WORLD BANK DISCUSSION PAPER NO. 422 WDP422 Work in progress W P2 for public discussion May 2001 Environmental Health Bridging the Gaps James A. Listorti Fadi U. Doumani Recent World Bank Discussion Papers No. 348 Did External Barriers Cautse the Marginalization of Suib-Saharan Africa in World Trade? Azita Amjadi Ulrich Reincke, and Alexander J. Yeats No. 349 Suirveillance of Agricultutral Price and Trade Policy in Latin America during Major Policy Reforms. Alberto Valdes No. 350 Who Benefitsfrom Public Education Spending in Malawi: Resultsfrom the Recent Eduication Reform. Florencia Castro-Leal No. 351 From Universal Food Subsidies to a Self-Targeted Program: A Case Study in Tutnisian Reform. Laura Tuck and Kathy Lindert No. 352 China's Urban Transport Development Strategy: Proceedings of a Symposium in Beijing, November 8-10, 1995. Edited by Stephen Stares and Liu Zhi No. 353 Telecommuinications Policiesfor Sutb-Saharan Africa. Mohammad A. Mustafa, Bruce Laidlaw, and Mark Brand No. 354 Saving across the World: Puzzles and Policies. Klaus Schmidt-Hebbel and Luis Serven No. 355 Agricultuhre and Gernan Reunification. Ulrich E. Koester and Karen M. Brooks No. 356 Evaluating Health Projects: Lessonsfrom the Literature. Susan Stout, Alison Evans, Janet Nassim, and Laura Raney, with substantial contributions from Rudolpho Bulatao, Varun Gauri, and Timothy Johnston No. 357 Innovations and Risk Taking: The Engine of Reform in Local Government in Latin America and the Caribbean. Tim Campbell No. 358 China's Non-Bank Financial Institutions:Trust and Investment Companies. Anjali Kumar, Nicholas Lardy, William Albrecht, Terry Chuppe, Susan Selwyn, Paula Perttunen, and Tao Zhang No. 359 The Demandfor Oil Products in Developing Couintries. Dermot Gately and Shane S. Streifel No. 360 Preventing Banking Sector Distress and Crises in Latin America: Proceedings of a Conference held in Washington, D.C., April 15-16, 1996. Edited by Suman K. Bery and Valeriano F. Garcia No. 361 China: Power Sector Regulation in a Socialist Market Economy. Edited by Shao Shiwei, Lu Zhengyong, Norreddine Berrah, Bernard Tenenbaum, and Zhao Jianping No. 362 The Regulation of Non-Bank Financial Instituttions: The United States, the Euiropean Union, and Other Countries. Edited by Anjali Kumar with contributions by Terry Chuppe and Paula Perttunen No. 363 Fostering Sustainable Development: The Sector Investment Program. Nwanze Okidegbe No. 364 Intensified Systems of Farming in the Tropics and Suibtropics. J.A. Nicholas Wallis No. 365 Innovations in Health Care Financing: Proceedings of a World Bank Conference, March 10-11, 1997. Edited by George J. Schieber No. 366 Poverty Reduction and Human Development in the Caribbean: A Cross-Country Stuidy. Judy L. Baker No. 367 Easing Barriers to Movement of Plant Varietiesfor Agricultuiral Development. Edited by David Gisselquist and Jitendra Srivastava No. 368 Sri Lanka's Tea Industry: Succeeding in the Global Market. Ridwan Ali, Yusuf A. Choudhry, and Douglas W. Lister No. 369 A Commercial Bank's Microfinance Program: The Case of Hatton National Bank in Sri Lanka. Joselito S. Gallardo, Bikki K. Randhawa, and Orlando J. Sacay No. 370 Sri Lanka's Ruibber Industry: Suicceeding in the Global Market. Ridwan Ali, Yusuf A. Choudhry, and Douglas W. Lister No. 371 Land Reform in Ukraine: The First Five Years. Csaba Csaki and Zvi Lerman No. 373 A Poverty Profile of Cambodia. Nicholas Prescott and Menno Pradhan No. 374 Macroeconomic Reform in China: Laying the Foundation for a Socialist Economy. Jiwei Lou No. 375 Design of Social Fuinds: Participation, Demand Orientation, and Local Organizational Capacity. Deepa Narayan and Katrinka Ebbe No. 376 Poverty, Social Services, and Safety Nets in Vietnam. Nicholas Prescott No. 377 Mobilizing Domestic Capital Marketsfor Infrastrnctutre Financing: International Experience and Lessons for China. Anjali Kumar, R. David Gray, Mangesh Hoskote, Stephan von Klaudy, and Jeff Ruster No. 378 Trends in Financing Regional Expenditures in Transition Economies: The Case of Ukraine. Nina Bubnova and Lucan Way No. 379 Empowering Small Enterprises in Zimbabwe. Kapil Kapoor, Doris Mugwara, and Isaac Chidavaenzi No. 380 India's Puiblic Distribution System: A National and International Perspective. R. Radhakrishna and K. Subbarao, with S. Indrakant and C. Ravi No. 381 Market-Based Inst rumentsfor Environmental Policymaking in Latin America and the Caribbean: Lessonsfrom Eleven Couintries. Richard M. Huber, Jack Ruitenbeek, and Ronaldo Ser6a da Motta. (Continuted on the inside back cooer) WORLD BANK DISCUSSION PAPER NO. 422 Environmental Health Bridging the Gaps James A. Listorti FadiM. Doumani The World Bank Washington, D.C. Copyright © 2001 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing May 2001 1 2 3 4 04 03 02 01 Discussion Papers present results of country analysis or research that are circulated to encourage discussion and comment within the development community. The typescript of this paper therefore has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. Some sources cited in this paper may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. 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For permnission to reprint individual articles or chapters, please fax your request with complete information to the Republication Department, Copyright Clearance Center, fax 978-750-4470. All other queries on rights and licenses should be addressed to the World Bank at the address above or faxed to 202-522-2422. ISBN: 0-8213-4687-3 ISSN: 0259-210X James A. Listorti is an environmental health consultant and Fadi M. Doumani is an economic consultant in the Private Sector and Infrastructure Group in the World Bank's Africa Region. Library of Congress Cataloging-in-Publication Data has been applied for. Table of Contents (The Table of Contents serves also as an Index) Foreword ................................................................ xv Abstract ................................................................ xvi Acknowledgments ................................................................ xvii How to Use This Volume ................................................................ xviii Part 1: Harmonizing Sectoral Priorities ................................................................ xviii Part 2: Environmental Health Assessment Guidelines ................................................................ xviii Part 3: Putting Theory into Practice ................................................................ xix Exclusions to this Volume ................................................................ xix Acronym List ................................................................ xxi Executive Summary ................................................................ xxiii Part 1: Harmonizing Sectoral Priorities: A New Approach to Environmental Health .................1 Chapter 1: Challenges of Environmental Health in Developing Countries ............... ....................3 Inadvertent Bias in Neglecting Environmental Health ................................................................. 3 How the Health Picture Differs in Developing Countries .................................................................S The Changing Face of Disease and the Developing World .............................................................. 7 Vector-Related Diseases .......................................................................7 The Double Burden of Disease in Developing Countries ....................................................................... 8 Global Change .......................................................................8 Multisectoral Approaches and the Challenges they Present .............................................................9 The Role of Knowledge Management ................................................................ 13 Chapter 2: Developing Solutions through Targeted Collaboration .............................................. 15 Objectives of Harmonizing Sectoral Priorities ................................ ................................ 17 Methodologies of Targeted Multisectoral Collaboration ................................................................ 19 Identifying and Prioritizing Measures Outside the Health Care System ...................................................... 19 Devising "Entry Points" ....................................................................... 20 Establishing Mutual Benefits for Sustainability ...................................................................... 21 Identifying the Stakeholders ...................................................................... 22 Establishing Mutual Benefits through Mapping ...................................................................... 23 Quantifying Untapped or Missed Health Benefits .................................................... ............ 24 Improved Service Delivery ...................................................................... 26 Estimating Beneficiaries ...................................................................... 27 Chapter 3: Socioeconomic Justification and Challenges ............................................................... 29 Why Do Mainstream Environmental Health in Development Work? .............................................. 30 Understanding Environmental Health Attributes ...................................................................... 33 Harmonizing Environmental Health with Environment Policies, Law, Institutions, and Monitoring Systems .................................................................. 36 Policy Failures .................................................................. 37 Structural and Sectoral Adjustment Lending: Macroeconomic Matrix .................................................... 38 Structural and Sectoral Adjustment Lending and Strategic Environmental Assessment: Action Impact Matrix ................................................................ 40 Public Expenditures Review ................................................................ 41 Country Assistance Strategy Environmental Analysis Matrix ................................................................ 42 Comprehensive Development Framework Matrix .......................... ...................................... 43 Poverty Reduction Strategy, Environmental Health, and Poverty Linkages ............................................ 44 iii Intermediation Mechanisms: Community-Driven Development .............................................................. 44 Institutional Failures ......................................................................... 45 Legislative Framework ......................................................................... 45 Institutional Framework ........................................................................ 46 Market Failures .... ................................................. . .................. 47 Monitoring ........................................................................ 48 Quantifying and Valuing the Environmental Health Burden of Disease ......................................... 50 Hypothesis for Back-of-the-Envelope Calculations ............................................... ......................... 50 Hypothesis for Quantifcation ........................................................................ 51 Hypothesis for Valuation ........................................................................ 52 Quantifying the Environmental Health Burden of Disease ......................................................................... 53 Valuation of Environmental Health Burden of Disease ......................................................................... 57 Prioritizing a Cluster of Environmental Health Interventions and Policy Responses ..................... 64 Prioritization ........................................................................ 64 Policy Response and Implications ........................................................................ 65 Concluding Remarks ................................................................. 66 Chapter 4: Gathering and Analyzing Information for Environmental Health ........... ................ 67 An Overview of EHAs ................................................................. 67 EHAs and Alternatives ................................................................. 69 Environmental Health Profiles ......................................................................... 69 Adapting an Existing Environmental Assessment as an EHA ..................................................................... 70 Adapting an Existing Health Assessment as an EHA ................................................................... ...... 70 Adapting an Existing Social Assessment as an EHA ....................................................... ................. 72 Adapting an Existing Poverty Assessment as an EHA ........................................................................ 72 Conducting a Complete EHA ........................................................................ 73 Chapter 5: Preparing an 'Environmental Health Profile" . ........................................................... 75 Preparing Sectoral Profiles ................................................................. 78 Poverty Profile ........ ................................................................. 79 Agriculture and Rural Development Profile ........................ ................................................. 79 Energy Profile ........ ................................................................. 80 Environment Profile ........................................................................ 80 Health Profile ......................................................................... 81 Industry Profile ........................................................................ 83 Infrastructure Profile ......................................................................... 83 Demographic Profile ......................................................................... 84 Institutional Profile ......................................................................... 84 Development Assistance Profile ........................................................................ 84 Analyzing the Data ................................................................. 85 Chapter 6: Adapting Environmental Assessments or Preparing Environmental Health Assessments ................................................................. 89 Adapting Existing Environmental Assessments to Serve as EHAs ......................... ......................... 89 Conducting a Complete EHA ................................................................. 96 Environmental Health Analyses ........................................................................ 97 Broad Picture and Overall Context ........................................................................ 97 Definition of Key, Confusing, and Misused Terms ........................................................................ 99 Individual Sector Factors and Issues ............................. 99 Typical Loans from the Sector ............................. 99 Environmental Health Assessment Outline ............................. 100 The Proposed Project ............................. 100 Institutional Strengths and Weaknesses ............................. 100 Occupational, High Risk and Vulnerable Groups .................................. 100 Hot Spots, Special Cases, and Key Pollutants .................................. 101 Inadvertant Professional Biases .................................. 101 On the Horizon .................................. 102 Research and Information Gaps .................................. 102 iv Recommendations .......................................................... 102 Part 2: Environmental Health Assessment Guidelines ................................................... 103 Chapter 7: Environmental Health Background Analyses ................................................... 105 Leading Health Problems ................................................. 105 Malnutrition ........................................................ 106 Respiratory Diseases, Tuberculosis, and Diseases Related to Air Pollution .............................................. 107 About Air Pollutants .............................................................................................. 108 Gastroenteric Diseases ................................... 110 Diarrheas ................................... 110 Intestinal Parasites ................................... 112 Malaria and Vector-Related Diseases ................................... 112 About Mosquitoes ................................... 113 Vector Control .................................... 115 Injuries and Accidents ................. 119 Physical and Mental Stress ................. 120 Diseasesfor Special Consideration .................................. 120 AIDS ........................................120 Epidemic Cholera ....................................... 121 Guinea Worm Infection ......................................... 121 Key Cross-Cutting Issues ................................. 122 Pesticide Use ..................................... 122 Biological Diversity and Traditional Medicines ..................................... 126 Chapter 8: Cross-Sectoral Linkages: Agriculture and Rural Development Sector .................. 129 Key Environmental Health Issues ........................................................... 129 Human Settlements ........................................................... 130 Housing ................................................................... 131 Energy Use and Generation ................................................................... 132 Traditional Fuel ................................................................... 132 Modern Fuels ........................................... 133 Power Generation ...................................... 133 Periurban Agriculture and Livestock ...................................... 134 Land Use and Natural Resource Management ....................................... 134 Food Production, Processing, Storage, and Transport ...................................... 134 Crops, Food Security, and Nutrition ........................ 134 Use of Pesticides and Fertilizers ........................ 136 Livestock and Animal Husbandry ........................ 138 Fisheries andAquaculture ............................... ... 140 Food Processing, Storage, and Transport . 140 Land Clearing for Agriculture or Settlement ............................. 142 Forestry, Biodiversity, and Traditional Medicines ............................. 143 Water and Waste Management ............................. 145 Rural Community Drinking Water Supply ............................. 145 Irrigation and Drainage . 147 Potential Impacts f rom Increased Agricultuire ............................. 147 Potential General Ecological Disturbances ............................. 148 Marshes and Other Wetlands ............................. 149 Reuse of Wastewater ............................. 149 Agricultural Waste Management ............................. 149 Domestic Waste Management ............................. 149 Wastewater ...................... 149 Periurban Waste ............. 150 Rural Transportation ................... 150 Roads, Trails, and Paths ................. 150 River Transport .................,......,.,......,,.,....,,,,....,.....,...,.151 Environmental Health Assessment Checklist ................................. 151 v Typical Loans and Components from the Sector ................................................. 151 Occupational, High Risk, and Vulnerable Groups ................................................. 151 Environmental Health Checklist for the Sector ................................................. 152 Chapter 9: Cross-Sectoral Linkages with the Energy Sector ............................................ 157 Key Environmental Health Issues ............................................ 157 Findings of a Literature Review ............................................ 157 Environmental Health Assessment Checklist ............................................ 160 Occupational, High Risk, and Vulnerable Group .................................................. 160 Environmental Health Checklist for the Sector ................................................. 161 Chapter 10: Cross Sectoral Linkages: Environment Sector ............................................ 163 Key Environmental Health Issues ............................................ 163 Findings of a Literature Review ............................................ 163 Environmental Health Assessment Checklist ............................................ 164 Chapter 11: Cross-Sectoral Linkages: Health Sector ............................................ 167 Key Environmental Health Issues ............................................ 167 Findings of a Literature Review ............................................ 167 Environmental Health Assessment Checklist ............................................ 169 Chapter 12: Cross-Sectoral Linkages: Industry Sector ............................................ 171 Key Environmental Health Issues ............................................ 171 Findings of a Literature Review ............................................ 171 Industrial Pollution and Waste .................................................. 171 Occupational Health ................................................. 172 Research on the Role of Governments ................................................. 172 A Note on the Role of the Private Sector .................................................. 173 Environmental Health Assessment Checklist ............................................ 174 Chapter 13: Cross-Sectoral Linkages: Infrastructure Sector ............................................ 177 Key Cross- Cutting Environmental Health Issues ............................................ 177 "Brown" Issues ..................................... ............ 177 Vector-Related Diseases .................................................. 177 Food Chain Contamination ................................................. 178 Special Note on AIDS ................................................. 178 Housing and Urban Development ............................................ 178 The Broad Picture .................................................. 178 Key Environmental Health Issues ................................................. 179 Housing Quality and Ventilation .................................................. 179 Energy Use ................................................. 180 Land Degradation ...................................... 180 Environmental Health Assessment Checklist ...................................... 181 Typical Loans and Componentsfrom the Sector ...................................... 181 Construction Activities and Mosquito Breeding ...................................... 181 Housing: Dirt Floors and Intestinal Worms ...................................... 181 Housing: Indoor Air Pollution ...................................... 182 Proximity to Large-Scale or Hazardous Pollution ...................................... 182 Tinkering, Cottage Industries, and Artisanal Markets ...................................... 183 General Markets ...................................... 183 Household-Related Injuries ....................................... . . . . . . 183 Occupational, High Risk, and Vulnerable Groups ...................................... 184 Telecommunications .................................. 188 Transportation .................................. 189 Key Environmental Health Issues ...................................... 189 Environmental Health Assessment Checklist ...................................... 191 Vi Typical Loans and Components,from the Sector ................................. . , .191 Injuries .............................11.........I.., 191 Train, Bus, Rail, and Taxi Stations .191 Ports and Harbors .192 Dredging .193 Airports .193 Vehicle-Related Pollution Control .193 Construction and Vector-Related Diseases .193 Roads.194 Railways ...................................................... 194 Water Supply and Sanitation .199 The Broad Picture and Key Environmental Health Issues .199 Key, Confusing, and Misused Terms .199 Environmental Health Assessment Checklist .200 Typical Loans and Components from the Sector .200 Water Quality and Quantity .201 Sanitation and Drainage .201 Disposal and Treatment of Human Excreta .202 Solid Waste Management .203 Drainage .207 Water Supply .208 Industrial Wastewater .210 Accidents and Safety .210 High Risk and Vulnerable Groups .210 Chapter 14: Global Issues .217 Key Environmental Health Issues .217 "New " and Re-Emerging Diseases .218 Food Production .219 Vector-Related Diseases .220 Part 3: Putting Theory into Practice: A Case Study in Ghana .223 Chapter 15: Ghana Sample Sectoral Profiles .225 Environment Sector Profile .225 Environmental Issues .225 Environmental Recommendations ...................................... 227 Health Sector Profile . 229 Infrastructure Sector Profile . 230 Urban ..230 Water Supply . 231 Transport ..231 Rural Infrastructure . 232 Energy Sector Profile . 234 Industry Sector Profile . 234 Demographic Profile . 235 Development Assistance Profile . 237 Institutional Profile . 238 Poverty Reduction Profile . 242 References . 244 World Bank Documents Cited . 244 Additional Useful World Bank Documents on Ghana . 244 Chapter 16: Sample Institutional Needs Assessment from Ghana .245 Environmental Health Needs Assessmentfrom Ghana .245 Introduction and Objectives . 245 vii Methods and Institutions Consulted .................................................................... 246 Geographic, Demographic, and Sanitary Background on SAEMA ........................................................... 247 Environmental Health Findings from the Need Assessment Survey ......................................................... 248 Top Ten Diseases in SAEMA ..................................................................... 248 Relationship between the Top Ten Diseases and Environmental Conditions ........................................ 249 Perceptions of the Health Problems ..................................................................... 250 Institutional Roles Regarding Entry Points ...................................................................... 251 Nonhealth Departments ..................................................................... 252 Civil Society ...................................................................... 254 The Weak or Missing Link in the Management of Urban Malaria ........................................................ 255 Institutional Priorities and Objectives ..................................................................... 255 Reporting ................................................................... 256 Conclusions .................................................................... 261 Terms of Reference for an Institutional Needs Assessment ........................................................... 262 Outline of the Needs Assessment ................................................................... 262 Content of the Needs Assessment ................................................................... 262 Public Health ..................................................................... 262 Institutional and Legal Aspects, Financing Mechanism, Capacity, and Recommendations ................. 263 Assignment ..................................................................... 263 References ............................................................... 264 Chapter 17: Sample Workshop on Targeted Collaboration in Ghana ....................................... 265 Background ............................................................... 265 USEP Mid-Term Reviewfor the Five Cities Workshop ............................................................... 266 Proposal 1 :Urban Malaria and other Vector Borne Diseases, Sanitation and Drainage ............................ 267 Proposal 2: AIDS Outreach ................................................................... 268 Proposal 3: Management of Health Facility Waste ................................................................... 268 Statement of the Problem ...................................................................... 268 Points of Intervention .................................................................................... 269 Soolutions ..................................................................... 269 Sekondi-Takoradi Workshop ............................................................... 269 Background ................................................................... 269 Objective and Participants ...................................................................... 269 Summary of Discussions on Entry Points and Proposed Solutions ........................................................... 270 Management of Health Facility Waste ..................................................................... 270 Points of Intervention ..................................................................... 270 Solutions ..................................................................... 270 Recommendations ..................................................................... 271 Urban Malaria ..................................................................... 271 Area Mapping and Assessment ..................................................................... 271 Recommendations ..................................................................... 275 Water, Sanitation, and Drainage ..................................................................... 275 Water ..................................................................... 276 Recommendations ..................................................................... 276 Sanitation ....... .............................................................. 276 Recommendations ..................................................................... 276 Drainage ..................................................................... 276 Recommendations ..................................................................... 276 Cross-Cutting Issues ...................................................................... 277 Summary of Participants' Comments ................................................................... 277 Summary and Recommendations ................................................................... 278 Sample Terms of Reference for the Sekondi-Takoradi Workshop .......................... ....................... 280 Background and General Assignment ................................................................... 280 Selection of City .................................................................................... 281 Consultant Assignments ..................................................................... 281 Consultations and Assessment ..................................................................... 281 Workshop Preparation Management and Report ................................................................... 281 viii Annexes ................................................ 283 Annex A: Environmental Health Assessments: Rapid Checklists .............................................. 285 Annex B: Basic Information on Important Diseases ................................................ 313 Individual Diseases ..................................................... 313 Cholera ............. . . . .313 Dengue Fever ............................314 Diarrheas and Dysentery ................. . . . ... . . . 315 Diarrheas: Undifferentiated (Childhood and Traveler's) ....................................... 315 Diarrheas: Specific ....................................... 316 Dysentery: Amebic ....................................... 317 Dysentery: Shigellosis ....................................... 318 Filariasis ...................318 Food Poisoning .............. 320 Giardiasis ...............320 Guinea Worm Disease ,,.,.,., .,. 321 Hepatitis ....................................322 Intestinal Wormns (Ascaris and Hookworn) . 323 Intestinal Worms: Ascariasis ................................... 323 Intestinal Worms: Hookworm ................................... 324 Malaria ....................................325 Onchocerciasis .............326 Respiratory Diseases (Acute, Flu, and Pneumonia) ..... 327 Respiratory Disease: Acute Respiratory Illnesses (Short-Term and Mild) ................................... ......... 327 Respiratory Disease: Influenza ..................................................... 327 Respiratory Disease: Pneumonias ..................................................... 328 Salmonelloses (Salmonella and Typhoid) ..................................................... 329 Salmonelloses: Salmonellosis (see also Dysentery) ..................................................... 329 Salmonelloses: Typhoid and Paratyphoid ..................................................... 329 Schistosomiasis ..................................................... 330 Tesetanus ........332 Trachoma ..............,....,...,.,........,.....,.332 Trypanosomiases (African Sleeping Sickness and Chagas' Disease) ................................................... 333 Trypanosomiases: African Sleeping Sickness ................................................... 333 Trypanosomiases: Chagas' Disease (American) ................................................... 334 Tuberculosis ................................................... 334 References ................................................... 337 Glossary .............................................. 343 General Terms on Environmental Health ................................................... 343 Terms on Environmental, Health, and Risk Assessments ................................................... 349 Environmental Health .....,......,,.349 Assessment .............................,,... ....350 Environmental Health Impact Assessment ............................ 350 Health Impact Assessment . 351 (Health impact assessment within an environmental impact assessment) .............................................. 351 Environmental Assessment and Environmental Impact Assessment ..................................................... 351 Environmental Assessment ..................................................... 351 Environmental Assessment (Regional) .................................................... 352 Environmental Assessment (Sectoral) ...................................................... 352 Environmental Impact Assessment ..................................................... 352 Risk and Hazard Assessment ............ 354 Hazard and Risk Assessment ................................... 354 Bibliography ................................... 357 Environmental Assessment Resources ................................... 357 Environmental and Health Resources ., 359 Environmental Health Links on the Internet ............................... 361 ix World Bank Intranet ................................................................. 361 Environment ................................................................. 361 Health ................................................................. 361 Infrastructure (Water) ................................................................. 362 Industry ................................................................. 362 Nonsector Specific ................................................................. 362 On the Internet ................................................................. 362 Agriculture ................................................................. 362 Environment ................................................................. 363 Health ................................................................. 364 Industry ................................................................. 365 Infrastructure (Water and sanitation) ................................................................. 365 Infrastructure (Energy) ................................................................. 366 Infrastructure (Transport) ................................................................. 366 Non sector specific ................................................................. 366 Audiovisuals ................................................................. 367 Notes .................................................................... 369 Boxes Box 1-]: The Case of Lead ..............................................................4 Box 1-2: Key Confusing and Misused Terms on Diseases and Statistics ........................................................5 Box 1-3: Urbanization in Sub-Saharan Africa .............................................................8 Box 1-4: The Health Situation in Sub-Saharan Africa ..............................................................9 Box 1-5: A Near Miss in an Environmental Assessment ............................................................. 12 Box 1-6: The Contributions of an Environmental Health Approach ............................................................. 14 Box 2-1: Mainstreaming the New Approach into Bank Development Work ................................................ 16 Box 2-2: Environmental Health Defined ............................................................. 17 Box 2-3: Key, Confusing, and Misused Terms on "Medicine" and "Health" ... .............................................. 18 Box 3-1: Working Definition of Environmental Health ............................................................. 30 Box 3-2: Key, Confusing, and Misused Economic Terms on Environmental Health ................................... 32 Box 3-3: Example of Legislation Adapted for Environmental Health ........................................................... 46 Box 3-4: Key, Confusing, and Misused Terms on Goods and Services ........................................................ 46 Box 3-5: Measuring the Burden of Disease: The DALY Concept ............................................................. 51 Box 3-6: Partnerships to Manage Vector-Related Diseases in an Urban Setting .......................................... 62 Box 4-1: Key, Confusing, and Misused Terms on Assessments and Plans ................................................... 67 Box 4-2: Clarifying the Objectives of Assessments and Projects ............................................................. 68 Box 4-3: Sample Outline for a Health Impact Assessment ............................................................. 70 Box 4-4: Sample Sequence of the EHIA Process ............................................................. 72 Box 5-1: A Word of Caution ............................................................. 79 Box 5-2: A Note on Sub-Saharan Africa ............................................................. 81 Box 5-3: Truckers in SSA and AIDS ............................................................. 82 Box 5-4: "Drop-Dead" Data ............................................................. 82 Box 5-5: Employing an EHP in Ghana ............................................................. 86 Box 6-1: Core Outline for an Environmental Health Assessment ............................................................. 97 Box 7-1: Potential Risks Associated with Pesticide Use in Malaria Control in SSA .................................. 117 Box 7-2: Key, Confusing, and Misused Terms on Pesticides ............................................................. 122 Box 7-3: Health Aspects of World Bank Policy on Pest Management (OP 4.09) ....................................... 123 Box 8-1: Key, Confusing, and Misused Terms on Human Settlements ...................................................... 131 Box 8-2: Key, Confusing, and Misused Terms about Rural Energy ............................................................ 132 Box 8-3: Drought in Sub-Saharan Africa ............................................................. 135 Box 8-4: Key, Confusing, and Misused Terms on Agriculture ............................................................. 136 Box 8-5: Key, Confusing, and Misused Terms on Fertilizers ............................................................. 138 Box 8-6: Medicinal Plants and Ghana ............................................................. 143 Box 8-7: Two Successes in Eradicating Guinea Worm Disease and River Blindness ................................ 145 Box 8-8: The Stressful Facts about Rural Water Supply ............................................................. 146 Box 11-1: Key, Confusing, and Misused Terms on the Heath Sector ......................................................... 167 x Box 13-1: Key, Confusing, and Misused Terms on Human Settlements ..................................................... 179 Box 13-2: Key, Confusing, and Misused Terms on Air Pollution ......................................................... 191 Box 13-3: Key, Confusing, and Misused Terms on Sanitation .......................................................... 200 Box 13-4: Medical Waste Management in Ghana .......................................................... 206 Box 13-5: Urban Malaria: The Need for Data from Sectors besides Health ................................................ 208 Box 14-1: Key, Confusing, and Misused Terms on Climate and Ozone Depletion ..................................... 218 Box 16-1: Mr. Ampadu Adjei (Head of Physical Planning Department) ..................................................... 251 Box 16-2: Market Women Association ........................................................................... 251 Box 16-3: Dr. Lynda Vanatoo (Metro Director of Health Services) .............................................. 252 Box 16-4: Robert Austin, Coordinator UESP .............................................. 258 Box 16-5: Deputy Coordinating Director, SAEMA .............................................. 258 Box B-1: Caveat on These Disease Descriptions .............................................. 313 Tables Table ES-1: Sample Linkages and Synergies to Harmonize Infrastructure Sectoral Priorities ................... xxv Table 1-1: Top Ten Diseases and Conditions (1998) by Indicative DALYs ...................................................6 Table 1-2: Environmental Factors and the Global Burden of Disease: Proportion of Global DALYs Associated with Environmental Exposures (1990) .......................................................................... 6 Table 1-3: Death and Disability of Top Ten Vector-Borne Diseases (1998) ...................................................8 Table 1-4: Rank and Share of Burden of Disease in SSA (1990) .....................................................................9 Table 1-5: Rank and Share of the Burden of Disease in SSA (1990-98) ....................................................... 10 Table 1-6: Possible Consequences from the Absence of Health in Decisionmaking ..................................... 13 Table 2-1: Sample Environmental Health Determinants and Consequences ................................................. 17 Table 2-2: Infrastructure Measures for Top Five Burdens of Disease in SSA ............................................... 19 Table 2-3: Top Ten Diseases in Ghana by Infrastructure Intervention (1994) ............................................... 20 Table 2-4: Sample Linkages and Synergies to Harmonize Sectoral Priorities ............................................... 21 Table 2-5: Stakeholders at Risk and Potential Partnerships for Entry Points in Ghana ................................. 22 Table 2-6: Ghanaian Recommendations for Entry Points Based on Multisectoral Collaboration ................. 23 Table 2-7: Burden of Disease in SSA by Main Remedial Measures (1990) .................................................. 25 Table 2-8: Burden of Disease Relieved by Remedial Measures (1998) ......................................................... 26 Table 2-9: Possible Health Benefits Missed by Focusing on a Single Disease .............................................. 26 Table 2-10: Sample of Increased Health Benefits in Long-Term Water Sector Project in Senegal .............. 27 Table 3-1: Back-of-the-Envelope Burden of Disease (BOD) Breakdown in SSA, 1998 ............................... 31 Table 3-2: Health Risks Attributable to Natural Disasters in SSA, 1990-2000 ............................................. 34 Table 3-3: Environmental Health Externalities Usually Neglected in Valuation ........................................... 35 Table 3-4: Macro Policies Impact on Environment and Environmental Health ............................................ 39 Table 3-5: Example of an Action Impact Matrix (AIM) ......................................................................... 41 Table 3-6: CAS Environmental and Environmental Health Analysis Matrix ................................................ 43 Table 3-7: CAS Country Program Matrix ......................................................................... 43 Table 3-8: Example of Environmental Health Monitoring System Targeting Poverty .................................. 49 Table 3-9: Back-of-the-Envelope SSA Environmental Health Quantification, 1998 (DALY and $Billion) 54 Table 3-10: Back-of-the-Envelope SSA Environmental Health Valuation, 1998 (DALY and $Billion) ...... 58 Table 3-11: Policies and Instruments for Sustainable Development .............................................................. 65 Table 5-1: Summary of Sectoral Problems, Strategies, and Actions for Ghana ............................................. 76 Table 5-2: Sample Sectoral Problems and Strategies/Actions from Ghana ................................................... 77 Table 6-1: The World Bank's Safeguard Policies ........................................................................ 89 Table 6-2: Adapting Bank EA Procedures to an EHA or Equivalent ............................................................. 90 Table 6-3: Adapting EA Content to an EHA ........................................................................ 90 Table 6-4: Adapting an EA Environmental Management Plan to an EHA .................................................... 91 Table 6-5: Adapting EA Checklists to an EHA or Equivalent Analysis ........................................................ 92 Table 6-6: Environmental Health in NEAPs ......................................................................... 95 Table 6-7: Sample Environmental Health Linkages of Bank Lending by Sector .......................................... 98 Table 6-8: Main EHA Points for SSA Infrastructure ........................................................................ 99 Table 6-9: Sample Occupational, High Risk, and Vulnerable Groups ......................................................... 101 Table 7-1: Major Risk Factors in Less Developing Countries (LDCs) ..................................................... 106 Table 7-2: Air-Pollution-Related Respiratory Illness ........................................................................ 109 Table 7-3: Major Components of Air Pollution ........................................................................ 109 Table 7-4: Multiple Sources of Lead ........................................................................ 110 xi Table 7-5: Main Excreta- and Water-Related Diseases ....................................................................11 I Table 7-6: Major Intestinal Parasites ................................................................... 112 Table 7-7: Transmission of Main Vector-Related Diseases ................................................................... 114 Table 7-8: Summary of Persistent Organic Pollutants (POP) Use and Restrictions by Country ................. 116 Table 7-9: Main Uses of POPs ................................................................... 126 Table 8-1: Main Intersectoral Environmental Health Linkages with the Agriculture Sector ...................... 129 Table 8-2: Health Consequences of Drought, Selected Examples 1970-2000 ............................................ 135 Table 8-3: Most Important Crops and Chemical Use, World and SSA (1970-91) ..................................... 138 Table 8-4: Diseases Transmitted from Animals to Humans ................................................................... 139 Table 8-5: Diseases Transmitted from Fish and Seafood to Humans .......................................................... 140 Table 8-6: Human and Livestock Diseases Treated by Plant Species ......................................................... 144 Table 8-7: Most Important Crops Grown in the World and SSA (1970-91) ............................................... 144 Table 8-8: Potential Environmental Health Impacts from Irrigation ........................................................... 147 Table 8-9: Potential Health Impacts from Increased Agriculture ................................................................ 148 Table 8-10: Major Hazards in Reuse of Wastewater ................................................................... 149 Table 8-11: Major Health Hazards of Agricultural Waste Management ..................................................... 149 Table 8-12: Occupational, High Risk, and Vulnerable Groups for Agriculture Sector ............................... 151 Table 8-13: Agriculture Sector Environmental Health Checklist ................................................................ 152 Table 9-1: Main Environmental Health Linkages with the Energy Sector .................................................. 160 Table 9-2: Occupational, High Risk, and Vulnerable Groups for the Energy Sector .................................. 160 Table 9-3: Energy Sector Environmental Health Checklist ................................................................... 161 Table 10- 1: Main Environmental Health Linkages with the Environment Sector ....................................... 164 Table 10-2: Environment Sector Environmental Health Checklist .............................................................. 164 Table 11 -1: Main Environmental Health Linkages with the Health Sector ................................................. 169 Table 11 -2: Health Sector Environmental Health Checklist ................................................................... 169 Table 12-1: Main Environmental Health Linkages with the Industry Sector .............................................. 174 Table 12-2: Industry Sector Environmental Health Checklist ................................................................... 174 Table 13- 1: Main Environmental Health Linkages for Housing and Urban Development ......................... 180 Table 13-2: Occupational and Vulnerable Groups for Housing and Urban Development .......................... 184 Table 13-3: Housing and Urban Development Sector Environmental Health Checklist ............................ 184 Table 13-4: Occupational and Vulnerable Groups for Telecommunications .............................................. 188 Table 13-5: Telecommunications Sector Environmental Health Checklist ................................................. 188 Table 13-6: Main Cross-Sectoral Environmental Health Linkages for Transport ....................................... 189 Table 13-7: Environmental Health Risks Associated with Transport .......................................................... 190 Table 13-8: Main Occupational, High Risk, and Vulnerable Groups for Transport .................................... 195 Table 13-9: Transport Sector Environmental Health Checklist ................................................................... 195 Table 13-10: Main Environmental Health Linkages for Water Supply and Sanitation ............................... 199 Table 13-11: Highlights of Waste Stabilization Ponds and Conventional Treatment ................................. 203 Table 13-12: Main Occupational and Vulnerable Groups for Water Supply and Sanitation ...................... 211 Table 13-13: Water Supply and Sanitation Environmental Health Checklist .............................................. 211 Table 14-1: Health Effects of Climate Change and Ozone Depletion ......................................................... 217 Table 14-2: Main Environmental Health Linkages with Global Issues ....................................................... 219 Table 14-3: World Hydro Power: Potential Number of Dams for Development ........................................ 220 Table 15-1: Common Diseases in Ghana 1994 ................................................................... 230 Table 15-2: Ranking of the Top Ten Diseases in Ghana 1991-94 .............................................................. 230 Table 15-3: Sectoral Participation of Selected Donors ................................................................... 237 Table 16-1: Institutions Consulted ................................................................... 246 Table 16-2: Health Care Facilities in SAEMA ................................................................... 248 Table 16-3: Top Ten Diseases in SAEMA ................................................................... 248 Table 16-4: Outpatient Attendance Due to Malaria ................................................................... 249 Table 16-5: Environmental Linkages of Top Ten Causes of Morbidity in SAEMA ................................... 250 Table 16-6: Capacity for Intersectoral Collaboration ................................................................... 260 Table 17-1: Institutional Partnerships to Reduce Urban Malaria ................................................................. 275 Table 17-2: Opportunities for Intersectoral Collaboration within the SAEMA ........................................... 279 Table A-1: Sample Environmental Health Linkages of Bank Lending by Sector ....................................... 286 Table A-2: Agriculture Sector Environmental Health Checklist ................................................................. 287 Table A-3: Energy Sector Environmental Health Checklist ................................................................... 291 Table A-4: Environment Sector Environmental Health Checklist ............................................................... 293 Table A-5: Health Sector Environmental Health Checklist ................................................................... 295 xii Table A-6: Industry Sector Environmental Health Checklist .......................................................... 296 Table A-7: Housing and Urban Development Sector Environmental Health Checklist .............................. 298 Table A-8: Telecommunications Sector Environmental Health Checklist ................................................... 301 Table A-9: Transport Sector Environmental Health Checklist .......................................................... 302 Table A-10: Water Supply and Sanitation Environmental Health Checklist ............................................... 306 Map Map 5-1: Environmental Health Needs Assessment Map for Sekondi-Takoradi, Ghana................. 87 xiii FOREWORD Environmental health remains at the periphery of sustainable development, because it is inade- quately defined, rarely quantified, and institutionally fragmented. Failing to address environ- mental health amplifies the burden of disease, which impinges on Sub-Saharan Africa's (SSA) overall economic performance and well-being of its population, especially the poor. The Envi- ronmental Health: Bridging the Gaps program is a phased effort developed under the World Bank's SSA Initiative on Urban Environmental Management with additional support from the Norwegian, Swedish, and Swiss governments. The program strives to highlight missing links among infrastructure, environment, and health by identifying health problems outside the health care system and proposing solutions. Environmental Health: Bridging the Gaps is a work in prog- ress. It addresses these issues by mainstreaming environmental health at the macro, sectoral, and project levels. It also provides practical guidance on how to tackle such issues through a mul- tisectoral approach and weave the program's three phases together, each with a different lesson. * Phase I focused on urban infrastructure and published the three-volume Bridging Envi- ronmental Health Gaps.' This phase (a) contained guidance on incorporating environ- mental health into urban infrastructure projects and policy, (b) proposed that enormous potential to relieve the SSA burden of disease remains untapped, and (c) estimated that up to 44 percent of that burden may be amenable to infrastructure improvements. * Phase II put into practice lessons of phase I in a pilot in Ghana (1 999), which proposed new ways to reduce poverty by increasing the efficiency of investments through collabo- ration based on institutional complementarity, synergies, and mutual benefits, rather than additional budgets. Health priorities are re-evaluated to maximize solutions outside the health sector through Intersectoral collaboration. Phase II estimates that infrastructure projects conceivably could relieve as much of the burden of disease as the health sector, about 20 percent, for a fraction of the cost, because infrastructure projects have already been justified on other grounds. Moreover, the environmental health burden of disease af- fecting the poorest of the poor represents 10 percent of SSA's total burden of disease. As- sociated lower bound social costs of environmental health problems are equivalent to 6 percent of SSA's 1998 GDP. * Phase III addresses rural infrastructure by complementing and expanding the prior urban focus (1999). Multisectoral linkages with urban and rural infrastructure are incorporated to include factors such as food production, pesticide use, irrigation, and so on. The implications of infrastructure in improving health need additional epidemiological and eco- nomic analyses. Until then, we must act on professional judgment to help fill in the gaps based on the tools we have available. Environmental Health: Bridging the Gaps tries to help. Praful Patel, Sector Director Private Sector and Infrastructure Group, Africa Region xv ABSTRACT Environmental Health: Bridging the Gaps, which is divided into three parts, is a work in prog- ress, aiming to help fill a void in economic development thinking as well as procedures to address multisectoral problems that require multisectoral responses. Intended for policymakers and prac- titioners alike, this discussion paper makes a modest step in helping address those problems by: (i) proposing a new approach of targeted collaboration among different sectors; (ii) devising new tools or enhancing existing ones to facilitate the contributions of different sectors to help relieve health problems; and (iii) putting theory into practice through a pilot in Ghana. Part 1: Harmonizing Sectoral Priorities. After laying out the foundations and challenges of envi- ronmental health, the discussion paper tries to tap, quantify and value health benefits systemati- cally outside the health sector, and prioritize as well as monitor interventions through a harmo- nized multisectoral collaboration. Back-of-the-envelope calculations are worked out showing that environmental health measures can target at least an equal share of the burden of disease than the health sector, that is, roughly 20 percent (10 percent affecting the poorest of the poor). Moreover, many health benefits are missed by being aggregated under the general rubric of "health benefits" in economic discussions, and by dealing with single diseases, when several diseases may be ad- dressed simultaneously by remedial measures outside the health system, such as reducing indoor air pollution. Part 2: Environmental Health Assessment Guidelines. In addition to discussing back-of the- envelope economic valuation of the burden of disease, three sets of new tools are proposed to help policymakers, Task Managers and other practitioners make sound decisions, devise entry points, and establish mutual benefits from targeted collaboration. First, an "Environmental Health Profile" (EHP) as means to derive a shortlist of potentially important issues through a desk re- view comparing priorities from several sectors without necessarily incurring the costs of more ambitious studies. Second, procedures to adapt existing environmental, social or poverty assess- ments to serve as environmental health assessments. Third, a set of Environmental Health As- sessment Guidelines and checklists, which relate to Bank projects and components, propose re- medial measures for multisectoral health problems, many of which could and do otherwise fall between the cracks in single sector projects. Part 3: Putting Theory into Practice. A pilot in Ghana, which could be developed as a case study for replication, puts theory into practice. Many cities in developing countries are facing difficul- ties because of efforts to decentralize or privatize services that were the responsibility of national governments and which fall on the shoulders of regional or municipal agencies. Unfortunately, many such governments and agencies do not have the in-house capacity and budgets to take on these added responsibilities, nor do they have adequate laws, bylaws and other regulatory meas- ures. The pilot, which took six months from preparing an Environmental Health Profile and an institutional needs assessment to making recommendations to an ongoing project, puts into prac- tice the ideas and tools that were developed above. After identifying multisectoral problems to- gether with the government and the stakeholders, three entry points were prioritized (urban ma- laria, AIDS prevention and proper management of waste from health care facilities), and recom- mendations were fed into the project. xvi ACKNOWLEDGMENTS Preparation of Environmental Health: Bridging the Gaps has been supported by the Swedish In- ternational Development Cooperation Agency (SIDA), the Swiss Development Corporation (SDC), and the World Bank's Urban Environmental Initiative of the Africa Region. (Prior work, the 1996 Bridging Environmental Health Gaps, was financed by the Norwegian government.) In addition to financial support from SIDA and SDC, special recognition and thanks are due to the remainder of the Bridging Environmental Health Gaps team for their invaluable assistance and major contributions to this work. To Denise Vaudaine, Task Team Leader, for overall guid- ance on keeping the work on target to its intended users in the Bank and outside. To Anne Ham- mer, Project Assistant, who provided invaluable editorial and research assistance and was instru- mental in handling many of the budgeting and administrative matters that made the workshop run smoothly. And especially to co-author Fadi Doumani, for writing chapters 3 (economics) and 16 (institutional needs assessment), for contributing to many others with innovative ideas, especially the application of aerial mapping to solve local environmental health problems, and for showing that missed environmental health benefits have their greatest impacts on the poor. All of these were key to the success of the Ghana pilot, including its initial funding, the overall success of our entire work and this Discusson Paper. In addition, Ernestina Attafuah, Connie Kok Shun, Sophie Hans-Moevi, and Norma Camacho of the Administrative and Client Support Group, as well as summer intern Ronald Subida (MD) for their technical and moral support. Letitia Obeng, sector manager, also deserves special recognition for institutional support and technical advice in past years for backing this new initiative, the Environment and Health: Bridging the Gaps program. Jean Doyen (Division Chief under whom the work was initiated), Snorri Hallgrimsson (Lead Transport Engineer), Meghan Dunleavy (Public Health Specialist), Lilian Pintea (GIS Specialist), and Michel Guillot (Post-Doctoral Fellow at Harvard Center for Population & Development Studies), also deserve thanks for their help and support. A number of people were instrumental in bringing about the Ghana pilot, and we are especially indebted to Jagdish Bahal, Charles Boakye, Peter Harrold, Guenter Heidenhof, David Henley, Claude Isaac Salem, Gerhard Tschannerl, (World Bank Headquarters and Country Office), S. Y. M. Zanu, Geoffrey Ewool (Ministry of Local Government and Rural Development), Ben Doe (Consultant), and Patsy Sterling (DflD). Special thanks are also in order for the staff of the Sectoral and Information Technology Re- sources Center, especially Chris Windheuser and Eliza McLeod, for their helpfulness, efficiency, and initiative in ferreting out reference material to help this work. We are also grateful for the following staff members for their review of the document and helpful comments: Christophe Bosch, Mariam Claeson, Ed Elmendorf, David Hanrahan, Rita Klees, Malik Khokar, John Lambert, Kseniya Lvovsky, Jean-Roger Mercier, Robert Robelus, Jennifer Sara, Lee Travers, and Harry van der Wulp. Thanks also for the able assistance of editor and writer, Pamela S. Cubberly, for her work in shaping and editing most of the chapters in this document for publication. James A. Listorti xvii HOW TO USE THIS VOLUME This volume is intended for use by staff from various agencies involved with economic develop- ment and are divided into different parts for different audiences. The guidelines are intended to fill a void in the literature by bridging gaps-in particular, gaps between environmental assess- ments, which are supported by a vast literature, and health assessments, which is only in a nascent state and by providing background on the set of environmental health problems associated with various sectors. The guidelines cover six broad sectoral areas, stressing the environmental health dimensions of each: * Agriculture and rural development * Industry * Energy * Infrastructure * Environment * Multisectoral global issues * Health The guidelines can help prioritize investments by: * Defining realistic expectations of projects to improve health, given the myriad of factors at play and the time it takes to improve health - Identifying areas in whichpiggybacking of resources can lead to broader health impacts than would otherwise be possible and multisectoral links can be forged based on institu- tional complementarity * Illustrating that health is not merely a sectorfor investments, but also a goal of the entire process of sustainable development. Part 1: Harmonizing Sectoral Priorities Intended for policymakers and practitioners alike, part 1 of this volume explains the foundations of environmental health and proposes a new approach that taps health benefits systematically out- side the health sector through multisectoral collaboration. Chapter I details the differences and challenges of environmental health in developing countries. The new approach introduced in chapter 2 addresses these challenges by harmonizing sectoral approaches through targeted col- laboration and partnerships to maximize health benefits outside the health sector. Chapter 3 as- serts that environmental health measures can target a greater share of the burden of disease as the health sector, that is, roughly 20 percent for a fraction of the cost of health sector interventions. Chapters 4 through 6 compare and contrast six alternatives to making sound decisions, devising entry points, and establishing mutual benefits from targeted collaboration. Part 2: Environmental Health Assessment Guidelines Intended for Bank Task Managers and practitioners in the field, part 2 of this volume provides basic tools to identify, prioritize, and propose remedial measures for many multisectoral health problems, many of which could and do otherwise fall between the cracks in single sector projects. Chapter 7 provides basic environmental health background pertinent to all sectors covered in part 2. Chapters 8-14 provide guidance on environmental health linkages within and among sectors, which are summarized in a checklist at the end of each chapter. This edition of Environmental Health: Bridging the Gaps focuses particular attention on cross-sectoral linkages with infrastruc- ture interventions between the agriculture and rural development sector (chapter 8) and the infra- structure sector (chapter 13). The other chapters briefly review linkages in the energy (chapter 9), environment (chapter 10), health (chapter 1 1), and industry (chapter 12) sectors and with global xviii issues, that is, those that affect the planet as a whole (chapter 14), because many of the issues have already been addressed in chapters 7, 8, and 13. Part 3: Putting Theory into Practice Chapters 15, 16, and 17 summarize the findings and present background material from a work- shop in Ghana, "Targeted Collaboration among Line Agencies, Local Communities and the Min- istry of Health," putting into practice the ideas of parts 1 and 2. Innovations included a multisec- toral environmental health needs assessment, as well as suggestions for remedial measures. The summaries can be useful for policymakers and the details, process, and recommendations can be useful for practitioners in the field. Annex A provides a rapid checklist on environmental health for practitioners and task managers. Annex B provides one-page summaries of about twenty ma- jor diseases (description, transmission, and intervention). A glossary and bibliography of resources available on environmental health and other forms of assessments may be found among other back matter for the volume. Exclusions to this Volume This volume does not deal with the several important issues described below. Individual industries. Pertinent environmental health issues are generally dealt with under the overall general best practice for "occupational health and safety." These practices are amply cov- ered in the literature and materials are readily available, for example, Pollution Prevention and Abatement Handbook 1998. Toward Cleaner Production (World Bank 1998*). In general, how- ever, occupational health and safety guidelines tend to focus on the workspace itself and in-house employees and do not cover residential areas surrounding individual plants or industrial zones. This leaves an important gap in coverage by such guidelines. Nutrition. Nutrition is dealt with only indirectly in three sets of linkages: (a) pesticide and fertil- izer use in food production, (b) deficiencies of sanitation that contribute to diarrheas and anemnia, and (c) the broad housing environment with respiratory diseases in infants and children. In addi- tion, the debate over meat (animal fat) is a new and rapidly evolving field that cannot be dealt with adequately in this volume. The debate revolves around the notion that production of meat for human consumption is not the least-cost solution to meet increasing global nutritional needs. (It is far less efficient to produce grains for animal food than grain for direct human consumption, and diets high in animal fat can be unhealthy.) Genetic engineering. Research is evolving so rapidly, much of it highly controversial, that it is difficult for this volume to make practical recommendations. Mental health. According to the World Health Organization (WHO), mental health problems are on the rise and constitute an increasing share of the burden of disease. This volume only calls at- tention to the existence of such problems in the context of rural to urban migrations, but do not propose remedial measures. Disasters. Pertinent material can be found through the Bank's "Disaster Management Facility," which concentrates on prevention and mitigation of the effects of disasters. (The extreme degra- dation created by warfare, especially the plight of refugees, is beyond the scope of this volume, especially because the Bank is not a relief agency.) This volume could, however, be appropriate Web site address: (accessed September 2000). xix in projects that deal with (a) reconstruction in the aftermath or provision of basic infrastructure for displaced persons and (b) efforts to derive economic estimates of health damages, which now tend to report and valuate property damage, but only cite death rates. Nuclear energy. The Bank does not lend for nuclear energy, except in selected cases that might involve mitigating measures for cleanup or reduction of hazards. Formal education. Although training is considered essential in this volume, they do not address proposals for adapting curricula in formal education. A proper understanding of environmental health, especially long-term and indirect effects, should eventually be incorporated into primary, secondary, and university education. xx ACRONYM LIST AGETIP Agence d'Execution des Travaux d'Interet Public AIDS Acquired immunodeficiency syndrome APOC African Programme for Onchocerciasis Control BOD Biological oxygen demand BOD Burden of disease BP Bank Procedure CAS Country assistance strategy CBO Community-based organization CDF Comprehensive development framework CFC Chlorofluorocarbon COD Chemical oxygen demand DALY Disability-adjusted life year DDT Dichlorodiphenyltrichloroethane EA Environmental assessment EHA Environmental health assessment EHP Environmental health profile EMP Environmental management plan ENSO El Nifuo Southern Oscillation EPA U.S. Environmental Protection Agency EU European Union GIS Geographic information system GP Good Practice GWh Gigawatt hour HA Health assessment HIA Health impact assessment HIPC Heavily indebted poor countries HIV Human immunodeficiency virus IBRD International Bank for Reconstruction and Development IDA International Development Agency IDWSSD International Drinking Water Supply and Sanitation Decade IFC International Finance Corporation IMF International Monetary Fund IMO International Maritime Organization IPCC International Panel on Climate Change IPCS International Programme on Chemical Safety IPM Integrated pest management LEAP Local environmental action plan LPG Liquefied petroleum gas MARPOL International Convention for the Prevention of Pollution from Ships MIGA Multilateral Investment Guarantees Agency MLGRD Ministry of Local Government and Rural Development MOA Ministry of Agriculture MOH Ministry of Health NEAP National environmental action plan NEHAP National environmental health action plan NGO Nongovernmental organization OECD Organisation for Economic Cooperation and Development O&M Operations and maintenance OCP Onchocerciasis Control Programme OP Operational Policies ORT Oral rehydration therapy PA Poverty assessment xxi PAH Polychromatic hydrocarbon PAHO Pan-American Health Organization PER Public expenditures review PM Particulate matter POP Persistent organic pollutant ppb Parts per billion ppm Parts per million PPS Public-private sectors and stakeholders PRSP Poverty reduction strategy paper QALY Quality-adjusted life year SA Social assessment SAEMA Shama-Ahanta East Metropolitan Area SAL Structural Adjustment Lending SDC Swiss Development Corporation SIA Social impact assessment SIDA Swedish International Development Cooperation Agency SPM Suspended particulate matter SSA Sub-Saharan Africa STD Sexually transmitted disease TB Tuberculosis TOR Terms of reference TOR Tema OH Refinery TPM Total particulate matter TSP Total suspended particulate UESP Urban Environmental Sanitation Project UNEP United Nations Environment Programme VIP Ventilated improved pit VOC Volatile organic compound VRD Vector-related disease WHO World Health Organization xxii EXECUTIVE SUMMARY Environmental Health: Bridging the Gaps is part of an effort by the World Bank's Environmental Health: Bridging the Gaps program to mainstream environmental health into World Bank opera- tions, particularly into environmental assessments. Part 1 of this volume provides background on environmental health and introduces a new, more effective approach to reducing poverty by ad- dressing environmental health problems. Part 2 provides the basic tools needed to implement this approach. Part 3 presents findings of and background for a workshop in Ghana that puts into practice some of the ideas of parts I and 2. A glossary and bibliography of resources available on environmental health and other forms of assessments may be found among other back matter for the volume. Part 1 Intended for policymakers and practitioners alike, part I of this volume explains the foundations of environmental health and proposes a new approach that taps health benefits systematically out- side the health sector through multisectoral collaboration. Chapter 1 details the differences and challenges of environmental health in developing countries. The new approach introduced in chapter 2 addresses these challenges by harmonizing sectoral approaches through targeted col- laboration to tap health benefits outside the health care system, benefits that tend to be missed. Chapter 3 asserts that environmental health measures can target at least an equal share of the bur- den of disease than the health sector, that is, roughly 20 percent for a fraction of the cost of health sector interventions. Chapters 4 through 6 compare and contrast six alternatives to making sound decisions, devising entry points, and establishing mutual benefits from targeted collaboration and provide practitioners with checklists related to Bank projects and components, proposing reme- dial measures. Chapter 1: Challenges of Environmental Health in Developing Countries * A great deal of the underlying causes of disease, injury, and death in developing countries lie outside the purview of the health care system and cover physical (inadequate sanita- tion, water, drainage, waste removal, housing, and household energy) and behavioral factors (personal hygiene, sexual behavior, driving habits, alcoholism, and tobacco smoking). Many of these turn into public health problems when they become widespread, a factor aggravated by inadequate public health infrastructure. * Yet, policies in the sectors responsible for negative health impacts are often not based on health criteria. The health sector itself tends to focus on interventions within the health care delivery system, not necessarily sectors that are the sources of the problem. The enormity of health benefits possible through interventions outside the health sector are only partially tapped. * Many analyses of environmental health issues in developing countries reflect an inad- vertent bias. Much information on environmental health is based on conditions in devel- oped countries, particularly ambient air pollution from vehicular and industrial sources. Poorly addressed is indoor air pollution from cooking, heating, and lighting, the more se- rious threat to human health in developing countries. Mosquitoes and snails, at best, con- sidered nuisances in industrialized countries, remain major health problems in developing countries. xxiii * Dispersal of responsibilities for environmental health among non-collaborating agencies has made environmental health an institutional "orphan," adopted by few multidisciplin- ary agencies as a priority or focal point. * Multisectoral problems clearly require multisectoral solutions. Yet, how can agencies be motivated to take on increased costs if they benefit society at large without furthering the sector's own priorities? Streamlining projects for administrative feasibility may also ne- glect many health risks or promote the wrong mix of investments. * Finding the right mixture of broad objectives tempered with administrative feasibility faces interrelated obstacles: (a) lack of attention to the whole picture, (b) absence of or insufficient procedures to cope with multisectoral issues and environmental health, (c) in- adequate budget, (d) poor availability and reliability of data, especially for monitoring and evaluation, (e) technologies not adapted to developing countries, (I) inadvertent pro- fessional bias (described above), and (g) inadequate input of health personnel in deci- sionmaking outside the health sector. Chapter 2: Developing Solutions Through Targeted Collaboration * Environmental Health. Bridging the Gaps helps identify opportunities for productive in- terventions outside the health sector. It should encourage a multidisciplinary approach to analyzing projects, one that ensures that investments in single sectors, especially for pol- lution management, also produce long-term health benefits. The intention is to alert staff to low-cost, often neglected measures that could anchor and enhance the health benefits of such investments. * The main objectives of this new approach are, first, to enhance the Bank's chief goal of poverty reduction by mainstreaming environmental health into World Bank operations and, second, to achieve multisectoral collaboration by harmonizing health and other sec- toral priorities. - Instead of focusing analysis on the statistical levels of death, disease, and disability, this volume shifts the focus to remedial measures outside the health care system to solve health problems. Harmonizing sectoral priorities depends on a process that targets col- laboration among those sectors and on those measures that, tempered by administrative considerations, have the best chance of generating health and other benefits, generally at a lower cost for all. The process involves identifying and prioritizing measures, devising entry points, and enhancing mutual benefits for the sectors involved. - The new approach has two prongs that develop (a) methodologies to target and facilitate multisectoral collaboration among a critical mass of players and stakeholders needed to solve the problems and (b) instruments to mainstream multisectoral collaboration in deci- sionmaking and integrate it into operations. * Harmonizing sectoral priorities depends on a process that targets collaboration among those sectors and on those measures that, tempered by administrative considerations, have the best chance of generating health and other benefits, generally at a lower cost for all. The process involves (a) identifying and prioritizing measures outside the health care system that will enhance efforts of the health care system, (b) quantifying missed or un- tapped health benefits, (c) devising entry points based on institutional capability to col- laborate, and (d) enhancing the mutual benefits for the sectors that agree to collaborate. xxiv Table ES-I: Sample Linkages and Synergies to Harmonize Infrastructure Sectoral Priorities* Environmental Possible Entry Sector Priority Health Priority Health Linkages Points Infrastructure Providing access to Diarrheal diseases, Water, air, and land Diarrheal diseases, water, sanitation, traffic injuries, pollution; traffic traffic injuries, and waste man- malaria, and respi- safety; and mos- medical waste dis- agement facilities; ratory diseases quito breeding posal, urban ma- pollution control; laria, traffic-related and drainage air pollution, and AIDS in transport, construction work crews, and markets Source: Authors' data. Chapter 3: Socioeconomic Justification and Challenges Relative to the other chapters, Chapter 3 is written with a greater emphasis on technical issues. Many ideas being presented are new, particularly those of health benefit valuations that have of- ten been missed. These new ideas have not been subjected to analyses from several sectors. As a result, greater attention has been placed on explaining methodology than on its application. * Over the 1990-99 period, the burden of disease growth outpaced the population growth in SSA (26 against 21 percent respectively over the period). This increase is a stern re- minder that communicable diseases (+41 percent), mainly HIV/AIDS, malaria, respira- tory diseases and water-related diseases, which have different growth rates over the pe- riod, represent a growing portion of SSA's burden of disease in relative terms (73 percent in 1999 against 66 percent in 1990). * More than 20 percent of SSA's burden of disease is attributable to environmental health problems (mainly attributable to communicable diseases), and 10 percent affect the poor- est of the poor. The environmental health problems, whose underlying causes lie outside the purview of the health care delivery system, impinge on SSA's population wellness, especially the poor; overall economic performance; and health care delivery systems. The latter inherit by default any disregarded environmental health problems. An environ- mental health approach is multisectoral and preventive in nature. It is intended to com- plement health care delivery system interventions by promoting a systematic approach to determining the environmental health attributes-that is, ecological, man-made, and be- havior-prone health risks-and to mainstream environmental health concerns in devel- opment work in a cost-effective manner. * Identifying environmental health attributes, including environmental health externalities, helps determine policy, institutional, and market failures. Harmonizing a cross-sectoral enabling environment subsequently helps formulate environmental health policies in line with cross-sectoral policies (e.g., regulations, financial mechanisms, and budget alloca- tion), designate a lead agency (health and/or environment and determine institutional re- sponsibility and accountability), and forge partnerships and devise cross-sectoral moni- toring systems to achieve outcome-based results. To this end, macro and sectoral Bank instruments, institutional and market concerns, as well as monitoring indicators are re- viewed to identify options for integrating environmental health concerns. * To help formulate an "environmental health-friendly" policy response, the SSA envi- ronmental health burden of disease is quantified, apportioned in terms of environmental burden of disease borne by the poorest of the poor, and valued in terms of lower-bound social cost. More specifically, the burden of disease is dis-aggregated and re-aggregated * See table 6-7 on "Sample Environmental Health Linkages of Bank Lending by Sector" for more detail. xxv in terms of targetable environmental health (20 percent) and health care system (18 per- cent) interventions. Back-of-the-envelope calculations are performed to determine possi- ble infrastructure-based intervention efficiency ratios. * Prioritizing a cluster of infrastructure interventions to relieve the burden on the popula- tion in general and the poor in particular should be associated with a critical need to bring awareness and educate the people to understand the full significance, impacts, and link- ages of environmental, environmental health, and health issues on their well-being, live- lihoods, and development options. Despite the intractable multisectoral issues that need to be carefully assessed at the Bank and in member countries, linking infrastructure with environmental health remains promising, yet fundamental: environmental health inter- ventions could have long-lasting positive results, only if a cross-sectoral and public- private-community mechanism is devised to internalize necessary behavioral change and insure a steady flow of resources for adequate and continuous asset management, upkeep, and monitoring to improve service delivery to the population. Chapter 4: Gathering and Analyzing Information for Environmental Health * Six different options exist for identifying entry points or prioritizing environmental health collaboration, all based on or relating to an environmental health assessment (EHA), a planning tool that helps prevent, mitigate, or manage health risks by gauging environ- ment-based risks and proposing remedial measures. * An EHA is not merely a health assessment within an EA, nor is it limited to pollution. It blends techniques from separate, but related fields, such as EAs, social assessments (SAs), health assessments (HAs), national or local environmental action plans (NEAPS/LEAPS), and comparative risk assessments of pollutants. Neither EHAs nor HAs have gained as much acceptance as the EA process. * No standardized reference texts, outlines, formats, or procedures have been accepted as international norms for EHAs, which have no set definition or criteria. Techniques used in EHAs are still evolving. They may, nonetheless, be confused with other types of as- sessments and action plans. * Because many EHA users will probably not have background in health or environment and possibly neither, an EHA, environmental health profile, or equivalent analysis should include background material that is easily skimmed and absorbed (i.e., avoiding technical jargon and complicated tables and calculations). * The six options to identifying entry points or prioritizing environmental health collabora- tion are (a) preparing an environmental health profile (EHP), (b-d) adapting an existing EA, HA, SA, or poverty assessment (PA) to serve as an EHA, and (e) conducting a com- plete EHA. Of these options, this volume recommends the first, preparing an EHP, a technique specifically developed for this volume. Chapter 5: Preparing an "Environmental Health Profile" * An EHP may be prepared by sectoral specialists not used to working with information outside their own sector, or, especially in the Bank, by economists who work on poverty reduction without focusing on any one sector. * A multidisciplinary team drafts an EHP by first compiling sectoralprofiles as back- ground information and then analyzing the data for sectoral linkages. Sectoral profiles fa- cilitate the EHP process by noting key players and stakeholders, facilitating intersectoral collaboration within agencies, fostering public-private stakeholder partnerships and helping to make decisions using incomplete data. * The team may confront two complementary problems in preparing these profiles: a pau- city of reliable data on environmental health and staff without background in environ- ment and/or health. This chapter and chapter 6 address these difficulties by identifying xxvi existing sources of data in World Bank documents from several sectors or similar sources in bilateral or government agencies. This reduces the need for basic research or data gathering. * The team then "cuts and pastes" from these different reports, helping to compensate for the team's lack of specialization in health and environment. Analysis of the information requires such background, which may be overcome through joint discussion and analysis. * Analysis of the data is then reviewed from the team's multiple perspectives, which should ideally include public health or epidemiology, sociology or anthropology, economics, en- vironment, and infrastructure. Chapter 6: Adapting Environmental Assessments and Preparing EHAs * Multisectoral teams may decide to prepare a complete environmental health assessment, whether as a first step or following preparation of environmental health profiles. The four other options to environmental health profiles differ from EHPs in that they result in a complete environmental health assessment. They are adapting an existing EA, HA, SA, or PA to serve as an environmental health assessment and conducting a complete EHA. The advantages and disadvantages of each are described at the end of chapter 4. This chapter describes the steps involved for each. * Adapting an existing assessment Existing EAs or even NEAPs can be tapped for infor- mation that may not be readily available in health agencies, especially because HAs are scarce, compared with EAs. Tables 6-2 through 6-5 in chapter 6 outline the contents of key Bank documents concerning EAs that illustrate how existing assessments can be adapted to serve as an EHA. * Adaptation is likely to remain the case in the Bank, because environmental health consid- erations are cross-sectoral and already partially addressed in various Bank policies. It could be considered administratively cumbersome to add another tier of analyses for de- veloping country borrowers, when it may be possible to integrate environmental health analyses into projects by adapting EA procedures that are already in place. * Conducting a complete EIlA. The process of preparing an environmental health assess- ment is new and rapidly changing, with no established procedures to follow. The process should, above all, identify the broad picture, on which to base priorities among practica- ble remedial measures for a given project. This section describes the kinds of information that are useful in an environmental health impact assessment and necessary to identifying remedial measures based on intersectoral linkages. Given the practical realities of ac- quiring accurate data, adapting information from alternative sources can be a useful op- tion. Part 2 Intended for Bank Task Managers and practitioners in the field, part 2 of this volume provides basic tools to identify, prioritize, and propose remedial measures for many multisectoral health problems, many of which could and do otherwise fall between the cracks in single sector projects. Chapter 7 provides basic environmental health background pertinent to all sectors covered in part 2. Chapters 8-14 provide guidance on environmental health linkages within and among sectors, which are summarized in a checklist at the end of each chapter. This edition of Environmental Health: Bridging the Gaps focuses particular attention on cross-sectoral linkages with infrastruc- ture interventions between the agriculture and rural development sector (chapter 8) and the infra- structure sector (chapter 13). The other chapters briefly review linkages in the environment (chapter 10), health (chapter I 1), and industry (chapter 12) sectors and with global issues, that is, those that affect the planet as a whole (chapter 14), because many of the issues have already been addressed in chapters 7, 8, and 13. xxvii Chapter 7: Environmental Health Background Analyses Chapter 7 provides basic environmental health background pertinent to all sectors covered in part 1, divided into sections on: Leading health problems: Diseases for special consideration: * Malnutrition * AIDS * Malaria and vector related diseases * Epidemic cholera * Diarrheas and gastroenteric diseases * Guinea worm infection * Respiratory diseases and diseases re- Key cross-cutting issues: lated to air pollution Pesticide use • lnj'uries and accidents Biodiversity and traditional medicines * Mental health and stress Each chapter contains definitions of key, confusing, and misused terms to help clarify their dif- ferent meanings to different professions as well as to those without health or environmental training. Chapter 8: Cross-Sectoral Linkages: Agriculture and Rural Development Sector The first five sections of the chapter weave together many seemingly unrelated topics, emphasiz- ing rural infrastructure in food production, for which linkages are strong with health. They are: * Human settlements. What are the risks, especially in farming, of living conditions in vil- lages and small towns? * Land use and natural resource management. What human health risks are associated with farming, forestry, and other activities? * Water and waste management. How is health linked with irrigation and drinking water? What risks link wastes to food and farmers? * Rural transportation. What type of health risks are associated with transporting products from the fields to markets? The sixth section, an environmental checklist, looks at these same issues in terms of Bank lend- ing. The most common environmental health linkages in the agriculture and rural development sectcr involve food production and other aspects of low-density rural life, such as poor access to water, sanitation, transportation, and electricity. These linkages can set in motion sometimes inter-linked health consequences, including malnutrition, spread of infectious diseases, deaths and injuries related to flooding, and so on. (See chapter 14 on how some of these effects are linked to climate change.) The most common linkages include: * Pollution from excessive use of agrochemicals (especially pesticides and nitrates from fertilizers) * Creation of nearly permanent vector breeding areas and other changes through, for exam- ple, year-round cultivation of food staples and impact of forestry projects * Malnutrition from inadequate food supply or contamination of the food chain * Water and soil contamination from inadequate processing of agricultural and animal wastes xxviii * Respiratory diseases from use of biomass fuels for cooking, heating, and lighting, as well as injuries from gathering fuels. Chapters 9 Energy, 10 Environment, 11 Health, 12 Industry, and 14 Global Issues Chapters 9 through 12 provide less detailed guidance on environmental health linkages within and among the energy, environment, health, and industry sectors, because many of the same is- sues have been covered in chapters 7, 8, 13, and 14. Each chapter contains a literature review that concentrates on the policy determinants as they impinge on health for each sector. Policy is stressed more than technical aspects, because the latter are changing daily and it is hoped that fu- ture versions of this work on environmental health will be able to address technical issues more appropriately. Nonetheless, each chapter contains three tables: (a) the main environmental health linkages, (b) occupational and high risk groups, and (c) a checklist showing the typical projects and components, their major health-related issues, and suggestions for remedial measures. Chap- ter 14 focuses on those environmental issues that affect the planet as a whole, that is, with the potential of affecting everyone. Chapter 13: Cross-Sectoral Linkages: Infrastructure Sector This chapter covers environmental health linkages with the infrastructure sector, weaving to- gether many seemingly unrelated topics with a common thread-urban and periurban human set- tlements-for which linkages are strong with health. Sections on cross-cutting issues and each of the four infrastructure subsectors present a broader range of environmental health issues than those traditionally associated with physical infrastructure: - Cross-cutting issues. What are the key broad and cross-cutting environmental health is- sues, and what is special about their urban settings? - Housing and urban development. What risks are presented by living conditions in big cities and surrounding areas? How, if at all, do secondary cities differ? * Telecommunications. How are rapid changes in modem telecommunications technologies affecting health? * Transportation. What type of health risks are associated with transporting products from rural fields to urban markets? * Water supply and sanitation. How are health risks linked with drinking water, drainage, waste disposal, and sanitation services? Discussion of each subsector concludes with an environmental health checklist. The chapter also discusses four environmental health issues-"brown" issues, vector-related diseases, food chain contamination, and AIDS-that impinge on all four subsectors. Part 3 Chapters 15, 16, and 17 summarize the findings and present background material from a work- shop in Ghana, "Targeted Collaboration among Line Agencies, Local Communities and the Min- istry of Health," putting into practice the ideas of parts I and 2. Innovations included a multisec- toral environmental health needs assessment, as well as suggestions for remedial measures. The summaries can be useful for policymakers and the details, process, and recommendations can be useful for practitioners in the field. Chapter 15: Ghana Sample Sectoral Profiles This chapter presents several individual sector "profiles," using data on Ghana that illustrates in- formation readily available in Bank files, according to Bank sector designations. Such profiles xxix contain considerable extra information to ensure that individual sectors are not summarized out of context. The material supported preparation of an environmental health needs assessment for Ghana and development of a workshop to determine priorities for targeted collaboration in Se- kondi-Takoradi, one of Ghana's five most populous cities. This chapter presents sectoral profiles on environment, health, infrastructure, energy, and industry, and multisectoral profiles on demo- graphic, development assistance, institutional, and poverty reduction aspects. Chapter 16: Sample Needs Assessment from Ghana This chapter is based on a pilot study in Ghana, "Targeted Collaboration Among Line Agencies, Local Communities, and the Ministry of Health." The work took place in Sekondi-Takoradi, one of the five largest cities in Ghana and also referred to as the Shama Ahanta East Metropolitan As- sembly (SAEMA). The chapter presents a needs assessment for a city, beginning with its terms of reference. Chapter 17: Sample Workshop on Targeted Collaboration in Ghana The objective of the sample workshop on targeted collaboration in Ghana was to enhance health improvement outside the health care system by fostering multisectoral collaboration among line agencies and civil society to improve service delivery to the people. The workshop was based on three "entry points," where the likelihood for interagency and stakeholder collaboration was ex- pected to be high due to common interests in solving these common problems: * Management of health facility waste * Urban malaria and other vector-related diseases * Water, sanitation, and drainage. The workshop participants, drawn from SAEMA departments, the Ministry of Health, MLGRD, UESP, civil society, and the World Bank, were asked to: * Identify risks and stakeholders, especially vulnerable groups, at risk. - Determine institutional and financial strengths and weaknesses, relying on the informa- tion provided in the institutional needs assessment prepared for the workshop.' - Suggest areas of mutual collaboration and partnership among infrastructure, environment, and health agencies and civil society at large. * Propose recommendations that could constitute the elements of an action plan for im- proving service delivery. See chapter 16. xxx Part 1: Harmonizing Sectoral Priorities: A New Approach to Environmental Health 1 CHAPTER 1: CHALLENGES OF ENVIRONMENTAL HEALTH IN DEVELOPING COUNTRIES A great deal of the underlying causes of disease, injury, and death in developing countries lie be- yond the purview of the health care system. They cover a range of physical factors (inadequate sanitation, water, drainage, waste removal, housing, and household energy) and behavioral factors (personal hygiene, sexual behavior, driving habits, alcoholism, and tobacco smoking). Many of these environment- and occupation-related health problems turn into public health problems when they become widespread, a factor aggravated by inadequate public health infrastructure. Yet, policies in the sectors responsible for these negative health impacts are often not based on health criteria. The health sector itself tends to focus its interventions within the health care deliv- ery system, not necessarily in other sectors that are the source of the problem. Similarly naturally occurring ecological factors that can exert negative impacts on all sectors (mosquito-borne dis- eases, arsenic in the water, floods, droughts, and so on) are seldom addressed systematically by any of the sectors at risk, even though some sectors may be exacerbating their effects (spreading mosquito habitats, consuming great quantities of water, or producing greenhouse gases that may worsen climate change). As a result, the enormity of health benefits possible through interven- tions outside the health sector are not being tapped. The enormity of health benefits possible through interventions outside the health sector are not being tapped. Part I of this discussion paper addresses these concerns by presenting a new multisectoral ap- proach to reducing poverty, one that employs preventive environmental health measures to im- prove the efficiency of development projects and investments in several sectors. This chapter be- gins by explaining the rationale for a multisectoral approach and its challenges, laying the basis for understanding the proposed approach, introduced in chapter 2. Inadvertent Bias in Neglecting Environmental Health Much general information about environmental health is based on conditions in developed coun- tries. This is not surprising, as the driving forces in research, development, and technology largely emanate from the industrialized world. About 90 percent of the $US56 billion currently invested in health research and development by the public and private health sectors goes to research con- cerning only 10 percent of the world's population.2 This situation has introduced an inadvertent bias into many analyses of environmental health is- sues in developing countries. Literature on air pollution in industrialized countries generally em- phasizes ambient air pollution from vehicular and industrial sources, while poorly addressing indoor air pollution from cooking, heating, and lighting, the more serious threat to human health in developing countries. Similarly, mosquitoes and snails are considered, at best, nuisances in industrialized countries, whereas they remain major health problems in developing countries. The underlying reasons for this bias are clear. Public health or environment students in training in industrialized countries hear only passing reference to vector-related diseases. Physicians receive little basic training in environmental health, except for a few diseases, such as asthma, which are extremely sensitive to pollution. 3 Little time is spent in medical school and residency training on environmental hazards and their relationship to illness. General medical and pediatric textbooks devote scant attention to illness as a result of environmental factors. Informnation pertinent to pediatric environmental health is widely scattered in scientific, epidemiological, and specialty journals not regularly read by clinicians.3 Nutritionists learn much about micronutrients, but little about malnutrition from diarrheal dis- eases caused by inadequate sanitation. Ecologists learn about reducing pollution to meet water quality standards, but water meeting those standards may still be pathogenic and unsuitable for drinking! (It does not generally harm, because it is diluted when released into receiving waters.) Policies also unintentionally embed these biases, because many scientific journals tend to spe- cialize and limit themselves to statistically significant results. They, therefore, underemphasize environmental health factors, which already tend to be underreported due to inadequate data. In addition, environmental health factors result in more disease and disability than death, and dis- ability that does not require hospitalization or a medical consultation is difficult to capture in health statistics. Inadvertent professional bias can also influence the effectiveness of remedies, for example, di- verting attention from other important sources of lead in children's blood (see box 1-1), and omitting possibly promising avenues of addressing critical health problems comprehensively with time. Box 1-1: The Case of Lead The case of lead is excellent for showing the power of interventions outside the health sector and the dif- ficulty of coordinating multisectoral interventions. Only in the past few decades have measures been taken to reduce human exposure to lead. These have only been partial, typically reflecting the ap- proaches of a single profession, such as engineering or medicine, and not coordinated explicitly among professions to improve health. Because lead risks are derived from many sources simultaneously (eaten, breathed, drunk, or absorbed by the skin, as shown in table 7-4) it may be more effective to coordinate sectoral approaches into preventive measures. Unfortunately, this seldom happens. In Mexico City, for example, the phase-out of leaded gasoline has been quite effective in reducing general human exposure to lead. Nevertheless, many people may be exposed to higher levels of lead from traditional blue-glazed pottery than from automobile emissions; yet, the thrust of remedial measures has been toward transportation. One study of school children with high blood levels of lead attributed 40 percent of individual levels to walking to school near heavy traffic, but another 40 percent came from chewing the lead paint on their pencils.4 The perceived direct cause, vehicle emissions, should indeed be reduced, but authorities should not neglect other equally or more important, but less obvious indirect sources (see table 7-4). Finding cost-effective measures to address the various sources collectively underlies a multisectoral approach. Unfortunately, this, too, seldom happens, because benefit-cost analyses tend to focus only on one sector. The case of lead also illustrates the positive effects that other sectors can have on human health, where some of the most important reductions in lead have come from the environment sector. In the Bank, for example, response by the environmental community to problems such as lead has evolved. Efforts to meet the needs of Bank borrowers initially focused on pollution abatement and control. Efforts now emphasize pollution management, which strives to address economic incentives and policies to reduce and avoid pollution in the first place. In public health terms, this would be equivalent to a temporary transformation emphasizing curative measures (abatement and control) until long-term preventive measures (management) could be developed and implemented. Even though lead poisoning would not statistically constitute one of the top ten health problems in developing countries, the collective positive effects of such interventions over time can be significant. Source: Authors' data. 4 How the Health Picture Differs in Developing Countries Understanding how the health picture differs in developing countries is the first step in countering this inadvertent professional bias. Chief among the differences is the nature of disease in developing countries. Infectious and para- sitic diseases, such as diarrheas, respiratory infections, and malaria-diseases traditionally asso- ciated with poverty-predominate. In contrast, "modern" diseases of affluence, such as cancer and heart disease, are associated more with developed countries. Box 1-2: Key Confusing and Misused Terms on Diseases and Statistics Burden of disease (BOD), also, global burden of disease. As used in health analyses, a compre- hensive, internally consistent, and comparable set of estimates of current patterns of mortality and disability from disease and injury for all regions of the world.5 Biological oxygen demand (BOD): As used in environmental analyses, a measure of the amount of oxygen in water needed to decompose organic matter and the propensity of water to eutrophy, that is, become unable to support aquatic flora and fauna. Can be used as an indicator of fecal contami- nation (organic). Disability-adjusted life year (DALY), a recently derived measure of health providing more infor- mation than mortality rates by combining premature deaths and years lived with disability. Vector-borne or vector-related diseases. Refers generally to diseases transmittable by an animal intermediary, such as mosquito, snail, or rodent. Also refers in a narrow, technical sense to dis- eases in which the disease agent undergoes a transformation in an internediate animal host that is necessary to develop the pathogen that eventually infects humans. Source: Authors' data. Table 1-1 summarizes this difference between developing and developed countries. Because death rates do not capture the full socioeconomic impact of death, disease, and injury, the table uses "disability-adjusted life years" (DALYs). These combine the effects of premature deaths and years lived with disability, according to a weighted average of the severity of the disease. The table shows that, in 1998, five of the top ten individual diseases, that is, respiratory infections, diarrheal diseases, HIV/AIDS, malaria, and measles, fall into WHO's broad category of infec- tious and parasitic diseases. This category ranked as the top source of DALYs in developing countries, compared with the tenth in the developed world, and accounted for 23 percent and 0.2 percent respectively of the global grand DALYs total. Another major difference between developing and developed countries is the proportion of dis- ability caused by disease. Table 1-1 also shows that developing countries exhibit nearly double the proportion of disability (i.e., included in DALYs) relative to death than developed countries. Significant to this observation, the overall share of DALYs attributable to environmental factors in developing countries is also high (see table 1-2), for example, 60 percent of respiratory and 90 percent of diarrheal diseases, respectively, and tend to affect the poor more than the rich. A large share of these environment-related diseases in developing countries are due to the absence of ba- sic services, such as potable water, decent housing with proper ventilation, nonpolluting house- hold fuels, and proper sanitation and waste disposal-services that, for the most part, are taken for granted in developed countries. * See box 3-5 for a fuller discussion of this measure. 5 Table 1-1: Top Ten Diseases and Conditions (1998) by Indicative DALYs World Developed Developing DALYs Deathsb Rank DALYs Deathsb Rank DALYs Deathsb Cause (1, OOs) (1, OOOs) (1,OOOs) (f, OOOs) (1, OOOs) (1,OOOs) 1. Acute lower resp. infections 82,344 3,452 8 1,355 306 1 80,990 3,146 2. Perinatal conditions 80,564 2,155 5 2,020 53 2 78,544 2,102 3. Diarrheal diseases 73,100 2,219 17 359 7 3 72,742 2,212 4. HIV/AIDS 70,930 2,285 46 1,022 32 4 69,907 2,253 5. Unipolar major depression 58,246 0 3 7,029 0 5 51,217 0 6. Ischemic heart disease 51,948 7,375 1 9,501 1,884 6 42,447 5,492 7. Cerebrovascular disease 41,626 5,106 2 5,219 893 8 36,407 4,213 8. Malaria 39,267 1,110 97 0 0 7 39,267 1,110 9. Road traffic accidents 38,849 1,171 4 4,556 142 9 34,293 1,029 10. Measles 30,255 888 67 188 5 10 30,067 882 Total of Top Ten 567,129 25,761 31,249 3,322 535,881 22,439 Grand Totals2 1,382,564 53,929 108,305 8,033 1,274,259 45,897 DALYs/deaths 26% 14% 28% a. Top ten and remainder. Totals may not add up due to rounding. b. In this table, refers to premature deaths. Source: WHO (1999b), pp. 85-115. Table 1-2: Environmental Factors and the Global Burden of Disease: Proportion of Global DALYs Associated with Environmental Exposures (1990) Percent Attributable to Environmental Percent of all Global DALYs Environmental DALYs DALYs (thousands) Factors (thousands) (all age groups) Acute respiratory infections 116,696 60 70,017 5.0 Diarrheal diseases 99,633 90 89,670 6.5 Vaccine-preventable 71,173 10 7,117 0.5 infections Tuberculosis 38,426 10 3,843 0.3 Malaria 31,706 90 28,535 2.1 Injuries 152,188 30 45,656 3.3 Unintentional 56,459 NEb NEb Intentional' Mental health 144,950 10 14,495 1.1 Cardiovascular disease 133,236 10 13,324 1.0 Cancer 70,513 25 17,628 1.3 Chronic respiratory disease 60,370 50 30,185 2.2 Total these diseases 975,350 33 320,470 23.0 Other diseases 403,888 NEb NEb Total all diseases 1,379,238 23 320,470 a. Intentional injuries account for homicide, violence, and warfare. b. Not estimated. Source: WHO (1997), table 5-14, p. 173. 6 Because environment-related diseases can cause recurrent or long-term disability without killing, they tend to be underreported in health statistics, which are still oriented toward death rates. The burden of disease on the poor is, thus, often understated because of statistical limitations. For the total burden of disease in the world, for example, disability is more than twenty-five times the proportion for premature deaths alone (see DALYs/deaths in table I-1). But, looking at vector- borne diseases, disability rises to more than 41 times the death rates (see table 1-3). The figures are even more skewed when analyzing data solely for developing countries, especially for dis- eases that are not tracked because mortality is low (e.g., intestinal worms). These observations underscore the importance of understanding the indirect impacts of disease, such as disability, in developing countries and the need to look systematically for new solutions inside and outside the health sector. Similar arguments are appropriate for economic evaluation techniques, which need considerable interpretation of their face value. It is important to understand the indirect impacts of disease and to look systematically for new solutions inside and outside the health sector. The Changing Face of Disease and the Developing World Not only is the health picture in developing countries different, it is continually changing. Since 1950 astronauts have gone to the moon and surgeons have replaced human hearts; yet, scourges of the early twentieth century, that is, tuberculosis, cholera, and malaria, are returning and twenty-nine new infectious diseases have been discovered in the past 20 years. This includes ac- quired immunodeficiency syndrome (AIDS), which accounts for 9 percent of adult deaths from infectious disease in the developing world; by 2020, that share will quadruple to more than 37 percent.6 Population increase, rapid urbanization, and global-level changes, such as climate change and ozone depletion, are also influencing the health picture around the world, but the de- veloping world is least prepared institutionally to respond to these changes. These new develop- ments in health present challenges that intensify the need for innovative approaches within and outside the health sector. Vector-Related Diseases Nearly one-third to one-half of the world's population is potentially at risk of exposure to vector- borne diseases. Table 1-3 shows estimates of the health consequences of the top ten of these dis- eases, which cause more than 1.2 million deaths annually. Malaria represents the lion's share- more than 1 .1 million deaths and 2.4 billion people at risk. The parasite's resistance to medications complicates the malaria situation, and no vaccines are likely for widespread use for at least 15 years.7 In 1976 drug-resistant malaria was confined to Southeast Asia; now it is global. The mosquito's resistance to DDT, its potential carcinogenicity, and the unavailability of an ecologically suitable yet equally effective substitute further compli- cate the situation (see also "Vector Control" in chapter 7). Malaria is surging in many countries where it had once been sharply reduced or eradicated. More than a third of the world's total population now live in malaria-endemic areas. 