Why are we all falling ill

Scientists worldwide now accept that along with industrialisation and urbanisation, there has been a steady destruction of nature. Cities and industries have both affected clean air and clean water.

Industries produce a lot of hazardous wastes; and cities produce a lot of garbage. Hazardous wastes pollute the groundwater. Accumulation of garbage allows disease-causing agents to proliferate. K C Sahu, formerly with the Indian Institute of Technology, Mumbai, raised the concern that heavy metal contamination was increasing due to mining, mineral processing, the burning of fossil fuels and industrial and agricultural activity. The annual toxic metal load added to the Yamuna exclusively from two thermal power plants- Rajghat and Indraprastha in Delhi are estimated to be 2.59 tonne of lead, 4.32 tonne of chromium, 5.58 tonne of arsenic and so on, totalling up to 23.07 tonne (See graph: Powerful currents).

Modern agricultural practices lead to the saturation of soil and water with chemicals used as fertilisers and pesticides. Data show that the total production of pesticides in India has increased from 13,948 tonne in 1966 to 88,890 tonne in 1994-95. By 2025 India may have to feed 1.6 billion people and may need about 301 million tonne (mt) foodgrain alone. This means more fertilisers and more pesticides. Scientists note that availability of good quality land and water is rapidly declining due to chemical-intensive agriculture practices. The toxins generated enter the human body through the food chain.

Intensive agriculture also leads to depletion of micronutrients such as copper and molybdenum from the soil. This leads to poor food quality and micronutrient deficiency in human beings (See box: Problems intensified).

Moreover, social and health implications of this shortage of water, grasslands, biomass, food availability as well as shift in agricultural patterns, have hardly been studied.
TOOLS OF DESTRUCTION
The tools that shaped the modern world not only depleted the wealth of nature, but also made the environment more hospitable to disease-causing agents. Irrigation and urbanisation have introduced into our ecology new conditions that promote the breeding of disease-spreading agents such as mosquitoes, notes V P Sharma, former director of the Malaria Research Centre (MRC), Delhi.

There has been a sharp increase in malaria along highways, irrigation canals and industrial areas as they promote water-logging and lead to the formation of depressions and trenches in which rainwater accumulates.

Another major factor contributing to ill-health is poverty. According to 1994 WHO estimates, 75 per cent of people in developing countries had access to potable water, and only 35 per cent to sanitation. Low income means limited money for obtaining health services, high risk of personal illness, limitations on mobility and limited access to education, information and training, the WHO notes. The poor cannot provide their children with opportunities for better health and education. The World Health Report 1995 concluded that poverty is the world's deadliest disease.

The process of impoverishment sets the scene for an increase in diseases. Disrupted social conditions, poor nutrition, poor housing and physical and emotional stress also contribute to diseases of various kinds. The working and living environment contributes to increase in tuberculosis (TB). For instance, TB was a big problem among the postpartition refugees in 1947. Tibetan refugee settlements in India have also reported a high prevalence of the disease.

Ill-ventilated houses increase the possibility of acute respiratory infections. Industrialisation and air pollution, growing at alarming rates, coupled with smoking also lead to the spread of infection.

Poor sanitation and unsafe drinking water have posed major health problems in India. Water and sanitation-related infections and the diseases of the alimentary tract constitute 60 to 80 per cent of illnesses in India, according to K J Nath, director of the All India Institute of Hygiene and Public Health, Calcutta. Several such diseases including diarrhoea, dysentery, typhoid fever, intestinal helminths, jaundice and cholera are endemic to India. Statistics reveal that only 200 out of approximately 4,000 towns in India have a sewage disposal system, and that too partially. We still have 400,000 scavengers in the country and there are 7.2 million dry latrines in 2,587 towns.

Environmental and public health interventions together can bring about dramatic results in disease reduction. It maybe noted that the Madhya Pradesh government adopted the Rajiv Gandhi Mission for Control of Diarrhoeal Diseases in 1994, incorporating effective monitoring, increasing access to ORS (oral rehydration solution), ensuring safe drinking water, control of cholera and rational treatment. Mobilising collective action and community leadership was to be central to the overall startegy of the mission. As a result, from 1994 to 1997, deaths due to diarrhoea came down from 2928 to 386 in the state.

