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Environmental health factors play a significant role in human health and the protection of the environment. The health impacts resulting from exposure to these factors are closely linked to social aspects such as socioeconomic status and access to health care. Three current environmental case studies are discussed from both an environmental and a social aspect.
- Social Determinants of Health
- Vulnerability and Human Health
- Environmental Case Studies
- Health Impacts of Climate Change
- Deepwater Horizon Oil Spill
- Fukushima Nuclear Power Plant Accident
- Sustainability and Future Challenges
As a cornerstone of public health, environmental health factors play a significant role in human morbidity and mortality in both developing and developed countries across the globe. The World Health Organization (WHO) recognizes the impact of these factors and has adopted a two-stranded definition of environmental health that embraces both the etiology of health problems and also the methodologies to manage them.
Environmental health addresses all the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviors. It encompasses the assessment and control of those environmental factors that can potentially affect health. It is targeted towards preventing disease and creating health-supportive environments. (WHO, 2013a)
In a 2006 WHO Report, “Preventing disease through healthy environments: Toward an estimate of the environmental burden of disease,” Pruss-Ustun and Corvalan reported that an estimated 24% of the global burden of disease and 23% of all premature mortality can be attributable to environmental factors with the specific fraction of disease attributable to the environment varying widely across different disease conditions due to differences in environmental exposures and access across the regions. In 2013, WHO (2013a) listed 10 facts on preventing death, illness, and disability through healthy environments, highlighting the need for environmental management of potential hazards. These statements highlight the disproportionate impact of environmental factors on vulnerable populations, particularly the impoverished in developing countries.
- ‘Worldwide, 13 million deaths could be prevented every year by making our environments healthier.
- In children under the age of five, one-third of all disease is caused by the environmental factors such as unsafe water and air pollution.
- Every year, the lives of four million children under 5 years of age – mostly in developing countries – could be saved by preventing environmental risks such as unsafe water and polluted air.
- In developing countries, the main environmentally caused diseases are diarrheal disease, lower respiratory infections, unintentional injuries, and malaria.
- Better environmental management could prevent 40% of deaths from malaria, 41% of deaths from lower respiratory infections, and 94% of deaths from diarrheal disease – three of the world’s biggest childhood killers.
- In the least developed countries, one-third of death and disease is a direct result of environmental causes.
- In developed countries, healthier environments could significantly reduce the incidence of cancers, cardiovascular diseases, asthma, lower respiratory infections, musculoskeletal diseases, road traffic injuries, poisonings, and drownings.
- Environmental factors influence 85 out of the 102 categories of diseases and injuries listed in the 2004 World Health Report (WHO, 2013a).
- Much of this death, illness, and disability could be prevented through well-targeted interventions such as promoting safe household water storage, better hygiene measures, and the use of cleaner and safer fuels.
- Other interventions that can make environments healthier include: increasing the safety of buildings; promoting safe, careful use, and management of toxic substances at home and in the workplace; and better water resource management.’
Environmental determinants of health have traditionally focused on areas of underdevelopment such as inadequate water quality, inadequate sanitation and waste disposal, presence of disease vectors, and poor housing. While most of these areas have been managed successfully in developed countries, they are still major causes of morbidity and mortality in less developed counties (Liamputtong et al., 2012). Paradoxically, many countries are now faced with modern threats that have emerged due to overconsumption and overdevelopment, compounded by emerging threats such as climate change. These new hazards are the result of often uncontrolled development activities occurring without sufficient safeguards and unsustainable consumption of natural resources (Earl et al., 2012; SERI et al., 2009). The Health Council of the Netherlands (2012) also noted that in Western nations, increased health risks are usually related to an accumulation of unfavorable physical and social circumstances. Rapid urbanization and large-scale movements of people have introduced a whole new set of environmental health hazards while exacerbating others (Margai, 2012).
In addition to environmental factors, human health is affected by many other interrelated and overlapping factors. One widely accepted model, which captures the interrelationships between various factors that affect human health is the Dahlgren and Whitehead (1991) ‘Policy Rainbow’ (Figure 1). This rainbow model conceptualizes the main determinants of population health and demonstrates the connections between health and socioeconomic, environmental, and cultural conditions. The inner layer represents personal factors and behaviors, the middle layer is the social and community networks that ideally support individuals as well as groups and families, and the outer layer is the environmental and social factors that play a more encompassing or overarching role in determining health. This reinforces the concept that despite favorable lifestyle factors and community support, environmental, cultural, and general economic conditions ultimately determine the state of human health.
