new natural products from wetland associated fungi, bacteria, animals and medicinal plants). In addition, some wetlands have “insurance” value, reducing our vulnerability to extreme events such as floods while others, such as peat-lands, play an important role in carbon sequestration.

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[insert Figure 2. Links between wetlands and wellbeing]

Although the different contributions wetlands make to people’s wellbeing are discussed separately below, there are linkages within and between each one. Food security, for example, links to water quality, household income, plant genetic resources and fisheries management. These linkages mean that in many cases, trade-offs between wetland conservation and development need to be carefully assessed and in some instances, comprises reached. Strategies in Bangladesh to reach trade-offs between floodplain conversion for rice production or wetland maintenance for survival and production of floodplain fish populations when both are important in the peoples diet are a good example18. Similarly, important trade-offs exist between development projects such as large dams on one hand, and infectious disease risk (such as schistosomiasis) or sustainable fisheries based on fish whose spawning or migrations are negatively impacted by large dams. Even recreational uses of wetlands, with the health and tourism benefits they provide may need trade-offs with conservation, such as removal of exotic salminoids from rivers in Chiles and New Zealand19.

4.1.2 Food securityFood security has three main components, each of which have links to wetland values for food and water. First, food availability (through the market and people’s own production). Second, enough buying power or social capital access food with

18 Shankar, B., A Halls and J Barr. 2004. Rice versus fish revisited: On the integrated management of floodplain resources in Bangladesh. Natural Resources Forum 28: 91–101

19 Dudgeon, D, H. Arthington, M O. Gessner, Z-I Kawabata, D J. Knowler, C Leveque, R J. Naiman, A-H Prieur-Richard, D Soto, M L. J. Stiassny and C A. Sullivan. 2006. Freshwater biodiversity: importance, threats, status and conservation challenges. Biological Review 81: 163–182

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cash or through barter. Third, that people get sufficient nutrients from the food they eat20. Nutrient intake is also influenced by people’s ability to digest and absorb nutrients, which is affected by human health, access to safe drinking water and the diversity and nutritional content of foods. Wetland degradation or loss impacts on all three components that comprise food security. Agricultural production and food security (including access to food) can be compromised with wetland degradation due to the value of wetland resources to peoples diet (for example from fisheries and food plants) and some of the genetic material wetland plants contain. Wild relatives of two important food crops, rice (Oryza species) and some cowpeas (Vigna) species are indigenous to African and Asian marshes and floodplains.

Starchy staple diets (rice, cassava, maize) are frequently deficient in nicotinic acid, vitamin C, calcium and riboflavin and protein21. Harvested wild foods are known to be a valuable source of these nutrients deficient in starchy staple diets, particularly protein from edible fish and shellfish, nicotinic acid from wild edible greens, vitamin C from wild fruits. Although many edible wild plants are harvested from forests or woodlands rather than wetlands, a wide diversity of wetland plants provide supplementary food sources. Popular food species are also traded. Examples are water-crass (Rorippa nasturtium-aquaticum) in Europe, Mauritia fruits and Euterpe palm hearts from South America floodplain forests, lotus (Nelumbo nucifera) seeds and water-chestnut (Eleocharis) tubers in Asia and wild rice (Zizania aquatica) and cranberries (Vaccinium oxycoccos) collected for food and trade by native Americans in the USA.

Fish are particularly important to people’s diet and health in developing countries where they often form the main source of animal protein. The Mekong river, for example, sustains one of the world’s largest freshwater fisheries, with an annual yields of 1 million tones of fish, most of which are harvested by small-scale artisanal fisheries22. In Cambodia, for example, people get about 60–80% of their total animal protein from the fishery in Tonle Sap and associated floodplains23. Floodplain fisheries are often very productive, although fish production is highly variable due to seasonal floods and longer-term climatic trends24 that threaten fisheries such as those around Lake Chad.

4.1.3 Water suppliesFresh water is a basic need for human health. This is widely recognized in national legislation of many countries. This provide an important opportunity for linking local action and public health to wetlands conservation. In the USA, for example, the Clean Water Act has become an important tool enabling Native Americans to 20 Boko, M, I Niang, A Nyong and C Vogel. 2007. Chapter 9: Africa. IPCC WGII Fourth Assessment Report.

21 Cunningham, A B and C M Shackleton. 2004 Use of fruits and seeds from indigenous and naturalized plant species. Chapter 20 in : H Eeeley, C Shackleton and M Lawes (eds) Use and Value of Indigenous Forests and Woodlands in South Africa. University of Natal Press, Pietermartizburg.

22 Valbo-Jorgensen, J and A F Poulsen. 2001. Using local knowledge as a research tool in the study of river fish biology: experiences from the Mekong. Environment, Development and Sustainability 2:253-276.

23 Millenium Development Assessment. 2005. Millennium Ecosystem Assessment, 2005. Ecosystems and human well-being: Wetlands and water Synthesis. World Resources Institute, Washington, DC.

24 Jul-Larsen, E., Kolding, J., Overå, R., Nielsen., J., and Zwieten, P.. 2003. Management, co-management or no management? Major dilemmas in Southern Africa freshwater fisheries. FAO Fisheries Technical Paper 426/1. Food and Agriculture Organization, Rome.

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leverage wetland conservation and restoration at a catchment level25. On average, people need 20-50 litres of clean water per person per day for drinking, cooking and personal hygiene, yet over 1 billion people lack access to safe water supplies and 2.6 billion people lack adequate sanitation26. Wetland vegetation plays an important role in improving water quality through extraction of pollutants and pathogens including nitrates, coliform bacteria and faecal streptococci27. In fact this role is so useful that artificial wetlands have been purposely created for this purpose in France for over 20 years28, with the design principles behind riparian wetland construction being developed for stream restoration29. Poor quality water contributes to a range of health problems such as diarrhoea, internal parasites and trachoma. Bad health due to lack of access to safe drinking water and poor sanitation affects the poorest sector of society, with follow-on affects for food security.

4.1.4 ShelterBuilding styles and the materials used reflect cultural diversity and preferences for particular species, as well as what is available from vegetation change. In many developing countries, where house construction reflects need rather than restrictive building codes of the developed world, locally harvested plants are the main source of low-cost housing. Although hardwoods from upland forests and woodlands are preferred for support poles, wetlands are a favoured source of thatching material and reds. In Africa, floodplain grasses and Cyperaceae are commonly used for thatching traditional houses. In southern Africa, the common reed (Phragmites australis) for were used for wall construction of up to 90% of homes30 and in Europe, the same species is used for expensive thatch.

4.1.5 Subsistence incomeFor rural people wanting to enter the cash economy, harvesting wild resources (salt, fish, shell-fish, useful plants) is an important option, as local knowledge and skills can be used to harvest products for trade without an initial investment of cash. Complex trade networks commonly characterise this hidden economy. As mentioned earlier, buying power can also help with food security. In many developing countries, these resources also provide a “green social security”, as unlike Europe, Australia and North America, there are no government social security payments in times of need. Although income from harvest and trade is small by western standards, its values to households should not be underestimated. Trade is fresh,

25 United States Environmental Protection Agency. 2000. Tribal Wetland Program Highlights. EPA 843-R-99-002. Office of Water, Office of Wetlands, Oceans and Watersheds, Washington DC 20460

26 Millenium Development Assessment. 2005. Millennium Ecosystem Assessment, 2005. Ecosystems and human well-being: Wetlands and water Synthesis. World Resources Institute, Washington, DC.

27 Ghermandi, A., D Bixio, P Traverso, I Cersosim and C Thoeye. 2007. The removal of pathogens in surface-flow constructed wetlands and its implications for water reuse. Water Sci Technol. 56(3):207-16.

28 Molle, P., A Lienard, C Boutin, G Merlin and A Iwema. 2005. How to treat raw sewage with constructed wetlands: an overview of the French systems. Water Sci Technol. 51:11-21.

29 D’Arcy, B J., N MacLean, K V Heal and D Kay. 2007. Riparian wetlands for enhancing the self-purification capacity of streams. Water Sci Technol. 56:49-57.

30 Cunningham, A.B. 1985. The resource value of indigenous plants to rural people in a low agricultural potential area. Faculty of Science, University of Cape Town.

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dried or smoked fish is widespread through Asia, Africa31 and Latin America. So to, is trade in basketry, including fish traps.

While bamboo and rattans from upland forests and agroforestry systems are a common source of basketry fibres in Asia, plants from wetland and high water-table palm savannas plants that dominate African basketry fibres. The development of commercial craft enterprises since the 1970’s has brought much needed income for producers and their families, where it is often used for school costs32. Most southern African basketmakers are women from low-income families, living in remote rural areas, and are subsistence farmers who own few (if any) cattle, and have little or no education. For most weavers, cash income is obtained through the sale of home-brewed beer, grain, bread, or thatching grass; casual labour or employment on public works; old age pensions; or money sent by family members who are migrant workers. For many, the only consistent source of cash income is through the production and sale of handicrafts, especially baskets. As a male basketmaker in Khwai, Botswana, stated, 'My baskets are my cattle'. Cultural values can also drive commercial harvest. Each year, several thousand Zulu women harvest mat rush (Juncus kraussii) from 20 hectare area of coastal salt-marsh at St Lucia estuary, a Ramsar site in South Africa. These culms are then resold or made into sleeping mats prized for their cultural significance at weddings or crafts for export, with intensive use causing concern about sustainability33.

While species-specific overharvest erodes values of wetlands to people’s livelihoods, salt harvest can be affected by industrial and agricultural pollutants, with serious health consequences. The Jabbul saline wetland, a Ramsar site in Syria is a good example of bad practice. Although salt production is an important source of income to local people, the quality of salt production has been so badly affected by pollutants seeping into the wetland its salt has been declared unfit for human consumption.

31 Abbott, J G., L M. Campbell, C J. Hay, T F. Næsje and J Purvis. 2007. Market-resource Links and Fish Vendor Livelihoods in the Upper Zambezi River Floodplains. Human Ecology 35:559–574

32 Cunningham, A B and M E Terry. 2006. African basketry: grassroots art from southern Africa. Fernwood Press, Cape Town.33 Heinsohn, D and Cunningham, A.B. 1991. Utilization and potential for cultivation of the salt-marsh rush Juncus kraussii. South African Journal of Botany 57(1) : 1 - 5.

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4.1.6 Traditional medicines and new natural productsAlthough traditional medicines are dominated by flowering plant use (most of them not from wetlands), it is wetland associated animals (such as leeches and frogs), fungi, bacteria and extremophile lower plants (algae)34 rather than flowering plants that provide the most productive sources of new natural products. In terms of people’s health, both sectors need to be considered. In some cases, there are close links between the new and old uses of organisms, sometimes from different wetlands on different continents. The medicinal leech (Hirudo medicinalis) from European freshwater wetlands provides a good example. Traditionally used for bleeding patients in medieval Europe, leeches are now the source of hirudin, the first major new anticoagulants brought into health care since heparin was discovered in the early 1900s35. The link between old and new doesn’t end there. To produce sufficient quantities of heparin for therapeutic use requires recombinant technology. This is done using bacteria, eukaryotes and yeasts to produce recombinant forms of hirudin (r-hirudin)36. Taq polymerase, widely used in polymerase chain reaction (PCR) technology, including DNA sequencing into the genetic material of another organism, is from DNA polymerase of Thermus aquaticus, a bacterial “extremophile” which occurs in the geysers of Yellowstone National Park, where its ability to survive extreme heat enables its DNA polymerase to survive the successive heating cycles of PCR. Aside from the direct health and economic values of hirundin is the value of the technology developed from Thermus aquaticus. Not only did this win its inventor, Karry Mullis, the Nobel Prize in 1993, but in 1991, the Swiss pharmaceutical company Hoffman-Laroche bought the exclusive world rights to the PCR process for $300 million from Cetus Corporation, for whom Karry Mullis worked at the time37. In 2005, worldwide sales of PCR enzymes were reported to be in the range of $50-100 million38 and may be more today, given growth in the biotechnology field.

34 E.g: Goss, W. 2000. Ecophysiology of algae living in highly acidic environments. Hydrobiologia 433: 31-37

35 Moreal, M., J Costa and P Salva. 1996. Pharmacological properties of hirudin and its derivatives. Potential clinical advantages over heparin. Drugs Aging. 8:171-82

36 Sohn, JH., H A Kang, KJ Rao, CH Kim, ES Choi, BH Chung and SK Rhee. 2001. Current status of the anticoagulant hirudin: its biotechnological production and clinical practice. Applied Microbiology and Biotechnology. 57:606-1337 Doremus, H. 1999. Nature, Knowledge and Profit: the Yellowstone’s Bioprospecting Controversy and the Core Purposes of America’s National Parks. Ecology Law Quarterly 402-405.38 Lohan, D and S Johnston. 2005. Bioprospecting in Antarctica. United Nations University Institute of Advanced Studies (UNU-IAS), Yokohama.

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This example illustrates several points relevant to the confluence between wetlands, Ramsar, natural products and human health. Firstly, the medicinal qualities of leeches are a good example of the continued value of traditional knowledge to health care today. Secondly, new technologies, such as rapid throughput screening39

and PCR are changing the face of new natural product development. Thirdly, links between wetland biodiversity and human health need to focus less on the obvious (such as birds, large mammals or plants), than on the “hidden biodiversity” (such as fungi and bacteria). Fourthly, the case of biodiversity prospecting for Thermus aquaticus illustrates how controversial this can be, with important policy implications and linsk to the Convention on Biodiversity (CBD). Finally, the most likely places for promising leads are wetland species from extreme environments (such as hot springs, alpine wetlands, particularly in high diversity montane systems such as the Andes or Himalaya, desert salt-pans, soda lakes, highly alkaline or acid streams and high diversity tropical rivers). Many of these are not listed by RAMSAR, although there are exceptions, such as the hot springs and soda lakes of East Africa’s Rift Valley (Lake Bogoria and Lake Elementeita)40. Given that most Ramsar sites are located on coasts, rather than mountains or deserts, wetlands new additions may be worth considering to attain several goals, including biodiversity conservation.

