*Every year, 4 million children in Africa and Asia die of diarrhoea.
* Nearly 800 million people in the 2 continents are at serious risk of contracting chronic respiratory diseases and cancer from indoor air pollution.
* It is believed that global warming could trigger epidemics of tropical diseases worldwide.
* More than 1 billion city dwellers the world over are regularly exposed to pollution from industry and transport.
Public policy planners the world over have begun to look retrospectively at the 20th century with uniform approval. With some exceptions, almost the past 100 years are seen as an era of progress and development -- abstract notions buttressed by more definitive statistical indicators brought out by governments and organisations to support the case that humankind lives better than ever before.
There are, however, grey areas and dark shadows to this bright picture. One is public health, as evident in the instances already mentioned. The World Bank's 1993 World Development Report, titled Investing in Health, noted that although there were "direct and significant gains in well-being...enormous health problems remain".
During the past 40 years, average life expectancy has improved more than during the entire previous span of human history and infant mortality has halved. Diseases like smallpox have been eradicated and others have been drastically checked.
Yet absolute mortality levels remain high in most developing countries and, as Nitin Desai, secretary general of the UN Commission on Sustainable Development (CSD) says, "are very depressing when compared to those of the developed countries". And even if mortality rates have declined, health experts are no longer sanguine about morbidity rates: old diseases are recurring and new ones are cropping up. Points out Desai, "In comparison to economic growth, a very noticeable health deficit has opened up, threatening to widen beyond control in the near future."
There is a body of experts that believes that this deficit is the direct consequence of sluggish national and international spending on public health systems. Argues Daniel Lopez-Acuna of the Pan-American Health Organisation (PAHO), "Much of the crisis of health systems in Latin America is the direct result of reduced social-sector spending, brought about by the economic stagnation of the 1980s."
This, according to him, generated "striking deficiencies" in drinking water supply, sanitation and the replacement of health services equipment and physical infrastructure. Besides, resources for these areas were allocated largely to those who could pay for them, ignoring a large proportion of the urban poor and the rural population.
There are other policymakers who, mindful of their countries' ailing economies, attribute the inadequacy of their health systems to restricted financial support. These countries include those that arose after the collapse of the Soviet Union. Julius Ptashekas, director of the Centre of Ecological Medicine at the Vilnius-based Institute of Hygiene in Lithuania, sums up: "Our health establishments are quickly approaching the verge of collapse for want of continued financial support."
Then there are those who agree that public health should never suffer for want of financial sources and suggest that any understanding of the health deficit needs a more comprehensive look. Pointing to the truism that the poor of the world have more than their share of health problems, Abdolaye Diaw, a health economist with Environment and Developmental Action (ENDA) in Senegal, asserts the need to realise the "corollary truth that these problems overwhelmingly originate in the deterioration of the environment upon which the poor depend for sustenance."
Experts have often articulated the impact of land-use changes -- in the quantity and quality of farms and forests, upon which a large number of the world's poor depend -- on public health in the developing world. In most developing countries, the spread of high-yielding, intensive agriculture has invariably been accompanied by the declining productivity -- even oblivion -- of smaller land holdings.
Almost as a rule, governments have ignored the plight of communities and families dependent on small farms, who are beset by the continuous degradation of their nutritional status. The problem is more acute for those who have been divorced of their farms altogether.
The process is especially marked in Rio Grande do Sul region in Brazil, where many small farmers have been forced out of their holdings, which have given way to large cattle ranches predominantly for beef exports, to become waged labour. However, the new vocation has not always ensured that families get enough to eat. As a result, the community of ranch workers experiences infant mortality rates (IMR) as high as 70 per 1,000 compared to the average of slightly more than 20 for medium and big farmers in the province.
Similar findings are available from Bihar in India, where 71 per cent of the children of marginal farmers are malnourished, compared to less than 39 per cent of those with middle-sized farms.
Small farmers and landless rural labour depend on forests for food, fuel and medicine, especially during droughts and other emergencies. Rampant deforestation all over has created a health crisis for these communities. This has had a particularly deleterious effect on rural women, who are mainly responsible for gathering fuel and preparing food.
Remarks Joseph Adusei, health planner with Ghana's ministry of health, "The responsibility for fuelwood collection has already stretched the labour of our women beyond bearable limits." Women in the northern part of Ghana carry out 24-hour expeditions for 3 days' supply of fuelwood. Elsewhere, as documented by Anil Agarwal and Sunita Narain for India, women in Karnataka state spend between 2.5 to 3 hours every day to gather firewood, traversing nearly 1,600 km over the span of a year.
