The time and space of water and health: an interview with Carmen Anthonj, PhD
Carmen Anthonj is a natural connector. Her profession as a medical geographer says it all. Connecting topics, people, disciplines, and methods, Carmen lives the first law of geography, “everything is related to everything else.” Carmen sees and studies those relations with a keen eye and endless enthusiasm. We caught up with Carmen over a coffee (wine in her time zone) and conversation shortly after she transitioned from UNC Postdoctoral Research Associate and lead communicator of the HWTS Network to Assistant Professor at ITC at the University of Twente.
We couldn’t pass up this opportunity to connect to learn more about her life, research, and advice for the future of the Household Water Treatment and Safe Storage (HWTS) Network and water, sanitation, and hygiene (WASH) in general.
So, you’re a Medical Geographer. Tell us about what that entails and how did you get into this line of work?
When I was a child, I decided I would work in international development. I wanted to work with Indigenous and rural communities. Later in life, when I first traveled to Brazil in 2006 to assist a medical doctor, who provided medical services in favelas, I had a recognition: clean water is at the core of development and of human health. There, I learned that to work effectively in the context of water, health, and development, one discipline alone would not suffice. From then on, I wanted to work on water and health issues. I debated whether to study medicine to become a doctor, engineering to learn how to build wells, social science or anthropology to learn how to see the communities’ perspectives. I even thought urban planning and infrastructure would be vital, as well as politics, economics, demography, and so many more disciplines. Ultimately, I came to realize that an interdisciplinary approach is what I was looking for, and geography—and specifically medical geography—was exactly what I needed.
Constantly bridging gaps, Carmen explores the health-promoting potential of water in North Carolina
The beauty of medical geography is that it is a very interdisciplinary field that uses holistic approaches. It draws on concepts, theories, and techniques of geography and geospatial analysis, but also spans environmental, biological, and social sciences, and uses both quantitative and qualitative methods. In medical geography, we apply geographical concepts and techniques to analyze spatial patterns of disease and health care provision. We look at the interactions of humans with the environment through time and space. That’s where spatio-temporal dynamics come in. Investigating spatio-temporal dynamics of disease involves epidemiology and disease ecology, and the geography of health services considering access to health care, health care delivery, and the planning of health services. However, we do not only look at disease, but also at how the environment can promote health. By health, I mean the World Health Organization definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
Through medical geography, I’ve had the opportunity to work and conduct water, environment, emergency, and health risk research with various research institutes, international organizations, and governments around the globe.
Back to my childhood ambition, my focus is on the links between global health and water security in areas of water abundance and water scarcity in rural, urban, and indigenous communities in low- and middle-income countries. I look at health promotion (i) through water (e.g. safe drinking water and sanitation) and (ii) from water (e.g. flooding, extreme weather events). My major interest is water- and health-related local knowledge and risk perceptions and how they determine risk behaviours, and the cultural context of water, health, and disease.
What is one of your favourite or most influential books that you’ve read?
Picking only one book is tricky. The book that fascinated me most is ‘On airs, waters and places’ by Hippocrates of Kos (~460-377 BC), a Greek physician of the Age of Pericles and one of the most outstanding figures in the history of medicine. I find it remarkable how almost 2,500 years ago Hippocrates related health and disease not only to the environment, but also to human behaviour. Hippocrates stated that whoever wishes to investigate human health properly should not only consider the geographical peculiarities of each locality, seasons of the year, characteristics of water, such as quality and quantity, but also human behaviour, different lifestyles, and habits. My favourite quote is in Part 7 of the book, and I love to use it to start my lectures and presentations. He says “I wish to give an account of the other kinds of waters, namely, of such as are wholesome and such as are unwholesome, and what bad and what good effects may be derived from water; for water contributes much towards health.” This is just as relevant now as it was then.
You are currently in transition from the University of North Carolina to ITC at the University of Twente. What are you looking forward to? What do you think you’ll miss?
