From discourse to incidence socio politi

Panagiota Kotsila Socio-political and Cultural Determinants of Diarrheal Disease in the Mekong Delta ZEF Development Studies edited by Solvay Gerke and Hans-Dieter Evers Volume 28 Center for Development Research (ZEF) University of Bonn www.zef.de LIT Panagiota Kotsila Socio-political and Cultural Determinants of Diarrheal Disease in the Mekong Delta From Discourse to Incidence LIT Cover image: Panagiota Kotsila The print is paid by the BMBF and the WISDOM project This dissertation has been accepted by the Faculty of Philosophy of the University of Bonn Bibliographic information published by the Deutsche Nationalbibliothek The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http://dnb.d-nb.de ISBN 978-3-643-90562-8 Zugl.: Bonn, Univ., Diss., 2014 A catalogue record for this book is available from the British Library L LIT VERLAG Dr W Hopf Klosbachstr 107 CH-8032 Zürich Tel +41 (0) 44-251 75 05 Fax +41 (0) 44-251 75 06 E-Mail: zuerich@lit-verlag.ch http://www.lit-verlag.ch Fresnostr D-48159 Münster Tel +49 (0) 51-62 03 20 Fax +49 (0) 51-23 19 72 E-Mail: lit@lit-verlag.de http://www.lit-verlag.de © IT VERLAG GmbH & Co KG Wien, Zweigniederlassung Zürich 2014 Berlin 2014 Distribution: In the UK: Global Book Marketing, e-mail: mo@centralbooks.com In North America: International Specialized Book Services, e-mail: orders@isbs.com In Germany: LIT Verlag Fresnostr 2, D-48159 Münster Tel +49 (0) 51-620 32 22, Fax +49 (0) 51-922 60 99, E-mail: vertrieb@lit-verlag.de In Austria: Medienlogistik Pichler-ÖBZ, e-mail: mlo@medien-logistik.at e-books are available at www.litwebshop.de Acknowledgments This book owes to the support, the guidance and the resources I received from many people and institutions I would like to express my gratitude to them for enabling this research project and for helping me to successfully complete it My sincere thanks go firstly to the German Federal Ministry of Education and Research (BMBF), for funding this study under the wider scope of the WISDOM1 project I would like to thank my supervisor, Prof Dr Solvay Gerke and my tutor Dr Subramanian Saravanan, for their invaluable academic guidance and support My appreciation goes also to all the lecturers, researchers and staff in the Center of Development Research (ZEF) of the University of Bonn, for accommodating my research and for opening up my academic horizons Especially I want to thank Dr Gabi Waibel and my colleagues Siwei, Linh, Sven, Sarah, Judith, Nadine, Simon and Carmen for the inspiration they generously offered to me through their work and their personalities This research would also not have been possible without the facilitation offered by the Can Tho University in Vietnam and particularly without the help and advice of Dr Bui Thi Nga I want to also send my gratitude to Nhan, for being a tireless research assistant and a positive spirit throughout my fieldwork Moreover, my thanks go to all the Vietnamese people who shared their time and their experiences, selflessly offering me their hospitality and kindness Finally, I want to thank my family and friends, for being my mental refuge and a neverending source of love Most of all, I thank you Alan, for this work would have never been started or completed without you by my side Water-Related Information System for the Sustainable Development of the Mekong Delta, Vietnam (www.wisdom.eoc.dlr.de) TABLE OF CONTENTS Table of Contents i List of Figures vii List of Tables ix List of Pictures xi Abbreviations xiii FRAMING THE PROBLEM OF DIARRHEAL DISEASE IN VIETNAM: AN INTRODUCTION CHAPTER 1.1 Holistic views on a globally persistent disease 1.1.1 Discourse and