24096 W~~ ! Environment Strategy Papers Health Ksenhya Lvovsky and Strategy Series * X * ~~~Number 1 Enmvronment October 2001 T-he World Bank E Environment Department ENVIRONMENT STRATEGY PAPERS No. I Health and Environment Kseniya Lvovsky October 2001 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. Manufactured in the United States of America First printing October 2001 In 2001, the World Bank completed the comprehensive two-year process of preparing its Environment Strategy, Making Sustainable Commitments: An Environment Stratlegy for the World Bank. It was endorsed by the Bank's Board of Directors and published in October 2001. Several background papers were prepared and published by the Bank's Environment Department to stimulate constructive dialogue and intellectual discussion on a range of issues within the Bank as well as with client countries, partners, and other interested stakeholders. The Environment Strategy Paper series includes revised versions of Environment Strategy background papers, as well as new reports prepared to facilitate irnplementation of the Strategy. This series aims to provide a forum for discussion on a range of issues related to the strategy, to help the transfer of good practices across countries and regions, and to seek effective ways Df improving the Bank's environmental performance. This report is a revised version of the environment strategy background paper on Health and Environment. Contents v Preface vii Acknowledgments 1 Chapter 1: Health, Environment, and Development 5 Chapter2: Environmental Health and Poverty 7 Chapter 3: Changing Landscape of Environmental Health Risks -Future Trends 9 Chapter4: Improving Environmental Health 11 Chapter5: Health and Cost-Effectiveness of Environmental Interventions 13 Chapter 6: Environmental Health and Bank Operations Guidelines 15 Chapter 7: Lessons from Bank Experience 19 Chapter8: Where Do We Stand? Regional Survey 25 Chapter 9: Cooperation within the Bank 27 Chapter 10: Collaboration with WHO and other Extemal Partners 29 Chapter 11: Health and the New Environment Strategy 30 Process 31 Annex A: Definitions of Environmental Health 33 Annex B: Estimating the Burden of Disease Related to Environmental Risks 39 Annex C: Africa - Burden of Disease from Environmental Causes and Intervention Measures 45 Annex D: Cost-Effectiveness of Environmental Health Interventions 49 Annex E: Analysis of Bank Documentation 51 Annex F: Regional Responses to EH Questionnaire 63 Notes 65 References Health and Environment Boxes 2 Box 1. What is environmental health? 3 Box 2. DALYs as a measure of the burden of disease 11 Box 3. Cost-effectiveness of interventions to improve environmental health 16 Box 4. ECA Regional Study - Health, sanitation, and hygiene in rural water supply and sanitation projects 22 Box 5. What is an environmental health project? Highlights from Regional survey Figures 3 Figure 1. Burden of disease and environmental risks: Developing versus developed countries Tables 6 Table 1. Burden of disease from major environmental risks 7 Table 2. Premature mortality and burden of disease due to air pollution, by region 10 Table 3. Health outcomes and environmental interventions 20 Table 4. Summary of Regional responses to environmental health questionnaire 34 Table B. 1. Burden of specific diseases 34 Table B.2. Hazard rates due to exposure to indoor air pollution 38 Table B.3. Burden of disease associated with agro-chemical exposure 39 Table C.1. Burden of disease relieved in Sub-Saharan Africa (SSA), by remedial measure 40 Table C.2. Burden of disease relieved in Sub-Saharan Africa (SSA), by remedial measures in DALY 42 Table C.3. Lower and higher percentage guesstimates for each disease 42 Table C.4. DALYs guesstimates attributable to air pollution 43 Table C.5. Guesstimates for indoor and outdoor air pollution 46 Table D.1. Summary of air pollution cost-effectiveness studies iv Environment Strategy Papers Preface T his paper highlights links between envi- those that promote strong growth and good ronment, public health, and poverty, and governance structures that are capable of discusses implications for the Bank safeguarding the environment and responding strategy to address environmental health to the needs of the poor. Tradeoffs are some- concerns. It shows that environmental risks times inevitable, however, and should be made have a significant impact on health outcomes in with a full understanding of the resulting net developing countries, and that traditional health impacts. The paper attempts to contrib- environmental hazards, such as lack of safe ute to improving this understanding. water and sanitation, indoor air pollution, and exposure to disease vectors, play by far the The environment-health nexus highlights that largest role. Also worrying, however, is that the improvements in people's health require a contribution of modern environmental risks- holistic, multisectoral approach to mitigating pollution by transport, industry, and agro- major risks by integrating cost-effective efforts chemicals-to the disease burden in many in infrastructure and human development areas developing countries is similar to that in rich and by building effective institutions at all ones, and sometimes is even greater. The levels of governance, including communities world's poor are most affected by this "double themselves. A holistic approach is particularly burden" of both traditional and modern important for improving the health of the poor, environmental risks. who are most vulnerable to both main environ- mental hazards and deficiencies in health While environmental challenges of develop- services delivery. The World Bank Environment ment and globalization require a concerted Strategy, developed in extensive consultation action, the much higher environmental health with various stakeholders in client countries, costs of living in poverty and lacking basic other donors, and international nongovernmen- infrastructure and other services must not be tal organizations, considers environmental neglected. Policies and actions that address health a top priority and calls for a greater both types of health risks and damages in a focus on this principal development outcome synergistic manner are the best, and include in Bank operations across all relevant sectors. v Acknowledgments T his paper was written by Kseniya Claeson, Jennifer Sara, and Enis Baris. On Lvovsky with contributions from several occasions throughout the text, the paper Maureen Cropper, James Listorti, Fadi uses materials from the draft Environmental Doumani, A. Edward Elmendorf, Candace Health Assessment Guidelines, prepared by the Chandra, Julian Lampietti, Ronald Subida, Rita SSA Environmental Health team. The authors Klees, Gordon Hughes, and Meghan Dunleavy. are also grateful to the participants at the two Regional assessments and valuable comments Bank-wide environmental health workshops, were provided by Rita Klees (ECA), Laura Tlayie held in September 1999 and March 2000, that and Horacio Terraza (LAC), Todd Johnson helped advance the preparation of this docu- (EAP), Sherif Arif (MNA), Elaine Ooi and ment. The authors would like to express their Anthony Measham (SAR), and Anne Hammer thanks to Linda Starke for editorial assistance and Robert Robelus (SSA). The paper benefited and Jim Cantrell for designing the book and from a peer review by Lee Travers, Mariam managing production. vii -. -| E * Chapter 1 Health, Environment, and Development H ealth and development are irrevocably resulting illnesses. The opportunity to do so interrelated. Infant/child mortality and emerged from work on the "global burden of life expectancy-conventional mea- disease," which uses a standardized measure of sures of the general health of large popula- health outcomes (disability-adjusted life years, tions-are considered key development indica- or DALYs) across various causes of illness and tors. Better health is both an outcome of and a death. (See Box 2.) Follow-up analysis, which vehicle for achieving economic prosperity and attributes the disease burden measured in poverty eradication. DALYs to environmental hazards, has brought our knowledge of environment and health Protecting health is the principal objective of linkages to a new level. protecting the environment. The vast majority of environmental policies and regulations Recent estimates suggest that premature death worldwide are motivated by public health and illness due to major environmental health concerns, and most economic valuation risks account for one-fifth of the total burden of exercises have found that health impacts disease in the developing world-comparable constitute the largest portion of environmental to malnutrition and larger than all other damages. It has long been recognized that the preventable risk factors and groups of disease environment in which people live-from the causes. While the total burden of disease in household to the global level-significantly rich countries, expressed in DALYs per million affects their health. (See Box 1.) Until recently, people, is about half that in developing coun- however, it was not possible to quantify the tries, the disease burden from environmental magnitude of health impacts from exposure to risks is smaller by a factor of 10. (See Figure 1.) various environmental factors. Nor was it This gives a new dimension to environmental possible to compare the cost-effectiveness of health (EH) as a principal indicator of develop- preventive measures to reduce such exposure ment and a major element in achieving the with health sector activities that cure the Bank's primary objective of reducing poverty. 1 Health and Environment BOX 1. What is environmental health? Environmental health refers to those aspects of human health, including quality of life, that are deter- mined by physical, biological, social, and psychosocial factors in the environment. Most causes of disease, injury, and death in developing countries lie outside the purview of the health sector. They cover a broad spectrum, ranging from physical factors such as inadequate sanitation, water, drainage, waste removal, housing, and household energy to behavioral factors such as personal hygiene, sexual behavior, driving habits, alcoholism, and tobacco smoking. The definition of environmental health is still evolving. The World Bank's Africa Environmental Health team, for example, proposes using a broad definition that would cover all activities "to prevent health risks through control of human exposure to: (a) biological agents, such as bacteria, viruses, and para- sites; (b) chemical agents, such as heavy metals, particulate matter, pesticides, and fertilizers; (c) disease vectors, such as mosquitoes and snails; and (d) physical and safety hazards, such as traffic accidents, fire, extremes of heat and cold, noise, and radiation." By comparison, the World Health Organization does not include traffic accidents in its extensive list of environmental health risks, but does include defores- tation and land degradation. (See Annex A for full definitions.) Moreover, the health and environment nexus is broader than simply environmental health; for example, it includes health care waste manage- ment and the impact of biodiversity loss on medicinal plants. The approach adopted by the Health and Environment team devising this Environment Strategy has not, therefore, been to create a formal definition of environmental health, but instead to agree on com- monly shared principles to guide the Bank's environmental health activities. These principles include: * A holistic approach to health as an outcome of numerous socieconomic and physical determinants * A focus on prevention of health risks and disease at the earliest opportunity * Selectivity, or a focus on cost-effective interventions that yield significant health impacts * Targeting of the poor by ensuring that environmental health projects benefit poor at least as much as non-poor groups of beneficiaries. Using this approach means that it does not matter whether, for example, traffic accidents are consid- ered under environmental health or not, as the approach calls for assessing the health dimensions of transport-sector projects in a holistic manner, including both traffic accidents and air pollution. The discussion in this paper focuses on the following environmental health risks that make the largest contributions to the burden of disease: * Poor water supply (quantity and quality) * Inadequate sanitation and waste disposal * Indoor air pollution * Urban air pollution * Malaria * Agroindustrial chemicals and waste (including occupational hazards). While this list is not exhaustive, it highlights the impact of environmental factors on health; illustrates environment, development, and poverty linkages; and helps foster discussion of strategic issues related to environmental work in the Bank. 2 Environment Strategy Papers Health, Environment, and Development BOX 2. DALYs as a measure of the burden of disease Disability-adjusted life years are a standard measure of the burden of disease. The concept of DALYs combines life years lost due to premature death and fractions of years of healthy life lost as a result of illness or disability. A weighting function that incorporates discounting is used for years of life lost at each age to reflect the different social weights that are usually given to illness and premature mortality at different ages. The combination of discounting and age weights produces the pattern of DALY lost by a death at each age. For example, the death of a baby girl represents a loss of 32.5 DALYs, while a female death at age 60 represents 12 lost DALYs (values are slightly lower for males). The use of DALYs as a measure of the burden of disease has provided a consistent basis for systematic comparisons of the cost-effectiveness of alternative interventions designed to improve health. When combined with the results of large-scale epidemiological studies, it enables public health specialists to identify priorities and focus attention on development programs that have the potential to generate significant improvements in the health of poor people in the developing world. Source: Murray and Lopez 1996. FIGURE 1. Burden of disease and environmental risks: Developing versus developed countries, 1990 c0 o n: 200_ C c>0 100 === Developing Developed countries countries O Other causes 0 Environmental factors Source: Murray and Lopez 1996, Smith 1998, World Bank staff. Kseniya Lvovsky Chapter 2 Environmental Health and Poverty E nvironmental health risks fall into two The relationship between the burden of broad categories: environmental diseases, traditional environ- mental risks, and poverty is further highlighted * Traditional hazards related to poverty and by regional analysis. (See Table 1.) The burden lack of development, such as lack of safe of disease from environmental causes varies water, inadequate sanitation and waste considerably among regions, but a clear trend disposal, indoor air pollution, and vector- emerges regarding how this burden and its borne diseases (malaria, for example) components change with income growth. * Modern hazards caused by development Overall, the environmental health burden as a that lacks environmental safeguards, such as ' ~~percentage of the total disease burden is urban air pollution and exposure to highest in regions that house most of the agroindustrial chemicals and waste. world's poor (27 percent in Africa and 18 percent in Asia) and lowest in industrial In developing countries, the increasing health countries. Decline in this burden is clearly burden from modern forms of exposure to associated with reduction in exposure to urban, industrial, and agrochemical pollution traditional risks. The impact of traditional adds to traditional household risks, which still environmental health hazards exceeds that of play the greatest role. On a global scale, lack of modern hazards by a factor of 10 in Africa, 5 in access to clean water and sanitation and indoor Asian countries (except China), and 2.5 in air pollution are the two principal causes of Latin America and Middle East. Modern threats to human health prevail in rich countries and in Illness and death, predominantly affecting Erpa onre negigeooi children and women in poor families. In all uran. countriesur g omic transition. Within individual countries, more- developing countries, more than 2 million over, the poor suffer disproportionately from people-priniarily young children and unsafe environmental conditions at the hoLise- women-may die as a result of indoor exposure hold and community levels. to dirty solid fuels each year. The health burden from poor water supply and sanitation is even Inadequate water supply and sanitation (WSS) larger. pose the largest threat to human health in Bank 5 Health and Environment TABLE 1. Burden of disease from major environmental risks (worksheet)* Percent of all DALYs in each country group Asia & Environmental health group SSA India Pacific China MNA LAC FSE ICs All DCs Water supply & sanitation 10.0 9.0 8.0 3.5 8.0 5.5 1.5 1.0 7 Vector diseases (malaria) 9.0 0.5 1.5 0.0 0.3 0.0 0.0 0.0 3 Indoor air pollution 5.5 6.0 5.0 3.5 1.7 0.5 0.0 0.0 4 Urban air pollution 1.0 2.0 2.0 4.5 3.0 3.0 3.0 1.0 2 Agro-industrial waste 1.0 1.0 1.0 1.5 1.0 2.0 2.0 2.5 1 All causes 26.5 18.5 17.5 13.0 14.0 11.0 6.5 4.5 18 Notes: * Regions slightly differ from World Bank Regions. See a definition in World Bank 1993 and Murray and Lopez 1996. Note that Asia and Pacific includes countries from East and South Asia, except for China, India, Pakistan, and Afganistan. FSE means "former socialist economies of Europe" and does not include Central Asia. SSA is Sub-Saharan Africa, LAC is Latin America and Caribbean, MNA is Middle East and North Africa, ICs stands for industrialized countries, and DCs is developing countries. Most of the data in the table are from the early I 990s. Sources: Murray and Lopez 1996; Smith 1993, 1998, 1999; WHO 1997a; World Bank 1999; World Bank staff (see Annexes 2 and 3). client-countries, except for China and the population of Sub-Saharan Africa. Although transition economies of Europe, where air malaria is not nearly as significant in other pollution causes the most damage. Indoor air regions, it is the third greatest environmental pollution is the greatest threat in Asia and health threat globally. Africa. Malaria has taken a heavy toll on the 6 Environment Strategy Papers Chapter 3 Changing Landscape of Environmental Health Risks - Future Trends T he majority of those suffering from high failures. In Africa, Asia, and Latin America, levels of indoor air pollution, lack of urbanization is changing the landscape of sanitation, scarce water supply, and environmental health concerns and posing new malaria live in rural areas. But rapid urbaniza- challenges on an unprecedented scale. tion and the uncontrolled growth of urban slums also create a 'double burden" for the In order to set strategic priorities for addressing urban and semi-urban poor. They are increas- environmental health issues, it is important to ingly exposed to "transition risk"-one portion estimate the "baseline" of how the burden of of that risk is from dirty cooking fuels, primitive environmental health risks is likely to change stoves, crowding, and poor access to water and over time. Table 2 summarizes the projections sanitation, while the other is a result of modern of the burden of disease caused by air pollution transport and industrial pollution. Further, in over the period 2001-20 under a "business as some parts of the world malaria is becoming an usual" scenario, expressed as annual averages urban issue, in part due to infrastructure for the 20-year period.' TABLE 2. Premature mortality and burden of disease due to air pollution, by region (projected annual averages for 2001-20) Premature deaths Burden of disease (thousand per year) (million DALYs per year) Outdoor Outdoor Region Indoor (urban) Total Indoor (urban) Total China 150 590 740 4.5 14.0 18.5 East Asia and Pacific 100 i50 250 3.5 3.8 7.3 Established Market Economies 0 20 20 0.0 0.5 0.5 Former Socialist Economies I 0 200 210 0.2 3.8 4.0 India 490 460 950 1 7.0 10.1 27.1 LatinAmericaandCaribbean 10 130 140 0.3 3.7 4.0 Middle East Crescent 70 90 160 2.4 2.5 4.9 South Asia 220 120 340 7.6 2.6 10.2 Sub-Saharan Africa 530 60 590 18.1 1.2 19.3 World 1,570 1,810 3,480 53.4 42.2 95.6 Source: World Bank 2000a. Also see Annex 2. 