7 Table 1-3. Death and Disability of Top Ten Vector-Borne Diseases (1998) DALYs Deaths Population at Risk Disease/Condition (thousands)a (thousands)b (millions)' 1. Malaria 39,267 1,110 2,400 2. Schistosormiasis 1,699 7 600 3. Dengue 558 15 2,500 4. Filariasis 4,698 0 1,000 5. Leishmaniasis 1,710 42 350 6. Trypanasormiasis 1,219 40 50-60 7. River blindness 1,069 0 123 8. Chagas' disease 589 17 100 9. Guinea worm NA NA 100 10. Yellow fever NA NA 450 Total 50,809 1,231 NA Source: a and b: WHO (1999b), pp. 85-115; c: WHO web site on specific diseases (, accessed Septemnber 2000) and McMichael and others (1996), table 4-1. Land use changes are influencing the pattern of vector-borne diseases. For example, primarily rural vector-borne diseases are adapting to urban conditions. Periurban agriculture, recreation, and ecotourism also play key roles by changing land use and increasing human exposure (see "Periurban Agriculture and Livestock" in chapter 8). The Double Burden of Disease in Developing Countries In the next 25 years, the world's population will grow from six to eight billion people. Ninety- eight percent of that increase will take place in developing countries and nearly entirely in urban areas. A large increase in urban poverty is expected, particularly in parts of Sub-Saharan Africa (SSA) and East and South Asia.8 Population increase and urbanization places a double burden on developing nations in terms of disease and death. In addition to the infectious and parasitic diseases of poverty-diseases that are exacerbated by the absence of basic services such as sanitation, water supply, housing, and health care-developing countries can expect an increase in modern diseases, such as cancer, hy- pertension, and so on, as more people move to the cities. This will increase pollution and mental stress and place ever greater demands on cities, especially large ones, to provide basic services, initiating a vicious circle. Box 1-3: Urbanization in Sub-Saharan Africa In 1999, for the first time, more people in the world lived in urban than rural areas. SSA, how- ever, is still predominantly rural, although expected to undergo rapid urbanization. Urban popu- lations are expected to grow by about 6 million people per year and would constitute 50 percent of the total population in about 10 years. In western Africa, the figures are even more daunting- an increase of about 43 million people in the next 10 years.9 Source: Authors' data. Global Change Global change, notably climate change and ozone depletion, will also affect the health picture in the future (see chapter 14). Ecological disturbances may cause or worsen health effects, many indirectly (see table 14-1). Injury and death due to heat waves and flooding from storms are obvi- 8 ous impacts. Not so obvious are the insidious, slow effects of drought or increases in moisture that influence the breeding patterns of mosquitoes and help spread malaria. Increases in tempera- ture can stimulate algal blooms that spread cholera. Multisectoral Approaches and the Challenges they Present Environmental health is intended to prevent human illness and injury. Past work on environ- mental health, however, has typically focused attention on individual diseases; sources of pollu- tion responsible for many health problems, especially in their occupational settings; and positive steps to correct these problems and calculate their economic implications. The broad picture in project planning, however, has often been neglected. This is particularly the case for cross- sectoral linkages, which could considerably enhance the value of single sector projects, if cor- rectly hamessed to avoid doing too much in a given project. Box 14: The Health Situation in Sub-Saharan Africa The face of disease and death in SSA is also changing, but in a different pattern. Diarrheal and respiratory diseases are no longer considered the single most important causes of disease and death, as they were in the 1970s; they are now competing with AIDS, and malaria. It is not that diarrheal and respiratory diseases have been reduced, but rather that HIV/AIDS (human immuno- deficiency virus) /AIDS and malaria have been added to the burden. The situation in SSA largely reflects the global situation shown above in table 1-1, where respi- ratory and diarrheal diseases are among the top three. Five of the top ten entries are infectious and respiratory infections, which rank in first and second place respectively. The main difference comes from HIV/AIDS, which is more widespread throughout the Africa Region than other re- gions, and from "unintentional injuries" for males, reflecting a high level of traffic-related and occupational causes (see table 1-4). Table 1-4: Rank and Share of Burden of Disease in SSA (f 990) Female Rank Percent Male Rank Percent 1. Malaria 11 1. Injuriesa 13 2. Respiratory infections 11 2. Respiratory infections 11 3. Diarrheal diseases 10 3. Malaria 11 4. Childhood cluster 9 4. Diarrheal diseases 10 5. HIVIAIDS and other STDs 9 5. Childhood cluster 10 Subtotal of topfive 50 Subtotal of top five 55 a. Includes intentional injuries, which account for homicides, violence, and warfare b. Childhood cluster consists of perinatal conditions: whooping cough, poliomyelitis, diphtheria, measles, and tetanus. Source: The World Bank 1994. table 92-4, p. 19. * Even plague may be re-emerging in about a dozen SSA countries. In the past 15 years, WHO has reported about 18,000 cases in twenty-four countries, more than half of them in Africa (Hawke 1999). 9 Box 1-4 (continued) Table 1-5 shows changes in SSA for 1990-98, including about a sixfold increase in AIDS and a continuing increase in malaria. Table 1-5: Rank and Share of the Burden of Disease in SSA (1990-98) Rank and Share of the Burden of Disease Percentage 1990' Percentage 1998b 1. AIDS 2.8 16.6 2. Malaria 9.2 10.6 3. Diarrheal diseases 10.9 7.5 4. Acute lower respiratory infections 10.2 7.0 5. Perinatal conditions 6.5 6.2 Subtotal of topfive 39.6 47.9 a. Murray and Lopez (1996), pp. 561-64. b. WIHO (1999b), p. 115. AIDS Nowhere is the AIDS epidemic more severe than in SSA, where it has become a health and development emergency. To date, 13.7 million African have died of AIDS. More than 23 million are currently living with HIV/AIDS, of whom 3.8 million were newly infected in 1999. A child born in Zambia or Zim- babwe tonight will, more likely than not, die of AIDS. In many other African countries, the lifetime risk of dying of AIDS is greater than one in three. '0 In June 1999 the Bank confronted these distressing facts in its strategy, IntensifringAction Against HIVIAIDS in Africa. Staff throughout the Region are being asked to incorporate AIDS prevention strate- gies in projects in all sectors. Accordingly, the checklists on environmental health found in Part 11 of this volume cite AIDS-preventive measures as appropriate. (see "Diseases for Special Consideration" in chapter 7.) Malaria More than 90 percent of the estimated 300-500 million cases of malaria worldwide occur in SSA. Chil- dren and pregnant women are the most vulnerable. Each year, the disease causes between 600,000 and I million deaths in children under five in Africa alone. When malaria does not kill, repeated bouts of fever lead to school absenteeism and impair physical and mental development in children. Rural African communities are affected the worst, due to poverty. Rapid urbanization and government decentralization, however, is exacerbating the situation, partly because periurban settlements often pro- vide similar breeding environments to those in rural areas and partly because expansion of water supply has allowed year-round breeding of mosquitoes. Various levels of governments may not have the institu- tional capabilities to cope with both urban and rural malaria. Malaria may annually cost African countries more than I percent of their gross domestic product." Ini- tial estimates of direct costs indicate that the disease places a major economic burden on households, which spend significantly on malaria prevention and treatment. Losses to productivity and output are substantial but not yet fully quantified. This tendency has been compounded by dispersal of responsibilities for environmental health among several agencies that generally do not collaborate. The result is that environmental health has become an institutional "orphan," adopted by few multidisciplinary agencies as a priority or focal point. 10 Environmental health has become an "institutional orphan, " adopted by few multidisciplin- ary agencies as a priority orfocal point. Economic analyses of environmental health have focused considerable attention on broad issues, under the rubric of "health effects," although sometimes intensely scrutinizing individual dis- eases. Such analyses, however, have paid little attention to multiple health effects, even though dis-aggregating them could greatly improve the economic impacts of projects. For example, analysis of the benefits of urban drainage to reduce breeding areas of mosquitoes that spread ma- laria could miss or neglect other diseases, such as dengue and filariasis, which are spread by mos- quitoes with slightly different breeding habits, but also reduced by the same drainage improve- ments (see chapter 3). Multisectoral problems clearly require multisectoral solutions. Yet, multisectoral approaches pre- sent a number of challenges in and of themselves. Agencies outside the health sector that would incur the costs of these solutions would not necessarily reap the benefits. How can agencies be motivated to take on these increased costs if they benefit society at large without furthering the sector's own priorities? Why, for example, should transport agencies take on added responsibili- ties to clean drains to reduce mosquito breeding sites for malaria control? Why should these agencies then spend time coordinating with other agencies on these efforts? This dilemma has, in part, turned environmental health into an institutional orphan; environ- mental health efforts are hampered by a lack of incentive or motivation in agencies with other priorities. Dilemma: How can agencies be motivated to take on these increased costs if they benefit so- ciety at large without furthering the sector's own priorities? Lessons from the past have repeatedly shown that projects that attempt too much, no matter how well intentioned, may become too cumbersome to achieve their original goals. This raises yet an- other dilemma: streamlining projects for administrative feasibility may inadvertently neglect many health risks, even in well-intentioned projects, or promote the wrong mix of investments. Dilemma: Streamlining projects for administrative feasibility can neglect many health risks, even in well-intentioned projects, or promote the wrong mix of investments. Collaboration with another agency can sometimes compensate for unintentional neglect based on administrative efficiency; yet, such coordination rarely occurs, primarily due to a lack of under- standing of environmental health linkages or poor interagency communication. Finding the right mixture of broad objectives tempered with administrative feasibility, however, faces a number of interrelated obstacles: * Lack of attention to the whole picture * Absence of or insufficient procedures to cope with multisectoral issues and environ- mental health * Inadequate budget * Poor availability and reliability of data, especially for monitoring and evaluation * Technologies not adapted to developing countries * Inadvertent professional bias (described above) * Inadequate input of health personnel in decisionmaking outside the health sector * Poor economic techniques to show value added from environmental health considerations 11 * Inappropriate technical assistance from industrial countries with very different environ- mental health methods and solutions. Box 1-5 presents a case illustrating nearly all these obstacles.* _ Box 1-5: A Near Miss in an Environmental Assessment The environmental assessment (EA) for a 15-year sanitary waste disposal site in Asia predictably centered on water pollution in identifying health issues and nearly omitted discussion of two potential epidemics. Preparation of the EA took place while local press carried headlines about rats spreading plague from an unrecognized virus. Intemational newspapers and television news programs discussed global travel restrictions from India, where plague had already broken out in 1995. The expatriate EA team and local office staff were well respected in their fields-engineering, ecol- ogy, environmental assessments, and economics. The team, however, did not contain a public health specialist and the expatriates considered rats and mosquitoes more as nuisances than health risks. The EA was eventually altered to address vector-related diseases. The case is striking, however, be- cause of the questions apparently not asked. This is not atypical in EAs, because current procedures do not systematically require health analyses, and illustrates the need to look at environmental health problems from a broader perspective. Source: Authors' data. The last obstacle listed, absence of input from health personnel in decisionmaking, is particularly subtle, but crucial to harmonizing sectoral priorities. Many development projects with health re- percussions are designed without direct input from health specialists, who, therefore, have little input into important decisions affecting human health (see table 1-6). Environmental health con- siderations are, at best, policy "afterthoughts" for the business, commerce, industry, and govern- ment agencies that create most environmental health problems, possibly inadvertently, and could help solve them. This includes 203 Bank SSA infrastructure projects (1984-94) designed mainly by engineers and economists. Neither these projects nor the events and documents cited in table 1-6 necessarily produce unintended health repercussions, but, it is possible that these projects could have helped alleviate poverty better with the input of health specialists. Lack of formal in- put from health personnel also stems from the current tendency in society for professionals to specialize, possibly aggravated by budget considerations, for example, precluding participation in conferences by staff of different specialties from the same organization. Absence of health input can lead to unintended results, often described as "unforeseen conse- quences." They are unforeseen, however, often simply because nobody looked. The examples of these omissions presented in table 1-6 are not meant as a criticism, merely an affirmation of the status quo and an indication that otherwise well-intentioned projects are achieving less than their potential. The situation could be turned around, if agency policies or environmental reviews com- pensated, for example, through environmental assessments that systematically include health. * Examples of interpreting the same data from several perspectives, uncovering potential cross-sectoral conflicts, and increasing economic benefits are presented in "Analyzing Data" in chapter 4 and in chapters 5 and 6 and annex A. 12 Table 1-6: Possible Consequences from the Absence of Health in Decisionmaking Agencies Not Consulted or Event or Sample Health Responsible with Minor Possible Health Document Issues Agencies Input Consequences HEALTH EXCLUDED BY OTHER SECTORS 203 World Bank Contaminated water, Infrastructure: water, Health Diarrheal diseases, infrastructure indoor air pollution, sanitation, housing, respiratory diseases, projects vector-related dis- transport, waste man- vector-related diseases, eases, and injuries agement, urban man- injuries, and so on agement, and telecom- munications World Bank Lead pollution, false Environment, urban Health Lead "replacements" "Green Top sense of security in development, and can cause equal or Ten," lead by dealing with part of transport. worse health damage. phase out of lead lead problem, and no Focus on gas can over- in gasoline in 5 health input into shadow other more years funding lead substi- serious lead problems tutes Kyoto Climate Several indirect ef- National governments, Health was not Fuel price changes: (a) Change fects, e.g., respiratory environment, and the part of the offi- use of cheaper fuels Conference and vector-related private sector cial agenda could negatively affect diseases respiratory disease and(b) economic analy- sis of dams could ex- pand dam construction increasing schistoso- miasis (and possibly malaria) Insurance Injuries and deaths Private sector, national Health Insurance industry cal- industry from storms, physical and local government, culates property dam- hurricane and mental stress infrastructure (water, age, but not health fac- analyses from loss of home or housing, transport, and tors covering a wide job, and so on telecommunications), range of conditions, ____________________ and emergency services e.g., sickness to suicide OTHER SECTORS EXCL UDED BY HEALTH WHO Malaria Help confront drug Health nfrastructure Missed opportunity to Rollback resistance, changes in transport, diminish malaria even Initiative breeding patterns, iousing, wa- more and spread of habitat er, waste management), d agricul- tue The Pan- Health and disaster Infrastructure Poor rnaintenance American Health (transport, makes public infra- Organization housing, water, structure more vulner- Disaster and waste man- able to severe weather. Preparedness agement) Conference Source: Authors' data and Listorti (1996). The Role of Knowledge Management Knowledge management could play an important role in reaching out to those sectors that could fruitfully contribute to a multisectoral effort. If knowledge management professionals had ac- quired a better understanding of environmental health issues, they might have applied better tech- nologies to address the problem. Acquiring such knowledge is certainly important. The task re- mains, however, to communicate remaining opportunities and risks to other sectors that could also be involved. Table 7-4 indicates the breadth of issues needing coordination concerning lead. 13 This volume is intended to build bridges to promote multisectoral teams in the Bank and in de- veloping countries to address multisectoral problems. This can also help improve service delivery in general. Box 1-6 summarizes the role of environmental health in meeting this challenge, and chapter 2 introduces methodologies and instruments that multisectoral teams may adopt, covered in more detail in chapters 4-6. This volume is intended to build bridges to promote multisectoral teams in the Bank and in developing countries to address multisectoralproblems, which can also help improve service delivery. Box 1-6: The Contributions of an Environmental Health Approach Each sector and professional group needs to define their contribution to overall health outcomes and development objectives, their comparative advantage and areas of convergence, linkages, in- teractions or interface, and the common goals to which they all can contribute. As we think beyond sectors, what can we do in the interface between health and environment? That is environmental health. Proponents of environmental health should define its comparative advantage, rather than focus on the limitations of others. What is the value added of an environmental health approach? For exam- ple, if the health sector has identified a set of priority health problems, what major risk factors should be addressed through an environmental health approach, for example, through water and sanitation and related behavior change interventions, reduction in indoor air pollution (technolo- gies and behaviors), vector control, improved housing and reduced crowding, behavior change in- terventions, and health promotion. Environmental health can promote a systematic approach to de- fine the most cost-effective, affordable, sustainable, culturally appropriate, and feasible set of in- terventions across sectors and achieve synergy through the multiple opportunities that policies and projects in different relevant sectors provide. Source: Memo, Dr. Mariamn Claeson, Lead Public Health Specialist, World Bank, November 20, 1999. 14 CHAPTER 2: DEVELOPING SOLUTIONS THROUGH TARGETED COLLABORATION Environmental Health: Bridging the Gaps helps multisectoral teams identify opportunities for cost-effective interventions outside the health sector, building its approach on three underlying principles: * The whole is greater than the sum of its parts. Coordinating interventions among envi- ronment, health, and other sectors will do more to reduce poverty than a series of single sector interventions. * Define halfa problem, devise halfa solution. Environmental health problems tend to be multisectoral and require multisectoral solutions. Any benefits from a single sector ap- proach come with a missed opportunity: the inability to prioritize the relative importance of various issues and their solutions within a broad context. * Do no harm. Putting health in its broader environmental setting can help fulfill one of the most important rules of public health: to do no harm. Single sector projects may miss op- portunities to address equally important health issues or sometimes inadvertently do harm by promulgating policies and promoting a mix of investments that fail to address health risks or give a false sense of security that the whole problem has been addressed. Adhering to these cautionary principles should encourage a multidisciplinary approach to ana- lyzing projects, one that ensures that investments in single sectors, especially for pollution con- trol, also produce long-term health benefits. The principles should not be misinterpreted, how- ever, as a recommendation to avoid investments in pollution management. The intention is simply to alert staff to low-cost, often neglected measures-sometimes only a small component within or parallel to a project-that could anchor and enhance the health benefits of such investments. Low-cost, often neglected measures-sometimes only a small component within or parallel to - a project-could anchor and enhance the health benefits of investments in other sectors. Implementation of multisectoral approaches, however, as explained in chapter 1, is fraught with challenges. This chapter presents a new approach that attempts to address these challenges and bridge gaps in current efforts and among various agencies by harmonizing health with other sec- tor priorities and targeting promising areas of collaboration on cost-effective health interventions. Box 2-1 explains some of the ways this new approach can be mainstreamed into the operations of the World Bank and other development agencies. 15 Box 2-1: Mainstreaming the New Approach into Bank Development Work Untapped environmental health benefits in development work need to be better quantified, valued and integrated into Bank strategies, policies, and lending procedures at all levels. Bank staff need to be sensitized to practical ways to tap these potential benefits and convey this message to other development agencies, donors and NGOs. Several areas could be explored to help win promulgating these into lending: (a) options to mainstream environmental health; and (b) meth- odologies and instruments for Bank staff and borrowing countries among others. Environmental health constitutes one of the building blocks of the forthcoming Bank Environment Strategy, which is a recent positive factor that could cata- lyze the mainstreaming effort. Environmental health concerns are also being integrated in Poverty Reduction Strategy Papers (e.g., Madagascar), thanks to a mounting interest in improving the wellness of the poor through the poverty re- duction. Several other areas could be explored as non-lending options inside and outside the Bank. For example, the Develop- ment Committee of the World Bank and the International Monetary Fund need to be sensitized on environmental health issues during IDA replenishment, mainly through the Bank's Environmentally and Socially Sustainable Development and Human Development networks. Bank, borrower countries, NGOs and CBOs can be sensitized on environmental health concerns which should also be included in Bank research programs and the World Bank Institute's curriculum; dissemination through publication, web sites, and distance learning. Several of Environmental Health: Bridging the Gaps chapters deal with developing, enhancing or suggesting a panoply of options and tools to mainstream environ- mental health concerns at the macro, sector and project levels (as shown below). Options to Mainstream Environmental Health Tools to Mainstream Environmental Health Country/Macro Strategies and Programmatic Instru- Analytical Tools to quantify and value environmental ments. Structural adjustment lending, country assistance health burden of disease (disability-adjusted life years to strategies, comprehensive development frameworks, pov- measure health outcomes besides mortality, and cost- erty reduction strategy credits, national environmental effectiveness) and help mainstream its concerns at the action plans (WHO-funded national environmental health macro, sector and project levels (chapters 3 and 6). action plans), and environmental action plans. Demographic and Health Surveys (DHS), Living Stan- dards Measurement Study (LSMS) household surveys, Economic and sector work (ESW). Integration into (a) World Development Indicators (WDI), and so on need to poverty reduction strategy papers, country economic be adapted to provide data on environmental health. memoranda, public expenditures reviews, sector reviews, sector strategy papers, poverty assessments, and social Sectoral Tools to bring about sectoral priorities to help assessments, and (b) Bank sector strategies, for example, harmonize environmental health with other sectoral pri- environment, health, social, poverty, energy, and water and orities, e.g., "shortcut tools," such as "environmental sanitation. health profiles," which provide a short list of issues through a desk review or "entry points," which focus on Global/Regional/Local Strategies and Instruments. issues for which a critical mass of the stakeholders are Including (a) intermediation mechanisms, e.g., community ready to take action (chapters 3-5 and 15-17). driven development, community action plan, and social funds and (b) other initiatives, programs, funds, and facili- Institutional Tools to help determine institutional com- ties, e.g., Carbon Fund, Cities without Slums, City Devel- patibility through institutional needs assessments and opment Strategy, Clean Air Initiative, Disaster Manage- foster multisectoral collaboration and forge partnerships ment Facility, Global Environment Facility (GEF), Local through entry points, incentives and mutual benefits Environmental Action Plans (LEAP), Multi-Country (chapters 2, 3, and 15-17). HIV/AIDS Program, Post-Conflict Reconstruction Pro- gram, and Rollback Malaria Initiative. Monitoring Tools to develop cross-sectoral outcome- based monitoring systems, e.g., application of quality Multisector/Single Sector Project and Monitoring. In- adjusted life years to measure years life gained from an cluding (a) integration of environmental health into envi- intervention (chapter 3), early warning monitoring indi- ronmental assessment procedures and into project docu- cators, and multilayered geographic information system, mentation, design summary, management, and monitoring which can combine information ecology, topography, and (b) preparation of environmental health projects (e.g., socioeconomic groups, and associated environmental as the one under preparation in South Asia). health risks (chapters 2, 5, and 17). DHS, LSMS and WDI need to be adapted. Operational Procedures, Quality at Entry, and Safe- guard Policies. Need to be adapted accordingly. Procedural and Operational Mechanisms to deal sys- tematically with environmental health concerns at all Evaluation. Informal reviews, as well as those of the Op- levels and possibly: enhance exiting procedures, e.g., erations Evaluation Department (OED), to take into ac- poverty, environmental and social assessments (chapters count missed opportunities and make recommendations to 4-6); and improve control mechanisms such as quality at be formulated and fed into new Bank sector strategies. entry and safeguard policies (chapters 7-14). Source: Authors' data. 16 The overall framework for implementing methodologies to tap missed health benefits through multisectoral collaboration is described below. Chapter 3 describes economic valuation. Chapters 4, 5, and 6 consider the gathering and analyzing of information to aid inclusion of environmental health in decisionmaking and chapters 8 through 15 present environmental health assessment guidelines. Objectives of Harmonizing Sectoral Priorities The main objective of the 1996 volumes of Bridging Environmental Health Gaps was to improve the well-being of the population at large. To this end, the Environmental Health: Bridging the Gaps program has worked to mainstream environmental health into World Bank operations. Cur- rent Bank attempts to bridge sectoral gaps through its "networks" help link two sectors, but diffi- cult problems in Bank projects could benefit from solutions in several sectors simultaneously. The approach introduced here facilitates multisectoral efforts to the Bank's chief goal of poverty reduction and sustainable development and expands health benefits beyond those of single sec- tors-health care, basic infrastructure services, and pollution management, fulfilling the first of the principles cited above. Box 2-2: Environmental Health Defined Environmental health is as much a way of thinking as a set of facts or professional discipline. Preventing disease, death, and disability should ideally form its core and entail looking at a problem in both its broad and narrow contexts. Broadly speaking, environmental health is in- tended to reduce exposure to adverse environmental conditions as well as promote behavioral change. More narrowly, it addresses the underlying causes of individual groups of diseases and injuries by looking at the direct and indirect causes and effecting relationships in the short and long term. Table 2-1 shows typical examples and their adverse health consequences. Table 2-1. Sample Environmental Health Determinants and Consequences Possible Adverse Health and Safety Underlying Determinants Consequences Inadequate water (quantity and quality), Diarrheas and vector-related diseases, e.g., sanitation, and solid waste disposal malaria, schistosomiasis, and dengue fever Improper water resource management (urban Vector-related diseases, e.g., malaria and and rural), including poor drainage schistosomiasis Crowded housing and poor ventilation of Acute and chronic respiratory diseases, smoke including lung cancer Exposures to vehicular and industrial air Respiratory diseases, some cancers, and loss of pollution IQ in children Changes in feeding and breeding grounds of Vector-related diseases, e.g., malaria, vectors, such as mosquitoes, from construction schistosorniasis, and dengue fever and population movement Exposures to naturally occurring toxic Poisonings from, e.g., arsenic, manganese, and substances fluorides * "Sanitation" in this document refers to the various formns of excreta and wastewater removal. 17 Possible Adverse Health and Safety Underlying Determinants Consequences Natural resource degradation, e.g., mudslides, Injury and death from mudslides and flooding poor drainage, and erosion, which create health and safety problems Climate change, partly from combustion of Injury and death related to extreme heat and greenhouse gases in transportation and industry cold, storms, floods, and fires. Also indirect and poor energy conservation in housing, fuel, effects, e.g., spread of vector-borne diseases, commerce, and industry aggravation of respiratory diseases, population dislocations, water pollution from sea level rise, and so on. Ozone depletion from industrial and Skin cancer, cataracts, and indirect effects, e.g., commercial activity compromised food production, and so on Environmental health is intended to prevent human illness and injury by systematically tap- ping resources outside the health care system to enhance those of the health sector. In this sense, "environmental health" differs from "medicine," "public health," and "occupational health" in emphasis and points of intervention (see box 2-3). The World Bank has no specific definition for environmental health. In practice, however, the use of the term is most fre- quently used in the context of pollution management projects. Source: Authors' data. The three underlying principles, stated above, however, call for multisectoral work among gov- ernment agencies and community groups from health, environment, and other sectors that are not used to working together. A secondary objective, implemented through this discussion paper, has, thus, been to achieve multisectoral collaboration by harmonizing health and other sectoralpri- orities, that is, identifying and prioritizing remedial measures that are practicable, as defined by national and local institutional capabilities. To this end, health-related measures that may other- wise seem too far removed from or too expensive given overall project objectives are undertaken for their residual health benefits. Box 2-3: Key, Confusing, and Misused Terms on "Medicine" and "Health" Medicine. Emphasizes curative andpreventive services oriented to individual diseases and inju- ries and operates mainly through the public and private health care system. Public health. Emphasizes preventive and curative services oriented to promoting health and safety in society and operates through the public and private health care system as well as other institutions in society at large. Environmental health. Emphasizes preventive services oriented to reducing exposures in society (current tendency toward pollution control) and operates through various public and private sec- tor institutions. Occupational health. Emphasizes curative and preventive health and safety oriented mainly to the workplace. Sometimes referred to as "occupational health and safety" or "occupational and environmental health." Source: Authors' data. The main objectives of the program are to enhance the Bank's chiefgoal ofpoverty reduction by mainstreaming environmental health into World Bank operations and achieve multisecto- * Chapter 4 and the glossary define terms for environmental health assessments. 18 ral collaboration by harmonizing health and other sectoral priorities. This discussion paper is a means to achieve these objectives. Methodologies of Targeted Multisectoral Collaboration Harmonizing sectoral priorities depends on a process that targets collaboration among those sectors and on those measures that, tempered by administrative considerations, have the best chance of generating health and other benefits, generally at a lower cost for all. The process in- volves four new tactics: * Identifying andprioritizing measures outside the health care system that will enhance ef- forts of the health care system * Quantifying missed or untapped health benefits * Devising entry points based on institutional capability to collaborate * Enhancing mutual benefits for the sectors that agree to collaborate. Identifying and Prioritizing Measures Outside the Health Care System Instead of focusing analysis on the statistical levels of death, disease, and disability, this volume shifts the focus to remedial measures outside the health care system to solve health problems that are based on the types of interventions used to help solve problems: leading health problems, dis- eases for special consideration, and key cross-cutting issues that are pertinent to all sectors. This innovative system of classification, new in this discussion paper, maintains the focus on tapping health benefits outside the health care system, complementing and not replacing traditional health data. Table 2-2 shows the range of possible remedial measures for the infrastructure sector, based on the top five burdens of disease in SSA (see also table 1-5.) This list would lengthen if other sec- tors were reviewed as part of a coordinated effort to deal with health systematically outside the health care system. Table 2-2: Infrastructure Measures for Top Five Burdens of Disease in SSA Disease/Condition Type of Infrastructure Remedial Measure 1. AIDS Outreach to high-risk groups, such as truckers, work crews, and market-related groups 2. Malaria Vector control, and sanitation and drainage .3. Diarrheal diseases Improved drnking water supply and waste management 4. Respiratory disease Improved housing and air pollution abatemnent 5. Perinatal conditions (Remedial measures handled primarily through the health ministry. Some hygiene educa- tion possible through outreach to infrastructure groups.) Source: Authors' data. As one example, table 2-3 shows that seven of the top ten health problems in Ghana are amenable to infrastructure improvements (see also table 17-2). Chapter 3, which discusses socioeconomic aspects of health interventions outside the health sector, estimates that infrastructure projects could conceivably relieve a greater level of the burden of disease than health investments, about 20 percent, for a fraction of the cost. This is because infrastructure projects have already been justified on other grounds. These links to other sectors also open the door to identifying untapped and missed benefits. 19 Table 2-3: Top Ten Diseases in Ghana by Infrastructure Intervention (1994) Disease 1994 Major Infrastructure Link Malaria l / Upper respiratory infection 2 1 Skin diseases 3 v Diarrheal diseases 4 1 Accidents 5 1 Intestinal worms 6 1 Pregnancy related complications 7 Acute eye infection 8 1 Gynecological disorders 9 Hypertension 10 Source: Country assistance strategyfor Ghana. Devising "Entry Points" Entry points are determined by institutional capability and complementarity, that is, the likelihood of successful interagency and stakeholder collaboration due to their common interest in solving common problems. Promising entry points demonstrate the following characteristics: * Widespread knowledge of the problem * Clearly identifiable stakeholders and players * Ability by the majority of actors in the situation to get to work. These factors could create a framework for working on a range of environmental health problems, as the individuals and groups involved build up experience and practice working together. A trial case in Ghana Sekondi-Takoradi, one of Ghana's five largest cities, for example, focused on the following entry points: * Management of health facility waste - Urban malaria and other vector-related diseases * Diseases related to water, sanitation, and drainage. Even though respiratory disease in Ghana ranks second out of the top ten diseases (see table 2-3), it was not selected for the case study, because the range of relevant players and stakeholders was so diverse. This increased the difficulty of those involved starting immediately to work toward a common goal without a delay involved in creating awareness among stakeholders from several sectors-health, energy, housing, transport, industry, environment-that they had a constructive role to play. With time, building on experiences with various successful entry points, other dis- eases and areas for collaboration may be identified in Ghana. Table 2-4 presents possibilities any country might consider. 20 Table 2-4: Sample Linkages and Synergies to Harmonize Sectoral Priorities Environmental Possible Entry Sector Priority Health Priority Health Linkages Points Agriculture Land degradation, Food security, nutri- Contamination of the Malaria and pesticide pesticide use, and tion, and malaria food chain, pesticide management stagnant water (rural use, exposure to grain and periurban agri- dust, vector-related culture) diseases Energy Air pollution and Acute respiratory Indoor and outdoor Household ventila- greenhouse gases diseases and indoor air pollution, and tion and improved air pollution cooking fuels cookstoves Environment Natural resource Pollution control Reduction of lead Lead reduction for management, climate from multiple sources nontransport sources change, global warmning, and pollu- tion control Health Medical waste dis- Infant and child Medical waste dis- posal and greenhouse health, AIDS, ma- _ posal gas generation laria, tobacco smok- ing, and TB Industry and Air, water, and Occupational health Mosquito breeding, Malaria reduction mining coastal zone pollution and exposure to respiratory diseases, and AIDS education heavy metals and and contamination of nmalaria food chain Infrastructure Providing access to Diarrheal diseases, Water, air, and land Diarrheal diseases, water, sanitation, and traffic injuries, and pollution; traffic traffic injuries, medi- waste management malaria safety; and mosquito cal waste disposal, facilities; pollution breeding urban malaria, traf- control; and drainage fic-related air pollu- tion, and AIDS in transport, construc- tion work crews, and markets Source: Authors' data. Health agencies may have a number of potential partners at any one entry point. For example, they might join with transport, water and waste management, and community groups, and schools to reduce urban malaria from mosquito breeding sites. Establishing Mutual Benefits for Sustainability Collaboration is more likely to be sustainable if it is based on sharing benefits, rather than merely increasing the budget for activities added. Establishing the mutual benefits that involved sectors may gain is, therefore, important to the process of harmonizing sectoral priorities. Methodologies for targeted collaboration try to reduce reliance on additional budget by identifying areas of mu- tual compatibility. Table 2-5 below shows the stakeholders at risk for each of two entry points in the Ghana trial and possible partnerships. Table 2-6 lists recommendations for the potential partnerships associated with the stakeholders at risk identified in table 2-5 (see chapters 16 and 17 for more details). * Details of the pilot study appear in chaptersl5 to 17 in this volume. 21 Table 2-5: Stakeholders at Risk and Potential Partnerships for Entry Points in Ghana Entry Point Populations at Risk Potential Partnerships for Solutions Urban * Children under 5 years * Hydro Division, Ministry of Works and Housing malaria and and other vulnerable * Ministry of Roads and Transport other vector- groups (women, elderly, * Ministry of Environment related sick, and so on) * Environmental Protection Agency diseases * Communities around * Ministry of Health bushy and marshy areas * Ministry of Industry * Densely populated areas * Media (press and radio) * Low income groups that * Ministry of Planning (Census Statistics), Education, Town, cannot afford any pre- and Country Planning ventive or curative treat- * Assemblymen, unit committees ments (bed nets or * Community, religious groups drugs). * Fishing industry * NGOs, community-based organizations, and private sector * Shama Ahanta East Municipal Area's (SAEMA's) Assembly, Environmental Health Unit, Public Relations Unit, Urban Roads Department, and Waste Management Department Management * Children * Environmental Protection Agency of health * Community * Environmental Health Department facility waste * Health workers * Ghana Medical Association * Patients * Medical drug vendors and pharmaceutical manufacturers * Scavengers * Pharmacy board * Waste management op- * Waste management department erators Source: Authors' data. Identifying the Stakeholders Transport agencies, for example, are typically responsible for monitoring and cleaning stormn drains to prevent highways and other roads from flooding. Clogged drains provide breeding grounds for malaria. Health agencies could collaborate with transport agencies by monitoring and reporting clogged drains at the neighborhood level. Transport agencies, saving monitoring time and money, could then devote more resources to cleaning. Health agencies could help reduce the spread of urban malaria and could use the monitoring for community outreach on urban malaria. As mentioned before, this collaboration could also address other mosquito-borne diseases, such as dengue (clean water) and filariasis (polluted water), often overlooked in malaria programs and economic analyses. Collaboration must also allow for changes in programs based on technical, social, or economic objectives of nonparticipants. The land reclamation recommended by the community stakeholders, for example, may not be ecologically sound and alternate means would need to be developed. 22 Table 2-6. Ghanaian Recommendations for Entry Points Based on Multisectoral Collaboration Entry Point Recommendation Urban * Land use management: malaria and (a) Land reclamation. Reconsider reclamation of marshy areas to destroy major mosquito- other vector- breeding grounds. Reclaimed lands could be used for agriculture, resettlement, or comnpati- related ble uses. diseases (b) Burrowpits in construction and mining sites. Involve construction, mining, and industry in malaria prevention efforts. For example, work out the social, economic, and technical de- tails of introducing tilapia and/or other appropriate fish species into unfilled areas and de- termine fishing rights. * Proper drainage. Clarify roles and respornsibilities for drain management and mnonitoring: (a) Develop clear maps of primary, secondary, and tertiary drains (1) Link maps (geographic information system) to existing roles and responsibilities (c) Assure an earmarked, nonfungible budget for desilting (d) Involve communities in drain clearing, drawing lessons from the Bank's Urban Environ- mental Sanitation Project (UESP). * Awareness creation. Build awareness on many alternatives to spraying to prevent mosquito breeding in households-for example, use of tilapia and sealed water tanks, storage, and con- tainers-at all levels of government and society. Management * Develop medical waste management bylaws. Medical waste management was recently dele- of health gated to the local assemblies, which have no bylaws to implement this policy. Such bylaws facility waste would need to be based on a multisectoral approach. * Build capacity to monitor. Improve the capacity of assemblies to monitor proper disposal of medical waste. * Add value to waste. Examine the medical waste stream to determnine those items with any eco- nomic value, removing hazardous materials from inexperienced waste pickers and disposing of them safely. Help scavengers to improve waste recycling in the medical waste. Iterns that are now being reused or sold with risk should be removed from the "informal market." * Increase awareness ofproper disposal ofmedical waste at all levels of government and soci- ety, especially target comrmunities and medical staff. Source: Authors' data. Establishing Mutual Benefits through Mapping The aim of the environmental health map is to devise a model that will help identify the geo- graphic incidence of environmental health effects at the national, regional, and communal levels. The map, which could evolve to become a decision support system to prevent environment health risks and formulate policy response, should combine environmental health risk factors and na- tional, regional, or urban social maps (to derive vulnerable groups incurring an environmental risk) with a GIS technology to performn an environmental health survey of patterns that could be integrated in an environmental or environmental health assessment: * Environmental health risk factors can include comparative risk assessment, risk commu- nication, and risk management (see glossary). * Data from social maps offer a means of exploring national or intra-urban environmental health differentials. Social maps can help identify data sources and contacts, relevant "hotspots," both topically and geographically, and the perceived social causes that under- lie and perpetuate observed patterns. They are an excellent way to begin any data search and, perhaps, frame the policy implications of later findings. * Geographic information systems (GISs) mapping can help establish benefits by adapting existing GIS maps for environmental health purposes. GISs permit a view of a true spa- tial relationship of geology, hydrology, and ecology, in conjunction with land use (urban and rural settlements, industry and mining, agricultural land, and so on), social factors (income group concentration, among others), and environmental health patterns. An environmental health map can effectively be done on a paper map, and a simple discussion note can describe how issues relate to geographic boundaries, as was demonstrated during the 23 Ghana pilot (see map 5-1 and chapter 17). A multidisciplinary group representing the public sec- tor and stakeholders drew this "low-tech" map to depict the incidence of vector-related diseases in Sekondi-Takoradi. A more advanced environmental health map could, however, be done by using a GIS or digitizing an approved map that could be used by all the sectors and tiers of the government. After produc- ing the map, participatory discussions involving a multidisciplinary group will help (a) identify the patterns, (b) question the patterns evidenced by the data, (c) recommend further types of pri- oritized data and queries, believed to be necessary to ascertain the environmental health concerns, (d) formulate a plan of action in conjunction with other sectors' goals and strategies, and (e) monitor the outcomes on a regular basis, allowing re-evaluation of policy response implementa- tion. Environmental health applications targeting specific health risks have been performed in several countries, but no comprehensive environmental health map has, as yet, been developed. The de- gree of sophistication of this decision support system will depend on time and resource con- straints, availability, reliability of collected data, and sustainability of the process (designation of a lead agency, update, maintenance, and information sharing), which will help formulate envi- ronmental health policy responses at the national, regional, and communal levels. Quantifying Untapped or Missed Health Benefits Potential health benefits outside the health care system remain untapped or underestimated and, therefore, unrecognized. Four crucial reasons for this, compounded by problems in data avail- ability and reliability, concern economic and health valuation techniques. - First, health benefits, especially when calculated within the health sector, tend to focus on measures implemented through the health care system, on a single disease or condition or on a single causal factor. Only occasionally are measures multisectoral. Such analyses of malaria control, for example, tend not to look at other mosquito-borne diseases and con- centrate on measures promoted by the health care system, such as bed nets, medications, and other medical treatment. In comparison, positive infrastructure interventions such as proper drainage tend to be excluded. Because drainage networks can support a variety of mosquitoes, drain cleaning and maintenance that reduces breeding sites for mosquitoes that spread malaria can also reduce breeding sites for mosquitoes spreading dengue and filariasis. * Second, health benefits, especially when calculated outside the health sector, tend to be aggregated under "health," without recognizing individual contributions of multisectoral causes or remedial actions. Reducing air pollution, for example, has impacts beyond res- piratory diseases, addressing impacts on the circulatory system, skin, and eyes. * Third, the tendency to focus on single diseases may also miss diseases that may be medi- cally different, but would respond to the same type of remedial measures. Under the broad category of respiratory diseases, for example, focusing on acute respiratory infec- tions-the number one cause of DALYs in developing countries (see table 1 - )-would miss diseases such as tuberculosis, asthma, and lung cancer. * Fourth, it is also possible to miss diseases and conditions that are indirectly related to the single disease being evaluated. For example, in an energy project evaluating the benefits of improved household fuel. Concentrating on indoor air pollution and respiratory disease could miss a range of factors that may be equally important. The consequences of fetch- ing firewood entail injuries (head, neck, and back) to women from carrying heavy loads, and perinatal problems if they are pregnant (low birth weight and miscarriages). Other 24 missed benefits could include better child nutrition, if mothers are able to improve cook- ing (boiling water to prevent diarrheas and more hot meals). These four factors will depend on local conditions, but, collectively, their effects can be consider- able. Analysis of the possible impacts of multisectoral approaches to environmental health, however, can be revealing. The World Development Report: Investing in Health 199312 estimated that the public sector health care system could relieve about 33 percent of the burden of disease. In com- parison, the 1996 Bridging Environmental Health Gaps volumes estimated that the infrastructure sector could target up to 44 percent of the burden of disease in SSA (see table 2-7). This points to the great potential of interventions outside the health care system. The infrastructure sector could target up to 44 percent of the burden of disease in SSA, indi- cating the great potential of interventions outside the health care system. Table 2-7: Burden of Disease in SSA by Main Remedial Measures (1990) Years with Annual Remedial Measures Disease or Condition Disability Deaths DALY Imnproved housing and air Respiratory disease 3,017,000 1,565,000 45,312,000 pollution abatement Vector control, sanitation, Tropical cluster or 8,064,104 1,123,300 35,922,104 and drainage vector related Improved water and waste Water and sanitation 1,468,000 888,539 31,208,000 mnanagement related Household and traffic Unintentional injuries 5,322,009 335,300 15,067,000 injury reduction Subtotal infrastructure related 17,871,113 3,912,139 127,509,104 Subtotal childhood clustera 1,501,000 788,000 28,093,000 Subtotal remaining burden ofdisease 48,158,000 3,326,861 137,236,104 Grand total burden of disease 67,530,113 8,027,999 292,838,208 Percentpotentialfor infrastructure interventions 26.5 48.7 43.5 a. Childhood cluster includes pertussis (whooping cough), poliomyelitis, diphtheria, measles, and tetanus. Source: Adapted from World Bank (1994) and WHO (). Table 2-8 takes the potential target of 44 percent a step further by estimating the possible range of health benefits available outside the health sector in SSA. Measures inside and outside the health care system could achieve the same order of magnitude, each averaging about 20 percent. In theory, therefore, it is possible to produce the same order of magnitude of health benefits at only a fraction of the cost, because investments have already been justified for reasons other than health (see chapter 3). Although the figures are still estimates and require rigorous statistical analyses, in the absence of statistically significant data, common sense and professional judgment argue for systematic examination of these possibilities. 25 Table 2-8. Burden of Disease Relieved by Remedial Measures (1998) Percent of the Range of DALYs Potentially Reduced Remedial Measures Low High Environmental health remedial measures for infrastructure and other sectors: Improved housing and air pollution abatement 6 8 Improved water and waste management 8 9 Vector control, sanitation, and drainage 3 4 Road, workplace, and housing design 1 1 Subtotal of environmental health types 17 22 Health care/education remedial measures: Subtotal of health care types 15 20 Other remedial measures: Subtotal other 68 58 Total 100 100 Source: Authors' calculations. Table 2-9 estimates that, for respiratory disease alone, 47 percent of the DALYs are often not analyzed for potential benefits available outside the health sector. For instance, the same factors responsible for acute respiratory infections, such as indoor air pollution from poor quality cook- ing, lighting, and heating fuels, can also cause or aggravate the remainder of respiratory diseases, which are analyzed separately in statistics. Table 2-9: Possible Health Benefits Missed by Focusing on a Single Disease World Developed Developing DALYs DALYs DALYs Respiratory Disease/Condition (1,OOOs) (1,OOOs) (1,OOOs) Counted in top ten or alone Acute respiratory infections (lower) 82,344 1,355 80,990 Subtotal "counted in top ten" 82,344 1,355 80,990 Diseases counted separately Acute respiratory infections (upper) 975 50 924 Tuberculosis 28,189 142 28,047 Chronic obstructive 28,654 2,449 26,205 Asthma 10,986 1,208 9,706 Other 18,932 1,303 17,089 Cancer (lung, trachea, bronchus) 11,176 3,122 8,054 Subtotal "counted separately" 87,736 5,152 81,971 Combined total 181,256 9,629 171,015 Possibly omitted in calculation of benefits 45% 14% 47% Source: For DALYs, WHO (1999b), pp. 85-115. Improved Service Delivery The single sector approach may underestimate the environmental health benefits possible through a broader approach to improving overall service delivery. In the case of transport and health agency collaboration on reducing mosquito-borne diseases, transport agencies could improve drainage and, to a lesser extent, traffic flow in the rainy season by transferring some of the drain monitoring to health or neighborhood groups. This concept is further explored in chapter 3's sec- tion on environmental health attributes, which dis-aggregates benefits that are typically listed un- der the "health" rubric. Table 2-6 above listed expanded health benefits that imply better service delivery, because they add to the types of beneficiaries otherwise excluded from a project. 26 Estimating Beneficiaries Single sector approaches traditionally calculate economic rates of returns on a development proj- ect by closely examining those directly affected by a project. An environmental health approach needs to examine if benefits can be appropriately applied to a wider audience. Better estimates of beneficiaries can help justify projects or components that are considered too costly. In the Long-Term Water Sector Project in Senegal, for example, initial economic calculations focused on water as the way to reduce diarrheal disease and on those who would benefit eco- nomically by having water conveniently and consistently accessible. An environmental health analysis, however, increased the number of beneficiaries by including (a) 70,000 people who live near a dam in the project zone that are exposed to schistosomiasis and (b) Dakar residents who might benefit from better management of market gardening to help curtail the current spread of urban malaria (see table 2-10). Table 2-10: Sample of Increased Health Benefits in Long-Term Water Sector Project in Senegal HEALTH BENEFIT STAGE OF DELIVERY HEALTH COST/RISK 1. Production of Water at Ultimate Source. Seneal River * Added income to promote s Local populations are moving * Spread of malaria and bilharzia. better nutrition, especially around the Lac de Guiers be- * Pesticide and fertilizer contamination. protein. cause of economic activity spurred by a link to the Sene- gal River. 2. Production at the Immediate Source A. Lac de Guiers (population estfmate, 70,000) * Fishing and livestock: added * Traditional agricultural activity * Fishing: creation of temporary fishing income to promote better nu- will expand on the lake's west- villages with low levels of hygiene and trition, especially protein. em shore and part of the east- sanitation; sexually transmitted diseases, * Agriculture: nutritional benefit em shore. Proposed manage- especially AIDS, from transient popula- from added crops (flood reces- ment plan will vary the water tion. sion cropping). level in the lake so that shores * Livestock: animal-borne diseases (and, * Reduction of aquatic weeds by dry up annually for 2-3 months for animals, Rift Valley Fever). shores will help break the cycle (to be determnined). * Agriculture: pesticide and fertilizer con- of malaria and bilharzia. tamination of the lake, and spread of ma- laria and bilharzia from improper agri- cultural practices. B. Water Production Plant * Added income to promote * Construction of plant will re- * Areas used for sand and soil can become better nutrition, especially quire sand, soil, and vehicles. vector breeding grounds, if not filled in. protein. * Construction vehicles can cause noise; dust, increasing the risk of respiratory disease in local populations; and traffic- related injuries. * Poor sanitation and drainage during con- struction by work crews can spread diar- rheal vector-related disease. * Sexually transmitted diseases, especially _AIDS, from transient population. * Health services available at the * Operation of plant. * Poor sanitation and drainage by workers water production plant. can spread diaffheal vector-related dis- ease. (None readily apparent) * Blockage of current watering * Increased risk of bilharzia for locals who site for local farmers. need to find a new watering site because the area now has no vegetation (breeding sites) at its shore, although other nearby suitable sites do. 27 HEALTH BENEFIT STAGE OF DELIVERY HEALTH COSTRISK C. Housing for Water Treatment Workers Improved housing, in addition * Vehicle traffic during opera- * Risk of noise pollution, traffic injuries, to water sanitation for about 75 tions. and respiratory disease from frequent ve- families. hicle traffic passing near homes. * Risk of spreading vector-related diseases due to poor sanitation and drainage. 3. Water transportation: Keur Momar Sarr-Thies main * Clean water. * Villages along water main. * Spread of malaria through improper agri- * Market gardening. cultural practices. * Additional sources of nutrition, * Small dams can lead to water contamina- especially protein from addi- tion and breeding sites for disease vec- tional crops possible. tors, if not correctly maintained. * Possible added income from * Legal connections for drinking * Spread of malaria through improper lower water costs. water. drainage of water. (None readily apparent) * Construction work crews and * Spread of AIDS worker camnps during pipe _____________________________ laying. (None readily apparent) * Illegal connections. * Spread malaria through improper drain- age of water. 4. Use: Greater Dakar (Agglomeration de Dakar) * Possible reduction in malaria * Market gardening in periurban * Increase in urban malaria from added by changing from sprinkle- Dakar and five secondary cit- water without proper drainage. saturation watering to drip. ies. * Reduction in diarrheas and * Improved sanitation and drain- * Spread of urban malaria from improper intestinal parasites through im- age. disposal and drainage. proved water, sanitation, and drainage. ____ _ 5. Use: Dakar City (Ville de Dakar) * Reduction in diarrheas and * Improved sanitation and drain- * Spread of urban malaria from improper intestinal parasites through im- age. disposal and drainage. proved water, sanitation, and drainage. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ * Reduction in diarrheal diseases * House connections. * Spread urban malaria through improper and intestinal parasites through drainage of water. improved hygiene._ * Reduction in diarrheal diseases * Standpipes. * Spread malaria through improper drain- and intestinal parasites through age of water. improved hygiene. * Increase diarThea from improper water management. (None readily apparent) * Illegal connections. * Spread malaria through improper drain- age of water. * Increase diarrhea from improper water management. Source: Senegal Long Term Water Sector Project, 2000, The World Bank. 28 CHAPTER 3: SOCIOECONOMIC JUSTIFICATION AND CHALLENGES Human beings are at the center of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature. Relative to the other chapters, Chapter 3 is written with a greater emphasis on technical issues. Many ideas being presented are new, particularly those of health benefit valuations that have of- ten been missed. These new ideas have not been subjected to analyses from several sectors. As a result, greater attention has been placed on explaining methodology than on its application. This chapter deals with the economic underpinnings of the new ideas being proposed in this dis- cussion paper: that considerable health benefits outside the health care sector remain untapped and require further research and analysis, for example, infrastructure interventions. The chapter builds on the tremendous environmental work that has been done to quantify these health effects and attempts to complement and expand the environmental scope, work, and analysis to look comprehensively and multisectorally at environmental health effects outside the health care sys- tem, especially those affecting the poor. More specifically, the chapter covers the following top- ics: * First, the chapter introduces the notion of environmental health and attempts to justify the need to mainstream environmental health concerns in development work, while empha- sizing that environmental health interventions are not competing with, but complement- ing health care delivery system interventions in a cost-effective manner. * Second, the chapter clarifies environmental health attributes, such as ecological factors, man-made factors (or environmental health externalities that tend to be treated under a general rubric of "health"), and human behavior. * Third, the chapter stresses the need to harmonize the enabling environment to formulate adequate environmental health policy responses (identifying environmental health exter- nalities and associated policy, institutional, and market failures) and devise monitoring systems to achieve outcome-based results. To this end, macro and sectoral World Bank instruments are reviewed to integrate environmental health concerns. * Fourth, the chapter quantifies and values in terms of social costs the environmental health burden of disease (BOD) in Sub-Saharan Africa and apportion the environmental health BOD borne by the poor. More specifically, the BOD is dis-aggregated and re-aggregated, which allows for "back-of-the-envelope" calculations on the SSA burden of disease that is targetable through environment health and health care interventions. These are quanti- fied in terms of lower-bound social cost to SSA economies. * Fifth, the chapter prioritizes a cluster of interventions based on environmental health BOD to relieve the burden on the entire population as well as on the poor. A cost- effectiveness analysis is performed and possible intervention efficiency ratios are derived by intervention. Also, policy response and implications are drawn. First principle of the Rio Declaration, United Nations Conference on Environment and Development (UNCED), Rio de Janeiro, June 1992. 29 Why Do Mainstream Environmental Health in Development Work? Economic thinking relies on the concept of utilitarianism, by which people strive for well-being and avoid pain. Sustainable development promotes non-declining well-being for present and fu- ture generations through a well-managed physical, natural, human, social, and financial capital."3 Growing sustainable development challenges in the 1 980s and 1 990s led to the development of institutional frameworks and application of conventional economic thinking to come up with op- timal economic solutions for addressing environmental problems. In contrast, environmental health (see box 3-1 for a working definition) problems (human health problems falling outside the purview of the health care sector, such as health effects resulting from economic activity affecting the environment) are still only partially identified and addressed through afragmented sectoral approach. Box 3-1: Working Definition of Environmental Health Environmental health' relates to ecological factors, human activity (production or consumption), and human behavior that impact socioeconomic conditions and environmental life support systems and potentially affect the well-being of present and future generations by increasing human disease, in- jury, conditions, and premature death.' Source: Authors' data. At the end of the 1 990s, major efforts were made essentially to recognize environment health problems, and numerous surveys and prospective studies were conducted to bring this important issue to the forefront. A worldwide public opinion survey conducted in thirty countries singled out children's heath affected by environmental problems as one of the most important concerns.'4 Over the 1990-99 period, the burden of disease (BOD) growth outpaced the population growth15 in SSA (26 against 21 percent respectively over the period). This increase is a stern reminder that communicable diseases (+41 percent), mainly HIV/AIDS, malaria, respiratory diseases and wa- ter-related diseases, which have different growth rates over the period, represent a growing por- tion of SSA's BOD in relative terms (73 percent in 1999 against 66 percent in 1990). A recent World Bank study suggests that the concentration of death and disability-adjusted life years (DALYs) lost to communicable diseases, of which almost a third can be attributed to environ- ment-related problems in SSA, affects the poor-about 60 percent of ill health for the poor com- pared with 8-10 percent among the richest quintile.'6 In terms of environmental health, commu- nicable diseases (excluding HIV/AIDS) represent the majority of the diseases affecting both, the entire population (86 percent) and the poorest of the poor (87 percent) (see table 3-1). Environmental health problems are rarely aggregated per se, but, collectively, they amplify the burden of disease, which impinges on Sub-Saharan Africa's (SSA) in the following ways: Definition: development that meets the needs of the present without compromising the ability of future generations to meet their own needs (Brundtland Report: World Commission on Environment and Development, 1987, p. 43). t See glossary for various definitions on environmnental health. t Future generation preferences and possible environment-related human genetic defects cannot be determined or documented ex ante and, therefore, constitute an unresolved issue that will not be addressed in this chapter (See also institutional failures). 30 Table 3-1: Back-of-the-Envelope Burden of Disease (BOD) Breakdown in SSA, 1998 Social Share of SSA Burden of Disease by Attributable Risk Benefits GDP BOD Lower Non- Percent- Possible Bound So- Commu- Commu- Total age of Interven- cial Cost nicable nicable Inju- BOD Total tion Effi- Equivalent Diseases Diseases ries (DALY BOD ciency to GDP Attributable BOD (%)M (%) (YO) Million) (%) Ratio (%) Environmental Health BOD 86 10 4 64.1 20 2.3 6.0 affecting the entire population Environmental Health BOD affecting 87 10 3 31.7 10 2.3 3.3 the poorest quintile AIDS/HIV affecdng the entire 100 0 0 54.1 17 Varies 7.0 populadon AiDS/HIV affecting 100 0 0 25.0 7.7 Vanies 3.6 the poorest quintile From SSA Burden 68 17 15 325.2 100 NA NA of Disease Note: See tables 3-9 and 3-10 for details. Source: WHO (1999) and Gwatkdn and Guillot (1999). * Population well-being. Environmental health effects account for at least 20 percent of the burden of disease (BOD); 10 percent affect the poorest of the poor (see table 3-1). In comparison, AIDS represents 17 percent of the BOD for the entire population and 7.7 percent for the poorest of the poor. Also, demographic growth and growing urbanization (one third of SSA population in 1998) could exacerbate and complicate environmental health problems, for example, a possible migration and adaptation of rural diseases, such as vector-bome, to urban settings (see box 1-3). * Overall economic performance. Environmental health BOD for the entire population is equivalent to approximately 6 percent of the 1998 nominal GDP in SSA. A recent study suggests that malaria and poverty are intimately correlated: in 1995 SSA countries with intensive malaria had income levels only 33 percent of countries without malaria and grew 1.3 percent less per person per year with a loss in GDP of more than $100 billion in 25 years (1965-1990), equivalent on average to one-fourth the net official development assistance per year for SSA. A 10 percent reduction in malaria translated to 0.3 percent higher growth,17 and a suggested $1 billion spending on malaria control and management could generate short term benefits accruing to SSA economies ranging between $3 and 12 billion per year. These results are staggering, especially because targetable malaria through environmental health interventions (land use/shore management, infrastructure improvement, and behavioral change) could represent up to 40 to 50 percent of the total burden of malaria. Without reverting to simple extrapolations, especially regarding AIDS, it is interesting to note that malaria represents 22 percent of the environmental health BOD in SSA. 31 Box 3-2: Key, Confusing, and Misused Economic Terms on Environmental Health Cost-benefit analysis (CBA). A normative technique that optimizes both the target and the means of a policy (macro and sectoral) choice, project, or intervention and is, therefore, more economi- cally efficient than the cost-effectiveness technique. The general premise is well accepted, but be- comes controversial when specific numbers are attached, for example, value of life, and so on. Cost-effectiveness. A normative technique that, in the absence of proper valuation of the benefits (unreliable or controversial data, and so on), sets the target (for example, standard for a pollutant or number of DALYs, HeaLYs, or quality-adjusted life year) and determines the means of a pol- icy choice, project, or intervention. Disability-adjusted life year (DALY). A numeraire or a metric that measures the burden of disease and expresses years life lost to premature death and years lived with a disability of specified se- verity and duration. One DALY is one lost year of healthy life (see box 3-5). Efficacy. Refers to the impact of a successful intervention when implemented in ideal circum- stances, such as a scientific trial. Effectiveness, in contrast, refers to the impact under routine con- ditions, when implementation is imperfect. Environmental health externalities. See Man-made environmental health problems. Healthy life years (HeaL Y). HeaLYs account for almost the same as DALYs, although within a slightly different theoretical framework. HeaLY could be applied to individuals or populations to determine the impact of a particular disease, determine the effects of interventions on populations and socioeconomic groups, or compare areas (see box 3-5). Incidence. The fraction or proportion of a group initially free of the disease, who develop the dis- ease within a given period of time (usually one year). Intervention. A specific activity meant to reduce morbidity and/or mortality risks, treat illness, or palliate the consequences of disease and disability. Man-made environmental health problems or environmental health externalities. The positive or negative effects of the action of a human agent (generator) on other human agents (affected par- ties), for which no organized market for this effect exists, for example, emission of pollutants or spread of disease that affects other individuals. Prevalence. A fraction or proportion of a group possessing a disease at a given point in time, measured by a single examination or survey of a group (usually two weeks). Quality adjusted life year (QAL D9. An outcome measure that expresses years life gained (oppo- site of DALYs) from an intervention, that is, the quantity and quality of the extra life in years provided by an intervention. It is the arithmetic product of the life expectancy and the quality of the remaining years. One QALY is one gained year of healthy life (see box 3-5). Risk assessment. Provides a framework for quantifying the adverse environment-related health ef- fects of a pollutant. Once a hazard has been identified, the researcher attempts to measure the ex- tent to which people in a population are exposed to the hazard, and the impact of the exposure on health, which is measured in a dose-response function. Value of life, value of statistical life, value of lives saved, and value of lives extended. All basi- cally synonymous terms for measures that permit reductions in mortality risks to be monetized. It is, thus, not life itself that is valued, but a reduction in the probability of avoiding a given risk. Values for these terms are derived by dividing an estimate of the value (see WTP) for avoiding (or obtaining) a given change in the risk of death by the risk change. Willingness to accept (WTA). In terms of health, WTA is the monetary value of compensation an individual is willing to accept, given a proven risk of illness, accident, or premature death. WTA is considered a benefit in a CBA. If an individual is not compensated, the WTA is considered a cost in a CBA. Willingness to pay (WTP). In terms of health, WTP is the monetary value an individual is willing to pay or forgo to reduce the risk of illness, accident, and/or premature death. WTP is considered a cost in a CBA. In case of an intervention, the WTP is considered a benefit measure in a CBA. Source: Authors' data and, Harou and Doumani (1998). 32 * Health care delivery systems. Environmental health problems are preventive in nature through mainly targeted infrastructure interventions* and need to complement public health interventions (public health expenditures18 averaged $33 per capita in 1990-98; lows reached $3 in certain countries, such as Kenya). Yet, in the absence of adequate environmental health interventions (land use/shore management, infrastructure provision, and associated behavior change), environmental health-related problems (20-25 percent of health care spending) turn into public health problems by default and burden the health care delivery system. The possi- ble average environmental health intervention efficiency ratio amounts to 2.3; in other words, each dollar spent toward an infrastructure intervention (water and sanitation, drainage, and so on), including education where environmental health considerations are taken into account, could also relieve the environmental health BOD and generate an average of $2.30 in social benefits for both the entire population, as well as the poorest of the poor (see tables 3-1 and 3- 9). These infrastructure interventions can relieve environmental health risks in a cost- effective manner. The estimated associated costs of adding an environmental health compo- nent to projects could be derived as a proxy and range from 0.119 to more than I 020 percent, depending on the sector, geographic location, topography, ecological zone, and/or project. The environmental health burden on the poor is a salient problem, and environmental health con- stitutes a potential entry point worth exploring to relieve the burden on the poor; this is in line with the Bank's objective to reduce poverty. It calls, however, for mainstreaming environmental health concems in Bank work or other developing institutions at all levels, that is, macro, secto- ral, and, mainly, project, by improving the environmental impact assessment process, in which environmental health problems need to be duly considered (see chapter 6 on mainstreaming health concerns in the EA process). Environmental health is multisectoral in nature and needs to be harmonized with environment, health, and other sector's interventions to identify problems, prioritize interventions, formulate policies, determine a cluster of interventions, and devise out- come-based monitoring systems across sectors. Comprehensive environmental health interven- tions, which call for cross-sectoral collaboration and partnerships, would not only prove cost- effective, have synergistic effects, and improve development outcomes, but, most important, would improve the well-being of the poor and increase IDAt efficiency. Understanding Environmental Health Attributes Understanding environmental health attributes can help establish the relationship between health effects on the one hand and ecological factors, man-made environmental problems, and human behavior-prone health problems on the other. Environmental health problems could also be at- tributed to civil strife and wars, but will not be covered in this section.: It is important to note that these attributes could vary according to ecological and geographic zones, as well as to urban compared with rural settings. Identifying environmental health attributes will help achieve out- come-based results through better (a) identification and quantification of problems and (b) priori- tization and formulation of multisectoral cost-effective interventions and monitoring systems (see "Prioritizing" and "Monitoring" below). Infrastructure interventions include improved stove and associated behavior change in this chapter. t IDA, the International Development Agency, is one of the five agencies that make up the World Bank Group, which consists of IDA, the International Bank for Reconstruction and Development (IBRD), the International Finance Cor- poration (IFC), the Multilateral Investment Guarantees Agency (MIGA), and the International Center for Settlement of Disputes. IDA lends to the poorest countries, i.e., per capita GNP less than $800. The credits are, in effect, interest free. All SSA countries except South Africa fall into the IDA lending category. t There is, however, a need to consider early on environmental assessment underscoring environmental health issues in Bank Post-Conflict Reconstruction programs whose aim are to easing the transition to sustainable peace and sup- porting socioeconomic development in conflict-affected countries. World Bank web site: Post- Conflict/Reconstruction, . 33 In addition to civil strife and wars, environmental health problems can subsequently be attributed to three main factors that may sometimes be interrelated and even self-reinforcing: Ecologicalfactors including natural disasters. Ecologicalfactors, such as specific ecosystems can impact human health (for example, ground- water contamination by naturally occurring arsenic in Bangladesh, marshes or a natural lake, in which mosquitoes can breed, can spread vector-related diseases). This can be mitigated through better environmental management, as was the case in Italy in the 1 930s, where proper land use/coastal shore management eradicated malaria. These interventions should, however, be com- plemented with traditional preventive measures in endemic areas (indoor and outdoor spraying, screens, impregnated bed nets, and prompt treatment, as appropriate). In the case of a lake, for example, introduction of larvivorous fish (tilapia or St. Peter's fish from the Nile river) can help control mosquito breeding sites (lake shores and shallow areas as appropriate) and form the basis for aquaculture. This intervention, for example, in Lake Tanganyika, could target the rural poor, provide them with fishing opportunities/rights, and supplement their dietary intake with protein.2' Valuation of these ecology-related health impacts, applying the same valuation techniques used to value environment health externalities, can help justify development projects on economic (in- creased opportunities and livelihood), as well as on social (improved health) grounds, provided proper and satisfactory environmental, environmental health, and social assessments are initially conducted. Table 3-2: Health Risks Attributable to Natural Disasters in SSA, 1990-2000 Natural Disaster People at Risk and Disaster High Occurrence Drought Famine Flood winds Other Total People affected 100.4 28.4 15.5 5.3 1.1 150.7 (millions) Occurrence 78 30 152 38 32 330 Death 239 6,087 6,423 1,316 387 14,452 Risk of communicable Potential risk following all major disasters, especially with lack of access to water and diseases sanitation. During the period, 223 outbreak of epidemics (not necessarily associated with the above-mentioned natural disasters) occurred, 8.4 million people affected, and 59,736 people reported dead. Note: Natural disaster figures, especially for severe injuries, are extremely underreported in SSA; these figures are only meant to give an order of magnitude on reported natural disasters. "Other" includes earthquakes, extreme temperatures, insect infestations, landslides, volcanoes, and wildfires. "Epidemic" includes anthrax, arbovirus (e.g., ebola and west Nile), diarrhea (e.g., cholera), malaria, measles, meningitis, plague, rabies, rickettsia, and outbreak of unknown origin. Year 2000 data until October. Source: Catholic University of Louvain, Louvain, Belgiumn, EM-DAT: The OFDA/CRED Intemational Disaster Data- base, web site: . Natural disasters, such as droughts, famines due to natural causes, flooding, torrential rains, and so on could be caused or accentuated, in some cases, by global externalities. Climate change, for example, accentuated the effects of El Niflo and La Nifia. Natural disasters are placing increasing economic and social costs on developed and developing countries. In SSA, almost 1 out 6 Africans was affected by reported natural disasters over the 1990-2000 period (see tables 3-2 and 8-2). WHO, for example, estimates that up to a third of the people who die of malaria every year in SSA are from countries affected not only by serious natural disasters, but also by wars and civil strife.22 Prevention and mitigation measures and improved emer- gency responses to reduce the vulnerability of the population at risk, especially SSA's popu- lation, are being pursued at the Bank's Disaster Management Facility23 (DMF). The DMF tries to prevent and mitigate the damage to physical assets. Anticipating environmental health 34 risks emerging after a disaster, especially because vulnerable groups are generally the most affected by natural disaster,24 could enhance the DMF emergency response by adapting the Rapid Environmental Health Assessment Checklists (see annex A). A checklist could be inte- grated into the DMF Rapid Response for Recovery Planning, especially regarding knowledge of vulnerability to risk aspects that is included in the DMF guidance on damage and needs as- sessments. * Man-made environment-related health problems or environmental health externalities. The latter, which are not explicitly recognized per se in development work, are defined as a spill- over of benefits or losses from one or several individual(s) to another,25 for example, water pollution causing water-related diseases, stagnant water due to clogged drains that spread vector-related diseases, and so on. Environmental externalities are usually dis-aggregated cross-sectorally by resource degradation and environmental problems. In contrast and ex- cepting diarrheal (water-related) diseases, respiratory-related diseases (from air pollution), and another few diseases, environment health externalities, when identified, are generally as- cribed to "public health," "health," or even occupational issues and are rarely dis-aggregated in terms of specific diseases and injuries (environmental and natural resource problems are integrated in each sector in table 3-3 below). * Human behavior-prone diseases and injuries, such as women who are cooking and inhaling fumes from indoor sources of pollution (from use of stoves, cooking oils, and heating fuels), driver habits (self-inflicted injuries due to car accidents), improper hygiene practices or sex- ual mores, among others, need to be identified through household surveys, social assess- ments, or other studies, and addressed through appropriate awareness and education cam- paigns and better regulation and enforcement measures. Table 3-3: Environmental Health Externalities Usually Neglected in Valuation Sector or Selected Ne ative Externalities Subsector Environment: Environmental Health: Typically Dis-aggregated Typically Aggregated as "Public Health" or _"Health" Agriculture, Slash and burn; salinization; land degra- Respiratory, eye, and circulatory system diseases Rural dation; land erosion; productivity loss; (slash and burn and food-smoking); food chain Development resource depletion; deforestation; runoff; contamination and food poisoning, including from and Natural depletion of carbon sink; biodiversity loss; lead (flour from traditional millstones reinforced Resource watershed pollution; aquifer pollution; with lead joints); vector-related diseases (VRD); Management waste water reuse; coastal and marine arsenic and nitrate poisoning; possible cases of pollution; and, resettlement and migration cancer from pesticides, and reproduction disorders; and spread of AIDS (seasonal, construction and O&M workers and so on) Transportation Air pollution from various pollutants; Respiratory, eye, and circulatory system diseases; (All modes) ozone layer damage; noise and odor pollu- VRD; transport injuries; physical and mental stress; tion; deforestation; coastal and marine and lower IQ in children (from lead in fuel); food chain river pollution; and resettlement contamination (for example, fish from coastal pol- lution), including food poisoning; possible cases of cancer due to chemical interactions in air; spread of infectious diseases (globalization and trade); and AIDS (truckers and workers) Water Supply Refuse; salinization; resource depletion; VRD; diarrheal, and other infectious diseases, in- land and water pollution; and, coastal and cluding cholera and typhoid; physical stress (water marine pollution carrying); food chain contamination, including food poisoning; arsenic and nitrate poisoning; lower IQ in children (from lead); and spread of AIDS (con- struction and O&M workers) 35 Sector or Selected Ne ative Externalities Subsector Environment: Environmental Health: Typicafly Dis-aggregated Typically Aggregated as "Public Health" or " Health" Sanitation Refuse; aquifer pollution; land and water VRD; diarrheal, and other infectious diseases, in- pollution; and, coastal and marine pollu- cluding cholera, typhoid and plague; food chain tion contamination, including food poisoning; and spread of AIDS (same as above) Drainage Refuse; aquifer pollution; watershed and VRD; diarrheal, and other infectious diseases in- surface water pollution; land and water cluding cholera and plague; food chain contamina- pollution; and, coastal and marine pollu- tion, including food poisoning; and spread of AIDS tion (same as above) Solid, Hazardous Air pollution; watershed and surface water VRD; AIDS, and other infectious diseases (infected and Medical pollution; aquifer pollution; land pollution; syringes), including plague and so on; respiratory, Waste coastal and marine pollution; noise and eye, and circulatory system diseases; food chain odor pollution; and resettlement contamination, including food poisoning; and mental stress Housing Air pollution (could include second-hand Respiratory, eye, and circulatory system diseases, smoke, which is not considered as envi- including TB; VRD (water tanks, containers, in- ronmental externalities) door plants, and so on); diarrheal and other infec- tious diseases, including cholera and typhoid; lower IQ in children (from lead-based paints); and spread of AIDS (construction and O&M workers) Energy Air pollution from various pollutants, in- Respiratory, eye, and circulatory system diseases; (which could cluding greenhouse gases; ozone layer VRD (dams); diarrheal, and other infectious dis- accentuate global damage; watershed pollution; coastal and eases; lower IQ for children (lead); physical (fuel- warming and marine pollution; deforestation; biodiver- wood) and mental stress; food chain contamination climate change) sity loss; resettlement; resource depletion; including food and arsenic poisoning; possible depletion of carbon sink, and, noise and cases of leukemia in children (transformers and odor pollution transmission lines); possible cases of skin cancer and cancer due to chemical interaction in air; and spread of AIDS (same as above) Industry Air pollution from various pollutants, in- Respiratory, eye, and circulatory system diseases; (which could cluding greenhouse gases; ozone layer VRD; diarrheal, and other infectious diseases; accentuate global damage; watershed pollution; land pollu- lower IQ for children (from lead); physical and warming and tion; aquifer pollution; coastal and marine mental stress; food chain contamination, including climate change) pollution; and, noise and odor pollution food and arsenic poisoning; mental stress; possible cases of skin cancer and cancer due to chemical interactions in air; and spread of AIDS (workers) Mining (which Land pollution and erosion; air pollution Respiratory, eye, and circulatory system diseases; could accentuate from various pollutants; ozone layer dam- food chain contamination, including food poison- global warming age; watershed pollution; aquifer pollu- ing; infectious diseases; VRD; mental stress; possi- and climate tion; coastal and marine pollution; re- ble cases of skin cancer and cancer due to chernical change) source depletion; noise and odor pollution; interactions in air; and spread of AIDS (workers) and resettlement Note: Environment and natural resources are integrated in each sector. VRD are transmitted through mosquitoes (i.e., anopheles [malaria and filariasis], aedes [yellow fever, filariasis, dengue, and Rift Valley Fever]; and culex [filaria- sis]), and other vectors (i.e., snails [schistosomiasis], rodents [leptospirosis], water flea [guinea worm], and blackfly [onchocerciasis]. For more details on exposures and effects, see tables 7-2 through 7-9. Source: Authors' data. Harmonizing Environmental Health with Environment Policies, Law, Insti- tutions, and Monitoring Systems Generally, policy, institutional, and market failures are attributed to, respectively, government's distortionary interventions, unclear "sets of rules," and lack of interventions, which cause or ex- 36 acerbate environment and environmental health problems. Regarding environmental health exter- nalities, these failures result in the conjunction of inappropriate prices needing correction and in- adequate institutional setup needing adjustment, if resources are to be allocated optimally throughout the economy. Prices corrected for various types of failures and appropriate institu- tional reforms targeting the environment and environmental health constitute, in certain cases, a "win-win" situation, because price adjustments and subsidy removal (although not in all cases, as shown in table 3-3) and/or institutional reforms benefit both the environment and environmental health. Some environmental interventions alone, however, can lead to partial environmental health solutions. A World Bank initiative, for example, in conjunction with other partners and consisting of elimination of lead from fuel worldwide, 26 proved a success. It overshadowed, however, the need to look comprehensively at the lead problem, identify the most important sources of lead, and prioritize cost-effective interventions (see table 7-4). Lead concentration in blood usually negatively affect children by lowering IQ and the elderly by causing pulmonary problems.27 Interventions targeting other sources of lead, such as water pipes made of lead, eye cosmetics (kohl in the Middle East or surma in Latin America), glazed pottery, lead-based paint, food chain contamination (in India, in wheat ground by millstones reinforced with lead joints), and so on could be as or even more cost-effective than eliminating leaded fuel, especially in most SSA countries where the number of automobiles per capita is low (two vehicles for every 100 persons in 1996 and no recent statistics available for two-stroke engines in SSA).2" Some vehicu- lar emission "hot spots," however, exist and need to be addressed along with other lead sources, especially in Lagos in Nigeria and Cape Town and Johannesburg in South Africa, where the population density per vehicle is higher than the SSA average. Policy Failures Policy failures are due to poorly designed macroeconomic and sectoral policies that do not prop- erly gauge the economic benefits and costs of these policies and compare them to their economic and social benefits and costs. Imperfect government interventions may exacerbate market distor- tions and lead to further environmental and environmental health problems. For instance, a de- valuation of the local currency could lead to increased logging, deforestation, and use of cheap fuel wood in the absence of clear property rights and socially optimal stumpage fees (fees charged to logging companies); hence, the social cost is not internalized in the private cost. The resulting effects stemming from poor environment management can lead, among others, to an increased incidence of VRDs (vector breeding increases due to stagnant water), respiratory dis- eases from indoor pollution (from use of fuel wood), and land erosion leading to landslides caus- ing injuries, death, and/or homelessness. Thirty-four African countriest prepared national environmental action plans (NEAPs) between the late 1980s and 2000, which were intended as a tool for integrating environmental concerns into national development, namely, at the macro and sectoral levels. Although, several NEAPs acknowledged health concerns (see table 6-6), environmental health concerns were rarely inter- nalized in the development strategies in most countries. Furthermore, regarding the NEAP expe- 29 rience, the Bank introduced a new optional procedure, the environmental action plan (EAP),$ which is a comprehensive and participatory national environmental policy backed by programs to In this specific case, policies are not confined to policy failures and could, for example, include: land use/shore management policies to mitigate ecological problems with environmental health effects; and behavior change poli- cies. t Along with all other IDA countries, in response to a requirement set out for IDA 10 financing. Four additional NE- APs are under preparation in 2000. World Bank Operational Policy and Bank Procedures 4.02, February 2000. The EAP, which is not compulsory, de- scribes a country's major environmental concerns, identifies the principal causes of problems, and formulates policies and actions to deal with the problems. 37 implement the policy. Countries are encouraged to prepare and implement an appropriate EAP and revise it periodically, as needed. A CAS and structural lending program could include part or all of an EAP (see below). A number of methods or tools, developed to establish the linkages between macro and sectoral policies and the environment, are adapted or enhanced below to include the environmental health dimension. Numerous tools exist; however, the main avenue by which EAPs are intended to inte- grate environment into national development (and possibly identify environmental health prob- lems) is through the CAS, which is adapted below to include the environmental health dimension. In addition to the CAS, selected conventional and emerging avenues to link environment and en- vironmental health to macroeconomics and other building blocks of sustainable development tar- geting the poor, are being considered: * Structural and sectoral adjustment lending: macroeconomic matrix * Structural and sectoral adjustment lending and strategic environmental assessment: action impact matrix * Public expenditures review * Country assistance strategy environmental analysis matrix * Comprehensive development framework matrix * Poverty reduction strategy paper * Intermediation mechanisms, for example, community-driven development. These tools could be self-standing or complementary, which could, therefore, constitute an inte- grated process to help mainstream environmental health, not only in EAPs, but also at the macro and sectoral levels. Environmental health could also be canvassed onto many initiatives, pro- grams, funds and facilities which is covered in chapter 2 (see Box 1-2 for options to mainstream environmental health concerns in Bank work and development or enhancement of tools). Some conceptual and practical concerns could, however, emerge on how all these tools could fit to- gether (see below). At the project level, mainstreaming environmental health in the environmental assessment process, which needs to be revisited to increase environmental health outcomes, is covered in chapters 4-7. Structural and Sectoral Adjustment Lending: Macroeconomic Matrix Macroeconomic policies, which include stabilization or structural adjustment programs, tend to reduce the composition and level of aggregate demand through a combination of monetary, fiscal, and exchange rate policies that could affect the environment and environmental health.t Sectoral policies complement macroeconomic work and determine the effects of general policy variables at the sectoral and project levels. Table 3-3 lists several policy variables, which are not covered in depth and could negatively impact environmental health. The World Bank did not require identification of linkages between the various reforms in adjust- ment lending and the environment until March 1999.1 Although the macroeconomic matrix is not compulsory in Bank work, it helps establish linkages among macroeconomics, the environment, and environment-related health problems (see table 3-4), where policy variables and their envi- ronmental and environmental health impacts are linked together. The macroeconomic matrix could prove essential when structural or sectoral adjustment loans are being considered (see table 3-4, which shows the impact of macro policies on the environment and environmental health). Since 1995, a new structural lending, Higher Impact Adjustment Lending (HIAL), was introduced in the Africa Re- gion. HIAL include more poverty-focussed operations. f The effects of globalization on environmental health are not covered in this section and require new research and analytical work. t Environmental provisions are set out in the World Bank's Adjustment Lending Policy, OP/BP 8.60. 38 Table 3-4: Macro Policies Impact on Environment and Environmental Health Macro Intervention Short- and Long-Term Selected Short- and Long-Term Selected Policies Instrument Environmental Impact Environmental Health Impact Fiscal Govt. Exp. Sectors: public infrastructure (e.g., roads Malnutrition could accentuate other and drainage), environmental manage- health risks, especially for children under ment, and so on 5 (mainly diarrhea, measles, acute lower respiratory infections, and malaria), in- Programs: drought relief, food aid, agri- creased VRDs, diarrhea, physical and cultural extension, and so on mental stress, and so on Taxes Reduction of demand for resources and Optimized use of resources could have environmental charges positive (less industrial pollution) or negative (substitution to fuel woods) impacts on respiratory diseases, de- pending on income groups Subsidies Input: machinery, fertilizers, pesticides, Reduced contamination of the food irrigation water, energy, and credit chain; respiratory diseases for low- income groups, due to substitution to Output: depends on crop characteristics, more polluting heating and cooking fu- mining, and industrial park els; improved nutrition or nutrition defi- ciency, depending on income groups; increase in VRDs (burrow pits from mining) and respiratory diseases (higher cost of production and possibly less _ maintenance). Monetary Credit Reduced credit for inputs, for examnple, Contamination of the food chain and fertilizers and pesticides, and invest- reduced industrial maintenance resulting ments, for example, leveling, irrigation, in increased respiratory diseases _ _ machinery, and so on Interest Rate Reduced investment, and resource and Contamination of the food chain and energy demand. increased (due to reduced industrial maintenance) or decreased (due to re- duced fuel consurnption) respiratory diseases. Price Control Rise in officialprices: impact on output Malnutrition responses depends on crop and farmiing practices. Fall in official prices: reverses the effect Exchange Devaluation or Import effect: increases price of im- Food chain contamination and respira- Rate Depreciation ported inputs, for example, fertilizers, tory diseases and VRDs due to defores- pesticides, raw materials, and energy. tation; respiratory diseases due to relo- Export effect: increased export crops cation of polluting industries and import depends on crop characteristics and of second-hand vehicles from countries farming practices; increased export of with more stringent emission standards; minerals, wood, and goods; and and sexually transmitted diseases, in- increased foreign direct investment, cluding AIDS by tourists and infectious polluting industries, second-hand vehi- diseases cles, ecotourism, and so on Trade Import/Export Removal ofprotectionist taxes: same Same effects as devaluation Taxes effects as devaluation, but on selected commodities 39 Macro Intervention Short- and Long-Term Selected Short- and Long-Term Selected Policies Instrument Environmental Impact Environmental Health Impact Trade Controls Samne effects as trade taxes; technologi- Respiratory and infectious diseases cal lock in. Institut. Land Encourage farm investments and long- Malnutrition, VRDs ,and contamination Reform term sustainable resource management of the food chain (pesticides) Financial Improved credit mobilization may bene- Malnutrition, VRDs, and contanmination fit rural farmers of the food chain (pesticides) Privatization Increased efficiency depends on regula- Privatized provision usually misses the tion, monitoring, and enforcement poorest of the poor: VRDs (stagnant water), diarrhea (water quality), respira- tory diseases, and spread of AIDS through work crews Research and Improved extension services promoting Malnutrition, VRDs, and contamination Extension sustainable resource management of the food chain (pesticides) Invest. Training Investment in human capital: agricul- Occupational hazards Policy tural extension, wildlife, resource man- agement, and vocational training Valuation Project evaluation to include environ- Project evaluation to include environ- mental cost and benefits mental health cost and benefits Technology Industrial abatement technologies, Respiratory diseases, nutrition, and adapted agricultural technologies, and VRDs mining practices Public Infra- increased access to natural resources, Malnutrition, VRDs (deforestation and structure and encouraged exploitation; supporting roads), and spread of AIDS through infrastructure for producers enabling work crews, truckers, and so on greater price responsiveness. Source: Adapted from Reed (1996) and Harou and Doumani (1998). Structural and Sectoral Adjustment Lending and Strategic Environmental Assessment: Action Impact Matrix The Action Impact Matrix30 (AIM) is not required by Bank rules and procedures, but it helps es- tablish the links among macroeconomic policies, poverty, the enviTonment, and environment- related health problems that were added to the matrix. The AIM, which also can be used in the context of structural or sectoral adjustment loans, is a tool for policy analysis and coordination of sectoral interventions. It helps identify important problems and links among sectors and policy decisions and environmental outcomes. Introducing the environmental health dimension by es- tablishing the linkages with macroeconomic, sectoral, and environmental policies may help achieve sustainable development goals in an integrated manner, with a special focus on the poor (for example, table 3-5 links and articulates various activities). A strategic environmental assess- ment, which is an environmental assessment performed at the macro, sectoral, and regional lev- els, is suggested to assess environmental and environmental health implications of a policy change on the poor, where its results can be integrated into the AIM. 40 Table 3-5: Example of an Action Impact Matrix (AIM) Selected Imp cts On Key Su tainable Devel pment Issues Environ- Concern/ Land Deg- Air Pollu- mental Policy Main Objective radation tfon Health Poor 1. Macroeconomic Macroeconomic and Positive impacts due to removal of distortions and sectoral poli- sectoral improve- negative impacts mainly due to remaining constraints cies ments a. Exchange rate Improve trade bal- (-H) (-H) (-H) (-M) ance and econov mc (Deforest Polluting in- Respiratory Income ero- growth open-access dustries relo- diseases; sion areas) cation vector-borne diseases b. Energy pricing Improve economic (+M) (±H) (+H) Revert- and energy use effi- (Energy Respiratory ing to cheaper ciency efficiency) diseases and polluting _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~ ~ ~~ ~~~ _ _ _ _ _ fuels 2. Complementary Specific and local Enhance positive impacts and mitigate negative impacts (above) of measures social and environ- broader macroeconomic and sectoral policies mental gains (+M) (-M) (+M) a. Market based Reverse negative (Pollution Respiratory Improved impacts of market tax) diseases health b. Nonmarket Failures, policy (+H) (+M) based distortions, and (Property (Public sector institutional con- rights) accountabil- straints ity) 3. Investment proj- Improve efficiency Investment decision made more consistent with broader policy and ects of institutional framework Investments a. Project 1 (hy- Use of project (-H) (+M) (-M) (+M) Im- dro dam) evaluation (cost (Inundate (Displace (Displace proved op- benefit analysis, forests) fossil people) portunities but environmental fuel use) (+M) negative b. Project 2 (re- assessment, multi- Vector-borne health effects afforest and criteria analysis, and (+H) diseases relocate) so on) (Reforesta- (+M) tion) (Relocate c. Project N people) Note: A few examples of typical policies and projects as well as key environmental and social issues are shown. Some illustrative, but qualitative impact assessments are also indicated: thus, "+" and "-" signify beneficial and harmful impacts, whereas "H' and "M" indicate high and moderate intensity. These qualitative scores are, however, site specific and could differ from region to region. The improved AIM process helps to focus on the highest priority environmental and environmental health issues and related social concerns. Source: Adapted from Munasinghe (1993), pp. 16-19. Such a strategic environmental assessment could be envisaged by using the AIM to target new sectoral tools that are gaining momentum at the Bank and could become full-fledged instruments, for which environmental health need to be considered. Given the global trend of city growth, two initiatives that emanate from the Bank urban strategy could be considered complementary and would require identification of environment and environmental health concerns and their impact on poverty at their onset; these are: City Development Strategy31 and the Cities without Slums ini- tiative,12 whose objective is to address the challenge of urban poverty by upgrading slums. Public Expenditures Review Budgetary processes may vary across countries and a public expenditures review (PER), which is not a compulsory Bank tool, is perhaps the only mechanism for a systematic (and often compre- 41 hensive) analysis of public sector issues.33 Macroeconomic imbalances underscore the need to cut spending and deficits. Governments, which strive for balanced budgets through deficit reduction packages, are required to adopt stringent fiscal and monetary policies. These policies entailed dif- ficult choices in terms of both spending and allocating scarce resources. To bring about the link- ages existing between investments, the macroeconomic and institutional constraints, and the available resources, a framework for evaluating the level and composition of public expenditures can be applied to analyzing broad allocations within and across sectors.34 Mainstreaming envi- ronment and environment health at the macro level could target PERs, for which (a) direct gov- ernment expenditures are allocated for environmental protection and environmental health pre- vention, (b) extra budgetary revenues and expenditures channeled through environment or social funds could be earmarked to mitigate environmental health externalities, (c) a recalibration of subsidies, tax relief, and taxes could correct or aggravate environmental and environmental health externalities, (d) the introduction of green taxes could mitigate both environment and environ- mental health concerns, and (e) multisectoral collaboration and partnerships could be fostered to create adequate opportunities to raise issues and influence allocations.35 Country Assistance Strategy Environmental Analysis Matrix The CAS36 is the central vehicle for the Bank's assistance strategy for all its IDA and IBRD bor- rowers. The CAS document, which is prepared with the government in a participatory way: (a) describes the Bank strategy based on an assessment of priorities in the country and (b) indicates the level and composition of assistance to be provided based on the strategy and the country's portfolio performance.37 The Country Assistance Strategy Environmental Analysis Matrix (CASE), which was developed to integrate environmental concerns primarily in EAPs that feed into the CAS, could be adapted to integrate the environmental health dimensions as well. This modified tool could build on the Macroeconomic Matrix, the adapted AIM, and PER to relate environmental impacts with environmental health impacts (see tables 3-6 and 3-7, which link the general context of a country, including the driving force, policy response, and projects, with envi- ronment, natural resources, and environmental health). The purpose of this framework is to provide a more structured and organized approach to envi- ronment and environmental health in CASs, in the belief that mainstreaming environmental and environmental health issues can lead to improved development outcomes.39 Environment and en- vironmental health, for example, appear as a cross-sectoral theme, including integration into CAS sections on the economy, poverty, urban and rural issues, and so on. Environment and environ- mental health, featured in the CAS process, include the participatory processes and targeted col- laboration among line agencies, NGOs, CBOs, the private sector, and the community. Lending or nonlending programs related to the environment and environmental health to be included in the CAS include specific projects, economic and sector work, technical assistance, various compo- nents distributed among several projects or other programs, such as energy, infrastructure, and macroeconomic reforms. Performance indicators for projects, programs, and components can be specified and tracked. 