Solid waste is also a major problem in India. Over 40 per cent to 60 per cent of our solid waste is not collected or disposed of in a proper manner. Hospital waste continues to be dumped along with other garbage in many cities. Recently, the Union government has come out with an order to prevent this. However, it will take time to be implemented countrywide. Large-scale soil and water pollution is one of the primary factors behind the high prevalence of soil and water-borne diseases, states Nath.

According to a WR study on India, environmental damages were to the tune of Rs 33,950 crore and the cost of inaction is 4.5 per cent of the GDP in 1992. Of this, over 70 per cent is in terms of the health impact of air, water and poor sanitation. Issues such as hospital waste are not given enough consideration.

The biggest problem is that people may never come to know how the environment is changing and leading to deterioration of their health. When an epidemic such as dengue haemorrhagic fever strikes, as it did in Delhi in 1996, and people die, there is a hue and cry. But slow, steady exposure to toxins affect the human body very differently, and stealthily. The toxins creep into the body, slowly, sometimes causing lethal diseases and even death.

The WB estimated that, in 1991-92, some 40,000 people died prematurely due to air pollution, caused only by high levels of poisonous particles in the ambient air of 36 Indian cities for which data was available. If data had been available for pollutants like ozone and benzene, the death count would have been higher. When CSE repeated the study, using air pollution data for 1995, it found that the death count had gone up to 52,000. Delhi alone had recorded an increase from 7,491 in 1991-92 to 9,859 in 1995. This means more than one person dies in Delhi every hour due to air pollution. This death count is more than all the people killed so far due to the insurgency in Punjab, Kashmir and the northeast. In comparison, the dengue epidemic of 1996 killed only one-twentieth of the number of people.

Doctors are often clueless about this slow murder. They cannot even tell a patient that he or she contracted cancer or a serious respiratory illness because of exposure to a particular pollutant. In India, doctors may not even recognise many new forms of diseases.

GASPING FOR BREATH
The water and soil is laden with toxins, the air we breathe is fast getting polluted by the noxious fumes spewed out by vehicles and industries. S K Chhabra of the Vallabhbhai Patel Chest Institute, Delhi, notes that the levels of suspended particulate matter (SPM) in Delhi's ambient air, on most days of the year, are much above the norms set by the Central Pollution Control Board (CPCB). "A crude prevalence of respiratory symptoms are found in 50 per cent of office-goers", says Manoj Dhingra of AIIMS.

Chhabra's study showed that short-term and acute exposure to air pollutants SPM, ozone, oxides of nitrogen and sulphur dioxide led to aggravation of symptoms and deterioration of lung function in patients with asthma and chronic obstructive lung function. S R Kamath an expert of respiratory medicine, formerly with KEM hospital, Mumbai, notes that the morbidity for cough, common colds, eye irritation and headache showed a strong correlation with air pollution.

What does environmental deterioration lead to? It leads to changes in the planet's life support systems. When these systems become weak, their ability to support life deteriorates. Consequently, the health of individuals living in that ecosphere is bound to be affected. Some species profit by these changes and others lose out in the struggle for survival. As a result, scientists have observed disturbing phenomena an increase in disease burden, genetic changes, new diseases, declining immunity, and a sharp decline in sperm count.

The health impacts of environmental degradation are varied:

• Genetic, hormonal changes brought about by toxins

• Harmful effects of toxins on the immune system and nervous system.

• Cardiac, respiratory and other disorders due to indoor and ambient air pollution.

• Rise in vector-borne diseases

P K Seth, director of Industrial Toxicology Research Centre (ITRC), Lucknow, notes that health-impact studies of pesticides in India indicate neurological, reproductive and immunological abnormalities. Seth stresses the need to monitor pesticides residues in water, human milk and tissues, meat and agricultural products. Findings of H N Saiyed, director, National Institute of Occupational Health, (NIOH), Ahmedabad, buttress the case against pesticides. Saiyed says that workers exposed to pesticides have revealed high levels of pesticide residue in the blood, immunological abnormalities, changes in their electro-cardiograms and altered enzyme activities.

