Urban Environmental Health Hazards and Health Equity

This paper outlines briefly how the living environment can affect health. It explains the links between social and environmental determinants of health in urban settings. Interventions to improve health equity through the environment include actions and policies that deal with proximal risk factors in deprived urban areas, such as safe drinking water supply, reduced air pollution from household cooking and heating as well as from vehicles and industry, reduced traffic injury hazards and noise, improved working environment, and reduced heat stress because of global climate change. The urban environment involves health hazards with an inequitable distribution of exposures and vulnerabilities, but it also involves opportunities for implementing interventions for health equity. The high population density in many poor urban areas means that interventions at a small scale level can assist many people, and existing infrastructure can sometimes be upgraded to meet health demands. Interventions at higher policy levels that will create more sustainable and equitable living conditions and environments include improved city planning and policies that take health aspects into account in every sector. Health equity also implies policies and actions that improve the global living environment, for instance, limiting greenhouse gas emissions. In a global equity perspective, improving the living environment and health of the poor in developing country cities requires actions to be taken in the most affluent urban areas of the world. This includes making financial and technical resources available from high-income countries to be applied in low-income countries for urgent interventions for health equity. This is an abbreviated version of a paper on “Improving the living environment” prepared for the World Health Organization Commission on Social Determinants of Health, Knowledge Network on Urban Settings.     

Street vending and waste picking in developing countries: a long-standing hazardous occupational activity of the urban poor

Uncontrolled urbanization in developing countries has led to widespread urban poverty and increased susceptibility to environmental exposures owing to the hazardous occupational activities of the urban poor. Street vending and waste picking are the dominant works undertaken by the urban poor, and besides the physical hazards, it also exposes them to several pathogens and high levels of air pollutants present in the outdoor environment. The situation has severe consequences for the health of the workers. Eliminating these occupational activities from the urban landscape of developing countries should therefore receive urgent attention from the global health community and governments. In this article, we provide evidence to support this policy recommendation by documenting exposure experiences of the workers, the associated adverse health effects, whilst also outlining measures for addressing the problem sustainably. We conclude that with the adoption of the sustainable development goals (SDG), governments now have a commitment to address poverty and the associated occupational health hazards experienced by the poor through their choices to help achieve the health-related SDG target (3.9) of substantially reducing the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination by 2030.     

The urban environment and health in a world of increasing globalization: issues for developing countries

Urban living is the keystone of modern human ecology. Cities have multiplied and expanded rapidly worldwide over the past two centuries. Cities are sources of creativity and technology, and they are the engines for economic growth. However, they are also sources of poverty, inequality, and health hazards from the environment. Urban populations have long been incubators and gateways for infectious diseases. The early industrializing period of unplanned growth and laissez-faire economic activity in cities in industrialized countries has been superseded by the rise of collective management of the urban environment. This occurred in response to environmental blight, increasing literacy, the development of democratic government, and the collective accrual of wealth. In many low-income countries, this process is being slowed by the pressures and priorities of economic globalization. Beyond the traditional risks of diarrhoeal disease and respiratory infections in the urban poor and the adaptation of various vector-borne infections to urbanization, the urban environment poses various physicochemical hazards. These include exposure to lead, air pollution, traffic hazards, and the "urban heat island" amplification of heatwaves. As the number of urban consumers and their material expectations rise and as the use of fossil fuels increases, cities contribute to the large-scale pressures on the biosphere including climate change. We must develop policies that ameliorate the existing, and usually unequally distributed, urban environmental health hazards and larger-scale environmental problems.     

Child poverty and environmental justice

BACKGROUND: Child poverty and social inequality in Western countries are growing both in scope and in complexity. The clustering of income poverty in urban settings reflects the complex process of residential segregation. Living in segregated neighbourhoods with much poverty and predominantly substandard housing is usually associated with poor physical, chemical and social environmental living conditions at the individual and community level which influence and shape children's health both directly and indirectly. OBJECTIVE: This paper shows research data on the link between child poverty and income-related health inequalities according to the unequal exposure to environmental hazards as well as the unequal distribution of environmental resources in the domestic environment and within the local context as an increasing public health issue in Germany. The links between these factors are drawn from the conceptual framework of environmental justice. Examples are shown of integrated approaches to alleviate social and environmental disparities at the community level. CONCLUSION: The implications of environmental justice for public health include the need to uncover the link between socioeconomic factors and environmental health disparities related to the man-made environment. Developing relevant indicators for environmental inequalities in the context of housing and health is an important task for public health research. More emphasis should be placed on a comprehensive holistic approach to understand the mechanisms by which socioeconomic factors modify children's susceptibility and exposure to environmental hazards, particularly in low-income areas.     

