Waterborne diseases in Peru

Pollcy Research WORKING PAPERS World Development Report Office of the Vice President Development Economics The World Bank August 1992 WPS 959 Background paper for World Development Report 1992 MWaterborne Diseases in Peru Sheila Webb and Associates The cost of constructing easy-access water facilities (a standpipe less than 1,000 meters from each house) and latrines is an estimated $30 per capita. In Lima's peri-urban areas the cost of not providing them is about $40 per capita. Providing those facilties would relieve the urban poor of devoting (directly and indirectly) an average 23 percent of theirincome to meeting their water needs. PocyReearch WoengPapdiseminatehe-fidingsof womk in pwgress and encowagetheaichangeofidenamognBankasaffand alloemintatsdindevelopmentaiThcpapea.distfdhatcdbythrRescarchAdvosyStaff,cylytenamesoftheauths,rcflect onlyotirviews.andthouldbduBaisnkited ccordingly.zefind, ints a a tit,ons.andoonclusionsametheruf sth'own.neysould not be sttnbuted to thie Wolid Bas, its Bonrd of Dimm, its managemcnl, or any of its member countrics.  Pollcy Research| World Development Report WPS 959 This paper- a product of the Office of the Vice President, Development Economics - is one in a series of background papers prepared for the World DevelopmentReport 1992. The Report, on development and the environment, discusses the possible effects of the expected dramatic growth in the world's population, industrial output, use of energy, and demand for food. Copies of this and other World Development Report background papers are available free from the World Bank, 1818 H Street, NW, Washington, DC 20433. Please contact the World Development Report office, room 17-101, extension 31393 (August 1992, 17 pages). The cholera epidemic in Peru brought to light the $180 in rural areas. The cost of constructing miserable state of local water and sanitation easy-access water facilities (a standpipe less than conditions. Webb discusses the relationship 1,000 meters from each house) and latrines in between waterbome diseases and water and urban and rural areas is an estimated $30 per sewerage conditions in Peruvian peri-urban capita. areas, orpueblosjovenes. In contrast, she estimates the annual per These diseases are associated with poor capita cost bome by urban households without living conditions. In 1989, only 52 percent of the in-house continuous water connections (that is, population had access to piped water, and only households that buy water from vendors) to be 39 percent to sewerage. About 52 percent of $40. schools lack light, water, and sewerage. In Lima, 2 million people daily eat meals from street In short, the total cost borne by the urban vendors who lack access to fresh water or toilet poor over four years is equivalent to the cost of facilities -90 percent of a sample of their food providing them with permanent water and was fecaily contaminated. sewerage facilities. Providing those facilities would relieve the urban poor of devoting (di- Webb estimates the per capita costs of rectly and indirectly) an average 23 percent of providing in-house water and sewerage facilities their income to meeting their water needs. in urban areas to be $150 in urban areas and The Policy Research Working Paper Series disseminates the fmdings of work under way in the Bank. An objective of the series is to get these findings out quickly, even if presentations are less than fully polished. The findings, interpretations, and conclusions in these papers do not necessarily represent official Bank policy. Produced by the Policy Research Dissemination Center  Waterbome Diseases in Peru Background Paper Prepared for the 1992 World Development Report Sheila Webb and Associates Cuanto S.A.  The World Development Report 1992, "Development and the Environment," discusses the possible effects of the expected dramatic growth in the world's population, industrial output, use of energy, and demand for food. Under current practices, the result could be appalling environmental conditions in both urban and rural areas. The World Development Report presents an alternative, albeit more difficult, path - one that, if taken, would allow future generations to witness improved environmental conditions accompanied by rapid economic development and the virtual eradication of widespread poverty. Choosing this path will require that both industrial and developing countries seize the current moment of opportunity to reform policies, institutions, and aid programs. A two-fold strategy is required. * First, take advantage of the positive links between economic