Holistic views on a globally persistent disease
Diarrheal diseases have been significant health challenges throughout human history, with extensive epidemiological and biomedical knowledge developed over centuries Despite effective prevention and control measures being available, diarrhoea remains prevalent, particularly among impoverished populations and those not reached by public health initiatives While questions about the spread of diarrheal diseases persist, the global health community has sufficient medical and microbiological insights to inform effective prevention strategies The successful implementation of these measures in the western world highlights that the primary issue is not the presence of diarrheal pathogens, but rather the lack of awareness and application of existing knowledge.
2 Incidence (of disease) = the number of new cases within a period of time (Joralemon,
2010) information for its effective management and control This chapter discusses the core elements that surround this problem while also introducing the study region in Vietnam's Mekong Delta
1 1 1 D isc o u r se a n d c o n tex t: W h y d ia r r h ea l d isea se is n o t o n ly a m ed ic a l p r o b lem
When planning a trip to Vietnam, many travel resources emphasize the risk of “travellers’ diarrhoea,” but the prevalence of this issue among locals is less documented Studies indicate that while various microorganisms cause diarrheal diseases, the notion that locals have developed immunity is questionable High rates of morbidity and mortality from diarrhoea in regions known for this issue suggest that it significantly affects local populations due to their continuous exposure Despite this, a local cadre I interviewed claimed that foreigners are more susceptible because locals have a higher resistance, attributing it to their acclimatization to local water However, a local farmer’s perspective hinted at a more complex reality, challenging the idea of immunity among residents.
Diarrhoea is an unavoidable health issue that can arise from various sources, such as contaminated food or surfaces For instance, leaving food exposed can attract flies, which may introduce harmful bacteria, or simply touching contaminated objects can lead to infection.
Diarrhoea is often attributed solely to inadequate modern water infrastructure and is commonly linked to impoverished populations in developing nations However, the situation is more nuanced Vietnam, which has officially overcome poverty, has demonstrated impressive economic growth in recent decades The Vietnamese government actively pursues modernization and progress (Ehlert, 2011: 2ff) Alarmingly, the WHO reports that diarrhoea accounts for 10% of deaths among children under five in Vietnam (WHO, 2012a), highlighting the ongoing health challenges despite the country's advancements.
Morbidity rate refers to the occurrence of a disease within a population, while mortality rate indicates the number of deaths caused by that disease The persistent presence of diseases like diarrhoea in Vietnam highlights the ongoing health challenges faced by the country Local perspectives suggest that diarrhoea is often linked to poverty, which Vietnam aims to overcome through modernization and improved public health This effort reflects the government's commitment to enhancing its image and ensuring that diseases associated with poverty do not undermine the population's health.
The perception of "traveller's diarrhoea" in Western contexts raises critical questions about the broader implications of this disease, which tragically claims the lives of millions of children While local perspectives may trivialize diarrhoea as an issue for those unaccustomed to it, the reality is that many endure this condition silently, highlighting a significant global health concern The seriousness of diarrhoea often only gains attention when it disrupts travel or is reflected in mortality statistics among the impoverished Although the United Nations has declared health a human right, defining it remains complex and subjective, influenced by individual feelings and societal debates Furthermore, health is not solely measured by physiological metrics; as an Indian proverb suggests, it is also tied to a person's happiness.
The definition of health and illness is constantly being debated and redefined across medical communities, private discussions, and public forums These discussions hold significant implications for policymakers and health guardians at both local and global levels Most crucially, health claims directly impact individuals whose well-being is at risk Furthermore, the complexities of social, institutional, and political factors contribute to the challenges of disease management, emphasizing that health issues are intertwined with broader societal dynamics.
Health is often viewed as paralleled to well-being, which in turn has been –at least in principle- the central purpose of worldwide development Following
Peet and Hartwick (1999) argue that development is often perceived as a "belief" and a "project" rooted in Western ideologies and neoliberal principles, which impose Western views and practices on the rest of the world, thus limiting the autonomy of other societies Critics of this approach advocate for a departure from rigid rational knowledge claims, emphasizing the need for postmodern, poststructural, and post-developmental perspectives that respect diversity and allow societies to define their own paths to progress Michel Foucault, a key poststructuralist thinker, emphasized the importance of granting individuals the freedom to identify and address their own challenges, rather than imposing external solutions Consequently, the concept of well-being should also be defined internally by societies, free from outside interventions.
Health definitions are deeply influenced by cultural and social contexts, encompassing not only national boundaries but also personal bodily perceptions Mary Douglas highlights the interplay between the human body and society, illustrating how individuals interpret bodily classifications based on their cultural backgrounds This is evident in cultural rituals that express social relations and help individuals understand their society, as these rituals utilize the physical body as a symbolic medium Different cultures also categorize natural bodily excretions in ways that evoke disgust or fear, maintaining societal order, despite the disconnect between pollution and moral rules Douglas emphasizes that physical and social processes occur simultaneously, making it essential to analyze disease within personal, social, and political contexts This analysis reveals how social and cultural actors assign meanings to disease, which in turn reflect broader social structures and moral values.
Health and disease should not be viewed solely as fixed bodily states or as mere activities aimed at illness prevention, as this perspective overlooks the cultural and social constructs surrounding them While certain physical conditions undeniably cause discomfort and can lead to severe consequences, such as diarrheal disease, interpretations of these health issues can vary significantly based on the source of discourse—be it popular media, government representatives, or local communities A purely biophysical understanding of health risks neglecting its social and cultural dimensions, while viewing health solely as a discursive construct ignores its biological realities Therefore, the dominance of Western medical science in defining bodily functions highlights the need to incorporate insights from the humanities into health studies for a more comprehensive understanding.
1 1 2 G lo b a l effo r ts a n d o m issio n s: w h y r e -p r io r itisin g d ia r r h o ea n eed s lo ca l r elev a n ce
At the 2010 UN Summit, global leaders and representatives from civil society and research pledged to strengthen their efforts towards achieving the eight Millennium Development Goals.