Ethical issues in international environmental health research

Environmental health problems are among the world's most significant health concerns. Although environmental risks are experienced disproportionately by people in developing countries, environmental health research (EHR) is conducted primarily in developed countries. Human subjects participate in five main types of EHR: (1) documentation and quantification of exposure to potentially hazardous substances; (2) elucidation of biological responses to these materials; (3) characterization and measurement of susceptibility to harmful effects of hazardous materials; (4) trials involving environmental interventions to reduce risk; and (5) documentation and measurement of various manifestations of disease putatively linked to environmental exposures. Although existing frameworks for the ethics of international clinical research are generally relevant to EHR, they currently lack the specificity necessary to confront three inherent problems in EHR, namely under-determination in EHR findings, the unavoidable nature of some environmental hazards, and environmental justice implications. We examine these issues as they relate to community partnership, risk assessment, and the assessment and management of economic and political interests in EHR. We believe that there are 3 general features of ethical EHR, it has health promoting value, the populations studied are not restricted in their ability to avoid environmental hazards by economic or political repression, and the justification for conducting EHR on populations with known exposure to environmental hazards gets stronger as the limits on populations to reduce the hazards or remove themselves from them becomes greater, as long as the first and second conditions are also met.     

Beyond Urban Penalty and Urban Sprawl: Back to Living Conditions as the Focus of Urban Health

Researchers have long studied urban health, both to describe the consequences of urban living and to design interventions to promote the health of people living in cities. Two approaches to understanding the impact of cities on health have been dominant, namely, urban health penalty and urban sprawl. The urban penalty approach posits that cities concentrate poor people and expose them to unhealthy physical and social environments. Urban sprawl focuses on the adverse health and environmental effects of urban growth into outlying areas. We propose a model that integrates these approaches and emphasizes urban living conditions as the primary determinant of health. The aim of the model is to move beyond describing the health-related characteristics of various urban populations towards identifying opportunities for intervention. Such a shift in framework enables meaningful comparisons that can inform public health activities at the appropriate level and evaluate their effectiveness in improving the health of urban populations. The model is illustrated with two examples from current urban public health practice.     

Understanding the cumulative impacts of inequalities in environmental health: implications for policy

Racial or ethnic minority groups and low-income communities have poorer health outcomes than others. They are more frequently exposed to multiple environmental hazards and social stressors, including poverty, poor housing quality, and social inequality. Researchers are grappling with how best to characterize the cumulative effects of these hazards and stressors in order to help regulators and decision makers craft more-effective policies to address health and environmental disparities. In this article we synthesize the existing scientific evidence regarding the cumulative health implications of higher rates of exposure to environmental hazards, along with individual biological susceptibility and social vulnerability. We conclude that current environmental policy, which is focused narrowly on pollutants and their sources, should be broadened to take into account the cumulative impact of exposures and vulnerabilities encountered by people who live in neighborhoods consisting largely of racial or ethnic minorities or people of low socioeconomic status.     

Issues in environmental epidemiological research: the example of environmental lead and health

Modern environmental epidemiology encompasses the "traditional" area of physico-chemical hazards, along with health hazards in the societal environment (e.g. noise, stress, social organisation), and, increasingly, supranational problems (e.g. ozone depletion, global warming). As governments undertake environmental management, improved quantitative estimates of environmental risks to health are needed. Methodological difficulties of environmental epidemiological research include problems of exposure measurement, of estimating exposure at the level of the individual, and of detecting relatively small effects (particularly at low exposure levels). The health hazards of occupational lead exposure are well documented. The health hazards of environmental exposure to lead, within the general population, remain a focus of continuing epidemiological research. Indeed, the reported adverse effects upon the developing central nervous system of young children are now central to public health debate about environmental lead exposure standards. Recent evidence from cohort studies in several countries indicates adverse effects of environmental lead exposure upon early childhood mental development. In South Australia, a cohort study of children born in a lead smelter community, Port Pirie, has revealed evidence of such an effect. After controlling for many potential confounding factors (social, behavioural, family, and medical), cumulative postnatal lead exposure was found to be weakly associated with an adverse effect upon mental development at age two years and, more strongly, at age four years. The relations between environmental epidemiological research and public health policy are discussed.     

