Begegnungen
Schriftenreihe des Europa Institutes Budapest, Band 20:51–60.

MIHÁLY KÖKÉNY–GYULA DURA

Environmental Health

The participants of the World Summit, despite the intricate and significantly conflicting interests among groups of countries, were not only expected to confirm their commitment to sustainable development (the Rio accords), but they had to prepare an Action Agenda for their practical implementation. In addition to several international conferences held during the past ten years, the Millennium Declaration of the UN also worded a high level of political commitment to sustainable development so that the living conditions of people may improve irrespective of where they live. Thus the World Summit on Sustainable Development was not aiming at the shaping of a new programme but it had to create the implementation and realisation of already existing ones. It was particularly the EU that pressed for measurable aims and for the wording of timetables for implementation.

The Plan of Implementation of the World Summit is based on the broad agreement that sustainable development has three basic pillars, such as an environmental, an economic and a social one, which should be assessed jointly in the concrete measures and activities knowing that man is in the focus of sustainable development.

Sustainable development and health

In addition to consumption habits and production processes, the protection of natural resources, globalisation, the development programmes of regions, the means and institutions of implementation the Plan of Implementation dedicates a separate chapter to issues of health and sustainable development. The action programme contains medium-term tasks but also encourages thinking in the longer run, up to 2050. Perhaps this is not in a very distant time if it is remembered that more than half of those people are already born who would live in 2050. This fact also stressed that care for our children and grandchildren cannot be postponed. Further on, in 2050, for the first time in human history, the number of elderly people (above 60) will be higher than that of the young (below 15). Ageing society means new opportunities as well as a very major challenge. The question is how the positive trend, that the population of the Earth has never been so aged in the history of humanity, can be utilised for the improvement of the quality of life for the extended lifespan. There is no time to be wasted. It is known that annually millions die in illnesses caused by air pollution and spread by water. If this loss were caused by a single pathogenic factor surely the world would hurry to find the possibility of curing it.

There were many criticisms of the Johannesburg Summit saying that “there had been many words and few deeds”. Even such remarks could, however reveal that several problems could be raised at least to the level of understanding. One such realisation, more over statement put into the limelight was that the good health of people is indispensable to sustainable development. It is not only impermissible that burdening the environment as a result of industrial and agricultural production should damage the health condition, but it should be clearly declared that human health and the creation of welfare have to be put into the focus of sustainable development.

The cardinal point of the relationship between the environment and health is to understand that the health condition of the population should be regarded as a basic principle of sustainable development. The rather flexible definition of sustainable development does not clarify its relation to human health. In certain wordings human health figures as a point of usefulness, like a factor of economic development saying that the healthier the population is the more efficiently the economy functions. Acknowledging the right of all to health, investment into public health would promote economic growth.

The issue of human health can also be approached from the angle of societal development. Health sustained in the longer run can be interpreted in a stable and productive natural environment, where food is of good quality, drinking water and air are clean, and even the climate is free of extremities (retaining biodiversity). Equality, the stability of the societal environment and ‘social capital’ are also important besides clean environment and welfare from the angle of human health. Hence human health cannot be considered as merely labour force investment, or as an accidental consequence of economic development. It is more than that, it is the centre of development as a special value. Therefore it is the primary aim of societal development to improve the conditions of healthy and happy life. If the process of development does not lead to the improvement of sustained and fair health, then, in keeping with the basic interpretation, there can be no ‘sustained development’.

The health condition of the world

Shocking figures of health statistics were presented to the World Summit. In the developing countries annually 11 million children below the age of five die. According to data of the WHO and the UNICEF 70% of them are killed by diarrhoea, infection of respiratory organs, malaria, measles, or malnutrition. Researches show that 40% of illnesses that can be globally associated to factors of environmental risk hit children below five, whereas this age group constitutes only 10% of world population. In the year 2000 unsafe drinking water, the lack of sewages, bad hygienic conditions caused the death of 1.3 million children below the age of 5 by a group of diarrhoeas in the developing countries. In the same age group acute infections of the respiratory organs cause the death of 2.2 million children annually, 60% of which can be related to indoor air pollution, mostly to the burning of dried manure, of biomass in unsuited stoves and to bad heating.