7 Health and Environment Exposure to Pollutants. The largest component change could be highly significant. (See, for of air pollution costs is the premature mortality example, Listori 1999.) Analysis of the effects and ill health caused by indoor and outdoor of global climate change (including the health exposure to high levels of pollutants. Projec- impacts) suggests that the long-run costs of an tions indicate that about 3.5 million people increase in global temperature of 2.5 degrees will die prematurely each year over the next Celsius will be highest for India and Africa (4.9 20 years as a result of indoor and outdoor air percent and 3.9 percent of gross national pollution. In Sub-Saharan Africa and South product, respectively, of which 2.3 percent Asia (excluding India), most of these deaths and 0.4 percent are associated with the will be the result of indoor air pollution, so the potential costs of catastrophic weather events). priorities identified in Table 1 hold. In India, Still, for both India and Sub-Saharan Africa the indoor and outdoor air pollution each account health damage caused by indoor air pollution for about half of the premature deaths. Out- alone is about twice as great as the total door air pollution is becoming the major issue (health and non-health) damage associated in China. For the world as a whole, while with global exposure to climate change indoor exposure dominated health damage (comparing various scenarios of present values from air pollution in the past decade, outdoor of these damages over the next 100 years). air pollution is projected to gain equal impor- tance as a grave risk to human health over the Changing Face of Disease. Recent worrisome next two decades. trends on the disease landscape that have implications for environmental health priori- The total burden of disease from air pollution ties include the increase of vector-borne amounts to almost 100 million DALYs per diseases, especially malaria in Sub-Saharan year, equivalent to a loss of slightly more than Africa, and the changing pattern of infectious one year of life over the life span of an average diseases (see, for example, World Resource individual. For India and Africa, the burden of Institute 1998). Twenty-nine new diseases ill health caused by air pollution is equivalent have been discovered over the past 20 years, to a loss of life of more than 1 .5 years. and former scourges, such as tuberculosis, are returning. AIDS is becoming one of the major Impact of Climate Change. For the world's causes of death, creating 5.5 percent of the poor who live in coastal areas and island burden of disease in developing countries, communities, which are vulnerable to climate according to the most recent estimates (WHO extremes, the potential impacts of climate 1999). 8 Environment Strategy Papers , aa ¢ -, Yf < , J Chapter 4 Improving Environmental Health E nvironmental health risks can be pre- were estimated to be capable of reducing the vented, or significantly mitigated, total burden of disease by 23-29 percent. through a variety of economic activities Health care interventions aimed at the same in different sectors-mainly infrastructure, clusters of diseases affected by environmental energy, and agriculture. Table 3 summarizes factors (such as diarrhea, respiratory symptoms, these activities and links them to possible eye diseases, and malaria) can reduce the indicators for monitoring health impacts. disease burden by a further 23-28 percent (see Interventions linked to measurable, significant Annex 3) (Listorti 1996; Listorti, Doumani, and environmental health impacts are referred to as Hammer, forthcoming). "environmental' interventions, regardless of the sector in which they are implemented. The data illustrate two important points: Better infrastructure and energy services for * Health, especially environmental health, is a households and communities are key measures principal outcome of many interventions for mitigating traditional environmental risks, and project activities outside the health along with improved housing and vector- sector. control interventions. Reducing modern risks * The key development objective of improving calls for pollution prevention and abatement people's health requires a holistic, measures, which in turn requires setting and multisectoral approach to mitigating major enforcing environmental standards, developing risks by integrating efforts inside and outside a culture of environmental compliance, and health care systems. A holistic approach is creating effective incentives. In Sub-Saharan particularly important for improving the Africa, for example, remedial measures outside health of the poor, who are most vulnerable health care systems-such as improved water to both major environmental hazards and and sanitation, household energy, housing, deficiencies in the provision of health vector control, and pollution management- services. 9 Health and Environment TABLE 3. Health outcomes and environmental interventions Environmental Associated Examples of monitorable risk factors sectors/projects Health outcomes Health indicators proxy indicators Indoor Air Energy (cleaner Child mortality Child deaths Estimates of exposure levels Pollution fuels, improved Chronic obstructive due to to indoor air pollution stoves) pulmonary disease respiratory Percent of households using Rural (COPD) illness clean fuels or/and improved development Acute respiratory Cases of ARI stoves infections (ARI) Incidence of Type of housing COPD Cooking practices Outdoor Air Energy Mortality Deaths (adult) Annual mean levels of PM,, Pollution Transport COPD Incidence of (pg/n3) ARI COPD Annual ambient Respiratory Hospital Cases of ARI concentrations of lead in the Admissions (RHA) Respiratory atmosphere (pg/n3) IQ impairment Hospital Lead level in blood, (lead) Admissions particularly children (pg/dl) Vector-Borne Irrigation Malaria mortality Deaths due to Application of bednets Disease Reforestation Malaria morbidity malaria Application of insecticides Infrastructure Malaria cases Indicators related to the (drainage) development and maintenance Health (vector of irrigation and drainage control) infrastructure Lack of water WSS Mortality due to Child deaths Relevant indicators of access supply and Infrastructure diarrheal disease due to diarrhea to water and sanitation (for sanitation (WSS) Social funds Diarrhea incidence Diarrhea cases example, percent of in children household with in-house connections, Ipcd,* percent of community coverage with sanitation facilities) Indicators of sustained and effective use of WSS facilities Quality of water at the source Hygiene/behavioral change indicators Pesticide Agriculture Acute poisoning Cases of acute Application norms Residues Cancer poisoning Storage and handling Fetal defects Cases of cancer practices Other Toxic Control of Cancers Cases of Environmental performance Substances industrial and IQ impairment cancers, blood Waste management codes transport (lead) lead level Land zoning regulations pollution, change Market share of leaded in fuel quality gasoline Note: * Ipcd = liter per capita per day. 10 Environment Strategy Papers L-V~~~~~~~~~- Chapter 5 Health and Cost-Effectiveness of Environmental Interventions A ctivities in a number of economic of the data on the costs of interventions per sectors aimed at reducing human DALY-saved come from malaria-control or ,A t exposure to environmental hazards urban air pollution studies. Box 3 summarizes not only have a direct and significant impact on available estimates. health, they also can be cost-effective in achieving health outcomes and preventing the The findings lead to two important policy loss of DALYs. A cost-effectiveness review conclusions, although the limited scope of the undertaken for this paper was constrained by assessment and reservations about the validity the limited number of studies that include this of using DALYs for cross-sectoral comparisons kind of assessment or provide data necessary to require careful interpretation and further make such an assessment. (See Annex 4.) Most discussion. Bearing this in mind, the data BOX 3. Cost-effectiveness of interventions to improve environmental health While the number of studies is limited, a World Bank review of available evidence undertaken to assess the effectiveness of measures outside the health sector in achieving health improvements (preventing the loss of DALYs) provided the following estimates of the costs per DALY saved for various interven- tions: * Water connections in rural areas: US$35 per DALY (World Bank 2000b) * Hygiene behavior change: US$20 per DALY (Stephen 1998) * Malaria control: US$35-75 per DALY (Binka 1997) * Improved stoves (indoor air): US$50- 100 per DALY (Smith 1998) * Use of kerosene and LPG stoves in rural areas: US$150-200 per DALY (World Bank 2000b) * Improved quality of urban air: large variations, from negative costs (electronic ignition systems in two-stroke vehicles) to US$70,000 per DALY and more for some pollution control measures, with most measures costing over US$1,000 per DALY. The World Development Report 1993 suggests that health sector interventions up to US$150 per DALY saved can be considered cost-effective (World Bank 1993). Source: Listorti 1996 and World Bank estimates. Health and Environment suggest that measures to mitigate traditional complex variety of factors. These factors health hazards (such as indoor air pollution, include the socio-demographic situation in a scant sanitation, or insect vectors) tend to be district, the urban or rural status of the com- more cost-effective than many of the measures munity, sanitation coverage, and type of to reduce modern risks, such as urban air service delivery. This complexity of interven- pollution.2 This finding, coupled with the tion-outcome linkages can be used to significant impact of these hazards on the strengthen the basis for collaboration with health of the poor, calls for greater attention to other sectors, as environment staff are often traditional household and community health well positioned to provide analytical input to risks in environmental work. Since interven- the design of infrastructure and energy projects tions to reduce these risks fall in the domain of that would help to achieve better health energy and infrastructure (WSS) sectors, there outcomes. is a need for closer collaboration with these sectors to achieve health outcomes. Additional controversy around these findings arises from the fact that many interventions at Second, large variations in the cost-effective- the household and community levels improve ness of various interventions (across health public health by providing private goods (for hazards and within one type of hazard, such example, better fuels or stoves, water supply, as urban air pollution) point to the need for and sanitation). The challenge, then, is how to rigorous analysis and skillful design of environ- reconcile the willingness-to-pay and commer- mental health projects to maximize health cial viability of services-the cornerstone of benefits in a cost-effective manner. A recently energy and infrastructure operations-with completed World Bank study of water, cost-benefit analysis based on health out- sanitation, and health linkages in the State of comes. This is another area in which cross- Andhra Pradesh, India, provides probably the fertilization of experiences in the health, strongest data in support of this point (World environment, rural development, energy, and Bank 2000b). The study found that costs per infrastructure sectors is the only way to find a DALY saved from water supply and sanitation workable solution. interventions vary greatly, depending on a 12 Environment Strategy Papers Chapter 6 Environmental Health and Bank Operations Guidelines B ank Policies. Only 1 out of 30 Opera- to develop these plans jointly with National tions Policies and Best Practices (OP/BP) Environmental Health Plans sponsored by the is devoted to environmental health World Health Organization (WHO). Still, (covering the use of pesticides), but it is limited project documents and other publications focus to public health uses of mosquito control, and mostly on pollution-control. The most compre- does not deal with the widespread use of hensive exercise to date was the study on pesticides in agriculture. Four other OP/BPs Environment and Health: Bridging the Gaps contain passing references to environmental (Listorti, Doumain, and Hammer 1999) and the health, either in a single paragraph or a foot- draft Environmental Health Assessment Guide- note. Overall, instructions to staff are sparse lines developed in the Bank's Africa Region and are not conducive to a process of cross- (Listorti, Doumain, and Hammer, forthcoming). fertilization. Environmental health is rarely on the agenda of Country Assistance Strategies (CASs). Bank Documentation. Bank documentation shows uneven treatment of environmental To a certain degree, Bank documentation and health. (See Annex 5.) Several Environment internal procedures reflect the same rough Department publications refer to the pollution/ distribution and accuracy as the outside health linkage in annual reports and other literature; whereas the health sector is inwardly evaluations of Bank work. In the Middle East focused, environmental health accentuates and North Africa Region and in the Europe and pollution, and cut-and-paste health information Central Asia Region, environmental health was is often misapplied. The problem, however, is used as an input into developing regional that the outside literature is essentially moti- strategies; in the Latin America and the Carib- vated by the needs and priorities of industrial bean, South Asia, and East Asia and Pacific countries, which are very different from those Regions, various attempts were made to of developing countries, especially with regard estimate the economic costs of human health to the health needs of the poor. Although a damages. Many National Environmental Action considerable number of worthwhile and Plans name environmental health as the highest cutting-edge activities occur Bank-wide, priority, and some attempts were made in ECA systematic advocacy for and internalization of 13 Health and Environment environmental health concepts has not taken Guidelines by the Africa EH team; an analysis place throughout the organization. (Listorti of the impact of the household environment 1996; Listorti, Doumani, and Hammer, on child mortality in India and a study of forthcoming). linkages between access to WSS and health in Andhra Pradesh, carried out by South Asia New Activities. A number of new, ongoing, Region and ENV; an ECA study on health and or recently completed activities address some hygiene in WSS; and, most recently, work on of these issues. Among them are the prepara- indoor air pollution in SAR, SSA, and LAC. tion of Environmental Health Assessment 14 Environment Strategy Papers 'a Chapter 7 Lessons from Bank Experience W rater and Sanitation. Bank experi- of future EH work should be to assist Bank ence with environmental health has staff in developing key performance monitor- been limited, as have the lessons ing indicators. learned. Many important environmental health * At least half of WSS investments are embod- issues fall through the cracks of development ied within "non-WSS" projects, most notably agencies because environment and health are Social Funds, which shows the high priority both cross-sectoral, and because institutions attached by communities to EH-related commonly lack clear directives for the activities and cross-sectoral links to EH. multisectoral dimensions of their work. An * An intersectoral approach to WSS projects, array of lessons has emerged in the WSS incorporating hygiene and water quality subsector from nearly a quarter-century of issues, is needed to realize maximum impaci research devoted to low-cost, appropriate from investments in infrastructure. technology and from an International Decade dediatedto mkingdrining aterandImproved Stoves. The most important Bank- sanitatidton u akiniversall avakigwable. r lons supported interventions addressing indoor air pollution were large-scale Improved Stove point to the value of an integrated approach to Programs in India and China in the late 1 980s environmental health interventions, for ex- (although these were motivated by energy ample, integrating water supply with sanitation, efficiency goals rather than environmental drainage, community education, and hygiene ones). Major lessons learned were the need to practices (Listorti 1 996). target efforts more clearly toward the most- affected communities; the need to complement A recently completed study in ECA on the financial support with local capacity-building, health and hygiene dimensions of water and training in maintenance, and health awareness sanitation projects (see Box 4) found the programs; the need for a greater role for local following: authorities and communities; and