Identifying environmental health priorities for a whole nation: the use of principal environmental exposure pathways in the Philippines

This paper presents a novel approach to establishing environmental health priorities for a large society, based upon the concept of principal environmental exposure pathways (PEEPs). Principal environmental exposure pathways extend the concept of a causal pathway backward from health outcome to exposure, then to the industrial, transportation, commercial, or living conditions that gave rise to the pollution of interest. In the Philippines, where the method was developed and used, five PEEPs were identified: an urban air-pollution pathway; a community water-supply pathway; an urban solid-waste pathway; a rural "point-source" pathway; and a pathway whereby fertilizers and pesticides affect food, worker health, and rural water supplies. Characterizing the PEEPs involved pinpointing the populations at risk necessary to estimate the burden of morbidity and mortality related to each as well as identifying the health outcomes that were experienced by those exposed along each pathway or that they could be expected to experience; determining where adequate health-outcome information was available or absent; where exposure sources were or were not adequately identified; where there were significant gaps in agency responsibilities; where new data flows were needed; and where things could have been improved by improving inter-agency cooperation. The most important success of the PEEP method was to reduce the "problem of everything" in a complex country of 65 million people to a small and manageable number of priority environmental exposures.     

Health and the urban poor

Traditionally, cities have benefited from a disproportionateshare of the resources available for health care and, as a result,most developments in primary health care have been in ruralareas. Recently, however, attention has been called to the inequitiesthat exist within cities and to the rapid growth of the urbanpoor. This paper reviews the topic of primary health care andthe urban poor in developing countries. The disease patternsof the urban poor reflect the problems of underdevelopment andindustrialization. The few studies that focus upon the healthproblems of the urban poor demonstrate a prevalence of infectiousdiseases and malnutrition which is comparable to and often greaterthan that observed in rural populations. At the same time, however,the urban poor suffer the typical spectrum of chronic and socialdiseases. The magnitude of the health problems of the urbanpoor rarely emerges in city health statistics. This is eitherbecause the ‘unofficial’ squatters and shanty townor slum inhabitants do not appear in the statistics or becausetheir conditions are obscured by the enormous difference thatexists between their status and that of the urban elite. Atthe community level there is now evidence of relevant, constructiveand hopeful approaches to helping the urban poor through primaryhealth care. Although there are few analytical or evaluativeexaminations of such initiatives, it is possible to identifyemerging trends such as the development of neighbourhood healthprogrammes, the use of community health workers and attemptsto link hospital services with community health action. It remainsto be seen whether the health departments in any cities canbring about the co-ordination and support needed for the improvementof environmental and socio-economic conditions which are fundamentalfor improving health. Also, international agencies need to focusmore attention upon the particular plight of the urban poor.     

Identifying Environmental Health Priorities for a Whole Nation: The Use of Principal Environmental Exposure Pathways in the Philippines

Abstract

This paper presents a novel approach to establishing environmental health priorities for a large society, based upon the concept of principal environmental exposure pathways (PEEPs). Principal environmental exposure pathways extend the concept of a causal pathway backward from health outcome to exposure, then to the industrial, transportation, commercial, or living conditions that gave rise to the pollution of interest. In the Philippines, where the method was developed and used, five PEEPs were identified: an urban air-pollution pathway; a community water-supply pathway; an urban solid waste pathway; a rural “point-source” pathway; and a pathway whereby fertilizers and pesticides affect food, worker health, and rural water supplies. Characterizing the PEEPs involved pinpointing the populations at risk necessary to estimate the burden of morbidity and mortality related to each as well as identifying the health outcomes that were experienced by those exposed along each pathway or that they could be expected to experience; determining where adequate health out come information was available or absent; where exposure sources were or were not adequately identified; where there were significant gaps in agency responsibilities; where new data flows were needed; and where things could have been improved by improving inter-agency cooperation. The most important success of the PEEP method was to reduce the “problem of everything” in a complex country of 65 million people to a small and manageable number of priority environmental exposures.     