All in all it can be stated that today 25% of all the preventable illnesses can be traced back to bad quality environment.

Bad health condition and illness cost a lot. Annually malaria kills one million people, 70% of them are children younger than five. It means an annual economic loss of USD 12 thousand million to the African countries. Had combating malaria been successful thirty years ago when already efficient means were available to it, the GDP of the African countries would be higher by USD one hundred thousand million today. In 2001 the number of HIV-infected persons is estimated as forty million, two-thirds of who are in the 15-24 year age group and 92% of them live in developing countries. The Director-General of WHO, Mrs Gro Harlem Brundtland pointed out that the often 10-15% prevalence of HIV results in the annual decrease of the GDP by 1%. Annually tuberculosis infects 8.8 million people and causes the death of 1.7 million. Ninety-nine per cent of the infected live in developing countries. It can be prognosticated that by 2020 as many as one thousand million may be infected and 200 million people may become actually ill, further on 35 million may die in it if adequate resources are not allocated for combating tuberculosis.

What is to be done?

An agreement was reached at the World Summit, partly in harmony with the UN Millennium Summit (September 2000), in that up to 2015

– the number of those living on one US dollar daily should be halved,

– the mortality rate of children below the age of five should be reduced to its two-thirds,

– maternal mortality should be reduced to its three-fourth,

– the spread of HIV/AIDS should be stopped and malaria and other illnesses should be pushed back.

A lot of money is needed to the realisation of the above aims. David Nabarro, Programme Director of the WHO’s Sustainable Development and Healthy Environment stated that governments should regard health care as an investment and not as expenditure. He quoted calculations from the Committee report entitled WHO Macroeconomics and Health according to which the developing countries currently spend USD thirty thousand million on health care and if they added another sum of thirty thousand million productivity would be multiplied by six and the life of eight million people could be saved. That USD thirty thousand million would correspond to about 0.1% of the GDP of developed countries.

The interrelationships among the condition of the environment, socio-economic conditions, demographic changes and human health are extremely complex. (Figure 1) The destruction and decay of the environment cause further damages, they may further harm the condition of health by polluted air, drinking water and food, or may promote the spread of infectious diseases. The influence of insufficient/deficient nutrition accompanying poverty, poor housing conditions, crowdedness, inadequate hygienic conditions, and the enhanced danger of infections on health are commonly known. Yet it is very difficult to scientifically determine the relationship between the environment, poverty and health, at most it is the downward spiral that can be sensed. Despite the complexity of factors determining health (Table 1) the formula is simple: the health of the population is the function of average income and of the condition of the environment.

The relationship between health and poverty can be simply characterised by the fact that poverty makes people more vulnerable towards illnesses, whereas illnesses make people more vulnerable to poverty. The interrelationship between water and health can be directly measured by the number of incidences in which children are rather significantly affected mostly in developing countries, but indirect connections for instance with food production and kitchen processing cannot be disregarded either. In the relationship between energy and health consequences on health deriving from air pollution and diseases caused by climatic extremities such as floods and heat waves are decisive. The interrelationship between agriculture and health such as the intensive use of chemicals and the enhancement of yields is also known. The appearance and spread of the new invasive species in the disturbed ecosystem, producing new forms of diseases refers to the relationship between biodiversity and health.

The tasks of environmental health care

The study of the relationship between the environment and health is facilitated by several factors, but there are circumstances that make it more difficult. A facilitating factor is that activities in environmental protection and health care are governed by identical principles, they use similar means and can be compared on the level of practical realisation. Both branches keep prevention in view, subsidiarity, equal rights to a clean environment and health, the principle of precaution and last but not least the fact that the preservation of a clean environment and of health can be achieved by a broad partnership of societal actors. Environmental protection and environmental health care operate similar systems of inspection and regulation (such as limit values, monitoring), based on good quality data, systems of observation and reporting, mechanisms of evaluation and analysis. And the national services presuppose the existence of quality-controlled laboratory work in network, scientific research and technical development, further on the preventive and/or sanctioning work of the authorities.