The accentuation of the problem is indicated by the fact that rural women are covering greater distances with every passing day -- in parts of Bihar, the distances have increased nearly 4-fold in the past decade. Other than increasing physical stress, fuelwood gathering implies that rural women are devoting less time and energy to household hygiene and child care.
Numerous rural communities are now resorting to low-quality, biomass fuelwood substitutes such as grass, which cause enormous pollution in kitchens. The impact of this is largely in the form of respiratory problems, ranging from acute infections (especially in children) to obstructive pulmonary disease in girls and women who tend the hearth. It is estimated that nearly 400 million women and their children have developed these diseases in serious form.
Health problems are being caused in rural areas by large-scale changes in water-use patterns as well. The creation of extensive irrigation schemes may provide water but it also increases the habitat of disease-causing mosquitoes and water-snails.
After the Diama dam project -- which created irrigation facilities for more than 300,000 ha in Senegal and Mali -- was commissioned in 1986, the 2 countries experienced some of the most intensive outbreaks of intestinal schistosomiasis, caused by the water-snail, in West Africa. By the end of 1989, almost 70 per cent of the population in the project area was gripped by the disease.
Diaw explains that before the construction of the dam, the vector for schistosomiasis was "only sparsely present and often not found in the Senegal river basin". The ecological changes brought about by the dam, including increases in water salinity, are believed to have created more favourable conditions for the water-snail.
Ideal conditions for disease carriers to flourish have also been created by largescale resettlement programmes in rural areas. In Brazil, the scheme that relocated more than 9 million people in rural Amazonia and brought new areas under cultivation was accompanied by a massive spread of malaria. The malaria epidemic in the Amazon now accounts for more than 60 per cent of all the malaria cases reported in the Americas.
Experts from the United Nations Environment Programme (UNEP) say that the story of malaria in the Amazon is by no means unique. High mortality and morbidity is reported from many largescale settlement schemes across the world. "Forest malaria" is rampant among the 1 million farm households in Thailand that have been forced by development schemes to "squat" on the country's forests.
Another environmental problem of rural areas with already pervasive health effects is the increasing use of agrochemicals. According to the World Health Organization (WHO), some 3 million people worldwide suffer annually from exposure to pesticidal chemicals, with 220,000 deaths.
A study by UNEP found that the proportion of agricultural workers handling hazardous pesticides was 29.8 per cent in Indonesia, 91.9 per cent in Malaysia, 38.3 per cent in Sri Lanka and 41.4 per cent Thailand. But these figures only point to the scale of the problem within pockets of intensive agriculture with a higher use of pesticides. In Kurunegala district of Sri Lanka's Mahaweli province, which has been developed as a paddy-growing bowl, annual deaths due to pesticide exposure increased 14-fold during 1977-81.
Food contamination due to pesticides is increasing as well. In India, toxic levels of DDT in milk have been reported by the Indian Council of Medical Research (ICMR) (Down To Earth, April 15,1994). Mycotoxins produced by fungi, in general, cause serious outbreaks of food poisoning. Their combination with hepatitis-B, according to Adusei, has been an important factor in primary cancer of the liver, one of the most common cancers in Asia and south of Saharan Africa.
Moreover, several disease-carriers develop resistance to pesticides quickly and long-term dependence on pesticides is an almost certain to ensure the resurgence of diseases they are meant to prevent.
The degradation of rural environments has had indirect manifestations, too. For large sections of rural populations, such degradation has brought immediate economic poverty.
As a general phenomenon, developing countries experience much higher urbanisation rates than developed ones. In 1950, only 17 per cent of the people in developing countries lived in urban areas -- in 1970 it had reached 25.4 per cent and in 1990, 33.6 per cent. The United Nations Population Fund estimates that by 2025 AD, 85 per cent of Latin Americans, 58 per cent of Africans and 53 per cent of Asians will live in urban areas.
Most urban growth has been in the form of unplanned "squatter" settlements. One billion people across the world live in shantytowns and slums (see table). The crunch for urban shelter has created enormous health problems of its own. There has been a massive resurgence of tuberculosis, classically a disease spread by overcrowding and poor ventilation. Forty per cent of all urban families in India live in single-room tenements and the figure is much higher for metropolises like Calcutta (70 per cent) and Bombay (82 per cent).