Environmental victims: environmental injustice issues that threaten the health of children living in poverty

Children living in poverty are disproportionately at risk from and affected by environmental hazards. According to the National Center for Children in Poverty, 13 million children in America live in poverty. Thus, not only are millions of children living in poverty but are also living in environments that are hazardous to their health. Impoverished children are more likely to live in environments with heavily polluting industries, hazardous waste sites, contaminated water and soil, in old housing with deteriorating lead-based paint, in areas with limited access to healthy food, and more. Poor children residing in these toxic environments are either at risk or suffer from a myriad of health disparities, such as asthma, cancer, lead poisoning, obesity, and hyperactivity. This unfortunate reality is better known as environmental injustice. Environmental injustice recognizes that economically disadvantaged groups are adversely affected by environmental hazards more than other groups. To remedy this dilemma, environmental justice seeks to address these unfair burdens of environmental health hazards on poor communities. The purpose of this article is to (a) examine the environmental living conditions of children living in poverty, (b) examine the environmental health disparities of children living in poverty, (c) discuss environmental justice legislation, (d) describe government initiatives to improve environmental health, and (e) propose recommendations that executes measures to protect the health of children.     

Environment and health in South Africa: gains, losses, and opportunities

South Africans face a range of preventable environmental hazards to their health, many of which are rooted in the country's colonial and apartheid past, and ongoing poverty and inequality. Since the advent of democracy in the country, government has made considerable progress in improving living conditions and in developing the legal framework to prevent and manage environmental contamination. Considerable, under-exploited potential also exists in South Africa to prevent disease, including infectious and chronic diseases, and to promote health through a more holistic and public health approach. This article summarizes the main environmental health concerns and reflects on mechanisms and opportunities to improve public environmental health.     

Evaluating the indoor and outdoor environment: using a simple method

Housing is the conjunction of the dwelling, the home, the immediate environment and the community. Between 1960 and 1980, the urban population in developing countries more than doubled and is expected to reach 56% of the total population by the year 2025. In many cities, the development of squatter settlements and shanty towns had grown rapidly causing the destruction of green areas. The number of people living in urban slums and shanty towns is an indicator of conditions in the cities and the United Nations had estimated that about one-third of urban dwellers in developing countries live in such settlements. Poverty is highly prevalent among the residents of these areas. Outdoor environmental degradation, together with the social degradation affects the health of the urban population especially the poor causing a burden of ill-health, disability, poor indoor housing, and high maternal and infant mortality. The aim of the present study is to evaluate the indoor and outdoor environment using a simple method and to assess its reliability and validity. The scoring system, which was developed for the assessment of the indoor and outdoor environmental levels included 36 items (18 for the indoor and 18 for the outdoor) using a questionnaire. Results revealed that the proposed scoring system was able to reveal significance difference between served (water, electricity, and sewerage system were available) and unserved areas when using t-test, z-test, and chi-square testing. The proposed scoring system was reliable and valid especially in indoor assessment. Outdoor scores might need more modifications to improve its reliability.     

Climate Change and Developing-Country Cities: Implications For Environmental Health and Equity

Climate change is an emerging threat to global public health. It is also highly inequitable, as the greatest risks are to the poorest populations, who have contributed least to greenhouse gas (GHG) emissions. The rapid economic development and the concurrent urbanization of poorer countries mean that developing-country cities will be both vulnerable to health hazards from climate change and, simultaneously, an increasing contributor to the problem. We review the specific health vulnerabilities of urban populations in developing countries and highlight the range of large direct health effects of energy policies that are concentrated in urban areas. Common vulnerability factors include coastal location, exposure to the urban heat-island effect, high levels of outdoor and indoor air pollution, high population density, and poor sanitation. There are clear opportunities for simultaneously improving health and cutting GHG emissions most obviously through policies related to transport systems, urban planning, building regulations and household energy supply. These influence some of the largest current global health burdens, including approximately 800,000 annual deaths from ambient urban air pollution, 1.2 million from road-traffic accidents, 1.9 million from physical inactivity, and 1.5 million per year from indoor air pollution. GHG emissions and health protection in developing-country cities are likely to become increasingly prominent in policy development. There is a need for a more active input from the health sector to ensure that development and health policies contribute to a preventive approach to local and global environmental sustainability, urban population health, and health equity.     