4.1.6.1 Traditional medicinesWorldwide, the skewed distribution of medical doctors is a weakness in public healthcare. Typically, high numbers of medical doctors practice in large cities of developed countries and low numbers in rural areas of developing countries41. As a result, traditional medicines continue to serve as the main form of health care for an estimated 80% of people in developing countries42. Across the world, diverse local health care systems have developed over hundreds, or thousands of years through complex and dynamic interactions between people and their environment, commonly used to treat parasitic diseases, diarrhoea, oral hygiene. Use of medicinal plants is also widespread in developed countries. In Australia, for example, 48% of people use complementary and alternative medicine (CAM) and 42% of the population in the United States reportedly use of CAM43, with use levels increasing significantly over the past44.

Worldwide it is estimated that of 422,000 flowering plants, 12.5 % (52,000) are used medicinally with 8% (4,160 species) of these threatened45. At a global scale, export of medicinal and aromatic plants to China, India and Germnay is huge, with China the largest exporter mainly to Hong Kong, (140 500 tonnes) as well as being the

39 White, RE. 2000. High-Throughput Screening in Drug Metabolism and Pharmacokinetic Support of Drug Discovery. Annual Review of Pharmacology and Toxicology 40: 133-157 40 The List of Wetlands of International Importance. 2007. www.ramsar.org

41 Wibulpolprasert, S and P Pengpaibon. 2003. Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Human Resources for Health 1: 12 [abstract only]

42 WHO, 2002. Traditional medicine strategy 2002–2005. www.who.int/medicines/library/trm/trm_strat_eng.pdf

43 Eisenberg DM, Davis RB, Ettner SL, et al. 1998. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 280:1569–1575.44 Pagán, J A and M V Pauly. 2005. Access To Conventional Medical Care And The Use Of Complementary And Alternative Medicine. Health Affairs 24: 255-26245 Schippmann, U, D J Leaman and A B Cunningham. 2003. Impact of cultivation and gathering of medicinal plants on biodiversity: global trends and issues. Case study no. 7. in: Biodiversity and the Ecosystem Approach in Agriculture, Forestry and Fisheries. Proceedings : Satellite event on the occasion of the Ninth Regular Session of the Commission on Genetic Resources for Food and Agriculture, Rome 12-13 October 2002. FAO, Rome. ISBN 92-5-104917-3 http://www.fao.org/DOCREP/005/Y4586E/y4586e08.htm#P1_0.

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http://www.fao.org/DOCREP/005/Y4586E/y4586e08.htm#P1_0.

http://www.who.int/medicines/library/trm/trm_strat_eng.pdf


world’s major importer (80 550 tonnes)46. Medicinal properties of plants are commonly concentrated in particular plant families, reflect their evolutionary history and ecological adaptations, such chemical defenses against herbivores, fungi or pathogens. Although common wetland plants such as bullrush (Typha), common reeds (Phragmites) and lotus (Nelumbo nucifera) seeds and are widely used in traditional medical systems, wetlands dominated by monocotyledons (Cyperaceae, Juncaceae, Typhaceae, Poaceae) are a far less important source of medicinal plants than flooded forests, swamp forests and mountain wetlands and seepage areas. Many of China and India’s most important medicinal plants, for example, are from montane bogs, seepage areas and alpine pastures of the Himalaya rather than the coastal systems better represented by RAMSAR sites. Nepal, for example exports between 7000 – 27000 tonnes of medicinal plants a year, most of them to India, worth between US$7 – 30 million/year47. Many of these are montane medicinal plants, including with threatened species, the Ranunculaceae (Aconitum), Papaveraceae (Meconopsis), Scrophulariaceae (Picrorhiza) and Valerianceae (Nardostachys). Exceptions to the limited number of medicinal plants in lowland systems are the flooded forests and swamp forests of the African, Asian and South American lowland tropics, which contain a high diversity of medicinal trees and shrubs in the Apocynaceae (Rauvolfia, Tabernaemontana), Clusiaceae (Clusia, Garcinia), Rubiaceae (Genipa) and Euphorbiaceae (Phyllanthus). In Asia, particularly China, India, Pakistan and Vietnam, government support for the development and modernization of traditional medical systems is likely to increase harvest levels from wild stocks. In India, where the Ayurvedic industry is worth an estimated US$1 billion per year, 7500 factories produce thousands of Ayurvedic and Unani formulae48. In China, clinical trials for TCM preparations are now frequent49 and the plan is to establish a series of standards for modern TCM products and a competitive modern TCM industry through new technology and standardization. In Africa and South America, production is less formalised and branding are less sophisticated, yet the scale of the trade is deceptively large. In South Africa, for example, 1.5 million informal sector traders sell about 50000 tonnes of medicinal plants annually in a region with an estimated 450 000 traditional healers50. In common with China, India and Nepal, relatively few medicinal species in African and Madagascar trade are from wetlands. Notable exceptions are a massive trade in endemic Drosera madagascariensis (Drosearaceae) from Madagascar to Europe51, and in southern Africa, three species from montane marshes and seepages, Allepidea amatymbica (Apiaceae) used for coughs and Gunnera perpensa (Gunneracae) which is used in herbal preparations prior to childbirth. Many wild

46 Lange, D. 1998. Europe’s medicinal and aromatic plants. Their use, trade and conservation. TRAFFIC International, Cambridge. 77pp.47 Olsen, C S. 2005. Valuation of commercial central Himalayan medicinal plants. Ambio 34:607-1048 Bode, M. 2006. Taking Traditional Knowledge to the Market: The Commoditization of Indian Medicine. Anthropology & Medicine 13:225–23649 Qiong W, Yiping W, Jinlin Y, Tao G, Zhen G, Pengcheng Z. 2005. Chinese medicinal herbs for acute pancreatitis. The Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD003631 1-14

50 Mander, M. 2004. Phytomedicines industry in southern Africa. in: N Diederichs (ed) Commercialising Medicinal Plants: A Southern African Guide. African Sun Media, Pretoria.

51 Paper, DH, E Karall, M Kremser and L Krenn. 2005. Comparison of the antiinflammatory effects of Drosera rotundifolia and Drosera madagascariensis in the HET-CAM assay. Phytotherapy Research 19(4):323-6

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species supplying medicinal plant markets are undergoing decline in availability, with important implications for primary health care52.

4.1.6.2 New natural productsNew natural products discovery have been radically changed due to the availability of molecular biology, PCR technology (thanks for Thermus aquaticus and innovative research) and genomic sciences53. In many ways, the biotechnology industry has become a major tool of the industry. Although the focus of this chapter is human health, new natural products have a wide range of other applications, from agriculture to cosmetics, including some with direct links to habitat conservation. The fungal infection, Phytophthora, for example, poses the major conservation threat to south-western Australia’s unique flora. One of the active ingredients used to treat Phytophtora, known as oocydin A, which has application in agriculture and forestry and conservation restoration was developed from Rhyncholacis penicillata (Podostemaceae), a plant from rivers in South-west Venezuela associated with an endophytes Serratia marcescens which produced oocydin A, a novel anti-oomycetous compound54. New antibiotics are a good example of health links to new natural products, with 5000-10000 new antibiotics discovered from bacteria and fungi since the 1950’s and 1960’s when well known drugs such as tetracycline were discovered55. The bulk of these have come from Streptomyces species, which are saprophytes found in soil, marine sediments and plant tissues. Endophytic microorganisms, which are commonly found on plants, including many wetland species produce a diverse range of compounds with potential use in medicine, agriculture and industry, including new antibiotics, anti-mycotics, immuno-suppressants and anti-cancer compounds56. The most promising wetlands to search for endophytes with commercial potential are high diversity systems of tropical lowlands, montane and boreal systems rather than mono-dominant wetlands. Recent studies in Canadian wetlands are a good example of this57.

In addition to Thermus aquaticus, as the best known extremophile, there is great interest in other extremophiles. Wetland examples are the green algae Dunaliella acidophila, which survives at pH 0 and Gloeochrysis which lives on stones in acidic (pH2) streams running out of active volcanoes in Patagonia, Argentina5859.to their chemical applications in industrial including as waste treatment, liposomes for drug delivery and cosmetics, and the food industry. This can have both positive outcomes 52 Cunningham, A B. 1993. African medicinal plants : setting priorities at the interface between conservation and primary health care. People and Plants Working Paper 1 : 1 - 50. UNESCO, Paris

53 Drews, J. 2000. Drug Discovery: A Historical Perspective. Science 287: 1960 - 1964

54 Strobel, G. A., J. Y. Li, F. Sugawara, H. Koshino, J. Harper, and W. M. Hess. 1999. Oocydin A, a chlorinated macrocyclic lactone with potent anti-oomycete activity from Serratia marcescens. Microbiology 145:3557–3564.

55 Challis, G L and D A Hopwood. 2003. Synergy and contingency as driving forces for the evolution of multiple secondary metabolite production by Streptomyces species. Proceedings of the National Academy of Sciences 100: 14555–1456156 Strobel, G and B Daisy. 2003. Bioprospecting for Microbial Endophytes and Their Natural Products. Microbiology and Molecular Biology Reviews 67: 491-50257 Kuhajek, J. M., Clark, A. M., Slattery, M. 2003. Ecological patterns in the antifungal activity of root extracts from rocky mountain wetland plants. Pharmaceutical Biology 41:522-53058 Goss, W. 2000. Ecophysiology of algae living in highly acidic environments. Hydrobiologia 433:11, 31-3759 Baffico, G D, M M. Diaz, M. T Wenzel, M Koschorreck, M Schimmele, T R. Neu and F Pedrozo. 2004. Community structure and photosynthetic activity of epilithon from a highly acidic (pH=2) mountain stream in Patagonia, Argentina. Extremophiles 8:463-473

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(such as waste treatment) and negative outcomes for wetlands and human health (such as their use in protein-degrading additives in detergents, made possible due to their with stand high temperatures).

4.1.7 ConclusionIn many parts of the world, indigenous and local peoples have existed in harmony with wetlands for centuries. In urban-industrial societies this is often not the case, resulting in adverse impacts not only on both wetlands and people’s wellbeing. Maintaining or restoring wetland goods and services cannot be achieved by working in isolation, but has to be achieved on the basis of entire watersheds. Achieving this is complex, even on a national scale, but can be done. A recent process that could be followed is the adaptive co-management system developed for a Ramsar listed wetland in the lower Helgeå River catchment, Sweden60. As wetland goods and services become scarcer, interest in the idea of paying others, such as communities on forested land, to provide environmental services on a sustained basis, is also growing6162. Worldwide, payment for ecosystem services (PES) is at an early stage, so as would be expected, fewer projects were identified in this recent inventory where money had exchanged hands. Ecouragingly for further development of policy and practice within Ramsar, these include five of the 17 Carbon PES projects (3 of them in Uganda), 2 out of 18 Biodiversity PES projects (one in Kenya, one in Uganda) and two out of 10 Water PES projects (all in South Africa). In addition, several projects, particularly those dealing with biodiversity conservation, also offered non-monetary compensation especially around biodiversity conservation. In Asia, PES schemes relevant to Ramsar are also growing. The first example is watershed management projects under RUPES (Rewarding Upland Producers for Environmental Services) in Philippines, Nepal, Indonesia63. The second case is at a much larger scale, costing 3.65 billion yuan (c. US2.4 billion dollars) between 1999 and 2001. Planned to reduce soil erosion from steep slopes in catchments, the “Grain for Green” programme in China has will ultimately involve nearly 15 million hectares of cropland and 40–60 million rural households (by 2010). Wetland restoration using ecological engineering is also being implemented in many parts of the world64. Since the wake-up call from hurricane Katrina, good science is also being applied to re-establish ecosystem services and reconnect the Missippipi

60 for example, see Olsson, P., C. Folke, and T. Hahn. 2004. Social-ecological transformation for ecosystem management: the development of adaptive co-management of a wetland landscape in southern Sweden. Ecology and Society 9(4): 2. [online] URL: http://www.ecologyandsociety.org/vol9/iss4/art2

61 Katoomba Group. 2007. Current ‘State of Play’ of carbon, water, and biodiversity markets. The full text of the inventories can be found at: http://www.katoombagroup.org/africa/pes.htm)

62 Wunder, S. 2007. The efficiency of payments for environmental services in tropical conservation. Conservation Biology 21(1):48–58

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? Swallow, B.M., Garrity, D.P. and van Noordwijk, M., 2001. The effects of scales, flows and filters on property rights and collective action in watershed management. Water Policy 3: 457 - 474. ftp://ftp.cgiar.org/IFPRItemp/Library/Effects%20of%20scales...pdf

Van Noordwijk, F., Chandler, F. and Tomich, T.P., 2005. Introduction to conceptual basis of rewarding upland poor for the environmental services they provide.http://www.worldagroforestry.org/sea/Networks/RUPES/index.asp

64 Mitsch, W J. 2005. Applying science to conservation and restoration of the world's wetlands. Water Science and Technology 51:13-26

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http://www.worldagroforestry.org/sea/Networks/RUPES/index.asp

ftp://ftp.cgiar.org/IFPRItemp/Library/Effects%20of%20scales...pdf

http://www.katoombagroup.org/africa/pes.htm

http://www.ecologyandsociety.org/vol9/iss4/art2


river to the deltaic plain65. The 'Water for Life' decade ends in 2015. Now is the time to effectively communicate links between wetlands and health to get policymakers to act.

[Tony Cunningham section ends]

4.2 Regulating: water quality; sanitation and sewage; biodiversity; climate

State of freshwater supplies for human useThe definition of water quality is not objective and depends on the desired use of the water resource. Hence, water quality is defined as the physical, chemical, and biological characteristics of water necessary to sustain water uses (UN/ECE 1995). For example, water of poor quality for drinking would contain dissolved and suspended constituents above a level that affects human health, but conversely the water may be acceptable for industrial purposes. This definition is a purely anthropocentric one, and the one used in this chapter.