Figure 1. The main determinants of health. Dahlgren, G., Whitehead, M., 1991. Policies and Strategies to Promote Social Equity in Health. Institute for Further Studies, Stockholm.
In 2012, the Health Council of the Netherlands released a report on the “Social Aspects of the Living Environment in Relation to Environmental Health.” They also noted that numerous relationships play a role in environmental-related health problems and that exposure to various environmental stressors or hazards can have a broad range of effects, with specific problems often the result of several stressors interacting on human health. The authors also noted that environmental stressors do not always have the same effect on health and that in addition to context and exposure, this is largely dependent on the social determinants of health which are the social, cultural, economic, environmental, and political factors that can impact on the health of individuals.
Social Determinants of Health
The WHO Commission on Social Determinants of Health broadly defines social determinants as “.the circumstances in which we are born; grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces such as economics, social policies and politics” (WHO CSDH, 2008: p. 1). These are all factors that impact on our vulnerability or immediate coping capacity as well as our ability to adapt to changing situations. In the WHO publication, The Solid Facts, Wilkinson and Marmot (2003) and Marmot and Wilkinson (2006) list and discuss the 10 widely accepted social determinants of health, from social status differences to transportation. All of these determinants have environmental dimensions. For example, social inequality can be linked to overcrowding and substandard housing, which in turn may increase the risk of exposure to contaminated air or unclean water.
Vulnerability and Human Health
The impact of environmental hazards on human health is generally dependent on the vulnerability of the affected population. What becomes apparent when looking at the morbidity distribution of illness and disease caused by environmental factors is that the health impacts of these factors disproportionately affect the poor and isolated, both those in developing countries as well as the socially disadvantaged groups in developed countries. These people are vulnerable in that not only are they unable to respond appropriately to cope with the immediate effects of environmental hazards or incidents, but also they are less likely to be able to recover and adapt their circumstances and situation to minimize ongoing impacts and mitigate or prevent effects from future events.
The social aspects of vulnerability are recognized although it is acknowledged that little is known about them as they are difficult to quantify. Social vulnerability is partially a product of social inequalities and also includes place inequalities, i.e., differences in community such as level of urbanization, infrastructure, and governance. In 2003, Cutter, Boruff, and Shirley constructed an index of social vulnerability called the Social Vulnerability Index by looking at conditions that contribute to making people or places vulnerable to extreme natural events. They also looked at communities’ resistance or resilience to hazards. Using a factor analysis approach and based on US data, they found that there were 11 factors that accounted for over 75% of the variance in vulnerability. Factors identified included personal wealth (of countries), age (elderly and young especially vulnerable), density of the built environment (manufacturing and commercial establishments) housing, single sector economic dependence (especially agricultural as it is very climate dependent), housing stock (quality), tenancy (home ownership, renters, mobile homes, etc), race and ethnicity (marginalization with racial disparities), occupation and finally infrastructure dependence (economic vitality and revenue generating capacity).
Environmental Case Studies
Previous discussion has focused on the magnitude and scope of the possible effects social determinants may have on the outcomes of environmental conditions and incidents. It should be noted that environmental incidents themselves can also have a significant impact on social and psychosocial determinants such as employment, social exclusion, social support, socioeconomic status, and in particular, stress. This section will discuss three very significant twenty-first century examples of environmental phenomenon or disasters that have had far reaching social as well as environmental implications: Climate change, the 2010 Deepwater Horizon oil spill, and the 2011 nuclear accident in Fukushima, Japan. Climate change is a unique environmental phenomenon in that it has the potential to affect ecosystems and populations all over the world. The drivers of climate change have been occurring over decades, basically since the industrial revolution, with changes to our surroundings so subtle that they have gone relatively unheeded for many years. The other two examples involve technological failures that have caused immediate devastation over a more defined area and both continue to be the subject of long-term ongoing attempts at cleanup and restoration.
Health Impacts of Climate Change
Climate change is an emerging threat to public health that has the potential to have extremely significant health and social impacts, as both a direct and indirect consequence of the effects on the environment. The environmental manifestations range from mild fluctuations in weather patterns to the catastrophic destruction that may result from an increase in both the frequency and intensity of extreme weather events such as storms, cyclones, flooding, and heat and cold waves. While there may be some positive effects of climate change, such as lower cold-related mortality, changes in agricultural yields, or vector survival rates in some areas (Confalonieri et al., 2007), the majority of impacts are predicted to be negative. There are also predicted to be significant social effects from the potential displacement of large numbers of people both from coastal areas in low lying countries and agricultural areas that are no longer viable or able to sustain crops and livestock. This displacement may lead to the loss of social infrastructure and support, unemployment and poverty, as well as psychological distress.