the impor- tance of sustainable financial arrangements. * Monitoring and evaluation of the health impacts of environmental interventions in Urban Air Pollution. Experience is also emerg- ECA is of erratic quality. Thus an objective ing with regard to urban air pollution manage- 15 Health and Environment BOX 4. ECA Regional Study - Health, sanitation, and hygiene in rural water supply and sanitation projects The goal of this study is to improve the design and implementation of rural water supply and sanitation (RWSS) projects in order to optimize health benefits associated with improved drinking-water supplies. The objectives are to examine the health impact of health, sanitation, and hygiene (HSH) components of RWSS projects; identify best practices in the design and monitoring of HSH of RWSS projects; and provide task managers with useful tools to assist in the design, monitoring, and evaluation of RWSS projects. The study was conducted through review of the literature, review of 20+ years of interna- tional and World Bank projects in RWSS, and review of all ECA projects with rural water supply, including non-water-sector projects, such as Social Funds and rural development projects. The study provides recommendations on operational, institutional, and monitoring and evaluation levels, as well as references, logframes, sample monitoring and evaluation programs, and other useful material for task managers. The study found that health benefits associated with improved rural drinking-water supply projects result from improved quality and increased quantity of water, adequate sanitation facilities, and changes in hygiene behavior. Sanitation and hygiene behaviors have as much, if not more, impact on improved health outcomes from WSS projects than the water infrastructure itself. A successful rural water-supply project or component of a non-sector project should include a health, sanitation, and hygiene compo- nent if its goal is to improve health. Bank-wide, non-water sector projects with RWSS components are a significant contributor to the sector, although often beyond the purview of the Bank's water sector. ECA has the most "other" projects with RWSS components, accounting for about half of total ECA investments in RWSS, or US$ 150 million. These "other" projects are social funds, rural development, or agriculture projects. The "other" projects are often well placed to promote HSH activities that would enhance the benefits of water-supply investments. However, the review found only one social fund in ECA (Moldova) that proposed HSH activities in the project. The characteristics of successful HSH components are well established, based on the experiences of the international development community, including the Bank. Most World Bank RWSS projects now in implementation with HSH components include the key ingredients of a successful HSH program, except for well-defined monitoring and evaluation programs. Examples of completed World Bank RWSS projects with documented health impacts are very rare. Most projects report improved health as an impact, but few have sufficient baseline information or monitoring to make this claim. Further, it is rare that policy issues or training related to strengthening of public health policies, institutions, and staff are included in RWSS projects at the Bank. ECA is in the forefront, with four RWWS projects (stand-alone and "other") emphasizing training and institutional capacity building of public health services, including surveillance and health and water- quality monitoring. ECA RWSS project design has been significantly guided by the results of needs and social assessments. Pilot projects that further investigated issues uncovered by social needs assessments and demonstrated new, community-based approaches to RWSS were also very useful in preparing ECA RWSS projects. Source: Bank staff 16 Environment Strategy Papers Lessons from Bank Experience ment projects, motivated by environmental these have not yet been summarized. A recent, health impacts (such as the Slovenia Environ- quite successful experience in which the Bank ment Project, the Mexico City Transport Air supported the global phaseout of leaded Quality Management Project, the Dhaka Air gasoline highlighted the crucial role of politi- Quality LIL, and the proposed Katowice urban cal commitment, public awareness, and air pollution project). The latest lessons from partnership with the private sector. Kseniya Lvovsky 17 r . Chapter 8 Where Do We Stand? Regional Survey T o get a grasp on the current status of and but media attention does not always focus on emerging trends in environmental health the most crucial area for intervention. work in the World Bank, Regional offices were asked to complete a questionnaire (see Current Bank Portfolio. It appears to be Annex 6 for a copy of the questions and the impossible to compare and summarize Re- responses from each Region). Table 4 summa- gional responses regarding portfolios of envi- rizes the responses; key observations are ronmental health projects, as each Region used discussed briefly in this section. its own unique (explicit or implicit) definition of an environmental health project. (See Box 5.) Environmental Health Priorities. Quite unex- If we look at all Bank projects with some pectedly, key issues and priorities identified by degree of impact on environmental health or the Regions, based on client demand and staff with the potential to achieve a significant perception, appear to be virtually identical to impact, the result would be a huge portfolio the ranking in Table 1, based on the burden of that includes all WSS projects, all urban disease assessment. projects, all pollution-control projects, and quite a few transport, energy, rural develop- Client Demand. Regional surveys indicate ment, and health projects. But this impressive considerable interest on the part of many of our portfolio is more likely to illustrate a dearth of clients in addressing environmental health, missed opportunities than a high priority on although some responses (for example, East environmental health. For example, after Asia) pointed to a greater interest in urban screening the projects according to a set of projects, despite significant EH problems in special criteria, South Asia reduced its list of rural areas. However, environmental health is "truly" environmental health projects from usually not an explicit objective of lending, several dozen to just three. On the positive except for a small portfolio of urban and side, this potential for addressing EH concerns industrial pollution projects. EH projects seem across sectors clearly shows the unique posi- to be driven mainly by client awareness and tion and advantage of the World Bank com- Bank staff knowledge. Public perception pared with other development organizations through local media is quite important as well, working on health issues. 19 o TABLE 4. Summary of Regional responses to environmental health questionnaire Questions AFR | !MENA ECA - LAC SA EA E_ Europe C. Asi l ________C _i Key EH issues Water-borne Water-borne Injuries Water-borne Water-borne Water supply and Water supply and diseases diseases Transport diseases disease/ sanitation sanitation (related sanitation Respiratory (indoor Respiratory (indoor accidents Indoor air (TB Respiratory illness diseases) Urban air quality air pollution) and urban air Worker safety communication) (urban air) Respiratory (indoor Indoor air (China: pollution) Sanitation, hygiene Sewage disposal in air pollution) air pollution is the Toxic industrial bay and coastal Urban air (from first priority) pollution areas energy and Also important: transport) industrial health and safety and traffic accidents Which sectors Health Health and Rural W&S Rural W&S Environment W&S Urban lend currently Infrastructure Education Health Social Funds Health Urban Environment Energy/Rural Infrastructure Environment Energy Some infrastructure Health Transport Development Rural Development Environment (W&S, mining, Environment (Water) Health transport) Environment Main types of Household energy W&S Health Health Air pollution Urban air Water supply projects Urban (flood Rural development Social W&S management Water supply Environment control) Solid waste development Social Funds Health care waste Sanitation Urban development Few health with Hospital waste Poverty alleviation management Nutrition Solid waste preventive measures management Vector control Vector control Air pollution/ Vector control Transport Urban and energy transport Industrial pollution m Level of client LOW MEDIUM HIGH MEDIUM to HIGH for publicized LOW but growing HIGH for water awareness/ Water (lack of, poor Air and water HIGH urban problems, Urban air pollution, issues, due to health o areas quality, waste pollution, medical Water supply and LOW otherwise pesticides, drinking GROWING for air treatment, waste sanitation Urban air, polluted water, sanitation, pollution, urban due D sanitation) rivers and beaches, indoor air pollution to damages to c-) _Urban air pollution _ _ hazardous waste _ agriculture, tourism ca Responsible Health ministries No one agency with No clear mandate No clear mandate Environmental No clear mandate Environment agency Maybe NGOs clear mandate Environment and Environment and authorities Default is bureaus and public Environment, health, health ministries health ministries environment health agencies; o housing, water ministry however, they are resources ministries not the key agencies _________ for Bank projects Cost effec- Unsure Pollution- abatement Extensive for W&S Cost benefits Generally not tiveness/ projects projects calculated for small Some environmental benefits number of projects health surveys _ DALYs (epidemiological) Drivers of Bank staff Client awareness Client awareness Client awareness Client counterpart Client demand Client attention to projects Media Desire to join EU interest Availability of urban environment Use of EH issues to Media sector work problems justify positive Knowledge and Economic losses environmental interest of Bank Human health impact staff damages _____, ___ __.. ___, ___M edia Difficulties Need more Need indicators No real decision- Need indicators Cross-sectoral Data is anecdotal awareness on client making process nature of projects No direct health side Few indicators data collected Need low cost Complexity Need health projects baselines for . ~~~~~~~~~~~~~~~country Proposed Integration of health Rapid health risk Need cost- Include More risk Advocacy Need work on air next steps in EA and review assessment in pilots benefit analysis environmental assessment Definitions of EH and water pollution Include in CAS Include in CASs health analysis in Incorporate and intersectoral impacts Develop case EA process occupational health collaboration Develop low-cost studies for Attention to and safety Pilots tracking and groundwater communicable Improve indicators/ monitoring for pollution diseases economic analysis health Health and Environment BOX 5. What is an environmental health project? Highlights from Regional survey Given the lack of agreement on a definition of environmental health, it is not surprising that it is even more difficult to define an environmental health project in the context of Bank operations. The analysis of regional responses to a questionnaire on the status of Bank environmental health work revealed that Regions adopt different approaches to defining their "environmental health" portfolio. For example, MNA provided an inventory of projects from all the relevant sectors, LAC focused on projects managed by environment and health staff, and ECA reported water supply and sanitation investments, over half of which are undertaken through Social Funds and poverty alleviation projects, rather than traditional WSS projects. South and East Asia attempted to select projects by a set of criteria they established for this purpose. South Asia staff screened the following information for all projects for which project completion documents or PAD/ staff appraisal reports are available: * Key strategic objectives * Summary analysis that provides cost-benefit analysis or cost-effectiveness of the intervention * Key performance/output /outcome indicators. If explicit reference to environmental health, or to environment and public health, was found in at least two of these areas, then the projects were qualified as EH projects and included in the primary list. Projects that did not meet these criteria but that were likely to have some EH impact were included in the secondary list of projects (both lists were submitted). East Asia submitted only projects in which one stated objective was to reduce human health impacts and there were indicators that relate to improving health outcomes (such as reducing BOD/COD levels in local water-bodies or reducing effluent or emissions). More than 50 projects passed these criteria in East Asia, while only three projects were included in South Asia's primary list. Many infrastructure projects from the South Asia secondary list are designed similarly to the selected projects in East Asia, and are likely to have similar health impacts, but the South Asia projects did not have as clearly stated environmental health objectives and indicators as those in East Asia. Thus even though consistent criteria were applied in both cases, the results are not compa- rable due to differing interpretations of project outcomes in Bank project documentation in two neighboring Regions. Further, some projects that have health as their major justification and rationale (such as industrial pollution control or wastewater treatment) may have less impact on health than other projects that do not emphasize health issues. The survey highlights the need for developing and consistently using indicators in project documents to allow for measuring and monitoring the impact of Bank activities on health. The survey also highlights that EH is not as much about a new category of projects as it is about a new generation of projects under existing categories that are more oriented toward outcomes and accountability for their impact. Counterpart Agencies. All Regions identified particular EH activity. The principal sectors for environment and health ministries as counter- EH are environment, health, infrastructure, parts and stressed the need to work across urban and rural development, and, to some several agencies-water resources, agriculture, extent, transport and energy. However, this and others-depending on the nature of the seems to create administrative problems for 22 Environment Strategy Papers Where Do We Stand? Regional Survey both Bank staff and client countries. In- exceeds reasonable project budgets and client country, the problem arises from the lack of a capacity. The difficulty and cost of measuring mandate to a definitive agency or ministry for the impact of a project on health further arises oversight of EH. In most Regions the default from the fact that environmental factors are falls to the environment ministry (sometimes in only one of many causes of disease, and if conjunction with the health ministry). other causes of disease change over time, it is necessary to monitor health outcomes for a Future Needs. WSS and urban projects control group as well as for the group receiv- represent the largest portion of the EH-related ing the environmental intervention. This limits portfolio (and a sizable proportion of the the possibility of making improved health Bank's overall lending portfolio); thus more outcomes a stated objective of many Bank rigorous attempts should be made to maximize projects that do, in fact, have an impact on health benefits through these projects. This health. requires more analytical work and a better understanding of specific linkages between Regions also stressed the need for linking with project designs and health outcomes. Indoor other sectoral efforts in an interdisciplinary air pollution has clearly emerged as an manner-nutrition and education, for ex- overlooked problem in a number of Regions; ample, or health issues associated with the no projects were associated with this signifi- localized impact of solid waste disposal and cant public health concern. Urban air pollu- occupational and traffic safety. tion remains high and is worsening in some countries, but Bank activities on this have Next Steps. Among the suggestions proposed been minimal to date. by Regions were to: Benchmarking and Monitoring. Another key * Improve the integration of environmental concern is the lack of indicators, baselines, health in CASs and low-cost monitoring of EH projects or * Embark on new analytical and advisory components. It is uniformly felt that increased activities (AAAs) in EH, while strengthening monitoring of EH health outcomes would capacity to increasingly apply existing improve the projects. Such monitoring would knowledge in the field also be helpful to economic analysis of EH * Define the scope for intersectoral collabora- projects, especially cost/benefit analysis, tion on EH work that will best meet needs which is rarely undertaken at present. Yet the (highly complex and multiple collaboration desirability of improved monitoring and will not succeed in practice) evaluation of EH outcomes of infrastructure * Include EH analysis in the environmental projects (such as WSS) must be weighed assessment process against the costs of conforming with these * Devise low-cost (appropriate to the level of requirements. The Bank has been working on expenditure on other issues) ways of this issue in water and sanitation projects. tracking and monitoring indicators of health Operational experience indicates that develop- outcomes or "reasonable" proxy indicators ing high-quality, project-level baseline infor- (see table 3 for some examples) mation and complementing that with equally * Develop case studies on specific priority high-quality monitoring and analysis usually issues and pilot project activities. Kseniya Lvovsky 23 Chapter 9 Cooperation within the Bank E nvironmental Health Work is Inherently Learn from Good Practice. A possible ap- Cross-sectoral. EH work will not mature proach is to take stock of ongoing attempts to without building ties across networks work across sectors and learn from successes and sectors. The current organizational set-up and failures. Examples can be drawn from in the Bank places strong emphasis on sectoral Africa (the work of Environmental Health and priorities, which sometimes makes it difficult to Malaria teams with Infrastructure staff), from maintain a coherent country focus in general, Environment and Health, Nutrition, Population let alone a focus on environmental health, (HNP) anchors (joint work on health care waste which has never had an "institutional home." management issues), from South Asia (Regional environmental health program proposed jointly Strengthen Links to Poverty Work. Health is by Health and Environment staff, Regional team not the only cross-cutting theme; poverty is composed of Energy and Environment staff), cross-sectoral to an even greater extent. The and from other Regions. These "bottom-up" Bank's reinforced commitment to poverty activities will provide important insights on reduction and a holistic approach to achieving what it takes to build good cross-sectoral development outcomes have already facilitated collaboration and what kind of incentives are cross-sectoral arrangements conducive to needed. promoting environmental health. Progress is most evident in poverty work, and there is a Clarify and Build on the Advantages of Envi- need for closer ties between staff and thematic ronmental Staff. The cross-sectoral nature of groups working on EH and poverty issues. This is consistent with the finding of the Poverty and envirnenthea ancts so inksto activities in other sectors also raise a question Environment Team that health is the most straightforward link between poverty and about the role and comparative advantage of environmental concerns. Still, the process of environmental staff. These individuals make a building effective multisectoral teams is at an valuable contribution in at least two areas, early stage, as most Regions noted that there using their cross-sectoral skills and approach. are few incentives for operational staff from One is to provide high-quality analytical inputs infrastructure and energy to work across to the design of "traditional" infrastructure, sectors. energy, and health projects that will increase 25 Health and Environment the impact of these projects on health and development project that is "area-based" and other development outcomes. An example is outcome-oriented, rather than sectoral. An the work of the EH and malaria teams in Africa example could be the ongoing effort in South (for example, an infrastructure project in Asia to put together a pilot project in India Ghana that has a pilot environmental health aimed at complementing traditional HNP component). The other is to promote a holistic activities to increase child survival with EH approach to health in CASs, AAAs, and activities, involving staff from the health, lending, which could result in a new type of environment, and energy sectors. 