Elsewhere, the incidence of tuberculosis has increased in direct proportion to expansion in cities ranging from Cairo to Manila and Bangkok during the past 2 decades. Governments -- national as well as local -- have been unable to cope with urban overcrowding and most developing-country cities are en route to becoming urban health disasters.
India's case is only typical. One-third of its urban population does not get safe drinking water, only 8 per cent have access to covered sewage disposal systems and 31 per cent are without sanitation facilities. The lack of such basic infrastructure, according to the Delhi-based Voluntary Health Association of India (VHAI), has made "the occurrence of vector-borne diseases the hallmark of the urban health situation in India".
Large water bodies are often left behind as a result of road or building construction, leading to a spurt of malaria, filariasis and dengue. An ICMR study team calculated that 50 per cent of malaria incidence in Tamil Nadu is in Madras city alone, largely because of hundreds of thousands of uncovered, overhead tanks. Filariasis is endemic in Patna, Kanpur and Guwahati, where it didn't exist until the '50s. ICMR experts estimate that nearly 300 million people in the country are vulnerable to filariasis.
The problem of urban waste -- domestic as well as industrial -- is even more daunting. Many city administrations have been unable to find new landfills (old ones get exhausted) and expand municipal services.
A WHO study estimates that only 30 to 55 per cent of the solid waste generated in developing cities is collected and transported out and reiterates that "disease vectors proliferate on waste and specially so in situations where human excreta are added to garbage".
The problems are compounded by the fact that thousands of urban poor depend upon these wastes. Manila's Smokey Mountain dump is estimated to provide a living to nearly 35,000 people who recover scrap for industrial reuse. Nearly 70,000 others retrieve waste for building material and domestic handicrafts. Dumping sites are used similarly by several hundred thousand wastepickers and scavengers. In most cities, hazardous material such as hospital wastes or effluents from chemical or metal processing factories are routinely dumped along with other solid waste.
The hazards of such practices were illustrated dramatically in 1987, when 217 people were seriously affected and 4 killed when an abandoned radioactive cancer treatment device was discovered among the rubbish in Goiania, Brazil, and its materials reutilised. More recently, a WHO-sponsored study established that slum-dwellers in Calcutta generally suffer high levels of ill health, and that wasteworkers among them have markedly greater prevalence of respiratory disease, diarrhoea and intestinal parasites (see graph: The spectre of sickness)
Even higher income settlements in cities are afflicted by air pollution of industrial and traffic origin. The problem is marked even in developed countries. Several Western studies have established the prevalence of elevated levels of lead in blood in the urban population of many parts of Europe and the US.
An estimated 675,000 US children have blood lead levels above WHO-prescribed safety limits and millions more worldwide are exposed to potentially toxic amounts of lead due to increased use of leaded petrol. And while western Europe, Canada and North America have thorough legislation and strict regulation in favour of deleaded petrol that has significantly reduced ambient lead levels, such a scenario is a long way off elsewhere, especially in Asia, Latin America and East Europe.
Although a fair amount is known about the scale and impact of vehicular pollution, several substances being increasingly used in industrial processes still have be evaluated in terms of potential impact on health and the environment. The number of new, artificial chemicals doubled during the past 3 decades and is expected to reach 100,000 by 2000 AD.
Says Wilfred Kriesel, head of WHO's Programme for the Promotion of Chemical Safety, "Potentially toxic chemicals are now found everywhere and it is a sobering thought that few countries have adequate technical capacities or resources to assess chemical risks under their particular local conditions"(see graph: Consuming acid).
In the absence of such information, occupational health hazards have emerged as a major source of concern. WHO studies estimate that there are about 32.7 million occupational injuries and 146,000 deaths in the world's workplaces every year -- nearly 15 per cent are directly or indirectly caused by hazardous exposure to chemicals (see graph). Voluntary agencies and NGOs point out that occupational health receives poor attention from planners in India and many other developing countries.
The evidence of such pressures on the environment has had one significant effect: there is increasing recognition that integrated approaches have to be developed to deal with health and environmental problems. Some analysts believe that this concern has been shared by nations for some time and point to the 1978 International Conference on Primary Health held in Alma Ata in the erstwhile Soviet Union.
