WATER P-NOTES 48724 ISSUE 36 JUNE 2009 Environmental Health and Child Survival I nterest in environmental health has increased in hygiene); acute respiratory infections (often linked with recent years, largely because the most vulnerable indoor air pollution); and malaria (from inadequate groups remain disproportionately exposed to and environmental management and vector control). affected by health risks from environmental hazards. More than 40 percent of the global burden of dis- This report concentrates on those three specific envi- ease attributed to environmental factors falls on chil- ronmental risk factors: that influence child health: dren below five years of age, who account for about · Poor access to water and sanitation (and asso- 10 percent of the world's population. Children are ciated poor hygiene) combine as a significant especially susceptible to environmental factors that problem. According to WHO and UNICEF (The put them at risk of developing illness early in life. United Nations Children's Fund), 1.1 billion Malnutrition is an important contributor to child people who lack access to safe drinking water mortality; malnutrition and environmental infections and 2.6 billion are without adequate sanitation. are inextricably linked, but these links have been Contaminated water and poor sanitation con- forgotten or neglected by policy-makers. The World tribute to diarrhea; intestinal worms due to poor Health Organization (WHO) recently convened an sanitary conditions infect close to 90 percent of expert panel, which concluded that about 50 per- children in the developing world. cent of the consequences of malnutrition are in fact caused by inadequate water and sanitation provision · Indoor air pollution results in respiratory infec- and poor hygienic practices. Recent recognition of tions. This is mainly due to the use of solid environmental linkages with malnutrition highlights fuels (such as coal) for household cooking and the urgent need to develop a spectrum of interven- heating; women and children spend the most tions to reduce exposure to environmental risks. time inside and are more affected; indoor air pollution is responsible for more than 1.6 mil- lion deaths per year and for 2.7 percent of the What is Environmental Health? global burden of disease; half of the deaths are children under the age of five. WHO defines environmental health as those health · Malaria continues to be a major problem. outcomes that are a result of environmental risk fac- Approximately 40 percent of the world's people tors, including all the physical, chemical, and biologi- are at risk, with most cases and deaths found in cal factors external to a person, and all the related Sub-Saharan Africa, and Asia, Latin America, factors impacting behaviors. It encompasses assess- the Middle East, and parts of Europe also ment and control of environmental factors that can affected. Pregnant women are at especially high potentially affect health, with the aim of preventing risk of malaria; WHO estimates 10,000 women disease and creating health supportive environments. and 200,000 infants die annually as a result of Environmental health is fundamental for child health: malaria infection during pregnancy. the three main causes of death of children younger than five years in developing countries are: diarrheal Improvements in environmental health could con- diseases (mostly from poor water, sanitation, and tribute to achievement of the Millennium Develop- This note reports key messages from Environmental Health and Child Survival, Epidemiology, Economics, Experiences, 2008, from the Environment and Development series. Readers may download the complete document from www.worldbank.org/water. WATER P-NOTES TABLE 1 Millennium Development Goals and Environmental Health Millennium Development Goal Environmental Health Determinants Relating to Child Health 1. To eradicate extreme poverty · Expenses incurred for informal sector delivery of water and sanitation ser- and hunger vices impose a burden on family budgets, as does costs of medical treat- ment due to diarrhea from lack of adequate water and sanitation services. In urban areas, time spent fetching or queuing for water limits earning capacity. 2. To achieve universal primary · The environmental health burden has significant effects on school atten- education dance and performance. 3. To promote gender equality · Women disproportionately suffer from exposure to smoke from cooking, and empower women drudgery of collecting water and firewood, and privacy issues related to inadequate sanitation. 4. To reduce child mortality · Sickness and deaths in children are a direct result of inadequate hygiene, water supply, and sanitation. Indoor air pollution adversely affects young children. 5. To improve maternal health · Inadequate hygiene and lack of access to clean water results in poor health outcomes related to delivery and birthing. Malaria and helminths affect pregnant women and can lead to malnutrition of the fetus. 