26 Environment Strategy Papers Chapter 10 Collaboration with WHO and other External Partners E nvironmental health is one of the key Agency for International Development, and the areas addressed by WHO. World Bank U.S. Environmental Protection Agency. UNICEF environment staff have collaborated with and the U.N. Development Programme, for WHO on a number of projects, programs, and example, often play a more significant role in issues, but the relationship lacks consistency improving environmental health (through WSS, and a systematic approach. Collaboration was improved stoves, or other rural development strengthened last year when a newly created programs) than WHO, which works predomi- WHO Cluster on Sustainable Development and nantly with national health agencies. Local Healthy Environments proposed working more agencies, programs, nongovernmental organi- closely with the Bank on environmental health. zations (NGOs), and community groups are This year WHO embarked on a Strategy for also involved in activities related to environ- Sustainable Development and Healthy Environ- mental health. NGOs play an essential role in ments that is being prepared in consultation many EH activities, and should be among the with the World Bank, especially the HNP Bank's major partners. Network, which is playing the lead role for Bank collaboration with WHO on environmen- Does the World Bank Have a Comparative tal health. While collaboration with WHO on Advantage? Bank staff in both health and this issue is clearly necessary, the framework environment consulted on this issue answered and agenda for such collaboration, which will positively. They pointed out that the World benefit both institutions and their clients, are Bank is in a unique position to have a strong still to be developed. impact on environmental health, since it is involved in dialogue and project development Other Key Partners. Quite a few international in all the sectors crucial for achieving such an and bilateral development and health agencies impact. The Bank's comparative advantage in work on environmental health issues in devel- addressing EH risks is its ability to design and oping countries. The list includes the United implement multidisciplinary projects with the Nation Children's Fund (UNICEF) and other breadth required to have an impact on health. U.N. agencies, the Centers for Disease Control Environment, infrastructure, and energy and Prevention in the United States, the U.S. interventions are usually not considered to be 27 Health and Environment key determinants of human health by govern- World Bank has tremendous potential to ments and health ministries, which tend to promote a holistic approach to health and help think of health investments in terms of number governments develop the capacity required to of hospital beds and doctors per person. The implement such an approach. 28 Environment Strategy Papers Chapter 11 Health and the New Environment Strategy T he World Bank's new Environment The new strategy proposes to undertake these Strategy pays serious attention to envi- activities by: ronmental health by promoting three major types of activities: , * Incorporating environmental health issues into CASs * Improving knowledge of EH problems and * Promoting a Bank-wide set of cross-sectoral developing an appropriate response that best practices and guidelines takes into account institutional, financial, * Integrating environmental health analysis and social constraints; launching advocacy into the Environmental Assessment process and dissemination activities; and strengthen- (based on draft Environmental Health ing collaboration with strategic partners such Assessment Guidelines prepared by the as WHO, other U.N. agencies, and bilateral Africa EH team) * Facilitating "targeted collaboration" among organizations with experience in environ- mental health. health and other ministries/agencies in client countries (through Joint missions and * Integrating critical EH issues into the opera- enhaned stor diaogueson EH) enhanced sector dialogue on EH) tions of relevant sectors-such as health * Launching AAA and project activities on considerations and hygiene promotion in indoor air pollution, which appears to have WSS projects, indoor air pollution in energy been overlooked in the Bank's portfolio operations, urban air pollution in transport despite the high priority it receives with the projects and city development strategies, and poorest countries fuel quality in petroleum-sector restructuring * Undertaking basic health surveys as part of work. preparation for projects in which EH is a * Adopting a holistic approach to develop- primary justification (such as air pollution ment impacts, which focuses on tangible control, sanitation, and wastewater), with improvements in human health and facili- further monitoring tates cross-sectoral collaboration inside the * Improving understanding of the linkages Bank and in client countries to achieve these between health outcomes and development improvements, activities in infrastructure, energy, and the 29 Health and Environment urban and rural sectors, including new and sectors. The work was undertaken in close concerns such as climate change collaboration with HNP staff and with the * Devising better estimates of the burden of active involvement of each Region. Consulta- disease due to environmental causes and tions also involved some staff from energy and the cost-effectiveness of environmental infrastructure groups, although these were less preventative interventions elaborate due to the lack of time (and probably * Developing measurable indicators of health interest, on their part). A Bank-wide workshop impacts for non-health-sector projects that on environmental health was sponsored jointly are simple, low-cost, reliable and accurate with HNP staff on September 9, 1999, fol- * Working more closely with HNP staff and lowed by a session on these issues during the the Public Health Thematic Group, particu- Environment Forum in March 2000 (with larly in promoting a holistic approach to participation from HNP and FPSI staff). These health and addressing health and poverty discussions and other communications with linkages Bank staff indicated a growing interest in * Establishing an Environmental Health environmental health, facilitated by a sharp- cluster of Bank staff from various sectors ened focus on poverty and outcome-oriented and units to foster exchange of information, activities. Since then, EH issues were dis- ideas, and experience cussed at the HNP Sector Board and HD * Promoting information-sharing and more week, and have been included in the Bank- effective collaboration with WHO and wide sectoral strategies for HNP, water and other international and bilateral institutions sanitation, energy, and transport. working on EH issues * Dissemination and training. PROCESS The preparation of this paper involved a consultative process across Regions, networks, 30 Environment Strategy Papers r -wR~~~~~~~~~~- Annex A Definitions of Environmental Health WORLD HEALTH ORGANIZATION * Inadequate solid waste disposal y adotingthe pinciles o theRio* Occupational injury hazards in agriculture y adopting the principles of the Rio and cottage industries 5 Declaration and Agenda 21 as the route * Natural disasters, including floods, droughts, to sustainable development in the and earthquakes. twenty-first century, the world's leaders recog- nized the importance of investing in improve- Modern environmental hazards to humans are ments to people's health and their environ- related to "development" that lacks health and ment. Humans experience the environment in environmental safeguards, and to the unsustain- which they live as an assemblage of physical, able consumption of natural resources, includ- chemical, biological, social, cultural, and ing: economic conditions that differ according to the local geography, infrastructure, season, * Water pollution from populated areas, time of day, and activity undertaken. industry, and intensive agriculture * Urban air pollution from motor cars, coal The environmental threats to human health can power stations, and industry be divided into "traditional hazards" associated * Solid and hazardous waste accumulation with lack of development, and "modern * Chemical and radiation hazards following hazards" associated with unsustainable devel- introduction of industrial and agricultural opment. technologies * Emerging and re-emerging infectious disease Traditional hazards related to poverty and hazards "insufficient" development include: * Deforestation, land degradation, and other major ecological change at local and * Lack of access to safe drinking water regional levels * Inadequate basic sanitation in the household * Climate change, stratospheric ozone deple- and the community tion, and transboundary pollution. * Food contamination with pathogens * Indoor air pollution from cooking and The main functions of the World Health heating using coal or biomass fuel Organization (WHO) in this area are to address 31 Health and Environment risks to health stemming from these hazards. extremes of heat and cold, noise, and radia- Environmental health risk assessment and tion. Human exposure pathways are air, water. research form the basis of all activities and land, and food. produce the evidence base for national legislation and standard-setting, a process that Environmental health strives to consider is supported through technical cooperation individual problems in as broad a context as with national health and environment authori- possible from which to set policies and ties. WHO also undertakes and supports develop reasonably practicable and cost- analysis of the situation and trends and effective preventive remedial measures. The supports development of international initia- broad context should include the driving tives to combat transboundary hazards. socioeconomic determinants leading to physical and mental stress, such as: WNORLD BANK AFRICA REGION * Population movements (population growth. ENVIRONMENTAL HEALTH AND rural-to-urban migration, resettlement, and MALARIA TEAMS so forth) .activity General lack of access to basic services or environmental healthorelates tot huan impa(transport, water, sanitation, energy) or environmental factors that have an Impact' * Inordinate time spent compensating for lack on socioeconomic and environmental condi- tions with the potential to increase human of basic services (hours devoted to fetching water and household fuels or to getting to disease, injury, and death, especially among sho,wr,o elhsrie) vulnerable groups, mainly the poor, women, ' and children under five. Environmental health preventive remedial Environmental health aims to prevent health measures complement health care system interventions to optimize health benefits. The risks through control of human exposure to: (a) broad context also allows for more efficient biological agents, such as bacteria, viruses, crosssctoralir ons as adressing and arastes;(b) hemial aents suc as cross-sectoral intervention, such as addressi ng and parasites; (b) chemical agents, such as the risk of sexually transmitted diseases in havy mertalzers,c pdiclate mcters, pesticies, infrastructure projects in cases where truckers and tertilizers; (c) disease vectors, such as mosquitoes and snails; and (d) physical and and work crews are at risk of acquiring or safety hazards, such as traffic accidents, fire, spreading the disease. 32 Environment Strategy Papers Annex B Estimating the Burden of Disease Related to Environmental Risks Diseases caused by lack of access to clean water/sanitation and vector control Amoebiasis Japanese encephalitisa Cholera (Vibrio cholerae) Leishmaniasisa Conjunctivitis Malariaa Dengue' Onchocerciasis (river blindness) Diarrhea (from Campylobacter jejuni, Poliomyelitis cryptosporidium, Giardia lamblia, Escherichia coli, Protein-energy malnutrition Salmonella spp., Yersinia, and other agents) Rotavirus Dysentery (includes Shigel/a, Ameobiasis) Scabies Filariasisa Schistosomiasisa Giardiasis Trachoma Guinea worma Trypanosomiasis (Chagas' disease) b Helicobacter Pylori Typhoid and Paratyphoid Helminths (roundworm, whipworm, threadworm, Well's disease (Leptospirosis) hydatid disease) Yellow fever a Hepatitis A, E a. Tropical cluster diseases in which water or excreta are a medium for part of the vector's life cycle. These v ectors (mosquitoes and black flies) are affected by water's quantity, exposure, temperature. pH, salinity, and other features: hence, both positive and negative effects from infrastructure changes may occur, depending on the impact of the intervention on t he vector's habitat and nutrients and those of any competitive species. b. Transmitted by insects, people, or animals to insects or people; Latin America. Related to housing conditions. c. Caused by contact with rodent urine; infects animal to person, wor Idwide. Related to housing conditions. The burden of disease due to lack of water and studies by Kirk Smith and various colleagues sanitation was calculated using data from the (Smith 1998, 1999; Smith and Mehta 2000, Global Burden of Disease by disease, causes, Reddy, Williams, and Johansson 1997). The and regions, and the assumptions about the most detailed analysis was carried out for India contributions from specific diseases indicated using census data for 1991, and yielded a range in Table B.1: of 410,000-560,000 premature deaths each year as a result of exposure to indoor air INDOOR AIR POLLUTION pollution, with a best estimate of 500,000. A separate study of mortality among children Estimates of the burden of ill health caused by under the age of five, using data from the indoor air pollution are based on a series of 1992-93 Indian National Family Health 33 Health and Env ronment TABLE B. I Burden of specific diseases indoor air pollution, it was assumed that the Diarrheal diseases: 80 percent death of a child under the age of five results, Hepatitis: 30 percent on average, in the loss of 30 DALYs, while the H. Pylori: 20 percent Trachlora: 25 percent death of an adult female (most of whom are Trachoma: 25 percent Intestinal helminths: 70 percent over the age of 45), results in an average loss Note Malaria-taken directly from Murray and Lopez 1996. of 1 0 DALYs. Finally, it is necessary to con- sider non-fatal illnesses resulting from expo- Survey, produced estimates of the excess risk sure to indoor air pollution. Again, based on of mortality associated with the use of solid or the Murray and Lopez data, it was assumed biomass cooking fuels of 45 percent for rural that for each death of a child under the age of households and 18 percent for urban house- five, a total of eight DALYs are lost due to holds (Hughes, Lvovsky and Dunleavy, 2001). other respiratory diseases. Furthermore, the Murray and Lopez (1996) study of the burden of ill health suggests that Since no comparably detailed studies have the number of deaths of adult women in India been made in other regions of the world, the each year due to respiratory diseases repre- mortality-hazard approach was used to sents 1 5-20 percent of the number of deaths generate projections of the burden of ill health of children under five from these diseases. for India as well as for the rest of the world. It was, however, necessary to make certain Combining these conservative end of these adjustments for the specific circumstances of estimates with data on the number of house- some regions. The final set of hazard param- holds using solid or biomass cooking fuels and eters is shown in Table B.2. with mortality rates produced estimates of the number of premature deaths due to indoor air Various commentators have suggested that the pollution for 1991 of 460,00-520,000, which hazard associated with solid or biomass is very close to Smith's figures. To obtain an cooking fuels in Africa is lower than that of estimate of the total number of disability- India, because such fuels are usually used for adjusted life years (DALYs) lost as a result of outdoor, not indoor, cooking. In the absence TABLE B.2 Hazard rates due to exposure to indoor air pollution Adult female deaths Excess hazard for under-S mortality as share of under-S associated with use of a dirty