Worldwide water quality conditions have degraded in almost all regions with intensive agriculture and large urban and industrial areas (Revenga et al. 2000). However, global water quality data are scarce and tends to be limited to chemical rather than biological measurements, and usually limited to developed countries. This trend is changing, given the high global burden of waterborne disease, to a greater emphasis on collecting microbiological data. Over the past century, chemical toxins and nutrients have increased in rivers in both industrialised and developing countries, with reductions in some pollutants such as metals and organic toxicants only in the last 30 years (Malmqvist and Rundle 2002). Pollution continues to be a major problem for many of the large freshwater lakes and wetlands around the world (Beeton 2002, Brinson and Malvarez 2002, Junk 2002). Algal blooms and eutrophication are being reported more frequently, and of 82 major river basins, North America, Europe and Africa had the highest organic matter concentration from 1976-90 (Revenga et al. 2000). Nitrate pollution of groundwaters is getting worse in northern China, India and Europe (Revenga et al. 2000).

In many parts of the world, agricultural land use has had a significant impact on freshwater quality and quantity, particularly in lowland streams. The decline in quality in these streams and the increased demand for freshwater are two of the most significant environmental issues facing us. The pressures on freshwater ecosystems and the resulting degradation of them have considerable public health implications. In the 19th Century the main health problems arose from faecal and organic pollution related to untreated human wastewater. Today much of this contamination has been eliminated in industrialised countries, however, this is still a problem in rapidly industrialising countries, such as China, India, Mexico and Brazil (Shiklomanov 1997), and in most tropical countries where their wastewater treatment systems are in a precarious state (Junk 2002). In addition, the disposal of untreated effluent e.g., marine and portable toilet waste directly into the environment still occurs in industrial countries. Need we forget the 3.5 billion people in mainly developing countries that still require improved sanitation or access to a secure supply of safe drinking water - a lethal combination for the transmission of waterborne diseases.

65 Day, JW, D F Boesch, E J. Cliaran, G P Kemp, SB Laska, W J Mitsch, K Orth, H Mashriqui, D J Reed, L Shabman, CA Simenstad, B J Streever, R R Twilley, C C Watson, J T Wells and DF Whigham. 2007. Restoration of the Mississippi Delta: lessons from Hurricanes Katrina and Rita. Science 315:1679-84

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Microbial water qualityIt was disappointing, but not surprising, that the latest cholera pandemic swept the globe only last decade. The re-emergence of this severe form of gastrointestinal disease occurred across the Western Hemisphere in the early 1990s (Carmichael 1997; see Response section for details of cholera pandemic; and Okun 1996 for an historical overview of waterborne diseases). Thus, despite the best efforts of John Snow and his followers (see Response section), the microbial state of drinking water, from a global perspective, is not good. Waterborne diseases continue to be a major cause of mortality and morbidity across the world. In 2000, waterborne and water-washed diseases killed 2.2 million people (most of these children) and affected more than 2 billion people (UNESCO 2003). It is likely that the reported numbers, although high, highly underestimate the real incidence of waterborne diseases. The large burden of disease is a direct result of water scarcity and poor water quality.

There are numerous classes of pathogens present in faeces that cause infections, including bacteria (enteric and aquatic), enteric protozoa, and enteric viruses, which are strongly resistant in the water environment and to most disinfectants. There are few data available on the incidence of endemic waterborne disease in the developed world, however, it appears that there are now an enlarged variety of waterborne pathogens, many with low infectious dose, and having moderate to high resistance to disinfectants. In addition, we are seeing the occurrence of waterborne disease without a faecal reservoir, with new pathogens including environmental bacteria that are capable of surviving and proliferating in water distribution and plumbing systems. For example, Legionella and Mycobacterium avium complex (MAC), which are environmental pathogens that have found an ecological niche in drinking and hot water supplies. Mycobacterium avium complex frequently causes disseminated infections in AIDS patients and drinking water has been suggested as a source of infection, in some cases the relationship has been proven (Leclerc et al. 2002).

Environments perceived as ‘pristine’ have not been spared even in developed countries: for example, in 2002 New Zealand had 2,060 water treatment plants and 2,138 distribution zones, servicing approximately 87.5% of the population. Of these, water supplies to 78% of the people complied with the E. coli criteria of the 2000 Drinking Water Standards for New Zealand (DWSNZ; MoH 2000), and 80% complied with the Cryptosporidium criteria (MoH 2003). Thus, approximately 752,000 (22%) of people were supplied with drinking water that failed to comply bacteriologically with the criteria. Microbial surveys of a number of swimming areas across New Zealand in 1994 revealed that over half the inland swimming areas were not fit for swimming, but only suitable for livestock watering (MfE 1997).

The infection dose of protozoan and viral agents is lower than bacteria, in the range of one to ten infectious units or oocysts (Leclerc et al. 2002). One of the most common protozoan agents that cause gastrointestinal disease in humans is Cryptosporidium. Oocysts of this protozoan have been identified in human faecal specimens from more than 50 countries on six continents. In developed areas such as Europe and USA the prevalence of infection ranges from 1% to 4.5%, while in developing countries it is significantly higher, up to 20% (Chin 2000). One of the modes of transmission is via water, and outbreaks have been associated with drinking water, and recreational water contact including rivers and lakes. Oocysts are highly resistant to chemical disinfectants used to purify drinking water, and advanced filtration systems are required to remove them. In 1993, an estimated 403,000 residents of the greater Milwaukee, Wisconsin, USA (population, approximately 1.61 million) became ill, and some 100 died, when an ineffective filtration process led to the inadequate removal of Cryptosporidium oocysts in one of

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two municipal water treatment plants (Mac Kenzie 1994). The documentation on the Milwaukee outbreak highlighted the need for better drinking water treatment, and the quality of public water systems have improved significantly since 1993 in the US and internationally, but there is still need for improvement.

A second common protozoan agent, which is distributed worldwide and has a high burden of disease, is Giardia. The prevalence of infection for this protozoan ranges from 1% to 30% in different parts of the world, with the highest levels occurring in countries with poor sanitation (Chin 2000). This enteric disease is similar to cryptosporidiosis but is milder and treatable, generally self-limiting and less resistant to chemical disinfectants, such as chlorine. Over the last 30 years, giardiasis has become the most common cause of human waterborne disease in the US. It is associated with drinking water from unfiltered surface water sources or shallow wells, and recreational contact in bodies of freshwater. In addition to Giardia and Cryptosporidium, some species of genera Cyclospora, Isospora, and of family Microsporidia are emerging as opportunistic pathogens and may have waterborne routes of transmission (Leclerc et al. 2002).

A further group of pathogens that are responsible for numerous cases of gastroenteritis worldwide are viruses, specifically Norwalk-like viruses (NLVs). In 2002 these viruses were reclassified into a new genus Norovirus in the Caliciviridae Family. Molecular detection methods indicate that NLVs are the major culprits for food and waterborne nonbacterial gastroenteritis. In the US, it is estimated that more than 60% of the population have antibodies to NLVs by their fifties (Chin 2000). While in developing countries antibodies are acquired at a much earlier age. Cases of gastroenteritis from NLVs most often occur in outbreaks rather than sporadically. For example, an outbreak of gastroenteritis due to NLV occurred in a Swedish ski resort during February-March 2002, affecting approximately 500 people (Carrique-Mas et al. 2003). Epidemiological investigations indicated that one of the communal water systems was a significant risk factor, however, microbiological findings were inconclusive. It was not until a month later when a crack in a sewage pipe 10 meters from the well was discovered, that an intervention was put into place.

Other viruses that are frequently transmitted via contaminated water are Hepatitis A (HAV) and Hepatitis E (HEV). Hepatitis A occurs worldwide, is sporadic and epidemic, with a tendency to cyclic recurrences. In developing countries, adults are usually immune and epidemics of HAV are uncommon (Chin 2000). Ironically, improved sanitation has resulted in individuals lacking immunity, and the frequency of outbreaks is increasing. In contrast, HEV has a more limited distribution, mostly confined to tropical and subtropical areas, primarily in areas with inadequate sanitation. However, recently it is becoming an issue in countries where it was not traditionally endemic, such as in Europe (Worm et al. 2002). Outbreaks of HAV and HEV typically follow heavy rains, when water sources become contaminated by sewage, or during dry periods when viruses are concentrated in contaminated water sources. Between December 1992 and April 1993, 3,682 individuals were affected by a large waterborne epidemic of hepatitis E in the city of Saharanpur, Uttar Pradesh, India (Singh et al. 1998). The source of the contamination was traced back to a leakage in the municipal water supply pipes, which passed through sewerage holes.

Chemical water qualityAs with the microbial state of drinking water, the chemical quality of drinking water on a global level is poor, particularly in developed and rapidly industrialising countries. In the 1970s the US Environmental Protection Agency found hundreds of

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organic chemicals in drinking water sources, many of which were believed to be carcinogenic and teratogenic (Okun 1996). Epidemiological studies in New Orleans at this time, revealed higher levels of cancer in individuals using the treated water supply versus those using untreated groundwater (Talbot and Harris 1974). This led to the passage of the Safe Drinking Water Act in the US in 1974. At the same time on the other side of the world, Rook (1974) showed that the common chemical used for water treatment, chlorine, created disinfection by-products (DBPs) which were carcinogenic in rodents. To date, epidemiological data indicate potential developmental, reproductive, or carcinogenic health effects in humans exposed to DBPs (Malcolm et al. 1999; Anderson et al. 2002). The data are so far inconclusive, and there is need for further research (see Research section). A further controversial topic is the occurrence of endocrine disrupting chemicals (EDCs) in aquatic environments, particularly freshwater systems used for human drinking water. Pollutants that contain EDCs include pesticides, dioxins, excreted drugs, alkylphenols, and furans, which enter the environment directly via agricultural or industrial activities or from treated sewage effluent. Although EDCs currently occur in low concentrations, they may cause significant health effects on aquatic organisms and humans (Melnick et al. 2002). Other chemicals of concern, are the growing number of cases of contaminated groundwater by metal ions from natural and anthropogenic sources around the world, as illustrated by the almost inconceivably vast scale of Arsenic poisoning on the Indian subcontinent (Frisbie et al. 2002).

Chemical contamination of freshwaters has occurred over a number of years as a result of both human activities and natural processes. At common concentrations, most chemicals are likely to cause adverse effects only after prolonged periods of exposure, and monitoring suggests chemicals in drinking water supplies do not contribute a major health risk. That aside, there are cases where chemical pollution of freshwaters have occurred and may be detrimental to human health. For example, base-metal mining in Te Aroha, North Island, New Zealand, has resulted in concentrations of arsenic, cadmium, lead and zinc above the levels recommended for drinking, in the Tui and Tunakohoia streams (Sabti et al. 2000).

Thus, there are two reasons why the foregoing discussion cannot be dismissed as irrelevant to developed world countries. Firstly, it is clear that we must think at a global scale. Freshwater ecosystem disruptions at this scale will affect both developed and developing countries, much as will be the case for the health effects of climate change (Woodward et al. 1998). On one hand we see that waterborne outbreaks of bacterial origin (particularly typhoid fever) have declined dramatically since the 1900s in the developing world, but on the other hand we have had increased rates of waterborne disease in the developed world. Secondly, consider the emergence of Giardia and Cryptosporidium as a significant waterborne pathogen in communities served by state of the art water treatment plants. These examples suggest that even the best 'western' drinking water supplies can pose a health risk, and that the sound state of drinking water is not one that we can keep taking for granted.

4.3 Cultural: spiritual; recreational; educational [to be added]

4.4 Enhancement: agricultural production and support of industrial development; disease elimination

The need to artificially increase water availabilityThe availability of freshwater has been a fundamental pre-requisite for human health since our ancestors first walked upright over four million years ago. Hunter-

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gatherer societies in the modern era provide some insight into the importance of water to these early ancestors, whose foraging patterns, migration routes, cultural evolution, health, and often very existence, were dependent on the availability of freshwater. Water availability was also critical to the development of the earliest settlements in the Old World, and to the agricultural practices that accompanied them. It is no accident that the first significant concentrations of cities, towns and villages all arose in major river valleys: the Nile, the Tigris and Euphrates, and the Indus.

[INSERT REVIEW FROM JARDINE HONS]

Human population size and water consumption rose sharply following the development of agriculture and urbanisation some 10,000 years ago. Water was used for irrigation, thus providing, for the first time in human history, a reliable source of food that permitted urban settlement and major population growth. This was the first epidemiological transition, and diseases of starvation and warfare were replaced by infectious diseases and specific nutrient deficiencies. We then became industrialised, only some 200 years ago, and water consumption again rose because of industry needs and further population growth. Water use became distributed roughly as it is today, with 70% going to irrigated agriculture, 20% to industry, and 10% to domestic use. This second epidemiological transition was associated with another shift in the disease burden as a result of exposure to environmental hazards and toxins, and a more sedentary lifestyle and over-consumption. The global population has now swelled to 6 billion (10 billion by 2050; UNESCO 2003), all growing food and therefore increasing water use further. Between 1900 and 1995, water withdrawal worldwide increased six-fold, more than twice the rate of population growth (Revenga et al. 2000). Ironically, as we head into the 21st century it is predicted that water availability will be one of the key factors that will limit development.

4.5 Deterioration: water purification, sanitation & sewage; loss of disease regulation and increased disease contact; vulnerability to drought, flood, disasters and climate change; arable land, irrigation and famine; biodiversity

Pressures on freshwater suppliesThe main pressure on the world's freshwaters arises, not surprisingly, through an imbalance between supply and demand. We consider freshwater to be a renewable resource, but it is also a finite resource. If a balance is to be maintained between its use and its renewal via the hydrological cycle, then the demand for freshwater must not exceed rates of supply. This is an obvious statement, however in many parts of the world this is not occurring. Although our 'blue planet' as seen from space is predominantly covered with water, less than 1% of this water is available for drinking: 97% of Earth's water is salt water, and more that 2/3 of the remainder is locked up in the polar icecaps (Mackenzie 1998). In addition, there are large disparities between global population densities and water availability. Asia is worst off, having the lowest volume of freshwater to population ratio, compared to Australia and Oceania with the highest ratio (Table 47.1). This situation will deteriorate as the world population grows. By 2025, at least 3.5 billion people or 48% of the world's population are expected to face water scarcity (Revenga et al. 2000).