Urbanisation: the implications for health

This article draws attention to the health implications of poverty in urban areas of developing countries. Migrants in Africa are depicted as bringing poverty with them and, in turn, being exposed to urban problems of access to water, sanitation, and shelter. Urban populations in low-income countries are viewed as carrying a double burden of health problems from communicable diseases and health problems typically associated with economically advanced societies, such as chronic diseases, accidents, and violence. Disease rates among children in urban slums from infectious diseases are reported to be sometimes higher than in rural areas. The rates of heart diseases and neoplasms are higher among the urban poor, even in Southern countries. The double burden is not shared equally by cities. The European experience is described as one where health professionals were instrumental in shifting policies to alleviating poor health conditions by changing physical conditions and socioeconomic conditions and improving the adjustment to the stresses of urban living. The European experience needs to be applied and is being applied by health professionals working in African cities. Urbanization is expected to increase by 40-66% by the year 2010. Shifts will occur due to the desire for better jobs and better lives and due to displacement from war and civil conflict. 30-60% of urban population already live in slums, which may have a lack of access to basic needs such water, sanitation, and adequate housing, or inadequate food supplies and expensive and scarce fuel. Slums are characterized by high population densities and location on hazardous sites. Children are at high risk.     

Brain drain from developing countries: how can brain drain be converted into wisdom gain?

Brain drain is defined as the migration of health personnel in search of the better standard of living and quality of life, higher salaries, access to advanced technology and more stable political conditions in different places worldwide. This migration of health professionals for better opportunities, both within countries and across international borders, is of growing concern worldwide because of its impact on health systems in developing countries. Why do talented people leave their countries and go abroad? What are the consequences of such migrations especially on the educational sector? What policies can be adopted to stem such movements from developing countries to developed countries? This article seeks to raise questions, identify key issues and provide solutions which would enable immigrant health professionals to share their knowledge, skills and innovative capacities and thereby enhancing the economic development of their countries.     

Occupational exposure and health problems in small-scale industry workers in Dar es Salaam, Tanzania: a situation analysis

BACKGROUND: Workers in informal small-scale industries (SSI) in developing countries involved in welding, spray painting, woodwork and metalwork are exposed to various hazards with consequent risk to health. Aim To assess occupational exposure and health problems in SSI in Dar es Salaam, Tanzania. METHODS: Focused group discussions (FGD) were conducted among SSI workers. Participants were assessed for exposure to occupational and environmental hazards, the use of protective equipment and health complaints by interview. The findings were discussed with participants and potential interventions identified. RESULTS: Three hundred and ten workers were interviewed (response rate 98%). There was a high level (>90%) of self-reported exposure to either dust, fumes, noise or sunlight in certain occupational groups. There was low reported use of personal protective equipment. There was a high level of self-reported occupational health problems, particularly amongst welders and metalworkers. Workers reported their needs as permanent workplaces, information on work related hazards, water and sanitation, and legislation for SSI. CONCLUSIONS: In SSI in Tanzania, our study suggests that workers have high levels of exposure to multiple health hazards and that use of protective equipment is poor. This group of workers warrants improved occupational health and safety provision.     

„Primary Health Care“ und Urbanisierung

Background

The world of the twenty-first century will be a predominantly urban world. By the year 2008, for the first time in human history, more people were residing in cities than in rural areas. The process of urbanization was mostly completed in the industrialized countries by the mid-twentieth century. In developing countries, however, both number and proportion of city dwellers are increasing.

Methods

To review the process of urbanization in developing countries, its relevance for the social and health situation of urban populations and the consequences arising thereof for the concept of Primary Health Care (PHC).

Results

A rapid urbanization poses great challenges to city councils, e. g. concerning infrastructure and distribution of societal wealth. Today, the process of urbanization is accompanied by a lack of jobs in the formal sector and a change in lifestyle which is not conducive to health, e.g. high calorie and fatty foods. A disaggregation of the health situation shows strong intra-city differentials between wealthy neighbourhoods and slum areas. Slum dwellers remain exposed to communicable diseases and are in addition at risk for non-communicable, chronic diseases. Many of the most prevalent health problems have social causes. Such health problems will persist as long as their social causes are not mended. Evidence-based interventions for tackling social causes of illness are lacking, however.

Discussion

Urbanization poses new challenges to PHC. The present strategies, e.g. prevention, are often restricted to health symptoms and reach the middle classes rather than the urban poor. Instead, strategies directed towards a more human urbanization are required. They would have to make full use of the primary health care approach.