Reproduced, with permission, from:World Health Organization Geneva 1992
Health and development are so intimately connected that the state of health within a country is one of the most revealing indicators of its development. Yet health is still seen as the responsibility of the health authorities alone, rather than as the shared responsibility of individuals, communities, employers, and all government agencies at all levels. Some of the limitations of the last four United Nations Development Decades may stem partly from that view and are reflected in the hundreds of millions of people still suffering from preventable diseases and working in environments that threaten life and health.
Sound management of the environment brings major health benefits while inadequate or no management results in large adverse effects on health. Sound management is essential to a sustainable interaction between people and their environment in a world where finite resources are being depleted and the capacity of natural cycles and systems to absorb wastes is being exceeded. There are limits to the extent to which the soil and freshwater resources can be exploited and ecosystems used as a receptacle for the wastes generated by human society. There are also global limits to the exploitation of non-renewable resources and to the capacity of the planetary system to absorb wastes. Only recently have these global limits become apparent, as in the depletion of the stratospheric ozone layer, which has implications for health and agricultural production, and in the possibility of climatic disruption as a result of the release of greenhouse gases. At local level the challenge is to meet human needs, including those essential to health, while also exploiting resources sustainably. At intercountry and global level, the challenge is to ensure that everyone can obtain the resources essential for health without imposing an environmental burden on natural cycles carrying health risks for present and future generations. Meeting this challenge will require intergovernmental agreements that limit each country's use of finite resources and its right to dispose of non-biodegradable wastes freely.
The need to act is as urgent in the developed as in the developing countries, although the priorities differ. In the developed world the priority is to arrive at more sustainable patterns of resource use and ecosystem exploitation. Developed countries have almost stable populations, most of which enjoy relatively good health and safe living and working environments. These countries enjoy increasing prosperity and a relatively equitable income distribution, and more effective preventive and curative government interventions have greatly reduced what are often termed the diseases of poverty (undernutrition and many communicable diseases), even if for some pockets or population groups they remain a serious problem. However, developed countries are increasingly exposed to many other health problems. Besides those related to pollution there are those due to dietary and behavioural patterns, such as a large proportion of neoplastic, chronic respiratory, and cardiovascular diseases, as well as various psychosocial problems such as alcohol and drug abuse, against which even the wealthiest governments have found few effective actions.
In addition, developed countries contribute more to the burden of waste in the environment, despite the implementation of strict controls on some types of emission. They also make larger claims per person on the global stock of non-renewable resources. New technological advances have brought many benefits to society, but they have also brought risks to health in the form of exposure to chemicals and to physical hazards. While there have been remarkable efforts in the past 20 years to understand better the significance of such exposure and the health effects it may have, large gaps in knowledge remain. Thus too many chemicals are released into the environment without prior toxicological testing. Broadening and improving programmes aimed at promoting and protecting health deserve increased consideration. From a global point of view the development of a coherent programme to achieve more sustainable levels of resource use and waste generation should receive a higher priority. There are no signs of such a programme, though steps are being taken in this direction, such as the Montreal protocol to limit emissions of chlorofluorocarbons, the Basel convention regulating the transport of hazardous wastes, and the European Charter.
By contrast, developing countries are striving to reduce morbidity from long-established disease patterns. But their inhabitants are also increasingly exposed to the hazards that beset the inhabitants of developed countries, from industrial and traffic pollution and urban stress to diet-related and behaviour-related diseases.
In most developing countries the priority is development in the sense of stronger, more stable and prosperous economies, where health, environmental protection, and a more equitable distribution of the benefits of economic growth take a central place. Lack of development frequently results in poor living conditions and poor health and education standards for the majority of the population, while current practices and trends in the exploitation of their natural resources, both renewable and non-renewable, are unsustainable. In many instances growth in agricultural, industrial, or mining production and in urban population has been accompanied by an increased incidence of environment-related diseases and physical hazards. While many developing countries have made substantial gains in the scale of their economies, these are often at the cost of severe degradation of their stock of natural resources and of air and water pollution, especially in urban areas. Commonly, too many of the workforce suffer exposure to occupational hazards that have long been controlled in developed countries.
