1

Introduction What is Environmental Health? To stay healthy, the water we drink, the air we breathe, and the food we eat must be clean, wholesome, and free from contamination. We all know this, and as soon as we can, we take measures to protect our environmental health. The poor in the South cannot protect themselves so easily, and thus pay the price in poor health. In some cases, protection of health is best achieved by keeping the environment clean; preventing pollution is not only good for the environment, but also good for our health. In other cases, health is best protected by the provision of an environmental service to each household or community; not all the water in our environment can be made fit to drink, but our health benefits from having a clean and plentiful water supply. Similarly, a community will not be healthy unless its wastes are collected and recycled or disposed of in a sanitary way.

1.7 million children, almost all of them poor, die from inadequate water, sanitation and hygiene every year. Nearly a million people die from malaria in Africa every year. An estimated 1.6 million women and young children die each year from lung diseases caused by indoor air pollution; this is comparable to the number of deaths due to smoking. More than half a million deaths are caused each year by road crashes, 70% of them in developing countries.

The boundaries of environmental health are not rigidly defined. The challenges and priorities of environmental health vary between communities, and the responsibilities can be shared in many ways. While some people spend more time than others working on these problems, we all affect environmental health through our individual and collective decisions.

Everybody who changes the natural or built environment has an impact on environmental health!

What is Environmental Health? Environmental health consists of: „ Sustaining a natural environment free from undue hazard, „ Ensuring a built environment free from undue hazard, and „ Providing essential environmental services to households and communities. These can include: Sanitation Water supply Traffic control Hygiene promotion Air pollution control Storm water drainage Solid waste management Food management and inspection Enforcement of building regulations Occupational health and safety inspection „ Vector control (e.g. control of rats, mosquitoes) „ Air and water quality monitoring and enforcement „ „ „ „ „ „ „ „ „ „

About this document This note seeks to show the importance of environmental health in eliminating poverty, and the impact which development projects in a wide range of sectors can have, for good or ill, on environmental health. The target audience is professionals working in development who are likely to come across Environmental Health issues and opportunities at the practical, management and policy level; the primary focus is on developing country nationals, as well as staff of external development support agencies. Information is presented in bite-size portions to help you pull out those aspects of most interest to you. The note illustrates the importance of environmental health and sets it in the context of the global burden of disease, of the overall goal of poverty elimination, and of the wider objectives of international development. It explores some of the key issues affecting environmental health improvement and ends by showing how, for a wide range of sectoral development projects, concrete measures are available which can improve environmental health for the poor.

2

Contents

The importance of environmental health Indoor air pollution Water, Sanitation and Hygiene Atmospheric lead Injuries Environmental health and the global burden of disease

4 4 4 5 5

Why environmental health matters to poor people Environmental health and the objectives of international development Reduction of poverty; better health for poor people Better education for poor people; removal of gender discrimination Better access to water and sanitation; protection of the environment Environmental health and the international development targets Shortcomings in environmental health cost money.

8 8 9 9 9

Issues in environmental health Factors affecting environmental health The brown and the green agendas; start from the household

10 10

Approaches to changing behaviour Finding the levers: Motivation The classic measure: Regulation Innovative approaches: Guidance and Support

12 12 13

Everyone’s responsible; each sector has a part to play Further information Environmental health on the world wide web Publications DFID reference point

17 17 17

3

The importance of environmental health The links between environment and health are intuitive to all of us. Some examples of the Health Impact of the Environment are given below.

Indoor air pollution Indoor air pollution due to solid fuel use in developing countries kills an estimated 1.6 million women and young children a year, mainly due to Acute Respiratory Infections in children under 5 years. This is the chief single cause of ill-health in India and the world as a whole. The health risks associated with Indoor Air Pollution also include the following: „ Chronic obstructive lung disease in nonsmoking women: associated with cooking with solid fuels, along with associated heart disease (cor pulmonale) in six Asian and Latin American studies „ Lung Cancer: Shown in more than twenty Chinese studies to be associated with cooking with coal (evidence for use of biomass is mixed). „ Cataracts: the chief cause of blindness in India, associated with biomass use for cooking in one national survey and one local study. „ TB: Shown to be associated with biomass use in one national and one local study in India. „ Asthma: Associated with urban outdoor and indoor pollution in middle income countries, and with indoor air pollution in studies in China, Kenya and Malaysia. „ Adverse Pregnancy Outcomes: Stillbirth and low birthweight have been associated with biomass smoke exposure in pregnant women in India and Latin America (low birthweight and early infant death have been associated with urban air pollution in China and less developed countries).