4 42 Table 3-6: CAS Environmental and Environmental Health Analysis Matrix Environment and Environmental 1ealth Impacts | Natural Water Airshed Global: Other,for resources and resourcesa, management climate example, land use coastal zone (indoor and change and cultural, management and watershed outdoor biodiversity other secto- mana ementa pollution) ral EH (in- Context, Driving Force, Policy Eb E E b EHb Eb EIH juries, and Response, and Projects so on) Current issues: local, regional, and global _ _ Driving force, e.g., population growth, migration, and concentration; and poverty and inequality Macro policies: impacts Sector policies: impacts Projects, programs, components: impacts _ Environment, resource, institutional, and budgeting issues . _ Environment health, institutional, and budgeting a issues . _ a From extraction/withdrawal to disposal as appropriate. b Representative environmental (E) and environmental health (EH) issues. Source: Adapted from World Bank (2000c). Table 3- 7. CAS Country Program Matrix Development Bank Group Instruments Objectives/Diagnosis of Strategy NL edn/iacn Other Donor Progress Problems /Actions NLS Lending/Financing Instruments Indicators Other sectors Environment and natural resources l_l __ _ Environmental health Source: Adapted from World Bank (2000c). Comprehensive Development Framework Matrix Structural adjustment or stabilization programs usually focus on reducing aggregate demand while relaxing supply-side constraints. These programs are intended to increase output from ex- isting capacity by prescribing a greater role for prices, markets, and the private sector in the de- velopment process. In recent years, such policies have been criticized on the grounds that the burden of adjustment has often fallen on vulnerable groups and on the environment.41 The World Bank Comprehensive Development Framework (CDF),42 which is being piloted in twelve coun- tries, is intended to address these policy failures and reach a better balance in policymaking by underscoring the interdependence and inclusion of all elements of sustainable development and poverty reduction, that is, social, structural, human, governance, environmental, economic, and financial. The CDF seeks to address the fundamental long-term issues of the structure, scope, and substance of societal development through close collaboration and participation of donors, the public sector, civil society, and the private sector. Poverty reduction is the main objective of the CDF, and it cuts across the CDF matrix, which includes structural elements where specific strate- gies relate to a sector or cross-sectoral issues, that is, vertically in the matrix. The development outcome of environmental concerns and their links to poverty, which are already addressed in ongoing CDF pilots, could be enhanced by introducing the environmental health dimension, 43 which should possibly cut across sectors together with environmental concerns, and be reflected "horizontally" in the CDF matrix. Poverty Reduction Strategy, Environmental Health, and Poverty Linkages Unlike extensive literature on the effects of macroeconomic policies on the poor, the exact impact of these policies on the environment and environment-related health problems remains difficult to generalize and depends on specific factors concerning each country's institutions, existing poli- cies (environmental policies, regulatory agencies, judicial system, and law enforcement), health standards, market organizations, and factor endowments. Still, clarifying the linkages among en- vironmental degradation, other externalities, environmental health, and the poor could be chal- lenging. The literature on poverty and the environment, however, offers several theories about different linkages without considering the environmental health variable as an important actual and causal factor. A new effort could help shed some light on all these linkages thanks to a new instrument in line with the Bank mission, poverty reduction strategies, as well known as poverty reduction strategy papers43 (PRSPs). PRSPs link poverty reduction to the Heavily Indebted Poor Countries (HIPC) Initiative44 and are the basis for World Bank and International Monetary Fund (IMF) debt relief (HIPC) and concessional assistance (IDA4s and Poverty Reduction Growth Fa- cility,46 formerly IMF's Extended Structural Adjustment Facility). PRSPs, which heavily indebted countries with good track records are preparing, will eventually be prepared by all IDA countries with the participation of local stakeholders, including the poor. In brief, PRSPs are prepared by national governments and result from a participatory process, lead to better and integrated country strategies, allow sector strategies to be seen through the lens of poverty reduction, and have a long-term perspective.47 PRSPs are meant to transform the prin- ciples underlying the CDF into a plan of action for poor countries.48 Although certain conceptual and practical links between the "over-elaborated" CDF and the PRSP* remain to be clarified, PRSPs embody the key principles of (a) the CDF, including comprehensive and long-term coun- try ownership, coordinated with partners and addressing the burden on the poor through outcome- based interventions across sectors and (b) the 2001 World Development Report49 on poverty's building blocks, that is, empowerment, vulnerability, security, and opportunity. Although no blueprint exists for a PRSP, a simple approach has been recommended based on core elements that are likely to be common to all strategies (diagnosing obstacles to poverty reduction and growth, setting objectives and formulating policies, monitoring, managing external assistance, and accounting for the participatory process). A PRSP "toolkit" was prepared including contribu- tions from all Bank sectors and cross-cutting themes to guide World Bank staff and their country counterparts in the development of PRSPs.50 Also, Poverty Reduction Strategy Credits are being developed and will become a fast disbursing lending instrument to implement PRSPs. Although the track record of the PRSP process is too short to really lend itself to serious analysis, it consti- tutes an entry point to target environmental health multisectorally at its onset. Those to date have tended to emphasize social sectors, such as health and education, but an effort is being made to adopt an environmental health approach for the PRSP in Madagascar and other countries.51 Intermediation Mechanisms: Community-Driven Development Community-Driven Development (CDD), which has an SSA-enhanced version emphasizing de- centralization and local capacity building called community action plans (CAPs), is not a Bank- compulsory instrument, but is an increasingly important intermediation mechanism or an en- hanced social fund for channeling funds directly to community groups. The objective of CDD is Seven out of the 12 CDF pilot countries are implementing both, the CDF and the PRSP and it would interesting to analyze, compare and contrast the processes to see how they fit together: Bolivia, C6te d'Ivoire, Ethiopia, Ghana, Kyrgyz Republic, Uganda and Vietnam. It is also worth mentioning that some countries have embarked upon devel- oping their own CDF, e.g., Tanzania, and so on. 44 to empower and assist people on the ground to steer their own course of development by defining their own priorities, managing their own resources in collaboration with central and local gov- ernments. This creates new challenges and opportunities for mainstreaming environment and en- vironmental health issues. Awareness raising and education are essential for people to understand fully the significance, impacts, and linkages of environmental and environmental health issues on their well-being, livelihoods, and development options; however, CDD offers a unique opportu- nity to provide targeted funds and incentives to encourage a cluster of efforts to upscale infra- structure (see "Prioritization" below) to maximize environmental health benefits. Institutional Failures Institutional failures* occur when formal and informal rules and practices that govern the behav- ior and actions of individuals are not obeyed. Unclear sets of rules, transaction costs (see "Market Failures" below), overregulation or underregulation could often exacerbate policy and market failures. Environmental institutions set the rules of natural resource management, especially in terms of defining property rights to mitigate open-access externalities and insure law enforce- ment. They also have a regulatory role regarding environmental impacts, including pollution control, emission standards, permits, and so on. Environmental institutions, however, tend to ad- dress specific environment-related health problems without looking comprehensively at these problems or even collaborating with the health sector. Unclaimed by practically any sector, environmental health is practically "institutionless" and fragmented across sectors and needs to be provided with a legitimate institutional setup to clarify the sets of rules that govern the behavior and actions of individuals. This institutional mandate could be jointly shared by environmental and health agencies with possibly one of them becoming the lead and coordinating agency. This requires a redefined and proper legislative and institu- tional framework to harmonize, coordinate, and implement environment and environmental health policies for better environmental health management. Legislative Framework Environmental law frameworks, which usually have a provision for a health code under pollution control, tend to contribute to the fragmentation of health issues outside the health care system. Environment-related health problems that are attributable to land use management (for example, contamination of the food chain), that are resource specific, such as deforestation or (man-made breeding sites for mosquitoes), or that involve, for example, traffic accidents or truckers and work crews (spread of AIDS) are usually not included in the health regulations that include emission standards and under the jurisdiction of the environment sector. A new or amended framework legislation (See box 3-3) should be conceived through a participatory process intended to imple- ment clear environmental health policy goals and strategies. These goals and strategies need to be established in conjunction with existing environmental and health strategies and be in tune with the government's overall strategy and policy goals. Institution failure is not discussed in terms of institution deficiency that fails to act on behalf of future generations in order to insure the same intergenerational well-being. To address this failure, the implementation of a fund for future generations is usually envisaged. 45 Box 3-3: Example of Legislation Adapted for Environmental Health The document could be designed as a model for revising existing legislation or adopting new legislation. The document includes general provisions including (a) designation of a lead agency responsible for overall policy formulation and harmonization, (b) the organizational system of environmental and environmental health safeguards, (c) right to information and public participa- tion and consumer advocacy in protecting the environment and preventing environmental health problems, (d) distribution of responsibilities and coordination among different tiers of govern- ment and the civil society at large, and (e) enforcement including the development of and access to the judicial system and legal expertise. Source: Authors' data. Institutional Framework Institutions refer to the sets of rules by which an entity (agency, association, and so on) functions in order to coordinate activities within (vertically) and between (horizontally) organizations. In- stitutions have three layers: (a) operational (laws and regulations), (b) govemance (who makes and applies the rules and how this is done), and (c) constitutional (rules that constrain rule mak- ing). The coordination mechanism, which is determined by the nature of the good (see market failures) and service, allows for provision of goods and services by the public sector (hierarchy) and/or the private sector (market) and/or stakeholders (collective action).53 Institutional reforms are challenging, due to recognition of the problem, existing institutional arrangements and the need to create incentives for agents making decisions, rent/profit-seeking situations, the nature of the goods and services (see box 3-4) that generate environmental health externalities, and the need for a harmonized environment and environmental health strategies.54 Box 34: Key, Confusing, and Misused Terms on Goods and Services Public goods and services, such as clean air, are characterized by a lack of rivalry in consumption (does not affect the quantity to individuals) and nonexcludability (nobody is excluded from bad or good effects or quality) features. Private goods and services, such as fertilizers, are highly rival and highly excludable. Toll goods and services, such as electricity, could be used jointly, but could exclude nonpayers. Common pool goods and services, such as ground water, are finite; therefore, it is difficult to ex- clude nonpayers from their consumption. Common pool goods can be coproduced, for example, rural water supply. Source: Gefrard and Kahkonen (1998) and Kessides (1993). Harmonized environment and environmental health strategies: Harmonizing environment, envi- ronmental health, and other sectors' strategies is not an easy task, but some general guiding prin- ciples exist that can help harmonization of the process. A strategy refers to a plan for change55 and should be based on some guiding principles. A first principle for a harmonized strategy would be to recognize that sustainable development is not a unidimensional concept56 and re- quires a multidisciplinary effort and commitment to reach a balance between economic develop- ment, environmental and environmental health concerns, and social issues. A second principle is to involve the public sector, the private sector, and stakeholders in determining and implementing the strategy. A third principle, prevention is better than cure, means that environmental health issues need to be quantified to set priorities and be integrated at the macro, sectoral, and project levels. These principles require an overall institutional assessment that will guide the develop- ment of the strategy. The institutional assessment can help determine a new multisectoral institu- tional setup and mandate. This will entail a workable collaborative framework among the public 46 sector, private sector, and stakeholders at the national, regional, and community levels that could translate into better service delivery benefiting notably vulnerable groups. An institution (envi- ronment and/or health) needs to be designated (constitutional) for: (a) determining the institu- tional responsibilities for addressing the various causes of environmental health risks (ecological, man-made, human behavior prone risks); (b) valuing the effects and setting priorities; (c) coordi- nating activities across line agencies and forging partnerships; (d) resolving conflicts; (e) and designating an entity for law enforcement and regulation. Also, the newly designated institu- tion(s) that will take the lead need(s) to (a) develop legislation and administrative structures pro- viding needed skills, information flow, and coordination among centralized and decentralized organizations and services, (b) ensure appropriate budget procedures, and (c) ensure desirable outcomes in terms of efficiency, equity, sustainability, and accountability (governance).57 A recent study58 suggests that, until 2000, at least twenty-four countries in SSA have come up with their own environmental rules and requirements regarding EAs and that participation and consultation in the EA process are being emphasized to insure better results and outcomes. Also, a process of harmonizing EAs across SSA is under way. The three ingredients (multidisciplinary commitment, participation and prevention) of a sound environmental strategy have, essentially, been successfully applied in half the countries of SSA and are well under way in the second half, which suggests that a strong commitment to enhance and adapt the environmental legislative framework could help internalize environmental health concerns in the existing framework, espe- cially through a harmonized EA process across SSA. Market Failures In conventional economics, market failures are an afterthought. They are, however, necessary for environmental health economics, because market failures are the norm for pollution problems in terms of emission sources and exposure, that is, spatial and temporal issues play a pivotal role.59 Market failures occur when a market is not able to set an equilibrium price of a good or service that equals the social marginal value. The social marginal value is the value that internalizes all the recognized and quantified externalities, including those pertaining to environmental health; hence, to adjust market failures, governments need to formulate policies to compensate for dis- torted market price and external social values. Public goods, open access (property rights and un- priced assets), and intertemporal externalities that affect future generations are the most important externalities that generate market failures in terms of the environment. In the case of environ- mental health, externalities, transaction costs, and short-sightedness could constitute the three main aspects of market failures. The consumption or production of any types of goods and services60 could generate environ- mental health externalities, because no organized market exists for these external effects. It is im- portant to note that a public good, for example, is not defined by the nature of the supplier of the good (public sector, private firm, or NGO), but by the technical nature of the good. The number of watchers or listeners of an AIDS media campaign aired by a private television/radio network will neither affect the quality nor the quantity of the message. In other words, public goods and services could be provided by the private sector, for example, and vice versa, a private good could be provided by the public sector (sales of fertilizers). Depending on the nature of goods and services, an appropriate coordination mechanism needs to be determined to mitigate environ- mental health externalities (see Institution Failues). Three basic mechanisms exist to coordinate economic activities, and one or a combination of mechanisms could be used to mitigate environ- mental health externalities, that is, markets and creation of markets (market-based instruments, such the introduction of pollution charges or tradable pollution permits), hierarchy and hierarchi- cal collaboration (multisectoral collaboration and regulation, such as the introduction of stan- dards), and collective action (engaging the public, such as public participation in monitoring, 47 public-private-community partnerships, disclosing information, consultation, collaboration, and empowerment). Environmental health externalities occur when a consumer or a producer affects other parties for which no organized market exists for these effects. All sorts of produced or consumed goods could entail environmental health externalities that generate market failures, for instance, (a) toll goods (a main sewerage system, if not properly operated and maintained, could spread vector- related and cause water-borne diseases), (b) public goods (ambiant air, if polluted, could produce respiratory diseases and possibly cancer), (c) private goods (pesticides and fertilizers could be overused and contaminate the food chain and spread water-borne diseases through polluted aqui- fer and watershed), and (d) common pool goods (tertiary urban roads [slums], if poorly designed and maintained, could generate accident injuries or fatalities and spread vector-related diseases due to bad drainage especially in rainy seasons). A quantitative analysis of environmental health externalities would usually require that both parties, the generators and affected agents, be pre- cisely identified and that these externalities be valued in monetary terms. These externalities could, however, be difficult to internalize if both parties are not properly identified and if the short- and long-term external health effects are not properly defined. This is due mainly to a lack of information that prevents a proper valuation of the short- and long-run effects in monetary terms. 61 Transaction costs, which are costs incurred gathering information, may be high, in formal and informal negotiations and monitoring, regarding environmental health and prevent both genera- tors and affected parties from beneficial environmental health exchanges, because the transaction costs exceed the trade of gain. Transaction costs could be reduced through a combined effort that should promote, encourage, and disseminate the results of epidemiological studies targeting envi- ronmental health externalities.62 Short-sightedness occurs when individuals and decisionmakers are not held accountable for the long-term impacts of their policies and actions. Policies and actions that have a short-term impact are complemented by high discount rates that outweigh the benefits that may be realized in the long run. Society, however, has a much longer time horizon and cannot discount future benefits in the same way as an individual might discount them. The prevalence of environmental health ef- fects that could sometimes occur fifty years later and need to be identified and discounted to re- flect social rates of time preference. The latter are generally below the private market rate and need to be adjusted to better gauge the benefiticost of an environmental health policy addressing market failures.63 Monitoring Proper policy response (see "Prioritization" below) needs to be monitored by selected indicators that need to be devised. Monitoring for sustainability at the macro, sectoral, and project levels is used to determine if progress is being made toward the goal of sustainability. It is different from traditional methods of monitoring policy and project process performance, progress, or impact. Sustainability monitoring is usually based on five interconnected core sustainability themes (fi- nancial, technical, institutional, social, and environmental) to which environmental health needs to be added either as a full-blown sixth theme or as a subset of the social and environmental themes. To monitor environmental health, simple and cost-effective indicators need to be devised based on key factors such as what (devising baseline data on health and environment and deter- mining a good indicator varies with the institutional setup and the country capacity and should attempt to involve stakeholders), how (collecting data on indicators and feeding the data in an information system/GIS (see chapter 2 and Map 5-1) that will allow analysis and readjustment of the policy, project, or component calls for an appropriate institutional setup to achieve sustainability), and when (monitoring indicators, early warning monitoring indicators [e.g., 48 plague], and their frequency need to be devised at all stages of a policy or project component, that is, planning, implementation, and operation and maintenance). Given the country's capacity, a national burden of disease (DALY) could be set up, but would be difficult to maintain. An easier tool would be to introduce health utilities based on QALYs (see box 3-2) as a tool to prioritize interventions based on cost-effectiveness and simpler outcome-based monitoring grounds. Based on the country monitoring capacity, selection of key indicators could be prioritized to monitor the highest disease risks. To measure environmental health outcomes, a number of indi- cators, which must satisfy a number of criteria, are needed. No single set of environmental health issues exists, nor do issues exist in isolation; instead, they connect, overlap, and intersect. To avoid complications, the widely used DPSEEA64 (driving force, pressure, state, exposure, effects and action) could serve as a base to determine the needed outcome-based indicators. In SSA, the outcome-based monitoring system could be based on the following health problems: in- door/outdoor air pollution and housing and settlements; water, sanitation, and waste management; vector-borne disease; traffic and possibly all modes of transport injuries and death; pesticides; other toxins and radiation; and natural disasters (see table 3-8). STD/AIDS, which is not a driving force, but rather an effect, is not included, because it is generally monitored by the health care system. A complementary tool would be to develop a QALY monitoring system (see above) that will allow measuring gains from interventions by calculating the years remaining to an individual of a specified age. Table 3-8: Example of Environmental Health Monitoring System Targeting Poverty Source of Cause Associated Public Health Outcome Monitorable Proxy Sector In- Damage Action Affected Health Indicators dicators Indoor Air Energy (cleaner fu- Mortality, chronic Death (including for Number/share of Pollution els, improved lung diseases children under 5), households using stoves), and rural (COPD), and acute symptom days, clean fuels/improved development respiratory infections COPD, cases of ARI, stoves/type of hous- (ARI) and QALYs gained by ing intervention ($/QALY) Outdoor Air Energy/heating; Mortality; COPD, Death (adult), Symp- Annual mean level of Pollution transport ARI, Respiratory tom days, COPD, PM1O; lead level in Hospital admissions cases of ARI, RHAs, blood (RHA); IQ impair- QALYs gained by ment (lead) intervention ($/QALY) Vector-borne Irrigation; reforesta- Malaria Mortality; Death due to malaria; Diseases tion; infrastructure Malaria morbidity malaria cases; QALY (drainage); health gained by intervention (vector control) ($/QALY) Lack of water, WSS Infrastructure: Diarrhea mortality; Death due to diarrhea Access to sanitation sanitation and provision and main- diarrhea morbidity (including children); (percent of house- hygiene education tenance Diarrhea cases (in- holds, urban/rural); cluding children); community coverage QALY gained by (percent of HHs on a intervention community); Access ($/QALY) to water (percent of households, percent of households with in-house connections, local, urban/rural); Distribution rate (days per month or quarter of provision of water); Cleaning 49 Source of Cause Associated Public Health Outcome Monitorable Proxy Sector In- Damage Action Affected Health Indicators dicators rate of on-site sanita- tion (sample) Death and injuries Improved transport Various injuries and Number of accidents, due to various management: educa- death injuries and death; modes of transport tion, enforcement QALY gained by and insurance intervention (S/QALY) Pesticides Residues Agriculture Acute poisoning; Cases of acute poi- Application norms; cancers; Fetal defects soning; Cases of can- storage and handling cer; Spontaneous practices abortions; QALY gained by intervention (S/QALY) Other Toxic Industrial pollution Cancers; IQ inipair- Cases of cancer; Environmental per- Substances control ment (lead) QALY gained by formance; waste intervention management codes; ($/QALY) land zoning regula- tions Natural Disasters Irnprove prediction, Various cases of Cases of cases of mal- Depending on the mitigation and emer- malnutrition, dis- nutrition, diseases, disaster, availability gency preparedness eases, injuries and injuries and death; of early warniing death to population QALY gained by systems directly and indi- intervention rectly affected ($/QALY) Source: adapted from PRSP Toolkit. The World Bank, Draft, July 2000. Quantifying and Valuing the Environmental Health Burden of Disease Environmental health should be considered a priority area that could help achieve the Bank's primary goal of reducing poverty. Because resources are limited, choices must be made; there- fore, environmental health effects need to be quantified and valued at the macro and sectoral lev- els to prioritize cost-effective interventions and formulate appropriate policy responses. Hypothesis for Back-of-the-Envelope Calculations In the absence of quantitative analysis and the difficulty of performing benefit transfers in SSA for willingness-to-pay (WTP) studies (although some have been done for the cost-effectiveness interventions), the reader should look to these back-of-the-envelope calculations as a way to give an order of magnitude to environmental health problem, which, therefore, need to be interpreted with extreme caution. These preliminary calculations should be seen as new areas or a "road map" to guide environmental health analytical work. Several hypotheses were made to be able to perform these calculations; for example, some of the re-aggregation of the environmental health BOD required some professional judgment in the absence of usable analytical work; cost- effectiveness interventions, which vary across countries, ecological zones, and urban compared with rural settings, required application of benefit transfers to reflect SSA's environment better; in the absence of WTP studies (which is by far the most accurate approach) for the cluster of en- vironmental health interventions, a cost-of-illness (COI) approach was retained for the calcula- tions. Although controversial, the COI approach remains the most appropriate one in these cir- cumstances, given the lack of environmental health quantitative work on SSA. 50 Hypothesis for Quantification Several analytical tools exist to quantify mortality and morbidity; however, the DALY65 (see boxes 3-2 and 3-5 for other metrics) was used to determine the environmental health BOD and apportion the environmental health BOD borne by the poor. The DALY was developed for the 1993 World Development Report, Investing in Health,66 and used to measure the state of health of a population by region and prioritize selected cost-effective health interventions. Two inherent problems in the Murray and Lopez67 BOD could characterize all the quantification calculations made below. The BOD is (a) mostly taken from urban centers and, hence, underrepresent dis- eases prevalent among rural populations in particular and (b) based on developing country rec- ords that tend to underreport diseases in general. Another important analytical tool is the com- parative risk assessment, which is an interrelated, phased (hazard identification, dose-response assessment, exposure assessment, and risk characterization) process to identify the impacts that a substance can have on human health. Box 3-5: Measuring the Burden of Disease: The DALY Concept What distinguishes DALYs from QALYs and HeaLYs (see box 3-2)? What is their order of magni- tude? These are important questions, because the justification for use of a single indicator is that such indicators enable decisionmakers-who are not necessarily health experts-to avoid having to choose among conflicting indications. These indicators present three common characteristics: (a) they are all expressed in years (quantity of time) adjusted for the quality of time lived, (b) they all generated much controversy, (c) and they are all complex. These indicators simultaneously raise is- sues of demography, epidemiology, health measures, economics, philosophy, and psychology. An understanding of these issues is needed to resolve difficulties with, for example, nonhomogeneous data on prevalence and incidence, the notion of expected gains, the definition of disability, time preference (why a year lived today is valued higher than a year lived in the future), or preference revelation (what makes people reveal their relative preference between different states of health). Only the DALY concept will be considered to address some of these issues. The World Bank, WHO, and Harvard School of Public Health initiated the Global Burden of Dis- ease study in 1992, which served as a background paper for the Bank's World Development Report of 1993. The study, which helped develop comparable regional and global assessments, provided detailed estimates of death and disability for eight regions, by sex and age, for more than 100 condi- tions and ten risk factors. A weighting function that incorporates a 3 percent discount rate was used to reflect the different social weights usually given to illness and associated with premature mortal- ity at different ages. A worldwide life expectancy age was set at 80 and 82.5, respectively, for men and women. The disability adjusted life year (DALY) was developed as a common metric for meas- uring years of life lost due to premature mortality (YLLs) and years of life lived with a disability, adjusted for severity (YLDs). Causes of death were first estimated for 1990 using a variety of data sources and adjusted procedures. Incidence, prevalence, and duration of diseases and injuries were estimated in collaboration with more than 100 scientists, and internal consistency with mortality es- timates was obtained through modeling. The DALY is a practical tool for prioritizing interventions at the regional and national levels. Sev- eral disadvantages are, however, associated with the DALY concept: (a) consideration of differ- ences among morbidity states is limited, for example, calculations for conditions with states of re- mission and relapse dynamics (cancer, malaria, hypertension, and so on) have not yet been resolved, (b) alternative valuations for the age weighting, such as an expenditure-sensitive age weighting or a differential gender or urban-rural functions, (c) DALYs do not take into account predisposing fea- tures that are biological (genetics), behavioral (smoking and drinking), cultural (ethnicity, care tak- ing of elderly), or economic (income group, access, and so on), and (d) DALYs do not consider the compounding disability status of comorbidity or the synergistic relationships among diseases. Source: Murray and Lopez (1996); Hughes and Dunleavy (2000); and Robine, Jean-Marie, Measuring the burden of disease (commentary), The Lancet Ltd, 1998. 51 The re-aggregation of the DALYs below are partly based on risk assessment68 studies on different pollutants. The breakdown of the BOD, however, remains an estimate due to the paucity of in- formation regarding disease etiology. Also, it is important to note that DALYs are bias-oriented toward urban areas, due to the quasi-exclusive availability of urban health data in SSA. Never- theless, both laboratory and epidemiological researches have attempted to identify risk factors in disease causation, which could be explored for this purpose. Table 3-9 estimates are largely guided by such studies and primarily based on Smith (1999)69 calculations of environmental at- tributable fractions. The method of calculation involves the listing of the different environment-related diseases and the risks and percentages that may be attributable to environmental factors. The Global Burden of Disease study by Murray and Lopez70 is the basis for the calculations, primarily because it re- flects both morbidity and mortality. The list of diseases was also taken from this source. Esti- mates for the region are also guided by the prevalence of the risk factors, such as traditional cooking fuels in SSA and smoking rates. Air pollution and housing-related diseases are an exam- ple for the methodology. This methodology of estimation is used to "guesstimate" the remaining environment-related diseases in the absence of reliable data. A range is shown for each dis- ease/remedial measure category to show conservative and liberal estimates. The re-aggregation of BOD attributable to environmental health is innovative, because it includes the compounding of several diseases by remedial measures that were not taken into consideration in previous studies, for example, diseases attributable to circulatory system, eye, and noninfec- tious diseases are compounded with respiratory diseases (see "improved housing and air pollution abatement" in table 3-9. For instance, compounded DALYs attributable to infrastructure and other sectors and categorized under environmental health remedial measures is on average 4 per- cent larger than single disease estimates and range between a 17 percent low and a 22 percent high with a 20 percent midpoint. To apportion the relative share of the environmental health BOD on the poor, the figures obtained in a recent Bank publication7' (56 percent of the SSA population was considered to be under the poverty line in 1990 and 48 percent in 1998 according to a more recent publication72) were ex- trapolated for the 1998 BOD and applied for each disease of the environmental health BOD. Hypothesis for Valuation Cost-effectiveness interventions per environmental health DALY saved (see box 3-2) have been compiled from different studies and the $/DALY saved numbers rely on global averages73 or a small sample of studies, so the rough meta-analysis performed should be used with care; for ex- ample, in the case of water and sanitation, only the Hughes and others study, cited above, is being used to derive cost-effectiveness, whereas, in the case of indoor air pollution, several studies have been distilled to come up with the cost-effectiveness intervention. Also, although calculated for different time periods, costs per DALY saved were not adjusted for inflation (see table 3-10 for additional notes and sources). Additional research is, however, needed to determine the BOD on the poor in an urban compared with rural settings. Most environmental health problems listed in tables 3-9 and 3-10, except traffic injuries, can be substantially controlled with cost-effective interventions at less than $350 per DALY saved. When adjusted efficacy could not be determined through existing analytical work, a professional judgrnent (which does not always produce the most accurate forecast) was applied to determine the adjusted efficacy of DALY (see box 3-2) saved through environmental health interventions. Disabilities are "adjusted" for their severity using a "quality-of-life scale," based on individual rankings of severity of disease and disability for the DALY. For the calculations, we assume that one DALY is one lost year of healthy life (see box 3-5) to apply the cost-of-illness (COI) ap- 52 proach for the entire environmental health BOD in one year. A cost per DALY intervention is translated, from a societal point of view, into averted COI or a lower-bound benefit to society at large. The COI approach, because it captures only the first two components of WTP (see box 3-2) should, in general, serve as a lower bound to WTP to avoid the risk associated with illness, acci- dent, and/or premature death, that is, the lost time associated with the illness (GDP per capita for a year, that is, DALYs are estimated at the regional average nominal GDP per capita, that is, a GDP per capita of $545 for people five years and older-62 percent of the environmental health DALYs-and for children under five'-38 percent of the DALYs. A third of the GDP per capita, $182, has been applied for each DALY lost.) and the private and public health expenditures asso- ciated with medical costs incurred in a year (health expenditures in SSA per DALY in 1998, which amounts to $32.9/DALY). In addition to lost income and medical costs, the WTP usually reflects any expenditures made to try to avoid the illness or ameliorate its effects and the value of the discomfort associated with the illness that are not captured in this analysis. Possible interven- tion efficiency ratios are the COT over the cost of DALYs averted (see table 3-9 and 3-10). Also, it is assumed that any cost-effectiveness intervention to relieve the burden of environmental health on a targeted group of individuals will generate health benefits that will start accruing on the group of individuals over the first two years of the intervention. Quantifying the Environmental Health Burden of Disease Quantifying the environmental health burden of disease, including the burden borne by the poor, cannot be determined without assessing quantitatively the relative importance of different disease problems on the health of the population. An additional step would be to map the BOD, which could be a useful first step in determining the health risks and people at risk at the national, re- gional, and local levels. An environmental health map (geographic information system) that could be superimposed on a multilayered topological, ecological, and socioeconomic map could be an extremely helpful tool in identifying health risks and vulnerable groups and setting up geographic priorities and designing appropriate policy responses (see chapters 2 and 5). The DALY, despite its limitations (see box 3-5), is used to dis-aggregate the Listorti (1996) guesstimated 44 percent SSA BOD for 1990, amenable to reduction through infrastructure inter- ventions and re-aggregate (see "Valuation of the Environmental..." below to understand the spe- cifics of each quantification entry) the same targeted diseases, which do not include AIDS, other STDs, and agrochemical-related diseases (agrochemical exposure). The re-aggregation allows derivation of the remedial measure estimates in 1998 DALYs and percentage terms attributable to environmental health on the one hand and health care delivery system on the other. Except for AIDS and other STDs, the entries under "Remainder Including Other Remedial Measures Not Included Above" (row 3 in table 3-9), including agrochemical exposure, are not broken down by disease or injury. The preliminary guesstimates of Listorti (1996) showed that infrastructure sec- tor interventions are amenable to relieving up to 44 percent of the 1990 BOD against 38 percent of the BOD in 1998 (the BOD reduction is due to the sharp increase in AIDS in relative terms during the period). This work takes the targets a step further by performing back-of-the-envelope calculations with 1998 figures (38 percent) and gives a possible range of health interventions out- side and inside the health sector. Environmental health-targetable remedial measures (20 percent of the BOD) can achieve more than the health care delivery system (18 percent of the BOD) for the same targeted diseases, that is, respiratory, circulatory system, gastrointestinal, tropical, and eye diseases, as well as traffic accidents and falls. These diseases do not, however, include AIDS, other STDs, and agrochemical exposure. No breakdown of data by year for children under five BOD exist to be able to apply a gradual increase in the GDP/capita. GDP was applied for children under and over five to account for in Idnd contribution and mnissed op- portunities, e.g., in-kind contribution to household and famnily livelihood, kindergarten, school, and so on. 53 Table 3-9: Back-of-the-Envelope SSA Environmental Health Quantification, 1998 (DALY and $Billion) Re-Aggregated 1998 Lower Bound Re-Aggregated 1998 SSA Bur- SSA Burden of Dis- Social Benefits den of Disease for the Entire ease for the Poorest for the Poorest Population Lower Bound Social Benefits for the Entire Population Quintile Quintile Low High Midpoint Cost Chil- Cost Chil- Lost Medical Cost of Ratio Ap- Midpoint Cost of Illness for Entire dren < 5 dren Income Cost llpness or plied on Poorest the Poorest Quin- Re-aggregation of the same reme- opopulation >= 5 Eocial Midpoint Quintile tile de-abgregadisese and ineuries ree-Eenefits Entire diable diseases and injuries (d ) (2) (3=(1+2)/2) (4) (5) (6 =4+5) (7) (8.6+7) Population through environmental health and DALY (10=3x9) (11= same meth- health care system targetable Inter- ods as 4 to 8) ventions _9) (000' (000' (000' ($ Bn) (S Bn) ($ Bn) ($ Bn) (S Bn) (%) (000' (S Bn) DALYs) DALYs) DALYs) DALYs) 1. ENVIRONMENTAL HEALTH REMEDIAL MEASURES IA. Air Pollution Abatement, Improved 18,648 27,052 22,850 2.7 4.2 6.8 0.8 7.6 50% 11,411 3.8 Housing and Education 1. Respiratory diseases a 16,753 24,688 20,721 2.6 3.2 5.8 0.7 6.5 50% 10,369 3.3 2. TB 1,088 1,361 1,224 0.0 0.6 0.6 0.0 0.6 47% 616 0.3 3. Circulatory system diseases b 608 766 687 0.0 0.3 0.3 0.0 0.4 47% 324 0.2 4. Eye diseases c 199 237 218 0.0 0.1 0.1 0.0 0.1 48% 103 0.1 a 5. Non-infectious diseases, e.g., cancer not NA NA NA included above MA_NA_NA NA 6. Malaria, Tropical diseases cluster and NA NA NA NA Dengue NA_NA_NA_N lB. Improved Water, Sanitation, Waste 25,478 29,561 27,519 4.1 2.5 6.5 0.9 7.5 51% 13,904 3.8 management and Hygiene EducationI 1. Diarrheal diseases 19,400 21,815 20,608 3.2 1.4 4.6 0.7 . 5.3 51% 10,56 2.7 2. Intestinal worm infections 396 446 421 0.0 0 .2 0.2 0.0 0.2 47% 216 0.1 3. Eye diseases d 274 312 293 - 0.2 0.2 0.0 0.2 47% 138 0.1 4. Tropical diseases cluster 213 275 244 0.0 0.1 0.1 0.0 0.1 48% 115 0.1 5. Malaria 5,191 6,708 5.950 0.9 0.6 1.4 0.2 1.6 51% 2,863 0.8 6. Dengue 4 5 5 0.0 0.0 0.0 0.0 0.0 50% 2 0.0 7. Non-infectious diseases, e.g., cancer not NA NA NA NA included above gafton (plus Sanitation and Waste M ) 9,096 12,632 10,864 1.2 2.3 3.5 0.4 3.8 50% 5,290 3.0 1. Tropical disease cluster e 2,697 3,485 3,091 0.0 1.6 1.6 0.1 1.7 48% 1,560 1.2 2.Malaria 6,395 9;142 7,768 1.1 0.7 1.9 0.3 2.1 51% 3,729 1.7 3. Dengue 4 5 5 0.0 0.0 0.0 0.0 I 0.0 50%1o 2 0.0 ID. Transport, Workplace, Housing 2,179 2,602 2,391 0.1 1.1 1.2 0.1 1.2 44% 1,045 0.5 Design and AIDS Education . . ___I 1. Road Traffic Accidents 1,589 1,898 1,744 O0.0 0.8 0.9 0.1 0.9 44% 762 0.4 2. Falls 590 704 647 0.0 0.3 0.3 0.0 0.3 44% 283 0.1 3. Drowning and Fires (no breakdown NA NA NA NA available) Re-Aggregated 1998 Lower Bound Re-Aggregated 199S SSA Bur- SSA Burden of Dis- Social Benefits den of Disease for the Entire ease for the Poorest for the Poorest Population Lower Bound Social Benefits for the Entire opulatlon Quintile Quintile Low High Midpoint Cost Chil- Cost Chil- Lost Medical Cost of Ratio Ap- Midpoint Cost of Illness for Entire dren < 5 dren Income Cost Illness or plied on Poorest the Poorest Quin- Re-aggregation of the same reme- population >= 5 Social Midpoint Quintile tile diable diseases and Injuries ~~~~~~~~~~~~~~~~Benefits Entire diable diseases and Injuries (1) (2) (3=(1+2)/2) (4) (5) (6 =4+5) (7) (8-6+7) Population through environmental health and DALY (10=3x9) (I 1= same meth- health care system targetable inter- ods as 4 to 8) ventions (9) (000' (000' (000' ($ Bn) (S Bn) ($ Bn) (S Bn) (S Bn) (M) (000' ($ Bn) DALYs) DALYs) DALYs) DALYs) 4. AIDS and other STDs (no breakdown NA NA NA NA available) mental Health (IA ID) 55,402 71,847 63,624 18.0 2.1 20.1 50% 31,651 11.1 mental Health (IA-ID) 1°c 2% 2%_1° % of Total SSA DALYs fromn Environ- 17% 22% 20% 10% mental Health (I-ID) II. HEALTH CARE SYSTEM/EDUCATION REMEDIAL MEASURES Selected Diseases (same diseases as in 1.) 49,335 65,780 57,558 2.7 22.5 25.2 1.9 27.1 49% 27,898 10.3 l. Diarrheal diseases 2,416 4,831 3.623 0.6 0.3 0.8 0.1 0.9 51% 1,779 0.5 2. Intestinal worm infections 50 99 74 0.0 0.0 0.0 0.0 0.0 47%e 38 0.0 3.Respiratorydiseasesa 2,974 10.909 6,942 0.9 1.1 1.9 0.2 2.2 50% 3,272 1.1 4. Circulatory system diseases b 11,978 12,136 12,057 0.2 5.9 6.1 0.4 6.5 47% 6,067 3.1 5. Tropical diseases cluster 1,798 2,648 2,223 0.0 1.1 1.2 0.1 1.2 48% 1,048 0.2 6. Malaria 18,656 22,920 20,788 0.9 8.5 9.4 0.7 10.0 51% 9,978 2.6 7. Dengue 6 8 7 0.0 0.0 0.0 0.0 0.0 51% 4 0.0 8. Eye diseases c 1,657 1,733 1,695 0.0 0.9 0.9 0.1 0.9 50%4 872 0.5 9. TB 4,082 4,354 4,218 0.1 2.0 2.1 0.1 2.2 47% 2,097 1.0 10. RoadTraffic Accidents 4,219 4,528 4,374 0.1 2.1 2.2 0.1 2.3 44% 2,062 1.0 l1. FaUs 1,501 1,615 1,558 0.1 0.6 0.7 0.1 0.8 44% 681 0.3 12. Drowning and Fires (no breakdown NA NA NA NA available) 13. AIDS and other STDs (no breakdown NA NA NA NA available) Subtotal SSA DALYs from Health 49,335 65,780 57,558 25.2 1.9 27.1 49% 27,898 10.3 Care/Edueation QI.)____ ______ % SSA DALYs from Health 15% 20% 18% 9% Care/Education (1.) 111. REMAINDER INCLUDING OTHER REMEDIAL MEASURES 220,461 187,571 204,016 99,252 NOT INCLUDED ABOVE I. AIDS 54,101 54,101 54.101 2.4 21.5 23.9 1.8 25.7 46% 25,041 11.9 2. Other STDs 5,249 5,249 5,249 0.4 1.5 1.9 0.2 2.1 46% 2,430 1.0 3. Drowning and Fires 5,705 5,705 5,705 0.3 2.2 2.5 0.2 2.6 44% 2,494 1.2 Re-Aggregated 1998 Lower Bound Re-Aggregated 1998 SSA Bur- SSA Burden of Dis- Social Benefits den of Disease for the Entire ease for the Poorest for the Poorest Population Lower Bound Social Benefits for the Entire Population Qintile Quintile Low High Midpoint Cost Chil- Cost Chil- Lost Medical Cost of Ratio Ap- Midpoint Cost of Illness for Entire dren < 5 dren Income Cost IDness or plied on Poorest the Poorest Quin- Re-aggregation of the same reme- population >- 5 Social Midpoint Quintile tile diable diseases and injuries Beneflts Entire through environmental health and () (2) (3=(1+2)I2) (4) (5) (6 =4+5) (7) (8rr6+7) Population tbrough environmental health and ~~~~~~~~DALY (10=3x9) (11= same meth- health care system targetable inter- I ods as 4 to 8) ventions odsas4(o9) (000- (000' (000' ($ Bn) ($ Bn) ($ Bn) (B Bn) (S Bn) (%) (000 ($ Bn) DALYs) DALYs DALYs) .D Y _ 4. Childhood diseases cluster f 25,375 25,375 25,375 3.9 1.9 5.8 0.8 6.6 52% 13.268 3.5 5. Agrochemical Exposure g 650 2,927 1,789 0.0 0.8 0.9 0.1 0.9 47% 843 0.4 6. All Others 129,381 914 11 3_ 6_ _ 49% 55,177 _ % SSA DALYs from STDs including AIDS __ _ __ __ __ _ _ % of SSA DALYs from other diseases 68% 58%1 63% 30% Grand total of SSA DALYs 325,198 _____ _ I - __ 10.7 44% 158,801 Source: Authors' calculations and see table 3-10 for additional notes and source. Note: a acute respiratory infections, chronic obstructive pulmonary disease, asthma, trachea, bronchitis and lung cancers. b heart disease and stroke. c cataracts and trachoma. d trachoma. e trypanosomiasis, Chagas disease, schistosomiasis, leishmaniasis, lymphatic filariasis and onchocerciasis. f pertussis, poliomyelitis, diphtheria, measles and tetanus. g liver and pancreas cancer, melanomas and other skin cancers, lymphomas and multiple myeloma, endocrine disorders, unipolar major depression, cata- racts, nephritis and nephrosis, rheumatoid arthritis, congenital anomalies (excluding spina bifida and congenital heart anomalies), and poisonings. This entry does not include possible health risks associated with biotech/genetically altered food. The relative share of the environmental health BOD in SSA, which is estimated to be at least 20 percent for the entire population, represents 10 percent for the poorest of the poor. The health carel delivery system share for the same diseases represents 18 percent for the entire population and only 9 percent for the poorest of the poor. Valuation of Environmental Health Burden of Disease Environmental health BOD estimates, which constitute about 70 million DALYs (20 percent for the entire population and 10 percent for the poorest of the poor) of the BOD in SSA, is equivalent to approximately 6 percent of the 1998 nominal GDP74 in SSA ($343.6 billion) or $35.8 billion. The environmental health BOD will be used to derive environmental health cost-effectiveness interventions for the entire population and the poorest of the poor and possible intervention effi- ciency ratios. An analysis based on the environmental health BOD borne by the entire population will be devel- oped below and concentrate on five main topics: (a) improved indoor air quality and improved housing and education (for example, respiratory diseases and so on), (b) improved outdoor air quality for transport, energy, and industry (for example, respiratory diseases and so on), (c) im- proved transport management: education, enforcement, and insurance (for example, traffic deaths and injuries), (d) improved water, sanitation, waste management, and hygiene education (for ex- ample, water-related, vector-borne diseases, plague, and so on), and (e) vector control through land use management and improved drainage and irrigation (plus partial sanitation and waste management, for example, vector- and water-related diseases). It is important to note, however, that the prevalence of malaria is increasing in urban areas in SSA, but no analytical work exists that allows determination of a conclusive breakdown of malaria between urban and rural areas. The malaria attributed to environmental factors amounts to 90 percent according to WHO75 and a professional judgment76 has been used to determine targetable malaria through environmental health interventions. Drugs are used to treat malaria victims but climate change, social instability, and increased resistance to pesticides and treatments have hampered the battle against the illness in SSA. Also, due to unavailable analytical work that allows for a breakdown of infrastructure outreach for high-risk groups (for example, AIDS and other STDs education campaign), living environment improvement (for example, avoided falls), and agrochemical exposure between en- vironmental health outreach and health care system remedial measures/outreach, these topics are addressed below, but no cost-effectiveness have been associated with these interventions. Improved indoor air quality, improved housing and education (for example, respiratory diseases, and so on). Based on Smith,77 indoor exposure to particulate matter accounts for at least 75 per- cent of the total indoor and outdoor exposure in developing countries. A midpoint $75 cost- effectiveness intervention to relieve this BOD was applied in tables 3-9 and 3-10. DALYs saved through indoor air interventions, that is, 19.2 million DALYs or almost 6 percent of the SSA BOD, are, by far, the most cost-effective among the five interventions. Improved outdoor air quality for transport, energy and industry (for example, respiratory dis- eases, and so on) accounts for only 3.7 million DALYs, a fifth of the indoor pollution BOD. The social benefits of this intervention are negative, that is, for a dollar spent, $ 0.90 is socially re- couped, due to the aging car fleet and obsolete industrial processes in SSA. These figures, how- ever, need to be refined to allow for better (a) differentiated cost-effectiveness for indoor (im- proved stove and ventilation) and outdoor (energy and industry specific to SSA) capital cost and recurrent cost and (b) marginal health benefits in terms of respiratory and associated diseases. 57 Table 3-10: Back-of-the-Envelope SSA Environmental Health Valuation, 1998 (DALY and $Billion) SOCIAL COST AND BENEFIT OF INTERVENTION Cost of Inter- vention for Cost of Intervention for the Entire Lower Bound Social Benefits for the Entire the Poorest Lower Bound Social Benefits Population Population I Quintile for the Poorest Ouintile Targetable SSA Cost/DALY Cost of Lost Medical Cost of Net Social Possible Cost of Averted Cost of Net Social Possible Burden of Dis- Saved Averted Income Cost Illness or Benefits Interven- DALYs Illness or Benefits Interven- ease: Midpoint DALYs Social tion Effi- Social tion Effi- Benefits ciency Benefits ciency _______ _______ ________ ~~~~~Ratio Ratio (1) 2 (2) (3=1 x 2) (4) (5) (6=4+5) (7=6-3) (8=6/3) (9) (10) (11=10-9) (12=10/9) (DALY (%) ($/DALY) (S Bn) ($ Bn) ($ Bn) (S Bn) (S Bn) ($ Bn) (S Bn) ($ Bn) INTERVENTIONS TO RELIEVE THE Mn) BURDEN OF DISEASE _ 1. REMEDIAL MEASURES THROUGH 63.6 20% VARIES 8.7 18.0 2.1 20.1 11.4 2.3 5.1 11.2 6.0 2.3 INFRASTRUCTURE and ENERGY INTERVENTIONS _ Improved Indoor Air Quality, Improved 19.2 5.9% 75 1.4 5.7 0.6 6.4 4.9 4.4 0.8 3.2 2.3 4.4 oo Housing and Education (e.g., respiratory dis- eases, etc.) _ Improved Outdoor Air Quality for Transport 3.7 1.1% 350 1.3 1.1 0.1 1.2 (0.1) 0.9 0.7 0.6 0.0 0.9 Energy and Industry (e.g., respiratory diseases, etc.)_ _ _ __ _ __ _ _ _ Improved Transport Management: Education, 1.7 0.5% 325 0.6 0.9 0.1 0.9 0.4 1.6 0.3 0.5 0.3 1.6 Enforcement and Insurance (e.g., traffic death and injuries) Improved Water, Sanitation, Waste Mgt. and 27.5 8.5% 158 4.3 6.5 0.9 7.5 3.1 1.7 2.6 3.8 1.2 1.7 Hygiene Education (e.g., water-related and vector borne diseases) Vector Control Through Land Use Mgt, Im- 10.9 3.3% 95 1.0 3.5 0.4 3.8 2.8 3.7 0.6 3.0 2.4 3.7 proved Drainage and Irrigation (plus partial Sanitation and Waste Mgt,, e.g., vector-/water- related diseases) Infrastructure Outreach for High Risk Groups NA NA NA NA NA NA NA NA NA NA NA NA NA (e.g., AIDS and other STDs Education; no breakdown available) Living Environment Improvement (e.g., 0.6 0.2% NA NA 0.3 0.0 0.3 NA NA NA 0.1 NA NA Avoided Falls; no breakdown available for Drowning and Fires) _ , SOCIAL COST AND BENEFIT OF INTERVENTION Cost of Inter- l vention for Cost of Intervention for the Entire Lower Bound Social Benefits for the Entire the Poorest Lower Bound Social Benefits P ulation Population Quintile for the Poorest uintile Targetable SSA CosttDALY Cost of Lost Medical Cost of Net Social Possible Cost of Averted Cost of Net Social Possible Burden of Dis- Saved Averted hicome Cost Illness or Benefits Interven- DALYs Illness or Benefits Interven- ease: Midpoint DALYs Social tion Effi- Social tion Effi- Benefits ciency Benefits ciency ___________ ________ ________ __________ Ratio Ratio (1) (2) (3=1 x 2) (4) (5) (6=4+5) (7=6-3) (8=6/3) (9) (10) (11=10-9) (12=10/9) (DALY (%) ($/DALY) ($ Bn) ($ Bn) ($ Bn) ($ Bn) ($ Bn) (S Bn) (S Bn) ($ Bn) INTERVENTIONS TO RELIEVE THE M) BURDEN OF DISEASE ___ 11. REMAINDER (A + B + C) 261.6 80%N A. HEALTH CARE SYSTEM REMEDIAL 57.6 18% VARIES NA 25.2 1.9 27.1 VARIES NA NA 10.3 VARIES NA MEASURES FOR THE SAME DISEASES and INJURIES (except for AIDS, other STDs, Drowning and Fires) B. OTHER ENVIRONMENTAL HEALTH 66.8 21% VARIES NA NA 2.2 NA VARIES NA NA NA VARIES NA PARTIALLY TARGETABLE DISEASES and INJURIES NOT INCLUDED ABOVE AIDS 54.1 16.6% 20-20,000 NA 23.9 1.8 25.7 VARIES NA NA 11.9 VARIES NA Other STDs 5.2 1.6% 100 0.5 1.9 0.2 2.1 1.6 4.0 0.2 1.0 0.8 4.0 Drowning and Fires 5.7 L8%/0 NA NA NA 0.2 NA NA NA NA NA NA NA Agrochemical Exposure (insecticides and 1.8 0.6% NA NA 0.9 0.1 0.9 NA NA NA 0.4 NA NA pesticides excluding biotech) C. All Others (with a breakdown of high 137.2 42% VARIES NA NA 4.5 NA VARIES NA NA NA VARIES NA percentages) of which: Childhood diseases cluster 25.4 7.8% 100 2.5 5.8 0.8 6.6 4.1 2.6 1.4 3.5 2.5 2.6 GRAND TOTAL (I. + 11.) 325.2 100%I O 10.7 _ I Note: NA Breakdown Not Available. For interventions, DALYs are bias-oriented towards urban areas due to the availability of mainly urban data in SSA. Cost-effectiveness interven- tions per environmental health DALY saved have been compiled from different studies and should be used with care. Health improvements from an intervention are assumed to start accruing on the well-being of the targeted population as of the first or second year of the intervention. When data were not available, a professional judgement was used to derive "Adjusted efficacy." Numbers may not add up due to rounding. Lower Bound Social Benefits cannot be fully quantified. Apportioning of environmental health affecting the poorest of the poor (48 percent in 1998 compared to 56 percent in 1990) derived from the application ratios available in Gwatkin and Guillot (1999). Average 1993-98 SSA Public and Private Health Expenditures were divided by the SSA total number of DALYs to get $/DALY spent and determine "Medical Cost." In the 1993 WDR, it is mentioned that SSA public sector's health care delivery system could relieve up to 32 percent of the burden of disease. However, a distribution of targeted diseases is unavailable to adapt it to this context. Therefore, it is assumed that 1998 SSA Public and Private Health Expenditures are equally distributed among 1998 SSA's burden of disease, that is, all the DALYs. Source: Authors' calculations. For Cost-Effectiveness, figures have been gathered from different sources and regions and should be applied with caution: Benefit transfers have been applied to certain data. Although calculated for different time periods, costs per DALY saved were not adjusted for inflation. Improved stoves (indoor air)-- $50-100 per DALY [Smith (1999)]. For Proportion of Outdoor/Indoor, 16 percent vs. 84 percent [Bridging... Guesstimate based on Ronald Su- bita, MD calculations]. Improved ambiant air --large variations, from negative costs (fuel savings) to $20,000 per DALY [Environmnent and Health, Background paper for the Bank Environment Strat- egy, Draft, April, 2000]-was set at $ 350. Water and Sanitation: cost per DALY is $ 235 (rural) and $ 385 (urban) for improved water supply and $120 for improved sanitation. A benefit transfer has been performed and a price differential and different rural (2) vs. urban (1) weights were assigned to data. [Hughes and Dunleavy (2000)]. Hygiene behavior change for water supply and sanitation interventions, $ 20 per DALY [Environmental Health Program, 1tSAID, 1998]. Malaria control: cost per DALY ranges from $ 35 to 75 [Environment and Health, Background paper for the Bank Environment Strategy, Draft, April, 2000]. Vector Control through improved Land use management, Drainage and Irrigation including partial sanitation is estimated at $ 158 per DALY [Bridging... guesstimate based on the case of Hardwar, India]. Traffic Injuries varies from $ 250 to $ 999 per DALY. $ 325 per DALY was applied for traffic management that includes seat belts, enforcement and insurance. [1993 WDR, the World Bank]. STD including HIV/AIDS, and TB remedial measures: cost per DALY is $20 for media AIDS campaign, $250 for condom distribution to combat AIDS and $1,500 to >=20,000 AIDS; >$100 for other STDs and >$50 for TBs. [Prabhat, Ranson and Bobadilla (1996)]. 1998 SSA: total population ( 627.1 million), urban population (208.8 million), rural population (418.3), GDP ($ 333.9 billion), GDP per capita ($ 532.4), GDP/Capita used for Children >- 5 per DALY Lost ($ 532.4), 1998 GDP/Capita divided by 3 used for Children < 5 per DALY Lost ($ 177.5), 1990-98 Public and Private Health Expenditures (PPHE) (3.2 percent of GDP and $ 10.7 billion on average over the period) and 1998 SSA PPHE/DALY ($ 32.9) [WDI 2000]. 1998 SSA breakdown of DALYs by disease (total: 325.2 million) [WHO 1999 Annual Report]. CN C0 Improved transport management. education, enforcement and insurance (for example, traffic death and injuries). Cost of averted DALY data is provided by the 1993 World Development Re- port and the wide range of cost-effectiveness, $ 100-999, is attributable to the variety of costs of interventions: these stretch from enforcing stringent measures to fight drunk and careless driving (progressive penalties, introduction of differentiated accident insurance premiums, and compul- sory seat belts) to improving road design. An adjusted efficacy of 30 percent was derived, thanks to a professional judgment and an adjusted midpoint cost-effectiveness of $325 was used for the least expensive interventions, that is, fighting drunk and careless driving. Cost of averted DALYs amounts to $0.6 billion and represents 1.7 percent of the SSA BOD. Improved water, sanitation, waste management and hygiene education (for example, water- related, vector borne diseases, plague, and so on). Improving the quantity and quality of water available for domestic use, as well as facilities for disposing of human waste, can significantly reduce illness and death from diarrheal diseases and waterbome illness. A recent review of the literature78 suggests that for diarrheal disease, ascariasis, hookworm, schistosomiasis, and tra- choma, the quantity of water and availability of excreta disposal facilities are more important in preventing disease than improving drinking water quality. This underscores the point that im- proved water and sanitation reduce illness by breaking the oral-fecal contamination route. A $285 and $467 per DALY for, respectively, rural and urban improvement in water supply by Hughes and Dunleavy (2000) was calculated for Andhra Pradesh in India without accounting for a differentiated water provision (in-house tap, communal hand pumps, vendors, and so on) by income group, which skew the results (Cost-effectiveness interventions, which are function of the level of provision, for example, piped water vs. well, were weighted by the breakdown of the ur- ban vs. rural population in table 3-10. See notes for weights and price differentials). This method- ology is, however, cutting edge and needs to be refined to allow for: (a) differentiated water pro- vision by income group; (b) differentiated cost-effectiveness for water supply and waste man- agement capital cost and recurrent cost; and (c) marginal health benefits in terms of vector con- trol, diarrheal and associated diseases, as well as tropical cluster. The cost-effectiveness figures in table 3-10, $158 for rural and urban areas, were adjusted with a crude India/SSA GDP differential and weighting was applied to the cost-effectiveness figure used for rural and urban areas (see notes to table 3-10). Bearing in mind that cost-effectiveness figures include capital cost, this in- tervention remains the least cost-effective among the four interventions and relieves almost 27.5 million DALYs or almost 9 percent of the SSA BOD for a cost ($4.3 billion), which is almost three times ($1.3 billion) that of improved indoor air quality and improved housing and educa- tion. Vector control through land use management and improved drainage and irrigation (plus partial sanitation and waste management, for example, vector- and water-related diseases). Based on USAID's Environmental Health Program,79 in 1998, a $20 per DALY could be achieved through hygiene behavior change for water supply and sanitation interventions. Concomitantly, based on Hughes and Dunleavy (2000), a $120 per DALY for improved sanitation was determined in In- dia. An investment threshold beyond a 60 percent sanitation coverage level was also established and could not procure any additional health benefits to the community. These remarkable pre- liminary findings call for further analysis along the issues identified for improved water and waste management: (a) differentiated sanitation provision by income group, (b) differentiated sanitation, drainage, and especially irrigation cost-effectiveness for capital cost and recurrent cost, and (c) marginal health benefits in terms of vector control, diarrheal, and associated diseases, as well as tropical cluster. It is important to note, however, that the prevalence of malaria is in- creasing in urban areas in SSA and a cost/DALY (derived by combining the Environmental Health Program, Hughes and Dunleavy (2000), and a guesstimate from an example of a success- ful partnership in an urban setting to managing vector-related diseases in Uttar Pradesh in India [see box 3-6]), amounts to $1 58/DALYs saved. Cost of averted DALYs ($ 1.0 billion for 3.3 per- cent of the SSA BOD) are the second-most cost-effective among the five interventions. 61 Box 3-6: Partnerships to Manage Vector-Related Diseases in an Urban Setting A collaborative and multipronged environmental health approach to controlling vector-related dis- eases was developed by a private manufacturer of heavy electrical equipment, Bharat Heavy Electri- cals Ltd. (BHEL), in 1987. BHEL is located in Hardwar, an industrial city in the State of Uttar Pradesh in India. BHEL took action due to an increasing rate of malaria-related absenteeism of the workforce, which affected productivity. BHEL's approach was characterized by a private-public- community collaboration that included (a) the use of BHEL's own resources, intersectoral technical expertise, and maintenance crews, (b) in-kind contribution from the state (for example, borrowing heavy equipment, such as bulldozers), and (c) community awareness and involvement in monitoring mosquito breeding sites. The innovative multipronged approach consisted of (a) infrastructure interventions targeting water, sanitation, and drainage, (b) bioenvironmental control, and (c) proper monitoring. Selected tasks consisted of (a) construction of stand posts and proper drainage and mosquito proofing of overhead tanks, (b) preventive maintenance of the water supply and sewage system, including the introduction of biolarvicides to blocked drains and larvivorous fish to stormwater drains and effluent ponds, and (c) filling pits and ditches with fly ash from coal-fired power stations. Prior to using fly ash (with the possibility of leaching into the groundwater), however, its content should have been analyzed to en- sure that neither environmental nor environmental health short- or long-term concerns were associ- ated with its application. Improved surveillance and treatment coupled with a comprehensive control approach led to a stun- ning reduction of the malaria incidence rate: from 6.7 percent of the total population in 1986 (3,733 cases and 1 out of 15 inhabitants for a population of 56,132) to a mere 0.2 percent in 1995 (190 cases and 1 out of 440 inhabitants for an estimated population of 83,500) or a reduction factor of 20. The outcome in terms of reduction of other vector-related diseases is not reported in the study, but sixteen different species of aedes, anopheles and culex were identified and ultimately targeted. Although a cost/benefit analysis was not performed, preliminary costs were estimated at less than $400,000 for the multipronged intervention compared with $ 2;2 million without intervention (cost of malaria treatment and BHEL's production loss only) for the 1986-95 period, that is, a ratio of 1/5.5. These figures do not include benefits such as (a) reduction of other vector-related health risks, such as filariasis, yellow fever, and dengue, (b) the averted cost of disposal of most of the fly ash ($40,000 per year), which was utilized to fill large ditches, burrow pits, and low-lying areas, or (c) reduction of cancer-causing DDT and HCH residues in blood that were samnpled in Hardwar (4.71 ,Lg/l and 1.2 .g/l respectively) in 1995 and compared with samples from neighboring towns (38.13 jg/l and 24.3 ,gg/l) where DDT and HCH spraying was still used for malaria control. Source: Authors' data and "Bioenvironmental Control of Industrial Malaria" (1997). Infrastructure outreach for high risk groups (for example, AIDS and other STDs education). AIDS and other STDs are listed in table 3-9 without being included under either environmental health or health care remedial measures due to the lack of analytical work that helps estimate a breakdown between both remedial measures. Growing AIDS challenges in SSA, however, led the World Bank to provide extensive assistance for efforts to collect information on surveillance and behavioral studies. A major effort is currently being made to mainstream AIDS concerns in Bank operations by (a) focusing its support for HIV prevention interventions on reaching groups at the highest risk of contracting and spreading HIV and (b) improving the economic analysis used in preparing Bank HIV-related projects and evaluating their effectiveness.80 It is, however, impor- tant to note that AIDS and other STDs represent 18 percent (16.6 percent for AIDS alone) of the SSA BOD. These lower-bound estimates (health expenditures associated with the disease could vary from $20 to more than $20,000) of cost of inaction per year will also need further investiga- tions. 62 AIDS prevention is far more cost-effective than its cure: media campaigns and behavioral change could cost from $20 (media campaign) to $100-250 (distribution of condoms) per DALY saved (see table 3-9); whereas, cost-effectiveness for AIDS medical care can range between $1,500 and more than $20,000, depending on the quality of care. In Senegal, AIDS retro-viral therapy per patient dropped to about $ 950-1,800 per year in 2000, thanks partly to the establishment of a partnership with private companies, which are manufacturing generic drugs. The conjunction of a strong governmental commitment, a well-orchestrated media and awareness campaign that led to behavioral change, paid off in Senegal where the spread of disease was contained (adult preva- lence rate is less than 2 percent). In contrast, in Ghana (prevalence between 2-8 percent), where AIDS is becoming a serious problem, a study has found the prevalence of HIV infection due to construction workers to be 5 to 10 percent higher in the population of a rural district,8" where the Akomoso hydroelectric dam was under construction than in neighboring districts. In Zimbabwe (prevalence between 16-32 percent), where the disease is endemic, the example of a trucking company is quite revealing: More than one-fourth of the cohort of employees had AIDS, which had cost the company more than $1 million in losses (direct and indirect, for example, increased medical and life insurance premiums), in 1997, or 20 percent of the company's profits.82 Some studies suggest that the spread of AIDS is partly due to truckers and force account/private con- tractor crews, but a breakdown between infrastructure-related AIDS and other means of spreading AIDS needs further analysis to target infrastructure-related AIDS spreading agents better through professional associations (truckers), labor union (workers), cart/street vendor groups, and so on. Living environment improvement (for example, avoidedfalls; no breakdown available for drowning andfires). Cost-effectiveness for falls, fire, and drowning could not be calculated. Agrochemical exposure.,3 The burden of insecticides and pesticides could be reduced through awareness, safety programs, and proper application of pesticides, that is, in integrated pesticide management programs, however, no cost-effectiveness estimates are associated with agrochemi- cal exposures. Estimates of the burden of disease potentially associated with acute and chronic exposure to pesticides and insecticides, which are known in the literature to be associated with the use of pesticides and insecticides, are based on conservative (0.2 percent of the total BOD in SSA) and liberal (0.9 percent) boundaries, related to the summation of more than fifteen disease sequelae. The disease groups summed include liver and pancreas cancer, melanomas and other skin cancers, lymphomas and multiple myeloma, endocrine disorders, unipolar major depression, cataracts, nephritis and nephrosis, rheumatoid arthritis, congenital anomalies (excluding spina bifida and congenital heart anomalies), and poisonings across all age groups. These diseases span the range of exposure duration from acute (accident where substance is poured on skin directly) to long-term (inhaling for 20 years, while working in field). As all of these diseases are multifac- toral (have many causal factors) and genetically influenced (i.e., endogenous as well as exoge- nous factors), it was not reasonable to assume that pesticide and insecticide exposure caused all of the disease events; thus, we used a low-end, high-end bracket of 0.2 percent and 0.9 percent, which could be interpreted as (a) 0.2 percent (likely proportion of DALYs attributable to recog- nized disease groups most strongly associated with morbidity and mortality due to short and long term exposure to pesticides/insecticides) and (b) 0.9 percent (potential proportion of DALYs at- tributable to recognized disease groups most strongly associated with high exposure to pesti- cide/insecticide use could summarize a small pocket of population who use canal water for drinking purposes and [both genders] work in the fields applying these chemicals). 63 Prioritizing a Cluster of Environmental Health Interventions and Policy Re- sponses Prioritization Prioritizing the five interventions based solely on optimum economic solutions by using the cost- effectiveness figures and especially the Possible Intervention Efficiency Ratio (the same for the entire population and the poorest of the poor [see table 3-10, column 8, which is the ratio of social benefits over social costs]) requires the sequencing of resources to avert the adjusted remedial DALYs. This is done as follows: applying the cheaper intervention option per unit of effective- ness first, (a) indoor air pollution with an efficiency ratio of 4.4 for each dollar spent, (b) vector control and sanitation with 3.7, (c) water and vector control with 1.7, (d) traffic accidents with 1.8, and outdoor air pollution with a ratio of less than one, 0.9. The reality is, however, more complex than a simple ranking of interventions on economic grounds, because most policies or interventions, which are based on political and socioeconomic grounds, try to achieve more than one objective at a time, for example, provision of safe drinking water or clean energy fuels are essential to sustain life, improve living conditions (hygiene, indoor air, and so on), reduce cost, time, and physical load borne by consumers, and so on. From an environmental health perspective, targeting the poor to improve their well-being would require a cluster of infrastructure interventions (see "Intermediation Mechanisms: Community- Driven Development") to complement necessary health care interventions such as nutrition and AIDS prevention, that is, to improve and/or maintain all at once indoor air (improved or clean- fueled stoves* associated with appropriate education), water and sanitation (better provision and hygiene education to reduce diarrhea), drainage, potholes and other standing water (vector con- trol), etc., as appropriate. From an environmental health standpoint-given the lack of infra- structure provision specific to each circumstance-, it is more effective to promote a cluster of infrastructure interventions that should target one specific geographic area/community/village than spreading uncoordinated single-sector interventions across several geographic ar- eas/communities/villages. Only then, compounded health benefits could accrue to the population at risk and outcome-based results could be monitored and achieved. The need exists, therefore, to look at confounding factors that would help achieve synergetic gains and increased health out- come. For example, malnutrition could accentuate mortality in children under 5 for the following main diseases: diarrhea in 70 percent of cases, tuberculosis in 60 percent, acute lower respiratory infections in 44 percent, and malaria in 40 percent, among other diseases,84 not to mention HIV/AIDS. In other words, targeting health outcomes through a sector specific approach could slightly reduce the probability of mortality or morbidity for children under 5 for a given risk without really resolving the problem, because children or adults are usually exposed to a multi- tude of health and environmental health risks. Therefore, there is a critical need to bring aware- ness and educate the people to fully understand the significance, impacts and linkages of envi- ronrmental, environmental health and health issues on their well-being and livelihoods. Also, a better understanding of the linkages between urban and rural areas in spreading new diseases, including vector-related diseases (especially because HIV-infected individuals are harboring a large reservoir of malaria parasites85 ) and their effects on the poor, needs to be thoroughly re- searched. In recent literature, it is suggested that clean-fueled stoves for the poor need to be considered an infrastructure invest- ment with a 5 to 10 year lifespan in Srnith and Mehta (2000). 64 Policy Response and Implications Policy response will be briefly described due to lack of environmental health policy examples that allow some lessons to be drawn. It is, however, important to note that a great deal of environ- mental policy responses targeted environmental health problems, but some environmental inter- ventions alone can, however, lead to partial environmental health solutions (see case of lead above). A policy response needs to be subjected to a social cost-benefit analysis before being im- plemented, monitored, and evaluated. A prerequisite to formulating a policy is to assess the ena- bling environment, that is, policy instruments, budgetary processes, institutions, and laws. Policy instruments. The Environmental Policy Matrix, which could be used to select environ- mental health instruments, organizes the different policy instruments approaches into four catego- ries depending on the principal emphasis of each policy instrument: the market, the creation of a market, environrental regulations, and engaging the public (all the instruments can be beneficial to both the environment and human health [see table 3-11]). Policy instruments need to be gauged to ensure the effectiveness of environmental health policy goals. Although market instruments are more flexible and allow for improved efficiency over time, regulatory instruments are often a necessary complement. Table 3-11 Policies and Instrumentsfor Sustainable Development Theme Policy Instruments (all instruments can be beneficial to both the environment and human health) Environmental Engaging the Pub- Using Market Creating Markets Regulations lic Subsidy reduction Property rights Standards Public participation Resource Targeted subsidies Decentralization Bans Information disclosure Management Environmental taxes Tradable permits/rights Permits/quotas and Pollution User fees International offset Control systems Deposit-refund system Source: World Bank (1997b). Budgetary processes. In addition to PER, which could be instrumental in allocating targeted re- sources toward environmental health mitigation (see "Public Expenditures Review" above), envi- ronmental health could be canvassed onto existing intermediation instruments, such as environ- ment, road, or water funds that could be used to generate extra revenues to internalize the social cost of environmental health concerns. These extra revenues could be channeled through inter- mediation mechanisms, such as the CDD or social funds and target specific clusters of interven- tions to mitigate the health risk of especially vulnerable groups. Institutions and law. The cluster of intervention raises an intractable multisectoral institutional issue within the Bank as well as at the country level (see chapter 1 and "Institutional Failures" above). Policy implications (see chapters I and 2) of a cluster of environmental health interventions should be gauged with care. In most cases, environmental health benefits are maximized and sustained only if infrastructure is properly used and maintained. Human behavior, at the house- hold (for example, hygiene, vector, and smoke prevention) and societal (institutions, governance, partnerships, social capital) levels play a major role. This raises the fundamental issue of linking infrastructure and environmental health. An environmental health policy needs to favor an envi- ronment conducive to the proper use and upkeep of infrastructure assets that should lead to envi- ronmental health improvements. Also, each cluster of interventions requires careful assessment based on a number of factors (environmental health attributes, socioeconomic group, and so on), which calls for careful valuation of environmental health issues at the local level for a particular intervention that should ideally be part of the EA process. In the short run, this could entail a cost- 65 effective intervention in favor of the health care sector, because the up-front infrastructure capital costs largely exceed health sector intervention costs for a given illness and time preferences for immediate life-saving programs (health care sector interventions) could be much higher than dif- fered health benefits associated with infrastructure interventions.86 The cost-effectiveness of interventions between health care sector intervention and infrastructure interventions, which could sequence interventions (short and long term), poses another funda- mental question. That infrastructure interventions try to achieve more than one objective at the time (see "Prioritization" above), which means that the cost-effectiveness per DALY saved in- cludes the capital investment (for example, provision of clean water) that generates health bene- fits. Further analytical work is needed, therefore, to extract the health benefits associated with an infrastructure intervention and compare it with a health care sector intervention over the duration of the investment, for example, the difference in costs between an inefficient stove (wood or charcoal fueled) and an efficient one (gel-fueled stove) could help derive the net health benefits from an intervention and possibly the marginal effects on global warming associated with wood and charcoal fueled stoves. Concluding Remarks This first attempt at identifying environmental health externalities and formulating policy re- sponses at the macro, sectoral, and project levels underscores the need to perform additional ana- lytical and applied work to expand the understanding of the linkages between economic devel- opment, environmental, and environmental health concerns and social issues in an urban com- pared with rural setting. Mainstreaming environment health in sustainable development work is still a challenge due to the difficulties of fostering collaboration across sectors and forging part- nerships with the private sector and stakeholders (see chapter on Ghana pilot) in this nascent field: additional efforts and commitments are required to address policy, institutional (need to designate a coordinating entity responsible for environmental health issues: environment and/or health), and market failures associated with environmental health effects. It is important to inter- nalize the additional health benefits in economic analysis resulting from a preventive cluster of infrastructure intervention approach, which could have long-lasting outcomes on the burden of the poor and outweighs a recurrent curative health care system intervention approach. These clusters or bundling of infrastructure interventions would obviously need to complement neces- sary health care interventions, such as nutrition, immunization and AIDS. Environmental health interventions need to be closely monitored and possibly evaluated to establish a badly needed track record in this nascent field. This will allow sharpening and development of new instruments that will positively improve the well-being of the population, especially the poor. 66 CHAPTER 4: GATHERING AND ANALYZING INFORMATION FOR ENVIRONMENTAL HEALTH Chapter 2 summarized the new approach to environmental health, harmonizing sectoral priorities, proposed in this discussion paper. Chapter 3 explored options for mainstreaming environmental health concerns at macro and sector levels by quantifying and valuing the environmental health burden of disease in SSA and prioritizing interventions. This chapter describes the environmental health assessment (EHA) process-a planning tool that helps prevent, mitigate, or manage health risks by evaluating environment-based risks and proposing remedial measures. The chapter then compares and contrasts two alternative approaches to completing a full EHA. Of these two, this discussion paper recommends the environmental health profile, whose preparation is detailed in chapter 5 and may also serve as a preliminary step to completing a full EHA. Chapter 6 presents two other alternatives, adapting an existing environmental assessment (EA) to serve as an EHA, as well as describes preparation of a complete EHA. An EHA is a planning tool that helps prevent, mitigate, or manage negative health risks by evaluating environment-based risks andproposing remedial measures. An Overview of EHAs An EHA is not merely a health assessment within an EA, nor is it limited to pollution. It blends techniques from separate, but related fields, such as EAs, social impact assessments (SIAs), health impact assessments (HIAs), national or local environmental action plans (NEAPS/LEAPS), and comparative risk assessments of pollutants. EHAs have no set definition or criteria, nonetheless, they may be confused with the other types of assessments and action plans (see box 4-1 and the glossary for terms used in environmental health assessments). Neither EHAs nor HIAs have gained as much acceptance as the EA process. Box 4-1: Key, Confusing, and Misused Terms on Assessments and Plans Environmental assessment. Focuses broadly on the environment, not necessarily including human health, except sometimes for health analyses on pollution treatment. Environmental health assessment. Blends an EA with a health impact assessment (HIA), but limited to curative or preventive measures in a sector. May cover socioeconomic groups, one or more sectors, a region, or a country. Health assessment (HA) or health impact assessment (HiA). Focuses broadly on health effects. Tends to focus on measures of the health care delivery system. Does not necessarily analyze the natural environ- ment or causes outside the health care system. Local environmental action plan (LEAP). Applies an EA to the local level (see NEAP). National environmental action plan (NEAP). Applies an EA to the national level (frequently in SSA countries). National environmental health action plans (NEHAPs). A NEAP that takes health into consideration. Prepared by far fewer countries (mostly in Eastern and Central Europe) than NEAPs, because the overall EHA process is less widely implemented than the EA process. Poverty assessment (PA). A tool developed for the World Bank, a PA provides the basis for a collabora- tive approach to poverty reduction by country officials and the Bank. It helps establish the agenda of 67 issues for the policy dialogue. The scope of the poverty assessment will necessarily vary across coun- tries, depending on the country situation, the government's commitment to poverty reduction, and the nature of available data. Risk assessment. Assesses the risks of biological and chemical pollutants. Social assessment (SA) or social impact assessment (SIA). Focuses broadly on socioeconomic issues with an emphasis on the community's role in defining and solving problems. Does not necessarily deal with health or environmental issues. Comparative risk assessment ranks actual risk from potential exposure to two or three pollutants or haz- ards. Does not look at the broad health context. Source: Authors' data. Box 4-2: Clarifying the Objectives of Assessments and Projects Titles of projects, components, and assessments should clearly avoid implying that they are intended to improve environmental health conditions more than they are capable of doing. Many waste man- agement and pollution abatement projects have been called "environmental," for example, possibly implying that they address a broader range of problems than is feasible, practicable, or intended. If the assessment or project concentrates on pollution, the title should clearly state this. Using "envi- ronment" in the main title and "pollution" in the subtitle may help avoid misinterpretation and clar- ify whether the project consists of measures for pollution abatement and control or management (see box 1-1). A project or assessment should also clearly define its pollution objectives to help identify other in- stitutions or projects that could help secure these objectives. Transport projects, for example, can greatly contribute to reducing lead pollution, but cannot address the full range of lead sources, some of which may be more important local health problems than vehicle exhausts. An air pollution focus in the energy sector could easily neglect the health consequences of the absence of electricity, possi- ble spread of vector-related diseases due to dams, physical stress and injuries from fetching large loads of biomass fuel, and possibly beneficial aspects of indoor air pollution in warding off mos- quitoes in areas with malaria or protecting food stored in the home from insects. Projects or compo- nents that address these potentially neglected areas could easily strengthen their funding possibili- ties. Source: Authors' data. The techniques used in EHAs are still evolving, and no standardized reference texts, outlines, formats, or procedures have been accepted as international norms for them. Because many EHA users will probably not have background in health or environment and possibly neither, an EHA, environmental health profile, or equivalent analysis should include background material that is easily skimmed and absorbed (i.e., avoiding technical jargon and complicated tables and calcula- tions). The EHA should also: * Provide the overall context * Differentiate between direct and indirect (the latter sometimes being more important) and short- and long-term effects, as appropriate * Illustrate the overall situation with descriptions of typical projects for the sector * Explain linkages with other sectors * Identify sources of information * Clarify relevant institutional strengths and weaknesses * Define terms * Identify high-risk and vulnerable groups * Describe special cases * Identify any hot spots and key pollutants, as appropriate 68 * Make recommendations for remedial actions. These points, explained in more detail in chapter 6, do not constitute an outline for an EHA, but indicate the types of information useful to decisionmakers for making informed choices on a full set of linkages. Examples of such information can be found in part II in sector-specific chapters covering agriculture and rural development (chapter 8), energy (chapter 9), environment (chapter 10), health (chapter I 1), industry (chapter 12), infrastructure (chapter 13), and global issues (chapter 14). EHAs and Alternatives Five different approaches may be taken to identifying entry points or prioritizing environmental health collaboration, all based on or relating to an EHA. This discussion paper recommends con- ducting an environmental health profile, a technique developed for this discussion paper that as- sists the targeting process by generating a short list of important issues and directing funds for environmental health problems more precisely. Four other alternatives, however, may also be considered. The first three involve with adapting existing assessments-environmental, health, or social-to serve as an EHA. The fourth involves conducting a complete EHA. The advantages and disadvantages of the five are detailed below. Disadvantages reflect difficulties in adapting an existing assessment to serve as an EHA and do not criticize the techniques themselves. It is ex- pected that these disadvantages will diminish with time, as all the techniques are improved. Environmental Health Profiles Environmental health profiles (EHPs) can be largely compiled from existing information from several sectors and then reorganized for analysis by a multidisciplinary team through an environ- mental health review. Because not all projects need a full EHA or equivalent and no universally accepted standard for EHAs exists, EHPs can help interpret priorities for high-risk groups from different sectors, which can then be compiled into a short list of possible entry points. If further analysis is needed, an EHA focusing on specific issues can be undertaken later. EHPs are in- tended as alternative, not additional sources of information. By avoiding having to generate new health analyses, EHPs save time and money that could be better spent on other tasks. EHPs also provide basic information that may later be used by a mul- tidisciplinary team in an environmental health assessment should they decide one is still needed. EHPs are a recommended, although not essential, preliminary step in preparing an EHA, because they: * Increase the likelihood of including important linkages and key players omitted in single- sector analyses * Identify priorities from other sectors that can serve as entry points for collaboration on environmental health * Reduce the potential for inadvertent professional bias, which accentuates analysis from one discipline, while excluding equally important inputs from other disciplines. EHPs would be one of only a few types of documents attempting to integrate materials from dif- ferent sectors. Bank documents, in contrast, usually separate material on sectors into different chapters. Except for general economic analyses and poverty reduction work, few documents at the Bank integrate information or look for common problems among sectors. 69 Adapting an Existing EnvironmentalAssessment as an EHA The environmental assessment process has been well established in industrialized countries for at least thirty years. In that time, techniques have been perfected, regulatory measures have been developed stipulating when and how EAs should be conducted, and responsibility for protecting public health and safety has generally been vested in environmental authorities. Similarly, EA procedures have been adapted for use in developing countries for at least a decade. This collective experience is a considerable advantage and could be tapped to facilitate inclusion of health fac- tors. In contrast, current EA procedures do not systematically address health, whose inclusion is largely determined by the preferences of the EA team. This poses a range of disadvantages. EA techniques were originally developed to suit the needs of industrialized countries, where indus- trial and vehicular pollution are focal points of environmental health, a factor carried over into many training programs. Practitioners may, thus, not address infectious diseases such as respira- tory or diarrheal infections appropriately as life threatening or may consider mosquito control as a nuisance rather than a source of malaria. (see box 1-5) or may assume a higher level of institu- tional capability than is available in developed countries. Adapting an Existing Health Assessment as an EHA In contrast with EAs, health assessments are tools currently under development. Adaptation would, therefore, depend on their availability. HAs would have a clear advantage by making health their focal point, identifying a wider range of health issues than would probably be avail- able in an EA and, thus, a wider range of remedial measures and institutional interventions, for example, schools, that may be required to address health problems with multiple causes. HAs may also already contain much useful demographic information needed to determine risk groups or target interventions.* As HAs are much less common, they are at a disadvantage. HAs may concentrate on services of the health care system, rather than on other sectors, and preventative measures are likely to reflect pollution-related diseases. HAs may, consequently, miss opportunities for collaboration that would not be obvious to an EA practitioner without a health background or, conversely, find them too broad or ambitious to include as a component. An HA of a development project that would stimulate local population growth, for example, a dam, road, or new housing, may cite multiple disease risks without clarifying potential for contributions from other sectors. For example, a transport agency could address the risks of accidents for numerous reasons or of AIDS to or from truckers and implement preventative measures, but would not be able to address the potential in- crease in respiratory disease from population congestion. Box 4-3 shows a sample outline of a health (or health impact) assessment. Box 4-4 shows a se- quence of steps that could be followed to adapt an HA to an EHA. Box 4-3: Sample Outline for a Health Impact Assessment Introduction: This states the purpose of the terms of reference, the type of product to be as- sessed, and the implementing arrangements for the health impact assessment.t * Examnples of information available in health reports is detailed in chapter 5 "Health Profile." t Terns of reference will have already been prepared for the project in question. 70 Background information: This provides a project description including objectives, status and timetable, and project proponent. Related projects within the region must be identified. Objectives: This states the general as well as specific objectives of the health impact assessment in relation to the project preparatory activities, such as feasibility studies (planning, de- sign, and execution), and as part of an environmental impact assessment. Environmental requirements: This section identifies regulations and guidelines that will govern the assessment, such as operational directives, national laws or regulations, regional or provincial regulations, and specific regulations of other funding organizations involved in the project. The requirement for health impact studies may be included in the EIA regula- tions. Study area: This specifies the boundaries of the study for the assessment. It should include the human communities downstream and downwind of the project. The HIA boundaries could go beyond the EIA boundaries, which are usually the watershed or air shed. Scope of work: The health hazards and communities that require particular attention are ob- tained from the "Initial Health Examination Summary Table." The consultant could be asked to refine the scope of work for contracting agency review and approval. Other agen- cies may be invited to comment, and public meetings may be held. Health risk assessment: The consultant will assess the health risk associated with each health hazard at each project stage. The assessment will include the following considerations: Community vulnerability: Identify the environmental factors that may contribute to an increase in health risk and define mitigating measures as input to project planning. Estimate the magnitude of the factors. Environmentalfactors: Consider the environmental factors that may contribute to an increase in health risk and define mitigating measures as input to project planning. Estimate the mag- nitude of the factors. Capability ofprotection agencies: Establish in more detail the capabilities of existing protection agencies, such as the environmental and health agencies with jurisdiction for the project site. The consultant should assess the limitations of existing data and recommend how to strengthen health information systems to meet requirements for health risk management. Health risk management: The consultant may be asked to formulate a monitoring program during the construction and operational stages, which includes a description of the work tasks; skills, tests, and interviews; frequency; institutional and financial arrangements; and justification and use of the monitoring data. The consultant should define safeguards and mitigating measures required as inputs to the feasibility study. Context for health risk management: Account should be taken of the availability of resources and funds, whether any interest groups are actively concerned about the project and its health impact, whether local environmental lobby groups exist, the attitudes of local authorities and government, and whether meetings have been held to promote changes in the project. Consideration should be given to any groups that may oppose change and any groups whose support could be obtained to increase the prospect of protective mitigating measures being applied. Consultant requirements: The consultant would ideally have previous experience assessing the health impacts of development projects. The consultant, however, must have specialist knowledge of the most significant health risks identified during the initial health examina- tion. If diverse health risks were identified, additional consultants may be required with specialist knowledge of each. Reports, duration and schedule: This will specify the total period of the study, staff-months of experts, dates for consultation, periodic reports, and other target dates. Other information: This will provide the consultant(s) with preliminary information on data sources, background reports and studies, and other relevant publications. Source: Birley (1995), pp. 31-33. 71 Box 44: Sample Sequence of the EHIA Process Step 1: Assessment of primary impacts on environmental parameters Step 2: Assessment of secondary and tertiary impacts on environmental parameters Step 3: Screening of impacted environmental parameters for health significance (identification of environmental health factors). Preliminary identification of environmental health impacts Step 4: Prediction on how project will affect exposure of populations to environmental health factors Step 5: Prediction of how project will affect size of health risk Step 6: Computation of predicted health impacts in terms of mortality and morbidity, if possible Step 7: Definition of significance and acceptability of adverse health impacts Step 8: Identification of mitigation measures to prevent or reduce significant adverse health im- pacts Step 9: Final decision on whether or not the project should proceed Source: Turnbull (1992), p. 90. Adapting an Existing SocialAssessment as an EHA The field of social assessment (SA) has a slightly longer history than HAs, but is still new and evolving when compared with EAs. The main advantage of SAs stems from their origin within and concentration on issues pertinent to the community. As with an HA, an SA could have par- ticularly useful demographic information about populations at risk and local institutions. This focus could be extremely helpful in defining remedial measures for which community support is essential. Social assessments, such as poverty assessments (see below), can contain key informa- tion to help health specialists prepare a response geared to local conditions. For example, a social assessment might reveal that fear of fires are a key neighborhood concern, a factor that would not necessarily be revealed in health statistics. Addressing fear of fires could have also served as an entry point for discussion of respiratory diseases due to cooking, heating, and lighting fuels, which the local population might not realize are linked to fuels and stoves (partly because they are used to smoke-filled rooms). The disadvantages arise from a lack of attention to environmental health issues. In many in- stances, the community may not understand the technical dimensions of risks, except in cases of epidemics or high pollution levels. For example, at the beginning of the International Drinking Water Supply and Sanitation Decade (1 970s), the link between high infant mortality and diarrheal diseases was poorly appreciated and diarrheal diseases were considered part of normal childhood. Since that time, hygiene education has become integrated into water and sanitation sector pro- grams. Adapting an Existing Poverty Assessment as an EHA Poverty assessments focus on the specific determinants of poverty (OP 4.15) and the design of targeted solutions. In countries where data are not available, analysis in the poverty assessments will necessarily be more qualitative. While preparing a PA, a critical need exists to fully under- stand the significance, impacts, and linkages of environmental, environmental health, and health issues on the well-being, livelihoods, and development options of the poor. A first step would 72 require identifying the major (top ten) diseases and apportion the environmental health burden of disease borne by the poor. A second step would require determining institutional, financial, and partnership (public-private-stakeholder) strengths and weaknesses to devise a pro-poor cluster of infrastructure interventions (see chapter 3). These interventions would, in turn, complement nec- essary health care interventions, such as nutrition, immunization, and AIDS prevention. Com- pounded health benefits could accrue to the poor at risk, and outcome-based results could be monitored and achieved. Poverty assessments can also provide a wealth of socioeconomic data that can be helpful for health specialists to interpret. For example, levels of economic development, quality of housing, access to basic services, availability of radios or televisions, number of people wearing shoes. All of these can be linked with malnutrition, diarrheal and respiratory diseases, intestinal worms, and so on. The disadvantages would be similar to those for a social assessment in that the information pro- vided may not deal with environmental health issues. Conducting a Complete EHA The main advantages of conducting a complete EHA are that it would analyze the problems and propose solutions in an appropriately broad context. These are addressed in the overview to this chapter and chapter 6. Disadvantages include cost, absence of current procedures, and the need for a multidisciplinary team. Moreover, interagency collaboration is difficult, because of the full range of factors de- scribed in chapter 1. In addition, current procedures, developed in industrialized countries, tend to focus on chemical and biological pollution and need to be adapted to conditions of developing countries, where, for example, indoor air pollution and vector-related diseases are far more im- portant than in developed countries. 73 CHAPTER 5: PREPARING AN "ENVIRONMENTAL HEALTH PROFILE" An environmental health profile (EHP), as stated earlier, is a new technique proposed in this vol- ume and presented as either an alternative or preliminary step to an EHA. The technique essen- tially involves a cut-and-paste desk review-not new research-that looks at priorities in other sectors. The result is a short list of significantpotential health problems on which to base action. A multidisciplinary team drafts an EHP by first compiling sectoral profiles as background infor- mation and then analyzing the data for sectoral linkages. Sectoral profiles facilitate the EHP proc- ess by (a) noting key players and stakeholders for individual sectors who may be the same for environmental health, (b) facilitating intersectoral collaboration within agencies, and (c) helping to make decisions using incomplete data. The multidisciplinary team may confront two complementary problems in preparing these pro- files: a paucity of reliable data on environmental health and staff without background in environ- ment or health. This chapter and the next help address these difficulties by identifying existing sources of data in World Bank documents from several sectors or similar sources in bilateral or government agencies, reducing the need for basic research or data gathering. The team then "cuts and pastes" from these different reports, helping to compensate for the team's lack of specializa- tion in health and environment. Analysis of the information, however, does require such back- ground. Joint discussion and analysis may help somewhat to overcome this deficiency. In this way, an environmental health profile may be prepared by sectoral specialists not used to working with information outside their own sector, or, especially in the Bank, by economists who work on poverty reduction without focusing on any one sector. Table 5-1 lists sectoral priorities for Ghana, illustrating how existing information can help set a short list of priorities. Table 5-2 provides sample sectoral problems and strategies and actions from Ghana. Its first two columns provide a sample of material drawn from sectoral reports on Ghana. "Possible Entry Points" (column 3) is new information presented in this volume. Both tables summarize information an example of an EHP for Ghana (see table 15-1) and a sample set of sectoral profiles for that country, cut and pasted from Bank and Ghanaian materials. This short list of issues and priorities (EHP) is the basis for developing a strategy or plan of ac- tion. This could take several forms, depending on the EHP's findings and local circumstances, such as an institutional needs assessment, risk assessment of different pollutants, or first draft of a broader analysis, such as an EHA. Based on the Ghanaian profiles, it was decided that the most appropriate follow-up was an institutional needs assessment (see chapter 16). Sectoral profiles can sometimes furnish as much, if not more, information than a field mission. Their analysis can, at a minimum, identify a short list of information gaps or issues to be raised during a mission. This kind of preparation is virtually standard operating procedure for a single sector. The difference is that review for an EHP is multisectoral and may require tapping different and less obvious resources. Within the Bank, the CAS provides a useful comparison of sectoral priorities, but does not necessarily weave them together, except at the macroeconomic level. It is, therefore, appropriate to prepare profiles from each of the sectors. Sources of information for these profiles include project appraisal documents (PADs), implementation completion reports (ICRs), project information documents (PIDs), country poverty strategies (CPSs), the newly initi- ated poverty reduction strategy papers (PRSPs), the country development framework (CDF), and various other sectoral reports accessible through the Bank's web sites. 75 Table 5-1. Summary of Sectoral Problems, Strategies, and Actions for Ghana Main Problems Strategies and Actions Environment * Water supply: limited access, water-related diseases, * Natural resource management: sustainable supplies of and water balance fuel wood, pesticide control, and water master plans * Urban decay: lack of adequate roads, sanitation, and for all river basins waste disposal * Institutional reform: institutional structure for inte- * Energy needs: increased energy requirements (80 grated land use planning, and sectoral and interagency percent from wood fuels) coordination * Land and coastal degradation, due to deforestation, * Environmental monitoring: environment- and health- mining, and waste disposal related indicators * Pollution: quality of air, water, soil, and life is af- * Built environment management: post-audits on indus- fected by industries and agrochemicals tries, and standard and regulation enforcement Health * Access to health care constrained by geographic dis- * Prioritizing health services for maximum benefits in tances and financial barriers terms of morbidity and mortality reduction * Poor community, intersectoral, and private sector * Empowering households and communities to take linkages more responsibility for their health * Promoting intersectoral action for health development particularly in the area of water and sanitation Agriculture * Poor basic infrastructure and support services 1 * Diversification of agricultural exports and improve- l ment of public investment in rural infrastructure Infrastructure * Inefficient and insufficient infrastructure services in * (See subsectors below) telecom, power, rails, ports, urban water supply, air- ports, and roads Urban Development * Water supply, sanitation, urban roads and traffic, and * Traffic management, storm drainage to alleviate others are a major constraint on urban productivity in flooding, comprehensive sanitation services by the Ghana year 2005 (prepared by metropolitan assemblies), di- rect septage hauling and solid waste collection turned over to operators, and properly engineered sanitary landfills built Water Supply and Sanitation * Inadequate access to safe potable water and sanitation [ * Private concessions in cities (see rural development) Transport * Deterioration of the transport network * Rehabilitation and maintenance of the road network, new institutional setup and financing mechanism (road fund), and private sector development includes small and labor-intensive contractors for upkeep Rural Development * Poor rural infrastructure, inadequate rural industriali- * Rural infrastructure facilities development in a more zation and off-farm processing integrated manner, and mitigation measures in semi- urban mining towns Energy * Energy (electric and fuel wood) production and distri- * Sustainable supplies of fuel wood bution are inefficient Industry * Concentration of industries in coastal zones, and * Emissions and effluents monitoring ernissions and effluents unmonitored I Poverty Reduction * One-third of the population is below the poverty line * Poverty reduction policies, monitoring and dialogue, (1991-92), and one-quarter of the Accra population is and increased public expenditure on targeted poverty poor. reduction schemes Source: 1990-99 Bank staff appraisal reports for Ghana for environment, health, agriculture, infrastructure, energy, and industry and mining; 1997 Bank country assistance strategy for Ghana; and Government of Ghana (1989). 76 Table 5-2: Sample Sectoral Problems and Strategies/Actionsfrom Ghana Main Problems Strategies/Actions Possible Entry Points Poverty Reduction * One-third of the population is * Poverty reduction policies, * Economic analyses that ex- below the poverty line (1991- monitoring, and dialogue plore health benefits outside 92). . Increased public expenditures health care system * One-quarter of the Accra on targeted poverty reduction * Reexamine economic indica- population is poor. schemes tor analyses from health per- spective. For example, could absence of shoes and radios be linked to malnutrition and in- testinal worms? Agriculture and Rural Development * Poor basic infrastructure and * Diversification of agricultural * Links between diversified support services exports and improvement of crops to health outcomes, re- public investment in rural in- lated to erosion, pesticide use, frastructure and irrigation * Poor rural infrastructure * Rural infrastructure facilities * Links between rural infra- * Inadequate rural industrializa- development in a more inte- structure and vector-borne tion/off-farm processing grated manner diseases * Mitigation measures in semi- * Links with transport, air pol- urban mining towns. lution and occupational haz- ards from mining Energy * Energy (electric and fuel * Sustainable supplies of fuel * Links with indoor air pollution wood) production and distri- wood and fuel use, and erosion from bution are inefficient denudation Environment * Water supply: Limited access, * Natural resource manage- * Links with (a) indoor air pol- water-related diseases, and ment: sustainable supplies of lution and fuel use, and ero- water balance fuel wood, pesticide control, sion from denudation, (b) pes- * Urban decay: lack of adequate and water master plans for all ticide use, and (c) vector- roads, sanitation, and waste river basins related diseases disposal * Institutional reform: institu- * Economic analyses to show * Energy needs: increased en- tional structure for integrated benefits of mutual collabora- ergy requirements (80 percent land use planning, and sectoral tion in agencies working on from wood fuels) and interagency coordination the same problem * Land and coastal degradation * Environmental monitoring: * Develop proxy indicators for due to deforestation, mining, environment- and health- health and waste disposal related indicators * Economic analyses to create * Pollution: the quality of air, * Built environment manage- incentives for pollution reduc- water, soil, and life is affected ment: post-audits on indus- tion by industries and agrochemi- tries, and standard and regula- cals tion enforcement Health * Access to health care con- * Prioritization of health serv- * Explore benefits of interven- strained by geographic dis- ices with maximum benefits in tions outside health care sys- tances and financial barriers terms of morbidity and mor- tem for urban malaria and * Poor community, intersecto- tality reduction medical waste disposal ral, and private sector linkages * Empowering households and communities to take more re- sponsibility for their health. * Promoting intersectoral action for health development, par- 77 Main Problems | Strategies/Actions Possible Entry Points ticularly in the area of water and sanitation Industry * Concentration of industries in * Emission and effluent moni- * Find proxies to monitor pollu- coastal zones toring tion, and promote home * Emissions and effluents un- monitoring kits to help public monitored do some monitoring Infrastructure (General) * Inefficient and insufficient in- (see subsectors below) (see subsectors below) frastructure services in tele- com, power, rails, ports, urban water supply, airports, and roads Infrastructure: Urban Development * Water supply, sanitation, ur- * Traffic management * Protective gear for traffic ban roads and traffic, and * Storm drainage to alleviate managers other factors as a major con- flooding . Calculate benefits of reducing straint on urban productivity * Comprehensive sanitation vector-related diseases in Ghana. services by the year 2005 to . Link with drainage services to be prepared by Metropolitan show benefits of combined Assemblies approach * Direct septage hauling and * Make protective gear available solid waste collection turned and create incentives for over to operators and properly proper disposal of medical engineered sanitary landfills to waste be built I Infrastructure: Water Supply and Sanitation * Access to safe potable water [ * Private concessions in cities [ * Make sure to include incen- and sanitation is inadequate (see above for rural areas) [ tives to protect purity Infrastructure: Transport * Deterioration of the transport . Rehabilitation and mainte- * Link with health bene- network nance of the road network fits of traffic safety * New institutional set up and financing mechanism (road fund) * Private sector development that includes small and labor- intensive contractors for up- keep Source: 1990-99 Bank staff appraisal reports for Ghana for environrnent, health, agriculture, infrastructure, energy, and industry and mining; 1997 Bank country assistance strategy for Ghana; and Government of Ghana (1989). Preparing Sectoral Profiles It is important to provide the environmental health assessment team a broad picture, which is so essential for decisionmaking. This section outlines typical content for each sectoral profile, pro- viding a representative sample of useful material on environmental health that could be drawn from sectoral reports. The cross-sectoral tables and analyses of linkages provided in chapters 8- 14 also suggest important points for follow-up. In some cases, cutting and pasting from the report's executive summary or introduction may suffice. It is possible that the first draft, which combines unedited material from a variety of sources, may reach 50-100 pages. This should then be cut down to a working reference document of about 20-25 pages or about 3-5 pages per sec- tor. 78 Box 5-1: A Word of Caution Because a team representing different disciplines will use the sectoral profiles, it is important that the material be excerpted intact and not summnarized. Summary and analysis constitute the next step (see below). Following this advice avoids incorrect rendition of technical terms that carry weighted meanings, often with policy implications within their profession, but not necessarily in common us- age. Examples are "privatization," "risk," " research," "sewerage," "management contracts," "fer- tilizer," "operation and maintenance," "economic analysis," and so on. Source: Authors' data. The profile development process outlined below represents two categories of information: * Individual sectors. Information on the following is generally available in sectoral reports: * Agriculture and rural development Health Energy Industry * Environment Infrastructure. * All sectors. Information on the following cuts across several sectors and may need to be gath- ered from several reports: * Urban and rural (demographic) Development assistance * Institutional Poverty reduction. Each area covered below includes a few examples of the types of information that should be culled from reports. Poverty Profile The process should begin with a poverty profile that defines poverty in local terms, indicates its breadth within the local population, and identifies any particularly disadvantaged segment of the population. Figures, such as employment rates, salary ranges, levels of schooling and housing, access to water, sanitation, and medical care, should be cited. Much socioeconomic information could be useful to health specialists in identifying problems not readily apparent to those who compiled data. Absence of shoes, for example, could indicate infestations with intestinal worms, a widespread problem, which is often not reported in statistics, because mortality is low. Numbers of radios and televisions might indicate the difficulty in health outreach in targeting key audi- ences for diseases, such as AIDS, tuberculosis, or cholera. Identifying the needs of vulnerable groups should be emphasized more than compiling data. If data are not available at the local level, some indication of the buying power for food staples, housing, clothing, and other basic needs would be useful. A poverty profile should also reflect the views of the local population on their problems and proposals for solutions. Local views are important in determining perceptions of risks of environmental and health issues, which vary enormously by culture, religion, and so- cioeconomic status. Agriculture and Rural Development Profile Analyses of agriculture and rural development contain a wealth of information about rural-urban population movements, rural infrastructure, overall nutrition, and so on. In SSA, agriculture sec- tor reports may fill in some of the gaps on periurban areas, especially because SSA is expected to undergo rapid urbanization. Agriculture reports can also help explain the spread of malaria. 