From international meetings held since Rio 1992, it has become evident that health issues are an increasingly important item on the broad environment and development agenda and that environmental issues are receiving more prominence on the public health agenda (von Schirnding 1998). Agenda 21 and the Johannesburg Plan of Implementation, negotiated in Johannesburg, placed much emphasis on the importance of health and included a chapter dedicated to human health. Health was also singled out as one of five priority issues in Johannesburg, along with water, energy, agriculture, and biodiversity (the WEHAB initiative).
The spectrum of health, environment, and development hazards has changed over the millennia of human existence. Yet despite impressive health gains, in many instances the health gaps between and within countries are widening. Sub-Saharan Africa, the worlds poorest region, still has average life expectancies far below those of the wealthiest countries. Underlying much of this unequal burden of disease is the fact that environmental factors are a major contributor to sickness and death throughout the world, especially in the poorest regions (World Resources Institute, UNEP UNDP, and the World Bank 1998).
Sustainable development cannot be achieved where there is debilitating illness, nor can good health be sustained when poor environments prevail (von Schirnding 2001, 2002b). Age-old public health hazards such as inadequate and unsafe food and water, microbiological contamination of the environment, and poor sanitation and environmental hygiene are still prevalent. In addition, new environment and development problems have emerged, some of which appear to threaten the entire ecosystem. The level of economic development and the policy choices of individual countries are important factors determining the nature of the problems faced and the ways in which they are addressed (von Schirnding 2002a).
Health concerns associated with air and water pollution, water supply and sanitation, waste disposal, or chemicals and food may be particularly relevant at the local or micro level (e.g., lead in household dust or environmental tobacco smoke) or may be important at the regional or global level (e.g., depletion of the ozone layer, global climate change, long-range transport of air pollution, or marine pollution). The problems to be dealt with are often simultaneously global and local. Global economic activities, escalation of travel and trade, and the changing use of technology all have significant implications for health and the environment.
Poverty remains the number one killer, with the poor bearing a disproportionate share of the global burden of ill health. Even in rich countries, the poor suffer worse health than do the better-off. Poor children are particularly affected: In the poorest regions of the world, one in five children dies before his or her first birthday, mostly from environment-related diseases such as acute respiratory infections, diarrhea, and malaria. Children are more heavily and frequently exposed to threats to their health in the environment because of their behavior (e.g., hand-to-mouth activity), because they are closer to the ground and more exposed to high concentrations of pollutants, and because they have a higher intake of harmful substances relative to their body weight than adults do. They are also more vulnerable to the ill effects on health because of their immature and changing stages of biological development. They often are particularly prone to preventable injuries and accidents.
Although the many hazards present in the environment today may have various effects on human health, it is difficult to quantify the risks attributable to these hazards with any degree of confidence. There are often difficulties in assessing people's exposures to environmental risk factors (which may vary widely in concentration from place to place and over time), and people's susceptibilities vary according to many factors. In the case of environmental pollution, the links to health are often uncertain and masked by other effects, such as social deprivation and lifestyle. Usually, large-scale, sophisticated epidemiological studies are needed to quantify health effects and to take account of other (nonenvironmental) factors that might influence the health outcomes. In addition, in many regions of the world the infrastructure for monitoring and health surveillance is poorly developed, so that the numbers of people at risk are largely unknown.
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