WORLD HEALTH DAY 1990

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Cover: The poster for World Health Day 1990 was published with the support of the Italian Ministry of Foreign Affairs.

IX ISSN 0043-8502

World Health is the official illustrated magazine oftheWorld Health Organization.

Editor:

John Bland Deputy Editor:

Christiane Viedma Art Editor:

Peter Davies

News Page Editor:

Philippe Stroot

World Health appears ten times a year in English.

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Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. The designatiDns employed and the presentation of material published in World Health do not imply the expression of any opinion whatsoever on the part of the Organization concerning the legal status of any country. territory or other area or of its authorities. or concerning the delimitation of its frontiers or boundaries.

WORLD HEALTH DAY 1990

A wounded planet

by Dr Hiroshi Nakajima

Director-Genera/ of the World Health Organization

JI

t is now increasingly evident that more and more diseases stem from the degradation caused by man to his own environment.

The potential harmful effects of industrial development on our global ecosystem are now better known. Ozone layer depletion, acid rain, climate change, chemical pollution are some examples of the man-made wounds to our planet.

We are at a tumin9 point; warn- ings of the damage to our health and quality of life are growing louder.

An

increasing number of people are acting to stop the degradation of our environment.

As Director-General of the World Health Organization, I have chosen the theme of Environment and Health for World Health Day, 7 Aprill990.

WHO intends to spotlight the measures that individuals, communities and nations can and must undertake to halt further deteriora- tion of the health of our planet.

Our own health and that of future generations depends on it.

I make a solemn appeal for solidarity among industrialised and developing countries. We must find viable options for sustainable development and to protect health everywhere on our planet.

Decisions taken by one country can have repercussions not only for its neighbours, but for all countries of the world.

On the occasion of World Health Day, I invite the Member States of

WHO, governmental and non-

More and more diseases stem from the degradation caused by man to his own environment.

Dr Hiroshi Nakajima {right) inspecting a solar-powered water purifier.

governmental organizations, and all concerned with the wellbeing of the world to embark on an awareness campaign. We must alert everyone to the dangers of an unhealthy environment and to measures they must take to avert them. The slogan we have chosen is: Our planet - our health: Think globally

- act locally. •

Hiroshi Nakajima, M.D., Ph.D.

Think Globally

WHO's Constitution first came into effect on 7 April 1948 and, since then, 7 April has been commemo- rated every year as World Health Day. This year, the Day focuses on environment and health, and the 166 member countries have been invited to find their . own ways of expressing the chosen

slogan: '

Our planet - our health Think globally - act

locally.

The Health Game published in our first issue of 1989 proved so popular that all copies are now exhausted. For 1990, we have devised another game which is both fun to play and also informative about the relationship between environment and health. "Our Planet - Our Health" appears in our centre-pages. You are invited to remove the Question and Answer section from the staples, so that the "board" is ready for playing the game. And the Rules of the Game appear on page 31. As was the case in 1989, limited quantities of a larger version of the

"board" can be ordered from: Division of Public Information, WHO, 1211 Geneva 27, Switzerland.

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In tune with Nature

by Mrs Gro Harlem Brundtland

D

uring the course of this century, the progress of civilisation has increasingly come into conflict with the natural world. Air and water are being polluted by acid rain. The world climate is being threatened by the possibility of global warming. The destructive processes of desertification, deforestation and soil erosion are continuing.

At the same time, the world population is growing faster than ever, and the gap between the industrialised and the developing countries continues to widen.

A

critical situation

In our report on Our Common Future, the World Commission on Environment and Development {sometimes called the Brundtland Commission) pointed out that the situation is getting increasingly critical.

At the present rate of development, we are rapidly depleting the natural resource base on which man's existence depends. The evidence is growing of a strong relationship between health and the environment. We are filling our environment and our food products with chemicals. Certain infectious diseases show signs of new gains as a result of increasing poverty and an inability to meet people's basic needs.

Malnutrition remains a serious obstacle to health and to the development of human resources.

If present trends continue, it will be 4

Former Prime Minister of Norway, Chairman of the Brundtland Commission

impossible for the World Health Organization to realise its goal of

"Health for all."

Several steps are needed in order for all countries to contribute their share towards solving the global environmental problems:

- Firstly, we have to spread more information about environment and development throughout the world. A heightened environmental awareness is necessary to ensure a reorientation of modem civilisation, so that we can achieve a new reconciliation with nature instead of appearing, as we so often do now, to be in conflict with it.

- Secondly, this kind of adaptation will call for economic growth and social progress. It is essential that this growth should take place mainly in the developing countries, and that it shall not be confined, as it is at present, to countries that are already prosperous.

Such growth must be used to relieve poverty and starvation. Only then will we free the resources that are needed to solve problems involving health and the environment.

- Thirdly, we must strengthen international cooperation by a re-commitment to multilateralism. And, since the problems are increasingly global, it is particularly important that we strengthen the United Nations and its family of agencies. The efforts to achieve sustainable development require a sys- tematic and integrated effort by practically all sectors of international cooperation. The work of promoting environment and development can

thus be a powerful stimulus to better coordination and more effective action within the UN system. WHO was the first specialised agency of the UN to take concrete steps in response to the General Assembly's call for a follow-up of the report on Our Common Future.