Among the circumstances making the relationship of the environment and health more difficult health care is demanded to supply proofs to such questions like

– how far the risk of the environmental factor is scientifically validated,

– what numbers of incidences of illnesses can be attributed to this environmental factor and by what strategy and cost can the cases of illnesses be avoided.

It is difficult to answer to the above questions because of the complexity of the environmental-health risk factors (Figure 2). The experts, the population and the government are increasingly anxious about dangers mediated by environmental elements threatening the health or welfare of people. An increasing number of new sources of danger threatening our health is discovered or rediscovered.

At least three causes may explain why the environmental damages have come to the foreground:

1. The rapid industrial development, and the introduction of new technologies often create new (chemical, physical, microbiological, accidents) sources of danger as side effects of economic development that could not be foreseen.

2. Increasing possibilities of accurate measurement and the constantly expanding networks of observation discover such sources of environmental danger that have been existing for a longer time but the conditions to their detection were missing.

3. The society becomes increasingly conscious about potential environmental dangers due to adverse experiences and reports on them by the mass media.

It is the task of risk assessment to recognise them, to estimate the extent of danger represented by them and to compare them to other sources of danger. It is environmental health care, linking public health, statistics and natural sciences, that is capable of giving an answer to the following issues:

– whether the environmental pollution of air, water and food represents a realistic threat to cause damages of health,

– whether exposure to chemicals would enhance the frequency of harmful long-term effects (tumours).

– Problems emerging during the course of answering to such questions also throw light on those difficulties that have to be faced when environmental health care assesses risks. These are for instance:

– the levels of the environmental exposure of toxic materials and their quantity penetrating the human body can be measured only with great uncertainties and at a high cost;

– at times it is not the environmental pollutant that is toxic, but its metabolite.

The dose and effect relationships of toxic materials are often disputable, as the variables reflecting the interrelationship are frequently unknown, or we are unable to measure them. It is particularly true in the case of low dose environmental damages that are effective for long periods of time. It can be justly assumed that such exposures cause real health problems, yet it is not easy to grasp their clinical or physiological effects on the level of the population. As often a long time elapses between the first exposure and the appearance of the illness, it may happen that one finds low incidence when the affected people are examined. Thus, particularly if the given agent reached only a small part of the population, changes in health status may remain hidden even for years. In addition, most of the people suffer complex damages therefore it is extremely difficult, if not impossible to explain a certain deterioration of health condition by a single environmental exposure. The situation is further complicated by the fact that several toxic materials do not cause characteristic reactions in the organism and an individual may be in contact with several toxic materials producing an identical effect. Thus, for instance, certain tumours may be equally related to certain carcinogenic exposure at the workplace, or to the individual’s habits and behaviour (like smoking, drinking alcoholic beverages). The elimination of such and similar disturbing effects is extremely difficult.

The available health data do not indicate unambiguously the influence of the physical, chemical and microbiological factors present in the environment in this complex system of interrelationships. Nevertheless, inequalities of health among the different social strata are often related to environmental conditions and hazardous factors enhance inequalities embodied in health status.

Factors of risk in health care

As far as health issues are concerned, there was no discussion in Johannesburg about combating the spread of infectious diseases, the need for increasing investments in health care and for an adequate and effective answer to the new challenges related to sustainable development. It is human health that is in the focus of attention without any doubt as the aims of sustainable development cannot be accomplished in places where there is poverty, the number of the incidences of avoidable/preventable diseases is high and the environment is degraded. Therefore the following should be considered as a strategic element:

– the study of factors of health risk and diseases that endanger sustainable development now and in the future;

– a broad analysis of factors determining health and illness;

– the application of sustainable systems of health care and of good management methods;

– bringing the above components together in cooperation within and outside the branch of health care.