6. To combat HIV/AIDS, malaria, · HIV-infected children especially need clean environments. Adequate water and other diseases resource management practices are needed to reduce mosquito breeding. 7. To ensure environmental sus- · Access to water and sanitation is a goal in itself; slum dwelling children with tainability poor access to services face dismal living conditions. 8. To establish a global partner- · Multisectoral coordination on environmental health issues is lacking. Both ship for development horizontal and vertical links are needed ment Goals (MDGs). The links between MDGs growth, especially during the "window of opportu- and environmental health are explained in Table nity," the period from the womb to about two years 1. There is an urgent need to mainstream environ- of age, when: mental health into the development agenda. · Pregnant women are often exposed to envi- ronmental risks that contribute to poor fetal Evidence on the Importance of growth and result in babies with low birth Environmental Health for Child weight. Survival and Development · In early infancy, improper feeding practices and poor sanitation have a pernicious synergistic Improvements in environmental health are very effect on a child's nutritional status. important for child survival and development. There is now strong evidence showing the link · Negative impacts on child growth may result in between infections and a child's nutritional status. cognition and learning impacts, and chronic dis- Several of the studies reviewed for this publication eases later in life. demonstrate that exposure to environmental health Current child survival strategies in developing risks in early infancy leads to permanent growth countries mainly focus on reducing child mortality faltering, lowered immunity, and increased mor- through treatment and case management, but do bidity and mortality. Malnutrition is an underlying not attempt to reduce exposure to environmental cause of death in half of the more than 10 million determinants of health. Appropriate environmental deaths globally in children under five; a recent col- health actions can complement and supplement lective expert opinion stated about 50 percent of strategies that focus on child health through: add- the consequences of malnutrition is in fact caused ing value to health systems; contributing to the by inadequate water and sanitation provision and adaptation of environmental management pro- poor hygienic practices. Environmental health grams; and promoting adjustments to infrastructure inputs play a critical role in a child's survival and strategies. 2 ISSUE 36 · JUNE 2009 Measuring the Burden of Disease try's GDP. These estimates are based on selec- from Environmental Health Risks tion of conservative assumptions, but the effects through malnutrition, including education costs, To help policymakers understand the burden of dis- are significant (Table 2). ease from environmental factors and the associated Results indicate that there is an urgent need for pol- economic costs, it is important to revise earlier esti- icymakers to position environmental health at the mates of the environmental health burden and links center of all child survival strategies. A multiplier with malnutrition. Policymakers can then decide on effect exists for environmental health interventions. how to integrate environmental health into economic Investments that address environmental risks, for development. They can also make informed decisions example through addressing the lack of water and on allocation of resources to improve child health. sanitation, have multiple effects on child mortality: The World Health Organization recently revised they reduce mortality due to diarrhea; they also global burden of disease estimates to specifically take reduce mortality from malnutrition-related diseases; into account the links between malnutrition and the and the reduction of illness from diarrhea has posi- impacts on health of inadequate water and sanitation tive consequences on education attainment. coverage and improper hygienic practices. The new WHO estimates reveal that the environmental health burden in children under five years is substantially Common Elements for Successful higher when all links through malnutrition are incor- Environmental Health Actions porated. In sub regions such as Sub-Saharan Africa and South Asia, the new estimates point to the burden Environmental health actions are the earliest pub- of malnutrition and poor environmental conditions. lic health activities on record. Lessons from history To examine the economic costs of environmental have shown the enormous benefits of multisectoral risks at the country level, case studies based on environmental health actions. There are interest- updates of earlier estimates were developed for ing examples of how different developing countries Ghana and Pakistan. For the first time, measures have incorporated environmental health activities of total effects provide estimates of longer-term within integrated child survival, nutrition, and other impacts of environmental health risks