The United Nations' goals established in 2010 aim to reduce child mortality rates (MDG 4) and increase access to safe drinking water and sanitation (Target 10) This emphasis on children's health and water facilities has brought diarrhoea to the forefront of global health discussions Significant efforts to control diarrhoea began in the 1980s, as noted by the WHO in 1987, and these initiatives have proven effective, evidenced by a decline in child deaths caused by diarrhoea (Chiabi et al., 2010).
Despite extensive knowledge and experience in disease prevention, the battle against its incidence remains unresolved The ongoing challenge for public health policy lies in the widespread adoption of well-publicized measures that lack local commitment and fail to produce positive health outcomes.
Diarrhoea significantly affects millions of individuals, impacting their overall well-being and quality of life, despite often being self-limiting and non-fatal While mortality rates provide some insight into the disease's severity, they do not fully capture the long-term health risks associated with frequent diarrheal infections This ongoing health issue poses serious challenges for both children and adults, highlighting the need for greater awareness and intervention strategies.
Thapar and Sanderson (2004) highlight that diarrheal diseases are often overlooked, especially in the absence of high mortality rates Guerrant et al (2002) indicate a significant rise in morbidity levels of diarrhea globally from 1992 to 2005, particularly affecting impoverished populations This suggests that the severity of diarrheal diseases is frequently underestimated, contributing to their deprioritization by national governments and global health initiatives.
Troubling diarrhoea: aetiologies and prevention
Diarrhoea is a waterborne disease closely linked to water quality, consumption habits, and surrounding environments Pollution and mismanagement of water resources can severely impact access to clean water, affecting both health and daily life While clean water has the potential to reduce disease risk, particularly in regions like the Mekong Delta, the spread of diarrhoea is influenced by a complex interplay of factors beyond just water quality.
1 2 1 I n fectio n p a th w a y s: a w eb o f h u m a n a n d n a tu r e in ter a ctio n s
Diarrhoea is a significant symptom of various pathogenic infections, defined by the WHO as the passage of three or more loose or liquid stools daily In this context, "diarrhoea" refers to the severe condition experienced by individuals for whom it is the primary symptom Common diarrheal diseases include cholera, typhoid fever, and dysentery, which typically spread through the faecal-oral route, with water serving as a medium for pathogens Transmission can also occur through contaminated food, flies, or unclean hands Infectious diarrhoea can be caused by bacteria, viruses, protozoa, or helminths, each exhibiting different epidemiological patterns, resistance levels, and geographical distributions.
2005, Karanis, 2006, Nguyen et al., 2007), causing distinct types of diarrhoea that differ in their symptoms, duration and severity
Diarrhoea often serves as a secondary symptom of diseases like measles and hepatitis, and it can also be both a cause and a consequence of malnutrition, particularly affecting children in poverty This dual role makes it challenging to determine if diarrhoea indicates underlying health problems or is simply a gastrointestinal infection Additionally, the life cycles and transmission routes of many known and emerging diarrheal pathogens are not well understood.
The heterogeneity of diarrheal diseases makes it challenging to pinpoint the exact cause of an episode, particularly in areas with limited medical resources and laboratory infrastructure This lack of capacity is often found in regions that are also hotspots for diarrheal diseases, complicating accurate diagnosis and documentation Consequently, healthcare practitioners frequently rely on clinical syndromic diagnoses to guide treatment decisions, categorizing the disease into acute watery diarrhoea, persistent diarrhoea, or bloody diarrhoea.
Table 1.1: Categorisation of common diarrheal diseases by aetiology, transmission and diagnostic characteristics
Aetiology Characteristics of trans- mission
Person to person, inan- imate objects, water, food
One type of dysentery (bacillary): watery diar- rhoea maybe bloody, including abdominal cramps, vomiting, fever
Vibrio cholerae Through food or water Acute watery diarrhoea Salmonella group
Water, food, and animal- human transmission
Gastroenteritis or food poisoning: nausea, vom- iting, and diarrhoea which may be bloody
Typhoid fever (diar- rhoea as one of the symptoms): green stools, characteristic smell
Escherichia coli group Water, uncooked food, cross-contamination
Can vary from watery, neonatal to bloody diar- rhoea, including with fever Might evolve into persistent diarrhoea
Watery and maybe bloody diarrhoea, dysen- tery, persistent diar- rhoea, nausea, anorexia and many other varia- tions
Rotavirus Faecal-oral, dirty hands and objects, food and water
Acute watery diarrhoea, fever and vomiting
Diarrhoea can be caused by various protozoa, including Entamoeba histolytica, Cryptosporidium spp., Giardia intestinalis, and Balantidium coli Additionally, certain helminths such as Trichinella spiralis, Trichuris trichiura, Strongyloides stercoralis, and Capillaria philippinensis are also known to contribute to diarrhoeal diseases.
Based on Grimwood and Lambert (2009), Karanis (2006), Keusch et al (2006) and
WHO (2009, 2011) The words in bold indicate the common names (other than “diar- rhoea”) used for the different diagnoses
Understanding the relationship between pathogen ingestion and the onset of diarrheal disease is complex, as identifying the specific pathways of infection in different contexts remains challenging.
The Mekong Delta, characterized by its dense population and complex hydro-social interactions, faces significant challenges in controlling diarrheal diseases This complexity makes it difficult to determine the impact of human behavior, health policies, or environmental sanitation on disease incidence However, research indicates that there are promising prevention measures that could be effective in addressing this public health issue.
1 2 2 C h a llen g es in th e p r e v e n tio n o f d ia r r h o e a : th e fa c to r o f h u m a n b e- h a v io u r
Establishing effective water quality systems and safe sewage disposal is crucial for disease control and is deemed essential for human life, dignity, and development (WHO, 2012b) Studies have shown positive health impacts from improvements in both water and sanitation (Fewtrell et al., 2005; WHO, 2012d), as well as from sanitation alone (Daniels et al., 1990; Cairncross et al., 2010a) However, a World Bank evaluation of projects from 1997 to 2007 revealed that evidence of improved water quality and health among beneficiaries remains limited (World Bank).