It has thereby provided leadership to the effort now needed, both interna- tionally and in member countries.

All the more, therefore, does WHO deserve our strong support in the formidable tasks ahead. The initiative now being taken to focus on the destructive effects that damage to the environment has on world health will be one of the mainstays of the efforts which lie ahead.

WHO's main goals also include making the national and international authorities, as well as the general public, aware of the close correlation between health and the environment.

Is our task impossible? To this I would answer firmly: No, it is not.

In Our Common Future, we pointed out that there are grounds for hope and optimism. For never have the world's human resources been greater than they are today. Never before have we had better insight into these problems. If we act according to the slogan of World Health Day 1990 - "Our planet - our health: Think globally - act locally" - I am convinced that we can manage to reverse the present negative trends, and to secure the resources to sustain a healthy environment for the present generations and

for those to come. •

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Environmental health in the 1990s

by Dr Wilfried Kreisel

Director, Division of Environmental Health, WHO

JHI

ow can we make

environmental health a more potent force to serve people faced with growing threats to their health? How can our improving environmental health technology be better used to foster positive health? I know of no country - developing or industrialised - in which this issue is not urgent and important. I know of many countries in which it is critical.

The remarkably wide range of environmental concerns includes the international problems of acid rain, the greenhouse effect, and depletion of the planet's ozone layer. It includes national concerns with medical wastes disposal, radioactive and toxic wastes control, transportation accidents, health aspects of urbanisation and traffic, occupational health and safety, and air and water pollution. It also includes local concerns over inadequate water supplies and sanitation facilities, water quality, clean air, solid wastes management, and finding a balance between the economic incen- tives of development and a decent quality of life.

Population growth

As the UN World Commission on Environment and Development has pointed out, developing countries face not only the public health problems that the industrialised world has largely solved over the last century, but also many of the problems that now con- front the rich countries. The Thailands, the Nigerias, the Brazils of the world have yet to ensure safe water, basic sanitation, and protection against communicable diseases for many of their people. At the same time, they must deal with the impacts on health of rapid, large-scale industrialisation, urbanisation, and technological development. Massive population growth makes it even more difficult to solve this double load of problems, because it outstrips these countries' economic development, retards their social development, and makes crushing demands

Whole forests in Europe and North America have been destroyed by acid rain - fall-out from industrial pollution.

WORLO HEALTH, January-February 1990

on services, resources, and the bearing capacity of the increasingly fragile environment.

In fact, in every country on this planet, man-made environmental problems are being generated faster than we can solve or prevent those problems. In every country, environmental health capacity is inadequate to meet human needs. And when we look forward to this new decade, we know that the problems will be changing, only to become more complex, more critical, more urgent.

Let me focus on what environ-

mental health must become in the 1990s, if human health is to be protected and promoted. I believe that increasing our effectiveness depends on bringing about changes in six aspects of environmental health, over the coming decade. Two changes pertain to the scientific and technical base of envirohmental health; two concern the resources of environmental health; and two changes are needed in the organization of environmental health. -

The environmental health worker of 1990 is far better armed technically

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Environmental health in the 1990s

than the environmental health worker of 1970. Yet we are all aware of our need for more tools and more powerful tools. These needs include both "hardware" and "software."

Changes in industrial technology chal- lenge our ability to provide adequate treatment of waste waters. New chemical compounds emerge faster than our capacity to assess their health effects. Protection against the hazards of nuclear energy development is only partially within our grasp.

Public pessimism

W

hat is claimed to be the first-ever worldwide survey of public opinion on the environment shows that people in developed and developing countries alike are concerned about the quality of the environment and sceptical of their leaders· ability to protect it.

Prepared for the UN Environ- ment Programme (UNEP) by a US public opinion group. the survey sampled public opinion and leadership attitudes in 14 nations on four continents.

Very large majorities - between 75 and 100 per cent of both the public and the leaders - agreed on the need for stronger action by their governments. stronger action by international bodies such as the UN. and stronger laws to contain industrial pollution. Large majorities among both public and leaders believed there was a direct link between the quality of the environment and public health. Most people rated their environment as only

"fair" or "poor." •

Another need is to reduce the gaps and uncertainties in our ability to assess risks. What can be demon- strated under laboratory conditions is challenged by the conditions and time factors of "real life". Although our knowledge about single toxins improves, we know too little about the combined and synergistic effects of multiple agents - this is a large "dark continent" that waits to be explored.

We need better techniques for inter- ventions and for impact assessment - in fact, health impact assessment lags behind the capability to assess impacts on the environment itself. So the first of my six changes is to develop more 6

adequate capacity to determine environmental risks and to intervene effectively.

The second - and the most basic one of all - is to formulate an appropriate redefinition of environmental health. I have deliberately put this issue in the category of science and technology, because we have made many mistakes in the past by not

treating it as a scientific question.

When we treat it as a political question, or a financial question, or a resource question, or an organizational question, we may be "realistic" in the short term, but we may also fail to identify the right targets to fulfill our social mission.

It is not for me to offer an operational definition of environmental health for the 1990s and beyond, if only because I don't believe that there is a single definition. Operational defi- nitions - in the plural - are needed for each situation, according to the stage of the development, the specific needs and problems, and the potential to

respond to a given situation.

The third change is the need for more adequate resources for the

"care" of environmental health itself, in agencies, in training institutions, and in research entities, because these resources are a prerequisite to resources development in other sectors and the community. Our most pressing needs are for human resources and inf01mation support.

Sad to say, environmental health globally suffers from informational malnutrition, ranging from mild to severe, while in many situations, environmental health is starved for information. We need information about environmental conditions - be it in the

Environmental health includes national concerns - keeping the seas free from oil pollution, for instance - and local concerns - finding a balance between economic development and a decent quality of life.

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restaurant, in the rivers, or in ambient air - but we also need information about health conditions, if we are to target our efforts and use our ever- limited resources to best serve health needs.

Resource shortfalls

As for manpower, WHO studies tell us that the resource shortfalls in developing countries are truly stagger- ing. To generate more and better human resources for environmental health is a global need, and progress in meeting that need is painfully slow.

Our progress to date has been outrun by population growth and by industrial development in Third World countries, which at present lack the capacity even to measure their needs.

And the fourth ·change is to upgrade resources in health-related sectors and in the community. What is done in housing, nutrition, industrialisation, forestry, urban and regional planning, and transport - to mention some prominent examples - has a direct effect on people, and it shapes the problems that our programmes must address. In housing, for example, we must sensitise architects, builders and materials fabricators, as well as housing officials. A new WHO project to incorporate health information in the professional training of architects is an example of how we might proceed.

WORLD HEALTH. January-February 1990

As for the community, during the International Drinking Water Supply and Sanitation Decade, we have seen many instances where the power of community organization has achieved goals beyond the capacity of governments to attain. So we must join in primary health care and other sectoral efforts to improve the capacity of community organization, seeking to integrate more environmental health targets into those efforts. And let us not forget that the impact of individual actions is massive, whether it is apathy toward latrines, patterns of automobile use or the neglect of housing hygiene.

Fifthly, we need better linked governmental efforts. Organization has become a critical issue in environmental management and health, especially so in the last 20 years, when the environment became a leading concern of public policy in the industrialised countries. In many countries, actions on the environment are not coherent; indeed, many environmental health policies and programmes have become more fragmented, as governments have reshuffled environmental management responsibilities among public agencies and private interests. WHO studies have told us that arrangements for effective multi-level, multi-lateral coordination of environmental management and health are truly rare.

Shell Photo Service © Environmental health cannot achieve its objectives by working through government alone. So the sixth change is to bring about better linkages with developing commu- nities. We need not only to form alliances with non-health environ- mentalists and their constituencies, but to influence the leaders of business and industry to be more sensitive to health factors in their choices and decisions. And we must organize our- selves so as to link better with communities. The community is potentially the most powerful component of the environmental health system. Our community targets should be not only local and national communities, but the international community as well.

Day by day, the image of the world as

"the global village" becomes more of a reality, not only through the media of communication and transportation, but as all people are affected by the fouling of the oceans, the destruction of the tropical forests, the desertification of land, and the drifting of acid rain and nuclear fallout. In positive terms, the communication and sharing of resources among peoples has become essential for the survival of the planet and our species. WHO -'- among other bodies - is pledged to support both national and international actions toward a livable environment for the

human community. •

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Air pollution in A&ica

by Or Henk W. de Koning

Regional Adviser for Environmental Pollution, WHO Regional Office for the Americas, Washington D. C., USA

T

he African continent as a whole confronts a widely divergent range of air pollution problems. At one end of the scale are communes and hamlets in rural areas, where traditional, very primitive means of cooking and heating cause dangerously high levels of indoor pollution. At the other end are cities where rapid population growth and industrial development pose ever-increasing risks to the health of resident populations.

Although by no means uniquely confined to Africa, these air pollution issues are of particular importance because of the low economic development level that most countries will have over the next few decades. By implication, air pollution issues may receive relatively low priority because of other more pressing concerns.

In rural Africa, both cooking and heating in houses are carried out in a traditional way. The most common arrangement is a fire inside the house with a cooking pot resting on three stones over the fire. The fuels used include such materials as agricultural waste and dried dung from animals.

The most important, however, is wood

WHO/C. Stauffer

in the form of logs, branches, twigs and leaves, all of which have different combustion characteristics. The fuel is largely gathered by women and children.

In some areas, for example in Kenya, cooking is done outside during the dry season. In others, a separate kitchen hut is used for cooking, as is the case in Gambia. Climate varies enormously in Africa, and this has a major influence on cooking and heating practices. Different cooking arrangements in turn influence the extent to which preschool children and women are exposed to air pollution from burning fires.

Combustion of wood, agricultural waste and dried animal dung under primitive conditions produces large quantities of smoke and pungent gases indoors. ^WHO has carried out two studies, one in Kenya (1986) and the other in The Gambia (1987), to measure indoor concentrations of different pollutants in African houses.

The results showed that the average level of respirable particulates was very high. The peak values that were measured were even higher, and a definite health hazard is indicated.

Concentrations of nitrogen dioxide,

carbon monoxide and formaldehyde often exceeded the WHO guidelines for the protection of human health. Poly- cyclic aromatic hydrocarbons also showed high levels; no guidelines exist however for these substances. As they have been shown to cause cancer, every effort should be made to elimi- nate them completely.

Health effects associated with exposure to indoor air pollution in Africa have not been very rigorously investi- gated. The picture that emerges from the data available, together with con- clusions drawn from comparisons with research in such areas as smoking, shows that the impact of indoor pollution as a risk factor for several illnesses is quite widespread and serious.

Morbidity and mortality from respiratory disease in children under five years is a serious problem. Studies carried out in several African countries show that wood smoke is a potent risk factor in the development of severe lower respiratory tract disease in infants. Health reports from Burkina Faso and Zambia, among others, con- firm that respiratory illness ranks among the top two or three causes of morbidity. In Nigeria, mortality rates were lowest during the driest months

Indoor air pollution in Afiica has not yet been thoroughly studied, but it undoubtedly entails health risks. Left:

Women in particular are exposed to wood smoke, with a consequent risk of respiratory illness. If they are pregnant, air pollution is one of the factors that · contribute to lower birth weight babies.

Right: In some areas, cooking is done outdoors during the dry season. Both mothers and children benefit from breathing fewer potentially dangerous fumes.

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when cooking was done outdoors, thus reducing exposure of infants to the fumes.

Exposure of pregnant women to indoor air pollution is one of the risk factors that contributes to lower birth weight. Low birth weight is associated with a range of perinatal and infant ill-health. This observation is corrobo- rated by the US National Academy of Science in a recent report on the relationship between the effects of environmental tobacco smoke and the health of pregnant women and children.

Women's work in rural Africa involves a variety of activities, including fuel gathering, agricultural work, childcare and cooking. Children often assist women in their tasks. A woman's work day is generally longer than that of a man, and in Africa it runs from 10 to 14 hours. It has been said that "the real energy crisis is women's time."

The possibilities for improving people's lives in Africa are tied to the education of women. It would be beneficial particularly in areas such as nutrition and cooking practices, including fuel- saving techniques and forest management. General education on hygiene and preventive medicine could also be included. The results of this training would be passed on to the children.

Outdoor air pollution

In African cities two types of outdoor air pollution problems occur most frequently and have the largest health impact. They are industrial pollution from large uncontrolled sources, such as power stations, cement plants, paper mills or chemical factories; and motor traffic with emissions from cars, buses and trucks, many with diesel

engines, which produce mixtures of different pollutants and cause a per- manent haze in many built-up areas.

The effects associated with emissions from industrial sources range from annoyance with odours and dust to exacerbation of respiratory diseases such as asthma, bronchitis and emphysema. If the pollution contains hazardous chemical substances such as asbestos, heavy metals or certain organic complex compounds, these may contribute to the incidence of cancer.

Health effects associated with motor traffic result from exposure to carbon monoxide, nitrogen oxides, ozone, hydrocarbons and fine particles.

Carbon monoxide reduces the oxygen- carrying capacity of blood and is liable to affect persons with heart disease.

Nitrogen oxides are powerful irritants to the lungs and lower the resistance to infections such as influenza. Ozone is also an irritant that causes impair- ment of the lung function. Hydrocar- bons are a diverse class of pollutants, some of which, such as benzene and formaldehyde, have a potent effect on human health. Tetra-ethyl lead is added to gasoline in most African countries, and lead is emitted to the urban air as fine particles. Its effects are on the blood-forming, nervous and kidney systems. Young children are especially vulnerable to the effects of lead exposure.

Sulphur dioxide levels in African cities are generally low in the residen- tial areas, but frequently exceed the

WHO guideline values in urban industrial and commercial zones. A Nigerian study on carbon monoxide levels in urban areas shows a strong diurnal variation of such levels, with

high concentrations often exceeding the WHO guideline during daytime hours.

Motor vehicle traffic is responsible for almost all carbon monoxide and hydrocarbons emitted, and for up to 50 per cent of the nitrogen oxides and particulate matter. Aside from the direct impact of these chemicals on health, they tend to react under the influence of sunlight to form an oxidis- ing type of air pollution which contains a high percentage of ozone - another substance that is potentially harmful to human health.

Measures to counteract air pollution should concentrate on the major sources of particular pollutants. These sources can best be identified by applying a procedure entitled: Rapid Assessment of Sources of Air, Water and Land Pollution, which was published by WHO in 1982. What is essential is regular inspection of air pollution control devices in the cement industry, fertiliser industries, thermal power plants and so forth. The most immediate results can probably be achieved in most African countries with stricter controls on diesel engines.

The Adriatic is sick

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taly's River Po discharges 230 tons of arsenic. 18.000 tons of phosphates and 135.000 tons of nitrates into the Adriatic sea every year. In the past two years the consequences have been disastrous for Adriatic seaside resorts. Robbed of oxygen. the sea has been overgrown by algae - a gelatinous soup of weeds and scum. up to 40 feet thick in places and weighing millions of tons. Fishermen's nets break under the weight of the jelly-like substance. and bathers who venture into the sea emerge covered with slime.

Tourists have boycotted the area. and the loss to the tourist and fishing industries is esti- mated to exceed one million

dollars. •

The picture that emerges in Africa with regard to health risks from air pollution is that, in the countryside, a substantial portion of infants, children and women are exposed to debilitating levels of indoor pollution; while in the cities a potential exists for increased ill-health, particularly among the old and sick. The overall effect of this on the relatively young nations in Africa may be one of reduced vigour and less potential to develop their economic strength and wellbeing. •

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WHO/L Taylor

Health and the city

by Professor Len Duhl

School of Public Health, University of California, Berkeley, USA

JB3

illions of people are becoming urbanised. Moving from countryside to city, from rural nations to massive metropolis, they bring with them, and create, problems of health and illness.

The changes come from changed aspirations. There is a universal desire to improve' ~onditions for themselves and their family. The excitement of the urban world is a magnet that is changing the complexion of the land- scape, the services given and the lives of all people.

The cost of even the simplest of medical care is becoming burdensome.

The kinds of dis-ease and illness that we deal with are changing rapidly into 21st century urban ills. Accidents, murder, suicide, alcohol, depression, drugs, infections - all these connect to the blight, poverty and homelessness 10

that is the lot of many of the world's peoples.

Each part of the world faces different dimensions of the problem.

The North, with a long history of urbanisation and affluence, is dealing with immigrants, deteriorating infra- structures of roads, water, sewage, transport and communication. Sex- ually transmitted diseases, including AIDS, burden health programmes.

Budget problems are almost universal.

The South, depleted of resources, debt-ridden and in many cases poverty-stricken, faces massive population increases. The 20,000,000 in Mexico City soon will be replicated in Sao Paulo, Dacca, Calcutta, Delhi, Cairo and many more. The infrastructure often does not exist. What does, is stretched beyond capacity and limited to aiding minimal numbers of the population. Primary health care in

many cases is inadequately achieved.

Some 21,000,000 children live on the streets of Latin America alone. Only minimal resources are available.

The demands upon health leadership are great. The complex problems of health and the changing nature of the city itself are forcing a new look at reframing the problems that are found

·and the solutions that are needed.

So what is needed to bring health to cities? To reframe or look differently at the new health needs requires a brief look at the past.

Cities developed, as did smaller communities, out of a variety of needs.

Security against hunger and the ravages of the climate drove people

When most cities are already bursting at the seams, what can be done to bring health to their inhabitants?

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together. There was a need to protect and store their resources, for use in times of need. Here was the place of trade and business.

Perhaps more important was the need to gather together to understand and deal with the unknown. Spiritual needs brought people together to religious sites, where their priest-leader- healers could intercede between themselves and an unknown world. Before modern science, there was still a need to understand. These gatherings became the fount of belief.

Shared beliefs

A cosmology developed to help understand the universe. It was the cosmology that created the rules, culture and behaviour which determined how people lived, worked and died.

These diverse cosmologies guided all the activities of life in the communities and cities. It was this set of shared beliefs that made a city a whole organism.

As we moved closer to the present, the sciences offered understanding.

The cosmology became more and more fragmented. Rules for business were separated from religion. Medicine gradually developed expertise. There was awareness that what we know of as health was a reflection of the total environment. Max von Pettenkoffer, attempting to show that the cholera bacillus did not in itself cause the disease, drank a vial of a concentrated culture in front of his distinguished colleagues. He did not come down with the disease.

Rudolph Virchow reminded us in 1848 to examine the total organism in its socio-political environment. He said that while "the improvement of medicine would eventually prolong human life . . . improvement of social conditions would achieve its result more rapidly and successfully." His most famous phrase is worth remembering:

"Medicine is a social science, and

politics are nothing else but medicine on a larger scale."

It was during this period that public health and urban-city planning became intertwined. Planning in England derived from Edwin Chadwick's development of sewers to clean out central London. Sir Benjamin Ward- Richardson in 1875 described utopian cities with clean air, public transport, small community-based hospitals, community homes for the aged and insane, no tobacco or alcohol, occupational health and safety. From him came Ebenezar Howard's development of the garden cities.

However, with the onset of the work of Louis Pasteur and Robert Koch, a new era of bio-medical views of health replaced this more holistic vision.

Public health visionaries continued into the 20th century. They dealt with housing and with a wide variety of environmental issues. The new ascendancy of scientific medicine changed the direction of public health as well.

In the South, these models of public health were transferred to the new cities. Though some major pro"

grammes of prevention and public health started, many activities did not respond to the unique needs of these under-developed countries. Resources were ravaged. With the transfer of colonial lands to their own people, many of the leaders trained in health and medicine in the "west," continued to replicate the predominant western model.

Now the cities of the world are changing. In large part this is a reflection of the economic develop- ments worldwide, independent of ideology. Industrial development in the South in an attempt to raise the standard of living has brought new pollution and degradation of the environment. The North has increasingly transferred its production to sites of low labour cost. In doing so they have improved their pollution, but at the cost of transferring it elsewhere.""

The migrants to the cities of the North have brought with them new values, cultures, beliefs and health systems. They do not "understand" the rules of living in their new communities. Like new migrants all over the world, they work at· low-cost service jobs. They bring with them infectious diseases, such as tuberculosis and new Air pollution in Mexico City has caused an upsurge in acute respiratory diseases.

Rapid urbanisation

D

^uhng^.each annual World Health Assembly, the dele- gates are invited to participate in Technical Discussions on a "

selected theme. The subject for the Technical Discussions in May 1991 has already been chosen: "Strategies for health for all in the face of rapid urbanisation." Within· this theme. the topics that are expected to be highlighted will include intersectoral action for a healthy environment ana healthy public policies. meeting basic needs in the city, urban primary health care and the role of hospitals and. health servic~s."

WHO's Healthy Cities project.

and the control of various kinds of urban pollution.

The theme to be debated at the Technicc;JI Discussions dur-· ing this year's World Health Assembly in Geneva is: "The role of health research in the strategy for Health for all by the

year 2000." •

viral infections. With the lack of jobs and income are associated hunger and poverty. Crime breeds in these areas.

The need for income tends to turn them towards an illegal economy, supplying those wanted things that are not legally obtainable. Drug economies abound, becoming one of the few sources of income for these populations.

Large segments of the world's population find that they have become superfluous. They are not needed for

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production, since they can always be replaced by new workers and immigrants. They have to take service jobs at minimal pay, since fewer and fewer highly skilled workers are required.

Thus much of the world becomes divided into a small group of very rich and a massive number of poor.

Though this may be less evident in Europe, both West and East, it is true of most of the developed world.

The implieations for the city are immense. More and more are national governments finding themselves unable to deal with health and illness issues in the huge cities. The responsibility then falls on the local communities. City states are emerging which gain their status from massive economic activity, but much of this is dispersed and no longer calls for thousands of manual workers close at hand.

One consequence is that concern with health issues in urban areas can no longer remain primarily focused upon high technology and costly treatment. Since every aspect of city life impinges upon the health of its population, there is a need to shift our image of health. We must reframe the question, "What is health?"

We have focused upon the symp- toms of a complex, ever-changing society. They include crime, corrup- tion, pollution, poverty, homelessness, hunger, as well as the new array of urban ills. Even the delivery of medical services is dependent on the total economy, and the ability to pay for services given. Questions about what

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A masterpiece of bridge-building dwarfs the busding crowds in Calcutta. And left, "sanitary waste disposal" means nothing to these small girls in Kuala Lumpur. The cities of the world are changing, calling for a new look at health issues in urban areas.

percentage of the GNP can go to health are being asked worldwide.

If a child has a problem in a family, the physician asks two questions. One, about the particulars of the child, the other about the family. Classically, medical care asks about the patient and the disease. Public health asks about the family and the environment.

When the external complex system is not working and breaks down, this often occurs at the weakest link. Most often it is the poor and the young who suffer. They and their illness are symp- toms of the larger dis-ease.

To make cities healthy we have to return to Virchow and Ward-

Mayan art at risk

A

cid rain is destroying the architecture and art of the

ancient Mayan civilisation in

the jungles of southern and eastern Mexico, according to expert archaeologists. Nitrogen and sulphur oxides, resulting from the burning of petroleum by-products at oil refineries in the Gulf of Mexico, are carried by prevailing winds to the Mayan ruins. Turned to acids by the rain, they corrode the elabo- rately carved buildings and sculptures, and bleach the once vivid colours of painted walls inside. Tourist buses too, with their output of diesel fumes, are taking their toll of rare murals and carvings, despite the con- servation efforts of the Mexican

authorities. •

Health and the

city

Richardson. We must ask all those who deal with aspects of the urban system that directly or indirectly affect health to involve themselves in urban health planning. A healthy city is one that meets all the developmental and social issues of its inhabitants. This means focusing on jobs and employment, transport to education, recreation, sanitation and social services. This is a process of governance which ought to include the total population, and which recognises that no part of the community organism can be dis-eased without affecting the whole.

In the Healthy City programme started by the European Region of

WHO, and in the industrialised countries generally, some 450 cities are trying to find new ways to deal with health. Focusing upon health pro- motion and the mobilisation of the total non-health community to play a role in making the city healthy, they are beginning to break important ground.

No longer does health depend upon what can be done with the money available. Rather the question is what can be done by all possible means to improve health? How can the informal sector help? How can participation by all sectors improve the infrastructure?

What new rules must emerge? What new arrangements? In many instances new ways of communicating are emerging. Economic language is taking precedence over the language of human needs.

In the South, WHO - with its concern for primary health care - is focusing upon the new urban developing world. There the critical issues, though ecological and systems- orientated, have different priorities.

The emphasis is upon basic needs such as food, shelter, housing, transport, water and sewage. Providing jobs and an economic base for the population constitutes a priority issue.

Though productivity needs are high, environmental issues will be ignored at our peril.

To choose just one example: in Botswana aluminium cans for soda- pop have newly arrived. Their pres- ence as part of household rubbish has served as a breeding site for mosqui- tos, even in arid areas. The solution to malaria is therefore both treatment of patients and finding a way to deal with cans that collect water. So the answer to this problem demands a total urban approach.

A healthy city can only be achieved when health rates the high priority that it deserves in the complex issues of

urban life. •

(13)

Do we need

aD these chemicals?

by Dr Jenny Pronczuk de Garbino

Associate Professor of Clinical Toxicology, Universidad de la Republica, Montevideo, Uruguay

T

he headlong expansion of science and technology is constantly providing human society and the environment with more and more new substances.

Different molecules are being created, tested, discarded or commercialised according to their usefulness or economic advantage. But little or no attention is being paid to the consequent risks for human or environmental health.

It is neither practical nor economically feasible to evaluate the short- and long-term effects of the vast numbers of chemicals which are being invented - and re-invented! The objectives of this dynamic creativity are usually beneficial: to protect crops, to increase food stocks, to simplify household chores, to protect our health and hygiene. But . . . are all those new chemicals really indispensable? Does mankind really need to be swamped by so many new chemical compounds?

What used to be "chemical development" - the production of highly useful pharmaceuticals, anilines, anti- septics and pesticides - turned into a

"chemical revolution", and is now well on the way to becoming "chemical chaos." Too many substances and compounds are entering our homes, our working place, our environment and our bodies without our really knowing their risks and benefits, without a true evaluation of their usefulness and - worse still - without complete studies of their harmlessness for other forms of life.

Examples of the poisonings and chemical disasters that have resulted are legion. It took many years to realise that industrial and domestic use of fluorochlorocarbon propellants in aerosols were contributing to the depletion of the ozone layer, with all its environmental consequencs. Pro- longed use of asbestos fibres have

The angular geometry of a big chemical refinery in Europe.

caused malignant mesotheliomas (tumours) in exposed workers. Clinical studies of patients who took high doses of analgesics showed that certain renal insufficiencies were due to those apparently innocuous pharmaceuticals. All too late did medicine link the drug thalidomide with the birth of children with deformed arms and legs. And the indiscriminate use of pesticides is still causing a high toll of morbidity and mortality in some rural areas of developing countries. Long- term "hidden" tragedies such as Mina- mata disease in Japan or explosive chemical disasters such as Bhopal in India are other examples where a large human group falls victim to uncontrolled chemicals.

Most countries, especially the industrialised ones, have special units located within universities or public health services that deal with toxicological matters. Called Poison Control Centres (PCC) or Toxicology Units, their main objective is to provide advice on how to manage a clinical

case of poisoning, or what should (or should not) be done, how to deconta- minate the victim or the area, which antidote should be given, what clinical and analytical controls are required, or whether further studies are needed.

Since they began more than 30 years ago, PCCs recognised the need to respond to more and more toxicological problems. The developed countries had the social and financial conditions that permitted the creation of these specialised medical units. We must recognise and honour those first clinicians and information scientists who pioneered them with enthusiasm and dedication. They acknowledged a responsibility with reference to toxicological problems and public health, and they found an answer. But in developing countries there has been a certain Jag: they have been hindered by financial, political, social and educational considerations, and over- whelmed by other medical priorities such as malnutrition or infectious diseases. In most of those countries the population has not received any information on toxicological risks, and some specific groups may become innocent victims of this lack of information and instruction.

Toxic exposure

Among the high-risk population are factory and farm workers, pregnant women and children - most of them unaware of the care they should take to avoid toxic exposures and protect their health. Doctors too may not have access to up-to-date toxicological information, or - even worse - they may have no access to health authori-

13

(14)

Do we need all these chemicals?

ties who can recognise the impact of poisons on public health. Fortunately, a number of motivated international bodies are helping those countries to initiate poison control programmes that include prevention and treatment of poisonings.

How can chemical poisonings be prevented? Firstly, any kind of activity in this area should be preceded by an evaluation of the most used chemicals and the impact they may have on populations at risk. Secondly, different methods of information and education should be carefully prepared, adapted and disseminated at professional and non-professional levels: to schools, community groups, labour unions and universities. The mass media have an important role to play in this field.

Longlasting PCBs

I

t will take up to 20 years to dispose of the PCB compounds that have accumulated worldwide since they first came into use in 1929. according to Or Alistair Hay, a specialist in chemical pathology at Leeds University, UK .. And a technically foolproof method of destruction has not yet even been found. Or Hay believes that incineration of polychlori- nated biphenyls is the best option. but he has doubts about the efficiency of existing incin- erators. Released largely from factory chimneys and from the open-air burning of plastic wastes. PC Bs are suspected of causing cancer in animals and of affecting their repro-

duction. •

Thirdly, preventive activities should be repeated periodically so as to maintain public awareness of toxicological risks. Poison prevention cam- paigns by radio and television have been run for a whole week, once a year, in some countries and have proved very useful. At university level, toxicology courses taken by students of chemistry, agronomy, biology, medicine and paramedical careers provide both scientific knowledge and awareness of how to promote the prevention of poisonings.

Chemical spraying is a valued weapon against locusts; but has enough atten- tion been paid to potential risks to human or environmental health?

14

In the highly specialised area of treatment, we can safely say that common sense is as essential as the advice of an experienced toxicologist.

Decontamination of the victim (for instance by vomiting, or washing affected skin) and life-saving . pro- cedures such as artificial respiration or external cardiac massage may be per- formed anywhere by a well-informed person. But the guidance of poison centres or consultation with toxicology services is indispensable for appropriate management of clinical cases (and also for epidemiological reporting purposes). It is important to know whether a gastric lavage can be per- formed, which kind of clinical compli- cations to expect, whether an artificial kidney is needed, or if antidotes are available and how they should be administered. Such management problems require the advice of an experienced clinician.

As we have seen, prevention and treatment of poisonings require information on chemicals, and well- trained personnel in medical and paramedical areas. Not all countries have reached the optimal situation of having a Poison Control Centre (to serve, say, five million inhabitants), good communications, up-to-date information sources and clinical toxicology units in their main hospitals. In fact, many countries have an absolute lack of toxicology centres, and have

not even recognised poisonings as specific medical situations. The international activities undertaken by such bodies as the International Programme for Chemical Safety (jointly conceived by UNEP, ILO and WHO), the World Federation of Poison Control Centres and Clinical Toxicology Centres, as well as regional toxicology associations, have encouraged the recognition of common problems and needs, as well as the value of inter-centre cooperation amongst countries.

Although these realities are suspected or known by scientists, health authorities and the layman, not much has been accomplished. The struggle of the sensible, informed citizen against uncontrolled chemical development is an uneven one. Scientific progress is certainly a need in such areas as medicine, food technology, agriculture and energy. But do we really need such an array of household products just to keep our homes clean and fragrant? Do we really need hundreds of variegated cosmetics in order to look good?

The more chemicals we have around us, the higher the risks of falling victim to them. We have to consider all the social, cultural and educational factors related to each episode of poisoning. A molecule by itself, a drug in a flask or a pesticide in a tank may be totally innocent. The risk starts when too many molecules

WHO/FAO

(15)

Fishy casualties of the chemicals boom.

Too many substances are entering our homes, workplace and environment before we have truly evaluated their harmlessness.

appear, when too many drugs are being used or when tons of pesticides are applied indiscriminately. Poison·

ings result from a "surplus" of chemicals in our society, coupled with a lack of information, respect and discretion in their use.

As clinical toxicologists, we are often astonished by cases of intoxication provoked by the most unexpected products under anomalous circum·

stances. Immigrants or tourists, for instance, are sometimes poisoned by foreign medications, cosmetics or herbs that are not registered or known locally. Or trouble arises from pes·

ticides which are introduced illegally into a country for application to crops and whose composition is totally un·

known. Not long ago, a clinical case of malaise followed by respiratory distress in a middle-aged factory worker, after he cleaned up a spill, turned out to be a case of exposure to a highly toxic chemical that was being used as tissue

Ten years of IPCS

I

PCS - the International Pro- gramme of Chemical Safety- celebrates its first decade of existence in April this year. The brainchild of three UN sister agencies. ILO. UNEP and WHO, the Programme involves 27 countries and 67 participating institutions in the work of chemical risk evaluation and the safe management of

chemicals. •

softener. We were surprised to discover that the product - dimethyl- sulfate - had been proposed years ago as a warfare agent! Scientists specialised in toxicology should be prepared for such surprises.

In this era of chemical sophisti- cation, new products risk getting out of hand like the broom and pail of the

"sorcerer's apprentice." On the other

hand, learning to identify the problems and find solutions, the community is better aware of the effects of poisons and pollution, and the author·

ities are more ready to admit their responsibility. Everybody knows that chemicals recognise no frontiers and @

should be dealt with by international .~

cooperation. The best antidote of all is

13

... prevention. • 0::

(16)

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(17)

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CH -1211 GenM 7:1 Suisse

A deluxe edition of Our PlaDCt, Our Health, printed on hard hoard will be available -at a later date from:

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Suisse C World Health Organization, 1990 Crtalion: G. Padey ( OMS Geneve) I/Justrations: lJitlM V. Hart ( OMS Geneve)

WORLD HEALTH DAY 1990

Contents

WORLD HEALTH DAY 1990

A wounded planet

by Dr Hiroshi Nakajima

JI

An

Think Globally

In tune with Nature

by Mrs Gro Harlem Brundtland

D

A

Environmental health in the 1990s

by Dr Wilfried Kreisel

JHI

Environmental health in the 1990s

W

Air pollution in A&ica

by Or Henk W. de Koning

T

I

Health and the city

by Professor Len Duhl

JB3

Shared beliefs

D

A

Health and the

Do we need

aD these chemicals?

by Dr Jenny Pronczuk de Garbino

T

Do we need all these chemicals?

I

I

13

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