on cognition health programs; infrastructure programs; and and learning and on future work productivity. vector-control programs. For example: · The total costs of environmental risks for Ghana · Innovative projects in Peru and Nicaragua and Pakistan range from 4 to 6 percent of each have promoted key hygiene behaviors within country's gross domestic product (GDP). The health programs that have resulted in significant revised estimates show that when malnutrition improvements in health outcomes; hygiene edu- linkages with health effects that are attributed cation is a specific component of the Honduras to environmental health risks are included, the Integrated Community-Based Child Care Pro- economic costs to the country are at least 40 gram; and the Integrated Child Development percent higher than when malnutrition effects Services in India includes hygiene and a multi- are not included. sectoral approach to health, education and nutrition interventions. · For Ghana and Pakistan, longer term impact · There are a few examples of integrated child of malnutrition translates into an annual cost of survival programs that are comprehensive, with stunting attributable to early childhood diarrheal multi-sector approaches to improving water, infections that is estimated to be 4 to 5 per- sanitation, hygiene, and reduction of indoor cent of the country's GDP. In the longer term, air pollution and vector diseases, as in Eriteria. malnutrition (partly attributed to environment- Thailand's national nutrition program is an related infections) is found to affect a child's effective multisectoral approach that includes cognitive function, school enrollment, grade water, sanitation, literacy, and other develop- repetition, school dropout rate, grade attain- ment projects. ment, and future income-earning potential. · Infrastructure programs with behavior change · The result is that the total estimated annual and education components, such as the Total costs may be as high as 9 percent of a coun- Sanitation Campaign in rural Bangladesh, have 3 WATER P-NOTES TABLE 2 Annual Cost of Direct and Indirect Impact of Environmental Risk Factors in 2005 Ghana Pakistan Cost Cost Cost Cost Cost Annual Cost (US$ (% of Annual (PRs (US$ (% of Deaths ( million) million) GDP) Deaths billion) million) GDP) Estimation Excluding Malnutrition-Mediated Effects Mortality effects 24,712 371 412 3.84 131,611 195 3,250 2.90 Estimation Including Malnutrition-Mediated Effects Mortality effects 35,702 537 595 5.55 187,429 278 4,633 4.13 Education effects 367 407 3.79 317 5,281 4.71 Total effects 904 1,002 9.34 595 9,914 8.84 Source: Compiled by World Bank team. Note: = Ghanaian new cedi. proved to be effective at improving health; the Key Conclusions success of this model has led to its adaptation to other countries. There is great potential in environmental health · Malaria control interventions that have empha- actions that complement existing health, infrastruc- sized a multiple of interventions have led to ture, and environment management strategies in the success in Malaysia; community participation developing world. The key conclusions of this report led to effective vector control of dengue virus are that: mosquitoes in Vietnam. · There is a larger role for environmental health There are common elements for successful envi- as diseases from environmental risk factors ronmental health actions in developing countries. remain the top killers of children under five in These include: developing countries; · Securing high level political commitment; · Specific sub regions of the world with high lev- els of burden of disease, notably Sub-Saharan · Involving and empowering communities; Africa and South Asia, should be targeted for · Allocating responsibilities and resources at the action; and local level; and · Developing countries can learn from experience · Finding a balance between private and public on addressing sanitation and air pollution with sector roles. relatively cost-effective interventions. Strong institutional underpinnings, with clearly Additional research is needed to guide govern- articulated roles at all levels of administration, are ments and donors in appropriate environmental key elements of successful environmental health health interventions, develop country level cost- governance. This means that national and local effectiveness and cost-benefit analysis to prioritize governments have defined roles to play in manag- interventions, and determine coordination mecha- ing and delivering environment health interventions, nisms and roles and responsibilities of different with support from the international community. agencies. The Water Sector Board Practitioner Notes (P-Notes) series is published by the Water Sector Board of the Sustainable Development Network of the World Bank Group. P-Notes are available online at www.worldbank.org/water. P-Notes are a synopsis of larger World Bank documents in the water sector. 4 THE WORLD BANK | 1818 H Street, NW | Washington, DC 20433 www.worldbank.org/water | whelpdesk@worldbank.org