Bank (WB), 2010: xiii) It is thus worth looking at when and how such im- provements can really be a powerful preventive measure against disease
Poor environmental sanitation significantly impacts human health, highlighting the need for improved living conditions to prevent disease transmission While the presence of better toilet facilities at the household level is important, it is not the sole indicator of effective environmental sanitation Other critical factors, such as street wastewater, refuse management, domestic water quality, feces disposal methods, vector presence, and flooding, also play a vital role in public health These community sanitation issues have been linked to the spread of diarrheal diseases, underscoring the importance of comprehensive sanitation strategies.
Clasen and Cairncross (2004) highlight that the health benefits of improved water quality are not solely dependent on the water source, as pathogens can re-emerge by the time water is consumed This notion is supported by Sobsey (2002) and Wright (2004), who indicate that household behaviors significantly affect water quality Fewtrel et al (2005) further assert that proper water treatment and storage at home can play a crucial role in disease prevention While many diarrheal pathogens are waterborne, as illustrated by Wagner and Lanoix (1985), not all cases stem from contaminated water; transmission also occurs through feces, fields, flies, fingers, and food (Jensen et al., 2004) Cairncross (2003) adds that a significant amount of endemic diarrheal disease is transmitted person-to-person due to unsanitary practices, emphasizing the importance of hygiene.
Curtis et al (2000) emphasize the importance of improving community hygiene, highlighting that effective sanitation goes beyond just building toilets; it also requires consistent hand-washing practices after defecation and handling infant stools The focus on constructing water supply and sanitation (WSS) facilities often overlooks the necessity for maintenance and sustainable use, which rely on public perceptions of safety and hygiene, as well as institutional support (Cairncross, 2003; Carter et al., 1999) According to updated WHO data (2012), while enhancements in water supply and sanitation can reduce diarrheal morbidity by up to 30%, combining these improvements with hygiene education can lead to a 45% reduction in global diarrheal cases Therefore, literature suggests that addressing water and sanitation requires a comprehensive approach that considers both community and household levels, as well as institutional and behavioral factors, through integrated delivery and treatment systems.
Figure 1.1: The F-diagram, depicting the main transmission routes of diarrheal diseases
Wagner and Lanoix (1959) adopted from Curtis et al (2000)
Addressing diarrheal diseases requires a comprehensive approach that extends beyond just improving water supply and sanitation Key strategies include promoting good nutrition and preventive Rotavirus vaccination to enhance population immunity Implementing better hygiene practices and utilizing oral rehydration treatments are crucial for recovery and preventing disease transmission As highlighted by Feachem et al (1983), a multifaceted strategy is essential, with oral rehydration being one of several complementary measures According to UNICEF and WHO (2009), adopting six concurrent measures—Rotavirus and measles vaccinations, early exclusive breastfeeding and vitamin A supplementation, hand-washing with soap, improved water quality and quantity, community sanitation promotion, and fluid replacement therapy—can significantly reduce diarrheal deaths and control disease incidence over the medium to long term.
Since the 1980s, the World Health Organization (WHO) has strongly endorsed the use of Oral Rehydration Therapy (ORT) as a vital method to reduce fluid loss and prevent severe stages of diarrhea, effectively saving children's lives Recent studies, such as those by Chiabi et al (2010), highlight that reduced osmolarity Oral Rehydration Solutions (ORS) combined with zinc supplementation are essential for managing diarrhea in children, significantly lowering mortality and morbidity rates Alongside Rotavirus vaccination, ORT stands out as a critical biomedical tool in combating diarrhea and preventing its transmission However, despite its proven effectiveness, ORT's adoption has not been as widespread due to insufficient promotion and public confusion about its unique benefits compared to other home-prepared fluids Additionally, there is resistance to following guidelines on continued breastfeeding and solid food intake during diarrhea episodes, practices that are known to enhance the positive effects of ORT (Santosham et al., 2010; Thapar and Sanderson, 2004).
Preventive health measures largely hinge on individual behaviors and choices at the household level, such as proper hand-washing, breastfeeding, seeking timely medical advice, and maintaining sanitation However, access to essential vaccines, medications, and information is often limited, especially for those living in poverty, which can hinder their ability to improve water, sanitation, and hygiene (WSS) conditions and negatively impact their health This illustrates that individual behavior is influenced by broader social and political contexts The Mekong Delta, with its unique social and environmental dynamics, offers a compelling setting for examining these interactions.
The Mekong Delta: diarrheal risks in an environment of
hydro-social interaction and change
The transformation of Vietnam from a planned to a market economy began in the 1980s, marking the start of the “ổi mới” reform era with legal policy changes initiated in 1986 This shift towards socialist capitalism has opened the country's markets to private activity, foreign investment, and external capital As a result, Vietnam has experienced a notable increase in national GDP levels and improved well-being indicators, such as the Human Development Index.
Despite significant economic growth and the establishment of a free market in Vietnam, challenges remain in wealth distribution, with poverty elimination still an ongoing struggle The surge in agricultural and industrial production has led to severe environmental degradation, particularly threatening the sustainability of the country's water resources This pollution crisis is especially pronounced in the Mekong Delta, a vital region for both agriculture and industrial development.
Water pollution control and wastewater treatment are critical yet often neglected areas, where lack of action can lead to significant health hazards for local communities, including diseases such as diarrhoea (Herbst et al., 2009; Reis and ).
1 3 1 E c o n o m ic g r o w th , p o llu te d w a te r e n v ir o n m e n ts a n d g r o w in g h e a lth d isp a r ities
Over the past two decades, Vietnam has experienced remarkable economic growth, with its GDP increasing from $6.3 billion to $103 billion since the ổi mới reform era This period has been characterized by a steady upward trend in annual economic growth, despite some fluctuations, reflecting the country's resilience and positive economic trajectory.