context: Why diarrheal disease is not only a medical problem 1.1.2 Global efforts and omissions: why re-prioritising diarrhoea needs local relevance 1.2 Troubling diarrhoea: aetiologies and prevention 1.2.1 Infection pathways: a web of human and nature interactions 1.2.2 Challenges in the prevention of diarrhoea: the factor of human behaviour 11 1.3 The Mekong Delta: diarrheal risks in an environment of intense hydro-social interaction and change 15 1.3.1 Economic growth, polluted water environments and growing health disparities 15 1.3.2 A blurry causality: water supply and sanitation and the control of diarrheal diseases 19 1.4 Study objectives and research approach 20 A POLITICAL ECOLOGY OF DISEASE INFORMED BY CRITICAL MEDICAL ANTHROPOLOGY 25 CHAPTER 25 2.1 Problematising health 25 2.1.1 Humanities in health and the link to development 26 2.1.2 Re-conceptualising health and disease 27 2.2 Theoretical grounds 32 2.2.1 Building on political ecologies of health 33 2.2.2 Borrowing from critical medical anthropology 36 2.3 Analytical fields 38 2.3.1 The politics of risk communication 39 2.3.2 The “epidemiology” of health messages 41 2.3.3 A framework of analysis 45 FIELDWORK METHODOLOGY 49 CHAPTER 49 3.1 Understanding the social side of disease using a mixedmethods approach 49 3.1.1 Abductive research strategy and the use of the case study 51 3.1.2 Methods of data collection and analysis 52 3.2 Location background: rural and urban case-studies 54 3.2.1 The rural communes of Phong Dien district 57 3.2.2 The urban ward of Cai Rang district 60 3.3 The field’s character: social research challenges in Vietnam 64 HEALTH AMIDST CHANGE 67 CHAPTER 67 4.1 Declared policy objectives and contradictory realities in healthcare 67 4.1.1 Past achievements and the challenges ahead 68 4.1.2 A pyramid with weak foundations 70 4.1.3 The weaknesses reflected in preventive health 75 4.2 Reshaping access to public health 81 4.2.1 New rules and new players in the “game” of healthcare: the private sector 81 4.2.2 Loopholes in the health insurance scheme 83 Combined impacts of inequality in health access 89 4.3 Controlling epidemics in Vietnam 92 4.3.1 The status of infectious diseases and the distribution of diarrhoea 92 4.3.2 The disease reporting mechanism and the case of diarrhoea 97 4.4 Conclusions 102 QUESTIONING THE PANACEA OF WATER SUPPLY AND SANITATION 105 CHAPTER 105 5.1.1 Water supply and sanitation vis-à-vis disease prevention 106 5.1.2 Seeing beyond “improved” indicators 108 5.2 Safe water access in the Delta: whose reality and whose delusion? 112 5.2.1 Rural supply schemes, urban water companies and the hampered alternatives 113 5.2.2 Reporting water supply: “hygienic” labels and data discrepancies 119 5.2.3 Water quality fluctuations from source to consumption 126 5.3 Cultural and structural constraints in sanitation .134 5.3.1 Sanitation types and blaming the “other” latrine 134 5.3.2 Implementing pro-poor programs for sanitation 142 5.4 Conclusions 151 PREVENTING DIARRHOEA: FRAGMENTED POLICY AND THE LACK OF EMPOWERING HEALTH EDUCATION 155 CHAPTER .155 6.1 Merging the gap between local and global approaches to diarrheal disease 155 6.1.1 Vietnamese perceptions about health 156 6.1.2 The international “toolkit” against diarrhoea 159 6.2 Derelictions of prevention: fragmented measures and weak implementation 161 6.2.1 The “old story” of diarrhoea: de-prioritising and underestimating a widespread disease 161 6.2.2 Streets to industries: the multilevel challenge of food safety 164 6.2.3 Anti-diarrheal vaccination: an inaccessible and unknown solution 169 6.2.4 Diarrhoea and malnutrition: the disregarded links 171 6.2.5 Polluted