Ramona Sunderwirth MD MPH

Global Health Fellowship

Lecture Series

Objectives

Definitions , Concepts & Scope of the environmental impact on health

Brief History of political ecology Environmental World Views Scale & distribution of environmental

risks to health

Definitions of Environment

Refers to our natural surroundings & their resources + built conditions + social relations

The combined exposures & processes that impinge on individuals & groups

Are beyond the immediate control of individuals

Definitions & Scope

Natural environmentPhysical, chemical, biological factors & processes

external to people Built environment

Human made settings – buildings, housing, sanitation, transportation systems – all settings

Social environmentConditions w/in which people live, shaped by

cultural, social, economic, political relations & factors

Sources: Evans (2002);Pruss-Ustiin & Corvlan (2006)

Definitions & Scope

EcologyStudy of relationships & interactions btw living

organisms & their environment

EcosystemSystem formed by the interaction of a community

of organisms & their natural environment geographically defined

Political ecologyUnderstanding of the relationship & tensions btw

natural (environment) & human led change

Environment: Categorized

Environmental mediaAir, water, soil & food

Economic sectorTransport, land use, energy generation

Physical scaleLocal, regional, global

SettingHousehold, working place, urban environment

Disease outcomeInfections, cancers, chronic diseases, endocrine

disruptions, behavior/mental health, congenital anomalies Cross scale

Scale at which an environmental health impact occurs may not be the scale at which the exposure was initiated

Environment definitional

considerations: Environmental

Exposures Natural exposures

Seasonal, latitudinal, altitudinal gradients in solar irradiation

Extremes of hot/cold weatherPhysical disastersLocal micronutrient deficiencies in soil

Human interventionsChemical contaminants → air, water, soil, food,

work placePhysical hazards: ionizing radiation, urban

noise, road trauma

Major Environmental concerns

Industrialized countriesChemical contaminants→ regional, global air/water/soil/foodPhysical hazards (ionizing radiation, urban noise, road

trauma)Hazards controlled by major investments in housing,

community infra structure (drinking water supply, sewerage, solid waste collection, etc)

Low & middle income countriesMicrobiological quality of drinking water/foodPhysical safety of housing/workIndoor air pollutionRoad hazards

Qualitative Dimensions

Familiar local physiochemical & microbiological environmentAs vehicle for specific hazards → injury, toxicity,

nutritional deficiencies, infections

Emerging disruptions to the biosphere’s ecological & geophysical system life support systems → stabilize, replenish, recycle,

cleanse, produce → climatic stability, food yields, clean freshwater, nutrient cycling, sustain biodiversity

Brief History of the World

Interactions of humans w/ the natural & built

environments Long term survival: maintaining assets of natural

environment All civilizations have subsumed nature in their

quest for progress Hunter gatherer societies (150,000yrs)

Lived w/in limits local environments, moving nearby as needed

Agriculturalism (10-15,000yrs ago) Initial human efforts to control environment Transformed social & economic relations Land productivity ↑, crop surpluses Water irrigated, more land cleared

History Cities (5,000 yrs ago)

Society more stratified by wealth/powerWars over territory & resources Class of leaders vs peasants/slavesTestaments to wealth/power: Monuments, precious

metals/mineralsEarly systems of commerce & extractive industries,

trade growsEnergy use: mined coal, wood burningCities grow → urban filth, rats→ Black Death (Plague)Decline/abandonment of ancient cities:

overgrazing/misuse

History

Feudalism & Industry→ Colonialism↑ exploitation of natural resources & extractive

industriesDistant lands for resources, labor, wealth &

powerMilitary conquest & political subjugation of

peoplesEnvironmental occupation

○ Strain on local environments: forest clearing, mining, building transport routes → nefarious health effects on local populations

History Mercantilism→ Capitalism

Colonial market system based on sale & circulation of labor & products yielded huge profits

+ scientific/ technical advances in production/transport/ communications

+ social policies pushing peasants off the land►

Capitalism based on private ownership of enterprise & free market economic principles

History Industrial Revolution

↑energy use, urban immiseration →environmental damage:

Sulfur, chlorine, ammonia, methane → backened air/lungs

Water contamination: industrial/human/animal waste

Deadly mix of environmental contamination & dangerous occupational & living conditions → hi mortality rates cholera, diarrhea, TB, etc

Industrial Capitalism → Electronic Era & Globalization

History Worker struggles → modern environmental

movementsAgainst noxious working & living conditions

Scale & character of European imperial enterprise made its environmental impact far larger than other civilizations (Chinese, Egyptian, Greek, Roman, Inca)

Industrial production, urban degradation, large scale depletion & contamination of life’s essentials (air, forests, groundwater, & soil) have continued, shaped & strained by economic, social & military exploits

Forces driving global economyIndustrial & agricultural production

Resource exploitation & contaminationEnergy extraction & useTransportation & building patternsMilitarismInadequate regulationMarket driven consumption patterns

↑ pressure on built & natural environments

Ecosystem & built environment alterations → range of direct, mediated & indirect human health consequences

Environmental health problems in developing

world Have become even worse than in developed

world

Economic processes of recent decades →accelerated industrialization, commerce, migration, exploitation & extraction from Asia, L. America, Africa

Environmental Threats

Household Exposures Sanitation & clean

drinking water Solid household fuels Housing quality

Workplace Environment Agriculture Mining & Extraction Construction Manufacturing Service Occupations

Community level Exposure Outdoor air quality Traffic & transport Industry & manufacturing Waste management Microbial & chemical

contamination or water & food Urbanization

Regional Exposures: Transboundary Atmospheric dispersion of

contaminants Land use & water Engineering

Global Environmental Change & Population

Health Climate Change Stratospheric Ozone depletion Biodiversity: Losses & Invasions Land Degradation, food & Malnutrition Persistent Organic Pollutants Exporting Hazards

Magnitude of environmental change

(Tony McMichael 2001) During the 20th century we humans

↑2x our average life expectancy ↑4x the size of our population ↑ x 6 the global food yield & water consumption ↑ x 12 the production of carbon dioxide ↑ x 20 overall level of economic activity

In so doing we had, by the end of the century, exceeded the planet’s carrying capacity by 30%

That is, we are now operating in ecological deficit These rates of change in human demography,

economic activity, and environmental conditions are unprecedented in history

Responses to determinants & effects Sustained political & organized

responses can mitigate or reverse underlying forces/pressures, environmental changes & health consequences at household, municipal, ecosystem & larger political levels

Environmental Worldviewsfor understanding environmental

concerns Market liberals

Institutionalists

Bioenvironmentalists

Social Greens

Market Liberals Neoliberal economics “economic growth & hi per capital incomes are essential for

human welfare & the maintenance of sustainable development” Main cause of environmental degradation

“lack of economic growth, poverty, distortions & failures of the market, and bad policies”

Voluntary corporate efforts will improve environmental managements

Reject catastrophic urgency of environmental degradation Emphasize scientific approaches to problems based on

ingenuity, technology & cooperation STO, World Business Council for Sustainable Development

Institutionalists Market liberal assumptions for economic growth, trade,

foreign investment technology

“emphasize the need for stronger global institutions & norms as well as sufficient state & local capacity to constrain & direct the global political economy”

Improved global governance & consensus building → enhance environmental cooperation & managements

Support diffusion of knowledge & resources from developed to developing countries and collective action to forestall environmental deterioration

Bioenvironmentalists

Scientific activists

“Human (pop growth & patterns consumption ) consume too much of planet’s finite/fragile resources, earth’s capacity to sustain this level of consumption already/soon reached”

Solutions to environmental degradationLimits to economic growth, curbs on immigration to hi

consumption countries, individual approaches to lowered consumption & family planning

Social Greens Political, economic & environmental problems

inseparable Physical limits to economic growth Overconsumption in industrialized countries is

(partially) to blame Reject positions on pop growth (control) as assault

on rights of women & marginalized peoples Major overhaul of the global economic social

system to ↓ inequalities, & advocate the abandonment of industrial & capitalist life

Clapp & Dauvergne (2005)

Ecological FootprintBill Rees &Mathis Wackernagle (1996)

Translates human consumption of renewable natural resources into hectares of average biologically productive land (Dauvergne 2005)

