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research evidence from various studies, this report demonstrates how exposures to environmental health risks jeopardize the health and nutritional status of young children. Poor environmental management and bad sanitation expose pregnant women to both malaria and hookworm infections. Left untreated, these infec- tions lead to permanent growth faltering, lowered immunity, and increased mortality for these women’s children. In early infancy, improper feeding practices and poor sanitation have a pernicious synergistic effect on the child’s nutritional status. Many of these impacts on a child’s growth also result in negative cogni- tion and learning impacts as well as chronic diseases later in life.
Although considerable progress has been made, this report calls attention to the potential of untapped environmental health actions to complement existing health, infrastructure, and environmental management strategies in the devel- oping world. Current child survival strategies in developing countries focus on case management and treatment, neglecting primary prevention, especially as it relates to reducing exposure to infections. The evidence of the impacts of envi- ronmental risks and subsequent infections on child malnutrition makes correcting the current neglect of environmental health in child survival and child health strategies even more imperative in developing countries.
Environmental health actions supplement existing strategies addressing child health. An analysis of results from Fewtrell and others (2007) shows that envi- ronmental health interventions have a multiplier effect on mortality: investments addressing environmental risks (for example, lack of water and sanitation) pay off with more than just their direct effect on disease (for example, reducing diar- rhea). This finding has important consequences for developing countries seeking to invest in environmental health interventions; their budgets will stretch further because of the nature of the externalities associated with such interventions.
Therefore, governments in developing countries have an enormous opportunity to incorporate environmental health interventions in existing strategies that affect child health and to provide a bigger “bang for the buck” in terms of health improve- ments. As has been discussed in this report, environmental health actions add value to existing programs for child care, micronutrient supplementation, and immunization. They can also be used to adapt environmental management programs in developing countries, such as those relating to vector control, as well as to form the basis of adjustments to strategies in the water sanitation and rural energy sectors to enhance health outcomes.
Revised country-level estimates show that when malnutrition-mediated health effects attributed to environmental health risks are included, the total costs are at least 40 percent higher for both Ghana and Pakistan. The longer-term effects of malnutrition (partly attributed to environment-related infections) on education and income are estimated to add another 3 to 4 percent in terms of annual costs.
The total annual cost attributed to environmental health risks, including all
malnutrition effects (such as higher education costs), are estimated to be as high as 9 percent of Ghana’s or Pakistan’s gross domestic product. Given this consid- erable social and economic burden, policy-makers in developing countries where malnutrition and poor environmental conditions coexist should place environ- mental health interventions high on the policy agenda. Furthermore, as developing countries strive to meet several of their commitments for the Millennium Development Goals, these interventions will remain critical for addressing poverty reduction and child mortality.
Growing evidence indicates the need to mainstream environmental health interventions in developing countries’ child survival strategies. With environ- mental health having fallen through the cracks in the development agenda, however, policy-makers in those countries will have to make a renewed effort to revitalize the environmental health content within existing child survival programs, nutri- tion initiatives, and infrastructure projects. Anecdotal evidence of such efforts is beginning to emerge in developing countries. Common criteria for successful implementation include obtaining high-level political commitment, involving and empowering communities, allocating responsibilities and resources at the local level, and finding a balance between private and public sector roles. Finally, successful environmental health governance requires strong institutional under- pinnings. This report discusses—through an institutional lens—the roles that national and local governments can play in delivering and managing environ- mental health interventions.
Next Steps
In many ways, this report represents a first step toward providing policy-makers with the epidemiological, economic, and experiential evidence to incorporate environmental health in the child survival agenda. However, in each of the three main sections of the report, additional research and studies will help donors and governments in developing countries choose to invest in appropriate environ- mental health interventions.
The epidemiological evidence presented in this report reaffirms the importance of environmental health for child survival, especially when considering the links through malnutrition. Further research on the environmental health impacts during pregnancy, additional disease transmission pathways, and better relative risk esti- mates will help improve disease burden and costing estimates while informing governments about appropriate programs. For example, in Sub-Saharan Africa, malaria and hookworm infections coexist to cause anemia and subsequent growth retardation of the fetus in pregnant women. Communitywide investments to improve water resources management, use of insecticide-treated nets and indoor residual spraying, and improved sanitation facilities would help improve birth weight.
This report demonstrates the substantial burden and consequent economic costs associated with environmental health risks, but important questions remain:
How should governments prioritize among the different environmental health, infrastructure, nutrition, and child survival interventions to improve child health?