efficiency, income growth, and protection of the environment. This calls for accelerating programs for reducing poverty, removing distortions that encourage the economically inefficient and environmentally damaging use of natural resources, clarifying property rights, expanding programs for education (especially for girls), family planning services, sanitation and clean water, and agricultural extension, credit and research. * Second, break the negative links between economic activity and the environment. Certain targeted measures, described in the Report, can bring dramatic improvements in environmental quality at modest cost in investment and economic efficiency. To implement them will require overcoming the power of vested interests, building strong institutions, improving knowledge, encouraging participatory decisionmaking, and buildir..; a partnership of cooperation between industrial and developing countries. Other World Development Report background papers in the Policy Research Working Paper series include: Dennis Anderson, "Economic Growth and the Fnvironment" Dennis Anderson and William Cavendish, "Efficiency and Substitution in Pollution Abatement: Simulation Studies in Three Sectors" William Ascher, "Coping with the Disappointing Rates of Return of Development Projects with Environmental Aspects" Edward B. Barbier and Joanne C. Burgess, "Agricultural Pricing and Environmental Degradation" Robin W. Bates and Edwin A. Moore, "Commercial Energy Efficiency and the Environment" Wilfred Beckerman, "Economic Development and the Environment: Conflict or Complementarity?" Richard E. Bilsborrow, "Rural Poverty, Migration, and the Environment in Developing Countries: Three Case Studies" Charles R. Blitzer, R.S. Eckaus, Supriya Lahiri, and Alexander Meeraus, (a) "Growth and Welfare Losses from Carbon Emission Restrictions: A General Equilibrium Analysis for Egypt"; (b) "The Effects of Restrictions of Carbon Dixide and Methane Emissions on the Indian Economy" Judith M. Dean, "Trade and the Environment: A Survey of the Literature"  Behrouz Guerami, "Prospects for Coal and Clean Coal Technology" David 0. Hall, "Biomass" Ravi Kanbur, "Heterogeneity, Distribution and Cooperation in Common Property Resource Management'" Arik Levinson and Sudhir Shetty, "Efficient Environment Regulation: Case Studies of Urban Air Pollution" Robert E.B. Lucas, David Wheeler, and Hemamala Hettige, "Economic Development, Environmental Regulation and the International Migration of Toxic Industrial Pollution: 1960-1988" Robert E.B. Lucas, "Toxic Releases by Manufacturing: World Patterns and Trade Policies" Ashoka Mody and Robert Evenson, "Innovation and Diffusion of Environmentally Responsive Technologies" David Pearce, "Economic Valuation and the Natural World" Nemat Shafik and Sushenjit Bandyopadhyay, "Economic Growth and Environmental Quality: Time Series and Cross-Country Evidence" Anwar Shah and Bjorn Larsen, (a) "Carbon Taxes, the Greenhouse Effect, and Developing Countries"; (b) "World Energy Subsidies and Global Carbon Emissions" Margaret E. Slade, (a) "Environmental Costs of Natural Resource Commodities: Magnitude and Incidence"; (b) "Do Markets Underprice Natural Resouce Commodities?" Piritta Sorsa, "The Environment - A New Challenge to GAIT?" Sheila Webb and Associates, "Waterborne Diseases in Peru" Background papers in the World Bank's Discussion Paper series include: Shelton H. Davis, "Indigenous Views of Land and the Environment" John B. Homer, "Natural Gas in Developing Countries: Evaluating the Benefits to the Environment" Stephen Mink, "Poverty, Population and the Environment" Theodore Panayotou, "Policy Options for Controlling Urban and Industrial Pollution" Other (unpublished) papers in the series are available direct from the World Development Report Office, room T7-101, extension 31393. For a complete list of titles, consult pages 182-3 of the World Development Report. The World Development Report was prepared by a team led by Andrew Steer; the background papers were edited by Will Wade-Gery.  Table of Contents Introduction ....................................... 1 Background: The Nature of the Problem .2............................ . 2 Water Supplies .......................................... Water Costs .......................................... 5 High Indirect Costs: Health and Hygiene ............................... 7 Conclusion: A Cost-Benefit Assessment ............................... 10 Sedapal Real Investment Expenditures, 1985-90; Water and Sewarage Services in Peru, 1990 ........ ............... 11 References .................................... 