40856 The World Bank Group 1818 H Street, N. W. Country Offi ce Manila Washington D. C. 20433, U.S.A. 23rd Floor, The Taipan Place Tel: 202-473-1000 F. Ortigas Jr. Ave. (formerly Emerald Ave.) Fax: 202-477-6391 Ortigas Center, Pasig City, Philippines www.worldbank.org Tel: 63-2-637-5855 to 64 Fax: 63-2-637-5870; 917-3050 www.worldbank.org.ph June 2007 The Philippines The Philippines The Philippines Environment Environment Environment Monitor 2000 Monitor 2002 Monitor 2004 presented snapshots on air quality. provided updates on of the general The Philippines The Philippines the state of the The Philippines environmental trends Environment Environment Philippine environment Environment in the country. Monitor 2001 Monitor 2003 and natural resources. Monitor 2005 on solid waste on water quality. on coastal and marine management. resource management. This document was prepared by a World Bank team composed of Jonas Bautista, Marija Kuzmanovic, Mikko Paunio, Tamer Rabie, Jitu Shah, Maria Consuelo Sy, Maya Villaluz, and John Morton (Task Team Leader). The document greatly benefited from the input of the following World Bank staff: Anjali Acharya, Yewande Awe, Kulsum Ahmed, Christopher Ancheta, Eduardo Banzon, Edkarl Galing, Timothy Johnston, Peter Kolsky, Jostein Nygard, Jemima Sy, and Josefo Tuyor. Special thanks to Magda Lovei, Maria Teresa Serra, Susan Shen and Joachim von Amsberg for their input and support during preparation. The document was developed through consultation with many government agencies, NGOs, international partners and practitioners in the Philippines, which contributed significantly to its messages and storyline. Comments from DENR-Environmental Management Bureau (EMB) Water Quality and Air Quality Management Divisions; WHO Philippines; and DOH-Environmental and Occupational Health Office (EOHO) during the finalization were especially useful in sharpening the document and messages. Special thanks to Director Yolanda Oliveros (EOHO) and Director Ely Ouano (EMB) for their input and support. Background information and data collection and initial drafting was undertaken by two consulting firms, INTEM and Getinsa. The INTEM team was composed of Dr. Elma Torres, Dr. Ronald Subida, Dr. Agustin Arcenas, Ms. Bernadette V. Gonzales, Mr. Joel Wayne Ganibe, Ms. Jeannette V. Pastorfide, Arman G. Balonkita, Henrietta V. Aguirre, Atty. Ana Leah Uy, and Mr. Soichi Takai. The GETINSA team included Dr. Ben S. Malayang III, Marisol Garrido, and Joel D. Adriano. This volume is a product of the staffof the International Bank for Reconstruction and Development / The World Bank. The findings, interpretations, and conclusions expressed in this paper do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. The material in this publication is copyrighted. Copying and/or transmitting portions or all of this work without permission may be a violation of applicable law. The International Bank for Reconstruction and Development / The World Bank encourages dissemination of its work and will normally grant permission to reproduce portions of the work promptly. For permission to photocopy or reprint any part of this work, please send a request with complete information to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA, telephone 978-750-8400, fax 978-750-4470, www.copyright.com. All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington D.C. 20433, USA, fax 202-522-2422, e-mail pubrights@worldbank.org. CTONTENTS ABLE OF Preface ii Executive Summary iii Scorecard vi Environmental Health Risks Map viii Abbreviations and Acronyms x Chapter 1. Introduction 1 Water Pollution- and Sanitation-Related Diseases 3 Air Pollution-Related Diseases 7 Chapter 2. Water Pollution, Sanitation and Health 11 Disease Burden 11 Environmental Risks 16 Chapter 3. Air Pollution and Health 25 Disease Burden 25 Environmental Risks 27 Chapter 4. Special Focus: Environmental Health, Poverty, and Vulnerability 34 Chapter 5. Legal and Institutional Framework 39 National Level 40 Local Level 42 Chapter 6. Management Response 43 Health Programs 43 Information Management 44 Infrastructure 45 Environmental Regulation 48 Local Initiatives 50 Chapter 7. Imminent Environmental Health Challenges 54 Annex 1. Methodology 60 Annex 2. Useful Websites 66 Annex 3. References 67 PREFACE THE PHILIPPINES ENVIRONMENT MONITOR series has been providing a snapshot of key environmental trends and indicators in the country for the past seven years. Its aim is to inform a broad range of stakeholders, including government, the public, practitioners, and educators in a simple, easy-to-understand format. Over the years, the Environment Monitor series has covered general environmental trends as well as specifi c topics such as water quality, air quality, coastal resources, and solid waste management. The latest Environment Monitor investigates environmental health in the Philippines. Every day people are exposed to different environments with different characteristics. Air quality, drinking water quality, sanitation conditions, and urban congestion are just a few examples of characteristics of the environment that can affect health. While the link between environment and health has been known among scientists and practitioners for at least a century, it is only in the past few years that it has been quantifi ed. Globally, it is estimated that 24 percent of the disease burden and 23 percent of premature deaths could be avoided through a better environment. This impact is especially high for children as worldwide each year four million children die prematurely due to environmental factors.1 The Philippines Environment Monitor 2006 is intended to bring greater attention and insight into the effect of the environment on health in the Philippines. It focuses on how air pollution, water pollution, sanitation conditions and hygiene practices affect the health of the country, and highlights what is being done to reduce health risks through a better environment. It is comprised of six sections: (1) an introduction to environmental health in the Philippines; (2) the disease burden and environmental risks of water pollution, sanitation and hygiene; (3) the disease burden and environmental risks of air pollution; (4) the effect of environmental health on the poor and vulnerable; (5) the institutional and regulatory framework; and (6) the management response. The document concludes with a set of challenges for the Philippines as it moves forward on this agenda. The document is a joint exercise among the Government of the Philippines and the World Bank. It was developed with the participation of national agencies, health practitioners, academia, and civil society. It will be disseminated widely throughout the Philippines and through regional and national workshops on water, sanitation, and air quality. Rahul Raturi Maryse D. Gautier Sector Manager Acting Country Director, Philippines Rural Development, Natural Resources East Asia and Pacifi c Region and Environment Sector Unit The World Bank East Asia and Pacifi c Region The World Bank 1 WHO, 2006b. ii PHILIPPINES ENVIRONMENT MONITOR ESXECUTIVE UMMARY THE QUALITY OF the environment that Filipinos are exposed to in their home, work. and throughout their daily lives is affecting the health of the country. Air pollution, water pollution, sanitation and hygiene practices are the most significant environment-related health risks in the Philippines, accounting for an estimated 22 percent of the reported disease cases and nearly six percent of reported deaths and costing PHP14.3 billion (US$287 million) per year in lost income and medical expenses. Reducing this disease burden and capturing the health benefi ts of an improved environment necessitates the involvement of a broad range of stakeholders and strong public interventions that can effectively address issues including the protection of public goods through environmental management, provision of basic needs, and changing individual behavior through awareness. The Philippines Environment Monitor 2006 is intended to provide government offi cials and decision makers, NGOs, practitioners, and the general public an overview of the health impacts and risks as well as ongoing environmental health initiatives. It also provides a set of proactive challenges that can be used as a stepping stone for further action. Water Pollution, Sanitation and Hygiene. In the Philippines, exposure to water pollution and poor sanitation conditions and hygiene practices account for one-sixth of the reported disease cases and nearly 6,000 premature deaths per year. The cost of treatment and lost income from these diseases amounts to PHP6.7 billion (US$134 million) per year. Diarrhea, which is one of most prevalent disease in the Philippines, is the most common health impact. Intestinal worms are similarly ubiquitous with studies fi nding them in over 40 percent of children. Typhoid and cholera outbreaks are also common. The major cause of these diseases is poor sanitation and hygiene in the household. Currently, 25 million people lack basic sanitation and 13 million lack water sources that can provide improved drinking water and hygiene. Another risk is from the fact that nearly all the domestic wastewater in the country is untreated, which can expose people to parasites, pathogens, and bacteria in water supplies, agricultural fi elds, drainage systems, and surface water. Fortunately, over the past 15 years there have been important improvements. Since 1990, the proportion of the population with access to basic sanitation has increased from 57 to 72 percent. Access to household water supply connections, which has been shown to increase the amount of water available for hygiene purposes, increased from 26 to 40 percent nationally and is now at 58 percent in urban areas. At the same time, over the last ten years the incidence of several water pollution-related diseases has declined substantially. Reported diarrhea incidence has decreased by 43 percent and hepatitis A has dropped by 70 percent. Reported incidence of schistosomiasis, a disease that uses a snail intermediary and is spread through exposure to human waste, has also dropped substantially (40 percent), and is contained to a few regions. ENVIRONMENTAL HEALTH iii These improvements, however, have not occurred evenly in the country. In particular, the Autonomous Region of Muslim Mindanao (ARMM) has the highest reported incidence of water pollution, sanitation and hygiene-related diseases in the country. The proportion of the population in the ARMM with access to improved sanitation (38 percent) is just over half the national average. Similarly, the proportion of the population in the ARMM with access to improved water sources is lowest in the country (60 percent) and 15 percent lower than in any other region. The disparity across income levels in the country is also striking. The proportion of low income families with access to basic sanitation is 22 percent lower than high income families and the proportion with access to water sources that can provide improved drinking water and basic hygiene is 17 percent lower. Air Pollution. Poor air quality from outdoor air pollution in urban areas and indoor air pollution is also affecting health, accounting for an estimated fi ve percent of all reported disease cases and four percent of all reported deaths in the country. Air pollution primarily causes respiratory diseases including acute and chronic bronchitis, pneumonia, and cardiovascular diseases. The impact on the economy from health expenditures and lost income is estimated to be PHP7.6 billion (US$153 million) per year. Levels of particulate matter--a signifi cant health concern and indicator of high levels of other pollutants--are estimated to be on average three times higher in urban areas than in rural areas. Over 18 million people in the Philippines live in cities with unhealthy levels of airborne particulate matter. Due to its large population and high air pollution levels, Manila has the largest health burden from air pollution. Eighty-four percent of particulate pollution is from motor vehicles, particularly motorcycles, tricycles, and utility vehicles such as jeepneys. Indoor air pollution is a health risk in both urban and rural areas, but the extent of the impacts are not fully understood. Forty-six million people in the country use fuelwood for cooking, which increases their risk of exposure to particulate matter, polycyclic aromatic hydrocarbons (PAHs), and carbon monoxide in households and kitchens. Tobacco smoke is another contributor to indoor air pollution and 56 percent of school children have parents that smoke. Several trends and interventions over the past ten years have improved air quality. The closure of a number of coal-fired power plants near Manila in 2001 has led to a reduction in sulfur dioxide concentrations. In addition, the phaseout of leaded gasoline has led to a ten-fold reduction in ambient lead levels since 1990. More recently, the implementation of the Clean Air Act has introduced fuel standards that would reduce aromatics and benzene in gasoline and the sulfur content of automotive diesel fuel. In 2003, the government also established hydrocarbon emission standards for motorcycles and tricycles in urban and rural areas and began requiring emission testing before registration of motor vehicles. In terms of indoor air quality, over the last ten years, people have been switching from traditional solid fuels to the cleaner burning liquefi ed petroleum gas. iv PHILIPPINES ENVIRONMENT MONITOR Moving forward, the high disease burden underlines the key role of environmental improvement in the health of Filipinos. Addressing this issue will necessitate a multi-pronged approach grounded in effective public interventions and broad stakeholder involvement. Among the key elements are commitment and coordination among government agencies; effective use of information by the government and public; improved infrastructure; and effective regulation. The priorities for immediate action include: Raising the profi le of the environment's role in health in government programs and policies and strengthening the institutional commitment to the agenda through the Interagency Committee on Environmental Health. Providing useful and easy to access information through more timely and complete disease surveillance, improving awareness materials and providing effective mechanisms for information sharing and dissemination. Improving infrastructure for health by fi lling in the gaps in basic sanitation, expanding water resource development, and reducing the health risks of polluted surface and groundwater. Improving regulation by strengthening local regulation and reducing particulate matter emissions from motor vehicles. Taking the agenda forward using the fi nalization of the National Environmental Health Action Plan as a stepping stone for commitment and action. ENVIRONMENTAL HEALTH v SCORECARD ENVIRONMENTAL HEALTH SCORECARD: RISKS Number of General Trend Indicators people exposed and (downward trend Status and Comments relative risk indicates reduced risk of disease) WATER: ENVIRONMENTAL RISKS Lack of access to 25 million people Sanitation access has improved sanitation Very high risk increased 15 percent This is exacerbated by the fact nationally since 1990; on that 45 percent of Filipinos do track to meet Millennium not wash their hands after using Development Goals sanitation facilities Lack of access to 13 million people The percent of population improved water High risk without access to improved sources Commonly contaminated water water sources is increasing; supply systems add to this risk not on track to meet Millennium Development Goals Lack of sewerage 37 million people Sewerage coverage has coverage in urban Medium risk increased slightly over areas Risk is high for those in contact the past few years due to with open drainage or waterways investments in Manila. Lack of septic tank 42 million people Septic tank maintenance maintenance Medium risk programs in Manila are Reduces sanitation in households gaining momentum. and contributes to contaminated water supplies, drainage systems, and waterways AIR: ENVIRONMENTAL RISKS Particulate matter 18 million people Has decreased slightly over concentrations in Medium-high risk the past ten years in Manila. urban air above Risk is high for those exposed to DENR standards traffic much of their day Use of fuel wood for 46 million people Use of wood has decreased cooking Level of risk unknown from 64 percent in 1995 to Depends upon degree of 55 percent today. ventilation Smoking in 30 million Filipinos smoke and Exposure to smokers at households 56 percent of children have home remained constant parents that smoke between 2000 and 2003. vi PHILIPPINES ENVIRONMENT MONITOR ENVIRONMENTAL HEALTH SCORECARD: DISEASE BURDEN General Trend Indicators Disease Burden (downward trend indicates reduced Status and Comments disease burden) WATER: DISEASE BURDEN Diarrhea 16.5 percent of reported disease Cases of diarrhea have cases decreased nationally by 43 percent over the last ten years Cholera 0.1 percent of reported disease Cholera outbreaks have cases reduced by half over the last ten years Schistosomiasis 0.2 percent of reported disease Schistosomiasis has cases declined by 40 percent over the last ten years nationally Soil-transmitted An estimated 40 to 95 percent of Remains at similarly high Helminthes school children are affected levels as it did ten years ago AIR: DISEASE BURDEN Cardiovascular and 4.9 percent of reported disease Overall, cardiovascular respiratory illnesses. cases and respiratory disease incidence has changed little over the past ve years; fi the trend of air pollution impacts on those diseases is not known. ENVIRONMENTAL HEALTH vii This map was produced by 120°E the Map Design Unit of The PHILIPPINES World Bank. The boundaries, colors, denominations and ENVIRONMENTAL HEALTH any other information shown on this map do not imply, on RISKS the part of The World Bank 20°N Group, any judgment on the Luzon Strait legal status of any territory, SCHISTOSOMIASIS ENDEMIC PROVINCES or any endorsement or acceptance of such boundaries. PROVINCES WITH LOW ACCESS TO BASIC SANITATION (<60%) Babuyan Channel PROVINCES WITH LOW ACCESS TO IMPROVED WATER SOURCE (<70%) CITIES WITH HIGHLY POLLUTED SURFACE WATER (CLASS C UNSUITABLE FOR < SWIMMING/BATHING) TOXIC RED TIDES (AVERAGE OF 1 EPISODE > EVERY 3 YEARS) MAIN CITIES NATIONAL CAPITAL PROVINCE BOUNDARIES INTERNATIONAL BOUNDARIES Dagupan Sources: Schistosomiasis, access to improved water source and sanitation: NSO, 2004a. Cities with polluted surface water: DENR, 2003. San Fernando Toxic red tides: Furio et al, 2002. 15°N Apalit 125°E 15°N MANILA Philippine Calapan Sea Mindor Sibuyan Sea oStrait 0 50 100 150 Kilometers Visayan Sea 0 50 100 Miles Iloilo Leyte Gulf Cebu 10°N 10°N Mindanao Sea Butuan Sulu Sea Zamboanga Moro Gulf Davao Gulf AUGUST 2007 MALAYSIA IBRD Celebes Sea 35573R 5°N 120°E 125°E viii PHILIPPINES ENVIRONMENT MONITOR This map was produced by 120°E the Map Design Unit of The PHILIPPINES World Bank. The boundaries, colors, denominations and ENVIRONMENTAL HEALTH any other information shown on this map do not imply, on RISKS the part of The World Bank 20°N Group, any judgment on the Luzon Strait legal status of any territory, CITIES WITH HIGH AIR POLLUTION or any endorsement or (TSP>DENR STANDARD) acceptance of such boundaries. PROVINCES IN REGIONS WITH HIGH FUELWOOD USE (>80%) Babuyan Channel MAIN CITIES Laoag City NATIONAL CAPITAL PROVINCE BOUNDARIES Tuguegarao INTERNATIONAL BOUNDARIES Sources: 1. DENR National Air Quality Status Report, 2003-2004. 2. Household Energy Consumption San Fernando Survey, 1995. Baguio 125°E Alaminos Cabanatuan San Fernando 15°N 15°N MANILA Batangas Philippine Calapan Iriga Legaspi Sea Mind Sibuyan Sea oroStrai t 0 50 100 150 Kilometers Visayan Sea 0 50 100 Miles Tacloban Iloilo Leyte Gulf Cebu 10°N 10°N Mindanao Sea Sulu Sea Zamboanga Davao Moro Gulf Davao Gulf General Santos MALAYSIA 35577 Celebes Sea IBRD 5°N 2007 120°E 125°E UGUSTA ENVIRONMENTAL HEALTH ix ABBREVIATIONS & ACRONYMS ADB Asian Development Bank LLDA Laguna Lake Development Authority ALRI acute lower respiratory infection LWUA Local Water Utilities Administration ARI acute respiratory infections MDGs Millennium Development Goals BOD biological oxygen demand MMDA Metro Manila Development Authority BSWM Bureau of Soils and Water Management MSSP Manila Second Sewerage Project BWSA Barangay Waterworks and Sanitation MTPDP Medium-Term Philippine Development Association Plan CAA Clean Air Act MWCI Manila Water Company, Inc CO carbon monoxide MWSS Metropolitan Waterworks and CO2 carbon dioxide Sewerage System COPD chronic obstructive pulmonary disease NCDPC National Center for Disease Prevention CWA and Control Clean Water Act NEC DA National Epidemiology Center Department of Agriculture NEHAP DENR National Environmental Health Action Department of Environment and Plan Natural Resources NEESSS National Epidemiological Epidemic DILG Department of Interior and Local Sentinel Surveillance System Governments NGO Nongovernmental organization DO dissolved oxygen NOAEL no adverse effect level DOE Department of Energy NOx nitrogen oxides DOH Department of Health NSO National Statistics Office DOTC Department of Transportation and Communications NWRB National Water Resources Board DPWH Department of Public Works and NWRC National Water Resources Council Highway O3 ozone EIA environmental impact assessment Pb lead EHS Environmental Health Services PHP Philippine peso EMB Environmental Management Bureau PM particulate matter ENRAP Environmental and Natural Resources PM10 suspended particulate matter smaller Accounting Project than 10 microns FAO Food and Agriculture Organization of POPs persistent organic pollutants the United Nations RfD reference dose FHSI Field Health Service Information SO2 sulfur dioxide System STH soil-transmitted helminths GDP gross domestic product TSP total suspended particulates HC hydrocarbon USAID United States Agency for International IACEH Interagency Committee on Development Environmental Health VOC volatile organic compounds LGU local government unit WHO World Health Organization x PHILIPPINES ENVIRONMENT MONITOR Chapter 1. INTRODUCTION INTRODUCTION EVERY DAY, PEOPLE are exposed to different A poor environment contributes to many environments. Depending on where they eat, common health conditions in the Philippines. sleep, work, play, and how and where they Many causes of diseases and death (Box 1.2) in travel, people breathe different air, drink the Philippines are due in part to different water, and are in contact with a environmental factors. Of all the environmental variety of surfaces, soil, and even insects. The factors that contribute to diseases, air pollution, quality and characteristics of the environments water pollution, sanitation conditions and people are exposed to can have important hygiene practices are the most important, implications on their well-being. Environmental accounting for an estimated 22 percent of the health (Box 1.1) as a discipline provides reported illnesses and six percent of the insight into the extent to which the reported deaths in the country.3 Diarrhea is the environment affects health, and, more leading environmental health ailment and air importantly, how the harmful impacts can pollution contributes to a similar quantity of be prevented by improving the quality of respiratory and cardiovascular diseases. the environment we live in. This Philippines Environment Monitor uses available data and knowledge to provide a quantitative and Box 1.1 Definition of Environmental Health qualitative assessment of this relationship in the Philippines. Environmental health focuses on those issues where environmental conditions contribute to a health problem that can be reduced through an Globally, environmental risks are responsible improved environment. It includes among other for one-quarter of all preventable diseases. things, the health effects of pollution as well as Of the 102 major disease types and injuries, habitats for disease vectors such as dengue and environmental risks contribute to 85. Nearly malaria; the effect of stressful work environments one-quarter of the global disease burden is due on heart disease; the impact of crowded living to poor environmental conditions.2 The relative conditions on tuberculosis; and the effect of lead importance of the environment in causing a on violence. Environmental factors that cannot be disease varies depending on the disease. For reasonably improved--such as natural disasters example, diarrhea is primarily caused by an and naturally occurring biological agents such as unsanitary environment; over 90 percent of pollen--are not included. all cases can be attributed to environmental Source: WHO, 2006b. factors. Lower respiratory infections, on the other hand, have a variety of causes, with poor air quality being one of the aggravating factors. The environment is estimated to account for only four percent of the cases of these diseases. 