DRAFT ENVIRONMENT AND HEALTH POSITION PAPER
A South African Civil Society Draft Submission for the Preparatory Process for the World Summit on Sustainable Development
At the United Nations Conference on Environment and Development (UNCED) held in Rio de Janeiro a decade ago, the inextricable links between the environment and development were highlighted. The Rio Declaration emphasized that "human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature." Chapter 6 of Agenda 21 (the "blueprint for sustainable development" which emerged from UNCED) dealt with health aspects. The key issue is that without healthy, productive people, sustainable development is not possible, and without sustainable development, the health and productivity of people is compromised.
2. THE IMPACTS OF DEVELOPMENT WHICH IS NEGLECTFUL OF HEALTH
2.1 The Double Burden of Disease
In general, environmental threats may be separated into ‘traditional’ and ‘modern’ hazards, associated largely with under-development, and inappropriate development, respectively. ‘Traditional’ environmental health concerns may include, for example, a lack of access to safe water supplies, sanitation facilities and adequate waste disposal services. ‘Modern’ environmental health concerns, on the other hand, may refer to exposure to lead in the environment, ambient air pollution from vehicles, and chemical pollution of the environment from industrial activity. Developing countries tend to experience predominantly the former, and developed countries the latter.
In countries such as South Africa, which have elements of both a developed and a developing country, people may be at risk of exposure to the environment and health concerns associated with both traditional and modern hazards. Communities living in squatter settlements in close proximity to industrial sites for example, may simultaneously face the hazards of a lack of water and sanitation and chemicals exposure in ambient air, water and soil.
In Africa, around one-third of the burden of disease is attributed to factors in the environment. Diarrhoeal diseases (associated with inadequate sanitation services and water supplies, poor surface water drainage and poor housing) and acute respiratory infections (associated with the use of polluting fuels such as coal, wood, animal dung, crop waste and paraffin, and poor housing) continue to be the biggest killers of young children, and the major reasons for use of the health services in the country. On a global level, 90% and 60% respectively of the burden of diarrhoeal diseases and acute respiratory infections are attributable to factors in the environment. Even less is known about other less obvious, but nevertheless significant environmental health threats, for example the "silent epidemic" of childhood lead exposure.
There is little doubt that poverty is a powerful determinant of environmental quality (and of levels of development), and of human health and well-being. A WHO report suggests that children from poor households in developing countries are 40 to 50 times more likely to die before the age of five years than their developed nation counterparts. Compared to Europe and North America, infants and young children in developing countries are several hundred times more likely to die from preventable, environment-associated diseases such as diarrhoea and pneumonia. In the poorest countries of the world between a quarter and a third of all children die before the age of five years. Among the poorest people within these countries, as many as one in two children die before that age. Much of the poverty-related burden of ill health is preventable.
Forces such as urbanization, levels of scientific and technological development and globalisation may also be at the root of certain environmental health problems. The HIV/AIDS epidemic may increase the vulnerability of people to environmental exposures, and reverse the gains made in respect of diarrhoeal diseases and acute respiratory infections, and mortality overall.
2.3 Racism in Environmental Exposures
While the course and effects of Racial Apartheid in South Africa (and its origins in the colonial period of occupation) are well documented, less has been written on the iniquitous system of Global Apartheid. Here the effects are seen worldwide in immigration policies and discrimination against the mobility of poor people. The same might be said of environmental hazards globally, which is usually foisted on poorer countries by an unsuspecting (or corrupt) government in collusion with transnational corporations. In South Africa, for example, the apartheid system through a combination of influx control legislation inside its own borders, the Group Areas Act, and education and labour preference policies, made sure that the worst environmental hazards were socially engineered to threaten the poorest communities.
2.4 The Role of Environmental Health Services
Many of the key determinants of health and disease (as well as their solutions) lie outside the direct control of the environmental health sector; for example in sectors concerned with housing, transport, energy, environment, water and sanitation, education, finance, and industry. When decisions in respect of policies and programmes are made in relation to these sectors, scant attention is usually given to the health implications, which may often be serious.
Emerging environmental health paradigms imply the need for a shift from reactive approaches towards comprehensive, integrated, preventive management of the environment for health - as for example with air quality management, as opposed to air pollution control. This shift suggests intervention by the environmental health sector at the early planning stage of development, and continuous environmental surveillance and evaluation within a context of trans-disciplinarity.