79 Agroindustry. Agroindustry patterns can help explain some urban-rural mechanics and waste handling issues and identify potential risks from chemical exposures in the air shed or watershed of the plant and, likewise, in dust. Irrigation. An understanding of irrigation activities can help determine the potential of agriculture projects to control or promote water-related and vector-related diseases. Food security. Food security issues are frequently dealt with in agriculture reports and provide excellent background on overall nutrition-related issues. Food security analyses, however, do not necessarily delve into contamination of the food chain by pesticides and fertilizers. Energy Profile An energy profile can point out the potential for indoor and outdoor air pollution and for illness related to transport or household energy use. The profile can also identify high-risk groups, the potential contribution to climate change and global warming, and more. Possible health problems depend, in large measure, on the use of traditional or modern fuels. Traditional energy. The degree of dependence on traditional energy can indicate (a) potential res- piratory problems because wood, fodder, charcoal, and so on are more hazardous to humans than modern fuels (e.g., gas and oil) and (b) occupational hazards, for example, physical stress from collecting fuel and high pollution exposure when preparing and bagging charcoal. Modem energy. The degree of modern energy use can indicate the type of ambient air pollution. Environmental health issues, however, tend to focus on ambient air pollution and often neglect indoor air pollution. Dams and irrigation. Dams for power or irrigation can promote the spread of vector-related dis- eases such as malaria, which is spread by mosquitoes, or schistosomiasis, which is spread by snails. Consultant teams from industrialized countries sometimes inadvertently omit these factors in environmental assessments. Vector-related diseases in industrialized countries have largely disappeared, or vectors such as mosquitoes have become "nuisances" more than health problems and, therefore, often dropped from EA methodologies. Environment Profile An environment sectoral profile can provide a wide range of information that might not be avail- able in health reports. Such information might include demographics, flora and fauna, climate and weather, topography, transportation networks, pollution levels, land use, housing patterns, energy consumption, health risks and responsibilities, and so on. All this information can be linked to disease transmission, but is not necessarily analyzed as such in typical health reports. Overall pri- orities are best designated, if possible, as general goals or as actual (budgeted) programs within a time frame. Environmental priorities are especially useful in determining the number of programs that can complement or compete with environmental health. Demographics. Demographic information in an environmental report may include geographic population distributions, population movements, urban-rural migration, and so on. A health re- port, in comparison, might contain much of this information, but emphasize age and sex distribu- tions and the availability of medical care. Demographic information may appear in a variety of sources other than environmental reports. 80 Climate, weather, and geographic features (e.g., flora, fauna, and topography). Climate and weather information can be essential in helping combat vector-related diseases by predicting their possible increase. This is because habitats of vectors (e.g., mosquitoes, flies, other insects, snails, rats, and other rodents) vary depending on temperature, humidity, and rainfall. In addition, infor- mation on climate can help communities prepare for reducing death and injury from storms, floods, heat waves, and so on. Pollution. Understanding pollution is important from several perspectives. Often overlooked is its psychological value. Because public awareness of pollution is generally high, addressing pollu- tion can provide an important rallying point, around which to promote other less visible or well- understood health factors. Looking at how different sources of pollution have been addressed, for example, solid waste, water, indoor and outdoor air, also measures local institutional capability to collaborate cross-sectorally. If pollution sources are varied, for example, for lead, it may be ap- propriate to clarify which ones are or are not being addressed in the project. Health risks and responsibilities. It is appropriate to touch here on (a) the type and probability of health risks and (b) institutional responsibility for addressing them or subsequent damages. If ap- propriate, this should include practices such as indiscriminate dumping of wastes with potential health risks, for which no agency is clearly responsible. Although it may not be possible at this stage to get accurate information, identification of risks and responsibilities can help identify the range of stakeholders that should later be involved. Box 5-2: A Note on Sub-Saharan Africa The Bank has required all International Development Agency (IDA) borrowers, which includes all of SSA except South Africa, to prepare NEAPs. In SSA, therefore, it might be best to research the environment sectoral profile first, because a NEAP and EAs are likely to exist, and health assess- ments or other environmental health analyses are still not systematically prepared. Source. Authors' data. Health Profile A health profile can provide useful information on disease patterns, the overall importance of health problems, high-risk groups, concentration or dispersal of causes of health problems, and, above all, the potential to complement efforts to improve health outside the health care system. Identifying priorities of the ministry of health is crucial for understanding where environmental health improvements inside and outside the health care system can complement or compete with activities outside the health care system. It is also helpful to note if priorities are considered over- all goals or budgeted time-bound programs and to determine how these priorities address the top ten causes of morbidity and mortality. The top ten causes. A health profile should list at least the top ten causes of morbidity, mortality, and injury for the country or, preferably, the project area in question and identify any special cir- cumstances or programs. The top ten along with government priorities can together help deter- mine which of the most serious problems lend themselves to remedial measures outside the health * IDA is one of five agencies that rake up the World Bank Group, which also includes the International Bank for Re- construction and Development (IBRD), International Finance Corporation (IFC), Multilateral Investment Guarantees Agency (MIGA), and International Center for Settlement of Disputes. IDA lends to the poorest countries, that is, those with a per capita GNP of less than US$800. The credits are, in effect, interest free. All SSA countries, except South Africa fall into the IDA lending category. 81 care system. A top ten list can also help identify needed agencies or specialties and, in turn, op- portunities for adding components to other programs and attacking a problem from several an- gles. Special problems. Identification in the profile of special problems or programs is important for many reasons, irrespective of their link to environmental health. For example, AIDS programs may have enormous budgetary implications and reduce the availability of resources within the health ministry for other health problems. Alternatively, because guinea worm is on the verge of eradication, it makes sense that every effort be made to ensure successful eradication, even through small components in rural projects might normally not address guinea worm. Box 5-3: Truckers in SSA and AIDS In SSA, truckers play a crucial role in spreading AIDS. Professional trucking groups could be tapped as a means to bring curative and preventative care to this high-risk group, as well as educate the public. Similarly, because malaria is "urbanizing" in SSA, infrastructure engineers could be tapped to adapt rural approaches to urban drainage and waste management. Better Health in Africa87 has identified six categories, each comprising about 10 percent of the SSA burden of disease (see table 1-3): malaria, respiratory infections, diarrheal diseases, childhood clus- ter, HIV/AIDS, other sexually transmitted diseases (STDs), and injuries. These might be a useful starting point for the analysis, if a "top ten" list is not available. Source: Authors' data. Data biases toward mortality. Typical morbidity and mortality data tend to underreport condi- tions related to environmental health. Health data, especially in SSA, more accurately reflect mortality than morbidity or injuries, because deaths are reported more systematically. Environ- ment-induced diseases tend to manifest themselves as chronic, long-term conditions, except in extreme cases such as natural disasters or road fatalities (see box 5-4 and discussion on disability in chapter 1.) Box 5-4: "Drop-Dead" Data Decisionmakers outside the health care system need help in prioritizing remedial measures to health problems because traditional health data do not reflect causes or solutions. Health-related policy is still heavily influenced by death rates. Some critics have referred to this as reliance on "drop-dead" data. In reality, long-term disability is more significant and tends to be underrepre- sented for environment-related diseases, even by disability-adjusted life years (see chapter 1). For example, the ratio of disability to death measurements for developing countries is twice that of the developed countries, that is, 27.8 percent compared with 13.5 percent (see table 7-4). Indeed, dis- ability due to intestinal worms, still a widespread problem in developing countries, is seldom even listed, because mortality from it is so low. Yet, the years lived with disability for this affliction are triple those from malaria!88 Source: Authors' data. High risk groups. Four groups to examine, because they tend to be most vulnerable or at high risk are women, children (especially under five), the elderly, and workers. Separate data for these groups may not be available for the project area, but, suitable demographic information might be available in other project files or reports such as EAs. 82 Private sector activity. The strength or weakness of private sector healthcare givers can identify an important audience for remedial measures, especially when private sector activity occurs in the "murky sector," as is so common in SSA. The data can also identify potential networks for pro- moting solutions, particularly through avenues of traditional medicine. Health agency structure. An "organogram" (organization chart) would help determine the range of possible offices with which to establish contact for multisectoral programs. Industry Profile An industrial profile can help establish the relative importance of occupational hazards and pol- lution levels and the institutional capability to promote regulatory measures. The absence of widespread public health infrastructure, such as "health rooms," health insurance, enforceable health and safety standards often means that health problems normally considered "occupational" become widespread public health hazards. Privatization. The degree that public services are privatized may indicate potential health prob- lems from business practices and policies that do not consider health consequences of their op- erations.* Neglect of health factors can also occur in government-run entities. The difference is one of degree and whether businesses automatically address health dimensions beyond those of safety. Industrial size. The proportion of small-, medium- and large-sized industries can help determine the degree to which occupational health and safety problems may become widespread public health problems. In general, the larger industries, especially if owned by expatriate countries with strict environmental regulation, are likely to be less hazardous to workers because they are more likely to implement occupational health and safety measures. The reverse can, however, be true if foreign firms move operations to developing countries to escape the stricter environmental regu- lations of industrialized countries. In comparison, large "responsible" industries can also play an important role in health education or funding worthy causes that promote their image. Industry type. The type of industry can determine the nature of health problems and high-risk groups. Agriculture, for example, entails exposure to vector-related diseases, pesticides, and fer- tilizers and sometimes dangerous machinery, depending on the local culture, for young to middle- aged males or females. In comparison, electronics industries are more likely to be hazardous to women, who are often subjected to solvent fumes. The two industries would have widely differ- ent risk groups and remedial measures. Infrastructure Profile An infrastructure profile can help establish a wide range of problems and solutions because of the broad set of subsectors involved: drinking water, sanitation, drainage, solid waste, housing, urban development, transportation (all modes), and telecommunications. Planning for these interlinking subsectors is, regrettably, not necessarily coordinated. Looking at priorities for all these subsec- tors at the same time could strengthen information on reducing diarrheal, respiratory, and vector- related diseases and injuries. * "Private sector" and "privatization" can mean either privatizing health care or privatizing public services that may have health repercussions. In this case, the latter is intended. 83 Demographic information (see also "demographic profile" below). Demographic information presented in an infrastructure report could contain useful material on remedial measures pertinent to the environment, which might not be considered in analyses of population movements in other reports such as health or education. Pollution levels (see also "environment profile" above). Pollution information presented in an infrastructure report could contain useful material on remedial measures pertinent to the environ- ment that may not be considered in analyses of pollution in other reports. Reports on industry, for example, may concentrate on industrial pollution abatement at the source and not surrounding areas. Levels of service. The level of service in providing drinking water (e.g., household compared with communal taps), can be an important indicator on diarrheas. Similarly, the adequacy of housing can relate to the extent of respiratory disease, although this link has not been statistically proven to the same degree as that of adequate quantities of safe drinking water with diarrheas. Geographicalfeatures. (See also "environment profile" above.) Basic geographic information can help determine the risks of flooding or landslides. These events can be exacerbated in areas of marginal economic value, because the poor tend to live and work in such areas. Geographical analysis can also help identify relative risks and exposures to vector-related diseases, such as malaria and dengue. Demographic Profile Depending on information available from environmental reports, a demographic profile could help identify and prioritize vulnerable groups and high risk areas. The information would proba- bly have to be culled from a combination of the sectors outlined in this chapter, in addition to education reports or, if available, a recent population census. A demographic profile should in- clude overall levels of urbanization, land use characteristics, density, levels of periurban agricul- ture, local definition of "urban," "suburban," "periurban," and "rural" population movements, and age and sex distribution. The process of "social assessment" is currently increasingly being employed in Bank projects. If a social assessment has been conducted, it may not be necessary to compile additional demo- graphic information (see also the sample needs assessment for Ghana in chapter 16). Institutional Profile The institutional profile can help determine the strengths and weaknesses of a multisectoral pro- gram. Useful information would include the overall organization of government agencies, their jurisdictions and responsibilities, an organogram, and, if possible, an assessment of various pri- orities and capacities to meet the legal responsibilities and stated priorities of the agencies in- volved. This could be helpful in determining the capability and willingness of different agencies to collaborate on multisectoral programs. During the regional cholera epidemic in Latin America of the 1980s, for example, Mexico devised a rapid response program by putting the water agency in charge of emergency services (e.g., providing or chlorinating water to villages) and the health agency in charge of publicity and communications. Development Assistance Profdle The Development Assistance Profile is useful to understanding the multisectoral involvement and priorities of the aid community, especially the difference between loans and grants. If possible, 84 the profile should also clarify whether aid agencies have any sectoral or geographic priorities. Such priorities can be instrumental in finding complementary funding for the types of issues that fall between the cracks in a single sector analysis. Agencies funding transport improvement, for example, can do an excellent job on reducing air pollutants such as lead, whereas other sources of lead pollution may be neglected because they fall under the purview of several other ministries. (See table 7-4 for multiple sources of lead.) Within the Bank, the CAS will probably be the most useful document in which to list potential involvement of different agencies, because it summarizes well the macroeconomic situation in the country as well as sectoral issues. Analyzing the Data The data compiled from the above profiles should be reviewed from several perspectives-disci- plines that should ideally be represented on the envirownental health assessment team, for exam- ple, public health or epidemiology, sociology or anthropology, economics, environment, and in- frastructure. The value of the exercise lies in its multidisciplinary analysis, that is, demonstration of the interdisciplinary nature of environmental health problems. No set outline for the results is presented here as the results may vary depending on synergy from the discussion. Three examples from World Bank activities indicate the kind of revelations provided by multidisciplinary analy- ses. * Interpreting the same data from several perspectives. Under poverty reduction analysis, an economist might cite the absence of shoes or radios as an indicator of economic bene- fits not trickling down to the poor. A public health specialist, in contrast, might interpret the absence of shoes as a risk factor in houses with dirt floors, poor hygiene, and inade- quate water and waste disposal. The latter might indicate the possibility of intestinal worms, which penetrate the feet. The absence of a radio would indicate difficulty in reaching the poor to promote basic health hygiene, especially during flooding from heavy rainfall or an epidemic. * Uncovering potential cross-sectoral conflicts. Energy and environmental goals may com- pete with public health goals. Tobacco production in SSA is a major foreign exchange earner. While environment staff were preparing a "best practice" note on more energy- efficient ways to cure tobacco, health staff were preparing a similar note advising staff that the Bank should not lend for tobacco because tobacco smoking exacted a high toll on human health. Discussions on the topic also heightened awareness that tobacco growing is "unhealthy" because of its heavy reliance on pesticides. Potential health and environ- mental damages from pesticide use and disposal would ideally be included in economic analyses of crops. * Increasing economic benefits. A multisectoral approach can capture additional benefits from one project. Urban drainage might include malaria reduction among its health and economic benefits, because it eliminates breeding grounds. The same drainage measures could also reduce breeding sites of other mosquitoes that spread diseases such as dengue and filariasis. Similarly, rural irrigation and drainage measures may also reduce schisto- somiasis (spread by snails, which breed in river banks and drainage canals). 85 Box 5-5: Employing an EHP in Ghana Chapters 15 to 17 provide details on how an EHP in Ghana helped integrate three environmental recommendations into an existing project and list seven more priorities for eventual consideration in upcoming projects. The Bank's Urban Environmental Sanitation project deals with Ghana's top five largest cities. The process, from preparing the EHP to making recommendations to the proj- ects, took about 6 months, beginning with a desk study in Washington to cull information from ex- isting Bank and Ghanaian reports. With an idea of multisectoral problems and government priori- ties, three entry points were chosen (urban malaria, proper management of waste from health care facilities, and interlinkages among water, sanitation, and drainage) as the basis for an institutional needs assessment, which was first intended to test whether the local community agreed with these entry points as serious problems and then determine the institutions to involve in their resolution. This was followed by a three-day local workshop of about forty people from the institutions identi- fied. The first day of the workshop focused on identifying the range of solutions needed to solve the problems. The second day of the workshop, attended by about 10 of the participants, focused on prioritizing the solutions and formulating them into practicable recommendations. These recom- mendations were presented on the third day to a meeting of the donor community. A second one-day workshop was eventually held, involving representatives of the four other cities under the project, to examine whether the circumstances in their cities were similar enough to take advantage the EHP and workshop to modify it and personalize it to all five cities. The participants agreed and then adapted the institutional needs assessment to include the names of their own insti- tutions for the institutional needs assessment as well as the recommendations. The five cities, thus, expanded the initial entry points to a set of ten priorities and agreed on the top three to present to the project management. For the future, a list of ten priorities reflecting community ideas was pre- pared in the next six months. Costs were minimized by relying on the EHP as a desk study to arrive at a short list of issues and by maximizing the use of local consultants to prepare the needs assess- ment and organize and conduct the workshop. EHPs help establish intersectoral problems and priorities, whereas social and environmental health mapping can help identify populations at risk. Like the profiles, environmental and social mapping can be compiled from existing information sources, with one important exception, GIS technology. In the Ghana case study, social mapping was used to identify low-income groups living in high-risk areas for vector-related diseases, that is, malaria, schistosomiasis (bilharzia), and guinea worm, combined with the different remedial measures needed to combat the disease (see map 5-1). The map was particularly helpful in facilitating interagency collaboration, because the administrative area for the pilot study, Sekondi-Takoradi, one of Ghana's top five largest cities, is actually an amalgam of rural and urban areas. Source: Authors' data. 86 Map 5-1: Environmental Health Needs Assessment Map for Sekondi-Takoradi, Ghana 7I' B#M P>Rem . 0 ,Er f HB, . R .k N,ppi dbyPa ot, OQtobr, 1999 ~~N 1,bUr ATOM r tV 87 t ; ~ , ? f 6 - >lnkta_w 87 CHAPTER 6: ADAPTING ENVIRONMENTAL ASSESSMENTS OR PREPARING ENVIRONMENTAL HEALTH ASSESSMENTS For reasons explained in chapter 4, at some stage, multisectoral teams may decide to prepare a complete environmental health assessment, whether as a first step or following preparation of environmental health profiles. As outlined in chapter 4, two approaches exist: (a) adapting an ex- isting environmental, health, social, or poverty assessment to serve as an environmental health assessment and (b) conducting a complete environmental health assessment. The advantages and disadvantages of each are also covered at the end of chapter 4. This chapter describes the steps involved in adapting an environmental assessment or preparing an environmental health assess- ment. The EA is used instead of the HA, SA, or PA, because EA techniques have been more widely utilized. Adapting Existing Environmental Assessments to Serve as EHAs Many EAs could be adapted to serve as EHAs. Existing EAs or even NEAPs can be tapped for information that may not be readily available in health agencies, especially because HIAs are scarce, compared with EAs. Bank staff familiar with EA procedures will find preparing EHAs easier if they follow the same general procedures. This section, therefore, outlines the basic simi- larities and differences between an EA and EHA. A cautionary note is appropriate here on applying the Bank's environmental assessment proce- dures. The Bank's EA procedures do not systematically address environmental health, nor are there current provisions on incorporating separate environmental health documentation into the Bank's existing range of "quality at entry" procedures or "Safeguard Policies," which consist of "Operational Policies" (OPs), "Bank Procedures" (BPs) and "Good Practices" (GPs). This vol- ume intends, among other things, to bridge the gap among these documents and between and among sectoral operations. Adaptation is likely to remain the case in the Bank, because environmental health considerations are cross-sectoral and already partially addressed in various Bank policies. Moreover, it could be considered administratively cumbersome to add another tier of analyses for Bank borrowers, when it may be possible to integrate environmental health analyses into projects by adapting EA procedures that are already in place. This is especially the case in the Bank's ten "Safeguard Poli- cies," whose primary objective is to ensure that Bank operations "do no harm" (see table 6-1 and the Bank's policy on Environmental Action Plans [OP 4.02].) Tables 6-1 to 6-5 below set forth environmental health dimensions that "safeguard" and other policies do not necessarily cover. Table 6-1: The World Bank's Safeguard Policies Environment Social Development OP 4.01: Environmental Assessment OP 4.11: Management of Cultural Property OP 4.04: Natural Habitats OD 4.20: Indigenous Peoples OD 4.30: Involuntary Resettlement Rural Development International Law OP 4.09: Pest Management OP 7.50: Projects on International Waterways OP 4.36: Forestry OP 7.60: Projects in Disputed Areas OP 4.37: Safety of Dams Source: World Bank web site ( (select "Table of Contents," then "Safeguard Policies") (accessed Septernber 2000). 89 Tables 6-2 through 6-5 outline the contents of key Bank documents concerning EAs. Table 6-2 shows overall linkages between OP/BP/GP 4.01 and environmental health. Table 6-3 lists the main elements to include in an EA. Table 6-4 explains the outline of a management plan on im- plementing the recommendations of an EA. Table 6-5 presents a broad checklist of issues that could typically be included in an EA and how they could be expanded to include environmental health. Tables 6-3, 6-4, and 6-5 show how key elements (i.e., OP, BP, and GP) of Safeguard Pol- icy 4.01 "Environmental Assessment" could be adapted to create an EHA or equivalent analysis. Table 6-6 takes advantage of more than a decade's work done on environmental assessments, providing a list of existing NEAPs and the nature of environmental health infornation they con- tain. These could be used as a starting point for an EHA or equivalent. Table 6-2: Adapting Bank EA Procedures to an EHA or Equivalent OP 4.01 Annex Link to ERA A. "Definitions" has eight entries: environmental audit, A. The Bank has no official definition of environmental environmental impact assessment, environmental health (see the glossary for definitions). management plan, hazard assessment, project area of influence, regional EA, risk assessment, and sectoral EA B. "Content of an Environmental Assessment Report for B. Changes in the outline for an EHA are described in Category A Project." For many category B projects, table 6-3. the EA may result in a management plan only. C. "Environmental Management Plan" covers mitigation C. Changes to a standard environmental mnanagement measures, monitoring, and institution strengthening plan are described in table 6-3. BP 4.01 Annex Link to EHA A. "Environmental Data Sheet for Projects in the A. No specific procedures exist for an environmental IBRD/IDA Lending Program" health data sheet. B. "Application of EA to Dam and Reservoir Projects" B. Environmental health problerns include vector- related diseases (especially malaria and schistoso- niiasis) in the dam as well as the water used for drinking and irrigation. C. "Application of EA to Projects Involving Pest Man- C. Environmental health issues could also include agement" contamination of the food chain well as drinking water (surface water, watershed, and groundwater) GP 4.01 Annex Link to EHA A. "Checklist of Potential Issues of an EA" A. Potential environmnental health issues are identified in table 6-5. B. "Types of Projects and Their Typical Classifications" B. No specific procedures exist for environmental health screening Source: World Bank web site ( (click "Operational Policies" and then" Environmental Assessment and Safeguard Policies") (accessed September 2000). Table 6-4: Adapting an EA Environmental Management Plan to an EHA SAMPLE ADAPTATION OF AN EA ENVIRONMENTAL MANAGEMENT PLAN CONTENT (OP 4.01 ANNEX C) TO AN EHA (Additions shown in boldfaced type) Mitigation The environmental management plan (EMP) identifies feasible and cost-effective measures that may reduce potentially significant adverse environmental impacts and health risks to acceptable levels. The plan includes compensatory meas- ures, if mitigation measures are not feasible, cost-effective, or sufficient. Specifically, the EMP: (a) Identifies and summarizes all anticipated significant adverse environmental impacts and health risks and popula- tion at risk (including those involving indigenous people or involuntary resettlement) (b) Describes in technical detail each mitigation measure, including the type of impact to which it relates and the con- ditions under which it is required (e.g., continuously or in the event of contingencies), together with designs, equipment descriptions, and operating procedures, as appropriate (c) Estimates any potential environmental impacts and health risks as well as population at risks of these measures (d) Provides linkage with any other mnitigation plans (e.g., for involuntary resettlement, indigenous peoples, or cultural property) required for the project. Monitoring Environmental monitoring during project implementation provides information about key environmental and environ- mental health aspects of the project, particularly the environmental impacts and health risks, as well as population at risk of the project and the effectiveness of mitigation measures. Such information enables the borrower and the Bank to evaluate the success of mitigation as part of project supervision and allows corrective action to be taken when needed. The EMP, therefore, identifies monitoring objectives and specifies the type of monitoring, with linkages to the impacts assessed in the EA report and the mitigation measures described in the EMP. Specifically, the monitoring section of the EMP provides: 91 SAMPLE ADAPTATION OF AN EA ENVIRONMENTAL MANAGEMENT PLAN CONTENT (OP 4.01 ANNEX C) TO AN ERA (Additions shown in boldfaced type) (a) A specific description and technical details of monitoring measures, including the parameters to be measured, methods to be used, sampling locations and population at risk, frequency of measurements, detection limits (where appropriate), and definition of thresholds that will signal the need for corrective actions (b) Monitoring and reporting procedures to (i) ensure early detection of conditions that necessitate particular mitigation measures and (ii) furnish information on the progress and results of mitigation. Capacity Development and Training To support timely and effective implementation of environmental and environmental health project components and mitigation measures, the EMP draws on the EA's assessment of the existence, role, and capability of environmental, health, and other units on site as appropriate or at the line agency and ministry levela as appropriate. If necessary, the EMP recommends the establishment or expansion of such units, a coordinaffon mechanism among them and the training of staff, to allow implementation of EA recommendations. Specifically, the EMP provides a specific description of institutional arrangements, that is, who is responsible for carrying out the mitigatory and monitoring measures (e.g., for operation, supervision, enforcement, monitoring of implementation, remedial action, financing, reporting, and staff training). To strengthen environmental and environmental health management capability in the agencies responsible for implementation, most EMPs cover one or more of the following additional topics: (a) technical assistance programs, (b) procurement of equipment and supplies, and (c) organizational changes and coordination. Implementation Schedule and Cost Estimates For all three aspects (mitigation, monitoring, and capacity development), the EMP provides (a) an implementation schedule for measures that must be carried out as part of the project, showing phasing and coordination with overall project implementation plans and (b) the capital and recurrent cost estimates and sources of funds for implementing the EMP. These figures are also integrated into the total project cost tables. Integration of EMP with Project The borrower's decision to proceed with a project, and the Bank's decision to support it are predicated in part on the expectation that the EMP will be executed effectively. Consequently, the Bank expects the plan to be specific in its de- scription of the individual mitigation and monitoring measures and its assignment of institutional responsibilities, and it must be integrated into the project's overall planning, design, budget, and implementation. Such integration is achieved by establishing the EMP within the project, so that the plan will receive funding and supervision along with the other components. Source: World Bank web site (click "Operational Policies" and then " Envi- ronmental Assessment and Safeguard Policies") (accessed September 2000). a. For projects with significant environmental implications, it is important that the implementing ministry or agency have an in-house environmental unit with adequate budget and professional staff strong in expertise relevant to the project. (For projects involving dams and reservoirs, see BP 4.01, Annex B.) Table 6-5. Adapting EA Checklists to an EHA or Equivalent Analysis Existing EA Procedures (GP 4.01 Annex A)a Sample Adaptations for an ERA or Equivalent Where applicable, EAs should address the following issues, Where applicable, EHAs should build on "Existing EA which are subject to the Bank policies and guidelines identi- Procedures" (to the left) and also consider the following fied here: factors: (a) Agrochemicals. The Bank promotes the use of integrated (a) Agrochemicals: pest management (IPM) and the careful selection, appli- * Transport, storage, repackaging and disposal of cation, and disposal of pesticides (see OP 4.09, "Pest containers Management"). Due to their impacts on surface and * Contamination of the food chain groundwater quality, the use of fertilizers must also be * Health effects of pollution of surface water, carefully assessed. groundwater, and watershed used for drinking wa- ter. (b) Biological diversity. The Bank promotes conservation of (b) Biological diversity. The protection and use of plants endangered plant and animal species, critical habitats, and animals with medicinal uses. and protected areas (see para. 9b of OMS 2.36, "Envi- ronmental Aspects of Bank Work," to be reissued as OP/BP 4.01, "Environmnental Assessment," and OP/BP/GP 4.04, "Natural Habitats"). (c) Coastal and marine resource management. The Guide- (c) Coastal and marine resource management. linesfor Integrated Coastal Zone Management is avail- * Contamination of the food chain from sewage, en- 92 Existing EA Procedures (GP 4.01 Annex A)a Sample Adaptations for an EHA or Equivalent able from the Environment Department (ENV) (Envi- ergy, and industrial sources and agricultural runoff ronmentally Sustainable Development Studies and * Special health risks to aquaculture and drinking Monographs Series No. 9, Washington, D.C.: World water supply from ports and harbor pollution. Bank, 1996) on the planning and management of coastal * Epidemic cholera, where appropriate. marine resources, including coral reefs, mangroves, and wetlands. (d) Culturalproperty. OP/BP 4.10, "Safeguarding Cultural (d) Cultural property. Health repercussions of visitors, Property in Bank-Financed Projects" confirms the especially foreigners, to tourist sites, which could Bank's commitment to protect archaeological sites, his- spread some infectious diseases, including AIDS. toric monuments, and historic settlements. (e) Global externalities. When a project has potential global (e) Global externalities. Health repercussions include environmental externalities (i.e., emissions of green- increased respiratory, eye, and circulatory system dis- house gases or ozone-depleting substances, pollution of eases; cases of skin cancer; vector-related diseases due international waters, or adverse impacts on biodiversity), to global warming and water use in water supply and the EA identifies the externalities, analyzes them in irrigation projects; as well as food chain contamina- terns of their impacts, and proposes appropriate mitiga- tion. tion measures. ffiHazardous and Toxic Materials. Guidelines are available (fi Hazardous and toxic materials. from ENV on the safe manufacture, use, transport, stor- * Occupational risks at the sources age, and disposal of hazardous and toxic materials. * Risk to scavengers and children playing at disposal sites, including special provisions to limit access and segregate waste * Risks of selling or recycling scavenged materials to purchaser or user. (g) Indigenous Peoples. OD 4.20, "Indigenous Peoples" (to (g) Indigenous peoples. Special risk of communicable be re-issued as OP/BP 4.10, "Indigenous Peoples"), pro- disease transmission to populations who may not have vides specific guidance for addressing the rights of in- built up immunity to many diseases that are not en- digenous peoples, including traditional land and water demic locally. rights. (h) Induced Development and Other Sociocultural Aspects. (h) Induced development and other sociocultural aspects Secondary growth of settlements and infrastructure, of- * Effects of inadequate drainage (often neglected), in ten referred to as "induced development" or "boom- addition to water and waste disposal (which tends to town" effects, can have major indirect environmental be addressed) impacts, which relatively weak local governments may * Vector-related diseases that can be spread by or to have difficulty addressing. "new" populations with no resistance or who travel back and forth to their former home * Respiratory disease from poorly ventilated, over- crowded housing (often neglected) (_) Sexually transmitted diseases, especially AIDS. (i) Industrial Hazards. All energy and industry projects (i) Industrial hazards. in areas around industry: should include a formal plan to prevent and manage in- * Residential areas, for factors considered under "(h) dustrial hazards. See Techniques of Assessing Industrial Induced Development" above Hazards: A Manual (Technical Paper No. 55, Washing- * Pollution effects beyond immediate surroundings, ton, D.C.: Technica, Ltd. and World Bank, 1988). possibly the watershed and air shed. 6) Industrial Pollution. The Bank supports an integrated a) Industrialpollution. As appropriate: approach to pollution control, viewing pollution preven- * Environmental health considerations, including res- tion as generally preferable to reliance on end-of-pipe piratory, eye, and circulatory system diseases; cases pollution controls alone. It encourages the adoption of of cancer due to chemical interaction and water and "cleaner production" and stresses the need for good irrigation; as well as food chain contamination in management and operating practices. Guidance on in- areas surrounding the pollution source as well as the dustrial projects is provided in the Pollution Prevention watershed and air shed and Abatement Handbook (The World Bank Group, * Laws and standards cover environmental health Washington, D.C., 1999). * Private sector arguments that health considerations are too costly or impracticable. 93 Exsting EA Procedures (GP 4.01 Annex A)a Sample Adaptations for an ERA or Equivalent (k) International Treaties and Agreements on the Environ- (k) International Treaties and Agreements on the Envi- ment, Natural Resources, and Cultural Property. The ronment, Natural Resources, and Cultural Property. EA should review the status and application of such cur- As appropriate: rent and pending treaties and agreements, including their * Environmental health considerations notification requirements. The Legal Department, which * Laws and standards covering environmental health maintains a list of international treaties, can obtain the * Private sector arguments that health considerations inforrnation required on applicable laws in individual are too costly or impracticable. countries. fl) International Waterways. OP/BP/GP 7.50, "Projects on (7) International waterways International Waterways," provides guidance. This * Provisions to avoid contamination of waterways statement exempts from notification requirements any with vehicle septage and garbage and, as appropri- rehabilitation projects that will not affect the quality or ate, for land-based facilities in which to place it quantity of water flows. * Possibility that tourists or traveling workers, such as truckers, will spread diseases * Short-term risk of spreading cholera, as appropriate (m) Involuntary Resettlement. OD 4.30, "Involuntary Reset- (m) Involuntary resettlement. tlement," to be reissued as OP/BP 4.12, "Involuntary * Possible malnutrition from food crops that may Resettlement," renders guidance. need time to mnature before producing food * Health care facilities and assistance for mental health problems arising from change * Proper water, sanitation, drainage, and waste dis- posal services, especially where vector-borne dis- eases are endemic. (n) Land Settlement. Due to the complex physical, biologi- (n) Land settlement cal, socioeconomic, and cultural impacts, land settlement * As for "Involuntary Resettlement." should generally be carefully reviewed. (o) Natural Habitats. OP /BP IGP 4.04, the Bank is com- (o) Natural habitats mitted to protecting natural habitats and provides for * Protection of biodiversity for medicinal plants and compensatory measures when lending results in adverse animals impacts. * Exposure of indigenous populations to vector-borne ._________________________________________________ diseases. (p) Natural Hazards. The EA should review whether the (p) Natural hazards project may be affected by natural hazards (e.g., earth- * Adequate provisions for safe food, water, waste quakes, floods, and volcanic activity) and should pro- disposal, and access to emergency health care pose specific measures to address these concerns when * In hazard-prone areas, preventive measures could appropriate (see OP/BP/GP 8.50, "Emergency Recovery include maintenance of roads and bridges and retro- Assistance"). fitting buildings to stabilize roofs. (q) Occupational Health and Safety. All industry and energy (q) Occupational health and safety. Residential areas projects, and projects in other sectors where relevant, surrounding industrial/energy premises, often low- should include formal plans to promote occupational income areas with highly vulnerable populations. health and safety (see World Bank, Occupational Health and Safety Guidelines, Washington, D.C., 1988). (r) Ozone-Depleting Substances. Use of ozone-depleting (r) Ozone-depleting substances. Health repercussions substances (e.g., chlorofluorocarbons and methyl bro- include the following: mide), which is widespread in such applications as re- * Skin cancer and eye diseases frigeration, foams, solvents, and fumigation, is regulated * Possibility of malnutrition from adverse effects of under the Montreal Protocol (OP/BP/10.21) and Vienna ozone of food production (photosynthesis). Convention. Guidance on ozone-safe alternatives is available from the Montreal Protocol Operations Unit in the Bank's Global Environment Coordination Unit (ENV). (s) Ports and Harbors. Guidelines are available from the (s) Ports and harbors Transportation, Water, and Urban Development De- * As for the three points under "International Water- partment on addressing common environmental con- ways" above cerns associated with port and harbor development (see * Offloading facilities and transport of hazardous 94 Existing EA Procedures (GP 4.01 Annex A)a Sample Adaptations for an EHA or Equivalent Environmental Considerations for Port and Harbor De- chemicals, including pesticides and their compo- velopments, Technical Paper No. 126, Washington, nents D.C.: World Bank, 1990). * Risks of respiratory diseases in surrounding areas from large scale granaries. (t) Tropical Forests. Guidance is provided by the Bank's (1) Tropical forests. possibilities of protection and proper July 1991 paper Forest Policy; OP /GP 4.36, "Forestry"; harvesting of plants and animals for medicinal pur- and OP/BP/GP 4.04, "Natural Habitats." poses. (u) Watersheds. Bank policy promotes the protection and (u) Watersheds management of watersheds as an element of lending op- * Possible contamination of food chain and water erations for dams, reservoirs, and irrigation systems (see supply with pesticide and fertilizer runoff OP 4.07, "Water Resource Management" and para. 6 of * Vector control on a watershed basis OD 4.00, annex B, "Environmental Policy for Dam and Reservoir Projects," to be reissued as OP/BP 4.01, "En- vironmental Assessment." (v) Wetlands. The Bank promotes conservation and man- (v) Wetlands. Possible breeding grounds for malaria could agement of wetlands (e.g., estuaries, lakes, mangroves, be addressed by: marshes, and swamps). OP/BP/GP 4.04, "Natural Habi- * Including health agencies to assist with preventive tats" covers this subject. measures * Consideration of land reclamation for malaria con- trol * Protection of biodiversity for medicinal plants and _ _ _ _ _ _ _ _ _ _ a~~~~~~~~~~~~~~uinmals. Source: "Existing EA Procedures" are available on the Bank website (under "Environment Assessment Policy") (accessed September 2000). Table 6-6: Environmental Health in NEAPs Country Date Health Concerns Identified by the Country Angola No action Benin 1993 Urban and industrial pollution, flooding, and transport Botswana 1990 Urban water pollution Burkina Faso 1991 Sanitation and water supply, solid and industrial waste, and pesticides Burundi 1993a Water supply and sanitation, sewage, solid and industrial waste, pesticides, fertilizers, and disaster mitigation Cameroon 1996a Pollution, solid and toxic wastes, and water supply and sewage Cape Verde 1994a (No translation from Portuguese available.) Central African No actionb Republic Chad No actionb Comoros _994a Water quality (water-borne diseases), sanitation, sewage, and solid waste Congo, Demo- Expected cratic Republic of completion date 2000a Congo, Republic 1994a Urban air pollution of C6te d'Ivoire 1993a Infectious and parasitic illnesses (linked to water supply, sanitation, waste d______________ bmanagement, and housing) Diiboutid _ Equatorial Guinea No action7__ Eritrea 1995a Human health and environmental issues: sanitation, vector-borne diseases (malaria, schistosomiasis, leishmaniasis, and onchocerciasis), water-borne diseases (diarrheas, shigellosis, amebiasis, and gastroenteritis), nutrition- deficiency diseases, and the working environment Ethiopia 1994a Sanitation and water supply Gabon 2000a Urban pollution, water-borne diseases (diarrhea, cholera, and so on), and vector-borne diseases Gambia 1992 Water supply, sanitation, waste management, fertilizers, pesticides, urbaniza- tion, coastal pollution, groundwater degradation, physical planning, infra- 95 Country Date Health Concerns Identified by the Country structure; environmental health program (urban waste management, pollution related to hazardous chemicals and fertilizers, and community participation) Ghana 1989 Sanitation and water supply, solid and liquid waste, land use, facilities short- age, mim , and pesticides Guinea 1 994a Water supply, sanitation, and waste management Guinea-Bissauc 1994" Potential for lead in motor fuel Kenya 1994a Adverse effects of motor fuels Lesotho 1 989a Sanitation, solid waste, air pollution, and pollution regulation Liberia No action Madagascarc 1988 Housing, water treatment, and solid waste Malawi 1994 Water supply and waste management, and occupational hazards, including chemicals Mali 1 996a Sanitation, water, industrial management, pesticide residues, agrochemicals, ________________ ~~and air Pollution Mauritania Ongoing but no due date b Mauritius 1988 Water supply, sewage, solid waste, land- and sea-based pollution, and agro- chemicals Mozambique 1 993a Urban (Maputo-Matola) sanitation and waste management, potable water, b______ infectious/parasitic diseases, and urban pollution Namibia No action Niger 1996a Water, public hygiene and sanitation, and pollution Nigeriac 1 990a Water supply, sanitation, wastewater, solid waste, pollution in general (no mention of vehicles), and soil erosion (threatens food supply) Rwanda 1991a Health and quality of life, sanitation, population growth, vector-borne dis- eases, and war (refugees) Sao Tome and 1993 a Water supply, solid waste, water-bome diseases, waste (human, hospital, and Principe' hazardous), malaria, agrochemicals, and pesticides Senegal 1997a Malaria, poverty, water supply, unclean living conditions, water, soil and air pollution, food contamination, sanitation, diarrhea, malnutrition, vaccine for targeted diseases, pesticides, and health care wastes Seychelles 1990 Sewage, animal waste, and vehicle and other pollution Sierra Leonec 1994a Poverty, water supply, waste disposal, sewage, soil erosion, and industrial and commercial pollution Somalia No action" j South Africa Not required' Sudan No action' Swaziland No action' Tanzania 1994a Urban pollution, water supply, sanitation, solid waste, sewage, pesticides, industrial wastes, cholera, dysentery, and typhoid Togo 1 999a Urban pollution, water-borne diseases (diarrhea, cholera, and so on), and vector-borne diseases Uganda' 1 994a Water supply and sanitation and water-related diseases; malaria; also notes rmalnutrition (kwashiorkor and marasmus) in preschool children Zambia 1 994a Water supply, industrial and domestic wastes, pollution, and agrochemicals Zimbabwec 1993a Water supply, sanitation and wastes, air pollution, and occupational health a. Not yet implemented. b. Not yet prepared or published. c. Prepared with the help of the World Bank. d. As of October 1999, Djibouti is part of the Middle East and North Africa Region at the World Bank. e. South Africa is not an IDA country, therefore, a NEAP is not required. Source: Country NEAPs. Conducting a Complete EHA An environmental health assessment should, above all, identify the broad picture, on which to base priorities among practicable remedial measures for a given project. The environmental health assessment process is new and rapidly changing, so no established procedures exist to be followed. This section describes the kinds of information that are useful in an environmental health impact assessment and necessary to identifying remedial measures based on intersectoral 96 linkages. Given the practical realities of acquiring accurate data, adapting information from alter- native sources can be a useful option. Box 6-1 below outlines the core content of an environmental health assessment as detailed in this section. Two other sample outlines, carefully thought through by health assessment practitioners, appear in boxes 4-3 and 4-4. The outline below differs from them by integrating the broader mul- tisectoral perspective presented in this discussion paper. This perspective will benefit any multi- disciplinary team required to plan and implement an EHA by ensuring that all team members share the same point of departure and contribute on a variety of issues, not merely those reflecting their professional expertise. Box 6-1: Core Outline for an Environmental Health Assessment I. Environmental Health Analyses A. Broad Picture and Overall Context B. Definition of Key, Confusing, and Misused Terms (Table on "Main Environmental Health Linkages") C. Individual Sector Factors and Issues D. Typical Loans from the Sector 11. Environmental Health Assessment Checklist A. The Proposed Project B. Institutional Strengths and Weaknesses C. Occupational, High Risk, and Vulnerable Groups (Table on Occupational, High Risk, and Vulnerable Groups) D. Hot Spots, Special Cases, and Key Pollutants E. Inadvertent Professional Biases and Policy Options F. On the Horizon G. Research and Information Gaps IV. Recommendations Source: Authors' data. The following sections detail the kinds of information to include in an environmental health as- sessment, following the above outline. The material should be organized to be easily skimmed, using headers and bullets. Depending on its dissemination, it may be appropriate to hire a profes- sional editor to avoid or clearly define technical jargon. Environmental Health Analyses Broad Picture and Overall Conlext * Include brief background material on the upcoming project and, as appropriate, its relation to potential health repercussions, positive or negative. Many users of this discus- sion paper will probably not have background in health or enviromnent and perhaps nei- ther; it is important that an EHA provide some at the start. This background material should be available in source reports from the environmental health profiles (if they have been prepared) or from various sector reports. Background should interest readers in learning more, not drive them away by too technical a level of writing or an emphasis on 97 negative outcomes and complex solutions. The multidimensional aspects of an EHA is an opportunity for collaboration. * Summarize multisectoral linkages. This could take the form of a chart, such as the one in table 6-7 (see also chapters 8-14 for more detailed examples, often by subsector). Table 6- 7. Sample Environmental Health Linkages of Bank Lending by Sector Environmental Possible Links and Cross-Sectoral Issues by Sector Health Effects Dimensions Remedial Measures Agriculture and Rural Contamination of water Waste management, land Land use management and inte- Development: and the food chain with use, soil and chemical grated pest management, water- Deforestation, agricul- pesticides and fertilizers, runoff, depletion of car- shed management, comprehen- tural chemicals, water spread of disease vectors, bon sink, loss of habitat, sive water resource manage- resource management, increased resistance to erosion, resettlement, ment, and affordable protective e.g., irrigation and pesticides, loss of medici- and so on gear and equipment for pesticide drainage, dams and res- nal plants, and injury or application ervoirs, and fisheries death from flooding Infrastructure: Diarrheal, respiratory, and Sexually transmitted Outreach to truckers, build Water supply and sani- vector-related diseases; diseases, including awareness of work crews as part tation, housing and ur- traffic injuries; and de- AIDS, spread by truck- of contracts, land use manage- ban development, trans- creased IQ from lead poi- ers or construction ment, waste management, and port, and telecommuni- soning in transport fuels crews; waste disposal; traffic law enforcement cations vector breeding sites; and resettlement Energy: Respiratory disease, Depletion of carbon Economic instruments, regula- Deforestation, indoor air physical stress from get- sink, deforestation, and tory measures, moral suasion, pollution, outdoor air ting firewood, vector- vector breeding sites stove and vehicle efficiency, and water pollution, related diseases, and con- alternative energy sources, and global warming, and tamination of the food land use and water resource dams chain from lead in fuels or management other sources of lead Industry: Air, land, water, coastal, Waste disposal, vector Occupational health and safety Air, water, and land and marine pollution breeding sites, and measures, economic instruments, pollution; climate leading to diarrheal, respi- chemical contamination regulatory measures, moral sua- change and global ratory, and vector-related sion, and land use management warming; and occupa- diseases, and contamina- tional exposures tion of the food chain Health: Medical waste from health Sexually transmitted Improved waste collection, Respiratory and diar- facilities leading to various diseases, including trucker outreach, building rheal diseases, AIDS, diseases, e.g., AIDS, can- AIDS spread by truckers awareness of work crews as part malaria, and injuries cers, diarrheas, and respi- or construction crews; of contracts, and affordable pro- ratory illnesses waste disposal; and tective gear and equipment vector breeding sites Environment and Natu- Potential for new medica- Climate change, global Management of land use, water- ral Resources: tions, and contamination warming, and ozone shed, and marine and coastal Forestry, biodiversity, of food chain depletion zones; and pollution control and marine management Multisectoral: Absence of health consid- Increased exposure of Lending instruments and man- Privatization of public erations from the business workers and general agement procedures services agenda public to health risks Global: Resistance to drugs, spread Individual sector contri- Lending instruments, training, Climate change and of vector-borne diseases, butions aggravate over- and grants to help address the global warrming skin cancer and cataracts all problem issue; and awareness campaigns from ozone depletion, death and injury from climate extremes, e.g., storms and heat waves Source: Authors' data. 98 Definition of Key, Confusing, and Misused Terms * Define basic technical jargon and cite differences in interpretation of terms. Basic concepts, which are often not explained in reports intended for audiences from the same profession, can confuse multidisciplinary audiences. "Sanitation" and "sewerage," for ex- ample, imply different technologies and policies that most infrastructure sector engineers take for granted (see glossary and box 13-3 for definitions of sanitation terms) Likewise, some communities may refer to malaria only as "fever," causing an outside project de- signer to misinterpret problems and design incorrect solutions that could exclude vector control. Individual Sector Factors and Issues * Explain those factors particular to the sector. The determinants of "indoor air pollu- tion," for example, will vary according to their rural or urban setting. These could include such confounding factors as the addition of industrial and vehicular air pollution, density of living conditions, costs of heating, and lighting and cooking fuels. * Explain specific issues pertaining to the sector(s) involved with the project, as ap- propriate. This section would complement the "Broad Picture and Overall Content" sec- tion above, for example, by citing overall objectives, policies, and specific strategies or special programs for a given sector. It may also be appropriate to show how, for SSA, sectoral projects can help address AIDS. This section can clarify for the multidisciplinary team aspects of the sector that are taken for granted as common knowledge by sector spe- cialists. Typical Loans from the Sector * Explain the basic types of loans from the sector for the benefit of those outside it. This need not be detailed. Give a flavor of the breadth of activities or recent trends to clarify a sector's objectives and priorities, for example, that housing loans do not gener- ally deal with indoor air pollution or other health factors. This section could clarify for the multidisciplinary team aspects of the sector that are common knowledge for sector specialists. - Begin to draw associations among health problems linked with different sectors and the potential to address those problems within a project. Table 6-8 summarizes these links for the infrastructure sector in SSA. Table 6-8: Main EHA Points for SSA Infrastructure Sample Project or Disease or Component Condition Sample Steps for EHA * Housing Respiratory disease * Determine levels of respiratory disease and overcrowded * Community facilities * Respiratory housing (in health, housing, urban planning, or school records) * Traffic management infections * Determine levels of uncontrolled burning and other dust from * Air pollution * Tuberculosis waste management sites and unregulated dumnps abatement * Determine degree of transport and industrial air pollution * Sites and services monitoring schemes * Determine degrees of regular flooding, because dampness can contribute to respiratory disease * Review geographic information system (GIS) information to determine flood-prone zones and frequency of flooding * Vector control Vector related * Review health records to determine presence of mnalaria and * Storm water * Malaria other vector-borne diseases and inquire at the ministry of drainage * Schistosomiasisa health if records for diseases other than malaria are not kept * Sanitation * Filariasisa systematically . Solid waste * Guinea worm a * Determine degree of transport and industrial water pollution * Solid waste a Guinea worrna monitoring * Sites and services * Onchocerciasisa * Assess conditions of drains in project area schemes * Review GIS information to determine flood-prone zones and 99 Sample Project or Disease or Component Condition Sample Steps for EHA * Rural water supply frequency of flooding * Roads * For any rural infrastructure project, review health records for current and past presence of guinea worm * Water supply Water and sanitation * Review health records for diarrheal diseases, vector-borne * Sanitation related diseases, and, if possible, intestinal worms * Solid waste * Intestinal worms a Consult project zone health centers for local information (or * Drainage * Diarrheal health districts that include project area) * Vector control * Schistosomiasis' * Review GIS information to determine flood-prone zones and * Road rehabilitation * Filariasisa frequency of flooding • Sites ad servics o Guina worie Review municipal records for distribution of industries, unsafe * Sites and services * Guinea worma . roadways, pollution distribution and waste sites for effects on schemes * Onchocerciasisa local populations, as well as provision of waste collection and * Hygiene education disposal services * Housing Unintentional injuries * Review health records on injuries, focusing especially on traf- * Public facilities * Traffic fic and bums, if child or household related * Erosion control * Poisoning * Review municipal records for distribution of industries, unsafe * Traffic mnanagement * Falls and buns roadways, pollution distribution, and waste sites for effects on * Traffic management ~~~~local populations * Solid waste * Drowning management * Occupational I a. These are counted in two categories because of complementary remedial measures. Source: Authors' data. Environmental Health Assessment Outline The Proposed Project - Describe the proposed project. Cite its overall objectives and possible positive and negative environmental health repercussions. Institutional Strengths and Weaknesses - Explain the primary problems. This section can help the multidisciplinary team clarify aspects of the sector that are common knowledge for sector specialists. Among possible topics are interagency communication, fragmented administration, absence of legal juris- diction, and outdated equipment. Institutional issues may sometimes be more important then technical issues, but are often not accorded the same importance. Precision is im- portant, for example, cite staffing and budgets or refer to proposals already prepared that address such issues (see the Ghana needs assessment in chapter 16). * Discuss, if appropriate, proposed solutions that are being discussed or tried. Occupational, High Risk, and Vulnerable Groups * Describe the main occupational, high risk, and vulnerable groups. Summarize them in a table (see table 6-9, for example). Occupational groups should include any groups exposed to occupational hazards, focus- ing on widespread cottage industries or other economic activities not likely to be covered by occupational health infrastructure, for example, "health rooms," protective clothing, health insurance, and ambulance services. Poor families are the most sensitive and vulnerable to the adverse effects of all sorts of environmental degradation due to high exposure levels. Poor families live in undesirable parts of the city, where it is often technically difficult to provide water and waste man- agement services. They also have the least access to other basic infrastructure and often 100 live near dumps. They live in crowded, poorly ventilated housing and are forced to cook, heat, and light with the cheapest but most polluting fuels. * Identify and target populations at risk for geographic, ethnic, or economic reasons for appropriate interventions. These populations might include resettled people or la- borers from construction crews. Table 6-9: Sample Occupational, High Risk, and Vulnerable Groups Main Activity Potential High-Risk Groups and Related Hazardous Activities Use and Sale of Basic health risks include (a) acute poisoning from short-term exposure and (b) accumulation in Pesticides body fat, leading to cancer or birth defects from long-term exposure. * Farmers and other farm workers from mixing and spraying pesticides * Women and children from improper storage and housekeeping activities, especially family members washing farmer's clothing * Retailers and wholesalers from (a) improper handling, storage, repackaging, or reformulating (mixing chemicals to become pesticides) and disposal of pesticides and containers and (b) re- cycling containers, e.g., bottles for beverages or drums for storage or incineration containers * Dockworkers and truckers from exposures from improper storage and transport * Community at large from (a) short- and long-term exposure in nearby fields, especially the first few days after spraying and (b) exposure from improper disposal of excess pesticides and empty containers and from runoff from the fields Use of Traditional Basic health risk from (a) acute or chronic respiratory disease from short- or long-term expo- (Biomass) Fuels sure and (b) lung cancer from long-term exposure Women and children from (a) gathering wood and other biomass fuels, which exposes them to safety problems, especially falls, and sorne vector-related diseases when fetching wood in en- demic areas and (b) cooking, especially in an enclosed space with poor ventilation, which in- creases the likelihood of respiratory and eye diseases Source: Authors' data. Hot Spots, Special Cases, and Key Pollutants - Identify areas that might require explicit attention beyond those covered by the pro- ject. This could include motorways with exceptionally high pollution or numbers of acci- dents, market areas with high activity and refuse, arsenic in the soil of a particular area, areas requiring special programs to address AIDS or guinea worm (which is on the verge of eradication), market gardening that provides year-round breeding sites for mosquitoes, major population movements, vulnerability to weather extremes created by El Niflo or La Nifia, and so on. * Identify key pollutants. Depending on local circumstances, pollutants addressed by the proposed project may have multisectoral sources which are not addressed by the project. Multiple sources should be described and suggestions made for other agencies that could complement project activities. Inadvertant Professional Biases * Describe the team and their individual contributions to the report (e.g., engineering, economic, sociological, legal, public health, and so on). This optional section can benefit multidisciplinary teams, because specialists will not necessarily raise issues that are common knowledge within their profession, including policy implications or the advan- tages and disadvantages of different technologies and clarify inadvertent professional bi- ases. Lack of understanding of health repercussions or their policy implications by team members from different specialties or the general public can lead to counterproductive and expensive overreactions, often sensationalized into front-page headlines in the popu- lar press, rather than resolved through balanced exchange in professional journals and conferences. Private sector research may be at the cutting edge, but its potential for bias depends on the type of industry. 101 Ignorance in industrialized countries that basic problems, such as diarrheal diseases, still exists. * At the community level, legitimate concern can turn into hysteria because scientific reports are taken out of context. For example, chlorination of drinking water can pro- duce carcinogenic byproducts (trihalomethanes). Public health specialists and engi- neers understand that water purification comes with tradeoffs, that is, elimination of most biological contaminants that could otherwise pose a major public health threat to the entire population against a smaller, high-risk group, such as pregnant women. On the Horizon * Cover, as appropriate, upcoming general activities or events. This might include the passage of laws, acquisition of funding, or opening of new facilities. Research and Information Gaps * Comment on pertinent research or information gaps that would help the current project or similar projects. Examples could include regulatory measures a the munici- pal level (as opposed to the national level), AIDS prevention strategies, and so on. Recommendations * Make recommendations on (a) solving environmental health problems in the short and long term, (b) potential benefits from multisectoral collaboration, and (c) including pilot projects, as appropriate, to foster multisectoral approaches. 102 Part 2: Environmental Health Assessment Guidelines 103 CHAPTER 7: ENVIRONMENTAL HEALTH BACKGROUND ANALYSES Basic knowledge about groups of diseases and individual diseases is essential to preparing an en- vironmental health assessment or equivalent analysis, especially if some team members lack health background. This chapter presents basic environmental health material that is useful back- ground for subsequent chapters, which deal with environmental health linkages by sector. The chapter discusses three categories of information-leading health problems, diseases for spe- cial consideration, and key cross-cutting issues-that is pertinent to all sectors. The health effects of pesticides, for example, usually considered under agriculture, are actually multisectoral and relevant to periurban agriculture, mosquito control in health projects, transport and disposal of hazardous materials, among others. The introductions of sectoral chapters 8-14 discuss environ- mental health information relevant only or primarily to that sector. Leading health problemss: Diseases for special consideration. Malnutrition * AIDS - Malaria and vector related diseases * Epidemic cholera * Diarrheas and gastroenteric diseases * Guinea worm infection * Respiratory diseases and diseases re- Key cross-cutting iues: lated to air pollution * Pesticide use * Injuries and accidents * Biodiversity and traditional medicines - Mental health and stress Source: Authors' data. General presentations of health data usually break down diseases and other conditions into two types-infectious and noninfectious-based on the seriousness of the disease. Infectious or "communicable" diseases are transmitted among humans by interpersonal contact, such as AIDS or flu, or through disease vectors, such as mosquitoes that spread malaria. Noninfectious diseases arise from other factors, such as pollution. In contrast to an approach based on the seriousness of disease, this discussion paper uses the above three categories, which are based on the types of in- terventions used to help solve problems. This innovative system of classification, new in this dis- cussion paper, maintains the focus on tapping health benefits outside the health care system, complementing and not replacing traditional health data. Leading Health Problems As already noted, infectious diseases, such as diarrheas, respiratory ailments, AIDS, and malaria, predominate in developing countries. This discussion paper only mentions noninfectious diseases, such as cardiovascular disease and cancers, in reference to pollution, because of its emphasis on SSA, where, aside from indoor air quality, air and water pollution have not yet reached the scale found in other regions, particularly, industrialized developing countries. The discussion of leading * Annex D presents detailed one-page descriptions on about twenty of the most important diseases, as does WHO's web site (). 105 health problems thatfollows covers key interventions outside the health care system and does not comprehensively cover health problems in SSA or developing countries. Malnutrition About 24,000 people die every day from hunger or hunger-related causes. Three-fourths of the deaths are children under five, and 10 percent of children in developing countries die before the age of five. An estimated 800 million people in the world suffer from hunger and malnutrition or about 100 times those who actually die from it each year.89 Malnutrition also impairs vision, stunts growth, complicates other health problems, and reduces natural resistance, predisposing the body to infection. Malnutrition can easily go unnoticed, unless it is severe. Table 7-1 summarizes the role that malnutrition plays in the overall burden of disease. Table 7-1. Major Risk Factors in Less Developing Countries (LDCs) Risk Factor Percent of Total LDC Deaths Percent of Total LDC DALYs Malnutrition 14.9 18.0 Water, hygiene, and sanitation 6.7 7.6 Solid fuel use 4.7 4.3 Unsafe sex and unwanted preg- nancies 2.5 3.7 Alcohol 1.6 2.7 Occupation 2.3 2.5 Traffic injuries 1.8 2.2 Tobacco 3.7 1.4 Hypertension 3.8 0.9 Illicit drugs 0.2 0.4 Outdoor air pollution 0.7 0.4 Totals 42.9 44.1 Source: Smith and Mehta (2000), p.15. Malnutrition is frequently equated with extreme food shortages, that is, starvation or famine. Al- though prominent in the popular press, such shortages occur only in pockets, representing the tip of the malnutrition iceberg. Famine and wars cause just 10 percent of hunger deaths, whereas the majority are caused by chronic malnutrition.9' The most widespread problem combines deficien- cies in certain food groups with long-term or intermittent shortage of food. This is hunger, not famine. (See chapter 8, table 8-2, for information on famines caused by desertification and drought.) Imbalance or inadequacy in nutrients contributes as much to malnutrition as starvation. Severe malnutrition is irreversible and can cause permanent brain damage and stunted physical growth. Two of the most common serious forms of malnutrition entail protein-carbohydrate and vitamin deficiencies. Vitamin A, for example, protects the mucous lining of the nose and mouth, which functions as the body's first line of defense against respiratory infections, one of the leading causes of death and disability in developing countries. Protein deficiency is a serious problem, because the body cannot itself manufacture certain proteins ("essential" amino acids). Protein sources (e.g., meat, fish, egg, dairy products, certain vegetables, and legumes) tend to be expen- sive. Discussion on malnutrition generally revolves around food security and diet, but malnutrition has several other environmental health dimensions. The link with sanitation, for instance, is often for- gotten. The health of a malnourished child is more severely compromised by infections with in- testinal parasites, mostly worms, caused in large part by deficiencies in sanitation. The most prevalent worm, ascaris, diverts nutrients to itself. Table 7-5 below summarizes the six most prevalent intestinal parasites. 106 Respiratory Diseases, Tuberculosis, and Diseases Related to Air Pollution Respiratory diseases cover a broad range of chronic and acute illnesses of the nose, ears, throat, and lungs (i.e., colds, influenza, pneumonia, tuberculosis, bronchitis, asthma, and lung cancer). Until the past decade, the literature has somewhat neglected indoor air pollution, largely because global interest in and technical capability to monitor industrial and vehicular pollution has instead focused on systematic ambient air monitoring, mainly in the industrialized countries. Recognition of the larger share of human health impacts due to indoor air pollution from cooking, heating, and lighting and tobacco smoke is increasing. Respiratory infections are transmitted by airborne particles, droplets, or physical contact, which are extremely difficult to confront using typical Bank project and component interventions, largely because interventions must involve behavioral change. Hygiene education is vital. Air- borne irritants-often overlooked in the transmission of respiratory diseases-cause diseases as well as predispose the body to respiratory diseases such as influenza or pneumonia. High-density living in slums and squatter settlements and poor quality housing in general intensify the risk of such diseases. Overcrowding itself is not the problem (high-density cities, such as Hong Kong and New York, have high health standards), but rather several negatively reinforcing factors. Smoke from cooking and heating with wood, charcoal, and kerosene irritate mucous membranes of the respiratory tract. Overcrowding increases exposure to droplet-spread infections, because poor ventilation inhibits their dispersion and lack of sunshine prevents natural sterilization of the air by sunlight. Tuberculosis (TB). Emphasis on ambient air pollution has also tended to overshadow the resur- gence of TB, especially in developing countries and among the poor in developed countries. Each year, of about 3.8 million cases of TB reported globally, 2.6 million prove fatal. The initial infec- tion may subside with no further symptoms, but still infect others. Most common in adults, TB is usually more serious in infants, children, and adolescents. The infection can be reactivated after years of quiescence. The weakened immune system of HIV-infected individuals may cause an old TB infection to flare up or increase the risk of a new infection. The pandemic of HIV infection and an increase in multi-drug-resistant TB bacteria have profoundly worsened this public health burden.9' Epidemiological evidence shows that decreasing overcrowding could reduce TB-something that housing projects could partially address-but reduction of respiratory infections requires more, including medical care and improved hygiene. Upsurge in air travel is helping to spread infec- tious diseases internationally, particularly, TB. Diseases related to air pollution. Respiratory diseases figure among the top burdens of disease throughout developing countries (see table 1-1). Major pollution sources are indoor and outdoor air pollutants and environmental tobacco smoke. Somewhat neglected, heart, skin, and eye dis- eases are also partially attributable to air pollution. Fine particles (significant in sizes of less than 10 microns in diameter and capable of penetrating deeply into the lung at under 2.5 microns) are serious offenders as indoor pollution, because people spend so much time indoors. Biomass fuels, especially from burning wood, are the major culprits, followed by fossil fuels (see definition in box 8-2). Although the main respiratory diseases vary little in rural compared with urban areas, risk and exposure factors differ considerably, as do pollution sources. For indoor air pollution, traditional fuels used for cooking, lighting, and heating in rural areas include a mixture of biomass fuels, such as charcoal, twigs, dung, and so on, and fossil fuels, such as kerosene and coal. These tradi- * Infection with tuberculosis requires prolonged exposure; risks are greatest for family members or coworkers, as physical closeness and recycled air appear adequate to facilitate its spread. 107 tional fuels tend to harm health more than cleaner modem fuels, such as gas and electricity. A key factor is exposure time. In a study of 500 children in Gambia, for example, children strapped to their mothers' backs were six times more likely to develop respiratory illness than other children, because of increased exposure to fumes from cooking and heating.92 Rural populations may be regularly exposed outdoors to high levels of dust; those working in ag- riculture can be periodically exposed to intensive, high levels of fumes from slash and burn, air- borne pesticides, fertilizer residues, and chaff and other dusts from food processing, especially smoking fish or meats. Small particles in dust can penetrate deeply into the lungs and compro- mise breathing. Dust can also compromise the body's first line of defense against respiratory ill- ness, the mucous lining of the mouth and throat. Human exposure to indoor air pollution in rural areas of developing countries is estimated to be sixty times greater than in urban areas of developed countries and overall daily exposures about 20 times greater.93 About one-third of energy consumption in developing countries comes from burning wood, crop residues, and animal dung, mostly in rural areas. Nearly 2 billion people do not have access to electricity and oil and will probably continue to rely on biomass fuels for up to fifty years. A recent World Bank energy study shows that, as people move up the economic ladder, they change fuels for heating and lighting, but not necessarily cooking.94 Although cooking is a rela- tively minor end use of energy consumption in industrialized countries and Eastern Europe, it is the largest home energy use in developing countries, where the main cooking fuels are liquid pe- troleum gas (LPG), biogas, kerosene, efficient charcoal, charcoal, household coal, wood, crop residues, and animal dung.95 A major concern is the low conversion efficiency rate of biomass stoves (about 12-18 percent), which, thus, produce high levels of pollution.96 In eight countries studied, this indoor pollution ranged from four to ninety times the WHO standard for peak pollu- tion guidelines.97 About Air Pollutants The literature generally refers to six "criteria" pollutants-particulate matter, sulfur dioxide, ni- trogen dioxide, carbon monoxide, lead, and ozone-which correspond mainly to outdoor or "am- bient" air pollution. No comparable criteria pollutants gauge indoor air quality. This imbalance in measurement capability has contributed to the relative neglect of indoor compared with outdoor air problems. Indoor air pollution is mistakenly disregarded as a problem in many parts of the world where people generally cook outside or windows and doors are kept open most of the time. Recent evidence shows that people create intense spikes in pollution whenever they stir fires. Although not equivalent to prolonged indoor exposure, these temporary increases in exposure cause significant respiratory irritation that can predispose people to disease. Tables 7-2, 7-3, and 7-4 list the major sources of respiratory illness and main pollutants. Table 7-3 lists the main components of ambient air pollution and their sources. Two categories have been added to the "criteria pollutants" to accommodate the role of indoor pollution, that is, "other smoke and fumes," and "inorganic dust." Table 7-4 indicates the range of sources for lead, for which automobile exhaust is only a minor source, even though it is often considered the main source, whereas other equally important factors are neglected. 108 Table 7-2: Air-Pollution-Related Respiratory Illness Pollution Type Main Sources Remedial Measures Indoor Cooking, heating, and lighting fumes; Better ventilation; less polluting fuel source for intrusion of outdoor pollution; and dust cooking, lighting, and heating; protection from ex- ternal air pollution and dust; adjustments in fuel prices- and education. Outdoor Vehicular exhausts; traffic, construction, Pollution abatement; traffic management, emission and solid waste dust; industrial and en- standards, vehicle maintenance, and adjustments in ergy emissions; and dust fuel prices; protection from dust as appropriate, e.g. tree barriers; and education Tobacco Important as predisposing or exacer- Better ventilation, education, specific antismoking Smoke bating factor, because contains concen- campaigns, and tobacco levies as appropriate trations of many indoor and outdoor pollutants Occupational Varies Varies Source: Authors' data. Table 7-3: Major Components ofAir Pollution Pollutant Main Sources Particulate matter Essentially refers to suspended matter small enough to penetrate the lungs (less than 10 rnicrons). Includes virtually anything that produces dust or smoke (also referred to as SPM, TSP TPM, PMlo, PM5 PM2.5). Carbon monoxide Prirnarily from transport sector (vehicular exhaust), and household emissions from cooking and (CO) heating, and tobacco smoke Sulfur oxides (SO, Cornbustion of coal, petroleum, wood (electricity, cooking, space heating, oil refrneries, smelters, S02) paper manufacture, and refuse buming). Major components of tobacco smoke. Nitrogen oxides Combustion of coal, oil, natural gas, and motor vehicle fuel. Biomass and fossil fuels especially im- (NO., NO2) portant for indoor pollution. Tobacco smoke, whose effects worsen in the presence of motor vehicle emissions. Component of smog. Lead Primary source is vehicular emissions and smelters, but other sources can be more detrimental to health (see table 7-4). Ozone (O9 Main component of smog; reacts with NO, and other pollutants, especially hydrocarbons, with sun- light; used in food industry to extend shelf-life; emitted by high-voltage electrical equipment; used to purify water and sugar Other smoke and Fossil fuels, such as coal, oil, kerosene, and natural gas; biomass fuels, such as wood, charcoal, fumes vegetable matter, dung, and biogas (also referred to as volatile organic compounds (VOCs); and polyaromatic hydrocarbons (PAHs) Inorganic dust and Essentially other factors not considered separately under another chemical designation and leading to other a wide range of respiratory illnesses, including mites, mold, mildew, hair, stored products (e.g., miscellaneous household cleaning and pesticide), residues from building materials, and so on a. Suspended particulate matter, total suspended particulate, total particulate matter, particulate matter less than 10 microns, particulate matter less than 5 microns, and particulate matter less than 2.5 microns. Source: Authors' data. Practical interventions by Bank projects to reduce respiratory illness could address poor air qual- ity, overcrowded housing, and infectious irritants to the respiratory tract. Any housing construc- tion projects should incorporate proper aeration and sunlight in designs to help reduce person-to- person transfer and proper ventilation to eliminate smoke and fumes. Outdoor exposure, for ex- ample, vehicle exhaust, especially near markets and stations, and recurrent exposure to dust and other particulate matter, is also significant. Small components often play a sizeable role in reduc- ing the basic irritation that predisposes people to respiratory infections. Air pollution abatement needs to address collectively the major indoor, outdoor, and occupational sources. Lead, as a major pollutant, is unquestionably a serious public health problem globally, but its role, especially in SSA cities, may be overstated, because studies of equally important factors have been less publicized, even in industrialized countries. Routine mention of lead in 109 environmental assessments does not necessarily make it important, unless associated with areas of high exposure, for example, populations in markets near bus stations, where vehicle emissions are excessively high. Table 7-4 lists lead's varied sources. Table 7-4. Multiple Sources of Lead Medium (Method) Sources Air (inhaled) Automobile emissions; primary and secondary lead smelters; foundries producing other metals; factories producing ceramics, glass, and armaments; weathering of lead-painted surfaces; combus- tion of lead-painted materials and solid waste; recycled motor oil used as fuel for industry and energy; and dust recycled within the environment for up to 30 years Water (drunk) Lead-lined storage tanks; lead pipes, fittings, and couplings; and air-borne particulate settling on water Food (ingested) Soil and dust deposits eaten directly in food; air deposits taken up in food, fertilizers, and irrigation water; food in contact with lead solder in cans and lead-glazed cookware and plates; chips from painted surfaces eaten and pencils chewed on by children; and flour from traditional stone mills, reinforced with lead joints Occupational Smelter workers, traffic police, and garage mechanics Other Diarrheal remedies and cosmetics (especially eye, e.g., kohl) Source: Authors' data. Gastroenteric Diseases Gastroenteric diseases cover a wide range of diseases from food poisoning to cancer. Two dis- eases-diarrheas and intestinal worms-for example, are responsible in developing countries for some of the greatest burden of disease. Gastroenteric diseases are diseases of the stomach (gastro) and intestines (enteric). Most are simply and cheaply preventable by keeping drinking water free of contamination and providing sufficient amounts of water and education to enable people to maintain good personal hygiene. Some 10 to 20 million children die yearly due to diarrheal dis- eases. Equally significant is high morbidity in the general population from intestinal parasites, primarily caused by inadequate disposal of excreta and lack of personal hygiene. These parasites currently infect some 3.5 billion people in developing countries and cause about 160,000 deaths per year. Even though their mortality rate-under 1 percent of the infection rate-is much less dramatic than infant mortality, the incalculable loss in human productivity is certainly significant. Diarrheas Diarrheas remain one of the greatest causes of death and disease, despite progress during the In- temational Drinking Water Supply and Sanitation Decade of the 1 980s. Epidemiologically, mor- tality from diarrheas, if untreated, can be high due to dehydration and depletion of essential body chemicals. Diarrheas are the main symptom of more than thirty diseases, but are also side reac- tions to other diseases or their treatments, or from travel, change of diet, or stress. Diarrheas radically upset absorption of nutrient fluids in the intestines, which expel fluids that should remain in the body. This can sufficiently alter the body's fluid/nutrient/electrolyte balance to cause death. Diarrheas are particularly devastating for children, who are more fragile and sus- ceptible to fluid loss. Due to the size of their intestines relative to body weight, the effects of de- hydration and shock are more pronounced in children. * About 8 liters of water daily pass through the intestines of the average adult. Only about 2-3 liters come from food and drink; the remainder comes from body fluids (e.g., mouth, stomach pancreas, liver, and small intestines). Of this, the large intestine expels only about 0.1 liter as water and the rest is absorbed or excreted in urine. 110 Humans may inadvertently ingest small amounts of feces containing the pathogens that cause di- arrhea. Inadequate excreta removal is probably the single greatest reason, followed closely by poor personal hygiene, accounting for hand-to-mouth transmission, and drinking contaminated water. Inadequate drainage compounds the problem, especially in slums and squatter settlements, when storm drains clog with all types of waste, exposing infants and children who play outside to high risks. Crowded housing conditions worsen the situation due to poor personal and domestic hygiene and food preparation practices, especially during cholera epidemics. Table 7-5 shows the main excreta-related diseases, including diarrheas. Table 7-5: Main Excreta- and Water-Related Diseases Disease Main Transmission Routes and Effects Main Control Measures Diarrheas: (a) General (a) Includes such fecal-oral routes as inter- (a) General: waste disposal to avoid personal contact, drinking water, con- water contamination in the first taminated food, and unwashed hands. place and ensure personal and food Causes dehydration, vomiting, and preparation hygiene. Water quantity cramps. Even in low doses, can cause crucial for hygiene. death, especially in children. (b) Dysentery (Ame- (b) As above. Rapid onset of "bloody diarrhea," (b) General: medication and oral rehy- biasis) causing anemia, fever, vomiting and dration therapy (ORT) and immuni- cramnps. Even low doses can cause infec- zation of carriers, e.g., typhoid tion. (c) Cholera (c) As above. Water and food contamninated by (c) General: heavy chlorination in epi- infected person. Rapid onset of diarrhea, demics, e.g., for cholera vomiting, cramps, dehydration, and shock. Mortality high if untreated. (d) Typhoid (Salmo- (d) As above. Intestinal infection causing fever nellosis) and headache. Can be fatal. Intestinal Worms: (a) Ascariasis (a) Ingested on food contaminated with worm (a) General: deworming medication eggs. Worm inhabits intestines. Main ef- fects are malnutrition. Can cause other problems. (b) Hookworm (b) Worm larvae penetrate feet or lower legs. (b) Improved sanitation, especially near Blood-sucking worm "hooks" itself to living quarters (children are the srmall intestine. Can cause severe anemia. main reservoir); personal hygiene; and food preparation (c) Improved sanitation, especially when human and animal waste is reused as fertilizer; education; wearing shoes and sandals; and attention to defecation sites Vector-related: (a) Malaria (a) Spread by mosquitoes. (a) General: curative and preventive medication (b) Schistosomiasis (b) Spread by snails, Very debilitating bladder (b) Control of mosquito breeding (Bilharzia) infection with worm and eggs. Spread to grounds, e.g., through landfills or periurban areas from rural to urban migra- insecticides tion. (c) Filariasis (Ele- (c) Spread by mosquitoes. Worm infections can (c) Improved sanitation; avoiding human phantiasis) cause headaches, nausea, fever, and pain- exposure to larvae; and eliminating ful swelling of legs, genitals, and breasts. snail habitat (d) Direct exposure to rodent urine or in water, (d) Leptospirosis especially during rainy season. Sudden on- (d) Ventilated, improved pit (VIP) la- (Weil's disease, set of fever and aches, hemorrhaging. Can trines effective in dealing with Mud fever) cause kidney failure and death. odors and insect breeding (e) Protective clothing, education, and medications for workers and scav- engers at waste disposal sites (espe- cially where rats are present) Source: Authors' data. 111 Intestinal Parasites Intestinal parasitic and protozoan infections are among the most common infections worldwide. An estimated 3.5 billion people are affected, of which 450 million, mostly children, are ill. Multi- ple infections with several parasites (e.g., hookworms, roundworms, and amoebae) are common; their harmful effects are often aggravated by malnutrition or micronutrient deficiencies (see table 7-6).98 These parasites interfere with digestion, absorb needed nutrients, and cause anemia and diarrhea. Each of these factors can, in tum, evolve into serious problems, such as stunting of growth, dehydration, and even asthma in poor communities-all more severely in children. Hookworm causes higher levels of anemia than malaria and schistosomiasis. Even though many curative medicines are effectively administered, the frequency of reinfection keeps the prevalence of these infections high, in part due to relative neglect in their research and control since World War II. Intestinal parasites remain an important health problem and contributing factor to malnu- trition, even though the death rate-under 1 percent of the infection rate in the six examples cited-is much less dramatic than, for example, for infant diarrhea. Table 7-6: Major Intestinal Parasites Infection Rate/Year Mortality Rate/Year Worms Roundworms (e.g., ascaris) 1,000,000,000 60,000 Hookworms (e.g., ancylostoma and necator) 900,000,000 65,000 Tapeworms (e.g., taenia) 50,000,000 50,000 Whipworms (e.g., trichuris) 500,000,000 (low) Other parasites Amoebas (e.g., Entamoeba histolytica) 500,000,000 70,000 Giardia 200,000,000 (low) Source: WHO web site, (accessed September 2000). Deficient sanitation primarily explains continuing high rates of infection by worms, chiefly asca- ris and hookworm. Ascaris, an important contributor to malnutrition, spreads through interper- sonal contact and ingestion of eggs deposited on poorly washed or uncooked vegetables that have come into contact with feces during growth or processing. Water that is used to keep vegetables fresh after picking is often contaminated. Hookworm is an important factor in anemia and one of the most common causes of hospitalization. Hookworm eggs deposited in moist soils develop into larvae. Inadequate feces disposal spreads the disease, when larvae penetrate the feet, com- monly around defecation sites (see annex B). With increased urbanization globally and more peo- ple living in shantytowns with poor sanitation, WHO expects infection levels to increase.99 Malaria and Vector-Related Diseases Vector-related diseases tend to be predominantly "rural" diseases, because they require an inter- mediate host, such as a mosquito or snail, whose habitats are more plentiful in rural areas. Ma- laria, the most significant (see table 1-3), is widespread; 2.4 billion people, more than one-third the world's population, are at risk. This rural predominance could be changing; malarial mosqui- toes are adapting to urban areas, many of which have extended mosquito breeding habits by in- creasing periurban cultivation and year-round supplies of water, which are often not properly drained. The mosquito species that transmits dengue fever is also becoming firmly entrenched in many urban areas. This group of diseases may be neglected, partly because vector-related dis- eases have been downgraded to "nuisances" in industrialized countries. They, thus, do not gain as much attention in public health literature, environmental health assessment processes, and univer- sity education, all of which tend to focus on pollution-related issues. 112 Schistosomiasis is another widespread vector-related disease. It is spread by snails, which favor slow-moving water, the type of habitat that dams create. Neglect of vectors in hydropower or irri- gation projects has worsened the spread of schistosomiasis, for which 600 million people are cur- rently at risk (see table 1-3). Prior to the 1985 damming of the Senegal River, for example, only one recorded case of schistosomiasis had occurred along the river. After damming, 187 villages were infected.'0° The effects on the local population of vector-related diseases less widespread than malaria or schistosomiasis can still be devastating. Black flies, for example, spread river blindness; these flies breed in fast-moving water in rivers, streams, spillways, and drainage canals (aerated water provides larvae the high amounts of oxygen needed for development), precisely where people wash clothing, fish, bathe, swim, and collect water. Socioeconomic costs of river blindness are high, because up to 50 percent of the local population can be infected-impairing vision for 30 percent and blinding 1O percent. People often abandon entire villages for higher ground, resulting in great economic costs, including less fertile soil and long travel distances to water. The disease often afflicts 50 percent of a village in endemic areas. About 30 percent of cases result in inca- pacitation, about 0.5 percent in permanent disability and 0. 1 percent in mortality. Disability ranges from five to ten weeks in untreated cases. In western Nigeria, for example, the average disability lasted for 100 days. Table 7-7 summarizes transmission routes for major vector-related diseases. Annex B provides one-page descriptions of transmission and remedial measures. About Mosquitoes Three mosquito species-aedes, anopheles, and culex-are important in transmitting malaria and the diseases noted above. Their different breeding habits call for different approaches to breaking the transmission cycle (see table 7-7). The implications for projects stem from the type of habitats that projects can create, alter, or eliminate. Because, for example, anopheles mosquitoes breed in natural marshes and impounded water, nature's role may be far more significant than water or irrigation projects. Culex mosquitoes, in contrast, breed in organically polluted water, and aedes in clean standing water; therefore, infrastructure projects can significantly alter the extent of breeding habitat. The implications of mosquito breeding habits are obvious for water, sanitation, or urban sector and irrigation and rural development projects and components. Drainage and waste disposal emerge as important as water provision itself. Despite specific breeding preferences, mosquito adaptability is impressive; they can breed in fresh, salt, or brackish waters and virtually anywhere where water collects in tree holes, fallen leaves, coconut shells, cut bamboo, gourds, cans, plastic residue, drying river beds, hoof prints, discarded car parts, and plant axils or leaves of pineapple, banana, cocoa yams, and paw. Mosquitoes thrive on living organic matter, but can eat almost anything small enough to ingest. Their potential flight range extends as far as 300 kilometers, but usually remains within 3.2 kilometers and averages about 1.2 kilometers. In most cases, compre- hensive environmental sanitation measures up to 1.6 kilometers are effective. A rule of thumb might be to consider the area extending a mile in all directions beyond human inhabitation as containing potential mosquito-breeding grounds. Various species of mosquitoes have different breeding andfeeding habitats, which calls for different approaches to breaking the transmission cycle in malaria and other diseases. In- deed, malaria is sometimes informally referred to as "urban," "industrial," "irrigation," and "forest." 113 Table 7-7: Transmission of Main Vector-Related Diseases Disease | Vector Breeding Environment and Primary Means of Transmission | Diseases Mosquitoes Anopheles Fairly clean, slow-moving brackish or fresh water, e.g., irrigation Malaria and water, ponds, and marshes. Flight range up to 3 miles (5 kilometers). filariasis Aedes Clean, fresh, and salt standing water, e.g., water pots, cisterns, small Yellow fever, containers, temporary pools, and periodic flooding. Potential flight dengue, and range of up to 160 kilometers. Feeding flights most likely 1.6 kilo- filariasis meters. Culex Fresh and salt water polluted with organic matter, e.g., pit latrines, Filariasis clogged storm drains, open sewers, waste stabilization ponds, and soaking pits. Flight range up to 16 kilometers. Feeding most likely I less than 8 kilometers. Other Vectors Snail Breeds along river and lake banks or irrigation and drainage ca- Schistosomiasis nals. Worm eggs in excreta develop into larvae (miracidia) that (bilharzia) infect snails. Snail eggs hatch into larvae (cercariae) that penetrate ==____=_____ skin. Larvae need to find host within 6 to 48 hours. Rodents (rats) Breed in and feed on uncollected solid waste and waste disposal Leptospirosis sites, Urine and feces can spread disease through direct contact or (Weil's disease) ingestion. and plague Water flea Breeds in small freshwater ponds. Humans ingest water flea (co- Guinea worm (Cyclops) pepods) in drinking water." "Flea" develops into a worm that (dracunculiasis) causes ulcers on leg and foot. Worm sheds eggs into water, com- pleting the cycle. Black fly Breeds on vegetation and rocks near or in fast-moving waters, River blindness e.g., dam spillways and irrigation channels. Disease is spread (onchocerciasis) I through fly bites. Flight range is more than 160 kilometers. Source: Authors' data. Bright light, dark clothing, carbon dioxide (from breath), warmth, and moisture attract mosqui- toes. They bite most frequently at dusk, although precise habits depend on the species. Spraying is effective in reducing exposure, but long-term effectiveness requires repeated (e.g., every four months) and comprehensive efforts (see "Vector Control" and "DDT" below). In most species, the female sucks the blood to produce eggs and lives, on average, about one month. Mosquito breeding takes from three to seven days from hatching to adulthood, shorter at high temperatures (e.g., 30°C) and longer at lower temperatures (e.g., 1 6°C). Current research shows change in some breeding, feeding, and biting habits, as predominantly rural diseases appear in urban areas. It is not yet clear whether these changes are due to urbaniza- tion (e.g., creating year-round habitats independent of seasonal change), global warming (e.g., geographic extension of habitat), pesticide application (e.g., genetic changes), or spreading the human host pool through population movement. Evidence shows that anopheline mosquitoes are adapting to urban conditions. Aedes mosquitoes, likewise, appear to be spreading to urban areas, but, because this species breeds in water storage containers found in both areas, it is less clear why. Its spread to urban areas might account for the increase of dengue fever in Central and Latin America, already considered a regional epidemic by some, and in some Asian cities. Dengue fe- ver exists in Africa, but is not as important as the other diseases listed above. Its relative impor- tance could increase, nonetheless, based on its spread to urban areas, but it is difficult to assess because WHO does not systematically track dengue as part of the "Tropical Cluster." 114 Vector Control Vector control is a complicated matter and not always suitable as a typical Bank project compo- nent, because curative and preventive measures will probably require years beyond the project cycle and miles outside the project zone. Neglect, however, can lead to devastating consequences; nonetheless, numerous short-term measures can be incorporated into projects by (a) providing technical assistance for designing an appropriate response outside the project, (b) adapting some of those measures as appropriate into the project zone, and (c) engineering designs to reduce breeding habitats. Because irrigation, solid waste, and drainage components can be designed to reduce or eliminate vector breeding habitat, they should always consider vector control in endemic areas. In periurban and rural areas, irrigation has permitted a sequence of multiple crops that no longer allows for a natural interruption of breeding sites in the dry season. Breaking the cycle of transmission entails (a) interrupting breeding patterns through infrastructure interventions and killing the vector and larvae, proceeding with extreme caution in applying pesticides and (b) interrupting human expo- sure, inducing behavioral change, and providing medication. Considerable information on pesticide use is available on the agricultural dimensions of inte- grated pest management, which combines natural resistance and biological control (e.g., natural predators, cultural practices, and pesticides), when nonchemical methods fail to keep pests below economically damaging levels.""1 (See also OP 4.09 "Pest Management" and GP 4.03 "Issues in Pesticide Use," the latter of which deals with general pesticide hazards and some health hazards. See also "Key Cross-Cutting Issues" below, which provides significant detail on the impacts of pesticide use.) If vector-related diseases are a local problem or local populations consider mosquitoes a nuisance, the team manager should consult with the ministry of health on what programs exist or could be extended to the project area. NGO interventions or a community participation component could promote self-help preventive measures and include studies to establish basic ecological and epi- demiological background information (e.g., identification of species, their habitats and feeding and breeding habits, socioeconomic description of the local population, designation of the popu- lation at risk, and so on) and the type of follow-up needed by the ministry of health and commu- nity. Recommendations are, in general, best executed outside the project, but a component could support a pilot project or work within the project zone. Ongoing monitoring by a project would, however, be appropriate. Table 7-7 above shows the linkages with diseases for which water and excreta disposal play an important role in vector transmission. Integrated vector control. Integrated vector control, an extension of integrated pest management, adapts to the needs of disease vectors, particularly mosquitoes, snails, and flies. It is based on the Bank's OP 4.09, which promotes strategies using biological or environmental control and reduces reliance on synthetic chemical pesticides. A Zambian tsetse fly control component, for example, reduced total pesticide application by applying less than 100 liters of endosulfan to traps instead of spraying 600 liters of deltamethrin. DDT. DDT use for widespread pest control has been banned in many countries (see table 7-8), but WHO still approves of DDT for limited public health uses, such as malaria control (mosquito spraying) in and around houses. Increasing evidence, still under study, however, postulates that DDT is carcinogenic in humans; hence, this approval may change (see "DDT" below). Research on alternate strategies, such as using several other pesticides in combination or sequence, is being pursued, mostly in Asia, not SSA. It is not yet clear what problems transport, storage, and dis- posal of new pesticides and disposal of obsolete stocks might pose. Because of the seriousness of malaria in SSA and the large volumes of pesticides used, box 7-1 summarizes some of the risks drawn from actual projects. 115 Table 7-8: Summary of Persistent Organic Pollutants (POP) Use and Restrictions by Country World Wildlife Fund List of Countries Where Permitted (SSA in bold) POP Countries Where Banned or Restricted in Italics (SSA in bold italics) DDT * Permitted for import to Bhutan, Bolivia, Ethiopia, Guinea, India, Kenya, Malaysia, Mauritania, Mexico, Nepal, Philippines, Sri Lanka, Sudan, Switzerland, Tanzania, Thailand, Republica Boli- variana de Venezuela, and Vietnam * Banned in Argentina, Australia, Austria, Bulgaria, Burkina Faso, Colombia, Costa Rica, Cote d'lvoire, Cuba, Cyprus, Denmark, Dominican Republic, Egypt, El Salvador, Ethiopia, Finland, Fii, Hong Kong (China), Indonesia, Japan, Republic of Korea, Lebanon, Liechtenstein, Mozambique, New Zealand, Nicaragua, Paraguay, Poland, Santa Lucia, Singapore, Switzerland, the United States, Yemen, and Zimbabwe Note: Some analysts estimate global curnulative production of DDT at 1.36 million tons. Aldrin * Permitted in Canada for below-ground termite control * Permitted for import to Republic of Congo, Ethiopia, Malaysia, Nepal, Sri Lanka, Sudan, Tanza- nia, Thailand, Trinidad and Tobago, and Repitblica Bolivariana de Venezuela * Used in Kenya for tsetse fly control and the United States for dipping nonfood roots or tops and moth proofing during manufacturing processes in closed systems * Banned in Russia and the United States Dieldrin * Permitted for import to Republic of Congo, Ethiopia, Malaysia, Nepal, Sri Lanka, Sudan, Tanza- nia, Trinidad and Tobago, Uganda, and Repablica Bolivariana de Venezuela * Used in Kenya for banding coffee trees and in the United States for dipping nonfood roots or tops and moth proofing during manufacturing processes in closed systems Endrin * Used in the Dominican Republic * Manufactured or imported in the United States, Philippines, and Japan Chlordane * Used in Mexico, Canada, China, United Kingdom, Belgium, Belize, and Cyprus * Permitted for imnport to Australia, Cuba, Ethiopia, Malaysia, Mexico, Oman, Philippines, Sri Lanka, Sudan, Tanzania, Thailand, and Trinidad and Tobago * Banned in Austria, Belgium, Bolivia, Brazil, Chile, Colombia, Costa Rica, Denmark, Dominican Republic, European Union (EU), Ecuador, El Salvador, Fiji, Germany, Guatemala, Hong Kong (China), Ireland, Italy, Kenya, Republic of Korea, Lebanon, Liechtenstein, Mozambique, Nether- lands, Norway, Panama, Paraguay, Philippines, Poland, Portugal, Santa Lucia, Singapore, Spain, Sweden, Switzerland, Tonga, Turkey, the United Kingdom, Yemen, and Yugoslavia Heptachlor * Permitted for import to Burkina Faso, Costa Rica, Ethiopia, Pakistan, Sudan, Tanzania, Thailand, Togo, and Trinidad and Tobago _ Used in Mexico, Bulgaria, and the United States for limited agriculture purposes Hexachlor- * Exported by both Organisation for Economic Co-operation and Development (OECD) and non- obenzene OECD countries * Banned in Austria, Belgium, Czech Republic, Denmark EU (as a pesticide), Germany, Hungary, Liechtenstein, Netherlands (as a pesticide), Panama, Russia (as a pesticide), Slovak Republic, Swit- zerland, Turkey, the United Kingdom (as a pesticide), and Yugoslavia Mirex Currently no known manufacturers and no production data available Toxaphene * Manufactured in China, Pakistan, and Nicaragua * Banned in Austria, Belgium, Belize, Bolivia, Brazil, Bulgaria, Burkina Faso, Costa Rica, Cuba, Denmark Dominican Republic, Ecuador, Egypt, El Salvador, EU, Germany, Guatemala, India, Ireland, Kenya, Republic of Korea, Liechtenstein, Mexico, Mozambique, Panama, Paraguay, Peru, Philippines, Portugal, Santa Lucia, Singapore, Switzerland, Thailand, Tonga, and the United King- dom PCBs * Use has been restricted to closed electrical systems, for which they remain in use throughout most of the world * Banned in Austria, Czech Republic,Finland, Germany, Liechtenstein, Netherlands, Norway, Slovak Republic, Switzerland, and the United States Note: Some analysts estimate global cunulative production of PCBs at 1.17 million tons. Dioxins and Not applicable. furans Note: Although numerous industry and government programs are investigating sources of dioxins and furans and developing control technologies, no known uses or emission data specific to dioxins and furans are available at this time. Source: World Wildlife Fund web site, (accessed September 2000). Information extracted from web page, "Assessment Report," on the twelve prioritized POPs, distrib- tied by the Intemational Programme on Chemical Safety (IPCS), beginning in 1995. The discrepancy regarding some POPs that are banned, yet permitted for restricted use, is due to compilation of data from different sources. 