2 WHO, 2006b. 3 Based on reported disease incidences and global knowledge of the environmental contribution to these diseases. See Methodology section and Chapters 2 and 3. ENVIRONMENTAL HEALTH 1 INTRODUC ION Chapter 1. INTRODUCTION Box 1.2 How much does the environment contribute to disease? The diagrams below show commonly reported causes of disease and death in the Philippines and the extent to which environmental factors contribute to these health impacts. The contribution of the environment is based on information from global scientific literature that has quantified the change in disease as a result of the improvement of a variety of environmental factors, for example, air quality, sanitation, congestion, stress, and vector habitats. Causes of Death and the Environment Heart diseases Pneumonia Tuberculosis Chronic lower respiratory disease Lung cancer Transport accidents Intestinal infectious disease Nutritional deficiencies attributable to environment Dengue other causes 0 10 20 30 40 50 60 70 number of deaths (thousands) Causes of Disease and the Environment Lower Respiratory Infections and Pneumonia Bronchitus/Bronchiolitis Acute watery diarrhea Influenza Hypertension heart disease Respiratory tuberculosis Chickenpox Heart diseases Malaria attributable to environment Dengue fever other causes 0 100 200 300 400 500 600 700 800 number of cases (thousands) Sources: Mortality data from NSO, 2000b. Morbidity from DOH-NEC, 2004a. The fraction of the cases caused by environmental factors was estimated using the approach described in the methodology section, which is largely derived from WHO 2006b. The role the environment plays in health involves many diseases and risks. In order to narrow the scope of this document, the Philippines Environment Monitor focuses on the environmental factors that contribute most significantly to the health burden in the Philippines. These are air pollution, water pollution, sanitation conditions, and hygiene practices. It should be emphasized that many other environmental health issues are also important and can have impacts nationally, among certain groups or locally. For example, congested urban settings and poor solid waste management are contributing to the growing number of cases of dengue in the country; and urban environments including the availability of pedestrian walkways are contributing to traffic accidents. In addition, exposure to chemicals and hazardous waste presents potential health risks including those associated with persistent organic pollutants, which could have harmful long-term health implications in part due to their ability to accumulate in the human body. While time, space and resources prevent the full treatment of all environmental health issues, we anticipate that the Environment Monitor will provide momentum for ongoing initiatives and a springboard for additional studies on these and other important issues. 2 PHILIPPINES ENVIRONMENT MONITOR INTRODUCTION Water Pollution and Sanitation- the body through ingestion via contaminated Related Diseases fi ngers, food, or water, and secondarily through inhalation or via absorption through cuts and The majority of the health burden from water other openings. Once human waste enters the pollution, poor sanitation and hygiene is due body, the bacteria, parasites, and viruses can to contact with human waste, a single gram grow, causing symptoms such as diarrhea, which of which can contain ten million viruses, one is common among bacterial infections, and million bacteria, and one million parasite cysts.4 diseases such as dysentery, cholera, hepatitis A, Human fecal matter most commonly enters and typhoid (Table 1.1). Table 1.1 Environmental risks of water pollution, poor sanitation and hygiene Major Risks in the Philippines Health Issues Symptoms Ingestion of feces through Diarrhea Loose, watery stools occurring more than three times Contact of mouth to ngers fi in one day, sometimes accompanied by cramping · Lack of sanitation facilities in household abdominal pain, bloating, and nausea; can lead to · Backed up septic systems, dehydration contaminated drainage systems Typhoid/Paratyphoid Fever, chills, sweating, slow heart rate, coughing, skin · Lack of adequate water for hygiene symptoms, headache; in children, it can induce vomiting purposes and diarrhea Contaminated food · Poor food preparation Cholera Profuse watery diarrhea, vomiting, leg cramps · Lack of water for hygiene purposes Hepatitis A Joint aches, abdominal pain, vomiting, loss of appetite, · Fecal contamination spread by insects dark urine, fever, enlargement and yellowing of the eyes Contaminated water supply · Inadequately treated or leaky piped water systems · Wells in proximity to human waste disposal areas · Vendors with poor water quality Ingestion or contact with soil- Soil-transmitted Ascariasis: Generally asymptomatic unless heavy contaminated with feces Helminthes (Trichuriasis, infestation, which can lead to fever, diarrhea, visceral · Unmaintained sanitation systems Hookworm or Ascariasis) damage, enlargement of the liver or spleen, toxicity, and · Drainage systems pneumonia. · Polluted rivers Trichuriasis: Generally asymptomatic unless heavy infestation, which may cause bloody diarrhea or anemia Hookworm: Fatigue, cough, fever, stomach pains, yellowing of skin, feet that go to sleep, head and joint aches, weakness, vomiting, constipation, and diarrhea Contact with fecal-contaminated water Schistosomiasis (Areas of Abdominal pain, cough, diarrhea, high white blood cell Mindanao and the Visayas) count, fever, fatigue, and enlarged liver and spleen Skin rashes Skin color change, blistering, itching, cracking, dryness, swelling, pain Polluted water that can serve as a Filariasis Tissue damage resulting in swelling, scarring, and breeding ground for Culex and Mansonia infections and affecting mostly the legs and groin area mosquitoes. Direct contact or injection of toxic Acute poisonings and Depending on the source, symptoms can include one or chemicals from water pollution through chronic affects, including more of the following: nausea, abdominal pain, vomiting, drinking water, eating of shellfish, and birth defects and cancer diarrhea, fever, headache, or fatigue fish and bathing 4Global Water Foundation. ENVIRONMENTAL HEALTH 3 INTRODUC ION Chapter 1. INTRODUCTION Water Pollution and Sanitation-Related Diseases sanitation systems is also a risk in many urban areas, where the water systems have high levels of leakage. In rural areas, many unprotected wells located in proximity to human waste have been found to be contaminated. The quantity of water available to maintain personal hygiene and clean household surfaces in order to prevent ingestion of fecal matter is also an environmental contributor to disease. Poor sanitation and exposure to water pollution are common in Thirteen million people lack improved water poor urban communities. sources such as protected wells and public taps Source: LLDA that can help ensure they have access to an The largest risk in the Philippines is among adequate quantity of safe water. Additionally, the 25 million people living in households another 50 million people lack individual water without sanitary toilets.5 In these households, supply connections. there is a high risk that human waste would not be safely removed from the household. Waste, worms, snails, and insects. Open This risk, combined with hygiene habits--such defecation and improper waste disposal are as washing hands before meals and after use of leaving many water bodies and land sanitation facilities--are the major risk factors contaminated with sewage. In addition to the contributing to diarrheal disease. risk of ingestion of feces, human contact with this waste is one of the main contributing Outside the household, the risk of exposure to factors to certain diseases that use worms or human waste is on average lower. However, snails as part of their lifecycle. the lack of sewerage systems and operational wastewater treatment facilities throughout Schistosomiasis is transmitted via contact with the country presents opportunities for direct water that contains a specifi c freshwater snail contact with human waste and indirect contact (Oncomelania hupensis quadrasi), which along through fl ies. In every city and many rural with the human host acts as a carrier for the areas, water contaminated with human waste parasite. Schistosomiasis incidence is attributed can be found in rivers, canals, bays and streets entirely to water pollution, poor sanitation and public walkways with poor drainage. and hygiene because its lifecycle is not only Groups especially at risk are children who play dependent upon the snail and human hosts, in or near polluted water, and fi shermen and but also requires human excreta in the water farmers, who are in contact with polluted water body and, therefore, is highly dependent on as part of their livelihood. poor household sanitation, and, in many cases, Drinking water from unprotected wells or defecation of farm workers and fi sherfolk in leaky piped water systems contaminated by water bodies and agricultural fi elds. The disease is commonly found in areas with irrigated 5 Twentyeightpercentofhouseholdsinthecountrydonothavesanitary agriculture in Eastern Mindanao and the Visayas, toilets (DOH-NEC 2004a). where the snail is found. 4 PHILIPPINES ENVIRONMENT MONITOR Water Pollution and Sanitation-Related Diseases INTRODUCTION A well-designed water supply system improves health by providing good quality water in sufficient quantity. Source: Water and Sanitation Program, Philippines Soil-transmitted helminthes (STH) are Filariasis is caused by worms that live in a widespread in the Philippines, affecting human host and are spread by mosquitoes. The many children. They include worm parasites worms eventually reproduce to the point that such as ascaris, trichuris, and hookworms they cause debilitating enlargement of legs, that deposit their eggs in soil contaminated feet, and other appendages. The highest risk for with human waste. Humans are infected filariasis is not related to pollution, but rather with STHs when they ingest the eggs through in areas with plantations of abaca, banana, gabi, contaminated fingers, food, or water or and other plants with axils. These areas are used through direct contact with contaminated as breeding sites for the Aedes poecilius mosquito, soil where the worms can penetrate skin. In which is the dominant vector for this disease. addition to the physical symptoms, STHs Of secondary importance in the Philippines are have been shown to reduce learning, memory, Culex mosquitoes, which breed in very polluted and verbal fluency skills in infected Filipino waters, including those associated with poorly children.6 maintained, open sanitation systems. Mansonia mosquitoes are also vectors for this disease and breed near floating plants such as water hyacinths, which proliferate in many rivers, 6 Ezeamama et al. 2005. ponds, and lakes polluted by domestic sewage. ENVIRONMENTAL HEALTH 5 INTRODUC ION Chapter 1. INTRODUCTION Water Pollution and Sanitation-Related Diseases Other health risks of water pollution. Other range from acute effects such as poisonings, to pollution-related health risks include industrial longer term impacts such as cancer. and agricultural waste and pesticides, which are potential sources of toxic chemicals, including Paralytic shellfish poisoning is caused by organic pollutants and heavy metals. consumption of shellfish contaminated with "saxitoxin," which is present when they are Sources of heavy metal pollutants in the harvested during blooms of marine organisms country include mercury from mining, and called dinoflagellates. The toxin causes lead and cadmium from industrial sources. neurological damage, paralysis, and in some Additionally, organic pollutants such as cases death. The blooms--characterized by solvents, pesticides, and byproducts of their reddish-brown color and thus referred chemical manufacturing are also potential to as "red tides"--are also linked to water sources of surface water and groundwater pollution, since they are in part caused by contamination. The impacts vary depending nutrient pollution from agriculture and on the pollutant and exposure level, but can domestic waste. Water-related environment health risks include: exposure to waste through hands, water and food due to poor sanitation and hygiene; and exposure to industrial or human waste in waterways and agriculture. Source: Authors. 6 PHILIPPINES ENVIRONMENT MONITOR INTRODUCTION Air Pollution-Related Diseases Table 1.2 Common air pollutants Pollutant Sources Common Health impacts Filipinos are exposed to air pollution each day: Particulate Particulates are directly Reduced lung function; in urban areas, in agricultural areas after the Matter emitted through dust inflammation of lungs; measured and combustion increased susceptibility harvest, and inside homes, where cooking, as TSP, processes, including to respiratory infections; heating, and smoking can degrade air quality. PM10, and vehicular exhaust, aggravation of heart PM2.5 burning of fossil fuels, and lung diseases; and burning of waste, may cause chronic The pollutants are a mix of gases, droplets, and or indirectly from bronchitis and lung reactions of other cancer particles, the composition of which is dependent pollutants (e.g, SO2 on the source. The main pollutants (shown in or NO2) Table 1.2) include particulate matter, which Sulfur Vehicular emissions, Breathing difficulties; Dioxide combustion of fossil eye irritation; chest when found in small sizes (<10 µm or <2.5 µm) (SO2) fuel (coal and heavy tightness, especially can penetrate the lungs deeply; highly reactive oils), industrial among asthma emissions sufferers; aggravation compounds such as carbon monoxide and of heart and lung ozone; and other gases that can have a variety diseases of short- and long-term effects depending on Nitrogen Vehicular emissions Irritation of the Oxide (NO2) resulting from respiratory tract; the contaminants present and their high temperature increased susceptibility concentration. Health effects usually result combustion to respiratory infection; impaired lung function from the combined effect of a mixture of pollutants and oftentimes are due to exposure Carbon Vehicular emissions Headaches; dizziness; Monoxide resulting from chest pains, over many years, even a lifetime. (CO) incomplete especially among combustion those suffering from cardiovascular diseases Volatile Vehicular emissions Irritation of the Organic and biomass burning eyes, nose and Compounds throat; headaches, nausea, and loss of coordination; in the long term, some VOCs are suspected to cause cancer and liver damage Ground- Reaction of NO2 and Itchiness and burning level VOCs in the presence of the eyes; irritation Ozone of heat and sunlight and inflammation of (O3) the lungs; breathing difficulty; increases susceptibility to respiratory infections Poly- Combustion Long-term exposure aromatic processes, including can lead to cancer; hydro- solid fuel use in affects reproductive carbons households; tobacco system, liver, lungs, (PAHs) smoke; vehicular and and skin industrial emissions A view of air pollution in Metro Manila. Source: Authors. ENVIRONMENTAL HEALTH 7 INTRODUC ION Chapter 1. INTRODUCTION Air Pollution-Related Diseases Tables 1.3 Common diseases caused by air pollution chronic lung ailments (premature aging of Diseases Symptoms the lungs and chronic obstructive pulmonary disease, or COPD). Allergic Reactions Air pollutants can trigger or exacerbate symptoms of existing respiratory conditions such as asthma ...and also the heart. Many air pollutants are able to pass through the lungs into the Chronic Obstructive Chronic bronchitis is Pulmonary Diseases (COPD) characterized by persistent bloodstream and are eventually transported cough producing sputum to the heart and the entire body through matter that is coughed up from the respiratory tract blood vessels. Because the cardiovascular Cardiovascular diseases Chest pain, tightness, heart system is dependent on the functioning of attack, heart failure, and the respiratory system, it is also indirectly irregular heartbeat affected by the deleterious effects of air Physical Damage and Air pollutants can cause Carcinogenesis physical damage to the lungs, pollution on the lungs. These impacts which may develop into a combined, damage and infl ame blood vessels malignant condition, including lung cancer and affect heart function. They have been Pulmonary Fibrosis Scarring of the lung shown to cause symptoms such as chest characterized by the tightness and pain and heart palpitations, replacement of the air sacs of the lungs with brotic fi as well as increased cardiovascular-related tissue reducing the number disease incidence and death. of alveoli Acute Respiratory infections Cough producing greenish or (pneumonia, acute bronchitis, yellow sputum, high fever and Other health effects of air pollution. Studies also and acute respiratory tract shaking chills, chest pain, have linked prolonged exposure to particulate infection) shortness of breath matter, sulfur oxides, and polyaromatic hydrocarbons from air pollution to a variety of cancers, including those affecting the heart Air pollution affects the lungs. Lungs-- and lungs. Additionally, there is evidence that comprised of exposed membranes designed absorption of air pollutants into the bloodstream to continuously transfer large quantities of affects other bodily functions, including the air into the blood stream--are sensitive to air nervous system and reproductive functions.7 pollutants. Air pollutants, particularly ozone or volatile organic compounds, are known Outdoor air quality is worst in urban areas. to injure lung tissue. Air pollution can also Concentrations of particulate matter, which increase susceptibility to respiratory infection is often used as an indicator of air pollution, and causes reduced lung function through are estimated to be three times higher on narrowing and infl ammation of the airways, average in urban roadsides than in rural areas abnormal fl uid production, and swelling. (Table 1.4). Many cities in the country8 have air pollution levels above national standards. Exposure to air pollution has been shown to aggravate or cause minor lung illnesses (cold, sore throat, runny nose, coughing, and irritation of the eyes), lung infections (acute bronchitis 7 For further information on the health effects of air pollution, see WHO 2005. and pneumonia), allergies (asthma), and 8 See DENR-EMB 2005a. 8 PHILIPPINES ENVIRONMENT MONITOR Air Pollution-Related Diseases INTRODUCTION The risks of exposure to poor air quality include: air pollution from industries, motor vehicles and waste burning; exposure to smoke from the use of solid fuel for cooking; and environmental tobacco smoke. Source: Authors. Air quality indoors is also a risk. Indoor air Table 1.4 Estimated average particulate matter pollution poses health risks in both urban and concentrations in urban and rural areas rural areas, as people spend a large portion of of the Philippines their time within the confi nes of their homes. Area TSP (µg/m3) PM10 (µg/m3) In the Philippines, many people use wood as Metro Manila 175* 65 cooking fuel, which (along with other biomass Other Urban Areas 129* 47 fuels such as charcoal) releases particulate matter, PAHs, and carbon monoxide. Depending Rural Areas 42 18 on the degree of ventilation, this can lead to DENR standard 90 60 increased risk of acute respiratory infections. Source: These estimates of PM10 concentrations were based on available data and information, including actual roadside PM10 measurements, annual roadside mean TSP levels, the predicted Tobacco smoke can also degrade indoor air, levels from the World Bank model, and information about fractions of PM10 in TSP. depending on the number of smokers in the * Averages of actual roadside measurements family and their smoking behavior. Thirty-five ** Population-weighted average percent of Filipinos are smokers.9 9 See DOST-FNRI 2003­04. ENVIRONMENTAL HEALTH 9 INTRODUC ION Chapter 1. INTRODUCTION Air Pollution-Related Diseases Burning of agricultural waste contributes to air pollution in rural areas. Source: R.E.A.P. ­ Canada. Other sources can increase exposure in certain knowledge on the relationship of pollution localities. In some rural areas, burning of and disease to Philippine circumstances in agricultural waste (rice hulls, cane trash, and order to estimate the burden of disease from other residues) and of forest and brushland environmental causes in the country and (as a result of slash and burn, Kaingin identify the environmental risks contributing activities) presents a seasonal air quality issue. to these diseases. The discussion incorporates Additionally, burning of garbage either at the disease-specific trends; the likely environmental household level (where there is no collection) hazards leading those trends; the key factors or in unmanaged dump sites, presents a local that account for people's vulnerability to these air quality problem. hazards; and the economic costs associated with the effects of pollution. The report also The following sections of the Monitor provide highlights the progress made, the policy and a more detailed examination of the main institutional barriers to improving health health issues related to air pollution, water through a better environment, and the main pollution, sanitation and hygiene in the challenges moving forward. Philippines. This report applies global 10 PHILIPPINES ENVIRONMENT MONITOR Disease Burden Chapter 2. WATER POLLUTION, SANITATION AND HEALTH NEARLY 6,000 PEOPLE die prematurely each Table 2.1 Proportion of reported diseases year from water pollution and poor sanitation attributable to water pollution, sanitation, and hygiene. Seventeen percent of reported and hygiene disease cases and one and a half percent of Reported cases % of reported reported deaths in the country each year can Disease attributable to water pollution, sanitation, cases for all be attributed to water pollution, sanitation and hygiene disease conditions and hygiene practices. Among them, Diarrhea 507,864 16.50 diarrhea is the third leading cause of disease Schistosomiasis 6,628 0.22 in the country. Typhoid and schistosomiasis and other diseases also are signifi cant, but Typhoid and 6,300 0.20 paratyphoid together account for less than one percent of Cholera 3,857 0.1 all reported disease cases (Tables 2.1 and 2.2). Hepatitis A 2,048 0.07 Filipinos are paying for treatment and losing Filariasis 21 0.0007 income. Each year these illnesses cost Filipinos Total 526,718 17 an estimated PHP2.8 billion (US$56 million) Source: Reported data from DOH-NEC 2004a. Outbreak cases in treatment costs, including drugs, hospital also included for typhoid and cholera (see Table 2.7). Number of cases attributable to water pollution, sanitation, and hygiene were fees, and the lost income from missing work determined as outlined in methodology section. to undergo treatment. Premature death from these diseases is also costing the economy an estimated PHP3.9 billion (US$78 million) per Table 2.2 Reported deaths attributable to water year in lost income (Table 2.3).10 pollution, sanitation and hygiene in 2002 Disease Number of deaths % of deaths by all causes The disease burden has steadily decreased since the mid-1990s. The incidence of Intestinal and 3,811 1.0 infectious diseases caused by water pollution, sanitation disease conditions and hygiene practices peaked in Nutritional 912 0.2 the mid-1990s and since that time steadily deficiencies decreased to less than half of that level Hepatitis A 693 0.1 (Figure 2.1). This reduction is largely a result Schistosomiasis 304 0.15 of a decrease in reported diarrhea cases and STH 174 0.05 has paralleled a reduction in deaths from infectiousdiseaseinthecountry.Schistosomiasis, Cholera 70 0.02 hepatitis A, and fi lariasis also are declining. Filariasis 2 0.0007 Total 5,619 1.5 Source: NSO 2000b, 2002. See Methodology section for determination of attributable deaths. Outbreak cases are also 10 This can be considered a lower bound estimate of economic included in the above numbers for cholera (Table 2.7). costs, as it only accounts for the costs associated with cases that are reported to undergo treatment at a clinic or hospital and does not include indirect costs such as pain and suffering associated with having an illness and does not include unreported treatment cases and those for which people do not seek treatment. ENVIRONMENTAL HEALTH 11 WATER POLLUTION, SANITATION AND HEALTH Chapter 1. INTRODUCTION Disease Burden Figure 2.1 Reported diseases attributable Figure 2.2 Reported diseases attributable to water pollution, sanitation and to water pollution, sanitation and hygiene by year hygiene by region Source: DOH-NEC 2004a data, including diarrhea, Source: DOH-NEC 2004a. See Methodology for calculation of schistosomiasis, viral hepatitis, typhoid and paratyphoid. attributable diseases. Includes diarrhea, cholera, dengue, lariasis, fi Comparable data not availabla for dengue, cholera, and lariasis. fi schistosomiasis, hepatitis A, and typhoid and paratyphoid. Regional disparities are high. The Autonomous Region of Muslim Mindanao (ARMM), the Figure 2.3 Diarrhea Central Visayas (Region VII), and Cordillera Reported Incidence (Per 100,000 per year) Administrative Region (CAR) have the highest Cases Deaths reported incidence of disease cases attributable Overall: 722 3.8 Children (<5 years): 3,872 18 to water pollution, sanitation and hygiene. Incidence rates are three to fi ve times higher High incidence areas: Guimaras Province: 2,660 than regions with the lowest incidence rates Antique Province: 2,332 (Figure 2.2). National trend over last 10 years: Reduced 43 percent Cases of diarrhea have declined substantially. Since 1995, there has been a steady decline of Estimated cases attributable to water pollution, reported cases of this disease, which is almost sanitation and hygiene 88 percent entirely caused by water pollution, poor sanitation and hygiene. However, it remains Includes reported cases only. DOH-NEC 2004a (national incidence); and NSO 2002 (deaths). Trend in incidence based prevalent throughout the country (Figure 2.3). on 1995­2004 data from DOH-NEC, 2004a and DOH, 2000. Schistosomiasis is found only in certain regions. Nationally, reported schistosomiasis incidence has decreased over the last ten years and is considered insignifi cant in half of the regions. Currently, nearly 90 percent of the reported cases are in CARAGA and the Eastern Visayas (see Map). 