Heavy metal pollution also has a serious health impact. Sahu notes that heavy metal accumulation in vital organs like the kidneys and liver have shown a distinct increase. Chemicals that cannot be digested or rejected reach the liver and kidney through the blood stream and often get accumulated.

Devika Nag, head of the department of neurology, King George's Medical College, Lucknow, notes that metals, along with pesticides, have been identified as a cause of neurological illnesses in humans. Exposure beyond a limit to organochlorines, such as DDT, and even mercury and manganese can lead to abnormal behaviour and nervous disorders. Nag noted that children are especially vulnerable, as their central nervous system is not protected from toxins that do not normally affect adults.

Sangamitra D Gadekar of Anumukti, Surat, quoted the results ofa 1991 study of five villages within 10 km from the Rajasthan Atomic Power Station (RAPS) at Rawatbhata near Kota. Gadekar's team observed an extraordinary rise in congenital and chronic diseases in the area since the plant came up in 1972. Significanly, there was a sharp increase in congenital deformities in people who were born after the plant came up. The team found that tumours were seven times more prevalent in villages near the plant, when compared with the control villages over 50 km away.

NATURE'S FURY
Pesticides and industrial waste contaminate water resources. Geological factors contribute to the problem. The problem is aggravated further by environmental degradation. For instance, the ground water in eight out of 16 districts of West Bengal contains arsenic, leading to the worst cases of arsenic contamination in the world. According to the state government, about 4.5 million people are exposed to the problem. Medical records show that apart from the known effects of arsenic poisoning such as skin abnormalities, lesions, thickening of the palms and soles, and liver problems, 44 per cent of the patients also had cough and breathing difficulty. About 200,000 people are suffering from arsenic related diseases (See box: Pumping poison).

Lead can also be an airborne threat. Though lead inhaled by human beings is ten times less than that which is ingested, absorption through inhalation is greater. Almost 90 per cent of the lead gets deposited in bones and 10 per cent in soft tissues, affecting intelligence and behaviour. Studies by Veena Kalra of AIIMS, showed unacceptably high blood lead levels in school children in Delhi. Of the 180 children studied, 64 per cent showed elevated blood lead levels. High quantity of lead intake can cause acute brain damage and can also lead to death. It can also affect the heart function as well as the kidneys.

Volatile organic compounds (voc) and ozone are also not far behind as environmental villains, "voc and ozone have a great role to play on health, both from the physiological and the psychological aspects," says C K Varshney of lawaharlal Nehru University (JNU). According to him VOC levels in JNU a comparatively clean, green area in Delhi is 19.96 per cent higher than the accepted level (HOum/m3), and is 4.2 times higher in the busy street, Vikas Marg. Ground-level ozone concentration is increasing continuously and consistently. Ozone can create respiratory problems and can increase the chances of cardiac arrest by more than 40 per cent, notes Varshney.



DEADLY CUISINE
"The kitchen kills more than the sword." Kirk R Smith, professor of environmental health sciences at the University of California, USA, invokes this Latin proverb, to describe indoor air pollution. Smith claims that foul indoor air has been responsible for a morbidity and mortality rate far higher than that caused by all the wars of this century put together. Poor sanitation, burning of dirty solid fuels such as biomass and coal for cooking and heating in poorly ventilated conditions are responsible for indoor air pollution. Whereas air in such cities as Delhi, Xian in China and Mexico City contains a daily average of 500 micrograms per cubic meter of total suspended particulates, smoky rural houses in Nepal, India and Papua New Guinea have peak levels of 10,000 or more, suggests Smith (See graph: Unhealthy cooking).

Recent estimates of the premature deaths in India from indoor air pollution exposures range from 500,000 to two million per year, he notes. Indoor air pollution contributes to acute respiratory infections in young children , chronic lung diseases and cancer in adults, and adverse pregnancy outcomes (such as still births) for women exposed during pregnancy. Acute Respiratory Infections (ARI) principally pneumonia are the chief killers of young children. ARI accounts for 13 per cent of illness in India, and 80 per cent of ARI is due to indoor air pollution.