cooking fuel deaths Region (percent) (percent) Urban Rural China 15 35 40 East Asia and Pacific 15 35 15 Established market economies 0 0 0 Former socialist economies 7.5 17.5 1 India 15 35 1 Latin America and Caribbean 7.5 1 7.5 15 Middle East 7.5 17.5 15 South Asia 15 35 15 Sub-Saharan Africa 7.5 1 7.5 1 5 34 Environment Strategy Papers Estimating the Burden of Disease Related to Environmental Risks of clear epidemiological evidence, hazard respiratory disease later in life, so that the ratio rates for the Sub-Saharan Africa, Latin America of adult female deaths to under-five deaths in and Caribbean, and Middle East regions have China was adjusted upwards to 40 percent, to been assumed to be one-half of the equivalent allow both for this effect and for the different values. The resulting estimates of the burden age structure of the population. Nonetheless, of ill health for Africa, where levels of urban the resulting estimate of the total number of air pollution contributing to excess mortality deaths due to indoor air pollution-235,000 in and disease from respiratory causes are 1 995-is only one-third of the estimates in the relatively low, are broadly consistent with the previous study. The figure of 700,000 prema- Murray and Lopez burden of disease esti- ture deaths, on the other hand, is entirely mates.' consistent with our estimate of the total burden of disease caused by indoor and The total number of deaths attributed to indoor outdoor air pollution combined. air pollution using this approach is nearly 1.7 million per year, which is also broadly consis- Comparisons of patterns of fuel use across tent with (although somewhat lower than) countries suggest that there is no consistent available global estimates. For example, WHO decrease in the proportion of the population (1997) estimates 2.8 million yearly deaths, and relying on solid and biomass fuels for cooking Smith (1999) estimates 2 million deaths. until per capita gross national product (G NP) exceeds US$500 per person (at 1995 prices). China faces a somewhat different problem. Hence the average burden of ill health per One study suggested that more than 700,000 person associated with indoor air pollution for premature deaths occur there per year as a each country with levels of GNP per person of result of household use of solid fuel. The less than US$500 in 1995 was assumed to composition of these deaths differed from the remain constant at its 1 995 level per person India estimates; a higher share of chronic until GNP per person reaches that threshold. respiratory disease and cancers, both of which After that, the average burden of ill health per affect adults rather than young children, were ' ~~person was assumed to decline linearly to zero found. However, it is very difficult to separate over 50 years. For countries where GNP per the effects of indoor and outdoor air pollution because the widespread use of solid fuels in persone ce U5 i , the a s- sumptions concerning the average burden of China is the source of particularly high levels ill health per person due to indoor air pollu- of urban outdoor air pollution in many tion were: localities. Applying the Indian parameters to the Chinese data yields an estimate of only * GNP/person between US$500 and about 195,000 premature deaths due to indoor US$1,000, declines linearly to zero over 40 air pollution in 1995. This low estimate is, in part, a consequence of the rather low mortality years ' ~~~~~~~~~* GNP/person between US$1,000 and rate for children under five in China-less than G one-half of the equivalent value for India. US$1,500, declines linearly to zero over 30 Even so, prolonged exposure to indoor air years pollution will be reflected in higher levels of * GNP/person greater than US$1,500, declines linearly to zero over 20 years. Kseniya Lvovsky 35 Hea th and Environment URBAN (OUTDOOR) AIR POLLUTION cient is almost certainly too low for urban areas in the FSE region and China, where The methods used to estimate the costs of cliatic cth ions an that ub ar climatic conditions mean that urban air local outdoor exposure are based on the dose- pollution is dominated by the burning of coal response and valuation assumptions, which and other fossil fuels for heating. However, it uLiderpin the analysis of the study of the social is reasonable for India and other countries costs of fuel use cited above (Lvovsky and with warmer climates, where natural sources others 2000). In that case, however, average of dust and transport are the major contribu- levels of exposure to particulates and other tors to monitored levels of TSP. The use of a Lirban air pollutants were linked to the use of relatively low conversion coefficient implies fossil fuels, an approach that is not feasible in that the costs of urban air pollution are the present context. Hence this study makes probably significantly underestimated, particu- use of data on ambient air quality from a large larly for the FSE region and China. Where sample of cities around the world, obtained available, data on average ambient levels of from a wide variety of sources.4 Both its sulfur dioxide and nitrogen dioxide were also quality and coverage are uneven, but it used in the estimation, although they account represents the most comprehensive informa- for a small fraction of the overall burden of tion about urban air quality that has been disease associated with urban air pollution. analyzed to date, covering 379 cities and metropolitan regions. Most epidemiological evidence suggests that even very low levels of exposure to PM,,- Relative to urban populations, the coverage of and, even more, to fine particulates or the sample is reasonable for the EME and FSE PM2.5-are associated with an excess burden regions, as well as for China and India. Data of mortality and disease. Still, it is unrealistic coverage is relatively poor for Africa, and only to assume that it would be possible to reduce somewhat better for the LAC region. For the average exposure to PM,O to close to zero. most part, availability of data is correlated with Hence the estimation is based on a threshold an awareness that urban air pollution is a of 2 0 g/m3 for exposure to PM,,and SO,, and significant problem, so that the limited data for 40 pg/m3 for NO,. These thresholds are Africa are reflected in low estimates of the consistent with the ambient air quality stan- costs of urban pollution in Africa today. Based dards for 2010 adopted recently by the United on anecdotal evidence, this is probably a States and the European Union. There is also reasonable assessment, but it does pose the uncertainty about whether estimated dose- question of what will happen as urban popula- response relationships can be extrapolated to tions and incomes increase. very high levels of average exposure. This is a matter of particular importance for China, Estimates of the costs of damage caused by where many cities have estimated average urban air pollution are based primarily on levels of PM10 in excess of 200,ug/m3. To average exposure to PM,,,. However, much of reflect this uncertainty, the analysis assumes the data refer to measurements of TSP, which an upper truncation of exposure at 200 pg/mi, were converted to PMl,equivalents using a which, again, implies that the burden of urban conversion coefficient of 1 ,ug/m3 of TSP = air pollution in China has been underesti- 0.55,ug/m' of PM,,. This conversion coeffi- mated. 36 Environment Strategy Papers Estimating the Burden of Disease Related to Environmental Risks Since the data cover only a sample of the old of a GNP per person of US$1,000. This is urban population in each country and not all equivalent to assuming that in countries with countries are represented, it was necessary to GNP per person below US$1,000, average extrapolate the sample data to estimate levels of urban air pollution will increase with average levels of exposure for all urban income while the average number of people populations. This was accomplished by using exposed will increase with the urban popula- the sample to calculate population-weighted tion. Global experience over the last 50 years average levels of the burden of ill health suggests that this is a reasonable approxima- associated with urban air pollution-measured tion of what has happened as a result of rapid in premature deaths and DALYs lost per 1,000 urban and industrial growth. It could be residents-for the cities in each country argued that this method of projection wi ll covered. For each country it was assumed that overstate the possible deterioration of urban estimates of the average burden could be air quality in China. This may be true for the applied to the entire urban population of each largest metropolitan areas, but concern about country. This assumption might be challenged future urban air quality in China should focus on the grounds that urban air pollution in on smaller, more rapidly growing cities, where medium-sized and large cities is not represen- air pollution is likely to worsen. Since the tative of the pattern for all urban areas. Such overall approach tends to underestimate the an assertion is usually predicated on the belief burden of urban air pollution in China, no that large cities are more polluted than smaller special adjustments were made in projecting urban areas, but this is not supported by the the estimates forward in time. Comparison of available data. In countries such as the United the projections for China with those generated States, Russia, and China, where data are by a different approach for the period to 2020 relatively plentiful, urban air quality tends to suggests that the estimates of the cost of urban be worst in medium-sized cities with popula- air pollution used here are probably on the tions in the range of 100,000-500,000. low side.5 Smaller towns and cities account for a modest share of total urban population, making it Analysis of patterns of urban air pollution likely that reliance on a sample biased toward across countries suggests that average levels of cities with populations of more than 500,000 particulates and sulfur dioxide in urban areas will tend to underestimate, rather than overes- tend to rise with income up to a level of GNP timate, the overall burden of ill health due to per capita of US$1,000-$2,000 at 1995 urban air pollution. For countries for which no prices.6 Hence the average burden of ill data were available, it was assumed that the health per person associated with urban air average burden of disease per 1,000 urban pollution for each country with levels of GNP residents was equal to the average for the per person lower than US$1,000 in 1995 was relevant region. assumed to remain constant at its 1995 level per person until per capita GNP reaches that To extrapolate the burden of urban air pollu- threshold. After that the average burden of ill tion over time, the analysis assumed that the health per person was assumed to decline burden of ill health increases in line with the linearly to zero over 100 years, reflecting the total level of urban incomes, up to the thresh- rate at which urban air pollution has been Kseniya Lvovsky 37 Health and Environment reduced in medium- and high-income coun- namely gastric, renal, skin, and blood.8 tries. For countries whose GNP per capita Poisoning is the most often cited health exceeded US$1,000 in 1 995, the assumptions consequence of pesticide use. Skin and eye concerning the average burden of ill-health per contact during application may lead to person due to indoor air pollution were: neurological or immunological reactions ranging from irritation to serious complications * GNP/person between $US1,000 and requiring immediate medical assistance. US$2,000, declines linearly to zero over 80 Usually, such incidences arise from improper years application or container disposal. * GNP/person between $US2,000 and US$4,000, declines linearly to zero over 60 In addition to occupational hazards, toxic years exposure to pesticides is believed to result • GNP/person between $US4,000 and under particular conditions, including the US$8,000, declines linearly to zero over 40 repeated application of a persistent compound over a period of years near to drinking-water y GNP/person between $US8,000 and sources. Even under these conditions, how- ever, at levels several times the quality stan- US$1,00 d dards, the resulting buildup has rarely been 30 years linked with observed or expected health * GNP/person greater than US$1 6,000, problems. declines linearly to zero over 20 years. AGRO-INDUSTRIAL POLLUTION Table B.3 presents estimates of the burden of disease potentially associated with acute and The most common health symptoms reported chronic exposure to pesticides and non- from chronic, low-dose exposure to toxic point-source industrial contaminants in the chemicals include vomiting, vertigo, nausea, environment. The estimates are based on conser- dizziness, anxiety, and headaches.7 Chronic vative (5 percent of the total burden) and liberal exposure at high levels is manifested by (20 percent of the total burden) boundaries, depression and cytogenetic effects, and can related to the summation of over 1 5 disease lead to an increased hazard of certain cancers, sequelae.9 Liberal estimates are used in the table. TABLE B.3 Burden of disease associated with agro-chemical exposure Agro-industrial As share of all DALYs Region Estimates associated DALYs (percent) Established market Conservative 619 0.6 economies Liberal 2,477 2.5 Sub-Saharan Africa Conservative 677 0.2 Liberal 2,708 0.9 India Conservative 886 0.3 Liberal 3,543 1.2 Latin America and Conservative 441 0.4 Caribbean Liberal 1 ,763 1.8 Former socialist Conservative 320 0.5 economies of Europe Liberal 1,279 2.1 Source: Murray and Lopez 1996. 38 Environment Strategy Papers ptS S Annex C Africa Burden of Disease from Environmen- tal Causes and Intervention Measures10 T he objective of the exercise described disease causation that could be explored for below is to determine the extent to this purpose. The estimates presented in Tables which interventions outside the health C.1 and C.2 are largely guided by such studies, care system may be beneficial to the health of and primarily based on Smith, Corvalan, and populations in Africa. Kjellstrom (1999), which provides estimates of environmentally attributable percentages. The burden of disease due to environmental factors is extremely important in public health, METHODOLOGY since certain environmental factors are ame- nable to specific remedial measures-most of The methodology involves listing the different which lie outside the health care system. environmentally related diseases and the risks However, estimates are difficult because of the and percentages that may be attributable to paucity of information about disease etiology. environmental factors. The Global Burden of Nevertheless, laboratory and epidemiological Disease study by Murray and Lopez (1996) was research has attempted to identify risk factors in used as the basis for the calculations primarily TABLE C. I Burden of disease relieved in Sub-Saharan Africa (SSA), by remedial measure (worksheet estimated from 1990 DALYs) Range of DALYs potentially reduced by the Remedial measures remedial measures (percent) (diseases potentially reduced by remedial measures) Low High Remedial measures outside health care system Improved housing and air pollution abatement 5.4 7.9 Improved water supply, sanitation, and waste 8.9 10.0 management Vector control, sanitation, and drainage 7.7 9.95 Road, workplace, and housing design 0.67 0.80 Percent of total SSA DALYs from remedial measures 22.7 28.7 outside the health care system Remedial measures through health care and health education Health care/education-type remedial measures 22.5 28 Other types of remedial measures Percent of SSA DALYs from other diseases 54.7 43.2 39 Hea th and Ervironment TABLE C.2 Burden of disease relieved in Sub-Saharan Africa (SSA), by remedial measures in DALY (estimated from 1990 DALYs) Range of DALYs potentially reduced by the remedial measures Remedial measures (Diseases affected by remedial measures) Low High Remedial measures outside health care system' Improved housing and air pollution abatement Respiratory diseases b 15,345 22.436 Circulatory system diseases ' 557 696 Eye diseases d 182 215 Subtotal 16,085 23,347 Improved water, sanitation, and waste management Diarrheal diseases 25,701 28,913 Intestinal worm infections 396 445 Eye diseases e 249 284 Subtotal 26,345 29,642 Vector control, sanitation, and drainage Tropical disease cluster 3,889 5,000 Malaria 18,962 24,380 Dengue 15 19 Subtotal 22,866 29,399 Road, workploce, and housing design Road traffic accidents 1,432 1,719 Falls 532 638 Drownings and fires n.a. n.a. Subtotal 1,964 2,357 Total SSA DALYs from remedial measures outside the 67,260 84,745 health care system Health care/education-type remedial measures Childhood diseases cluster g 30,445 n.a. Gastrointestinal diseases 3,262 6,524 Respiratory diseases b 22,301 28,991 Circulatory system diseases c 6,266 6,405 Tropical diseases cluster, malaria, and dengue 3,267 9,800 Eye diseases e 858 891 Subtotal 66,339 83,056 SSA DALYs from other diseases 161,695 127,493 Grand total of SSA DALYs 295,294 Notes: a. Includes, for example, improvements in water supply, sanitation, waste management, drainage, transportation, housing, house- hold fuel efficiency. b. Acute respiratory infections, chronic obstructive pulmonary disease, asthma, trachea, bronchus and lung cancers. c. Heart disease and stroke. d. Cataracts and trachoma. e. Trachoma. f. Trypanosomiasis, Chagas disease, schistosomiasis, leishmaniasis. lymphatic filariasis, onchocerciasis. g. Pertussis, poliomyelitis, diphtheria, measles, tetanus. h. Diarrheal diseases and intestinal nematode infections. 