The available reserves of freshwater are therefore limited, and importantly, not growing. The population on the other hand is growing and, seen simplistically, consuming an ever-increasing proportion of an ecologically limited resource. The

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imbalance arises from the technological advances that have accompanied our cultural evolution: whereas animal populations are generally limited by the availability of resources, human population size and water consumption rose sharply following the development of agriculture and urbanisation some 10,000 years ago. Water was used for irrigation, thus providing, for the first time in human history, a reliable source of food that permitted urban settlement and major population growth. This was the first epidemiological transition, and diseases of starvation and warfare were replaced by infectious diseases and specific nutrient deficiencies. We then became industrialised, only some 200 years ago, and water consumption again rose because of industry needs and further population growth. Water use became distributed roughly as it is today, with 70% going to irrigated agriculture, 20% to industry, and 10% to domestic use. This second epidemiological transition was associated with another shift in the disease burden as a result of exposure to environmental hazards and toxins, and a more sedentary lifestyle and over-consumption. The global population has now swelled to 6 billion (10 billion by 2050; UNESCO 2003), all growing food and therefore increasing water use further. Between 1900 and 1995, water withdrawal worldwide increased six-fold, more than twice the rate of population growth (Revenga et al. 2000). Ironically, as we head into the 21st century it is predicted that water availability will be one of the key factors that will limit development.

The increasing pressures on freshwater ecosystems, both via demand for water and anthropogenically driven ecosystem disruption, has resulted in a loss of available water and a reduction in its quality, both for human consumption and in a wider ecological sense for “healthy” ecosystem function. The risk now is that water consumption will keep rising at a rate that is not ecologically sustainable, or, in other words, that it will be drawn off more rapidly than it can be replenished. Because biological systems are often not linear in their responses to such pressures, positive feedback loops can result where they have not been anticipated. In Mexico City for example, groundwater has been drawn off so rapidly that the city has subsided several meters in the last decade (Lanz 1995). The result is a cracked and leaky water distribution system, leading to more rapid draw-off and further subsidence, and to the loss of a full one third of this valuable resource to leakage. Another example of a non-linear response is afforded by the advent of arsenic into drinking water wells in Bangladesh; upon lowering the water table through excess draw-off, some minerals became exposed to atmospheric oxygen, were oxidized, and released arsenic into the remaining groundwater (Frisbie et al. 2002).

Demand for water for all purposes is increasing. Water is valued for many reasons including economic (for irrigation and industry), environmental (maintaining ecosystems that rely on streams and groundwater), health (for water supply and safe swimming), cultural and recreation (for fishing, boating and canoeing). However, the increasing demand for water (in terms of both higher quantity and quality) has brought about considerable public debate on the uses that water is put to, and how much is available for different purposes. Among the greatest impacts are agriculture and horticulture, and water supply and demand factors will be of increasing prominence in agricultural investment decisions over the next 10 years and beyond.

The pressures on freshwaters are not only an important economic issue, but they also have considerable public health implications, as in the example above of arsenic contamination of groundwater in Bangladesh. As pressure builds upon the world's freshwater and other ecosystems, some researchers have argued that we have begun a third epidemiological transition - where the disease burden results from global ecosystem disruptions. The research literature on the health effects of

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climate change, the emergence of infectious diseases, and the disruption of social systems is extensive and tends to support this suggestion (e.g., Grifo and Rosenthal 1997; Aron and Patz 2001; Martens and McMichael 2002). The health impact of the third epidemiological transition is likely to be felt hardest where resources are most limited i.e, water.

Human activities such as agriculture, industry and mining, and their associated inputs (run-off or byproducts) into freshwater ecosystems can directly affect human health (Table 47.2). Industrial developments frequently modify water catchments, and often result in the reduction in water quality or the complete loss of the water resource. Industries can affect water chemistry via SO2 and NO2 emissions, leading to water acidification, and via the addition of nutrients, toxic metals, organochlorine toxins (e.g., DDT) and organohalogens (e.g., PCBs). Additional health problems caused by anthropogenic ecosystem disruption include waterborne diseases e.g., Cryptosporidium outbreaks, increased Giardia prevalence, and possible waterborne transmission of Campylobacter (see next section).

An important and highly charged issue in many countries is the debate concerning farming and grazing and the degradation of waterways and groundwater aquifers. This is a concern globally, as increasing stock levels, poor management practices and the clearing of riparian vegetation for further grazing allows high volumes of farm effluent, excess nutrients and chemicals to enter waterways, contributing to microbiological contamination and excess nutrient loadings. For example, in May 2000, Escherichia coli O157:H7 and Campylobacter jejuni contaminated the drinking water supply in Walkerton, Ontario, Canada (Anonymous 2000). Six people died and over 2,000 people were ill as a result. Investigation of the outbreak traced the source of the disease to a contaminated well supplying the municipal water system. Evidence from molecular subtyping suggested that the pathogens originated from cattle manure on an adjacent farm. The most pathogen (e.g., Campylobacter) contaminated waters are usually in intensively farmed areas, and waters where lots of birds live (McBride et al. 2002).

In addition, demands on water supplies and anthropogenic environmental change can result in indirect health affects, by limiting the availability of safe drinking water. Not only are communities forced to access unsafe drinking water, but water scarcity also increases the risk of disease from lack of sanitation. This will be exacerbated by climate change. Although precipitation will probably increase from latitudes 30ºN and 30ºS, many tropical and subtropical regions are likely to receive lower and more erratic rainfall. It is estimated that climate change will account for approximately 20% of the increase in global water scarcity over the next 20 years (UNESCO 2003).

5. Health Effects of disrupted Wetland ecosystems (15pp.)(direct and indirect effects of non-sustainable extraction and contamination)

Introduction

The health effects of wetland ecosystem disruption can be directly traced to the particular ecosystem service that has been disrupted (Section 4.0). However, because services are often over lapping and health effects complex and indirect, it is important from the outset to contextualise the relationship in terms of whole-of –ecosystem health supporting human health at both the individual and population level. The term ‘health’ here as applied to the human population is used in the broadest possible sense - although the definition of the term is the subject of

31


constant debate, redefinition, and review, for the purposes of this report a useful operational definition is that of the WHO (19xx): [citeXXXX]

The definition reflects the spectrum of possible health effects that can result from human exposure to unhealthy wetland ecosystems, from thirst because of lack of water, through acute infectious disease and chronic toxicity because of contaminated water, to unhappiness because of an unstimulating environment. Although we have emphasised the ‘holistic’ nature of the relationship between ecosystem health and human health, it is nevertheless necessary to adopt a reductionist approach for the purposes of understanding particular health outcomes. Therefore, a table of ecological exposure pathways has been included in which disease outcomes are related to those wetland ecosystem services most directly responsible (Tables 5.1, 5.2)

[Description of individual health outcomes based on table]-% population under water stress- acute (microbial)- chronic (chemical)- cultural- indirect (climate change)

One approach to quantifying the disease burden that results from water related disease, and therefore the cost associated therewith, is the use of DALYS.

[INSER PARA ON DALYS]

On a broad scale, it has been estimated that (cite environmental disease burden as % of global Dalys and water-related Dalys as a % thereof). Based on Daly calculations it is possible to estimate the cost of the health consequences of disrupting wetland ecosystem services, but these often include only direct costs of clinical disease (See Section 6). Harder to cost but more disastrous is of course the ultimate price of loosing wetland ecosystem services: the collapse of civilization, or in ecological terms, local extinction of humans. Jared Diamond (2005) illustrates this point better than anyone in Collapse, citing non-sustainable water management as a key factor in the demise of the Anasazi and a number of other historical civilisations.

Water pollution

The relationship between healthy humans and clean drinking water goes back to over 200,000 years ago when modern humans first emerged. We were hunter-gatherers and directly dependent on the availability of resources in our immediate environment – foremost of which was a reliable and clean source of drinking water. Later, when we developed agriculture and industry, the increasing rate of human exploitation and modification of the environment adversely affected the health of wetlands, some of which are now no longer able to provide the clean drinking water upon which we are dependent. Sources of drinking (and irrigation) water now contain toxic pollutants that poison plants, fish and people, and microbial pathogens that kill almost two million children annually.

Despite the capacity of freshwater wetlands to purify water, they do have their limits. They can only deal with so much agricultural runoff, so much inflow from domestic and industrial wastes. And of course the human species is capable of adding much more – toxic chemicals (such as PCBs, DDT and dioxins), antibiotics from animal husbandry, untreated human sewage, pesticides that act as ‘endocrine

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disrupters’ . . . and more. We can, and do, readily move beyond the purifying powers of wetlands so that these sources of freshwater, and the food they supply, are rendered unfit for consumption and pose a danger to human health.

Wetlands act as filters or traps for many of these toxins and pathogens - when the passage of water through wetlands is slow enough, toxic compound break down or are removed by chemical and biological processes in the water column, and pathogens lose their viability or are consumed by other organisms in the aquatic food chain. Human-made wetlands are now being constructed in both urban and rural areas to capitalize on the purification capabilities of wetlands, thus preventing untreated sewage from reaching natural wetlands that are used as immediate sources of drinking water.

It is only in the last couple of decades that we have come to appreciate the strength of the fundamental relationship between wetland ecosystems health, sustainable supplies of clean drinking water, and human health. New environmental management strategies are therefore being developed that support the maintenance of wetland ecosystem health and human health concurrently. One valuable strategy for doing so may lie in using the human water-borne disease burden as a bio-indicator to help target and prioritise wetland remediation: Because human health data are generally collected more widely and more reliably than are ecosystem health data, they can provide a cost-effective guide to identifying wetland that are no longer capable of providing clean drinking water to the populations that are dependent upon them.

Closer collaborations between wetland ecologists and health researchers could help sure up the sustainable provision of wetland ecosystem services such as the provision of clean drinking water, and thereby minimize the human health risk from water pollution.

Water-related diseases

Human health is directly dependent on wetlands, but wetlands can also be associated with an increased incidence of particular human diseases. The draining of swamps is a well know example of human modification of wetlands to improve health, and contributed to the eradication of malaria in many parts of Europe. However, the deliberate removal of wetlands because of the diseases they may harbour is a non-sustainable approach to wetland management that can backfire through ecological mechanisms that are only just beginning to be understood.

In many parts of the world, human health is directly affected by wetland-associated diseases. Malaria (because mosquitoes breed in wetlands), and diarrheal infections including cholera (because of sewage contamination) are globally the worst wetland-associated diseases in terms of their human impact, accounting for 1.3 and 1.8 million deaths respectively in 2002, and causing disability and suffering in many millions more. While malaria and diarrheal diseases are the two worst in terms of human impact, a serious disease burden also results from other diseases such as schistosomiases, Japanese encephalitis, filariases, onchocerciasis and others that affect millions. The vast majority of these diseases are seen in children under 5 years old, particularly in Africa, Asia, and parts of the Americas.

On the other hand, diseases resulting from the absence or removal of wetlands also needs to be considered: Controlling malaria was one of the driving forces for wetland destruction in the past, but such destruction has led to the loss of vital ecosystem services such as the provision of clean water and supply of food. One

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third of the world’s population lacks sufficient clean water for drinking, personal hygiene and cooking. This staggering health statistic is a direct result of human populations exceeding the carrying capacity of the wetlands that provide our basic water supplies. Even when water is available in abundance, wetland ecosystem disruptions can carry a heavy disease burden: Over-irrigation results in standing water in which disease carrying mosquitoes breed, and water used by industry often allows toxins to enter the human food chain. Altered hydrologies and vegetation structures can lead to hardship, global environmental change, and, most recently, a host of new, ’emerging’ infectious disease epidemics.

The removal of wetlands is therefore not a disease management option that should generally be considered. The incidence of many of these diseases can instead be reduced through provision of clean water, improved sanitation, and – importantly – good management of wetlands. Sustainable approaches to the management of wetlands includes, for example, the use of fish that consume mosquito larvae, or bacterial larvicides that kill them without affecting other organisms. Better design, management, and regulation of dams and irrigation schemes and water drainage systems are other examples of such practices, and significant disease reduction can be achieved by combining different approaches.

When ecosystems services fail, human health suffers, and every attempt sould therefore be made to find management solutions that benefit both ecosystem health and human health concurrently.

5.1 By type of wetland5.1.1 Freshwater: water borne disease; vector borne disease;

malnutrition5.1.2 Saltwater: malnutrition; vector borne disease5.1.3 Artificial: vector borne disease; displacement

The disruption or elimination of wetland ecosystems by urbanisation can lead to health gain with the disappearance of vector borne “rural” diseases such as malaria (Macau, Réunion). However, the creation of artificial urban wetlands can equally enhance the transmission of vector borne diseases such as dengue, which depend on “peri-urban” vectors.

Mosquito-borne diseases are re-emerging as a significant threat to public health worldwide (Gubler 2002). Malaria, dengue and other mosquito-borne diseases are increasing in incidence in areas where they were previously thought to be under control, and expanding into new geographic regions (Campbell 1997; Baird 2000; Gubler 2001). Changes in vector density and distribution following anthropogenic ecological and environmental changes, are among a range of factors are responsible for this (Gratz 1999; Molyneux 2001; Gubler 2002). Water resource developments such as dam construction (Ghybreyesus et al. 1999; Singh et al. 1999) and agricultural irrigation (Mulla et al. 1987; Service 1989; 1991; McMichael 2001) are important examples of such changes that may support mosquito breeding and adversely impact on associated disease transmission. More recently, the soil salinization that follows land clearing has joint the list of mechanisms that enhance vector mosquito breeding. The aquatic ecosystems upon which all of these re-emerging mosquito-borne diseases depend are the result of anthropogenic changes in hydrogeology.