12 PHILIPPINES ENVIRONMENT MONITOR Disease Burden WATER POLLUTION, SANITATION AND HEALTH APRIL 2007 IBRD 35224 ENVIRONMENTAL HEALTH 13 WATER POLLUTION, SANITATION AND HEALTH Chapter 1. INTRODUCTION Disease Burden Table 2.3 Treatment costs and lost income from diseases attributable to water pollution, sanitation and hygiene Morbidity Mortality Water-related Direct income losses Medical Expenses and Income losses to GDP Total Disease due to hospitalization Hospitalization due to lost productive (PHP million/yr) (PHP million/yr) (PHP million/yr) life years (PHP million/yr) Diarrhea 139 2,522 2,827 5,488 Nutritional deficiencies NA NA 676 676 Cholera 1.3 28 14 43 Typhoid 2.5 51 NA 54 Hepatitis A 2,048 17 0.07 222 Schistosomiasis 3.1 50 162 215 Filariasis 0.02 0.3 1 1.3 Total PHP147 million/yr PHP2,668 million/yr PHP3,884 million/yr PHP6,700 million/yr (US$2.9 million/yr) (US$53 million/yr) (US$78 million/yr) (US$134 million/yr) Source: See methodology section for details. Figure 2.4 Hepatitis A Reported Incidence (Per 100,000 per year) Cases Overall: 5.1 Children (<5 years): 3.8 High incidence areas: Guimaras Province: 82 Antique Province: 49 National trend over last 10 years: Reduced 70 percent Estimated cases attributable to water pollution, sanitation and hygiene 50 percent Medical expenses is one of the costs families are paying due to water pollution, poor sanitation and hygiene. Includes reported cases only. DOH-NEC 2004a (national Source: Association of Medical Doctors of Asia (AMDA International) incidence); and NSO 2002 (deaths). Trend in incidence based on 1994­2004 data from DOH-NEC, 2004a. ago, but lower than in 2001 and 2002, when incidence rose to 2.5 cases per 100,000. Ninety Hepatitis A has declined 70 percent over the percent of the reported cases are limited to three last ten years. Water pollution, sanitation and regions--CARAGA, Western Mindanao, and the hygiene are estimated to account for 50 percent Eastern Visayas. The highest rates are found in of the reported cases of this disease. It is found Surigao del Sur (74 cases per 100,000 per year) throughout the country, with relatively little and Agusan del Norte (38 cases per 100,000 per variation among regions (Figure 2.4). year).11 It is estimated that a relatively small portion of the cases of this disease are due to Filariasis is limited to a few regions. Thereported water pollution, poor sanitation and hygiene. incidence of fi lariasis in 2005 was 0.5 cases per 100,000 Filipinos. This is similar to a decade 11 DOH-NEC 2004a. 14 PHILIPPINES ENVIRONMENT MONITOR Disease Burden WATER POLLUTION, SANITATION AND HEALTH Cholera is an outbreak threat. While overall number of outbreaks per year, however, has reported cholera incidence is low relative to reduced since the 1990s. other diseases (0.4 cases per 100,000 each year), it occurs in outbreaks and thus, can have high At least 40 percent of schoolchildren have incidence in localized areas, typically in urban soil-transmitted helminthes. Studies have slums, where water supply and sanitation consistently indicated a very high prevalence systems are inadequate. NCR (Pasay and Quezon of these diseases among Filipino children. An City) and Western Mindanao (Zamboanga average of between 40 and 95 percent of the City) are the only areas that consistently report children studied were found to be infected with cholera cases. The largest recent outbreak was at least one of these parasites, and between 4 in Pangasinan in 2004, which resulted in 3,424 and 22 percent were heavily infected.12 Studies cases. The number of outbreaks per year has undertaken ten years ago show similarly high decreased by half over the last 10 years. prevalence rates. Reported cases of typhoid remain high. An Paralytic shellfi sh poisonings have declined. estimated 50 percent of typhoid cases are due to During the 1980s and early 1990s there were water pollution, sanitation conditions and many outbreaks of paralytic shellfi sh poisoning hygiene practices. Outbreaks are commonly resulting in as many as 200 to 300 reported cases associated with contaminated water supply per year. In 2005, there were no reported cases systems. Reported cases of typhoid and in the Philippines, while in 2004 there were only paratyphoid have not declined over the last ten four cases. In 2004, disease cases were due to years and are found in all regions; seven red tides in Negros Occidental and Masbate.13 consistently report it as one of the top ten leading causes of disease (Figure 2.5). The Figure 2.5 Typhoid and Paratyphoid Trends Incidence (Per 100,000 per year) Cases Deaths Overall: 16 1.1 Children (<5 years): 18 0.3 High incidence areas: Ifugao Province: 271 Quirino Province: 457 National trend over last 10 years: No Trend Soil transmitted helminthes are found in over 40 percent of Filipino children and are spread through soil contaminated by Estimated cases attributable fecal matter. to water pollution, Source: LLDA. sanitation and hygiene 50 percent 12 Kim, B. et al. 2003 survey of 301 children in Roxas City; and Includes reported cases only. DOH-NEC 2004a (national Balazario et al. 2000 survey of 1, 871 children in Luzon, Visayas, incidence); and NSO 2002 (deaths). Trend in incidence based on and Mindanao; Surveys done in 1995 (UNHP) and 1998 (CDCS) 2001­2005 data from DOH-NEC, 2004a. indicated a 57 and 64 percent prevalence, respectively. 13 BFAR website and DOH-NEC 2004a. ENVIRONMENTAL HEALTH 15 WATER POLLUTION, SANITATION AND HEALTH Chapter 1. INTRODUCTION Environmental Risks The Risks of Poor Sanitation and Figure 2.6 Percent of households with Water Pollution sanitary toilets by region Basic household sanitation, including sanitary toilets and septic tanks, combined with hygiene practices such as washing hands, provides a means of removing human waste safely away from the household and has been shown worldwide to substantially reduce incidence of disease. There have been large improvements in basic Source: Department of Health National Epidemiology Center 2004a. household sanitation. Construction of sanitary toilets has increased the proportion of the population with access to basic sanitation in Hand washing is among the most effective ways the country from 57 percent in 1990 to 72 of reducing disease. Studies worldwide have percent in 2004 (Table 2.4). The 15 percent shown that programs to encourage the habit improvement is comparable to other Asian of washing of hands with soap can reduce countries. The gap in access to basic sanitation diarrhea by between 30 and 50 percent. Recent facilities in rural and urban households, evidence has indicated that pneumonia can be however, remains high. Only 59 percent of reduced by similar levels.14 In the Philippines, rural households have access to basic sanitation, surveys have shown that nearly all Filipinos well behind urban households with 80 percent regularly wash their hands before eating. (Table 2.4). In many rural areas, open However, only 26 percent of households defecation is common as a means of waste regularly wash their hands before handling disposal among groups such as farmers, and preparing food, and less than 50 percent fi shermen, and children. Several regions are regularly wash their hands after going to the signifi cantly behind the 72 percent national toilet (Table 2.5).15 average, notably the Autonomous Region of Muslim Mindanao (ARMM) (Figure 2.6). Table 2.5 Hand washing habits Timing of hand washing % of households Table 2.4 Percent of households with access to improved sanitation Before handling and preparing food 25.7 1990 2004 Before eating 96.9 Urban 66 80 After going to toilet 45.1 Rural 48 59 Source: DOH 2000. Total 57 72 Source: UNICEF 2006. 14Esrey et al. 1991; Hutley et al. 1997; Luby et al. 2005. 15Data from DOH 2000 also See ISF 2004. 16 PHILIPPINES ENVIRONMENT MONITOR Environmental Risks WATER POLLUTION, SANITATION AND HEALTH Box 2.1 Examples of sanitation conditions in poor communities in the Philippines Barangay Tangnan, Panglao, Bohol. This is a coastal community on the northern side of Panglao with a total population of 2,957. Eighty-two percent of the community uses pour flush pit latrine systems, largely without septic tanks. Waste is leaking into the porous ground (limestone) and into the groundwater. Defecation behind bushes or in fields is common. The water supply is contaminated with bacteria (E. coli). Barangay Looc, Dumaguete City: This community is located near the pier in Dumaguete City and is composed primarily of informal settlers. Most residents have simple houses made of boards, cement floors, and iron sheets that do not contain sanitarytoilets.Sixty-threepercentofthehouseholds surveyed send their sewage to the barangay canal, which emits foul odors, while the remainder goes into the groundwater (30 percent) or the nearby creek (6 percent). Flooding is common at times of heavy rainfall, in part due to clogged drainage systems. Groundwater used by some residents for drinking water was recently declared unfit to drink. Communities near waterways in Metro Manila. Low income areas are found throughout Metro Campaign advertisement encouraging regular maintenance of septic tanks. Manila. Many of these communities are located Source: USAID Philippines and Municipality of Iloilo near waterways such as the Pinagsama Creek (Taguig) and Manggahan floodway. Most houses have flush toilets and individual septic tanks that Septic tanks are commonly used. Motivated by are not maintained, in part due to their requirements under the National Building inaccessibility. Some children defecate outdoors. The waste from septic tanks and other liquid Code, half of Filipino households overall and waste (kitchen, laundry) is deposited in an open most urban dwellers have septic tanks that area or drained from the house to open concrete, collect wastewater from their households.16 earthen drains, and some covered concrete drains. Septic tanks are designed to treat waste These drains are often in disrepair or get clogged, through the removal of solids and assist in necessitating periodic maintenance. It is estimated that with improved drainage and septic tank disinfection. The tanks generally receive only management systems, these areas could have toilet wastes while wastewater from other health benefits of PHP30 million per year (PHP300 household activities is discharged directly to per person per year). the surface drainage system. Source: World Bank 2003b; WSP.2006. 16NSO 2000b. ENVIRONMENTAL HEALTH 17 WATER POLLUTION, SANITATION AND HEALTH Chapter 1. INTRODUCTION Environmental Risks Poor construction and maintenance of septic treatment in largely unmaintained septic tanks reduces their effectiveness. Many septic tanks. This has left urban drainage systems tanks are poorly or improperly constructed and groundwater contaminated with human without lining and underground fi lters. waste. It poses a risk for the portion of the Moreover, to function as designed, septic tanks urban population proximate to open drainage need to be maintained regularly in order to systems. It is also a risk to those that rely on remove built-up solids. Nationally, less than groundwater wells and leaky water distribution one percent of tanks are known to undergo systems for their water supply (Table 2.6). regular desludging with acceptable treatment.17 In most cases, they are only maintained in Table 2.6 Bacteria concentration in drainage response to emergency situations when the systems in Manila septage backs up into the household or the E-Coli Community Type of drainage (million/ tank is otherwise clogged. When they are 100mL) desludged, the waste sludge is not disposed Taguig Open drains and covered 0.2­0.9 according to DENR standards, except in portions concrete draining to creek of Manila, Baguio, and a few cities in Palawan Manggahan Shallow lined channels draining 0.2­0.9 Floodway to creek or larger roadside that have public treatment facilities. channels Sitio Olandes Shallow concrete channels in 0.2­5 Drainage systems and groundwater receive much streets with drainage to deeper channels of the waste in urban areas. Only seven cities Camp Atienza Covered concrete channels 0.2­23 have piped sewer systems. These systems cover and Industrial along street draining to open a small percentage (between one and 15 percent) Valley channel/creek of their respective populations. As a result, 95 Source: World Bank 2003b. percent of the wastewater fl owing from households directly or via septic tanks is transported into groundwater or into public canals and drainage systems and eventually into rivers and other water bodies.18 For example, in Metro Manila, only 15 percent of the population is connected to the sewerage system. As a result, 192,000 tons of domestic waste enters the drainage system and groundwater each year after only minor 17 The exact quantity is not known as the disposal practices of private septic tank maintenance companies are not regulated or monitored. Of the regulated systems, there are only three known cities with public facilities for maintenance and treatment of septage waste, which together serve 0.3 percent of the country's population. There are plans to expand treatment of septage in Manila (see Management Response section). 18 A total of 2 million people in urban areas (4.7% of the urban population) are connected to sewerage systems (Manila, 15%; Baguio City, 2%; Zamboanga City, 1%; Vigan City, 3%; Bacolod City, An open drain in Metro Manila. <1%; Cauayan, Isabela, 2%; Davao City, <1%). Source: LLDA 18 PHILIPPINES ENVIRONMENT MONITOR Environmental Risks WATER POLLUTION, SANITATION AND HEALTH Much of the surface water in urban areas is a public health risk. Monitoring of surface water indicates that most of the larger urban centers in the country have rivers that pose a contact risk to public health (below a Class C standard) (Table 2.7). Levels of coliform bacteria in all rivers in Manila, including tributaries of Laguna de Bay, exceed DENR standards in some cases by several orders of magnitude. Many beaches in Manila Bay, especially those along the eastern side, also have levels of bacteria that present Waterways polluted with sewerage are common in urban areas a signifi cant health risk to those using it for in the Philippines. transport, fi shing, and bathing.19 Source: Authors. Rural surface water can also spread disease. Table 2.7 Urban or peri-urban areas with rivers Contaminated surface water from open (Class C or below) that pose contact risk to public health defecation and sewage in rural areas are also an important risk. It has been shown that contact City River(s) with contaminated water in rural areas can Metro Manila Parañaque River; San Juan River; lead to the spread of schistosomiasis and other NMTT River; Marikina River; Pasig River diseases (Box 2.2). North Manila Bay Area Marilao River; Sta Maria River; San Jose del Monte; Pampanga River; Meycauayan Marilao; Sta. Maria; River; Guiguinto River Box 2.2. Schistosomiasis in Gonzaga, Apalit; Calumpit; Cagayan Province Meycauayan; Guiginto West Bay of San Pedro; Cabuyao; San Cristobal; Barangay Tapel is a rural barangay, where the Laguna de Bay Santa Cruz main sources of livelihood are farming and shing. Most of the farming areas are irrigated fi Dagupan City, Dagupan River Pangasinan by community-constructed irrigation canals. A study in 2004 found that 6.3 percent of the population-- San Fernando City, San Fernando River most of whom were farmers--tested positive for Pampanga schistosomiasis. The disease was found to be Calapan City, Calapan River transmitted via the Nagbabaguian Creek. The creek, Mindoro Oriental which is near the farmers' elds and commonly fi Cebu City Guadalupe River; Cotcot River oods them, is inhabited by 92,000 vector snails fl Iloilo City Jaro River; Iloilo River and is visibly contaminated with human waste. As nearly 90 percent of the barangays have sanitary Zamboanga City Saaz River; Manicahan River toilets with septic tanks and open defecation by Butuan, Agusan del Agusan River farmers is common, the disease is likely spread Norte through water contaminated by farmers who Source: DENR-EMB 2003. defecate openly in their elds or in the creek and fi then wade in the water without protective boots, allowing for transmission of the disease through 19 It is estimated that between 1995 and 1998 water-related the skin. disease and red tides cost the population near Manila Bay a total of PHP327 million (US$7.3 million) per year in lost income and health Source: DOH-NEC 2004b. expenditures. See GEF/UNDP/IMO 2004. ENVIRONMENTAL HEALTH 19 WATER POLLUTION, SANITATION AND HEALTH Chapter 1. INTRODUCTION Environmental Risks leading to the accumulation of the metal in fi sh and in people in the area; · gold mining activities in Sibutad Western Mindanao that contaminated surface water, leading to elevated levels of mercury in the exposed population; · gold mining activities in Monkayo Mindanao that contaminated the Naboc River with mercury, which accumulated in fi sh and in rice cultivated in the area and led to high levels of mercury in a portion of the Farmers in schistosomiasis endemic areas such as CARAGA risk population; and acquiring the disease when in contact with contaminated water. Source: World Bank Photo Library. · gold processing activities in Apolon, Tagum, Red tides are common in Philippines. Between Davao Del Norte that caused elevated levels 1983 and 2002, there were 42 major red tides of mercury in water and a portion of the fi sh with toxic algal booms that cause paralytic and children in the area. shellfi sh poisoning. These occur in coastal areas Studies in the Philippines have found that in many parts of the country and were very people with elevated levels of mercury can have common in the Visayas in the 1980s and 1990s. higher incidence of some health problems such The most common areas for red tides more as gingivitis, skin discoloration, neurological recently have been on the coast of Zamboanga disorders, and anemia.21 del Sur and in Manila Bay. The impact of the occurrence of red tide on health has declined Other toxic pollution incidences have also signifi cantly due to government monitoring and been reported. For example, an electronics regulation of the consumption of shellfi sh in company reported to DENR (March 2007) affected areas.20 that groundwater in Las Piñas in the vicinity of a site previously used by the company Heavy metal contamination from mining was contaminated by trichloroethylene. activities is a commonly reported source of Trichloroethylene and the chemicals it forms toxic water pollution. In 1996 the Marcopper after decomposition can lead to short-term mine released an estimated 1.5 million m3 of symptoms such as dizziness and headaches mine tailings containing heavy metals which and longer term effects such as cancer. The contaminated drinking water, agricultural fi elds, municipality, the company, DENR, DOH, and the Boac River, and nearby villages, causing Maynilad Water Company are working to elevated levels of heavy metals in some of the better understand the extent of the residents of the area. In addition to this case, contamination and provide those people using several other mining operations have exposed the groundwater with alternative sources of populations to heavy metals. These include: water supply. · a mercury mine near Honda Bay that 21Akagi et al. 2000 (Apokon case); Maramba et al. 2006 (Honda contaminated surface water with mercury, Bay case); Castillo et al. 2003; Cortes-Maramba et al. 2006 (Sibutad case); Tauli Corpez http://www.twnside.org.sg/title/toxic-ch.htm 20BFAR website and NEC-DOH 2004a. (Marcopper case); Appleton et al. 2006 (Moncayo case). 20 PHILIPPINES ENVIRONMENT MONITOR Environmental Risks WATER POLLUTION, SANITATION AND HEALTH percent of the population in urban areas and The Risks of Inadequate Water 23 percent in rural areas have water supplied Supply through house connections.22 Both the quantity and quality of water supplied The larger quantity of house connections has to households are important factors that can increased the water available for hygiene increase exposure to water pollution and waste. purposes. Surveys have found that people with The source of the water and the distribution house connections use 150 liters of water per system can create opportunities for water day, which is two to three times higher than supplies to be contaminated in poorly designed those using other sources. It is estimated that wells, leaky public distribution systems, or optimal health benefi ts can be achieved using through transport from trucks and water 100 liters of water per day combined with vendors. Having an adequate quantity of water good hand washing habits (Figure 2.7). to undertake hygienic practices (including hand washing and bathing) and for household People are increasingly reliant on water vendors. cleaning of sanitation facilities and food While household connections have expanded preparation areas is also an important factor nationally, they have not been able to keep in reducing disease transmission. up with population growth, resulting in an increased use of water peddlers, trucks, bottled water, or water refi lling stations. Twelve percent of the population in urban areas is dependent on these alternative sources of water.23 Figure 2.7 Water use by level of service A house water supply connection in Manila. Source: Authors. Gains made in household connections have Level I: Point sources, including shallow wells, deep increased the amount of water available hand pumps, and spring development. for hygiene. Between 1993 and 2003, Level II: Communal faucets and public taps. Level III: Individual household connections. the use of traditional water sources such Source: SWS and World Bank, 2000. A similar, more recent as wells, ponds, rivers, and springs for survey in Metro Manila found similar results, MWSS/MWSI, unpublished data, 2007. drinking water decreased from 62 to 40 percent, while piped household connections increased from 26 to 40 percent over the 22 same time period. As a result, an estimated 58 Taken from data and trends presented in WHO/UNICEF 2006. 