What are the cost-benefit ratios and the levels of cost-effectiveness of individual interventions? Some research on this subject has provided answers at the global level—with hygiene promotion measures emerging as the most cost-effective intervention (Laxminarayan, Chow, and Shahid-Salles 2006). Carrying out such cost-effectiveness and cost-benefit analyses at a country level is the next step in guiding decision-makers in specific countries in prioritizing among the various available interventions. Some recent analyses in Colombia and Peru have begun to explore the ranking environmental health interventions through cost-benefit analyses (World Bank 2006a, 2007g).
In addition to conducting economic analyses, governments in developing coun- tries need to look toward implementing specific environmental health actions. The effectiveness of such interventions ultimately depends on the enabling environment in the country, which highlights the need to assess (a) institutional mandates and capacities for addressing environmental health issues, (b) regulations on environ- mental health, and (c) availability of budgets (Poverty Environment Partnership 2008). However, a one-size-fits-all solution will not work, and policy-makers will need to look beyond the generic roles and responsibilities for better environmental health governance discussed in this report. An important next step would be to carry out an in-depth institutional analysis at a country level to better understand the coordination mechanisms between ministries and the ways mandates and budgets are assigned. Such an understanding is critical for environmental health—
an issue that is inherently multisectoral and that requires collaborations across health, environment, and infrastructure ministries.
Temporality is also an important consideration in how governments choose between various interventions that address child survival, because the costs of programs are often incurred in the short term and are front-loaded, whereas the benefits—especially those relating to cognition and learning—are spread over the long term. In the absence of appropriate economic analysis at the country level, governments may be tempted to choose interventions that are cheaper in the short term, such as oral rehydration programs, rather than the more expensive water and sanitation programs, even though the latter may have greater benefits over the long term.
Additionally, over the longer term, environmental health concerns are expected to grow. As the world’s climate changes, diseases such as diarrhea and malaria, among other important health burdens that are the result of environmental risk factors, are likely to worsen, particularly for the poor and in developing countries (Campbell-Lendrum, Corvalán, and Neira 2007; IPCC 2007). Changing
temperature and precipitation will also affect agricultural production and threaten food security, thus having implications for malnutrition. Therefore, scaling up preventive environmental health interventions (such as clean water and sanitation) to reduce the current burden of disease is a prudent investment (Campbell-Lendrum, Corvalán, and Neira 2007).
Given the multisectoral nature of environmental health issues, the advocacy and regulatory role of the health sector and the supporting roles of other sectors (for example, environment, infrastructure, agriculture, and education) in promoting and delivering environmental health actions need to be revitalized. Without focused and targeted attention to improving environmental health, governments and donors are losing out on the significant opportunities to make dramatic changes in the child health scenario in the world’s poorest countries.
Ultimately, good environmental health governance is about how policy-makers in the poorest countries develop mechanisms to pick up signals on environ- mental risks and then find ways to translate these findings into appropriate and well-targeted actions. These governments will also need to adjust their policies to address environmental health outcomes and set up institutional mechanisms to successfully implement interventions. Finally, the creation of long-term constituencies within a country will help to continually raise attention to issues related to the environment, health, and poverty and to promote social account- ability among public officials for effective action on these issues (Poverty Environment Partnership 2008).
A concerted and continuous effort is needed on behalf of both developed and developing countries to ensure that environmental health is placed high on the development agenda and that corresponding interventions are financed and under- taken to improve children’s survival and development potential.
Background
The World Health Organization (WHO) monograph by Scrimshaw, Taylor, and Gordon (1968) initiated a lengthy discussion on whether repeated infections in childhood resulted in permanent growth faltering and stunting in adulthood.
Results from observational cohort follow-up studies on effects of infections over time—and ultimately over generations—have provided evidence to stimulate the debate.
By the time the WHO monograph was published, extensive microbiological, immunological, and physiological studies—partly based on human experiments—
favored the idea that all infections contribute to growth faltering, but the long-term effects of infections on nutritional status were still lacking (Scrimshaw 2003). Diarrheal diseases are very common from infancy up to early childhood.
Unlike upper respiratory infections, which are relatively uncommon in early infancy because of maternal antibodies (Nair and others 2007; Sato and others 1979), diarrheal diseases affect the gastrointestinal tract of the child from birth onward, causing malabsorption. For this reason, diarrheal diseases have been particularly studied to investigate their impact on growth faltering (Scrimshaw 2003; Stephensen 1999).