Climate change has the potential to cause a broad range of impacts by various direct and indirect pathways (Figure 2). Human health may be affected directly through phenomena such as heat and cold waves, drought and extreme weather events such as storms, tsunamis, and cyclones. Indirect effects that may be detrimental to health generally result from changes to existing conditions such as an increase in the formation, dispersion, and deposition of air pollutants such as ozone and particulates and changes in water quality and availability. There may also be corresponding changes in vector ecology and ecosystems, with subsequent changes in communicable disease as well as changes to agriculture and food quality, industry, and settlements. Climate change can also cause social and economic disruption by forcing the displacement of populations following adverse weather conditions such as droughts and floods, extreme weather events, and also the loss of coastal regions due to rising water levels. There may also be a financial burden associated with property and personal loss as well as a reduction in personal wealth associated with displacement (Kreigler et al., 2012; WHO, 2013b).
Figure 2. Schematic diagram of pathways by which climate change affects health, and concurrent direct-acting and modifying (conditioning) influences of environmental, social, and health system factors. Confalonieri, U., Menne, B., Akhtar, R., Ebi, K., Hauengue, M., Kovats, R., Revich, B., Woodward, A., 2007: Human health. Climate change 2007: impacts, adaptation and vulnerability. In: Parry, M., Canziani, O., Palutikof, J., van der Linden, P., Hanson, C. (Eds.), Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge University Press, Cambridge.
As illustrated in Figure 2, environmental, social, and health system conditions all have the potential to have a modifying influence on the health impacts of climate change as they are all fundamental to determining adaptive capacity. From an environmental aspect, the prevailing environmental conditions will have a large bearing on the outcomes of any change. The higher the standard of water and air quality, the lesser the effect is likely to be. In countries that already have poor water, air, and soil quality, a further reduction in quality may have a devastating effect. The geography of a community will also be important with low lying or drought-prone areas being particularly vulnerable. Social conditions such as community organization, employment, and economic status will all be important in determining the resilience and adaptability of a community or county to the possible effects of climate change. Health system conditions such as access, affordability, and quality of health care will also be important determinants of health impacts (Confalonieri et al., 2007).
As a relatively recently recognized and studied phenomenon, there is little long-term epidemiological evidence about the effects of climate change. Research into climate change impacts and adaptation is particularly complex due to the many uncertainties surrounding the various ecosystems’ responses to warming, as well as the difficulty associated with contextualizing the heterogeneity in impacts and adaptive capacity (Kreigler et al., 2012). In many parts of the world there has been very limited funding available especially where there has been a history of skepticism regarding the scope and magnitude of the predicted outcomes. Despite the limited research that has occurred, it is generally acknowledged that the key to mitigating the potential effects lies in a country or a population’s adaptive capacity. Many developed countries appear to have refocused their priorities and rather than trying to reduce greenhouse emissions and slow the potential effects, they are instead investing in researching adaptation strategies to reduce the adverse consequences for various future scenarios. Given that these strategies require significant financial investment, it follows that developing nations who have extremely limited finances and therefore a limited capacity to adapt will be impacted far more severely. Many of these countries already have high rates of disease and debility and are less able to cope successfully with stresses of all kinds, including the environmental and social impacts of climate change (NCCARF, 2013; WHO, 2013b).
Deepwater Horizon Oil Spill
In April 2010, a system malfunction on the Deepwater Horizon mobile offshore drilling rig, situated in the Gulf of Mexico, led to an explosion that killed 11 workers, injured 17 others, and caused large quantities of crude oil to be released. By the time the well was capped 87 days later, the equivalent of 4.9 million barrels of crude oil had escaped into the Gulf, making it the largest oil spill in recorded history (Ramseur and Hagerty, 2013). The oil slick covered 6500 km2 of ocean and polluted hundreds of kilometers of beaches, wetlands, and estuaries on the Gulf leading to a complete loss of vegetation in some areas and the death of thousands of fish, birds, and mammals. The cleanup was also surrounded in controversy over the use and quantity (at least 6.8 million liters) of dispersants which contained both carcinogens and endocrine disrupting chemicals, and are now known to have increased the toxicity of the oil up to 50 times through a synergistic effect. There were also serious environmental concerns about in situ burning of the oil, which released dioxins and other harmful chemicals into the atmosphere (Rico-Martinez et al., 2013).