In order to improve environmental health for all, we call for:
- Commitments to the goals and targets of the renewed Health for All strategy and the Millenium Development Goals
- Meaningful implementation and enforcement of the conventions, accords and declarations that support sustainability of the environment and human health. There should be effective participation of the health sector to ensure that health protocols are included in Multilateral Environmental Agreements (MEAs)
- Setting and implementation of commitments and action plans for moving environmental consumption patterns at the individual, national, and international levels towards options that are sustainable and health-promoting
- Support for research into the linkages between environment and health, and into the interventions appropriate for developing country settings
- Support for research into the environmental causes of the major burdens of disease
- Development and Provision of Specialist Training at tertiary institutions - in respect of, for example, environmental epidemiology and health impact assessment.
- The establishment of a meaningful national environment and health surveillance network
- Develop indicators to monitor environment and health status, and efforts toward sustainable development
- Increased attention to the role of environmental health promotion (in accordance with the strategies of the Ottawa Charter for Health Promotion) in public health
- A programme of action, based on a multi-sectoral effort, to empower people to protect and promote their health and well-being through improved health literacy by 2010
3.1.1. Air quality (lead, asbestos, noxious gases, particulates, hydrocarbons)
- Banning of asbestos products, especially roofing
- Stricter protective measures for asbestos workers
- Public education programmes aimed at raising awareness of the hazards of asbestos, the need for adequate housing maintenance, and the risks associated with informal or self-implemented repair, renovation, removal and disposal of household asbestos products.
- Provision of services for the safe removal and disposal of asbestos in low-cost housing and schools, as necessary.
- A commitment to the widespread use of unleaded exposure
- The establishment of a national childhood blood lead surveillance programme
- The development of childhood blood lead standards
- The development of standards for lead in paint
- The development of protocols for the screening and treatment of children at high risk of lead exposure
- Increasing the consumption of unleaded fuels by enforcing conversion measures of older vehicles. Introduction of unleaded diesel.
3.1.2. Water quality (e-coli, cholera, bilharzia, contaminants)
- Governments must act decisively against industries polluting groundwater and surface water resources
- Industrial effluent must be tested using whole-effluent-toxicity (WET) tests
- Regulations are urgently needed to give effect to the South African National Water Act of 1998, in particular regulations on water quality
3.1.3. Soil quality (parasites, pesticide-herbicide residues, POPs, heavy metals)
- Governments must fulfil their obligations to the UN Stockholm Convention on Persistent Organic Pollutants (POPs) by putting in place action plans and time frames for the phasing out and eventual elimination of dioxins and furans.
- Governments must compile inventories of all POPs sources and stockpiles.
3.1.4. Energy (fires, paraffin, gas, candles)
- Develop standards for safe appliances for use in the home.
- An agreement on measures to reduce death and suffering from indoor air pollution by 50% by 2015, through the use of cleaner sources of energy, safer appliances and provision of means for removing the products of combustion in homes where the continued use of solid or liquid fuels seems likely.
- The establishment of a national database on paraffin ingestion and carbon monoxide asphyxiation.
- Electricity must not be privatised because privatisation puts electricity for domestic consumption beyond the reach of the poor.
- Research and promote safe renewable sources of energy (e.g. solar, wind) and make these available to communities
- People must be protected from industrial and community sound pollution to prevent hearing loss and elevated stress and anxiety levels
- To protect against industrial sound pollution (from factories, machines, etc.), workers must be given protective gear. These activities must be far away from residential areas or the buildings must have adequate insulation to keep the noise inside. Also, open-plan or shared office environments must be regulated to protect workers from environments that are so cramped and noisy that their stress or anxiety levels rise.
- To protect against community sound pollution, bars, clubs and restaurants must be regulated to emit only certain levels of noise from music, air conditioning systems and patrons. Declining building quality must be regulated to establish adequate sound proofing in buildings to protect against noises from neighbours and fellow occupants. Residents of formal and informal settlements must have legal recourse against sound pollution offenders. This must extend beyond warnings to possible fines and confiscation of noise-generating equipment from repeat offenders. Noises emanating from vehicles (engine, exhaust and "music") must be regulated and punishable in the same way that driving recklessly is punishable.