12 Appendix 1 .................................. 14 Appendix 2 .................................... 15  Introduction The cholera epidemic in Peru has brought to light the miserable state of local water and sanitation conditions. This report discusses the relation4hip between waterborne diseases and water and sewerage conditions in Peruvian peri-urban areas, or pueblos jovenes. As water and sewerage conditions in Peru have deteriorated in the past decade, the incidence of waterborne diseases has increased, implying a correlation between the two. Like other waterborne diseases, cholera is most prevalent among the poor, who thus bear a disproportionate share of the costs of inadequate water and sewerage services. This suggests that social investment in public services is a priority in terms of fighting poverty, improving living conditions, and increasing productivity in Peru. In addition to drawing upon the results of previous studies, this study is based on interviews carried out by Cuanto in October 1991 in pueblos jovenes in all four of Lima's "'cones"I (see Appendix 1). These interviews were not meant to prove or disprove any particular hypothesis; the objective was rather to gather information which would increase our understanding of the ways in which families "cope" with a limited and/or laborious water supply, particularly in terms of the resulting costs to the family. Although the interview results generally corroborated findings of studies on related topics, the anecdotal information gathered from conversations and open questions has been valuable in helping to contextualize the facts. Greater Lima is divided into four cones: North, South, East, and Center. 1  Background: The Nature of the Problem As in many parts of the world, waterborne diseases (WBD) continue to figure significantly in overall morbidity apd mortality rates in Peru. WBD prevalent in Peru include gastroententis, bacterial dysentery, infectious hepatitis, tuberculosis, typhoid, paratyphoid, salmonellosis, shigellosis, and most recently, cholera. Between 1980 and 1988, the last year for which reliable statistics are available,2 WBD were responsible for more deaths than any other transmissible disease.3 The prevalence and intensity of these diseases are directly associated with poor living conditions. In 1989, twelve million Peruvians were unable to satisfy minimum daily protein and calorie requirements; more than sixty percent of the population lives at or below subsistence level, and nearly forty percent of children are malnourished.4 Fifty-two percent of the population has access to piped water; only thirty-nine percent, to sewerage.5 Sixty- four percent of schools lack the basic services of light, water, and sewerage.' In Lima, 2 million people daily eat meals from street vendors who lack access to toilet facilities or fresh water.7 A survey in April of this year found that 90 percent of sampled food and drink sold 2 Employees in the public health sector have been on strike intermittently since 1989, which has interrupted normal data collection. 3 APIS, 1990. 4 UNICEF, 1991. 5 INAPMAS, 1991. 6 UNICEF, 1991. 7 This is because laborers and informal woikers cannot afford to eat in restaurants, or to go home for lunch given the distance and cost of transportation. 2  by street vendors was fecally contaminated.8 Living conditions have worsened partly as a result of increased migration to the cities. This migration has several causes. Rural social service spending has been virtually eliminated.9 Ten of twenty.four geographical departments, encompassing more than half of the total population, are under a total state of emergency as a result of terrorist activity. The agricultural and mining sectors have both faltered. As a result, marginal urban communities, or pueblos jovenes, have swollen to a third of the total population, forty-six percent of the total urban population,'0 and 58 percent of Lima's population." Poor migrants, the majority of whom are employed in the informal sector or as unskilled workers, move into an existing pueblo joven, or "invade" a vacant plot of land with the intention of establishing a permanent residential community. Although wood or cement comes in time to replace straw as construction material, permanent water and sewerage services are extremely slow in coming. Despite the fact that 60 percent of Lima's recognized pueblos jovenes were established before 1980, only twenty-seven percent have in- house water and sewage facilities.'2 I El Comercio "Ambulantes de Lima venden alimentos contamidados," August 2, 1991. 9 Rural illiteracy rates are some 40%; urban rates, only 8%. '