53658 Environmental Health at a glance Environmental health (EH) is concerned with preventing disease, death and disability by reducing exposure to adverse environmental conditions and promoting behavioral change. It focuses on the direct and indirect causes of diseases and injuries, and taps resources inside and outside the health care system to help improve health outcomes. Typical Environmental Health Issues: Determinants and Health Consequences Possible Adverse Health and Underlying Determinants Safety Consequences Inadequate water (quantity and quality), sanitation Diarrheas and vector-related diseases, eg, (wastewater and excreta removal) and solid waste malaria, schistosomiasis, dengue disposal, improper hygiene (hand washing) Improper water resource management Vector-related diseases, eg, malaria, (urban and rural), including poor drainage schistosomiasis Crowded housing and poor ventilation of smoke Acute and chronic respiratory diseases, including lung cancer (from coal and tobacco smoke inhalation) Exposures to vehicular and industrial air pollution Respiratory diseases, some cancers, and loss of IQ in children Population movement and encroachment and Vector-related diseases, eg, malaria, construction, which affect feeding and breeding schistosomiasis, and dengue fever, may also help grounds of vectors, such as mosquitoes spread other infectious diseases eg HIV/AIDS, Ebola fever Exposure to naturally occurring toxic substances Poisoning from, eg, arsenic, manganese, and fluorides Natural resource degradation, eg, mudslides, Injury and death from mudslides and flooding poor drainage, erosion Climate change, partly from combustion of Injury/death from: extreme heat/cold, storms, greenhouse gases in transportation, industry floods, fires. Indirect effects: spread of vector- and poor energy conservation in housing, fuel, borne diseases, aggravation of respiratory commerce, industry diseases, population dislocation, water pollution from sea level rise, etc. Ozone depletion from industrial and Skin cancer, cataracts. Indirect effects: commercial activity compromised food production, etc. Source: adapted from Listorti and Doumani 2001. Environmental health and poverty Water-related diseases caused by inadequate water supply and sanitation impose an especially large Environmental health risks can be grouped into two health burden in Africa, Asia, and the Pacific region. broad categories. Traditional hazards related to In India alone, over 700,000 children under 5 die poverty and lack of development affect developing annually from diarrhea. In Africa, malaria causes countries and poor people most. Their impact exceeds about 800,000 deaths annually. More than half of the that of modern health hazards by a factor of 10 in world's households use unprocessed solid fuels, Africa, 5 in Asian countries (except for China), and particularly biomass (crop residues, wood, and dung) 2.5 in Latin America and Middle East (see figure). for cooking and heating in inefficient stoves without June 2003 proper ventilation, exposing people--mainly poor women sanitation, drainage, transportation, housing, urban and children--to high levels of indoor air pollution (IAP). development and energy projects could avert a large IAP causes about 2 million deaths in each year. percentage of the deaths and disability-adjusted life year (DALY) loss from four of the top-ten global burden of Modern hazards, caused by development that lacks disease causes: acute respiratory infections (1st), environmental safeguards, such as urban (outdoor) air diarrheal diseases (3rd), malaria (8th), and traffic pollution and exposure to agro-industrial chemicals and accidents (9th). waste, prevail in industrialized countries, where exposure to traditional hazards is low. But the contribution of Environmental protection regulations and their modern environmental risks to the disease burden in most enforcement are a major tool. Other policies also have developing countries is similar to ­ and in quite a few large potential health benefits but are not generally countries, greater than ­ that in rich countries. Urban air considered in an EH context, e.g., policies on taxation, pollution, for example, is highest in parts of China, India advertising and use of tobacco products. Similarly, and some cities in Asia and Latin America. Poor people import/export and tariff policies related to pesticides and increasingly experience a "double burden" of traditional their use in agriculture, and impregnated bednets to and modern environmental health risks. Their total control malaria, or protective gear for handling burden of illness and death from all causes per million hazardous waste are often outside the purview of people is about twice that in rich countries, and the agencies dealing with EH, but could have a large disease burden from environmental risks is 10 times positive health impact. greater. Cost-effectiveness of interventions to Best interventions to reduce improve environmental health EH burden Many EH interventions are very cost-effective. Although Environmental health risks can be prevented or the number of studies is limited, a review of available significantly mitigated, by activities in various sectors in evidence of the effectiveness of measures outside the addition to health--especially infrastructure, energy, and health sector in achieving health improvements found the agriculture. The infrastructure sector has huge potential to following estimated costs per DALY saved (see Listorti improve health outcomes and save lives: water, and Doumani 2001 for full references): Traditional environmental health hazards prevail in developing countries but modern risks are also significant... Percent of total health risks 30% 700,000 DALYs per million people 25% 600,000 20% 500,000 400,000 15% 300,000 10% 200,000 5% 100,000 0% 0 pe a a na es a fic a ric ic ric di tri ro ci hi er In Af Af un Pa C Eu Am co th an & rn or tin ar ste ed ia N La ah As liz Ea & -S ia st l& b str Ea Su tra du le en In d id C M Disease burden due to traditional environmental risks as % of the total Disease burden due to modern environmental risks as % of the total Total disease burden, DALYs per million people Source: Lvovsky 2001. o water connections in rural areas: US$35 per DALY