3.2. Community Health
3.2.1. Communicable diseases (cholera, diarrhoea, malaria, TB, STDs)
- Better surveillance and monitoring of communicable diseases
- More resources needed to support research and development of new and improved technologies to intensify routine prevention and control of communicable diseases
- Comprehensive immunization programme against cholera must be implemented
- Greater allocation of resources to the fight against TB and a more concentrated effort by government to eradicate this disease
- National STD treatment and education campaign
- Country-wide administration of anti-retroviral medications to reduce mother-to-child transmission
- Post-exposure anti-retroviral prophylaxis for sexual assault
- 100% coverage of treatment for people with HIV/AIDS who utilise the private health sector by the end of 2002
- Further price reductions for anti-retrovirals to make them accessible to all
- Price reductions for diagnostic tests and tests monitoring the efficacy of anti-retroviral treatment (ARV)
- Grant-driven research (rather than profit-driven research by pharmaceutical companies) into ART determining the most appropriate and well-tolerated combinations of medicines taking into account the needs of women and children as well as conditions that exist in developing countries such as South Africa; improved clinical algorithms or simple laboratory markers that can replace some expensive current laboratory monitoring; long-term cohort studies investigating adverse drug events; and the interactions between TB and HIV therapies.
- A minimum of three drugs as the standard of ART care
- Respect for patients' rights to information and to fully-informed consent before starting treatment
- Comprehensive and urgent training of nurses, doctors and community health care workers in ART in the public and private sector
- Health systems ensuring patient care and support, efficient delivery of medicines, adherence monitoring and staff support
- Public information and education that creates a culture of openness about HIV and AIDS and awareness that it can now be medically managed with ART
3.2.3. Chronic diseases (mental illness, cancer, diabetes, hypertension, substance abuse, respiratory diseases, malnutrition)
- A more inclusive definition of mental health must be promoted that does not relate mental health merely to psychiatric aspects and mental disability, but also to the whole dimension of psycho-social competency, skills and well-being
- Appropriate treatment and training programmes must be accessible to people with special mental health care needs. These programmes must be non-discriminatory and geared towards social integration
- There must be adequate consultation regarding the development of regulations to implement the new SA Mental Health Care Bill (published in the Government Gazette in August 2001)
3.2.4. Women's health and reproductive health
- Mainstream gender at every level and every facet of development
- Recruit women in employment/development programmes, for example, Working for Water, but not as exploitation or cheap labour, where women are found to be more reliable workers and family health improved
- Use women as lay counselors, e.g. HIV/AIDS
- Sustainable reproductive health programmes must focus on the physical, psychological, educational and economical development of women as a whole.
- A participatory approach highlighting the critical role that women play in society is needed for the sustainability of long-term objectives of any reproductive health projects.
- Women must be provided with the knowledge (contraception, nutrition, health risks eg. STDs & HIV/AIDS) to make decisions regarding their reproductive role in society, the means (contraception, prenatal services, delivery, postnatal and obstetrics), to undertake this role, and the support (family, finances, emotional support, child care facilities) for the implementation of this role. All of this should be promoted in an environment of care, concern, respect and dignity for women as critical role players in nation building.
- Stricter legislation and monitoring of child labour
- Safer control of landfill sites and dumps
- Improved traffic legislation and control, increased numbers of pedestrian crossings
- Safe play and walk areas
- Legislated child restraints in all vehicles, especially buses and taxis
- Enforcement of the Tobacco Act prohibiting public smoking and sale of cigarettes to minors
- Education of pregnant mothers and fathers of the influence of tobacco smoke on unborn babies and children in the home
- Education of parents about nutrition and rehydration of infants to prevent death through diarrhoea
3.2.6. Housing and settlements
- Specific commitments to set housing standards that reflect the need for thermally-efficient, properly ventilated housing, particularly in high-lying areas where winter nights are cold.
- Specific commitments to environmental upgrading in sites of environmental health crisis (such as the efforts now underway as part of the Alexandra Renewal Project).
3.2.7. Poverty and community development
- To improve health and prevent the physical, mental and sexual abuse resulting from poverty, people must be enabled to lift themselves out of poverty through removing the obstacles preventing them from doing so
- Give people - especially those in informal settlements and rural areas - access to good quality services which are affordable (transport, water, sanitation, low-cost housing, infrastructure, etc)
- Promote rural development
- Densify our cities so that people live close to work and public transport becomes viable
- Improve social grants, social services, food security and other safety nets for impoverished communities
- Access to land and employment opportunities
- Provide excellent education
- Train community development workers
- Promote effective community leadership and governance
- Reduce barriers to the start-up of small businesses (simplifying rules and regulations)
3.3. Industrial/Occupational Health
- Development of occupational health and safety education and materials for small businesses and their workers. This will require specific campaigns as this sector is not represented in the usual forums, nor the workers unionised.