Global inequalities remain one of the most serious constraints on the improvement of health and environment, and over 40 years of international discussion about North South relations, trade and aid have done little to alleviate them. The discussion has not produced tangible results helping poorer countries achieve the prosperity and economic stability they need to underpin sustained improvement in health and in the institutional capacity for sound environmental management. High standards of health could, however, be achieved in developing countries without a high per caput income and without heavily industrialized and urbanized economies. But governments cannot maintain a role as promoters and supporters of health and of a sustainable use of environmental resources with unstable economies and severely limited public funds. Everyone needs a certain income to gain access to the goods and services essential to health. Economic instability or decline, and large debt repayment burdens, are also incompatible with environmental management, especially for the many countries dependent on the export of natural resources for much of their foreign exchange.
Priority given to human health raises an ethical dilemma if "health for all" conflicts with protecting the environment. Two extreme positions may be envisaged. The first stresses individual rights, societal good being seen as the aggregate of everyone's personal preferences and any controls over the individual's use of resources as an infringement of the individual's freedom. The other extreme--a response to increasing environmental degradation gives priority to the environment and to the maintenance of the ecosystem. All species are seen as having rights as people do, environmental welfare thus coming before human welfare. A middle ground between these extremes can be found by distinguishing between first-order and second-order ethical principles (1). Priority to ensuring human survival is taken as a first-order principle. Respect for nature and control of environmental degradation is a second-order principle, which must be observed unless it conflicts with the first-order principle of meeting survival needs.
The first order assigned to meeting human survival needs is consistent with the United Nations Universal Declaration of Human Rights (1948), which states that all people have the right to a standard of living adequate for the health and well-being of themselves and their family, including food, clothing, housing, health care, and the necessary social services. This implies the right of all individuals to have access to the resources needed to meet their needs. The second-order principle of respect for nature and control of environmental degradation should guide all human activities except where they conflict with the first-order principle, as recognized by the World Charter for Nature (1982) (2) and the WHO European Charter on Environment and Health (1989) (3).
The report of the World Commission on Environment and Development, Our common future, defined sustainable development as development meeting the needs of all the present population without compromising the ability of future generations to meet their own needs (4). This could prove contradictory if meeting present needs implies the irreversible depletion of natural resources and the degradation of ecosystems. But the intelligent application of what is known, combined with caution and a continuous commitment to improving understanding of links between the environment, development, and health can change these trends. Ensuring that everyone has access to the environmental resources needed to fulfill their rights under the Universal Declaration of Human Rights need not imply an unsustainable level of resource use. Nor need it overwhelm the finite absorptive capacities of natural ecosystems if development is guided by a commitment to ensuring that costs are not passed on to future generations. Development must also be pursued with caution in the face of uncertainty concerning its environmental and health implications, with action being taken early to address global threats to health and the environment, even if present knowledge is insufficient to evaluate the risks fully.
Focusing on health provides many insights into how a better balance can be achieved between the environment and development. This report draws on the knowledge and experience of the last few decades on how to reduce the prevalence of disease with levels of resource use that can be sustained. The existence of villages, cities, regions, and countries where good health has been achieved with much less use of resources and environmental degradation than elsewhere provides clues for the strategies and recommendations presented in subsequent chapters. It also helps to broaden the discussion of health and environment beyond concern with levels of income and consumption only, and permits consideration of non-consumption aspects of health and well-being. The extent to which sustainable development and health for all can be made compatible depends on a new understanding of what is meant by development in which health takes a more central role.
The complex relationship between health and the environment extends the responsibility for promoting health to all groups in society. Health is no longer the responsibility only of doctors, nurses, midwives, and other health professionals who seek to prevent or cure disease or of those who seek to remove pathogens from the human environment and reduce accidents. It is also the responsibility of planners, architects, teachers, employers, and all others who influence the physical or social environment. It is the responsibility of health professionals to work with all groups in society in promoting health.
This understanding of health also means, above all, that individuals, households, and communities have substantial responsibility for their own health. Personal and community responsibilities for health are essential adjuncts to individual and community rights. The right of individuals to adequate shelter, health care, and education (including health education) must have as a counterpart their commitment to the promotion and protection of their own and their neighbours' health and welfare. Indeed, each adult has the duty as a citizen to ensure that health risks within human environments are minimized and government resources wisely used. Citizens' rights and citizens' capacity to organize and act become crucial in health. Households and communities with the knowledge, confidence, and capacity to improve their own environment are likely to be more healthy, not only because of the physical improvements they can make but also because of the important links between mental health and self-esteem and capacity for action.