Statistics show that there is one premature death for every 200 open biomass stoves per year. Lung disorders have a high correlation to fuel type and the environment. Studies have shown that up to half of adult women (few of whom smoke) suffer from chronic lung and heart diseases. Non-smoking women exposed to indoor coal smoke have a risk of lung cancer similar to that of men who smoke lightly says Smith. It has also been established that cooks receive a larger total dose of pollutants than residents of the dirtiest urban environment.

To avoid the harmful effects of indoor air pollution, people should be ^ encouraged to move up the energy ladder, notes Jamuna Rarnakrishna, Head, Humanist Institute for Cooperation with Developing Countries (mvos), Bangalore. Energy sources of the well-to-do, such as cooking gas, pollute less. She complains that India's numerous stove programmes have failed miserably. She also notes that the potential of chimneys has not been explored and exploited so far.

Each region needs a different kind of stove based on regional patterns of climate, ventilation, house types , fuel availability, diet, cooking practices and the function of the stove. Says Madhu Sarin, an architect working on design aspects of the stove: "Designing a nuclear reactor is easier than designing a chullah."

HUMANS AND VECTORS
If the bitter battle between humans and pathogens is fought on a badland, humans stand to lose. "The occurrence of major vector-borne disease is closely related to a naturally existing environmental condition to human activities and to urbanisation," says Ramalinga swami. Malaria is a perfect example of a human-made epidemic. Sharma of MRC notes that when highways are built, trenches are dug, canals lead to water-logging and construction sites leave puddles. All these activities contribute to the proliferation of mosquitoes.

T Jacob John, professor of Indian Council of Medical Research (ICMR) and professor of eminence at Christian Medical College, Vellore, notes that apart from malaria, kalaazar, Japanese encephalitis, dengue and lymphatic filariasis, vector-borne diseases such Kyasanur forest diseases, sandfly fever, Indian tick and plague are found in India. "Due to the abundance of vectors, we are now vulnerable to the reintroduction of chikungunya and importation of yellow fever," says John (See box: The riceroot vectors).

One of the most serious hidden disease threats is that of plague. The reason behind the threat is the changing vector ecology, effected by human activity, says Ishwar Prakash, a leading rodent expert with Zoological Survey of India (ZSI). Plague spreads through rodents and rat fleas. "As a consequence of increasing irrigated agriculture, not only is the population of several rodent species increasing, but their reproductive rate has significantly enhanced," Prakash points out. Ever since the Green Revolution, irrigated cultivation is increasing, and new areas are being brought under cultivation, even in the Rajasthan desert. In recently transformed irrigated agriculture lands, the changing ecology of rodents has been well studied in Punjab, Haryana, the Aravalli mountain range and Rajasthan desert, claims Prakash. He notes that ecological changes promote intermingling of several domestic and wild species.

This intermingling is a dangerous trend, Indian gerbil (Tetera indica),s the reservoir of the plague bacillus. The house rat (Rattus rattits) is highly susceptible to plague bacillus. Several other species found in India, including the bandicoot (Bandicota bengalensis) and desert gerbil have been found seropositive to the plague bacillus.

Pondicherry. About half the filaria cases in the world are distributed in the south east Asia region (of World Health Organisation classification, which includes India.) The Culex quinquefasciatus is ubiquitous in India. "Environmental sanitation and targeted vector control are the ways to prevent filariasis, Das notes.

Kalaazar (Visceral Seishtnaniasis) has been a bane in the humid eastern parts of India, mainly Bihar. But of late, new outbreaks have been reported in irrigated tracts of Gujarat and the sub-Himalayan belt of Jammu and Kashmir, Himachal Pradesh and Uttar Pradesh. This is due to environmental changes brought about by irrigation projects and deforestation since the green revolution years, experts note. The disease vector sandfly thrives under humid conditions. "Changing vector ecology of kalaazar is one of the least investigated topics," says N L Kalra of Malaria Research Centre (MKC), an expert on the disease (See graph: Vector control).