However, Nay Htun, deputy executive director of UNEP, feels otherwise. According to him, the "explicit articulation for an integrated approach was actually much strongly heard" at the 1992 Earth Summit in Rio de Janeiro. In the agreements reached at Rio -- the Rio Declaration and Agenda 21 -- health was the primary consideration of development and its environmental consequences.
The 2 years since Rio have indeed witnessed a range of international health-and-environment initiatives, some of which seek to enhance the planning capabilities of national governments and international organisations. One is a scheme launched last year by WHO in collaboration with the United Nations Development Programme in Barbados, Ghana, Guatemala, Jordan, Lithuania, Nepal, the Philippines and Sri Lanka.
According to Kriesel, although the immediate aim was to sensitise development agencies to the links between public health and environment, "its long-term purpose is to gain greater involvement of the health and environment sectors in national planning for sustainable development".
To this effect, national plans for health and environment are being developed in Barbados, Guatemala and Nepal. On the other hand, in Lithuania and Sri Lanka, the initiative focusses more on assessing the consideration given to human health in existing environment programmes. And in Jordan and Ghana, the emphasis is on creating institutions that can suggest strategies for the implementation of Agenda 21. The objective of these attempts is obviously to begin from scratch and create planning capabilities.
Elsewhere, inter-regional planning and cooperation has already matured to deliver concrete policies. This is exemplified by the gigantically ambitious regional plan for investment in the environment and health shared by 23 Latin America and Caribbean countries. Drawn up by the Pan-American Health Organisation in 1992, the plan details a strategy to equip the health and environmental sectors with fresh services and assets worth $216 billion by 2004 AD.
Specific targets include the provision of drinking water and sanitation facilities for nearly 190 million people, a refuse collection system to cover nearly 125 million urban inhabitants, the creation of nearly 680 major and minor wastewater treatment plants and a 350 per cent increase in the number of district hospitals and rural clinics along with the numbers of doctors and paramedical staff.
Acuna asserts, "It would be a mistake to see the regional plan merely as a matter of replicating existing systems." Pointing to the environmental strategies in the plan, he argues that "we are talking of bringing about actual quantitative as well as qualitative changes that will ensure universal health access to health and environmental services to our populations".
However, it's not as though these approaches have been endorsed without criticism. Several experts feel such attempts may well be conditioned by institutional handicaps.
Martin Birley of the Health Impact Programme of the School of Tropical Medicine in Liverpool, England, feels believes that one hurdle is unreliable health information. "Many countries have lagged in establishing effective or functional health surveillance systems," he says. Moreover, even if they are operational -- as in India and Kenya -- they almost never have the authority or the resources to act as watchdogs for the health implications of developmental activity. And although agencies to prevent environmental degradation have been created in many countries, they cannot make sustained health impact assessments.
The end result, according to Birley, is that "while environmental impact assessments in most countries have a theoretical concern with health, it is rarely borne out in practice". This, he says, has led to inadequate health and environment planning even in countries where governments have developed the motivating concern.
More criticism is levelled by grassroot and voluntary organisations. Typically, they point out that plans like those of WHO and PAHO are in their infancy and in the several decades it may take for their outcome to be realised, there may be several hurdles.
The most significant of these, according to Diaw, is "the essential requirement of governments to keep matching their concern with sustained high levels of spending". Simply put, largescale schemes for better health or environment -- even through integrated approaches -- do not come cheap and the question of who will fork out the cash may always beset them.
There are those who are convinced that the capital-intensive approach itself is the root cause of public health system inadequacies. In India, this view has for long been pushed by health policy expert N H Antia, who feels that "even public health systems are ultimately paid for by the people". According to Antia, expensive health systems invariably lead poor and middle-class people to spend "far higher amounts of money on medicine and doctors than they should or can afford to".
Antia's organisation, the Foundation for Research in Community Health, found that in Maharashtra's Jalgaon district, families with the lowest income levels diverted nearly 8 per cent of their expenses from food to medicines in the '80s. "The short-term as well as the long-term consequences of this nutrition gap can only be described as horrendous," says Antia.
The need to recover costs usually influences expensive health systems to make higher-earning urban groups the privileged target. This, according to Antia, "is borne out by the fact that over the years, 70 per cent of public health spending in India has gone to the urban sector". Of the rest, almost all aspects of rural health have been subordinated to population control and ancillary programmes.
