Environmental Health

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

Source:  adapted from Listorti and Doumani 2001.

Environmental health and poverty

Environmental health risks can be grouped into two broad categories. Traditional hazards related to poverty and lack of development affect developing countries and poor people most. Their impact exceeds that of modern health hazards by a factor of 10 in Africa, 5 in Asian countries (except for China), and 2.5 in Latin America and Middle East (see figure).

Water-related diseases caused by inadequate water supply and sanitation impose an especially large health burden in Africa, Asia, and the Pacific region. In India alone, over 700,000 children under 5 die annually from diarrhea. In Africa, malaria causes about 800,000 deaths annually. More than half of the world's households use unprocessed solid fuels, particularly biomass (crop residues, wood, and dung) for cooking and heating in inefficient stoves without proper ventilation, exposing people—mainly poor women and children—to high levels of indoor air pollution (IAP). IAP causes about 2 million deaths in each year.

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Best interventions to reduce EH burden

Environmental health risks can be prevented or significantly mitigated, by activities in various sectors in addition to health - especially infrastructure, energy, and agriculture. The infrastructure sector has huge potential to improve health outcomes and save lives: water, sanitation, drainage, transportation, housing, urban development and energy projects could avert a large percentage of the deaths and disability-adjusted life year (DALY) loss from four of the top-ten global burden of disease causes: acute respiratory infections (1st), diarrheal diseases (3rd), malaria (8th), and traffic accidents (9th).

Environmental protection regulations and their enforcement are a major tool. Other policies also have large potential health benefits but are not generally considered in an EH context, e.g., policies on taxation, advertising and use of tobacco products. Similarly, import/export and tariff policies related to pesticides and their use in agriculture, and impregnated bednets to control malaria, or protective gear for handling hazardous waste are often outside the purview of agencies dealing with EH, but could have a large positive health impact.

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Cost-effectiveness of interventions to improve environmental health

Many EH interventions are very cost-effective. Although the number of studies is limited, a review of available evidence of the effectiveness of measures outside the health sector in achieving health improvements found the following estimated costs per DALY saved (see Listorti and Doumani 2001 for full references):

• water connections in rural areas: US$35 per DALY (World Bank 2000);
• hygiene behavior change: US$20 per DALY (Stephen 1998);
• malaria control: US$35-75 per DALY (Binka 1997);
• improved stoves (indoor air): US$50-100 per DALY (Smith 1998);
• kerosene and LPG stoves in rural areas: US$150-200 per DALY (World Bank 2000);
• tobacco tax increases that raise real prices 10%: US$2-42 (World Bank, 1999);
• improved quality of urban air: large variations, from negative costs (electronic ignition systems in two-stroke vehicles) to US$70,000 per DALY and more for some pollution control measures, with most measures costing over US$1,000 per DALY.

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Monitoring environmental health improvements

Infrastructure, energy and agriculture projects seldom try to monitor EH impact or maximize EH benefits. For this to change, better links between activities in these sectors and EH indicators are needed. This table summarizes environmental risk factors, sectors in which interventions could take place and possible indicators for monitoring health impact.

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Measuring environmental health outcomes of multi-sectoral interventions

Do's and don'ts

Environmental health involves many ministries. So do take a holistic, multi-sectoral approach to mitigating major risks to health, integrating cost-effective efforts in infrastructure and human development, and building effective institutions at all levels, including in communities. A holistic approach is particularly important for improving the health of poor people, who are most vulnerable to environmental hazards and deficiencies in health services delivery.

At the same time, however, do be selective since capacity, knowledge and awareness are always inadequate to tackle everything at once. Focus first on issues where a big impact is possible. For example, a pilot study in Ghana examined how the five largest cities could implement their new responsibilities without jeopardizing human health and focused on three key areas: (i) urban malaria and other vector-borne diseases (ii) AIDS outreach, and (iii) health facility waste management. Respiratory disease, the second biggest health problem after malaria, was not chosen because it was felt to be too difficult to move forward effectively. (Listorti and Doumani 2001.)

DO look for opportunities to act where institutional capability is adequate, stakeholders have a common interest in solving a problem which is clearly understood, and are committed to addressing it.

DO bring together a multi-sectoral team. Each profession brings a different angle, contributing to a whole picture. Only effective cross-sectoral teamwork can ensure that missed opportunities to improve environmental health are seized.

DON'T rely solely on technology changes. When introducing new technologies, consider carefully the feasibility of uptake, behavioral aspects, other inputs needed, maintenance, cost, etc.

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Useful resources

Documents

HNP "at a glance" fact sheets on: indoor air pollution, malaria, water & sanitation, road safety, nutrition, tobacco, smoke-free workplaces. http://www.worldbank.org/phataglance

Listorti JA and FM Doumani, Environmental Health: Bridging The Gaps. World Bank Discussion Paper No.422. World Bank, Washington, D.C., 2001. Part 1 suggests how to find "entry points" for collaboration, and economic justification. Part 2 provides environmental health assessment guidelines. Part 3 is a Ghana case study. Part 4 contains: "Environmental Health Assessments: Rapid Checklists", short summaries of 20 diseases and remedial measures, a glossary, and annotated bibliography including websites. http://www.worldbank.org/afr/environmentalhealth/

Lvovsky K, Health and Environment, Environment Strategy Paper 1. World Bank 2001.

Poverty, Health and Environment. Our Planet, UNEP, Vol. 12, Number 2, 2001

Environmental Health Project, USAID http://www.ehproject.org Contains basic information, publications, including many lessons learned, upcoming conferences.

World Health Organization http://www.who.int click on topics, environmental health.

World Health Report 2002. Reducing risks, promoting healthy life. WHO 2002 www.who.int/whr/2002/en

People
World Bank: Mariam Claeson (physician) mclaeson@worldbank.org;
Rita Klees (environmental engineer) rklees@worldbank.org;
Kseniya Lvovsky (economist) klvovsky@worldbank.org;
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

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PDF Versions

• English, June 2003 (PDF 679kb)
• French, March 2004 (PDF 30kb)
• Russian, April 2004 (PDF 51kb)

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