2012: 78) Poverty levels have improved in the country, with the percentage of poor people dropping from 37.4% in 1998 (GSO, 2012a) to 11.1% in 2012
(GSO, 2013) The poverty indicators used in Vietnam however, are as low as
400,000 VND 6 monthly for the upper threshold to be considered impover-
In Can Tho City, local district officials reported that the equivalent of approximately 20 USD is necessary to meet basic needs, with a threshold of 400,000 VND for rural areas and 500,000 VND for urban areas This amount is barely sufficient to cover essential expenses such as food and clothing, highlighting the financial challenges faced by residents in both settings.
A recent World Bank report reveals that employing newly-calculated and more suitable poverty indicators could result in a poverty rate of 27%, which is more than double the officially reported figures.
The disparity between rising GDP and the effectiveness of poverty reduction is increasingly evident While it's debated how much extreme poverty has been alleviated through economic growth, a more pertinent question is to identify who has benefited from this growth and who has been marginalized in the process.
Modern Vietnam exhibits significant wealth disparities, with the richest household quintile earning an average monthly income per capita that is 8.9 times greater than that of the poorest quintile, as reported in 2008 by the General Statistics Office (GSO).
In 2008, the national Gini coefficient rose to 0.43, highlighting persistent inequalities in poverty and deprivation, particularly in rural areas with concentrated ethnic minorities (Ibid 2008; Taylor, 2004; UNDP, 2011: 47) This wealth stratification adversely affects overall well-being and health, as evidenced by the highest under-five mortality rates and lowest high school education levels found in ethnically diverse regions like the Northern midlands/mountainous areas and the central Highlands (GSO, 2011b: 90; GSO, 2010b: 78) Minh Nguyen Thang and Popkin (2003) documented significant changes following the renovation period, further emphasizing the impact of these disparities.
(1993 – 1998) and underline how aspects of health appear to be closely linked with poverty:
Recent years have seen significant improvements in the health status of the Vietnamese population; however, the poor continue to face substantial challenges According to Pham et al (2000), this demographic endures a higher disease burden and has greater health needs Furthermore, as noted by Minh Nguyen Thang and Popkin (2003), they are less likely to seek healthcare services and often struggle to afford user fees, highlighting the ongoing disparities in health access and outcomes.
The authors highlight a significant connection between poverty and health indicators related to diarrhoea, such as infant mortality and child malnutrition, while noting the inadequate access to healthcare in the country (Ibid 2003) Fritzen (2007) emphasizes that, despite improvements in the health sector's organization, the poor continue to rely on low-quality local health services Although there have been advancements in legislation and data collection by the GSO of Vietnam, the adjusted poverty thresholds for 2011 were set at 480,000 VND for rural areas and 600,000 VND for urban areas, accounting for inflation (GSO, 2012a) Furthermore, the Vietnamese government has struggled to address critical political issues, including necessary reforms to public health, despite efforts to increase health insurance coverage among the population (Fforde, 2013: 103).
Rural areas and impoverished communities are increasingly facing disparities in access to resources and healthcare, while simultaneously suffering from the adverse effects of water pollution In the Mekong Delta, where local culture is deeply intertwined with water resources, the presence of agrochemicals, pesticides, and waste in nearby rivers and canals poses significant health risks Traditionally, surface water has been utilized for essential daily activities like bathing and drinking; however, rising concerns over water quality are leading to a decline in these practices Additionally, frequent flooding exacerbates the spread of waterborne diseases, particularly amidst rapid urbanization and ongoing pollution challenges in the Delta.
(Saravanan et al., 2011, WHO, 2012d, Confalonieri et al., 2007: 400) The Hau
The river in the central Delta, flowing through Can Tho City, faces significant pollution from organic, chemical, and microbiological substances Despite its remarkable self-cleaning capabilities, the river is adversely affected by untreated wastewater discharges from adjacent drainage canals.
Individuals strive to comprehend the risks and adjust to the evolving conditions of their hydro-environments; however, the resulting complexities can be challenging to manage, particularly for those with few resources available.
Water pollution is a nationwide issue in Vietnam, as untreated wastewater is released into streams and canals across the country (DONRE, 2009) The combination of a booming economy and a rising population leads to increased water pollution and consumption, resulting in the depletion of underground reservoirs and the salinization of coastal aquifers.
Environment Protection Agency, 2004, World Bank (WB), 2008) Environmen- tal sanitation and health issues have made the news (Le Kien, 2011, Ha Van,
2010a), but, in legislative terms, they remain only partly addressed (Nguyen Thi
Study objectives and research approach
This study aims to explore how cultural, social, and political environments influence the spread of diarrheal disease in Can Tho City, located in Vietnam's Mekong Delta To achieve this, data collection and analysis were guided by four key objectives, including an examination of the institutional structures involved in the prevention and control of diarrheal disease, as well as an assessment of their effectiveness in reducing the disease's prevalence in the region.
This article aims to identify the environmental and socio-economic factors that contribute to the worsening of diarrheal diseases in the Mekong Delta Additionally, it explores the current perceptions and knowledge regarding diarrhoea, as well as the practices that may facilitate its transmission in both urban and rural areas of Can.
The article aims to explore and analyze the socio-political factors that influence the discourse and implementation of public policy regarding diarrheal diseases at both national and local levels.
This study utilizes Political Ecology to explore the interconnectedness of ecological and social phenomena, emphasizing the role of power in shaping socio-ecological interactions Political Ecology investigates the roots of inequalities linked to natural resource use, highlighting the uneven distribution of risks and benefits It also examines how knowledge about these risks is constructed, revealing that power is a driving force in transforming policy into practice and determining who benefits from these processes.
Identifying the political aspects of disease is crucial for understanding its spread, control, and the barriers that prevent individuals from receiving adequate protection This study seeks to address key questions regarding the physical factors influencing disease transmission, the institutional challenges hindering effective control measures, and the socio-political dynamics that disempower communities in safeguarding their health.