This experience has been almost duplicated by most developing countries. Time and again, they show up to be hopelessly inadequate in the face of rapid epidemics or problems brought about by environmental degradation. The dramatic outbreak of cholera in South America in 1991 is a classic example that underscores this point. It began in January in a remote part of Peru and 8 months later, had spread to the entire continent, affecting vast populations. This was despite the supposedly adequate investments made in the health sector by most of these countries throughout the '70s.
Such national and international experiences have prompted several activists to look for low-cost, decentralised alternatives. Diaw's work in Senegal has convinced him of "the value of a bottom-up approach, where health-environment systems are conceived and operationalised within the communities in which people live and work". The most important advantage of such schemes, according to him, is that they ensure direct participation of local populations, especially when local health-environment traditions are deliberately incorporated into the schemes.
There are notable examples of such efforts carried out by NGOs in India. Prominent among them are the Comprehensive Rural Health Project at Jamkhed in Maharashtra's Ahmadnagar district, conducted by Rajnikant Arole, and the work of the Society for Education, Welfare, Action - Rural (SEWA Rural) in Jagadia block of Gujarat's Bharuch district.
Alok Mukhopadhyay, editor of State of India's Health, published by VHAI, studied both projects and points out that the most significant lesson is that "most, if not all, health problems of a community can be tackled by members of that community itself if necessary knowledge and training is made available".
In both Jamkhed and Jagadia, despite the presence of health activists from outside, the local people decided the priorities of health goals. And, crucially, the successful projects are never restricted to discrete solutions of local health problems alone. Says Antia, "It is interesting that even what begins as purely health intervention invariably spreads to education and local resource management." Thus, the scope of the Jamkhed and Jhagadia projects eventually extended to local water sources, forests and agricultural activities.
Such processes have been also been observed in the reverse in resource regeneration experiments such as that of Sukhomajri village of Pinjore district in Haryana, where the reclamation of local wastelands through a community initiative had corollary improvements in local health status (Down To Earth, February 15, 1994(?).
But the projects are eminently successful on purely health considerations alone. Antia never tires of asserting that these projects are better than government-run health programmes. "Almost all local health projects run with local participation prove that infant mortality rates can be reduced to 60 even with marginal external inputs. For all their seemingly vast scale, government-run mother-and-child welfare programmes have found it difficult to match this." He suggests a comparison of the performances of the SEWA-Rural project with locally present government programmes to support his point (see table: Who is the saviour?).
Moreover, these programmes, with their minimal reliance on exclusively external skills and materials, have immense potential to become self-supporting. In Jamkhed, the promotion of simple diagnostic skills among village health workers drastically cut the need for doctors to be present. In a pneumonia epidemic in Gadchiroli district in Maharastra, illiterate yet skilled village health workers used basic drugs to significantly bring down the prevalence of the disease in 58 villages which were brought under the umbrella of community health programme.
This has also enabled community-run projects to be largely self-sufficient. Only 4 per cent of the annual expenses of the Jamkhed programme are met through government grants and administrative and salary expenses account for only 10 per cent of overall costs. In contrast, 72 per cent of the Union government's health expenditure is taken up by salaries.
According to Mukhopadhyay, this gap widens if community initiatives intensify the use of indigenous medicines. A VHAI programme to promote solutions through indigenous medicines and health practices has been launched in parts of West Bengal, Bihar and Orissa. The programme, called Operation Akhra, has already shown that impoverished tribals can get extremely cost-effective treatments for common ailments and even chronic diseases.
Nonetheless, some health activists argue that NGO-run health projects must be given a hard look. There are an estimated 7,000 such projects in India. "Not all of them," warns Antia, "are premised on the principle of participation. Many advocate totally external technologies or practices that are unsustainable in the long run." Other observers bemoan the fact that such projects, even successful ones, do not offer any "model" that can be duplicated with a certainty of success.
Similar approaches to local community run projects are followed in other developing countries. And this raises apprehensions about whether the gap between local initiatives, on the one hand, and national and international efforts, on the other, can ever be bridged.
Perhaps the problem arises when experts, policymakers and NGOs go in for mere duplication of the nuts and bolts of successful health projects instead of the principle of sustainable health and environment.
The latter clearly calls for a reversal of the political and economic policies that marginalising the role of millions over their environment and other factors of sound health. This reversal can be achieved only through empowering communities and people in programmes to regulate their health and resources. Because the latter aspect is usually missed in mega health and environment schemes, and so evidently informs the successful smaller initiatives, sustainability in these spheres has tagged along only with the small.
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