- Greater and enforced penalties for violating the law (including failure to report occupational injuries or diseases).
- Protection of special vulnerable and disempowered groupings, primarily children at work; pregnant females (or females of childbearing age); agricultural, forestry and farmworkers.
- Serious upgrading of the Labour inspectorate, with ergonomics, occupational hygiene and medicine expertise to deal with complex occupational exposures and diseases.
- Improved forms of chemical hazard communication for supervisors and workers rather than reliance on Material Safety Data Sheets (despite their endorsement in SA statute and by the ILO).
- Overhaul of the inequitable and inefficient compensation system for occupational diseases.
- Improvement of the system of assessing ex-workers who have been exposed to silica and asbestos (and other respiratory hazards) for purposes of diagnosis and compensation.
- Rights of disabled workers must be protected, especially those disabled through workplace injuries or diseases, with regard to protection of jobs and benefits.
3.4. Public Health
3.4.1. State hospitals and clinics
- Better health budgets and delivery capacity
- Better health service management and information systems
- More resource provision/distribution from central to provinces, regions and districts
- Reverse the deterioration of existing health facilities
- Creation of community facilities and support systems
- Funding and sustainability for NGOs and health sector
- Greater accessibility of health services/bureaucratic processes
- Greater accessibility of available resources, for example, ambulances. Transfer resources to level of delivery in the community/district
- Better human resource development and training and better attrition and retention.
- More community health workers/auxiliary
- Continuity of care required. For example, treatment in hospital not available in community after discharge (especially in research trials)
3.4.2. Public health programmes and policy
- Rather than merely respond to health problems through treatment at hospitals and clinics, a pro-active, preventive focus is called for, which is based on the analysis of routine monitoring and surveillance data, and an examination of the root causes of ill health in society (for example poverty, industrial pollution and use of polluting sources of energy).
- Develop/strengthen mechanisms for inter-sectoral action.
- Preparation of a national State of Environmental Health Report
- Preparation of a National Environment and Health Action Plan (NEHAP)
- The preparation of local action plans for health.
- Implementation/strengthening of Healthy Cities initiatives
- Widespread, compulsory use of Health Impact Assessments for major development policies, development plans, programmes and projects.
- Improve implementation of post 1994 policies and participation of civil society. Better accountability re implementation and delivery required, for example, national transportation plan essential for access to services has not been implemented
- Old legislation still in place, for example, the Mental Health Act, Nursing Health Act, Provincial, town and Regional Planning Act, National Health Bill
3.4.4. Water reticulation, drainage and flood control
- Improved drainage and flood control in informal settlements to prevent health hazards
3.4.5. Water supply and sanitation
- Strengthened action on commitments to reduce water-related diseases through improved sanitation, personal and environmental hygiene, and quality and quantity of water.
- Better management of scarce water resources
- Water services must not be privatised, because privatisation puts safe water supplies for domestic consumption beyond the reach of the poor. Instead, large commercial enterprises and factories must pay more for their water consumption.
- Reduce costs by providing potable water (water of drinking water standard) for drinking and cooking only and not for washing, irrigation, and sanitation
- Educate households about the removal of turbidity and microbiological activity through filtering and disinfection using bleach, or using ultra-violet light in a process called solar disinfection.
- Waterborne sewage for all is unsustainable given the cost involved and the lack of adequate water supplies. Sustainable dry sanitation systems must be implemented where possible and people educated about its benefits.
- A regulatory environment is needed that gives incentives to those prepared to implement sustainable sanitation systems and penalises those who use excessive amounts of water (by means of a rising block tariff, for example).
- Communities must be empowered to participate in decision-making regarding the type of sanitation service suitable and affordable to them
- Sanitation schemes must be managed as locally as possible to reduce the cost of running the schemes and ensure that money is retained in the local area
- Improved sanitation in schools must be prioritised to enable school children to act as change agents for their communities.
- Where it is not possible to monitor actual incidences of disease, authorities should monitor that the conditions are in place for improved sanitation
3.4.6. Solid waste management (including toxic and medical waste)
- The "polluter pays" principle should be applied when health and the environment are threatened and the precautionary principle adhered to.
- Integrated waste management systems that promote waste minimisation, prevention, recycling and reuse must be implemented.