Atmospheric lead The use of leaded petrol, declining in developed countries, is the major source of childhood lead poisoning in urban areas of many developing countries. Two thirds of urban children in China, more than half in India, and over 90% in Cape Town, South Africa have enough lead in their blood to cause an IQ deficit of 1 to 3 percentage points.

Water, Sanitation and Hygiene Diarrhoea causes 2 million deaths per year, mostly amongst children under the age of five. This is equivalent to one child dying every fifteen seconds, or the massacre of an entire primary school every half an hour. This is estimated as about a third of total child deaths under the age of five in developing countries. There are approximately a billion cases of diarrhoea each year. Water, sanitation, and hygiene interventions have been shown to reduce sickness from diarrhoea on average by between a quarter and a third. About a third of the population of the developing world is infected with intestinal worms which can be controlled through better sanitation, hygiene and water. These parasites can lead to malnutrition, anaemia, retarded growth and impeded school performance, varying with the severity of the infection. 6-9 million people are estimated to be blind from trachoma. The more rigorous studies show that provision of adequate quantities of water can reduce this disease by 25%. The kind of fly mainly responsible for transmitting the disease from person to person breeds in scattered human excreta, so that sanitation is also an effective control measure. 200 million people in the world are infected with schistosomiasis (bilharzia), of whom 20 million suffer severe consequences. The disease is still found in 74 countries of the world. Studies show a median 77% reduction from well-designed water and sanitation interventions. Guinea worm eradication has made dramatic progress over the past ten years, with the number of cases dropping by 95% from 890,000 in 1989 to less than 50,000 today. The disease is mainly found in the Sahel region of Africa. India, Pakistan, Senegal and Cameroon recently interrupted transmission of the disease completely, and several African countries are close behind them. An estimated 1.1 billion people are without access to water supplies, and 2.4 billion lack adequate sanitation. The number of people without access to adequate sanitation rose by around 150 million in the period 1990 to 2000.

4

Injuries

Environmental burden

Over half a million deaths are caused each year by road crashes, 70% of them in developing countries. Nearly half the victims are pedestrians, and 25% are under 16. Many more are injured.

Nearly three quarters of this environmental burden is attributed to diarrhoea, respiratory disease, and injury

Up to 125 million cases of occupational injury and disease occur each year, with 220,000 fatalities. Nobody knows how many people are injured or killed at home by falls, burns, floods, and electrocution. What is certain is that the rate is far higher in the developing world and among the poor than in industrialised countries, and that home accidents are a major cause of death for children and the elderly.

Mental health 5% Cancer

The World Health Organization estimates that environmental health problems account for 23% of the overall burden of disease worldwide. Environmental improvements are often more costeffective as health measures than the curative efforts of the health sector. After all, prevention is better than cure.

Global burden of disease Nearly a quarter of the global burden of disease is related to environmental health

Environmental 23%

Other 77%

Diarrhoea 28%

6%

Malaria 9%

Chronic respiratory Acute respiratory

9%

Environmental health and the global burden of disease

Cardio Other vascular 3% 4%

22% Injuries 14%

5

Why environmental health matters to poor people There are many reasons why environmental health is particularly important to the poor: „ Poor people live where environmental health conditions are worst. This is no accident. Poor people cannot afford to live on spacious, welldrained land away from busy roads and with clean air, good water supply and sanitation, and effective solid waste management. Those who can afford to pay for good environmental conditions generally do so. The poor cannot afford these, and so live with the consequences of a dirty and unhealthy environment.

Disease does not warn you of its coming. It just comes. Shangaan proverb

We never know the worth of water till the well is dry. English proverb

„ The poor cannot afford good housing. Besides, it would not be sensible for them to invest their scant resources in housing improvements when they are liable to eviction or damage by flooding, fire or landslides. That means they suffer more from malaria as mosquitoes can get in, from indoor air pollution and the resulting lung disease, and from diseases such as tuberculosis which spread in overcrowded conditions. „ The burden of environmental disease falls more harshly on the poor. The poor are vulnerable not only because of where they live, but also the work they do, the greater risks they run, and lower resistance to infection. In poor families, it is not only those who are ill who suffer; the others have to make sacrifices to care for them or to work in their place, especially if it is the breadwinner or child carer who is ill or injured. When poor adults die, their children often die soon afterwards. „ The poor already pay more for environmental health services. In low-income urban areas, many people buy their water from vendors, who sell it for 10 to 20 times more than the official water tariff charged to people who can afford house connections. Other costly items are mosquito control, latrine emptying and rubbish collection when purchased from the informal sector. These items can amount to over 20% of a poor household’s income, and the money for them comes out of the food budget. Affordable environmental health services therefore enable people to eat better!

