Environmental Determinants of Health
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Sustainable Development Goals related to environmental determinants of health
Sustainable development goal
Clean water and sanitation
Affordable and clean energy
Decent work and economic growth
Industry, innovation, and infrastructure
Sustainable cities and communities
Definitions of Environmental Health
Environmental health can be defined in numerous ways; however most definitions share common features with an assumption that it involves an acknowledgment of the ways in which the environment influences human health; it includes natural and human-made environments. Definitions also refer to the need to assess and control factors impacting on human health. Those factors that can potentially impact upon environmental health are extensive and wide ranging; WHO (2018a) defined environmental determinants as things such as clean air, water, healthy workplaces, safe housing, community spaces, traffic, and climate change. The extensive nature of environmental health concerns has produced pockets of interventions that have historically worked in isolation. It is now widely accepted that policy makers across the broad spectrum of services need to work collaboratively if sustained improvement is to be achieved. This includes an acknowledgment of the links with the social determinants of health and a commitment to address these. Historically an emphasis on illness and the treatment of illness has ignored the contention by public health experts that many of the illnesses being dealt with currently are preventable.
The Effects of the Environmental Health Crisis
It is crucial to consider the immediate and long-term effects of environmental determinants on global health issues. In 2011 it was estimated that 80% of communicable and noncommunicable disease and injury was a result of environmental factors (WHO 2018a). Ischaemic heart disease (2.3 million) and stroke (2.5 million) have been identified as the top two killers attributed to environmental factors (WHO 2018a). It is estimated that 4.9 million deaths occur annually in adults aged between 50 and 75 because of poor environmental health rather than communicable diseases. 1.7 million deaths in children under the age of 5 are directly related to lower respiratory infections and diarrheal diseases (WHO 2018a) often caused by poor living conditions; a further 1.2 million deaths are attributable to urban air pollution with citizens dying prematurely from cardiovascular and respiratory diseases (WHO 2010).
The current figures for the global population exceed 7.5 billion people (WHO 2018a). The figure is increasing by one billion every 15 years (United Nations [UN] 2017b). The UN have stated by the year 2050 the global population will reach 9.8 billion people; this is an increase of 30%. Predictions of the unsustainability of the present situation are worrying, with the UN estimating we are currently using the renewable resources of 1.7 planets, and they estimate by 2050 this will increase to the resources of three planets (UN 2017b). This continued growth clearly has implications for sustainability as it is estimated food production will need to increase by 70% by 2050, and this rises to 100% in developing countries within this timeframe. It is sobering to contemplate that the UN (n.d.) estimate one third of food production for human consumption is either lost or wasted each year. The increasing housing needs of an ever-increasing population will inevitably conflict with sustainable land usage. The notion of urbanization has become an increasingly challenging feature of sustainability objectives as globally the amount of people living in urban areas has surpassed the numbers of those living in rural areas (WHO 2014).
Urbanization is described as a move from rural living to city living. The term urban sprawl is used to describe the rapid expansion of urban areas which sees the boundaries of cities expanding beyond traditional borders encroaching further and further into agricultural and natural environments. Urbanization is occurring most quickly in those countries that have a low or middle income. Verma et al. (2017) argued that people are moving from rural areas to urban centers to achieve a better socioeconomic standard of living. However, this movement has seen a shift in socioeconomic inequalities with some of the poorest populations now living in urban areas (Verma et al. 2017).