I am very excited to join ITC, the University of Twente’s Faculty of Geo-Information Science and Earth Observation. Our mission is to develop capacity, particularly in less developed countries, and to utilize geospatial solutions to deal with national and global problems. What I like most is that students are educated to be capable of acquiring knowledge and translating this into practical solutions to real-world problems, aligned with the Sustainable Development Goals (SDGs).
From a professional point of view, I am looking forward to transitioning from a Postdoctoral Research Associate position at the Water Institute at University of North Carolina (UNC) into my new position as Assistant Professor GeoHealth with new, challenging responsibilities. These include building the GeoHealth team, teaching and mentoring students, developing educational materials, and shaping the direction we are taking in water and health issues. From a disciplinary point of view, I am looking forward to integrating water and health issues at a larger scale and linking global challenges with local solutions and perspectives. From a cultural and personal point of view, I am looking forward to moving back to Europe after many years of living abroad, and to join an international team of wonderful individuals. And I certainly am excited for new collaborations in the Netherlands, Europe, and the world.
I will miss the amazing team at the Water Institute at UNC most. Thankfully, I am staying connected with my former colleagues, jointly working on some publications and a side event for this year’s UNC Water & Health Conference.
How did you become involved as the communications lead of the HWTS Network? Tell us about the intersection between Medical Geography and HWTS.
Carmen presents the value of local communities as key informants in wetland management that promotes health, Institute for Hygiene and Public Health at the University of Bonn
From 2013 to 2017, as Research Associate at the GeoHealth Centre at the Institute for Hygiene and Public Health at the University of Bonn, a World Health Organization Collaborating Centre for Health Promoting Water Management and Risk Communication, I co-edited the bi-annual WHO Water & Risk Newsletter. So, issues related to water quality and household water treatment and storage became very familiar to me.
When joining the Water Institute at UNC, I became the lead researcher for two large UNICEF-funded research projects. One of them was on WASH Sector Monitoring in Pacific Islands project in households, schools, and healthcare facilities in Fiji, Kiribati, and the Solomon Islands. This project was amazingly complex, given that small island developing states are at the frontline of climate change, and frequently hit by extreme weather events, such as tropical cyclones and flooding. Extreme weather events massively impact health service provision – this an ideal topic for a medical geographer. Drinking water access and behaviours were one of the components of the project, and highly interesting, as the people in the Pacific used various drinking water sources throughout the year, according to the season. Related to this, we also produced a WASH Policy Research Digest under Clarissa Brocklehurst’s lead on multiple water source use as a common household practice that contributes to resilience. I believe those different experiences caused Prof. Dr. Jamie Bartram to offer me the opportunity to lead the communications on HWTS and I was grateful. I took the communications lead over from Dr. Edema Ojomo, who did a wonderful job in introducing me to the world of HWTS, the Network, the Secretariat, and our partners. I am excited that now CAWST is taking the Network to the next level.
What is your hope for the future of the HWTS Network? Do you have any words of wisdom for those of us engaging in the Network?
What I love about the HWTS Network is the variety in network members, coming from UN agencies, development agencies, non-governmental organizations, research institutions, international professional associations, and the private sector. I have seen the Network grow closer over the course of the past 2.5 years, and my hope is to see this continue.
I hope to see the facilitation of even more exchange of thoughts, ideas, solutions, and technologies. This Network is a unique opportunity to bridge the gaps between research, policy, and practice; my hope would be to see even more engagement across disciplines, sectors, and levels.
You have a long list of publications and projects. What is one of your favourites and why?