hydro-environments and weaknesses in advocating personal hygiene 174 6.2.6 The lost chance for an integrated approach: the policy of “healthy and cultural villages” 176 6.3 Health education and the public communication of disease 178 6.3.1 The Vietnamese approach to health education 178 6.3.2 Directing funds, expertise and information 180 6.3.3 Content and quality of the produced messages 188 6.3.4 The hollow construction of a success story 197 6.4 Conclusions 201 PRACTICES, PERCEPTIONS AND BEHAVIOURS AROUND DIARRHEAL DISEASE IN URBAN AND RURAL HOUSEHOLDS 205 CHAPTER 205 7.1 The complex diversity of water use and treatment 206 7.1.1 Household water sources and water preferences 206 7.1.2 Drinking-water treatments 213 7.1.3 Water for daily use 217 7.1.4 A web of waterborne risks of disease 218 7.2 Sanitation realities 220 7.2.1 Household sanitation and community hygiene 220 7.2.2 Sanitation ideas and preferences 224 7.3 Identification of risks and local awareness about diarrheal disease 227 7.3.1 Where does diarrhoea come from? 228 7.3.2 Senses of water safety and hygiene 231 7.3.3 Identifying, preventing and treating diarrhoea 236 7.4 Conclusions 243 DISCUSSION AND CONCLUSIONS 247 CHAPTER 247 8.1 The interplay of factors shaping the risk of disease: a synthesis of findings 248 8.1.1 Health policy and the “normalisation” of diarrheal disease 249 8.1.2 Constructing sick identities of poverty and rurality 256 59.649 556.331 76.711 778.552 778.552 total (2010) 2.583 6.168 Urban 2006 212.095 130.537 93.839 78.708 Rural 2006 - Total 2006 212.095 130.537 93.839 78.708 Reporting on rural and parts of urban districts Ninh Kieu O Mon Binh Thuy Cai Rang Yearbook of Can Tho: 182 2.791 6.410 13.019 295 Annex 29.552 1.014 276 988 1.245 3.766 1.721 2.596 47.95 43.39 213.894 5.282 4.834 18.93 9.311 47.95 43.39 18.93 69,21 2,0 213.894 5.276 4.834 9.303 * Case-study districts Source: (CERWASS, 2011a, CERWASS, 2010) 71,46 77,76 68,75 28.72 28.72 6.861 9.694 68.60 64.58 8.914 7.866 286.966 304.473 38.524 34.365 Urban 2009 244.065 130.274 111.306 86.328 Rural 2009 - Urban 2011 249.451 131.972 116.349 88.432 Rural 2011 - Total 2011 249.451 131.972 116.349 88.432 100.269 40.380 76.711 CERWASS 2010182: Table 5: Reported rural and urban population in Can Tho City from the Statistical Yearbook and by CERWASS 538.824 67.683 98.450 Phong Dien * Cai Rang * total 172.413 139.363 153.091 104.072 568.939 195.941 152.737 179.138 104.072 1.147.067 159.461 17.302 12.979 10.643 10.746 783.104 95.586 111.266 110.678 88.921 406.451 161.563 17.458 13.071 10.735 10.828 799.859 96.900 111.718 111.517 89.198 409.333 161.563 114.358 124.789 122.252 100.026 1.209.192 Based on data by Can Tho Statistica Office (2007, 2011, 2009) and CERWASS (2011a) 23.528 13.374 26.047 578.128 126.828 104.867 114.138 116.909 98.450 556.331 522 14,81% 1171 2954 748 63, 87% Total water factories were checked Total testing checks in a water factory Total testing checks that showed non compliance with general hygiene Percentage of non-compliance in the total of factories 3003 3525 6515 1610 Total water factories in the area 2011 2010 Testing the general hygiene in water factories Table 6: Results from hygiene and water quality checks in water factories (serving>500hh) in 10 provinces of the Delta Thot Not Vinh Thanh Co Do Thoi Lai Phong Dien Total Socio-political and Cultural Determinants of Diarrheal Disease in the Mekong Delta From Discourse to Incidence 83,27% 777 3077 2251 73,16% 826 Total water samples are tested Total water samples that complied with hygienic standards Percentage of water samples that reached hygienic standards Total water samples that did not reach hygienic