116 Box 7-1: Potential Risks Associated with Pesticide Use in Malaria Control in SSA Transport. Some projects involve large volumes of pesticides, for example, a project in Madagas- car provided about 1,000 tons of DDT or about fifty shipping containers or truckloads. Interna- tional transport of pesticides is governed by regulations based on U.N. norms for dangerous goods, for example, the International Maritime Dangerous Goods Code. National legislation, however, often does not regulate transport within SSA. Bad roads and old vehicles, often passing through densely populated areas, contribute to the risks. Storage. Pesticide stores in SSA do not meet basic safety standards. In Zanzibar, DDT and malathion were stored inside a wooden shed on school grounds. In another case, they were stored inside corroded shipping containers within the compound of the Ministry of Health, located next to another school, which regularly complained about strong pesticide vapors in the classrooms. Diversionfor other uses. Public health pesticides get diverted to agricultural purposes and cause significant residue problems and subsequent risk to consumers. DDT is occasionally reported in food residues and blood samples. Environmental impact. DDT and its metabolites remain biologically active a long time. In the long term, a significant proportion of 1,000 tons of DDT applied inside houses is likely to end up out- side. Occupational risks. Respiratory protection masks (or cartridges for them) need to be changed regularly but are not always available in sufficient quantities or affordable to many workers. Obsolete stock. Tanzania, for instance, has a serious contamination problem due to about 300 tons of obsolete DDT. Such stockpiles pose a hazardous waste problem in Tanzania and Malawi, but have been removed at high cost (US$ 4,000 per ton) from Zanzibar and Zambia. South Africa also had large stocks but these may have been removed by now. The total of obsolete pesticide stock- piles in Africa is estimated at 20,000-30,000 metric tons. Re-use of containers. Empty containers, widespread in SSA, have economic value and are typically used for storage or as building materials. For many pesticides, containers cannot be cleaned to hold water or food, although they are still used in this way. Most countries also do not have safe disposal facilities for contaminated packaging, which is also hazardous. A thousand tons of pesticides in 200 liter drums will result in 5,000 contaminated drums, whereas 1,000 tons in 25 kilogram bags result in 40,000 contaminated bags. Source: Memorandum, Harry van der Wulp, Pesticide Specialist, World Bank (November 11, 1999). The Bank's Operational Policy 4.091O2 stipulates that Bank projects addressing pest management or vector control should promote strategies using biological or environmental control and reduce reliance on synthetic chemical pesticides. If nonchemical methods alone are insufficient, the Bank may finance the purchase of pesticides. These should have negligible adverse human health ef- fects and minimal effects on the natural environment. In view of OP 4.09 and the trend in POP negotiations, malaria projects requiring chemical control should not automatically fall back on DDT, but explore less persistent alternatives in which Bank client countries have expenence. Pesticide storage. Improper pesticide storage can generate substantial local pollution with wide- ranging effects, if pesticides seep into ground and surface waters. Improper storage results from The Bank has been working closely with countries that still employ DDT for malaria control to reassess their reliance on spraying as a control method and to develop strategies for reducing their use of DDT. As the alternatives are viewed as more expensive (because they are employed differently and have different levels of effectiveness), costs are implied in making the transition (training, new procurement, safeguards, and equipment). The Bank has stated its willingness to consider requests from clients seeking financial assistance in making the transition. India, Madagascar, and Eritrea are good examples of where this is currently happening. 117 (a) purchase of more than what can be used before the expiration date, (b) unprotected storage areas promoting deterioration of pesticide containers, often nothing more than paper or cloth sacks, and (c) improper labeling. Human health risks associated with acute and chronic exposure depend on location and use, the size of the company or farm, and the degree to which the facili- ties involved are set up to handle dangerous or hazardous materials. Locations include: * Ports and harbors, where risks extend to workers as well port users * Transportfacilities, including temporary truck stops * Formulation centers, where standards can be relaxed because individual components mixed into pesticides are not harmful * Wholesalers, who may repackage pesticides into containers marked as hazardous * Retailers, who repackage pesticides, are exposed to spills and leakages and rarely have the necessary equipment and gear to handle and clean up products safely * Households, where the risk of poisoning is high. Control of migratory pests pose a special hazard due to the lack of proper temporary facilities for large quantities. Pesticide overuse or misuse. A wide range of factors lead to the overuse and misuse of pesticides: (a) repackaging of bulk quantities, often in unmarked packages, for possibly illiterate users, (b) using the wrong concentrations, for example, of persistent pesticides on vegetables, (c) using equipment without protective gear, (d) cleaning clogged equipment, (e.g., sprayers) without proper tools, (e) applying higher doses when pesticides do not appear to work immediately, (9 "using up" excess old stock, and (g) using restricted pesticides such as DDT for other uses than allowed. Overapplication can build up resistance, rather than killing more pests. Pesticides are used in food for human consumption and poured into rivers and ponds to kill fish, rodenticides are used to kill wild game, and fungicides and other pesticides are used as food preservatives. In addition, birds, locusts, and grasshoppers killed in emergency pest control campaigns are sold in markets. Expired or obsolete pesticides. Expired or obsolete pesticides, even though no longer considered appropriate for effective application, and their empty containers remain hazardous materials, re- quiring precautions often not available in rural areas. As a result, stocks deteriorate and contami- nate the local environment and water table. Companies from industrialized countries often donate pesticides that are nearly expired or already obsolete to developing countries for tax benefits in their home country. In SSA, donations for emergency locust control have resulted in excess ex- pired stocks. Transport ofpesticides. Often neglected, this aspect raises health concerns from the port of entry to transport of containers to a disposal site; the transport system may not be equipped to reduce human exposure at all levels in the following ways: * Ports and harbors: (a) handling and locking up hazardous materials, (b) protecting bulk supplies, often in paper or cloth sacks, from wind, rain, and sun, (c) distinguishing haz- ardous from nonhazardous materials intended for reformulation into pesticides in order to take appropriate precautions, (d) protecting the general public and port employees from exposure when reloading material for intra- and inter-city transport * Intra- and inter-city transport system: (a) segregation of pesticides from other cargo, (b) proper loading and unloading at different stages, that is, from intermediate dollies and from carts to trucks, (c) safely repackaging containers damaged in storage or loading, (d) protecting cargo at truck stops, especially in the rainy season when roads may be blocked for several days, (e) cleaning and monitoring trucks for carrying pesticides after having carried food. * Disposal: (a) proper temporary storage of discarded chemicals and their empty contain- ers, (b) safe loading of stored material to collection vehicles for transfer or final disposal, 118 (c) safe consolidation and transfer to final disposal site by truck, boat, or train, and (d) proper disposal at the final destination, and (e) protecting material at the disposal site from scavenging or improper recycling. Injuries and Accidents "Unintentional injuries" include a broad range of accidents, primarily, in terms of mortality, traf- fic, falls, drowning, bums, poisoning, and occupational injuries. Falls account for nearly half the years lived with disability in the world and less for traffic, because of high mortality in this cate- gory. The transport sector has for years integrated the most easily addressed causal factors, that is, road safety. Many other injuries are work related and easily prevented using existing best prac- tices. In most developing countries, however, no safety net exists for people suffering occupa- tional injuries. Structural designs in the neighborhood or the house can often address drowning, household falls, and bums. Agriculture. Around the world, farming is one of the highest-risk occupations, partly due to inac- cessibility of health care after accidents. In developing countries, the situation is aggravated by illiteracy and poverty, which often means faulty, poorly maintained, or inadequate equipment and no protective clothing or gear. Few data are available, unfortunately, concerning farming acci- dents and injuries in SSA. Housing. Not all projects can control construction designs and standards, but, when they do, proj- ects can build in low-cost modifications to stoves and cooking areas, protective barriers or cat- walks in housing projects near or over water, fencing around landfills, and so on. A technical as- sistance component may help identify practical risks and recommend solutions to implement out- side the project. This is especially helpful when behavioral change is needed and an accident pre- vention component is administratively difficult to incorporate directly into a project. Traffic. Apart from fatalities, data on traffic injuries are difficult to obtain, except as broad cate- gories. Injuries are particularly high among teenagers. The transport subsector has already dealt with remedial measures for traffic accidents, but erosion's role in causing pedestrian and vehicu- lar accidents needs strengthening. Erosion can eat away the shoulder of a road, forcing pedestri- ans to walk in traffic. In extreme cases, erosion can eat into the roadway itself, forcing vehicles into another lane. Because the remaining broad categories of injuries and accidents are difficult to define, it is also difficult to design precise project interventions. Remedial measures could include safety measures and education implemented by a local NGO. To preventfalls, task managers can follow best practices that are often standardized safety precautions during project construction. The ministry of health or local health agency or NGO may be able to indicate the seriousness of drownings, bums, and poisonings. It is helpful to: * Determine the extent to which children slip into water bodies next to paths or fall from catwalks or residences in housing built over water * Determine the degree to which burns are caused by home cooking, lighting, and heating fires * Separate out, if possible, cases due to intentional poisoning and suicides, which might ac- count for the majority, and determine the degree to which poisonings are caused by im- proper storage. Subsector sections discuss respective occupational measures. 119 Physical and Mental Stress Poverty creates much stress: women and children routinely spend hours every day finding drink- ing water and household fuel, and poor people live in areas of marginal economic value, exposed to noise, air, and water pollution and uncollected solid waste. Although data on physical and mental stress are difficult to find, especially for SSA, WHO estimates that mental stress will sub- stantially increase worldwide in the next decade and its effects will increase its share of the bur- den of disease. The scientific community is examining another form of stress: violence. Still limited research, however, makes it difficult to demonstrate causality in a manner that Bank-type projects could incorporate. In rural areas, some pesticides have been shown to be neurotoxic, which may lead to violent behavior. Diseases for Special Consideration AIDS, epidemic cholera, and guinea worm infection are special cases of diseases, which demand or have demanded unique approaches. AIDS In SSA, AIDS has become a major problem affecting all facets of society (see box 1-4). Four ac- tivities play an important role in transmitting AIDS-urban and rural transportation (most notably truckers), food markets, construction work crews, and rural-to-urban migration. These all provide opportunities for addressing the problem, because they are frequent components in Bank projects. They also can facilitate access of health personnel to do AIDS prevention or provide the frame- work for interventions outside the health care system. Various project interventions could in- clude: * High-risk groups in infrastructure and energy projects. Compared with other sectors, in- frastructure and energy projects tend to contain large construction components, in which workers often live in temporary camps. Many operations have been or are being privat- ized, but the private sector is not prepared to deal with AIDS prevention (indeed, many firms hire "duplicate" employees, because they expect to lose staff to AIDS). * Urban market associations. Many urban projects contain components improving man- agement of markets (especially waste disposal). These markets often contain strong mer- chant groups. * Urban "addressage" components. Many urban projects contain components for mapping streets and assigning addresses to residences. This provides a good opportunity to do AIDS prevention, as well as provide health ministries with address records. * Municipal management. Although the bulk of AIDS treatment and prevention falls on ministries of health, just as many outcomes fall on the shoulders of municipal govern- ments, for example, coping with a shortage of burial plots or housing and caring for or- phans and "street kids." * Trucker groups. Compared with other Bank Regions, SSA still relies heavily on truck transportation, which is both an asset and a risk. It is a risk because truckers help spread AIDS, especially at regular truck stops (where, in the rainy season, truckers can some- times wait days because roads are blocked). It can be an asset because trucker associa- tions are well organized to send public health messages effectively to peers. * Waste management. With decentralization, many municipalities must cope with disposal of medical waste, but do not have regulatory measures in place. This is an important fac- tor for waste containing blood and syringes (which are recycled in Ghana as hair curl- ers!). 120 Epidemic Cholera Bank projects are, in general, not designed for epidemics or emergency relief measures except on an impromptu basis for technical assistance or rehabilitation and reconstruction. Cholera could be such a case. It is important because it strikes the victim rapidly, spreads throughout a community quickly, and, untreated, can have a high mortality rate. Furthermore, if an epidemic lasts long enough to become endemic, based on history, eradication may take up to 50 years. Cholera epi- demics are increasingly associated with global warming, because one possible impact, increased algal blooms, are known to spread cholera (see chapter 14). Projects, particularly existing water and sanitation projects, coordinating with the water agency and ministry of health, can rapidly implement six interventions for cholera epidemics: * Chlorinating water supply in key areas * Providing water trucks to key areas * Purchasing trucks and chlorination equipment through appropriate budget alterations or schedules or linkages with other projects * Providing transportation and logistical support to health personnel to help administer care and medications, primarily oral rehydration therapy (ORT), to the victims * Promoting public education campaigns through newspapers, television and radio spots, and fliers, focusing on areas not effectively addressed by the above through, for example, NGOs or religious groups * Changing the geographic distribution of project works as appropriate to prevent the spread of future epidemics. Governments are often reluctant, however, to declare a cholera epidemic due to potential negative repercussions to trade and tourism. Guinea Worm Infection Guinea worm disease is nearly eradicated worldwide, thanks to the Global 2000 Program; most remaining cases occur in SSA.* Guinea worm is the only disease spread exclusively through wa- ter. If humans drink water containing the small water flea (cyclops), within two to three months, the flea develops into a 1-meter-long worm, causing pain, fever, and nausea. Long-term effects include recurring infections, arthritis, tetanus, and crippling. The worm typically migrates to the lower extremities, where the female emerges through the skin, causing an open ulcer. Immersion in water triggers the worm to shed eggs when people fetch water or try to cool the itching and burning from the blister with water. Where endemic, this debilitating, mainly rural disease can infect as much as 50 percent and inca- pacitate up to 30 percent of a population for up to three months, devastating agricultural produc- tivity or those who depend on seasonal labor. Consequently, any rural project in an endemic area should examine the feasibility of including a small water supply, filtering, or monitoring compo- nent. Protecting water sources with stepping stones and well caps to prevent immersion of feet and legs in water can controlled the disease. * Guinea worrn exists in Benin, Burkina-Faso, Cameroon, Chad, Cote d'Ivoire, Ethiopia, Ghana, Kenya, Mali, Mauri- tania, Niger, Nigeria, Senegal, Sudan, Togo, and Uganda. 121 Key Cross-Cutting Issues The issues of pesticide use and biodiversity are particularly multisectoral and deserve greater at- tention, because they are typically handled as environmental or agricultural issues, thus, limiting the understanding of their widespread impacts on health. Pesticide Use Chemical and biological contamination of soil, land, and water in rural areas can come from agroindustry, farming, livestock, and aquaculture, as well as domestic and municipal or village waste. The primary chemical contaminants come from application of pesticides and fertilizers, processing wastes, and agricultural runoff. Pesticide contamination of humans occurs by: * Consuming food with pesticide residues not removed from fruit and vegetable skins in food preparation or absorbed by edible roots and foliage * Consuming meat, fish, and dairy products from animals whose tissue and organs have ac- cumulated pesticides * Direct occupational exposure or indirect exposures to fields after spraying. Repeated application of some pesticides to perennial crops can with time increase pesticide con- centrations in crop plants. When consumed by people, some contaminants are "flushed" from the body naturally or through medical treatment, but others, especially fat-soluble pesticides and other pollutants, may accumulate and reach harmful levels in the body. Box 7-2: Key, Confusing, and Misused Terms on Pesticides DDT or dichloro-diphenyl-trichloroethane. One of the best known POPs (see below) and for- merly the most widely used pesticide. It has been banned in many countries, because of its ecological toxicity. "Dirty dozen. " Originally a list of pesticides slated for phase out as part of an international NGO campaign. Now sometimes used synonymously with POPs (see below). Endocrine disrupters, also, endocrine mimickers. Group of pesticides and by-products that, when absorbed by the body, can mimic hormone activity leading to negative impacts in humans and animals, such as birth defects or breast cancer. Organochlorines. Class of chemicals common in pesticides. Important because they can dissolve in body fat and accumulate to harmful levels. Persistent organic pollutants (POPs). Group of chemnicals, including eight pesticides, that are es- pecially hazardous to humans and animals, because they (a) take so long to break down chemically to harmless substances and (b) can be absorbed into body fat and accumulate to harmful levels in the food chain. Sometimes used synonymously with "the dirty dozen" (see above). Pesticides. General term for substances used to kill plant or animal pests. Pesticides include in- secticides (for killing nuisance insects and disease vectors), fungicides (for killing molds), herbicides, "weedicides," nematocides (for killing worms in soil or plants), rodenticides, and growth regulators (for inhibiting growth of pests). Source: Authors' data. Any discussion of the human health effects of pesticides must raise the trade-offs between benefi- cial and harmful uses. Pesticides have certainly contributed to public health by improving crops for food, clothing, and shelter and reducing vector-borne diseases, such as malaria and yellow fever. DDT spraying during World War II decreased hospital admissions for army personnel by more than half. In SSA pesticides helped control black flies, substantially reducing onchocerciasis 122 (river blindness).'03 The problem with pesticides is not so much their toxicity, as how they can be misused, that is, unnecessary and excessive application, choosing highly toxic pesticides over less toxic alternatives, which are affordable, readily available, and convenient to use even with pro- tective gear. This section mainly examines the potential negative effects of pesticides, so devel- opment projects can avoid them. Pesticides have received inadequate attention as a cross-sectoral issue, which primarily means as an occupational hazard to farmers and their families and a threat to rural populations from expo- sure to residues after application. Nonetheless, pesticides directly affect urban populations through (a) pesticide buildup in the food chain, (b) recurring exposure to residues on fruits and vegetables, (c) improper storage of bulk pesticides at entry points and their later transport and storage in or through cities to points of use, (d) hazards of manufacturing or reformulating pesti- cides in or near urban areas, (e) reuse of containers for water storage or makeshift housing parts in slums and squatter settlements, and 69 exposure from rodent and insect control in small towns as well as apartment buildings. (See "Small Town and Urban Pesticide Usage" below.) Three other aspects relate to rural, as well as urban and periurban populations: (a) depletion of fish and seafood resources, a major source of protein, due to contamination of rivers, lakes, and coastal waters over time, (b) proliferation of new pesticides whose health effects, singly, incre- mentally, or in conjunction with other pollutants, are not known, and (c) seasonal variations in concentrations of pollutants in waters used for drinking, and watering and washing vegetables. "The International Code of Conduct on the Distribution and Use of Pesticides" deals with many of these above issues, and most SSA countries have passed legislation in line with this code. In- stitutional capability for enforcement, however, remains problematic; little intercountry collabo- ration exists to help find solutions to these problems. Integrated pest management. This system controls pests by combining natural predators and bet- ter management of natural resources and local ecosystems. Integrated pest management is in- tended, overall, to reduce and, if possible, eliminate primary reliance on synthetic and chemical pesticides. For details, consult Operations Policy (OP) 4.09, "Pest Management" and its web pagel'4 and Good Practices (GP) 4.03, "Agricultural Pest Management."'05 The policy makes two key provisos concerning health, as shown in box 7-3. Box 7-3: Health Aspects of World Bank Policy on Pest Management (OP 4.09) Pest management in public health: In Bank-financed public health projects, the Bank supports con- trolling pests primarily through environmental methods. Where environmental methods alone are not effective, the Bank may finance the use of pesticides for control of disease vectors. Criteriaforpesticide selection and use: The Bank refers to WHO in applying the following four selection criteria: pesticides have negligible adverse human health effects, are shown to be effective against the target species, and must be demonstrated to be safe for inhabitants and domestic animals in the treated areas, as well as for personnel applying them, when used in public health programs, and use must take into account the need to prevent the development of resistance in pests. Any pesticides the Bank finances should be manufactured, packaged, labeled, handled, stored, dis- posed of, and applied according to standards acceptable to the Bank. The Bank does not finance pesticides in WHO classes IA and IB, or in WHO Class II, if the country lacks restrictions on their distribution and use or they are likely to be used by or be accessible to lay personnel, farmers, or others without adequate training, equipment, and facilities to handle, store, and apply these products properly. Source: World Bank OP 4.09 and Authors' data. 123 Health effects. Negative health effects from pesticides fall roughly into two categories: (a) poi- sonings and intoxications from short-term (acute or single) exposures and (b) cancers, reproduc- tive disorders, and neurological damage from long-term exposures. Both categories are life threatening. * Acute exposures cause (a) rashes and skin disfigurement, (b) headache and giddiness, (c) nausea and vomiting, (d) blurred vision, nervousness, and rapid heart rate, (e) cramps, convulsions, coma, and anxiety, 69 numbness, and (g) death. Underreporting of poison- ings is common, perhaps because farmers find it too expensive or inconvenient to seek medical care or because many take it for granted that they will get sick after applying pesticides. Depending on the pesticide, its toxicity, dosage, and length of exposure, these effects can be immediate or occur up to a few months after exposure; some of the symp- toms persist for years. * Long-term exposures can result in (a) cancers, such as leukemia, breast cancer, and per- haps liver cancer, (b) reproductive disorders, such as birth defects, sterility, and miscar- riages, (c) neurological effects, such as paralysis, impaired mental development, and ag- gressive behavior, and (d) compromised immune systems. Disorders to the reproductive system have recently been linked to chemical pollutants, including pesticides, caused by "endocrine disrupters" (see glossary). These chemicals mimic hormones in the body, which reacts accordingly. (Endocrine glands produce the human sex hormones, estro- gen and androgen.) Environmental estrogens from pesticides such as DDT and heptachlor appear to be among the most serious human health threats, as they come from organochlorines (see box 7-2 above and paragraph below), which are fat soluble in the body, have been shown to cause breast cancer in animals, and are suspected of doing so in humans.106 Three salient points to consider in human health are (a) whether a pesticide can be absorbed by body fat, (b) the duration of its potency after application, and (c) the extent of exposure, espe- cially to children. Pesticides absorbed in body fat pose additional hazards to infants, because pesticides can be passed to infants in mother's milk. Potential damage from pesticides is more significant and pro- nounced in fetuses, infants, and children, whose organs are still developing, than in adults. Re- search has revealed specific "windows" in human development when sensitivity to toxic chemi- cals is greatest, for example, during fetal development or, for the infant, when the mother begins to lactate.107 Nonetheless, broadly speaking, the benefits of breast feeding still appear to outweigh the risks of chemical contamination.108 Potential damage from pesticides is more significant and pronounced in fetuses, infants, and children, whose organs are still developing, than in adults. Classification systems. Pesticide terminology varies among references to agricultural, manufac- turing, health, and environmental repercussions and can be, at best, extremely confusing, because they were designed for specific uses, for example, food or worker protection. Two classification systems pertinent to human health, WHO hazard ratings and chemical types, are described below. WHO hazard ratings use four categories, based on the direct hazard from toxicity, to classify hu- man health effects: * Class I A is "extremely hazardous" and class I B is "highly hazardous" * Class II is "moderately hazardous" * Class III is "slightly hazardous" * Class IV is "unlikely to present an acute hazard in normal use." 124 The chemical type system classifies pesticides into about a dozen types based on their chemical properties and toxic effects. Of these, these guidelines address two types, organochlorines and organophosphates, because they are used so widely and cited so frequently in the literature. Nu- merous other pesticide types, however, could likewise be harmful. * Organochlorines. These can be absorbed in body fat, break down slowly in the environ- ment, and are slowly released to the rest of the body in the long term and may lead to cancers, reproductive disorders, and neurological damage. Examples are DDT, mirex, al- drin, kepone, lindane, heptachlor, and toxaphene. * Organophosphates. Many of these are extremely toxic and can easily penetrate the skin and eyes, for example, during application or afterward as residue in dusts, so that even small amounts can be serious or fatal, making proper handling and labeling essential. They break down relatively quickly into harmless substances, for example, diazon and parathion. (Some organophosphates, such as malathion, are slightly toxic.) Individual classification systems, designed for specific purposes, such as occupational health, food safety, or cancer risk identification, may fail to capture the full range of health repercus- sions, sometimes because of inadvertent professional bias (see chapter 1). Pesticide regulations for commercial vegetable production, for example, focus on occupational and ecological hazards, but not necessarily on exposures of people who grow, sell, or purchase flowers, because flowers are not food. In comparison, dioxin, a by-product of pesticide manufacture, is a known carcino- gen, but its carcinogenic properties break down in soil, making it "less hazardous" in soil relative to other carcinogens. Dioxin, however, is known to cause reproductive and immunological disor- ders, properties that do not break down in soil, and has found its way into the food chain in cow's milk and human breast milk.'09 Citing potential hazards without referring to specific reasons for which the classification system was designed and, thus, its limitations may, therefore, miss many risks. In other cases, classification systems may not account for bioaccumulation of pesticides, which is not harmful to plants, but may be to humans. Copper sulfate, for example, is used extensively in coffee production and builds up after repeated applications, for instance, in each harvest of coffee beans. These potentially overlooked human health hazards are especially pertinent in considering persistent organic pollutants, some of the most potent pollutants. These limitations of classifica- tion systems underscore the need for multidisciplinary teams to make sure that technical informa- tion is not used out of context. Persistent organic pollutants. Because of the importance of POPs to agriculture and industry (eight are used mainly as pesticides), they receive more attention. Intergovernmental agencies and NGOs are striving to ban POPs; many govemments have already done so or otherwise restricted their use (see table 7-9). Nonetheless, many other harmful pesticides with less persistent effects are still used with food and other cash crops. In spite of government limitations on POPs, many other harmful pesticides, whose effects are not so persistent, are still used with food and other cash crops. * Carbamates, chloronitrophelon derivatives, organochlorine compounds, organomercury compounds, organophospho- rous compounds, organotin compounds, pyridyl derivatives, phenoxyacetic acid derivatives, pyrethroids, triazine de- rivatives, and thiocarbamates. 125 Table 7-9: Main Uses of POPs Name Uses and Sources Main Use as Pesticide Aldrin, chlordane, dieldrin, Mainly to protect crops, livestock, and wooden structures (against termites). Also to endrin, toxaphene, and hexa- control rodents, soil insects, and textile pests. chlorobenzene DDT and heptachlor Main use as an insecticide. Both have been used for malaria control, but more often DDT. Pesticide and Other Uses Mirex As an insecticide; otherwise, its main uses are industrial. Other Uses Dioxins, furans, and poly- Mainly used in industry or are generated by-products from production of other chlorinated biphenyls chemicals. Dioxin is released in pesticide production, by incineration of medical, municipal, hazardous wastes, coal, peat, and wood, and from car emissions. Source: Authors' Data. Suicides and poisonings. Developing countries carry the greatest burden in negative health effects from pesticides. In 1985 WHO estimated that industrial countries used about 80 percent of the world's agrochemicals, but probably suffer only 1 percent or less of deaths due to acute poison- ing.110 The dimensions of the problem have not changed markedly since then. Moreover, models have projected increasing numbers of pesticide poisonings throughout the world. In 1972 poi- sonings were estimated at 500,000 cases yearly, increasing to 25,000,000 in 1990. Data on pesti- cide poisoning are regrettably poor; pesticides are frequently used for suicides, and data suitable for use in the model's projections come mainly from Thailand and the United States."' Small town and urban pesticide usage. Pesticide usage in small towns and urban areas includes control of (a) rodents, mainly rats, (b) termites, (c) roaches and other household pests, (d) weeds, insects, and fungi in vegetable and ornamental gardens, (e) insects and mold for food protection, and 6f) fleas, lice, and ticks on pets. The potential hazardous effects of pesticide application in these instances can be more intensive because confined spaces can intensify exposures, and wind, sun, and rain do not dilute, disperse, or degrade the pesticides. In homes sprayed with a legal pes- ticide (chlorpyrifos) to control fleas, for example, absorption by infants was one to five times the "no observable effect level."'112 Biological Diversity and Traditional Medicines Traditional medicines have enormous untapped social and economic value. Many of today's wonder drugs are based on traditional medicines that have been synthetically reproduced."3 Bio- logical diversity (biodiversity) among plant and animal species, which harbor potential medicines and other values to humankind, is jeopardized by, among others, human encroachment, agricul- ture, climate change, stratospheric ozone depletion, chemical pollution, acid rain, introduction of incompatible alien species, overexploitation, and fragmentation, degradation, and reduction of habitat. Although such threats are global, their consequences are far more severe in "megadi- verse"-chiefly developing-countries. Megadiversity refers to richness in biodiversity based on national boundaries, not ecosystems. Seventeen countries contain 60-70 percent of total global terrestrial, freshwater, and marine biodiversity. Three of the seventeen-South Africa, Madagascar, and Democratic Republic of the Congo-occur in SSA.* Three areas of the world-the Amazon Basin, Congo Basin, and New * The seventeen countries are Australia, Brazil, China, Colombia, Democratic Republic Congo, Ecuador, India, Indo- nesia, Madagascar, Malaysia, Mexico, Papua New Guinea, Peru, Philippines, South Africa, United States, and Repuiblica Bolivariana de Venezuela. 126 Guinea/Melanesian Islands-contain major, virtually intact tropical wilderness areas. These "hot- spots," that is, ecosystems with great biodiversity most severely threatened with destruction, contain roughly two-thirds to three-quarters of the most endangered species of plants and animals in the world.' 14 The potential for medicinal and public health uses of threatened species in these hotspots has not been fully evaluated. Until such research is done, the "precautionary principle" argues that the risk to traditional medicines be from the same list of countries. Three examples may help illustrate the potential economic, social and public health value of threatened biological resources. * Plants. The Pacific yew tree was not considered a commercially viable species in the Pa- cific Northwest, especially for logging, and was routinely discarded. Then, "taxol," a substance that can kill cancer cells and found in these trees, turned out to be one of the most promising new medicines for breast and ovarian cancer. * Marine. A compound (peptide) contained in snails inhabiting threatened coral reefs shows promise for blocking pain and keeping nerve cells alive, but does not necessarily cause addiction or drowsiness and may be much stronger than morphine. A new drug de- rived or based on this compound could potentially contribute enormously to heart surgery and treatment of head injuries, strokes, and chronic pain, particularly for AIDS and can- cer patients. * Animals. Some bear species are endangered because of habitat destruction and overhunt- ing for their organs, believed in some cultures to have medicinal value. Bear gallbladders are worth eighteen times their weight in gold! Yet, the ability of bears to hibernate- without eating, drinking, urinating, defecating, or losing bone or body mass for up to 7 months-and then deliver and nurse young is poorly understood by modern medicine. Knowledge of the physiology of hibernation could help prevent osteoporosis, renal fail- ure, and a variety of other health problems."' 127 CHAPTER 8: CROSS-SECTORAL LINKAGES: AGRICULTURE AND RURAL DEVELOPMENT SECTOR This chapter discusses a broader range of environmental health issues than those traditionally as- sociated with agriculture and rural development, that is, food security and ecological damages from pesticide use. The first five sections of the chapter weave together many, seemingly unre- lated topics, with an emphasis on rural infrastructure in food production, for which linkages are strong with health. They are: * Human settlements. What are the risks, especially in farming, of living conditions in vil- lages and small towns? * Land use and natural resource management. What human health risks are associated with farming, forestry, and other activities? * Water and waste management. How is health linked with irrigation and drinking water? What risks link wastes to food and farmers? * Rural transportation. What type of health risks are associated with transporting products from the fields to markets? The sixth section, an environmental checklist, looks at these same issues in terms of Bank lend- ing. Key Environmental Health Issues The most common environmental health linkages in the agriculture and rural development sector involve food production and,other aspects of low-density rural life, such as poor access to water, sanitation, transportation, and electricity. These linkages can set in motion sometimes interlinked health consequences, including malnutrition, spread of infectious diseases, deaths and injuries related to flooding, and so on. (See chapter 14 on how some of these effects are linked to climate change.) The most common linkages include: * Pollution from excessive use of agrochemicals (especially pesticides and nitrates from fertilizers) * Creation of nearly permanent vector breeding areas and other changes through, for exam- ple, year-round cultivation of food staples and impact of forestry projects * Malnutrition from inadequate food supply or contamination of the food chain * Water and soil contamination from inadequate processing of agricultural and animal wastes * Respiratory diseases from use of biomass fuels for cooking, heating, and lighting, as well as injuries from gathering fuels. Table 8-1 summarizes the intersectoral environmental health linkages with the agriculture sector. Table 8-1: Main Intersectoral Environmental Health Linkages with the Agriculture Sector Sector Main Linkages Infrastructure and Water pollution (mostly nitrates), the common practice of periurban agriculture (production of urban development food primarily for urban consumption), land clearing for agriculture or settlement, aquacul- ture, pesticide transport and storage, keeping animals in human settlements, crop losses from air pollution, and so on Energy Polluting biomass fuels for heating, cooking, and lighting; particulate matter causing crop 129 Sector Main Linkages losses; energy deficit compromising provision of health care (e.g., no cold storage of medi- cines or sterilization of syringes); charcoal production and respiratory impacts; and spread of vector-borne disease from hydropower dams and irrigation and resultant standing water in fields Industry Variety of health irnpacts from air, water, and land pollution as well as climate change and global warming Health Contamination of food chain, exposure to pesticides and risk of accidents due to illiteracy of agricultural workforce, stress from rural-urban migration (mental health problers, unem- ployment, and noisy or undesirable living conditions), food security and basic nutrition, population pressures on agricultural productivity, and vector-related diseases (spread by mos- quitoes, snails, and flies) Environment and Deforestation, desertification, and land degradation and their effects on food production, natural resources biodiversity, and traditional medicines and in flooding and so on Source: Authors' Data. The following four sections-human settlements, land use and natural resource management, water and waste management, and rural transportation-describe, in no order of priority, some of the most important environmental health issues relating to the agriculture and rural development sector and its thirteen subsectors (table 8-13 summarizes impacts of each at the end of the chap- ter). Human Settlements This section primarily deals with conventional issues relating to rural human settlements, that is, housing, energy use, and periurban agriculture and livestock, whereas the next section on land use and natural resource management addresses issues more traditionally associated with agriculture. It is important to note first, however, the special, important, and often neglected health concerns presented by rural-to-urban migration and environmental refugees in human settlements, men- tioned here because most migrants-move to periurban areas, which have many rural characteris- tics. Health concerns include: * Physical and mental stress. It is difficult to document stress and, thus, elaborate on pre- cise sources of health risk; however, they broadly include inadequate provision of basic shelter, water, sanitation, waste removal, household energy, medical care, schooling, and control of industrial and traffic noise, among others. * Propensity for accidents. Even though data are scarce, accident levels, especially pedes- trians hit by motor vehicles, are high among recent migrants. This stems partly from the "automobile culture clashing with immigrant culture."I"6 Poor road quality in rural areas, which often restricts vehicle speed, coupled with low pedestrian density makes basic ac- tivities such as fetching water, shopping, or visiting others potentially less hazardous. In- migrants to urban areas, generally pedestrians, are less accustomed to automobile traffic and, thus, more vulnerable to being hit and injured. * Temporary or emergency housing. "Environmental refugees," whether from natural dis- aster or warfare, need temporary shelter that often becomes long term. Although the fac- tors discussed below are pertinent, planning temporary and permanent settlements should generally be approached differently. The choice of site and types of services financed by emergency relief, for example, may not be optimal or cost-effective as long-term solu- tions. 130 Box 8-1: Key, Confusing, and Misused Terms on Human Settlements Rural-periurban. Strictly speaking, the terms "rural" and "urban" reflect administrative designa- tions of governments or types of economic activity and are not necessarily based on population size. "Periurban" refers to areas surrounding cities retaining rural characteristics of low density and sub- stantial agricultural activity. From an environmental health point of view, periurban agriculture can (a) facilitate breeding of mosquitoes that spread malaria (which tends to be a rural disease) and (b) pollute water with agricultural and animal waste. Kitchen or cooking area. Areas used for food preparation. Defined by culture, cooking areas range from a one-room hut with no windows, a separate room with or without ventilation, or an outside area. Health consequences include exposure to smoke from cooking fires and oils and the risk of bums, especially for children, from exposure to cooking fires or the contents of pots. Source: Authors' Data. Housing Health linkages often focus on the structure of housing, but health repercussions also derive from poor indoor air quality and accidents, among others. The main aspects of housing quality that im- pinge on human health are housing quality and proper ventilation, especially of cooking fumes. Choice of fuel for cooking, lighting, and heating can also lead to several negative health repercus- sions (see "Energy Use" below.) Structure. Basic housing is essential to protect people from extremes of heat and cold and inclem- ent weather, all significant determinants of disease in malnourished populations. Dampness con- tributes to respiratory disease; recent research specifically highlights molds as a factor."17 Shoddy structures can harbor disease-spreading insects, such as the "cone nose" bug, which lives in cracks and crevices of walls and can cause Chagas' disease (common in Latin America). Location. Housing for the poor is often erected in economically marginal areas prone to flooding (from occasional storms or flooded water bodies), landslides, and so on. Other hazards include accidents and, in houses erected over or near water, drowning. Dirtfloors. Dirt floors present significant health hazards through long-term, recurrent exposure to dust and exposure to intestinal worns that penetrate the feet, particularly in areas with poor sani- tation. Intestinal worms are common throughout developing countries and responsible for sub- stantial disability, although mortality rates from worms are low. Ventilation. Ventilation may be the single most important factor in housing that impacts health, because of the direct links to indoor air pollution, particularly from cooking, heating, and lighting fumes. Proper ventilation can help reduce respiratory infections, which derive from close personal contact, as well as reduce the irritation of smoke, which worsens or predisposes people to respi- ratory illnesses. At the same time, in areas with endemic mosquito-borne diseases, indoor smoke has the "beneficial" effect of keeping mosquitoes away. Cooking area. Exposure to cooking fumes (from cooking fires or the food itself) and accidents, primarily bums, are the main risks. High levels of exposure occur even in outside cooking areas, because of the long periods spent close to the source of fumes. Indoor exposure is compounded by cigarette smoking. Numerous, often energy-based programs have increased stove efficiency, benefiting human health. 131 Energy Use and Generaton The broad range of energy-health linkages goes well beyond air pollution, often focusing on in- dustrial and vehicular sources. Access to electricity in rural and urban areas is crucial to improv- ing the quality of life. It permits the "cold chain" sequence of refrigeration that ensures a reliable supply of medications in pharmacies and health care facilities. Access to modem fuels also re- duces some of the risks of indoor air pollution from burning cheaper, but more polluting tradi- tional fuels. The various factors influencing health are covered in the following sections. Box 8-2: Key, Confusing, and Misused Terms about Rural Energy Biomass fuels (wood, twigs, leaves, grasses, crop wastes, other vegetation, and dung). Renewable energy in the form of plant and animal matter that can be used as fuel. As a group, do not bum as cleanly as fossil fuels (see definition below), which include a range of clean and "dirty" fuels. Tend, therefore, to be more harmful to health, as incomplete combustion greatly contributes to indoor air pollution. Poor households, however, tend to rely more on the cheaper biomass fuels. Dust. Suspended particulate matter. Receives less attention than chemical pollutants, but virtually ubiquitous in rural areas. An important respiratory irritant contributing to high rates of respiratory disease, one of the most important burdens of disease in developing countries. Range from large particles, which adhere to the surface of nose, mouth, and throat, to those small enough to penetrate deeply into the lungs. Chemical substances may adhere to or be incorporated into these particles. Fossilfuels (coal, oil, kerosene, natural gas, and liquefied petroleum gas [LPG]). Nonrenewable en- ergy sources, basically fossilized remains of plants and animals with a high carbon and hydrogen content and varying levels of sulfur contamination. Sulfur reacts with air and other compounds to form air pollutants, for example, sulfuric acid and other acid aerosols, which have varying impacts on agriculture, such as, damage to the foliage of food crops, and the human lungs. Vehicular and industrial sources generate the main ambient air pollutants from fossil fuels. Coal, kerosene, and oil are generally more hazardous to human health than natural gas and LPG. (See biomass fuels above.) Greenhouse gases Mainly carbon dioxide (CO2), methane (CH4), ozone (03), and chlorofluorocar- bons (CFCs). Direct effects as irritants, causing respiratory disease, the most important direct health consequence. Indirect effects can be considerable and wide ranging, such as vector-borne diseases (malaria and schistosorniasis), which could spread as global warming extends vector breeding habitats. Vector-borne, vector-related diseases. Diseases transmitted by an intermediate animal host. Broadly include pathogens transferred mechanically by flies or rats. Specifically involve development of a parasite within the intermediate host, such as mosquitoes or snails, which eventually infects hu- mans. Source: Authors' Data. Traditional Fuels Reliance on traditional fuels presents a series of household occupational and health hazards re- sulting mainly in respiratory, skin, eye, and, in some cases, heart diseases. In addition, such reli- ance can lead to accidents while gathering biomass fuels and, in extreme cases, when fuel collec- tion causes erosion, accidents and drowning from flooding in the rainy season. (See "Respiratory Diseases, Tuberculosis, and Diseases Related to Air Pollution" in chapter 7). Charcoal. A major source of fuel in rural areas, charcoal presents both household and occupa- tional hazards. Entire families may be exposed to high levels of charcoal smoke from household cooking and, less so, heating. Occupational exposures range from the carbonization process (i.e., burning wood slowly to create coals) to bagging charcoal for wholesale and retail sales. Rebag- ging for sale and household use of charcoal entail high exposure to charcoal dust. Women should 132 be considered a high-risk group, because they are often vendors and the most common household user. Wood fuels. Hazards incluide exposure to fumes from burning and physical strain, accidents, in- jury, and, in severe cases, miscarriages from collecting wood fuels. In periurban areas or small towns, gathering fuel wood may also increase exposure to disease vectors with habitats within a few kilometers of residences. Stoves. Stoves present hazards from pollution, accidents, and burns. The type of stove determines fuel efficiency and the pollution generated. Of particular concern is the low conversion efficiency of biomass stoves; traditional stoves convert energy at about a 12-18 percent efficiency rate, pro- ducing high levels of pollution."8 Indoor pollution from biomass combustion in eight countries studied ranged from four to ninety times the WHO standard for peak pollution." 9 In addition, stoves can cause household fires, accidents, and burns, especially to children. Areas with poor quality and flammable housing risk neighborhood fires, more a problem in periurban than rural areas in SSA. Community use. Many villages use traditional fuels for curing meat and fish, often for prolonged periods, mainly by smoking. Such exposures can cause a range of diseases related to air pollution. Modern Fuels Household and community use. The health risks from modern fossil fuels depend on the degree to which pollution is (a) produced during indoor burning, (b) vented outdoors, and (c) dispersed in the community. Fossil fuels range from dirty to clean, roughly as follows: coal, kerosene, oil, natural gas, and LPG. Distribution, storage, and use. The risks attached to distributing modern fuels depends on the fuel. These risks also vary among periurban areas, small towns, and rural areas. All trucks trans- porting bulk fuel risk accidents, but tankers carrying kerosene and LPG also risk explosion. At the wholesale level, dust from coal storage can pollute the local environment. Oil and kerosene drums can pollute groundwater. Stoves. Coal and kerosene stoves present a high risk of indoor air pollution. In China, where coal is a common household fuel, women have the highest rates of lung cancer in the world for those who do not smoke tobacco.120 Stoves also present the risk of fires and accidents, especially for children. Coal stoves are often designed to keep the elements out and not for efficient ventilation. Some are even designed to keep smoke within homes to drive out insects; in areas with endemic mosquito-borne illnesses, those implementing stove programs to reduce air pollution shouid con- sider alternative means of mosquito repellants. Power Generation Fuelproduction. In general, large-scale power generation should benefit health overall by reduc- ing dirty fuel use in households. Its main health risks stem from industrial accidents and from oc- cupational and local exposures from contamination around power plants. The risks to local and regional populations from air pollution vary depending on the production process, that is, coal- fired or hydro. (Because the Bank does not lend for nuclear power, these guidelines do not con- sider its risks.) Spread of vector-borne diseases. The spread of vector-related diseases in power generation is of- ten overlooked. Hydropower dams and irrigation canals and resulting standing water in fields, for example, may spread schistosomiasis and malaria by expanding habitat for snails and mosquitoes. 133 Solar and wind (also known as eolic or eolian) energy. As a clean technology, the benefits of so- lar and wind energies far outweigh their risks. Limitations in storage and transmission capabilities restrict them, regrettably, to local uses. Health risks include those presented by battery disposal, which can pollute groundwater. Periurban Agriculture and Livestock Periurban agriculture and livestock activities affect periurban settlements because of the higher density of population than in rural areas. Such activities range in scope from households to agri- businesses. Although accurate data are scarce, those available suggest substantial periurban agri- culture exists. In Lusaka, for example, 37 percent of urban households surveyed (1991) produced food, and 29 percent raised livestock. In Jakarta, a poultry plant employs 800 people,2' and, in Khartoum, 27 percent of all solid waste was eaten by cattle.'22 Market gardening andfood crops. Small-scale cultivation of food, flowers, and ornamental plants for resale, primarily a periurban phenomenon, has been increasing. Much food is also grown for household consumption. The main risks are: * Provision of year-round habitat for disease vectors, mainly mosquitoes * Contamination of the local water table and surface water sources with pesticide and fer- tilizer runoff * Exposure to pesticide residues on crops for household consumption or sale * Where sewerage treatment facilities exist, improper use of sewage effluent, which can also contaminate the water table and local surface waters, spreading diarrheal diseases and diseases related to pesticide and fertilizer exposure. Livestock. It is common for people in periurban and low density areas to keep animals. The main health risks arise from: * Contamination of the water table and surface water sources with nitrate runoff * Contamination of water table and surface waters by slaughtering facilities, which can lead to a range of diseases, exacerbated by the rainy season * To a lesser extent, traffic injuries caused by animals. Land Use and Natural Resource Management This section covers environmental health risks presented by food production, processing, storage, and transport as well as in land use and forestry. Food Production, Processing, Storage, and Transport Food security and malnutrition, followed by pesticides and malaria, tend to dominate discussions of the health dimensions of agriculture and rural development and are discussed below. Other environmental health linkages, however, also exist, for example, with livestock and animal hus- bandry, fisheries and aquaculture, and food processing, storage, and transport. Crops, Food Security, and Nutrition Land degradation. Pressures to increase food production and find household fuel can lead to overfarming, overgrazing, and stripping land of its vegetation. Energy policies or local market forces that result in overpricing of fodder and fuel wood can aggravate such pressures. All these factors can cause erosion, a decrease in arable land, loss of soil fertility and nutrient productivity, and eventually malnutrition. During the rainy season, particularly in China and India, land degra- 134 dation can also lead to injuries and deaths from flooding. In severe cases, land degradation may result in drought, famine, and mass movements of populations, frequent events in SSA (see box 8-3). Land degradation can increase water pollution by reducing the absorptive capacity of the soil. This increases runoff of agricultural chemicals into surface waters, which, in turn, increases turbidity, interfering with chlorination and decreasing biological and chemical water quality. Droughts and desertqication. The health repercussions of droughts consist of malnutrition and infectious diseases due to poor personal hygiene because of inadequate water and waste disposal, which worsen when victims are dislocated. Adequate services such as these are crucial in most of SSA, where rainfall is the main environmental determinant affecting human activity (see box 8- 3).123 Box 8-3: Drought in Sub-Saharan Africa The Sahel region has been hit hardest by drought, adversely affecting about 750.000 people in 1973-74 and in northeast Africa. 4.3 million people in early 1991. In 1985. 70 percent of Ethio- pian children in refugee camps for drought victims were malnourished.'24 Between 1990 and 2000, the number of people affected by droughts increased dramatically from hundred of thou- sands to several millions. (It is not clear, however, whether the increases between 1990-2000 ARE due to worsening conditions or better data gathering.) No estimates exist of the collective toll of desertification. Table 8-2: Health Consequences of Drought, Selected Examples 1970-2000 Year Place Consequence Number of Persons 1973 Sahel Famine-related deaths 100,000 1974 Niger Dependence on food aid 200,000 1974 Mali Food refugees 200,000 1974 Mauritania Destitution 250,000 1990 Niger Food shortage 1,630,000 1991 Sudan Drought 8,600,000 1993 Ethiopia Food shortage 6,700,000 2000 Ethiopia Drought 10,000,000 2000 Kenya Drought 2,700,000 2000 Sudan Drought 2,500,000 Source. Alexander (1993), cited in McMichael and others (1996), p.133, and Centre for Research on Disas- ters (n.d.). Locust control. Locusts and locust control present a number of health problems, particularly the impacts of malnutrition from crop losses and improper pesticide use. Aerial pesticide spraying, in addition to occupational hazards, can contaminate village residents and their exposed food and water supply. Wide areas must be covered rapidly, leading to problems of scale, for example, (a) decentralized stocks become obsolete and rural farmers are ill equipped to dispose of them prop- erly, (b) application by untrained farmers leads to high incidences of intoxication, and (c) the pesticides, often distributed free, are used for other, possibly unsuitable purposes. 135 Cash crops. By and large, cash crops improve health because of added income in the local econ- omy. Cash crops, however, can lead to several unintended negative effects on health, depending on the scale of operations: Neglect of nutritious food crops can cause malnutrition in local popu- lations. Improper use of pesticides and fertilizers can lead to contamination of the local and re- gional food chain. Although, the economic and sometimes environmental costs of pesticides and fertiiizers required for different crops tends to be calculated, the sometimes considerable human health effects tend to be neglected (see "Use of Pesticides and Fertilizers" below). Slash-and-burn agriculture. Difficult to measure but often significant, exposures to fumes from slash and burn tend to be neglected. Slash and burn (see box 8-4) can lead to disease from local and regional exposure. First, seasonal burning of old crops creates high occupational risks through intense, recurrent exposure to smoke and dust. Second, burning to clear land for other purposes, depending on the scale, may also pose regional health hazards. Uncontrolled fires in drought conditions can exacerbate the situation. This occurred in Asia in 1997, exposing an esti- mated 20 million Indonesians to dangerously high levels of air pollution'25; in Malaysia, air pol- lution indices recorded values four times as high as unhealthy values.' Box 84: Key, Confusing, and Misused Terms on Agriculture Slash and burn, swidden agriculture, or shifting cultivation. Traditional agriculture, primarily by seminomadic peoples, that bums forest or fields for temporary cultivation (e.g., 1-5 years), after which the cultivated areas are abandoned. Source: Authors' Data. Slash and burn does have a health benefit by returning nutrients to the soil, improving soil pro- ductivity and indirectly improving nutrition. This benefit, however, needs to be weighed against the long-term cost of soil depletion and erosion and their negative effects on nutrition. Animal waste fertilizer. Subsistence agriculture uses animal waste as a fertilizer, which, with time, can lead to nitrate and fecal contamination of drinking water. Nitrate contamination presents a high risk to infants with blue baby syndrome (methemoglobinemia) and for gastric, bladder, and esophageal cancers, for which nitrates have been implicated. Use of Pesticides and Fertilizers Pesticide application. Three levels of health exposures occur: * Occupational, mainly for farmers, but also those involved in transport, storage, and re- packaging * Family members, for example, washing clothes or storing equipment * Community, for example, access to sprayed areas or animals too soon after application of pesticides and contamination of water sources from washing equipment, containers, and clothing after application. Reasons for high exposure include: * Unnecessary and excessive use, often due to promotion by agrochemical companies * Inadequate packaging, for example, lack of labels, instructions, or their translation, or re- use of empty containers, especially beverage bottles * Fang and others (1999). "[An] air pollution index as high as 839 has been reported in Malaysia. API is calculated based on the five pollutants: N02, S02, 03, CO, and respirable suspended particulates (PMI 0). It ranges in value from 0 to 500. An index above 101 is considered to be unhealthy, and a value over 201 is very unhealthy." 136 * Inadequate application equipment, for example, sprinkling pesticides with brooms be- cause appropriate equipment is not available or too expensive * Inadequate protective gear, because, for example, appropriate gear is not available for sale, too expensive, or too hot to wear * Training, for example, poor commonsense precautions because of inadequate labeling or instruction (e.g., blowing through sprayers to unclog them) * Farmer ignorance, for example, illiteracy or lack of understanding of the proper dosage or hazards (some farmers expect to get sick after pesticide use) * Inadequate parts or service, for example, spare parts and maintenance services are un- available or unaffordable. A study of 161 women sprayers in Indonesia showed that they mixed pesticides with their bare hands, filled backpack sprayers with ordinary buckets, and had clothing soaked with pesticide touching their skin. Almost none had gloves, and about 20 percent cleaned blocked nozzles with their mouths.i26 Excessive use can stem from even well-intentioned promotional activities by agrochemical com- panies facilitated by (a) subsidized or free pesticides, (b) marketing concentration on chemical approaches, as opposed to integrated pesticide-vector management, and (c) sales commissions. Several factors can increase human health risks. In SSA, most pesticides and application equip- ment are imported or donated, creating problems for supply and standardization of spare parts. In addition, small-scale farmers share, borrow, or rent equipment, exacerbating the risks of expo- sure, partly because of poor equipment maintenance. Commercial suppliers may not package pesticides in quantities small enough to be affordable to many farmers, increasing the likelihood of improper repackaging and attendant hazards. Farmers may also use whatever is on hand, ap- plying persistent pesticides intended for other uses to food crops. Women may not know they are pregnant when using pesticides, thus, increasing risks to the fetus. Moreover, symptoms of pesti- cide poisoning are often misdiagnosed by users, supervisors, and medical staff, resulting in im- proper first aid or long-term care, if needed. Large-scale commercial operations tend to reduce some of these risks. In SSA sleeping in poorly ventilated rooms while burning mosquito coils, which are often not considered pesticides, adds to exposure. (Mosquito coils have also been linked to lung cancer.) Inappropriate application of pesticides can also lead to pest resistance, because farmers skimp on dosages to save money, put on too much pesticide to make sure it works, or shorten the duration because the pests seem to have died off. This has two public health repercussions: (a) pests can build up resistance to pesticides and (b) parasites that infect humans can build up resistance to medications. For example, in 1976, drug-resistant malaria was confined to Southeast Asia; now it is global. This is further complicated by the mosquito's resistance to DDT and its potential car- cinogenicity, because an ecologically suitable yet equally effective substitute is not yet available. Packaging and resale. Few pesticides are manufactured in SSA; the bulk are imported or refor- mulated, for example, in Angola, Mozambique, Tanzania, Zambia, and Zimbabwe. Pesticides are repackaged in Malawi, Swaziland, Tanzania, Zambia, and Zimbabwe.127 Use on major crops. Table 8-3 lists the major crops that use pesticides and fertilizers and the po- tential health effects of pesticide use. Large-scale national integrated pest management programs in Asia have demonstrated that drastic reduction of present use of insecticides on rice, vegetables, and cotton will not affect yields and increase farmers' net profits. 137 Table 8-3: Most Important Crops and Chemical Use, World and SSA (1970-91) Crops Chemicals Used Health Effects and Comments Rice Mostly organophos- Acute poisoning is common among applicators due to a lack of education and phates, carbamates, training on protection procedures and equipment and safety in their use. Storage and pyrethroids; problems lead to household exposures, especially endangering children. Although sometimes organo- these chemicals have varying hazard scores, the risk of poisoning remains high in chlorines developing countries because of management problems. Organochlorines are generally persistent in the environment and can contaminate the food chain. Cottonseed Same as above According to FAO, more insecticides are used on cotton than in any other crop. See comments under rice. Coffee, tea, Same as above; in See comments under rice. In addition, high copper content in plants may lead to and cocoa addition, copper retardation and other effects. Deficient intake, however, poses more health prob- compounds as fungi- lems than excessive intake, except perhaps for individuals with a genetic sensi- cides tivity to copper in their diet. Fruits and Mainly organophos- See conmments under rice. vegetables phates, carbamates, and pyrethroids Source: WorldAgriculture (1993), pp. 17-18 and 57-58. Use on animals. Disposal of pesticide dips poses a special hazard, because they contain a large quantity of water that is often emptied into pits, increasing the risk of groundwater contamination. Fertilizer application. Compared with the wide array of documented negative consequences of pesticides, fertilizers are relatively harmless to wildlife, livestock, and human health (see box 8- 5). In humans, however, they can cause two types of diseases: blue-baby syndrome (methemo- globinemia, which also affects livestock) and cancers of the stomach, bladder, and esophagus. Blue baby syndrome is clearly linked to excess ingestion of nitrates, a basic component of fertil- izers and animal waste, the latter of which can run off into drinking water or enter crops when applied as manure. The linkages with the three cancers are not as well understood. Neither blue baby syndrome nor these cancers are global problems, but they can be quite serious regionally. For example, gastric cancer is rare in Africa, Southeast Asia, and Central America, but common in Chile, Colombia, Costa Rica, parts of Brazil, and parts of China (Shanghai and Singapore's Chinese population). In Egypt bladder cancer comprises about 30 percent of all cancers in males and 12 percent in females. Esophageal cancer is common in some provinces of northerm China, where mortality rates reach as much as 150 per 100,000.128 Other research shows that fertilizers may contribute to the growth of cancer-causing algae, which can be transported long distances in the air. 129 Box 8-5: Key, Confusing, and Misused Terms on Fertilizers Fertilizers. Plant nutrients. Commercial fertilizers are primarily composed of nitrogen, phosphate, and potassium. Livestock manure is also used, as well as appropriate types of garbage, that is, biodegradable waste from commercial, industrial, or household sources. The main health conse- quences consist of occupational exposures and high nitrate levels in drinking water, which can lead to "blue baby syndrome" (methemoglobinemia) and to diarrheas in localized areas. Soil conditioners. Improvements to soil moisture, for example, humus and mulch. As moisture increases, so can microbes in the soil. This can extend mosquito habitat, which would otherwise dry up in dry seasons, producing the main human health consequence. Source: Authors' Data. Livestock and Animal Husbandry Animal-to-human transmission of diseases. A wide range of diseases transmitted from animals to humans (see table 8-4) occurs through occupational exposures, such as in animal husbandry and 138 fishing or by living near areas where animals are kept. Pigs and birds (mainly ducks and chicken) are part of a complicated cycle in the development of viruses that spread human influenza. The influenza virus breeds first in poultry, then moves to swine, and then to humans. Direct exposure is not a common global problem, but can be important locally, most frequently in Asia. Broad public health consequences arise from flu-type epidemics that spread, often annually, before a suitable vaccine can be developed. Animals that transmit diseases to humans fall roughly into four categories: * Farm andfood supply animals. Poultry, goat, sheep, cattle, pigs, and horses * Common domestic animals. Cats, dogs, and birds * Insects. Mosquitoes, lice, fleas, ticks, mites, and flies * Others. Snails and rodents. The main diseases transmitted by animals to humans are malaria, schistosomiasis, Africa sleeping sickness, and leptospirosis (Weil's disease).* (See also chapter 7 on "Gastroenteric Diseases" and table 84 below.) Table 8-4: Diseases Transmittedfrom Animals to Humans Main Animals Some Associated Diseases Comments Farm/food animnals: Anthrax, brucellosis, tetanus, Q Pesticides similar to those used on plants are also used * Poultry Fever, Rift Valley fever, and on animals to prevent infestation by ticks, lice, and * Goats and sheep other arthropod-borne diseases; other nicroorganisms. High-risk populations are care- * Cattle and horses enteric diseases; and skin dis- takers and workers in slaughterhouses. The general * Pigs eases public is also at risk when eating infected meat. Domestic animals: Asthma, toxoplasmosis, psitta- Caretakers and handlers are generally considered the * Cats cosis, enteric diseases, and skin high-risk group. * Dogs diseases * Birds Insects: Malaria, dengue, and yellow High-risk groups include farmers, forest workers, min- * Mosquitoes fever and other arthropod-borne ers, construction workers in endemic areas, animal * Lice diseases, such as rickettsia and caretakers, and children. * Fleas and ticks trypanosomiasis * Mites * Flies Other vectors: Schistosomiasis and leptospiro- High-risk groups are farm workers, freshwater fisher- * Snails sis (Weil' s disease) men, and individuals who live in areas prone to flood- * Rodents ing. Source: Authors' Data. Other concerns. Pesticides are often used on animals, presenting a similar range of human haz- ards as in crop application. Compared with crop use, pesticides to control animal pests tend to receive less attention. (See also "Use of Pesticides and Fertilizers" above.) In addition, runoff from feeding areas can contaminate water sources. Solid waste problems also exist with feed, waste, and slaughterhouses. As the most widely consumed meat globally, chickens deserve special mention. Dust at all stages of poultry production-from feedlots to processing plants-is a significant occupational hazard. Salmonella is an extremely common form of food poisoning, readily spread by poor hygiene in poultry processing, even in industrialized countries. * Leptospirosis (Weil's disease), considered the most widespread animal-to-human disease in the world, spreads through exposure to mammalian urine, most frequently rats. It is generally an occupational hazard for those involved in waste management, animal husbandry, and meat processing, but sometimes becomes a public health problem in residential areas when poor drainage and heavy rains cause flooding that carries animal excreta. 139 Nitrate contamination of drinking water. Animal wastes contaminate the water table and individ- ual wells. In rural areas, animals kept near residences and in feedlots are the source. In some in- stances, wells have been sunk away from residences to avoid such contamination, unintentionally resulting in reduced use of water, leading to poor hygiene. This could result in diarrheas that are more serious than nitrate-related diseases, for which the highest risk group is infants. (See also "Use of Pesticides and Fertilizers" above.) Fisheries and Aquaculture Diseases from livestock are generally more hazardous than those from fish (see table 8-5). A high rate of accidents, however, especially drowning, in open waters and the high seas, makes fishing one of the most hazardous of all occupations. Aquaculture is comparatively less hazardous. Oc- cupational health hazards include schistosomiasis (see "Malaria and Vector-Related Diseases" in chapter 7) and skin and eye diseases due to long-term exposure to water and dampness. Hepatitis and parasitic infections can be transmitted from eating uncooked fish and seafood, both of which are common sources of food poisoning from poor storage. Table 8-5. Diseases Transmittedfrom Fish and Seafood to Humans DISEASE EFFECTS TRANSMISSION CONTROL Fish tapeworm Nornally not Parasite spread in humnan feces, which Sanitation; not eating (Diphyllobothriasis) serious. Can cause infects a copepod ("water flea"), which, undercooked or raw bloating, diarrhea, in turn, develops into a tapeworm in fish; and medication and anetnia freshwater fish, and is then transmitted to humnans, who eat them undercooked or raw. Lung fluke Symptoms simnilar Two-vector series: spread to humans by Better sanitation and (Paragonimiasis) to bronchitis eating uncooked freshwater crabs, which breaking cycle of have been infected by freshwater snails, transmission with which have been infected by larvae in education on uncooked __human, cat, dog, and pig feces. crabs Hepatitis A (also known Infection of the Transmnitted in feces and urine. Person- Improved sanitation, as infectious hepatitis liver causing fever, to-person contact is the main route. personal hygiene, and and jaundice) discomfort, and Epidemnics occur due to contaminated food preparation severe fatigue water. Can also be spread in rnilk and lasting up to undercooked mollusks. several months Schistosomiasis, Infection of Worm eggs in human feces and urine Break cycle of (Bilharzia) bladder with worm hatch into larvae (miracidium) which transrmission by and eggs, causing infect snails that, in tum, shed eggs that preverting eggs from complications. Can hatch into larvae (cercariae) that reaching water, humans be extrernely penetrate the sldn. from exposure to larvae, debilitating or eliminating snail habitat Food poisoning Nausea, vomniting, From fish and seafood that is raw, Proper cooking and cold and diarrhea undercooked, or spoiled in storage storage Source: Authors' Data. Food Processing, Storage, and Transport Health linkages entail processing facilities that generate animal and plant wastes. Animal waste. Health hazards include solid and liquid wastes that arise from inadequate disposal. Solid animal wastes are generated in abattoirs, slaughterhouses, feedlots or the equivalent, and fish drying. Liquid waste, frequently containing solids, is often dumped into the nearest water body. In many developing countries, even if pollution emission standards exist, they are often not enforced. Transferring animal waste to a disposal site may only move the health hazard to a dif- ferent location, unless the site is operated as a proper sanitary landfill. 140 Diseases include leptospirosis (Weil's disease), diarrheas, filariasis (spread by mosquitoes that breed in anaerobic conditions, such as latrines or improperly discarded animal waste). Smells from fish drying pose more of a nuisance than a health hazard. (See also footnote on leptospirosis above, paragraph on nitrate contamination of drinking water above, and table 8-4 above for a list of diseases transmitted by animals to humans.) In addition, smoking meats and fish can cause cancers from smoke residue that escapes from the "smoker" or collects on the meat or fish. Plant wastes. Health hazards associated with plant wastes, often viewed as less serious because plants do not contain animal blood and feces, are, in fact, merely different and more subtle. Haz- ards include water pollution with pesticide and fertilizer residues and high exposures to dust, chaff, and chemical residues in processing grains. Mills and granaries also pose hazards from (a) high exposures to grain dusts, which can lead to lung diseases in mill workers and those delivering grains for grinding and (b) lead poisoning from lead binding in the grinding wheels. (Grinding wheels sometimes consist of several large stones bound together with lead straps or have lead fillings in the gaps or holes of individual stones.) Noise. Stress from noise pollution, for example, from on-site threshing machines and 24-hour processing factories can pose hazards for workers and nearby residents. Noise may be a seasonal reality, increasing during harvesting season, and boost the rate of accidents by preventing ade- quate sleep in workers and adding to on-the-job stress. Storage facilities. Food storage facilities, such as granaries and mills, contain the following four main types of risk, which generally do not pose major occupational or public health hazards. Lo- cal circumstances determine their seriousness. Molds from grain storage at local level. Risks from molds (aflatoxins), known carcinogens gen- erated by humidity, vary with local weather conditions. In addition to occupational exposure, molds can make their way into the food chain in staples, such as breads and baked goods. Afla- toxins are also known hallucinogens, affecting entire communities in unusually long wet sea- sons.'130 Dust and molds from storage and transport. Storage of grains for commercial use changes the risks somewhat by increasing the scale: in addition to worker exposure, large facilities may ex- tend these risks to the community. Snake bites. Storage facilities attract rodents, which in turn, attract snakes. Hanta virus. Hanta virus is one of the recently discovered diseases attributable to global change in the past twenty years (see chapter 14). The disease is spread to humans through rodent urine (mainly rats and mice). Humans are exposed in dwellings near fields or food storage areas, when rodents enter them. Transport. Transport of food to processing areas, wholesalers, or markets entails hazards in road safety and food contamination. The latter comes primarily from: * "Unprotected" vehicles, in which food is exposed during transport to a wide range of contaminants, for example, pesticides, fuels, and oils * Inadequate refrigeration to protect food from spoilage, shortening its "shelf life" * Contaminated vehicles not reserved solely for or properly maintained for food. To avoid a return trip empty, for example, trucks sometimes haul garbage or hazardous materials. 141 Land Clearing for Agriculture or Settlement Land use is linked to an array of familiar human health repercussions, ranging from the spread of vector-related diseases to death and injury from flooding. Complicated interactions in land use lead to transmission of human diseases originating in animals, thus, presenting risks in animal husbandry. Land clearing has four potentially major health repercussions through (a) change of vector habi- tat, (b) erosion, desertification, and other forms of land degradation, (c) floods, and (d) saliniza- tion. The indirect consequences of expansion of agriculture or settlements, for example, for for- aging for food, fodder, and firewood, can be equally destructive in the long term. Each of the four repercussions cited above has many other causes besides land clearing, for example, climate change (see chapter 14). The information below provides an idea of the health dimensions and does not necessarily attribute causality, although land clearing may help cause or exacerbate the problems. Spread of vector-borne disease. Although land clearing would seem to eliminate mosquito vector habitats, in reality, it only changes them. More than 3,000 different species of mosquitoes exist, indicating that mosquitoes are extremely adaptable in finding new breeding sites with slightly different breeding habits in terms of salinity, moisture, temperature, and so on. For example, in Indonesia and South America, two species of mosquitoes that spread malaria disappeared after deforestation, but the reverse occurred in the Indo-Australian region with the intrusion of three species.131 About fifty species (anopheles) spread malaria, undoubtedly the most widespread vector-borne disease; two other mosquito species (culex and aedes) also spread diseases of global importance (see also annex B). Erosion, desertification, land degradation, and salinization. The potential result from a health perspective is the same for each: (a) compromised food supply, leading to malnutrition and low- ered resistance to other diseases, (b) physical stress from foraging for food, fodder, and firewood, (c) irregular supply of water for food, and (d) in extreme cases, resettlement, coupled with infec- tious diseases related to poor personal hygiene, due to inadequate water and waste disposal. These factors worsen when victims are dislocated. In addition, salinization of soils increases salts in water, which, among other impacts, can com- promise nutrition by reducing water use for drinking and irrigation and is linked to high blood pressure in residents near saltwater bodies because they breathe in salt in the air. The Aral sea, for example, contains salts up to twice WHO standards. Floods. The main health repercussions from floods are deaths (mostly drowning), injuries, lost housing and jobs, contaminated water and food, malnutrition, spread of vector-borne diseases, electrocution (from power lines), and inoperable emergency services. Mortality ranges from 500,000-800,000 in China (1969) to 2,000 each for the Netherlands (1953) and Italy (1963).'32 Epidemics caused by flooding can also be significant. In Bolivia, flooding related to the El Nifno Southern Oscillation (ENSO) in 1983 increased salmonella poisoning by 70 percent'33; similar increases were reported in Bangladesh, Brazil, Chile, Mauritius, Sudan, and the United States. In July 1996, 1,500 died in floods across China; in the city of Hubei alone, tens of thousands fell sick or were injured, leading to nearly 400 deaths, and 2.36 million became homeless.134 Although a global phenomenon, flooding tends not to be as severe in SSA, compared with Asia during the monsoon season or Latin America, as measured by death rates. As the most urbanized region in the world, Latin America has large numbers of housing settlements up hillsides on mar- ginal and degraded land surrounding urban areas. Some of the lower death rates may be due to lower population density in SSA. Between 1990 and 2000, however, flooding became a serious problem in SSA; about 15 million people have been affected, and 6,500 deaths have occurred in 142 this period. Major floods occurred in Ethiopia (1990), Nigeria (1994), Ghana (1995 and 1999), Kenya (1997 and 1998), Mozambique (1997), Malawi (1997), Somalia (1997), Benin (1998), Su- dan (1998), Zambia (1998 and 2000), Sudan (1999), and Swaziland (2000). Floods were particu- larly severe in Mozambique (2000), affecting 979,000 people and killing 492. Floods have an indirect effect in SSA where road transportation is more important than other forms of transport for commerce. When flooding occurs and roads are either blocked, sometimes for days, or washed out, road barriers are often erected at the nearest town or "truck stop" to alert drivers. Many of these areas are frequented by prostitutes, contributing to the spread of AIDS by the truckers. Floods also destroy important infrastructure, ranging from roads to irrigation sys- tems, each with negative effects in the short term on providing emergency services, as well as, in the long term, producing food. In addition to its immediate effects on injury and death, flooding can also cause long-term physi- cal and mental stress ("post-traumatic syndrome"), even suicides. These latter health effects tend not to be reported in health statistics related to flooding. Forestry, Biodiversity, and Traditional Medicines Forest management projects have five broad environmental health repercussions from: • Spread of vector-related diseases, especially as roads penetrate into forested areas • Use of pesticides - Unsustainable land use * Spin-off activities, such as opening up forested areas for logging, agriculture, farming, or human settlements X Threat to medicinal plants. The first four topics are covered in chapters 7, 8, 13, and 14, whereas the effects on traditional medicines are considered here. Medicinal plants in tropical forest and nonforest habitats are highly important sources of tradi- tional medicines. An estimated 80 percent (4.8 billion people) of the world's population depend on medicinal plants for health care; in rural areas, the figure is more likely to be 100 percent. Me- dicinal plants are generally free or available at affordable cost. The range of benefits for humans and livestock from traditional herbal medicines, however, generally escape economic analysis. Box 8-6: Medicinal Plants and Ghana In the northern savanna regions of Ghana, residents rely on locally available medicinal plants for the majority of health care needs, but are exploiting them at an unsustainable rate. The Ministry of Health estimates that Ghana has one traditional healer per 400 people and one allopathic doctor per 10,000. The Ministry of Lands and Forestry under the Savanna Resource Management Program is working with northern rural residents to identify collaborative resource management strategies for community- dependent habitats for sustainable harvest of medicinal plants. 135 Source: Authors' Data. EM-DAT: The OFTA/CRED International Disaster Database www.cred.be/ Data for 2000 includes only three quar- ters. 143 Medicinal plants are increasingly threatened by logging operations, deforestation, expanding ag- ricultural lands, buming, and grazing. All user groups lose out from overexploitation of natural stocks of such plants. Developing countries, especially African countries, are the greatest losers, as they depend greatly on medicinal plants, particularly in traditional health systems (healers and birth attendants) and by mothers for primary health care needs. Forty percent of the plants im- portant in treating the top eleven human and four livestock diseases (see table 8-6) are presently threatened. Table 8-6: Human and Livestock Diseases Treated by Plant Species Northern Upper West Upper East Region Region Region Human Disease (number of species/number of species threatened) Malaria 12/4 14/4 3/2 Diarrhea 11/1 7/5 5/4 Pneumonia 12/0 7/3 Hypertension and stroke 14/9 1/1 Dysmenorrhea 20/2 - 2/1 Sinusitis, headaches, and colds 12/5 3/1 Diabetes 14/6 - - Pelvic inflammatory disease 13/3 7/5 Stroke 11 4 Snake bite 7/5 Piles - 3/1 5/2 Animal Disease Diarrhea 10/4 - 2/1 Anthrax 15/7 Liver fluke 14/8 Newcastle disease - 2/1 Source: Draft of Bank project concept proposal for Ghana (1999). Table 8-7 indicates the type of agriculture threatening wild sources of medicinal plants by listing production trends for the four types of major crops in terms of areas harvested during 1970-9 1. Table 8-3 above lists some of the human health effects resulting from use of chemicals in the production of these four major crops. Rice harvest and acreage roughly doubled. Agricultural in- tensification offers opportunities for farmers and the ministry of agriculture to identify cultivation methods and practices for medicinal plants that are compatible with agricultural crops. Such ad- ditional crops would offer alternate income. In agricultural and rural development projects that concern these crops, considering how to reduce the threat to medicinal plants or promote their conservation may be appropriate. Table 8-7: Most Important Crops Grown in the World and SSA (1970-91) World Area Harvested Area Harvested Production (flOOs of SSA Production (1 OOOs of (millions of tons) hectares) (millions of tons) hectares) Crops 1970 1991 1970 1991 1970 1991 1970 1991 Rice 316,519 517,875 133,122 146,970 4,680 10,071 3,526 6,362 Cottonseed 22,480 38,438 34,144 34,958 1,560 1,836 4,101 3,478 Coffee,tea,cocoa 6,664 11,107 NA. N.A. 2,537 2,868 - - Fruits and vegetables 509,608 797,544 N.A. N.A. 35,578 52,270 - Note: N.A. Not Available. Source. World Agriculture (1993), pp. 17-18 and 57-58. 144 Water and Waste Management This section covers environmental health risks related to drinking water supply, irrigation and drainage, and agricultural and domestic waste management. Rural Community Drinking Water Supply According to a recent World Bank study on health, rural water supply, and sanitation, global cov- erage for water supply was 61 percent in 1990 for rural and urban areas combined and only 50 percent for rural areas. By 1994 global rural coverage reached 70 percent, which means that 30 percent of the world still have no water in the house. For sanitation, the challenge is even more daunting. WHO estimates that more than 3 billion people are without adequate means of excreta disposal. Sanitation coverage, however, fell globally in the 1990s from 36 percent in 1990 to 34 percent in 1994. WHO estimates 3.3 million people die every year from diarrheal diseases and 1.5 million suffer at any one time from parasitic worm infections stemming from human excreta and solid wastes in the environment.'36 During the International Drinking Water and Sanitation Dec- ade, 1981-90, SSA experienced an increase in water supplv coverage from 32 to 46 percent, whereas sanitation coverage increased from 28 to 36 percent Progress since, however, has stag- nated, and more people lack adequate services in Africa today than in 1990. "7 Despite these gloomy statistics, considerable progress has been made in nearly eradicating two scourges, Guinea worm disease and river blindness (see box 8-7). Box 8-7: Two Successes in Eradicating Guinea Worm Disease and River Blindness Guinea worm disease. The eradication of guinea worm disease (dracunculiasis) is an encouraging story and salient to this discussion, because the infrastructure sector took the most important meas- ures in close collaboration with health, agriculture, and rural development sectors. Guinea worm, first described in Egyptian medical texts in the fifteenth century BC, is the only dis- ease spread exclusively by drinking water and is restricted to sixteen African countries. According to a Nigerian study, guinea worm infections cost an estimated US$20 million in lost labor each year and cause about 60 percent of school absenteeism in that country. Guinea worm eradication was initiated during the U.N. International Drinking Water Supply and Sanitation Decade of the 1980s. WHO officially called for its eradication in 1986 when cases reached an estimated 3.5 million and 100 million at risk due to unsafe water supply. By 1998 pro- tection of water supplies, mainly digging wells and boreholes, applying larvacide, and filtering water, had dropped infection rates to less than 80,000. It is hoped that, by the year 2001, guinea worm eradication will be added to smallpox eradication as one of the major accomplishments of the twentieth century-the result of practical collaboration among health programs outside the health sector. River blindness. A second case illustrating the power of interagency collaboration is the Onchocer- ciasis (River Blindness) Control Programme (OCP) in western Africa, begun in 1974. Eradication of this disease has been even more daunting, because (a) its vector, the black fly, has a flight range of up to 400 kilometers, (b) the population at risk covers eleven countries from Senegal to Benin, mostly along main rivers, (c) individuals carrying the disease can remain infective for 10-15 years, and (d) remedial measures must continue for 20 or more years. The black fly breeds in fast-moving waters of rivers, streams, spillways, and drainage canals (where the aerated water provides the larvae the high amounts of oxygen they need to develop). This is precisely where people wash clothing, fish, bathe, swim, and collect water. Socioeconomic costs of the disease have been high, because up to 50 percent of the local population can be in- fected, 30 percent with impaired vision and 10 percent blind. Often, entire villages have been abandoned for higher ground with less fertile soil. Remedial measures have centered on insecticide application, medication, education, and, to a limited extent, promotion of sustainable resettlement of areas brought under control. 145 OCP initially entailed collaboration among seven poor countries in western Africa, but was ex- panded in the early 1 980s to eleven countries to control all black fly-breeding locations throughout the West African subregion. Launched in December 1995, the African Programme for Onchocer- ciasis Control (APOC) is following up on OCP by attacking the problem in the remaining nineteen countries eastward where onchocerciasis still exists, from Benin to Ethiopia and, in central Africa, from Angola and Malawi. OCP virtually eliminated the disease within the eleven western African countries and is scheduled conclude in 2002. Some 18 million people are currently infected in the remaining nineteen countries of APOC, which will end in 2007. At that point, national govern- ments, local communities, and NGOs will take over responsibility for drug distribution. Source: "Onchocerciasis." River Blindness Unit, Africa Region, World Bank, November 1999. Rural water supply projects sometimes fall under the aegis of health or agriculture agencies, which do not necessarily have the in-house competence to deal effectively with engineering and maintenance of drinking water supply and sanitation services. Conversely, periurban water supply under the water supply and sanitation agency may not have the in-house competence to deal with essentially rural conditions. Both types of projects could benefit from a component to deal with institutional weaknesses in engineering and maintenance, hygiene education, or health risk as- sessment. Many of these activities (or components) have been successfully introduced into water and sanitation sector projects. In addition, many periurban settlements around African cities re- semble rural villages with characteristics that have important health repercussions. Even high- density areas contain zones that require a rural approach to an urban problem. Chapter 13's last section on infrastructure water supply and sanitation discusses issues in rural water supply. Guinea worm. Because guinea wormn is the only disease linked exclusively to drinking water, control measures should focus on preventing people from immersing their feet and lower legs in water sources when fetching water. Boiling, filtering, and treating water are also effective meas- ures, but not holding tanks because the water flea (copepod), which spreads the disease, can sur- vive in holding tanks for long periods. Stress on women and children fetching water. Fetching water can consume several hours per day, a factor sometimes overlooked by those not familiar with rural water supply, and explained in box 8-8. The physical stress can predispose people to other illnesses. Box 8-8: The Stressful Facts about Rural Water Supply Taking South Africa as an example, an estimated 16 million people or 3.2 million households (aver- aging 5 persons each) have no operating water supply and must travel an average of I kilometer each way to fetch water. Assuming that each household sends one member, usually a woman, twice a day for water, she must walk an average of 4 kilometers a day. Collectively, then, these women walk 12.8 million kilometers a day. If the average distance to the moon is 384,000 kilometers, this means that together they walk 33 times the distance to the moon just to fetch water every day. If each trip takes an average of I hour to walk to the water source, wait in a queue, collect the water, and walk back, they collectively make 6.4 million trips taking 6.4 million hours a day. This repre- sents nearly 3,500 working years each day fetching water (assuming 21 working days a month for 11 months a year). These figures are just for South Africa; if you consider the rest of Africa, they be- come staggering. These women walk to fetch only 10 liters of water each trip, usually of suspect quality. The figures are estimated, but of a tight order of magnitude Source: Adapted from information in "The Africa Water page," (accessed December 1999). 146 Arsenic. Arsenic is a naturally occurring pollutant in soil and groundwater, often bound in ores of copper, lead, and zinc. Arsenic is also a common ingredient in pesticides. Chronic, low-dose ex- posure can cause problems with the skin, liver, and circulatory, nervous, and respiratory systems. Irrigation and Drainage Irrigation generally contains four types of components: (a) dams, watersheds, and reservoirs, (b) diversion and intake facilities, (c) wells, pumping stations, canals, ditches, and pipelines for water supply and drainage, and (d) distribution systems for sprinkle and drip irrigation. Irrigation gen- erally refers to the use of surface waters, but, for the past thirty years, tube wells have been used to tap groundwater in parts of Asia, for example, India, Pakistan, and China. Groundwater use poses the same environmental health hazards as surface waters, but the water may also contain naturally occurring contaminants such as arsenic or manganese.138 Two factors link irrigation to cities. Overall population growth and continuing migration to cities have increased competition for water for drinking, irrigation, and industrial uses. Developing new water sources that are increasingly farther away from the point of use has also increased costs. This encourages skimping on expenditures and compromise on environmental issues, such as capital investments (e.g., drainage) or recurrent costs (e.g., operations and maintenance). A well- developed literature exists on these long-recognized topics, but implementation still presents problems in the field. Table 8-8 summarizes the potential negative environmental impacts of irrigation and their health impacts. The major environmental health risk entails the spread of vector habitats (see "Malaria and Vector-Related Diseases" in chapter 7). For example, a recent study in Ethiopia showed a sevenfold increase in malaria among about 7,000 children under 10 years living within 3 kilome- ters of small dams, compared with children living outside mosquito flight ranges.'39 The overall negative impacts need to be weighed, however, against benefits in improved nutrition that dams permit in arid areas, tempering the devastating effects of drought, such as famines in 1974 and 1984.140 Such dual effects underscore the need to make single sector decisions within a broad en- vironmental health context. Risks other than the spread of vector habitats are discussed below. Table 8-8: Potential Environmental Health Impacts from Irrigation Negative Environmental Impact Potential Negaffve Health Impact Water logging and salinization of soils Diminished crop productivity and malnutrition, and, in extreme cir- cumstances, relocation of the population Expansion of habitat for snails and mosqui- Increased incidence of water-related diseases, in particular, schistoso- toes miasis and malaria Resettlement Diarrheas, respiratory diseases, malaria and other vector-borne dis- eases, malnutrition, mental stress, and aggravation of normal health problems because of inadequate health facilities Increased pesticide use from expanded agri- Possible increase in malaria or other mosquito-borne diseases culture. Pesticide runoff can kill local popu- lations of frogs and fish that keep mosquito larvae in check. Increases in agricultural pests and diseases Spread of vector-borne diseases and possible malnutrition from de- resulting from elimination of dry season die- creased food production back and creation of a more humid microcli- mate Source: Authors' Data. Potential Impacts from Increased Agriculture The expansion and intensification of agriculture made possible by irrigation also may also cause problems (see table 8-9). 147 Table 8-9: Potential Health Impactsfrom Increased Agriculture Potential Impacts from Increased Agriculture Potential Negative Health Impact Increased erosion Death and injury due to floods, especially in rainy season Pollution of surface and groundwater from agricultural Contamination of the food chain biocides Deterioration of water quality Decreased water usage and possible increase in water-related diseases and personal hygiene Increased nutrient levels in the irrigation and drainage Contamination of the food chain and, depending on local canals, resulting in algal blooms, proliferation of conditions, promotion of cholera by conveyance in algal aquatic weeds, and eutrophication in irrigation canals blooms and downstream waterways Source: Authors' Data. Potential General Ecological Disturbances Large irrigation projects have a number of potentially negative environmental health repercus- sions. Three already discussed include (a) biodiversity loss and the risk to traditional medicines, (b) flooding and the risk of injury and drowning, and (c) spread of vector-related diseases through change of habitat. A fourth repercussion is the involuntary or voluntary resettlement of popula- tions. Involuntary resettlement. Involuntary settlement involves such direct and indirect health reper- cussions as: * Diarrheal and respiratory diseases stemming from the absence of basic infrastructure (water, sanitation, drainage, housing, and basic community infrastructure) * Malnutrition from inadequate food supply, especially when people grow their own food crops, and inadequate food security and nutrition, for example, some crops and trees do not bear fruit for a year or two after planting * Spread of malaria (and other vector-borne diseases) by transferring an infected popula- tion to a noninfected area or vice versa on a temporary or permanent basis, exposing new populations * Aggravated illnesses and injuries from inadequate health facilities, at least compared with the level migrants had before (if the basic environment and population have changed as a result of the resettlement) * Mental stress from being uprooted, especially on old people, may require social service outreach to compensate for the stress of upheaval. The World Bank's Safeguard Policies OD 4.30 and GP 4.12 "Involuntary Resettlement" deals with some of these factors, but lack detail on specific health repercussions (see "Human Settle- ments" above). Voluntary or seasonal resettlement. Voluntary and seasonal resettlement could involve all the conditions noted above, but may pose additional conditions stemming from spontaneous or un- planned growth: * Diarrheal and respiratory diseases related to temporary unplanned settlements * Vector-related diseases and health and safety hazards related to solid and liquid waste management, when economic activity, such as harvests or fishing spurs resettlement * Spread of AIDS among temporary workers and local residents. In SSA, for example, voluntary resettlement has occurred in areas where river blindness (oncho- cerciasis) has been controlled (see box 8-7). Economic activity can also spur voluntary, but often unplanned, resettlement. For example, in Senegal, the Lac de Guiers was dammed in the 1 980s to furnish a constant supply of water drawn from the Senegal River, which feeds the lake, to Dakar and other cities. 148 Marshes and Other Wetlands "Wetlands are not wastelands!" Marshes and other wetlands and have a vital role to play in maintaining human health by naturally purifying water of fecal and some chemical contaminants and by absorbing excess flood waters. Wetlands, however, also provide habitat for mosquitoes that spread disease. Human settlement and transport projects considering drainage management should take these contrasting roles into account. Reuse of Wastewater Reuse of wastewater for irrigation is practiced throughout the world, especially in Latin America and Asia, and will no doubt increase in use due to future population growth and water shortages. Wastewater is also reused in aquaculture, the practice of raising fish and seafood in specific areas. It primarily involves reuse of sewage and industrial waste (see "Fisheries and Aquaculture" above and table 8-5). Table 8-10 shows the major health hazards of such practices: Table 8-10: Major Hazards in Reuse of Wastewater Irrigation Aquaculture * Food chain contamination * Occupational hazards, such as skin and eye diseases * Spread of vector-related diseases for fishermen with long-term exposure to water and * Pollution from pesticides, fertilizers, and animal accidents and drowning (on boats and in deep water) waste. Their adherence to food surfaces may be more * Contamination of the food chain through accumulat- hazardous than their absorption by plants. ing pesticides and heavy metals in the organs of fish * Plant absorption of heavy metals. In SSA, these risks and other seafood are highest near mining activities, which produce * Diarrheal diseases spread by fecal contamination of tailings that wash away sometimes into irrigation fish and seafood, if not properly cooked. water downstreanm Source: Authors' Data. Agricultural Waste Management Animal and crop waste pose a number of environmental health risks (see table 8-1 1). Table 8-11: Major Health Hazards ofAgricultural Waste Management Animal Waste Crop Waste * Occupational exposures, mainly diarrheal diseases, * Fertilizer runoff in particular, nitrates for those disposing of or reusing waste as fertilizer or * Occupational exposures, mainly to pesticide residues slaughtering and dressing animals and for those * Diarrheal diseases from fecal, biological, and working in abattoirs and food processing plants chemical contamination of water * Diarrheal diseases from fecal contamination of wa- * Change in vector habitats, which permits mosquito ter supply breeding. * Nitrate contamination of water, which, in extreme cases, can lead to blue baby syndrome (methemoglo- binemia). Source: Authors' Data. Domestic Waste Management Wastewater and periurban waste pose specific environmental health risks. Wastewater The health hazards of rural wastewater are mainly: * Diarrheal diseases from inadequate disposal facilities * Vector-related diseases because of poor drainage. 149 Sanitation technologies range from small bore sewers for small towns to on-site latrines for rural and low-density urban areas. Small towns and rural areas mostly rely on systems such as septic tanks and latrines, but sewerage systems may possibly be appropriate for dense populations in regional centers depending on the capability of local institutions to sustain a water and sewerage authority. For a detailed discussion of sanitation, see "Infrastructure: Water Supply and Sanita- tion" in chapter 13. Periurban Waste Periurban agriculture is growing, partly due to continued urbanization. Health hazards due to periurban waste combine hazards already addressed under urban and rural waste, although cir- cumstances vary according to local conditions. Municipal administrations are not set up to deal with urban and rural problems simultaneously, so addressing health problems face administrative as well as technical difficulties. (See also "Periurban Agriculture and Livestock" above.) Rural Transportation Roads are often managed by a central transport ministry and suffer from a lack of budget and subordination to urban concerns. Health repercussions are largely the same as in urban areas with differences in scale, institutional capability, education levels of affected populations, and avail- ability of resources to address problems. Roads, Trails, and Paths Rural roads fall roughly into three categories: (a) paved and graded roads, (b) paths, trails, and access roads, and (c) post-harvest roads (something more than tracks in fields, which are used only at harvest time). Hazards are roughly the same for the three, and local factors determine their relative importance. Primary health hazards include: - Injuries from accidents, unsafe driving habits, and poor maintenance of vehicles and roads - Occupational hazards, including respiratory diseases in truckers from, for example, expo- sure to petroleum-based fuels, and injuries to farm workers from poorly maintained paths and trails and harvest vehicles * Respiratory diseases from air pollution, especially dust * Spread of AIDS by truckers at truck stops, especially at temporary stops due to blocked roads in storms, and from work crews involved with road construction, rehabilitation, and maintenance * Lead pollution in heavily traveled areas, which may be absorbed by some crops and also ingested by children. * Dust. Dust is an important health hazard that is often underestimated due to an emphasis on fuel-derived vehicular air pollution and cancers. Risks derive more from the size of particles than their chemical composition, as small particles penetrate deeply into lungs, impeding breathing. * Lead. Lead from heavy nearby traffic could contaminate crops and, therefore, the food chain. Similarly, lead that settles along heavily traveled roads, particularly during the harvest season, put children at risk of lead poisoning (children acquire lead from eating soil and putting toys into their mouths, a source of lead that tends to be neglected in the literature). Lead can recirculate in the environment for up to 30 years, accumulating to harmful levels. 150 River TRansport Fishing is one of the most hazardous occupations that exists, particularly because of injuries and drowning due to rough waters, especially, on the high seas and large lakes. The lower risks of river transportation are, however, similar in nature and include occupational health hazards such as (a) injuries to and drowning of boat crew members, (b) accidents and injuries to dock loaders and others involved in loading crops and other materials, especially at harvest, (c) exposure of boat crews to fuel emissions, (d) exposure to hazardous materials transported, and (e) exposure to vector-borne diseases. Environmental Health Assessment Checklist This section presents a set of tools that can be used to determine a broad range of environmental health issues, from which to view direct and indirect repercussions, determine which are most important, and then set priorities according to institutional capabilities and budgets. This inten- tionally broad approach gives a better idea of the range of institutions that may need to be in- volved in finding solutions. In keeping with the overall poverty reduction objectives of this dis- cussion paper, the material also describes the main high risk and vulnerable groups. Typical Loans and Components from the Sector The official World Bank designations for the agriculture and rural development sector are as fol- lows: rural development, natural resources, fishing, livestock, irrigation and drainage, perennial crops, research and extension, food security, forestry and so on, sector loan, marketing, agroin- dustry, perennial crops, research and extension, food security, forestry, and other agriculture. Occupational; High Risk, and Vulnerable Groups The main occupational health and safety issues concern pesticides, accidents, and exposure to vector-related diseases (see table 8-12). Table 8-12: Occupational, High Risk, and Vulnerable Groups for Agriculture Sector Activity Potential Health Risk Use and sale of pesti- Basic health risks, include (a) acute poisoning from short-term exposure and (b) cides long-term exposure, which may lead to accumulation in body fat, leading to can- cer or birth defects. * Farmers and other farm workers: mixing and spraying of pesticides * Women and children: (a) improper storage and (b) housekeeping activities, especially family members washing the farmer's clothing * Retailers and wholesalers: (a) improper handling, storage, repackaging or reformulating (mixing chemicals to become pesticides) and disposal of pesti- cides and containers and (b) containers often recycled, for example, bottles for beverages or drums for storage or incineration containers * Dockworkers and truckers: exposures from improper storage and transport * Community at large: (a) short- and long-term exposure in nearby fields, es- pecially the first few days after spraying, (b) improper disposal of excess pesti- cides and empty containers, (c) runoffs from the fields, and (d) spills from transport accidents. Fanning * Inaccessibility to health care after accidents, in part explaining why fanming is one of the highest-risk occupations internationally * Exposure to malaria, in Africa, particularly women. Women and children * Physical stress, because these activities can take up to 8 hours a day fetching fodder and * Exposure to accidents * Exposure to malaria, in some periurban areas where urban malaria is not en- 151 Activity Potential Health Risk water demic. Silage storage and * Occupational exposures loading at ports and * Exposures to food dusts and molds and pesticide residues by people living in harbors surrounding areas Rural housing * Exposure to indoor air pollution by general population from poorly venti- lated traditional housing, for example, huts, and other locations with concen- trations of fumnes Traditional fuels prepa- * Exposure to charcoal dust in preparing, packaging, and selling charcoal, ration and sales which tends to be a cottage industry run largely by women Agroindustry * Exposure to pesticide residues, dusts, and molds from food processing * Exposure to carcinogens from smoking foods. Source: Authors' Data. Environmental Health Checklist for the Sector The Agriculture Sector Environmental Health Checklist (table 8-13) shows the range of agriculture sector projects by subsector, identifies the main potential environmental health problems, and suggests remedial measures. Table 8-13: Agriculture Sector Environmental Health Checklist' Typical Agriculture Projects Probable Environmental and Components Health Issues Remediable Measures Agency Reform Generally, involve development or Rural water supply, watershed Besides water provision (quantity restructuring of institutional ca- management, or irrigation projects and quality), preparation of termns pacity in agriculture. Some con- could entail diarrheal diseases, of reference (TORs) for rural wa- tain studies on rural water supply, skin diseases, eye infections, vec- ter supply and sanitation projects watershed management, or irriga- tor-related diseases, especially should determnine if disease is or tion. malaria, schistosomiasis, and on- has been endemic. If so, the proj- chocerciasis. ect could assign responsibilities for monitoring stagnant water and drainage to stakeholders. If dis- ease is still endemic, the project should provide for protecting the water source and appropriate edu- cation. TOR implementation should provide for proper 0 & M outside the ministry of health or agriculture (MOH/MOA), if ap- propriate. A community participa- tion cornponent may be needed for O & M and cost recovery. Agricultural Credit Deal with financial services and Only relevant if funds are "on- See "Agroindustries" restructuring. lenft to buy inputs, for example, fertilizers and pesticides and to other subsectors, but without EAs or EHA reviews Agricultural Extension Generally involve development or Same as for "Agency Reformn" Same as for "Agency Reform" restructuring of institutional ca- subsector subsector pacity in agriculture. * These and other sectoral checklists are available at . 