This study explores how the risk of disease is constructed, communicated, and understood, emphasizing the importance of the agents involved in the dissemination of this knowledge It highlights the central role of "behavior" in controlling diarrheal disease, necessitating an analysis of prevailing beliefs, habits, and public perceptions By incorporating cultural and agency perspectives commonly used in anthropology, the research aims to illustrate how the risk of disease is perceived and experienced in the daily lives of individuals.
Critical Medical Anthropology This field proved extremely useful in exploring
9 Prevalence (of disease) = the proportion of the population that is infected at one time
Human health is deeply intertwined with socio-political factors, revealing disparities in access to wealth and power These elements not only influence patterns of disease but also shape the cultural meanings associated with health conditions.
To conduct a comprehensive analysis of disease from a social science viewpoint, the study employed an abductive research strategy, which involves a dynamic interplay between data and theoretical concepts, fostering a developmental and innovative approach (Blaikie, 2009).
The research employed an abductive approach to explore disease concepts beyond the traditional biomedical framework, integrating both technical and lay perspectives Without a predefined hypothesis, it aimed to understand health issues through the lenses of political ecology and critical medical anthropology A mixed-methods paradigm was utilized, combining qualitative and quantitative data that at times complemented and contradicted each other While qualitative analysis was prioritized, quantitative data provided an objective viewpoint that enriched the interpretative understanding of participants' perspectives Data collection involved 87 semi-structured and in-depth interviews, supplemented by field observations and daily notes A household survey was conducted across 131 urban and rural households to contrast findings with unstructured discussions Health communication materials were analyzed both quantitatively and qualitatively, linking ongoing discourse on disease among state representatives and community members Secondary statistics on disease prevalence, water supply, and sanitation were primarily used for critical reflection rather than as definitive sources Additionally, scientific literature and media reports shaped the discussion, while photographic documentation provided visual insights into the research context.
The subsequent chapters discuss the findings of this work, with Chapter 2 focusing on the literature surrounding environmental health and disease It highlights the connections between development approaches and identifies critical gaps in scientific knowledge regarding health The chapter integrates concepts from political ecology of health and critical medical anthropology, establishing a comprehensive analytical framework This framework outlines the prevention-infection-cure-control pathway of diseases, emphasizing the interplay of personal, social, environmental, and political contexts, as well as the emerging issues from their interactions.
Chapter 3 elaborates more on the methodological approach, offering a detailed description of the steps followed during the data collection and analysis The chapter also justifies the selection of the case-study areas and provides some background on their significant characteristics for this study Furthermore, chapter 3 reflects upon the limitations posed by the “character” of the research field and discusses how those challenges were addressed
Chapter 4 of the article presents an empirical analysis of the health sector, examining the impact of renovation and decentralisation policies on current healthcare services, particularly public access and utilisation It details the organisational structure of the sector, emphasizing critical management aspects of diarrheal disease, including primary healthcare, preventive health education, and epidemic reporting Furthermore, the chapter discusses the status of key infectious diseases, with a critical focus on the incidence of diarrheal disease as reflected in national, regional, and local statistics.
Chapter 5 examines the expansion of water supply and sanitation in the region of the Delta and uses empirical and secondary data to question the actual con- tribution of WSS infrastructure in reducing the risks of diarrheal disease Look- ing at the results of policy implementation, particularly in the region of Can
The chapter critically examines the values underpinning the water and sanitation sector, focusing on equity, transparency, and efficacy While advancements in water and sanitation services (WSS) are often touted as vital for health prevention, the findings in Chapter 5 raise concerns about their ability to sustainably deliver clean water and sanitary living conditions.
Chapter 6 tries to look at the prevention of diarrheal disease holistically, mov- ing beyond the technical measures of water supply and sanitation expansion It traces the fragments of policy that exist in national legislation and examines their implementation within Can Tho City The chapter particularly emphasizes the health education mechanisms that are employed to raise awareness about the issue of diarrheal disease It analyses the means and methods used in the circulation of information, with a focus on the content of messages that are communicated to the public
Problematising health
Health issues in development studies are often seen as a result of socio-economic challenges, linked to inadequate growth and weak institutional frameworks While it is true that economic and institutional weaknesses can exacerbate public health problems, the anticipated benefits of economic and technological progress have not been fully realized in terms of health and well-being in either the global North or South This gap arises because such assumptions frequently overlook the socio-ecological dynamics and cultural contexts that influence how these advancements are distributed and experienced by the broader population.
1996 cited in Chay Navuth, 2006: 24, Power 2008 cited in Potter et al., 2012:
When considering health as an integral aspect of human development, it prompts the question of what type of development is being pursued A modernist perspective on health progress emphasizes technological and economic advancements based on Western biomedical paradigms However, this approach often overlooks the inequalities and injustices present in local health institutions and dismisses alternative beliefs about health and disease Therefore, it is essential to critique these visions, not as unrealistic or unattainable, but as intentionally apolitical.
2 1 1 H u m a n itie s in h e a lth a n d th e lin k to d e v e lo p m e n t
Modernist perspectives on human health and development share significant parallels, particularly in the criticism of development as a rigidly defined "outcome" that societies should pursue Post-modern and deconstructionist theorists, such as Parfitt (2002), argue that this modernist approach disempowers and controls nations, groups, and individuals (Sachs 1992, cited in Schuurman, 2000) In contrast to the monolithic views of modernism, scholars have explored alternative frameworks for identifying desired societal outcomes, emphasizing concepts like "development from below" and "people-centred development."
“another development” (Potter et al., 2012: 75ff)
Deborah Lupton critiques the Western-centric focus on health, arguing that it prioritizes biomedical solutions as the primary means to combat illness, often neglecting cultural aspects of health (Lupton, 2012a) This Western narrative shapes global perceptions of health and disease, promoting ideas that overlook the human body's fragility and mortality Bambra et al (2005) suggest that this medicalization contributes to the depoliticization of health, establishing a dominant global paradigm Nichter and Nichter (1996a) further assert that these processes create a socialization agency that reflects power dynamics and reinforces capitalist ideologies, effectively intertwining them with medical practices.