23NSO 2003b. ENVIRONMENTAL HEALTH 21 WATER POLLUTION, SANITATION AND HEALTH Chapter 1. INTRODUCTION Environmental Risks Unsafe water quality is common. Studies of groundwater quality found that 58 percent of the sampled groundwater tested positive for coliform bacteria. Surveys of LGUs have also indicated that one half or more of their public water systems do not meet drinking water quality standards.25 In addition to contributing to endemic levels of disease from daily consumption and exposure, contaminated water supplies have resulted in outbreaks causing 5,000 cases of diarrhea, typhoid, and cholera over the past three years (Table 2.7). The reasons for the contamination can largely be traced to a combination of an inadequate sanitation system and a water supply system that is susceptible to contamination (Box 2.4 A water vendor in Manila. and 2.5. Source: Water and Sanitation Program. Regular monitoring of water refi lling stations Table 2.7 Recent diseases outbreaks caused by and bottled water has been strengthened contaminated water supplies signifi cantly through the DOH and local Diseases sanitary inspectors, which helps better ensure City (# of cases) Deaths the quality of the water from these sources. Ibajay, Aklan (2006) Typhoid (82) ­ Informal, unregistered peddlers, however, are Sibulan , Negros Oriental Typhoid (82) ­ in many cases not regulated or monitored (2005) actively. The quality of the water and San Andres and Virac , Cholera (444) 14 handling practices and their associated health Catanduanes (2005) risks are therefore largely unknown. The high Virac, Catanduanes (2004) Diarrhea (675) ­ cost and time necessary to obtain water from Tondo, NCR (2003) Diarrhea (385 ) 8 water vendors can also reduce water use and Cholera (41) diminish the associated hygiene benefi ts in 45 locations, Pangasinan Cholera (3,424) 47 many cases. In part due to these concerns, (2004) they are not recognized as improved water Muntinlupa, NCR (2004) Cholera (82) ­ sources for purposes of meeting the country's Marabut, Samar (2004) Typhoid (32) 3 Millennium Development Goal for water Source: NEC. supply. With this growing dependence on these sources, the Philippines is now off track to meet this goal.24 24The joint monitoring program for the MDGs has reported that access to improved water sources declined from 87 to 85 percent between 1990 and 2004. UNICEF 2006. In urban areas, access to 25Compiled from feasibility studies under the World Bank LGU Water improved water sources decreased from 95 to 87 percent. and Sanitation Project. 22 PHILIPPINES ENVIRONMENT MONITOR Environmental Risks WATER POLLUTION, SANITATION AND HEALTH Wells such as these can be contaminated if located close to an The quality of water supply depends on the distribution system. unprotected sanitation facility. Source: Authors. Source: World Bank Photo Library Box 2.3 DENR's Tapwatch Program Box 2.4 Cholera outbreak in Caloocan City Jail In 2005, DENR monitored 88 shallow wells used for water supply in targeted areas. Overall, 21 sites During August and September 2001, 15 percent were found to be potable, 27 failed to meet of the 1,245 inmates in the Caloocan Jail had drinking water standards for fecal coliform, and the diarrhea, resulting in one death. Tests confirmed remainder needed further testing to determine cholera to be the cause. After investigation by the potability. The suspected sources of contamination DOH, it was determined that it was due to a were defective septic tanks, untreated wastewater, contaminated water supply. Water supply pipes tied and animal wastes. together using rubber bands were submerged in Proportion of stagnant water where human feces were found to Location Wells Below Standard be coming from the septic tank pipes, which were Cagayan, Nueva Vizcaya 6 out of 10 damaged and leaking. A shallow well being used by Pampanga 3 out of 3 some of the inmates for washing kitchen utensils Oriental Mindoro 3 out of 8 and bathing was also found to have a pipe from Iloilo City 6 out of 8 the septic tank lying in it. The Caloocan LGU, Bureau Cebu City 2 out of 6 of Jail Management, Maynilad Water and DOH Leyte 1 out of 6 responded to the ndings by treating the inmates, fi Zamboanga City 3 out of 8 repairing the distribution pipes, improving hygiene, Davao City 1 out of 4 and improving the septic tank system. Source: DENR-EMB 2005b. Source: DOH-NEC 2001. ENVIRONMENTAL HEALTH 23 WATER POLLUTION, SANITATION AND HEALTH Chapter 1. INTRODUCTION Environmental Risks Box 2.5 What are the risks to your water supply? Individual well systems. The depth and location of a well are risk factors for well-water systems. Shallow wells draw from groundwater nearest to the land surface, which is the most likely to be affected by contamination sources. Deeper wells extract groundwater from areas that benefit from further filtration through soil and from sources less likely to be affected by surface activities. Countermeasures. Locate the well away from and on higher ground than sanitation facilities, sewers, fuel tanks, livestock activities, and solid waste disposal sites; dig deep wells where possible; prevent channeling of surface water into well systems using a casing around the well borehole and a well cap; and regularly test the water quality. Piped water supply. Risks to piped water systems relate to the adequacy of treatment and the integrity of the distribution system. Typically water service providers treat the water using sediment removal and disinfection and other treatment depending on the quality of the source water. In cases where the treatment system is adequate, the risk is associated with a malfunctioning water system, especially in cases of flooding or power failure. Low water pressure due to aging or unmaintained pipelines also provides an opportunity for sewage to flow into the water supply system or for backflow of contaminated water from users with direct connection to a contaminated pipe or vessel, such as illegal connections or industrial processes. Stores of bacteria and other material in sediment deposits in low water pressure networks or biofilm formation on pipes can also be resuspended in cases of rapid changes in flow. Countermeasures. Operation, testing, and public information on treatment system performance; providing residual chlorine to disinfect leakages and control biofilms; reducing the length of time in distribution systems and pressure surges; providing devices (stop valves or air gaps) that prevent backflow into the water system; providing regular maintenance and rehabilitation of network leaks; and locating new network systems away from septic tanks and sewers. Water vendors. Registered water refilling stations and bottled water are regularly monitored by the Department of Health. However, there is limited knowledge and transparency about the source, treatment, and water quality from informal water vendors. The major risks depend on the source of water and share similar risks as piped water and wells. For example, shallow wells in urban areas would be considered high-risk sources, while illegal connections or reselling of utility water would share similar risks associated with piped water supply. During transport, delivery, and storage, there are risks associated with the contamination of public faucets, tanks, or other vessels. Countermeasures. Better knowledge of the source, treatment process, and quality; similar measures to ensure quality of source water as above; and disinfection and covering water transport and storage containers. 24 PHILIPPINES ENVIRONMENT MONITOR Disease Burden AIR POLLUTION AND HEALTH Chapter 3. AIR POLLUTION AND HEALTH AIR POLLUTION ADDS to the large health Table 3.1 Proportion of reported disease cases burden of cardiovascular and respiratory attributable to air pollution in 2004 disease. These diseases are consistently among Number of reported % of all the leading causes of disease and death in Disease cases attributable to reported air pollution diseases the Philippines. There has been no signifi cant ALRI/Pneumonia 92,077 2.9 reduction in their overall incidence over the (Children <5 yrs old) past five years. In 2004, air pollution-related COPD (Adults) 47,190 1.5 cases of these diseases amounted to an Cardiovascular 15,814 0.5 estimated fi ve percent of all reported diseases (Adults) in the country. Air pollution is also estimated Total 155,081 4.9 to account for over four percent of all deaths Source: Reported disease cases DOH-NEC 2004a; see methodology section for determination of attributable cases. in the country (Tables 3.1 and 3.2). The costs are high. The costs associated with Table 3.2 Reported deaths attributable to air pollution in 2002 treating the reported disease cases attributed Number of % of all reported to air pollution amount to PHP962 million Disease deaths diseases (US$19 million) per year (Table 3.3). Similarly ALRI/Pneumonia 1,031 0.3 air pollution-related deaths due to pneumonia (Children <5 yrs old) in children, and cardiopulmonary disease and COPD (Adults) 4,853 1.2 lung cancer in adults, resulted in an additional Cardiovascular (Adults) 6,949 1.8 PHP6.7 billion (US$134 million) in lost income Lung Cancer (Adults) 2,849 0.7 per year.26 Total 15,682 4.0 Source: Reported mortality from NSO 2002; see methodology section Metro Manila is estimated to have the largest for determination of attributable deaths. disease burden from outdoor air pollution. Estimates based on the correlations of particulate Table 3.3 Costs of treatment of reported disease matter concentration in outdoor air and cases attributable to air pollution in 2005 mortality, indicate that there are nearly 5,000 Air Income losses Medical and pollution due to reduced Hospitalization Total Cost premature deaths each year in Manila due to related workdays expenses (PHP million/yr) respiratory and cardiovascular diseases from disease (PHP million/yr) (PHP million/yr) exposure to poor air quality. This amounts to ALRI/ Pneumonia 12 percent of all deaths in Metro Manila, which (Children is the highest of any city in the country (Table <5 yrs old) 24 436 461 3.4). COPD >30 22 347 368 Cardio- 26 This can be considered a lower bound estimate of economic vascular costs, as it only accounts for the costs associated with cases that Diseases 6.4 127 134 are reported to undergo treatment at a clinic or hospital and does PHP52 PHP910 PHP962 not include indirect costs such as pain and suffering associated Total (US$1 million) (US$18 (US$19 with having an illness and does not include unreported treatment million) million) cases and those for which people do not seek treatment. It also only includes those diseases for which a good correlation to air pollution Source: Based on reported cases (DOH-NEC 2004a) attributable to could be made for the Philippines, and therefore excludes asthma air pollution; see methodology section for details. See text for costs of and lung cancer morbidity. premature death. ENVIRONMENTAL HEALTH 25 AIR POLLUTION AND HEALTH Chapter 1. INTRODUCTION Disease Burden Table 3.4 Additional deaths due to outdoor Indoor air pollution may also be an important air pollution in cities contributor to disease. While comprehensive Premature % of all reported data on indoor air quality is not available, City Deaths diseases estimates using global relationships between Metro Manila 4,968 12 disease and use of solid cooking fuel indicate Cabanatuan 134 11 that it may be an important contributor to Metro Cebu 608 10 disease in the Philippines, especially in households with poor ventilation. Under Zamboanga City 240 8 conditions where kitchens using solid fuel Butuan 104 8 have good ventilation, it is estimated that Davao City 414 7 indoor air pollution would account for just Gen. Santos 117 7 under 5,000 deaths from respiratory and Baguio 102 7 cardiovascular disease nationally, which is one-third of the total estimated deaths due Tacloban 88 7 to air pollution (Table 3.2). The high Iloilo City 204 5 dependence on solid fuel for cooking in Source: Based on DENR air quality data and dose-response functions. rural areas is estimated to contribute over 70 See methodology section for details. Cities included are those with a population over 200,000 monitored by DENR for air quality. percent of these deaths. Many rural household use solid fuels for indoor cooking. Source: R.E.A.P ­ Canada. 26 PHILIPPINES ENVIRONMENT MONITOR Environmental Risks AIR POLLUTION AND HEALTH The Risks of Outdoor Air Figure 3.1 Average roadside TSP levels in Metro Manila, 2003­04 The health risks of exposure to outdoor air pollution are assessed by monitoring different pollutant concentrations in urban air and comparing them against guidelines established based on health considerations. While there are no minimum levels of air pollution that eliminate health impacts, air quality guidelines can be used as a target to help minimize health impacts and provide a warning sign when levels become high. The Note: DENR standard is shown by dotted line. Source: DENR-EMB 2005a. guidelines generally recommend maximum concentrations of pollutants for short-term exposure (typically less than a day) and long-term exposure (typically annually), since concentration (175 µg/m3) was nearly twice pollutants can cause acute effects from high as high as the standard (90 µg/m3) (Figure 3.1, concentrations and chronic effects from Box 3.1). For smaller particulate matter (PM10 long-term low-level exposure. Most of the and PM2.5), monitoring has been undertaken monitoring is done at roadsides, and thus most regularly since 2000, but in fewer sites.28 accurately represents the risk in these areas. The available data indicates concentrations of PM10 and PM2.5 exceed standards in some Particulates are at unhealthy levels in Metro stations and are increasing health risks. Annual Manila. Particulate emissions in Manila are average concentrations of PM10 range from largely from motor vehicles (84 percent), solid 30 to 84 µg/m3; 24-hour mean concentrations waste burning (10 percent), and industries were between 32 and 100 µg/m3, with one (5.5 percent). Seventy percent of these motor site exceeding the guidelines. Annual average vehicle emissions come from the more than concentrations of PM2.5 were between 18 and 200,000 diesel-powered utility vehicles--such 28 µg/m3; three sites exceeded the USEPA as jeepneys and the 170,000 gasoline-powered annual average guideline (15 µg/m3). Over a motorcycles and tricycles in the city.27 24-hour period, concentrations range between 18 and 75 µg/m3; half of the sites measured Measurements of total suspended particulates exceeded the USEPA 24-hour guideline in 2003­04 indicate that all stations exceeded (65 µg/m3). DENR standards and that the average 28DENR-EMB 2003, 2005a. 29AsianRegionalResearchProgrammeonEnvironmentalTechnology 27See ADB, WHO-WPRO, and DOH 2004. and Manila Observatory 2004. ENVIRONMENTAL HEALTH 27 AIR POLLUTION AND HEALTH Chapter 1. INTRODUCTION Environmental Risks Health risks of particulate pollution are concentration is 84 µg/m3. People in these highest in Valenzuela and Quezon City. areas were found to have a 17 percent higher Quezon City (along EDSA) and Valenzuela risk for asthma and 6.5 percent higher risk of City consistently have high roadside bronchitis relative to people in the lower risk concentrations of particulate matter (Figure areas of Antipolo and Las Piñas,30 which had 3.2). In these areas, the average PM10 an average PM10 concentration of 30 µg/m3. Heavy motor vehicle traffic in Edsa, Quezon City exposes people to high levels of air pollution. Source: Bjorn Wahlstedt (left photo); Authors (right photo). Box 3.1 Levels of particulate matter and your health Total suspended particulates (TSP) include all particulates of any size, only some of which are of health concern. TSP is used as an indicator of air pollution, as it generally is accompanied by pollutants of health concern, including small particulates and other pollutants from motor vehicles and other combustion processes. DENR has set a guideline value of 230 µg/m3 for short-term (24-hour average) exposure and of 90 µg/m3 for long-term (annual average) exposure. PM10 (particulate matter <10 µm) includes smaller particles of less than 10 µm, which are of direct health concern due to their ability to penetrate the lungs. Approximately 55 percent of TSP in Manila is made up of these particles. DENR has set a guideline value for short-term (24-hour average) exposure of 150 µg/m3 and long-term (annual average) exposure of 60 µg/m3. A recent epidemiological study covering 24 barangays in various parts of Metro Manila found that for every 10 µg/m3 increase in PM10, the incidence of respiratory deaths and natural deaths increased by 2.6 and 3.9 percent respectively.31 PM2.5 (particulate matter <2.5 µm) includes smaller particles, which are the most dangerous to health. Between 35 and 75 percent of PM10 in Manila contain these particles. No DENR guideline exists. The WHO guideline is 25 µg/m3 (24-hour exposure) and 10 µg/m3 for long-term (annual average) exposure. These values represent the lower level identified by studies to cause statistically significant health effects. Source: World Bank 2001; and ADB, WHO-WPRO, and DOH 2004; Manila observatory (percent content of PM10 and PM2.5); WHO 2006a. 30 ADB, WHO-WPRO, and DOH 2004. 31 ADB, WHO-WPRO, and DOH 2004. 28 PHILIPPINES ENVIRONMENT MONITOR Environmental Risks AIR POLLUTION AND HEALTH Additionally, over the last 15 years, lead gasoline Figure 3.2 Model of PM10 concentrations has been phased out, which has resulted in a in Metro Manila ten-fold decrease in ambient lead levels since 1990 to 0.2 µg/Nm3, well below the national guideline of 1.0 µg/Nm3. A recent decrease in lead levels in children may be due to the lead phaseout (Figure 3.3). Figure 3.3 Ambient lead concentrations and lead in blood of children in Metropolitan Manila Source: ADB, WHO-WPRO, and DOH 2004 Source: Adapted from ADB, WHO-WPRO, and DOH 2004 . Ozone and carbon monoxide may present a Lower sulfur dioxide and lead concentrations potential health risk. Measurements of ozone have reduced health risks. During the late at one monitoring station at the Manila 1990s, sulfur dioxide concentrations were Observatory exceeded the DENR guidelines, steadily rising in Manila due to coal-fired and with average concentrations of 60 ppm and bunker fuel power plants that operated during 50 ppm over 1-hour and 8-hour periods, that time but have since closed. In 2003­04, respectively. Carbon monoxide measurements sulfur dioxide concentrations at Manila at the same station in 1999 indicated that Observatory were on average less than the DENR guideline for 8-hour exposure was 10 µg/m3, which is two to three times lower exceeded in three out of the four months than in 1997­98. Similar trends were also measured. An estimated 88 percent of carbon found at the Metro Memorial Park station monoxide emissions in Manila are from in Parañaque.32 motor vehicles. 32Monitoring data from Manila Observatory and DENR-EMB, Central Office. ENVIRONMENTAL HEALTH 29 AIR POLLUTION AND HEALTH Chapter 1. INTRODUCTION Environmental Risks Measurements of volatile organic compounds Box 3.2. Levels of selected outdoor air at the same station found low levels of benzene pollutants and your health (2 ppb), toluene (12 ppb), and xylene (1 ppb). While there are no national guidelines for Carbon Monoxide interferes directly with oxygen uptake, causing poisoning at very high these parameters, these values are lower than concentrations. At low levels, it impacts the nervous available international guidelines (Box 3.2). system. The DENR guideline is 35 µg/m3 for 1-hour Similar results have been found for NO2, where exposure and 10 µg/m3 for 8-hour exposure. the concentration was between 0.005 and 0.03 ppm, well below the 24-hour guideline Ozone causes direct damage to lung tissue and in high concentrations can cause breathing, eye, and value of 0.08 ppm. nose irritation. It also contributes to respiratory and heart ailments. The DENR guideline is 140 µg/Nm3 High concentrations of particulates are found for 1-hour exposure and 60 µg/Nm3 for 8-hour in most major cities. Based on monitoring of exposure. total suspended particulates (TSP) in 2003­04, Sulfur and nitrogen oxides contribute directly or 19 cities have average annual concentrations indirectly through reactions with other pollutants that exceed the standard, with an average to respiratory and heart conditions and disease. concentration of 130 µg/m3. Very high levels DENR has set 24 hour exposure guidelines of 150 were observed in roadsides in Baguio City, µg/Nm3 for both pollutants. The 1-year exposure Alaminos City, and Calapan City (Figure 3.4). guideline for S02 is 60 µg/Nm3. Below these levels, SO2 has been shown to have health effects at concentrations as low as 10­20 µg/m3. Monitoring of other parameters is limited outside of Metro Manila. Data for other Lead in air is primarily from leaded gasoline. parameters is not yet regularly monitored and Exposure even at low concentrations leads to reported except for a few cities. accumulation in blood and neurological damage, especially among children. The DENR guideline is Cagayan de Oro. Continuous monitoring data 1.5 µg/Nm3 for 3-month exposure and 1 µg/Nm3 for 1-year exposure. for PM10 in 2003 showed a 24-hour average of between 35­50 µg/m3 or an annual average Volatile Organic Compounds include benzene, of 40 µg/m3. Both are within the air quality toluene, and xylene. Depending on the compound, guidelines. Measurements of SO2 over the long-term exposure can cause cancer and immune same time period also showed levels below the disorders, and can also affect the nervous system. standard (24-hour average between 1 and 13 There are no DENR guidelines. International µg/Nm3 and an annual mean of 4.1 µg/Nm3. standards for benzene are 5 ppb (national average-UK); for toluene, 2,000 ppb for 24-hour exposure (Australia); and for xylene, 10,155 ppb Davao City. Sulfur dioxide monitoring has over a 24-hour exposure (WHO). indicated low levels with annual averages between 1.4 and 2.0 µg/Nm3. 30 PHILIPPINES ENVIRONMENT MONITOR Environmental Risks AIR POLLUTION AND HEALTH Figure 3.4 Average annual TSP levels in The Risks of Indoor Air major cities and urban centers, 2003­04 While most people are aware that outdoor air pollution can damage their health, globally the worst air pollution conditions have been found in indoor environments. The potentially high risk of indoor air pollution relates to the fact that even small pollution sources can reduce air quality substantially under the confi ned conditions of indoor environments. It is also related to long exposure times to indoor air, Source: DENR-EMB 2005a. especially among women that spend much of their day in households. In the Philippines, indoorairquality,itshumanexposureandhealth Agriculture and household waste burning is impacts, have only just begun to be understood. common in rural areas. Burning of household The use of traditional, more polluting household waste emits particulates, organic compounds fuels and the high prevalence of smoking have as well as more persistent and noxious been identifi ed as the major potential risks. compounds, such as dioxins and PAHs. Nationally, 46 percent of all waste is burned Table 3.5 Percent of households using by individual households and the practice is major types of fuel most common in rural areas.33 1995 2004 Change Electricity 84 88 +4 LPG 33 52 +19 Kaingin (slash and burn practices), charcoal Kerosene 80 56 ­14 production, and the burning of agricultural Fuelwood 64 55 ­9 wastes and savannah are also seasonal activities Charcoal 39 35 ­5 that emit large quantities of carbon monoxide Biomass 29 19 ­10 and particulates. This can impact the farmers Source: NSO 2004. or land owners undertaking the burning as well as the community nearby. The country has over 225,508 hectares of grasslands, 344,671 hectares of land under sugarcane production, and almost four million hectares of land under rice cultivation. Much of this land undergoes periodic burning to remove waste or to otherwise manage the land. Slash-and-burn agriculture is a seasonal activity that contributes to air pollution. 