KEY ENVIRONMENTAL HEALTH BURDENS

This section very briefly examines the most important health conditions that
relate to the environmental issues that are discussed in this chapter. The section
will then examine the burden of disease from those condition.
Indoor Air Pollution
WHO estimates that about half of all of the people in the world depend on solid
fuel for their cooking and heating. The indoor air pollution that is discussed here
is related to these uses. Such fuels include the fossil fuel coal, and the biomass
fuels of cow dung, wood, logging wastes, and crp waste. In the cases that most
concern us, cooking and heating are done on open stoves that are not vented to
the outside. These are generally used by poorer segments of society, because
people usually move to kerosene of gas for cooking and switch to improved
stoves as their family income grows.
Biomass fuels and coal do not completely combust when they are burned.
Instead, they leave behind breathable particles of a variety of gases and
chemical products. The amount of these substances in a poorly ventilated home
can exceed WHO norms by more than 20 times. Smoke from burning biomass
inside the home can produce conjuctivitis, upper respiratory irritation, and acute
respiratory infetion. The carbon monoxide produced can lead to acute
poisoning. Other gases and smoke are associated over the long term with
cardiovascular disease, chronic obstructive pulmonary disease, adverse,
reproductive outcomes, and cancer. As discussed further later, women and
children are especially vulnerable to the effects of indoor air pollution.
OutdoorAir Pollution
Manypollutans can be found in the urban air. The most common effects of
outdoor air pollution are respiratory symptoms, including cough, irritation of the
nose and throat, and shortness of breath. Table 7-3 indicates some of the most
common pollutans in the outdoor air, examples of their sources, and the most
important health effects. Some preexiting health fators make some people
susceptible to being harmed by air pollution. Older and younger people are
generally most susceptible to the health effects of outdoor air pollution.
There have been a number of instances in which servere air pollution has been
associated with considerable excess mortality in a very short time. Among the
most famous cases was in London, England, in 1952. Because of what is called

a temperature invention, a dense fog, full of pollutans, hung over the city center
for several days. The value of certain particulates in the air was 3 to 10 times the
normal value. On December 13, 1952, the city administration reported a death
rate per 100.000 people that was more than four times the normal daily death
rate for that period.
Sanitation, Water, and Hygiene
Only about 60 percent of the people in the world have access to improved
sanitation. This ranges from about 80 percent in south America to only about 30
percent in sub-Saharan Africa. Many of the large cities in Africa have modern
sanitation system, and in Asia large shares of the populations in some areas also
have no access to sanitary disposal of human waste.
There is good evidence that improved disposal of human waste is associated
with reductions in diarrheal disease, intestinal parasites, and trachoma. Failure
to dispose properly of human waste contaminates water and food sources and
leads to an increase in transmission of pathologens through the oral-fecal route.
Failure to improve sanitation is also associated with the spread of parasitic
worms, such as ascaris and hookworm. Improved sanitation reduces the burden
of trachoma, because the flies that are significantly involved in the spread of
that disease breed, among other places, in human waste.
More than 1 billion people, mostly in low-and middle-income countries, lack
access to safe water sources within a reasonable distance of their home. Access
to improved water sources in 2004 was estimated to range from 56 percent in
sub-Saharan Africa to about 70 percent in Asia to almost universal access in
high-income countries. It is estimated that about 400 million children lack
access to safe water. In addition, even the water that people do have access to
and that is deemed safe in official statistics often contains important pathogens.
Many disease relate to water in a variety of ways.
Waterborne disease are among the most important in terms of the burden of
disease, and they are numerous in low-and middle income countries. Table 7-4
indicates how water-related disease may be classified. Some of the most
important waterborne pathogens are shown in Table 7-5.
These pathogens are associated with diarrhea and a host of other gastrointestinal
problems. As you will read about further in the chapters on child health and
infectious disease, they can be deadly when they lead to severe diarrhea and

dehydration. Such disease are especially risky for the very young, the very old,
and people who have compromised immune systems, such as people living with
HIV/AIDS.
THE BURDEN OF ENVIRONMENTALLY RELATED DISEASE
As noted earlier, it is estimated that about 8.4 percent of the total burden of
disease in low-and middle income countries is due to water, sanitation, and
hygiene; urban air pollution; and indoor air pollution. The relative share of each
of these factors is:
Indoor smoke from household use of solid fuels3.7 percent
Unsafe water, sanitation, and hygiene3.2 percent
Urban air pollution1.5 percent
These are explored more fully later.
Many people believe that the most important environmental risk factor in lowand middle income countries is outdoor air pollution; however, this is not true.
Rather, indoor air pollution is the third most important risk factor in high
mortality developing countries, exceed only by malnutrition and unsafe sex, and
similar in importantce to water, sanitation, and hygiene. It is estimated that
indoor air pollution from the use of solid fuels is responsible for 1.6 million
deaths annually from pneumonia, chronic respiratory disease, and lung cancer.
It is thought, in fact, that indoor air pollution is responsible for about 700,000 of
the 2,7 million annual deaths from chronic obstructive pulmonary disease
(copd) and about 15 percent of all deaths from lung cancer.
These figures include only those diseases for which there is solid evidence of a
link with indoor air pollution from the use of solid fuels. However, this may be
an underestimate of the real burden of disease from indoor air pollution because
there is some evidence that indoor air pollution of this type is also associated
with asthma, cataracts, and TB. There is also tentative evidence of links with
adverse pregnancy outcomes, especially low birthweight, ischemic heart
disease, and two types of cancer other than lung cancer.
Almost all the burden of disease from indoor air pollution from the use of solid
fuels is in low-and middle income countries. Omen do most of the cooking in
low-and middle-income countries and they are most subject to the health risks
from indoor air pollution. Indeed, it is estimated that 59 pecent of all of the
deaths attributable to indoor air pollution are among females. Young children in