- Improved disposal of domestic waste, especially in informal settlements
- Where centralised refuse collection is unaffordable, it must be demonstrated to households how to safely dispose of refuse in this environment
- New waste incinerators must be banned and existing incinerators phased out and dismantled.
- Composting must be used for biodegradable municipal waste and recycling for non-biodegradable municipal waste. Alternative, non-thermal technology, such as autoclaves and sterilizers, must be used to dispose of medical waste. Resources must be allocated for research into safe alternatives for disposing of hazardous waste.
- The use of mercury and PVC must be phased out in all health care institutions and governments must prescribe procurement practices for health care facilities that would ensure that unnecessary pollutants (eg. excess plastic packaging, mercury-containing products, etc) do not enter the facilities.
- Governments must develop guidelines for the safe management of health care waste and allocate more funding to the implementation of these guidelines and to education around safe health care waste management, particularly regarding the need to sort and separate.
- Governments must develop a standards and authorities directorate/agency to monitor the procurement of health care waste equipment and resources and must establish regional/district advisory forums to deal with health care waste.
- Strict tracking systems of health care waste from point of delivery to final disposal must be developed and maintained. Mechanisms should be developed to ensure that small health care operators, rural clinics and private practitioners also comply with health care waste disposal requirements.
- Contracts between private waste contractors and government departments responsible for health care waste must be reviewed and reassessed.
3.4.6. Air, water, soils and food quality control
- More comprehensive routine air quality monitoring programmes
- On both national and local level an adequate air quality management strategy that includes air quality standards, legislation and the identification of authorities that will enforce emission standards and penalties
- Stricter measures to control industrial air pollution must be instituted
- Reduce NO2 pollution in cities by improving public transport system and reducing amount of car traffic
- Pave roads in informal settlements to improve ambient air quality
- Use odour threshold levels (detection threshold, recognition threshold, and nuisance threshold) to ensure that quality of life is not adversely affected by the presence chemical odours
- The quality of fresh water and marine sources must be continually monitored and the results made known to the public
- Measures should be taken to ensure that industrial pollution and sewage disposal do not endanger our water resources
- Large-scale recycling of waste must start in earnest to minimize the size of land fills and the resulting contamination of groundwater sources
- Our water supplies should not be fluoridised because fluoride is toxic when ingested
- Formal and informal food production, storage, handling, and trade must be monitored more rigorously to ensure compliance with hygiene and statutory requirements. Monitoring must extend beyond just the meat and dairy industries.
- Consumers must be informed about the content and quality of food products, including whether the food is genetically modified and what the levels of pesticides in the food are.
- A national education campaign to promote hygienic food practices should be launched targeting mainly informal urban and rural settlements. People must be encouraged and enabled to grow their own vegetables and fruit.
- Meat inspections should take place to ensure meat safety and humane slaughtering practices where informal slaughtering of animals for sale of meat is taking place, especially in townships. Measures must be implemented to ensure that slaughter by-products do not pollute the environment.
- Where pasteurised milk exceeds acceptable bacteriological standards, the public must be informed about it. The monitoring of the dairy industry must be extended to informal settlements.
- Government should prohibit the sale of genetically modified food products. Pending such a prohibition, people must be educated about the dangers of genetically modified products and these products must be labelled clearly to indicate their genetically modified status.
- Organically grown products must be encouraged.
- The use of pesticides must be discouraged and their levels in foods strictly monitored.
3.4.7. Access and support for disabled people
- The public must be educated about the needs and rights of disabled people.
- Information about primary health care issues, HIV/AIDS, balanced diet, accident prevention, and first aid must come in formats (e.g. Braille, Sign Language) accessible to the Blind and the Deaf.
- Family planning clinics, ante-natal clinics and other PHC facilities must be accessible to disabled people (e.g. interpreters must be available for the Deaf).
- Assessment units, especially in rural areas, are needed for early detection and treatment.
- The built environment and roads must be made accessible to people with disabilities, including wheelchair users and the Blind (e.g. ramps for wheelchairs, voice activated lifts for the Blind, light alarms for the Deaf).
3.5. Health and Human Rights
- Combat discrimination and stigma, for example, with regard to people living with HIV/AIDS
- Act against medical aid schemes that violate human rights and health rights
- Provide cover for employed contract and casual workers
- Ensure accessibility to health care
- Make provision for women, youth, and the disabled