standards 614 163 300 3868 619 Source: (IHPH, 2011a, IHPH, 2011b) - of which, how many did not reach physical and chemical indicators - of which how many were due to microbiological indicators 2011 2010 Results from water samples 4645 Total facilities that were tested for a second time and were still found to not comply checked Annex O Mon Binh Thuy Co Do Thoi Lai Vinh Thanh Thot Not 8.025 35,9 4.386 44,4 23.327 9.878 4.240 7.845 42,92 35,14 27,05 7.364 27.221 7.787 28,6 39,31 25.806 10.524 40,8 10.144 49,8 28.534 15.510 54,3 14.211 % of total 49,33 hh % hyof gienic total toilet 9.463 3.974 5.177 5.347 4.188 3.974 5.159 5.204 4.188 12.414 12.333 9.463 # latrines 266 2.607 2.073 5.804 1.878 1.827 266 2.573 2.057 5.676 1.878 1.826 23 0 30 23 0 27 90 103 297 69 other 90 103 280 69 5.492 14.297 19.434 15.282 13.024 11.228 # hyg la# latrines trines pit latrine with aeration # hyg la# latrines trines two-vault composting # hyg # lalatrines trines pour-flush latrines # hyg la# latrines trines % hh having septic tank lahygienic toilet trine 23.080 11.852 51,4 11.385 # hh hh using hyg toilet % of hh using hygienic toilet: Table 7: Sanitation information for the districts of Can Tho, provided by CERWASS Can Tho Socio-political and Cultural Determinants of Diarrheal Disease in the Mekong Delta From Discourse to Incidence * study districts 34,06 65,28 42,11 41,39 7.834 70,2 12.064 45,1 75.087 43,6 73.807 35,2 9.248 6.017 55.946 55.586 55.946 55.586 9.363 6.019 2.816 1.603 17.609 17.415 18.889 18.695 2.831 1.603 Source: (CERWASS, 2011a, CERWASS, 2010) septic tank latrine pit pour-flush latrine (THẤM DỘI NƯỚC) two-departments composting latrine (HAI NG N) sink with aeration latrine (CHÌM CĨ ỐNG THỐNG HƠI) Phong Dien * 22.998 8.102 Cai Rang * 18.479 12.975 Total of 2011 178.323 80.461 total of 2010 178.323 77.716 Annex 111 111 58 108 108 58 715 715 156 98.824 5.504 14.563 698 100.169 698 156 Septic latrines Total latrines Number of hygienic latrines Percentage of hygienic latrines (compared to total septic latrines) Number of newly built hygienic latrines in the report duration Number of latrines becoming unhygienic latrines in the report duration Total latrines Total hygienic latrines Percentage of hygiene Number of hygienic latrines that newly built in the report duration Number of latrines becoming unhygienic latrines in the report duration Details of the specific type of latrines 1.651.401 1.452.951 87,98% 38.676 13.156 46.935 20.254 98.125 108.927 3.641.083 2.707.845 74,37% 2.929.496 2.156.207 73,6 52.307 4.042.074 2011 5.534.034 3.738.730 67,56% 65.619 5.904.427 General information Total households (in the study area) 2010 Data provided by IHPH Ho Chi Minh City Table 8: Sanitation information from 10 Provinces of the Mekong Delta Socio-political and Cultural Determinants of Diarrheal Disease in the Mekong Delta From Discourse to Incidence 81,17% Average Pit latrines with Two vault compost latrines= NHÀ TIÊU HAI NG N Pour-flush latrines= NHÀ TIÊU THẤM DỘI NƯỚC Annex Percentage of septic latrines % (compared to total households) Total latrines Number of hygienic latrines Percentage of hygienic latrines (compared to total pit pour water latrines) Number of newly built hygienic latrines in the report duration Number of latrines becoming unhygienic latrines in the report duration Percentage of pit latrines % (compared to total households) Total latrines Number of hygienic latrines Percentage of hygienic latrines (compared to total two compartments latrines) Number of newly built hygienic latrines in the report duration Number of latrines becoming unhygienic latrines in the report duration Percentage of two-vault compost latrines % (compared to total households) Total latrines 3,04% 1,10% 63.051 745 1.743 118.467 212 22,50% 18,35% 215 8.366 8.604 50.155 37.493 74,75 14.257 18.336 64.698 51.591 79,74% 909.408 743.490 81,76 40,86% 1.083.602 882.754 81,46% 61,67% 2.07% 20.43% 51.26% (IHPH, 2011a, IHPH, 2011b) Number of hygienic latrines Percentage of hygienic latrines (compared to total pit latrines with aeration) Number of newly built hygienic latrines in the report duration Number of latrines becoming unhygienic latrines in the report duration Percentage % of pit latrines with aeration (compared to total households) Number of latrines Percentage % (compared to total number of households) 3155 3,82% 695 3,25% 503.564 12,46% 266 959 626.184 31,10% 45.159 71,62 96.540 81,49% Drinking water Total Coliform Parameter Maximum limit Bacterial/100ml Unit 21.78% 3.54% TCVN 6187 – 1, 2: 1996 (ISO 9308 – 1,2 – 1990) or SMEWW 9922 Testing method Table 9: Microbial water quality standards for drinking and daily use water in Vietnam Other kinds aeration = NHÀ TIÊU CHÌM CĨ ỐNG THỐNG HƠI Socio-political and Cultural Determinants of Diarrheal Disease in the Mekong Delta From Discourse to Incidence Bacterial/ 100ml Bacterial/ 100ml Total Coliform E.coli or thermotolerant coliform Bacterial/ 100ml Annex 0* 50* 20** 150** TCVN 6187 – 1, 2: 1996 (ISO 9308 – 1,2 – 1990) or SMEWW 9922 TCVN 6187 – 1, 2: 1996 (ISO 9308 – 1,2 – 1990) or SMEWW 9922 TCVN 6187 – 1, 2: 1996 (ISO 9308 – 1,2 – 1990) or SMEWW 9922 * Applies for water provision units ** Applies for water exploitation of individual, household (piped water supply through simple treatment e.g drilled wells, dug wells, rain-tank, gravity pipeline) According to the National Technical Regulations (MoH, 2009b) Domestic water E.coli or thermotolerant coliform 32.482 32.031 34.593 133.936 7.218 4.732 6.229 25.180 0 0 9.492 0 0 1.865 435 222 302 906 2.372 0 25.338 4.629 7.964 1.710 994 1.000 4.260 # 4.520 842 1.052 1.174 1.452 hh 2007 21.495 3.323 5.822 4.688 7.662 # 7.736 2.144 1.067 2.254 2.271 hh 2008 40.170 10.500 7.239 9.015 13.416 # 6.340 2.003 1.358 2.307 672 hh 2009 37.280 13.600 10.284 10.708 2.688 # 4.719 805 1.033 1.181 1.700 hh 2010 27.027 5.460 7.692 7.071 6.804 # Data source: (VBSP, 2011) Notes (by the issuing authority): These numbers include loans for water supply network connection and for building toilets / Only give loans to hh in rural areas (communes) / In 2009 Thot not changed from rural to urban district and Co Do split to create Thoi Lai and Co Do in 2009 (Unit: households / million) Thốt Nốt Thới Lai Cờ ỏ V nh Thạnh Phong iền Total hh hh # 2006 2005 Total (20052010) hh # Table 10: Number of loans for WSS from the VSPB for the years 2005 – 2010 Socio-political and Cultural Determinants of Diarrheal Disease in the Mekong Delta From Discourse to Incidence 3 3 2 2 2 2 1 CHECC pPHC dPHC Cook food well and boil water Wash hands clean before having meals, when preparing food Wash hands after using the toilet Do not eat fish and seafood, especially not raw 5 Use a hygienic toilet Do not exercise open defecation Use clean water for cooking Use chloramine B or alum to disinfect water When someone in the family gets acute diarrhoea, inform the nearest health care centre 10 Do not eat raw vegetable Selected recommendations 9 7 10 11 0,5 0,75 0,62 0,62 0,25 0,62 0,67 0,75 0,75 Overall Average CHECC 13 0,33 0,33 0,67 0,67 0,67 0,67 0,33 0,67 Average pPHC 0,67 0,4 0,4 0,4 0,6 0,4 0,2 0,6 0,6 Average dPHC 0,6 0,31 0,56 0,56 0,44 0,44 0,56 0,44 0,62 0,69 Average overall 0,81 Table 11: Analysis of the IEC material acquired by three types of organizations, according to the number of times selected recommendations were