33NSO 1998. Source: Authors ENVIRONMENTAL HEALTH 31 AIR POLLUTION AND HEALTH Chapter 1. INTRODUCTION Environmental Risks Most Filipinos are reliant on more polluting it can vary with the use of outdoor "dirty sources of fuel. While the gradual move to kitchens" with signifi cant ventilation as well as liquefi ed petroleum gas (LPG) has reduced the confi ned household kitchens. use of traditional more polluting fuels, they are still used by more than half the households in the country. In 2004, 55 percent of the country Box 3.3 Health and household fuel used wood; 34 percent used charcoal; and 56 percent used kerosene (Table 3.5). Levels of Wood and Charcoal. Wood and charcoal are indoor air pollution and the exposure from predominantly used for cooking in the Philippines. Charcoal is predominantly used for grilling. Fuelwood using these fuels are not well studied. However, use can vary from an in-house kitchen with or studies in Metro Manila have shown that without a chimney to a "dirty kitchen" separate from the use of fuelwood and kerosene increase the house. It can include different technologies, hospital admissions and the risk of developing including open wood fires and simple clay stoves. respiratory symptoms relative to that of LPG.34 These fuels emit soot and fine dust particles, polyaromatic hydrocarbons, and carbon monoxide. Use of these fuels in confined environments has A major factor determining the level of risk is been shown to substantially increase chronic the quality of kitchen ventilation. Use of fuel bronchitis, lung and throat cancer, and susceptibility in more confi ned areas can increase the level to respiratory illness. of exposure signifi cantly. In the Philippines, this can vary depending on the geographic area and Biomass residues. Agricultural residues--including rice hulls, coconut husks, and shells--are primarily modes of cooking adopted by a given household. used as a cooking fuel in just under 20 percent of the In Metro Manila, 90 percent of households have households. They are generally used as a substitute in-house kitchens,35 while in many rural areas for fuelwood when it is limited in supply or higher in cost. Air pollution emissions and health risks are similar to that of fuelwood, although lower polluting stoves that utilize rice hulls have been adopted by some households in the Philippines Kerosene. Forty-four percent of the households use kerosene for lighting while eight percent use it for cooking. It is a cleaner burning fuel than biomass residue, wood and charcoal fuels, but still emits significant quantities of particulates, carbon monoxide, and other more noxious gases. Its use leads to increased incidence of respiratory ailments. Use of solid fuel such as wood in households without proper ventilation represents a health risk. Liquefied Petroleum Gas. Use of liquefied petroleum Source: R.E.A.P.­Canada gas has grown substantially over the last 10 years and is now used in over half the households, almost exclusively for cooking. It is a clean burning fuel 34Relative to those using LPG, hospital admissions were 8 percent and 6 percent higher for those using wood and kerosene respectively. producing the lowest quantity of air pollution of all Similarly, the risk of respiratory symptoms was 19 percent and 9 the fuels common in the Philippines. percent higher for those using wood and kerosene respectively. See ADB, WHO-WPRO, and DOH 2004. Source: NSO 2004. 35 ADB, WHO-WPRO, and DOH 2004. 32 PHILIPPINES ENVIRONMENT MONITOR Environmental Risks AIR POLLUTION AND HEALTH Box 3.4 Environmental tobacco smoke Environmental tobacco smoke (ETS), also known as secondhand smoke, is a combination of exhaled smoke from active smokers and the smoke coming from smoldering tobacco between puffs. ETS contains the same toxic components as mainstream tobacco smoke, although in somewhat different relative amounts. In 2002, WHO evaluated all published evidence related to tobacco smoke and concluded that there is clear scientific evidence of an increased risk of lung cancer in nonsmokers exposed to ETS. The risks increase 20 percent in women and 30 percent in men who live with a smoker, and about 16­19 percent in the workplace. Exposed nonsmokers also have a 25 to 35 percent increased risk of suffering from acute coronary diseases. Studies have observed more frequent chronic respiratory conditions occurring among nonsmokers who are exposed to ETS. Tobacco smoke is also linked to reduced lung function and exacerbation of asthma. Children whose parents smoke at home have increased risks of suffering from ALRI and Otitis media. WHO estimates that over 50 percent of children worldwide are exposed to ETS in their homes. Source: WHO Fact Sheet on Tobacco Smoke Pollution, April 2005. Exposure to tobacco smoke at home is common. Table 3.6 Smoking prevalence among Filipinos (%) Thirty-five percent of Filipinos and 56 percent Overall Youth (13-15 years) of males are smokers (Table 3.6).36 Additionally, Males 56.3 21.8 56 percent of school children have parents Females 12.1 8.8 that smoke.37 While the impacts on air quality Overall 34.8 15 and health have not been systematically Source: DOST-FNRI 2004; CDC-WHO 2005. assessed in the Philippines, in Manila it was found that children with fathers who smoke have a 60 percent higher risk of asthma.38 In urban areas outdoor air pollutes indoor air. Urban air pollution levels have been shown to directly affect the quality of indoor air. In Metro Manila, it has been shown that the areas of the city with higher outdoor air pollution levels also have higher indoor air pollution levels.39 The high prevalence of smoking among adult males in the Philippines is increasing the health risks of environmental 36These figures are based on the DOST- FNRI 2003­04. tobacco smoke among children. 37CDC-WHO 2005. Source: Authors. 38ADB, WHO-WPRO, and DOH 2004. 39ADB, WHO-WPRO, and DOH 2004. ENVIRONMENTAL HEALTH 33 Chapter 4. SPECIAL FOCUS: ENVIRONMENTAL HEALTH, POVERTY, ANDVULNERABILITY AGE, GENDER, AND INCOME level have a little mortality in adults, they remain a leading signifi cant impact on a person's susceptibility cause of death among children. Diarrhea, for and exposure to environmental hazards. People example, is not among the top ten causes of of different ages and genders have unique death among adults, yet it is the third leading physiological characteristics that infl uence cause of death among children. Similarly, the extent to which they are affected by STH cases and deaths occur predominately disease. It also can affect levels of exposure to in children. environmental pollution. This section presents the factors that infl uence susceptibility and This pattern is similar with respect to air exposure among different groups and their pollution. Acute respiratory infections, including relevance in the Philippines context. acute bronchitis and pneumonia, affect mostly children. As illustrated in Table 4.1, children account for 82 percent of pneumonia cases and Age 70 percent of bronchitis cases each year. Children are most vulnerable. Children's Table 4.1 Major water and air pollution-related illnesses predominantly affecting children bodies are in a dynamic state of development characterized by high breathing and metabolic Proportion of Proportion of Disease cases affecting deaths afflicting rates and higher nutrient absorption rates children (%) children (%) than adults. As a result, their bodies absorb Diarrhea 85 62 more pollutants than the bodies of adults. Helminthiasis NA 75 Furthermore, children's food and liquid Schistosomiasis 51 0.3 consumption in proportion to their body Cholera 78 17 weight is signifi cantly higher than that of Pneumonia 82 16 adults, which results in greater exposure to Bronchitis 70 47 ingested pollutants. Children are also commonly Source: Includes reported cases only. DOH-NEC 2004a (morbidity) and NSO 2002 (mortality). Morbidity data is for children under 14; exposed more to pollution in their daily lives. mortality data is for children under 10. Bronchitis morbidity includes They spend a lot of active time outdoors, acute and chronic forms, however among children the acute is expected to predominate. The mortality data covers acute bronchitis. commonly in unsanitary conditions, and their mouths can be exposed to everything from fi ngers to toys to soil, increasing the likely transmission of disease. Additionally, if children do not practice regular hand washing, the risk of transmission can nearly double.40 In the Philippines, 80 percent of the reported cases of diseases attributable to water pollution, sanitation and hygiene affect children. Moreover, while these diseases cause Children playing in polluted water. 40 Esrey et al., 1991; Hutley et al., 1997; Luby et al., 2005. Source: USAID Philippines 34 PHILIPPINES ENVIRONMENT MONITOR SPECIAL FOCUS: ENVIRONMENTAL HEALTH, POVERTY, AND VULNERABILITY The health consequences for the elderly accounting for 58 percent of the total.41 In are higher. The elderly are, in general, less addition to potential differences in exposure exposed to environmental hazards, and hence, among men and females, one of the main are less likely to be afflicted with environment- reasons for this is that women's coronary related diseases. Once they do get sick, however, arteries are smaller and their microvessels they are much more likely to die than either more frequently dysfunctional than men's. children or adults. For many diseases such Women with coronary disease also have a as pneumonia and schistosomiasis, the elderly higher risk of dying from the disease than men. account for less than 20 percent of the cases but over 65 percent of the deaths (Table 4.2). Table 4.2 Major water and air pollution-related illnesses affecting the elderly (>50 yrs) Proportion of Proportion of Disease cases affecting deaths afflicting elderly (%) elderly (%) Schistosomiasis 18 65 Cholera 7 39 Filariasis 18 57 Pneumonia 9 75 Bronchitis 12 84 Women are more susceptible to diarrhea because of their close Source: DOH-NEC 2004a (morbidity) and NSO 2002 (mortality). contact with children. Morbidity data is for children under 14; mortality data is for children Source: World Bank Photo Library under 10. Bronchitis morbidity includes acute and chronic forms. The mortaility data covers COPD only. Women can have increased exposure to environmental pollution at home. The disproportionate time that women spend Gender inside the house, especially in households where cooking and heating are carried out Gender also affects vulnerability and using biomass fuels, increases their exposure exposure to environmental hazards, but this to indoor air pollution. Women generally impact varies across age, geographic area, spend more time with their children than and profession. men do. Contact with children and the associated hygienic risks also increase their Women's bodies are more susceptible to risks for contracting diarrhea symptoms, cardiovascular disease. The overall incidence which contributes to the larger incidence of cardiovascular diseases including those of this disease found in adult women caused by air pollution, is higher in women, (Figure 4.1). 41DOH-NEC 2004a. ENVIRONMENTAL HEALTH 35 SPECIAL FOCUS: ENVIRONMENTAL HEALTH, POVERTY, AND VULNERABILITY Chapter 1. INTRODUCT ON Exposure is a major determinant in disease trends among males. Their everyday work-- whether it be on the farm, factory, or as fi sherfolk--can increase exposure to water pollution, poor sanitation conditions and hygiene practices. In general, males account for 55 percent of all water pollution- and sanitation-related diseases in the country. Adult males have a higher incidence of schistosomiasis, fi lariasis, and hepatitis A than women. Among boys, the trend is more pronounced, with higher incidences found in every pollution related disease except cardiovascular disease (Figures 4.1 and 4.2). Men account for 63 percent of reported schistosomiasis cases, mainly due to their exposure to polluted water in agriculture. Source: World Bank Photo Library Figure 4.1 Gender distribution of reported Figure 4.2 Gender distribution of reported diseases related to water pollution and cases of air-pollution related diseases sanitation in children and adults in children and adults Children Children boys Total boys Cardiovascular girls girls disease Diarrhea Typhoid and parathyphoid Bronchitus Viral hepatitis Schistosomiasis ALRI and Cholera Pneumonia Filariasis 0% 50% 100% 0% 50% 100% Adult Adult Total men Diarrhea women Cholera Typhoid and parathyphoid Schistosomiasis Viral hepatitis Filariasis 0% 50% 100% Source: DOH-NEC 2004a. Source: DOH-NEC 2004a. 36 PHILIPPINES ENVIRONMENT MONITOR SPECIAL FOCUS: ENVIRONMENTAL HEALTH, POVERTY, AND VULNERABILITY The poor are more exposed. Access to water Poverty supply among the poorest 40 percent of the population is only 70 percent compared to While pollution affects all income groups, the 87 percent of the households in the higher people most at risk are the poor, who lack basic income group. This divergence is even larger resources and often times, live and work in poor with respect to access to sanitary toilets, where quality environments. On average, provinces only 73 percent of the poorest households with an income less than PHP 100,000 have have a sanitary toilet, compared to 95 percent twice the incidence of diarrhea, a six times of the richer households.43 higher incidence of typhoid fever, and a 50 percent higher incidence of pneumonia as compared to those with average incomes of Figure 4.3 Malnutrition in children over PHP200,000 (Table 4.3). by income level Malnutrition among the poor is linked to diarrhea. The proportion of children suffering from malnutrition is four times higher among the lowest income households relative to the highest income households (Figure 4.3). Diarrhea contributes to malnutrition as it reduces dietary intake, increases loss of nutrients, and affects absorption of nutrients. Additionally, studies in the Philippines and worldwide have shown increased child Source: FNRI, 2003 as cited in Pedro et al. mortality from diarrhea and other infectious diseases among those with malnutrition.42 Table 4.3 Incidence of disease (cases per 100,000) by average income Average annual income Disease >200,000 100,000­ 200,000 <100,000 Diarrhea 493 773 898 Typhoid and paratyphoid 4.1 12.0 27.2 Pneumonia 773 1,244.0 1,172.0 Source: Based on DOH-NEC 2004a(provincial disease data), and NSCB, 2005 income data. Represents the overall incidence for Poor sanitation in slum areas increases the risk of transmission provinces in each income category that have reported disease cases. of water-borne diseases. Source: LLDA 42Rice et al. 2000; Yoon et al. 1997. 43NSO 2002. ENVIRONMENTAL HEALTH 37 SPECIAL FOCUS: ENVIRONMENTAL HEALTH, POVERTY, AND VULNERABILITY Chapter 1. INTRODUCT ON Lower income groups are also nearly four air pollution. Jeepney drivers were found to times more likely to use fuelwood for cooking have a 50 percent higher risk of abnormal and heating and have a higher smoking pulmonary function and a 100 percent prevalence.44 This puts them at higher risk of higher risk of COPD. Additionally, respiratory exposure to indoor air pollution. symptoms were twice as prevalent in jeepney drivers relative to air-conditioned bus drivers An increased susceptibility to outdoor air and commuters.45 Child street vendors have pollution has also been observed in commuters also been shown to have a higher health risk and drivers, who use forms of transport that than other children due to their exposure to are cheaper and more exposed to outdoor air pollution and lack of access to health care.46 Studies have shown that jeepney drivers and street vendors are susceptible to the health effects of air pollution. Source: Authors. 45 Subida and Torres, 1991. 44Smoking data from NSO 2003a and NSO 2006. 46 Subida and Torres, 1994. 38 PHILIPPINES ENVIRONMENT MONITOR Chapter 5. LEGALF&RAMEWORK INSTITUTIONAL THE PHILIPPINE CONSTITUTION has embodied cut across disciplines and sectors and, the basic right to a healthy environment for therefore, are governed by many laws and its citizens, stating that "the State shall protect agencies making coordination and institutional and advance the right of the people to a commitment across agencies a key issue at the balanced and healthful ecology in accord with national level. Second, the devolution of the rhythm and harmony of nature" (Section 6, many health and environment functions in Article II, State Policies). There are two main 1991 put local governments in control of features of environmental health in the many environmental health-related functions, Philippines that affect its governance structure. making implementation capacity a key issue The fi rst is the fact that environmental issues at the local level. Table 5.1 Key laws for environmental health Agency Law Health related provisions I = implementation E = enforcement Code on Sanitation of the Philippines, An overarching health protection law that includes the National Drinking DOH (I/E), LGU (I/E), PD 856, 1975 Water Standards, protection for drinking water sources, sanitation and DPWH (I) refuse rules, and public swimming and bathing regulations Rural Health Act (1954) Requires sanitary inspectors within the local health unit LGU Environmental Health Impact Assessment Environmental health assessment of development projects DENR (E/I) Act 1994 Philippine Environment Policy, Recognizes the right of the people to a healthy environment DENR (E/I) PD 1151, 1978 Local Government Code, Devolves enforcement of laws on sanitation to LGUs and the provision of DILG (E), LGU (I) RA 7160, 1991 basic services such as health, water supply, sanitation and ood control. fl Pollution Control Law, PD 984, 1976 Establishes guidelines, a permit system, and nes for the control of water fi DENR-EMB (E/I) and air pollution from industry Philippine Environment Code, Provides guidelines to protect and improve the quality of water resources DENR (E/I) PD 1152, 1978 and defines responsibilities for surveillance and mitigation of pollution incidences Clean Water Act, RA 9275, 2004 An overarching law with regard to water and its use aiming to protect DENR (E/I), LLDA (E/I), human health, including source protection through a geographical NWRB (E/I), LGUs (I), strategy, effluent standards, new strict targets to control domestic sewage, DOH, DAO, DOST (I), water pollution permits, and criminalization of dumping and discharging LWUA, MWSS (I), DPWH (I) Philippines National Standards for Drinking Sets standards for quality of drinking water. DOH (E), LGUs, LWUA, Water, DOH Adminstrattive Order 2007 MWSS (I) Laguna Lake Development Authority Act Regulates and controls pollution of the Laguna de Bay Region. LLDA (E/I) RA 4850, 1966 as amended Marine Pollution Control Decree, PD 600, Regulates and controls the pollution of seas PCG (E/I) 1976 as amended The Philippine Water Code, PD 1067, 1976 Consolidates legislation relating to ownership, development, exploitation NWRB (E/I) and conservation of water resources National Building Code, PD 1096, 1977 Requires connection of new buildings to a waterborne sewerage system NPWH (E), LGU (I) Clean Air Act, RA 8749, 1999 Overarching air pollution control law, including enforcement of smoking DENR (E/I) in public buildings( including vehicles) and implementation of air quality standards Toxic and Hazardous Waste Management To protect public health from adverse effects of toxic wastes DENR (E/I) Act RA 6969, 1990 ENVIRONMENTAL HEALTH 39 LEGAL AND INSTITUTIONAL FRAMEWORK Chapter 1. INTRODUCTION National Level Governance at the national level. At the and evaluate environmental health programs national level, environmental health in the and development projects; (c) undertake Philippines is led by DOH with activities information dissemination and education coordinated through the Interagency campaigns; and (d) coordinate, assist, and/or Committee on Environmental Health (IACEH) support the conduct of research and relevant (Figure 5.1). The functions of the IACEH activities for environmental maintenance and are to (a) formulate policies and guidelines protection. The IACEH has also established and develop programs for environmental regional interagency committees for health protection; (b) coordinate, monitor, implementation at the regional level. Figure 5.1 Distribution of reported cases of air-pollution related diseases in adults and children by gender Inter-Agency Committee on Environmental Health (IACEH) Implementing National Environmental Health Action Plan (NEHAP) Chair: DOH & Vice-Chair: DENR Members: DPWH, DILG, DA, DTI, DOTC, DOST, DOLE, NEDA, and PIA General Guide for EH through the Implementing Rules and Regulations of the Sanitation Code Technical Working Group Technical Working Group Chair ­ WSS-DILG Chair ­ EMB-DENR Vice ­ BFAR-DA Solid Waste Sector Vice ­ DOTC Members: Members: BOI, DTI, ITDI, DOST, PCG-DOTC, Water Sector BOI-DTI, ITDI-DOST, OSHC-DOLE, LLDA, DPWH, MWSS, LWUA, DOE, MMDA, DPWH, PNP-DILG, NWRB, BSWMDA, WASCO-NAPC, PIA, NEDA WPEP-WB,GTZ-DILG, PIA, NEDA Sanitation Sector Technical Coordinator: Technical Coordinator: EOHO-DOH EOHO-DOH Air Sector Toxic Substances and Clean Water Act Hazardous Waste Sector Clean Water Act Clean Air Act Interagency Steering Committee Occupational Health Sector Multi-Sectoral Commission for the National Sewerage and chaired by DENR Septage Management Program (NSSMP) chaired by DPWH Food Safety Sector BFAR ­ Bureau of Fisheries and Aquatic Resources; BSWMDA ­ Bureau of Soils and Water Management; BOI ­ Board of Investments; DA ­ Department of Agriculture; DILG ­ Department of Interior and Local Governments; DOE ­ Department of Energy; DOLE ­ Department of Labor and Employment; DOTC- Department of Transportation and Communications; DOST ­ Department of Science and Technology; DPWH ­ Department of Public Works and Highway; DTI ­ Department of Trade and Industry; EMB ­ Environmental Management Bureau; EOHO ­ Environmental and Occupational Health Office; GTZ ­ German Technical Cooperation; ITDI ­ Industrial Technology Development Institute; LLDA ­ Laguna Lake Development Authority; LWUA - Local Water Utilities Administration; MMDA ­ Metro Manila Development Authority; MWSS ­ Metropolitan Waterworks and Sewerage System; NAPC ­ National Anti-Poverty Commission; NEDA ­ National Economic Development Authority; NWRB­NationalWaterResourcesBoard;OSHC­OccupationalHealthSafetyandHealthCenter;PCG­PhilippineCoastGuard;PIA­Philippine Information Agency; PNP ­ Philippine National Police; WASCO ­ Water and Sanitation Coordinating Office; WPEP-WB ­ World Bank's Water and Sanitation Performance Enhancement Project; WSS ­ Water Supply and Sanitation 40 PHILIPPINES ENVIRONMENT MONITOR National Level LEGAL AND INSTITUTIONAL FRAMEWORK The roles of the individual national institutions Department of Environmental and Natural are as follows: Resources (DENR). DENR through its Environmental Management Bureau is the Department of Health (DOH). Beyond its environmental pollution regulatory agency. chairmanship in the IACEH, DOH's role includes In this role, it formulates and regulates air development of guidelines, standards, and and water quality, effl uent standards, and policies on public health; monitoring monitoring of disposal sites and waste implementation (including drinking water management practices. The Laguna Lake standards); development of rules for waste Development Authority (LLDA) is also part of management; and regulating food hygiene. DENR and regulates water pollution and sells The recent reforms triggered by Executive surface water abstraction rights in the Laguna Order 102 outline a structure based on de Bay Region. subnational steering, where the DOH Central Offi ce and its bureaus provide support to Department of Agriculture (DA). DA manages regional centers for health development, while an inspection system for export standards for fi sh LGUs have a large degree of autonomy from products and fi sh processing establishments. DOH. The key bureaus in the Central Offi ce of DOH are: Department of Energy (DOE). DOE sets National Center for Disease Prevention and Control specifications for all fuel types and fuel-related (NCDPC). NCDPC has the Environmental products, which are then established by the and Occupational Health Offi ce, which is Bureau of Product Standards as Philippine responsible for developing the core National Standards. environmental health policy related to controlling water-related diseases and policies Local Water Utilities Administration (LWUA). related to water and sanitation. The Infectious LWUA promotes and oversees the development Disease Offi ce is responsible for special disease of waterworks outside of Metro Manila. programs, including schistosomiasis, malaria, filariasis, and soil-transmitted helminthiasis. Department of Public Works and Highways (DPWH). DPWH constructs water supply