EHJ November 2002, pages 340-343 Latin America has no tradition of public health within local government, so it is being left to a handful of charities and dedicated individuals to fill the vacuum. Stuart Spear reports from Peru

Each morning as sunrise spreads over the vast Amazon basin, health workers from the charity Salud Para el Pueblo prepare for the daily routine of chlorinating water, hut by hut, in 32 districts in the remote Peruvian town of Pucallpa. These are the shock troops in the battle against waterborne diseases that claim so many lives in the developing world, and without them, infant mortality would rocket with disease spreading through the town's slums.

Pucallpa nestles on the banks of one of the Amazon's major tributaries, the Ucayali River, lazily flowing from the Andes towards the nearest neighbouring town of Iquitos, five days away by riverboat. This vast region, which makes up just over half of Peru, is remote and thinly populated with wet and dense forest making access to rural communities virtually impossible unless by boat.

It is into this region that six EHOs from the US, UK, Panama, Australia and Gambia, working with the UK environmental health charity Water for Kids, arrived in September. Their mission, to explore the possibility of an alternative to chlorination as a way of controlling the spread of disease.

The charity Salud Para el Pueblo, or health for the villages, first arrived in Pucallpa two years ago. Based on a project in Ecuador, launched to combat a cholera outbreak, a health centre was established and three nurses employed to start a health education programme involving water chlorination. But two years later, there are now fears that funding may dry up raising the spectre of increased disease rates. To date it has cost in the region of US$200,000 to maintain the project and there is a dawning realisation that this is unsustainable. Funding is up for renewal next year and even if more cash is provided, there will inevitably come a time when the plug is pulled.

Pucallpa is a vibrant frontier town. First settled just over a hundred years ago, it is now home to a quarter of a million inhabitants. The main source of income is timber, with the heavy scent of sawdust hanging thick in the air after a downpour. Twenty per cent of the people scratching a living here have been driven out of the Amazon rainforest by deforestation, terrorism and the cocaine trade, which saps nutrients from the soil. Most of the remainder have become economic migrants fleeing the hardships of the arid coastal region and the Andes.

Migration was at its fiercest between 1991 and 1995, when Peru was in the grip of civil war. Farmers and agricultural workers came to Pucallpa by the thousand as government troops fought brutally with Sendero Luminoso, or Shining Path, a revolutionary terrorist group, for control of the region. It was during this period that the sprawling slums, now home to over 80 per cent of Pucallpa's population, grew, spawning disease from contaminated water and poor sanitation.

"Health education is very difficult here as many different cultures are coming to Pucallpa from the Andes, the coast and the dry forest, [while] some of the population are indigenous and do not speak Spanish," says Dr Luis Alberto, a local doctor studying a public health masters at the local university. People still believe Shamans can cure every sickness, he explains. So it is only when children are close to death that the mother or father will go to the hospital, often when it is too late.

According to Dr Alberto, who has worked in the rural villages and the local hospital, diarrhoea is the main cause of illness in the region. Other disease such as pneumonia, respiratory disease, skin infections and intestinal worms from contaminated water are also behind the region's high rates of infant morbidity and mortality. "Chlorination is not the solution to building a system of potable water in Pucallpa. Thirty per cent of people have drinkable water, the rest use different sources and wells, but water chlorination is only a short-term solution. Only a few people are getting chlorinated water because they don't like the taste, so they end up drinking contaminated water," says Dr Alberto.

But the problem is not just drinking water, poor sanitation is also at the root of the spread of disease. From October to March, the rainy season starts with frequent heavy downpours at least once a day making travel by road almost impossible. Surface water builds up on the impermeable red clay on which Pucallpa is built causing flooding. The slums have no drains or sewers, so surface water acts as a vector for the spread of pathogens. Between April and October, the red clay bakes in the dry season as temperatures climb to above 35¡C. It is impossible to build pit latrines, as the clay provides no drainage, so a night soil system is used. Raised toilets enable faeces to be mixed with ash and then piled in a communal area. But in the fierce tropical sun it turns to dust, again spreading disease.

According to the Institute of National Statistic of Peru, figures for the region of Pucallpa for 2000 show that one in three children under five suffer malnutrition and almost one in two have anaemia - intestinal worms being the main cause. One in four children are suffering diarrhoeal disease at any one time, with infant mortality at 5 per cent for under ones and 8 per cent for under fives.

But unlike Africa, where white four-wheeled-drive vehicles advertise the presence of the major aid agencies, this corner of the developing world has been left to fend for itself, with the exception of missionaries, some USAid projects and a handful of small charities. In addition, there is no tradition of public health within local government - Latin America has no equivalent profession to EHOs.

So it has been left to local businessmen to fill the public health vacuum. Hugo Lopez Egoavil has lived in the town all his life and runs a brick factory. He makes a living from the clay that, ironically, is the root cause of so many of the town's health problems. For Mr Lopez Egoavil, health education is key to the survival of his people and along with education will come the realisation that they must take ownership of these health projects. But he recognises this will take time with today's school children providing the best hope of any real change in behaviour.