TILTING THE BALANCE
Changes in environment not only shoot pollution and vector populations up, but also depletes natural resources, throwing life-supporting systems in disarray. In turn, people become more susceptible to illnesses. )ashodhara Dasgupta of the NGO Sahayog, Almora, points out that the rural women of Uttarakhand, the Himalyan belt of Uttar Pradesh, spend all their waking hours deal Prakash points out that the recent resurgence of plague, after almost 25 years, at Mamla (Beed, Maharashtra) and Surat ; (Gujarat), occurred mainly due to disturbance in the ecology due to natural calamities. The Latur earthquake changed the g vector ecology at Manila while the floods disrupted it in Surat. The new foci may be sites of human induced ecological upheavals, such as small pockets along the Indira Gandhi canal, he notes.

Filariasis and kala azar can be classified as diseases of bad environment. "Filariasis is spreading all over the country," says P K Das, director of the Vector Control Research Centre, ing with soil, water and forests. They lead a tough life, trekking many kilometres for water and firewood. Dasgupta's 1996-97 study on 1,000 women in 10 locations in Uttarakhand showed about 30 per cent of the women had spontaneous abortions. Elsewhere in the country, deforestation has caused a shortage of forest produce, breakdown of existing community systems and poverty. Says Narendra Gupta of Prayas, a Jaipur based NGO: "This has resulted in elimination of trees, increased water shortage, increased crowding and dust, and an increase in the virulence of vectors and rodents. Coupled with this is the decreased availability of nutritious food."

Afforestation measures have brought relief to rural communities in many places. But introducing alien species may have its own problems. Prosopis juliflora, a favourite amongst horticulturists, has spread in wastelands of India reducing the fuel-wood crisis in many areas. But its pollen has led to a number of allergenic reactions, points out A B Singh of the Centre for Biochemical Technology, New Delhi.

WASTED EFFORTS
The desire to be clean and modern creates further problems. Most conventional sanitation technologies are based either on removal of human excreta through a network of underground pipes or on-site storage in deep pits. In both cases there arc disposal problems. Says Uno Winblad, a Swedish consultant, "The sewage system is causing a major ecological problem. Not only does it lead to contamination of our lakes and rivers, but it also leads to a lot of wastage of water."

There is a need for a third option. Dry compost latrines which disintegrate the waste are the solution, he says. For this purpose is required a latrine where faeces and urine do not come into contact with each other.

Our bodies exist in the environment and we carry a soup of chemicals within us and we cannot stay insulated from the changes taking place in the environment. If the environment degrades, so does the state of our health. The key to good health is therefore in many ways a good environment If we pollute the environment our bodies arc polluted in turn. Therefore, it is vital to manage the environment in a manner that it does not become a health problem.

There are two approaches to the problem. The technocratic approach and the Gandhian approach. One talks about living in wealth, the other suggests staying away from wealth and managing with bare prerequisites.

If Indians live a frugal life in tiny self-supporting villages, if farming is organic, population levels remain low and industry exists only in the cottage sector, there will hardly be any waste or pollution. There will also be no need to manage waste as people will have already managed to limit want, because it is the unrestricted multiplication of wants which leads to the generation of waste which is the characteristic of a consumer economy as opposed to a Gandhian village economy.

But the concept of a 'no-progress' village may not succeed in today's India. Therefore, responsibility for the management of waste and for the safeguarding of the environment has to be fixed. If industry generates waste, it must be made to manage it. The same applies to those who realise revenues by degrading the environment. They must be made to plough back their earning to safeguard the environment.

What India needs is not just the ability to manage in poverty, but to manage wealth in such a manner that we can become Gandhians in the management of that wealth. Only then can sustainable development become a reality, noted Anil Agarwal, the director of CSE. When wealth generates waste it leads to squalor and filth and there is virtually no difference between the quality of life of the very poor and the slightly rich. Degraded environment is bad for both the rich and the poor.