Despite the advancements in biomedicine and socio-economic growth leading to the eradication of many diseases, significant health challenges persist globally In affluent Western countries, issues such as obesity and rising mortality from chronic diseases highlight that good health is not solely a product of technological progress or economic prosperity Social scientists argue that health assessments should extend beyond mere statistical indicators, such as disease mortality rates or hospital bed availability, to encompass the social structures and cultural contexts influencing public health This perspective reveals that a decline in disease mortality does not necessarily correlate with reduced disease morbidity, indicating a gap in preventive health measures despite awareness of available treatments.
Problems of financial or know-how constraints might be part of the reason why advancements in medicine have not been able to reach everyone in need
The humanities highlight the importance of incorporating ethnographic insights into health as a crucial aspect of development, as emphasized by Schlipküter and Flahault (2010) Leonard Syme articulates the need for this ethnographically informed approach to better understand health within the broader context of societal development.
“We epidemiologists have suffered a whole series of very embarrassing failures
Our approach aims to identify risk factors and communicate them to the public, encouraging individuals to modify their behaviors for better health outcomes While this model seems logical, it has proven ineffective Public health messages are crucial, yet they often clash with people's daily lives, creating a significant disconnect Anthropologists have insights that could enhance our understanding of this issue, suggesting that their perspectives should be integrated into the development of more effective health interventions.
(Leonard Syme in Trostle, 2005: xi)
2 1 2 R e- co n cep t u a lis in g h e a lt h a n d d ise a se
In anthropology, sociology, and ethnography, researchers often explore the meanings individuals attribute to their experiences and challenge the objectivity of established "facts." Nichter and Nichter (1996b) highlight the crucial role of metaphor and analogy in conveying health messages, while Myrick (1996) contends that AIDS-related campaigns create specific narratives that unfairly assign blame to the gay community.
The holistic approach to health has expanded across various disciplines, emphasizing the intrinsic connections between human societies and their ecological environments Health Ecology, for instance, views health as an ongoing dialogue influenced by environmental changes on both local and global scales Similarly, Medical Geography and the Geography of Health utilize spatial analysis to bridge medical, natural, and social explanations of health These interdisciplinary approaches facilitate a comprehensive understanding of how interconnected systems shape human health, particularly through the study of epidemics, which vividly illustrate the interplay of biological, social, and cultural factors in disease experiences.
Interdisciplinary efforts to understand human health often fall short by not adequately exploring concepts beyond their traditional methodologies For instance, while epidemiologists may analyze statistical correlations between disease prevalence and socioeconomic factors, they frequently neglect to investigate the underlying reasons for these relationships and fail to critically assess the limitations of their quantitative data Although large-scale statistical approaches can yield valuable insights, they lack the interdisciplinary depth needed for a comprehensive understanding Some researchers have attempted to address the cultural dimensions of health by examining genetic and evolutionary traits, yet these approaches often overlook the crucial behavioral and social factors that, in conjunction with biology, influence individuals' vulnerabilities and adaptability to disease As highlighted by Joralemon, a critical interpretive framework is essential for understanding who benefits and suffers from the economic conditions that facilitate the spread of disease.
In response to the limitations that the above approaches have presented, the works of critical and cultural disease ecologists and epidemiologists (such as:
Recent research by Brown (2006), DiGiacomo (1999), Trostle (2005), and Amsterdamska (2005) highlights the significant impact of social factors on health, expanding the scope of health studies For instance, Akala (2006) explores the social and political implications of health in Kenya, illustrating how these dimensions influence overall well-being.
HIV is a complex social condition that contributes to significant social injustices, particularly impacting young, uninfected individuals who often lack a voice This perspective encourages a broader understanding of AIDS and its societal implications.
“just a health condition requiring anti-retroviral treatment, a balanced diet and research focused on evolving a cure and/or vaccines”
Medical Sociology situates health and disease within their social, cultural, and behavioral contexts, as highlighted by the American Sociological Association (2002) Rudolf Virchow, regarded as the discipline's founder, emphasized the link between epidemics and socio-economic conditions, famously stating that "medicine is a social science, and politics nothing but medicine on a grand scale." This perspective suggests that adopting a sociological approach to health is not a novel concept but rather a return to a holistic examination of individual well-being.
In the nineteenth century, health and disease were not strictly viewed as biological or physiological processes; rather, they were understood in broader terms related to well-being During this time, medicine had not yet fully integrated with experimental laboratory sciences, and sociological perspectives still retained influences from psychology, organicism, and physiology.
This blending of disciplines in the attempt to approach health socially, howev- er, has often maintained strong ontological dividers between society and health
Falola and Healton (2006) emphasize the interplay between real medical risks and the social environment that often exacerbates these risks Their work highlights the existence of socially produced health inequalities, suggesting that health can be understood through an objective lens—biological and scientific—without questioning its validity This perspective positions society as an external force in defining health risks Conversely, cultural theories of risk acknowledge the significant role of individuals in shaping the meaning of risk, recognizing the intricate relationship between societal factors and health outcomes.
Theoretical grounds
This study is grounded in the principles of Political Ecology, which, as defined by Baer and Singer (2009), explores the interplay between power dynamics and natural resources Political ecology serves as a crucial framework for understanding environmental-society interactions, emphasizing the roles of political economy, including factors like capitalist production, market distribution of resources, urbanization, and population growth This approach is particularly relevant for examining diarrheal disease, primarily transmitted through water, highlighting the importance of these socio-political factors in addressing public health issues.