"We have to educate people to understand that, rather than spending money on seeing the doctor, they must spend the money on nutritious food and clean water," he explains. He also hopes that forthcoming local elections in November will herald a change in political will, with local government taking more responsibility for waste removal in the slum areas.

If it had not been for Mr Lopez Egoavil and his fellow Rotarians, the chlorination project which has undoubtedly saved thousands of lives would never have happened. Pucallpa's three Rotarian clubs, charitable groups run by local businessmen, have been able to access funds from Rotary International, which in turn has funded the Salud Para el Pueblo project through the US charity Public Health International (PHI).

Mr Lopez Egoavil acts as the link between PHI and the local Rotarians and he recognises that chlorination is a short-term solution, suitable for crisis situations such as a cholera outbreak, but is not sustainable in the long term. He understands that if funding dries up, disaster will strike the town. "What is going to happen when the money from Rotarian International ends, which could be next September?," he sighs. "We need specialist support in public health so that people can stand on their own feet and are not dependent on aid."

One possible source of hope has come in the form of Scott Grant, a former Westminster EHO who, two months ago, gave up housing inspections in the capital to join Water for Kids as a volunteer. And it is in the hope of offering him advice that the international team of EHOs and the head of Water for Kids, Stewart Petrie, travelled to Puccalpa in September. Working with the Salud Para el Pueblo workers, Mr Grant is on a steep learning curve to try and provide a sustainable solution to the spread of disease based on basic environmental health principles.

One option being suggested is to use slow sand filters to clean the water as much as possible at source. This would mean that less chlorine would be needed to stop contamination, making the water both more palatable and less harmful. Another possibility to buy more time, is for the project to make its own chlorine which it can then sell on in a bid to become self-funding. Although persuading villagers to buy chlorine that they previously had received free will be an uphill struggle, it will be an important stage in breaking the community's dependency on aid.

"Ideally, I would have taken a different course from the beginning and provided the villages with safe water. But now we have to look at making the chlorine sustainable so that villages pay for it through community run schemes which treat water at source, so that even if funding disappears they can continue getting safe water," explains Mr Grant. He adds that, in an ideal world, each house would have a well, limiting the amount of handling of water where much contamination occurs.

He is also looking to emulate the success of other Water for Kids projects by providing a model solution for some of the town's basic health problems such as sanitation and waste disposal. This could even be a model home built out of local materials which when proven to work could then be replicated by the community or other agencies. He believes his training to look at public health holistically will prove invaluable to achieve this.

"I see composting as the way forward, as human and organic waste can be used for growing crops," he explains. "This will cut down on the burning of waste, which is causing some respiratory problems, and increase nutrition once water contamination is sorted. I have been looking at filtration processes using aggregates for human waste disposal to provide safe water for growing crops. Composting other materials will produce good topsoil. In this way, different things all tie in to provide a public health solution." The charity is also looking at using tower composters for the night soil, which could be used to grow produce and to fertilise raised beds for crops.

But Mr Grant is acutely aware that only after he has lived through the rainy season, which starts this month in the Amazon basin, will he be able to realistically assess what will or will not work in the slums. He knows he needs more local knowledge and to work closer with the communities he is trying to help. An advantage that Water for Kids has is access to advice from the environmental health profession. The network of EHOs working in the developing world is growing, as is the realisation among EHOs working at home that environmental health skills can provide sustainable aid to developing countries.

Among the EHOs who have arrived in Pacullpa to offer help is Teresa Isaacs, who has been working for over a year in a remote Gambian village with her engineer husband Steve. Diane Gorch, an epidemiologist and EHO from Michigan, Julia Pears, a Spanish speaking former EHO, now living in Panama, with experience of Latin America, Dan Barr, an Australian EHO, and Peter Phillips, a private EHO with knowledge of small-scale composting and sanitation, complete the team. Within days of the team's arrival, the need for an epidemiological study became quite apparent. As Ms Gorch explains: "When people first come out to a place like Pucallpa they just want to get stuck in and fix things. But there is so much we don't know about, so the role of epidemiology is to prove scientifically that the project is working and that when we make an intervention it is having the desired effect."

One statistic that she isolated as a useful indicator is absenteeism from school. Each morning a school register is taken, so records are available. Headmasters and teachers in local schools are claiming that diarrhoea is one of the main causes of school absenteeism. "If we can prove that absenteeism has dropped because of intervention by Water for Kids, then we know we are on the right course," she adds.

Epidemiology also has a role to play in understanding how disease is being spread. The handling of water by different people is one route of contamination and it will be necessary for the project to understand exactly how water is being supplied from wells to houses, at what time of day, and by whom.

What becomes clear as the week unfolds for the visiting EHOs is that they have more questions than answers about how to solve this Amazonian town's public health problems. Pucallpa needs public health knowledge and education, something that some EHOs can offer. But meanwhile, the heath workers of Salud Para el Pueblo prepare for another day of chlorinating water supplies, in the desperate hope that a solution can be found to Pucallpa's public health problems before funds run dry.

For more information on Water for Kids, visit: www.waterforkids.org