"The issue therefore is of making prudent choices. What should we manufacture and what should we produce? We certainly need to think of alternatives to such products that cannot be easily decomposed by nature or those that will eventually end up poisoning us," said Vice President of India Krishan Kant, while inaugurating CSE'S health and environment conference. He was echoing a very valid fear. For in the last 50 years, the quantum of industrial production has exceeded all the industrial production in human history before it. This has created so much waste and environmental pollution that the natural restorative process is unable to cope with it.

An unrestrained faith in technology and materialism has resulted in creating monstrous cities and weakening community ties. Lack of interpersonal relations leads to lack of consideration for our fellow beings. This is only a short step away from littering the streets with garbage, dirtying the streams and tanks, polluting the air and creating various other forms of social nuisance. If the size of a city is too large people often think that solving its problems is beyond their individual capabilities. They begin to feel that everything will be done by the government. It is therefore vital to reduce the scope for government intervention and to determine an optimum size for cities.

"I submit that besides technology and the vision of small manageable urban communities, as thought of by Gandhi and Nehru, we must seriously think of people's action plans. That is the most difficult issue. After independence an attitude has been created that the government should do everything. 'Since we have given them our votes our responsibility ends here'. But that is dependence on government, not independence." noted Krishan Kant stressing the need to involve local communities in environment management.

"Gandhi and Gandhian constructive workers cannot be made to order or manufactured. They are the product of an inspiring challenge and a brighter vision of society," he added.

In our march towards economic growth targets we must ensure that the environment is not degraded further. While economic growth leads to health improvement, unless it is reconciled with disparity reduction and environmentally sustainable development, it would have failed in its social mission, notes V Ramalingaswamy. Community health is the single most sensitive indicator of the state of the environment.

Utilising scientific knowledge for society's good has to be the cornerstone of any policy aimed at bettering the state of community health in India. In the case of water management while 85 per cent of India's population has access to safe water, only 20 per cent is covered by latrines. To regulate air pollution a national transport policy based on the science of pollution and pollutants is required.

But tough laws do not help by themselves. While many developing countries pride themselves in having passed tough environmental regulations, compliance is tragically inadequate.

The government can help promote this by increasing transparency in decision making. In fact, environmental measures can bring about a great deal of change in the disease burden of a place.

As biological vector control of malaria in Goa showed, even when a disease is on the rise countrywide, ecological measures can make a dent in its incidence.

In Panaji, Goa MRC initiated bioenvironmental control with community participation in 1989. Swimming pools and tanks were cleaned. Microbes and tiny larvivorous fish such as Guppy (Poedlia reticulata) and Gambusia (Gambusia affinis) were introduced in water bodies. Intensive campaigns encouraged people to prevent mosquito breeding in tins, buckets, tyres and coconut shells. The results were dramatic. From 6,732 cases in 1988, malaria cases came down to 852 by 1992, according to government statistics. But malaria shot up again, once the community efforts lost steam. (Refer Down To Earth, Vol 7, No 4)

It is vital to remember that naked lands breed naked people. A dirty river is a sign of a dirty community. Only a people who are disciplined and manage their environment properly end up being prosperous and healthy.

Narrating an incident of the time when the plague hit Surat in 1995 when he was the Governor of Andhra Pradesh, Krishan Kant described his visit to a hospital in Hyderabad. Garbage was strewn around the hospital entrance. Krishan Kant stopped the car, picked up some garbage and walked up to a small temple nearby and placed it before the idol.

Turning towards the welcoming committee, he said, "God is omnipresent and knows us inside out. In the temple we surrender ourselves before God and offer all that we have to get his blessings. We cannot surrender what we do not have. We have garbage and dirt lying around us, so I have offered whatever we have." This proved to be shock therapy.

Similarly, shock therapy is needed to make the people respect the environment. Humans must realise that we all live downstream. If we offer pollution and waste to the environment we can only expect the same in return.

Written with inputs from Max Martin, Manish Tiwari, Yoga Rangatia, Indira Khurana, Vineet Katariya, Achila Imchen and Kaztmuddin Ahmed. The conference was organised by Priti Kumar and the Health and Environment Unit of CSE