The physical environment has a major influence on human health not only through temperature, precipitation and composition of air and water but also through its interaction with the type and distribution of the flora and fauna (the biological environment). The biological environment is a major influence on the food supply and on the reservoirs and transmission mechanisms of many diseases. Box 2 is a much simplified illustration of these interrelationships.
Environmental factors that impair health include:
Restricting discussion of the interactions of health and the environment to the three groups of factors described above excludes noxious agents to which humans are exposed largely as a result of their own chosen form of behaviour. The health problems resulting from the use of tobacco and the excess consumption of alcohol, saturated fat, and salt, which in many societies have become the principal causes of avoidable disease, will therefore not be covered in detail in this report, although some will be referred to as affecting the way in which individuals react to agents in the environment.
However, the average level of income per person in a country is only one among many social, economic, cultural, and political factors that influence people's health. These factors range from the wealth of a society (which in turn is influenced by its role within the world economic system) to the level of education of each individual, including knowledge of health-enhancing action and behaviour. Between these two extremes come a large range of variables: the distribution of incomes and capital assets within a society; the quality of the housing and living environment; and the quality of the infrastructure and services (of which the quality and availability of water supply, sanitation, and health care services are perhaps the most important). The health profile of any society is influenced not only by the scale of incomes and assets and their distribution but also by taxation structures and the macroeconomic policies of governments. This complicates the task of establishing the contribution of different factors to health, but it also provides policy-makers with a much greater range of possible interventions to promote it.
The limitations to equating the wealth of a society with its health can be seen in the many countries where health indicators such as infant mortality rates or average life expectancy at birth are well above or below the average for countries with the same level of income per person. These exceptions provide important clues as to how health improvement can be achieved without high levels of per caput income, resource use, and waste generation. Box 4 shows that countries such as China, Costa Rica, Cuba, and Sri Lanka and the Indian state of Kerala have life expectancies well above the norm for their per caput income level. The appendix to this chapter (p. 17, p. 18, p. 19) ranks all developing countries according to life expectancy at birth and in regard to average per caput income and to an index of human development (a composite indicator incorporating life expectancy, educational attainment, and real per caput income, developed by UNDP). It also shows the many countries where high life expectancy at birth has been achieved without a high per caput income and also several countries with among the highest per caput income and a relatively low life expectancy.
While life expectancy at birth has been increasing in the great majority of countries, suggesting that global health is improving, national statistics conceal extreme variability within countries. Because income level and social status are important determinants of health, higher-income groups enjoy longer lives and better health than lower-income groups. The differentials tend to be greatest in Africa, Asia, and Latin America, where life expectancy among poorer groups is often 20-30 years less than for richer groups. The proportion of children born to poorer groups who die before the age of five is often 40 or more times that of richer groups (7). Disparities in health between rich and poor are also apparent within developed countries, although they are usually smaller; wealthy groups have the most concentrated medical attention, eat better, tend to smoke less, and have the opportunity to live away from industrial effluents and disaster-prone areas.
Although this report concentrates on the links between health and the environment, it should be stressed that growing prosperity in any society provides significant advantages for achieving health only if it also means that a growing proportion of the population enjoy adequate incomes, an improved housing and working environment, and access to preventive and curative health services. The rapid increase in life expectancy achieved in the developed world at the end of the nineteenth and the first half of the twentieth century was much influenced by the increased purchasing power of most people, combined with better public health. It is also notable that the countries with above-average health indicators relative to their per caput income level tend to be those with the most equitable distribution of income. Differences in average life expectancy between the richer developed countries may be more influenced by the degree of inequality in income distribution than by the average level of income (8). Box 5a, 5b shows one indicator of income distribution: the proportion of total GNP accruing to the poorest 40% of households for 46 countries or territories for which data were available. Many of the countries in which the poorest 40% of households had relatively high proportions of the total GNP are also countries with a high average life expectancy relative to average income level. UNICEF has argued that the per caput GNP of the poorest 40% of the population might be a more meaningful development indicator than the average per caput GNP (9).