The notion of urbanization brings with it critical issues for sustainability. Urbanization has been linked to increased incidence of depression (Wang et al. 2018) and increased exposure to environmental stressors such as traffic, pollution, violence, and poorer living conditions (Chen et al. 2014). The WHO (2010) emphasized several other issues associated with rapid urbanization; these included access to clean water and sanitation; noncommunicable diseases because of unhealthy diet, particularly an increase in the consumption of cheaper processed food and a reduction in physical activity; communicable disease outbreaks; and an increase in substance misuse. These are important considerations for sustainability when currently it is estimated that one in three city dwellers lives in slum conditions (WHO 2010). This is not exclusively an issue in developing countries with reports of increased communicable diseases such as tuberculosis in New York; WHO have contented this is four times the national average (WHO 2010). This may be due to overcrowding in accommodation as extended families live together alongside others to afford the higher city rents. Human well-being can be measured alongside quality of life gradients which Villamagna and Giesecke (2014) refer to as the spatiotemporal variability of material needs listed as food, water, and shelter as well as nonmaterial needs. They suggest that there is a need to consider the effect to ecosystems, in the measurement of changes in HWB, whether biophysical or socioeconomic. The result of flooding or contamination from combining treated water with human fecal waste (Birkett 2017) means there is the risk of exacerbating existing diseases or introducing new communicable ones. These communicable diseases are categorized into two distinct types: one being waterborne (typhoid fever, cholera, leptospirosis, and hepatitis A) and the other vector-borne diseases which include malaria, dengue, yellow fever, and West Nile fever (WHO 2018a). These risks are heightened if there is mass displacement or water is contaminated, although this is not commonplace. What creates more volatility is vector-borne diseases resultant from standing water, consequently ideal situations for mosquito breeding and a well-known problem in malaria-endemic areas worldwide.
The cumulative effects of these factors are citizens leading more sedentary lifestyles because of concerns regarding traffic and pollution, fear of violence or injury, and a lack of green space for recreational purposes. These factors must be addressed to ensure sustainable urban health to combat the increasing numbers of noncommunicable diseases in urban populations.
China is an example of a country that has witnessed massive urbanization over the past 40 years with over one billion people now living in cities in China. The notion of megacities is now a part of global discourse with the creation of an estimated 43 megacities with a population of over 10 million citizens in each city by the year 2030 (UN 2018a). The world’s most heavily populated city is Tokyo which currently has 37 million citizens and Delhi with an estimated population of 29 million citizens (UN 2018a). The UN predicts that by 2050, 68% of the global population will live within an urban environment. Global future hotspots are Africa and Asia currently accounting for 90% of the world’s rural population; however it is estimated that 90% of the urbanization occurring by 2050 will take place in these regions.
Road traffic accidents have been identified as a significant issue related to urban living. The 2030 Agenda for Sustainable Development has set a target of halving the number of global deaths and injuries from road traffic accidents by 2020; for most countries this accounts for 3% of the gross domestic product. Who (2018b) estimate that road traffic accidents account for 1.25 million deaths globally per year and is the leading cause of death in 15- to 29-year-olds. The main risks factors have been identified as speeding, driving under the influence of alcohol/psychoactive substances, nonuse of safety equipment, distracted drivers, safety of road infrastructure, unsafe vehicles, poor post-crash care, and poor traffic law enforcement. To support the 2030 Agenda for Sustainable Development target, WHO launched Save LIVES in 2017 (UN 2015; WHO 2017). The initiative targeted the key risk factors and encouraged policy makers to consider issues such as speed management initiatives, infrastructure design and improvement, enforcement of traffic laws, and improvement in post-crash survival rates. The reduction of deaths from road traffic accidents is an excellent example of the requirement for policy makers to work collaboratively across disciplines and responsibilities to ensure positive outcomes for citizens globally.