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Decreased biodiversity leads to increased opportunities for single species to become dominant, and this effect has been observed in the aquatic ecosystems that mosquito larvae for part of (Cramer and Hobbs (2002), Halse et al. (2003), Pinder et al. (2004), Pinder et al. (2005).

One important outcome of EDS is changes in disease prevalence human populations as the ecosystem services that sustain human health are eroded (Rapport et al. 1985). While humans have developed technological buffers against environmental change to a certain extent, these are rarely available in developing countries, where populations are therefore ultimately dependent on proper ecosystem functioning for wellbeing and survival (McMichael 1993; Rapport 1999, 2002).

Changes in vector density and distribution following ecological and environmental disruption are major factors responsible for increasing mosquito-borne disease transmission worldwide (Gratz 1999; Gubler 2002; Jardine et al. 2004; Molyneux 2003; Vasconcelos et al. 2001). Anthropogenic changes in land use and land cover are primary drivers of such ecological disruption and have the potential to strongly influence human vulnerability to vector-borne diseases, particularly those carried by mosquitoes (Sutherst 2004). Such land use changes can be broadly classified into the following non-mutually exclusive categories: water resource developments; deforestation; agricultural development; and urbanisation (Norris 2004).Ecological changes following development of agricultural irrigation schemes do not necessarily increase the overall number of mosquitoes present. In some cases the species composition of the mosquitoes present changes significantly rather than an increase in absolute number, as irrigation development favours the breeding of some species but not others (Amerasinghe & Indrajith 1994; Hearnden & Kay 1995). Given that some species are more competent disease vectors than others, this has clear implications for health.

The complex nature of mosquito-borne disease transmission means that the exact impact on health is variable and difficult to predict. While water resource developments generally create the potential for increased disease transmission, the actual effects on health are a product of many factors and the subtle interactions between them. These factors include the virus itself, the mosquito vector population, the vertebrate host population, the human population and the environment/climate (Monath 1993; Weinstein 1997).

5.2 By type of health effect5.2.1 Malnutrition*5.2.2 Sanitation-related infectious disease

Campylobacteriosis was first recognised as an 'emerging' human gastrointestinal disease in the late 1970's (Skirrow 1977), and is now the most commonly notified disease in the Western World. It accounts for about 10% of all diarrhoea world wide. Other gastrointestinal diseases have not demonstrated such marked changes, suggesting that the rise in campylobacteriosis is greater than what could be expected as a result of improved ascertainment alone. The question arises, therefore, as to what unique aspects of disease ecology have led to this pattern.

Campylobacter jejuni is a bacterium that invades the intestinal lining. The consequences range from asymptomatic infection, through diarrhoea with abdominal pain, to rare but severe complications that include arthritis and nerve inflammation. The characteristic acute diarrhoea arises 2-5 days after exposure (ingestion), and is usually associated with abdominal pain, malaise, fever and

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nausea. An acute episode is usually over within 2-5 days, but sometimes lasts for up to 10 days and longer in case of complications (Benenson 1995).

Campylobacteriosis is a food and water-borne zoonosis with a reservoir often consisting of domesticated animals including poultry, sheep and cattle. Only in these reservoirs, and in humans, will Campylobacter multiply, and it is therefore known as thermophilic. Its transmission in food and water does not depend on growth rates in these media as is the case with some other gastrointestinal pathogens, but is rather a matter of 'survival trajectories' between excretion by the reservoir and ingestion by the case (Skelly and Weinstein, ref). The survival of this organism in the environment is subject to the influence of a variety of abiotic factors. To understand the variety of independent variables acting at different levels of organisation, and the interactions between host agent and environment factors, it is necessary to broaden the traditional epidemiological perspective into one more closely aligned with the science of ecology (Weinstein 1997, Aron and Patz 2001).

Environmental prevalence of CampylobacterExample: New Zealand. NZ is a fertile, mountainous country, separated by thousands of miles of ocean from neighbouring land masses. New Zealand has over 770 lakes, 70 major rivers, and thousands of streams that provide about 60% of the water consumed by the human population of 3.8 million (MfE 1997). Pastoral farming has a major impact on both water flow and quality. Over the last 150 years, deep-rooted vegetation has been removed from hill sides and riverbanks, increasing the volume and speed of runoff during heavy rains that in some places reach 11,000mm per year. Much of the farming land is heavily stocked with sheep and cattle, and over XX million heads of stock excrete about 40 times the mass of faeces produced by the human population (MfE 1997). Some of this excrement is washed into waterways with heavy rains, where it may come into contact with humans both directly (drinking, recreation) and indirectly (by 'seeding' secondary cases; see following section).

The natural self-purification of water percolating through soil and vegetation is reduced as a result of changes in land cover. This exposes both stock and humans downstream to a variety of zoonotic pathogens, including Campylobacter, Cryptosporidium, and Giardia (Weinstein et al. 2000). Recent surveys have found over 50% of New Zealand's surface waters appear to be contaminated with Giardia (Brown reference [?]). Even in undeveloped catchments, Campylobacter occurs in over 50% of samples (McBride et al. 2001). Campylobacter levels in the Taieri River near the Southern city of Dunedin ranged from X to Y maximum probable number (MPN) in a recent study (Eyles et al. in review), exceeding drinking water standards in x% of samples and recreational water standards in y% of samples [PW insert data].

Given the prevalence of Campylobacter in the environment, drinking water is clearly one possible source of exposure for the human population. The organism is sensitive to chlorine, but the quality of water treatment across New Zealand varies widely. About 20% of the population is served by supplies that have not been graded as “satisfactory”. This includes supplies for populations of less than ?250 people, which are not covered by the public health water grading system, and supplies that have been assessed, and have been found to deficient .(reference - ? Ministry of Health source) Exposure may also occur through an outdoor lifestyle that includes much hiking (and drinking from untreated surface waters) and recreational water use (in untreated surface waters). Thus, the New Zealand environment contains a widespread hazard in the form of contaminated surface water, to which a significant proportion of the population is regularly exposed through drinking water and/or

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outdoor activities. It is perhaps not surprising then that New Zealand has very high notification rates, by international standards, of most zoonotic and potentially water borne gastrointestinal disease (Weinstein et al. 2000, Duncanson et al. 2000).

What of other sources of infection? A New Zealand case control study found an association between notified illness and consumption of certain foods, notably grilled chicken. (ref – MAGIC study) Other risk factors include …….?working in day care centres etc But these within-population studies cannot provide an insight into differences between populations. There is no evidence or a priori reason to indicate that New Zealanders have poorer hygiene or significantly different cooking practices to other countries with a similar sociocultural makeup, such as Australia, the UK, or Canada, where campylobacteriosis rates are as much as an order of magnitude lower (CHECK). (Table 1) Variations in health care services and disease notifications are also unlikely to produce such marked differences in disease rates. But as we have indicated already, agricultural development directly influences biodiversity, ecosystem health, and hence the risk of disease transmission in freshwater ecosystems (Townsend et al. 2002). Therefore high rates of campylobacteriosis may result, in significant part, from the unusual ecology of the causative organism in New Zealand's uniquely modified ecosystem.

Drinking water quality and gastroenteritis

Although most Western drinking water supplies are treated and monitored, infection in a small number of supplies could theoretically generate a disproportionately large number of cases. In addition to direct transmission, pathogens in water may affect humans through occupational exposures to infected stock, contamination of the food chain, or contamination of a variety of fomites by faeces from both infected humans and infected stock. Generation of cases in this way could obscure the importance of potential 'seeding' sources of infection: for example, recreational use of an untreated rural freshwater body may lead to faecal-oral transmission in an urban environment, with the latter accounting for the majority of cases. It is difficult to track the development of outbreaks, or even to make urban-rural comparisons of incidence rates, because of limited data for geo-referencing .(Skelly et al, 2000) However the potential for seeding of secondary cases means that simple spatial comparisons are not necessarily helpful in assessing the extent of waterborne transmission.

The frequency of infection with another zoonotic water-borne pathogen, Cryptosporidium, has been shown to relate directly to drinking water quality.

The relationship between campylobacteriosis ecology, rainfall, and temperature

Some of the features of the epidemiology of campylobacteriosis are consistent with signficant water-borne transmission; others are not. For example, one might expect that both environmental pathogen levels and human illness would peak in winter, when run off from pastoral landscapes is at its maximum. However, notifications of illness show a consistent summer peak. On the other hand, many people lead an active, outdoor lifestyle, with exposure to pathogens in surface waters both through drinking and recreational water use. These behaviours peak during the warmer months of summer, which is also the time when environmental levels of Campylobacter are highest.

In America and Europe winter tends to be the peak time for environmental prevalence of viable Campylobacter (CHRIS references). This seasonal pattern is

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explained in terms of increased survival of the organism at lower temperatures, a decreased Campylobacter mortality with lower exposure to ultraviolet radiation, and increased runoff with winter rainfall (CHRIS references). Historically, catchment areas providing water destined for human consumption have been closed to agricultural use or recreation. The advent of powerful, high volume water treatment plants has made the protection of catchments a less pressing concern. From the perspective of campylobacteriosis and other enteric infections such as cryptosporidisos and giardiasis, however, there are good reasons to review catchment management. For instance, many catchment areas have been cleared and left as grassland or planted in exotics (Pinus radiata in particular), but native vegetation has the highest natural filtration capacity of any land use, slowing runoff and increasing percolation (Mosley 1992). Water from catchments with native vegetation is less likely to contain viable pathogens than water from catchments with no native cover. Replanting and protecting native vegetation in these areas reduces erosion and enhances conservation, and may bring public health benefits also. Importantly, it is not only the direct transmission of Campylobacter in drinking or recreational water exposure that will be affected. If stock infections are also decreased as a result of re-growth of native plants in water catchments, then the number of human infections acquired occupationally (in farms and abattoirs) and by the food-borne route (via animal products) will also be reduced.

One response to this challenge would be an accelerated vegetation restoration programme in water catchment areas. Such a programme would not only retard runoff and improve the self-purification of water from appropriately re-afforested catchments, but would also provide an additional carbon sink to help mitigate the climatic changes that are putting pressure on the catchment in the first place.

For a variety of vector-borne, water-borne and other 'environmental' diseases, appropriate, scientifically based public health interventions can only be devised with an understanding of the ecology of the disease. By extension, effective adaptation to the potential effects of climate change is more likely to occur if based on a sound understanding of the relationship beween ecosystem health and human health. An accelerated programme of re-afforestation in water catchments would serve as a means of reducing simultaneously greenhouse gases and the burden of gastrointestinal disease. Adaptation to climate change in this case provides the opportunity to improve both ecosystem health and human health concurrently.

5.2.3 Toxic and mutagenic effects5.2.4 Sociocultural

In the social sciences, the concept of ‘sense of place’ is one of the most common that can improve understanding about the relationship between wellbeing and human-environment relationships, and is summarized in Tucker et al (2006): “ Sense of place may broadly be described as the meanings which people assign to a landscape through the process of living in it, and comprises the cognitive, emotional and behavioural dimensions of place identity, place attachment and place dependence (Ryden, 1993). Place identity involves “those dimensions of self that define the individual’s personal identity in relation to the physical environment by means of a complex pattern of conscious and unconscious ideas, beliefs, preferences, feelings, values, goals and behavioural tendencies and skills relevant to this environment” (Proshansky, 1978, p. 155). Place attachment is a positive bond that develops between groups or individuals and their environment (Altman and Low, 1992). Place dependence is an “occupant’s perceived strength of association between him or herself and specific places” (Stokols and Shumaker, 1981, p. 457) and incorporates

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the manner in which environments facilitate the achievement of valued behavioural goals.” To determine the relationship between sense of place and a preparedness to invest in protecting ecosystems and the water services they provide, Tucker et al carried of a questionnaire based survey of residents in the Hawkesbury river area (NSW, Australia). They found that “in terms of intentions for performing protective behaviours or being willing to pay for protective measures, these are clearly linked to a number of threats that are directly associated with the urban water system, specifically: sewage/wastewater disposal; algal blooms; and litter. Further, it was evident that all Sydneysiders were concerned for the health of the river system, regardless of where they lived, and that it was the river system as a whole that was of interest, rather than any specific location.” (Tucker et al 2006, p.25)

5.2.5 Indirect effects (to include climate change - 1896 Svante Arrhenius CO2 and global warming)

Long term effects of failing to regulate natural hazards: “not all health problems recede with the floodwaters”.

Long-term health impacts in communities that have experienced natural disasters are often overlooked. Recovery from natural disasters such as flooding, mudslides, or hurricanes is often a long, drawn-out process. Recovery plans need to address these interruptions in the return to pre-disaster functioning and make provisions for addressing ongoing health problems. It is therefore relevant to examine illness patterns that may arise, directly or indirectly, in the months and years following a wetlands-related disaster event.

Natural disasters are extreme environmental events that may cause substantial morbidity and mortality in the population.[1] Some disasters are discrete, relatively infrequent events (such as earthquakes), whereas others may follow an intermittent or cyclical pattern, including monsoonal floods, bushfires, and cyclones. At the other extreme, disasters may occur as a long-term and ongoing process: it may be argued that climate change increasingly falls into this category, and that this global phenomenon drives the frequency and intensity of other wetlands-relevant disaster events.

Although each of these natural disasters may produce serious health consequences for victims, it is often the identification and management of short-term ill-health that captures most of the attention and resources. In contrast, long-term health impacts in communities that have experienced natural disasters are often overlooked. Recovery from natural disasters is often a long, drawn-out process. Ongoing assistance is often required for long-term physical needs, and adverse impacts on psycho-social well-being can be protracted. In addition to defined clinical entities such as post-traumatic stress disorders (PTSD), many families suffer considerable financial hardship and social displacement following a disaster event. Recovery plans need to address these interruptions in the return to pre-disaster functioning and make provisions for addressing concomitant mental health problems.