Gauge the rate at which consumption patterns compare to the natural environment’s ability to renew itselfConsumption patterns require over 20% more

ecological productivity /per person that the earth’s biocapacity can sustain (WWLF 2001) (Loh & Wackernagel 2004)

Ecological Footprint Individual’s ecological footprint

Total area in productive hectares required to sustain a way of life (food/water/energy/household materials/other/services)

Global ecological footprintChanges w/ average consumption per person, resource

efficiency & pop sizeWWLF 2001: estimated was 13.5B global hectares

(2.2global hectares/person), with 11.3B global biologically productive hectares (1.8 hectares/person)

Carbon footprints Reflect bioenvironmentalist view (human consumption &

behavior change at the center of environmental strategy)

Scale & Distribution of Environmental Risks to

Health Relative importance of environmental exposure as

cause of human disease & premature death remains contentiousKnowledge of disease etiology incompleteStatistic is moving target:Latency period (for nonacute outcomes)Past exposures that have changed/ceased

Complex bidirectional relationshipsEnvironmental conditions, socioeconomic

circumstances, demographic change & human healthDifficulty estimating the environmental contribution to

disease burden

Environmental Risk Transition

Smith 1997 Environmental health risks shift during the economic development process

Risks in low & middle income societies Dominated by poor food, water, & air quality Household level Poor sanitation, contaminated water, low quality fuels Activities that solve these problems→ Community problems

○ urban air pollution, hazardous waste, chemical pollution

Industrialized societies Household and community problems have come under control Problems → Global scale

○ Greenhouse gas emissions

Characteristics of Environmental Risk

Transition Economic Development

→Environmental Risk Transitions

→Epidemiological transition (shift in diseases)

Shift in Temporal Scale: Latency →Infectious diseases (short period btw

exposure & disease) →Cancer, chronic non infectious diseases (long)

Estimates of Environmental contribution to the total avoidable

global burden of disease World Bank (1993): 1ST Systematic use of a standard metric (DALY)

50% all global DALYs to diseases associated w/ environmental exposures in households

30% additional to diseases associated w/ the community environment Only small % deemed amenable to feasible preventive interventions

Rio Earth Summit, WHO, 1992 25% global DALYs caused by environmental/workplace hazards

Smith, Corvalan, & Kjellstrom (1999) 25-30% global burden of disease & premature death attributable to direct

environmental risk factors

World Health Report, WHO, 2002

World Health Report 2002 (WHO)

1st truly integrated comparative risk assessment of global & regional burden of disease due to

major risk factors Compared w/ nonenvironmental hazards (smoking,

unsafe sex, malnutrition, HTA)

Environmental hazardsUnsafe water, sanitation, & hygieneUrban air pollutionIndoor smoke from solid fuelsLead exposureClimate change5 types occupational risks

World Health Report Low & middle income countries

Largest environmental health burden○ Significant household level risks, ↓ w/ development○ Young children particularly affected○ Community level environmental risks (urban air pollution) ↑ w/

development, then ↓

Rich countriesEnvironment least important factor in illnessBehavioral risks dominate (smoking, diet, physical activity, etc)

Global level risks (climate change)Highest in poor countriesGreenhouse gases emitting activities in rich countries→“environmental risk transition”

Global Statistical Data

Increasingly ambitious & sophisticated & multidisciplinary

Health & Environment-related Indicators (MDG monitoring)

→Global & national time trend analyses for certain environmental health hazards

# proportions of pop w/ sustainable access to improved water source & sanitation

using solid fuels

access to secure residential tenure (slum patterns)

BibliographyBirn, Anne Emanuelle, Pillay, Yogan, (2009) Textbook of

International Health Global Health in a Dynamic World

M Merson, R Black, (2006) International Public Health (pp.393-397)

Rodgers A, Ezzati M, Vander Hoorn S, Lopez AD, Lin R-B, et al. 2004 Distribution of Major Health Risks: Findings from the Global Burden of Disease Study. PLoS Med 1(1): e27. doi:10.1371/journal.pmed.0010027

Smith K, Ezzati M, (2005) how environmental Health Risks Change with Development Annu. Rev. Environ. Resour. 30:291-333

WHO Global Burden of Disease and Risk Factors DCPP