Capturing local knowledge on water-related health risks in Laikipia, Kenya
There are several publications and projects I find exciting. One study I really enjoyed was on water-related infectious disease exposure among wetland users (farmers, nomadic pastoralists, service sector) in Kenya. It included a literature review to ground a theory on disease exposure related to different wetland uses, a health risk assessment with innovative approaches, such as observational assessments and syndromic surveillance, and risk perception and behaviour studies. The study revealed that the literature on wetland use-related disease exposure does not reflect real risks that the rural marginalized population faces. These real risks differ between different occupational groups, and are perceived differently according to cultural aspects and prevailing health beliefs. The study demonstrated that local risk perceptions reflect real risks, and that risk perceptions determine health-related (protective and risk) behaviour. This study underpinned the vital role of wetland users as key informants. It demonstrated that risk perception studies and resulting recommendations from the grassroots level serve as supportive tools for wetland management that also promotes health. This requires a sensitive, integrative approach that takes into consideration any and all of the humans, ecology, and animals affected. The resulting recommendations are relevant on the national and international level, for global policy making and for achieving progress towards SDG 6 to “ensure access to water and sanitation for all”, and others.
Five papers were published from this project, and my favourite is:
Anthonj, C., Diekkrüger, B., Borgemeister, C., Kistemann, T., 2019. Health risk perceptions and local knowledge of water-related infectious disease exposure among Kenyan wetland communities. International Journal for Hygiene and Environmental Health 222 (1), 34-48.
Why are local knowledge and risk perceptions so important? How can WASH practitioners leverage that in their work?
The above-mentioned study shows that communities’ risk perceptions realistically reflect prevalent health risks related to inadequate WASH conditions, the seasonality of diseases, the difference in disease exposure among different occupational groups, and the peculiarities of health risks in a semi-arid environment. The facts that (i) the perceptions correspond to the actual risks, and that (ii) the emic perspectives of the community members in the wetland allow for a more detailed picture of the situation, make the local communities’ perceptions invaluable. Risk perception studies, particularly in data-scarce settings, are precious for capturing the situation and challenges that communities are facing. Moreover, the subjective perceptions and judgements of affected individuals towards health hazards are vital in managing health and controlling diseases in complex environments.
Experiencing the semi-arid part of the investigated wetland in Laikipia, Kenya
Most importantly, local knowledge and risk perceptions have the potential to motivate and shape health-related behaviour, thereby reducing or accelerating the risk and exposure to diseases, e.g. through the application of (or failure to apply) protective health measures such as household water treatment and safe storage, or, in the current context of the COVID-19 pandemic, hygiene measures. Risk perceptions can provide an entry point to inform targeted health messaging and health-related interventions. If community members are acknowledged as valuable informants, they can inform health officials and managers.
Our study, for example, resulted in detailed and concrete community-based, low-cost, and locally feasible recommendations to improve WASH and health-promoting wetland management that health officials and WASH practitioners could make use of.
In your work, how have you seen cultural contexts influence health, disease, and WASH?
Let me refer to two studies here, starting with the one I have introduced already. In the Kenyan wetland where I captured health-related local knowledge and risk perceptions, the nomadic pastoralists had more distinct health beliefs as compared to the majority population. This animated the group to use surface water sources for bathing, for example, as this was perceived as health-promoting and healing. However, contact with standing water sources in that region could pose the risk of infection with water-based diseases such as schistosomiasis. Moreover, due to their semi-nomadic lifestyle deeply rooted in their tradition, pastoralists’ sanitation infrastructure was either unimproved and less reliable or inexistent, leading to a higher level of open defecation among this group. Such risk behaviour also comes with a higher likelihood of water-related infectious diseases such as waterborne, e.g. diarrheal, diseases. There are numerous other examples that show the influence of the cultural context on health, disease, and WASH – not only from Kenya, but also from Europe.