40 Environment Strategy Papers Africa- Burden of Disease from Environmental Causes and Intervention Measures because it reflects both disability and death. pollution, and dividing this by the total DALYs The list of diseases was also taken from this for the region or world yields the percent source. Estimates for the region were also guesstimate of regional or world DALYs guided by the prevalence of risk factors, such attributable to air pollution. as the use of traditional cooking fuel in Africa and smoking rates. Air pollution and housing- Separate guessstimates for indoor and outdoor related diseases are used as an example for the air pollution were reached similarly for the methodology. This methodology of estimation world DALYs. For the Africa Region, in order was used to obtain "guesstimates" for the to separate the contribution of indoor and remaining environmentally related diseases. A outdoor air pollution, the levels of industrial- range is shown for each disease/remedial ization, transportation, use of traditional measure category to show conservative and cooking fuel, and smoking rates were exam- liberal estimates. ined. Guided by these figures, allocations of percentages attributable to indoor and outdoor Based on literature reviewed, the following air pollution were made. The resulting guessti- pollution-related diseases are listed: acute mates were interpreted as the DALYs that respiratory infections; chronic obstructive could be mediated by improved housing and pulmonary disease; asthma; trachea, bronchus, air pollution abatement, including a change in and lung cancer; tuberculosis; ischemic heart cooking/heating/lightingfuel. disease; cerebrovascular disease; trachoma; and cataracts. For DALYs mediated by other interventions, such as water supply, sanitation, vector A listing of relative risks and percentages control, and waste management, a similar attributable to both indoor and outdoor air method for guesstimating was used. Using the pollution was compiled, based on several environmental fractions of Smith, Corvalan studies. This list was then compared with the and Kjellstrom (1999), guesstimates for approximations reached by Smith and others. diseases mediated by other interventions were Sources of air pollution were likewise listed. computed. By gross examination of the list above, and in Diseases related to water, sanitation, and comparison with Smith's figures, lower and waste management: upper guesstimates of percent attributable were reached. World and African DALYs of * Diarrheal diseases the aforementioned diseases were then listed. * Intestinal nematode Infections The lower and upper guesstimates of the * Trachoma percent attributable were multiplied by the * Other gastrointestinal diseases, such as DALYs from each disease. The products hepatitis and ulcers derived represent the number of DALYs attributable to air pollution. A range of DALY Diseases related to vector control, sanitation, guesstimates was produced for each disease. and drainage: Totaling the DALY guesstimates of the diseases * Tropical disease cluster gives the total DALYs attributable to air Kseniya Lvovsky 41 Health and Environment * Malaria was assumed to be alleviated 100 percent by * Dengue the immunization program (Smith, Corvalan, and Kjellstrom 1999). For other diseases, the Diseases related to road, workplace, and complementary value of the environmental housing design: portion was assumed to be the value that could be mediated by health care and health * Road traffic accidents education, and was applied to the DALYs * Falls accordingly. * Drownings * Fires Tables A3.3-A3.5 illustrate the methodology employed, using housing- and air pollution- For DALYs mediated by the health care system elated d is e asiexamples. and health education, the childhood cluster TABLE C.3 Lower and higher percentage guesstimates for each disease Percent attributable Africa: Air pollution-related diseases(inloutdoor) (lower) (higher) Acute respiratory infections 0.4 0.6 Ischemic heart disease 0.08 0.1 Chronic obstructive pulmonary disease 0.33 0.5 Asthma 0.2 0.25 Trachea, bronchus, and lung cancer 0.2 0.25 Cerebrovascular diseases 0.08 0.1 Tuberculosis 0.2 0.25 Trachoma 0.17 0.2 Cataract 0.17 0.2 TABLE C.4 DALYs guesstimates attributable to air pollution DALYs Percent Percent DALYs attribu- attribu- Attribu- attribu- table table table table (lower (higher Africa: Air pollution-related diseases (inloutdoor) (lower) (higher) Total DALYs estimate) estimate) Acute respiratory infections 0.4 0.6 30,941 12,376.4 18,564.6 Ischemic heart disease 0.08 0.1 2,367 189.36 236.7 Chronic obstructive pulmonary disease 0.33 0.5 1,826 602.58 913 Asthma 0.2 0.25 1,426 285.2 356.5 Trachea, bronchus, and lung cancer 0.2 0.25 225 45 56.25 Cerebrovascular diseases 0.08 0.1 4,595 367.6 459.5 Tuberculosis 0.2 0.25 10,184 2,036.8 2,546 Trachoma 0.17 0.2 262 44.54 52.4 Cataract 0.17 0.2 811 137.87 162.2 52,637 16,085.3 23,347.1 42 Environment Strategy Papers Africa -Burden of Disease from Environmental Causes and Intervention Measures TABLE C.5 Guesstimates for indoor and outdoor air pollution Outdoor-% Indoor-% DALYs-attr. DALYs-attr. attribut- attribut- (higher) (higher) Africa: Air pollution-related diseases(in/outdoor) table able OUT IN Acute respiratory infections 0.1 0.9 1,856.46 16,708.14 Ischemic heart disease 0.6 0.4 142.02 94.68 Chronic obstructive pulmonary disease 0.7 0.3 639.1 273.9 Asthma 0.5 0.5 178.25 178.25 Trachea, bronchus, and lung cancer 0.7 0.3 39.375 16.875 Cerebrovascular diseases 0.4 0.6 183.8 275.7 Tuberculosis 0.3 0.7 763.8 1,782.2 Trachoma 0.1 0.9 5.24 47.16 Cataract 0.1 0.9 16.22 145.98 3,824.26 19,522.8 Kseniya Lvovsky 43 A- ~ ~ ~ - J 00~~~~~~~~~~~~~~ Annex D Cost-Effectiveness of Environmental Health Interventions T his annex compares the cost-effectiveness Sorne interventions, such as installing elec- of a range of environmental health (EH) tronic ignition systems in two-stroke vehicles in interventions. Knowledge in this area Delhi and replacing gasoline with LPG in can be used to set priorities for investment and trucks in Mexico City, can be characterized as to improve budget-allocation decisions. The "win-win," in that they result in both cost analysis identified considerable differences in savings and DALYs averted. Other interven- both the cost and effectiveness of different EH tions, such as re-engining light diesel buses in interventions. Some interventions are "win- Mexico City to 1991 U.S. emissions standards, win" (such as installing electronic ignition produce large, positive health gains at a cost of systems in two-stroke vehicles in Delhi) and about US$300 per DALY averted. Air pollution therefore can be justified on economic criteria interventions can also be a very expensive way alone. In general, interventions that reduce of averting DALYs. (See Table D.1.) For ex- indoor air pollution, improve water supply and ample, applying the low-emission vehicle sanitation, and prevent malaria appear to be standards adopted in California to passenger more cost-effective than those that reduce cars in Mexico City costs over US$70,000 per outdoor air pollution. DALY averted. The variation in the cost-effectiveness ratio of ANALYSIS different interventions is a function of local conditions. Costs are influenced by the pres- The analysis identified marked differences in ence of other interventions (through joint both the cost and effectiveness of various ec fohritretos(hog on both he cst an effctivness f vaioussharing of costs) and by local market distor- health interventions. Figure 1 presents both the ting Effctss dnd s on the siz rn cost-effectiveness (in US$ per DALY) and gains comsitionoft aeced opltion and in DALYs for 29 different interventions that composition of the affected population, and the reduce ambient concentrations of air pollution cers a puioF e intervention s in three cities. Lower points represent interven- tha reduceiions Fromptwo-stro engine that reduce emissions from two-stroke engine tions that are more cost-effective, and points vehicles in Delhi tend to be very cost-effective farther to the right represent interventions that because they have a relatively low cost in a produce larger numbers of DALYs averted. high-density urban environment. 45 Health and Environment TABLE D. I Summary of air pollution cost-effectiveness studies Total cost Total DALYs Delhi Santiago Mexico City Intervention (1997 US$) averted (1997 US$) (1997 US$) (1997US$) Modern carburetor (entire fleet) (2.93) 1,148 (2,553) New 4-stroke (10 percent of fleet) (2.73) 1,926 (1,417) Convert to CNG vehicle (30 percent of fleet) (6.22) 5,260 (1,182) Engine rebuild (30 percent fleet) (0.84) 2,077 (404) Electronic ignition (entire fleet) (1.64) 4,604 (356) Fuel-oil premix (30 percent fleet) (0.54) 2,077 (260) PLS with smokeless oil (50 percent fleet) (1.39) 8,772 (158) Periodic l&M (entire fleet) 1.26 4,604 274 Phaseout (17 percent of fleet) 3.05 3,839 794 Gasoline trucks: LPG (55.28) 2,682 (20,614) Gasoline trucks: CNG (29.93) 2,366 (12,652) Minibus retrofit/replace CNG (22.94) 1,843 (12,445) Diesel light bus -re-engine US '91 5.38 17,899 300 Diesel light bus: Re-engine CA '88 7.54 11,026 684 Minibus: Mex 92 standards 26.82 3,203 8,372 Gasoline trucks: Mex 93 standard 36.77 2,638 13,941 Minibus re-engine 34.51 1,843 18,720 New Taxi: Mex 93 51.28 2,446 20,960 New Taxi: Tier 1 56.41 2,446 23,060 Gasoline trucks: Re-engine 78.54 2,366 33,200 NewTaxi: LEV 81.64 2,446 33,371 Passemger car: Mex 93 120.07 3,543 33,889 Passemger car: Tier 1 158.17 3,543 44,642 Passemger car: Mex 91 98.05 1,993 49,204 Gasoline trucks: Replace 139.10 2,366 58,802 Passemger car: LEV 265.55 3,543 74,946 Wood stoves to distillate fuel oil 13.08 4,209 3,108 Diesel truck control (2) 4.76 793 5,997 Compressed natural gas for buses 35.67 5,128 6,957 Gasoline vehicle standards (I) 16.65 1,080 15,415 While the purpose of the analysis is to facili- prevention interventions for children range tate the systematic comparison of interven- from US$5 to US$400 per DALY averted (see, tions, a note of caution is urged in making for example, Binka 1997). "Win-win" interven- cross-country comparisons. Costs are assessed tions aside, reducing indoor air pollution, using local prices. Thus if the price of gasoline improving water supply and sanitation, and is subsidized in one country, the cost of a preventing malaria all appear to be more cost- gasoline-intensive intervention will be lower effective than reducing outdoor air pollution. there than in a country where there is no subsidy. Ideally, border prices should be used METHODS to make cross-country comparison correctly. Different environmental health interventions These results for air pollution can also be can be compared by what it costs to achieve compared with the cost-effectiveness of other one additional year of healthy life. This annex EH interventions. Reducing indoor air pollu- measures cost-effectiveness as the ratio of U.S. tion through improved stoves in India costs dollars over DALYs. "Costs" are the annual- from US$50 to US$100 per DALY averted. ized cost of an intervention, and "effective- Water and sanitation interventions range from ness" is the annual number of DALYs avoided US$20 to US$120 per DALY averted. Malaria- due to an intervention. This measure does not 46 Environment Strategy Papers Cost-Effectiveness of Environmental Health Interventions include non-health burdens, such as income Unfortunately, relatively little information is lost due to illness, available on cost. While costs associated with specific air-pollution interventions are avail- Whenever possible, the analysis relies on able, costs of water supply and sanitation dose-response functions to quantify the impact interventions are not. of EH interventions in terms of DALYs. For air pollution, estimates of the annual health effect Although comparing costs and effects for a associated with a unit change in PM10 are wide range of EH interventions is desirable, it taken from Ostro (1994). For water supply and does not make sense to compare estimates that sanitation, the expected reduction in morbidity may not be reliable. The data, therefore, are and mortality is detailed in Esrey et al (1991). taken only from studies that contain sufficient information on both cost and effect to under- DATA stand how the estimates were derived. Unfor- tunately, sufficient information is not available The data are drawn from a review of published for many interventions, particularly in the and unpublished studies. To facilitate cross- water supply and sanitation sector, making it is study comparisons, attempts were made to impossible to calculate the cost-effectiveness identify studies that provide both cost and ratio. The data presented here make up only a effect information and use similar analytical very small proportion of the many possible methods (such as the same discount rate). interventions. Kseniya Lvovsky 47 d ~~~~~~~~~~~~~~~~~~1 Annex E Analysis of Bank Documentation M ost project-related work carried out sector, not environmental, issues. A literature to date on environmental health in search of Bank documentation found only one the Bank has been done by the peer review by health professionals, which was Europe and Central Asia (ECA) and the Middle presented at a workshop on methodologies East and North Africa (MNA) Regions, where used in evaluating the economic costs of environmental health has played a role in pollution on human health.`2 Apart from that determining overall environmental strategies for observation, it is hard to draw conclusions the area, essentially emphasizing pollution because there is no Bank-wide definition of control (World Bank 1994b, 1995c)." The East environmental health. Asia and Pacific (EAP) and the Latin American and the Caribbean (LAC) Regions have worked Guidance that would allow staff to deal on economic evaluation of the human-health competently with environmental health issues damages from pollution (World Bank, 1 994a, is lacking, especially when compared with the 1994c, 1 994d, 1995a, 1995g). Numerous other broad range of documentation on environmen- projects dealing with pollution-control and tal management. Within the Staff Operations waste management have yielded important Manual, only one Operations Policy/Best positive environmental health repercussions, Practice (OP/BP) deals directly with environ- but the latter are not necessarily separated into mental health. Operational Directive (OD) components or other disaggregated activities. 4.03, "Guidelines for Use, Selection and Only one pollution control project, in ECA, Specification of Pesticides in Public Health was designed based on health criteria; the Programs," deals with spraying to reduce reverse is more common (World Bank, 1995b). vectors, but does not address general pesticide use in agriculture sector. OD 4.30 ("Involuntary Environmental health in Bank documentation Resettlement") contains one footnote on health; has received uneven attention, and tends to be GP 4.37 ("The Safety of Dams") refers to public subsumed by other, related topics. Many health in general; OD 4.01 ("Environmental traditional health concerns (for example, indoor Assessments," Annex A) lists 'Occupational household pollution or vector-related diseases Health and Safety" in a checklist; OP 4.02 such as malaria) have been treated as health ("Environmental Action Plans") mentions a public health specialist as part of the EA team, 49 Health and Environment and lists public health and safety as general Cross-fertilization on health issues within and objectives; GP 4.03 ("Agricultural Pest Man- among sectors and networks could be im- agement") refers to proper disposal of pesti- proved in a broader context, and strengthen cide containers; and OP 4.76 ("Tobacco") the focus on development outcomes, such as refers to the dangers of tobacco smoking. (The health. Some examples are: ODs listed here are to be reissued as OPs.) * Health and nutrition activities-addressing A literature search of non-project documents anemia through links with deficient nutri- reveals a primary emphasis on pollution tion as a cross-cutting health-sector issue control-that is, "brown issues," followed by would further benefit from linking it also to development of techniques to evaluate the hookworm, a major contributor to anemia, health costs of environmental degradation. with deficient sanitation (the worms hook Frequent references to environmental health onto the intestines, causing blood loss). can be found, but few substantive health * Work on air pollution and health, mostly analyses are seen. Typical is Mvaking Develop- focused on ambient air pollution so far, ament Sustainable: From Concepts to Action, would benefit from complementing it by which presents the approaches of sociologists, links between indoor pollution and respira- ecologists, and economists in separate chap- tory diseases, now considered one of the ters; explicitly mentions gender and poverty in most important health problems in develop- separate sections; refers to urban pollution ing countries. issues; and features diagrams of pollution * The use of pesticides is traditionally linked indicators. (Others are World Bank 1 995d, with water quality, but less so with breast 1 995e, 1 995f, and the Bank's Annual Reports cancer in women farmers or with general on the Environment.) An annotated bibliogra- contamination of the food chain. phy, "Sociology, Anthropology and Develop- ment," covering Bank publications from 1 975- These and other cross-sectoral issues and 93, lists only two entries on health out of 390 integrated approaches that could tangibly publications. The annual sustainable develop- improve the development impact of Bank ment conferences of 1994 and 1995, however, operations need to be given more attention in included many presentations on health. future work. 50 Environment Strategy Papers Annex F Regional Responses to EH Questionnaire 1. What are the main environmental health second is malignant neoplasms. Injuries problems in your region? and poisonings are responsible for close to 10 percent of mortality. Accidents SAR: Water supply and sanitation-related associated with cars and the workplace diseases from polluted drinking water are the most prominent. Better charac- and dearth of sanitation and good terization of the environmental factors hygiene practices; respiratory diseases that increase the risk of accidents for and other adverse effects from indoor children is considered as a priority topic air pollution resulting from the use of for research by WHO and the EC-EH traditional biomass fuels in primitive commission. cookstoves and urban air pollution from a variety of energy, transport, and other We need to separate ECA into Europe, the sources. newly independent states (NIS), and Central LAC: (a) Water-borne disease resulting from Asia (CA) for these purposes. Outbreaks of inadequate water supply and sanitation. disease related to environmental pollution are Sanitary education may be weak in poor relatively rare in Europe, but common in CA. areas of the region. Communicable disease contributes to a small (b) Serious respiratory illness, particu- proportion of all deaths in ECA (1.3 percent); larly within vulnerable groups, from air mortality rates were four times higher in the pollution in Mexico City and Santiago. NIS than in the rest of Europe in the mid-1 990s. Cities with growing localized problems In the NIS, mortality from communicable include Lima, Rio, Buenos Aires, and diseases increased by more than 40 percent many medium-size cities with high during 1990-95. Close to half of the mortality growth. in this group is caused