The disease burden following major disaster events ranges from psychopathology (e.g.depression and generalized anxiety; substance use) to physical injury and systemic illness. The pathways to such disease events may be direct or indirect, and Galea (2007) notes, such illness may become apparent across a spectrum of

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community members following a catastrophic event, including: people injured during the mass trauma; rescuers; people who have lost property, belongings or capacity to sustain a livelihood; families of those injured; and the more general population who may lie outside the ‘disaster zone’ but are nonetheless affected in indirect ways by the event.[2] The principal health outcomes, as well as possible pathways to community health impact and morbidity measures that could potentially be used to evaluate such endpoints, are summarized in Table X.

Table X. Summary and review of post-disaster community health indicators

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QuickTime™ and aTIFF (LZW) decompressor

are needed to see this picture.

. The principal injuries reported after flooding include lacerations, blunt trauma, and puncture wounds, often in the feet and lower extremities.[3] Ahern’s 2005 review of flood-related conditions reported sprains/strains (34%), lacerations (24%), ‘‘other injuries’’ (11%), and abrasions/contusions (11%).[4] A follow-up analysis after Hurricane Iniki in 1992 reported that a total of 1 584 injuries were treated compared with 231 injuries treated in the pre-Iniki period (relative risk = 6.86, 95% CI 5.98-7.87); of the disaster-related injuries, over half were open wounds.[5, 6]

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Similar patterns of injury were observed after the 2004 South Asia tsunami, with many patients requiring amputation because of surgical irreparability, delays in care or trauma-related complications.[7] Major head and chest injuries, usually fatal, crush injuries and peripheral limb injuries are characteristic of major earthquakes, such as the 2003 Bam earthquake and 2005 Kashmir quake.[8] [9, 10] Although many of these injuries are limited and non-disabling, the pathway to recovery may not be complete for many individuals. Brain injury, limb amputation or paralysis may require prolonged rehabilitation and institutional care.[11] Orthopedic services are often limited in less industrialized nations, as are options for post-surgical management, such as fitting of prostheses, physical and occupational therapies, and other pathways for remobilization and return to work-related activities.[8, 12]

There is ample evidence that natural disasters are linked to increased rates of infectious disease. However, this is not an inevitable consequence. The majority of infections of concern occur during or shortly after the acute disaster phase. Post-injury complications are an immediate concern: after the 2004 tsunami, for example, polymicrobial wound infections were common and contained pathogens from sea-water, freshwater and soil.[15] Injuries with secondary Gram-negative bacilli and anaerobic infections have been noted from flying debris arising with tornados and other high-velocity winds. [16] Tetanus is an associated risk; 106 cases (including 20 deaths) were described in the early weeks in Aceh after the Asian tsunami. Following cyclonic events and flooding, infections transmitted by the fecal-oral route are a risk in the short- to intermediate term. For example, Hurricane Mitch in 1998 caused a documented increase in the frequency of acute diarrheas in the post-disaster population ofNicaragua.[17] The 2004 floods in Bangladesh resulted in more than 17 000 confirmed cases of enterotoxigenic Escherichia coli, Vibrio cholerae, Shigella spp and other enteric pathogens in one treatment centre,[18] with those affected by milder diarrhea in the population overall estimated to be far greater. Other fecally transmitted pathogens, such as hepatitis A and E, Salmonella typhi and enterica (typhoid and paratyphoid fever, as occurred in Mauritius in 1980 and in Indonesia in 1992, respectively) and Cryptosporidium parvum have all been documented in the wake of natural disasters.[19, 20] Slightly delayed clinical problems may arise because of indirect or unanticipated transmission pathways. A typhoon in the Truk territories in the Pacific in 1971, compromised the usual groundwater sources and alternate sources used were contaminated by pig feces leading to an outbreak of balantidiasis. [21]

Although most of these events are relatively short-lived, the potential for a more protracted risk of communicable disease may arise if these post-disaster problems are not resolved. In general, the main risks arise as a result of population displacement, [20] which creates situations in which poor sanitation, overcrowding and contamination of food or water sources arise. Full-scale epidemics are more likely in communities experiencing associated conflict, poor underlying health status (including immunity to vaccine preventable diseases), and limited availability of health care.[23, 24] If the disaster is sufficiently severe, community destruction and dislocation may force populations to remain in camp accommodation for months or years. Communicable diseases usually present at lower levels in the community may display epidemicity in the disrupted setting after a disaster. Delayed increases in a number of infectious diseases, including typhoid and paratyphoid fever, infectious hepatitis, gastroenteritis, and measles, was reported five months after Hurricanes David and Fredrick in the Dominican Republic in 1979. These deferred outbreaks were attributed to extended residence in crowded shelters coupled with insufficient sanitary facilities, disruption and contamination of food and water supplies, and

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suboptimal immunization rates.[3]

Displacement may also favour malaria transmission. Nonimmune refugees may contract the disease by passing through or settling in high-risk areas, or – conversely – infectious cases may disseminate disease to other areas.[28] Environmental changes caused by a major catastrophe may act as an ongoing driver of infectious disease. Inundation or disruption of water services, such as damaged or overwhelmed sewerage or drainage systems, provide ideal conditions for proliferation of disease vectors. In particular, ecological disturbances that contribute to the collection of stagnant or slow-moving water tend to favou r mosquito breeding.[4] As Gubler (2001) notes: “Climate-related natural disasters may change the dynamics of human–mosquito contact; floods may create conditions that allow mosquito proliferation and enhance mosquito–human contact.”[29] Following the Mozambique floods of 2000, the number of malaria cases within the displaced population increased by a factor of 1.5 to two times compared with previous levels.[30] Saenz (1995) reported an increase in malaria rates in the months after the 1991 Limón earthquake and subsequent floods in Costa Rica, and attributed this increased disease burden to habitat changes that expanded available mosquito breeding sites (landslide deforestation, river damming, and rerouting) in combination with disruptions in malaria control activities.[31]

In the aftermath of giant waves and local subsidence following the massive 2004 South Asian earthquake, the problem of saltwater intrusion became more acute for the Andaman Islands.[32] Paddy fields and fallow land which once contained mainly freshwater turned increasingly brackish, resulting in profuse breeding of a salt-tolerant malaria vector, Anopheles sundaicus. The authors note that vector abundance and increased malaria transmission potential is likely to be a permanent feature of the islands, given the extent of the tsunami-created breeding grounds and their continued flooding from land subsidence. The increase in water availability and disrupted flow also raise the likelihood of arboviral epidemics following natural disasters. Heavy rains and flooding have been have been associated with elevated dengue rates in Thailand, Indonesia, Venezuela, and Brazil, although the longer-term disease risks from flood-related modification of these environments is less certain.[18] In the US, vector species for a number of arboviruses - including eastern equine encephalomyelitis (EEE), western equine encephalomyelitis (WEE), and St. Louis encephalitis (SLE) - have the potential to increase significantly in response to heavy rainfall or flooding.[33] Similarly, heavy rains in Europe led to the re-emergence of West Nile Fever in Romania in 1996, the Czech Republic in 1997 and Italy in 1998. [34]

Relevant disease vectors of course do not only include arthropods: vertebrate populations may also dramatically increase in the period after disaster events.[35] Ivers (2006) notes the potential risks of infection from the proliferation of rodent populations - including carriage of leptospirosis, hantavirus and plague: Leptospirosis may occur from contact with infected water and a number of outbreaks have been described in the aftermath of floods in Portugal (1967), Brazil (1978), in Taiwan after Typhoon Nali in 2001, and in the Krasnodar region of Russia in 1997.[36]

Following a disaster, chronic physical illnesses in the intermediate- to long-term often arise because of the disruptions in medical care and management. The increased strain on, or collapse of, existing medical facilities following such events may destabilize normal patterns of care. As Greenough noted in wake of Hurricane Katrina: “[t]he biggest health issue …was and will continue to be the inability of the

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displaced population to manage their chronic diseases.”[38] The failure of the health infrastructure to care for displaced (and often impoverished) people has profound implications for those who require medications, ongoing procedures (for example, dialysis; pain management), or a high level of care (including those with diabetes, epilepsy, heart disease and respiratory illnesses; those with disabilities; the elderly). In the weeks and months following Hurricane Iniki in 1992, Hendrickson (1996; 1997) identified a significantly higher incidence of injuries, asthma and cardiovascular disease in the population of Kauai.[5, 6] However, the authors concluded that the increased asthma and cardiovascular rates were not representative of acute exacerbations per se, but instead were attributable to the need to replace medications or to power outages that disrupted use of home nebulizers for patients with respiratory illness.

Disasters also have the capacity to exert ongoing health effects by dispersal of toxic agents - including petrochemicals, human and agricultural wastes, and asbestos – which may persist for long periods in wetaland ecosystems. The disease process, and the risks posed by such hazards, may not be apparent until many years after the event, and are likely to be subsumed by more immediate concerns in the immediate disaster aftermath. Young (2004) identifies a number of pathways by which high levels of anthropogenic contaminants may be released, including through the action of floodwaters, seismic activity or extreme winds damaging storage sites, pipelines, and sewage disposal systems.[39] Analysis of contaminant levels after the floods of 2002-2003 in the UKindicated that dioxin residues accumulated in rivers, canals, storm water and sewage drains, and were likely to have been deposited in publicly accessible areas, including household gardens.[40] A combined flood and fire at a Gloucestershire waste management site in 2000 liberated 160 tonnes of hazardous waste containing a wide range of chemicals including cyanide, pesticides, solvents, low-level radiation waste and asbestos, some of which entered and prompted evacuation from surrounding homes.[40] Considerable concern has been expressed about the potential toxicity of the floodwaters in post-Katrina New Orleans. A systematic study indicated that levels of lead, arsenic, and chromium exceeded drinking water standards. Although contamination levels were not notably high, the extent of their dispersal and the potential population affected was considerable. [41] The receding waters also left sediments at risk of eventually becoming desiccated and windborne. These dusts, which are potentially respirable and contain toxicants such petrochemical residues and asbestos, may continue to pose a hazard for many years into the future. This process of dust mobilization is occurring in combination with a serious mold hazard [42]: a study of water-damaged homes in New Orleans and surrounding parishes estimated that 63% of homes are experiencing mold contamination. It has recently been hypothesized that the combination of exposure to mold and the contaminated dusts is likely to result in increased susceptibility to allergies and respiratory illness in New Orleans residents who are trying to return to their lives and businesses.[43]

The spectrum of malnutrition in the wake of a disaster is highly variable, and may occur as a consequence of general calorie- or protein-deficiencies, inadequate intake of micronutrients, or excessive ingestion of trace elements. Impaired nutritional intake is also a risk factor for mortality from infectious diseases, such as gastroenteritis and measles, which are often also more common in the post-disaster phase. Noji (2005) discusses a range of nutrition-mediated outcomes, including the relationship between vitamin deficiencies and increased childhood mortality in refugee populations. [37] Most dramatically, flooding disasters can directly decrease the quantity of food supplies (such as cropyields; fish stocks) or access to such supplies. Populations already vulnerable to poverty and food insecurity, such as in

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Sub-Saharan Africa, are particularly likely to succumb to superimposed crises.[50] Droughts over many years are associated with increased risk of disease and malnutrition, and are likely to become more prolonged and widespread if climate change predictions are correct. [51, 52] Monsoonal floods in Bangladesh have resulted in adverse long term outcomes for a range of developmental and nutritional indicators.[53]

Mental health issues following natural disasters including flooding are well documented, and it is common for individuals to experience acute distress in the face of such overwhelming events. Although the majority do not continue to be adversely affected in the long-term, a significant proportion of disaster victims experience persistent mental ill-health, including posttraumatic stress disorder (PTSD), major depression, or other psychiatric outcomes.[57] Galea [58] contrasts the early-onset post-traumatic stress disorder that resolves quickly versus those who experience it over a longer term. Some analyses have suggested that post-disaster PTSD may persist in more than one third of the initial cases for more than a decade. [58] Suicide and child abuse are other reported consequences of disasters. [3] In children, Ahern [4] reviewed the evidence of mental illness after flooding, and noted evidence for long-term increases in posttraumatic stress disorder (PTSD), depression, and dissatisfaction with life. Children may be particularly traumatized by the loss of one or both parents.[24] This prolonged clinical trajectory in the post-disaster phase is supported by numerous findings. A surveillance survey of displaced and nondisplaced participants was conducted in Thailand following the 2004 tsunami: this event affected all 6 southwestern provinces of Thailand, in which 5395 individuals died, 2991 were unaccounted for, and 8457 were injured. The loss oflivelihood as a result of the tsunami in southern Thailand was profound, with major disruption of fishing and tourist industries. At nine months after the event, prevalence rates of symptoms of PTSD, anxiety, and depression among displaced persons were 7%, 24.8%, and 16.7%, respectively, compared to rates in the non-displaced of 2.3%, 25.9%, and 14.3%, respectively.[60]

The role of the social and economic consequences of disasters in shaping long-term health should not be underestimated.[61, 63] The immediate impact of the 2004 tsunami provides a recent example of profound social disruption: in the three Sumatran coastal communities of Calang, Rigah and Sayeung, almost 100% of structures were destroyed and an estimated 64% of the total population was killed or missing. Almost two-thirds of households in Calang reported the death of at least one immediate family member directly attributable to the tsunami impact.[54, 64] Hurricane Katrina caused population displacement of hundreds of thousands of Gulf Coast residents to at least 18 different states.[65] As Wilson (2006) notes: “Because of stress and disenchantment, evacuees are at increased risk for depression and posttraumatic stress disorder, domestic violence, and domestic abuse.” [43] Following a disaster, many families suffer considerable financial hardship and may become temporarily displaced or permanently relocated, thereby interrupting established community, cultural and social ties.[68] The impacts are usually greatest in lower income households, who because of limited resources, often take longer to pass through the transition to recovery. Indeed, many are forced to remain in “temporary” living arrangements long after other sections of the community have re-established their predisaster status.[69] Fernandez (2002) notes the particular difficulties experienced by the elderly in relation to financial recovery, noting that younger age groups are better able to return to their pre-disaster standard of living.[70]

Prolonged disasters may also take a more widespread economic toll, escalating the

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health effects from socioeconomic deprivation. Ongoing drought is particularly damaging in its contribution to loss of livelihood, incurred debts, and closure of essential services. In Australia, the 2002 – 2003 drought is estimated to have cost 1.6% of GDP and about 70,000 jobs, with an on-going Federal Government commitment of $AUS740 million in drought relief between 2002 and 2005.[1, 71] In industrialized countries, creation of regional poverty is the process by which drought is most likely to be lead to adverse health consequences, as opposed to the malnutrition-related effects described in the previous section.