vehicles) to US$70,000 per DALY and more for some (World Bank 2000); pollution control measures, with most measures costing over US$1,000 per DALY. o hygiene behavior change: US$20 per DALY (Stephen 1998); o malaria control: US$35­75 per DALY (Binka 1997); Monitoring environmental health improvements o improved stoves (indoor air): US$50­100 per DALY (Smith 1998); Infrastructure, energy and agriculture projects seldom try to monitor EH impact or maximize EH benefits. For this o kerosene and LPG stoves in rural areas: US$150­200 to change, better links between activities in these sectors per DALY (World Bank 2000); and EH indicators are needed. This table summarizes o tobacco tax increases that raise real prices 10%: environmental risk factors, sectors in which interventions US$2-42 (World Bank, 1999); could take place and possible indicators for monitoring health impact. o improved quality of urban air: large variations, from negative costs (electronic ignition systems in two-stroke Measuring environmental health outcomes of multi-sectoral interventions Environmental Associated sectors/ Health outcomes Examples of monitorable risk factors projects and indicators proxy indicators Indoor Air Pollution Energy (cleaner fuels, Child deaths due to Estimates of exposure levels to indoor improved stoves) respiratory illness air pollution Health Acute respiratory Percent of households using clean fuels Rural development infection (ARI) cases or/and improved stoves Macroeconomic Chronic obstructive Type of housing (tobacco taxes) pulmonary disease Cooking practices Various (smokefree (COPD) incidence Tobacco use public places) Lung cancer Outdoor Air Pollution Energy Deaths (adult) Annual mean levels of PM10 (ug/m3) and Other Toxic Transport COPD incidence Annual ambient concentrations of lead Substances ARI cases in the atmosphere (ug/m3) Respiratory hospital Lead level in blood, particularly children admissions (ug/dl) IQ impairment (lead) Waste management codes Cancer incidence Environmental performance Vector-Borne Disease Irrigation Deaths due to malaria Use of bednets Reforestation Malaria cases Application of insecticides Infrastructure (drainage) Indicators related to the development Health (vector control) and maintenance of irrigation and drainage infrastructure Lack of water supply and WSS Infrastructure Child deaths due Access to water and sanitation (e.g., sanitation (WSS) Social funds to diarrhea % households with in-house connections, Diarrhea cases liters per capita per day, % of in children communities with sanitation facilities) Sustained and effective use of WSS facilities Quality of water at the source Hygiene/behavioral change indicators Pesticide Residues Agriculture Acute poisoning cases Application norms Cancer incidence Storage and handling Fetal defects practices Source: Lvovsky 2001 Do's and don'ts Useful resources Environmental health involves many ministries. So do take a holistic, multi-sectoral approach to mitigating Documents major risks to health, integrating cost-effective efforts in infrastructure and human development, and building HNP "at a glance" fact sheets on: indoor air pollution, effective institutions at all levels, including in malaria, water & sanitation, road safety, nutrition, communities. A holistic approach is particularly tobacco, smoke-free workplaces. important for improving the health of poor people, who www.worldbank.org/phataglance are most vulnerable to environmental hazards and Listorti JA and FM Doumani, Environmental Health: deficiencies in health services delivery. Bridging The Gaps. World Bank Discussion Paper No. 422. World Bank, Washington, D.C., 2001. Part 1 At the same time, however, do be selective since suggests how to find "entry points" for collaboration, capacity, knowledge and awareness are always and economic justification. Part 2 provides environmental inadequate to tackle everything at once. Focus first on health assessment guidelines. Part 3 is a Ghana case study. Part 4 contains: "Environmental Health issues where a big impact is possible. For example, a Assessments: Rapid Checklists", short summaries of 20 pilot study in Ghana examined how the five largest cities diseases and remedial measures, a glossary, and could implement their new responsibilities without annotated bibliography including websites. jeopardizing human health and focused on three key http://www.worldbank.org/afr/environmentalhealth/ areas: (i) urban malaria and other vector-borne diseases (ii) AIDS outreach, and (iii) health facility waste Lvovsky K, Health and Environment, Environment Strategy Paper 1. World Bank 2001. management. Respiratory disease, the second biggest health problem after malaria, was not chosen because it Poverty, Health and Environment. Our Planet, UNEP, Vol. was felt to be too difficult to move forward effectively. 12, Number 2, 2001 (Listorti and Doumani 2001.) Environmental Health Project, USAID http://www.ehproject.org Contains basic information, DO look for opportunities to act where institutional publications, including many lessons learned, upcoming capability is adequate, stakeholders have a common conferences. interest in solving a problem which is clearly understood, World Health Organization www.who.int click on topics, and are committed to addressing it. environmental health. DO bring together a multi-sectoral team. Each profession World Health Report 2002. Reducing risks, promoting brings a different angle, contributing to a whole picture. healthy life. WHO 2002 www.who.int/whr/2002/en Only effective cross-sectoral teamwork can ensure that missed opportunities to improve environmental health are People seized. World Bank: Mariam Claeson (physician) mclaeson@worldbank.org; DON'T rely solely on technology changes. When Rita Klees (environmental engineer) introducing new technologies, consider carefully the rklees@worldbank.org; feasibility of uptake, behavioral aspects, other inputs Kseniya Lvovsky (economist) klvovsky@worldbank.org; needed, maintenance, cost, etc. Rachel Kaufmann (environmental epidemiologist) rkaufmann@worldbank.org WHO: Yasmin von Schirnding (physician) vonschirndingy@who.ch Consultant: James Listorti (environmental health specialist) james.listorti@verizon.net Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp