lvovsky health

Health and Environment

October 2001

ENVIRONMENT

STRATEGY PAPERS NO. 1

Kseniya Lvovsky

The International Bank for Reconstructionand Development/THE WORLD BANK1818 H Street, N.W.Washington, D.C. 20433, U.S.A.

Manufactured in the United States of AmericaFirst printing October 2001

In 2001, the World Bank completed the comprehensive two-year process of preparing its EnvironmentStrategy, Making Sustainable Commitments: An Environment Strategy for the World Bank. It was endorsedby the Bank�s Board of Directors and published in October 2001. Several background papers were preparedand published by the Bank�s Environment Department to stimulate constructive dialogue and intellectualdiscussion on a range of issues within the Bank as well as with client countries, partners, and other interestedstakeholders. The Environment Strategy Paper series includes revised versions of Environment Strategybackground papers, as well as new reports prepared to facilitate implementation of the Strategy. This seriesaims to provide a forum for discussion on a range of issues related to the strategy, to help the transfer of goodpractices across countries and regions, and to seek effective ways of improving the Bank�s environmentalperformance.

This report is a revised version of the environment strategy background paper on Health and Environment.

iii

Contents

v Preface

vii Acknowledgments

1 Chapter 1: Health, Environment, and Development

5 Chapter 2: Environmental Health and Poverty

7 Chapter 3: Changing Landscape of Environmental Health Risks — Future Trends

9 Chapter 4: Improving Environmental Health

11 Chapter 5: Health and Cost-Effectiveness of Environmental Interventions

13 Chapter 6: Environmental Health and Bank Operations Guidelines

15 Chapter 7: Lessons from Bank Experience

19 Chapter 8: Where Do We Stand? Regional Survey

25 Chapter 9: Cooperation within the Bank

27 Chapter 10: Collaboration with WHO and other External Partners

29 Chapter 11: Health and the New Environment Strategy

30 Process

31 Annex A: Definitions of Environmental Health33 Annex B: Estimating the Burden of Disease Related to Environmental Risks39 Annex C: Africa � Burden of Disease from Environmental Causes and Intervention

Measures45 Annex D: Cost-Effectiveness of Environmental Health Interventions49 Annex E: Analysis of Bank Documentation51 Annex F: Regional Responses to EH Questionnaire

63 Notes

65 References

iv


Environment Strategy Papers

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 health16 Box 4. ECA Regional Study � Health, sanitation, and hygiene in rural water supply and

sanitation projects22 Box 5. What is an environmental health project? Highlights from Regional survey

Figures

3 Figure 1. Burden of disease and environmental risks: Developing versus developedcountries

Tables

6 Table 1. Burden of disease from major environmental risks7 Table 2. Premature mortality and burden of disease due to air pollution, by region10 Table 3. Health outcomes and environmental interventions20 Table 4. Summary of Regional responses to environmental health questionnaire34 Table B.1. Burden of specific diseases34 Table B.2. Hazard rates due to exposure to indoor air pollution38 Table B.3. Burden of disease associated with agro-chemical exposure39 Table C.1. Burden of disease relieved in Sub-Saharan Africa (SSA), by remedial measure40 Table C.2. Burden of disease relieved in Sub-Saharan Africa (SSA), by remedial measures

in DALY42 Table C.3. Lower and higher percentage guesstimates for each disease42 Table C.4. DALYs guesstimates attributable to air pollution43 Table C.5. Guesstimates for indoor and outdoor air pollution46 Table D.1. Summary of air pollution cost-effectiveness studies

v

T his paper highlights links between envi-ronment, public health, and poverty, anddiscusses implications for the Bank

strategy to address environmental healthconcerns. It shows that environmental riskshave a significant impact on health outcomes indeveloping countries, and that traditionalenvironmental hazards, such as lack of safewater and sanitation, indoor air pollution, andexposure to disease vectors, play by far thelargest role. Also worrying, however, is that thecontribution of modern environmental risks�pollution by transport, industry, and agro-chemicals�to the disease burden in manydeveloping countries is similar to that in richones, and sometimes is even greater. Theworld�s poor are most affected by this �doubleburden� of both traditional and modernenvironmental risks.

While environmental challenges of develop-ment and globalization require a concertedaction, the much higher environmental healthcosts of living in poverty and lacking basicinfrastructure and other services must not beneglected. Policies and actions that addressboth types of health risks and damages in asynergistic manner are the best, and include

those that promote strong growth and goodgovernance structures that are capable ofsafeguarding the environment and respondingto the needs of the poor. Tradeoffs are some-times inevitable, however, and should be madewith a full understanding of the resulting nethealth impacts. The paper attempts to contrib-ute to improving this understanding.

The environment-health nexus highlights thatimprovements in people�s health require aholistic, multisectoral approach to mitigatingmajor risks by integrating cost-effective effortsin infrastructure and human development areasand by building effective institutions at alllevels of governance, including communitiesthemselves. A holistic approach is particularlyimportant for improving the health of the poor,who are most vulnerable to both main environ-mental hazards and deficiencies in healthservices delivery. The World Bank EnvironmentStrategy, developed in extensive consultationwith various stakeholders in client countries,other donors, and international nongovernmen-tal organizations, considers environmentalhealth a top priority and calls for a greaterfocus on this principal development outcomein Bank operations across all relevant sectors.

Preface

vii

T his paper was written by KseniyaLvovsky with contributions fromMaureen Cropper, James Listorti, Fadi

Doumani, A. Edward Elmendorf, CandaceChandra, Julian Lampietti, Ronald Subida, RitaKlees, Gordon Hughes, and Meghan Dunleavy.Regional assessments and valuable commentswere provided by Rita Klees (ECA), Laura Tlayieand Horacio Terraza (LAC), Todd Johnson(EAP), Sherif Arif (MNA), Elaine Ooi andAnthony Measham (SAR), and Anne Hammerand Robert Robelus (SSA). The paper benefitedfrom a peer review by Lee Travers, Mariam

Claeson, Jennifer Sara, and Enis Baris. Onseveral occasions throughout the text, the paperuses materials from the draft EnvironmentalHealth Assessment Guidelines, prepared by theSSA Environmental Health team. The authorsare also grateful to the participants at the twoBank-wide environmental health workshops,held in September 1999 and March 2000, thathelped advance the preparation of this docu-ment. The authors would like to express theirthanks to Linda Starke for editorial assistanceand Jim Cantrell for designing the book andmanaging production.

Acknowledgments

1

Health, Environment, and Development

Chapter 1

Health and development are irrevocablyinterrelated. Infant/child mortality andlife expectancy�conventional mea-

sures of the general health of large popula-tions�are considered key development indica-tors. Better health is both an outcome of and avehicle for achieving economic prosperity andpoverty eradication.

Protecting health is the principal objective ofprotecting the environment. The vast majorityof environmental policies and regulationsworldwide are motivated by public healthconcerns, and most economic valuationexercises have found that health impactsconstitute the largest portion of environmentaldamages. It has long been recognized that theenvironment in which people live�from thehousehold to the global level�significantlyaffects their health. (See Box 1.) Until recently,however, it was not possible to quantify themagnitude of health impacts from exposure tovarious environmental factors. Nor was itpossible to compare the cost-effectiveness ofpreventive measures to reduce such exposurewith health sector activities that cure the

resulting illnesses. The opportunity to do soemerged from work on the �global burden ofdisease,� which uses a standardized measure ofhealth outcomes (disability-adjusted life years,or DALYs) across various causes of illness anddeath. (See Box 2.) Follow-up analysis, whichattributes the disease burden measured inDALYs to environmental hazards, has broughtour knowledge of environment and healthlinkages to a new level.

Recent estimates suggest that premature deathand illness due to major environmental healthrisks account for one-fifth of the total burden ofdisease in the developing world�comparableto malnutrition and larger than all otherpreventable risk factors and groups of diseasecauses. While the total burden of disease inrich countries, expressed in DALYs per millionpeople, is about half that in developing coun-tries, the disease burden from environmentalrisks is smaller by a factor of 10. (See Figure 1.)This gives a new dimension to environmentalhealth (EH) as a principal indicator of develop-ment and a major element in achieving theBank�s primary objective of reducing poverty.

2



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 ofdisease, injury, and death in developing countries lie outside the purview of the health sector. Theycover 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, sexualbehavior, driving habits, alcoholism, and tobacco smoking.

The definition of environmental health is still evolving. The World Bank�s Africa Environmental Healthteam, for example, proposes using a broad definition that would cover all activities �to prevent healthrisks 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) diseasevectors, 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 doesnot 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 environmentnexus 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 oftransport-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 largestcontributions 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; illustratesenvironment, development, and poverty linkages; and helps foster discussion of strategic issues relatedto environmental work in the Bank.

3Kseniya Lvovsky

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 DALYscombines life years lost due to premature death and fractions of years of healthy life lost as a result ofillness or disability. A weighting function that incorporates discounting is used for years of life lost ateach age to reflect the different social weights that are usually given to illness and premature mortalityat different ages. The combination of discounting and age weights produces the pattern of DALY lost bya death at each age. For example, the death of a baby girl represents a loss of 32.5 DALYs, while afemale 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 systematiccomparisons of the cost-effectiveness of alternative interventions designed to improve health. Whencombined with the results of large-scale epidemiological studies, it enables public health specialists toidentify priorities and focus attention on development programs that have the potential to generatesignificant 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

Source: Murray and Lopez 1996, Smith 1998, World Bank staff.

DA

LYs

per

mill

ion

peo

ple

(tho

usa

nd

s)

0

100

200

300

Developing

countries

Developed

countries

Other causes Environmental factors

5

Environmental Health and Poverty

Chapter 2

Environmental health risks fall into twobroad categories:

! Traditional hazards related to poverty and

lack of development, such as lack of safe

water, inadequate sanitation and waste

disposal, indoor air pollution, and vector-

borne diseases (malaria, for example)

! Modern hazards caused by development

that lacks environmental safeguards, such as

urban air pollution and exposure to

agroindustrial chemicals and waste.

In developing countries, the increasing health

burden from modern forms of exposure to

urban, industrial, and agrochemical pollution

adds to traditional household risks, which still

play the greatest role. On a global scale, lack of

access to clean water and sanitation and indoor

air pollution are the two principal causes of

illness and death, predominantly affecting

children and women in poor families. In all

developing countries, more than 2 million

people�primarily young children and

women�may die as a result of indoor exposure

to dirty solid fuels each year. The health burden

from poor water supply and sanitation is even

larger.

The relationship between the burden ofenvironmental diseases, traditional environ-mental risks, and poverty is further highlightedby regional analysis. (See Table 1.) The burdenof disease from environmental causes variesconsiderably among regions, but a clear trendemerges regarding how this burden and itscomponents change with income growth.

Overall, the environmental health burden as apercentage of the total disease burden ishighest in regions that house most of theworld�s poor (27 percent in Africa and 18percent in Asia) and lowest in industrialcountries. Decline in this burden is clearlyassociated with reduction in exposure totraditional risks. The impact of traditionalenvironmental health hazards exceeds that ofmodern hazards by a factor of 10 in Africa, 5 inAsian countries (except China), and 2.5 inLatin America and Middle East. Modern threatsto human health prevail in rich countries and inEuropean countries undergoing economictransition. Within individual countries, more-over, the poor suffer disproportionately fromunsafe environmental conditions at the house-hold and community levels.

Inadequate water supply and sanitation (WSS)pose the largest threat to human health in Bank

6



TABLE 1. Burden of disease from major environmental risks (worksheet)*

Notes: * Regions slightly differ from World Bank Regions. See a definition in World Bank 1993 and Murray and Lopez 1996. Notethat 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 andCaribbean, MNA is Middle East and North Africa, ICs stands for industrialized countries, and DCs is developing countries. Mostof the data in the table are from the early 1990s.

Sources: Murray and Lopez 1996; Smith 1993, 1998, 1999; WHO 1997a; World Bank 1999; World Bank staff (see Annexes 2and 3).

client-countries, except for China and thetransition economies of Europe, where airpollution causes the most damage. Indoor airpollution is the greatest threat in Asia andAfrica. Malaria has taken a heavy toll on the

population of Sub-Saharan Africa. Althoughmalaria is not nearly as significant in otherregions, it is the third greatest environmentalhealth threat globally.

Percent of all DALYs in each country group

Environmental health group SSA IndiaAsia &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

7

Changing Landscape of Environmental HealthRisks — Future Trends

Chapter 3

T he majority of those suffering from highlevels of indoor air pollution, lack ofsanitation, scarce water supply, and

malaria live in rural areas. But rapid urbaniza-tion and the uncontrolled growth of urbanslums also create a �double burden� for theurban and semi-urban poor. They are increas-ingly exposed to �transition risk��one portionof that risk is from dirty cooking fuels, primitivestoves, crowding, and poor access to water andsanitation, while the other is a result of moderntransport and industrial pollution. Further, insome parts of the world malaria is becoming anurban issue, in part due to infrastructure

failures. In Africa, Asia, and Latin America,urbanization is changing the landscape ofenvironmental health concerns and posing newchallenges on an unprecedented scale.

In order to set strategic priorities for addressingenvironmental health issues, it is important toestimate the �baseline� of how the burden ofenvironmental health risks is likely to changeover time. Table 2 summarizes the projectionsof the burden of disease caused by air pollutionover the period 2001�20 under a �business asusual� scenario, expressed as annual averagesfor the 20-year period.1

TABLE 2. Premature mortality and burden of disease due to air pollution, by region(projected annual averages for 2001�20)

Source: World Bank 2000a. Also see Annex 2.

Premature deaths(thousand per year)

Burden of disease(million DALYs per year)

Region IndoorOutdoor(urban) Total Indoor

Outdoor(urban) Total

China 150 590 740 4.5 14.0 18.5

East Asia and Pacific 100 150 250 3.5 3.8 7.3

Established Market Economies 0 20 20 0.0 0.5 0.5

Former Socialist Economies 10 200 210 0.2 3.8 4.0

India 490 460 950 17.0 10.1 27.1

Latin America and Caribbean 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

8



Exposure to Pollutants. The largest componentof air pollution costs is the premature mortalityand ill health caused by indoor and outdoorexposure to high levels of pollutants. Projec-tions indicate that about 3.5 million peoplewill die prematurely each year over the next20 years as a result of indoor and outdoor airpollution. In Sub-Saharan Africa and SouthAsia (excluding India), most of these deathswill be the result of indoor air pollution, so thepriorities identified in Table 1 hold. In India,indoor and outdoor air pollution each accountfor about half of the premature deaths. Out-door air pollution is becoming the major issuein China. For the world as a whole, whileindoor exposure dominated health damagefrom air pollution in the past decade, outdoorair pollution is projected to gain equal impor-tance as a grave risk to human health over thenext two decades.

The total burden of disease from air pollutionamounts to almost 100 million DALYs peryear, equivalent to a loss of slightly more thanone year of life over the life span of an averageindividual. For India and Africa, the burden ofill health caused by air pollution is equivalentto a loss of life of more than 1.5 years.

Impact of Climate Change. For the world�spoor who live in coastal areas and islandcommunities, which are vulnerable to climateextremes, the potential impacts of climate

change could be highly significant. (See, forexample, Listori 1999.) Analysis of the effectsof global climate change (including the healthimpacts) suggests that the long-run costs of anincrease in global temperature of 2.5 degreesCelsius will be highest for India and Africa (4.9percent and 3.9 percent of gross nationalproduct, respectively, of which 2.3 percentand 0.4 percent are associated with thepotential costs of catastrophic weather events).Still, for both India and Sub-Saharan Africa thehealth damage caused by indoor air pollutionalone is about twice as great as the total(health and non-health) damage associatedwith global exposure to climate change(comparing various scenarios of present valuesof these damages over the next 100 years).

Changing Face of Disease. Recent worrisometrends on the disease landscape that haveimplications for environmental health priori-ties include the increase of vector-bornediseases, especially malaria in Sub-SaharanAfrica, and the changing pattern of infectiousdiseases (see, for example, World ResourceInstitute 1998). Twenty-nine new diseaseshave been discovered over the past 20 years,and former scourges, such as tuberculosis, arereturning. AIDS is becoming one of the majorcauses of death, creating 5.5 percent of theburden of disease in developing countries,according to the most recent estimates (WHO1999).

9

Improving Environmental Health

Chapter 4

Environmental health risks can be pre-vented, or significantly mitigated,through a variety of economic activities

in different sectors�mainly infrastructure,energy, and agriculture. Table 3 summarizesthese activities and links them to possibleindicators for monitoring health impacts.Interventions linked to measurable, significantenvironmental health impacts are referred to as�environmental� interventions, regardless of thesector in which they are implemented.

Better infrastructure and energy services forhouseholds and communities are key measuresfor mitigating traditional environmental risks,along with improved housing and vector-control interventions. Reducing modern riskscalls for pollution prevention and abatementmeasures, which in turn requires setting andenforcing environmental standards, developinga culture of environmental compliance, andcreating effective incentives. In Sub-SaharanAfrica, for example, remedial measures outsidehealth care systems�such as improved waterand sanitation, household energy, housing,vector control, and pollution management�

were estimated to be capable of reducing thetotal burden of disease by 23�29 percent.Health care interventions aimed at the sameclusters of diseases affected by environmentalfactors (such as diarrhea, respiratory symptoms,eye diseases, and malaria) can reduce thedisease burden by a further 23�28 percent (seeAnnex 3) (Listorti 1996; Listorti, Doumani, andHammer, forthcoming).

The data illustrate two important points:

! Health, especially environmental health, is aprincipal outcome of many interventionsand project activities outside the healthsector.

! The key development objective of improvingpeople�s health requires a holistic,multisectoral approach to mitigating majorrisks by integrating efforts inside and outsidehealth care systems. A holistic approach isparticularly important for improving thehealth of the poor, who are most vulnerableto both major environmental hazards anddeficiencies in the provision of healthservices.

10



Note: * lpcd = liter per capita per day.

Environmentalrisk factors

Associatedsectors/projects Health outcomes Health indicators

Examples of monitorableproxy indicators

Indoor Air

Pollution

Energy (cleaner

fuels, improved

stoves)

Rural

development

Child mortality

Chronic obstructive

pulmonary disease

(COPD)

Acute respiratory

infections (ARI)

Child deaths

due to

respiratory

illness

Cases of ARI

Incidence of

COPD

Estimates of exposure levels

to indoor air pollution

Percent of households using

clean fuels or/and improved

stoves

Type of housing

Cooking practices

Outdoor Air

Pollution

Energy

Transport

Mortality

COPD

ARI

Respiratory Hospital

Admissions (RHA)

IQ impairment

(lead)

Deaths (adult)

Incidence of

COPD

Cases of ARI

Respiratory

Hospital

Admissions

Annual mean levels of PM10

(µg/m3)

Annual ambient

concentrations of lead in the

atmosphere (µg/m3)

Lead level in blood,

particularly children (µg/dl)

Vector-Borne

Disease

Irrigation

Reforestation

Infrastructure

(drainage)

Health (vector

control)

Malaria mortality

Malaria morbidity

Deaths due to

malaria

Malaria cases

Application of bednets

Application of insecticides

Indicators related to the

development and maintenance

of irrigation and drainage

infrastructure

Lack of water

supply and

sanitation (WSS)

WSS

Infrastructure

Social funds

Mortality due to

diarrheal disease

Diarrhea incidence

Child deaths

due to diarrhea

Diarrhea cases

in children

Relevant indicators of access

to water and sanitation (for

example, percent of

household with in-house

connections, lpcd,* 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

Residues

Agriculture Acute poisoning

Cancer

Fetal defects

Cases of acute

poisoning

Cases of cancer

Application norms

Storage and handling

practices

Other Toxic

Substances

Control of

industrial and

transport

pollution, change

in fuel quality

Cancers

IQ impairment

(lead)

Cases of

cancers, blood

lead level

Environmental performance

Waste management codes

Land zoning regulations

Market share of leaded

gasoline

TABLE 3. Health outcomes and environmental interventions

11

Health and Cost-Effectiveness ofEnvironmental Interventions

Chapter 5

A ctivities in a number of economicsectors aimed at reducing humanexposure to environmental hazards

not only have a direct and significant impact onhealth, they also can be cost-effective inachieving health outcomes and preventing theloss of DALYs. A cost-effectiveness reviewundertaken for this paper was constrained bythe limited number of studies that include thiskind of assessment or provide data necessary tomake such an assessment. (See Annex 4.) Most

of the data on the costs of interventions perDALY-saved come from malaria-control orurban air pollution studies. Box 3 summarizesavailable estimates.

The findings lead to two important policyconclusions, although the limited scope of theassessment and reservations about the validityof using DALYs for cross-sectoral comparisonsrequire careful interpretation and furtherdiscussion. 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 assessthe effectiveness of measures outside the health sector in achieving health improvements (preventingthe 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 (Stephen1998)! 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, withmost measures costing over US$1,000 per DALY.

The World Development Report 1993 suggests that health sector interventions up to US$150 per DALYsaved can be considered cost-effective (World Bank 1993).

Source: Listorti 1996 and World Bank estimates.

12



suggest that measures to mitigate traditionalhealth hazards (such as indoor air pollution,scant sanitation, or insect vectors) tend to bemore cost-effective than many of the measuresto reduce modern risks, such as urban airpollution.2 This finding, coupled with thesignificant impact of these hazards on thehealth of the poor, calls for greater attention totraditional household and community healthrisks in environmental work. Since interven-tions to reduce these risks fall in the domain ofenergy and infrastructure (WSS) sectors, thereis a need for closer collaboration with thesesectors to achieve health outcomes.

Second, large variations in the cost-effective-ness of various interventions (across healthhazards and within one type of hazard, suchas urban air pollution) point to the need forrigorous analysis and skillful design of environ-mental health projects to maximize healthbenefits in a cost-effective manner. A recentlycompleted World Bank study of water,sanitation, and health linkages in the State ofAndhra Pradesh, India, provides probably thestrongest data in support of this point (WorldBank 2000b). The study found that costs perDALY saved from water supply and sanitationinterventions vary greatly, depending on a

complex variety of factors. These factorsinclude the socio-demographic situation in adistrict, the urban or rural status of the com-munity, sanitation coverage, and type ofservice delivery. This complexity of interven-tion-outcome linkages can be used tostrengthen the basis for collaboration withother sectors, as environment staff are oftenwell positioned to provide analytical input tothe design of infrastructure and energy projectsthat would help to achieve better healthoutcomes.

Additional controversy around these findingsarises from the fact that many interventions atthe household and community levels improvepublic health by providing private goods (forexample, better fuels or stoves, water supply,and sanitation). The challenge, then, is how toreconcile the willingness-to-pay and commer-cial viability of services�the cornerstone ofenergy and infrastructure operations�withcost-benefit analysis based on health out-comes. This is another area in which cross-fertilization of experiences in the health,environment, rural development, energy, andinfrastructure sectors is the only way to find aworkable solution.

13

Environmental Health and BankOperations Guidelines

Chapter 6

Bank Policies. Only 1 out of 30 Opera-tions Policies and Best Practices (OP/BP)is devoted to environmental health

(covering the use of pesticides), but it is limitedto public health uses of mosquito control, anddoes not deal with the widespread use ofpesticides in agriculture. Four other OP/BPscontain passing references to environmentalhealth, either in a single paragraph or a foot-note. Overall, instructions to staff are sparseand are not conducive to a process of cross-fertilization.

Bank Documentation. Bank documentationshows uneven treatment of environmentalhealth. (See Annex 5.) Several EnvironmentDepartment publications refer to the pollution/health linkage in annual reports and otherevaluations of Bank work. In the Middle Eastand North Africa Region and in the Europe andCentral Asia Region, environmental health wasused as an input into developing regionalstrategies; in the Latin America and the Carib-bean, South Asia, and East Asia and PacificRegions, various attempts were made toestimate the economic costs of human healthdamages. Many National Environmental ActionPlans name environmental health as the highestpriority, and some attempts were made in ECA

to develop these plans jointly with NationalEnvironmental Health Plans sponsored by theWorld Health Organization (WHO). Still,project documents and other publications focusmostly on pollution-control. The most compre-hensive exercise to date was the study onEnvironment and Health: Bridging the Gaps(Listorti, Doumain, and Hammer 1999) and thedraft Environmental Health Assessment Guide-lines developed in the Bank�s Africa Region(Listorti, Doumain, and Hammer, forthcoming).Environmental health is rarely on the agenda ofCountry Assistance Strategies (CASs).

To a certain degree, Bank documentation andinternal procedures reflect the same roughdistribution and accuracy as the outsideliterature; whereas the health sector is inwardlyfocused, environmental health accentuatespollution, and cut-and-paste health informationis often misapplied. The problem, however, isthat the outside literature is essentially moti-vated by the needs and priorities of industrialcountries, which are very different from thoseof developing countries, especially with regardto the health needs of the poor. Although aconsiderable number of worthwhile andcutting-edge activities occur Bank-wide,systematic advocacy for and internalization of

14



environmental health concepts has not takenplace throughout the organization. (Listorti1996; Listorti, Doumani, and Hammer,forthcoming).

New Activities. A number of new, ongoing,or recently completed activities address someof these issues. Among them are the prepara-tion of Environmental Health Assessment

Guidelines by the Africa EH team; an analysisof the impact of the household environmenton child mortality in India and a study oflinkages between access to WSS and health inAndhra Pradesh, carried out by South AsiaRegion and ENV; an ECA study on health andhygiene in WSS; and, most recently, work onindoor air pollution in SAR, SSA, and LAC.

15

Lessons from Bank Experience

Chapter 7

W ater and Sanitation. Bank experi-ence with environmental health hasbeen limited, as have the lessons

learned. Many important environmental healthissues fall through the cracks of developmentagencies because environment and health areboth cross-sectoral, and because institutionscommonly lack clear directives for themultisectoral dimensions of their work. Anarray of lessons has emerged in the WSSsubsector from nearly a quarter-century ofresearch devoted to low-cost, appropriatetechnology and from an International Decadededicated to making drinking water andsanitation universally available. The lessonspoint to the value of an integrated approach toenvironmental health interventions, for ex-ample, integrating water supply with sanitation,drainage, community education, and hygienepractices (Listorti 1996).

A recently completed study in ECA on thehealth and hygiene dimensions of water andsanitation projects (see Box 4) found thefollowing:

! Monitoring and evaluation of the healthimpacts of environmental interventions inECA is of erratic quality. Thus an objective

of future EH work should be to assist Bankstaff in developing key performance monitor-ing indicators.

! At least half of WSS investments are embod-ied within �non-WSS� projects, most notablySocial Funds, which shows the high priorityattached by communities to EH-relatedactivities and cross-sectoral links to EH.

! An intersectoral approach to WSS projects,incorporating hygiene and water qualityissues, is needed to realize maximum impactfrom investments in infrastructure.

Improved Stoves. The most important Bank-supported interventions addressing indoor airpollution were large-scale Improved StovePrograms in India and China in the late 1980s(although these were motivated by energyefficiency goals rather than environmentalones). Major lessons learned were the need totarget efforts more clearly toward the most-affected communities; the need to complementfinancial support with local capacity-building,training in maintenance, and health awarenessprograms; the need for a greater role for localauthorities and communities; and the impor-tance of sustainable financial arrangements.

Urban Air Pollution. Experience is also emerg-ing with regard to urban air pollution manage-

16



BOX 4.ECA Regional Study � Health, sanitation, and hygiene in rural water supply and sanitationprojects

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) componentsof RWSS projects; identify best practices in the design and monitoring of HSH of RWSS projects; andprovide task managers with useful tools to assist in the design, monitoring, and evaluation of RWSSprojects. 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 studyprovides recommendations on operational, institutional, and monitoring and evaluation levels, as well asreferences, logframes, sample monitoring and evaluation programs, and other useful material for taskmanagers.

The study found that health benefits associated with improved rural drinking-water supply projectsresult from improved quality and increased quantity of water, adequate sanitation facilities, and changesin hygiene behavior. Sanitation and hygiene behaviors have as much, if not more, impact on improvedhealth outcomes from WSS projects than the water infrastructure itself. A successful rural water-supplyproject 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 thesector, 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, orUS$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 benefitsof water-supply investments. However, the review found only one social fund in ECA (Moldova) thatproposed HSH activities in the project.

The characteristics of successful HSH components are well established, based on the experiences of theinternational development community, including the Bank. Most World Bank RWSS projects now inimplementation with HSH components include the key ingredients of a successful HSH program, exceptfor 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 ormonitoring to make this claim. Further, it is rare that policy issues or training related to strengthening ofpublic 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 andinstitutional 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 andsocial assessments. Pilot projects that further investigated issues uncovered by social needs assessmentsand demonstrated new, community-based approaches to RWSS were also very useful in preparing ECARWSS projects.

Source: Bank staff

17Kseniya Lvovsky

Lessons from Bank Experience

ment projects, motivated by environmentalhealth impacts (such as the Slovenia Environ-ment Project, the Mexico City Transport AirQuality Management Project, the Dhaka AirQuality LIL, and the proposed Katowice urbanair pollution project). The latest lessons from

these have not yet been summarized. A recent,quite successful experience in which the Banksupported the global phaseout of leadedgasoline highlighted the crucial role of politi-cal commitment, public awareness, andpartnership with the private sector.

19

Where Do We Stand? Regional Survey

Chapter 8

To get a grasp on the current status of andemerging trends in environmental healthwork in the World Bank, Regional offices

were asked to complete a questionnaire (seeAnnex 6 for a copy of the questions and theresponses from each Region). Table 4 summa-rizes the responses; key observations arediscussed briefly in this section.

Environmental Health Priorities. Quite unex-pectedly, key issues and priorities identified bythe Regions, based on client demand and staffperception, appear to be virtually identical tothe ranking in Table 1, based on the burden ofdisease assessment.

Client Demand. Regional surveys indicateconsiderable interest on the part of many of ourclients in addressing environmental health,although some responses (for example, EastAsia) pointed to a greater interest in urbanprojects, despite significant EH problems inrural areas. However, environmental health isusually not an explicit objective of lending,except for a small portfolio of urban andindustrial pollution projects. EH projects seemto be driven mainly by client awareness andBank staff knowledge. Public perceptionthrough local media is quite important as well,

but media attention does not always focus onthe most crucial area for intervention.

Current Bank Portfolio. It appears to beimpossible to compare and summarize Re-gional responses regarding portfolios of envi-ronmental health projects, as each Region usedits own unique (explicit or implicit) definitionof an environmental health project. (See Box 5.)If we look at all Bank projects with somedegree of impact on environmental health orwith the potential to achieve a significantimpact, the result would be a huge portfoliothat includes all WSS projects, all urbanprojects, all pollution-control projects, andquite a few transport, energy, rural develop-ment, and health projects. But this impressiveportfolio is more likely to illustrate a dearth ofmissed opportunities than a high priority onenvironmental health. For example, afterscreening the projects according to a set ofspecial criteria, South Asia reduced its list of�truly� environmental health projects fromseveral dozen to just three. On the positiveside, this potential for addressing EH concernsacross sectors clearly shows the unique posi-tion and advantage of the World Bank com-pared with other development organizationsworking on health issues.

20Environm

ent Strategy Papers

TABLE 4. Summary of Regional responses to environmental health questionnaire

Questions AFR MENA ECA LAC SA EA

E. Europe C. Asia

Key EH issues Water-borne

diseases

Respiratory (indoor

air pollution)

Water-borne

diseases

Respiratory (indoor

and urban air

pollution)

Toxic industrial

pollution

Injuries

Transport

accidents

Worker safety

Water-borne

diseases

Indoor air (TB

communication)

Sanitation, hygiene

Water-borne

disease/ sanitation

Respiratory illness

(urban air)

Sewage disposal in

bay and coastal

areas

Water supply and

sanitation (related

diseases)

Respiratory (indoor

air pollution)

Urban air (from

energy and

transport)

Water supply and

sanitation

Urban air quality

Indoor air (China:

air pollution is the

first priority)

Also important:

industrial health and

safety and traffic

accidents

Which sectors

lend currently

Health

Infrastructure

Energy/Rural

Development

Health and

Education

Infrastructure

Rural Development

(Water)

Environment

Rural W&S

Health

Environment

Rural W&S

Social Funds

Energy

Environment

Health

Environment

Health

Some infrastructure

(W&S, mining,

transport)

W&S

Urban

Health

Environment

Urban

Environment

Transport

Main types of

projects

Household energy

Urban (flood

control)

Few health with

preventive measures

Vector control

W&S

Rural development

Solid waste

Hospital waste

management

Transport

Health

Social

development

Health

W&S

Social Funds

Poverty alleviation

Air pollution

management

Health care waste

management

Vector control

Urban air

Water supply

Sanitation

Nutrition

Vector control

Urban and

transport

Industrial pollution

Water supply

Environment

Urban development

Solid waste

Air pollution/

energy

Level of client

awareness/

areas

LOW MEDIUM

Water (lack of, poor

quality, waste

treatment,

sanitation)

Urban air pollution

HIGH

Air and water

pollution, medical

waste

MEDIUM to

HIGH

Water supply and

sanitation

HIGH for publicized

urban problems,

LOW otherwise

Urban air, polluted

rivers and beaches,

hazardous waste

LOW but growing

Urban air pollution,

pesticides, drinking

water, sanitation,

indoor air pollution

HIGH for water

issues, due to health

GROWING for air

pollution, urban due

to damages to

agriculture, tourism

21Kseniya Lvovsky

Responsible

agency

Health ministries

Maybe NGOs

No one agency with

clear mandate

Environment, health,

housing, water

resources ministries

No clear mandate

Environment and

health ministries

No clear mandate

Environment and

health ministries

Environmental

authorities

No clear mandate

Default is

environment

ministry

Environment

bureaus and public

health agencies;

however, they are

not the key agencies

for Bank projects

Cost effec-

tiveness/

benefits

Unsure Pollution- abatement

projects

Extensive for W&S

projects

Cost benefits

calculated for small

number of projects

DALYs

Generally not

Some environmental

health surveys

(epidemiological)

Drivers of

projects

Bank staff Client awareness

Media

Use of EH issues to

justify positive

environmental

impact

Client awareness

Desire to join EU

Client awareness Client counterpart

interest

Media

Client demand

Availability of

sector work

Knowledge and

interest of Bank

staff

Client attention to

urban environment

problems

Economic losses

Human health

damages

Media

Difficulties Need more

awareness on client

side

Need low cost

projects

Need indicators No real decision-

making process

Need indicators Cross-sectoral

nature of projects

Few indicators

Complexity

Data is anecdotal

No direct health

data collected

Need health

baselines for

country

Proposed

next steps

Integration of health

in EA and review

Rapid health risk

assessment in pilots

Include in CAS

Develop case

studies for

groundwater

pollution

Need cost-

benefit analysis

Include in CASs

Include

environmental

health analysis in

EA process

Attention to

communicable

diseases

More risk

assessment

Incorporate

occupational health

and safety

Improve indicators/

economic analysis

Advocacy

Definitions of EH

and intersectoral

collaboration

Pilots

Need work on air

and water pollution

impacts

Develop low-cost

tracking and

monitoring for

health

22



Counterpart Agencies. All Regions identifiedenvironment and health ministries as counter-parts and stressed the need to work acrossseveral agencies�water resources, agriculture,and others�depending on the nature of the

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 evenmore difficult to define an environmental health project in the context of Bank operations. The analysisof regional responses to a questionnaire on the status of Bank environmental health work revealed thatRegions 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 managedby environment and health staff, and ECA reported water supply and sanitation investments, over halfof which are undertaken through Social Funds and poverty alleviation projects, rather than traditionalWSS projects. South and East Asia attempted to select projects by a set of criteria they established forthis purpose.

South Asia staff screened the following information for all projects for which project completiondocuments 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 leasttwo 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 inthe secondary list of projects (both lists were submitted).

East Asia submitted only projects in which one stated objective was to reduce human health impactsand there were indicators that relate to improving health outcomes (such as reducing BOD/COD levelsin local water-bodies or reducing effluent or emissions).

More than 50 projects passed these criteria in East Asia, while only three projects were included inSouth Asia�s primary list. Many infrastructure projects from the South Asia secondary list are designedsimilarly to the selected projects in East Asia, and are likely to have similar health impacts, but the SouthAsia projects did not have as clearly stated environmental health objectives and indicators as those inEast 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 twoneighboring 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 thanother projects that do not emphasize health issues.

The survey highlights the need for developing and consistently using indicators in project documents toallow for measuring and monitoring the impact of Bank activities on health. The survey also highlightsthat EH is not as much about a new category of projects as it is about a new generation of projectsunder existing categories that are more oriented toward outcomes and accountability for their impact.

particular EH activity. The principal sectors forEH are environment, health, infrastructure,urban and rural development, and, to someextent, transport and energy. However, thisseems to create administrative problems for

23Kseniya Lvovsky

Where Do We Stand? Regional Survey

both Bank staff and client countries. In-country, the problem arises from the lack of amandate to a definitive agency or ministry foroversight of EH. In most Regions the defaultfalls to the environment ministry (sometimes inconjunction with the health ministry).

Future Needs. WSS and urban projectsrepresent the largest portion of the EH-relatedportfolio (and a sizable proportion of theBank�s overall lending portfolio); thus morerigorous attempts should be made to maximizehealth benefits through these projects. Thisrequires more analytical work and a betterunderstanding of specific linkages betweenproject designs and health outcomes. Indoorair pollution has clearly emerged as anoverlooked problem in a number of Regions;no projects were associated with this signifi-cant public health concern. Urban air pollu-tion remains high and is worsening in somecountries, but Bank activities on this havebeen minimal to date.

Benchmarking and Monitoring. Another keyconcern is the lack of indicators, baselines,and low-cost monitoring of EH projects orcomponents. It is uniformly felt that increasedmonitoring of EH health outcomes wouldimprove the projects. Such monitoring wouldalso be helpful to economic analysis of EHprojects, especially cost/benefit analysis,which is rarely undertaken at present. Yet thedesirability of improved monitoring andevaluation of EH outcomes of infrastructureprojects (such as WSS) must be weighedagainst the costs of conforming with theserequirements. The Bank has been working onthis issue in water and sanitation projects.Operational experience indicates that develop-ing high-quality, project-level baseline infor-mation and complementing that with equallyhigh-quality monitoring and analysis usually

exceeds reasonable project budgets and clientcapacity. The difficulty and cost of measuringthe impact of a project on health further arisesfrom the fact that environmental factors areonly one of many causes of disease, and ifother causes of disease change over time, it isnecessary to monitor health outcomes for acontrol group as well as for the group receiv-ing the environmental intervention. This limitsthe possibility of making improved healthoutcomes a stated objective of many Bankprojects that do, in fact, have an impact onhealth.

Regions also stressed the need for linking withother sectoral efforts in an interdisciplinarymanner�nutrition and education, for ex-ample, or health issues associated with thelocalized impact of solid waste disposal andoccupational and traffic safety.

Next Steps. Among the suggestions proposedby Regions were to:

! Improve the integration of environmentalhealth in CASs

! Embark on new analytical and advisoryactivities (AAAs) in EH, while strengtheningcapacity to increasingly apply existingknowledge in the field

! Define the scope for intersectoral collabora-tion on EH work that will best meet needs(highly complex and multiple collaborationwill not succeed in practice)

! Include EH analysis in the environmentalassessment process

! Devise low-cost (appropriate to the level ofexpenditure on other issues) ways oftracking and monitoring indicators of healthoutcomes or �reasonable� proxy indicators(see table 3 for some examples)

! Develop case studies on specific priorityissues and pilot project activities.

25

Cooperation within the Bank

Chapter 9

Environmental Health Work is InherentlyCross-sectoral. EH work will not maturewithout building ties across networks

and sectors. The current organizational set-upin the Bank places strong emphasis on sectoralpriorities, which sometimes makes it difficult tomaintain a coherent country focus in general,let alone a focus on environmental health,which has never had an �institutional home.�

Strengthen Links to Poverty Work. Health isnot the only cross-cutting theme; poverty iscross-sectoral to an even greater extent. TheBank�s reinforced commitment to povertyreduction and a holistic approach to achievingdevelopment outcomes have already facilitatedcross-sectoral arrangements conducive topromoting environmental health. Progress ismost evident in poverty work, and there is aneed for closer ties between staff and thematicgroups working on EH and poverty issues. Thisis consistent with the finding of the Poverty andEnvironment Team that health is the moststraightforward link between poverty andenvironmental concerns. Still, the process ofbuilding effective multisectoral teams is at anearly stage, as most Regions noted that thereare few incentives for operational staff frominfrastructure and energy to work acrosssectors.

Learn from Good Practice. A possible ap-proach is to take stock of ongoing attempts towork across sectors and learn from successesand failures. Examples can be drawn fromAfrica (the work of Environmental Health andMalaria teams with Infrastructure staff), fromEnvironment and Health, Nutrition, Population(HNP) anchors (joint work on health care wastemanagement issues), from South Asia (Regionalenvironmental health program proposed jointlyby Health and Environment staff, Regional teamcomposed of Energy and Environment staff),and from other Regions. These �bottom-up�activities will provide important insights onwhat it takes to build good cross-sectoralcollaboration and what kind of incentives areneeded.

Clarify and Build on the Advantages of Envi-ronmental Staff. The cross-sectoral nature ofenvironmental health and its strong links toactivities in other sectors also raise a questionabout the role and comparative advantage ofenvironmental staff. These individuals make avaluable contribution in at least two areas,using their cross-sectoral skills and approach.One is to provide high-quality analytical inputsto the design of �traditional� infrastructure,energy, and health projects that will increase

26



the impact of these projects on health andother development outcomes. An example isthe work of the EH and malaria teams in Africa(for example, an infrastructure project inGhana that has a pilot environmental healthcomponent). The other is to promote a holisticapproach to health in CASs, AAAs, andlending, which could result in a new type of

development project that is �area-based� andoutcome-oriented, rather than sectoral. Anexample could be the ongoing effort in SouthAsia to put together a pilot project in Indiaaimed at complementing traditional HNPactivities to increase child survival with EHactivities, involving staff from the health,environment, and energy sectors.

27

Collaboration with WHO and otherExternal Partners

Chapter 10

Environmental health is one of the keyareas addressed by WHO. World Bankenvironment staff have collaborated with

WHO on a number of projects, programs, andissues, but the relationship lacks consistencyand a systematic approach. Collaboration wasstrengthened last year when a newly createdWHO Cluster on Sustainable Development andHealthy Environments proposed working moreclosely with the Bank on environmental health.This year WHO embarked on a Strategy forSustainable Development and Healthy Environ-ments that is being prepared in consultationwith the World Bank, especially the HNPNetwork, which is playing the lead role forBank collaboration with WHO on environmen-tal health. While collaboration with WHO onthis issue is clearly necessary, the frameworkand agenda for such collaboration, which willbenefit both institutions and their clients, arestill to be developed.

Other Key Partners. Quite a few internationaland bilateral development and health agencieswork on environmental health issues in devel-oping countries. The list includes the UnitedNation Children�s Fund (UNICEF) and otherU.N. agencies, the Centers for Disease Controland Prevention in the United States, the U.S.

Agency for International Development, and theU.S. Environmental Protection Agency. UNICEFand the U.N. Development Programme, forexample, often play a more significant role inimproving environmental health (through WSS,improved stoves, or other rural developmentprograms) than WHO, which works predomi-nantly with national health agencies. Localagencies, programs, nongovernmental organi-zations (NGOs), and community groups arealso involved in activities related to environ-mental health. NGOs play an essential role inmany EH activities, and should be among theBank�s major partners.

Does the World Bank Have a ComparativeAdvantage? Bank staff in both health andenvironment consulted on this issue answeredpositively. They pointed out that the WorldBank is in a unique position to have a strongimpact on environmental health, since it isinvolved in dialogue and project developmentin all the sectors crucial for achieving such animpact. The Bank�s comparative advantage inaddressing EH risks is its ability to design andimplement multidisciplinary projects with thebreadth required to have an impact on health.Environment, infrastructure, and energyinterventions are usually not considered to be

28



key determinants of human health by govern-ments and health ministries, which tend tothink of health investments in terms of numberof hospital beds and doctors per person. The

World Bank has tremendous potential topromote a holistic approach to health and helpgovernments develop the capacity required toimplement such an approach.

29

Health and the New Environment Strategy

Chapter 11

T he World Bank�s new EnvironmentStrategy pays serious attention to envi-

ronmental health by promoting three

major types of activities:

! Improving knowledge of EH problems and

developing an appropriate response that

takes into account institutional, financial,

and social constraints; launching advocacy

and dissemination activities; and strengthen-

ing collaboration with strategic partners such

as WHO, other U.N. agencies, and bilateral

organizations with experience in environ-

mental health.

! Integrating critical EH issues into the opera-

tions of relevant sectors�such as health

considerations and hygiene promotion in

WSS projects, indoor air pollution in energy

operations, urban air pollution in transport

projects and city development strategies, and

fuel quality in petroleum-sector restructuring

work.

! Adopting a holistic approach to develop-

ment impacts, which focuses on tangible

improvements in human health and facili-

tates cross-sectoral collaboration inside the

Bank and in client countries to achieve these

improvements.

The new strategy proposes to undertake theseactivities by:

! Incorporating environmental health issuesinto CASs

! Promoting a Bank-wide set of cross-sectoralbest practices and guidelines

! Integrating environmental health analysisinto the Environmental Assessment process(based on draft Environmental HealthAssessment Guidelines prepared by theAfrica EH team)

! Facilitating �targeted collaboration� amonghealth and other ministries/agencies in clientcountries (through joint missions andenhanced sector dialogue on EH)

! Launching AAA and project activities onindoor air pollution, which appears to havebeen overlooked in the Bank�s portfoliodespite the high priority it receives with thepoorest countries

! Undertaking basic health surveys as part ofpreparation for projects in which EH is aprimary justification (such as air pollutioncontrol, sanitation, and wastewater), withfurther monitoring

! Improving understanding of the linkagesbetween health outcomes and developmentactivities in infrastructure, energy, and the

30



urban and rural sectors, including newconcerns such as climate change

! Devising better estimates of the burden ofdisease due to environmental causes andthe cost-effectiveness of environmentalpreventative interventions

! Developing measurable indicators of healthimpacts for non-health-sector projects thatare simple, low-cost, reliable and accurate

! Working more closely with HNP staff andthe Public Health Thematic Group, particu-larly in promoting a holistic approach tohealth and addressing health and povertylinkages

! Establishing an Environmental Healthcluster of Bank staff from various sectorsand units to foster exchange of information,ideas, and experience

! Promoting information-sharing and moreeffective collaboration with WHO andother international and bilateral institutionsworking on EH issues

! Dissemination and training.

PROCESS

The preparation of this paper involved aconsultative process across Regions, networks,

and sectors. The work was undertaken in closecollaboration with HNP staff and with theactive involvement of each Region. Consulta-tions also involved some staff from energy andinfrastructure groups, although these were lesselaborate due to the lack of time (and probablyinterest, on their part). A Bank-wide workshopon environmental health was sponsored jointlywith HNP staff on September 9, 1999, fol-lowed by a session on these issues during theEnvironment Forum in March 2000 (withparticipation from HNP and FPSI staff). Thesediscussions and other communications withBank staff indicated a growing interest inenvironmental health, facilitated by a sharp-ened focus on poverty and outcome-orientedactivities. Since then, EH issues were dis-cussed at the HNP Sector Board and HDweek, and have been included in the Bank-wide sectoral strategies for HNP, water andsanitation, energy, and transport.

31

Definitions of Environmental Health

Annex A

WORLD HEALTH ORGANIZATION

By adopting the principles of the RioDeclaration and Agenda 21 as the routeto sustainable development in the

twenty-first century, the world�s leaders recog-nized the importance of investing in improve-ments to people�s health and their environ-ment. Humans experience the environment inwhich they live as an assemblage of physical,chemical, biological, social, cultural, andeconomic conditions that differ according tothe local geography, infrastructure, season,time of day, and activity undertaken.

The environmental threats to human health canbe divided into �traditional hazards� associatedwith lack of development, and �modernhazards� associated with unsustainable devel-opment.

Traditional hazards related to poverty and�insufficient� development include:

! Lack of access to safe drinking water! Inadequate basic sanitation in the household

and the community! Food contamination with pathogens! Indoor air pollution from cooking and

heating using coal or biomass fuel

! Inadequate solid waste disposal! Occupational injury hazards in agriculture

and cottage industries! Natural disasters, including floods, droughts,

and earthquakes.

Modern environmental hazards to humans arerelated to �development� that lacks health andenvironmental safeguards, and to the unsustain-able consumption of natural resources, includ-ing:

! Water pollution from populated areas,industry, and intensive agriculture

! Urban air pollution from motor cars, coalpower stations, and industry

! Solid and hazardous waste accumulation! Chemical and radiation hazards following

introduction of industrial and agriculturaltechnologies

! Emerging and re-emerging infectious diseasehazards

! Deforestation, land degradation, and othermajor ecological change at local andregional levels

! Climate change, stratospheric ozone deple-tion, and transboundary pollution.

The main functions of the World HealthOrganization (WHO) in this area are to address

32



risks to health stemming from these hazards.Environmental health risk assessment andresearch form the basis of all activities andproduce the evidence base for nationallegislation and standard-setting, a process thatis supported through technical cooperationwith national health and environment authori-ties. WHO also undertakes and supportsanalysis of the situation and trends andsupports development of international initia-tives to combat transboundary hazards.

WORLD BANK AFRICA REGION

ENVIRONMENTAL HEALTH AND

MALARIA TEAMS

Environmental health relates to human activityor environmental factors that have an impacton socioeconomic and environmental condi-tions with the potential to increase humandisease, injury, and death, especially amongvulnerable groups, mainly the poor, women,and children under five.

Environmental health aims to prevent healthrisks through control of human exposure to: (a)biological agents, such as bacteria, viruses,and parasites; (b) chemical agents, such asheavy metals, particulate matter, pesticides,and fertilizers; (c) disease vectors, such asmosquitoes and snails; and (d) physical andsafety hazards, such as traffic accidents, fire,

extremes of heat and cold, noise, and radia-tion. Human exposure pathways are air, water,land, and food.

Environmental health strives to considerindividual problems in as broad a context aspossible from which to set policies anddevelop reasonably practicable and cost-effective preventive remedial measures. Thebroad context should include the drivingsocioeconomic determinants leading tophysical and mental stress, such as:

! Population movements (population growth,rural-to-urban migration, resettlement, andso forth)

! General lack of access to basic services(transport, water, sanitation, energy)

! Inordinate time spent compensating for lackof basic services (hours devoted to fetchingwater and household fuels or to getting toschool, work, or health services).

Environmental health preventive remedialmeasures complement health care systeminterventions to optimize health benefits. Thebroad context also allows for more efficientcross-sectoral intervention, such as addressingthe risk of sexually transmitted diseases ininfrastructure projects in cases where truckersand work crews are at risk of acquiring orspreading the disease.

33

Estimating the Burden of Disease Related toEnvironmental Risks

Annex B

Diseases caused by lack of access to clean water/sanitation and vector control

Amoebiasis

Cholera (Vibrio cholerae)

Conjunctivitis

Denguea

Diarrhea (from Campylobacter jejuni,cryptosporidium, Giardia lamblia, Escherichia coli,Salmonella spp., Yersinia, and other agents)

Dysentery (includes Shigella, Ameobiasis)

Filariasisa

Giardiasis

Guinea worma

Helicobacter PyloriHelminths (roundworm, whipworm, threadworm,

hydatid disease)

Hepatitis A, E

Japanese encephalitisa

Leishmaniasisa

Malariaa

Onchocerciasis (river blindness) a

Poliomyelitis

Protein-energy malnutrition

Rotavirus

Scabies

Schistosomiasisa

Trachoma

Trypanosomiasis (Chagas’ disease) b

Typhoid and Paratyphoid

Well’s disease (Leptospirosis) c

Yellow fever a

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 ldwide. Related to housing conditions.

The burden of disease due to lack of water andsanitation was calculated using data from theGlobal Burden of Disease by disease, causes,and regions, and the assumptions about thecontributions from specific diseases indicatedin Table B.1:

INDOOR AIR POLLUTION

Estimates of the burden of ill health caused byindoor air pollution are based on a series of

studies by Kirk Smith and various colleagues(Smith 1998, 1999; Smith and Mehta 2000,Reddy, Williams, and Johansson 1997). Themost detailed analysis was carried out for Indiausing census data for 1991, and yielded a rangeof 410,000�560,000 premature deaths eachyear as a result of exposure to indoor airpollution, with a best estimate of 500,000. Aseparate study of mortality among childrenunder the age of five, using data from the1992�93 Indian National Family Health

34



TABLE B.1 Burden of specific diseases

Survey, produced estimates of the excess riskof mortality associated with the use of solid orbiomass cooking fuels of 45 percent for ruralhouseholds and 18 percent for urban house-holds (Hughes, Lvovsky and Dunleavy, 2001).Furthermore, the Murray and Lopez (1996)study of the burden of ill health suggests thatthe number of deaths of adult women in Indiaeach year due to respiratory diseases repre-sents 15�20 percent of the number of deathsof children under five from these diseases.

Combining these conservative end of theseestimates with data on the number of house-holds using solid or biomass cooking fuels andwith mortality rates produced estimates of thenumber of premature deaths due to indoor airpollution for 1991 of 460,00�520,000, whichis very close to Smith�s figures. To obtain anestimate of the total number of disability-adjusted life years (DALYs) lost as a result of

indoor air pollution, it was assumed that thedeath of a child under the age of five results,on average, in the loss of 30 DALYs, while thedeath of an adult female (most of whom areover the age of 45), results in an average lossof 10 DALYs. Finally, it is necessary to con-sider non-fatal illnesses resulting from expo-sure to indoor air pollution. Again, based onthe Murray and Lopez data, it was assumedthat for each death of a child under the age offive, a total of eight DALYs are lost due toother respiratory diseases.

Since no comparably detailed studies havebeen made in other regions of the world, themortality-hazard approach was used togenerate projections of the burden of ill healthfor India as well as for the rest of the world. Itwas, however, necessary to make certainadjustments for the specific circumstances ofsome regions. The final set of hazard param-eters is shown in Table B.2.

Various commentators have suggested that thehazard associated with solid or biomasscooking fuels in Africa is lower than that ofIndia, because such fuels are usually used foroutdoor, not indoor, cooking. In the absence

TABLE B.2 Hazard rates due to exposure to indoor air pollution

Diarrheal diseases: 80 percentHepatitis: 30 percentH. Pylori: 20 percentTrachoma: 25 percentIntestinal helminths: 70 percentNote: Malaria�taken directly from Murray and Lopez 1996.

Region

Excess hazard for under-5 mortalityassociated with use of a dirty cooking fuel

(percent)

Adult female deathsas share of under-5

deaths(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 17.5 15

Middle East 7.5 17.5 15

South Asia 15 35 15

Sub-Saharan Africa 7.5 17.5 15

35Kseniya Lvovsky

Estimating the Burden of Disease Related to Environmental Risks

of clear epidemiological evidence, hazardrates for the Sub-Saharan Africa, Latin Americaand Caribbean, and Middle East regions havebeen assumed to be one-half of the equivalentvalues. The resulting estimates of the burdenof ill health for Africa, where levels of urbanair pollution contributing to excess mortalityand disease from respiratory causes arerelatively low, are broadly consistent with theMurray and Lopez burden of disease esti-mates.3

The total number of deaths attributed to indoorair pollution using this approach is nearly 1.7million per year, which is also broadly consis-tent with (although somewhat lower than)available global estimates. For example, WHO(1997) estimates 2.8 million yearly deaths, andSmith (1999) estimates 2 million deaths.

China faces a somewhat different problem.One study suggested that more than 700,000premature deaths occur there per year as aresult of household use of solid fuel. Thecomposition of these deaths differed from theIndia estimates; a higher share of chronicrespiratory disease and cancers, both of whichaffect adults rather than young children, werefound. However, it is very difficult to separatethe effects of indoor and outdoor air pollutionbecause the widespread use of solid fuels inChina is the source of particularly high levelsof urban outdoor air pollution in manylocalities. Applying the Indian parameters tothe Chinese data yields an estimate of onlyabout 195,000 premature deaths due to indoorair pollution in 1995. This low estimate is, inpart, a consequence of the rather low mortalityrate for children under five in China�less thanone-half of the equivalent value for India.Even so, prolonged exposure to indoor airpollution will be reflected in higher levels of

respiratory disease later in life, so that the ratio

of adult female deaths to under-five deaths inChina was adjusted upwards to 40 percent, to

allow both for this effect and for the different

age structure of the population. Nonetheless,the resulting estimate of the total number of

deaths due to indoor air pollution�235,000 in

1995�is only one-third of the estimates in theprevious study. The figure of 700,000 prema-

ture deaths, on the other hand, is entirely

consistent with our estimate of the totalburden of disease caused by indoor and

outdoor air pollution combined.

Comparisons of patterns of fuel use acrosscountries suggest that there is no consistent

decrease in the proportion of the population

relying on solid and biomass fuels for cookinguntil per capita gross national product (GNP)

exceeds US$500 per person (at 1995 prices).

Hence the average burden of ill health perperson associated with indoor air pollution for

each country with levels of GNP per person of

less than US$500 in 1995 was assumed toremain constant at its 1995 level per person

until GNP per person reaches that threshold.

After that, the average burden of ill health perperson was assumed to decline linearly to zero

over 50 years. For countries where GNP per

person exceeded US$500 in 1995, the as-sumptions concerning the average burden of

ill health per person due to indoor air pollu-

tion were:

! GNP/person between US$500 and

US$1,000, declines linearly to zero over 40

years! GNP/person between US$1,000 and

US$1,500, declines linearly to zero over 30

years! GNP/person greater than US$1,500,

declines linearly to zero over 20 years.

36



URBAN (OUTDOOR) AIR POLLUTION

The methods used to estimate the costs oflocal outdoor exposure are based on the dose-response and valuation assumptions, whichunderpin the analysis of the study of the socialcosts of fuel use cited above (Lvovsky andothers 2000). In that case, however, averagelevels of exposure to particulates and otherurban air pollutants were linked to the use offossil fuels, an approach that is not feasible inthe present context. Hence this study makesuse of data on ambient air quality from a largesample of cities around the world, obtainedfrom a wide variety of sources.4 Both itsquality and coverage are uneven, but itrepresents the most comprehensive informa-tion about urban air quality that has beenanalyzed to date, covering 379 cities andmetropolitan regions.

Relative to urban populations, the coverage ofthe sample is reasonable for the EME and FSEregions, as well as for China and India. Datacoverage is relatively poor for Africa, and onlysomewhat better for the LAC region. For themost part, availability of data is correlated withan awareness that urban air pollution is asignificant problem, so that the limited data forAfrica are reflected in low estimates of thecosts of urban pollution in Africa today. Basedon anecdotal evidence, this is probably areasonable assessment, but it does pose thequestion of what will happen as urban popula-tions and incomes increase.

Estimates of the costs of damage caused byurban air pollution are based primarily onaverage exposure to PM10. However, much ofthe data refer to measurements of TSP, whichwere converted to PM10 equivalents using aconversion coefficient of 1 µg/m3 of TSP =0.55 µg/m3 of PM10. This conversion coeffi-

cient is almost certainly too low for urbanareas in the FSE region and China, whereclimatic conditions mean that urban airpollution is dominated by the burning of coaland other fossil fuels for heating. However, itis reasonable for India and other countrieswith warmer climates, where natural sourcesof dust and transport are the major contribu-tors to monitored levels of TSP. The use of arelatively low conversion coefficient impliesthat the costs of urban air pollution areprobably significantly underestimated, particu-larly for the FSE region and China. Whereavailable, data on average ambient levels ofsulfur dioxide and nitrogen dioxide were alsoused in the estimation, although they accountfor a small fraction of the overall burden ofdisease associated with urban air pollution.

Most epidemiological evidence suggests thateven very low levels of exposure to PM10�and, even more, to fine particulates orPM2.5�are associated with an excess burdenof mortality and disease. Still, it is unrealisticto assume that it would be possible to reduceaverage exposure to PM10 to close to zero.Hence the estimation is based on a thresholdof 20 µg/m3 for exposure to PM10 and SO2, and40 µg/m3 for NO2. These thresholds areconsistent with the ambient air quality stan-dards for 2010 adopted recently by the UnitedStates and the European Union. There is alsouncertainty about whether estimated dose-response relationships can be extrapolated tovery high levels of average exposure. This is amatter of particular importance for China,where many cities have estimated averagelevels of PM10 in excess of 200 µg/m3. Toreflect this uncertainty, the analysis assumesan upper truncation of exposure at 200 µg/m3,which, again, implies that the burden of urbanair pollution in China has been underesti-mated.

37Kseniya Lvovsky

Estimating the Burden of Disease Related to Environmental Risks

Since the data cover only a sample of theurban population in each country and not allcountries are represented, it was necessary toextrapolate the sample data to estimateaverage levels of exposure for all urbanpopulations. This was accomplished by usingthe sample to calculate population-weightedaverage levels of the burden of ill healthassociated with urban air pollution�measuredin premature deaths and DALYs lost per 1,000residents�for the cities in each countrycovered. For each country it was assumed thatestimates of the average burden could beapplied to the entire urban population of eachcountry. This assumption might be challengedon the grounds that urban air pollution inmedium-sized and large cities is not represen-tative of the pattern for all urban areas. Suchan assertion is usually predicated on the beliefthat large cities are more polluted than smallerurban areas, but this is not supported by theavailable data. In countries such as the UnitedStates, Russia, and China, where data arerelatively plentiful, urban air quality tends tobe worst in medium-sized cities with popula-tions in the range of 100,000�500,000.Smaller towns and cities account for a modestshare of total urban population, making itlikely that reliance on a sample biased towardcities with populations of more than 500,000will tend to underestimate, rather than overes-timate, the overall burden of ill health due tourban air pollution. For countries for which nodata were available, it was assumed that theaverage burden of disease per 1,000 urbanresidents was equal to the average for therelevant region.

To extrapolate the burden of urban air pollu-tion over time, the analysis assumed that theburden of ill health increases in line with thetotal level of urban incomes, up to the thresh-

old of a GNP per person of US$1,000. This isequivalent to assuming that in countries withGNP per person below US$1,000, averagelevels of urban air pollution will increase withincome while the average number of peopleexposed will increase with the urban popula-tion. Global experience over the last 50 yearssuggests that this is a reasonable approxima-tion of what has happened as a result of rapidurban and industrial growth. It could beargued that this method of projection willoverstate the possible deterioration of urbanair quality in China. This may be true for thelargest metropolitan areas, but concern aboutfuture urban air quality in China should focuson smaller, more rapidly growing cities, whereair pollution is likely to worsen. Since theoverall approach tends to underestimate theburden of urban air pollution in China, nospecial adjustments were made in projectingthe estimates forward in time. Comparison ofthe projections for China with those generatedby a different approach for the period to 2020suggests that the estimates of the cost of urbanair pollution used here are probably on thelow side.5

Analysis of patterns of urban air pollutionacross countries suggests that average levels ofparticulates and sulfur dioxide in urban areastend to rise with income up to a level of GNPper capita of US$1,000-$2,000 at 1995prices.6 Hence the average burden of illhealth per person associated with urban airpollution for each country with levels of GNPper person lower than US$1,000 in 1995 wasassumed to remain constant at its 1995 levelper person until per capita GNP reaches thatthreshold. After that the average burden of illhealth per person was assumed to declinelinearly to zero over 100 years, reflecting therate at which urban air pollution has been

38



reduced in medium- and high-income coun-tries. For countries whose GNP per capitaexceeded US$1,000 in 1995, the assumptionsconcerning the average burden of ill-health perperson due to indoor air pollution were:

! GNP/person between $US1,000 andUS$2,000, declines linearly to zero over 80years



! GNP/person between $US8,000 andUS$16,000, declines linearly to zero over30 years

! GNP/person greater than US$16,000,declines linearly to zero over 20 years.

AGRO-INDUSTRIAL POLLUTION

The most common health symptoms reportedfrom chronic, low-dose exposure to toxicchemicals include vomiting, vertigo, nausea,dizziness, anxiety, and headaches.7 Chronicexposure at high levels is manifested bydepression and cytogenetic effects, and canlead to an increased hazard of certain cancers,

namely gastric, renal, skin, and blood.8

Poisoning is the most often cited healthconsequence of pesticide use. Skin and eyecontact during application may lead toneurological or immunological reactionsranging from irritation to serious complicationsrequiring immediate medical assistance.Usually, such incidences arise from improperapplication or container disposal.

In addition to occupational hazards, toxicexposure to pesticides is believed to resultunder particular conditions, including therepeated application of a persistent compoundover a period of years near to drinking-watersources. Even under these conditions, how-ever, at levels several times the quality stan-dards, the resulting buildup has rarely beenlinked with observed or expected healthproblems.

Table B.3 presents estimates of the burden ofdisease potentially associated with acute andchronic exposure to pesticides and non-point-source industrial contaminants in theenvironment. The estimates are based on conser-vative (5 percent of the total burden) and liberal(20 percent of the total burden) boundaries,related to the summation of over 15 diseasesequelae.9 Liberal estimates are used in the table.

TABLE B.3 Burden of disease associated with agro-chemical exposure

Source: Murray and Lopez 1996.

Region EstimatesAgro-industrial

associated DALYsAs share of all 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

39

Africa — Burden of Disease from Environmen-tal Causes and Intervention Measures10

Annex C

T he objective of the exercise describedbelow is to determine the extent towhich interventions outside the health

care system may be beneficial to the health ofpopulations in Africa.

The burden of disease due to environmentalfactors is extremely important in public health,since certain environmental factors are ame-nable to specific remedial measures�most ofwhich lie outside the health care system.However, estimates are difficult because of thepaucity of information about disease etiology.Nevertheless, laboratory and epidemiologicalresearch has attempted to identify risk factors in

disease causation that could be explored forthis purpose. The estimates presented in TablesC.1 and C.2 are largely guided by such studies,and primarily based on Smith, Corvalan, andKjellstrom (1999), which provides estimates ofenvironmentally attributable percentages.

METHODOLOGY

The methodology involves listing the differentenvironmentally related diseases and the risksand percentages that may be attributable toenvironmental factors. The Global Burden ofDisease study by Murray and Lopez (1996) wasused as the basis for the calculations primarily

TABLE C.1 Burden of disease relieved in Sub-Saharan Africa (SSA), by remedial measure(worksheet estimated from 1990 DALYs)

Range of DALYs potentially reduced by theremedial measures (percent)Remedial measures

(diseases potentially reduced by remedial measures) Low High

Remedial measures outside health care systemImproved housing and air pollution abatement 5.4 7.9

Improved water supply, sanitation, and waste

management

8.9 10.0

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

outside the health care system

22.7 28.7

Remedial measures through health care and health educationHealth care/education-type remedial measures 22.5 28

Other types of remedial measuresPercent of SSA DALYs from other diseases 54.7 43.2

40



TABLE C.2 Burden of disease relieved in Sub-Saharan Africa (SSA), by remedial measures inDALY (estimated from 1990 DALYs)

Notes:a. Includes, for example, improvements in water supply, sanitation, waste management, drainage, transportation, housing, household 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.

Range of DALYs potentially reducedby the remedial measures

Remedial measures(Diseases affected by remedial measures) Low High

Remedial measures outside health care systema

Improved housing and air pollution abatementRespiratory diseases b

Circulatory system diseases c

Eye diseases d

Subtotal

15,345

557

182

16,085

22,436

696

215

23,347

Improved water, sanitation, and waste managementDiarrheal diseases

Intestinal worm infections

Eye diseases e

Subtotal

25,701

396

249

26,345

28,913

445

284

29,642

Vector control, sanitation, and drainageTropical disease cluster f

Malaria

Dengue

Subtotal

3,889

18,962

15

22,866

5,000

24,380

19

29,399

Road, workplace, and housing designRoad traffic accidents

Falls

Drownings and fires

Subtotal

1,432

532

n.a.

1,964

1,719

638

n.a.

2,357

Total SSA DALYs from remedial measures outside the

health care system

67,260 84,745

Health care/education-type remedial measuresChildhood diseases cluster g

Gastrointestinal diseases h

Respiratory diseases b

Circulatory system diseases c

Tropical diseases cluster, malaria, and dengue

Eye diseases e

Subtotal

30,445

3,262

22,301

6,266

3,267

858

66,339

n.a.

6,524

28,991

6,405

9,800

891

83,056

SSA DALYs from other d iseases 161,695 127,493

Grand total of SSA DALYs 295,294

41Kseniya Lvovsky

Africa � Burden of Disease from Environmental Causes and Intervention Measures

because it reflects both disability and death.The list of diseases was also taken from thissource. Estimates for the region were alsoguided by the prevalence of risk factors, suchas the use of traditional cooking fuel in Africaand smoking rates. Air pollution and housing-related diseases are used as an example for themethodology. This methodology of estimationwas used to obtain �guesstimates� for theremaining environmentally related diseases. Arange is shown for each disease/remedialmeasure category to show conservative andliberal estimates.

Based on literature reviewed, the following airpollution-related diseases are listed: acuterespiratory infections; chronic obstructivepulmonary disease; asthma; trachea, bronchus,and lung cancer; tuberculosis; ischemic heartdisease; cerebrovascular disease; trachoma;and cataracts.

A listing of relative risks and percentagesattributable to both indoor and outdoor airpollution was compiled, based on severalstudies. This list was then compared with theapproximations reached by Smith and others.Sources of air pollution were likewise listed.

By gross examination of the list above, and incomparison with Smith�s figures, lower andupper guesstimates of percent attributablewere reached. World and African DALYs ofthe aforementioned diseases were then listed.The lower and upper guesstimates of thepercent attributable were multiplied by theDALYs from each disease. The productsderived represent the number of DALYsattributable to air pollution. A range of DALYguesstimates was produced for each disease.

Totaling the DALY guesstimates of the diseasesgives the total DALYs attributable to air

pollution, and dividing this by the total DALYsfor the region or world yields the percentguesstimate of regional or world DALYsattributable to air pollution.

Separate guessstimates for indoor and outdoorair pollution were reached similarly for theworld DALYs. For the Africa Region, in orderto separate the contribution of indoor andoutdoor air pollution, the levels of industrial-ization, transportation, use of traditionalcooking fuel, and smoking rates were exam-ined. Guided by these figures, allocations ofpercentages attributable to indoor and outdoorpollution were made. The resulting guessti-mates were interpreted as the DALYs thatcould be mediated by improved housing andair pollution abatement, including a change incooking/heating/lighting fuel.

For DALYs mediated by other interventions,such as water supply, sanitation, vectorcontrol, and waste management, a similarmethod for guesstimating was used. Using theenvironmental fractions of Smith, Corvalanand Kjellstrom (1999), guesstimates fordiseases mediated by other interventions werecomputed.

Diseases related to water, sanitation, andwaste management:

! Diarrheal diseases! Intestinal nematode infections! Trachoma! Other gastrointestinal diseases, such as

hepatitis and ulcers

Diseases related to vector control, sanitation,and drainage:

! Tropical disease cluster

42



! Malaria! Dengue

Diseases related to road, workplace, andhousing design:

! Road traffic accidents! Falls! Drownings! Fires

For DALYs mediated by the health care systemand health education, the childhood cluster

was assumed to be alleviated 100 percent bythe immunization program (Smith, Corvalan,and Kjellstrom 1999). For other diseases, thecomplementary value of the environmentalportion was assumed to be the value thatcould be mediated by health care and healtheducation, and was applied to the DALYsaccordingly.

Tables A3.3-A3.5 illustrate the methodologyemployed, using housing- and air pollution-related diseases as examples.

TABLE C.3 Lower and higher percentage guesstimates for each disease

TABLE C.4 DALYs guesstimates attributable to air pollution

Percentattributable

Africa: Air pollution-related diseases(in/outdoor) (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

Africa: Air pollution-related diseases (in/outdoor)

Percentattribu-

table(lower)

PercentAttribu-

table(higher) Total DALYs

DALYsattribu-

table (lowerestimate)

DALYsattribu-

table(higher

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

43Kseniya Lvovsky

Africa � Burden of Disease from Environmental Causes and Intervention Measures

TABLE C.5 Guesstimates for indoor and outdoor air pollution

Africa: Air pollution-related diseases(in/outdoor)

Outdoor-%attribut-

table

Indoor-%attribut-

able

DALYs-attr.(higher)

OUT

DALYs-attr.(higher)

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

45

Cost-Effectiveness of Environmental HealthInterventions

Annex D

T his annex compares the cost-effectivenessof a range of environmental health (EH)interventions. Knowledge in this area

can be used to set priorities for investment andto improve budget-allocation decisions. Theanalysis identified considerable differences inboth the cost and effectiveness of different EHinterventions. Some interventions are �win-win� (such as installing electronic ignitionsystems in two-stroke vehicles in Delhi) andtherefore can be justified on economic criteriaalone. In general, interventions that reduceindoor air pollution, improve water supply andsanitation, and prevent malaria appear to bemore cost-effective than those that reduceoutdoor air pollution.

ANALYSIS

The analysis identified marked differences inboth the cost and effectiveness of varioushealth interventions. Figure 1 presents both thecost-effectiveness (in US$ per DALY) and gainsin DALYs for 29 different interventions thatreduce ambient concentrations of air pollutionin three cities. Lower points represent interven-tions that are more cost-effective, and pointsfarther to the right represent interventions thatproduce larger numbers of DALYs averted.

Some interventions, such as installing elec-tronic ignition systems in two-stroke vehicles inDelhi and replacing gasoline with LPG intrucks in Mexico City, can be characterized as�win-win,� in that they result in both costsavings and DALYs averted. Other interven-tions, such as re-engining light diesel buses inMexico City to 1991 U.S. emissions standards,produce large, positive health gains at a cost ofabout US$300 per DALY averted. Air pollutioninterventions can also be a very expensive wayof averting DALYs. (See Table D.1.) For ex-ample, applying the low-emission vehiclestandards adopted in California to passengercars in Mexico City costs over US$70,000 perDALY averted.

The variation in the cost-effectiveness ratio ofdifferent interventions is a function of localconditions. Costs are influenced by the pres-ence of other interventions (through jointsharing of costs) and by local market distor-tions. Effectiveness depends on the size andcomposition of the affected population, and thedegree to which the intervention penetrates orcovers a population. For example, interventionsthat reduce emissions from two-stroke enginevehicles in Delhi tend to be very cost-effectivebecause they have a relatively low cost in ahigh-density urban environment.

46



While the purpose of the analysis is to facili-tate the systematic comparison of interven-tions, a note of caution is urged in makingcross-country comparisons. Costs are assessedusing local prices. Thus if the price of gasolineis subsidized in one country, the cost of agasoline-intensive intervention will be lowerthere than in a country where there is nosubsidy. Ideally, border prices should be usedto make cross-country comparison correctly.

These results for air pollution can also becompared with the cost-effectiveness of otherEH interventions. Reducing indoor air pollu-tion through improved stoves in India costsfrom US$50 to US$100 per DALY averted.Water and sanitation interventions range fromUS$20 to US$120 per DALY averted. Malaria-

TABLE D.1 Summary of air pollution cost-effectiveness studies

InterventionTotal cost

(1997 US$)Total DALYs

avertedDelhi

(1997 US$)Santiago

(1997 US$)Mexico City(1997 US$)

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 I&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

New Taxi: 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 (1) 16.65 1,080 15,415

prevention interventions for children rangefrom US$5 to US$400 per DALY averted (see,for example, Binka 1997). �Win-win� interven-tions aside, reducing indoor air pollution,improving water supply and sanitation, andpreventing malaria all appear to be more cost-effective than reducing outdoor air pollution.

METHODS

Different environmental health interventionscan be compared by what it costs to achieveone additional year of healthy life. This annexmeasures cost-effectiveness as the ratio of U.S.dollars over DALYs. �Costs� are the annual-ized cost of an intervention, and �effective-ness� is the annual number of DALYs avoideddue to an intervention. This measure does not

47Kseniya Lvovsky

Cost-Effectiveness of Environmental Health Interventions

include non-health burdens, such as incomelost due to illness.

Whenever possible, the analysis relies ondose-response functions to quantify the impactof EH interventions in terms of DALYs. For airpollution, estimates of the annual health effectassociated with a unit change in PM10 aretaken from Ostro (1994). For water supply andsanitation, the expected reduction in morbidityand mortality is detailed in Esrey et al (1991).

DATA

The data are drawn from a review of publishedand unpublished studies. To facilitate cross-study comparisons, attempts were made toidentify studies that provide both cost andeffect information and use similar analyticalmethods (such as the same discount rate).

Unfortunately, relatively little information isavailable on cost. While costs associated withspecific air-pollution interventions are avail-able, costs of water supply and sanitationinterventions are not.

Although comparing costs and effects for awide range of EH interventions is desirable, itdoes not make sense to compare estimates thatmay not be reliable. The data, therefore, aretaken only from studies that contain sufficientinformation on both cost and effect to under-stand how the estimates were derived. Unfor-tunately, sufficient information is not availablefor many interventions, particularly in thewater supply and sanitation sector, making it isimpossible to calculate the cost-effectivenessratio. The data presented here make up only avery small proportion of the many possibleinterventions.

49

Analysis of Bank Documentation

Annex E

Most project-related work carried outto date on environmental health inthe Bank has been done by the

Europe and Central Asia (ECA) and the MiddleEast and North Africa (MNA) Regions, whereenvironmental health has played a role indetermining overall environmental strategies forthe area, essentially emphasizing pollutioncontrol (World Bank 1994b, 1995c).11 The EastAsia and Pacific (EAP) and the Latin Americanand the Caribbean (LAC) Regions have workedon economic evaluation of the human-healthdamages from pollution (World Bank, 1994a,1994c, 1994d, 1995a, 1995g). Numerous otherprojects dealing with pollution-control andwaste management have yielded importantpositive environmental health repercussions,but the latter are not necessarily separated intocomponents or other disaggregated activities.Only one pollution control project, in ECA,was designed based on health criteria; thereverse is more common (World Bank, 1995b).

Environmental health in Bank documentationhas received uneven attention, and tends to besubsumed by other, related topics. Manytraditional health concerns (for example, indoorhousehold pollution or vector-related diseasessuch as malaria) have been treated as health

sector, not environmental, issues. A literaturesearch of Bank documentation found only onepeer review by health professionals, which waspresented at a workshop on methodologiesused in evaluating the economic costs ofpollution on human health.12 Apart from thatobservation, it is hard to draw conclusionsbecause there is no Bank-wide definition ofenvironmental health.

Guidance that would allow staff to dealcompetently with environmental health issuesis lacking, especially when compared with thebroad range of documentation on environmen-tal management. Within the Staff OperationsManual, only one Operations Policy/BestPractice (OP/BP) deals directly with environ-mental health. Operational Directive (OD)4.03, �Guidelines for Use, Selection andSpecification of Pesticides in Public HealthPrograms,� deals with spraying to reducevectors, but does not address general pesticideuse in agriculture sector. OD 4.30 (�InvoluntaryResettlement�) contains one footnote on health;GP 4.37 (�The Safety of Dams�) refers to publichealth in general; OD 4.01 (�EnvironmentalAssessments,� Annex A) lists �OccupationalHealth and Safety� in a checklist; OP 4.02(�Environmental Action Plans�) mentions apublic health specialist as part of the EA team,

50



and lists public health and safety as generalobjectives; GP 4.03 (�Agricultural Pest Man-agement�) refers to proper disposal of pesti-cide containers; and OP 4.76 (�Tobacco�)refers to the dangers of tobacco smoking. (TheODs listed here are to be reissued as OPs.)

A literature search of non-project documentsreveals a primary emphasis on pollutioncontrol�that is, �brown issues,� followed bydevelopment of techniques to evaluate thehealth costs of environmental degradation.Frequent references to environmental healthcan be found, but few substantive healthanalyses are seen. Typical is Making Develop-ment Sustainable: From Concepts to Action,which presents the approaches of sociologists,ecologists, and economists in separate chap-ters; explicitly mentions gender and poverty inseparate sections; refers to urban pollutionissues; and features diagrams of pollutionindicators. (Others are World Bank 1995d,1995e, 1995f, and the Bank�s Annual Reportson the Environment.) An annotated bibliogra-phy, �Sociology, Anthropology and Develop-ment,� covering Bank publications from 1975�93, lists only two entries on health out of 390publications. The annual sustainable develop-ment conferences of 1994 and 1995, however,included many presentations on health.

Cross-fertilization on health issues within andamong sectors and networks could be im-proved in a broader context, and strengthenthe focus on development outcomes, such ashealth. Some examples are:

! Health and nutrition activities�addressinganemia through links with deficient nutri-tion as a cross-cutting health-sector issuewould further benefit from linking it also tohookworm, a major contributor to anemia,with deficient sanitation (the worms hookonto the intestines, causing blood loss).

! Work on air pollution and health, mostlyfocused on ambient air pollution so far,would benefit from complementing it bylinks between indoor pollution and respira-tory diseases, now considered one of themost important health problems in develop-ing countries.

! The use of pesticides is traditionally linkedwith water quality, but less so with breastcancer in women farmers or with generalcontamination of the food chain.

These and other cross-sectoral issues andintegrated approaches that could tangiblyimprove the development impact of Bankoperations need to be given more attention infuture work.

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Regional Responses to EH Questionnaire

Annex F

1. What are the main environmental healthproblems in your region?

SAR: Water supply and sanitation-relateddiseases from polluted drinking waterand dearth of sanitation and goodhygiene practices; respiratory diseasesand other adverse effects from indoorair pollution resulting from the use oftraditional biomass fuels in primitivecookstoves and urban air pollution froma variety of energy, transport, and othersources.

LAC: (a) Water-borne disease resulting frominadequate water supply and sanitation.Sanitary education may be weak in poorareas of the region.(b) Serious respiratory illness, particu-larly within vulnerable groups, from airpollution in Mexico City and Santiago.Cities with growing localized problemsinclude Lima, Rio, Buenos Aires, andmany medium-size cities with highgrowth.(c) Localized health impacts of inad-equate disposal of sewage in bay andcoastal areas.

ECA: The most common cause of death inEurope is cardiovascular disease; the

second is malignant neoplasms. Injuriesand poisonings are responsible for closeto 10 percent of mortality. Accidentsassociated with cars and the workplaceare the most prominent. Better charac-terization of the environmental factorsthat increase the risk of accidents forchildren is considered as a priority topicfor research by WHO and the EC-EHcommission.

We need to separate ECA into Europe, thenewly independent states (NIS), and CentralAsia (CA) for these purposes. Outbreaks ofdisease related to environmental pollution arerelatively rare in Europe, but common in CA.Communicable disease contributes to a smallproportion of all deaths in ECA (1.3 percent);mortality rates were four times higher in theNIS than in the rest of Europe in the mid-1990s.In the NIS, mortality from communicablediseases increased by more than 40 percentduring 1990�95. Close to half of the mortalityin this group is caused by tuberculosis; much ofthe rest is attributable to water-borne diseases.In 1995, tuberculosis incidence in the NIS andCentral and Eastern Europe was more thanthree times greater than in the European Union.Among the factors facilitating the spread of

52



communicable diseases in the population,poor environmental conditions play animportant role. Insufficient housing andcontamination of indoor air with microorgan-isms contribute to morbidity. Murray andLopez (1997) have shown that poor water,sanitation, and hygiene are still among the 10most important risk factors for burden ofdisease throughout all of ECA. NationalEnvironmental Health Action Plans for NIScountries, particularly Central Asia, showwater-related diseases to be the top environ-mental health priority.

EAP: The primary problems include watersupply and sanitation, urban airquality, and indoor air pollution.Secondary problems are industrialhealth and safety and traffic accidents.

MNA: Diarrhea (including dysentery, cholera,and typhoid) from lack of safe waterand sanitation and poor hygiene is avery serious problem. Respiratoryinfections from air pollution due toovercrowded housing, transport, andindustry also affect many people.Carcinogenic and cardiovascularproblems resulting from toxic industrialpollution are also serious, but difficultto quantify.

2. Please list current projects (on-going orpipeline) in your region that address environ-mental health issues to some extent.

SOUTH ASIA

Approach

In South Asia, we essentially looked at projectsat the PCD and PAD/SAR stages that wereonline, and therefore took place within the last

three to four years. To identify the projects thataddressed environmental health, directly orindirectly, within the project documents, welooked at a) key and strategic objectives; b)summary analysis, which provides the cost-benefit analysis or cost-effectiveness of theintervention; and c) key performance/output/outcome indicators. If there was explicitreference to environmental health or toenvironment and public health, in at least twoof these areas, then the projects were includedin the primary list of projects (PLP). Those thatdid not meet this criteria, but that are likely tohave an environmental health impact, wereincluded in the secondary list of projects (SLP).

Implications

Depending on how the project documentswere written up, a project could be doingquite a bit on environmental health, but if itwas not described explicitly as doing so, wewould not have included it in the PLP. Further-more, there is no guarantee that projects withexplicit EH objectives will actually carry outthe activities, unless they are also to bemonitored under key performance/output/outcome indicators.

For example, an environment project mayhave as key objectives provision of mitigatingmeasures to clean up, build, and treat waste,air, and water emissions from an industrialfacility. Under performance/monitoringindicators, if they are monitoring BOD, COD,and particulates to the general environment,these would be considered �indirect indica-tors.� We have assigned such projects to theSLP, even though the impact on the health ofthe surrounding communities may be consid-erable.

Likewise, a health project that, among otherobjectives, addresses communicable diseases

53Kseniya Lvovsky


(which are environmentally related) may, in itsperformance indicators, be monitoring envi-ronmental health benefits but may not explic-itly describe the results in the document. Suchprojects were also placed on the SLP. A largenumber of projects in the Urban, Energy,Transport, Infrastructure/Rural Development(including Water Supply and Sanitation(WSS)), and Health sectors have the potentialto address EH issues to some extent. But mostof them do not, as few people are aware of theissues or knowledgeable of how to addressthem. Some projects (especially those thatinclude urban/industrial air pollution or WSSactivities) indirectly address EH, even thoughthe specific project objectives may not havebeen EH-driven. Environmental health, as akey objective, drives only a very small sampleof projects in South Asia.

Primary List

Dhaka Air Quality Management (Urban Air)Bangladesh Arsenic Mitigation Project (Drink-

ing Water)Bangladesh School and Community Sanitation

(Sanitation/Hygiene)

Secondary List

A sample list of projects that indirectly, or tolesser degree, address EH issues or that havethe potential to address these issues wouldinclude:

WSS ProjectsBombay Sewage DisposalKerala Rural Water Supply & SanitationKarnataka RWSSChennai Urban Water II/IIICommunity and Private Sector Water in Sri

LankaNepal Rural Water Supply and SanitationNepal Urban Water Rehabilitation

Health and Nutrition ProjectsICDS II (nutrition)Woman and Child Development (nutrition)Malaria Control (India)TB control (India)

Urban ProjectsColombo Environmental ImprovementTamil Nadu Urban Development FundMunicipal Services Project (Bangladesh)Slum Upgrading (Bangladesh)Urban Development (Bhutan)Clean Settlements (Sri Lanka)Lahore Urban Development

Transport ProjectsDhaka Urban TransportMumbai Urban Transport

Environmental Capacity Building ProjectsEnvironmental Management Capacity Building

(India)Environmental Action (Sri Lanka)Metropolitan Environmental Improvement

Program (Bombay, Kathmandu, Colombo)

Industrial Pollution ProjectsCoal Environment and Social Mitigation (India)Industrial Pollution Prevention Project (India)

Since last year, the South Asia region hasstrengthened its EH work through the follow-ing activities:

! Andhra Pradesh study on water, sanitation,and health

! ESMAP study on household energy, airpollution, and health proposal to launch theSouth Asia Environmental health programand pilot an EH project in India

! The South Asia Environmental Strategy forthe Energy Sector, which attaches the

54



highest priority to indoor and outdoor airpollution from energy use because of itshealth impacts.

LATIN AMERICA AND THE

CARIBBEAN

Environment Portfolio

Mexico: Air Quality Management IIArgentina: Pollution Management (air quality

monitoring and long-term strategy develop-ment)

Caribbean: OECS Solid Waste

Health Portfolio

Some of the projects listed below includeactivities related to the management ofhazardous hospital waste, and some financeactivities related to management of vector- andwater-borne diseases. They tend to combineeducation, clinical services, and localizedenvironmental management interventions.These include malaria control, or moregenerally, tropical disease control (includingdengue and others)¾typically in a verylocalized fashion¾including measures such asthe cleanup of discarded tires or improvementof buildings/drainage to prevent mosquitoesfrom breeding.

Argentina: Provincial Health Sector Develop-ment; AIDS and STD Control; ProvincialReform Loan 2; Public Health Surveillanceto monitor disease from air pollution (underpreparation)

Brazil: Disease Surveillance and Control(monitors air-related disease in São Paulo);Second AIDS and STD Control

Chile: Health Sector DevelopmentDominican Republic: Provincial Health

Services

Ecuador: Second Social Development: Healthand Nutrition

Honduras: Health and Nutrition and supple-mental credit for health and nutrition

Panama: Rural HealthPeru: Health Reform (in preparation)Uruguay: Health Sector DevelopmentVenezuela: Health Services Reform

EUROPE AND CENTRAL ASIA

The following list of ECA projects includesthose that address some aspect of water- andsanitation-related disease (based on a recentstudy). It is less clear which projects affectother areas of environmental health. In ECA,all stand-alone Rural Water Supply andSanitation (RWSS) projects in Central Asia aimat improving health through improving watersupply and sanitation, carrying out healthpromotion, and monitoring water quality.

Albania: Rural DevelopmentAzerbaijan. Urban EnvironmentBulgaria: Environmental LiabilitiesECA: Regional Environment ProjectKazakhstan: Environment IKyrgyzstan: RWSSLatvia: EnvironmentLiepaja: Solid waste managementLithuania: GeothermalPoland: GeothermalPoland: Rural DevelopmentRomania: Rural DevelopmentRussia: Environmental ManagementRussia: TB and AIDSSamarkand and Bukhara: WSSSlovenia: Environmental ManagementTurkmenistan: WSSUkraine: EnvironmentUzbekistan: WSS

55Kseniya Lvovsky


EAST ASIA AND THE PACIFIC

The projects listed below meet the followingcriteria: they have as one of their statedobjectives to reduce human health impacts,and they have indicators that relate to improv-ing health outcomes (for example, reducingBOD/COD levels in local water bodies orreducing effluent or emissions).

Water Pollution and Solid Waste

Cambodia: Water Supply RehabilitationChina: 16 urban infrastructure and environ-

ment projectsChina: three rural water supply projectsChina: Huai River Pollution Control IChina: Qinba Mountains Poverty Reduction

ProjectIndonesia: seven urban development/infra-

structure projectsIndonesia: Urban Poverty ProjectIndonesia: Second Water Supply and Sanita-

tion for Low Income CommunitiesIndonesia: West Java and Jakarta EnvironmentKorea: Kwangju and Seoul SewerageKorea: Waste DisposalLao PDR: Provincial Infrastructure ProjectMongolia: Ulaanbaatar Services Improvement

ProjectPhilippines: Municipal Development IIIPhilippines: Manila Sewerage IIPhilippines: Water Districts DevelopmentPhilippines: LGU Urban Water and Sanitation

ProjectPhilippines: Solid Waste Ecological Enhance-

ment ProjectThailand: Bangkok Urban Environment

Program ProjectThailand: Environment ProjectVietnam: Ho Chi Minh City Sewerage ProjectVietnam: Three Cities Sanitation Project

Air Pollution

China: seven transport projectsChina: four urban environment projectsChina: Air Pollution ControlIndonesia: Renewable Energy Small PowerPhilippines: Metro Manila Urban Transport

ImprovementThailand: Clean Fuel and Air QualityThailand: Bangkok Air Quality ManagementThailand: Highways V

MIDDLE EAST AND NORTH AFRICA

Pollution Abatement and Control

Algeria: Industrial Pollution ControlEgypt: Pollution Abatement

Water/Waste Water and Sanitation:

Algeria: Water Supply and SewerageEgypt: Social Fund III (infrastructure compo-

nent), Sohag Rural Development (commu-nity development component)

Iran: Teheran WastewaterJordan: Amman Water and Sanitation, Waste-

water Reclamation, Disi Amman WaterConveyor

Lebanon: Greater Beirut Water and Sanitation,Awali-Beirut Water Supply, Coastal Pollu-tion

Morocco: Water Supply V, Sewerage andWater Re-use, Rural Water and Sanitation

Tunisia: Water Supply and Sewerage, GreaterTunis Sewerage, Water Sector InvestmentLoan

West Bank/Gaza: South Area Water, Commu-nity Development I & II ( component), Wa-ter/Sanitation Service/Gaza, Southern AreaWater and Sanitation

Yemen: Taiz Water Supply, Public Works II(component), Sana�a Water and Sanitation

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Solid Waste

Algeria: Algiers Solid WasteLebanon: Solid Waste and Environment

ManagementTunisia: Municipal Development II ( compo-

nent)West Bank/Gaza: Solid Waste and Environ-

ment Management

Health Sector

Egypt: Schistosomiasis Control Health Sector (hospital waste compo-

nent)Iran: Health Sector Development (waste from

rural clinics)Jordan: Health Sector Reform (hospital waste)Lebanon: Health Project (hospital waste)Morocco: Health Finance and Management

(hospital waste)Tunisia: Health Sector Loan (hospital waste)West Bank and Gaza: Health System Devel-

opment (clinical waste)Yemen: Child Development (clinical waste)

Transport

Jordan: Amman Ring RoadLebanon: Urban TransportTunisia: Transport Sector InvestmentYemen: Multi-mode Transport

3. Are your clients (borrowers and stakehold-ers) aware of environmental health issues? Ifso, which areas are most important in theirperception? Why?

SAR: They are largely aware of vehicular andindustrial air pollution, pesticides,polluted drinking water, and poorsanitation. Recently, Indian environ-mental authorities started paying moreattention to indoor pollution (thanks tonew assessments of immense damage

to the health of children and women),because these are high-visibilityproblems and there is high clientdemand for projects. (Although de-mand for non-sewerage, non-urbansanitation by the actual end-users isquite low.)

LAC: Air pollution is very prominent inpublic awareness in Mexico City andSantiago for obvious reasons. In othercities with important water bodies,polluted rivers and beaches attractconsiderable attention (possibly morefor concerns on aesthetics and healthconcerns during recreational activities).Media attention to hazardous wastetends to get the attention of borrowersand stakeholders.

ECA: Clients demonstrate awareness ofenvironmental health issues in all ofthe national environmental healthaction plans we have conducted. ECAhealth sector notes for various coun-tries discuss environmental health,although the depth varies. Demand forwater supply and sanitation projects ishigh in Central Asia.

EAP: Lack of adequate water supplies andinadequate sanitation have long beenrecognized in the region as key devel-opment issues, due in part to theimpacts on human health. The largelending program in the region for watersupply and sanitation shows the greatimportance that our clients (and theBank) have placed on water pollution,and, by association, water-relateddiseases.

57Kseniya Lvovsky


There is a growing concern among ourclient countries over urban air pollu-tion issues: lending in this area�whilestill lagging far behind water supplyand sanitation�has been growing. Theextent to which human health concernshave dominated the concern for airpollution control, in comparison toeconomic and productivity impacts,such as damages to agriculture (acidrain) or tourism, is not clear. Studiesfunded by the Bank and others haveshown that human health damagesfrom air pollution far outweigh othereconomic losses and, in China, areprobably larger than the impact ofwater pollution.

MNA: Water pollution is considered to be themost important health issue. The MNAregion is characterized by lack of waterresources, poor water quality, and lackof wastewater treatment and sanitation.Of 250 million people in 1990, 45million lacked access to safe drinkingwater, 85 million lacked access to safesanitation, and only 20 percent ofurban wastewater was treated. Airpollution from industry and transport isalso gaining the attention of our clients,largely because of media coverage.

4. How are decisions made in your regionwhether or not to include environmentalhealth issues in lending (cost? availabletechnology? media attention?) What are thetradeoffs?

SAR: The decisionmaking process dependson client demand, availability of sectorwork, and the knowledge and interestof Bank staff in response to issues. For

clients, water and sanitation has beenalways high on the agenda, but thiswas not considered to be a healthintervention, and project designs didnot aim to maximize the health im-pacts. Urban air pollution is an emerg-ing priority (Dhaka Air Quality LILunder preparation, request for an airpollution project in Delhi). Recently,regional management has becomemore aware and supportive of EH,resulting in a small budget to promoteEH activities. Integrating these issues inprojects is still a challenge because ofthe complex and multisectoral natureof environmental health.

LAC: If the counterparts in a country areinterested in addressing a problem withEH implications, the project tends toinclude such issues. However, exceptfor �brown� environment projects (andeven in those), few activities directlyaddress environmental health issues.

ECA: No explicit decisionmaking process,until recently, in regard to includingEH issues in lending.

EAP: The majority of projects addressingenvironmental health issues fall withinthe urban environment portfolio, andare driven by demand for urbanenvironmental projects by our clientcountries. There is limited involvementin EH issues by the health sector, orthrough �health� projects.

Most projects in the region address EHissues only indirectly; health outcomeindicators associated with air-pollutioncontrol or wastewater projects are

58



rarely measured, and only a few healthsurveys have been conducted before orduring project implementation.

MNA: The decisionmaking process forlending is not principally guided by EHissues. With the exception of thepollution abatement and control andthe wastewater treatment projects, EHissues are identified to justify aproject�s positive environment impact.

5. Who is responsible for environmentalhealth issues in your client countries (environ-ment and/or health ministries/agencies orother)?

SAR: No single agency actually has clearresponsibility for EH, due to itsmultisectoral nature. But the environ-ment department or ministry would bethe default, especially for industrialpollution and air pollution (outdoorand indoor). Other agencies or depart-ments that have played a role includehealth and family welfare, irrigation/agriculture, social welfare, transport/civil works. Because EH is a cross-sectoral issue, inevitably all theseagencies have been involved at onepoint or another, although none takesprimary responsibility for EH.

LAC: Years back, health authorities used tohandle these issues, but gradually theyhave been moved to the purview ofenvironmental authorities. In general,there is animosity between theseagencies and little communication andcoordination.

ECA: EH falls between the cracks. Bothenvironment and health ministries take

some interest, but neither has a man-date.

EAP: Environment bureaus and public healthagencies are responsible for themajority of EH issues; however, theseagencies are not usually the key actorswith which the Bank is involved in itsenvironmental health�related projects.

MNA: No single agency has responsibility forenvironmental health issues. Usuallythe ministry of environment is respon-sible for ensuring that the responsibleagencies (ministries and local govern-ment) apply environmental laws andguidelines. The ministry of health isresponsible for all health-relatedprojects. Ministries of equipment,housing, and water resources areresponsible for water and wastewaterissues.

6. Did the projects listed in response toquestion 2 attempt to quantify and prioritizeenvironmental health (cost/benefit, cost-effectiveness)? If so, which ones?

SAR: Cost-benefit analysis was carried outfor a small number of projects, includ-ing components in Dhaka Air QualityManagement, Bangladesh Arsenic andSchool and Community SanitationProjects, India Fifth Rural Water SupplyProject, Chennai Urban Water, andClean Settlements in Sri Lanka. Forothers, the economic rate of return wascalculated, but for the entirety of theproject¾not uniquely for the EHcomponents. The India State HealthSystems Project looked at DALYs lost/saved from communicable diseases,

59Kseniya Lvovsky


which can be prevented by EH inter-ventions.

LAC: The health projects above addressthese topics as secondary or localizedactivities. It has not been possible tocheck whether quantification ofbenefits or cost-effectiveness analysiswas carried out for those activities.Reviewing the project assessmentdocuments might reveal something inthis regard. The rest of the portfoliocontains limited examples of cases inwhich indicators of environmentalhealth have been used, in part becausemany are too upstream from actual EHimprovements (such as ArgentinaPollution Management). Only theMexico Air Quality II project underpreparation is attempting to quantifyhealth outcomes as end-of-programindicators (in addition to air qualityindicators). These indicators would besupported under the project through aseries of special studies.

ECA: We have extensive information on WSSprojects, both stand-alone and otherprojects�that is, when WSS is but onecomponent, as in social funds.

EAP: Generally not. We have not had timeto go through all 50-plus projectdocuments (and this is only a partiallist). Regarding water pollution, staffappraisal reports often claim, correctly,that it is difficult to quantify the EHeffects. Baseline health information isthus often deduced from experiences inother countries, or relies on studiesdone by other agencies (such as WHOand UNICEF). Few EH surveys have

been undertaken as part of projectpreparation for any of the projectsmentioned in question 2. TheChongqing epidemiological survey ofair pollution health effects, funded byPHRD funds, is an exception.

MNA: Algeria: Industrial Pollution Control Egypt: Pollution Abatement

7. Which sectors normally provide loans forEH issues in your region?

SAR: Water and sanitation, urban, health,and environment sectors. To imple-ment a new energy and environmentstrategy, the energy unit would have tojoin the list.

LAC: Environment and health. Infrastructure,if you count the improvements in watersupply, sanitation (including solidwaste), drainage, transport, andmining, could also be included.

ECA: A recent review shows that ruraldevelopment and Social Fund projectsrepresent a significant share of theinvestments in WSS�almost equal tostand-alone projects. Social Funds arespread around in different departments.It took a lot of research to determineexactly what is included in the SocialFunds/rural development projects. Adetailed examination of projects inother sectors might reveal that, in fact,environmental health is being ad-dressed. Officially, EH is being coveredthrough infrastructure (WSS), energy,environment, and health.

EAP: Urban, environment, urban transport.

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MNA: Health and education, infrastructuredevelopment, rural development,water, and environment.

8. Have indicators been developed tomonitor the current projects? Who is respon-sible for enforcing and evaluating the compo-nents in your client countries?

SAR: (a) Bangladesh Arsenic MitigationProject, Bangladesh School & Commu-nity Sanitation, Sri Lanka Clean Settle-ments, Chennai Urban WSS, MumbaiUrban Transport, Dhaka Air QualityManagement.(b) Evaluation of components is jointresponsibility of governments and theBank. Government agency or agenciesinvolved would be the borrowers.

LAC: Examples from Mexico Air Quality II(under preparation): Cases of respira-tory attacks, rate of emergency roomvisits for respiratory problems, emer-gency alerts for air quality.

Responsibility rests with the executingunits of each project.

ECA: The only information on indicators iswhat we found in the recent study�Performance Monitoring Indicators forSanitation and Health Components ofRural WS&S Projects.�

EAP: All �A� and �B� projects have toestablish environmental-mitigationplans (EMPs), which monitor waterquality, effluent loads, and otherpollution-related indicators. Whilehealth issues are almost always men-tioned, data are usually anecdotal, and

direct health data is almost nevercollected as part of the project.

MNA: Algeria: Industrial Pollution ControlProject: Reduced perceived respiratorymorbidity (%); decrease of pollutionloads of TSS, SO2, and NOx in City ofAnnaba.

Egypt: Pollution Abatement Project: Outputindictors for major pollutants weredeveloped for each industrial sub-project.

Tunisia: Transport Sector Investment: Reduc-tion of lead in gasoline.

The project implementation unit ofeach project is responsible for evaluat-ing these indicators. Ministries of theenvironment are responsible for follow-up.

9. What environmental health issues do youfeel still need to be addressed in your region?

SAR:! Indoor air pollution (energy, health, and

environment nexus).! Emphasizing the linkages and interventions

between WSS diseases and health out-comes.

! Urban air pollution.! Linking with other sectoral efforts in

interdisciplinary manner, especially withnutrition and education (formal and non-formal) activities, since nutritional status ofa young child determines the degree ofvulnerability to respiratory and diarrhealinfections.

! Focus on health, especially child survival,as a major outcome of a variety of cross-sectoral activities.

61Kseniya Lvovsky


LAC:! We do not have a good handle on the

localized implications of poor solid-wastedisposal practices for municipal andindustrial/toxic waste. We need to use morerisk assessment in projects to determinewhich conditions warrant often costlyremedial action.

! Occupational health and safety�should thisbe part of our labor markets reform orhealth reform dialogue?

! We need to improve our work on indicatorsfor the existing projects that may rendersome environmental health benefits,including a number of infrastructureinvestments (water, transport, and others).This would help improve the economicanalysis of projects (from the benefits side).

ECA:! Communicable diseases, especially tubercu-

losis (health department working on this).! Urban air pollution.! Sanitation.! Rural water supply.

EAP:! Urban air pollution and its relationship to

public health.! Public health benefits of the Bank�s WSS

program in the region.! Indoor air pollution.! Industrial health and safety.! Traffic safety.

MNA:! Morbidity due to air pollution (indoor,

industrial, and urban).! Linkages between WSS diseases and health

outcomes.! Food and health hygiene.! Environment education in schools.

10. What steps would you like to take in thenear future to address these issues (if moneyand time were no concern)?

SAR: Resources to be used for advocacy,sector work, and project preparation ofEH projects or components.

Also, efforts to be spent on defining theintersectoral collaboration necessaryfor EH activities. Learn from work/experience from other regions to beable to apply existing knowledgewithin Bank to actual country activities.Go beyond studies and developingmonitoring indicators to pilot existingindicators and make them workableand user-friendly to non-environmentand non-health disciplines (such asinfrastructure, energy, and ruraldevelopment. Implications: dependingon how project documents are writtenup, a project could be doing quite a biton EH, but if not described explicitly,we would not have included it in theprimary list. Further, there is noguarantee that projects with explicit EHobjectives will actually carry out theactivities unless they are also to bemonitored under Key Performance/Output/Outcome indicators.

LAC: Develop a few case studies withinprojects that can fund risk-assessmentexercises for solid waste dumps andcontaminated sites.

ECA: Include an environmental healthanalysis in the EA process.

EAP: Additional sector work on air andwater pollution impacts in our client

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countries. For operations, it is impor-tant to develop low-cost ways (or costsappropriate to the level of expenditureon other issues) of tracking and moni-toring health outcomes or �reasonable�indicators of health outcomes. Under-taking basic health surveys as part ofproject preparation for projects inwhich EH is used as a primary justifica-tion for the project, such as wastewa-ter, sanitation, and air pollutioncontrol.

MNA: Rapid health-risk assessment should beundertaken in pilot countries to

evaluate the magnitude and severity ofair and water pollution and its linkagesto public health. EH issues should bepart of the CAS. Non-lending servicesshould be provided to strengthen thecapacity of institutions on environment/health issues, provide reliable healthand environment information, intro-duce a methodology for quantifyinghealth impacts, and develop healthindicators. Develop case studies forstudying groundwater pollution due tonon-point and point sources of pollu-tion.

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Notes

1. See Annex 2 for more detail on the methodology,as well as World Bank, 2000a, pp. 92�100.

2. Note that large variations were found incost-effectiveness of urban air pollutioncontrol measures�from negative costs (win-win solutions) to several thousand and evenmillions dollars per DALY saved. Thisstresses the need for a more rigorouseconomic analysis of Bank-supported urbanair quality management strategies.

3. Estimates by Murray and Lopez 1996 assign13 percent of the total burden of disease inSub-Saharan Africa in 1990 (38 millionDALYs) to respiratory diseases. Adjustingfor population growth, the estimate of theill health associated with indoor air pollu-tion was about 13 million DALYs in 1990,or about 35 percent of the total burden ofrespiratory disease. This share is consistentwith the difference between Africa and, forexample, Latin America and the Caribbean,in terms of the respective contributions ofindoor air pollution to the total burden ofrespiratory disease.

4. The main sources of data were the AMISdatabase, compiled by WHO, and statisticsreported by various environmental agen-cies, in particular the U.S. EnvironmentalProtection Agency and the EuropeanEnvironmental Agency. Limitations in the

coverage of monitoring systems means thatmost of the non-U.S. data is for cities ormetropolitan regions with populations ofmore than 500,000.

5. For the different approach, see Chapter 3 inWorld Bank 1997.

6. See, for example, Overview and Chapter 1in World Bank 1992 and references.

7. Described in Sivayorathan and others 1995;Lessenger, Estock, and Younglove 1995.

8. Parron, Hernandez, and Villanueva 1996;Ruijten and others 1994.

9. The disease groups include: liver and pancreascancer, melanomas and other skin cancers,lymphomas and multiple myeloma, endocrinedisorders, unipolar major depression, cataracts,nephritis and nephrosis, rheumatoid arthritis,congenital anomalies (excluding spina bifidaand congenital heart anomalies), and poison-ings across all age groups.

10. This Annex is based on Listorti, Doumani,and Hammer 1999.

11. This Annex is based on Listorti 1996, Vol. III.12. Reviewers from the London School of

Hygiene and Tropical Medicine, St.George�s Hospital Medical School (Lon-don) and the Centers for Disease Control(Atlanta) were asked to participate in aworkshop June 1�2, 1995, to comment onWorld Bank 1994c.

65

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