A safe built environment? Urban drains blocked with rubbish become breeding sites for mosquitoes. The sewage they usually contain infects children who play in them, and can also contaminate nearby water sources such as the hand pump in the background.

“Expenditure on health appeared to be by far the strongest impediment for a poor household to remain afloat. Households with sick and elderly people were invariably on the brink, on account of heavy expenditure on treatment of the patients.” India National Report, World Bank Poverty Study

„ Disease contributes to poverty. When poor people fall ill, they lose income and often lose their jobs. When the illness is serious or affects the breadwinner, desperate relatives spend their savings on treatment, often on inappropriate cures prescribed by charlatans. Impoverished

6

Health is not the whole story; the table below lists benefits from some environmental health services

Environmental service

Areas of benefit

Water supply

Savings in time and drudgery, or in cost paid to vendors, time for education, reduced diarrhoeal disease and skin and eye infection

Excreta disposal

Privacy, convenience, security from harrassment and rape, reduced diarrhoeal disease and worm infections.

Surface water drainage

Permits housing improvement, reduced flood damage, mosquitoes and sewage contamination

Solid waste collection and disposal

Reduced rat, fly and smell nuisance, less diarrhoea and rat-borne infection, particularly leptospirosis

Vector control (e.g. rats, mosquitoes)

Reduced expense of mosquito repellents and less biting nuisance, reductions in malaria, filariasis and other diseases transmitted by the vectors

families can often trace the origin of their predicament to the cost of a health disaster affecting one of their members. Environmentally-caused disease affects their prospects in other ways, too; children with intestinal worms or exposed to environmental lead may be stunted in their growth or handicapped in their intellectual performance. „ Environmental health is about more than health. In a number of studies, “environmental health interventions” (improved water supply, drainage, sanitation, roads) rank highly among the poor as signs of progress, as ways of knowing that life has improved. But for the poor, health is only a side benefit of these improvements. The main benefits are often about

„ „ „ „ „ „

Saving precious time Reducing the burden of daily life Lowering the basic cost of living Emancipation of women Increasing dignity, self-respect, and safety Creating a more pleasant and ordered living space „ Increasing income through service provision and sound resource management (recycling rubbish, building latrines, etc.)

These are not “Wrong” reasons to want environmental health improvements; rather, they are additional benefits. Moreover, they mean that people are often willing to pay for the services.

7

Environmental health and the objectives of international development Reduction of poverty; better health for poor people As described above, poor environmental health is not only a feature of poverty, but an important cause of it. The causal interaction between health and poverty is often stressed by the poor themselves. The case for environmental health as contributing to better health and the elimination of poverty is beyond dispute.

“We face a calamity when my husband gets ill. Our life comes to a halt until he recovers and goes back to work” A poor woman, Zawyet Sultan, Egypt “Poor people cannot improve their status because they live day by day, and if they get sick then they are in trouble because they have to borrow money and pay interest.” A woman, Tra Vinh, Vietnam Crying out for Change, the World Bank

development. Other diseases keep children away from school, not only when they are ill themselves, but also when they have to work in the fields instead of their ill parents; in villages with Guinea worm disease, schools have to close for weeks at a time. Controlling these hazards therefore contributes to the ability of children to take advantage of education. In communities where children (usually girls) are responsible for water collection, time spent collecting water can interfere with homework, and even with attending school. A more convenient water supply can free up that time. A recent study found that piped water supply to villages in North India contributed to higher school enrolment rates. The lack of environmental services at schools, particularly sanitation and water supply, is also an important deterrent to school enrolment and attendance by girls, especially after puberty. In Bangladesh, a school sanitation programme is reported to have boosted girls’ attendance by 11%. Could that be said of any curriculum reform?

Better education for poor people; removal of gender discrimination

School sanitation and hygiene; a contribution to life-skills learning

Environmental health also contributes to education and gender goals. Lead in the atmosphere and intestinal worms jeopardise children’s cognitive

Developing countries have built many thousands of primary schools in recent years, but many do not have adequate water supply and sanitation. Where school sanitation has not been forgotten, it has been an add-on to the school building, rather than an integral part of the school curriculum. Teaching children to use toilets at school is important because:

School absenteeism and worm infection in Jamaica

Proportion of year absent

0.3

0.2

0.1

0 Uninfected 0

Low 1-