by tuberculosis; much of (c) Localized health impacts of inad- the rest is attributable to water-borne diseases. equate disposal of sewage in bay and In 1995, tuberculosis incidence in the NIS and coastal areas. Central and Eastern Europe was more than ECA: The most common cause of death in three times greater than in the European Union. Europe is cardiovascular disease; the Among the factors facilitating the spread of 51 Health and Environment communicable diseases in the population, three to four years. To identify the projects that poor environmental conditions play an addressed environmental health, directly or important role. Insufficient housing and indirectly, within the project documents, we contamination of indoor air with microorgan- looked at a) key and strategic objectives; b) isms contribute to morbidity. Murray and summary analysis, which provides the cost- Lopez (1997) have shown that poor water, benefit analysis or cost-effectiveness of the sanitation, and hygiene are still among the 10 intervention; and c) key performance/output/ most important risk factors for burden of outcome indicators. If there was explicit disease throughout all of ECA. National reference to environmental health or to Environmental Health Action Plans for NIS environment and public health, in at least two countries, particularly Central Asia, show of these areas, then the projects were included water-related diseases to be the top environ- in the primary list of projects (PLP). Those that mental health priority. did not meet this criteria, but that are likely to have an environmental health impact, were EAP: The primary problems include water included in the secondary list of projects (SLP). supply and sanitation, urban air quality, and indoor air pollution. Implications Secondary problems are industrial Depending on how the project documents health and safety and traffic accidents. were written up, a project could be doing MNA: Diarrhea (including dysentery, cholera, quite a bit on environmental health, but if it and typhoid) from lack of safe water was not described explicitly as doing so, we and sanitation and poor hygiene is a would not have included it in the PLP. Further- very serious problem. Respiratory more, there is no guarantee that projects with infections from air pollution due to explicit EH objectives will actually carry out overcrowded housing, transport, and the activities, unless they are also to be industry also affect many people. monitored under key performance/output! Carcinogenic and cardiovascular outcome indicators. problems resulting from toxic industrial pollution are also serious, but difficult Fo xml,a niomn rjc a polluantify. are also serious,butdifficult have as key objectives provision of mitigating measures to clean up, build, and treat waste, air, and water emissions from an industrial 2. Please list current projects (on-going or a facility. Under performance/monitoring pipeline) in vour region that address environ- initos if teyoare emonitoring indicators, if they are monitoring BOD, COD, m-nental health issues to some extent. and particulates to the general environment, these would be considered "indirect indica- SOUTH ASIA tors." We have assigned such projects to the SLP, even though the impact on the health of Approach the surrounding communities may be consid- In South Asia, we essentially looked at projects erable. at the PCD and PAD/SAR stages that were online, and therefore took place within the last Likewise, a health project that, among other objectives, addresses communicable diseases 52 Environment Strategy Papers Regional Responses to EH Questionnaire (which are environmentally related) may, in its Health and Nutrition Projects performance indicators, be monitoring envi- ICDS 11 (nutrition) ronmental health benefits but may not explic- Woman and Child Development (nutrition) itly describe the results in the document. Such Malaria Control (India) projects were also placed on the SLP. A large TB control (India) number of projects in the Urban, Energy, Transport, Infrastructure/Rural Development Urban Projects (including Water Supply and Sanitation Colombo Environmental Improvement (WSS)), and Health sectors have the potential Tamil Nadu Urban Development Fund to address EH issues to some extent. But most Municipal Services Project (Bangladesh) of them do not, as few people are aware of the Slum Upgrading (Bangladesh) issues or knowledgeable of how to address Urban Development (Bhutan) them. Some projects (especially those that Clean Settlements (Sri Lanka) include urban/industrial air pollution or WSS Lahore Urban Development activities) indirectly address EH, even though the specific project objectives may not have Transport Projects been EH-driven. Environmental health, as a Dhaka Urban Transport key objective, drives only a very small sample Mumbai Urban Transport of projects in South Asia. Environmental Capacity Building Projects Primary List Environmental Management Capacity Building Dhaka Air Quality Management (Urban Air) (India) Bangladesh Arsenic Mitigation Project (Drink- Environmental Action (Sri Lanka) ing Water) Metropolitan Environmental Improvement Bangladesh School and Community Sanitation Program (Bombay, Kathmandu, Colombo) (Sanitation/Hygiene) Industrial Pollution Projects Secondary List Coal Environment and Social Mitigation (India) A sample list of projects that indirectly, or to Industrial Pollution Prevention Project (India) lesser degree, address EH issues or that have the potential to address these issues would Since last year, the South Asia region has include: strengthened its EH work through the follow- ing activities: WSS Projects Bombay Sewage Disposal * Andhra Pradesh study on water, sanitation, Kerala Rural Water Supply & Sanitation and health Karnataka RWSS * ESMAP study on household energy, air Chennai Urban Water 11/111 pollution, and health proposal to launch the Community and Private Sector Water in Sri South Asia Environmental health program Lanka and pilot an EH project in India Nepal Rural Water Supply and Sanitation * The South Asia Environmental Strategy for Nepal Urban Water Rehabilitation the Energy Sector, which attaches the Kseniya Lvovsky 53 Heath and Environment highest priority to indoor and outdoor air Ecuador: Second Social Development: Health pollution from energy use because of its and Nutrition health impacts. Honduras: Health and Nutrition and supple- mental credit for health and nutrition LATIN AMERICA AND THE Panama: Rural Health CARIBBEAN Peru: Health Reform (in preparation) Uruguay: Health Sector Development Environment Portfolio Venezuela: Health Services Reform Mexico: Air Quality Management 11 EUROPE AND CENTRALMA Argentina: Pollution Management (air quality monitoring and long-term strategy develop- The following list of ECA projects includes ment) those that address some aspect of water- and Caribbean: OECS Solid Waste sanitation-related disease (based on a recent Health Portfolio study). It is less clear which projects affect other areas of environmental health. In ECA, Some of the projects listed below include all stand-alone Rural Water Supply and activities related to the management of Sanitation (RWSS) projects in Central Asia aim hazardous hospital waste, and some finance at improving health through improving water activities related to management of vector- and supply and sanitation, carrying out health water-borne diseases. They tend to combine promotion, and monitoring water quality. education, clinical services, and localized environmental management interventions. Albania: Rural Development These include malaria control, or more Azerbaijan. Urban Environment generally, tropical disease control (including Bulgaria: Environmental Liabilities dengue and others)¾/4typically in a very ECA: Regional Environment Project localized fashion3/4including measures such as Kazakhstan: Environment I the cleanup of discarded tires or improvement Kyrgyzstan: RWSS of buildings/drainage to prevent mosquitoes Latvia: Environment from breeding. Liepaja: Solid waste management Lithuania: Geothermal Argentina: Provincial Health Sector Develop- Poland: Geothermal ment; AIDS and STD Control; Provincial Poland: Rural Development Reform Loan 2; Public Health Surveillance Romania: Rural Development to monitor disease from air pollution (under Russia: Environmental Management preparation) Russia: TB and AIDS Brazil: Disease Surveillance and Control Samarkand and Bukhara: WSS (monitors air-related disease in Sao Paulo); Slovenia: Environmental Management Second AIDS and STD Control Turkmenistan: WSS Chile: Health Sector Development Ukraine: Environment Dominican Republic: Provincial Health Uzbekistan: WSS Services 54 Environment Strategy Papers Regional Responses to EH Questionnaire EAST ASIA AND THE PACIFIC Air Pollution The projects listed below meet the following China: seven transport projects criteria: they have as one of their stated China: four urban environment projects objectives to reduce human health impacts, China: Air Pollution Control and they have indicators that relate to improv- Indonesia: Renewable Energy Small Power ing health outcomes (for example, reducing Philippines: Metro Manila Urban Transport BOD/COD levels in local water bodies or Improvement reducing effluent or emissions). Thailand: Clean Fuel and Air Quality Thailand: Bangkok Air Quality Management Water Pollution and Solid Waste Thailand: Highways V Cambodia: Water Supply Rehabilitation MIDDLE EAST AND NORTH AFRICA China: 1 6 urban infrastructure and environ- ment projects Pollution Abatement and Control China: three rural water supply projects Algeria: Industrial Pollution Control China: Huai River Pollution Control I Egypt: Pollution Abatement China: Qinba Mountains Poverty Reduction Project Water/Waste Water and Sanitation: Indonesia: seven urban development/infra- Algeria: Water Supply and Sewerage structure projects Egypt: Social Fund Ill (infrastructure compo- Indonesia: Urban Poverty Project nent), Sohag Rural Development (commu- Indonesia: Second Water Supply and Sanita- nity development component) tion for Low Income Communities Iran: Teheran Wastewater Indonesia: West Java and Jakarta Environment Jordan: Amman Water and Sanitation, Waste- Korea: Kwangju and Seoul Sewerage water Reclamation, Disi Amman Water Korea: Waste Disposal Conveyor Lao PDR: Provincial Infrastructure Project Lebanon: Greater Beirut Water and Sanitation, Mongolia: Ulaanbaatar Services Improvement Awali-Beirut Water Supply, Coastal Pollu- Project tion Philippines: Municipal Development III Morocco: Water Supply V, Sewerage and Philippines: Manila Sewerage 11 Water Re-use, Rural Water and Sanitation Philippines: Water Districts Development Tunisia: Water Supply and Sewerage, Greater Philippines: LGU Urban Water and Sanitation Tunis Sewerage, Water Sector Investment Project Loan Philippines: Solid Waste Ecological Enhance- West Bank/Gaza: South Area Water, Commu- ment Project nity Development I & 11 (component), Wa- Thailand: Bangkok Urban Environment ter/Sanitation Service/Gaza, Southern Area Program Project Water and Sanitation Thailand: Environment Project Yemen: Taiz Water Supply, Public Works 11 Vietnam: Ho Chi Minh City Sewerage Project (component), Sana'a Water and Sanitation Vietnam: Three Cities Sanitation Project Kseniya Lvovsky Health and Env ronment Solid Waste to the health of children and women), Algeria: Algiers Solid Waste because these are high-visibility Lebanon: Solid Waste and Environment problems and there is high client Management demand for projects. (Although de- Tunisia: Municipal Development 11 ( compo- mand for non-sewerage, non-urban nent) sanitation by the actual end-users is West Bank/Gaza: Solid Waste and Environ- quite low.) ment Management LAC: Air pollution is very prominent in Health Sector public awareness in Mexico City and Egypt: Schistosomiasis Control Santiago for obvious reasons. In other Health Sector (hospital waste compo- cities with important water bodies, nent) polluted rivers and beaches attract Iran: Health Sector Development (waste from considerable attention (possibly more rural clinics) for concerns on aesthetics and health Jordan: Health Sector Reform (hospital waste) concerns during recreational activities). Lebanon: Health Project (hospital waste) Media attention to hazardous waste Morocco: Health Finance and Management tends to get the attention of borrowers (hospital waste) and stakeholders. Tunisia: Health Sector Loan (hospital waste) West Bank and Gaza: Health System Devel- ECA: Clients demonstrate awareness of opment (clinical waste) environmental health issues in all of Yemen: Child Development (clinical waste) the national environmental health action plans we have conducted. ECA Transport health sector notes for various coun- Jordan: Amman Ring Road tries discuss environmental health, Lebanon: Urban Transport although the depth varies. Demand for Tunisia: Transport Sector Investment water supply and sanitatiorn projects is Yemen: Multi-mode Transport high in Central Asia. 3. Are your clients (borrowers and stakehold- EAP: Lack of adequate water supplies and ers) aware of environmental health issues? If inadequate sanitation have long been so, which areas are most important in their recognized in the region as key devel- perception? Why? opment issues, due in part to the impacts on human health. The large SAR: They are largely aware of vehicular and lending program in the region for water industrial air pollution, pesticides, supply and sanitation shows the great polluted drinking water, and poor importance that our clients (and the sanitation. Recently, Indian environ- Bank) have placed on water pollution, mental authorities started paying more and, by association, water-related attention to indoor pollution (thanks to diseases. new assessments of immense damage 56 Environment Strategy Papers Regional Responses to EH Questionnaire There is a growing concern among our clients, water and sanitation has been client countries over urban air pollu- always high on the agenda, but this tion issues: lending in this area-while was not considered to be a health still lagging far behind water supply intervention, and project designs did and sanitation-has been growing. The not aim to maximize the health im- extent to which human health concerns pacts. Urban air pollution is an emerg- have dominated the concern for air ing priority (Dhaka Air Quality LIL pollution control, in comparison to under preparation, request for an air economic and productivity impacts, pollution project in Delhi). Recently, such as damages to agriculture (acid regional management has become rain) or tourism, is not clear. Studies more aware and supportive of EH, funded by the Bank and others have resulting in a small budget to promote shown that human health damages EH activities. Integrating these issues in from air pollution far outweigh other projects is still a challenge because of economic losses and, in China, are the complex and multisectoral nature probably larger than the impact of of environmental health. water pollution. LAC: If the counterparts in a country are MNA: Water pollution is considered to be the interested in addressing a problem with most important health issue. The MNA EH implications, the project tends to region is characterized by lack of water include such issues. However, except resources, poor water quality, and lack for "brown" environment projects (and of wastewater treatment and sanitation. even in those), few activities directly Of 250 million people in 1990, 45 address environmental health issues. million lacked access to safe drinking water, 85 million lacked access to safe ECA: No explicit decisionmaking process, sanitation, and only 20 percent of until recently, in regard to including urban wastewater was treated. Air EH issues in lending. pollution from industry and transport is also gaining the attention of our clients, EAP: The majority of projects addressing largely because of media coverage. environmental health issues fall within the urban environment portfolio, and 4. How are decisions made in your region are driven by demand for urban whether or not to include environmental environmental projects by our client health issues in lending (cost? available countries. There is limited involvement technology? media attention?) What are the in EH issues by the health sector, or tradeoffs? through "health" projects. SAR: The decisionmaking process depends Most projects in the region address EH on client demand, availability of sector issues only indirectly; health outcome work, and the knowledge and interest indicators associated with air-pollution of Bank staff in response to issues. For control or wastewater projects are Kseniya Lvovsky 57 Health and Environment rarely measured, and only a few health some interest, but neither has a man- surveys have been conducted before or date. during project implementation. EAP: Environment bureaus and public health MNA: The decisionmaking process for agencies are responsible for the lending is not principally guided by EH majority of EH issues; however, these issues. With the exception of the agencies are not usually the key actors pollution abatement and control and with which the Bank is involved in its the wastewater treatment projects, EH environmental health-related projects. issues are identified to justify a project's positive environment impact. MNA: No single agency has responsibility for environmental health issues. Usually 5. WVho is responsible for environmental the ministry of environment is respon- health issues in your client countries (environ- sible for ensuring that the responsible ment and/or health ministries/agencies or agencies (ministries and local govern- other)? ment) apply environmental laws and guidelines. The ministry of health is SAR: No single agency actually has clear responsible for all health-related responsibility for EH, due to its projects. Ministries of equipment, multisectoral nature. But the environ- housing, and water resources are ment department or ministry would be responsible for water and wastewater the default, especially for industrial issues. pollution and air pollution (outdoor and indoor). Other agencies or depart- 6. Did the projects listed in response to ments that have played a role include question 2 attempt to quantify and prioritize health and family welfare, irrigation/ environmental health (cost/benefit, cost- agriculture, social welfare, transport/ effectiveness)? If so, which ones? civil works. Because EH is a cross- sectoral issue, inevitably all these SAR: Cost-benefit analysis was carried out agencies have been involved at one for a small number of projects, includ- point or another, although none takes