Everyone has responsibility in the achievement of health and a good environment. Successful solutions to most health and environmental problems depend on a great variety of actions by a considerable range of people working within different sectors and at different levels, united by the common goal of health and environmental quality. Government still retains its central responsibility for protecting individuals against threats to their health and environment and ensuring that all people have access to health care and other services and resources essential to health. But it also has an important strategic role in promoting and supporting the initiatives of individual community organizations, local governments, consumer associations, non-governmental organizations, and businesses in favour of improved health and environment through the "governance of diversity" (10), i.e., incentives and legislation encouraging and supporting the multiple interventions of citizens, businesses and municipal governments in promoting health at minimal environmental cost. Such governance must also ensure that short-term and long-term environmental health considerations are systematically taken into account in all new developments.
There can be conflicts in the short term and within specific localities between the cheapest means to improve health and the maintenance of a healthy functioning environment. In most instances this is because the action taken to improve health simply transfers risks to other locations or to the future. Tall chimneys for coal-fired or oil-fired power stations can greatly reduce air pollution within their immediate environment, but they contribute to acid deposition at a considerable distance. A country with the resources to import timber and minerals avoids the environmental degradation that often accompanies logging and mining, the environmental costs being transferred to the producing country. This transfer of costs can also be intergenerational: the use of fossil fuels or the cutting down of forests to meet present needs or desires contributes to global warming. The health impact will be felt in future years and, perhaps most acutely, by future generations.
There are also differences between richer and poorer groups in relation to the environmental damage arising from resource use. In the case of richer groups, the costs of this damage are rarely borne by those responsible for it. Their health is not immediately impaired by the diminution of resources and the waste generated. Poorer groups generally bear the immediate cost and suffer the direct consequences of the environmental degradation.
Case studies of particular cities or regions confirm that wealthy groups generally enjoy the least polluted environments and work in the safest occupations. The contrary is true for poorer groups. Richer and poorer groups also differ in the type and extent of environmental damage they produce. Most of the wealthiest societies have been more successful in removing pathogens and pollutants from the human environment (or treating the health problems they cause) and in maintaining the quality of key renewable resources such as soils and forests, but at the cost of high levels of non-renewable resource use and greenhouse gas emissions. Poorer societies draw much less on the planet's stock of non-renewable resources and contribute much less to greenhouse gas emissions, but it is more common for their soils to be overexploited and their living and working environments degraded.
Market forces have exerted a major influence on economic growth in many countries. While this growth has provided a small proportion of the world's population with the income to pay for goods and services essential for health, many countries have not been able to develop the necessary economic basis. Furthermore, uncontrolled market forces can contribute to ill health and to the degradation of the environment. Where unregulated disposal of health-threatening products or wastes into the human environment is allowed, there may be serious adverse health effects for many people.
Countries--and the planet--need mechanisms to ensure that market forces do not result in the depletion of finite resources and the degradation of the environment. But no simple set of indicators exists for permitting measurement of the quality of each country's environment and the extent to which current patterns of resource use can be sustained. New techniques are being developed to incorporate environmental costs into national accounts, including estimates of the depletion of non-renewable resources and of the capacity of soils and forests to produce sustainable yields. If these were included as "capital depreciation" in national accounts, the economic growth rates achieved by many countries over the last few decades would be substantially lower (11). But these techniques have yet to gain widespread acceptance by governments.
There is also no agreement on appropriate indicators for measuring the extent to which any national economy draws on the world's resources or the environment is capable of absorbing pollutants. This makes it difficult to compare the performance of different nations in using resources sustainably. It will be even more difficult to reach international agreement on reducing the disparities. At present most of the focus is on domestic issues within each country's boundaries. There is a need for citizens with a commitment to the planet and the welfare of all its people. Only they can press their governments to reach the international agreement on which a healthy and sustainable planet depends.
3. European Charter on Environment and Health. Copenhagen, WHO Regional Office for Europe, 1990.
5. Todaro, M.P. Economics for a developing world. Hong Kong, Longman, 1977.
6. UNICEF. The state of the world's children, 1990. Oxford, Oxford University Press, 1990.
8. Donnison, D. Sinking with the tide. The Guardian, Wednesday 21 August 1991.
9. UNICEF. The state of the world's children, 1989. Oxford, Oxford University Press, 1989.
10. Duhl, L. J. The social entrepreneurship of change. New York, Pace University Press, 1990.