Water is a vital yet often scarce resource, frequently analyzed through the lens of political ecology, which reveals that the exhaustion, pollution, and distribution of natural resources are socially and politically constructed As a carrier of intestinal pathogens and a key factor in hygiene, water plays a crucial role in disease studies Water pollution poses significant environmental challenges that directly impact human health, particularly through diseases like diarrhoea The effectiveness of water pollution control mechanisms is critical in influencing disease spread, as pathogens are often concentrated in untreated sewage and inadequate water supply systems within households and communities Furthermore, the benefits of safe water and sanitation are not evenly distributed, exacerbating health disparities.
Access to water is intricately linked to other vital factors affecting disease, such as healthcare access, as both water and health governance operate within the same social and institutional framework A comprehensive analysis of diarrheal diseases should encompass not only water supply and sanitation but also health and healthcare sectors Political ecology serves as an effective lens to uncover and explain existing inequalities in these areas, while also addressing how knowledge about environmental health risks is developed and disseminated Central to this discussion is the concept of power, which underscores the political dimensions of political ecology.
Power serves as an underlying force that bridges the divide between policy and practice, determining how discourse translates into action Understanding the political dimensions is crucial for addressing questions related to the physical spread of diseases, the lack of preventive measures in environmental and health policies, and the challenges individuals face in protecting themselves from these health threats on behavioral and social levels.
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Political ecologists examine how the marginalization and vulnerability of populations are created and sustained, linking these issues to unequal access to resources, power, and knowledge This dynamic not only influences the fate of environments and natural resources but also reflects broader societal structures In the context of water, Swyngedouw highlights these critical relationships.
In 2009, the concept of the "hydro-social cycle" was explored through a political economy and political ecology lens, highlighting the significance of social power relations—be they material, economic, political, or cultural—in driving hydro-social transformations This perspective is crucial for development studies, as emphasized by Bryant in 1991.
In recent years, water has become a focal point for political ecologists, with significant research contributions from scholars like Budds (2013), Kaika (2003), Loftus (2005), Otero et al (2010), and Swyngedouw (1997) However, there remains a notable gap in the integration of water studies with health-related issues.
The political ecology of health and disease, although limited in scope, has historical roots dating back to Turshen (1977) Mayer emphasizes the necessity of examining the social, cultural, and political factors that shape disease dynamics, alongside the environmental characteristics that influence host-agent interactions Additionally, understanding the behavioral aspects of individual or group susceptibility to disease is crucial for a comprehensive perspective on health issues.
Mayer (1996b) emphasizes the importance of considering human agency within specific spatial, cultural, political, and social contexts to uncover previously unrecognized factors influencing the spread of diseases and epidemics However, King (2010) critiques Mayer's work, highlighting a lack of theoretical and empirical evidence supporting his assertions, as well as a misinterpretation of political ecology as merely a blend of cultural ecology and political economy.
King (2010) highlights the importance of political ecology in understanding the interplay between social and environmental systems that influence health over time and space, suggesting it can clarify disease transmission and institutional responses While King (1996) illustrates the political dimensions of HIV policy in South Africa, he lacks empirical depth in explaining these dynamics In contrast, Richmond et al (2005) effectively apply Mayer's concept to the Aboriginal Canadian Peoples, demonstrating how globalization disrupted aquaculture and deprived local communities of vital land and water resources, leading to economic and social decline They detail the health impacts of environmental changes and emphasize the community's responses, bridging global and local perspectives and incorporating human agency into the analysis.
A notable study by Guénel (2004) examines the historical relationship between French colonization and the spread of malaria in Vietnam, framing it within the context of political ecology The research highlights how ecological factors and population migrations influenced malaria epidemiology while emphasizing the significant impact of economic and political transformations on the development and effectiveness of malaria control strategies in the region.
A comprehensive political ecology of health examines access to health services alongside disease patterns, highlighting the socially-produced inequalities in decision-making that increase vulnerability for certain groups (Blaikie and Brookfield, 1987) This perspective is echoed by various authors outside the political ecology sphere who employ relevant methodologies and analyses For instance, Susanne's 2006 study on South Africa's birth-control policy illustrates how official decisions were influenced by national pride, discrimination against "poor whites," and competing political pressures from diverse interest groups, including nationalists and feminists.
Farmer (2005) explores the deep connection between access to healthcare and the fight for social and economic rights, highlighting that inequalities in these areas can lead to a "quiet brutality" (Amartya Sen, Foreword of Farmer, 2005) that adversely affects the health of the most vulnerable populations.
Current studies on health care primarily focus on political economy and institutional analysis, often neglecting the crucial aspects of access to natural resources and environmental change As highlighted by Collins (2001), there is a scarcity of research that explores the processes and perceptions defining a political ecology of healthcare By integrating this perspective, future research can better understand health as a complex institutional phenomenon and examine it as a cultural and social construct linked to control mechanisms Thus, a political ecology of disease should encompass the concept of health not merely as an outcome but as an integral part of the processes that influence health outcomes.
Figure 2.1: From non-problematised views to an integrated and critical analysis of water-related disease
According to Roseberry (1988, as cited in Leatherman, 2005), the true power of political ecology emerges from the integration of structure and agency To fully understand the interactions between health, water, and power structures, it is essential to incorporate agency into the analysis This approach highlights the importance of utilizing conceptual and methodological tools from critical medical anthropology to explore these complex relationships effectively.
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Analytical fields
This study examines the interplay between risk communication politics and the epidemiology of health messages, particularly regarding diarrheal diseases According to Bennett et al (2010), risk-related information is continuously constructed and validated, highlighting the significance of the underlying political discourse that shapes health policies The communicative process, described as a "tangled web of signs, symbols, and messages" (Krimsky and Plough), influences public perception of risk, contributing to risk amplification and stigmatization (Kasperson and Kasperson, 2005) The effectiveness of health messages in promoting healthy behaviors hinges on their content and the extent to which they engage the public This analysis emphasizes the importance of health education and the circulation of health-related information, exploring the levels of public participation and social empowerment involved in these processes.