and National Epidemiology Center (NEC). NEC sewerage facilities. provides surveillance and survey information through its channels to the Central Offi ce of Department of Transportation and DOH and is responsible for conducting Communications (DOTC). DOTC, through outbreak investigations and compilation of its Land Transportation Offi ce, undertakes health statistics. roadside inspection and emissions tests for Bureau of Quarantine and International Health approval and renewal of vehicle registrations. Surveillance (BQIHS). This bureau undertakes international health surveillance required National Water Resources Board (NWRB). by WHO, such as bird fl u containment The NWRB is in charge of licensing water measures, and is responsible for complying resources for development and overall with international commitments made by coordination of water rights. the Philippines. ENVIRONMENTAL HEALTH 41 LEGAL AND INSTITUTIONAL FRAMEWORK Chapter 1. INTRODUCTION Local Level Governance at the local level. As a result of to protect the health and welfare of residents the devolution of authority for many health in the area. and environment functions under the Local Government Code (1991) and related laws, LGUs by themselves or through private many of the responsibilities for environmental companies also develop and operate public health promotion, protection, and provision infrastructure, including water supply systems, of infrastructure lie at the local level. sewerage and drainage systems, waste treatment facilities, and solid waste collection Local Government Units (LGUs). Under the and disposal facilities. Rural Health Act and Code on Sanitation of the Philippines, local governments are required to The Local Health Board is also a key local have a sanitary inspector as part of their local government-led entity in charge of proposing health team who is in charge of most policies, budgets and appropriations for environmental health functions, including public health. water supply, food safety, sewage and excreta Metro Manila. Metro Manila has two special collection and disposal, refuse disposal, organizations that, in addition to local pollution of the environment, vermin control, governments, play a role in environmental health. and industrial hygiene. The functions of the sanitary inspector related to air pollution, Metropolitan Waterworks and Sewerage System water pollution, sanitation and hygiene are (MWSS). Through two concessionaires, MWSS shown in Table 5.2. constructs, operates, maintains, and manages water supply, sewerage, and sanitation facilities In addition to the role of the sanitary in the Metro Manila area. It also regulates inspector in air quality, LGUs through their construction of privately owned sewerage systems. Environment and Natural Resources Offi ce, share responsibility for the management of air Metro Manila Development Authority (MMDA). quality in their jurisdiction; implement air MMDA is responsible for environmental issues, quality guidelines; prepare air quality action including air quality, that go beyond LGU plans; and implement air quality programs territorial boundaries in Metro Manila. Table 5.2 Roles of sanitary inspectors related to air pollution, water pollution, sanitation and hygiene Water supply Sewage, excreta and wastewater disposal Air pollution Sanitary surveys of water sources Inspection of sewage and sanitation facilities for structural Enforcement of smoking bans in enclosed requirements and contamination of water resources public areas Inspection of water supply systems Provision of technical advice on installation of facilities Enforcement of practices for burning of backyard waste biomass Drinking water quality monitoring Education and awareness Identification of major sources of air pollution Supervision of water disinfection Inspection of establishments with regard to compliance Public education and awareness programs processes with pollution and waste disposal Establishment of domestic water Investigation of public complaints related to pollution Reducing garbage burning through better supply surveillance program solid waste collection and disposal Issuance of drinking water site clearances and certificate of water potability 42 PHILIPPINES ENVIRONMENT MONITOR Health Programs Chapter 6. MRESPONSE ANAGEMENT AS A LEADING agency for health governance, improve surveillance are also part of the DOH has set a vision for the nation's health program. The program sets targets for 2004, through Executive Order 102: Health for All including disease incidence levels (Table 6.1). Filipinos (1999). The vision includes a strong Although not comprehensively monitored, mandate for disease control and prevention. available indicators show that many but not all The three broad environmental health goals of the targets have been met. More recently, are as follows: (i) improvement in the general DOH has championed a program of disease health status of the population, (ii) elimination elimination with the goal of declaring "disease or eradication of schistosomiasis, fi lariasis, free zones" for targeted diseases, including and malaria; and (iii) pursuing environmental fi lariasis and schistosomiasis. health and sustainable development. The Interagency Committee on Environmental In addition to improvements in health Health chaired by DOH has been active treatment, mass treatment programs (e.g. STHs), as representatives in global and regional health manpower development and similar environmental health initiatives, including programs to improve the healthcare system, the development of a National Action Plan for other "environmental health interventions" Environmental Health. They also coordinate that focus on preventing environmental the response to environmental health exposure are part of the program. These emergencies, including pollution and toxic include improved access to sanitary toilets exposure incidents. In 2006, these included and water supply; improved awareness in a mercury spill at St. Andrews school in disease endemic areas; reduced exposure to Parañaque City, a chemical spill in San Isidro water infested with the schistosomiasis vector; School in Makati City, and the oil spill in hand washing; and footwear usage. In addition, Guimaras. specifi c actions to increase awareness and Table 6.1 Selected targets under the National Objectives for Health Disease Prevention and Control Disease Objectives Baseline Targets 2004 Actual Units Reduce mortality 8.1 (1995) 4.0 4.6 (2004) Deaths per 100,000 per yr Diarrhea Reduce morbidity 1,250 (1995) 1,000 722 (2004) Cases per 100,000 per yr Cholera Reduce outbreaks 12 (1988-1998) 8 6 (2004) Outbreaks per year Typhoid Reduce outbreaks 8 (1988-1998) 6 2 (2004) Outbreaks per year Hepatitis A Reduce outbreaks 1 (1988-1998) <1 1 (2004) Outbreaks per year STH Reduce prevalence 54-67 <50 Percent 40-95 Percent of population in 25 pilot provinces (1995, 1998) (2000, 2003, 2004) Dengue Reduce morbidity in 32 (1994) 20 20 (2004) Cases per 100,000 per yr 25 pilot provinces Pneumonia Reduce mortality for 140 (1994) 120 60 (2002) Deaths per 100,000 per yr children under 5 Schistosomiasis Reduce prevalence 4.7 (1997) 2.5 3 (2002) Percent of population ENVIRONMENTAL HEALTH 43 MANAGEMENT RESPONSE Chapter 1. INTRODUCTION Information Management One of the key elements of effective prevention timely manner, at times forcing DOH to rely on of environmental health-related disease is other local reporting mechanisms to provide information that allows national and local initial information on outbreaks. governments to set environmental health policies and to target interventions and allow Air quality exposure. DENR monitors data on the public and civil society to be aware of total suspended particulates for 24 cities. Other health risks. Of particular importance is spatial criteria pollutants are monitored for Metro and temporal information on mortality and Manila, Cebu City, Davao City, and Cagayan morbidity due to endemic diseases, timely de Oro City. This data was published in 2003 epidemiological intelligence of emerging (2002 data) and in 2005 (2003­04 data). The infections and outbreaks, and accurate Manila Observatory also monitors air quality monitoring information about air and in Metro Manila and Cebu and publishes its water pollution. data in a variety of research reports. Both systems have set up an online monitoring Mortality and Morbidity. Morbidity data is system designed to provide weekly or monthly contained in the Field Health Service updates on air quality. Neither online system has Information System (FHSIS), which compiles been regularly updated. In addition to data nationwide from designated health the lack of publicly available real-time facilities through the provincial and regional data, limited use and analysis at the local health offi ces. It includes many environmental level limits its effectiveness. health-related diseases (i.e. diarrhea and lower Water quality exposure. The Water Quality respiratory tract infections). It is published Management Program of DENR-EMB is annually. It is complemented by data on active taking the lead in surface and groundwater registration of death by cause, including monitoring. Periodically, they publish a water environment-related disease, which is compiled quality status report that provides data for and published by the National Statistics Offi ce rivers, lakes, and bays (including their on a regular basis. Both reporting and use are classifi cation for use) in all regions of the not effectively implemented at the local level, country. DENR also spearheaded a public where it is considered more of a requirement disclosure program for groundwater for reporting than a tool for public health ("Tapwatch"), industrial pollutors ("Ecowatch"), decision making. and beaches ("Beachwatch"). Additionally, the performance of the water treatment plants Disease Surveillance. The National for some water utilities in the country is Epidemiological Epidemic Sentinel Surveillance reported. Bottled water and water refi lling System (NEESSS) utilizes hospital admissions stations are similarly monitored by DOH. from designated health facilities to monitor the The quality of water in water distribution occurrence of 14 different diseases in order to systems and from informal water vendors is provide rapid, timely, and accurate information, not commonly monitored and reported and early warning on disease outbreaks, (except in Manila).47 including cholera, hepatitis A, and typhoid fever. The main shortcoming of this system is 47 For example, Metro Manila Drinking Water Committee is mandated that it is not able to provide information in a to meet once a month to monitor drinking water in Manila. 44 PHILIPPINES ENVIRONMENT MONITOR Infrastructure MANAGEMENT RESPONSE (US$120-140 million) per year is necessary. For sanitation and sewerage, an average of PHP25 billion (US$500 million) per year in investments is necessary between now and 2015 to improve the situation.49 Investments in basic sanitation have made a large impact. Largely private investment in sanitary toilets has increased access to basic sanitation substantially since 1990. This is Monitoring of water quality is undertaken regularly in the one of the major contributing factors to the Philippines. reduction in disease incidence from water Source: USAID Philippines pollution, sanitation and hygiene-related Red tides. The Bureau of Fisheries and illnesses. In contrast, public investments in Aquatic Resources (BFAR) monitors seawater sewerage have only increased sewerage and organisms for red tide toxins. Based on coverage in urban areas nationwide to fi ve the results, DOH and BFAR publish red tide percent. Additionally, while half of the updates that outline the areas that are banned households in the country have septic tanks, for shellfi sh harvesting. facilities for proper treatment of sludge from these tanks cover less than one percent of the Public investment in water supply and population.50 sanitation is estimated to be three to four billion pesos per year. These are fi nanced through the national government, local governments, LWUA, and through the Manila water concessionaires. Sewerage and sanitation investments are only a fraction of total investment, amounting to PHP500 million (US$10 million) per year. The majority of the investments have been through LWUA (53 percent over last ten years) and in Metro Manila (50 percent of total investment over the last fi ve years).48 Local government-sourced fi nancing has largely focused on operational costs of maintaining these systems. It is estimated that to reach the Millennium Millions of toilets such as these have been purchased in the Development Goal for water supply, an Philippines in the past decade. Source: Water and Sanitation Program, Philippines investment of six to seven billion pesos 49Detailed investment estimates are in World Bank 2005. 48 World Bank 2005. 50See chapter 2 for data. ENVIRONMENTAL HEALTH 45 MANAGEMENT RESPONSE Chapter 1. INTRODUCTION Infrastructure Water resource development is limiting less available with only 40 percent of the potential health improvements from water surface water classifi ed for use as a public supply. Groundwater is the source of 86 water supply52, and most urban rivers are percent of the piped water supply in the severely polluted. This is forcing some localities country.51 The dependability and to look for more expensive and technically sustainability of the groundwater resources complicated water resource options to meet is questionable in many urban centers due current and future demand. The slow to the increasing extraction, increasing development of these water resources has groundwater contamination from poor contributed to the inability of water utilities to sanitation systems, and salt water intrusion in keep up with demand for connections from the coastal areas. Surface water resources are also growing population (Box 6.1). Box 6.1. Water supply in Metro Manila and Metro Cebu Manila and Cebu are the largest metropolitan centers in the country and, due largely to limited water resources, provide only 67 percent and 40 percent of their respective populations with household connections. Demand for water (MLD). 2000 2025 Metro Manila 3,800 8,000 Metro Cebu 254 520 Current water resources development. MWSS in Metro Manila obtains 97 percent of its water from the Angat Dam, which can provide 4,000 MLD. The Metro Cebu Water District produces 130 MLD from groundwater. In both cities, groundwater resources are being extracted beyond their recharge capacity, resulting in saline intrusion and contamination from sewage. Future water resource plans. In Metro Manila, the strategy being pursued is to reduce the losses of water in the system and expand resources by building a plant to treat water from the polluted Laguna de Bay to drinking water standards plus a US$1 billion dam in Rizal Province. In Metro Cebu, studies for future water resource development have looked at a combination of groundwater and surface water to increase the capacity of MCWD to 418 MLD by 2025. Source: Water use in Metro Manila and Metro Cebu, C. Bumatay, NWRB 51 Based on the water rights granted by the NWRB since 2002. 52 DENR 2005b. Out of the 525 classified rivers, only 208 are class A or better, meaning they can be used as public water supply after treatment. 46 PHILIPPINES ENVIRONMENT MONITOR Infrastructure MANAGEMENT RESPONSE Box 6.2. Infrastructure and health in Metro Manila Suffering from nearly nonexistent sewerage and sanitation service, inadequate water connection coverage and service levels, leaks in water pipes, and increased risks of waterborne disease, Metro Manila in 1997 took an ambitious approach to provision of water supply and sanitation. At that time, operation of the water supply and sanitation services was handed over from Metropolitan Water Supply and Sanitation Service (MWSS) to two private companies for a concession period of 25 years. The companies had specific targets for expanding and improving service levels for both water supply and sanitation that would be regulated by MWSS. The goals and achievements of the privatization have reduced health risks, although there are many other contributing factors to this trend, including improved basic household sanitation. Increased household connections. An additional 491,000 water supply connections in the east concession and 175,000 in the west concession have provided millions of people the opportunity to increase their water consumption. With more water available for cleaning and general hygiene, important health benefits were achieved. Improvements in water pressure and leakage. Improvements in water pressure and leakage reduced the risk of contamination of the water supply in the distribution system and improved financial revenues through reduced non-revenue water. The east concession made substantial improvements in leakage and water pressure through a pipe replacement program that improved their non-revenue water by 14 percent and increased average water pressure from 7 to 11 psi. The west concession reduced leakage through non-revenue water less substantially (5 percent) and has an average water pressure lower than that of the east zone (7 psi). Sanitation. The concessionaires are largely responsible for maintenance of septic tanks, sewerage, and wastewater treatment. Progress has been slow, however, with the proporation of households connecting to sewers growing from 8 to 15 percent during this time, with only half of that being treated in wastewater treatment plants. The number of septic tanks maintained increased from incidental levels to two percent in 2004. Ambitious plans by one of the concessionaires (Manila Water) may improve this situation over the next five years. Since 1996, Diarrhea has decreased substantially in Figure 6.1 Diarrhea incidence in Metro Manila, with incidence down 50 and 40 percent Metro Manila in the east and west concession areas respectively. Similar trends exist for paratyphoid and typhoid. In the west concession, cholera outbreaks are still common in Pasay City (9 cases per year) and Quezon City (31 cases per year), while they have disappeared in the City of Manila. The east concession area never had substantial cholera outbreaks. Source: DOH-NEC 2004a. ENVIRONMENTAL HEALTH 47 MANAGEMENT RESPONSE Chapter 1. INTRODUCTION Environmental Regulation Implementation of the Clean Air Act. The Emissions testing. Requirements for an Clean Air Act was passed in 1999, followed emissions test before registration began by the implementing rules and regulations in implementation in 2003. Since then, 2000. Implementation was comprehensively 377 accredited emissions testing centers reviewed in the Philippines Environment were established. DENR has been actively Monitor 2002. It reported some success in monitoring these centers and issued 69 implementation, but not yet to the point temporary suspensions and eight cancellations where outcomes were being felt. Since that of permits in 2004. Challenges still remain on time, more concrete measures have been governance, uniform testing procedures, and developed that are likely to have health results interpretation. outcomes. These include: Emissions standards. · A standard for hydrocarbon emissions from motorcycles and tricycles in urban and rural areas was established in 2003. · Emissions standards for in-use motor vehicles were updated and harmonized, providing for separate standards for vehicles registered before and after January 1, 2003. · Smoke capacity standards for in-use diesel Smoke belching is prohibited under the law and reported belching vehicles are apprehended. vehicles were revised to set emissions Source: DENR standards covering all diesel vehicles. Anti-Smoke Belching. 16,250 diesel-fed vehicles were apprehended for smoke belching. Fuel standards. Fuel standards have been established for diesel oils, two-stroke lubricating oils, coco methyl esters, and LPG for motor vehicle fuel. This has resulted in: · A reduction in aromatics and benzene in gasoline to 35 percent and two percent by volume, respectively. · Areductioninthesulfurcontentofautomotive Emissions testing in Mandaue City. Source: City of Mandaue Air Management Program diesel fuel to 0.05 percent. 48 PHILIPPINES ENVIRONMENT MONITOR Environmental Regulation MANAGEMENT RESPONSE Alternative fuels. In addition to encouraging wastes water in particular, it will take time the use of coco methyl ester, compressed natural to have an impact. Accomplishments thus gas, and liquefi ed petroleum gas in transport far include: as part of the Clean Air Act activities, the Biofuel Act was passed in January 2006. It will · Completion of the implementing rules and require all diesel fuel to contain one percent regulations in 2005. biodiesel and all gasoline to contain fi ve · Publication of the Regional (Regions 3, 6 percent ethanol. However, the health benefi ts and 12) and National Water Quality Status of replacing gasoline with ethanol use are still Reports. under debate. In addition, DOH has recently established The Clean Water Act was passed in 2004. drinking water standards, strengthened the It is intended to manage water quality in regulation of water supplied by water vendors designated water quality management areas and bottled sources, and has undertaken through a combination of multi-sectoral training on sanitary inspectors on the topic. planning and regulatory controls and incentives on polluting sources, including barring the expansion of polluting sources in water quality management areas designated as nonattainment areas. It includes the preparation of a National Sewerage and Septage Management Program that requires connection of households and businesses in major urban areas to a sewerage system and at the same time provides funding opportunities. It also includes the implementation of wastewater discharge permits and charges. The revenues from these fees will be used for investments to improve water quality. The act is still in its infancy; considering the fi nancial resources needed to make substantial improvement in the treatment of domestic The Clean Water Act requires proper treatment of wastewater. Source: USAID Philippines ENVIRONMENTAL HEALTH 49 MANAGEMENT RESPONSE Chapter 1. INTRODUCTION Local Initiatives SINCE THE DEVOLUTION in 1991, the focus Third Sewerage Project, this will be expanded, of implementation of environmental health with the goal of maintaining 80 percent of programs has shifted to local governments. the septic tanks in the east concession area and While widespread implementation still treating the waste sludge using treatment remains a challenge, many promising programs plants constructed under the project. The have been initiated--in partnership with remainder will be left to private contractors that the private sector, NGOs, and donors--by are currently not actively regulated for disposal forward looking leaders and champions. practices and do not have a formal program Some have proven successful, while for others of accreditation, providing an opportunity for it is still too early to tell. open dumping of the septic sludge. In response to this gap, the project will develop regulations Managing septic tanks. While nationwide and standards for these contractors. septic tank maintenance remains very low, programs in Manila and in some LGUs show The municipality of Muntinlupa has a growing commitment to address this issue. developed creative means for reaching out to the public. The Public Information Offi ce of the City has taken the lead in raising awareness of the need to manage septic tanks. The program--referred to as "Poso Negro" --uses an innovative approach that employs provocative materials that take on the issue directly. One example is the use of images of families drinking water poured from a toilet coupled with the message that people should "check your septic tank or swallow the consequences." Reducing pollution from tricycles and motorcycles. Several successful LGU-led initiatives have been implemented in the country to help reduce particulate matter emissions from highly polluting tricycles and motorcycles. In San Fernando City, La Union, the city Regular desludging is undertaken in many parts of Manila. government has successfully phased out the Source: Authors. nearly 1,200 highly polluting two-stroke motorcycles and tricycles, which have been In Manila over the last ten years, septage in use in the city for nearly 30 years. In management has grown through private exchange for switching to a four-stroke contractors and programs of