152 Typical Agriculture Projects Probable Environmental and Components Health Issues Remediable Measures Agricultural Adjustment Involve environmental manage- As part of studies and training, ment, including environmental environmental health issues, such education and some studies on as vector-related diseases, should vector control and climate change. be included in preparation of TORs, when appropriate. Agroindustry and Marketing Main objectives involve increas- Pesticide andfertilizer use: ing agricultural productivity and (a) Acute poisoning to farmers For (a)-(d), implementation TORs marketing efficiency. Common and family members due to should include procedures for components include (a) pesticide storage problems in houses health hazard awareness campaign use and fertilizer distribution, (b) (b) Fertility and reproductive and provide for affordable protec- rehabilitation andlor construction problems, for example, spon- tive gear and equipment. of rural roads to increase access to taneous abortions markets, (c) small-scale water schemes, and (d) food processing (c) Weakened immune system and storage. (d) Other possible long-term ef- fects, such as cancer and birth defects. Rehabilitation and construction: Implementation TORs should include: (a) Accidents during construction (a) Provision for affordable pro- tective gear and equipment (b) Increased vehicle use can (b) Appropriate road design and cause traffic injuries better law enforcement (drunk driving, seat belts, and so on) (c) Better law enforcement (emis- (c) Increased exposure to vehicle sion control) and awareness fumes can cause respiratory campaign for population at diseases in populations along risk roadsides (d) In the short term (preparation (d) Lead-related conditions such TOR should identify popula- as anemia and neurological tion at risk), Vitamin A sup- effects, especially in children plement for population at risk, and, in the long term, introduction of nonleaded (e) AIDS spread by construction fuel workers and truckers. (e) AIDS and STD awareness in conjunction with MOH cam- paign targeting workers (la- bor unions and associations) and truckers (associations), a clause on AIDS and STDs (and possibly hygiene) in the subcontractor contract, and distribution of condoms as appropriate. Food processing and storage: Contamination with pesticides or For (a) and (b), implementation other chemicals and/or microor- TORs should include a health ganisms may occur during han- hazard awareness campaign. dling, transport, or storage of foodstuffs resulting in: (a) Acute poisoning (O) Diarrheal diseases 153 Typical Agriculture Projects Probable Environmental and Components Health Issues Remediable Measures Small-scale water systems: See "Irrigation and Drainage" See "Irrigation and Drainage" Annual Crops Similar to "Agroindustry and Similar to "Agroindustry and Similar to "Agroindustry and Marketing" Marketing" Marketing" Fisheries and Aquaculture Focus on fishing, fish processing, Fishing and processing: developing of shore-based facili- (a) Drowning and accidents from For (a)-(b), implementation TORs ties and jetties for fish landings, falls should include and awareness and rehabilitating roads to increase fb) Skin diseases due to constant campaign and affordable protec- access to markets. moisture, especially the ex- tive gear and equipment and for tremities (c) counseling and (d) affordable (c) Occupational injuries and protective gear and equipment, physical stress, e.g., overex- including insect repellant. ertion and back pains (d) Vector-borne diseases, e.g., schistosomiasis, onchocercia- sis, and malaria Road rehabilitation: See "Agroindustry and Market- See "Agroindustry and Market- ing" ing" Forestry Involve conservation of forests (a) Vector-related diseases, espe- For (a), implementation TORs and wildlife, environmental edu- cially malaria should include affordable protec- cation, tree-farming and other (b) Accidents, e.g., falls, cuts, and tive gear and equipment including related activities. abrasions insect repellant and for (b)-(d) (c) Snake and animal bites awareness campaigns. (d) Occupational injuries and physical stress, e.g., overex- ertion, back pains Irrigation and Drainage Involve food security, water man- (a) Vector-related diseases For (a)-(c), implementation TORs agement, small-scale irrigation, (b) Diarrheal diseases from im- should include vector control tar- irrigation rehabilitation, drainage proper drainage and sanita- geting drainage, sanitation, and structures and flood warning sys- tion; stagnant water (stakeholder in- tems, sewerage facilities, and ac- (c) Long-term, low-level exposure volvement in monitoring and in- cess roads for markets. to pesticides due to reuse and troduction of larvivorous [larva- exposure of irrigation waters, eating] fish as appropriate) as well as an awareness campaign in- cluding hygiene behavior. Livestock Main objectives include increasing Health issues mostly related to meat, eggs, and milk production, exposure of workers to animal providing livestock health serv- waste: ices, developing water resources, (a) Brucellosis and anthrax from For (a)-(c), implementation TORs improving breeding stock, proc- contact with infected cattle, should include awareness cam- essing food, and other related swine, goats, and sheep paigns and affordable protective activities. (b) Other infectious diseases from gear and equipment. occupational exposures to livestock, poultry, and abat- toirs, for example, Q fever, asthma, psittacosis, fungal and parasitic diseases, and leptospirosis (Weil's disease) (the latter of which can be spread to communities during 154 Typical Agriculture Projects Probable Environmental and Components Health Issues Remediable Measures heavy rains in areas of poor drainage) (c) Diarrheal diseases in workers and village due to contamnina- tion of drinking water. Other effects may include the nui- sance of smells and aesthet- ics. Food processing: See "Agroindustry and Market- See "Agroindustry and Market- ing" ing" Water resources: See "Irrigation and Drainage" See "Irrigation and Drainage" Other Agriculture Focus on food security, nutrition, As covered above. As covered above. finance, road upgrading, water supply, crop technology, irriga- tion, livestock, veterinary services, and infrastructure Perennial Crops Focus on pest management, re- As covered above in other sub- As covered above in other sub- search, breeding, road rehabilita- sectors, especially agroindustry. sectors, especially agroindustry. tion, factory and infrastructure rehabilitation, and irrigation Research Varies Varies Varies Source: Authors' Data. 155 CHAPTER 9: CROSS-SECTORAL LINKAGES WITH THE ENERGY SECTOR This chapter provides a brief overview of key environmental health and energy sector linkages. It was based on a review of the literature conducted during preparation of the 1996 volumes of Bridging Environmental Health Gaps, the stage of work preceding the research and writing of this discussion paper. The chapter concludes with an environmental health checklist for the sec- tor. Future versions of this paper will expand coverage overall. For the moment, the chapter con- centrates on infrastructure sector linkages with the energy sector. As such, more detailed infor- mation than is described below is available in chapter 7 on "Respiratory Diseases," chapter 8 on "Human Settlements," and chapter 13 on "Housing and Urban Development." The literature re- view concentrates on policy determinants of energy policies as they impinge on human heath, because policy issues are less likely to change in the short term relative to technical issues, which are changing rapidly. Key Environmental Health Issues The main links between environment and health in the energy sector stem from indoor air pollu- tion for heating, lighting, and cooking and resultant accidents (mainly burns) from fires, ambient air pollution from coal-fired electricity plants (although this tends to be more an ecological than environmental health problem), spreading of vector habitat (mainly snails and mosquitoes) from dams, and physical stress and injuries from getting firewood. Energy policies in developing countries have not given adequate attention to the health conse- quences of the different stages of energy production, that is, extraction, distribution or transmis- sion, consumption, and pricing. Deforestation has led to added stress and threatens to reduce nu- trition in poor households, in which women spend ever-increasing amounts of time gathering firewood. Policies to increase wood fuel reserves rarely consider households suffering from "fuel poverty," the tendency of the poor to use cheaper, more polluting fuels. Efforts have been di- rected at increasing domestic fuel efficiency, but only recently has attention been devoted to im- proving housing and cook stoves in terms of health risks associated with chronic in-house expo- sure to fumes from biofuels (see box 8-2 for definitions of energy terms). The health effects of household smoke from cooking, heating, and lighting tend to take a backseat to tobacco smoke, which is known to be a confounding, if not more important, factor in respiratory illness. Fuel sub- sidies have not taken health and pollution into consideration, nor have they promoted nonpollut- ing, safe fuels. Pricing policies tend to favor urban areas, where ambient air pollution is generally greater, over rural areas. Hydropower, especially large dams, remains high on development prior- ity lists. Yet, associated health risks still do not figure prominently in project preparation and im- plementation. Findings of a Literature Review In general, literature on this sector addresses environmental health considerations mainly in terms of pollution-increasingly air pollution-and the risks of nuclear power.141 For pollution, the lit- erature has focused on the impacts of individual ambient air pollutants, especially lead, and not more broadly on those of other pollution sources, such as indoor air pollution and, in particular, tobacco smoke, as it relates to respiratory disease. (Tobacco smoke has long been established as a predisposing and exacerbating factor and, more recently, expanded to include the role of passive 157 inhalation.) Discussion of the social context-that is, physical stress from fetching fuel, the cost implications of household fuel prices on nutrition, and so on-has been lacking. Environmental health has also received ample consideration in other areas, for example, spread- ing disease vectors (e.g., snails and mosquitoes) through dam construction and hydropower, al- though their relative importance in the literature appears to be declining. The most important strides have been made in thinking out the economic dimensions of petroleum use and associated damages to human health. In terms of overall health, respiratory infections directly linked to air pollution have recently increased in importance in the literature, offsetting diarrheal diseases as the major source of morbidity and mortality. This might have occurred because the literature was overdue in finding what was already there. The concepts of "fuel poverty" and the "energy ladder" are gaining in acceptance. The poor tend to use cheaper fuels, which are more detrimental to health. As they move up the "energy ladder," they use more expensive, more efficient, and less polluting fuels and suffer fewer respiratory ail- ments. Ambient air pollution. The bulk of the literature on health and energy (as well as transport) tends to focus on ambient air pollution, with a particular emphasis on vehicular sources, even though indoor air pollution is a serious problem in rural and periurban areas. Fuel subsidies encourage use of modern, less polluting fuels, but are often directed at urban areas and those who have al- ready have climbed the "energy ladder," rather than helping rural and periurban poor move up that ladder to use less polluting fuels. Emphasis on ambient air pollution stems in part from three factors. First, the earliest studies in the 1950s were provoked by drastic episodes of this kind of pollution in London and Donorra (Penn- sylvania), although resultant studies inevitably drew attention to indoor pollution as predisposing or confounding factors. Second, indoor air pollution research in the industrialized countries has focused on tobacco smoke, which, however important, diverted attention from a range of other factors, such as heating, cooking, and lighting fuel, plus a wide array of chemicals emanating from building materials, such as carpeting, paint, and asbestos that, in extreme cases, result in "sick building syndrome." Third, serious widespread indoor air pollution, excluding tobacco smoke, is largely a rural and periurban phenomenon linked with poverty and, thus, has had less influence on research directions. Epidemiological evidence is increasing on the links among energy use, outdoor air pollution, and the incidence of respiratory illness and cancer; although few studies have recommended regula- tory measures or identified high risk populations or areas for special attention.'41 Indoor household pollution. Given the importance of respiratory ailments, indoor household pol- lution has been poorly represented in the literature and in developing countries, although it is growing in importance relative to current emphasis on ambient air pollution. Literature has documented the relationship among domestic fuel use, respiratory infections, and low birth weights, identifying biofuel use as a major hazard. This information, however, has not yet been integrated into energy policies mitigating urban or rural indoor air pollution. Developing coun- tries need better analysis of the effects of fuel gathering, its shortage, fuel substitution, and food preparation. Approximately one-half the world's population cooks with biofuels, that is, firewood, dung, twigs, and crop residues, whose use in cooking accounts for about one-third of this fuel's con- sumption. In developing countries, women and children encounter the greatest risk because of poor ventilation in poor housing. Estimates of exposure to rural indoor air pollution in developing countries are sixty times greater than those in urban areas of developed countries, and overall daily exposures are about twenty times greater.143 In addition to biofuels, coal is also a major 158 contributor to indoor air pollution (although coal does not constitute a major energy source in Af- rica). Research is under way to improve stove designs that can improve fuel efficiency, but the research does not necessarily aim to reduce smoke. Nor is such research currently a high priority in the energy sector. Householdfuel supply. Fuel supply, or more commonly, fuel scarcity, has received ample atten- tion in the ecological literature, in particular the link between deforestation and fuel poverty. Wide-ranging health consequences-the physical stress from gathering firewood, diminished nu- trition because of fuel prices, and the disproportionately higher impacts on women and children- have received less attention. The caloric energy expended to do daily chores, of which large shares are devoted to fetching fuel and water, can consume one-third of a woman's daily energy expenditure. To earn income, many women prepare food for sale, using several stoves at once or extending their cooking time in general. Both consume more fuel and increase exposure to cook- ing fumes. Conversely, to save on cost, some women shorten cooking time or flame intensity, resulting in undercooked foods that can cause diarrheas and worm infections or, in some cases, poisoning (e.g., some pesticides are broken down by heat). Similarly, low-cost fuels tend to emit higher levels of pollution. Industrial energy supply. Industrial energy supply has received considerable attention in the lit- erature; a range of new studies have been devoted to the economic evaluation of damage to hu- man health. In this regard, large cities in developing countries encounter a double-edged sword: high levels of industrial and vehicular pollution coupled with the range of indoor air pollution discussed above. Because Africa has a low level of industrial activity relative to other parts of the world, industrial energy supply is not a regional problem there, except in pockets. Most of the literature on the health effects of such pollution tend to be based on monitored air quality, ex- trapolated to humans and combined with health statistics, such as hospital emergency room ad- missions. Studies of ambient air pollution dealing with the air as it enters the lungs, for example, in the form of acid aerosols, are few. In terms of mining, occupational health literature, for exam- ple, on black lung disease and accidents, is well established. Hydroelectric power. The environmental health consequences of hydroelectric power have been similarly well documented. Dam safety has been considered integral in best practices for engi- neers, and vector-related diseases, most notably schistosomiasis and malaria, was the subject of some of the first environmental backlashes by the public described, due to development projects that neglected environmental analyses during planning. Onchocerciasis is also a problem in dam spillways. Temporary concentrations of workers and the permanent settlements that may later develop from them can spread these and other diseases. These risks, according to WHO, have regrettably "rarely been adequately addressed."144 The literature has also extensively described resettlement associated with dams. Two main analytical contexts seem to exist but do not neces- sarily dovetail: one addresses socioeconomic issues such as tenure, access to credit, community participation, and so on, and the other, with many fewer citations, deals with a wide array of health-related issues. The latter includes a decline in nutrition status from the upheaval, exposure to pollutants from industries that cluster nearby hydroelectric facilities, poor community health services that were initially intended to deal with work accidents, and so on. Competition between environmental and health objectives have unusual results and negative trade-offs. To reduce deforestation and oil imports, many developing countries are promoting coal as a substitute for wood. Where coal might not provide a feasible alternative for widespread industrial use, countries can produce or even import enough for household use. As a household fuel, coal is a particularly noxious pollutant because household stoves (compared with industrial ovens) tend to burn it inefficiently, expelling fumes within houses, which are usually designed to * The tsetse fly that spreads "river blindness" needs high oxygen content water for breeding. 159 keep the elements out and not for efficient ventilation. (Indeed, sometimes they are designed to keep smoke in to keep insects out.) Table 9-1: Main Environmental Health Linkages with the Energy Sector Sector Linkages Agriculture and rural Spread of malaria and schistosomniasis from all sized dams; indoor air pollution from use development of biomass fuels; food chain contamination and food poisoning including lead poisoning in granaries using traditional millstones reinforced with lead joints Infrastructure and Household ventilation to reduce indoor air pollution; water pollution caused by vehicu- Urban Development lar/industrial fuels (diarrhea and food chain contamination); outdoor air pollution from: vehicular/industrial fuels (especially from inefficient combustion of two-stroke engines); waste management facilities generate dust (e.g., from trucks on access roads) and toxic fumes (from incineration); health effects of climate change and global warming due to various uses of fuel Health Vector-related diseases spread through dams; acute respiratory diseases from use of poor quality household fuels; diminished operation of health facilities from energy deficit (e.g., basic lighting, no cold storage of medicines or sterilization of syringes); women's and children's health problems from fetching heavy loads of biomass fuels (e.g., injuries, mis- carriages for women), child and peri-natal health problems due to household fuel short- ages (e.g., malnutrition from fewer cooked meals, diarrheas from unboiled water) Industry Health consequences of fuel changes in small and medium sized industries; contributions to indoor air and water pollution and climate change and global warming; lead smelters; health and safety inside industrial power plants as well as surrounding areas. Environmental and Injury and disease from effects from deforestation (e.g., floods, landslides), desertification, Natural Resources land degradation from foraging for biomass fuels Source: Authors' Data. Environmental Health Assessment Checklist This section presents a set of tools that can be used to determine a broad range of environmental health issues, from which to view direct and indirect repercussions, determine which are most important, and then set priorities according to institutional capabilities and budgets. This inten- tionally broad approach gives a better idea of the range of institutions that may need to be in- volved in finding solutions. Occupational, High Risk, and Vulnerable Group In keeping with the overall poverty reduction objectives of this discussion paper, table 9-2 de- scribes the main high risk and vulnerable groups. Table 9-2: Occupational, High Risk, and Vulnerable Groups for the Energy Sector Activity Potential Health Risk Gathering traditional (biomass) fuels Accidents, exposure to disease vectors, and physical stress Fuel use, e.g., cooking, heating, and Exposure to indoor air pollutants (e.g., upper respiratory diseases and lung can- lighting cer), and accidents (mainly bums) Traditional energy production, e.g., Extremely high occupational exposures to charcoal dust from bagging and sales charcoal preparation and sales (e.g., upper respiratory diseases and lung cancer) Modem energy (LPG) use Accidents and explosions (e.g., mainly bums) Modem energy transport Truck calamities Source: Authors' Data. 160 Environmental Health Checklistfor the Sector The Energy Sector Environmental Health Checklist (table 9-3) shows the range of energy sector projects by subsector, identifies the main potential environmental health problems, and suggests remedial measures. Table 9-3: Energy Sector Environmental Health Checklist* Typical Energy Projects and Main Remedial Measures ari Components Major Health-Related Issues Comments _ Distribution and transmission Implementation TORs should inchld- Aside from installation and improve- ment of transmission lines or distribu- (a)Occupational health and safety (a)Awareness campaign and afford- l tion system, also includes upgrading, issues such as exposures to able protective gear and equip- maintenance, and rehabilitation of chemicals, excessive heat, dust, ment power facilities; provision of work- noise, biological agents such as shop equipment and maintenance ve- mosquitoes (malaria) and the hicles; management information sys- like, and ergonomic hazards for tem; technical assistance; and institu- workers during construction, tional strengthening maintenance, rehabilitation, and/or upgrading of power fa- cilities, including installation or improvement of transmission or distribution system. (b)Ambient air pollution is an issue (b)Gradual reduction of emissio'i.; t a especially for populations living reach WHO standards through within a certain distance from (as appropriate) regulatory power plants. Most common measures, economic instruments l pollutants are S02, PMIO, CO, and moral suasion; demand and other chemicals. NO, may management programs; im- also be present, especially in ar- provement of production proc- eas in which vehicular traffic esses; altemative energy sourLe. ; may increase due to activities and so on related to the installation or up- grading of power plants and/or transmission systems. Respira- tory diseases in the exposed population may increase due to such activities. (c) Resettlement of population at risk (c) Some studies show childhood can- cers due to exposure to electro- magnetic fields (EMFs) in peo- ple living around high-voltage installations or equipment. (d)Counseling (d)Physical and mental stress due to displacement of populations from construction of power plants and transmission lines (e) Adequate mitigation and prz e (e) Safety concerns for the surround- tive measures and awareness ing communities due to the dan- campaign ger of fire and explosions from accidents in the power plants and transmission system. (9 Herbicide exposures from inten- sive use of herbicides underneath Wo Awareness campaign and around electricity power lines and oil pipelines Electric power and other energy adjustment Similar to former Refer to above Refer to above * This and other sectoral checklists can be found at . 161 Typical Energy Projects and Main Remedial Measures and Components Major Health-Related Issues Comments Hydro Similar to former, but more focused on Refer to above. In addition, water and Refer to above. Implementation TORs hydroelectric generation vector-related diseases, such as schis- should include possible alteration of tosomiasis and malaria, must be con- habitats for snails (schistosomiasis) sidered. Safety concerns from acci- and mosquitoes (malaria) and aware- dental drowning may also be consid- ness campaign. ered. Other power and energy conversion: Similar to hydro. In addition, includes Refer to above. However, coal-fired Implementation TORs should include development and adaptation of other power plants and bagasse have been gradual reduction of emissions to types of power generation, e.g., ba- shown to be especially polluting in reach WHO standards through (as gasse-coal plants, environmental proj- terms of SO2 and dust particulate, thus, appropriate) regulatory measures; ects, e.g. tree planting, forest protec- emphasis must be given to respiratory economic instruments and moral sua- tion, and so on diseases. sion; demand management programs; improvement of production processes; alternative energy sources, and so on Thermal Similar to former but focused on gas Refer to above. In addition, drillings Implementation TORs should include and steam turbine generator sets and for geothermal may unearth certain proper disposal of unearthed soil. exploring geothermal sources heavy metals that may pollute surface and groundwater, thus, giving rise to certain diseases depending on the chemical or heavy metal. Source: Authors' Data. 162 CHAPTER 10: CROSS SECTORAL LINKAGES: ENVIRONMENT SECTOR This chapter briefly reviews environmental health and environment sector linkages. Coverage will be expanded in future versions of these guidelines, which, for the moment, concentrate on infrastructure sector linkages. As such, more detailed information than described below is avail- able in Chapter 8: Cross-Sectoral Linkages Agriculture and Rural Development Sector, in chapter 13 on infrastructure, and in chapter 14 on global issues. The literature review concentrates on policy determinants of environment policies as they impinge on human heath, because policy is- sues are less likely to change in the short term relative to technical issues, which are changing rapidly. Key Environmental Health Issues The main links between environment and natural resource management and environmental health not already covered in chapter 8 are the changing patterns of vector-related disease due to climate change and global warming; lost potential for medicinal drugs due to loss of flora and fauna; can- cers and cataracts due to ozone depletion; and multisectoral interactions. (For purposes of this study, various types of pollution are considered under the sector that generates them, not under en- vironment.) Findings of a Literature Review Literature on environmental health is expanding rapidly, and the topic is recognized as a separate discipline within the health field. Enormous strides have been made in precisely identifying the roles of individual factors in the etiology of morbidity and mortality. Drawing attention to the costs of human health, the literature is especially useful in categorizing and economically evaluating the effects of environment-related diseases; however, the topic of pollution tends to dominate. Scien- tific studies on pollutants tend to be focused and depend heavily on statistical significance, compli- cating their application to society at large. They are also often too technical to be read by a nonsci- entific audience, limiting the utility of their findings. The literature devotes a high degree of attention to the deleterious effects of pollution and spin-off subjects dealing with regulatory and economic consequences. Beyond these, it has been uneven in its treatment of environmental health issues. As a health field or discipline, "occupational and envi- ronmental health," despite its name, concentrates on the former. Environmental assessment proce- dures and their literature have been instrumental in drawing attention to a broad range of previously neglected health issues. Nonetheless, integration of multidisciplinary factors is still relatively weak compared with the knowledge base and the breadth of the literature. Treatment is extensive for am- bient air issues, but often uncoordinated for indoor air pollution, which can be equal to or even more important than ambient air. Uneven treatment is partly due to the predominance of specialists com- pared with generalists in modern society. This has led, for example, to attention on water pollution, but not the stress of fetching water or fuel at a distance from residences, common in much of Africa, nor the socioeconomic dimensions that can lead to the spread of vector-borne diseases, such as ma- laria or filariasis, which are often treated as health sector problems The newest topics to enter the literature in the past decade and, thus, the least developed academi- cally are the health consequences of global warming and ozone depletion (see table 14-1).145 Can- 163 cers and cataracts due to ozone depletion probably do not rank among the top ten in developing countries, given the level of existing respiratory and diarrheal illnesses and accidents. In compari- son, the numbers that global warmning and climate change could potentially affect are enormous, because of the direct consequences of the spread of vector habitats, in particular mosquitoes, and the effect of change in water temperatures on aquatic pathogens. Although the particulars of cli- mate change are still under discussion, the reality of endemic vector-related diseases is not. The important point is that, once established, vector-related diseases, such as malaria and schistoso- miasis, and waterborne diseases, such as cholera, may take 50-100 years to eradicate. Table 10-1: Main Environmental Health Linkages with the Environment Sector Environment Sector Linkages Agriculture and rural devel- Land clearing issues, e.g., loss of plant species with potentially important medici- opment nal uses; pesticide runoff; animal waste management; flooding; land pollution; marine life destruction, eventually affecting food supply Infrastructure and urban de- Air, water, and land pollution, especially solid waste management velopment Energy Air pollution, land clearing issues, and change in animal vector habitat and be- havior Industry Air, water and land pollution; climate change and global warming Health Resettlement issues: domestic waste management, choice of housing areas, and water supply and sanitation Source: Authors' data. Environmental Health Assessment Checklist This section presents tools that can be used to determine a broad range of environmental health issues, from which to view direct and indirect repercussions, determine which are most important, and then set priorities according to institutional capabilities and budgets. This intentionally broad approach gives a better idea of the range of institutions that may need to be involved in finding solutions. The Environment Sector Environmental Health Checklist (table 10-2) shows the range of envi- ronment sector projects by subsector, identifies the main potential environmental health prob- lems, and suggests remedial measures. Table 10-2: Environment Sector Environmental Health Checklist Typical Environment Projects Major Health-Related Issues Main Remedial Measures and and Components Comments Environmental Adjustment Projects include soil, water, and Vector-related diseases, such as Implementation TORs should in- forest ecosystem management; na- malaria, schistosomiasis, filariasis, clude: tional parks and ecotourism; marine and others, for communities living and coastal management; general near or within the management Vector control, especially drainage, environmental management and areas and areas where public works targeting stagnant water, and intro- public works, namely rnaintenance are being done. ducing larvivorous (larva-eating) of roads; rehabilitation of drainage fish (tilapia) as appropriate. systems; urban infrastructure; and Occupational health issues for public services. Training and tech- workers both for the enviromentl Awareness campaigns and afford- nical support and study comiponents management projects and public Aablrotessctmpivegear and equipment also occur. services construction and rehabili- tation, e.g., prolonged exposure to the sun and heatstroke, exhaustion, * This and other sectoral checklists can be found at . 164 Typical Environment Projects Major Health-Related Issues Main Remedial Measures and and Components Comments and, in the long term, skin cancer. Accidents, such as drowning, falls, and animal bites, especially for those engaged in forestry and ma- rine conservation activities as well as in the community near the activi- ties. Environmental Institutions Concerned with developing institu- Similar to above Similar to above. and preparation tional and technical capabilities for TORs should attenpt to harmonize environmental monitoring, policy environmental and environmental formulation and coordination, and health strategies and other sectoral dealing with management issues in strategies as appropriate, and foster environmental action plans. Also, multisectoral collaboration through conducts program, pilot, or other- entry points. wise on preventing soil degradation and erosion and further degradation of fragile ecosystems. Natural Resource Management Similar to environmental adjust- Similar to the above. In addition, Similar to the above, and imple- ments. In addition, village, regional, due to the waste management com- mentation TORs should include and local level investments to set up ponent, skin diseases, parasitic and adequate landfill management and natural resource management plans other infectious diseases could be restriction of waste disposal areas to and environmental information prevalent among those living near workers; awareness campaign; and systemns. Other projects may include waste disposal areas and, especially, creation of an interface that allows fisheries management, research and the scavengers. Exposure to chemi- for using the environmental infor- studies, policies and laws, water cal pollutants in the water and air mation system to map and prevent quality monitoring, industrial and from the waste may also be promi- environmental health risks. municipal waste management, land nent. use and wetland management, soil conservation, and reforestation. Pollution Control and Waste Management Mostly pollution management proi- Monitoring of respiratory diseases Implementation TORs should in- ects on water, air, and land for air pollution and heavy metal clude an awareness campaign and poisoning for both air and water emission reduction targeting popu- pollution must be considered. lation at high risk of exposure first. For other relevant diseases, refer to For other relevant diseases, refer to the natural resource management the natural resource management subsector subsector and table 9-3 for energy. Resettlement Issues of resettling populations, e.g., Mental and physical stress due to Counseling tribal groups from ancestral homes displacement. Other Environment Similar to the above with more fo- Similar to the above. In addition, Similar to the above, and imple- cus on urban infrastructure and focus on urban infrastructure brings mentation TORs should include law services, including studies on sani- in road accidents as a safety risk. enforcement (drunk driving, seat tary landfills, industrial parks, ma- belts, insurance liabilities, and so rine conservation, and so on on). Source: Authors' data. 165 CHAPTER 11: CROSS-SECTORAL LINKAGES: HEALTH SECTOR This chapter provides a brief overview of linkages between environmental health and the health sector (see box 11-1 on this and other terms). Coverage will be expanded in future versions of these guidelines, which, for the moment, concentrate on infrastructure sector linkages. See also "Devising Entry Points" in chapter 2 and chapter 16 on one attempt to bridge the gaps. The lit- erature review concentrates on policy determinants of health policies as they impinge on human heath, because policy issues are less likely to change in the short term relative to technical issues, which are changing rapidly. Box 11-1: Key, Confusing, and Misused Terms on the Heath Sector Health care system. Refers to provision of health care through a health care delivery system, con- sisting of a network of personnel and services providing medical, dental, nursing or convalescent care, and physical therapy, and a network of providers for the equipment and medications to do so. Health sector. Term with several uses that can refer to (a) the health care system, (b) lending and investments that tend to reflect the health care system, or (c) an even broader notion to include measures to protect and promote human health inside and outside the health care system. The broader public health notion would include environmental protection, private sector research, regulatory measures, and so on. Public health service. Branch of government in some countries charged with maintaining public health and safety through various services, such as occupational health and safety, sanitation, quar- antines, and so on, mainly through preventive measures. Usually considered part of the overall health care system or health sector, depending on definition. Source. Authors' data. Key Environmental Health Issues The main links between environment and public health stem from factors outside the purview of ministries of health.146 These include respiratory diseases from poor housing; diarrheal diseases from poor water supply and sanitation; respiratory disease due to tobacco smoking and air pollu- tion from transport, energy, and industry; contamination of the food chain from air and water pollution and poor storage of food; accidents; and injuries, illness, and deaths from extreme weather events, climate change and ozone depletion. Findings of a Literature Review The most important finding of the literature review was that health factors do not play an impor- tant role in policy setting, except for the health sector itself. The literature has firmly anchored the importance of tobacco smoking as a detriment to health and of nutrition as an oft-forgotten factor. The literature also reveals good understanding of both health care services as a sector, rather than simply focusing on treatment of individual diseases, and the important role of institutional fac- tors, such as health legislation and insurance. In addition, after years of neglect, the crucial role of micronutrients in nutrition and links to female literacy, coupled with women's advocacy, have made their way into the literature. The literature, however, still tends to focus on the health care system, relatively neglecting the influences of forces outside the health sector. Literature on nu- 167 trition establishes a link with anemia and parasitic infections, but concentrates on iron deficiency rather than deficiencies in sanitation as a contributing cause. Similarly, basic research priorities and, thus, the literature bear the mark of teaching hospitals and not basic public health. Despite enormous progress in combating individual diseases, fine-tuning health statistics, and developing areas of economic evaluation, many remaining health sector problems in developing countries, especially HIV/AIDS, still appear insurmountable. This notion stems, in large part, from continued consideration of the health sector as social overhead. Some problems are being slowly overcome by advances in health economics, advocacy of women's groups, and recognition of interlinkages between population growth and degradation of the natural resource base and be- tween fertility and female education. Nonetheless, much promotion of female participation has been stronger on attaining a voice, than on specifics of women's occupational or environmental health. One example is the risk of cancer from exposure to pesticides (although some articles ap- pear on the subject). Similarly, literature on anemia concentrates on iron deficiency, but gives scant attention to a major causal factor, that is, deficient sanitation and personal hygiene. The intersectoral dimensions of the health sector are still poorly developed. For example, occu- pational health is often under the ministry of industry, which usually has little in-house capacity to deal with problems of such a scale. In Africa, the ministry of health (MOH) might be responsi- ble for rural water supply, but not have the in-house engineering capacity, for example, to deal with preventive remedial measures for diarrheas and malnutrition, for example, sanitation and water supply. Human fertility analyses, for example, often do not link environment to carrying capacity, urban squalor, degradation of the natural resource base for fuel, and so on. Likewise, works on tobacco and addictive substances do not draw the link between tobacco-related health problems as a predisposing factor to other air pollution-related health problems. MOHs are notoriously weak financially and, although willing to cooperate, might not possess the competence or resources to take on additional work without compromising existing activities. Similarly, it is highly probable that they might not be able to budget for recurrent expenses, even if they have staff available. Although this statement can potentially be made about any ministry in a developing country, MOHs tend to be the weakest, except in cases of national emergencies or epidemics. The actual influence of an MOH is, thus, curtailed, because they only have input into setting environmental and occupational standards, whereas enforcement, even if adequately funded in different ministries, lies outside their portfolio A variety of occupational health problems have been documented in developing and industrial- ized countries, but only a few in-depth studies exist on the subject. Particularly lacking are studies on newer technologies and their consequences, for example, neural toxicity of substances other than heavy metals, such as lead, and reproductive effects of pesticides. Mental health problems, for example, stress, have been even more neglected than in industrialized countries. Inadequate data are a major hurdle. Existing research on occupational health concentrates on large factories, which only covers approximately 15 to 20 percent of the workforce. Workers in small industries, agriculture, and fisheries face different occupational and environmental hazards in precisely those areas in which health facilities, adequate financial resources, and political pressures are weakest. The "chemicalization" of agriculture and agricultural processing are particularly important fac- tors. Some research indicates that health problems are, indeed, more severe in these areas. Children and women are at special risk, because they form the largest pool of cheap labor. Mal- nutrition and communicable diseases are already high in these low-income groups, and resistance to other health problems is proportionately reduced. Those working in export zones, as opposed to the informal sector, appear to be healthier overall, probably because of higher incomes. 168 By and large, occupational health standards are severely lacking and, if they do exist, are not en- forced or inappropriately modeled after distinct conditions in industrialized countries. Training in occupational health overall has not been a priority in either the industrial or health sector.147 Table 11-1: Main Environmental Health Linkages with the Health Sector Sector Main Linkages Agriculture and rural development Food security and population pressure outstripping capacity Infrastructure and urban development Stress and mental health problems from rural-urban migrations Energy Indoor air pollution as a major determinant of respiratory infections Industry Air, water, and land pollution and hazardous waste disposal Environmental and natural resources Climate change, ozone depletion, and global warming Source: Authors' data. Environmental Health Assessment Checklist This section presents tools that can be used to determine a broad range of environmental health issues, from which to view direct and indirect repercussions, determine which are most important, and then set priorities according to institutional capabilities and budgets. This intentionally broad approach gives a better idea of the range of institutions that may need to be involved in finding solutions. In keeping with the overall poverty reduction objectives of this discussion paper, the material also describes the main high risk and vulnerable groups. The Health Sector Environmental Health Checklist (table 11-2) shows the range of health sector projects by subsector, identifies the main potential environmental health problems, and suggests remedial measures. Table 11-2: Health Sector Environmental Health Checklist Typical Health Projects and Components Major Health-Related Issues Proposed Remedial Measures Targeted health Projects focus on women's Same as above. In addition, emphasis Implementation TORs should include AIDS health, including family must be made for occupational health and STD awareness in conjunction with planning and sexually issues for health caregivers dealing MOH campaign targeting worker (labor transmitted diseases, espe- with hepatitis B and IRV. Also in the unions and associations) and truckers (asso- cially AIDS. Africa region, transmission of STDs ciations), a clause on AIDS and STDs (and via the truckers and work crews must possibly hygiene) in the subcontractor con- be given importance. tract, and distribution of condoms as appro- priate. Medical waste Health hazard from contaminated Preparation TORs should include identifi- medical wastes cation of the type of medical waste and ways they are segregated. Implementation TORs should consider in- cineration and proper transportation and disposal. Other population, health, and nutrition Similar to the above Similar to the above Similar to the above Source: Authors' data. * This and other sectoral checklists can be found at . 169 CHAPTER 12: CROSS-SECTORAL LINKAGES: INDUSTRY SECTOR This chapter provides a brief overview of environmental health and industry sector linkages. Coverage will be expanded in future versions of these guidelines, which, for the moment, con- centrate on infrastructure sector linkages. The literature review concentrates on policy determi- nants of industry policies as they impinge on human heath, because policy issues are less likely to change in the short term relative to technical issues, which are changing rapidly. Key Environmental Health Issues The main links to industry are (a) air, water, and land pollution from nonhazardous wastes, coupled with the special circumstances associated with disposal of toxic materials and their by-products, including contamination of the food chain, especially with heavy metals, (b) noise pollution, (c) widespread occupational health and safety deficiencies, and (d) human settlements near industrial concentrations. 148 The strengths of the literature on the industry sector stem from extensive work done on a huge array of topics, which, in turn, has been applied to general living conditions. Findings of a Literature Review Literature on pollution generation, control, and evaluation has been especially extensive. Most lit- erature on environmental health in industry, however, deals with occupational health, which, for years, has been extremely well covered in industrialized countries. Industrial Polludon and Waste Even though data on actual industrial pollution levels have increased in the past decade, only rough estimates are available for developing countries that are generally not suitable for proper analysis of the effects of pollution on health. Literature on air and water pollution is still too inconclusive to permit precise determination of cause and effect by industry or pollutant on a given population, al- though high degrees of association are possible. Several factors have hindered research, that is, in- adequate data on populations, time lags (up to 30 years) between exposure and actual disease, ab- sence of monitoring equipment, costs of monitoring, and poorly understood theoretical effects ap- plied to defined topographical conditions or applied to the siting of pollution-intensive industries. According to the UNEPVWHO Global Environment Monitoring System (GEMS), 70 percent of populations live in areas with "unacceptable" annual averages of air quality. A promising trend does appear to exist in that the number of areas in which air quality is improving is greater than the num- ber in which it is deteriorating. The high rates of illness in some areas appear to be associated with topographical factors that inhibit the natural dispersion of pollutants. The adverse effects of water pollution, similarly, are most acute in areas where industrial waste is dumped into waters near large populations. Seasonal variation of water tends to concentrate pollutants. The absence of licensing requirements for industry in developing countries makes prediction of the effects of new chemicals problematic.149 Research on the health risks of hazardous chemical waste is still in its formative stages, even in in- dustrialized countries, which have a wide range of regulatory agencies and research institutes. 171 Quantification and classification have been limited by problems of definition and inadequate data collection. UNEP and WHO have developed a system to analyze hazardous waste "from cradle to grave," and INFORM (a U.S.-based environmental research organization) has proposed a waste management hierarchy, consisting of (a) reduction in waste production, (b) recycling, (c) destruc- tion, and (d) disposal. Nonetheless, developing countries cannot coordinate all the various stages of hazardous waste monitoring, that is, production, transport, and disposal. Moreover, industrialized countries rely too heavily on pollution control rather than on broader objectives of pollution man- agement, which reduces generation of pollution in the first place and creates institutional, regula- tory, and economic incentives for businesses, industries, and municipalities. Pollution management is more difficult to implement in developing countries and, in some cases, can have unintended ef- fects. For example, regulatory measures may inadvertently make it harder to monitor transport and disposal of wastes if they are too stringent and drive service providers to clandestine operations. Occupational Health Research on occupational health in industry, although extensive, has dealt primarily with acci- dents and exposures to pollutants, but not their underlying causes, inside and outside the work- place. Researchers have emphasized the need for adjustments in health policy where the potential for change seems the greatest, for example, standards, availability of health services, training, and safe equipment, rather than overall strategies and policy changes from within those industries them- selves. Occupational health literature also does not extend to areas outside the workplace, for example, to the risks of populations living in the surrounding air shed and watershed (as opposed to general pollution analyses), and is poorly developed regarding problems in developing countries, where problems of injuries and accidents and environmental hazards of catastrophic dimensions, such as Bhopal, are particularly important. The difference in institutional responsibilities for dealing with environmental and occupational health at the municipal, state, and national levels has also not been developed. The tendency exists to consider occupational health a distinct specialty applying to the workplace and, therefore, only of tangential importance to environmental or public health. This is a fair gener- alization in industrialized countries, because a much greater portion of the labor force is employed by industries in which some form of health care or preventive measures are provided by the compa- nies themselves, national occupational health and safety regulations, or health insurance. In devel- oping countries, however, approximately 60 to 85 percent of the labor force is not similarly cov- ered, because they work in small-scale industry or agriculture, in which such provisions are absent. In Africa, these figures would probably be higher. If some national regulatory measures do exist, the likelihood is high that monitoring and enforcement are also absent. The huge difference in pro- portion of direct and indirect coverage, therefore, changes the dimensions of the problem and blurs the distinction between the general population and the workplace. An occupational health problem in developing countries, then, becomes a public health issue. Research on the Role of Governments The role of government in industrialized and developing countries in setting policy to promote economic growth has received considerable attention in the literature. The unintended conse- quences of these actions to occupational and environmental health, however, have not. Many countries, particularly developing, have specialized in areas in which they did not have prior experi- ence in producing or regulating the industries involved. Economic analysis has often not considered socioeconomic costs, such as pollution, health, and safety. Even though these considerations have increased in importance for governments, enforcement capacity has not been able to keep pace. 172 Similarly, export processing zones, compared with industrial estates, were designed to attract for- eign industry, rather than control known or predictable pollutants. Industrial estates as well as ex- port processing zones attract a large labor pool, which is potentially at high risk because of the ab- sence or weakness of adequate environmental, health, or safety provisions.150 In addition, the health risks of populations living in air sheds and watersheds near industrial concentrations have re- ceived relatively little attention from governments or in the literature, compared with in-plant hazards, except in the case of large-scale accidents. Governments often see industrial dispersion as a means to distribute income potential and reduce population pressures on capital cities. Countering this tendency is the penchant to site industries in urban areas away from neighborhoods where wealth and political influence are strongest. Industrial areas initially situated outside cities have later been swallowed up by rapid growth, typically un- planned, resulting in increased health and safety risks to the surrounding population (e.g., Bhopal). Industrial dispersion and concentration, thus, have both positive and negative aspects, depending on local circumstances.'5' Governments often inadequately weigh the benefits of either trend against repercussions on health, housing, and the natural environment. Govermments have emphasized industrial growth and social welfare by considering types of indus- trial specialization, ownership, and siting, for example, industrial zones, "with relatively little atten- tion to the consequences for health." Many developing countries are actively promoting growth of their private sector by emphasizing small- and medium-sized industries, which tend to be more lax in complying with environmental, occupational, health, and safety regulations. These trends have consequences for low-income factory workers or inhabitants near industries, resulting in part from a lack of understanding of the clear-cut cause and effect of pollution and deterioration of health. Current emphasis on occupational health and safety issues is being directed inside factories, whereas surrounding communities remain a low priority. The deleterious effects of water and air pollution and hazardous waste control have, however, been receiving increased attention. Nonethe- less, more work is needed in developing countries on understanding the health consequences of heavily polluted areas, in particular the multiple sources of different pollutants and their relative effects on the body. A Note on the Role of the Private Sector The trend toward privatization of industry and infrastructure in general is increasing, a process that will rely more heavily on economic criteria and cost reduction than on public health. Virtually no literature exists in this area, however, analyzing the long-term consequences for environmental health. Most related literature deals with the legal dimensions and standards of privatization, not its potential health consequences. The literature has not conclusively shown how foreign or domestic ownership influences environ- mental degradation or health risks. It is clear, however, that domestic firms, even though they tend to be smaller and less pollution intensive than foreign firms, are harder to regulate, leading to greater occupational hazards. Likewise, domestic firms in developing countries use and produce hazardous chemicals that have been banned or strictly regulated in industrialized countries. Al- though multinational firms might close individual facilities rather than incur the cost of pollution abatement, domestic firms do not have the capital to do so and continue operation with increased risk to workers and the environment. The type of ownership also accounts for double standards that multinational firms maintain regarding their domestic branches with breaches in occupational health and safety measures (e.g., protective clothing, training, and so on) and the use and production of hazardous materials (e.g., asbestos, DDT, or other hazardous pesticides). Multinational firms do not necessarily resist added expenses associated with these improvements, but are not asked or forced to do so by domestic governments.152 173 Table 12-1: Main Environmental Health Linkages with the Industry Sector Industry sector Main linkages Agriculture and rural development Toxic waste mnanagement and land use conflict possibly threaten- ing food supply Infrastructure and urban development Periurban agriculture and pollution management (water, air, and solid and toxic waste Energy Ambient air pollution Health Resettlement issues Environmental and natural resources Land clearing issues (can spread malaria) Source: Authors' data. Environmental Health Assessment Checklist This section presents tools that can be used to determine a broad range of environmental health issues, from which to view direct and indirect repercussions, determine which are most important, and then set priorities according to institutional capabilities and budgets. This intentionally broad approach gives a better idea of the range of institutions that may need to be involved in finding solutions. In keeping with the overall poverty reduction objectives of this discussion paper, the material also describes the main high risk and vulnerable groups. The Industry Sector Environmental Health Checklist (table 12-2) shows the range of industry sector projects by subsector, identifies the main potential environmental health problems, and suggests remedial measures. Table 12-2: Industry Sector Environmental Health Checklist* Typical Industry Projects and Main Remedial Measures and Components Major Health-Related Issues Comments Fertilizer and other chemicals To improve food security, projects Methemoglobinemia and some can- Implementation TORs should in- in this subsector are geared toward cers, such as gastric, esophageal, clude awareness campaign through developing the fertilizer sector, and bladder, have been associated research and extension and afford- including through policy reforms with exposure to fertilizers. Acute able protective gear and equipment. and promoting the safe use of fer- poisoning must also be considered tilizers by as many farmers as pos- with exposures to any chemical as sible. well as malignancies due to low- level long-term exposure. Due to exposure to night soil or manure as fertilizer, parasitism and diarrhea may also occur among farmers and other farm workers. Industrial adjustments Provision of infrastructure for in- Occupational health and safety is- Same as above dustrial estates, institutional sues for workers in industrial es- strengthening, and training of both tates. Toxic waste may also be a entrepreneurs and labor are some problem, thus, poisonings, malig- examples of the components of nancies, and fertility problems may some projects in this subsector. be of concern * This and other sectoral checklists can be found at . 174 Typical Industry Projects and Main Remedial Measures and Components Major Health-Related Issues Comments Industrial restructuring Includes projects that restructure Same as above Same as above new industrial investments, retrain- ing and lending program to assist displaced workers in the industrial sector, rehabilitation of enterprises, technical assistance, among others. Small-scale enterprises Some projects include developing Same as above. In addition, due to Same as above. Implementation export processing zones, providing improper waste disposal-a typical TORs should include, in the short capital for investment projects of problem among small scale enter- term, the identification of popula- small- and medium-scale enter- prises-diarrhea and other infec- tions at risk and determination of prises, human resource develop- tious diseases and exposure to toxic mitigative measures and, in the long ment, support for domestic enter- waste may be prevalent in the sur- term, introduction, as appropriate, prises, and institution strengthening. rounding community. of regulatory enforcement (polluter pays principle), economic instru- ments, and moral suasion. Mining Some components of projects in this Occupational health and safety is- Implementation TORs should in- subsector include attracting more sues for the miners and other work- clude awareness campaigns and investments in the mining sector; ers in the mines including silicosis affordable protective gear and assistance to small-scale miners; and other diseases of the lung equipment, including insect repel- rehabilitation of mines to increase (pneumoconiosis). Malaria for mine lant; vector control targeting stag- output, improve efficiency, and workers in endemic areas, espe- nant water; burrow pits; and intro- reduce safety hazards; and support- cially when opening new mines. duction of larvivorous (larva-eating) ing the mines department. Also, other vector-related diseases. fish as appropriate For small-scale miners of gold, use of mercury is rampant. This may result in acute poisoning andlor neurological problems. Respiratory diseases have also been shown to increase among those exposed to mercury. If mercury is used within the household, immninent risk also exists to other members of the household and to the community at large due to air pollution and toxic waste disposal. Oil and gas Exploration and development, ad- Occupational health and safety is- Implementation TORs should in- justment, transportation, refining, sues; much concern for problems of clude awareness campaigns and storage, and distribution workers in off-shore drilling opera- affordable protective gear and tions; road traffic accidents; equipment; law enforcement (drunk fatal accidents from fires, explo- driving, seat belts, insurance liabili- sions, and chemical disasters; long- ties, and so on); counseling; and term exposure to toxic waste (refer gradual reduction of emissions to to industrial adjustment subsector); reach WHO standards (see table 9- physical and mental stress for dis- 3) placed populations; and respiratory diseases for populations surround- ing refineries that may not have air pollution control Source: Authors' data. 175 CHAPTER 13: CROSS-SECTORAL LINKAGES: INFRASTRUCTURE SECTOR This chapter covers the environmental health linkages with the infrastructure sector, weaving together many seemingly unrelated topics with a common thread-urban and periurban hu- man settlements-for which linkages are strong with health. Sections on cross-cutting issues and each of the four infrastructure subsectors present a broader range of environmental health issues than those traditionally associated with physical infrastructure: * Cross-cutting issues. What are the key broad and cross-cutting environmental health is- sues, and what is special about their urban settings? * Housing and urban development. What risks are presented by living conditions in big cities and surrounding areas? How, if at all, do secondary cities differ? * Telecommunications. How are rapid changes in modem telecommunications technologies affecting health? * Transportation. What type of health risks are associated with transporting products from rural fields to urban markets? * Water supply and sanitation. How are health risks linked with drinking water, drainage, waste disposal and sanitation services? Discussion of each subsector concludes with an environmental health checklist. Key Cross-Cutting Environmental Health Issues Four environmental health issues-"brown" issues, vector-related diseases, food chain contami- nation, and AIDS-impinge on all four subsectors: "Brown " Issues "Brown" environmental issues-in contrast to "green" issues, which deal with ecology-concern pollution, a reflection of cities' inability to accommodate the effects of economic growth and ru- ral-to-urban population migrations. Traffic congestion and air and water pollution figure among the most pressing problems internationally; these are coupled in developing countries with inade- quate solid waste disposal. An understanding their economic dimensions, particularly costing the effects of pollution on human health, has gained brown issues significant attention. But they are only partially understood, because many studies have only looked at a few pollutants or their sources and not captured the full range of health repercussions. Sections on the four subsectors will explain these in more detail below; the overall picture, however, is daunting. In SSA, for ex- ample, populations in the seventy largest cities are expected to increase by 140 million inhabi- tants in 1990-2020. By 2020 a thousand medium-sized cities (50,000-500,000) will house 175 million new urban dwellers-more than the total urban population in 1990. In 1990 no SSA cities had more than 5 million inhabitants; by 2020, five will have reached that size."53 Vector-Related Diseases Vector-related diseases (see chapters 1, 8, and 9) are frequently associated with rural areas, which provide much of the habitat for the main disease vectors-mosquitoes, snails, and flies. In the 177 past few decades, migrants to periurban areas with some rural geographical features have ex- panded vector breeding habitat to urban areas. Another factor is provision of drinking water to urban areas, which has created year-round breeding habitats for vectors that were once limited by the sequence of dry and rainy seasons. Many development projects have not yet fully accepted as health risks the links among vector diseases, construction sites, and workers' camps. Technical assistance could help define relative risks by identifying potential vectors, their breeding and feeding habits, the distribution of sus- ceptible population, and the roles of drainage and construction camps. If reasonable risk exists, appropriate mitigating measures should be designed. Food Chain Contamination Although addressing malnutrition problems has become an accepted part of health care in the past decade, the impacts of food chain contamination have not. At best, studies call attention to pesti- cide use and, to a lesser extent, selected industrial pollutants, for example, mercury. The growth of agribusiness and periurban agriculture has increased pesticide and fertilizer use and reuse of wastewater, all with known risks, from diarrheas to cancer. Technical assistance can help assess practical risks by examining food sources, agricultural practices, and consumption patterns. (See "Food Production, Processing, Storage, and Transport" in chapter 8.) Special Note on AIDS All four infrastructure subsectors can play a significant role in AIDS prevention, mainly by fa- cilitating contact of health professionals with groups at risk. Compared with other sectors, infra- structure projects usually entail work crews, who sometimes reside in camps away from home, thereby presenting a high risk for contracting and spreading AIDS. Local project managers are usually in a position to provide a venue for health professionals to offer AIDS awareness educa- tion. In addition, many infrastructure projects, especially urban projects, deal with construction or upgrading of commercial centers, such as food markets, cottage industries, or industrial centers, possibly providing an effective means of communicating to hard-to-reach audiences. In the trans- port sector, well-organized trucker organizations could be tapped for educational efforts, as truck- ers play a significant role in spreading AIDS; this is particularly the case in SSA, where trucking is an important mode of transport for goods. Housing and Urban Development This section first looks at the broad picture of environmental health issues in housing and urban development, then examines key environmental health issues: housing quality and ventilation, energy use, and land degradation. The Broad Picture The main links between environmental health and housing and urban development include indoor air pollution, inadequate provision of basic shelter, drowning, accidents from poor housing sites, exposure to waste disposal, and physical stress. Housing and urban development subsector proj- ects can help alleviate respiratory disease, accidents, and vector-related diseases in many ways. Better ventilation, improved cook stoves, and reduction in overcrowding should help, but the number of variables involved have prevented statistically significant associations between these remedial measures and actual health improvement. Improvements to neighborhood environments, 178 for example, modifying paths, walkways, and cooking areas, can help reduce accidents. Improved water supply, sanitation, and drainage-frequent components in housing and urban develop- ment-when linked with increased awareness and hygiene education, can markedly reduce diar- rheal and vector-related diseases. In areas with houses already constructed over water, upgrading projects can help control drownings, mainly of infants and toddlers. Additional links include: * Search for employment and housing by rural-to-urban migrants, creating mental stress * Underlying policy factors, such as building restrictions, tenure, allocation of public serv- ices, and others, which result in poor quality housing and related health problems * High costs of some housing (sometimes government), leading to diminished food expen- ditures in low-income populations and possibly lowering nutritional intake * The tendency of marginal areas to have inadequate physical infrastructure and public services and lack consumer protections, such as property leases. Box 13-1: Key, Confusing, and Misused Terms on Human Settlements Periurban. Strictly speaking, the terms "rural" and "urban" reflect governmental administrative designations and are not necessarily based on size. Periurban refers to areas surrounding cities that have retained low-density characteristics and have substantial agricultural activity. From an envi- ronmental health point of view, periurban agriculture can (a) facilitate breeding of mosquitoes that spread malaria (which tends to be a rural disease) and (b) pollute water with agricultural and ani- mal waste. Kitchens and cooking areas. Areas used for food preparation. Defined by culture. Range from a single-room hut with no windows or a separate room with or without ventilation to a place in the open. Health consequences involve exposure to smoke from cooking fires and oils and the risk of bums, especially for children, from cooking fires or contents of pots. Markets. Covers a broad range of activities in developing countries, including sales of fresh food, clothing, household items, live animals, automobile parts, among others, or a collection of stalls for sewing clothing or producing artisanal goods for tourists. Take place in the open or in partially covered or permanent structures. May be vast or tiny, filthy or clean, muddy or dry, with or with- out electricity or refrigeration, and with or without toilets, depending on local arrangements for waste management and proper drainage. Do not refer to "supermarkets" modeled on those in in- dustrialized countries, which are also common. Ambient air pollution. In contrast to indoor air pollution, refers to outside air pollution. Pollution risks entail the six major criteria pollutants defined below, but do not generally account for the va- riety of other individual pollutants or those chemically combined with others, for example, aero- sols of sulfuric acid, which can jeopardize human health more than the pollutants monitored. Indoor air pollution. In contrast to "ambient" air pollution, refers to air pollution inside houses, workplaces, schools, and other buildings. Indoor air pollution is not monitored as regularly as am- bient air pollution. Source: Authors' data Key Environmental Health Issues The following sections describe issues that housing and urban development projects could ad- dress. Housing Quality and Ventilation Structure. Basic housing provides essential protection from extremes of heat and cold and in- clement weather, all of which can be significant determinants of disease in malnourished popula- 179 tions. Dampness also contributes to respiratory disease; recent research points to the presence of molds.154 Shoddy structures may harbor insects that spread disease, such as the "cone nose" bug, which lives in cracks and crevices of walls and causes Chagas' disease. Location. Housing location influences health as much as structure. Housing for the poor is often erected in economically marginal areas that are prone to flooding (from occasional storms or in flood plains), landslides, and so on. Other hazards include accidents (e.g., due to steepness of hills or proximity to traffic or industry) and, in houses erected over or near water, drowning. Dirtfloors. Dirt floors present two significant health hazards: (a) long-term recurrent exposure to dust and (b) exposure to intestinal worms that penetrate the feet, particularly in areas with poor sanitation. Common throughout developing countries, intestinal worms are responsible for sub- stantial disability, although low mortality. Ventilation. Ventilation may be the single most important health factor in housing, because of direct and causal health links with indoor air pollution, particularly cooking, heating, and lighting fumes. Proper ventilation can reduce respiratory infections, which are spread through close per- sonal contact, as well as respiratory irritation from smoke, which can worsen or predispose people to respiratory illnesses. Cooking area. The main health risks are exposure to cooking fumes (from cooking fires or the food itself), followed by accidents, mainly burns. Even cooking in the open produces high levels of exposure, because people spend a great deal of time close to the source. Indoor exposure to cooking fumes can be compounded by cigarette smoking. Numerous, often energy-related pro- grams have increased stove efficiency, indirectly benefiting human health. Ambient air pollution. Environmental health linkages with outdoor air pollution are addressed in discussion of the transportation subsector below. Energy Use Energy-health linkages cover a broad spectrum that go well beyond air pollution, which is rea- sonably well recognized and often tends to focus on industrial and vehicular sources. Access to electricity in rural areas is crucial to improving quality of life in many ways. It permits the "cold chain" sequence of refrigeration, ensuring a reliable supply of medications in pharmacies and health care facilities. Access to modern fuels also reduces some of the risks of indoor air pollution from burning cheaper, but more polluting traditional fuels. The section on "Housing: Indoor Air Pollution" below describes various factors. Land Degradation Land degradation can lead to injuries and deaths from landslides and flooding. Land degradation is indirectly linked to economic policies; for example, policy-related increases in fuel or land costs may encourage people to gather fuel wood or construct housing in areas prone to erosion. Table 13-1. Main Environmental Health Linkages for Housing and Urban Development Sector or Ministry Linkages Agriculture and rural "Urbanization" of rural diseases, e.g., malaria and dengue (periurban water supply and development urban commercial gardens provide year-round vector breeding habitats); food chain contamination by pesticides and fertilizers from rural and periurban agriculture; in- door air pollution and accidents from storing agrochemicals; waste from periurban agriculture and food production for urban markets Enery Contribution of heating, lighting, and cooking fuels to indoor air pollution 180 Sector or Ministry Linkages Environment Deforestation and land degradation Health Provision of health services for health impacts in subsectors, and medical facility waste Industry Settlements sited near industrial areas: risk of large-scale accidents and exposure to toxic chemicals and air, water, land, and noise pollution Infrastructure: tele- Better comnrnunications warn or prepare for "extreme events" (e.g., floods or storms) communications and facilitate emergency responses to these and industrial accidents. Other minor link- ages: reduction of traffic congestion; improved ernergency conmnunications; spread of vector habitat in temporary holes created for transmnission line poles Infrastructure: trans- Major contributor to pockets of localized air pollution, and minor contnibutor to respi- portation ratory illness through traffic fumes and dust (in African cities); pedestrian traffic acci- dents due to lack of road maintenance, erosion, and flooding; and traffic accidents involving children fetching water Infrastructure: Deficient water supply, sanitation, and drainage (major sources of excreta-related water supply and sani- diseases); deficient drainage (major contributor to insect-borne diseases and flooding, tation which can cause food contamination, injury, or death); risk of accidents to children fetching water Source: Authors' data. Environmental Health Assessment Checklist This section presents tools for use in identifying and prioritizing a range of environmental health issues and their direct and indirect repercussions and in setting priorities according to institutional capabilities and budgets. This intentionally broad approach gives a better idea of the array of pos- sible institutions to involve in finding solutions. In keeping with the overall poverty reduction objectives of these guidelines, the material also describes the main high-risk and vulnerable groups. Typical Loans and Components from the Sector The official World Bank designations for the urban development subsector are urbanization, housing, housing finance, urban development, and other urban. Many projects within the housing and urban development subsector are actually multisectoral, because they contain components from the transportation and water supply and sanitation subsectors. Construction Activities and Mosquito Breeding Beyond being an important public health problem, in nonendemic areas, mosquitoes are nui- sances and not considered significant enough to include in a public health project. Nonetheless, mosquitoes may still be important enough a problem to local residents for them to take remedial measures. Household measures could focus on water storage containers, roof catchments, and a range of water-retaining receptacles near living areas, for example, discarded tires and tins, de- funct vehicles, and so on. Malaria is statistically the most significant disease, but filariasis, den- gue, and yellow fever are also important locally (see "Malaria and Vector-Related Diseases" and table 7-6 for a description of mosquito breeding.) Studies have shown that mosquitoes favor housing construction sites for breeding. Housing. Dirt Floors and Intestinal Worms The most common worms are hookworm and ascaris. Hookworm is commonly spread near defe- cation sites, which are frequently near households, schools, and places of employment. Because 181 the larvae penetrate the feet, it is more common in poor areas where people do not wear shoes. Schools often have deworming campaigns, but reinfection levels (recidivism) are high because children are easily re-exposed at home. Deworming campaigns should be based on regular cycles, for example, three times per year, emphasizing breaking the transmission cycle within a five-year period. (Ascaris, which is spread mainly through food, is not covered here. For details on both ascaris and hookworm, see annex B.) Housing: Indoor Air Pollution Indoor air pollution is a major contributor to respiratory infections, but is neglected in housing and urban development components. It readily lends itself to remedial measures, such as adapta- tions in housing design to improve aeration, sunlight, and ventilation of smoke from cooking, lighting, and heating sources. Technical assistance based on actual and changed consumption patterns in income groups wouid help identify high-risk groups and fuels that exacerbate house- hold pollution, especially cooking fuel, which appears not to change as incomes rise.'55 Proximity to Large-Scale or Hazardous Pollution The main sources of hazardous or dangerous materials include the following: * Industrial sources: facilities involved with wood preservation, paints, chemicals and pharmaceuticals, agrochemicals (fertilizers and pesticides), explosives, petroleum refin- ing, iron and steel, textiles and dyeing, tanning, electroplating, smelting, cement, and pulp and paper. In addition, industrial waste that has entered the environment and is trapped in sediment can be recirculated by human activities, such as dredging or con- struction in areas of former industrial activity. * Food processing sources: slaughterhouses (abattoirs) and feedlots. - Granaries, silos, and grain storage near ports and harbors: facilities with frequent emis- sions of contaminated grain residue (from fumigation to prevent spoilage of stored grain in silos ), which settles in the immediate area. (Much food processing waste is not neces- sarily toxic, but poses ecological problems, because of its high organic strength, which depletes oxygen and can create indirect health hazards.) - Industrial parks or export-processing zones. Facilities that are harder to characterize, be- cause they can contain such a wide variety of industries. They are potentially, if not often, dangerous, for example, if they handle hazardous materials or produce toxic wastes. Such facilities are often run by local business groups or international companies that follow proper waste management procedures, or, as in the case of large-scale garment manufac- turing, do not produce hazardous waste. * Municipal dumps and specialized markets. facilities whose waste becomes hazardous due to its volume, for example, animal feces from the sale of animals as well as motor vehicle waste, such as used motor oil and battery acid from vehicle maintenance. Vehicle grave- yards and mounds of used tires can furnish excellent sites for mosquito breeding. Settlements near any of these sources should be examined for potential exposures and accidents. These factors are likely to be considered in projects with new construction, but harder to deal with in upgrading projects, because project scope cannot include changes in the surrounding area. Remedial measures in these cases should be to assist communities in devising self-help methods to, among others: * Build protective enclosures or barriers * Monitor pollution at the neighborhood level (e.g., low-cost monitoring kits alerting authorities when permissible pollution standards are surpassed) * Devise first-aid or emergency responses to accidents * Recycling * Tree planting. 182 In the many cities where a "potential hazard" inventory has never been prepared, a local univer- sity, NGO, or other development agency could do one at low cost. Such inventories may be as useful in identifying neglected areas, such as pollution threats that are exaggerated or underplayed because they are not known or well understood. A word of caution is needed here: many pollution abatement issues are politically explosive be- cause of treatment in the local press or other information that is based on political posturing, vested interests, and inaccurate information. Advice is available from staff who have dealt with such issues before, for example, the country offices, regional environment divisions, the Envi- ronment Department, or others with experience dealing with community participation, resettle- ment, and access to project-related information. (See also, OD4. 12 Involuntary Resettlement, OP/BP/GP 17.50 Disclosure of Operational Information, and OD 14.70 Involving NGOs in Bank Operations.) Tinkering, Cottage Industries, and Artisanal Markets Hazards in informal or small-scale shops that produce or repair products may still create hazards great enough to affect people, at least in the immediate area. Of particular importance and often neglected is exposure to lead in processing brass, copper, silver, and gold. Jewelers and metal- workers are at risk occupationally, but also generate lead waste affecting the local community. Dyeing cloth and tanning are common and impact local surface water particularly severely. Re- medial measures for proper disposal of this waste are similar to those for large-scale operations, but probably more labor intensive and more difficult, because of their scale. General Markets Waste from general markets (see definition above) can create a variety of health problems, as de- scribed below under "Municipal and Domestic Waste Generation." Likewise, markets create con- gestion resulting in air pollution and pedestrian accidents. (See "Passenger Transport: Train, Bus, Rail, and Taxi Stations" in discussion of the transportation subsector below) An urban project could make a substantial contribution to improving health by undertaking basic studies appropriate to overall fiscal management and potentially the basis for revenue generation, where such basic information is lacking. These would entail, among others, a market inventory, flow of products in or out, traffic patterns, and specific water, sanitation, and drainage issues. A component could outline the overall framework for conducting such studies over the long term, with technical assistance if necessary. Or a component could build on existing information to rec- ommend procedures for better management of environmental factors. Household-Related Injuries Risks for injury include the following: * Fire. Low-income groups commonly cook, heat, and light using methods such as kero- sene lamps, charcoal, or various biomass fuels, which greatly threaten children with the risk of burns. The risks are great of spreading fire throughout areas built of wood and other combustible materials. As income rises and people climb the energy ladder, so do the types of fuel for heating and lighting, and eventually cooking, ultimately lowering the risk of fire. * Falls. Falls are a common source of injury. Low-income housing is often constructed with inferior materials and without proper support to prevent falls from stairs and rail- ings. Uncollected domestic waste can also cause falls. * Drowning. Low-income housing sites (in particular, latrines) are often constructed over or near water. The risk of infants and toddlers falling into the water are high. 183 * Disasters and "extreme events. " Flooding, storms, and earthquakes result in a high toll of injury and death and set the stage for a wide range of diseases, many of which are exac- erbated by poor quality housing, drainage, and other conditions, especially in disaster- prone areas. * Mudslides and erosion. Housing on or near hillsides and flood plains can be destroyed in storms, leading to the same effects as disasters and extreme events. A community education, "safe stove" component in the project could help address these risks through self-help and modest constructions. Considerable work throughout Africa on stoves has more often had an ecological than safety basis. Health and safety dimensions could, nonetheless, be added. Modifications to housing designs can help prevent storm damage. In flood-prone areas, basic infrastructure, for example, retaining walls, drainage canals, and so on, can help reduce im- pacts of flooding. Planting vegetation in areas prone to erosion, especially hillsides, can help re- duce risks of mudslides and similar hazards. Fear of fire could be a strong motivation for com- munity participation, even if fire reduction is not necessarily part of the project. Occupational, High Risk, and Vulnerable Groups Table 13-2: Occupational and Vulnerable Groups for Housing and Urban Development Activity Potential Health Risk * Fetching fuel and water * Child accidents * Fuel use, e.g., cooking, * High exposure, especially of women and children, to indoor air pollutants heating, and lighting (resulting in, e.g., lung cancer) and accidents (mainly bums) * Solid waste management * Accidents and exposure to excreta and toxic materials at solid waste sites * Housing construction of workers, scavengers, and children playing after hours * Added risk of accidents for children playing after hours in unfinished con- struction * Unprotected cutting or handling by workers of asbestos construction mate- rial Source: Authors' data. The Housing and Urban Development Sector Environmental Health Checklist (table 13-3) shows the range of sector projects by subsector, identifies the main potential environmental health problems, and suggests remedial measures. Table 13-3: Housing and Urban Development Sector Environmental Health Checklist Typical Housing and Urban Main Remedial Measures and Development Projects and Comments Components Major Health-Related Issues Housing construction (including temporary worker hous- a) Pools of standing water and (a) Preparation TORs should en- ing) flooding can lead to increased sure proper measures are taken incidence of malaria and other during construction and after- mosquito-borne diseases, espe- ward to eliminate breeding and cially during the rainy season; feeding grounds and acconimo- workers and local residents are date proper drainage in flood- at risk. prone areas, especially in rainy seasons. May also be appropri- ate to include comntnunity edu- cation component. (b) If housing designs are to be b) Poor ventilation associated with specified, preparation TORs ______________ ______________ cooking, heating,_and lih ting I _ _ _ _ _ _ _ _ _ _ _ _ _ _ * This and other sectoral checklists can be found at . 184 Typical Housing and Urban Main Remedial Measures and Development Projects and Comments Components Major Health-Related Issues sources (other than electricity or should include provisions to gas) can lead to respiratory dis- maximize ventilation and, as eases, especially important to appropriate, exhaust cooking women when cooking and chil- area. If designs are completed, dren who spend time indoors. it may be appropriate during implementation to include tech- nical assistance in a community participation or other type of component. If malaria is en- dernic, housing design should include option of window screens. c) Accidents can occur during (c) Implementation TORs should construction, when workers and ensure that proper occupational nearby residents are at risk from health and safety measures are flooding, erosion, and mud- provided for workers and access slides and children are at risk of children is limited after playing after hours at construc- hours. If housing designs are tion sites; during or after im- not complete, preparation TORs plementation, when children should accommodate ventilation risk burns from unprotected and safety features (the latter cooking, heating, and lighting may be pertinent in a commu- sources; and in housing near or nity education component. over water, where infants and children risk drowning. d) Work crews can be at high risk (d) Preparation TORs should ar- for AIDS. range for health agencies to reach out to work crews. Sites and services (a) See "Housing Construction." (a) See "Housing Construction." (b) Poor maintenance of neighbor- (O) Preparation or implementation hood services can lead to a full TORs should provide for com- range of excreta- and vector- munity education and, as ap- related diseases; mnain weak propriate, cost recovery points include clogged storm schemes to cover maintenance drains, poor drainage at water costs; might be appropriate to distribution points, inadequate involve local community (in- trash collection, and special formal and fornal leaders) and needs of markets for proper NGOs, religious groups, and waste management. others. Preparation TORs should ensure that adequate water, sanitation, and drainage services are included as a corn- ponent. Drainage Poor drainage, quite common after TORs should provide for adequate storms, can lead to leptospirosis drainage. (Weil's disease), which is spread through rodent urine and poor drain- age in construction (see "Water and Sanitation") Dredging See "Ports" in table 13-9 Public facilities: markets (a) Vehicular congestion contrib- (a) Preparation or implementation utes to air pollution and injuries TORs should ensure that proper (see also table 13-9) measures are taken to identify groups at risk of pedestrian in- jury or regular exposure to ve- hicle exhausts and propose re- medial measures as appropriate. As feasible, include measures to lessen existing and prevent new congestion around public mar- 185 Typical Housing and Urban Main Remedial Measures and Development Projects and Comments Components Major Health-Related Issues kets, build wider access roads and sidewalks, install sidewalks and barriers across roads to pre- vent pedestrian crossing, and explore public safety cam- paigns. (b) Preparation designs and imple- (b) Frequently lack toilets, trash mentation TORs should allow receptacles, as well as drainage for customer and merchant from uses of drinking water, needs in new markets and, as market cleaning, and rainfall. appropriate, for upgrading. (c) Market designs should include (a) Irnproperly rnanaged solid space for waste receptacles, waste can clog storm drains, protected storm drains, and a cause flooding, create garbage plan for general waste removal. heaps in surrounding areas, and Assuring proper operation and provide breeding and feeding maintenance and cost recovery grounds for mosquitoes, flies, could be adequately addressed and rodents. Collectively, these through a community participa- can cause diarrheas, parasitic tion component. infections, and injuries. Sepa- rate attention is needed to ac- commodate waste of specialized markets, such as live animals or automobile repairs, e.g., animal excreta and motor oils. (d) See also "Water and Sanita- (d) Itemns (a)-(c) above should tion," table 13-13, for waste involve local government, management by the markets community leaders (forral and _____________________________ themselves. informal), and NGOs Public facilities: washing and See table 13-13 See table 13-13 bathing and toilets Public facilities: public buildings (a) Pools of standing water and (a) Preparation designs should flooding can lead to increased ensure that proper measures are incidence of malaria and other taken during construction and mosquito-borne diseases, espe- afterward through implementa- cially during the rainy season, tion TORs to eliminate breeding placing workers and local resi- and feeding grounds and ac- dents at risk. commodate proper drainage in flood-prone areas, especially in rainy seasons. It may also be appropriate to include technical assistance for residents in com- munity education-type compo- nent (b) Public facilities often fall into (b) Preparation TORs should in- disrepair for lack of mainte- clude maintenance programs nance, setting the stage for ac- (including, if feasible, provi- cidents and poor waste man- sions for health safety and aes- agement. thetics) (c) Hospitals should always be (c) Implementation TORs should considered a special case (see include provisions for proper "Water Supply and Sanitation waste management, citing spe- Subsector") cial conditions for industrial and other hazardous rnaterials (see also "solid waste management" in table 13-13). Water supply See table 13-13 Sanitation See table 13-13 186 Typical Housing and Urban Main Remedial Measures and Development Projects and Comments Components Major Health-Related Issues Waste management See table 13-13 Urban transport See table 13-9 Traffic management and road See table 13-9 rehabilitation Motor parks Covered motor parks can lead to Implementation TORs should incor- buildup of air pollution from vehicle porate appropriate ventilation proce- fumes inside and exhaust streams to dures and monitoring, where appro- areas and buildings nearby. Gasoline priate, and, iffeasible, cleaning up and oil leaks from vehicles can pose gasoline and oil leaks. safety hazards. Capacity and institution building Community involvement is an im- Design component to reflect the portant aspect in devising curative level of organization of local com- and preventative measures for health. munity groups and problems being Local talent is often not tapped, be- addressed. It may be useful during cause of poor community organiza- preparation to solicit help of NGOs tion, rather than lack of technical for topics difficult to deal with dur- knowledge. ing works or after project cycle, e.g., accident prevention; collection of contributions for operation and maintenance of communal facilities; appropriate methods to eliminate improper water storage, standing pools of water, or clogged drains where mosquitoes can breed; house- hold methods to reduce injuries (es- pecially bums and drowning); and efficient waste management of mar- kets and other community facilities Source: Authors' data. 187 Telecommunications Telecommunications subsector projects mostly have indirect effects on health, shown in table 13- 4 below. Health benefits of interventions are, therefore, also not significant. Direct benefits from use of telecommunications, however, can be great in the case of extreme events, such as storms and floods or major industrial accidents. In these cases, better communication facilitates rapid response of emergency health services and advance warnings for weather events. Other linkages of note exist. Of particular note for SSA, increased use of satellites can avoid ex- tension of mosquito habitats due to hole digging for transmissions poles. Satellite and other wireless communications may also reduce the need for relay stations and, thus air conditioning. This would decrease the use of chlorofluorocarbons (CFCs), lessening contributions to depletion of the ozone layer, which can cause cataracts and skin cancers (minor health problems in SSA compared with infectious diseases). Other slight benefits from better telecommunications, such as faxes and computers, might be to help reduce use of motor vehicles and, thus, air pollution. An emerging literature on global warming implicates transportation pollution as an important con- tributor. Increased temperatures can move vector habitats inland from coastal areas and farther north toward temperate climates, spreading diseases such as malaria and precipitating increases in epidemics such as cholera and plague. Table 13-4. Occupational and Vulnerable Groups for Telecommunications Activity Potential Health Risk Installing telephone poles, Exposure to vector-borne diseases, especially malaria, of road crews or local popula- and other infrastructure. tions not already exposed Working at video display Comprornised use of wrist and arm muscles (e.g., carpal tunnel syndrome), back and terminals (VDT) spine problems from poor posture during use, and possible link to cancers from ex- tended exposure Using portable telephones Increase in automobile accidents due to distraction of telephone use (same for other ________________________ machinery or dangerous equipment) and possible link to cancer from extended use Source: Authors' data. The Telecommunications Sector Environmental Health Checklist (see table 13-5) presents tools that can be used to determine a broad range of environmental health issues, from which to view direct and indirect repercussions, determine which are most important, and then set priorities ac- cording to institutional capabilities and budgets. This intentionally broad approach gives a better idea of the range of institutions that may need to be involved in finding solutions. In keeping with the overall poverty reduction objectives of this discussion paper, the material also describes the main high risk and vulnerable groups. The table shows the range of sector projects by subsector, identifies the main potential environmental health problems, and suggests remedial measures. Table 13-5. Telecommunications Sector Environmental Health Checklist* Typical Telecommunications Projects and Major Health-Related Components Issues Main Remedial Measures and Comments Installation of telephone (a) Can spread vector-borne (a) Preparation TORs should include provisions for lines diseases, especially for ma- vector control and procedure for health agency laria and dengue to reach workers. (b) Can expose work crews to (b) Implementation TORs should monitor malaria AIDS and AIDS and respond with remedial measures. Source: Authors ' data. * This and other sectoral checklists can be found at . 188 Transportation This section covers environmental health issues linked with transport, providing the broad pic- ture, key environmental health issues, and typical loans and components from the sector. An envi- ronmental health assessment checklist concludes the section. Key Environmental Health Issues The main linkages between transportation and environmental health are (a) air, water, and land pollution from fuel sources, (b) indiscriminate waste disposal of river and maritime vessels, (c) water and land pollution from maintenance of vehicles and vessels, and disposal of maintenance by-products and defunct vehicles and vessels, some of which are hazardous, (d) spread of mos- quito habitats from discarded tires and vehicles, (e) spread of diseases, in particular malaria, through transport projects, 6/ accidents from erosion of roads and transportation of chemicals and hazardous substances, and (g) contribution of transportation fuels to ozone depletion, global warming, and climate change. Health impacts of mining for construction materials, for example, includes accidents due to erosion of roads and pedestrian shoulders and spread of vector habitat from mining for gravel. Transport also plays an indispensable role in road safety, providing ac- cess to health care, schools, markets, and other services that directly affect human health. The single most important environmental health aspect treated under transportation is air pollu- tion. This focus on ambient air pollution from transport, industry and energy sources stems from its importance in industrialized countries; this emphasis has tended to overshadow the health ef- fects of indoor air pollution in developing countries. Other factors, however, are more localized, for example, mosquito breeding from road construction and rehabilitation and in discarded tires or wrecked vehicles. In addition, the role of truckers in spreading AIDS in SSA is important as a general health risk. Table 13-6: Main Cross-Sectoral Environmental Health Linkages for Transport Sector or Ministry Linkages Agriculture and rural develop- Transport, storage, and shipment of agricultural products, including pesticides ment or other hazardous materials used in formulating pesticides; periurban agri- culture; rural roads as a factor in spreading vector-related diseases; acid rain (from energy and transport), which can harm food crops Energy Contribution of outdoor air pollution to (a) indoor pollution (from cooking, heating, and lighting fuel) exacerbating its effects and (b) global warming from inefficient energy production and use; global warming can spread vec- tor-borne diseases, such as malaria, by extending vector habitats or diarrheas, such as cholera, by allowing pathogens to survive longer in the warmer water Industry Type of industrial development facilitated by transport system and type of industries clustering around ports Infrastructure: housing and ur- Contribution to indoor air pollution from vehicular emissions and to global ban development warming, which can spread vector-borne diseases, such as malaria, by ex- tending vector habitats, turning predominantly rural diseases into urban ones) Infrastructure: telecommunica- Minor contribution to reducing air pollution by reducing traffic tions Infrastructure: water supply and Disposal of vehicles contributing to spread of mosquito habitats; risk of acci- sanitation dents to children fetching water and disposing of garbage; special waste dis- posal needs of ports, railways, airports, and motor vehicles (can be hazardous, e.g., oils and battery acid) Source: Authors' data. Regarding air pollution abatement, even though vehicular air pollution is not widespread in Af- rica because the population/vehicle ratio is low, transport-related respiratory disease is serious for the population at large around public transportation depots and an occupational hazard for traffic 189 police and others exposed to vehicle congestion for long periods. (Nigeria is the only country in SSA currently considering the phase out of leaded gasoline in the medium term.) In addition, dust is an important pollutant, which is often neglected in analyses that focus on fuel-based pollution. An additional link with transport in SSA is AIDS, because of the role truckers play in contracting and spreading the disease. Besides the toll in human lives, the economic effects can be staggering. For example, a Zimbabwean trucking company reported that 3,400 of its 11,500 employees were seropositive, costing the company about $1 million in 1997 or 20 percent of their profits.'56 (See chapter 3 for more details on environmental health costs.) Fortunately, trucker groups are well organized in SSA, which can facilitate education on preventive measures. Transport has many other indirect linkages, such as facilitating disaster preparedness and emer- gency responses. Transport also plays a major role in stabilizing food prices by keeping rural ar- eas linked with markets. Interruptions to markets can increase food prices, especially for staples, in a matter of days. Although health analyses of transport often focus on motorized transport, nonmotorized village transport can reduce the burden of access to crop fields and water sources. A number of project interventions can help reduce health impacts in the transport subsector, for example, efforts to decrease ambient air pollution, a contributing factor of respiratory disease in congested urban areas. In addition, better port management can help reduce water pollution and improve handling of hazardous materials. Improved drainage can help reduce water pollution and curtail the spread of vector habitats. Enhanced road maintenance can reduce traffic fatalities and injuries, and better traffic management can help reduce air pollution, which contributes to respi- ratory disease in congested areas. Furthermore, proper disposal of vehicles can help reduce the spread of mosquitoes, and doing the same for wastes from vehicles (e.g., oils and batteries) and transport maintenance workshops can help reduce water pollution. For other areas, project inter- ventions are less clear, but do exist. Air travel is contributing to the spread of tuberculosis, which is currently staging a global comeback, and remediation of asbestos insulation in railway cars can reduce lung disease. Table 13-7. Environmental Health Risks Associated with Transport Mode of Environmental Health Risk Transport Roads and * Road injuries to drivers and pedestrians from poor driving habits, poor vehicle and road main- highways tenance, and road erosion * Water and land pollution from vehicle maintenance and road runoff and from poor disposal of vehicles, oil, batteries, and construction debris * Spread of mosquito habitat from poor disposal of vehicles and tires and road construction . Widespread occupational exposure of drivers to gasoline and exhaust fumes . Spread of AIDS and other sexually transmitted from work crews' temporary residences . Special problems of train, bus, and rail stations, including widespread exposures to fumes . Noise pollution . Transport and storage of hazardous materials, including pesticides Rail * Air pollution from vehicle congestion and servicing at stations W water pollution from runoff W water and solid waste pollution from vehicle maintenance . Noise pollution Ports and * Water pollution from (a) domestic, sanitation, commercial, and bilge waste, (b) runoff from harbors pesticides and other hazardous chemicals in storage, (c) vehicles using the port, and (d) vessel * WHO uses two standards for lead exposure: 50 micrograms per cubic rneter for 8 hours and 0.5 micrograms per cubic meter for ambient air (measurement at one point in time). The U.S. Environmental Protection Agency (EPA) sets the ambient air standard at 1.5 micrograms per cubic meter (measurement at one point in time). 190 Mode of Environmental Health Risk Transport and vehicle maintenance and disposal of defunct vessels . Injuries and exposure to hazardous chemicals from loading activities . Silage-related problemns, including exposure to fumigants and dust and grain chaff and expo- sure to hazardous materials and chemicals in storage Airports * Runoff and localized air and stratospheric pollution from runways . Spread of disease by humans and vectors, including possibly tuberculosis . Water pollution from plane and service vehicle maintenance Source: Authors' data. Box 13-2: Key, Confusing, and Misused Terms on Air Pollution Indoor air pollution. See box 13-1. Ambient air pollution. See box 13-1. Criteria pollutants. Six common pollutants often monitored in ambient air are (a) sulfur dioxide (SOx,) mainly from industrial and energy (heating) sources, (b) oxides of nitrogen (NOx), carbon monoxide (CO), ozone (03), and lead (Pb), mostly from motor vehicles, and (c) total suspended particulate (TSP) or particulate matter (PM), a general measures capturing all sources of pollu- tion, including dust. (For more information, see the glossary.) Source: Authors' data. Environmental Health Assessment Checklist This section presents tools that can be used to determine a broad range of environmental health issues, from which to view direct and indirect repercussions, determine which are most important, and then set priorities according to institutional capabilities and budgets. This intentionally broad approach gives a better idea of the range of institutions that may need to be involved in finding solutions. In keeping with the overall poverty reduction objectives of this discussion paper, the material also describes the main high risk and vulnerable groups. Typical Loans and Components from the Sector The official World Bank designations for the transport subsector are urban transport, rural roads, railways, highways, ports and waterways, aviation, and other transportation. Injuries Accidents and road safety have been a fundamental part of transportation sector projects for years. Factors contributing to road accidents include (a) lack of driver and pedestrian education (drunken driving remains a major factor), (b) poor maintenance of vehicles and roads, (c) inade- quate inspection of vehicles, (d) erosion of roads and shoulders, and (e) inadequate sidewalks, pedestrian paths, signs, and stoplights. Mitigation of these factors relies on behavioral change- generally demanding more time and labor than possible within the timeframe of the typical Bank project-and carefully designed programs with Bank help, for example, insurance and liability schemes. Children fetching water or disposing of garbage are often the victims of road accidents, especially after dark, a neglected element of accident programs. To help prevent these injuries, a component could provide lighting, signs, protective barriers, paths, crosswalks or pedestrian bridges, and education. Train, Bus, Rail, and Taxi Stations Although ambient air pollution is not considered a major health problem in SSA, the low level of vehicle maintenance coupled with the use of leaded fuel makes it potentially severe in urban 191 pockets, where the population is subjected to widespread, long-term, high-dose exposure to fumes. Clusters around public transport facilities, such as bus and taxi stations, are often near open air markets, where trucks exacerbate the problem. Occupational exposures tend to be haz- ardous for traffic police, drivers, and service station attendants, among others. Similarly, the lo- cation of schools along or near major urban thoroughfares puts children at risk. Project interven- tions include identification of risk groups, protective barriers, change in traffic flow, if appropri- ate, economic incentives or construction (e.g., space for a proper terminal) and alternatives to dis- perse congestion. Ports and Harbors Traditional approaches have focused on safety and on wastes from the port itself and vessels us- ing it, emphasizing ecological, not human health threats. Port waste covers five categories, based on the International Convention for the Prevention of Pollution from Ships (MARPOL [ 1 973, modified in 1978]) of the International Maritime Organization (IMO): oil, noxious liquid sub- stances shipped in bulk, harmful substances carried in packaged form, sewage from ships, and garbage from ships. In addition to the MARPOL categories for vessels, typical port waste includes oil residues (dirty ballast and bilge water, sludge, and fuel residues), liquid residues from transported materials, materials damaged in shipment, septage, domestic waste, and materials lost or damaged during loading and storage. Fishing industries, maritime commerce, and, if appropriate, naval operations are major players. Relatively little has been done on other pollution linkages, for example, analysis of the types of industries that tend to cluster near ports and their relative risks to the health of nearby people. These industries might include granaries and other kinds of grain storage and fumigation of silage (to prevent spoilage) resulting in exposure to fumigants by local residents and dock workers (shipping and receiving) and those cleaning vessel holds. Careful attention tends to be given to storage of flammable gases (liquefied petroleum gas [LPG], propane, and butane), especially those normally needing pressure and refrigeration (e.g., ammonia), fuels (jet, diesel, and regular gasoline), and other petroleum products, because the consequences, ranging from fires to disas- ters, are reasonably well known. Careless storage of hazardous materials, such as industrial chemicals, pesticides, and fertilizers, is more problematic, because of the larger number of people affected. Some chemicals, such as ammonium nitrate, that are common components of fertilizers become hazardous, because they are stored in large quantities, which can lead to explosions of toxic clouds. Another example are the large amounts of chlorine required by power stations and water treatment plants to disinfect water. Weak points in the system are ship-to-shore transfer, temporary and permanent port stor- age, delivery to bulk user, and distribution to and repackaging for the ultimate user. Air pollution at ports and harbors depends on the volume of traffic and the nature of commercial activities clustering around the port. These would be more appropriately covered under industry, waste management, or urban development activities. Only one SSA project, Mauritius: Port Development and Environmental Protection (1995), has had a health risk assessment of port activities. Where local capabilities or an overall port and har- bor management plan are lacking, remedial measures could help set up a mechanism to deal with long-term solutions, providing technical assistance if needed. 