developing countries are often carried by their mothers on their backs as they
attend to household and work chores, such as cooking. They also tend to spend
long hours at home with their mothers. Therefore, they are also exposed more
than others to indoor air pollution. It is estimated that 56 percent of all deaths
attributable to indoor air pollution are among children younger than 5 years.
Urban Outdoor air pollution
One study of the global burden of disease attributed 1.5 percent of annual deaths
and 0.5 percent of the total burden of disease to outdoor air pollution. The study
further indicated that 81 percent of the deaths and 49 percent of the DALYs
attributable to outdoor air pollution occur among people 60 years of age or
older. Three percent of the deaths and 12 percent of the DALYs occur in
children younger than 5 years. It also has been estimated that outdoor air
pollution by urban particulate matter causes about 5 percent of the global cases
of lung cancer, 2 percent of the deaths from cardiovascular and respiratory
conditions, and 1 percent of respiratory infections.
India and china have major burdens of disease that relate to outdoor air
pollution from particulate matter. In fact, about two thirds of the global burden
of disease from outdoor air pollution is in the low-and middle- income countries
of Asia. A number of countries in Eastern Eourope also face a high burden of
disease from outdoor air pollution. In some countries of that region, between 0.6
and 1.4 percent of the burden of disease is attributable to outdoor air pollution
from particulate matter.
Sanitation, Water, and Hygiene
Unsafe disposal of human waste, unsafe water, and poor hygiene are associated
with 3.2 percent of the total deaths in low-and middle-income countries 3.7
percent of the DALYs. Studies that have been done suggest that within the
African region, about 85 percent of the DALYs from these risk factors are
related to the oral-fecal route of disease transmission and to diarrheal disease,
primarily among young children. These studies also suggest that
schistosomiasis, in the water-based group, has the second largest loss of DALYs
related to these risk factors in Africa.
We should expect globally that the burden of disease related to these risk factors
will fail disproportionately on children, who suffer such a large share of the
global burden of disease from diarrhea. The burden of these risk factors will

also fall overwhelmingly on poor and less well-educated people in the poorer
countries of South Asia and sub-Saharan Africa. They have less access than
others to improved water supply and sanitation and to the knowledge of good
hygiene they need to avoid illness in the face of unsafe water and sanitation.
It is very complicated to try to assess individually the relative contribution of
unsafe sanitation, unsafe water, and poor hygienic practices to the burden of
diarrheal disease, partly because they are all so closely linked with each other.
Nonetheless, both historical experiences in what are now the high-income
countries and a number of studies in low-and middle-income countries suggest
that improving water supply alone will not reduce diarrheal disease as needed.
This seems to stem from the large amount of diarrhea that is associated with
food that is unsafe and poor personal hygiene. More will be said about these
later.
Separates from any impact on the reduction of diarrheal disease, improvements
in water supply are associated with important reductions in the burden of
disease from dracunculiasis, schistosomiasis, and trachoma.
THE COST AND CONSEQUENCES OF KEY ENVIRONMENTAL HEALTH
PROBLEMS
The social and economic consequences of the key environmental health issues
that have been discussed are enormous. First, they constitute 8.4 percent of the
total deaths in low and middle-income countries and 7.2 percent of their total
burden of disease. Taken together, the burden of disease from these causes is
about 25 percent more than unsafe sex and about twice as much as tobacco use.
The magnitude of their burden itself suggests substantial social and economic
costs related to these issues.
Second, as indicated earlier, the burden of these causes falls disproportionately
on relatively poorer people. It is the poorer people who cook with biomass fuels
and coal, not the better-off people. These burdens also fall on low-and middleincome countries more than on high-income countries. People in high-income
countries do not customarily cook with biomass fuel or coal and they do not
have to contend with the problems of unsafe water and sanitation that people in
lower-and middle income countries face. Their knowledge of good hygiene
practices is also superior to the level of knowledge of most peope in developing
countries.

Third, these environmental health burdens have very negative consequences on

productivity. It is women who suffer the ill effects of indoor air pollution the
most. The results of this are very costly to women in terms of morbidity and
disability and days of reduced productivity from both acute and chronic illness.
In addition, the economic and sosial consequences of ill health for women in
many low-and middle income countries go considerably beyond just womens
health. Rather, they spill over onto the health of the rest of her family, especially
young children, whose own health and survival depend in important ways on
the health of the mother.
Young children are especially at risk from all three forms of the environmental
issues discussed in this chapter. They are especially vulnerable to unsafe water,
and diarrheal disease can put them into a cycle of infection and malnutrition,
ultimately retard their growth and development, or be deadly. Indoor air
pollution can also lead to a cycle of illness and respiratory infection, death from
pneumonia, or disability from asthma. To a lesser extent, outdoor air pollution
can do the same. The elderly face particularl risks from outdoor air pollution.
This can exacerbate chronic health problems they already have, leading to
additional disability and its attendant reduction in produvtivity.