Following the oil spill, fishing areas were closed and fears about sea food safety lead to a dramatic reduction in local sea food harvesting even in areas away from where the oil spill reached resulting in people working in the commercial fishing industry losing their employment and sea food prices rising in the USA (Grattan et al., 2011). There was also a decrease in tourism in the coastal areas affected by the oil spill with a loss of over 400 000 tourism jobs (Diaz, 2013). Lack of fishing and tourism caused substantial economic hardship to the residents in the area (Cleveland, 2013).
Oil spills contain a mixture of chemicals that can include benzene, polycyclic aromatic hydrocarbons, toluene, xylenes, ethylbenzene, and other compounds that may be toxic to human health (Mendelssohn et al., 2012). An article by Levy and Nassetta (2011) analyzing previous studies on the health effects of oil spills identified that in addition to acute and chronic physical health effects, oil spill cleanup workers also suffered psychological disorders. In 2010, a study of 1200 residents who lived within 16 km of the affected coastline reported that one-third of parents indicated that their children experienced mental health distress or physical ill-health (mainly respiratory symptoms and skin irritations) as a direct result of the oil spill (Abramson et al., 2010). Twentyfive percent of the coastal residents interviewed were planning to move from their home and the coastal area due to the effects of the oil spill. Children’s leisure activities were also changed with 84% of parents decreasing their children’s swimming time, 81.8% decreasing fishing time, 73.2% decreasing boating time, and 65% of parents believing that local sea food was not safe to eat. Woodward (2010: p. 1292) reported that Gulf States residents who lived close to the areas of the oil spill, and people whose business had decreased or closed due to the oil spills “have been exhibiting signs of acute anxiety, depression, increased and excessive drinking, and suicidal ideation” which may contribute to mental health issues in children.
Research conducted by Lee and Blanchard (2012) found that after the Deepwater Horizon disaster, community attachment, and the fear of losing members of the community, was a problem, particularly for residents who had lived in an area for generations working in the fishing industry or in the oil industry, or who were of Cajun descent, who were unwilling to relocate when there was no longer work available in their community. These residents were highly susceptible to psychological trauma when economic loss occurred. Community indignation about the Deepwater Horizon oil spill amplified resident’s fear, anxiety, and worry (Lee and Blanchard, 2012). Grattan et al. (2011) conducted research comparing the psychological impacts of the Deepwater Horizon oil spill on people who had direct experience dealing with the spill with those that suffered economic loss due to the oil spill, but who were located away from the coast where the oil spill reached. They found that participants with oil spill related income loss had higher scores for being depressed, having tension, anxiety, fatigue, confusion, mood disturbances, and had lower scores for being resilient. They were more likely to use behavioral disengagement (withdrawal from society) as a coping strategy. Levy and Nassetta (2011) reported postdisaster changes in the community including struggling over where to place blame. Poor risk communication following the event with authorities being evasive and unresponsive led to the community, particularly affected individuals becoming suspicious and cynical.
Fukushima Nuclear Power Plant Accident
In March 2011 an earthquake of magnitude 9 in the Pacific Ocean (Tohoku) triggered a tsunami that inundated the north east coast of mainland Japan. This caused the loss of cooling to four reactors at the Fukushima Daiichi nuclear power plant, which led to a partial meltdown and exposure of spent fuel stores and the consequent release of significant amounts of radiation into the surrounding environment (Murayama, 2012; Prati and Zani, 2012). The incident rated 7 on the International Atomic Energy Agency rating scale, which is the highest possible level and equal to the level given to the catastrophic meltdown that occurred at Chernobyl in 1986, even though the total amount of radiation released was considerably less. In a 2011, discussion paper questioning the ethical issues surrounding nuclear energy, Blowers (2011: p. 73) described the event as “a cataclysmic event, creating widespread ecological devastation, displacement of population, economic catastrophe, social disruption and psychological trauma.” The author also noted that the effects are likely to persist far into the future. An independent investigation by a National Diet of Japan (2012) Commission into the accident reported that while the cause of the accident was clearly attributable to natural phenomena, the resulting nuclear accident was “a profoundly manmade disaster – that could have and should have been foreseen and prevented” (p. 9).