192 Dredging Dredging operations can spread accumulated sewage and toxic materials to surrounding areas, contributing to diarrheas, skin and eye irritations, and poisonings for those in contact with the water. Disposal of the sludge can contaminate local groundwater and surface water. In some cases, dredging can cause saltwater intrusion in drinking water, forcing local populations to rely on other sources of poor quality or more expensive water. Likewise, suspended sludge can also contaminate the food chain, if fish and shellfish are harvested. In addition, dredging can recircu- late industrial and toxic waste trapped in sediment. The health dimensions of inland navigation are similar to those of dredging and port management. Airports The environmental health hazards of airports fall into two broad categories: airport operating haz- ards and passenger hazards. For the former, the major health hazards are pollution and ozone de- pletion from jet emissions. Planes create noise pollution, greatly contributing to physical stress, which, in turn, reduces the body's overall resistance to disease. Airport runoff can contaminate water supplies. Planes and vehicle traffic contribute to air pollution in general, raising it to haz- ardous local levels. Jet fuel contributes to ozone depletion, which can cause cataracts and skin cancer (the latter does not rank high among SSA health priorities). Vehicle-Related Pollution Control Vehicle-related pollution presents a wide spectrum of potential health repercussions. Disposal of vehicles contributes to water pollution from petroleum products and batteries. Discarded tires and stripped-down auto bodies provide vector breeding habitat for mosquitoes. Regular vehicle maintenance contributes to ground and surface water pollution from washing and oil changes; however, used motor oil, if applied judiciously, can control mosquito breeding, because an oil layer on water deprives mosquito larvae of needed oxygen. Air pollution from vehicles can be considerable in localized areas and become an occupational hazard for drivers, traffic police, and vehicle service employees. Remedial measures could include technical assistance to help establish systematic recycling of vehicles and parts. This could help reduce environmental health hazards created by haphazard practices currently based largely on an item's value for reuse or resale. Depending on current re- cycling activities, technical assistance could help set up long-term measures as part of an overall program for recycling and internalizing disposal costs and health risks. Road project components can assist in the safe disposal of transport waste. Traffic management projects could provide high-risk groups with protective measures, for example, education, protective clothing and masks, and work schedules, and help overcome air pollution, for example, through protective barriers near markets and stations. Lead reduction. Inadvertent professional bias has given lead in gasoline considerable attention, diverting attention from other sources of lead (see table 7-4) posing at least as great (if not greater) health hazards. The seriousness of lead pollution, thus, depends on local conditions, par- ticularly urban vehicular emissions and these other sources. Unleaded fuel has been used in Brazil since 1993, but the literature is weak on any health aspects that may have led to the switch and no monitoring programs follow health repercussions closely. (Unleaded fuels produce by-products, aldehydes, which can produce an aerosol of formaldehyde, a known carcinogen.) Construction and Vector-Related Diseases The transportation sector contributes in three major ways to spreading vector-borne diseases, of which malaria, filariasis, and schistosomiasis are most important. First, construction activities can spread habitat for mosquitoes and snails, for example, burrow pits, sand and gravel mining, tem- 193 porary or permanent excavations, deposition of construction debris, and holes for utility poles. Second, drains and drainage areas that are not adequately constructed or maintained retain water, allowing mosquitoes and snails to breed and spreading diseases to nonendemic areas. Third, road crews can either bring in or be susceptible to various vector-related diseases. The use of "im- ported" road crews, however, appears to be declining. A major problem relates to construction activities, particularly the spread of malaria, although typically the role of truckers in spreading disease tends to receive more attention. Where drainage and waste disposal and risks of exposing local populations and road crews to vector-borne diseases exists, projects with construction activities might include vector-control components., Technical assistance would probably be available from the ministry of health for education and prophylactic medications. Roads In general, Bank road and highway projects deal with existing rehabilitation or upgrading of ex- isting networks. Health consequences derive from the condition of the road or highway and the driving abilities of users. Road safety is a generally accepted practice in such projects. In addi- tion, inadequate drainage and waste disposal at construction camps can contribute to spreading diarrheas among workers and the local population. Mining for construction materials present several health repercussions that might be significant in localized areas. Quarries and burrow pits can spread mosquito habitat and also increase the risk of accidents for workers and local children. Mining for sand and small gravel can cause erosion of roadways leading to vehicle and pedestrian accidents. Deposition of construction materials can contribute to accidents and the spread of mosquitoes. Although contractors are still often recruited from abroad, road crews from local villages are often employed, reducing the potential for spreading epidemics. When temporary construction camps become long-term or even permanent worker shelters and equipment storage areas, potential health risks markedly increase. Asphalt plants, storage of blasting materials, and fuel can increase the risk of accidents and cause local pollution, in addi- tion to the normal range of problems involved in providing shelter, water, and waste services. In these larger operations, blasting can create accidents as well as air and water pollution. Road projects could contain components for controlling pollution and vectors. Projects entailing the mining of construction materials could provide for proper disposal of debris, worker safety, and protection of mining sites through public education and barriers, giving special consideration to children. Where truckers are an appropriate audience, a component could address risk aware- ness, with technical assistance available from the ministry of health. Railways Asbestos insulation in railroad cars is primarily an occupational hazard during their construction (not an important economic activity in Africa). A significant hazard exists, however, for workers refurbishing imported older railroad cars and maintenance workers, particularly when recycling or "cannibalizing" parts; when asbestos maintenance is inadequate, train attendants and frequent passengers are also at risk. Railway projects could contain a component on waste disposal, * Resistance to disease can be limited to only one of a large number of strains. "Imported" workers may not have been exposed to local disease strains and could fall victim to serious illness that mnight be mnild to locals. Conversely, "im- ported" workers could carry a strain of malaria or another disease that could get passed on to local populations, for example, by mosquito bites, and cause a local epidemic. 194 worker and pedestrian safety, and worker protection from exposure to asbestos (the latter might require expatriate technical assistance). Table 13-8: Main Occupational, High Risk, and Vulnerable Groups for Transport Activity Potential Health Risk * Transport-related construction * Exposure of drivers and mechanics to fuel and ex- * Vehicle maintenance haust fumes, road crews to dust and surfacing fumes, * Traffic management and merchants to air pollution near heavily traveled * Operation of public transport roads, congested intersections, and passenger stations * Exposure of road crews not already exposed to vec- tor-borne diseases * Truck transport * Risk of truckers acquiring and spreading AIDS through prostitutes at various types of truck and rest stops * Road maintenance and construction project work * Risk of work crews acquiring and spreading AIDS crews through prostitutes at various temporary work camps Source: Authors' data. The Transport Sector Environmental Health Checklist (table 13-9) shows the range of transport sector projects by subsector, identifies the main potential environmental health problems, and suggests remedial measures Table 13-9: Transport Sector Environmental Health Checklist Typical Transport Projects and Main Remedial Measures and Components Major Health-Related Issues Comments Roads: (a) Mosquito-related diseases, especially (a) Preparation TORs should deterrine the rehabilitation and malaria and dengue, can be spread by importance of malaria locally and risks of maintenance extending breeding areas in water that its spreading and include provisions for has accumulated in disposed con- appropriate mosquito control in work struction materials and holes dug for sites. sand and gravel. (b) Pollution of local water from im- (b) Preparation TORs should determnine im- proper disposal of excreta and do- portance of vector-related diseases locally mestic waste at work camps, leading and risks of their spread. Should include to vector-related diseases, particularly provisions for proper waste disposal and malaria, filariasis, and, sometimes, vector control as appropriate. schistosomiasis. (c) Road erosion due to digging for sand (c) Preparation TORs should contain provi- and gravel, leading to pedestrian and sions for safety, with appropriate instruc- vehicle accidents tions for subcontractors providing the materials and conditions for disposal of debris. (d) Flooding and extension of vector (d) Preparation TORs should contain provi- habitats from impropeily disposed sion for safe disposal of mining debris. mining debris. (e) Asphalt production and work dust can (e) Preparation TORs should include provi- cause local air pollution, aggravating sions for worker health and safety. Im- respiratory disease. plementation TORs should contain provi- sions for reducing air pollution as appro- priate. Designs should incorporate provi- 69 Commnunal and rural road projects sions accordingly. may require special assistance to edu- CL) TORs should contain provisions for cate community on hazards described community education awareness with above help from local NGOs as appropriate. I (g) See also "Roads: Drainage" (g) See also "Roads: Drainage" * This and other sectoral checklists can be found at . 195 Typical Transport Projects and Main Remedial Measures and Components Major Health-Related Issues Comments Roads: (a) Conditions and risks are similar to (a) See "Rehabilitation and Maintenance." construction those of "Rehabilitation and Mainte- nance," except on a large scale. (b) On a large scale, greater probability (b) Implementation TORs should cover of established work camps and expa- worker protection and education (as ap- triate personnel contributing to the propriate) and basic on-site health facili- spread of vector-related diseases and ties (as appropriate). AIDS Roads: (a) Blockage of stormn drains plus inade- (a) Implementation TORs should provide for drainage quate drainage of general area can regular maintenance of storm drains, pos- cause flooding, contamninating water sibly requiring a component for conmmu- supply and causing injuries. This can nity education and participation, Designs cause vehicle and pedestrian acci- should include appropriate provisions for dents and spread mosquito-related proper drainage of project zone and con- diseases. tiguous areas. (b) In rural and periurban areas near (b) If schistosomiasis is endemic in the gen- dams and irrigation schemes, blocked eral region, implementation TORs should drains can extend snail habitat and provide for appropriate preventive meas- spread schistosomniasis. ures to keep drains from spreading habi- tat. A health component might also be appropriate to curtail further spread. (c) See "Drainage" in Water and Sanita- (c) See "Drainage" in table 13-13. tion subsector below. Roads: Liquid and solid waste from workshops Designs should include proper waste dis- workshops can contamninate local ground and surface posal facilities. water supply and spread vector habitat by creating breeding grounds. (notably, motor oil can be reused for mosquito control.) Roads: Safety components can be useful in ad- Implementation TORs should incorporate, as safety dressing a wider range of issues than appropriate, these wider health and safety traffic accidents: (a) accident prevention concerns. in construction activities, (b) safe han- dling of hazardous chemicals and wastes, and (c) AIDS and sexually transmitted diseases (STDs), including inumuniza- tions for vector-related diseases and STDs. Roads: (a) Improper disposal of excreta and (a) Preparation TORs should determine the private sector domestic waste at work camps can importance of vector-related diseases lo- development pollute local water leading to vector- cally and risks of their spread. Imple- (abor intensive) related diseases, particularly malaria mentation TORs should include provi- (and sometimes schistosomiasis). sions for proper waste disposal and vector control as appropriate. (b) Work crews, particularly not local, (b) Preparation TORs should provide for can introduce vector-related diseases appropriate immunizations and education. and can spread AIDS and sexually transmitted diseases. Roads: Ecological issues could be enhanced to Preparation TORs could also address reduc- conservadon include preventive measures for workers tion of disease vectors in consultation with management spreading disease vectors. the MOH as appropriate. Traffic management Air pollution can be an important direct Preparation TORs should define appropriate or predisposing factor for respiratory high-risk groups and current air pollution disease and increased lead level in the monitoring efforts, assess relative hazard blood of the population at risk (resulting with the MOH, and propose designs as ap- in lowered IQs for children and cardio- propriate, e.g., protective kiosks and masks vascular diseases for elders). High-risk and barriers, Vitamin A supplements for groups are traffic police and concentra- children with lead in the blood in the short tions of people at congested areas (espe- term and introduction of unleaded fuel in the 196 Typical Transport Projects and Main Remedial Measures and Components Major Health-Related Issues Comments cially bus and taxi stations) and markets, long term schools, and workplaces near heavily traveled roadways. l Pollution (a) For air pollution see "Traffic Man- (a) For air pollution see "Traffic Manage- management agement" ment." (b) For water pollution, see "Ports" be- (b) For water pollution, see "Ports" below. low. Railways: (a) Passenger trains can contribute to (a) Preparation TORs should determine if rehabilitation excreta- and vector-related diseases in excreta removal is a problem If so, im- congested areas where toilets empty plementation TORs should recommend directly onto tracks. locally acceptable methods for collection, removal, or disinfection. Community education component might be advisable (b) Combustion engine smoke can be (b) Preparation TORs should determine if major contributor to respiratory dis- smoke is a problem. If so, recommend lo- ease to residents in railway air shed. cally acceptable methods. Might require design modifications or other protective measures, including using trees as barri- ers for pollution. Community education component might be advisable during implementation. (c) Rehabilitation of railroad cars can (c) Implementation TORs should include expose workers to asbestos (used in worker protection measures. insulation). Railways: See "Roads: Workshops." See "Roads: Workshops." workshops Ports (a) Storage and transport of hazardous (a) Preparation TORs should determine types chemicals can cause serious damage and volume of hazardous chemicals to workers and any local population passing through, and, as appropriate, im- exposed to regular transport or acci- plementation TORs should design safety dents. component. (b) Preparation TORs should include provi- (b) Traffic congestion can lead to air sions for assessing traffic management pollution and accidents. data on congestion, pollution, and port accidents, and inplementation TORs should include recommendations for im- provements. (c) Vessels can cause pollution from (c) See "Ports: Maine Pollution." domestic and hazardous waste (see "Ports: Marine Pollution"). Ports: Improper disposal of sludge can (a) pol- Preparation TORs should contain provisions dredging lute surface water and groundwater and for appropriate disposal of sludge in terms of lead to diarrheas and poisoning (from pathogen removal, chemical content, and chemical content) and (b) create mos- vector breeding. quito breeding grounds causing malaria and filariasis and other vector-borne disease. Ports: (a) Petroleum refinement and shipping (a) Preparation TORs should make provi- petroleum and can cause air and water pollution. sions for appropriate treatment of waste, cement terminal Uncontained fires and accidents at re- controls for air pollution, emergency pro- fineries can become world-class dis- cedures, and first aid. May require formal asters. loan and credit covenant. (b) Preparation TORs should ensure that (b) Cement dust is primarily a nuisance, assessment of dust is considered. Imple- but an important irritant to workers mentation TORs should make appropriate and residents in the air shed, causing recommendations for dust reduction from skin and eye disease and predisposi- manufacture and local transport. tion to respiratory disease. 197 Typical Transport Projects and Main Remedial Measures and Components Major Health-Related Issues Comments Ports: (a) Discharge of domestic wastes from (a) Preparation TORs should recommend marine pollution pleasure craft, commercial boats, and provisions for pleasure, commercial, and passenger transport, worsened by ab- passenger boats. Solid waste component sence of convenient onshore waste might be advisable. Imnplementation discharge points, can lead to excreta- TORs should include consumer education related diseases and skin and eye in- and might also require special considera- fections. tion for signs, translations, and so on. (b) Implementation TORs should include (b) Discharge of mnaintenance and bilge provisions for pollution monitoring in cleaning can contaminate food sup- ports and make appropriate recommen- ply, if seafood and shellfish are har- dations. vested locally. Ports: See "Roads: Workshops." See "Roads: Workshops." workshops Rivers See "Ports" See "Ports" Airports and (a) Air and water pollution from plane (a) Preparation TORs should ensure provi- aviation fumes and fallout can exacerbate res- sions are made to reduce air-noise-water piratory illness. Noise pollution can pollution as much as possible. They contribute to stress for workers and might entail designs for physical barriers nearby residents. Ozone depletion and zoning plans and laws to control caused by jet fuel can contribute to flights. Response to ozone might be ap- cataracts and cancers. propriate in collaboration with Global Environment Facility activity. (b) Implementation TORs should contain (b) Traffic congestion from vehicles provisions for proper traffic management. servicing airports can lead to air pol- lution (and possibly accidents) (c) Preparation TORs should contain provi- (c) Hazardous chemicals (including tem- sions for handling, storing, and trans- porary storage and transits) porting hazardous waste, including first- aid and washing facilities for workers. (d) Implementation TORs should contain ... Possibility of air accidents provisions for formulating and imple- menting emergency airport procedures. (e) Implementation TORs should contain (e) Basic health precautions for intema- provisions for collaboration with MOH tional travelers on appropriate inspection, inoculation, and quarantine procedures as appropriate. Airports and See "Roads: Workshops" See "Roads: Workshops" aviation workshops Capacity and (a) Inadequate attention to road and (a) Preparation TORs should contain provi- institution building: driver safety can cause accidents from sions for maintenance, enforcement, and public health and a myriad of factors: poor maintenance public awareness campaigns as appropri- safety of vehicles, drunk driving, and no ate. Involving NGOs in community par- driver education or seat-belt cam- ticipation might be advisable. paigns, among others. (b) See "Capacity and institution building: (b) Truck drivers are at high risk of AIDS awareness and prevention" below. spreading or getting sexually trans- mitted diseases. See below for AIDS. Capacity and Truckers can be major factor in spread- An education component is appropriate for institution building: ing AIDS and other sexually transmitted truckers. It may also be appropriate to con- AIDS awareness and diseases. In small towns, depots, and sult with the MOH, religious groups, or prevention places where flooding has forced travel- NGOs to "tailor" a response and, if appropri- ers to congregate local circumstances ate, incorporate it into the project. might allow for a tailored response not possible in cities. Source: Authors' data. 198 Water Supply and Sanitation This section covers environmental health issues linked to water supply and sanitation. It first dis- cusses the broad picture and key environmental health issues, then concludes with an environ- mental health assessment checklist. The Broad Picture and Key Environmental Health Issues Water, sanitation, and drainage have their greatest impacts on diarrheas and vector-related dis- eases. Provision of clean drinking water can markedly reduce diarrheas by providing basic hy- giene, but must go hand in hand with improvements in sanitation; lack of it is one of the major reasons that water is contaminated. Improved sanitation reduces intestinal parasites. Better waste management and drainage plus improved water storage at the household level can reduce the spread of mosquito habitat and reduce flooding, which causes injury and death and may lead to food and water contamination. Proper management of waste disposal sites can help reduce water and air pollution that affects workers and residents near disposal sites. Table 13-10. Main Environmental Health Linkages for Water Supply and Sanitation Sector or Ministry Linkages Agriculture and rural Transport, storage, and shipment of agricultural products (waste problems, traffic injuries, development and air pollution); rural road construction, maintenance, and work crews (spreading vec- tor-related diseases); water supplies (contamination with pesticides and fertilizers) Energy Contribution to indoor and outdoor air pollution from cooking, heating, and lighting fuels and to global warming from inefficient energy production and use. Global warming can spread vector-borne diseases, such as rnalaria, by extending vector habitats or diarrheas, such as cholera, by allowing pathogens to survive longer in the warner water. Industry Type of industrial development facilitated by transport system and the type of industries clustering around ports (air pollution, hazardous waste, exposure of nearby residents to industrial accidents) Infrastructure: housing Contribution to indoor air pollution from vehicular emissions and to global warming (can and urban development spread vector-bone diseases, such as malaria, by extending habitats, tuniing predomi- nantly rural diseases into urban ones) Infrastructure: Minor contribution to reducing air pollution by reducing traffic telecommunications Infrastructure: water Disposal of vehicles contributing to spread of mosquito habitats; risk of accidents to chil- supply and sanitation dren fetching water and disposing of garbage; and special waste disposal needs of ports, railways, airports, and motor vehicles (can be hazardous, e.g., oils and battery acid) Source: Authors' data. Key, Confusing, and Misused Terms Confusion abounds in the use of waste management terminology. Because so many systems worldwide consist of sewerage and buried storm drains, many terms have acquired meanings per- tinent to industrialized countries, but that adopted by professionals around the world. Their appli- cation, however, is not always appropriate in developing countries. Engineers recognize each other's "dialects" and readily overcome semantic differences. Misinterpretation and misuse oc- curs, however, when nonspecialists-task managers to mayors-use the terms in project man- agement. The problem is exacerbated when multidisciplinary teams work together-a factor to be encouraged-but, one that leads to many health dimensions falling between the cracks, because terms of reference and other documentation do not always include definitions. For example, in some places, "sanitation" refers mainly to street cleaning, but an environmental dictionary also defines it as culling diseased branches from trees. The job of a "sanitary inspector" changes from 199 maintaining overall neighborhood cleanliness in one country to surveying the food industry in another. The definitions in box 13-3 refer to the main health dimensions of waste management as used in this work (also see the glossary). Sanitation and drainage represent two ends of a spectrum of services in waste management with different emphases and, together with medical care, are at the core of public health. Box 13-3: Key, Confusing, and Misused Terms on Sanitation Sanitation. Deals with wastewater and solid waste (see below). Removal of human excreta should be considered uppermost, coordinated with its appropriate treatment and proper disposal, which will depend on local circumstances. The importance of solid waste will vary depending on its content and amount, but can be equally important. Wastewater. Generally refers to the removal of liquid waste, which consists of sewage (mainly excreta) and sullage (also known as gray water (from bathing, laundry, and food preparation in domestic, industrial, and commercial uses). Sewage and sometimes sullage are conveyed in sew- ers. The sewer network is sewerage. Sludge is a residue from sewage treatment. Sewage treat- ment consists of three interrelated stages, for which the full sequence is not always considered necessary: "primary treatment" focuses on physical removal, for example, of grit, grime, and grease; "secondary treatment" emphasizes biological quality for the receiving waters; and "terti- ary treatment" addresses the remainder not eliminated in primary and secondary stages. (Even after tertiary treatment, however, water is not necessarily suitable for drinking.) No commonly used term exists for the wide range of nonsewerage options, such as latrines or septic tanks. Solid waste. Refers to nonliquid waste emanating from domestic, commercial, and industrial sources. "Municipal waste," "domestic waste," and "garbage" generally refer to the same thing and constitute the bulk of solid waste. It can, however, contain some excreta, deposited directly or as sludge. Solid waste also covers toxic and hazardous waste. "Hazardous" and "toxic" waste are generally synonymous and require special handling, but have a slightly different emphasis. Mate- rial can be hazardous in terms of a risk of fire and injury without necessarily being toxic. More important is the distinction between industrial wastes, which will vary in type and volume from city to city, and hospital waste, which is likely to consist of the same types of waste. Drainage. Deals with the removal of excess storm water and gray water or sullage. The overrid- ing concern of drainage is removing water, which has not necessarily been contamninated. Pre- vention of flooding and attendant risks of injury, drowning, loss of housing, and contamination of drinking water are the prime health concerns. The spread of vector (e.g., mosquito) habitats will vary depending on local circumstances. Source: Authors' data. Environmental Health Assessment Checklist This section presents tools that can be used to determine a broad range of environmental health issues, from which to view direct and indirect repercussions, determine which are most important, and then set priorities according to institutional capabilities and budgets. This intentionally broad approach gives a better idea of the range of institutions that may need to be involved in finding solutions. In keeping with the overall poverty reduction objectives of this discussion paper, the material also describes the main high risk and vulnerable groups. Typical Loans and Components from the Sector The official World Bank sector designations for the water supply and sanitation subsector are ru- ral water supply and sanitation, urban water supply, and other water, solid waste, water supply and sanitation, and sewerage. 200 Project interventions can play an important role in control of water and sanitation-related diseases and hinge on three key factors: * Protection of drinking water quality and provision of adequate quantity * Provision of adequate sanitation and drainage * Hygiene education that covers personal, domestic, and food preparation habits. Hygiene education is as important as water quantity and quality, sanitation, and drainage, but is not discussed below, because the likely type of project response would be a component based on the socioeconomic and behavioral aspects of water and waste management. Such components are not unique to infrastructure, but would be in keeping with the general desirability of community involvement. Water Quality and Quantity Basic water supply services include, among others, open wells with buckets, boreholes with pumps, roof catchment systems, communal fountains and standpipes, and yard taps and house connections. Infrastructure projects even outside the water and sanitation subsector can contribute in a variety of ways to eliminating diarrheas through components that address any of the three factors noted above. The primary lesson from the literature points squarely to the need for water and waste management as an integrated set of services. Oral rehydration therapy (ORT), that is, providing packets of essential nutrients to replenish those lost through dehydration, is one of the most important curative interventions, which should also be considered to combat diarrheas. Sanitation and Drainage From a health perspective, water supply, sanitation, drainage, and hygiene education should al- ways be considered as a package, although project responses will vary enormously and not neces- sarily contain all four. About 75 percent of the water introduced into areas for domestic and in- dustrial uses, plus rain water, need to be removed. Nonetheless, sanitation and drainage are fre- quently neglected, because political pressure is strongest for promoting water supply rather than sanitation and drainage; politicians like to cut ribbons at dams and airports, not at sewage treat- ment plants and latrines! The range of complementary services between the two consist of collec- tion, removal, and disposal of: * Exereta, in solid and liquid forms * Liquid wastes, whether contaminated or not with excrement, and excess water from pre- cipitation, * Solid wastes, whether domestic or industrial, contaminated or not with excrement and hazardous materials. The emphasis accorded to each depends on local conditions. Because sanitation and drainage tend to be forgotten, they are described in detail below. Sanitation technologies for the safe collection, removal, treatment, and disposal of human excreta range from off-site sewage treatment plants to on-site latrines. The key factors in all the above situations are the degree to which fecal matter can be rendered biologically safe through natural or biochemical methods to release to the natural environment or kept from reaching humans, while still pathogenic. In this regard, the choice of on-site and off-site options are important, because the reliability of the system will, in turn, determine the potential for exposure. Because excreta removal is so im- portant to the control of water and sanitation-related diseases, table 7-5 above lists the main ex- creta-related diseases and their control measures. 201 Sewage treatment spans a wide spectrum of options, selected according to local circumstances. Too often, the "latest and the best" are bought for political rather than technical reasons. Even if they are expensive, off-site systems may be appropriate in high-density urban areas for disposing of excreta, but they can also be disasters, for example, when frequent power outages, service cuts and scheduling, or low pressure are inadequate to maintain the self-cleansing capacity of sewer- age. An insufficient quantity of water means that solids and suspended solids may settle and clog the system; in extreme cases, the sewage can evaporate and become a solid crust. Many on-site or off-site alternatives have been designed to accommodate smaller amounts of water or have other factors adapted for collection, treatment, and disposal in developing coun- tries. Small bore sewers, for example, have the added advantage of not needing to be buried so deeply, allowing for reduction of construction and maintenance in appropriate situations. Where land is available, waste stabilization ponds allow nature to do most of the work after wastewater is conveyed to the ponds through conventional sewers or other means. Long retention time allows pathogens to die off or otherwise lose their viability; worm eggs settle to the bottom and can be removed in the sludge. Many of these are low-cost systems designed to be upgraded. Ventilated improved pit (VIP) latrines, septic tanks, pour-flush, and low-volume flush toilets all have inter- esting features, which provide different service levels that can accommodate the needs of differ- ent users. "Gray water" or sullage is frequently discharged from buildings without any treatment, but needs to be considered separately for two reasons. First, accumulated water should be removed to avoid providing mosquitoes with breeding habitat or exposing children playing nearby to contaminated water. Second, treatment needs of gray water are different, because, theoretically, it does not contain fecal pathogens; gray water often does, however, contain high pathogen levels, because of overall poor sanitation. Gray water can be accommodated by soakage pits, drainage pits, or a range of lined and unlined and covered and uncovered drains and is often emptied into sewers. The key factor in avoiding health hazards is the degree to which the drains can be kept flowing freely, ponding avoided, and accidents posed by the drains themselves prevented. Disposal and Treatment of Human Excreta Sewage, septage, night soil, gray water, and other forms of wastewater and their sludges can all contain fecal matter responsible for a broad range of diseases that include diarrheas (most com- mon or serious are dysentery, gastroenteritis, cholera, and giardiasis), intestinal worms (most common or serious are hookworm and ascariasis, but others include tapeworm, threadworm, and whipworm), hepatitis, typhoid, polio, and a range of fevers and blood parasites. In addition, fila- riasis and schistosomiasis are spread to humans indirectly by mosquitoes, and snails, respectively, which depend on excreta for their life cycles (see tables 7-5 and 7-7). The diarrheas and intestinal worms are epidemiologically important and their economic impacts significant throughout Africa; the others can be important in pockets (see table 7-6). Animal excreta is an important factor where exposure to animal urine exists. Leptospirosis (Weil's disease) is spread by exposure to urine of rodents (especially rats), dogs, swine, and cat- tle. It is an important occupational hazard for scavengers or "pickers" at sanitary landfills and other solid waste disposal sites. Waste stabilization ponds and conventional treatment. Task managers and governments fre- quently confront a confusing array of sewage treatment technologies. Waste stabilization ponds (sewage lagoons or oxidation ponds) and conventional sewage treatment (activated sludge, trick- ling filters, and so on) represent two ends of the operational spectrum with different emphases and measurement criteria, but are seldom compared as alternate options. Conventional treatment (with the exception of chemical processes) merely speeds up natural processes. Nearby human settlements complicate the issue by imposing time and space constraints on waste treatment. 202 Ecological standards include biological oxygen demand (BOD) and chemical oxygen demand (COD) (see glossary), and public health standards include pathogen reduction. Conventional treatment plants can deliver high levels of BOD reduction, but organic matter remaining in the effluent is technically pathogenic (although not necessarily posing a public health threat, because it is diluted and dispersed in receiving waters). In comparison, waste stabilization ponds can ren- der effluent up to 99 percent pathogen free. As a rule of thumb for a city of 1 00,000, a waste sta- bilization pond system would need about 15 hectares and take about one month (more sun and a higher temperature reduce time, but not necessarily space), but other alternatives are available that reduce space requirements. In comparison, a conventional treatment plant occupies 1-2 hec- tares and requires only a few hours for treatment. (Table 13-11 summarizes this discussion.) Table 13-11: Highlights of Waste Stabilization Ponds and Conventional Treatment Type of Treatment Objective Advantages Disadvantages Conventional treatment High removal of Smaller overall processing High capital cost and high opera- organic matter (low area and shorter treatment tion and maintenance and skilled BOD) for direct re- time labor requirements. Poor patho- lease to receiving gen removal and needs tertiary waters treatment. Produces large vol- umes of sludge Waste stabilization High removal of Low capital costs and Land requirement high for hold- ponds pathogens and pre- flexibility in operation. ing ponds pares for land dis- reasonably pathogen-free posal or to receiving effluent. Low operation waters and maintenance. Can reuse effluent Source: Authors' data. Undefined technology in sewage treatment. In many new projects, technologies for sewage treat- ment are often not yet determined before the project appraisal or negotiations stage, especially in those with privatization. Bidding documents or other contractual arrangements should, therefore, consider environment and health in specific clauses. Because sewage treatment technology is so varied, sections on technology choice should clearly describe pathogen removal or equivalent health analysis in setting effluent standards. This is important, because health criteria are often neglected or presumed covered under ecological criteria such as BOD. Engineers do not confuse biochemical water quality with pathogenicity, as do many others involved in managing water quality. Even when public health is the objective of sewage treatment, the engineer running the plant will be more concerned about the toxic chemicals being used (because they can compromise biochemical processes, corrode machinery, or even force a shutdown of the plant) and less be- cause untreated water could poison people or cause an epidemic. It may be necessary to include a special covenant in the loan or credit to ensure public health criteria are met. It is most important to ensure that excreta disposal is considered a dimension of water supply projects. The precise components might be straightforward excreta removal and safe disposal, with explicit mention of health criteria and technology choice adapted to local conditions and consumer demand. In periurban areas, a component might deal with the often neglected special requirements of animal excreta. Any of the above should consider including community educa- tion and worker protection elements. Because technology choice is so important, technical assis- tance may be appropriate as a separate component to match local conditions with feasible options or as a workshop during project preparation. Solid Waste Management Solid waste management can be a significant part of any project, even if not formally identified as a component, for example, deposition of construction materials in any sector. Solid waste man- agement is broken into municipal and domestic, hospital, and industrial waste management, be- 203 cause their technical requirements for safe handling and disposal will vary, especially if they contain toxic, hazardous, or radioactive components. In addition, recycling, scavenging, accidents and safety are important factors. Solid waste disposal also plays a key role in controlling diarrheas and intestinal worms, but often emphasizes smell and unsightliness more than sound epidemiology. The waste disposal process consists of: * Collection from the household to local consolidation points * Sometimes transfer to a station, which further consolidates the waste for bulk transport in trucks or other means * Transport to the disposal site * Operation of the disposal site itself. From a health perspective, the first and last stages are most important; each stage, however, has public and occupational health and safety concerns. An important but often overlooked institu- tional aspect of these concerns is that different municipal or regional agencies as well as private contractors may be responsible for each of the four steps, including the three collection stages; thus, even though health and safety concerns might be clear from the household to the disposal site, they can easily fall through institutional cracks because terms of reference, budgets, and le- gal jurisdictions do not spell out details on monitoring or responsibilities for enacting corrective measures. The household and neighborhood stage is important, because diarrheas are most prevalent in chil- dren and infants, who spend most of their time there and are exposed to a wide range of contami- nants. The neighborhood level is also problematic in management of the whole waste disposal system because of the enormous role socioeconomic and behavioral factors play in organizing and paying for waste disposal. Poor solid waste collection at the neighborhood level can lead to clogged drains, which can spread filariasis, and an accumulation of small containers, which pro- vides breeding habitat for mosquitoes that spread dengue fever. These are particular problems in poor neighborhoods. At the disposal stage, the greatest hazards are contamination of groundwater and overflow from the site during rains. Children are also at risk, because they are often the ones charged with dis- posing of household waste and go to disposal sites to play.'57 Municipal and domestic waste. Water and sanitation subsector projects will probably always ad- dress domestic and municipal waste issues and might also include hospital, industrial, and other specialized wastes. The main problem normal domestic and municipal waste present in waste dis- posal projects is groundwater and surface water pollution from leachate (an accumulation of liq- uid seeping through the waste) and runoff. Leachate should always be considered potentially toxic and treated accordingly. Its toxicity, however, will have destroyed most pathogens. Those responsible for transporting waste from households to collection points and scavengers are at high risk, because they require appropriate protective gear to prevent direct contact with the waste, which could contain fecal and toxic material. These are consistent weak links in the chain of personal hygiene and public health. Projects can make a difference through community partici- pation components that study and design activities to be implemented outside the project, for ex- ample, access paths where trucks cannot pass to ensure the safety of those carrying waste from within the neighborhood to the collection site. Another example is encouraging wheelbarrows and other transport containers that are more hygienic than open baskets. Equal managerial attention should be given to transfer stations. Although the volume of waste transferred and vehicle traffic varies, lack of supervision can lead to enough waste strewn about to contribute to water pollution, noxious odors, and vector breeding. 204 During construction or rehabilitation of landfill sites, traffic and dust can pose a major problem to nearby populations. Standard best practices for occupational health and safety procedures already exist and should be implemented. After construction, traffic and dust may continue to be prob- lematic along access roads. Dust can be a major irritant, causing or predisposing individuals to a full range of infectious and noninfectious respiratory disease; scheduling truck deliveries to off- peak traffic hours can sometimes help. Design of remedial measures outside the project area's access roads is difficult. If the access route happens to be near or through a poor residential area with already high levels of respiratory disease, it might be advisable to work with the ministry of health or community groups to design a road upgrading program, such as tree planting, to help filter the dust. In general, the project could deal with access roads as an extension of the landfill site, even though, they may not technically be part of the project. Often overlooked as a health hazard is air pollution from the waste itself. Dust is frequently only considered a nuisance, but can be considered a health hazard if it contains residues from industrial waste. Covering the waste with tarps or soil at the disposal site for transport can help curtail the problem. In addition, fires are often intentionally set to reduce waste volumes, and spontaneous fires are a regular problem; both contribute to air pollution. Throughout operation of a landfill site, new areas must be dug to accommodate additional waste until the site completely fills up and is definitively closed. Site development and extension can pose recurrent health hazards. Two factors are extremely important. First, the soil removed from within the site might already be saturated with potentially hazardous waste from underground water movement, surface saturation, or leachate and should be treated as potentially contami- nated. Second, digging holes and depositing soils can contribute to spreading mosquito habitat. Project components could address (a) water and air pollution, (b) neglect of health considerations at and around transfer stations and disposal sites, (c) traffic and access roads to waste disposal sites, and (d) long-term site management as new sections are opened and old ones closed and sometimes returned to public use. In all the above, worker protection as well as access of children to work sites should be considered. Community participation components can help with basic logistical support to community organizations, religious groups, and NGOs. A technical assis- tance component might be necessary in selecting technology most suitable to local conditions. Industrial waste. The chief sources of hazardous and toxic industrial waste were reviewed above under "Proximity to Large-Scale or Hazardous Waste" and "Tinkering, Cottage Industries, and Artisanal Markets" under "Housing and Urban Development." Epidemiologically, the most important factors concerning industrial waste entail (a) acute intoxi- cation, from which the body may recover, (b) acute poisonings, which can kill or permanently harm, (c) chronic low-dose exposures, which may accumulate to toxic doses, (d) retention of fat- soluble toxins in the body, and (e) low-dose chronic exposures possibly leading to more serious effects, such as cancers or birth defects. Tackling the full gamut of these waste sources may be too ambitious as a component for any project, except a full-scale waste management project that implements an appropriate, modest technical assistance component. This component could undertake a waste inventory, determine potential health risks, and make recommendations on how the different sources can be most ef- fectively managed. Medical waste. Waste from hospitals and other health care facilities is often not managed sepa- rately; adverse consequences may range from polluting water to exposing scavengers at waste facilities.158 Hospital waste contains human tissue, blood, and other infectious waste (e.g., from operating rooms); sharp objects (e.g., needles and glass); disposable medical equipment (e.g., gloves, aprons, and urine or blood containers); pharmaceutical wastes; solid and liquid radioac- 205 tive wastes; and domestic garbage. With the probable exception of radioactive material, hospital wastes are either flushed into toilets or mixed with domestic waste, even though they could be collected and stored separately. Sometimes they are burned on site; the residue of unburned mate- rial is then mixed with municipal waste. Incineration poses a high risk of spreading disease, be- cause of the potential for incomplete combustion of toxic or contaminated waste settling in the immediate area. Hospital waste, such as leachate, should always be considered extremely toxic, but may be overstated in the popular press as a public hazard and lead to hysteria rather than con- cern. Pathogens in hospital waste, such as the Ebola virus, however, are fragile outside the human body, readily die off, and require interpersonal contact for transmission. A cholera epidemic may be far more significant as a public health hazard. Box 13-4: Medical Waste Management in Ghana The Shama-Ahanta East Metropolitan Area (SAEMA), one of Ghana's five largest cities, is at the forefront of major and secondary SSA cities that are responsible for a combination of urban, peri- urban, and rural conditions and are confronting challenging multisectoral issues involving risks to human health and the natural environment. Many cities address these problems lacking adequate tools. They need assistance to meet these local challenges locally, where they are the key actors, as well as nationally, where they can contribute to policy. Such was the case in SAEMA, where, for example, decentralization policies of the central government have transferred responsibility for safe disposal of medical waste to the city level. The challenge facing such cities is daunting, especially because they need to develop bylaws and other statutory measures to regulate the safe collection and disposal of waste from health care facilities, ranging from laboratories to hospitals. The task is even more daunting, considering the open sale of used syringes (with needles re- moved) in markets as hair curlers (see chapters 16 and 17). Source. Authors' data. If a specific hospital waste component is not affordable or technically feasible within a project, a reasonable objective might be technical assistance to design a waste management program with two foci: * In-house. A system of collection, destruction (of infectious waste), and storage, while educating hospital staff X At the disposal site. A system of segregation, collection, disposal, and destruction (of in- fectious waste) in a separate, inaccessible area of the sanitary landfill with provisions for its immediate cover. Other measures include educating scavengers and local residents on the dangers of hospital waste and its incineration and the importance of (especially kids) avoiding contact with or proximity to it. The disposal site might require some construc- tion to prevent scavengers or children from access to the landfill and could be incorpo- rated into the project. A local NGO or development agency could assist with implemen- tation of the program. Scavenging. The main environmental health risks come from accidents and exposing scaven- gers-whether organized workers with protective gear, individual pickers, or children playing- to toxic and other hazardous materials that have not been separated from waste before delivery to the site. Scavengers also risk contracting a full range of excreta-related diseases, of which lepto- spirosis (Weil's disease) is a particular occupational hazard. Reuse and resale of contaminated materials that are not removed from the waste stream but treated as recyclables pose an additional public health risk. They include (a) cast-off food, bottles, and tin drums that once contained poisons, (b) newspaper and cardboard saturated with toxic run- off and residues, and (c) in some instances, discarded hospital waste, such as syringes and reus- able containers (although hospitals in developing countries do tend sterilize and reuse items a 206 great deal). If food processing waste or food storage wastes (e.g., grains wasted during packaging, storage, or shipping) are delivered to the waste site, special care is needed to determine if the food has been exposed to pesticides or fumigants used in preventing mold or spoilage. In addition, large or industrial producers sometimes throw out food on the verge of spoiling or approaching its sale expiration date. Several realistic measures can be undertaken in projects, based on government policy on scaven- gers. All these would depend on how scavengers currently handle waste. An appropriate study would be on the risks scavengers face and remedial measures that are practical under local condi- tions. Provisions should be made to segregate toxic and hospital waste, if possible. A first-aid station could help scavengers deal with routine wounds, or transportation could be provided to a clinic or hospital for more serious accidents. Upgrading sorting conditions in terms of equipment (conveyor belts, sorting screens, and tools), protective clothing (gloves, boots, glasses, and aprons), washing facilities, and shelter from the sun and rain would help increase productivity and reduce accidents. Recycling. The most common health hazards stem from routine accidents in handling glass and sharp metal, which could lead to serious infections in unsanitary working conditions. Two other factors present potentially serious problems. First, recycling would spread the hazard of toxic materials contained in glass and metal containers, which may have saturated paper and cardboard. Second, the literature review indicated that, in places, toxic material has intentionally been "dis- guised" as recyclables. Design of a component could follow the same norms as those for scav- enging by providing for first-aid and upgraded sorting facilities. Drainage A wide range of drains or various forms of water diverters, from stone-lined ditches to buried storm drains, can accommodate storm water. Water from houses or industries cover an equally wide range of technologies-from simple soakage pits outside a house to elaborate plumbing systems connected to sewers. Storm drains, however, need to accommodate large surges of water that can lead to flooding and soil erosion, which lead to accidents and contamination of people's living areas. Storm drains in residential areas are often cement-lined ditches covered by cement slabs or metal grates. In short order, however, the covers disappear and the drains become open sewers in which people dump garbage of various kinds. In these cases, the drains themselves be- come the hazard. Otherwise, the major health problems stem from areawide flooding from clogged or undersized drains, which can cause fecal contamination of living areas, particularly in urban areas where roadways and haphazard residential development cut off natural drainage pat- terns. Injuries and drowning are also common. In addition, standing water can allow for mosqui- toes to breed, which can take less than a week. A component can address this problem by relying on community involvement to keep the drains flowing. Such components, however, are only practical in areas with well-organized or active community groups, NGOs, small enterprises (AGETIP-type activities), or business associations that perceive a benefit. Possible health repercussions of inadequate drainage range from nuisances, especially odors, to more serious problems, such as filariasis. All forms of wastewater and storm water can transmit excreta-related diseases. In addition, inappropriate drainage allows for accumulation of water that is not necessarily contaminated, but can spread vector habitats for malaria (see box 13-5) and schistosomiasis (in low-density or periurban areas), so the emphasis should be on free-flowing drains. Dirty water actually repels malaria mosquitoes and snails that spread schistosomiasis, but can attract other mosquito species that spread other diseases, such as filariasis. Projects can help resolve the problem through a range of straightforward measures, such as cement slabs to cover * Agences d'Execution des Travaux d'lnteret Public. 207 storm drains and sturdy metal grates to block solid waste, which can later block drains when wa- ter flow is low. These physical measures cannot, however, be effective if local populations do not keep drains clean. Some kind of community participation managed by user groups or local NGOs is necessary. Box 13-5: Urban Malaria: The Need for Data from Sectors besides Health Although it may be relatively easy and inexpensive to establish the presence of malaria in a given population and treat individual patients, it is far more difficult and costly to reduce breeding and feeding sources through a mosquito reduction strategy, due to the need for extensive information. Malarial mosquitoes can fly up to 5 kilometers away and breed in the same areas as other mos- quitoes that are mainly nuisances. A control plan, therefore, needs detailed information on spe- cies, habitats, potential exposure to humans, and so on; this information may not be available in health reports. Environmental assessments, in comparison, may contain significant background information, describing climate, rainfall, land use, and more and providing maps. Simnilarly, infra- structure or education projects could provide information on population distribution. This readily available material could collectively obviate extensive new research. Source: Authors' data. Water Supply A variety of components are possible under straightforward water supply projects, for example, water pollution control, vector control, rainwater catchment, and hygiene education. The greatest contribution that task managers can make is to ensure that provisions for sanitation and drainage included at project preparation are not cut later for budgetary reasons. Surface water. Surface water is susceptible to a wide range of urban and rural pollution. In some cities, air pollution is a major source of water pollution (not generally in Africa, however). Be- sides key industrial sources, mining runoff and processing wastes can contain highly toxic mate- rials such as lead, mercury, and solvents. Water heated and emitted by power plants can some- times indirectly affect health by increasing the reproduction rate of pathogens to unsafe concen- trations. In addition, chlorination by-products, which remain in drinking water, have been proven carcinogenic; the relative risks of cancer, even in industrialized countries, however, are insignifi- cant compared with the risks of no chlorination. Dams, barrages, weirs, storage reservoirs, and other water impoundments can spread habitats for mosquitoes that can spread malaria, yellow fever, and filariasis and for aquatic snails that spread schistosomiasis. In addition, certain flies that breed in fast-running, oxygen-rich water spread onchocerciasis (river blindness). Groundwater. Groundwater tends to be free of pathogens, but might contain toxic levels of natu- rally occurring chemicals, such as arsenic, manganese, and iron, and salt, intruding from nearby saltwater bodies. In general, these chemicals do not pose major widespread public health prob- lems and can be handled through water treatment, although increasing its costs. Nitrates either occurring naturally or from fertilizers or animal wastes may contaminate groundwater in areas with heavy agricultural activity. Nitrates can cause blue baby syndrome (methemoglobinemia), which also affects animals. In high-density or industrial areas with poor sanitation, fecal and in- dustrial waste and leachate from landfills and dumps can also, of course, contaminate groundwa- ter. * A "dam" generally means a structure holding back water. High dams are higher than 1o meters. "Barrages" allow water to spill over. "Weirs" divert water flow. A "reservoir" is a water body that holds water to irrigate or generate power. 208 Rainwater. Rainwater in itself is pure, but can easily become contaminated by particulate matter in air pollution and dust,* both of which can be concentrated to hazardous levels in runoff of the rooftop or community collection system. (Ambient air pollution is generally not a problem for the SSA Region as a whole, but it can be in large areas.) Agricultural dust can contain pesticide and fertilizer residues. Air sheds can contain a wide array of toxic pollutants from local industries, power activities, and solid waste facilities as well as motor vehicle emissions, containing lead. Power plants and industries are the main culprits in producing acid rain. Water delivery and storage. Water delivery and storage typically open the door to several health problems. Standpipes generally deliver potable water. Contamination leading to excreta-related diseases frequently occurs when water pressure falls, drawing in surrounding liquid in holes, cracks, and loose connections; this is particularly severe in areas with illegal connections or pipes running through storm drains and even open sewers. Similarly, water storage in drinking pots or rainwater catchment systems can become contaminated with pathogens from people's hands. At distribution points, such as communal standpipes or catchment systems, lack of drainage can contribute to breeding mosquitoes, spreading yellow fever, dengue, and filariasis. These problems can be reduced through construction of concrete platforms with adequate drainage or soakage pits, plus hygiene education. Women and children can daily spend hours and walk miles fetching water, leading to physical stress that can impair health, a situation exacerbated in rural areas by the search for fuel and fod- der. Often, women and children wait a long time for the water truck to arrive, for adequate water pressure, or simply in long lines. Some of this stress can be alleviated by a small component to build shelter from the sun and rain. Its size and sturdiness (e.g., just a foundation with a simple roof of palm fronds) would depend on local needs and maintenance ability of the community, for example, to replace the fronds. If traffic injuries are a problem for children fetching water, a component could include such protective measures as crosswalks, fences, and so on. Piped water can contain lead, emanating from old systems that commonly used lead pipes or from new systems using lead in their solder. Lead also factors in air pollution in areas with heavy traf- fic and vehicles still using leaded gas. Many other sources of lead exist that may actually be more significant in health impact than either air or water pollutants; hence, dealing with lead requires some idea of its relative importance locally in order not to overestimate the role of water and air pollution abatement in projects (see table 7-3). (In Africa, lead pollution is probably not signifi- cant; therefore, it may be appropriate to seek additional information on lead sources, because lead reduction is regularly included in pollution management proposals. Money spent on lead may be better directed to other investments or, conversely, to efforts on other significant local sources, in the process, anchoring the benefits of reduced lead.) The question often arises on the risk of using asbestos cement pipes for drinking water. Asbestos is a known carcinogen; however, no clearly established health hazard links asbestos to drinking water, even though asbestos may appear in small amounts. Asbestos does pose an occupational hazard in pipe installation, but cutting pipe while it is wet can reduce the risk. Other issues. Fine water spray or vapor from flush toilet use and irrigation can cause some enteric infections, for example, polio and hepatitis, by spreading viruses contained in feces. This ac- counts for an insignificant amount of disease, except as an occupational hazard. In addition, air pollution from automobile exhaust and industrial waste can cause lung cancer and other respira- * Particulate rnatter is referred to as either total suspended particulates (TSP), suspended particulate matter (SPM), or PM10 (particulate matter smaller than 10 [or sometimes 5] microns in diameter, that is, small enough to penetrate deeply into the lungs). 209 tory diseases. Unfortunately, these are difficult to trace systematically, because, cancers often do not develop until twenty years after exposure. Industrial Wastewater Industrial wastewater should always be considered at least potentially dangerous to human health, although often it is not. Potential diseases transmitted in industrial wastewater are too numerous to mention in a checklist; they would largely be a compendium of toxic compounds and heavy metals that result in poisonings. Where industrial wastewater treatment facilities are not part of the project, but industries exist in the project area, it may be appropriate to determine the bio- chemical composition of the wastewater through a modest technical assistance component and assess potential risk. If treatment is unaffordable, other options include provisions for communal treatment facilities in industrial areas or safe transport to a suitable treatment facility or disposal site. If industrial wastewater contains domestic waste, it can also spread excreta-related diseases. A modest technical assistance component could inventory waste sources, determine their poten- tial risks, and evaluate potential solutions. If the wastewater is deemed hazardous, provisions could be made for treatment. Accidents and Safety The risk of accidents is enormous in the water and sanitation subsector, because so many activi- ties are still labor intensive and potential exposures in waste management are exceptionally high. People at risk include: * Workers in waste disposal. They are probably at highest risk because of the types of ma- terials they handle. Recycling exposes workers to contaminated materials and to cuts that may develop into more serious infections. * Scavengers, where they exist. They are at an even greater risk, because they may not have access to protective gear or be aware of the toxic content of materials once they are mixed together in trucks. After-hours access of scavengers to waste disposal areas exac- erbates the situation. * Children at play. They play after hours at unprotected construction sites, waste disposal sites, and around uncovered storm drains. Moreover, they are exposed to a myriad of pathogens around the household from deficient sanitation and waste disposal. Fires are a constant hazard at waste disposal sites, whether they ignite spontaneously or are set intentionally. Gas (methane) is naturally formed in the process of anaerobic (i.e., without oxygen) decomposition of wastes. Unless the gas is vented or the waste is aerated, the accumulation of gas can migrate under the waste to surrounding areas, where it can dissipate naturally or accumulate in structures along its path. This high concentration of methane, which is combustible, may also contain other toxic gases from other materials. Accident and safety components dealing with any of these issues can be included in any water, sanitation, or drainage project. High Risk and Vulnerable Groups The Water Supply and Sanitation Sector Environmental Health Checklist (table 13-13) shows the range of sector projects by subsector, identifies the main potential environmental health problems, and suggests remedial measures. 210 Table 13-12: Main Occupational and Vulnerable Groups for Water Supply and Sanitation Activity Potential Health Risk Wornen and children fetching Physical and mental stress from hours spent a day; risk of accidents (e.g., falls) if water water source is not readily accessible in rural and periurban areas; and risk of traf- fic injuries when children fetch water in urban areas Unprotected cutting of as- Asbestosis bestos pipes Work crews on infrastructure Risk of exposure to vector-borne diseases (mainly in rural areas), occupational projects hazards, potential for high risk of exposure to or spreading HIV/AIDS in ternpo- rary work camnps, and exposure to diarrheal diseases related to inadequate sanita- tion in poorly maintained work camps. Scavengers and waste pickers Accidents and exposure of workers, scavengers, and children playing after hours to excreta and toxic material at solid waste sites Truck delivery of waste to Heavy dust affecting residents along site access roads sanitary landfills Source: Authors' data. Table 13-13: Water Supply and Sanitation Environmental Health Checklist' Typical Water Supply Projects and Main Remedial Measures and Com- Components Major Health-Related Issues ments Construction and General hazards in excavations, deposition, works: general and temnporary storage of construction and comment excavation debris, among others, due to the construction stage of water and waste man- agement components: (a) Pools of standing water and flooding (a) Preparation TORs should ensure that can increase malaria and other mos- proper measures are taken during con- quito-borne diseases, especially during struction and afterward to eliminate rainy seasont workers and local resi- breeding and feeding grounds and to ac- dents are at risk. commodate proper drainage in flood- prone areas, especially in rainy seasons. May also be appropriate to include tech- nical assistance for residents in conmmu- nity education-type component. (b) Accidents are important: (a) during (b) Preparation TORs should ensure that construction, when workers and proper occupational health and safety nearby residents are at risk of flood- measures are provided for workers and ing, erosion, and mudslides and chil- to limit access of children after hours. dren are at risk when playing at sites The latter might be pertinent in a com- after hours and (b) after construction, munity education-type component. in housing near or over water, infants and children are also at risk of (c) Preparation TORs should arrange with drowning. health agencies, as appropriate, to ad- (c) Work crews can be at risk of AIDS. dress worker camps. Low-cost (a) Poor maintenance of latrines can lead to (a) Implementation TORs should include sanitation and full range of excreta-related diseases procedures for hygiene education; com- on-site sanitation: and also create odors, which discour- inunity participation component might construction and age their use be appropriate for maintenance and cost disposal of recovery, as appropriate. latrines and (b) When latrines or septic tanks are emp- (b) Preparation TORs should include provi- septic tanks tied, ground and surface water can be- sions for proper treatment and disposal come polluted and create vector- of septage sludge; community participa- breeding habitats, leading to full range tion and education; design of appropriate of excreta- and vector-related diseases. treatment facilities. * This and other sectoral checklists can be found at . 211 Typical Water Supply Projects and Main Remedial Measures and Com- Components Major Health-Related Issues ments If no proper treatment of solids (night soil, septage, and nonstabilized sludge), can lead to same health risks. (Note: some latrines are designed to treat waste.) (c) See also "Public Facilities: Washing and (c) See also "Public Facilities: Washing and Bathing and Toilets" Bathing and Toilets" Public facilities: Public facilities require adequate mainte- Implementation TORs should include proce- washing and nance to prevent clogging of toilets and dures for adequate maintenance, including bathing and drains for drinking and gray water runoff, cost recovery scheme. Public education com- toilets which can pollute ground and surface water ponent might also be appropriate. and create vector breeding habitats, leading to full range of excreta- and vector-related diseases. Waste (a) Periods of low sunshine or temperature (a) Design should account for effects of stabilization can lengthen holding time needed for weather in retention time. Depending on ponds good pathogen removal. population at risk of poor quality efflu- ent, operation might require emergency disinfection back-up. (b) Improperly managed facilities can at- (b) Implementation TORs should reflect need tract flies and mosquitoes that spread for vector-control as appropriate. Com- disease. munity participation and education may also be appropriate, if community is nearby. Conventional Skilled labor required to control flow of Preparation TORs and designs need to assure treatment plants: influent through various steps, especially to proper operation and maintenance (or dis- activated sludge prevent "shock loading" (surge in influent), courage use of conventional treatment). TORs and trickling which otherwise results in high pathogen need also to determine if receiving waters of filters content in effluent. effluent is destined for drinking or domestic uses and consider tertiary treatment or other alternatives. Rural water (a) Final stages of guinea worm eradication (a) Preparation TORs for rural water supply supply feasible in next decade. and sanitation projects should determine if disease is or has been endemic; if so, project could contain monitoring. If still endemic, project should include provi- sions for protecting water source and education as appropriate. (b) Implementation TORs should provide for (b) Water supply and sanitation are often proper operation and maintenance, out- the responsibility of MOH or ministry side ministries of health and agriculture, of agriculture, which might not have if appropriate. Community participation engineering competence necessary for component might be needed for opera- installation, operation and mainte- tion and maintenance and cost recovery. nance, and so on. Periurban water Periurban areas are often similar to rural Preparation TORs should reflect low-density supply areas with different needs for water and living conditions and accommodate agricul- waste management to accommodate water, tural and animal waste. Anti-malaria consid- waste, and drainage. Range of diseases erations might need special attention. might include malaria. Urban water (a) Lack of drainage, especially in areas of (a) Designs should account for proper drain- supply communal water supply, breeds mos- age, soakage pits, and runoff. Commu- quitoes and flies, which can be a nui- nity participation comnponent may be sance and spread disease. necessary for proper maintenance. (b) Designs should take into account risk of (b) Water lines flow next to storm drains, illegal connections, poor operation and which become open sewers (with time, maintenance. It may require community water lines can sag directly into storm participation component. drains from neighborhood activity and 212 Typical Water Supply Projects and Main Remedial Measures and Com- Components Major Health-Related Issues ments illegal connections). Low water pres- sure causes intake of pathogens into water lines. This is especially prob- lematic in areas with illegal connec- tions. Public facilities: (a) Markets can generate special waste (a) Preparation TORs should include waste markets needs, e.g., slaughterhouse and vehicle generation inventory and type of scav- maintenance (battery acid and oils). enging or recycling. Designs should re- flect special waste collection and dis- posal needs and, if appropriate, provi- sions for scavengers and recycling. .) Cloged rais cahepsreadvecor (b) Preparation TORs should include de- Cloged drinsecael scription of mnarket business and user related diseases. groups. Community participation com- ponent rnight be appropriate to help with operation and maintenance and cost re- covery. (c) Preparation TORs should examine appro- (c) Poor community organization can lead priate use of user charges. to (a) and (b) above. (d) Preparation TORs should design for sani- (d) Lack of water and excreta disposal fa- tation and drainage in new markets and cilities can spread diarrheal diseases appropriate renovations in upgraded through food and poor personal hy- markets. Implementation TORs should giene. address sound management practices with cost recovery. (e) See also "Public Facilities: Markets" and (e) See also "Public Facilities: Markets," in "Housing and Urban Development." "Housing and Urban Development." Solid waste (a) See also "Construction and Works: (a) See also "Construction and Works: Gen- management: General Comment" eral Commenf' municipal and (b) See also "Solid Waste Management: (b) See also "Solid Waste Management: domestic Sanitary Landfills" Sanitary Landfills" (c) See also "Public Facilities: Markets" in (c) See also "Public Facilities: Markets" in "Housing and Urban Development" "Housing and Urban Development" Solid waste Hazardous and commercial waste can cause Preparation TORs should include provisions, management: a wide range of public health problems, as appropriate, for inventory of sources and hazardous which night require separate treatment. volumes of waste and recommend appropriate commercial and special handling or treatment. Designs should industrial reflect these accordingly. Monitoring program and user charges may be appropriate. Solid waste (a) Nonsegregated waste can expose hos- (a) Designs should provide for separate col- management: pital and waste disposal staff (and lection and storage of nondomestic medical wastes scavengers) to hazardous waste. waste within hospitals and separate dis- posal under cover preventing access to scavengers. It may require physical bar- riers. .) Incineratio can expose local workers (b) Preparation TORs should determine if ab) Incinera to nexoe local dors incineration is appropriate. If so, designs and residents to unburned hazardous should provide for safe incineration and waste. disposal. (c) Preparation TORs should determine use (c) Radioactive waste is a special hazard to of radioactive wastes and design han- workers and local residents and needs dling measures, as appropriate. special, long-term, and highly techni- cal attention. Solid waste (a) Improperly designed landfills can lead (a) Designs should provide for appropriate management: to water and air pollution. disposal of leachate and air pollution from dried waste and soil cover. 213 Typical Water Supply Projects and Main Remedial Measures and Com- Components Major Health-Related Issues ments sanitary landfills (b) Designs should provide for control of (b) Controlled and spontaneous fires can fires and accidents from bums. lead to air pollution and bums. (c) Preparation TORs should include a de- (c) Traffic during construction and opera- scription of possible road accidents and tion can cause road dust and accidents. inventory of schools and workplaces Dried waste can cause dust. along the traffic routes, assess health data that indicate high-risk areas for res- piratory disease along the access roads and site itself, and mnake appropriate rec- ommendations for design modifications. Solid waste (a) Scavengers are exposed to excreta- and a) Implementation TORs should plan for management: vector-related diseases, accidents, and safe handling of wastes, and, as appro- scavengers hazardous waste. priate, protective clothing and first aid. Designs should provide for sorting areas with appropriate construction or barriers and so on and, if appropriate, areas pro- tected from sun and rain, benches, screening for sorting or sifting (on con- veyor belts). (b) Scavengers sometimes consume or re- b) Implementation TORs should determine if sell food that is contaminated, spoiled, reuse or resale of food is common. If so, or near its expiration date. Waste from describe basic sources and make appro- periurban food processing and storage priate provisions to reduce risk. Com- can be contaminated with fumigants munity participation component may be and pesticides. useful to educate scavengers and solicit help of food producers. Solid waste (a) Recycling can cause accidents, in par- (a) Preparation TORs should inventory main management: ticular, cuts that can lead to serious ill- types of recyclables locally, indicate po- recycling ness given unhygienic conditions. Pa- tential health hazards, and provide for per and cardboard taken from disposal first aid as appropriate. TORs should sites can be saturated with toxic mate- determine potential sources of hazardous rials. Recycled bottles and containers and caustic materials and make provi- from pesticides and industrial chemi- sions excluding or processing them from cals can lead to acute and chronic poi- the waste stream- It may require a com- soning. munity participation component for to educate workers or solicit assistance from industries. (b) Hazardous materials can be intention- (b) Implementation TORs should determiine if ally disguised as recyclables to reduce recyclables include imported materials disposal costs, e.g., of manufacturers, and, if so, contain provisions to ascertain and sent illicitly to developing coun- that exporters are legitimate companies tries. and, if necessary, examine waste to en- sure it contains no hazardous materials. (c) Preparation TORs should determine basic health risks from mosquito-related dis- (c) Collections of tires, bottles, and cans eases and provide appropriate education and other containers that hold water to reduce risks. can spread mosquito habitat and vec- tor-related diseases. Hygiene Health education is appropriate at almost Preparation TORs should include, as appro- education every level. Frequently encountered prob- priate, a multidisciplinary team and design lems are training materials and translations programs, at least in personal hygiene, food into local languages. preparation, and waste disposal. Pollution control: Pollution control covers a broad spectrum Preparation TORs and design standards general comment and could be part of any project. Health should include explicit references to pathogen aspects to humans might be relatively ne- removal, vector control, and, as appropriate, glected or subsumed by standards to meet identification of the population at risk or pol- engineering or ecological criteria, which lution inventory. It might be appropriate to rmight also omit role of community partici- include pollution monitoring and community 214 Typical Water Supply Projects and Main Remedial Measures and Com- Components Major Health-Related Issues ments pation in resolving or monitoring the pollu- involvement. tion. Drainage (a) Blockage of storm drains and inade- (a) Implementation TORs should provide for quate drainage of general area can regular maintenance of storm drains, cause flooding, which can contaminate which may require component for com- water supply and cause accidents. munity education and participation. De- signs should provide for proper drainage of project zone and contiguous areas as (b) Blockage of storm drains around mar- appropriate. kets and public facilities can spread fb) Designs should include soakage pits, run- vector habitat for filariasis. off, spillways, and so on. (c) General inadequate drainage can spread habitat of vectors that spread malaria. (c) Preparation TORs should allow for proper geographic planning area (neighborhood . ~~~~~~~~~~and town) and appropriate regulatory (d) "Solving" drainage problem of one area needs. may merely shift ft to another. nes (d) Designs should verify if they need to ex- tend drainage provisions beyond the immediate project area. Sewage treatment (a) Poor quality effluent can promote ex- (a) Designs should adequately consider BOD plants creta-related diseases. and pathogen removal. (b) Improper sludge disposal can lead to (b) Designs should provide for proper sludge water pollution, which can promote disposal and incorporate measures to re- exereta-related diseases and provide duce mosquito and fly breeding. habitat for mosquitoes and flies. (b) Preparation TORs snould ensure that en- (c) It is not always possible to know in vironmental health considerations are advance the technology to be used and, considered in bidding documents or en- therefore, design in advance for poten- vironmental assessments. tial health or occupational risks. Emergency Contaminated water and interpersonal con- Preparation TORs could address (a) chlorina- cholera response tact are considered the main transmission tion, (b) water delivery (trucks), (c) logistical route in epidemics. Epidemic spread can be support, e.g., labs and staff, (d) loan of vehi- rapid, necessitating quick response, e.g., cles and equipment to MOH, e.g., water test- diarrheas cause dehydration and shock ing, chlorination, and so on, (e) public educa- within hours and up to 60 percent fatality, if tion campaigns, 6) as a preventive measure, untreated (medication and rehydration). reordering geographic distribution of future MOHs are not well equipped to provide project water and sanitation works. clean water or chlorinate local water supply and need help from water agency or com- pany. Source: Authors' data. 215 CHAPTER 14: GLOBAL ISSUES This chapter provides a brief overview of linkages between environmental health and global is- sues. Coverage will be expanded in future versions of these guidelines, which, for the moment, concentrate on infrastructure sector linkages. Key Environmental Health Issues Global issues relevant to environmental health span many topics, including international travel, instantaneous communications, multinational companies, the flow of goods and resources, the changing face of disease, global warming, and ozone depletion. Each has some form of health repercussion. This chapter deals particularly with those environmental health issues that affect the planet as a whole, that is, they have the potential to affect everyone, in contrast to issues happen- ing in many places simultaneously. Of this narrower set of issues, climate change, global warm- ing, and ozone depletion are recognized as key issues. Table 14-1 shows the range of health dimensions for climate change and ozone depletion and demonstrates the need to take a broad perspective, that is, find remedial measures both inside and outside the health sector. Linking changes in climate with those in disease patterns, in particular, raises appreciation for the complexity of interrelationships in a rapidly changing world. The po- tential for overall adverse health consequences is indeed staggering.159 Indirect effects have sub- stantial and often neglected spin-offs, such as mental stress from loss of home or job after a dis- aster. Table 14-1: Health Effects of Climate Change and Ozone Depletion Possible Main Direct Health Effects I Possible Main Indirect Health Effects Ozone Depletion UVradiation: skin cancer and cataracts (perhaps depres- Impairment of photosynthesis: compromised food pro- sion of immune system) duction (may exacerbate illnesses in groups with already weakened immune systems) Climate Change Extreme temperature variations: death, illness, and in- Extreme cold: transport-related injuries and death jury from thermal stress Storms: drowning and injury Storms: loss of housing, mental and physical stress of displaced persons, and increase in water-related infec- tious diseases Floods: drowning and injury Floods: (same as storms) Brush andforestfires: injury and death Brush andforestfires: (same as indirect effects of storms, but to a lesser extent) Habitat alteration: infectious diseases, plus epidemics Foodproduction: malnutrition Water quantity and quality: diarrheal diseases Aggravation of air pollution: aggravation of existing illnesses Thermal stress refers to the body's inability to respond to rapid changes of extremes in heat or cold, such as heat waves or cold spells. Cold spells are relevant, because global warming, that is, increase in the average temperature of the earth's atmosphere, entails greater climate variability and a wide range of weather extremes. 217 Possible Main Direct Health Effects Possible Main Indirect Health Effects Desertifi cation and droughts: malnutrition, plus mental and physical stress of displaced persons Rising sea level: water pollution, saltwater intrusion, susceptibility to storms, vector diseases, and malnutri- tion Social and demographic dislocations: mental and physi- cal stress in displaced persons and loss of infrastructure Source: Adapted from figure 1-1 in McMichael and others (1996), p. 12. An example of how climate change may influence disease is cholera. This disease was once re- garded as one of deficient sanitation and poverty, passed on by drinking water and poor hygiene. It is now clear that cholera bacteria live in small crustaceans (copepods), are transported farther, and live longer than formerly assumed. Global warming plays a role in the growth and distribu- tion of algal blooms that harbor these copepods, which are spread over larger areas, indeed, as far north as Norway!160 A number of key linkages with global issues demand more detailed discussion. They include new and re-emerging diseases, food production, and vector-related diseases. "New" and Re-Emerging Diseases Besides a resurgence of old scourges, such as TB and malaria, twenty-nine new infectious dis- eases were discovered in the past 20 years. New and re-emerging diseases are not confined to re- mote areas, as Ebola is in the forests of former Zaire. AIDS, for example, has gone well beyond African forests to become a modem pandemic, although its impacts are still severest in Africa (see section on AIDS in chapters I and 8.) In 1990, in Milwaukee, Wisconsin (United States, pop. 850,000), Cryptosporidium in drinking water caused 100 deaths and 400,000 cases of sickness, 4,000 of which required hospitalization. The disease, previously associated with poverty and poor sanitation, was linked to farm runoff and agroindustrial pollution that had contaminated Milwau- kee's drinking water supply. Cryptosporidium is not killed by most disinfectants and was once filtered out naturally by wetlands, many of which have now been developed. In other words, the same economic growth that contributes to improving the standard of living of the world's poor may also play a role in new and re-emerging diseases. Continued economic growth (in developing countries, much of it urban) is outstripping the capa- bilities of governments and the private sector to provide reliable infrastructure services-the same infrastructure that was responsible a century ago for reducing a wide range of respiratory and di- arrheal diseases that took a high toll. Box 14-1: Key, Confusing, and Misused Terms on Climate and Ozone Depletion Climate change. Refers to a complex set of disturbances to intricate ecological systems, not to a single event. Heat waves and storms, for example, are both manifestations of increased climatic variation, a related but different aspect of climate, as are the frequency of extreme variations in climate. Global warming. Refers to increases in mean global temperature, which may entail not only the extreme case of heat waves, but also subtle increases in temperature that occur during cooler sea- sons.Source: Authors' data 218 Food Production The actual effects of climate change and ozone depletion on the productivity of animal, fish, and agricultural food sources are still uncertain. But many positive and negative factors are postu- lated. For example, a 2°-3°C warming in mean global temperature could affect crop production with enormous economic consequences. Changes in temperature and rainfall would directly im- pact productivity in animals and food crops, as well as growth rates of their pests, predators, and diseases. Lower yields would presumably involve major areas in the middle-to-lower latitudes, which include global breadbaskets, for example, the U.S. Great Plains, parts of southern Europe, the Ukraine, parts of south and southeast Asia, and western Australia, plus arid areas, such as the Sahel. In comparison, higher yields would be expected at higher, temperate latitudes, such as Canada, Siberia, and Patagonia. At present, models indicate that the world would still be able to produce enough food to feed future populations.161 The main direct health consequences of climate change entail nutrition, particularly in areas, such as the Sahel, where malnutrition is already common; more than 800 million in the world are now chronically malnourished. The consequences of malnutrition, however, go well beyond issues of food adequacy, that is, providing enough energy to perform bodily functions; they also include, for example, maintaining resistance to infection. It is well known that malnutrition predisposes the body to infectious diseases,162 but new evidence is helping to clarify the relationship between malnutrition and the immune system. The most worrisome aspect of the re-establishment of in- fectious diseases is that malnutrition might facilitate transformation of otherwise benign viruses into pathogens.163 Moreover, application of fertilizers and pesticides to address decreases in food production, possibly compromised by climate change, as well as attain normal growth in agricul- tural output would increase exposures to pesticide residues; this might bring some of the most worrisome indirect health consequences, including the potential for hormone disruption and re- productive disorders (see chapter 8's section on "Use of Pesticides and Fertilizers"). Crops. Increased ultraviolet light (UV-B) on photosynthesis on land- and water-based flora could also reduce food production. The International Panel on Climate Change has estimated that the overall effects of climate change on crop production would be negative, but on a modest scale and the negative aspects would be concentrated in the tropical regions. These are precisely the areas where malnutrition is common, that is, parts of Sub-Saharan Africa, south and east Asia, southeast Asia, and some Pacific Islands. Most of these studies, however, do not account for changes in distribution of weeds and plant diseases.'64 Possible resulting changes in fertilizer and pesticide use have some of the most troublesome health repercussions. These include the potential for hormnone disruption and reproductive disorders. Drought. Drought is also a determinant of food production, but is discussed in chapter 8 on the agriculture sector in box 8-3 and related text. Table 14-2. Main Environmental Health Linkages with Global Issues Sector Main Linkages Agriculture and Agricultural expansion, including slash-and-bum agriculture, and commercial logging can rural contribute to deforestation (depletion of carbon sinks) and land erosion and, consequently, development increase global warming and frequency of extreme weather events; drought and desertifica- tion, hence, flooding (causing drowning, migration, and mental stress); water pollution and food contamination (causing diarrhea and intestinal disease, among others); and changes in vector habitats (causing vector-related diseases). It can also cause loss of biodiversity (loss of environmental life support systems and potential curative medicinal plants). Infrastructure Air shed pollution from vehicular transportation (which could exacerbate watershed and and urban land pollution) contributes to ozone depletion (causing skin cancer and cataracts), global development warmiing and frequency of extreme weather events, drought and desertification, hence, causing the same health effects as listed under agriculture. Deforestation (depletion of car- 219 Sector Main Linkages bon sinks) caused by human settlernents and extension of roads and railways can increase global warming (can cause same health effects as listed under agriculture). Energy Deforestation (depletion of carbon sinks) due to increased use of biofuels and oil and gas exploration and exploitation; fuels used in vehicular transportation and industry, home heating, and so on and pollutant emissions; and hydroelectric schemes (e.g., organic matter washed into reservoir and plant growth on reservoir can increase greenhouse gases) all con- tribute to ozone depletion (causing skin cancer and cataracts), global warming and frequency of extreme weather events, drought and desertification, hence, causing the same health ef- fects as listed under agriculture. Industry Deforestation (depletion of carbon sinks) from wood meant for industrial purposes (land erosion) and pollutant emissions contribute to ozone depletion (causing skin cancer and cataracts) and global warming and frequency of extreme weather events, drought and deser- tification, hence, causing the same health effects as listed under agriculture. Health Need to increase provision of health services for indirect and direct effects, especially in re- mote areas. Environment Deforestation (depletion of carbon sink) can cause loss of biodiversity (loss of environ- and natural mental life support systems and potential curative medicinal plants) and can contribute to resources global warming and frequency of extremne weather events, drought, and desertification, hence, causing the same health effects as listed under agriculture. Source: Authors' data. Intestinal worms. The literature deals little with changes in soil moisture that affect the habitats or ground worms (nematodes), which cause intestinal worms, still a major problem in developing countries. A 2°C increase in mean soil temperature would probably cause nematodes to in- crease.165 Intestinal worms do not kill, but result in high costs in lost labor. In 1990 intestinal worms accounted for 17,059,000 years lived with disability globally, roughly triple those of ma- laria.166 Vector-Related Diseasej Climate change may have specific impacts in spreading vector-related diseases. In SSA, Rift Valley fever is spread by mosquitoes, but mainly affects livestock. It can be spread to humans, if they eat meat from infected animals or handle sick livestock. An epidemic in 1997- 98 in Tanzania, Kenya, Somalia, and Ethiopia was attributed to the unusually moist climate asso- ciated with El Nifio.167 Spread of schistosomiasis and malaria could increase in some parts of the world, if greenhouse gas reduction measures increase energy prices. This is because higher energy costs might spur dam construction that is now considered technically, but not economically feasible. Twenty-nine of the dams under consideration are located in developing countries where these two diseases ex- ist. Table 14-3: World Hydro Power: Potential Number of Dams for Development Technically Economically Region Feasible Feasible Difference Africa 39 20 19 Asia 33 26 7 Austral-Asia and Oceania 4 4 _ Europe 36 32 4 North and Central America 15 9 6 220 Technically Economically Region Feasible Feasible Difference South America 12 9 3 Total 139 100 39 Gigawatt hours/year 14,000,000 8,905,000 _ __ __ I Source: The International Journal on Hydropower and Dams: World Atlas and Industry Guide (1997). 221 Part 3: Putting Theory into Practice: A Case Study in Ghana 223 CHAPTER 15: GHANA SAMPLE SECTORAL PROFILES This chapter presents several individual sector "profiles," using data on Ghana that illustrates in- formation readily available in Bank files, according to Bank sector designations. At this initial stage, such profiles contain considerable extra information to ensure that individual sectors are not summarized out of context. The material supported preparation of an environmental health needs assessment for Ghana and development of a workshop to determine priorities for targeted collaboration in Sekondi-Takoradi, one of Ghana's five most populous cities. Chapter 16 presents the needs assessment and workshop results. Preparing a profile is a relatively simple exercise in excerpting existing material to compile information useful in obtaining a short list of environ- mental health issues and priorities. Analysis of this information takes place at a later stage. This chapter presents sectoral profiles on environment, health, infrastructure, energy, and indus- try, and multisectoral profiles on demographic, development assistance, institutional, and poverty reduction aspects. The profiles consist of excerpts from the sources indicated in italics. Environment Sector Profile (This section contains materialfrom the World Bank's 1997 Ghana Country Assistance Strategy.) Protecting the environment and improving it is also an objective. This is to be achieved by en- couraging private investors to incorporate environmental impact assessments and adopt mitiga- tion measures up-front during investment calculations and through public investments in urban sanitation and drainage. One major intervention of the environment sector will consist of im- proving environmental management in rural areas to reduce deforestation and land resource deg- radation. The National Environment Action Plan (NEAP) and the recent Government report on environment seek to: * Develop capacity at the center and at the local government level to monitor environ- mental impact and to enforce EPA standards in respect of mining and manufacturing in- vestments. * Raise awareness of environmental problems and their solutions * Increase public investment in urban sanitation, drainage, and solid waste management, given a rapidly growing urban population. To ensure sustained maintenance of such in- frastructure in the absence of willingness to pay, efforts must be made to increase local government revenue collection, as well as development of local government capacity to subcontract services (p. 10). (This section contains materialfrom the World Bank's 1992 Ghana National Environmental Ac- tion Plan.) Environmental Issues Land Tenure Security: The nonexistence of a coordinated and comprehensive land use/management policy is considered Ghana's most critical problem in environmental manage- ment. A multiplicity of agencies are responsible for various aspects of land management, which further complicates the situation. The traditional system holds land in trust for the community as a whole. On top of this base are the state's and private developers' systems of land use. Ownership 225 boundaries are not clearly marked or mapped, and title is not well documented and registered. A growing population furthermore puts pressure on available land. Certain land use practices, such as use of agrochemicals, shifting cultivation, and bush fires, have degraded soil conditions and reduced crop output. Wildlife Depletion: The forest policy of 1948 neglected to consider the benefits of trees in land use systems beyond reserved forests. The policy permitted the progressive utilization of forest resources in areas outside the permanent forest estates, which has led to uncontrolled deforesta- tion. Wildlife populations are severely depleted as a result of hunting. Animal habitats in unpro- tected forests and savannas continue to be threatened by hunting, agricultural expansion, fires, mining, and road construction. About 8.22 million hectares of Ghana is comprised of closed for- ests (34 percent of total land area). But much of the original vegetation has been removed or modified. It is estimated that only about 2 million hectares of the closed forest remain. A defor- estafion rate of about 22,000 hectares per year was projected by FAO/UNEP for the period 1981- 85. Ghana has no adequate system for monitoring the exact rate of deforestation or forest de- struction. The forest, coastal savanna, and interior savanna of Ghana have unique wildlife. Bush meat is a source of protein and is the most expensive form of meat in most population centers; thus, wild animal populations are severely depleted. Energy Needs: As an oil-importing country, Ghana spent about 50 percent of foreign exchange earnings on crude oil imports during the oil crisis of the 1980s. Though this figure dropped to 16 percent in 1988 and 24 percent in 1989, crude oil imports still constitute the single largest con- sumer of the country's export earnings, but petroleum provides only 13 percent of the energy consumed in Ghana. Over 80 percent of Ghana's energy is derived from wood fuels. Energy pro- duction and utilization constitute the most pervasive source of environmental pollutants in Ghana. The depletion of forests reduces the size of the carbon sink and contributes to carbon emissions, loss of biodiversity, soil erosion, etc. Major problems include the need to meet the increasing en- ergy requirements of a rapidly expanding population, inefficient production and use of charcoal and firewood, failure to regenerate forest resources more quickly than they are used, and the per- sistence of inefficient and soil-degrading shifting cultivation and swidden methods as the major agricultural and firewood production system. Water Supply: At present, there are no procedures requiring organizations and agencies wishing to abstract water to submit their requires to an authority responsible for the overall management of water resources, so that the right to abstract water without any detrimental effect can be granted. Although laws exist that prohibit the pollution of water bodies, they are not enforced. Water cycle data, including maps, is inadequate, which hampers comprehensive assessment of water resources. Only 30 percent of the population definitely has potable water access. Water- borne, -related, and -associated diseases plague rural dwellers. Domestic and municipal wastes pollute water bodies. Land degradation and soil exposure results in desertification in parts of Ghana such as the Upper East Region, and changes in the relationship between the water balance components are expected to arise. Coastal Degradation: There are important resources for tourism, fishery, industry and mineral development in Ghana. The lagoon, estuary, and delta ecosystems provide suitable environments for oyster and fish culture. The zone also provides feeding, roosting, and nesting sites for thou- sands of birds and marine turtles. The beaches, cliffs, lagoons, wildlife, cultural and historical sites, and coastal landscape all provide an immense potential for tourism development. Minerals have been identified within the coastal belt; copra production has been an important economic activity. Current development trends and pressures exerted on the coastal zones and the marine environment not only conflict with resource utilization, but also lead to degradation and interfer- ence with the various components of the zone. Persistent coastal erosion and net loss of land from waves and waste disposal in the ocean degrades the marine and coastal ecosystems. 226 Pollution. The presence of hazardous substances affects the quality of air, water, soil, and life. Industry uses a wide variety of chemicals for various purposes, while agricultural productivity has come to depend on agrochemicals. Concern about industrial pollution is growing. The quantity and diversity of industrial wastes have increased over the years, and there are hardly any waste recycling or proper management practices in the country. There are over 4,000 manufacturing industries in Ghana inducing rural to urban migration. The concentration of industries in the Ac- cra-Tema metropolis has aggravated the environmental stresses caused by industrial activities. The textile, food manufacturing, petroleum refining and handling, and mineral exploitation and processing are the most polluting industries. Urban Decay: There is an explosion in lawlessness and uncontrolled growth in urban areas. In the last decade and a half virtually no new service roads have been built to the sprawling shelters in urban fringes, and existing roads are in disrepair. Sewage drains are broken and choked, refuse collection and street cleaning are unable to cope with mounting refuse and filth, and there is a lack of service personnel. Many uncontrolled private dumps exist, creating high risks of rodent infestation and disease outbreak. Environmental Recommendations Land Use Planning: The NEAP recommends the following actions: collect land resource infor- mation in a form suitable for planning; elaborate land resource use policy aimed at resolving con- flict, achieving multiple uses, projecting major user requirements in the long term; make recom- mendations to government. Natural Resource Management: The NEAP recommends the following actions: speed up and broaden the current land registration exercise; sustain and enforce current bushfire legislation and strengthen control organization; implement a soil conservation program with a focus on restoring fertility; continue support of the Interdepartmental Pesticide Control Program; support current agroforestry programs and encourage the development of private and community forests; assure sustainable supplies of fuel wood by requiring industries to meet fuel wood needs from planta- tions and by licensing charcoal burners and commercial fuel wood producers; improve the col- lection of water cycle data; expand and update water resources assessment; prepare Water Master Plans for all river basins; implement measures for the rational management of fish stocks; estab- lish protected areas to be managed for multiple use in the coastal zones; control agricultural de- velopment in the coastal zone; implement the national Oil Spill Contingency Plan; and conduct additional research. Energy Program: The energy sector institutions should pursue the following objectives: restore improved productivity and efficiency in the procurement, transformation, distribution, and use of all energy sources; reduce the country's vulnerability to short-term disruptions in the energy re- sources and supply bases; ensure the availability and equitable distribution of energy to all socio- economic sectors and geographical regions; consolidate and accelerate the development and use of the country's indigenous energy sources, especially wood fuels, hydropower, petroleum, and solar energy; and secure future power supply through thermal complementation of the hydroelec- tric system. Education, Training, Public Awareness: The NEAP recommends the following actions: prepare and implement a program of informal environmental education directed at the district and local levels; establish an Environmental Information Center to provide documentation, information, and referral services to the general public; prepare and publish an annual report on the State of the Environment in Ghana; implement the formal environmental education program in schools; im- plement environmental education in teacher training institutions; introduce agroforestry in the curriculum of all agricultural training institutions; provide training in environmental aspects of 227 human settlements in polytechnics and technical institutions; and conduct baseline studies on people's perceptions and knowledge of the environment. Environmental Monitoring: A fair amount of environmental data already exist in Ghana but are scattered and largely uncoordinated. The NEAP recommends the following actions: establish data collection networks for land use; establish a computerized data bank; implement a monitoring program consisting of synoptic monitoring of environmental indicators at the national level and health-related monitoring of water and air quality, emissions, and noise at selected sties; collect baseline data and monitor changes in wildlife populations; monitor the level of chemicals in food; prepare and publish an annual report on National Environmental Data. (This section contains material on the ecological zones of Ghana from the 1998 Ghana Natural Resource Management Project.) Ghana comprises two broad ecological zones: the high forest and the savanna. The high forest zone covers roughly one-third of the country and supports two-thirds of the population. Most of the country's economic activity (cocoa, oil palm, rubber, timber, and mining) is concentrated in this zone. At the turn of the century, the area of high forest was 8.2 million hectares, but this has been reduced to about 1.7 million hectares today, of which 1.64 million hectares is within the 216 forest reserves gazetted in the 1930s. Since then, almost all off-reserve forest has been clear- felled under a deliberate policy to open up farm land. It was not until 1994 that this policy was reversed and controls were put in place to extend harvesting of the small remaining off-reserve resource over a longer period. The boundaries of the reserves are still intact today, with very little farming encroachment. Within the reserves, about 0.4 million hectares are degraded (mainly by bush fires) and in need of replanting, 0.35 million hectares are classified as needing permanent protection (hill and swamp sanctuaries, biodiversity, etc.) and the remaining 0.9 million hectares are classified suitable for timber production. Based on recent forest inventories, the estimated sustainable annual allowable cut (AAC) from the high forest is 1.0 million cubic meters of round logs for the wood processing industry-with half coming from reserve forests and half from scattered trees on farmland, off reserve. The actual tree harvest is difficult to quantify accurately because of illegal felling, but it is generally accepted to be at least twice this level. The savanna zone covers the drier northern two-thirds of the country, where the main economic activities are the production of annual crops (cereals, root crops, and cotton) and livestock. Woodland covers about 9.4 million hectares of the savanna zone, producing mainly wood fuel and a small amount of building poles for local use. An estimated 70 percent of Ghana's primary energy requirements come from wood fuel, and this comprises about 10.0 million cubic meters of firewood and an additional 4.0 million cubic meters converted into charcoal for use in urban ar- eas. Although current aggregate wood fuel supply exceeds demand, regional deficits occur in the Upper East, Volta, and Brong-Ahafo regions. (Thefollowing section contains material on climatefirom the 1996 Ghana Village Infrastructure Project Environmental Assessment.) The climate in Ghana is tropical. Southern Ghana is humid, whilst northern Ghana, which falls partly in the Sahelian zone is relatively dry. During the harmattan season, the northern savannah area becomes extremely dry with relative humidity as low as 25 percent or less in January. Aver- age temperatures vary from about 24°C in the south to around 36°C in the north. In Ghana the mean annual rain varies from 2,250 millimeters in the West Coastal area to about 750 millimeters in the eastern coastal area and 100 millimeters in the North. The rainfall distribu- tion during the year follows four main patterns. These are a single rainy season increasing from March with the peak in August/September (this occurs in the northern savannah areas typified by Tamale and Navrongo), single rainy season of steady rainfall between March and October (this 228 occurs in the transition zone and is typified by Kete Krachi), two rainy seasons with peaks in May/June and October (this occurs in the forest zone typified by Kumasi), two rainy seasons, the principal one reaching its peak in May/June and subsidiary one in October (this occurs in the whole of the coastal region); however, the western section has the heaviest rainfall in the whole country typified by Axim, whilst the dryer eastern section is typified by Accra. Surface water: The main river basins in Ghana, which constitute the available surface water sources are the White Volta, Black Volta, Oti, Lower Volta, Pra, Arikobra, Tano, Bia, Coastal Drainage (mainly Ayensu and Densu), and Tordzie/Aka Basins. Rain water harvesting also serves as a source of surface water available to many rural communities. The mean annual rain varies from 2,250 millimeters in the west coastal area, to about 750 millimeters in the eastern coastal area (around the capital, Accra) and 100 millimeters in the North. This indicates that the South- western part of the country is well watered, unlike the semiarid savannas to the North and the Central and Eastern coastal plains. The variability and uneven distribution of rainfall results in water deficit in some parts of the country during the year. Investigations reveal that although sur- face water quality is generally good, local pollution, however, exists particularly in mining lo- calities and areas of intensive agricultural activities. Groundwater: Aquifers underlie almost all areas in the country. Occurrence of groundwater. however, is controlled principally by local geology and other factors, such as topography and climate. In northern Ghana, aquifers have been located at between 10 meters and 60 meters depth with an average of 27 meters. In southern Ghana, due to thicker soil cover, boreholes are deeper, ranging between 25 meters and 90 meters depth with an average of 42 meters (Bannerman 1986). Health Sector Profile (This section contains materialfrom the World Bank's 1997 Ghana Country Assistance Strategy.) Improving the quality of and access to primary health services. Improving quality of and access to primary health services is also part of the health sector. While district health management and physical access to health services in Ghana is significantly better than the regional average, low public health spending per capita and the high share of such spending being allocated to nonpri- mary services leaves district facilities poorly equipped with trained staff and medicine. To over- come this, the Government has begun to: * Establish standards of practice for a priority package of primary services * Reorient and retrain health workers to provide such a basic package of services * Rehabilitate clinics, health centers, and regional hospitals * Provide essential drugs, equipment, and supplies * Decentralize delivery and strengthen district and subdistrict management and administra- tive systems * Reorient secondary and tertiary service delivery to support primary services * Support local training institutions to ensure the availability of sufficient technical man- power and capacity building. (This section contains materialfrom the 1997 Ghana Health Sector Support Program.) The Ministry of Health summarized the systemic problems of the health system as (a) people cannot access the health care they need because of geographic distances, limited provision of ba- sic services, and financial barriers, (b) inadequate service quality and a lack of quality assurance efforts and resource management results in services, which do not respond to what people want, (c) inadequate findings of health services, (d) inefficient allocations of resources, with insufficient 229 findings of primary services, misallocation of health personnel, and inadequate benefits reaching the poor, and (e) poor community, intersectoral, and private sector linkages. Table 15-1: Common Diseases in Ghana 1994 Disease Reported incidence per 10,000 pop Malaria 1,464 URI 295 Diarrhea 185 Skin diseases 184 Accidents 170 Intestinal worms 106 PRC 104 Source: MOH (1994) Annual Report 1993. Table 15-2: Ranking of the Top Ten Diseases in Ghana 1991-94 Disease 1991 1992 1993 1994 Malaria 1 1 1 1 Diarrhea diseases 2 3 3 4 Upper respiratory infection 3 2 2 2 Accidents 4 4 5 5 Skin diseases 5 5 4 3 Pregnancy related complications 6 6 7 7 Intestinal worm 7 7 6 6 Gynecological disorders 8 8 9 9 Acute eye infection 9 10 8 8 Hypertension 10 9 10 10 Source: World Bank's 1997 Ghana Country Assistance Strategy. Infrastructure Sector Profile (This section contains materialfrom the World Bank's 1997 Ghana Country Assistance Strategy, p. 13) Shifts in Bank Group support to infrastructure in the sense of IDA lending moving away from infrastructure investments in telecommunications, power, rails, ports, and large urban water sys- tems, while supporting privatization and/or private participation with enhanced support from IFC and MIGA. Promoting private participation in infrastructure wherever possible is viewed as nec- essary to reduce cost and improve the quality of infrastructure services, as well as to overcome the fiscal constraint on infrastructure investment. The Government is very conscious that, despite a highly liberal policy framework, inefficient and insufficient infrastructure services-in telecom, power, rails, ports, urban water supply, airports, and roads-make Ghana-based firms and Gha- naian exports less competitive. Urban (This section contains materialfrom the 1996 Ghana Urban Environmental Sanitation Project.) An Urban Strategy Review carried out in 1993-94 with World Bank support produced the fol- lowing main conclusions: (a) continued improvements in basic urban infrastructure and services are needed to increase the productivity of urban households and firms, but investments must be carefully selected, (b) infrastructure and services for the urban poor can be improved through tar- 230 geted upgrading programs, (c) urban service delivery should be made more efficient and sustain- able by greater competition, more reliance on commercial principles, private sector participation, and attention to demand, (d) further efforts are needed to obtain long-lasting improvements in revenue mobilization by local governments, (e) sanitation and waste management are the highest priority urban environmental problems, and () impediments to land transfer, land titling and pri- vate land development need to be removed to make urban areas more efficient and productive. These points are consistent with a 1993 Ghanaian Task Force proposal for a human settlements strategy, which reflects a broad national consensus on four basic elements: (a) improving the economic performance of towns and villages, with particular attention to strengthening the eco- nomic linkages between urban and rural productive sectors, (b) increasing access to basic serv- ices, (c) improving the living conditions of the poor and vulnerable groups, and (d) building hu- man capacity for urban planning and management. Water Supply (Information on water supply was from the 1999 Ghana Water Sector Restructuring Project.) Water supply systems in Ghana deteriorated rapidly during the economic crisis of the late 1970s and early 1980s when Government's ability to adequately operate and maintain essential services was severely constrained. The economic recovery program the Government of Ghana embarked on during the mid-1980s set about to, among others, reform public enterprises by increasing their autonomy with the objective to create effectively managed, financially viable institutions. In the water sector, the focus was on expansion and rehabilitation in the Accra-Tema Metropolitan Area in addition to technical assistance to the country's water supply agency, Ghana Water and Sewer- age Corporation. In 1993, the Government of Ghana (GOG) initiated a restructuring program of the water sector aimed at segregating responsibilities for urban water, rural water and sanitation, and sewerage. Late in 1995, the Government took initial steps to consider options for sectoral reform involving private sector participation, with the objective of improving levels of service and operational efficiency. Under current proposals, which have evolved from those initial steps, water supply for small communities will be the responsibility of the Community Water Supply Agency (CWSA, soon to be devolved from Ghana Water and Sewerage Corporation) and/or the District Assemblies, and responsibility for operation of urban water supply, comprising about 101 water systems in 10 regions, from source to end user, will be contracted to private operators in two separate packages under enhanced lease arrangements (meaning that the private operators will also be responsible for some investment). Transport (Key elements of the transport sector system, sector objectives, road administration and institu- tional achievements are excerptedfrom the 1991 Ghana National Feeder Roads Rehabilitation and Maintenance Project.) Key elements of Ghana's transport system are (a) a network of about 14,400 kilometers of truck and urban arterial roads and about 21,300 kilometers of feeder roads, (b) an over-aged road fleet of some 130,000 vehicles, (c) a 950-kilometer railway system linking Accra, Tema, Kumasi, and Takoradi, (d) deep water ports at Tema and Takoradi, (e) an inland water transport system on the Volta Lake, 61) an international airport at Accra and domestic airports at Kumasi and Tamale, and (g) a national airline providing international and domestic services. Road transport is the domi- nant mode in the system, and about 90 percent of it is operated by the private sector, with easy market entry and little government regulation of its operations. Ports, lake transport, railways, and civil aviation are dominated by the public sector. Though it intervened on a large scale in the 231 transport sector in the past, GOG now clearly favors strengthening private sector operations, streamlining and reorganizing public transport enterprise, and privatizing many of them. Sector objectives. Government's primary sector objectives emphasize (a) rehabilitation and maintenance of existing transport infrastructure in a phased program, with a minimal amount of new construction and (b) strengthening institutions in the sector. The network of rural roads is by far the most important part of the transport system. Though recent projects are gradually improv- ing road conditions, particularly for the trunk roads, the overall road network is still in generally poor quality. It, therefore, needs the largest share of resources and the longest period to regain capacity. Rural Infrastructure (This section contains materialfrom the 1996 Ghana Village Infrastructure Project.) While Ghana has an abundance of water from rainfall, this resource is very unevenly distributed both geographically and seasonally. Even in the high rainfall (over 1,500 millimeters per annum) belt in the south and west of the country, water can be scarce in the dry season, which lasts three to five months. In the northern and the southeast regions, annual rainfall is normally less than 1,500 millimeters, and, in some areas, below 500 millimeters, with the dry season spreading over eight to nine continuous months. In much of the drier regions, a large part of villagers' time, par- ticularly of women and children, is occupied in collecting water from distant and often unsafe sources. This takes away a substantial amount of time from other gainful activities. Only an esti- mated 35 percent of rural communities presently have continuous and easy access to safe potable water. Scarcity of potable water increases the risk of water-borne diseases and has a very negative impact on labor availability and productivity. Provision of safe water and good sanitation in the rural areas is high among the rural development priorities of government. Recent client consulta- tions among rural communities also indicate that the most pressing demands in the northern drier half of the country are for safe and reliable supplies of water. Even in the higher rainfall areas, the need for water is high among the priorities of rural communities particularly for intensification of valley bottom cultivation. The scarcity of water, particularly in the low rainfall areas, is also a major limiting factor to crop and animal production. The rainfall in the drier parts of the country could be more effectively utilized for intensifying the production of crops and livestock. This would involve appropriate water conservation practices, such as storage in accessible aquifers and in simple surface storage facilities such as ponds, tanks, dugouts, and small reservoirs for use in the dry months. In addi- tion, free-flowing seasonal springs and streams could be important sources for supplemental irri- gation in the rainfall months or for diverting to storage facilities for later use during the drier months. There are also good prospects for making better use of water in the higher rainfall zones for producing high-value crops and livestock and for fish culture to improve incomes and nutri- tion of the populations. Rural transport infrastructure. In addition to low coverage, two-thirds of Ghana's feeder road network are in poor condition due to past neglect. Good rural roads are essential for achieving increases in agricultural production, especially in nonfood export crops, which in turn, can lead to expanded use of agricultural credit, increases in land values, proliferation of traders and small shops, and expansion of rural markets. Improvements in rural transport infrastructure benefit the rural poor in two distinct ways: (a) directly, by generating employment through labor-intensive construction and maintenance programs, and (b) indirectly, by reducing the cost of transport for goods and passengers. Since the rural poor tend to be small farmers or landless laborers, they benefit, along with the rural population at large, from better roads to the extent that roads de- crease the cost of agricultural inputs and/or essential consumer goods within the village or expand 232 the labor market and increase the demand for unskilled labor; however, the extent to which the poor would benefit from rural roads to increase their access to output markets or economic and social services would be enhanced, if they have access to affordable means of transport. The need, therefore, is not only for transport to link larger communities and markets, but also for ap- propriate and cost-effective means of getting produce from farms to villages, including the use of nonmotorized wheeled vehicles. (pp. 4-5) (Information on rural development is firom the World Bank's 1997 Ghana Country Assistance Strategy.) Promoting rural development and faster agricultural growth by diversifying agricultural exports and improving agricultural productivity is critical both for accelerating growth and promoting a pattern of growth more conducive to reducing poverty. Increasing farm income and speeding up growth in food crops and exports will be facilitated by greater small-holder access to better tech- nology and inputs, public investment in rural infrastructure (safe water, roads, post-harvest facili- ties, electricity), and better access to finance. Decentralizing the delivery of social services and rural infrastructure maintenance has been initi- ated; however, many steps remain to be taken before sufficient capacity is generated and adequate revenue is mobilized at the district level to deliver quality primary health and education services and ensure sustainable maintenance of rural infrastructure. Empowerment of local communities through increased participation is the cornerstone of the Government's decentralization policy. Promoting agricultural growth and rural development, Bank assistance in this area will be aimed at promoting private investment (including foreign) in agricultural production in general and in nontraditional exports in particular. For this purpose the Bank will support improvements in agri- cultural services and in investments in rural infrastructure aimed at enhancing access to new tech- nology and profitability of private investments. In addition, the development of Ghanaian capac- ity to monitor and protect the environment will be critical to sustainable rural development. (Information on the agricultural sector and irrigation is from the 1994 Ghana Agricultural Sector Investment Project.) The total land area of Ghana is about 22.4 million hectares, of which 20 percent is cultivated and 7 percent is under perennial tree crops (cocoa, oil palm, and rubber). Ghana's agriculture is pre- dominantly smallholder, traditional, and rain fed. The mean farm size is less than 1.6 hectares (4 acres). Small- and medium-sized farms of up to 1O hectares account for 95 percent of all culti- vated land. Of the total 2.37 million farms operated in Ghana by smallholders, about one-quarter produce mainly for subsistence, about 55 percent sell up to half of their produce, and less than a quarter market more than half of their produce. This signifies the importance of smallholders, for family, regional, and national food security and for achieving sustained growth in agricultural production. Common factors in Ghanaian agriculture are the use of bush to restore soil fertility, mixed crop- ping to minimize risks and, in the uorth of the country, the widespread integration of livestock into farming systems. Women head 30 percent of rural households and are responsible for about 70 percent of the total food production. They often make decisions about the type and area of crop to be planted and have a key role in weeding, harvesting, and processing. Even in male- headed households, women take care of small livestock. There is little use of purchased inputs and land preparation is manual in most areas, though ox-traction is important in the North. Mechanization is used only by a few large enterprises, and irrigated agriculture is poorly devel- oped, covering only 9,000 hectares throughout the country. 