Based on what was heard and seen at the World Summit, the following aims can be worded that may contribute to sustainable development by framework /action programmes of health care:

1. Reduction of poverty and malnutrition.

It should be achieved that the needy may have access to sufficient, safe and physiologically adequate food. The protection of health in consumption should be enhanced. A proper supply of microelements should be ensured.

2. The possibilities of the systems of health care should be broadened and their capacity increased so that they may guarantee an efficient and accessible health care that is affordable by all.

Infant and child mortality should be reduced. Equal access to financially affordable and efficient health care should be guaranteed, including access to basic medicines and vaccines. The efficient traditional knowledge of healing should be preserved and developed and its practice should be combined with modern medical science. Public health should be strengthened. The evolution of a healthy way of life should be effectively supported in forms suited for the age of the individual.

3. Struggle against the main diseases.

Security against epidemics should be corroborated. Preventive, promotional and curative programmes should be evolved and strengthened against non-contagious diseases, with special regard to cardiovascular, tumorous and chronic illnesses of the respiratory organs, to diabetes, and to risk factors related to alcohol, smoking, unhealthy nutrition and physical inactivity.

4. Perfecting the planning of health and sustainable development.

Considerations of health, particularly issues related to the vulnerable segment of the population should be integrated into strategies, policies, and programmes elaborated in the interest of sustainable development and reduction of poverty. A development of capacities and extension trainings should be initiated for the analysis of the relationship between health and the environment.

5. Tasks of environmental health.

The number of those who have no access to healthy drinking water should be halved by 2015 so that the prevalence of water-related diseases may be significantly moderated. By an efficient prevention of water pollution the hazards of health should be reduced and the ecosystems should be protected. Environmental effects damaging health should be reduced with special regard to the specific needs of children, and relationships between poverty, the environment and health. Illnesses of the respiratory organs caused by air pollution should be reduced with special regard to women and children. Exposure to chemicals in the environment and at the workplace should be reduced. Based on the Bahia declaration, the strategic line of the treatment of chemical materials led by the IFCS, should be further developed by 2005. The scientifically based estimate of the risk of chemicals and wastes should be strengthened from the aspect of human health, water base, vectors of illnesses, of biodiversity and the ecosystems.

6. The handling of risk should be supported by the health profession in preparations for disaster recovery.

The local, national and regional development of relevant early warning systems should be supported. Programmes should be elaborated for reducing the health effects of extraordinary events.

Systems of environmental health inspectorates, monitoring and health information should be incorporated into the plans of protection/preparation. Considerations of health should be integrated into the analyses, risk assessment of multi-factor hazards and risks, and into disaster management.

Naturally the international, regional and national institutions should be utilised for the realisation of the above aims, including the domestic Committee for Sustainable Development. A comprehensive national strategy of sustainable development should be elaborated, and within its framework the strategy of health care and environmental health should be coordinated with the programmes in progress and with the planned ones with special regard to the related aims of the “Johan Béla National Programme of the Decade of Health”, so that sustainable development may not remain only a superficial slogan. Their implementation should be pursued and the necessary conditions should be created. Due to obvious reasons the strategy of sustainable development, already approved by the EU, should be taken into consideration together with the programmes of the all-European ministerial conferences called Environment and Health.

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Finally, the question arises why there is no progress if the vision of the future is so very clear. Perhaps because the world has changed extremely rapidly during the past ten years. In Rio the concept of globalisation was hardly used, whereas today, as it can be seen, inequalities have become even more marked, moreover, the information gap has been widening between the rich and the poor, inside and among countries. Trade and financial liberalisation has not been able to improve the global environment of macroeconomics either. Then why was it necessary to deal with an almost complete list of socio-economic and environmental issues? The answer is clear: so far the possible solutions to problems have been sought mostly by concentrating on one set of problems only and not on the issue as a whole. Its failure is well known. The situation may be changed by partnership cooperation and by commitments that can be measured and accounted for.