ing components in Dhaka Air Qualitv primary~ ~ ~~~~~~~n componentsit inr DhkEArQult primary responsibility for EH. Management, Bangladesh Arsenic and School and Community Sanitation LAC: Years back, health authorities used to Projects, India Fifth Rural Water Supply handle these issues, but gradually they Project, Cnnai uran Water and have been moved to the purview ofPrjc,CeniUbnWt,ad Clean Settlements in Sri Lanka. For environmental authorities. In general, others, the economic rate of return was there is animosity between these calculated, but for the entirety of the agencies and little communication and calculated, utifor the tie oH coordination. ~~~~~~project¾/not uniquely for the EH coordination. components. The India State Health Systems Project looked at DALYs lost! ECA: EH falls between the cracks. Both y environment and health ministries take saved from communicable diseases, 58 Environment Strategy Papers Regional Responses to EH Questionnaire which can be prevented by EH inter- been undertaken as part of project ventions. preparation for any of the projects mentioned in question 2. The LAC: The health projects above address Chongqing epidemiological survey of these topics as secondary or localized air pollution health effects, funded by activities. It has not been possible to PHRD funds, is an exception. check whether quantification of benefits or cost-effectiveness analysis MNA: Algeria: Industrial Pollution Control was carried out for those activities. Egypt: Pollution Abatement Reviewing the project assessment documents might reveal something in 7. Which sectors normally provide loans for this regard. The rest of the portfolio EH issues in your region? contains limited examples of cases in which indicators of environmental SAR: Water and sanitation, urban, health, health have been used, in part because and environment sectors. To imple- many are too upstream from actual EH ment a new energy and environment improvements (such as Argentina strategy, the energy unit would have to Pollution Management). Only the join the list. Mexico Air Quality 11 project under preparation is attempting to quantify LAC: Environment and health. Infrastructure, health outcomes as end-of-program if you count the improvements in water indicators (in addition to air quality supply, sanitation (including solid indicators). These indicators would be waste), drainage, transport, and supported under the project through a mining, could also be included. series of special studies. ECA: A recent review shows that rural ECA: We have extensive information on WSS development and Social Fund projects projects, both stand-alone and other represent a significant share of the projects-that is, when WSS is but one investments in WSS-almost equal to component, as in social funds. stand-alone projects. Social Funds are spread around in different departments. EAP: Generally not. We have not had time It took a lot of research to determine to go through all 50-plus project exactly what is included in the Social documents (and this is only a partial Funds/rural development projects. A list). Regarding water pollution, staff detailed examination of projects in appraisal reports often claim, correctly, other sectors might reveal that, in fact, that it is difficult to quantify the EH environmental health is being ad- effects. Baseline health information is dressed. Officially, EH is being covered thus often deduced from experiences in through infrastructure (WSS), energy, other countries, or relies on studies environment, and health. done by other agencies (such as WHO and UNICEF). Few EH surveys have EAP: Urban, environment, urban transport. Kseniya Lvovsky 59 Health and Environment MNA: Health and education, infrastructure direct health data is almost never development, rural development, collected as part of the project. water, and environment. MNA: Algeria: Industrial Pollution Control 8. Have indicators been developed to Project: Reduced perceived respiratory monitor the current projects? Who is respon- morbidity (%); decrease of pollution sible for enforcing and evaluating the compo- loads of TSS, S02, and NOx in City of nents in your client countries? Annaba. SAR: (a) Bangladesh Arsenic Mitigation Egypt: Pollution Abatement Project: Output Project, Bangladesh School & Commu- indictors for major pollutants were nity Sanitation, Sri Lanka Clean Settle- developed for each industrial sub- ments, Chennai Urban WSS, Mumbai project. Urban Transport, Dhaka Air Quality Management. Tunisia: Transport Sector Investment: Reduc- (b) Evaluation of components is joint tion of lead in gasoline. responsibility of governments and the Bank. Government agency or agencies The project implementation unit of involved would be the borrowers. each project is responsible for evaluat- ing these indicators. Ministries of the LAC: Examples from Mexico Air Quality 11 environment are responsible for follow- (under preparation): Cases of respira- up. tory attacks, rate of emergency room tory attacks, rate of emergency room 9. What environmental health issues do you visits for respiratory problems, emer- gencysalerts for aespiratory quablty, efeel still need to be addressed in your region? gency alerts for air quality. Responsibility rests with the executing SAR: Reisponsibilit projests wih heexcuin * Indoor air pollution (energy, health, and units of each project.eniomtnxu) environment nexus). * Emphasizing the linkages and interventions ECA: The only information on indicators is between WSS diseases and health out- what we found in the recent study comes. "Performance Monitoring Indicators for U Urban air pollution. Sanitation and Health Components of U Linking with other sectoral efforts in Rural WS&S Projects." interdisciplinary manner, especially with nutrition and education (formal and non- EAP: All "A" and "B" projects have to formal) activities, since nutritional status of establish environmental-mitigation a young child determines the degree of plans (EMPs), which monitor water vulnerability to respiratory and diarrheal quality, effluent loads, and other infections. pollution-related indicators. While * Focus on health, especially child survival, health issues are almost always men- as a major outcome of a variety of cross- tioned, data are usually anecdotal, and sectoral activities. 60 Environment Strategy Papers Regional Responses to EH Questionnaire LAC: 10. What steps would you like to take in the * We do not have a good handle on the near future to address these issues (if money localized implications of poor solid-waste and time were no concern)? disposal practices for municipal and industrial/toxic waste. We need to use more SAR: Resources to be used for advocacy, risk assessment in projects to determine sector work, and project preparation of which conditions warrant often costly EH projects or components. remedial action. * Occupational health and safety-should this Also, efforts to be spent on defining the be part of our labor markets reform or intersectoral collaboration necessary health reform dialogue? for EH activities. Learn from work/ * We need to improve our work on indicators experience from other regions to be for the existing projects that may render able to apply existing knowledge some environmental health benefits, within Bank to actual country activities. including a number of infrastructure Go beyond studies and developing investments (water, transport, and others). monitoring indicators to pilot existing This would help improve the economic indicators and make them workable analysis of projects (from the benefits side). and user-friendly to non-environment and non-health disciplines (such as ECA: infrastructure, energy, and rural * Communicable diseases, especially tubercu- development. Implications: depending losis (health department working on this). on how project documents are written * Urban air pollution. up, a project could be doing quite a bit * Sanitation. on EH, but if not described explicitly, * Rural water supply. we would not have included it in the primary list. Further, there is no EAP: guarantee that projects with explicit EH * Urban air pollution and its relationship to objectives will actually carry out the public health. activities unless they are also to be * Public health benefits of the Bank's WSS monitored under Key Performance/ program in the region. Output/Outcome indicators. * Indoor air pollution. * Industrial health and safety. LAC: Develop a few case studies within * Traffic safety. projects that can fund risk-assessment exercises for solid waste dumps and MNA: contaminated sites. * Morbidity due to air pollution (indoor, industrial, and urban). ECA: Include an environmental health * Linkages between WSS diseases and health analysis in the EA process. outcomes. * Food and health hygiene. EAP: Additional sector work on air and * Environment education in schools. water pollution impacts in our client Kseniya Lvovsky 61 Health and Environment countries. For operations, it is impor- evaluate the magnitude and severity of tant to develop low-cost ways (or costs air and water pollution and its linkages appropriate to the level of expenditure to public health. EH issues should be on other issues) of tracking and moni- part of the CAS. Non-lending services toring health outcomes or "reasonable" should be provided to strengthen the indicators of health outcomes. Under- capacity of institutions on environment/ taking basic health surveys as part of health issues, provide reliable health project preparation for projects in and environment information, intro- which EH is used as a primary justifica- duce a methodology for quantifying tion for the project, such as wastewa- health impacts, and develop health ter, sanitation, and air pollution indicators. Develop case studies for control. studying groundwater pollution due to non-point and point sources of pollu- MNA: Rapid health-risk assessment should be tion. undertaken in pilot countries to 62 Environment Strategy Papers / Notes 1. See Annex 2 for more detail on the methodology, coverage of monitoring systems means that as well as World Bank, 2000a, pp.92-100. most of the non-U.S. data is for cities or 2. Note that large variations were found in metropolitan regions with populations of cost-effectiveness of urban air pollution more than 500,000. control measures-from negative costs (win- 5. For the different approach, see Chapter 3 in win solutions) to several thousand and even World Bank 1997. millions dollars per DALY saved. This 6. See, for example, Overview and Chapter 1 stresses the need for a more rigorous in World Bank 1992 and references. economic analysis of Bank-supported urban 7. Described in Sivayorathan and others 1995; air quality management strategies. Lessenger, Estock, and Younglove 1995. 3. Estimates by Murray and Lopez 1996 assign 8. Parron, Hernandez, and Villanueva 1 996; 13 percent of the total burden of disease in Ruijten and others 1994. Sub-Saharan Africa in 1990 (38 million 9. The disease groups include: liver and pancreas DALYs) to respiratory diseases. Adjusting cancer, melanomas and other skin cancers, for population growth, the estimate of the lymphomas and multiple myeloma, endocrine ill health associated with indoor air pollu- disorders, unipolar major depression, cataracts, tion was about 13 million DALYs in 1990, nephritis and nephrosis, rheumatoid arthritis, or about 35 percent of the total burden of congenital anomalies (excluding spina bifida respiratory disease. This share is consistent and congenital heart anomalies), and poison- with the difference between Africa and, for ings across all age groups. example, Latin America and the Caribbean, 10. This Annex is based on Listorti, Doumani, in terms of the respective contributions of and Hammer 1999. indoor air pollution to the total burden of 11. This Annex is based on Listorti 1996, Vol. IlIl. respiratory disease. 12. Reviewers from the London School of 4. The main sources of data were the AMIS Hygiene and Tropical Medicine, St. database, compiled by WHO, and statistics George's Hospital Medical School (Lon- reported by various environmental agen- don) and the Centers for Disease Control cies, in particular the U.S. Environmental (Atlanta) were asked to participate in a Protection Agency and the European workshop June 1-2, 1995, to comment on Environmental Agency. Limitations in the World Bank 1994c. 63 / References Binka F. 1997. "The Cost-Effectiveness of Management-Science, Economics and Law. Permethrin Impregnated Bednets in Prevent- Washington, D.C.: World Bank, pp. 94-114. ing Child Mortality in Kassena Nanakana Listorti, J., F. Doumani, and A. Hammer. 1999. District of Northern Ghana." Health Policy Environment and Health-Bridging the 41:229-39. Gaps. Washington, D.C.: World Bank. Esrey, S.A., J.B. Potash, L. Roberts, and C. Shiff, . Forthcoming. Environmental Health 1991. Effects of Improved water supply and Assessment Guidelines. Africa Region. sanitation on ascariasis, diarrhea, dracuncu- Washington, D.C.: World Bank. liasis, hookworm infection, schistosomiasis, Lvovsky, K., G. Hughes, D. Maddison, B. an trachoma. Bulletin of the World Health Ostro, and D. Pearce. 2000. Environmental Organization, Vol. 69 (5), pp. 609-621 Costs of Fossil Fuels: A Rapid Assessment Hughes, G., K. Lvovsky and M. Dunleavy, Method with Application to Six Cities. 2001. Environmental Health in India: Environment Department Paper No. 78. Priorities in Andhra Pradesh. South Asia Washington, D.C.: World Bank. Social Development and Environment Unit, Murray, C., and A. Lopez. 1996. The Global Washington, DC. Burden of Disease. Cambridge, Mass.: Lessenger, J. E., M. D. Estock, and T. Young- Harvard University Press. love. 1995. "An Analysis of 190 Cases of . 1997. "Global Mortality, Disability, and the Contribution of Risk Factors: Global Suspected Pesticide Illness." Journal of theBudnoDiesSty.ThLnct39 American Board of Family Practice 8:278-BudnoDiesSty.ThLact39 82i Ostro, B. 1994. "Estimating the Health Effects of Air Pollutants: A Method with an Applica- Listorti, J. 1996. Bridging Environmental Health to tAk Pol icy Research Working Gaps:Lessns frm Su-Sahaan Arication to Jakarta.' Policy Research Working GnfrapstrLesso fromects. Wubasharang AfiCa Paper 1301. Washington, D.C.: World Bank. Infrastructure Projects. Washington, D.C.: Parron, T., A. F. Hernandez, and E. Villanueva. World Bank. 1 996. "Increased Risk of Suicide with . 1999. "Environmental Health Dimen- Exposure to Pesticides in an Intensive sions of Climate Change and Ozone Deple- Agricultural Area: A 12-Year Retrospective tion." In I. Serageldin and J. Martin-Brown, Study." Forensic Science International eds., Partnership for Global Ecosystem 79:53-63. 65 Health and Environment Reddy, A. K. N., R. H. Williams, and T. B. WHCO (World Health Organization). 1997. Johansson. 1997. Energy After Rio: Pros- Health and Environment in Sustainable pects and Challenges. New York: United Development. Geneva. Nations Development Programme. .1999. Annual Report. Geneva. Ruijten, M. J., et al. 1994. "Effect of Chronic World Bank. 1992. World Development Mixed Pesticide Exposure on Peripheral and Report: Development and Environment. Autonomic Nerve Function.' Archives of Washington, D.C. Environmental Health 49:188-95. .1993. World Development Report: Sivayorathan, C., et al. 1995. "Protective Investing in Health. Washington, D.C. Measures Use and Symptoms among Agro- _ . 1 994a. Chile: Managing Environmental Pesticides Applicators in Sri Lanka." Social Problems-Economic Analysis of Selected Science Medicine 40:431-36. Issues, Report 13061-CH. December. Smith, K. R. 1993. "Fuel Combustion, Air .1 994b. Environment and Health in Pollution Exposure, and Health: The Central and Eastern Europe, Report 12270- Situation in Developing Countries." Annual ECA. February. Review of Energy and Environment _ . 1994c. Estimating the Health Benefits 18:529-66. of Air Pollutants: A Method with an Appli- . 1998. Indoor Air Pollution in India: catlion to Jakarta. Policy Research Working National Health Impacts and the Cost- Paper 1301. May. Effectiveness of Intervention. Goregaon, _. 1994d. Thailand-Mitigating Pollution Mumbai, India: Indira Gandhi Institute for and Congestion: Impacts on a High-growth Development Research. Economy. Country Economic Report .1999. "Indoor Air Pollution.' Dissemi- 11 7700-TH. February. nation Note, Pollution Management Series, .1995a. Argentina: Managing Environ- Washington, D.C.: World Bank. mental Pollution-Issues and Options, Smith K and S. Mehta, 2000. The Burden of Report 14070-AR. October. Disease from Indoor Air Pollution in . 1995b. Kyrgyz Republic: National Developing Countries: Comparison of Environmental Action Plan, World Bank Estimates. Background paper for US AID/ Inlrastructure, Energy and Environment WHO Global Consultation on Indoor Air Division, Country Department 3, Europe pollution and household energy in develop- and Central Asia Region, No. 13990. March ing countries, Washington, DC. May 3-4. 13. . C. Corvalan, and T. Kjellstrom. 1999. _. 1995c. Middle East and North Africa "How Much Global Ill-Health Is Attribut- Environmental Strategy: Towards Sustain- able to Environmental Factors?" Epidemiol- able Development, Report 13601-MNA. ogy Journal. September. . 1995d. "Monitoring Environmental Stephen C. 1998, Providing Urban Environ- Progress: A Report on Work in Progress." mental Services for the Poor: Lessons March draft. Learned from Three Pilot Projects, Environ- _. 1995e. "National Environmental ment Health Project, Washington, D.C.: Stiategies: Learning from Experience." U.S. Agency for International Development. March. 66 Environment Strategy Papers References _ .__* 1 995f. "Taking Stock of National ---. 2000a. Fuel for Thought: An Environ- Environmental Strategies." March. mental Strategy for the Energy Sector . _ . 1995g. Valuing Environmental Costs in Annex. 2 Washington D.C. Pakistan: The Economy-Wide Impact of . 2000b. India, Andhra Pradesh: Water, Environmental Degradation, Country Household Environment and Health. South Economic Memorandum for Pakistan FY95, Asia Environment Unit, Washington, D.C. World Bank Asia Technical Department, World Resources Institute. 1998. A Guide to Environment Division. April. the Global Environment: Environmental . 1997. Clear Water, Blue Skies: China's Health and Human Health. New York: Environment in the New Century. Wash- Oxfordl University Press. ington, D.C. ____. 1999. World Development Indicators. Washington, D.C. Kseniya Lvovsky 67 Environment Department The World Bank 1818 H Street, NW Washington, DC 20433 USA For information: ESSD Advisory Service Telephone: 202-522-3773 Facsimile: 202-522-3243 E-mail: eadvisor@worldbank.org Web: www.worldbank.org/eadvisor