233 Energy Sector Profile (Energy information is from the 1995 Ghana Thermal Power Project.) Government policy in the energy sector is designed to (a) reduce the real economic cost of energy supply through rehabilitation and proper maintenance of installations in the petroleum and elec- tricity subsectors, (b) reduce dependence on petroleum imports through promotion of more effi- cient energy use and proper pricing, (c) improve forestry management to provide an adequate long-term supply of fuel wood, and (d) strengthen sector institutions through a program of public enterprise reform focusing on commercialization, and, in the case of the power sector, regulation and increased private sector participation. Ghana has substantial energy resources, of which fuel wood and hydropower are the most im- portant. About 18.3 million hectares are under tree cover, equivalent to three-quarters of the country's land area, of which about 8.8 million hectares is forest. The high forest zone is concen- trated in the southwest, where most of the timber industry is located. The northern savanna woodland has less timber potential, but is the most important source of domestic fuel wood. De- forestation is a growing problem in this area and fuel wood scarcities are beginning to develop as a result. This issue is being addressed under the Ghana Environmental Action Plan and the Ghana Forest Resource Management Project. Ghana's hydroelectric potential has been the subject of many studies, some dating from the 1920s, but which have mainly covered specific projects or regions. The country's total technically exploitable hydro potential is estimated at 10,000 Gigawatt hours annually (2,300 megawatts in- stalled capacity), derived mainly from three major river systems (Volta, Tano, and Pra) in the central and western regions. The presently installed hydro plant capacity is 1,072 megawatts, based on two dams on the Volta River. Other sites on the Black Volta, Pra, Tano, and Oti rivers have been studied to prefeasibility stage, and one of these, Bui (300 megawatts and 1,175 Giga- watt hours) has been studied to full feasibility level. There has been a comprehensive, country- wide survey of small hydro potential, and some recently identitied sites could possibly provide an economic supply to isolated centers. Offshore deposits of both crude oil and natural gas have been identified, but their size and commercial viability remains to be confirmed. Ghana has no known deposits of coal. Solar energy is plentiful with most regions receiving in excess of 1,900 hours of annual sunshine. This potential has not yet been exploited to any extent. Wind regimes are moderate and insufficient for energy purposes based on existing technology. None of these options are suitable to provide for the large increment of supply needed to meet the existing load and medium-term load growth on the Ghana electricity grid. Net domestic energy consumption in 1992 is estimated at 4.4 million tons. The bulk of consump- tion is wood fuel and agricultural residues (59.5 percent) followed by petroleum products (18.8 percent), and electricity (10.1 percent). Households and commerce accounted for 66 percent of domestic energy consumption, industry/mining 17.2 percent, and transportation 11.2 percent. Pe- troleum products and electricity consumption increased steadily throughout the period of low economic growth in the 1970s and negative growth in the early 1980s despite the deteriorating economy, spurred by subsidized petroleum products and low real prices for electricity; however, consumption declined sharply after 1982 because of shortages of both petroleum and electricity, but have since recovered as supply conditions returned to normal. Industry Sector Profile (Information on the industry sector is scattered through enterprise restructuring projects or pri- vate sector development projects. It was easier and quicker to retrieve information available from the World Bank's 1997 Ghana Country Assistance Strategy, which is excerpted here.) 234 Selected key recommendations included the following: ensure regular dialogue between govern- ment and private sector, improve procedures for business transactions, the privatization of state- owned manufacturing and agribusiness enterprises, and strengthen microfinance institutions. Demographic Profile (7his section contains materialfrom the World Bank's 1997 Ghana Country Assistance Strategy.) Reducing population growth rate to around 2 percent by 2020 is an important objective of the Government's Vision 2020. (This section, including the city profiles, contains materialfrom the 1990 Ghana Urban Il Proj- ect) Thirty-one percent of Ghana's 14 million people live in some 189 urban areas. The two large cit- ies Accra (the national capital) and Kumasi (the capital of Ashanti Region) dominate, accounting for 35 percent of the urban population, and together the five largest towns account for 50 percent of the urban population. Urban population growth rates have been declining-from 4.0 percent in 1960-70 to 3.22 in 1970-84. While still higher than rural rates (2.3 percent in 1970-84), they signal a significant shift in favor of the rural area, no doubt as a result of the economic dislocation that occurred in the 1970s, and continued up to the early 1980. As the economy continues to im- prove under the Economic Recovery Program, urbanization can be expected to accelerate, placing even greater stress on already overburdened urban systems. Signs of this are already evident in the recent traffic jams in Accra. It is estimated that about 1.6 million persons will be added to the urban population between 1995 and the year 2000, an increase of 35 percent. Profile of the cities. The following is a brief profile of Accra and the four secondary cities: Accra. The capital city and main administrative and commercial center, Accra's population was estimated at 1.0 million in 1984. If the 1970-84 growth rate of 3.2 percent per annum persists, Accra's population would be about 1.2 million in 1990 and would grow to about 1.6 million by the year 2,000. This represents a 33 percent increase over the next 10 years, a situation that will place great stress on already overburdened infrastructure, services, and housing facilities. Accra's road network is fairly extensive, covering about 950 kilometers, of which about 550 kilometers are paved; however, due to inadequate maintenance in recent years the paved roads suffer from varying degrees of pavement distress, with much of the trunk and arterial roads showing signs of severe distress. This deterioration of the network plus a number of network gaps has contributed to extensive delays in the movement of people and goods, as well as damage to vehicles and equipment, very high vehicle operating costs, and loss of life in accidents. Other infrastructure and services leave much less than to be desired. For example, only about 400 properties are linked to sewerage. The sewage treatment facilities are in a state of complete disrepair, and raw sewage is being dumped into the ocean. Solid waste management has shown considerable im- provement over the last 3-4 years, due largely to West German technical assistance. It is now estimated that about 60-70 percent of the solid waste is now being collected, as compared to about 20 percent just 5 years ago. Although a fairly extensive program of road maintenance has been undertaken, and it has become clear that major road reconstruction is now necessary due to the age of much of the road network and the significant increase in traffic. Modest drainage, sanitation, and urban upgrading improvements are being done. These need to be continued. Key items for the future (beyond Urban II) include sewerage, major drainage plan review, and envi- ronmental improvements in the Korle Lagoon area. Also, efforts need to be made to encourage much better use of existing land resources and to curtail urban spread. In particular, densities need to be considerably increased in the inner city, that is, inside the ring road. 235 Kumasi. Kumasi, with a population of about 400,000 in 1984, is Ghana's second largest city, the capital of the Ashanti Region, and the center of the most productive agricultural region of the country. The average rate of population growth during the period 1970-84 was 2.2 percent. As- suming that this rate of growth persists, Kumasi's population would be about 450,000 in 1990 and would grow to about 570,000 by the year 2000, that is, by about 25 percent over the next 10 years. Despite its critical role in the national economy, Kumasi's infrastructure and services have been severely neglected. In 1986 it was estimated that as little as 20 percent of the road network was in a serviceable condition. GOG, with assistance from the German Democratic Republic has recently embarked upon a program to rehabilitate approximately 100 kilometers (50 percent) of primary and secondary roads. This program has been very successfully implemented, but much remains to be done, particularly improvements to drainage, street lighting, traffic management, and sanitation. There are still 4,000 bucket latrines in the city, and it is estimated that only 40 per- cent of solid waste is being collected. The 8,000-stall Kumasi Central Market, one of the largest in Africa and the hub of the regional agricultural (food) economy, is overcrowded, subject to flooding, and without adequate sanitary facilities. The city's thousands of microenterprises oc- cupy marginal, flood-prone land with poor access to infrastructure and services, and many resi- dential areas are very poorly serviced. Modest drainage and sanitation improvements are being done under PWP. Tema. Ghana's main port and industrial center, Tema had a population of about 180,000 in 1984. Built as a new town in the 1960s, Tema's fortunes have ebbed and flowed with Ghana's changing political and economic circumstances. Despite this, Tema experienced the second highest popu- lation growth in the period (4.6 percent per annum) and is fast becoming a suburb of Accra just 27 kilometers away. Assuming that this rate of growth persists, Tema's population would be about 250,000 in 1990, and would grow to about 390,000 by the year 2,000, that is, by more than 50 percent over the next 10 years. Although infrastructure provision has been generally of a high standard, maintenance has been neglected. Roads are potholed, significant sections of the sewer pipelines have collapsed creating a public health hazard, and the main pumping stations to the sea outfall have long ago ceased to function. In addition to the above problems, significant informal settlements have developed within the city limits without the benefit of some basic services. Re- pair of sewer lines and modest drainage, sanitation, and urban upgrading improvements are being done under PWP; however, much needs to be done to rehabilitate the sewage pumping stations and treatment plants. There is no shortage of developable land. On the contrary, land is very un- derutilized. Sekondi-Takoradi. The capital of the Western Region, Sekondi-Takoradi with an urban popula- tion of about 116,000 in 1984 is Ghana's second largest port. Although the population is growing very slowly (0.32 percent per annum), there is a significant potential for industry, commerce, and possibly tourism; however, poor infrastructure retards development. Only about 23 percent of the primary roads are surfaced, and even these are badly in need of repair. The water system meets only 50 percent of the estimated demand, solid waste collection is inadequate, and sanitation is a serious problem. The port, which is the center of the local economy, is badly deteriorated and is being rehabilitated with Bank assistance (Credit 1674-GH). Modest road, drainage, and sanitation improvements are being done under PWP. Assuming that Sekondi-Takoradi's slow growth rate persists, its population in 1990 would be about 182,000 and would grow to about 194,000 by the year 2000. Tamale. The capital of the Northern Region with a population of about 160,000 in 1984, Tamale, was the fastest growing urban area during the period (4.92 percent per annum). Tamale's infra- structure is in very poor shape. Because of unreliable electricity supply for pumping, water supply is inadequate and irregular. Also, domestic sanitation is very bad, with over 2,400 bucket latrines in operation and open defecation in many areas of the town. Only 27 percent of the roads are paved, though these are in fairly good condition. Like most other cities and towns, refuse collec- tion systems are inadequate. Tamale was excluded from PWP largely because of its far northerly 236 location and the difficulty that this posed for project management. Assuming that the 1970-84 growth rate continues, Tamale's population in 1990 would be about 210,000 and would increase to 340,000 by the year 2000, that is, a 60 percent increase over the next 10 years. This growth will severely strain Tamale's capacities. Development Assistance Profile (Information on development assistance is from the World Bank's 1997 Ghana CAS.) The Bank Group is trying to increase its collaboration with donor agencies, the U.N. system, and NGOs and benefit from the complementarities in the activities of these organizations with those of the Bank. On project aid, most donors in Ghana support agriculture and water and sanitation with social sectors and roads corming after that. The recent road and basic education sector in- vestment programs and the planned health sector program have enhanced donor coordination considerably. There has always been a close relationship between the Bank and other donors. Ghana continues to receive support from a broad donor base. The Bank, as chair of the Consulta- tive Group (CG), provides the forum for CG meetings in Paris every alternate year. Donor organizations. There has always been a close relationship between the Bank and other do- nors. Ghana continues to receive support from a broad donor base. The Bank, as chair of the Con- sultative Group (CG), provides the forum for CG meetings in Paris every alternate year and regular consultations among official donors. Consultations with individual bilateral and multilat- eral donors take place in the context of specific projects or programs and also under the Special Program of Assistance (SPA) for Africa. The relationship is strengthened through weekly "heads- of-donor-agency" meetings and sectoral working level meetings in Accra, and through the sector investment programs in roads, education, and health, which require intensive donor coordination. While sectoral preferences, project vs. program aid emphasis, and comparative advantage differ among donors, the Bank is seeking to make maximum use of the opportunities for complemen- tarities and collaboration. Table 15-3 below shows the sectors where donors are providing aid. Table 15-3: Sectoral Participation of Selected Donors Donors Water Health Roads Mining, and and and Energy and Bilateral Agriculture Sanitation Education Population Transport Environment Canada x x x x Denmark x x x x France x x x x Germany x x x x Japan x x x Netherlands x x x x United Kingdom x x x x _ United States of x x America Multilateral AFDB x x x EU x x x x x FAO/IFAD x UJNDP x x x x UNICEF x x x WHO x x Source: World Bank's 1997 Ghana Country Assistance Strategy. 237 U.N system. The Bank works closely with the U.N. system in Ghana with respect to both pro- gram planning and operations implementation. The Government-U.N. Country Strategy Note, the LTN Joint Consultative Group's Common Country Assessment, and the UNAIDS Programs are current examples of collaboration. Of particular significance is the U.N. Special Initiative for Af- rica. The Bank's role as resource mobilizer, its experience with the Special Program of Assistance for Africa (SPA), and its piloting of sector investment approaches to development cooperation among domestic external partners are contributing to the formulation of ways and means by which these partners-the Government, civil society, NGOs, donors, and investors-can work together more effectively. Emphasis is being placed on value-added cooperative arrangements in all phases of the development cycle-performance criteria, procurement, disbursement, reporting, and monitoring. The emerging priority areas ofjoint activity with the U.N. system are good gov- ernance, food security, health, and education, with the overarching concern being poverty reduc- tion. Institutional Profile (Information is from the World Bank's 1992 Ghana National Environmental Action Plan.) Recommendation. Built Environment Management Description. The NEAP recommends the following actions: conduct post-audits on industries in the coastal zone that appear to be contributing to environmental damage; enforce standards and regulations on wastewater discharges, emissions, and disposal of solid wastes; support ongoing waste management programs of the Accra Metropolitan Area, District Assemblies, and townships in the coastal zone; improve urban drainage in the coastal zone; improve the siting of industries and enforce zoning regulations in the coastal zone; develop selected sites in urban areas for rec- reation and tourism, implement an appropriate strategy for coastal protection, taking into account the efforts of other countries; implement a coastal zone management plan; continue support for the National Program on Chemical Safety; review and update the National Physical Development Framework; acquire government lands in advance of anticipated development needs; reinforce selected settlements to act as rural service centers and reduce congestion in Accra area by pro- moting the development of secondary centers in the coastal zone; implement an urban sanitation program in Accra and other urban areas; require commercial houses to provide public places of convenience for customers; and implement urban landscaping and urban forestry programs (1992 Ghana NEAP). Recommendation. Institutional Reforn Description. Ghana's NEAP makes the following policy recommendations: strengthen and ex- pand the responsibilities of the Economic Planning Council; strengthen the NDPC and establish a Human Settlements Unit within it; create an institutional structure for integrated land use plan- ning; strengthen selected sectoral agencies and interagency coordination; support district assem- blies; and involve community groups and NGOs in informal education, tree planting, and agro- forestry initiatives, and the creation of community environment committees. (Health information is from the 1995 Ghana Medium-Term Health Strategy: Toward Vision 2020.) The health sector will collaborate with the Ghana Water and Sewerage Corporation (GWSC), District Assemblies, and other agencies in the water and sanitation sector. Act 426 allocates the responsibility for sanitation to the Ministry of Local Government. District, Municipal, and Met- 238 ropolitan Assemblies are, therefore, responsible for providing environmental health services (p. 30). (Health information is from the 1997 Ghana Health Sector Support Program.) There are four main types of health care providers in Ghana: public, private not-for-profit (mis- sion), private for-profit, and traditional. Until the establishment of the Ghana Health Service (GHS) and teaching hospital boards during the program period, the Ministry of Health (MOH) will be the main provider of formal modem services. It is a hierarchical organization with a cen- tral headquarters in Accra, ten regional administrations responsible for supervision and monitor- ing, and district health teams in each of the 110 districts. Public facilities include two teaching hospitals, ten regional hospitals, 48 district hospitals, and over 1,600 health centers and clinics based in subdistricts. The mission sector is estimated to provide coverage to 30 percent of the population covered by health services, predominantly in rural areas. They account for about 30 percent of hospital beds and 35 percent of outpatient care. There is a good working relationship between the public and mission sectors, with the Government providing salaries for many of the health workers at mis- sion hospitals. The private for-profit sector is growing, particularly in urban areas, whose practi- tioners consist of physicians, midwives, pharmacists, and laboratory technicians. In addition to having their own associations, private practitioners are registered by statutory bodies associated with the MOH. Traditional providers, who range from spiritualists and psychic healers to herbal- ists, are likely the most popular first line of health care provider, though quantitative information on the levels of use and costs is not known. At present, traditional practice is not well regulated nor understood by the public sector, though stories of both dangerous practices and miraculous cures are common. Systemic problems of the health sector. Some of the main problems in health service delivery are well recognized by Ghanaians. In its Five-Year Sector Program of Work 1997-2001 (POW), which details the operational framework for the health sector for the medium term, the MOH aptly summarizes the main problems as: (a) people cannot access the health care they need be- cause of geographic distances, limited provision of basic services, and financial barriers, (b) in- adequate service quality and a lack of quality assurance efforts and resource management results in services that do not respond to what people want, (c) inadequate findings of health services, (d) inefficient allocations of resources, with insufficient funding of primary services, misallocation of health personnel, and inadequate benefits reaching the poor, and (e) poor community, intersecto- ral, and private sector linkages. Overall, access and utilization of allopathic services are quite low; 30-40 percent of the population, mostly those in rural areas, do not have easy physical access to health services. Utilization of public curative services was about 0.39 visits per capita in 1996, though this has been increasing steadily, since the late 1980s; however, the use of antenatal care is much higher-over 80 percent coverage in 1995-while 40 percent of births were supervised by trained health personnel. Traditional donor assistance has led to fragmented approaches to dealing with these problems. Rather than build Govermnent systems to tackle these problems, each donor has tended to establish management and reporting systems for their own project, fur- ther serving to dissipate Government resources. Health expenditure patterns. Absolute resources for the health sector have been shrinking over the last decade. Since 1990, the proportion of Government recurrent funds expended in the health sector has also been declining. Although Government has allocated between 8-1 1 percent of the recurrent budget to health in the 1990s and 2-9 percent of its capital budget, this represents be- tween 1.0 to 1.5 percent of gross domestic product and from US$4 to US$6 per capita. This places Ghana among the lower half of Sub-Saharan countries in terms of Government expendi- ture on health (Better Health in Africa) and represents a real decline from the late 1 970s, when Government spent around US$ 10 per capita. The poor also receive proportionately less public 239 expenditures than others. In 1992-93, Ghanaians from the lowest income quintile received 12 percent of public expenditure on health, compared to 33 percent for the top quintile. External support has increased for health sector, amounting to about US$30 million per year in 1995. The resources available for capital expenditures were not well known prior to the preparation of the sector program, and planning for new capital projects often bypassed the MOH. Private funding is poorly captured in official data, but is estimated to be about equal to the Government expenditure. User fee policy has been a sensitive issue in Ghana. After user fees were initially introduced in 1985, utilization of health services at public clinics fell markedly. It took nearly ten years for utilization rates to recover to the same levels prior to the use of user fees. Many did not associate user fees with improvements in quality, though in the last five years, the availability of drugs may have improved with the use of "cash and carry" payment for drugs. Out-of-pocket expenditures officially recovered at public facilities have been fairly stable in the last ten years, so that nearly 10 percent of Government recurrent expenditures are financed by these internally generated funds, which are used at the point of collection. This level of expenditures recovered is among the highest in Africa; however, current user fee practices are not transparent and create an obstacle for the poor to access health care. Whilst centrally approved official user fees have not changed since they were introduced, in practice, fees have been rising due to unofficial fees and locally sanctioned official fees. Such fees are inequitable; they should subsidize the poor who are par- ticularly vulnerable. Since they do not, the poor often do not seek care or seek care too late. Those conditions that have value as a public good should also be protected (e.g., free treatment of tuberculosis and sexually transmitted diseases), but are not currently exempted. Revising the ex- emption policies is a significant part of the current reform program. The reforms include making the fees more transparent to the public, building in a system to regularly review and change rates, exempting vulnerable groups, and incorporating incentives for patients to initially use primary services over more expensive services (p. 2-5). (Urban information is jrom the 1996 Ghana Urban Environmental Sanitation Project.) The most important government policy related to urban development is the recent decentraliza- tion initiative. Under the 1992 Constitution and the Local Government Act (No. 462) of 1993, Ghana's Metropolitan, Municipal and District Assemblies are autonomous local governments with legislative and executive powers within their areas. They are empowered to prepare and ap- prove their annual budgets, to raise revenues from taxes and fees, to borrow funds, to acquire land, and to provide basic services and local infrastructure. A Letter of Local Government Devel- opment Policy prepared by the Ministry of Local Government and Rural Development (MLGRD) in conjunction with the latest IDA-financed urban project focuses on two key points. First, local governments should eventually be able to employ their own staff accountable to them. The 1993 Act calls for the creation of a Local Government Service, and proposals for this are being studied. Second, the Assemblies are to have discretion in selecting of projects to be financed with reve- nues of the District Assemblies Common Fund. (Transportation information isfrom the 1996 Ghana Urban Environmental Sanitation Project.) Road administration. The Ministry of Roads and Highways (MRH) and its three agencies, Ghana Highway Authority (GHA), Department of Feeder Roads, and Department of Urban Roads (DUR), are the organizations that plan and implement road construction, rehabilitation, and maintenance. MRH was set up in 1982, as a separate ministry in charge of roads and highways, with a nucleus of technical staff that reports to the Secretary of Roads and Highways. GHA was established in 1974 as an autonomous body with its own Board of Directors appointed by the Government, but the Board has recently been replaced by an Interim Management Committee. GHA has a staff of some 6,500 spread over the central office in Accra, 10 regional offices and 32 road area offices. It also has a central workshop and a number of small regional workshops. GHA has 70 engineers, 60 technician engineers as well as some 670 technical and supervising staff. 240 DFR and DUR were established in 1981 and 1983, respectively, and function as civil service agencies under MRH. DFR staff includes 36 engineers, some 40 other professional staff and 330 technical personnel. It maintains small offices in all regions and in 10 road areas. DUR has a staff of about 200, including 10 engineers and offices in the main cities, where it works with the city councils. Annex 2-1 shows the organization chart of MRH. Institutional achievements and requirements. The most important achievements in recent trans- port and road projects include: (a) implementing a phased 10-year program (1988-1997) to reha- bilitate and maintain the trunk road network, and start of work to organize feeder roads planning, rehabilitation, and maintenance, (b) strengthening MRH, GHA, DFR, and DUR through technical assistance in key areas and through training, (c) reducing the share of force account works carried out by direct departmental labor, (d) setting up a Road Fund to ensure the regular flow of funds to the agencies and contractors, (e) starting pilot projects for introducing labor-intensive rural road rehabilitation, and 6) improving contractor capacity through subloans for equipment and spare parts, training, competitive bidding for all works, and ensuring prompt payments to contractors. The main institutional support needs that remain in MRH, GHA, DFR, and DUR are: (a) techni- cal assistance in specialized areas where local engineers are not available, (b) an enlarged inter- agency training program to improve existing staff skills and to train newly graduated engineers, (c) incentives such as housing for key officials and food aid through the World Food Program (WFP), which has helped to improve productivity, and (d) training and advice to domestic con- tractors and consultants to further improve their technical and managerial efficiency. The ongoing First and Second Transport Rehabilitation Projects and the Second Urban Project provide such support to MRH, GHA, DFR, and DUR; additional support for DFR will be provided through th s project (1991 National Feeder Roads Rehabilitation and Maintenance Project). (Agriculture information is from the 1994 Ghana Agricultural Sector Investment Project.) The Ghana Irrigation Development Authority (GIDA) is the main irrigation development institu- tion and operates under MOFA as a semiautonomous body with four regional representatives. Since 1977, GIDA has built and continues to manage most irrigation schemes, although autono- mous operating authorities have been set up for some larger schemes. Local authorities operate small water projects. In the North, the Small Irrigation Division of the Upper Region Agricultural Development Project (URADEP), the Irrigation Company of the Upper Region (ICOUR), and some NGOs assist local communities to develop irrigation. Regional MOFA offices are responsi- ble for extension services. Where crop husbandry practices for rainfed and irrigated crops differ, GIDA assists farmers and MOFA staff with technical advice on irrigated crops. Most of the irrigation in Ghana, totaling about 7000 hectares, has been developed and is managed by GIDA. GIDA's schemes vary in size from 100 to 2,500 hectares and most of them are beset with problems. Poor site selection, inappropriate design and unsuitable contracting arrangements have led to unacceptably high costs. Poor extension services have resulted in low yields, while land tenure problems, high maintenance costs and a dependence on GIDA for land preparation have resulted in a lack of farmer interest. This has been exacerbated by a lack of farmer partici- pation in irrigation design and management. Private irrigation is very limited in scope. Small dams and dugouts for drinking water have been constructed in the northern regions, and these sometimes allow small-scale irrigation for tradi- tional vegetable production on small plots. Some private irrigation schemes for commercial crops have also been constructed along river banks, using low-lift pumps, and a number of community- owned valley bottoms in the South have shown potential for rice under increased water control. Additional studies to identify valley-bottom schemes need to be carried out, however. (Note: Industry information was not available.) 241 (Energy information is from the 1995 Ghana Thermal Power Project.) The Ministry of Mines and Energy (MOME) has principal responsibility for petroleum and elec- tricity; it establishes and implements sector policy. MOME supervises the state-owned Ghana National Petroleum Corporation (GNPQ, Ghana Oil Corporation (GOEL), and the refining com- pany Tema OH Refinery (TOR), as well as the two power sector entities-the Volta River Authority (VRA) and the Electricity Corporation of Ghana (ECG). VRA supplies electricity in bulk to ECG, the Volta Aluminum Company (VALCO), several mines, the Akosombo Textile Company, and Akosombo Township. VRA also exports electricity to Communaute Electrique du Benin (CEB) and, until 1994 Energie Electrique de la C6te d'lvoire (EECI). Under the IDA- assisted Northern Grid Extension Project (Credit 1759-GH) of February 1987, the responsibility for generating and distributing electricity in Northern Ghana was transferred to VRA from ECG. These responsibilities are handled by VRA's Northern Electricity Department (NED). ECG dis- tributes the electricity it receives from VRA throughout the rest of Ghana. Since its foundation in 1961, VRA has operated as a quasi-enclave within Ghana, enjoying a high degree of autonomy. VRA is a relatively well-run public utility with few institutional and finan- cial problems. ECG, which is a much larger organization, was set up in 1967 to succeed the Elec- tricity Division of the Ministry of Works and Housing. It is now beginning to make the transition from a Government department to a commercially viable enterprise, the objective being to estab- lish itself as an autonomous and effective public utility. Attention has been focused upon sector reforms and other measures needed to strengthen ECG. With the Electricity Supply Board of Ire- land's (ESB) assistance, progress has been made in technical operations under the Power System Rehabilitation Project (Credit 1628-GH) and ECG Fifth Power Project (Credit 2061-GH); how- ever, ECG's commercial operations need substantial improvement, in respect of which a per- formance-based management contract with a private firm is being financed under the recently approved National Electrification Project. Prices of petroleum products and electricity fell sharply in real terms from the mid- I 970s until 1983, as a result of Governmental energy pricing management, which failed to fully reflect in petroleum product and electricity prices the extent of high domestic inflation to adjust for over- valued exchange rates during that period. After the major devaluation of the cedi in 1983, domes- tic energy prices were increased very sharply to bring them back into line with their international equivalents. Subsequent increases in petroleum prices have kept up with the successive devalua- tions. Petroleum product prices are now within the range of international levels and are unsubsi- dized. Ghana's total installed public generating capacity is about 1,102 megawatts, of which 1,072 megawatts (95 percent) is hydroelectric from two stations on the Volta River at Akosombo (912 megawatts), and Kpong (160 megawatts). Both stations are owned by VRA and are capable of providing firm energy of about 4,343 Gigawatt hours/year and can deliver 6,100 Gigawatt hours/year on average. The Akosombo power station is being retrofitted under the ongoing VRA Sixth Power Project (Credit 2109-GH). Total diesel capacity is less than 50 megawatts of which Tema (30 megawatts) is the largest and has been rehabilitated with U.K. financing. The remain- der comprises a number of small isolated stations, which are being retired under the ECG Fifth Power project. Poverty Reduction Profile (Poverty reduction information isfrom the 1999 Ghana Community Development Project.) Recent poverty assessments estimated that some 32 percent of the total population lived in pov- erty. This is overwhelmingly a rural phenomenon, with over 72 percent of the poor living in rural 242 areas; however, urban poverty is becoming more pronounced. For a large segment of the Ghana- ian population, the quality of life is poor, with high levels of malnutrition and infant and child mortality, low life expectancies, low levels of education and literacy and limited access to em- ployment and economic services. Objectives. The project proposes to (a) test approaches and mechanisms for delivering, coordi- nating, monitoring and evaluating poverty reduction programs, (b) build capacity for TCOP/NDPC to coordinate and monitor cross-sectoral poverty reduction programs carried out by different line ministries and at decentralized district and community levels, (c) strengthen col- laboration between government and NGOs in targeted service delivery, with NGOs providing the actual services and government providing supervision and support, and (d) strengthen collabora- tion between the Bank and the UNDP and other development partners in supporting the govern- ment's poverty reduction programs. The project has identified three areas of specific focus-community-based nutrition and food se- curity, street children, and poverty measurement and monitoring. It will test, in selected districts and urban centers, strategies and operational modalities to: * Strengthen the capacity of communities and districts to take action against the local causes of malnutrition and to improve nutrition and food security especially for children under five and pregnant and lactating mothers * Meet the needs of various groups of street children and deepen public awareness and un- derstanding of the street children phenomenon * Build the capacity of the districts to measure and monitor changes in welfare at house- hold and community levels. Experience from past operations supported by the Bank and other development partners (e.g., the UNICEF Iringa model for nutrition activities) indicate the following lessons. First, communities should actively participate in the design and implementation of project interventions. This gives them a greater sense of ownership and leads to more sustainable results. Project preparation and implementation should be based on strong coordination and consensus-building mechanisms, al- lowing for flexibility based on community readiness. Second, there are plenty of resources avail- able for infrastructure development from ongoing Bank operations and from other external sources' however, these resources are generally poorly coordinated and not effectively used. Also, the "software" aspects-how to do what needs to be done-have been underfunded. These are the aspects that need to be strengthened, if investments in infrastructure are to be effectively used and sustained. 243 References World Bank Documents Cked Additional Useful World Bank Documents on Ghana * Community Development Project (1999) * Private Sector Adjustment (1997) * Water Sector Restructuring Project * Public Finance Management (1997) (1999) * Public Enterprises (1996) * Natural Resource Management Project * Highway Sector Investment (1996) (1998) * Non-Bank Financial Institutions (1996) * Ghana Country Assistance Strategy * Private Sector Adjustment (1995) (1997) * Mining Sector Development and the En- * Health Sector Support Program (1997) vironment (1995) * Urban Environmental Sanitation Project * Fisheries (1995) (1996) * Private Sector Development (1995) * Village Infrastructure Project and EA * Local Government Development (1994) (1996) * Agricultural Sector Investment (1994) * Medium-Term Health Strategy: Toward * Ghana Urban Strategy Review (1993-94) Vision 2020 (1995) * Enterprise Development (1993) * Ghana's 2020 Vision (1995) * Urban Transport (1993) * Thermal Power Project (1995) * National Electrification (1993) * Agricultural Sector Investment Project * Livestock (1993) (1994) * Agricultural Extension (1992) * Ghana National Environmental Action - Agricultural Research (1991) Plan (1992) - Economic Management Support (1991) * National Feeder Roads Rehabilitation * Health and Population 11 (1991) and Maintenance Project (1991) - Transport Rehabilitation 11 (1991) * Urban II(1990) * Agricultural Diversification (1991) * Power VI (1990) * Water Sector Rehabilitation (1990) 244 CHAPTER 16: SAMPLE INSTITUTIONAL NEEDS ASSESSMENT FROM GHANA This chapter is based on a pilot study in Ghana, "Targeted Collaboration Among Line Agencies, Local Communities, and the Ministry of Health." The pilot sought to address the following is- sues: how can health, environment, and infrastructure agencies collaborate on a daily basis and with what benefits and costs? As a background for the pilot, the needs assessment was discussed at a workshop in October 1999, which is discussed in chapter 17. The needs assessment took place from July to October 1999 in Sekondi-Takoradi, one of the five largest cities in Ghana and also referred to as the Shama Ahanta East Metropolitan Assembly (SAEMA). Environmental Health Needs Assessment from Ghana Introduction and Objectives The objective of the pilot study was to develop a methodology to define a parallel set of health priorities based on cost-effective interventions through infrastructure and environmental projects, rather than on typical morbidity and mortality data. An additional objective of the pilot would be to replicate analysis of the needs assessment and recommendations of the workshop for other cit- ies in Ghana. The work was initially based on common "entry points" through which health, in- frastructure, and environment agencies can agree on objectives. The three main entry points were selected after preparation of an "environmental health profiie," discussed chapter 15 (see chapter 5 for general methodology). The entry points for the pilot study included: * Management of wastes from health care facilities * Urban malaria and other vector-borne diseases * Water, sanitation, and drainage. The pilot was intended to build on a research report undertaken between April and August 1998 on development of collaborative linkages between sanitation infrastructure and public and envi- ronmental health in the context of the World Bank Urban Environmental Sanitation Project (UESP) in Ghana (Stephens and others 1998). The pilot was divided into three parts: Part one institutional needs assessment. This would consist of consultations and needs assess- ment on the Metropolitan District Assembly (MDA), private sector, and civil society to ascertain the opportunities and constraints of intersectoral collaboration and build on the "Consultative As- signment on Urban Public and Environmental Health in Ghana" report. (See "terms of Refer- ence," below.) Part two, workshop. Plan and organize a workshop to present findings, propose next steps, and engage government officials and agencies and stakeholders in a dialogue. Part three, summary report and recommendations. Produce a final report on the pilot workshop for replication of its findings to other cities in Ghana and possible Bank projects. 245 Methods and Institutions Consulted A questionnaire was prepared to solicit response from approximately thirty institutions, including government agencies, the private sector, and civil society, for the needs assessment during two- and-a-half weeks in Sekondi-Takoradi. More than one person was contacted in some institutions (see table 16-1 for a list). Table 16-1: Institutions Consulted Health Care Facilities Public Departments Private Sector * Effia Nkwanta Regional Hospital * SAEMA Administration * SNV * Kwesimintim Polyclinic * Works Department * Friends of the Nation * SAEMA Health Administration * Public Relations Unit * African Centre for Human Devel- * Western Regional Health Admnini- * Physical Planning Department opment stration * Legal Department * Community Development and * Aunty Lily's Maternity Home * Department of Community Devel- Environmental Protection Asso- * Qui-Wal Private Hospital opment ciation * Development Planning Unit * Takoradi Market Association * Environmental Health Unit * An assemblyman for New Ta- * Waste Management Department koradi School Health Education Pro- * Unit cominittee chairman, Effia gramme Electoral Area * Urban Environrmental Sanitation * A private water vendor at New Project Takoradi * Department of Urban Roads * A public toilet operator at Sekondi * Environmental Protection Agency * Community Water and Sanitation Agency = Ghana Water Company Source: Authors' data. SAEMA was chosen instead of the cities of Accra, Tema, and Tamale, because: (a) SAEMA has started a nucleus of collaboration and coordination under the leadership of the metro chief executive and the metro coordinating director. Assembly department heads meet every Monday morning to take stock of the previous week's achievements and plan activities for the coming week. This approach appears to increase awareness among all the departments of the assembly and provides a good example of intersectoral collaboration, which could be developed along the entry points. (b) Accra is already benefiting from a similar initiative sponsored by the Department for In- ternational Development of the United Kingdom (DFID-UK). This initiative, the Accra Metro Environmental Health Initiative (AMEHI), are intended to build meaningful part- nerships among the Accra Metropolitan Assembly (AMA), organizations, and commu- nity to bring about improved protection and promotion of environmental health in the Accra Metropolitan Area. The key principles include: * Intersectoral collaboration to improve the environment and health of commu- nities * Institutional capacity building in terms of required skills, personnel, policies, and systems * Community participation in the design, planning, and implementation of ini- tiatives * Information for good management. 246 Geographic, Demographic, and Sanitary Background on SAEMA SAEMA is one of the four district assemblies in the Western Region and one of three metropoli- tan assemblies in the country. SAEMA is located about 210 kilometers along the coast, west of Accra. SAEMA covers a land area of 334 square kilometers and is divided into three sub-metro district councils: Shama, Sekondi, and Takoradi. The twin city of Sekondi/Takoradi is both the regional and district capital. The topography of the metropolis varies from sandy coastline in the south to low-lying areas in- terspersed with ridges and hills (with altitudes ranging from 30-60 feet) in the north. The coast- line has many bays with serious erosion problems around Shama, Essaman, Sekondi, Nkontompo, and New Takoradi. Low-lying areas (with altitudes of around 4.5 meters) can be found in the central area of Takoradi. Consequently, Takoradi's central market is in a flood-prone area. Due to the undulating nature of the topography, a number of muddy lagoons and swampy marshlands are common features of the landscape (SAEMA 5-Year-Development Plan). Natural drainage channels. The metropolis is drained by a number of rivers. On the western bor- der lies the Whim River with its main tributary, the Ayire, flowing through the Whim Lagoon on its way to the sea. On the east lies the Pra River. These two rivers flow throughout the year. The Kansawurado River flows into the Butua Lagoon past the Takoradi Polytechnic, creating coastal marshlands. The Essie Lagoon is another important lagoon. These lagoons and drainage channels create breeding places for mosquitoes and other vectors of diseases. Climate. Like other parts of southern Ghana, the metropolis experiences an equatorial type of climate with high temperatures ranging from 22°C to 33°C. Precipitation occurs mainly from March to July (70 percent) and between late September and November (30 percent). The dry sea- sons are short, occurring from August to early September and December to February. Population and settlement patterns. The population of SAEMA in the last census (1984) was 249,371 and reached an estimated 357,431 in 1996, representing a growth rate of 3.5 percent a year. The population density also grew from 746 persons per square kilometer in 1984 to 1,069 in 1996. The largest communities are concentrated in Sekondi and Takoradi, which continue to grow due to the high levels of services available. Other large communities with major increases are Shama, Effia-Kuma, Kwesimintim, Adiembra, and Nkotompo. The Shama subdistrict has dispersed communities exhibiting rura; characteristics. Much inequity exists in the service deliv- ery system: curative facilities are available in urban areas, whereas rural poor lack access to health care. Areas that lack basic infrastructure have more environment-related health problems. Occupation. Current information on occupation and employment are not available. The 1984 cen- sus figures indicate that retail trade is the major occupation in SAEMA, employing more females than males. Retail trade is followed by the following primary occupations: agriculture, forestry, and fishing. The manufacturing industry, especially processing of primary products, such as wood and food, is next in line. Many wood-processing industries exist due to the tropical rain forest location and variety of timber species. Solid waste. The assembly collects only 43 percent of total refuse generated monthly, approxi- mately 4,500 metric tons. Business and industrial establishments must dispose of their own waste, but only a few have the capacity to do so. A huge backlog of refuse exists, therefore, creating spontaneous dumps in the communities. The situation is worsened by uncovered refuse trucks littering the streets. The assembly operates two disposal grounds. Dump sites in other communi- ties have become places for indiscriminate defecation, creating environmental hazards. SAEMA has introduced door-to-door collection of refuse in high-income areas with good roads, using pri- vate contractors, and SAEMA continues to collect refuse in the other parts of the city. 247 Liquid waste. SAEMA produces an estimated 1,750 cubic meters of liquid waste a month. SAEMA is responsible for dislodging all liquid waste, except for that of the Ghana Ports and Harbours Authority and Ghana Armed Forces. With the lirnited holding capacity of its equip- ment, SAEMA can only handle 50 percent of the total volume generated. Many septic tanks are consequently left unattended when they are full, creating environmental hazards and nuisances. Toilet facilities. About 60 percent of the total population use private toilet facilities. The remain- ing 40 percent either depend on public toilets or do free-range defecation. The metropolis has 101 public toilets, which are flush, aqua privy, or KVIPs (Kumasi ventilated improved pit). The use of pan latrines is also widespread. Night soil and effluent are discharged untreated into the sea. Health care facilities. Table 16-2 shows health care facilities in SAEMA: Table 16-2: Health Care Facilities in SAEMA Facility Number Goverunent hospital 2 Private hospital or clinic 31 Government health center 5 Comnunity and maternity clinic 5 Doctors 57 Nurses 248 Auxiliary health staff 211 Hospital beds 457 Population per doctor 4,012 Population per nurse 922 Population per hospital bed 500 Source: SAEMA Five-Year Development Plan 1996-2000 (1995). Environmental Health Findingsfrom the Need Assessment Survey Top Ten Diseases in SAEMA Table 16-3 shows the top ten causes of morbidity reported to health institutions for SAEMA within 1997 and within 1998. Table 16-3. Top Ten Diseases in SAEMA 1997 1998 Rank Disease Number Percent Disease Number Percent I Malaria 62,304 36.1 Malaria 70,030 37.4 2 Upper respiratory tract 10,222 5.9 Upper respiratory tract infection 12,724 6.8 infection 3 Acute eye infections 7,733 4.5 Acute eye infections 11,212 6.0 4 Diseases of skin 7,201 4.2 Diseases of skin 8,872 4.7 5 Diseases of oral cavity 4,813 2.8 Diarrheal diseases 6,797 3.6 6 Diarrhea diseases 4,203 2.4 Accidents 5,324 2.8 7 Accidents 3,777 2.2 Diseases of oral cavity 5,237 2.8 8 Ear infections 3,761 2.2 Ear infections 3,774 2.0 9 Intestinal worms 2,070 1.2 Pregnancy related diseases 3,513 1.9 10 Rheumatism, joint pains 1,631 0.9 Rheumatism and joint pains 3,012 1.6 Total 107,715 62.4 Total 130,049 69.8 Total OPD' attendance 172,659 100 Total OPDa attendance 187,053 100 Note: a. Outpatient Department. Source: SAEMA Metro Health Department (1999). 248 Total outpatient attendance at health institutions within SAEMA in 1997 and 1998 were 172,659 and 187,053, respectively. Malaria has consistently remained the top reason for seeking medical treatment at outpatient departments of all health institutions from year to year. In 1997 and 1998 malaria accounted for 36.1 percent and 37.4 percent, respectively, of all hospital attendance in SAEMA. Table 16-4 shows some of the statistics. Table 16-4: Outpatient Attendance Due to Malaria Health Institution Year Total OPD Attendance Percent Due to Malaria Kwesimintim 1997 30,011 32.0 1998 28,307 34.5 Effia Nkwanta 1997 28,324 33.7 1998 20,997 36.0 SAEMA 1997 172,659 36.1 1998 187,053 37.4 Western Region 1998 573,632 42 Source: Kwesimnintim Polyclinic, Effia Nkwanta Hospital, SAEMA Health Department, Western Region Health Office 1999. A word of caution. Health statistics either overestimate or underestimate the disease burden. As Dr. Linda Vanatoo, medical director of health services said, "It is important that reported data be interpreted carefully, because of the difficulties in obtaining accurate and reliable data." Figures may be overestimated because: * Almost all diagnosis of malaria is made without laboratory confirmation. In an endemic area, such as SAEMA, the real possibility exists of diagnosing every fever at clinics as malaria. * Return attendance at the health institutions is usually not recorded. The system is also not designed to deduct previous diagnosis from the statistics, should a change occur in diag- nosis on return. Figures may be underestimated because: X The reported figures do not include statistics from the private sector, the quasi- government health institutions, and traditional medical practitioners, all of whom treat malaria. * Most people with a fever take a course of chloroquine by themselves and only report to the health institution if they do not recover. Relationship between the Top Ten Diseases and Environmental Conditions Health cannot be achieved by the health sector alone. The Ministry of Health recognizes this and, in its program of work, emphasizes development of broadly based approaches to public health, including collaboration between the other sectors and the public (Ministry of Health 1996). The ministry realizes that other MDAs control most determinants of health, especially environmental health, whereas members of the public play a significant role in causing disease through their ac- tions. Table 16-5 summarizes the ten top diseases and their relationship to environmental condi- tions. 249 Table 16-5: Environmental Linkages of Top Ten Causes of Morbidity in SAEMA Disease or Comments (Linkage to Environmental Conditions, Required In Last Five Condition Intervenffons, and Other Factors) Years Malaria * Anopheles mosquitoes breeding in accumulated brackish water, due to Stable inadequate vector control, sanitation, drainage, and public awareness * All ages affected, but mostly children ages 0-15 years * Lower socioeconomic areas are most affected Upper respira- * Poor housing, indoor and outdoor pollution, crowding, and poor nutri- Stable tory tract infec- tional status tion * Cormmon among children 0-4 years and also workers and populations near quarries, cernent works, and mines Acute eye infec- * High reported number of eye conditions, believed to be reduced due to Increasing, due tions support area receives from NGO Eye Savers on eye conditions to cases coming * Inadequate supply of safe water and poor personal hygiene from outside _________________________________________SAEMA Diseases of skin * Inadequate supply of safe water and poor personal hygiene Stable * Includes ulcers Diarrheal dis- * Water and food contamination from poor solid and liquid waste man- Stable eases agement and poor personal hygiene * Common among fishing communities, especially during fishing season Accidents * Household and road traffic accidents and burns Stable * The 15-45 year age group rainly affected Diseases of oral * Ignorance and poor personal hygiene and poverty Stable cavity * High numbers due to presence of dentists at some hospitals. Patients come from within and outside SAEMA, seeking health care for this rea- son Ear infections * Ignorance and poor personal hygiene and poverty Stable * The reason for the high number of ear infections not totally clear Pregnancy- Re- * Inadequate antenatal care and inaccessible health care facilities Fluctuates lated Diseases * Also reflects the high total fertility rate in the area Rheumatism and * Mostly due to sickle cell disease, a common inherited disorder among Fluctuates Joint Pains Africans. Lack of premnarital counseling services for sickle cell patients. Source. Data compiled for the study. Perceptions of the Health Problems All health institutions generally agree that no policy and operational guidelines exists for manag- ing hospital waste in the city. Both private and public health institutions currently either bury or burn their waste. They concede that this is not hygienic and could lead to health hazards to scav- engers, staff, and general public. The institutions observe that the absence of an operational or policy guidelines for managing and disposing of hospital waste is a fundamental issue to tackle and suggest the involvement of SAEMA's Waste Management Unit. Nonhealth institutions, particularly waste management, the UESP, and Ghana's EPA, recognize the risk to both the community and health service staff and have recently begun investigating the issue. These actions are in the conceptual stage and may take some time to effect. The Western Regional Health Administration, which has the institutional responsibility for developing such a policy, should play the lead role in addressing the problem. The health institutions are unanimous in their perception of the linkages among the ten top dis- eases and unsanitary environmental conditions in communities, demonstrated by accumulation of solid waste, indiscriminate defecation on beaches and in open spaces, choked gutters, and poor toilet management. Drainage in the metropolis is grossly inadequate, making the area susceptible 250 to flooding and stagnant water. The rainy season consequently records the highest frequency of environmentally related diseases, such as malaria and diarrheal diseases. Nonhealth agencies attribute health problems to inadequate provision of basic facilities in both homes and communities. The head of the Physical Planning Department notes that topographic characteristics of the area combine with absence of proper land-use guidelines to contribute to flooding and formation of vector-breeding sites. Box 16-1: Mr. Ampadu Adjei (Head of Physical Planning Department) "The topographic characteristics of the SAEMA area make environmental management a critical issue. There are a number of lagoons and water courses that need to be managed properly, The absence of proper land use guidelines in developing the areas around the lagoons has led to a fun- damental problem and has adverse effects on health, for example, flooding and malaria control." Source: Authors' data. Housing development characterized by multiple-unit dwellings and overdevelopment has also had an impact on health and hygiene (ventilation, crowding, and lack of amenities and circulation spaces and inadequate provision of sanitation services within homes). Another dimension of the problem has to do with apathy, attitudes, behavior, and ignorance of the people toward sanitation issues. The public believes that because they pay property rates and levies, SAEMA should alone be responsible for handling waste in the metropolis and the public carries no further obligation. Regulations and bylaws of the General Assembly are flouted and the courts are not able to prosecute offenders. Box 16-2: Market Women Association "We are aware of the poor sanitation that is in the markets, but we have no control or manage- ment role. It is the responsibility of SAEMA, because we pay market tolls." Source: Authors' data. In the rural area, poor health is the outcome of an inadequate supply of potable water and poor sanitation facilities, coupled with poor personal hygiene, which is directly related to poverty and ignorance. Perception of the linkage between environmental factors and diseases exists at all levels. This perception, however, is not translated into action at the intersectoral level. Institutional Roles Regarding Entry Points Health institutions. Malaria and other vector-borne diseases are major causes of morbidity and mortality in SAEMA. Both private and public health institutions are responsible for providing curative care for patients. In the design of the health care delivery system, these health care fa- cilities currently emphasize their curative more than preventive role, which is relegated to the public health sector. The public health institutions or units of health care facilities are responsible for the following: * Health education for the public at health institutions and in comnmunities * Curative and preventive outreach services to the communities 251 * Monitoring the disease trends in the region and feeding information to lower structures * Carrying out surveys on prescribing habits and training of prescribers in properly man- aging malaria and other vector-borne diseases * Training others, for example, community-based health care workers, day care teachers, chemical dealers, and so on as primary care providers for malaria * Liaison with other sectors at the SAEMA and Regional Coordination Committee levels for improved management of the environment to control vectors and sources of infections * Organizing the Regional Malaria Awareness Program for the public * Promoting screening of houses and use of insecticide-treated materials (ITM), for exam- ple, pyrethroid-impregnated bed nets for vector control. In its supervisory and monitoring role, the District Health Administration collects and collates data on all diseases from public health institutions and sub-metro health management teams. These data are used in planning health service delivery, including public health education. The District Health Administration also assists in drafting the assembly's bylaws on sanitation. The District Health Administration serves as the link between the public and private health insti- tutions and the nonhealth departments of SAEMA. It liaises with the Environmental Health Divi- sion, the Waste Management Department, and other stakeholders in maintaining sanitation and vector control. The administration, thus, plays an advocacy role at intersectoral levels to ensure incorporation of health considerations in planning and managing assembly projects. This is achieved by the Metropolitan Director of Health Services serving on a number of subcommittees of the assembly. Box 16-3: Dr. Lynda Vanatoo (Metro Director of Health Services) "In the current year, the department has actively worked with the Environmental Health Unit on the following: * Weeding, spraying around houses and water bodies to control the breeding of mosquitoes . House-to-house inspection to detect and enforce the control of breeding sites of the disease vectors * Public education on personal hygiene and sanitation practices * Routine cleansing of public and community drains." Source: Authors' data. The private sector health institutions, private medical and dental practitioners, quasi-government hospitals, traditional herbal practitioners, and private maternity homes play important roles in the curative management of diseases in the metropolis. Nonhealth Departments The nonhealth institutions are responsible for providing and maintaining urban infrastructure and putting in place regulatory measures for using and managing these facilities. All departments per- ceive public health to be a problem and link disease causation to poor environmental conditions, low infrastructure provision, and lack of community participation and involvement in project planning and implementation. In managing urban malaria and other vector-borne diseases, the roles of the MDAs outside the health sector focus on controlling vectors of diseases by preventing formation and removal of vector-breeding sites and public education on environmental health. The following areas are particularly highlighted: 252 * The Physical Planning Department is involved in land use planning that considers envi- ronmental constraints and health needs. These enhance living conditions and improve personal hygiene and public health. * The Works Department of the assembly is involved in approving building plans, devel- opment control and enforcement of building regulations, thus ensuring that environ- mental health is taken care of in physical developments. The Department also undertakes the design, construction, and supervision of assembly projects including toilets, drains and health institutions. * The Public Relations Department conducts public education on issues of health, hygiene, and disease prevention. It undertakes community and stakeholder mobilization and acts as a mediator between the public and the departments of the assembly. * The Legal Department is responsible for the formulation and implementation of policies, preparation of the bylaws, prosecution of sanitary offenders, regulation of demolitions that do not conform to building regulations, defending the assembly and education of le- gal implications of actions of Departments and how they relate to the community. The Department admits that the assembly has been very apathetic to its legal responsibilities and sanctions, which should help improve hygienic practices and public health. By its activities, the Legal Department contributes to both the removal of obstacles to proper drainage as well as public education to remove the breeding sites of vectors. * The Environmental Protection Agency provides technical assistance to the assembly to enable it meet its responsibility for managing the environment. EPA works in partnership with all stakeholders to ensure implementation of environmental policy and planning to achieve long-term maintenance of environmental quality. The agency also carries out re- search and public education and awareness on environmental issues and enforces legal provisions on the environment, where necessary. One of the priorities of EPA is to mini- mize flooding and mosquito breeding. EPA is involved in assessing the impact of envi- ronmental nuisance that affect people, particularly waste management of industrial con- cerns in the city and proposed mitigating measures. • The Metro Development Planning Unit coordinates and monitors implementation of all development projects of the assembly, including physical infrastructure. It also coordi- nates with other development agencies to improve infrastructure. * The Waste Management Department is responsible for collection, transportation, and dis- posal of solid and liquid wastes; supervision of solid waste contractors for door to door services; and management of disposal sites. * The Environmental Health Division plays a pivotal role in preventive measures for vector and disease control in SAEMA. The division carries out the following responsibilities: * Inspecting houses to ensure that basic household sanitation facilities are available to discourage disease vectors * Monitoring collection of garbage at communal sites by private waste collec- tors and the Waste Management Department * Undertaking water usage education and reporting burst pipes to the Ghana Water Company Limited (GWCL), which is responsible for producing and distributing safe water in adequate quantities for all purposes and rehabili- tating and expanding the water supply system X Spraying and weeding around houses and water bodies * Educating the public through announcement vans on personal hygiene and sanitation practices * Routine cleansing of public and community drains * Assisting the Bank's UESP program in promoting household toilets * Educating on food hygiene * Prosecuting sanitary offenders. 253 The Community Water and Sanitation Agency (CWSA) is involved in training and mobilizing CBOs and community education on hygiene, water, and vector-borne diseases. CWSA also con- ducts school and institutional hygiene programs in collaboration with the Ministry of Education hygiene education program. It educates on water usage, food and personal hygiene, and manage- ment of facilities; promotes development of household latrines; and encourages households to develop and manage soakage pits for domestic wastewater management. The School Health Education Programme (SHEP) under the Ghana Education Service handles production of education materials in schools and lectures to pupils and teachers on personal envi- ronmental hygiene, nutrition, social public health issues, and community involvement in school affairs. UESP was set up as a unit under SAEMA. Besides providing hardware for sanitation, this Bank project is assisting SAEMA by: * Improving internal management of the Waste Management Department * Building human resource capacity of the department in supervising and monitoring the private waste contractors * Developing modalities and strategies for improving waste management service delivery, including handling of hospital waste and support for logistics * Developing basic infrastructure, including water supply, toilets, solid waste disposal points, and an upgrading package in two low-income communities in SAEMA * Planning, designing, and developing a landfill site for proper disposal of solid waste (provisions are being made for handling hospital waste) * Initiating action to collect data to design a program that would address absence of a pol- icy guide in managing hospital waste. All the nonhealth departments are aware of the link between disease causation and poor hygiene and liquid waste management, inadequate supply of safe water, lack of sanitation facilities, and ignorance. They all would like to do more to prevent the situations and conditions responsible for creating an environment for mosquito and vector breeding in the city. Civil Society The general public, particularly in poor areas, contribute significantly to disease causation and prevention. Most of the environmentally related diseases seen in SAEMA can be directly attrib- uted to public attitudes and practices, which can be behavioral, cultural, or traditional. They in- clude: * Open defecation along beaches, even where toilets exist * Poor personal hygiene, leading to outbreaks of cholera and yaws in Shama * General apathy to sanitation and the environment * Lack of community initiative, due to lack of leadership initiatives, often complicated by chieftaincy disputes, for example, in the New Takoradi Area * Direction of untreated effluent from soakage pits and liquid waste into drains * Superstition and belief in spiritual causes of diseases * Preferences for traditional sources of water, such as streams and rivers, compared with piped water. To reverse the trend and bring about improved management of the environment and personal hy- giene, a number of NGOs and CBOs have sprung up. These organizations play an important role in making people aware of the consequences of poor personal hygiene and environmental prac- tices. They are involved in education on the need for a high level of personal hygiene and inten- sive public education intended to bring about attitudinal change. 254 The thrust of their programs is to remove barriers to changing attitudes and behavior. Some NGOs are involved in information dissemination on urban malaria, that is, creating awareness of the health situation and prevention. Some of their activities to maintain a clean environment in- clude cleanup campaigns, desilting of drains to maintain free flow and avoid stagnation of wastewater. Examples of such NGOs are SNV, CODEPA, and a CBO in New Takoradi. The Weak or Missing Link in the Management of Urban Malaria The management of urban malaria and other vector-borne diseases is a continuum of activities that begins with preventing formation of breeding sites for vectors and continues through treat- ment of patients affected by these diseases. These roles actually fall under different MDAs, each of which may perform to the best of its ability, but have weak linkages with the rest of the chain of measures to control malaria. The role of the various MDAs in managing urban malaria and other vector-borne diseases is not always clear to all stakeholders. Although it is usually obvious to the health sector that the causa- tive factors of the diseases presented to health institutions are the responsibility of other MDAs, those MDAs are most of the time not aware of their roles in disease prevention. Rather, they see the service they render as an end in itself and not a means to an end. For example, although the city administration may see clearance of refuse to clean up the city as an end in itself, the health sector sees it as a way to decrease factors causing diseases. In effect, each MDA may render its services to the best of its ability, but leave undone "gray areas," because of the absence of effec- tive collaboration in bridging gaps between curative and preventive services. Institutional Priorities and Objectives Decentralized departments under SAEMA. Priorities and objectives of the assembly are generated through the assembly mechanism, that is, subcommittees with full participation of the department heads. These are forwarded through the Accra Metropolitan Authority (AMA), which is the ex- ecutive arm to the General Assembly. The subcommittees, which are comprised of assemblymen, heads of departments, and co-opted members, are responsible for collating and deliberating on issues to assist and guide policy formulation of the Executive Committee and the General Assem- bly. The outcome of General Assembly deliberations are compiled into annual and five-year de- velopment programs. The various departments under the assembly adhere to the assembly's policy guidelines. Before year end, departments are requested to present action plans and budgets to the authority for the following year that are in line with the assembly's policy. These are then compiled into annual development plans. For all departments under SAEMA. Decisionmaking is limited to day-to-day administration, done in consultation with the coordinating director. Other environmental priorities for SAEMA are contained in the district environmental manage- ment plan for district assemblies of Ghana, Report on Training Workshop 1996, prepared by the Environmental Protection Agency. In the case of UESP, the priorities and objectives are predetermined in the project documents. Management actions and daily decisions are taken by the project manager in consultation with the coordinating director. Other issues, requiring further consideration are referred to the project co- ordinator and chief director at the Ministry of Local Government and Rural Development. Nonassembly departments. For agencies not directly under the assembly, the objectives and pri- orities are based on the agency's mandate. The main priorities are national and regional in char- acter. These decisions are taken at the management level and passed down to the regions and dis- trict offices. The local level priorities are intended to achieve improvement in service delivery 255 and efficient management. The decisionmaking and financial autonomy of these agencies are limited either by financial sealing on projects that can be initiated by them, purchasing, contracts and recruitment limits, or day-to-day management decisions. Health institutions derive their priorities from Ministry of Health policy guidelines, which are further developed into localized priorities to suit prevailing conditions of the district or clinic. These are determined by the local health management teams of the various institutions. CBOs and NGOs. The priorities of CBOs and NGOs are determined through community needs or by the mandate of the head offices of these agencies. Some CBOs and NGOs carry out needs as- sessments in communities to determine what actions to take to fulfill their mandate. Reporting Reporting by the agencies under the assembly is clearly outlined. All correspondence (letters, memos, and monthly reports) to the department are routed from the metro chief executive through the coordinating director and vice versa. Reporting and discussions on roles and assignments are also undertaken at the various meetings, that is, the management team meeting, subcommittee meetings, and planning and technical subcommittee meetings. Reports are also made at the weekly management meetings. All these meetings are covered by minutes. The heads of depart- ments also have verbal discussions with the director and metro chief executive when necessary. In cases where ties with the regional and national offices are close, some decision and reporting are also forwarded to higher levels of government with or without recourse to the assembly. The non-SAEMA agencies report monthly, quarterly, and annually through their regional offices to the head office. Because the head offices sign performance contracts with the State Enterprise Commission, the reports form the basis for measuring departmental performance. NGOs report to their headquarters and donors, with whom they design a program of action by sending quarterly and annual reports and end-of-program reports. Quarterly reports are also sub- mitted to the metro assemblies and other NGOs. The level and regularity of reporting by CBOs is not clear. Reporting across sectors is not common. Legalframework. The basic legal framework for the decentralized departments under the assem- bly is the Local Government Law, 1993, Act 462, and the legislative instrument that established SAEMA. The act defines the functions and operational modalities for district assemblies. It also defines creation of the assemblies and subdistrict councils, election of members of the assemblies, and other issues connected with running the assemblies. One of the strong points of the law is that it provides arrangements to avoid duplication, rivalry, empire building, and waste of resources. The intention is also to promote and sustain coordinated and integrated planning and implemen- tation and ensure complementarity of activities. In practical terms, achievement of these ideals is thwarted, because professionals are not trained on how to achieve collaboration, mechanisms and processes are not created for collaboration, and provisions are not made in sector budgets for intersectoral collaboration. In addition to Act 462, many of the decentralized departments are govemed by laws and ordi- nances under which they were operating before promulgation of Act 462, particularly where these laws were not repealed by Act 462. Other laws that support Act 462 are National Development Planning Commission Law (Act 479), National Planning Systems Law (Act 480), National Building Regulations LI 1630, Criminal code Act 29 of 1960, and Sekondi/Takoradi City Council Bylaw of 1948. 256 The Town and Country Planning Ordinance Cap 84, EPA Act 490, and LI1 652 are a few of the legal provisions for some of the other agencies. Limited liability companies, such as GWCL, operate under provisions of the Companies Code (1963) and GWCL Law Act 179 of 1999. Until last year, the company used to be a government department operating under Act 310 of 1965 as the Ghana Water and Sewerage Corporation. The change occurred in part due to privatization of the department. For the public health institutions, the legal provisions of the Ministry of Health, which establishes hospitals for the delivery of curative services, provides the legal framework for delivery of serv- ices. Legal provisions for establishing private clinics and maternity homes provide the legal framework for delivery of curative services by the private sector. Financial. The sources of funding for the General Assembly are mainly from the Common Fund, local revenue generated from property rates, levies, and services. The assembly can also get bilat- eral assistance or any other donor assistance funds under projects, such as UESP and the Urban Infrastructure Improvement Programs of the road sector. All departments under SAEMA receive financing through the assembly budgeting and auditing mechanism, that is, the Treasury and Audit Departments. Department budgets are presented through the Finance and Administration Subcommittee to the General Assembly, and, when ap- proved, these become the basis for disbursing the assembly's funds for the year. Projects and pro- grams that have gone through the subcommittee system and been approved are more likely to be financed and implemented than those developed by central government departments for the as- sembly. Implementation capabilities of many of the departments are limited, as they all depend on the as- sembly to enforce and implement decisions. Due to financial constraints, many of the action plans are not undertaken. Some central government departments, such as EPA, have their own funding sources; however, their projects must also be approved by the head office of the agency. All the departments, especially decentralized ones, cited the problem of low financial support. The community development officer noted that, as a decentralized department, financial support is expected from the assembly but has not been forthcoming. This year, the department has re- ceived only ¢30,0OO from the regional office and is, therefore, financially handicapped. The de- partment also receives some assistance, usually in the form of transport allowances and leftover stationery and other logistics, from NGOs who work with the department Departments within the assembly that generate revenue pay these monies into the General As- sembly Treasury and do not retain any percentage for their own use. All requisition for logistics must be approved by the coordinating director before the Treasury can release monies for pur- chase. A well-structured purchasing system is available under the assembly system. Collaboration. As noted above, the Local Government Act provides for intersectoral collabora- tion for the decentralized departments in theory but, in practice, collaboration among most de- partments is weak. Some district assemblies are trying to secure collaboration. SAEMA is one such district assembly. The degree of collaboration among departments under SAEMA is appreciable. Agencies visited under the General Assembly were all happy with their involvement in the functioning of other 257 agencies. The following avenues for collaboration have been noted: development office, through organization of the radio talk show and public education programs, Environmental Health Unit and their linkage with the Metro Health Management Team, core group meeting under UESP, statutory planning and technical committees, and project monitoring teams. The assembly decisionmaking mechanism presents a platform for the necessary collaboration at the project formulation stage. It ensures that the contribution of all relevant agencies and deci. sions are based on consensus. The central role of SAEMA's coordinating director, through whom all correspondence passes, is a role that should be developed for collaboration and coordination. By coordinating all activities and reporting on them, the administration is aware of areas of duplication or gaps in activity and able to redirect activity accordingly. It puts the director on top of issues emanating from every department. The greatest benefit of the weekly management meetings is to resolve conflicts and harmonize programs and plans before implementation. This is laudable, because officers whose actions and inability to deliver and draw back the assembly are made to sit up. These meetings have made every head of department aware of progress on all assembly projects and programs. The meetings can be used to link activities of nonhealth departments to disease causation and help find ways to bridge gaps. Although the meetings are meaningful, the fact that they sometimes take more than half a day is of concern. Box 16-4: Robert Austin, Coordinator UESP "These meeting are not just talking shop. Every Monday morning, members check on their schedules and make sure that they fulfill commitments and have some progress to report on." Source: Authors' data. Box 16-5: Deputy Coordinating Director, SAEMA "You cannot joke with the Monday morning meetings. Heads of Departments are eager to attend every Monday. It is like a ritual. There is effective contribution from all heads." Source: Authors' data. Obstacles to effective routine collaboration between the health sector and other MDAs. In spite of the avenues for collaboration within SAEMA, attempts at collaboration for health have been ad hoc, that is, most active during epidemics or disease outbreaks and poor on a routine basis. A number of factors account for this: * The Health Information System is not designed to link environmental conditions to health. Health data from health institutions are collated and passed on to regional and na- tional levels and not routinely used to inform decisions on activities by other MDAs. * Routine reporting among departments has no format. Infrastructure agencies do not rou- tinely monitor the effect of infrastructure development on health; even though other MDAs may be aware of the linkage between their responsibilities and public health, they are not aware of the magnitude of the problem nor their potential contribution in disease prevention. * Information flow from management to general staff levels is poor, because heads of de- partments do not have a platform through which they can explain issues discussed in 258 these meetings to their staff. This information gap should be closed to enable staff to un- derstand their actions and get them involved in the day-to-day running of the depart- ments. * No system effectively supervises private sector health institutions, and monitoring of ac- tivities at these institutions is inadequate. General health statistics of SAEMA, therefore, do not incorporate data from the private sector, and health data are incomplete. The rate of returns on cases these institutions treat and send to the district health administration is also low, as is collaboration between private health and other sectors. * A limitation noted by Ghana's EPA is that some projects that are technically objection- able have been implemented, because they meet with the aspirations of the assembly, for example, developing KVIPs in the waterlogged areas of Effia Song. * The interface between the public and private sectors is weak. The general public is seen as consisting of clients and not partners. In the few instances in which the traditional chiefs were used for identifying and acquiring sites for UESP projects, they were found quite helpful. These partnerships must be extended to other areas of development. Although the health sector is conscious of the need to link closely with the nonhealth sector in preventive health care, the health sector is more immediately concerned with extending and ex- panding physical and curative health services. The health sector has identified promotional health roles and the need for collaboration as priorities, but collaboration between the health and non- health sectors is not given much importance. Health data are collected but not disseminated to nonhealth departments for use. Similarly, the format of data collection needs to be reviewed to make it usable to these institutions. The main objective of the nonhealth sector is to provide physical infrastructure and services. Even though the sector perceives related health promotional benefits, they take them for granted and incorporate little activity into their programs and projects to achieve these benefits. Many cite recent experience with collaboration in the core group meeting on the School Health Education Programme and improving the health benefits of infrastructure as a great benefit that has im- proved health in communities. The health sector has a role to play in supporting the decisionmaking process with the necessary health statistics. Health information is currently collected for use by health institutions alone, but must be structured to be relevant to the Environmental Health Unit and other nonhealth depart- ments. Table 16-6 is a matrix for linking the three entry points to the various MDAs; it shows the de- partments that can support and collaborate with each other on disease prevention. 259 Table 16-6. Capacity for Intersectoral Collaboration MDA Role Linkage Strengths Weaknesses Works Supports all urban in- Identification, Development office Staffing, financing, and frastructure develop- implementation, role widely accepted by logistics; no general ment within SAEMA supervision, and other MDAs; direct reporting format, espe- enforcement contact with private cially from the subdis- sector; representatives trict level; low motiva- at the submetro levels; tion reporting format for project monitoring and supervision PRO Focal point for infor- Collaboration with all Good rapport with all Staffing, training, and mation dissemination; agencies for public agencies and the press logistics; staff with collates public views education double allegiance to and complaints and parent department and forwards them to rele- SAEMA vant MDA for resolu- tion Physical Land use planning and Research, Ability to collaborate Finance, logistics, planning development control policy development and under the statutory training, and skill im- implementation, and planning and technical provement; lack of regulation committees; good technical and policy community develop- directive on technical ment skills; and a sup- issues porting legal instrument for action Legal Policy in terms of for- Providing legal assis- Appropriate legal Staffing and logistics, section mulation of by-laws tance to MDA backing and capacity low development of and procedures; enforcement would enhance the local legal instruments, enforcement through work of all other sec- poor record keeping, prosecution; imnple- tions, i.e., PRO, secu- poor support from the mentation, e.g., per- rity, city guards, and so judiciary/courts system formance contract de- on come under one for prosecution. sign; education of the umbrella public on legal obliga- _ tions UESP Provision of conmuu- Policy implementation, Financial support for nity infrastructure strengthening the ca- project; technical sup- pacity of other MDAs, port always available education, and commu- through additional con- nity involvement sultancies; technical resources available; experience with stakeholders; and sup- port of core group through allowance payments EPA Education and en- Policy, enforcernent, Legal backing for ac- Lack of staff; logistics forcement of EPA laws regulation, and tivities and no enforcement on the environment education powers and funding for activities PHD Education on environ- Policy implementation; Enough staff at metro Lack of bylaws under mental issues; enforce- education and submetro levels; which to prosecute, ment and prosecution ability to work with lack of education mate- others rials, and lack of logis- _____________________________ ~~~~ ~~~~~~tics WMD Management of solid Strong linkage with Support from UESP Inadequate equipment, and liquid waste UESP funding, and vehicles CWSA Support for communi- Strong links with com- Staff, and donor sup- Incentives for staff ties obtaining water munities and donors port GWCL Provision of potable Policy City-wide coverage Old reticulation system, water implementation staff, equipment, and seasonal variations in reservoirs 260 MDA Role Linkage Strengths Weaknesses Civil Community education Policy, education, and Autonomy to operate Not hindered by bu- society on enviromnental implementation and access to donor reaucracy health issues support Health Preventive and cure of No strong linkage with Organized management Financial constraints institu- diseases MDAs system and good team and lack of policy on tions work management of hospital waste Source: Authors' data. Conclusions The following conclusions can be drawn at this stage in fulfilling the objectives of the study: * Environmental conditions in SAEMA have contributed greatly to causing disease in the metropo- lis. Five out of the ten top diseases are related to environmental conditions. Hospital waste is a potential danger, but no current evidence links any particular diseases to poor disposal of hospital wastes. * Developing intersectoral collaboration between health and environmental initiatives remains diffi- cult and underresourced. Many agencies have roles that can help overcome these problems, but fi- nancial and logistic restrictions have led departments to pay more attention to their primary role, leaving "linkage" roles in the background. Local institutions have the advantage of seeing the linkages clearly and how their involvement in total can help improve the conditions they seek to solve. Improving agency perception of the linkages will encourage them to collaborate and share tasks, facilitating their achievement. * As noted by Stephens and others (1998), "The process of decentralization in Ghana has the great- est potential to facilitate collaboration of professionals of all disciplines that work at the level of local government. The merging of different vertical agencies with complementary themes has the - potential to straighten intersectoral collaboration." * Some limitations have been experienced in achieving linkages and collaboration. Current ap- proaches consist of basic reporting, mostly verbal and at meetings. Technical directives or proce- dures for further action have been blurred. No routine reporting format links all departments. * Few legislative and administrative controls exist to ensure those involved will play their roles. and their follow-up actions have not been well defined. * Monitoring responsibilities are also unclear. Although SAEMA has recorded a number of in- stances of collaboration, these have not been fully structured and have coordinated sectors that are not of immediate concern. * The interest of the assembly is to offer efficient delivery of services to prime areas. Prioritization and balancing of concerns between health and efficient urban services must be taken up as a main policy issue at the assembly and followed up through the various agencies of the assembly. * Logistic and staffing requirements have limnited the ability and capacity of agencies to perform complementary roles effectively. Except for UESP, which has external funding, many of the de- partments are financially constrained in performing and delivering on their mandates of incorpo- ration. * Decentralization and the state of the decentralized departments regarding budgeting, allegiance, and others is reinforcing separation and discontentment. Resources must be shared collaboratively to enable all departments to play their roles effectively. * The linkages and the roles played by NGO, CBO, and the private sector have not been fully util- ized. All indications are that they have not been getting needed assistance and support from the as- sembly and no supervision of their activities and impact. 261 Terms of Reference for an Institutional Needs Assessment Outline of the Needs Assessment The consultant(s) will conduct an institutional needs assessment to assess the opportunities and constraints of intersectoral collaboration and build on the "Consultative Assignment on Urban Public and Environmental Health in Ghana" report. The needs assessment for Sekondi-Takoradi will be conducted for: (a) National, regional, and district and subdistrict levels of government, which will target key government officials, agencies, and ministries in environment, health, infrastructure (roads, housing, water supply, sanitation, and drainage); local governments; government agencies in rural development; line agencies (Ghana's Environmental Protection Agency [EPA] and others); and district assemblies that are in- volved with (or should be involved with) the pilot's three "entry points"-that is, urban malaria, man- agement of waste from health care facilities, and environmental health linkages arnong water, sanita- tion, and drainage-to learn their views on what they would need to improve service delivery. (b) Selected private sector providers and stakeholders (NGOs, community-based organizations [CBOs], and professional associations, among others) that are involved with (or should be involved with) the pilot's three "entry points" to learn what they provide as a (private sector) service and expect in terms of improved service (to stakeholders). (c) All of the groups above to learn what they might be able to contribute in exchange for improved serv- ice. The completed needs assessment will be analyzed to update the "Ghana Health Assessment" (a quantitative method of assessing the health impact of different diseases) aiid produce a prelimi- nary issues paper and an action plan (of no more than forty pages) on public health, institutional and legal, decentralization, financial/incentive, capacity-building aspects, all of which will also be tackled at the workshop. The consultant(s) will also gather data that will feed into developing a social map for Sekondi- Takoradi to help to ascertain data sources and contacts, relevant "hot spots," both topically and geographically, and the perceived social causes that underlie and perpetuate observed patterns. Content of the Needs Assessment The needs assessment has two main sections: * Public health * Institutional and legal aspects, financing mechanism, capacity, and recommendations. Public Health Use Bridging Environmental Health Gaps checklists [ 1996 volumes] for integrating environ- mental health considerations into projects as background material: * Define the main health problems in Sekondi-Takoradi. * Describe in detail linkages to the three "entry points" (management of wastes from health care fa- cilities, urban malaria and other vector-borne diseases, and water, sanitation, and drainage) * Describe the full range of possible remedial measures in health, environment, and infrastructure sectors. 262 Institutional and Legal Aspects, Financing Mechanism, Capacity, and Recommendations Background * Definition of institutions 68: sets of rules by which a ministry, agency, group, association, and so on functions to coordinate activities within (vertical) and between (horizontal) organizations (see chapter 3). Institutions have three layers: * Operational (laws and regulations) * Governance (who makes and applies the rules and how this is done) * Constitutional (rules that constrain rule making) (Not to be covered in this assignment) The coordination mechanism, which is determined by the nature of the good and service (in our case, a public, toll, or common pool good for water, sanitation, and drainage and private or public good for hospital wastes) will allow for provision of goods and services by the public sector (hi- erarchy), the private sector (market), and/or stakeholders (collective action). Assignment Institutional and Legal Aspects and Financing Mechanism. Assess, clarify, or identify the set of rules that will help determnine sectoral linkages at the national, regional, district, and subdistrict levels as well as the interface between the public, private sector, and stakeholders (PPS). Operational aspects include: - Institutional set up (provide an organization chart for line ministries and agencies and identify pri- vate sector participation and stakeholder involvement) and legal framework * Levels of responsibilities for identification, planning, design, implementation, operations and maintenance, monitoring, evaluation, and reporting (to whom, how often, when, adherence, penal- ties, and rewards) - Financial set up, that is, levels of financial mobilization for each ministry or agency * Institutional collaboration (with whom to interface PPS, formal and informal relationships, and in- centives and disincentives) * Willingness to collaborate (examples of past collaboration and so on) * Information management in a decentralized setting (horizontal, that is, national to subdistrict and vice versa, and vertical, that is, across): data flow, in general, and for monitoring, in particular. * Portfolio (ongoing activities in each sector in Sekondi-Takoradi that are related to the three entry points) * Environmental, health, and environmental health linkages, as identified by ministries and agencies * Public, private, stakeholder interface, that is, who does what and the terms of these relationships. Governance aspects (ownership of the decentralization process): * Level of determination of objectives, priorities, and policies * Level of the decisionmaking process: What are the "limits" and constraints? To what degree are they achieved locally without hierarchical or outside pressure? What are the incentives and disin- centives? * Level of appropriation of funds * Accountability and transparency (financial, managerial, and result based as well as incentives and disincentives) * Recent changes created by the decentralization process in institutional lines of responsibility, re- flecting newly identified responsibilities and collaboration across/among different line ministries. 263 Capacity * Technical resources (instruments, intervention policies, monitoring indicators, and others) * Technical and managerial staff composition and capacity * Staff needs, including training and recruitment * Human health-related resources (capacity to identify, evaluate, and prioritize health problems out- side the health sector, managerial skills, and so on). Recommendations * Recommendations to foster collaboration among PPS * Action plan in terms of institutional, legal, and financing set up and training needs * Expected outcomes from the collaboration in terms of equity, efficiency, sustainability, and ac- countability. References AMA (1998), Accra Metro Health Initiative (AMEHI) Briefing Paper, UK Department For International Development (DFID) in partnership with the Accra Metropolitan Assembly (AMA). Environmental Protection Council, Ghana (1989), Ghana Environmental Action Plan Vol. Iand Il. Government of Ghana (1993), Local Government Act, Act 462. Listorti, James (1990), Environmental Health Components for Water, Sanitation, and Urban Projects, World Bank Technical Paper No 121, World Bank, Washington D.C. Listorti, James (1996), Bridging Environmental Health Gaps. Lessons for Sub-Saharan Africa Infrastruc- ture Projects. Vol. I-IlI; AFTES Working Paper no. 20, Urban Environmental Management. The World Bank Ministry of Health (1996), 5 Year Programme of Work Ministry of Local Government and Rural Development (1998) ESICOME Programme and Implementation Guidelines: Expanded Sanitary and Inspection and Compliance Enforcement Programme, MLG and RD, Ghana. Ministry of Local Government and Rural Development (1999), National Sanitation Policy. Stephens, Carolyn, Ben Doe, Helen Dzikunu, and Doris Tetteh (1998), "Consultative Assignment on Urban and Environmental Health in Ghana." Supported by Managing the Environment Locally in Sub- Saharan Africa (MELISSA) and prepared for the Government of Ghana, Ministry of Local Govern- ment and the Urban Environmental Sanitation Project. Taylor, Woodrow (TWI) (1997) Accra Waste Project. Project Briefing Document, Taysec, Accra, Ghana. The World Bank Group (1996), Staff Appraisal Report Republic of Ghana Urban Environmental Sanitation Project, Infrastructure and Urban Development Division, West Central Africa Department, Africa Re- gional Office, Report No 15089. 264 CHAPTER 17: SAMPLE WORKSHOP ON TARGETED COLLABORATION IN GHANA Chapter 17 puts into practice the lessons and recommendations of parts 1 and 2 in a pilot study in Ghana. The pilot, conducted in four phases, shows how targeted collaboration can lead to positive results without conducting expensive and time consuming studies: * a desk review to identify key problems and priorities from all sectors and select entry points accordingly (Chapter 15), * an institutional needs assessment to identify the stakeholders that needed to be involved and understand their perspectives (Chapter 16), * the first workshop held in a "trial" city with stakeholders to get their views in proposing solutions, and * the second workshop with participants from four other cities to see how the entry points and proposals could be replicated elsewhere, and eventually integrated into an ongoing project. Background The "Targeted Collaboration among Line Agencies, Local Communities, and the Ministry of Health in Ghana" workshop for Sekondi-Takoradi and its subsequent meeting (October 12-14, 1999) were organized by the Ministry of Local Government and Rural Development (MLGRD) and the Shama-Ahanta East Metropolitan Area (SAEMA) in collaboration with the World Bank and funded by a grant from the Swedish government. The workshop was executed under the World Bank Ghana Urban Environmental Sanitation Project (UESP). A follow up workshop was organized in February 2000, with the four other cities of the UESP (Accra, Tema, Tamale, and Kumasi) and representatives from Sekondi-Takoradi. The objective of the follow up workshop was to replicate the approach of the first workshop to the other cities, identify a new set of priori- ties common to the five cities and include the summary and recommendations of the five cities into the mid-term review of the USEP. These undertakings were part of the World Bank's pro- gram "Environment and Health: Bridging the Gaps," which is intended to mainstream environ- mental health into World Bank operations as well as developmental operations and to look sys- tematically for health benefits outside the health care system. The program has also been funded by the Swiss and Norwegian governments under the Africa Regional Initiative on the Urban En- vironment. The process, from preparing an environmental health profile (determine entry points, and es- tablish intersectoral problems and priorities) to making recommendations to an ongoing proj- ect, took about 6 months, beginning with a desk study in Washington to cull information from existing Bank and Ghanaian reports and followed by the preparation of an institutional needs assessment. Two workshops were organized in Ghana to: (i) identify the range of solutions needed to solve the problems in one city; (ii) prioritize the solutions and formulate them into practicable recommendations in one city; and (iii) replicate the process to four other cities and expand the initial entry points to a set of ten priorities and agree on the top three that were piggybacked onto an ongoing project (see box 5-4). Report prepared by Angela Adama, Dela Attipoe, and Ben Doe; Edited by Fadi Doumani, Anne Harmer, and Jarmes Listorti 265 Both workshops were based on two key documents: (a) "Consultative Assignment on Urban and Environmental Health in Ghana." (Stephens and others 1999)