the two private vehicle, drivers were offered concessional water concessionaires. Through the Manila loans with a two-month moratorium on 50 PHILIPPINES ENVIRONMENT MONITOR Local Initiatives MANAGEMENT RESPONSE payments, an interest-free repayment plan, Delivering water to poor communities. and a free driver's uniform with sun protection Programs to deliver water supply to poor features. The initiative, which is part of communities in both rural and urban areas San Fernando's City Development Strategy, are numerous and include work by LWUA, resulted in the complete phaseout of these DSWD, the private sector, and many donor motorcycles and tricycles within its first year projects. An important challenge for this of implementation. work has been in reaching poor communities in urban areas, many of which are informal settlers without land tenure. While other major cities in Asia have not been able to address the technical and legal barriers, Manila has been able to provide safe affordablewatertomanyofitspoorcommunities. Many of the poor in Metro Manila are dependent upon informal water vendors, who sell water of uncertain quality at prices that require families to expend between 8 and 20 percent of their income on water. This often forces them to use less water, forgoing important hygiene and health benefits. Source: USAID Philippines and Municipality of Puerto Princesa. Programs developed by the water concessionaires in Manila have allowed poor In Puerto Princesa City, the local government households to obtain water connections, has introduced a "50/50" scheme to reduce the increasing water use by as much as six times pollution from tricycles and three wheel taxis while lowering expenditures on water by traveling in the city. The program includes between 40 and 60 percent. The savings in training in proper maintenance, and limiting the time necessary for retrieving water have the operation of trycicle taxis to four days been shown to result in more time spent on per week. It has succeeded in reducing the income-earning activities. The programs do not number of tricycles and motorcycle taxis on require land titles to install the connections, the street by 50 percent with no reduction in and they provide lower connection fees and income of the taxi drivers. The maintenance installment programs for payment. As of the program has reduced hydrocarbon and carbon end of 2005, the programs combined have monoxide emissions by 40 and 30 percent provided 1.6 million people with water respectively.53 connections.54 54ADB, 2002. Data is from MWSI and MWCI for 2005. Costs and 53USAID, Clean Air Toolkit for Local Governments, part 3 Clean Air water use are based on a survey of households in the west concession Program Case studies. area in 2006 and Aiga and Umenai, 2002. ENVIRONMENTAL HEALTH 51 MANAGEMENT RESPONSE Chapter 1. INTRODUCTION Local Initiatives Wash your hands! Programs to encourage Lilo-an, a beach community that is enjoyed hygiene in the country have been by visitors from Cebu City, has taken steps to underemphasized, considering the potential improve water quality to protect swimmers' health gains they hold. Several groups, health. In response to declining tourism income however, are actively involved in programs as a result of increased pollution, the Lilo-an such as the Water Sanitation for All ("WASH") municipal government--in partnership with program and hospital and university-led the ADB, DENR, and the Lilo-an Community hygiene promotion campaigns. The Molave Multipurpose Cooperative--built a rotating Development Foundation, Inc., a nonprofi t biological contactor treatment facility to collect group working on the front lines of and treat waste from residential sources and environmental health advocacy, has developed the market and treat it. The treatment facility useful materials for hygiene awareness. The is a fi rst step in maintaining fecal coliform materials are information technology-based levels within the criteria for bathing water modules that provide a fun and effective means along the Lilo-an coastline. Boracay, a beach of communicating the importance of hygiene. community in Caticlan, has also developed domestic wastewater treatment systems in Materials developed through multi-stakeholder response to similar economic threats of poor "write-shops" include "Safe water and clean water quality. DENR is encouraging beach environment for a healthy school," "Your health communities such as these to make similar is in my hands"(for food preparation), as well investments through their Beach Ecowatch as others targeted for hygiene and sanitation in program, which monitors beaches for coliform the home and on the farm. They disseminate bacteria and other parameters indicative of the materials in community "WASH" days in its suitability for recreation. The resulting poor communities and schools in Manila and knowledge of water quality allows resort through a "WASH" Caravan that will visit owners and municipalities to design programs targeted municipalities to promote the water and to reduce pollution as needed. As part of the sanitation Millennium Development Goals.55 program in 2005, DENR tested 26 beaches in the country and reported that one third of Treating domestic wastewater. Installation of them failed to meet water quality standards treatment systems for domestic wastewater-- for bathing.56 by LGUs and other local organizations--has been very limited outside of Metro Manila, Technologies for better health. As part of in part due to the cost. With the Clean Water local government and NGO-led programs, Act, several initiatives have been developed, technologies have been introduced to reduce including those targeted toward improving environmental risks in the Philippines. water quality for beach recreation. 55 The program partners include the Water Supply and Sanitation Collaborative Council, which sponsors the Water and Sanitation for All (WASH) campaign globally; UNDP; NEDA; City Schools of Manila; and PLAN Philippines. 56 DENR-EMB 2005b. 52 PHILIPPINES ENVIRONMENT MONITOR Local Initiatives MANAGEMENT RESPONSE Improved Biomass Cookstoves. Rice is the Philippines. In many communities, existing staple food in the Philippines which has dug wells contain water that is unfi t for nearly four million hectares devoted to rice human consumption and rainwater is a more farming. It is, however, also a major source reliable source of safe drinking water. In the of pollution in rural areas, as rice residues are past, people collected roof runoff in small often burned, creating localized air pollution containers, which was not sustainable. In problems. Many Filipinos also use rice hulls periods without rain, people had to travel for cooking fuel, which generates indoor air long distances to other islands to buy drinking pollution. Several groups have developed water at high prices. rice hull stoves designed to reduce indoor air pollution and also provide an effi ciently In 2004, the Philippine Center for Water and burning fuel source. Among the groups Sanitation piloted the ferrocement technology include PhilRice, IRRI, Central Philippine for building large rainwater harvesting tanks University, and REAP-Canada. Dissemination in ten barangays of South Ubian, Tawi-Tawi. has been signifi cant, with thousands of these Ferrocement is about 80 percent cheaper stoves adopted in communities throughout than conventional construction methods, and the Philippines. reportedly lasts up to 50 years. Under the PCWS initiative, 65 containers of three cubic meters and ten containers of 11 cubic meters were built, providing the households in South Ubian with a cheap, safe and reliable water supply system. Since its initial success, this project has been extended to the remaining nine neediest municipalities in this province. Ecological sanitation. Ecological sanitation has been implemented in the Philippines through an innovative sanitation scheme that provides safe sanitation to poor households and helps alleviate groundwater pollution and water scarcity problems. The technology involves separation and treatment of the urine and feces for their subsequent use as agricultural fertilizer. The Ecosan technology does not rely on clean drinking water for fl ushing, Mayon Turbo rice hull cookstove. Source: R.E.A.P.­Canada and hence it does not generate signifi cant amounts of wastewater. It has been Providing safe rain water for drinking. implemented at a pilot level in several areas An initiative designed to bring safe water of the country. In San Fernando, La Union 1,217 to poor communities has been launched in toilets and 310 urinals were installed as part the Tawi-Tawi Island group (ARMM region), of a partnership with WASTE, GTZ, and the which is among the poorest provinces in the Center for Advanced Philippines Studies. ENVIRONMENTAL HEALTH 53 Chapter 7. IMMINENT ENVIRONMENTAL HEALTH CHALLENGES ENVIRONMENTAL CONDITIONS IN the Table 7.1 Health burden of air pollution Philippines are contributing signifi cantly to and water, sanitation and hygiene the health and economic burden in the country. % of % of Economic costs Air pollution, water pollution, sanitation reported reported diseases deaths (PHP billion/yr) conditions and hygiene practices alone are Air pollution 5 4 7.6 responsible for nearly one-quarter of all reported diseases and six percent of all reported Water pollution, sanitation 17 1.5 6.7 deaths in the country. The cost--in terms of Total 22 5.5 PHP14.3 treatment and lost income alone--amounts to PHP14.3 billion (US$287 million) each year. tricycles; and the strengthening of the vehicle inspection system. The gradual switch from Most at risk are the 25 million people without fuelwood-based cooking to liquefied petroleum access to improved sanitation facilities and the gas is also encouraging news. 13 million people without improved sources of water. Commonly contaminated water supply Continual improvement of environmental systems and heavily polluted urban drainage conditions to address health problems requires a systems and rivers are also increasing risks. truly multiagency, multidisciplinary approach. The major air pollution-related risks affect Several key elements of an effective the 18 million people in urban areas with environmental health system include a strong particulate matter concentrations above DENR interagency commitment to the environmental standards, largely as a result of emissions from health agenda; responsive and effective use motor vehicles. The 46 million people using of information by government and the fuelwood for cooking may also have elevated public; well functioning and well-designed risks from air pollution, especially those with infrastructure; and environmental and health poorly ventilated kitchens. regulations that effectively reduce health impacts. The Philippines has the basic There has been important progress in reducing institutional framework to address these these health risks through environmental issues. To help further reduce health impacts improvement. Over the past 15 years, the caused by a poor quality environment, the reported incidence of diseases related to water following are the immediate priorities: pollution, sanitation conditions and hygiene practices has declined by 50 percent, when Challenge 1: Raising the profi le of the there were substantial improvements in access environment's role in health to improved water supply and basic sanitation. The 1999 National Objectives for Health Additionally, levels of several air pollutants presented a multifaceted response to disease have dropped substantially in Manila. Through prevention that included many environmental the Clean Air Act, initiatives have been health-related illnesses. Many of the disease introduced to reduce pollution from motor targets under the plan have been achieved and vehicles, including the introduction of even exceeded, due in part to the program's emission and fuel standards; programs to treatment interventions and measures aimed reduce pollution from motorcycles and at reducing exposure to environmental risks. 54 PHILIPPINES ENVIRONMENT MONITOR IMMINENT ENVIRONMENTAL HEALTH CHALLENGES Diarrhea incidence, for example, has declined accountabilities of the committee and its by 43 percent, typhoid and cholera outbreaks members, expanding IACEH resources and have reduced, and pneumonia deaths in activities, and supporting the national and children under fi ve have dropped by 60 regional IACEH to enhance their pro-active role percent. Schistosomiasis incidence was also in mainstreaming environmental health. reduced by 40 percent. Challenge 2: Useful and easy to access In addition, the Interagency Committee on information Environmental Health (IACEH) is a key Providing accurate and reliable information organization both in terms of leadership and on environmental health risks and remedies is coordination. The committee has played crucial for policy makers and practitioners to an important role in reacting to emergency make decisions and is a prerequisite for active toxic releases and advising on policy. Most engagement of advocacy groups and the general importantly, it has taken the lead in the public in environmental health. DOH and process of development of the National DENR have developed nationwide systems for Environmental Health Action Plan. disease surveillance and monitoring air quality and water quality to provide publicly available In spite of these successes, the environmental comprehensive reports. However, use of these health agenda does not have the broad-based systems by policy makers has been constrained government support and political profi le by gaps in the timing and quality of data. that an interdisciplinary issue with such Additionally, advocacy materials that can be important health implications should have. The used by the public, schools, local governments, successful experiences of DOH in disease and NGOs have been developed by various prevention and the IACEH's pivotal role, are a groups; however, they do not cover all topics, starting point in bringing the environmental and access to these materials is variable. health agenda to the forefront of the health, environmental protection, and development Providing the right information. Considering agenda. Particular challenges are for DOH to deadly outbreaks of cholera and typhoid are raise the institutional profi le of environmental still prevalent in the Philippines, an immediate health through its plans and programs and to priority for disease reporting is to improve build capacity at the local and national level surveillance systems in order to allow DOH and on environmental health issues to mainstream local authorities to better react to disease issues them throughout the health system. DENR as they emerge. and other agencies also need to provide a strong commitment to support this agenda by The completeness and timeliness of exposure bringing environmental health issues into data also could be improved to be more their policies and programs, as well as working responsive and useful. In particular, online air proactively with other agencies through the quality systems need to become functional and IACEH. The central role of the IACEH in be used to inform the public of the risks. facilitating these changes needs to be supported Monitoring should also be expanded to better through better defi nition of the role and focus on health risks through regular ENVIRONMENTAL HEALTH 55 CHAPTER 1. INTRODUCTION IMMIN NT ENVIRONMENTAL HEALTH CHALLENGES measurements of PM10 for air quality, and hygiene and sanitation issues--including hand expanding the monitoring program for bacteria washing,water-sourceprotection,andsanitation to include a larger number of monitoring sites facility design and use--could have an impact in for those areas with potentially high health underserved or vulnerable communities. impacts such as urban drainage systems, groundwater, and water supplies. The gaps in Challenge 3: Infrastructure for information on the health risks of indoor air better health pollution, garbage, burning, and agricultural Since 1990, an additional 24 million people waste burning also need to be fi lled through a acquired basic sanitation facilities and national study. an additional 18 million people acquired household water supply connections. These Information on environmental health for the improvements have coincided with reductions purposes of advocacy and public awareness in infectious diseases in the country, including is also a priority issue as it is limited to a few diarrhea. Looking ahead, as with many environmental health topics. Working from countries at the same level of development, the existing good practices examples, similar the Philippines faces the dual challenge of materials can be developed for a range of ensuring access to basic water supply and environmental health issues and localities. sanitation facilities to underserved groups, and reducing the health risks of the remainder of Getting information to the right people. the population due to the inadequacies of Currently, there are limited mechanisms for their water supply and sanitation infrastructure national and local governments, hospitals, and and services. other practitioners and policy makers to access and share environmental health information. Filling the gaps in basic sanitation. Currently, The challenge is to develop a coordinated 25 million Filipinos still lack access to basic mechanism to both disseminate reliable sanitation. This underserved population is information and to share information and more heavily concentrated among low-income experience among practitioners and policy groups, where coverage is 22 percent lower makers. This would result in better coordination than higher income groups and in certain between agencies and local governments, and regions such as the ARMM, where the would encourage better use of the data in proportion of households with sanitary toilets decision making and planning. is 32 percent lower than the national average. Due to the susceptibility and inherent From a public awareness perspective, the lack disadvantages of these groups, including of readily available information has limited the access to know-how and capital, many will be engagement of local governments, the public, left behind without special programs. The advocacy groups and other organizations on immediate priority is to ensure basic sanitation environmental health. Providing a mechanism is integrated into targeted poverty reduction for systematic dissemination of this information programs in slum areas and lagging regions. is thus an important opportunity to improve Targets for these groups should also be health. In particular, more widespread monitored as a complement to the Millennium dissemination of information in basic water, Development Goals. 56 PHILIPPINES ENVIRONMENT MONITOR IMMINENT ENVIRONMENTAL HEALTH CHALLENGES Expanding water resources. In urban areas, high frequency of contamination. In addition despite improvements in the number of to contributing to the endemic disease household water supply connections, the burden, outbreaks of cholera, typhoid, and proportion of people with access to improved diarrhea due to contaminated water supplies water sources that could help ensure safe are common. drinking water and improved hygiene has decreased from 95 to 87 percent between 1990 These health risks are commonly overlooked and 2004. One important reason for this is in water resource infrastructure development that the contamination of surface water in the country. For example, design and sources and overabstraction and contamination maintenance practices can put water supply of groundwater have constrained the water systems at risk and a lack of sewerage and available to meet the growing demand in wastewater treatment systems increases cities, thus, forcing a portion of the population exposure to domestic waste. The main challenge to rely on less reliable sources of water. While here is two-fold: (1) reducing exposure to this underlines the importance of protecting contaminated water by covering open drainage water resources in the long run, it also systems where they exist, and enforcing highlights the short-term need to mobilize standards for siting and design of wells and large capital outlays for water resource drinking water distribution systems; and development. Government budgets cannot (2) developing a strategy that integrates support these investments at present. wastewater considerations into water resource Therefore, public-private financing schemes planning by providing a fl exible approach for water-source development will have to that can be catered to different situations to be explored. provide low-cost solutions and the necessary financial incentives to make sewerage and Reducing health risks of polluted surface wastewater treatment more affordable and and groundwater. An estimated 95 percent of sustainable. the wastewater fl owing from urban households in the Philippines is transported into Challenge 4: Improving Regulation groundwater or public canals and drainage Along with the Code on Sanitation, the systems, and eventually into rivers and passage of the Clean Water and Clean Air Acts bays. As a result, drainage systems and rivers have provided a robust framework for in major cities have very high levels of improvements in environmental health. bacteria. Rural areas are facing similar health Initiatives under the the Clean Air Act are risks from untreated waste, for example, waste now taking shape on the ground, while the in agricultural fields in schistosomiasis Clean Water Act is only just beginning to be endemic regions. implemented. As these important pieces of legislation move forward, the key challenges Additionally, surveys of water supply from are to support the local governments in wells have found that at least 30 percent of environmental health regulation and to use sampled wells are contaminated by bacteria; the Clean Air Act to target air pollution control piped water systems can show similarly to the polluters with the highest health impact. ENVIRONMENTAL HEALTH 57 CHAPTER 1. INTRODUCTION IMMIN NT ENVIRONMENTAL HEALTH CHALLENGES Strengthening local regulation. At the local- Reducing particulate matter emissions from government level, the sanitary inspector is a commercial vehicles. Motor vehicles account key player for on-the-ground implementation for much of the particulate pollution in the of environmental health protection, covering urban areas of the country. In Metro Manila such functions as inspection of water supply alone, vehicles account for 84 percent of and sanitation systems and enforcement of the particulate emissions, with motorcycles, laws on backyard waste burning. Additionally, tricycles, jeepneys, and other utility vehicles initiatives such as the successful programs in accounting for the majority of those emissions. San Fernando, La Union, and Puerto Princesa Recent initiatives under the Clean Air Act to control air pollution from motor vehicles have improved emissions and fuel standards have been led by local governments. While and established 377 emissions testing centers. the devolution of public health and With these efforts beginning to take hold, environment functions to local governments it is critical to continually improve the is an important opportunity to create an regulation of the 5.3 million registered vehicles enabling environment for responsive local in the country. The immediate challenges are solutions to local environmental health to review and strengthen emissions standards issues, the capacity of these groups is weak. for new and in-use vehicles, and to improve Strengthening them could potentially result the quality and consistency of inspection in large health improvements. procedures. Additionally, while the vehicle regulation system begins to take hold, other The first key challenge will be to clarify complementary mechanisms should be the strategic approach of the DOH vis-à-vis explored, including promoting natural gas local governments in light of devolution, the vehicles; importing better used engines; Code on Sanitation, and the Clean Water supporting fuel maintenance programs; import and Clean Air Acts. This will both help clarify duties on polluting vehicles and engines, and what is expected of local governments, and expanding the anti-smoke-belching program enhance DOH's ability to provide oversight. through the use of innovative technologies such as camera traps and cell phone text The second key challenge is to expand the reporting the license plates of violators. program of training for sanitary inspectors by DOH, as well as the programs for local The Way Forward government air pollution capacity building by The finalization of the National Environmental DENR. Priority issues would depend on the Health Action Plan provides both a conceptual locality. In general, the regulation of septic framework and an important window of tanks, monitoring of water supply systems, opportunity to take on the challenges of and sanitation system design would have environmental health. Taking advantage of high health impacts in areas where they the strategic insight provided by the plan, are deficient. Similarly, cities suffering from governmentagenciescanworktogetherthrough air pollution from mobile sources would be the IACEH and independently under their able to maximize the health benefits from respective mandates to achieve the targets and programs targeted at reducing motorcycle, actions under the plan. jeepney, and tricycle emissions. 