Another study on WASH among Roma communities, Europe’s largest ethnic minority, shows that Roma populations commonly have a very distinct understanding of the meaning of health and health risks. This is partly because of limited access to formal or informal health education, partly because of prevailing health beliefs. Considering that their WASH access in the marginalized, low quality housing at the outskirts of cities and informal settlements is often inadequate and worse than that of the majority population, this increases risk of contracting diseases, and can create an extra health burden. Distinct health beliefs and attitudes related to health and diseases may impact health-seeking behaviour and management of ill-health. In Roma culture, a spiritual base exists for certain kinds of illness and they believe in traditional curative remedies such as the power of spittle to treat wounds. Besides, in some communities, patients fear to disclose their health status because a severe illness triggers shame, social rejection, and stigmatization. Perception, acceptance, or rejection of certain diseases may determine the willingness to seek medical help or support from the communities, affecting rehabilitation. For the Roma, there is an extra layer of complexity when it comes to WASH- or health-related behaviours. Due to their centuries-long experience of discrimination and stigmatization, they oftentimes hold negative attitudes and distrust in non-traditional health practices, which may for example cause reluctance to receive immunization or other health services.
Both examples show that the cultural and traditional understanding of the ‘real’ causes of illness goes far beyond (and can contradict) the biomedical concepts of health promotion and disease risks.
Convictions, health beliefs, social stigma, and (mis) conceptions about the health scare sector are decisive factors as well. These can also go beyond, or in some cases even against, the biomedical understanding of diseases. Some illnesses are simply perceived as ‘not for hospital’, are treated by traditional healers or herbalists, by self-treatment, or not treated at all.
This is relevant both to the WASH and the health sector, as practitioners and decision-makers must consider that the success of interventions will critically depend on the involvement, support, commitment, and participation of the community.
How do you see the WASH sector changing in the next 10 years?
Global environmental change, increasingly frequent and unpredictable extreme weather events, water scarcity, food insecurity, conflict, migration, urbanization, and other processes have been impacting water security at global, regional, national, and local levels over the past decades. The contexts within which safe WASH for all shall be achieved by 2030 (UN SDG 6) are increasingly complex, and this will further challenge the WASH sector—not only in low- and middle-income countries, but among minority populations and low socio-economic and other groups in high-income countries as well.
The unprecedented COVID-19 pandemic is a brutal reminder of how vital WASH in households, schools, and health care facilities is for survival, and that the progress that has been made in achieving SDG 6 so far is vulnerable. The pandemic has also shown how vital science is for decision-making. COVID-19 is not the first, and won’t be the last pandemic. This is what the WASH sector needs to prepare for, on top of the complexities and unprecedented changes that accompany global environmental change.
Carmen tells us when she’s not conducting researching or teaching class, she’s being a social butterfly, often doing extreme outdoors activity
The First Law of Geography, according to Waldo Tobler, is “everything is related to everything else, but near things are more related than distant things.” The WASH sector must address and manage this complexity by the means of even closer collaboration between science, practice, and policy, collaboration across and beyond sectors, and the involvement of the private sector. Interdisciplinary, holistic approaches and system thinking—and in my opinion, medical geography and GeoHealth—are more important than ever. It is time to facilitate the transfer of local solutions to other areas of the globe, and bring global knowledge back to the local level.
Moreover, there is a tremendous opportunity for the sector in using existing data and applying new technologies to address and solve WASH challenges. But the sector is still behind in adopting such. Remote sensing, Earth observation, geospatial analysis, big data, artificial intelligence: these and other technologies bear huge potential to inform WASH-related understanding and decision-making. It is time for the WASH sector to divert its focus from mainly using primary data towards also making use of existing information and secondary data, in order to reach its full potential.
ITC at the University of Twente has been using these technologies in disaster management, water and natural resources management, governance, urban planning, food security, and GeoHealth, and I am excited to be part of a team with the skillset to apply the same technologies to solve WASH-related problems globally. If you would like to learn more, please reach out to us at ITC.
Warmest gratitude to Carmen for her leadership and contributions to the HWTS Network, and all the best in her new role! We’re excited to follow this inspiring rising star as she continues to cleave insights in the space of water and health. Do you share our mutual passion for water and health? Please join us as a member of the HWTS Network! Membership is free.