Although no short-term radiation exposure fatalities were reported, there were approximately 18 500 deaths directly related to the earthquake and tsunami. Estimates of the health and social impacts from exposure to radiation are only speculative, however, as based on the experiences with Chernobyl, there is likely to be a long-term, possibly permanent disruption and dislocation for people who lived and worked in what is now an exclusion zone. They have been forced to abandon their homes, communities, livestock, and livelihoods at short notice and are no longer able to live in their own homes or neighborhoods (Blowers, 2011).
The differing views on the health effects of low radiation doses made communication about radiological health risks particularly difficult. After the accident the level of risk communicated to the public differed significantly between local and national governments. Several standards for radioactive substances in food and drinking water and for radiation levels in school facilities were relaxed leading to distrust in the judgment of the national government (Murayama, 2012). The survivors felt powerless and lacking control over their future, especially when faced with unknown future health effects for themselves and future generations (Blowers, 2011). In the 5 months following the incident approximately 27 000 people moved out of the Fukushima Prefecture. The continued decrease in population in the area made it clear that anxiety about radiation risk had a significant social effect leading to the collapse of local communities in the Prefecture. Localized citizen activist groups also emerged and anxiety about radiation risks also appeared to have an adverse effect on the price of agricultural produce in the area.
Nuclear energy presents an ethical dilemma in that worldwide concerns about the effects of carbon dioxide levels on climate change have in fact driven the push for the development of alternative noncarbon dioxide emitting energy sources. The incident at Fukushima occurred at a time when people were beginning to accept nuclear power as safe, clean, and reliable. Twenty-five years on from Chernobyl, it appeared that it was now an economically viable alternative and proponents promote it as an extremely efficient, low-carbon emitting option to highly polluting fossil fuels. Environmental concerns have been pushed aside by fears of climate change, energy security, and concern about dependence on foreign energy supplies (Blowers, 2011). While it is unlikely that the Fukushima incident will ever be replicated, the demand for cheap, efficient, and reliable power puts increasing pressure on new high-risk technologies that are being developed on a larger and faster scale than ever before.
In addition to influencing the feelings of those most directly affected by the disaster, the Fukushima accident has also changed public perception in other countries not affected. In 2012, Prati and Zani hypothesized that a major nuclear accident may affect the most durable cognitive and cultural foundations that underpin public perceptions of nuclear power. Their studies included only Italian participants and reported decreases in nuclear trust, environmental organization trust and pronuclear attitudes as well as changes in risk perception, and antinuclear behavioral intentions. Despite a relatively small sample size, they concluded that major accidents may have the potential to influence values and proenvironmental beliefs. Their research provides support for the notion that a nuclear accident may have a deep impact on public views regarding nuclear power in the short term.
Sustainability and Future Challenges
The environment is a major determinant of human health and well-being. Despite advances in knowledge regarding the links between human health and the environment, there continues to be unprecedented exploitation of the natural environment to meet the needs and desires of the current population. Natural resources such as water, air, and fertile land which are fundamental to our existence continue to be exploited, with humans today extracting and using approximately 50% more of our natural resources than we did 30 years ago (SERI, 2009). There is growing concern that if scarce resources are depleted at an unsustainable rate they will not be available to future generations. A 2009 Sustainable European Research Institute report on the global use of resources noted the inequitable consumption of resources across the planet. People in rich countries were found to consume up to 10 times more natural resources than those in the poorest countries, even though many of the resources have actually been extracted from the poorer countries. In many cases the rush for more secure, reliable, and financially viable energy sources has often meant that the precautionary principle, as it applies to development, has been set aside, leading to potential exposure to both traditional and new hazards from technological advances such as nuclear energy and fracking.
Earlier this century Al Gore, a former US presidential candidate, took environmental issues to the world arena and in doing so raised awareness of the links between our actions, the health of the environment, and impacts on human health. At a grassroots level this increased awareness has empowered groups and communities and given rise to an increasing number of environmental or green groups whose agenda is fundamentally the protection of the environment and ultimately human health. Concern for the environment and human health is now firmly entrenched on the political agenda, with the governments of many countries now containing members from parties whose platform is based on socially responsible and humanitarian sustainable development. Environmental and social determinants both play a very significant role in the health and well-being of all inhabitants of the earth, whether they live in affluent communities in developed countries, the slums of poorer developing countries, or belong to a vulnerable group. The challenge for the future is to recognize the strong connections between these determinants if sustained improvement in global community health and well-being, as well as protection of the environment, is to be achieved.
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