mentioned Annex 11 Avoid eating out in mass servings like in weddings etc 12 Keep your latrines clean, have enough water and soap 13 When having diarrhoea, one must throw powdered lime or Chloramine B with water to flush the toilet (magazine on food poisoning) 14 Don’t throw garbage or dead animals into the rivers, lakes and ponds 15 Control the spread of flies (magazine – on flies) 2 3 1 1 4 0,12 0,37 0,37 0,37 0,25 0,33 0,67 0,33 Socio-political and Cultural Determinants of Diarrheal Disease in the Mekong Delta From Discourse to Incidence 0,2 0,2 0,2 0,12 0,37 0,25 0,25 0,19 Annex 31% 37% the connection between diarrhoea and malnutrition, exhaustion and other health impeding conditions the different stages of diarrhoea and the recommended treatments 60% 50% 20% 25% 40% 20% 70% 30% 40% 44% 25% 65% 20% 75% district 80% provincial ministry the general connections between water, sani69% tation and diarrhoea the importance of in-the-house behaviours 56% for the prevention of diarrhoea the importance of hand-washing to be pro31% moted as a prevention measure Issues that were discussed /brought up after or without prompt by the interviewer the high prevalence of diarrhoea in the region the distinction between different epidemiological causes and knowledge on the symptoms 100% 25% 50% 75% 25% commune /ward 100% 0% 50% 50% 0 hamlet/area Table 12: Analysis of semi-structured interviews with preventive health offices in Can Tho, based on the mention of selected issues around diarrheal disease understandings 60% 40% Knowledge of diarrheal disease pathways (faeces, fingers, water, food, people, digestive 50% system) Total score 50% 40% The role of IEC in enhancing understandings around disease and changing behaviours 56% other than WSS improvements 42% 30% 60% Socio-political and Cultural Determinants of Diarrheal Disease in the Mekong Delta From Discourse to Incidence 39% 25% 50% 22% 0 ZEF Development Studies edited by Solvay Gerke and Hans-Dieter Evers (Center for Development Research (ZEF), University of Bonn) Sven Genschick Aqua-‘culture’ Socio-cultural peculiarities, practical senses, and missing sustainability in Pangasius aquaculture in the Mekong Delta, Vietnam Water pollution in Pangasius aquaculture endangers its economic success and meaning for rural development in the Mekong Delta With the help of Bourdieu´s theory of practice, the author considers the interplay of subjective and objective structures to conclude on the conduct of practices in Pangasius cultivation The study shows that economic dependencies in a global commodity production system have led to a transformation process that most aquaculturists cannot cope with The discrepancy between the ideal and real situation can no longer be ignored otherwise the downward trend continues Farah Purwaningrum Knowledge Governance in an Industrial Cluster The Collaboration between AcademiaIndustry-Government in Indonesia This book explains why there persists a divergence of academia-industry- government inter-linkage in the Indonesian science system This divergence constrains the capacity of the science system in localising knowledge from the supply chain linkage The study shows the centralised character of the Indonesian science system The Jababeka Industrial Cluster is shaped by the supply chain linkage and, thus, lacks the capacity of a knowledge cluster The horizontal collaboration between academia-industry is restricted and limited Bd 27, 2014, 296 S., 39,90 €, br., ISBN 978-3-643-90508-6 Bd 26, 2014, 280 S., 29,90 €, br., ISBN 978-3-643-90485-0 LIT Verlag Berlin – Münster – Wien – Zürich – London Auslieferung Deutschland / Österreich / Schweiz: siehe Impressumsseite