6. Costs of Health consequences* (5pp.) [to be added](Environmental resource and/or health economics)

[Note to workshop participants by ND: could Lucy Emerton and/or Dolf de Groot help with this section??]

Total Economic Value Scheme

USE ValuesDirect (Provisioning services: Food, fuel, shelter, recreation)Indirect (supporting & maintaining services; flood control, disease

suppression)Option (genetic diversity, biodiversity)

NON-USE ValuesExistence (spititual)Bequest (intergenerational equity)

7. Interventions and recommendations (10pp.)

7.1 Trade-offs:Ecosystem maintenance vs human disease risk

Response to inadequate supplies and quality of drinking waterThe re-emergence of cholera in the Western Hemisphere in the early 1990s was unwelcome news to all sectors of society, except, arguably, the media. This severe form of gastrointestinal disease results from infection with the potentially food or waterborne bacterium Vibrio cholerae, and the finger was rapidly and probably accurately pointed at the ecosystem disruptions that might have resulted in this public health catastrophe (including the recent upsurge in global travel and trade). Importantly though, this was indeed a re-emergence of a familiar disease which had first emerged some 200 years earlier: the first cholera pandemic originated in India in 1817 and spread across Asia to Europe in the following decades (Carmichael 1997).

Although global travel and trade probably also contributed to the spread of this first cholera pandemic, it is unlikely at that time to have accounted for the emergence of the disease in the first place. A more likely scenario is a complex ecological and social disruption in the form of urbanisation. In earlier centuries, most of India was still sparsely settled, and semi-nomadic subsistence farmers formed part of a sustainable and cholera-free rural ecosystem (Watts 1997). Under the influence of British rule, these peoples were gradually concentrated into villages, many of which were in direct contact with environments that we now recognise as cholera reservoirs - the zooplankton of brackish water estuaries, such as the Ganges delta. In addition, such population concentrations were at greater risk of exposure to

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faecally contaminated food and water, creating opportunities for the evolution of a new microbial ecology with dire consequences for human health.

This pandemic occurred in an era that was still pre-germ theory of disease, and medical intervention in the modern sense was therefore extremely limited. People who contracted the infection suffered severe gastrointestinal upset with vomiting and diarrhoea, resulting in the rapid loss of both salts and fluid. With a significant proportion of the population already weakened by famine, mortality often exceeded 50%, and tens of millions died (Carmichael 1997). The only effective medical response, seen from our perspective, was palliative care, and the more fortunate victims survived.

Responses at the individual level By the time the latest cholera pandemic reached Peru in 1991, all of this had changed. Over a million cases had been recorded in South America by 1994, but mortality was kept below 1% (Chin 2000). Rehydration therapy was readily available, effective antibiotics (tetracyclines) had been developed, and tertiary medical centres were able to deal with the majority of complications. Medial interventions thus proved their worth, and there is no question that making western medical services widely available is one very effective response to the emergence of infectious diseases. Many readers will now be thinking about 'public health' responses rather than 'medical' responses and, inevitably, about the work of John Snow.

Responses at the population levelJohn Snow was a physician in 19th century London. He was Queen Victoria's physician, but is most famous for his study of the 1853-4 cholera epidemic. This study was arguably the most significant milestone in the development of modern epidemiology, and demonstrated for the first time (1) that cholera was waterborne, and (2) that an epidemic could be curtailed by public health intervention. His almost legendary map of London demonstrates cases clustered around Broad Street, where the water being drawn by the pump had become faecally contaminated (For a good map reproduction and historical account see Stolley and Lasky 1995). John Snow, although operating before the germ theory of disease, realised that the disease was waterborne, and had the pump handle removed to abort the epidemic. The provision of clean drinking water and adequate sanitation is now the mainstay of public health interventions to combat cholera and other waterborne diseases, and to some extent has the capacity to reverse the damage done by ecological disruptions in rural India over 200 years ago. In the current day and age this includes installation of water treatment plants, which filter and chlorinate water destined for human consumption.

Response at the community levelA population weakened by famine is more vulnerable to cholera, and it is a reasonable assumption that any socio-economically deprived community will be more vulnerable to the health effects of ecosystem disruptions (Woodward et al. 1998). John Snow himself observed that in addition to the quality of the water supply, there was an association between cholera and "poverty, and the crowding and want of cleanliness which always attend it" (cited in Cliff and Haggett 1988, p.7). His "want of cleanliness" preempts the importance of health education in combating cholera, in so far as good toilet hygiene and hand washing are essential elements that we in the industialised world usually take for granted. Thus a complex set of interventions at the community level operate synergistically to combat cholera or the risk of cholera and other waterborne diseases, and these include nutrition, hygiene, crowding, and implicitly, addressing socio-economic deprivation generally.

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Responses at the community level include government and industrial initiatives to conserve water. None of our water uses were originally designed for efficiency - a result of water generally having been treated as an endless resource. Much emphasis has therefore been placed recently on improving this efficiency, and we have seen the introduction of Government subsidies for water efficient showers, washing machines, and other domestic water uses in some countries. Remembering that domestic use accounts for much lower water consumption than does agriculture, the most significant water savings could arguably be made by improving the efficiency of agricultural irrigation. Low pressure drip-irrigation for example can decrease use of water by over half, and has the additional advantage of not creating a mosquito breeding hazard. It is likely that the year-round availability of standing water in irrigation channels and flooded areas has resulted in the establishment of an endemic foci of vector borne disease. This is yet a further example of ecosystem disruption leading to flow on health effects. Additional responses at the community level include the introduction of market mechanisms such as pricing to promote water efficiency, or a more draconian one (although often needed), is the introduction of water restrictions, as we have seen recently throughout Australia, where it has resulted in fines being issued to residents breaching the restrictions.

Response at the ecosystem levelBeyond the community lies the ecosystem that sustains that community. A healthy ecosystem provides services to the community that enable the community to remain healthy and continue to exist on a sustainable basis. In this case, the provision of clean water from a less disturbed/modified catchment avoids the health hazards of drawing water from, say, the contaminated River Thames in the 19th Century. More recently, water treatment plants have of course facilitated the provision of microbiologically safe drinking water. However, there are recent indications that more emphasis needs to be (re)placed on maintaining ecosystem services. In the case of providing good quality water, these indications come in the form of: outbreaks of cryptosporidiosis from treated water supplies; the health risks associated with chlorination by-products; and insecurity of the supply itself in cities like Mexico City, and Perth, Australia. Responses at the ecosystem level to address disruption to freshwater ecosystems include the reforestation of water catchments and planting of riparian vegetation along river banks (Weinstein et al. 2000; Vant 2001), and the construction of wetlands (Stott et al. 2001). Such responses have been shown to decrease the volume and speed of runoff during heavy rains, and increase the natural self-purification of water via soil filtration of contaminated stock excrement (including filtering off of protozoan oocysts), thus, improving the quality and security of drinking water supplies downstream.

Another response that could be seen as operating at the ecosystem level would be the limitation of population growth and urban development to levels that were sustainable with existing resources. Rome grew into the world's first city of one million people only by bringing water from surrounding areas through an architecturally magnificent series of aqueducts, thereby enlarging, like any city, its 'ecological foot print'. Although these aqueducts remain awesome feats of engineering even 2000 years later, they also represent the tendency of urban populations to outstrip the local natural resources essential to their own survival (Lanz 1995). This tendency has been exacerbated by the Judeo-Christian belief in man having dominion over all the earth, to the point where we now appear to have reached the third epidemiological transition (see Pressure section). In this context it is tempting to suggest that city planners should heed sustainability considerations and put a cap on the population size based on limited water (or other resource) availability.

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Certainly, the re-emergence of waterborne diseases as a significant health risk in developed countries has highlighted the importance of source water quality and the protection/management of water catchments. What is required is an integrated catchment approach that incorporates all stakeholders within the catchment, community groups, government and local authorities to provide sustainable management of the ecosystem i.e., ecosystem integrity (Parkes and Panelli 2001; UNESCO 2003). Thus, such ecological analyses and integrated responses can result not only in ecosystem integrity but also provide public health benefits, with a consequent reduction in the frequency with which pathogens contaminate water. A 'ridge tops to the sea' perspective takes a holistic approach to the large-scale regional environmental issues, particularly those concerning water. In the health industry, this is also related to ‘water cycle’, in terms of taking into account upstream and downstream effects, water intakes and discharge points, and recycling of lower grade water for appropriate uses such as watering gardens.

At a global level, we have recently seen water explicitly recognised as a fundamental human right (ECOSOC 2002). Although not legally binding, the 146 countries that signed the agreement will now be compelled to progressively ensure that everyone has access to safe and secure drinking water. It requires governments to adopt national strategies and plans of action to "move expeditiously and effectively towards the full realisation of the right to water". The proof will be in the pudding, if it will ensure equitable access to water and reduce the global burden of waterborne disease.

The example of cholera has provided the opportunity to explore possible medical and public health responses to ecosystem disruptions at a variety of different levels. To devise the optimal response (or set of responses) to any particular ecosystem disruption, one requires a detailed understanding of that ecosystem, and it is natural, therefore, to draw on the science of ecology. Ecology is the study of the distribution and abundance of organisms, and the interactions that determine distribution and abundance. We can look at emergent infectious disease research as the study of the distribution and abundance of pathogens, and the interactions that determine their distribution and abundance. This is in effect ecology, and in devising our medical and public health responses, we can follow true and tried ecological principles (Weinstein 1997). Processes and interactions are usefully categorised as those affecting individuals (a simple organism), populations (many individuals of the same species), communities (a set of interacting populations of different organisms), and ecosystems (all interacting organisms and their environments) (Townsend et al. 2000). In discussing responses to the emergence of cholera and other waterborne disease, these same categories have been followed, moving from individual health care, to population health interventions, to community based programmes, to the management of freshwater ecosystems. We propose this to be a useful and generalisable framework in which to consider the possible range of medical and public health responses to address the health effects of ecosystem disruptions, and the interactions and complementarities between such responses.

7.2 Approaches to intervention- Primary (conservation); Secondary (screening and treatment); Tertiary (arrest development of complications)- Local; Regional; Global

7.3 Surveillance:[ADD ABC of Env Health: Data; Epidemiology; Intervention; Feedback]

Monitoring data requirements for human health

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The human health risk posed by a wetland in a particular state can be determined by standard Health Risk Assessment (HRS). A simple and generally applicable 4 stage approach is readily adapted to a wetland:

* Hazard assessment : determination of the nature and intensity of those hazards that could have health effects (here microbial pathogens, chemicals, mosquitoes, or other hazards)

* Dose response: determineation of the effect likely to result from an exposure (here the infective dose or toxic dose, and the nature of the dose-response curve).

* Exposure: determination of the size and nature of the population at risk, including numbers of users of different wetland services and populations particularly at risk (eg infants and the elderly)

* Risk characterisation: an integration of the above information into summary statement, often of the form “ x people will contract disease Y with average duration of z days if exposed”.

The detail of the risk characterisation will depend on the available details of hazard concentration, dose-response relationship, and exposure intensity. Of these, the hazard concentration is often the most difficult to quantify because of the technical and financial demands of obtaining such information. In developing countries, microbiological analytic laboratories are often not available for example. Where hazard concentration data can be obtained, the dose response information required is generally readily available in the literature (eg recreational water quality guidelines or medical microbiology and epidemiology journals), and exposure assessment then often becomes the rate limiting step. For accurate quantitative data on exposure, a specific time-activity survey of the human population may be necessary. If all data ARE available, it is possible to perform a highly accurate risk characterisation in the form of a quantitative microbial risk assessment (QMRS), giving an estimate of the likely human disease burden in terms of disability adjusted life years (DALYS) a measure of health outcome that, unlike raw mortality data, takes into account pain, suffering and disability. The Risk characterisation would then take account of determinants such as concentration of pathogen, pathway of exposure, frequency, duration and size of dose, dose response, number of exposed, length of time disability suffered, and number of deaths (for details on calculation of QMRA see ref x; for details on calculation of DALYs see ref y).

In industrialised countries, the approval process for proposed anthropogenic modifications to wetlands include a full health impact assessment and data to the level of detail above, are generally required by law. In developing countries, it is often unrealistic to seek this level of detail, and other approaches to HRA may be more appropriately used to prioritise the management of wetlands (See Section on Human disease outbreaks as bio-indicators of ecosystem health).

Despite this difference, there is a fundamental need in both developed and in developing countries to minimise the microbial pathogen content of wetlands to provide the safest possible drinking (or other) water exposure for humans: In developing countries, if drinking water treatment does not occur, it is imperative to ensure that sewage contamination of wetlands does not occur (or occurs at a rate below the purification capacity: generally, contaminated water flowing through a wetland can be expected to undergo a log reduction in pathogens in the range 1.5 – 2.5, based on studies with micro organisms such as Rotavirus, Campylobacter, and

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Cryptosporidium. Refs: recycled water guidelines). The wetland can then provide both pathogen free drinking water and a healthy aquatic ecosystem.

In developed countries, even if water treatment does occur, there is a movement to a hazard removal concept to decrease the need for costly testing and to insure against failures in the treatment system (see HACCP approach to risk reduction, Ref. ) thus also providing both pathogen free drinking water and a healthy aquatic ecosystem upstream.* [Exposure pathway flow charts at end of document]

Human health as bioindicator of wetland ecosystem disruption

Surveillance and interventionMeasurable bioindicators of ecosystem health were first described in detail by Rapport et al. (1985). These include: changes in nutrient cycling; decreased species diversity as a result of decreasing habitat diversity; retrogression (a reversal of the normal process of species succession as the ecological community is simplified); and increased fluctuations in population size. Presence of disease also explicitly formed one of the bioindicators, and it was suggested that increased disease incidence among plant, animal and human populations would become manifest as the fabric of the ecosystem begins to deteriorate and natural buffering and protective mechanisms break down.