Risk communication is deeply intertwined with political dynamics, as it involves contestation over the origins and nature of risks and strategies for mitigation According to Bryant (1998b), the identification of societal problems is a political process that often mirrors and reinforces existing social and economic inequalities Since risks frequently manifest as social problems, any informative or educational message inherently asserts the validity and relevance of certain knowledge claims over others Therefore, it is essential to analyze the prominent messages in health risk communication, the processes that elevated these messages, and the interests they represent.
Risk communication extends beyond the content itself, as the methods and language used can reflect intentions of authority and control The way messages are framed, the extent to which questioning is permitted, and the accompanying discourse can influence power dynamics For example, certain groups or locations may be unfairly stigmatized as sources of health risks Bennett et al (2010) highlight that the language surrounding complex scientific issues shapes the debate and understanding of these risks Additionally, Kasperson and Kasperson (2005) note that when a place is dominated by a single negative attribute, other characteristics fade, leading to altered and stigmatized identities.
The concept of political and social power plays a crucial role in shaping risk communication, prompting an exploration of the nature of "the political." Power is defined not merely as external pressure but as a social relation characterized by an unequal distribution of resources and risks, as highlighted by Paulson (2003) and Hornborg (2001) This understanding frames politics as the practices and processes through which various forms of power are exercised and negotiated Consequently, politics extends beyond formal political arenas to encompass everyday interactions, language, and individual behaviors, often manifesting in subtle, indirect, or underlying ways.
Examining risk communication processes in both formal and informal contexts reveals the significance of discourse and lay discussions Swyngendouw (2008) challenges the idea of politics as merely a power-controlling mechanism, defining the political as a platform for diverse voices and public interactions In contrast to Parfitt (2002), who views politics as a means to regulate power and prevent abuse, Swyngendouw suggests that contemporary politics is post-political However, Parfitt acknowledges that the political sphere operates in the tension between indecision and decision, where choices inherently disadvantage some while benefiting others This exacerbation of inequalities can lead to a situation where individuals' political rights are diminished, rendering their voices ineffective in influencing policy, as noted by Farmer (2005).
Vietnam, as a one-party rule state, presents a unique landscape for analyzing the dynamics of power through political processes of risk definition and communication The central government's authoritarian approach has hindered genuine bottom-up participation, as noted by Brocheux (2012) Critics argue that Vietnam's Leninist tradition restricts true public involvement, limiting it to a process of co-production, which entails executing pre-made decisions (Roeder, 1989 cited in Smith, 2002) However, scholars like Gainsborough (2010a) and Smith (2002) acknowledge that the Vietnamese populace has found ways to engage politically despite formal restrictions Beresford (2008) highlights that the 'ổi mới' policy has improved information accessibility and fostered critical discourse from both the press and government circles Furthermore, Fforde (2013) questions the ruling Party's sovereignty in light of significant criticism following economic policy failures Nonetheless, Fforde (2012) points out that local party-state branches remain committed to state ideology, successfully maintaining top-down authority, which has led to notable outcomes in local development and order.
The Vietnamese state plays a crucial role in shaping public opinion regarding disease causes and solutions through its communication of health-related information In a political landscape characterized by direct party control and socio-cultural influences, it is essential to analyze how water-related diseases are discussed and represented Key questions arise about the representation of affected individuals' voices compared to other stakeholders, the state's methods of managing public concerns, and the inclusivity of discourse surrounding health issues Furthermore, understanding the factors that influence health decision-making and the access different societal groups have to essential resources and information is vital for empowering communities in addressing health challenges.
Despite significant advancements in disease prevention and treatment, public health failures persist globally A key challenge is adapting knowledge and expertise to diverse contexts while ensuring local community involvement and cultural respect.
Research on risk perception highlights a significant gap between scientific understanding and public awareness of risks, underscoring the critical need for effective education and information dissemination.
Effective health communication requires interaction between the sender and recipient to create a shared understanding of the problem (Hampel, 2006) Nichter (1996b) emphasizes the importance of analyzing health communication alongside disease epidemiology, as understanding why certain health messages resonate while others do not is crucial for developing effective public health strategies He advocates for a health education approach that focuses on what populations already know, rather than imposing knowledge about issues they are presumed to be unaware of.
Public participation plays a vital role in shaping health messages, as it provides policymakers with insights into community concerns and demands regarding health risks Ignoring public knowledge and attitudes can lead to misunderstandings and resentment (Bennett et al., 2010) The effectiveness of health communication is largely determined by how useful the public finds the information, as individuals seek knowledge to make informed personal choices and enhance their well-being (Moore, 2002, cited in Bennett et al., 2010) Therefore, successful health communication must be grounded in the experiences and understandings of the affected communities (Nichter, 1996a).
Ignoring the health concerns of the general public and delivering educational messages that do not align with their health culture can lead to misunderstandings, fragmented information, and a reduced awareness of critical health issues.
There is an urgent need to explore the "epidemiology of health messages" related to diarrheal disease in high-prevalence areas like Vietnam's Mekong Delta, as highlighted by academics such as Nichter and Nichter (1996a) This examination should assess whether health education approaches have been participatory and inclusive, impacting public receptiveness and the sustainability of health messages in local communities Engaging directly with local perspectives and concerns is essential for understanding the effectiveness of health education A medical anthropology approach would analyze the discourses and practices surrounding disease through cultural and institutional lenses, while also critically addressing risk communication within the broader context of health politics.
A historical review by Tros- tle (2005: 21-41) highlights the evolving relationship between Anthropology and Epidemiology in the late 19th century This connection emphasizes the significance of health education, particularly its potential to empower individuals and communities.
The empowering potential of health education
Effective health education can significantly enhance disease prevention and management, leading to improved well-being throughout a population's life span (Fisher et al., 2011) By providing comprehensive information on various health topics, health education strengthens health literacy, which Nutbeam (1998, cited in Nutbeam, 2000) defines as the cognitive and social skills that enable individuals to access, understand, and utilize information to promote and maintain good health.