58 PHILIPPINES ENVIRONMENT MONITOR IMMINENT ENVIRONMENTAL HEALTH CHALLENGES Box 7.1 What are your priority issues? The Philippines Environment Monitor benefited from four consultation workshops throughout its preparation. The nal workshop broke into ve focus groups. They were asked to identify the priority issues that they would fi fi address. These were used as an input to the challenges. Information Education and Advocacy: An information clearinghouse to provide reliable information and a mechanism to disseminate to local governments. Infrastructure: Water resource development in urban areas through public/private partnerships and in rural areas through better local government capacity and financing. Better public awareness and regulation of septic tank maintenance and sanitation facility design and financial incentives for wastewater treatment. Institutional and Cross-Sectoral Issues: Prioritizing environmental health in DOH plans and programs through strengthening the national and regional IACEH and local health boards and capacity building for DOH and LGUs. Health Surveillance and Information: Providing an integrated surveillance, tracking and early warning system aligned to national targets that functions effectively, efficiently, and sustainably. Regulation: Clarifying roles under the Clean Water Act and Sanitation Code and the role of LGUs as regulators and service providers. Improving enforcement of laws related to vehicle emissions, identifying alternatives to incinerators, and strengthening air quality monitoring. ENVIRONMENTAL HEALTH 59 Chapter 1. INTRODUCTION Annex 1. METHODOLOGY 1. Data limitations and presentation The analysis used available data and scientifi c information to assess the burden of disease for air pollution, water pollution, and sanitation and hygiene. The analysis considered the source and treatment of the data. In particular: Morbidity data (disease cases) relied upon the Field Health Surveillance Information System (FHSIS), which provides data on cases reported by municipalities of the different disease cases found in their hospitals and clinics. It includes those cases where people visit the hospital and therefore does not include situations where the disease is either not severe enough to warrant a visit or where people just do not visit the doctor due to behavioral choices or access to the facility. It also suffers from variability of reporting among municipalities and provinces. Incidence fi gures and absolute number of cases should be read with this in mind. Recognizing these limitations, the report does not focus on the absolute numbers of cases, but rather, highlights the information provided on the proportion of cases of an individual disease or those attributed to environmental causes in relation to the total of all disease cases reported. This provides important information on the relative importance of a given disease or disease causes. Disparities in reporting practices across provinces and to a lesser extent, across regions, are also believed to affect the precision of the provincial differences in reported disease incidence. With this in mind, only the relatively large disparities found between provinces and regional data were emphasized in the discussion in the report. The economic analysis also considers the source and limitations of the data (see below). Mortality data (disease cases) relied upon the National Statistics Offi ce data, which provides data on the causes of death reported as part of the vital statistics of the country. Reporting of deaths is more reliable than of disease cases due to the nature of the event, as well as the legal requirements associated with reporting. Under reporting due to lack of death certifi cates is relatively low, amounting to approximately 10 percent. The absolute numbers for mortality are highlighted in the report, along with the distribution relative to other reported causes of death. 2. Diseases attributable to environmental factors Estimates of the environmental burden of disease were modeled after the analysis done by WHO (2006) in Preventing Disease Through Healthy Environments. The defi nition of environment used includes all physical, chemical, and biological factors external to the human host, and all related behaviors, but excluding those natural environments that cannot reasonably be modifi ed. The defi nition excludes behavior not related to the environment, as well as behavior related to the social and cultural environment, genetics, and parts of the natural environment. Using this as a basis, the fractions listed in Table A.1 represent the decline in the disease that could be achieved in a given population by reducing the environmental risk. The environment-related fraction was calculated by multiplying the attributable fraction for each disease by the reported cases of disease (Department of Health­National Epidemiology Center 2004a) and reported causes of death (Department of Health­National Epidemiology Center 2002). 60 PHILIPPINES ENVIRONMENT MONITOR ANNEX 1. METHODOLOGY Table A.1 Fraction of disease cases attributable to the environment for top ten causes of morbidity and mortality in the Philippines Disease Attributable fraction Source Notes Acute lower respiratory infections 4 % See Section 4 Calculated using global formulas and Pneumonia applied to the Philippines Cardiovascular diseases 16 % WHO, 2006b Based on global data (including all heart diseases) Tuberculosis 19 % WHO, 2006b Based on global data (including respiratory tuberculosis) Intestinal infectious disease 94 % WHO, 2006b Based on global data Chronic lower respiratory disease 42 % WHO, 2006b Based on global data (including chronic obstructive pulmonary disease and bronchitis) Malaria 50 % WHO, 2006b Regional (southeast asia) numbers Dengue fever 95 % WHO, 2006b Based on global data Nutritional deficiencies 50 % WHO, 2006b Based on global data Lung cancer 17 % WHO, 2006b Based on global data Transport accidents 42 % WHO, 2006b Based on global data 3. Water pollution and hygiene contribution to disease Estimates of the contribution of the environment to disease were made for diseases for which data was available and that are categorized according to the Bradley classifi cation of disease as being caused by water pollution, poor sanitation and hygiene. The fraction of diseases attributable to environmental causes were based on international data applied to the Philippines based on expert judgment and scientific literature (Table A.2). The environment-related fraction was calculated by multiplying the attributable fraction for each disease by the cases of disease (Department of Health National Epidemiology Center 2004a) and causes of death (Department of Health National Epidemiology Center 2002). ENVIRONMENTAL HEALTH 61 ANNEX 1. METHODOLOGY Chapter 1. INTRODUCTI N Table A.2 Attributable fractions due to water pollution, sanitation and hygiene Disease Relationship to Attributable Pollution and Sanitation Fraction Sources Notes Diarrhea Fecal contamination due to 88% WHO, 2006b Based on global data indicating that domestic water pollution 88 percent is due to water and sanitation related issues Helminthiasis Transmitted via soil 100% WHO, 2006b Considered fully attributable to poor contaminated with fecal water and sanitation pollution due to domestic water pollution Schistosomiasis Transmitted through contact 100% WHO, 2006b Current understanding is that it is with water contaminated with fully attributable to environmental human waste with eggs from risks host snail Typhoid and Fecal contamination due to 50% Expert opinion of paratyphoid domestic water pollution World Bank staff Cholera Fecal contamination due to 100% Widely accepted Known to be entirely attributable to domestic water pollution poor sanitation conditions Hepatitis A Fecal contamination due to 50% Expert opinion of domestic water pollution World Bank staff Filariasis Two vectors in the Philippines 20% Expert opinion of An estimate based on the fact that breed in water that is polluted; World Bank staff much of the liariasis is due to a fi Either dirty (Culex) and mosquito vector that is associated lled with aquatic weeds fi with plantations, with only a fraction (Monsania) of those related to vectors that breed in polluted water Nutritional Malnutrition increases as a 50% WHO, 2006b Water and sanitation are the deficiencies result of the above diseases. predominant environmental factor to It also increases the which malnutrition is attributable. susceptibility to the above diseases. 4. Disease burden of outdoor air pollution Disease attributable to outdoor air pollution was determined for those age groups for which a correlation between particulate matter concentration has been established based on scientifi c literature as outlined in Environmental Burden of Disease Series No. 5 by Bart Ostro. This was done using data on particulate matter concentration and mortality and morbidity data of the relevant diseases from the Department of Health (FHSIS reports). The present data on particulate matter concentration suitable for long-term exposure assessment are limited. There were three data sources: (a) direct measurements of PM10 and PM2.5 concentrations in some parts of Metro Manila from special studies, which also yielded ratios of PM10/PM2.5 (fractions of PM2.5 in PM10 ranged from 68 to 81 percent, or an average of 76 percent); (b) roadside TSP measurements by DENR from fixed monitors in selected cities, including cities in Metro Manila and some urban towns (ratios of PM10 and TSP in few locations where DENR and ADB measurements coincided ranged from 32 to 60 percent, or an average of 46 percent); and (c) World Bank-WHO econometric model estimates of PM10 concentrations in Philippine cities with populations over 100,000. The concentrations used in the assessment and their bases are summarized in Table A.3. 62 PHILIPPINES ENVIRONMENT MONITOR ANNEX 1. METHODOLOGY Table A.3 Particulate matter concentrations used in the analysis Particulate matter concentration Metro Manila (National Capital Region) Other urban areas (Cities) PM10 (ug/m3) 64 Average of actual measurements from 43 Based on conversion of DENR TSP ADB study (ADB, 2004) and 46% of TSP monitoring data (2002­03) to PM10 values from DENR's monitoring stations using average PM10/TSP ratio and WHO- (NAQSR, 2002­03) and WHO-World World Bank estimates. Bank estimates. PM2.5 (ug/m3) 50 Average of actual measurements from 32 Based on conversion factor of 76% ADB Study (ADB, 2004) and values (average ratio) of PM10 to PM2.5. obtained as 76% (average ratio) of PM10. Note: Background values for PM10 and PM2.5 of 15µg/m3 and 7.5µg/m3 respectively, are adopted from Ezzati et al. (2002). The fractions attributable to outdoor air pollution were calculated as: AF = (RR ­ 1)/(RR), where AF is the attributable fraction and RR is the relative risk of air pollution exposure. The formulas for RR are given in Table A.4, using as inputs actual and counterfactual or baseline PM10 and PM2.5 concentrations. Table A.4 Relative risks from exposure to outdoor air pollution Health Outcome Model Respiratory mortality (e.g. Acute Lower Respiratory Infections) RR = exp [0.0016*(PM10(actual) ­ PM10(counterfactual))] among children <5 years old due to short term exposure to PM10 Cardiopulmonary mortality (e.g. COPD and cardiovascular diseases) RR = [(PM2.5(actual) + 1) / (PM2.5 (counterfactual)+ 1)]^0.15515 among adults >30 years old due to long term exposure to PM2.5 Lung cancer mortality among adults >30 years old due to long term RR = [(PM2.5(actual) + 1) / (PM2.5 (counterfactual)+ 1)]^0.23218 exposure to PM2.5 The resulting RR and AF values are presented in Table A.5. The disease burden is calculated as: E = AF x B x P, where E is the expected number of deaths due to exposure to air pollution, B is the incidence rate of deaths, and P is the relevant exposed population. The attributable fractions were used to calculate expected number of morbidity cases due to outdoor air pollution. National data on age and sex distribution of disease cases and mortality was used and assumed to be the same for Metro Manila, other cities, and the provinces. Table A.5 Particulate matter concentrations used in the analysis Metro Manila Other Cities Disease RR AF RR AF ALRI (<5 years old) 1.09 7.9% 1.05 4.5% Cardiopulmonary (<5 years old) 1.32 24% 1.24 19% Lung Cancer (>30 years old) 1.51 34% 1.37 27% ENVIRONMENTAL HEALTH 63 ANNEX 1. METHODOLOGY Chapter 1. INTRODUCTI N 5. Disease Burden of Indoor Air Pollution The assessment considers only exposure to solid fuel smoke, particularly exposure to fuelwood smoke from domestic cooking. The disease burden was determined following the method outlined in Environmental Burden of Disease Series No. 4 by Desai Manish et al. (2002). The data on fuelwood use were obtained from National Census and Statistics Offi ce (NSO). A global assessment by Smith et al. (2004) estimated household fuel use in 156 countries and puts the solid fuel use in the Philippines at 85 percent, with a ventilation coeffi cient of 1.00. Actual surveys on the ground revealed that many Philippine houses and kitchens are well-ventilated, and cooking outside the house is common in rural areas. Hence, following Desai Manish et al. (2002), a ventilation coeffi cient of 0.25 is used instead of 1.00. Philippine households rarely used coal, which is linked to lung cancer, for cooking. The 1995 Household Energy Consumption Survey (HECS) of the National Census Offi ce (NSO) revealed that some 63.5 percent of Philippine households used fuelwood for cooking. The proportion is about 10 percent in Metro Manila and about 30 percent in other urban areas. The most recent HECS survey was conducted in October 2004, but only preliminary results have been published. Table A.6 shows the estimated proportions of households using fuelwood. Table A.6 Fuelwood use in the Philippines as of 2004 Proportion of Proportion adjusted Area households using by ventilation factor Basis fuelwood for cooking of 0.25 Countrywide 0.55 0.138 Preliminary result of the October 2004 HECS by the NSO estimates fuelwood using households has dropped to 55% Metro Manila 0.088 0.022 10% estimate for Metro Manila from the 1995 HECS adjusted based on preliminary result of the 2004 survey Other Urban Areas 0.28 0.071 1995 HECS estimate for urban areas adjusted based on the 2004 survey results Rural Areas 0.87 0.216 1995 HECS estimate for rural areas adjusted based on the 2004 survey result Following Desai Manish et al. (2002), the fractions of mortality and morbidity cases attributable to fuelwood smoke exposure for each disease were calculated as: AF = (P*RR + -P) / (P*RR+ 1-P), where RR is the relative risk obtained from epidemiological studies and P is the proportion of the population that are exposed to fuelwood smoke, adjusted for ventilation factor as estimated in Table A.5. The disease burden is calculated as: E = AF x N, where N is the number of morbidity or mortality cases observed or reported on the relevant age group. National data on age and sex distribution of disease cases and mortality was used and assumed to be the same for Metro Manila, other cities, and the provinces. 64 PHILIPPINES ENVIRONMENT MONITOR ANNEX 1. METHODOLOGY Table A.7 Fractions of disease cases attributable to fuelwood smoke Attributable Fractions (AF) (%) Health Outcome Relative Risk* Country Metro Manila Other Cities Other Cities ALRI Children aged <5 2.3 15 3 8 22 COPD Women aged >30 3.2 23 5 13 32 COPD Men aged >30 1.8 10 2 5 15 Lung Cancer Women aged >30 1.5 6 1 3 10 *Source of RR is WHO, Desai Manish et al. (2002) 6. Economic costs The economic cost estimates focus on the costs associated with treatment and hospitalization and the lost income associated with those visits for those people that reportedly visited the hospital and clinic. It also includes the loss of potential income due to premature death. It is considered a lower bound estimate due to (a) the likely gaps in reporting from municipalities and provinces through the FHSIS; (b) it does not consider other costs such as home treatment and the pain and suffering experienced due to medium- to long-term affliction with a disease; (c) it does not consider diseases where either good morbidity or mortality data was not available and also a good basis for estimating the fraction that is attributable to the environment. The most notable gaps are lung cancer and asthma morbidity; typhoid mortality, and morbidity due to nutrititional defi ciencies. Economic Costs of Premature Death. The economic cost of premature death is calculated as the present value of the forgone income stream (at a discount rate of 5 percent) of the remaining productive life, reckoned from the average age of death and the average life expectancy for Filipinos (70 years). The productive year of the person is assumed to begin at age 21. In calculating lost income, we used the average annual employee compensation of P38,000 from the Philippine National Income Account. Economic Cost of Morbidity. The economic cost of morbidity includes direct costs (i.e., medical and hospitalization costs) and indirect cost (i.e. loss income due to reduced workdays). In terms of direct costs, it is assumed that all cases of morbidity result in some kind of medical treatment and hospitalization or at least a visit to a doctor or a medical clinic. Data on the average costs of medical treatment (i.e. average payments made on hospital bed, professional fees, medicine and hospital services) of various illnesses were obtained from Philhealth. The total direct cost of morbidity of a particular illness is estimated by multiplying the number of reported cases with the average medical costs incurred for the illness. In terms of indirect cost, it is assumed that each reported morbidity case results in a reduced number of workdays of at least one adult. If the sick person is a small child, it is assumed that one working adult would have to skip work. The average number of days of hospital confi nement per illness obtained from Philhealth provided an indicative estimate of the number of workdays lost. The average annual compensation obtained from the Philippine National Income Accounts divided by 250 workdays in a year provided an estimate of the lost income per day. ENVIRONMENTAL HEALTH 65 Chapter 1. INTRODUCTION Annex 2. USEFUL WEBSITES Organization Website Address Description Department of Environment and www.denr.gov.ph Overview of the programs and projects that help Natural Resources (DENR) protect, preserve, and enhance the natural resources of the Philippines Environmental Management www.emb.gov.ph Focuses on environmental laws for various Bureau (EMB) environmental media, standards, and environmental quality status of the country Department of Health (DOH) www.doh.gov.ph Programs and projects to improve health and sanitation National Water Resources Board www.nwrb.gov.ph Water resource regions and water quantity and (NWRB) availability Manila Observatory www.observatory.ph One of the objectives of this institution is to help measure pollutants; the site is currently under construction Asian Development Bank (ADB) www.adb.org ADB environmental-health-related programs Clean Air Initiative (The World www.worldbank.org/ Provides information on all topics under air quality Bank, ADB, and others) cleanair/caiasia/ management and also the linkages to various ongoing environment activities in the region; it has discussion space aimed to exchange ideas on various topics affecting the region US - Asia Environmental www.usaep.org Links to recent development in environment and its Partnership (USAEP) own projects in the region U.S. Environmental Protection www.epa.gov Extensive information available on all technical and Agency (USEPA) legal aspects of environment, including air, water and health United Nations Development www.undp.org UNDP environmental-health-related programs Program (UNDP) World Bank Water and Sanitation www.wsp.org Description and details regarding the World Bank Program (WSP) Water and Sanitation Program World Health Organization (WHO) www.who.int Provides extensive information on all technical aspects of environmental health, including air pollution and WHO guidelines for various pollutants 66 PHILIPPINES ENVIRONMENT MONITOR Annex 3. 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PHILIPPINES AT A GLANCE GEOGRAPHY ECONOMY / SOCIETY Area: Total..................................... 300,000 sq. km GDP (2005) ...................................................5,379 B Land .................................... 298,170 sq. km GDP growth rate (2005) ................................ 5.1% Water ................................ 1,830,830 sq. km GDP ­ composition by sector: Boundaries: Agriculture................................................ 14% North: Balintang Channel Industry.................................................... 33% South: Sulu and Celebes Seas Services ..................................................... 53% East: Philippine Sea/Pacific Ocean Unemployment rate (2005) ........................ 10.3% West: South China Sea Gross Domestic Investment/GDP.............. 15.7% Coastline...............................................17,460 km Exports of goods and services/GDP .......... 46.4% Maritime claims: Gross domestic savings/GDP...................... 19.5% Total territorial water area incl. Gross national savings/GDP ....................... 18.2% Exclusive Economic Zone ..... 2,200,000 sq. km Industrial production growth rate ............. 5.3% Coastal ................................. 266,000 sq. km Agricultural production growth rate ......... 2.0% Oceanic .............................. 1,934,000 sq. km Agriculture ­ products: rice, coconut, corn, Continental shelf area ............ 184,600 sq. km sugarcane, banana, hog, broiler chicken, layer Climate: Tropical: northeast monsoon chicken, carabao, beef cattle, dairy cattle, (Nov. to April); southwest monsoon duck, goat, chicken eggs, duck sardines, (May to October) milkfish, oyster, mussels, tilapia, catfish Terrain: Mostly mountains, with narrow to Exports (2005)....................................... PHP2,496 B extensive coastal lowlands Imports (2005) ...................................... PHP2,533 B Elevation extremes: Exchange Rate .........................................PHP56.04 Lowest point ..................... Philippine Sea 0 m Population (2005) ............................... 85.2 million Highest point ........................Mt. Apo 2,954 m Population growth rate ................................ 2.2% Natural resources: timber, nickel, cobalt, Urban population (% of total) ........................ 62.6 silver, gold, salt, copper, petroleum Access to safe water Land use: (% of population 2004) ....................... 85%** Arable land............................................ 19% Access to sanitation Permanent pastures .................................. 4% (% of population 2004) ....................... 72%** Permanent crops ..................................... 12% Life expectancy at birth (2003).............69.8 years Forest & wetlands ................................... 46% Literacy (total population 2003) ....................92.3% Others ................................................... 19% Elementary participation rate (2003) ........90.1% Environment ­ International agreements: National capital: Manila Party to: Climate Change, Endangered Administrative divisions (July 2004): Species, Hazardous Wastes, Marine 17 regions, 79 provinces Dumping, Nuclear Test Ban, Ozone Layer Independence: June 12, 1898 Protection, Biodiversity, Wetlands, Whaling, POPs