The intrinsic link between ecosystem health and human disease has been discussed in a number of previous papers (Cassis 1998; Chivian 2001; Epstein 1995; Forget and Lebel 2001; Haines et al. 2000; McMichael 1997; Nielsen 2001; VanLeeuwen et al. 1999; Waltner-Toews 2001). These authors have noted that ecosystem health is heavily influenced by human activities and vice versa, human health is dependant on proper ecosystem functioning. Reflecting this close relationship, it has been suggested that disease incidence within a human population can be used as a bioindicator or ‘yardstick’ of the health of the ecosystem of which the community is a part (Rapport 1999; Cook et al 2005). Human disease incidence is in fact one of the most useful and practical bioindicators of the health of an ecosystem, and using human health as a bioindicator in this way can assist in guiding rapid and appropriate ecosystem interventions (Cook et al 2005). A major advantage in using disease outbreaks as bioindicators of even subtle ecosystem disruptions is that the health of human populations is generally subject to more widespread and more accurate surveillance than is ecosystem health. Nowhere is this more relevant thank in the tropics, where the infrastructure and resources to monitor disruptions to the hydro-geosphere are simply not available. By contrast, many sources of data - such as those obtained from infectious disease notification systems – provide ongoing measurement and monitoring of human communities in even the most challenging of socio-economic environments. As will be outlined in the examples given below, many stresses and disruptions to natural ecosystem functioning are only identified as a result of detailed epidemiological investigations, which in turn follow an increase in human disease incidence detected by routine surveillance. While it is still possible to detect ecosystem disruption using the traditional environmentally based bioindicators of ecosystem health, it is a much more complex and difficult undertaking that requires an expensive and dedicated research effort, often over many months or years (see Schaffer 1996, Patil et al. 2001).

By identifying ecosystem disruptions that impact on human health using this disease outbreak based approach, appropriate strategies for intervention and remediation can be introduced at an earlier stage than would be possible based solely on environmental monitoring. To illustrate our argument, we consider a vecto-borne

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disease outbreaks that have led to the identification of ecosystem disruptions at local, regional and global levels, and the appropriate corresponding ecosystem interventions.

Recent evidence has shown that intermittent irrigation and other water management practices can be used effectively to control Anopheles larval development in rice fields in Africa (Mutero et al. 2000; Klinkenberg et al. 2002). The importance of over-irrigation and inefficient drainage is brought into perspective when considering the potential area of mosquito breeding habitat produced by an inundated field compared to a relatively much thinner irrigation drain (Klinkenberg et al. 2003). Thus surface area, rather than volume, of water present is likely to be more important in terms of potential provision of mosquito breeding habitat.

The primary control strategies should be based on environmental modification to reduce potential mosquito-breeding habitats within the irrigation area as discussed in detail above. Adulticiding and/or larviciding may also be useful but the acceptability of such measures to the community should first be determined. Finally, the use of personal protective measures, such as mosquito repellents, insect screening and appropriate protective clothing, should be encouraged year round, not just during the wet season.

Multiple ecosystem interventions are suggested for dengue control which operate at numerous, often overlapping levels: locally, to remove artificial breeding habitats for the Aedes mosquito vectors which are provided by containers (Knudsen 1995; Moore et al. 1990; Tauil 2001); regionally, to limit the disruption of waterways (which encourage stagnation and high nutrient loads) (Forattini et al. 2001); and globally, to minimise the effects of global warming which encourages mosquito breeding for longer durations at a wider range of latitudes (Chan et al. 1999; Hales 2002 et al.; Hopp and Foley 2003). The climatic instability associated with the warming trend may also drive excess rainfall and flooding in many areas, thus again providing ideal breeding sites. In summary, information about outbreaks of dengue fever, reliably monitored in many countries, can inform an integrated approach - operating at three levels - to the management ecosystem disturbances.

We have highlighted how the anthropogenic disruption of the interactions between land, soil and water in tropical ecosystems can cause or facilitate the re-emergence of vector borne diseases. As will all problems in medical geology, the interventions required to address these problems are likely to be multidisciplinary (Selinus et al 2005). Thus, while targeting interventions by means of monitoring [TURBIDITY, DO, PH] would be possible, we suggest that a multidisciplinary solution that uses human health data would be more cost effective in a tropical setting. While currently ‘there is no simple solution to a quantitative and quick assessment of ecosystem health’ (Ramade 1995), we contend that human disease surveillance (particularly notification systems for infectious disease) at a local, regional and global level is often a readily available and accurately recorded bioindicator that could be used for such purposes, particularly in the context of tropical vector-borne disease. Monitoring of disease events is more widespread, accurate and subject to ongoing quality assurance than many of the traditional "indicators of ecosystem health" which have been proposed in the past and are challenging to monitor both because of their ecological complexity and because of the resource-intensive nature of environmental surveillance. Burger and Gotchfeld (2001) highlight the need for development of cost-effective, easily understood bioindicators that can be used for integrated assessment of both ecological and human health. It would appear that human disease incidence is the only existing bioindicator that meets all of these

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requirements. Early identification of ecological disruption through the human disease surveillance pathway also allows early intervention, which in turn can decrease the level of ‘ecosystem distress’, and the resultant disease burden in humans. Surveillance could therefore help define local, regional and global areas at ecological risk (Weinstein et al. 1994). This process would capitalise on an existing health infrastructure that must remain intact in any case if our societies are to maintain the public health gains of the last century. Outbreak data act as a pivotal warning system for ecosystem injury and suggest logical interventions for the simultaneous preservation of ecological and human health: our recommendation is to acknowledge and exploit the strengths of using human disease surveillance for these purposes.

7.4 Improving ecosystem health and human health concurrently

Research needsAs we highlighted in our introduction, the contribution of population health research comes to the fore in devising appropriate responses, because such responses will ultimately depend on the level of health risk from human use of freshwaters that the population is prepared to tolerate. In so far as health planners need to allocate financial resources to provide a given set of population health interventions, the selection of an appropriate response or set of responses from those discussed above is unlikely to be made on a scientific basis alone. Ultimately, cost-benefit decisions about investment in the provision of safe drinking water will depend on the disease burden that the community is prepared to tolerate. Currently, there is a general lack of awareness by the public of water related health risks, and once they are made aware of them and the costs of reducing them, they may accept higher risks rather than paying for improvements.

In most communities in developed countries, we have a zero tolerance for waterborne cholera outbreaks. However, we accept relatively low risks of possible cancers and birth defects resulting from DBPs in our drinking water. Importantly, the health effects of DBPs must be weighed against the cost of DBP reduction and not against the potential waterborne disease prevented by disinfection. However, further research is needed on the occurrence of DBPs and their health consequences in order to undertake a properly informed risk assessment and cost-benefit analysis.

With increasing public awareness of water quality issues, there has been increased demand for higher quality water supplies, this is mirrored by the increasing global consumption of bottled water, introduction of grading systems and classes of water for different purposes, and water re-use. This raises the dilemma of increasing quality versus the problem of economically achieving this. As water of good quality becomes scarcer, there will be increasing pressure to lower drinking water standards, and thereby possibly also increasing the disease burden. Evidence of this is already apparent in Europe, where EUREAU (European Association of Waterworks) has campaigned for the abolition of the 'zero' standard for levels of pesticides in drinking water (Lanz 1995). The contention is that there is no scientific evidence that low level exposure has any health effect, and while this might be true at present, an informed decision clearly cannot be made without specific laboratory and population health research. If pressures to reduce drinking water standards lead to poor decisions about investment in the provision of safe drinking water, then the cost of the resultant disease burden and community outrage may exceed the cost of retaining more conservative drinking water standards.

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The relationship between microbial water quality and disease burden also needs direct quantification, rather than depending exclusively on risk assessment models that may not take account of unique aspects of local aquatic ecosystems. The integrated catchment approach to water management, although appealing, requires considerable co-operation between stakeholders and must be based on sound research. Sustainable management is certainly the current buzz word, but there is considerable research yet to be done. This research will flourish with a cross-disciplinary approach incorporating fields such as environmental health, ecology and health, zoology, geography, and commerce (e.g., Parkes et al. 2003).

[ADD:- Implications of the Millennium Development Goals on water and sanitation

(inc MA view that MDG delivery can run counter to maintaining ecosystem services).

- Potential Ramsar-WHO collaborations]

Recommendations

1. Identify and implement interventions that benefit both wetland ecosystem health and human health concurrently.

In support of this recommendation, it would be useful to:- pursue multidisciplinary research to provide an evidence base (a) to identify

appropriate interventions and (b) monitor the efficacy of those implemented (including human health outcomes).

- Apply the principles of conservation through sustainable use to wetlands where conservation needs and human needs are in apparent conflict (with particular emphasis on disease suppression).

- Engage with ecological economists and health economists to establish dollar values for the wetland ecosystem services conserved

- Engage with wetland ecosystem managers to demonstrate the value of best practise in terms of (a) economic gain from maintaining wetland ecosystem services (including human health) or (b) other paradigms that resonate with the particular communities concerned.

2. In the first instance target wetlands that are high on the priority list for both their conservation value and their human health benefit. Successful demonstration projects that include quantifiable environmental, societal and economic benefits should provide the necessary leverage to gain support for then expanding the type and number of wetlands involved.One possible strategy for identifying target wetlands involves the use of human health surveillance data as bio-indicators of disrupted wetland ecosystem services.

[add concrete examples from main text: cheaper food, safer drinking water].

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Acknowledgements

1. The contributing authors to the three sections that were “plugged in” (marked *)2. For directly contributing to the ideas and publications drawn upon in this

review: Andrew Jardine, Alistair Woodward, David Slaney, Lara O’SullivanWe thank David Slaney and Mike Lindsay for their contribution to the development of parts of the material presented, and Jose Centeno, Bob Finkelman and Olle Selinus for Cook Woodward

SOME POSSIBLE FIGURES AND TABLES

FOR LATER INSERTION

Table 47.1 Global population and freshwater availability.

Continent Freshwater volume %

Population %

Water to population ratio

Asia 36 60 0.60

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Europe 8 13 0.62Africa 11 13 0.85North and Central America 15 8 1.88South America 26 6 4.33Australia and Oceania 5 <1 5Data from UNESCO (2003).

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Table 47.2 Human activities and associated inputs into freshwater ecosystems with human health risks.Activity Inputs Health RisksAgriculture, Horticulture

Sediments FertilisersPesticides and other toxic chemicals and metalsAnimal faeces

Immune and endocrine disruptionRetarded physical and cognitive developmentBlue baby syndromeFetal malformations/death Nervous system and reproductive dysfunctionBehavioral changesCancersWaterborne disease

Industry NutrientsToxic chemicals and metals Oils

Mining SedimentsToxic chemicals and metals

Urbanisation, Infrastructure development

SedimentsPesticides and other toxic chemicals and metals Oils Sewage

Recreation OilsFuelToxic chemicals

Table 47.3 Rates of notified giardiasis and cryptosporidiosis per 100, 000 population in selected countries in 2001.Country Giardiasis CryptosporidiosisNew Zealand 1 42.9 32.3United States 2 9.5 (in 1997) 1.3England and Wales 3 6.9 7.1Northern Ireland 3 0.9 21.3Belgium 4 13.1 6.01 Sneyd and Baker (2003)2 www.cdc.gov/epo/dphsi/annsum/index.htm, Furness et al. 2000 - giardiasis is not a nationally notifiable disease in USA3 www.hpa.org.uk/infections/topics_az/topics.asp4 www.iph.fgov.be/epidemio/

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Fig. 47.1 Number of notified campylobacteriosis cases per year from 1980 to 2002. Data from Sneyd and Baker (2003).

Fig. 47.2 Rates of notified cryptosporidiosis per 100,000 population in New Zealand June 1996 to August 1998 by distribution zone component of the public health grading of community drinking water supply where a = very satisfactory, b = satisfactory, c = marginal, d = unsatisfactory, e = very unsatisfactory and u = ungraded. Log scale on Y axis. Error bars indicate standard error. Modified from Duncanson et al. (2000).

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68


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5.1 Health effects of wetland ecosystem disruption

Ecosystem service Disruption Health outcome

Drinking water Sewage contaminationInfectious disease (eg. Gastroenteritis)

Industrial/Agricultural contamination

Acute or chronic poisoning (eg mercury)

Depletion Thirst, poor hygiene

Irrigation water Sewage contaminationInfectious disease (eg. Gastroenteritis)

Industrial/Agricultural contamination

Food chain bioaccumulation/tox (eg.DDT)

Depletion StarvationProvisioning food imbalance/depletion Starvation fuel/shelter imbalance/depletion Exposure pharmaceuticals imbalance/depletion Compromised careRecreational water Eutrophication BGA toxicityAesthetic Modification Depression Devaluation SuicideBiodiversity maintenance & disease supppression

Interspecies interactions Vector bore disease emergence

Table 5.2 Water-related disease burden and exposure pathways

Pathway Physical Microbial Chemical Cultural(ecosystem service) (acute) (chronic) Drinking water ingestion lack of virus/bacteria/protozoa

ingestion (Clemencia list) Viability

Recreational water drowning

aerosol/transdermal/ingestion

aerosol/transdermal/ingestion Viability

Irrigationmosquito borne disease

aerosol/transdermal/ingestion

food chain/ingestion Viability

Industial accidentsaerosol/transdermal/ingestion

occupational exp/food chain economic

Geophysical flooding/tsunami Sewage and corpses Acid Sulphate Soilspsychiatric

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Ramsar & hu… · Web viewIvers (2006) notes the potential risks of infection from the proliferation of rodent populations - including carriage of leptospirosis, hantavirus and