A consideration of the structure of towns and cities is not a new phenomenon. The garden city movement originated in the UK at the end of the nineteenth century and is a method of urban planning. Ebenezer Howard, a radical socialist of the time, argued that town and country should be integrated and enjoyed by all. Howard recognized the potential positive impact on health of a well-integrated landscape and developed the concept of the ideal town. The ideal town was based on a concentric model with civic functions in the middle and green belt areas on the outer edges. The concept had its critics with some arguing the movement used up too much rural space. However, the idea has continued in various forms, and in 2014 WHO published the Healthy Cities program. This document set out an aim to address the increasing health inequalities resulting from rapid urbanization. The focus of the program is to improve the health of city populations by reducing poverty; increasing sustainable housing; improving infrastructure such as sanitation, transport, and access to clean water; and the facilitation of community connectedness. These are all aspects of urban living that have been identified as having a detrimental effect on health and well-being and should be targets for all agencies interested in achieving sustainable health and well-being improvements. What is indisputable is the enormous effect the environment has on an individual’s well-being, and although individual choices are an important part of change, the environmental infrastructure in which we live and work will ultimately make or break any sustainability initiatives. It is therefore imperative to consider sustainable development in the new geological epoch, the “Anthropocene” (Steffen et al. 2011; Gigg et al. 2013), and the significance of this with foresight to securing, developing, and then protecting peoples’ dwellings. The Anthropocene relates to the point in time – argued as now – when, collectively, humankind can have a decisive and positive influence on the earth’s geology, alongside climate change. In relation to health, particularly in environmental terms, people’s dwellings and opportunities to rebuild them sustainably are thus critical.
Home, Dwellings, and Threats to Health and Well-being
As a concept, the meaning and definition of what is understood as a person’s dwelling or “home” is difficult to interpret. In their thematic analysis, Magalhães et al. (2013, p. 58) found that “…the household is [considered] a place that goes beyond the physical and material dimension, it is a space of care, where social bonds and relations between family members are built and consolidated.” Hollows (2008), 5 years earlier, discusses the public and private sphere, with home being the realm of family, personal life, and domesticity. Mallett (2004) however made an important distinction that “home” can be in a number of places. She described it thus as place(s), space(s), feeling(s), practices, or an active state of being in the world that are interrelated but that are also contradictory in nature. Despite it being over a decade old, it is this definition that has most value here particularly in terms of the dwellings as essential places and spaces for well-being.
Systems of safety and security
Interpersonal bonds and networks
Roles and identities
Existential meaning and coherence
While the above tensions are relevant to what Silove et al. (2017) seem to exclusively refer to as the “psychosocial pillars” of conflict and displacement, they are applicable in most, if not all, situations where people’s dwellings have been compromised. It is not possible to address sustainable structural solutions if we fail to consider one of the tensions outlined by Silove et al., security and safety. The focus of the remainder of the entry is therefore on building resilience and possibilities which bear a critical focus on this concern. Tackling these security and safety issues however is not necessarily in terms of the structure and building of dwellings but more so on community sustainability. Essentially, the key message here is to begin by understanding peoples’ psychosocial connections to their dwelling(s) or home(s), alongside factors that detriment their well-being. This must be the first priority before the proposal of any sustainable development and subsequent implementation.
There are many associated health complications following and during threat to security and safety. These are not only extant in the Middle East, Africa, South America, and Asia but also in Europe and countries such as Russia and Turkey on the Asian-European borders. In explicating people’s threats to security and safety, it is useful to consider some recent examples, ranging from Asia to Europe, alongside the associated health implications. A good starting point is in the instance of young refugees from Syria. Unquestionably they attach meaning to home very differently from children in the West, as do their parents and wider families. Bradley Secker, a 27-year-old British journalist based in Istanbul, Turkey, sought to understand this and decided that rather than exploiting misery, he would photograph the hands and keys to the homes of these Syrian refugees, many of whom had kept these items for several years. “My soul… the place I was going to put down roots” were some of their replies when asked what home means to them. The keys to their previous dwellings, where they were once safe, had become symbolic of their homes, “…and by extension…” representative of what was happening in their country (Orr 2014). Silove et al. (2017) contend that the instances of any violation of human rights impact on coherence, resulting in chronic anger, isolation, and the mistrust in organizations of authority. They go on to say that this can also result in “a cycle of violence that may have profound transgenerational effects” (p. 133). Unfortunately, it is not uncommon for refugees to want to return to their homeland and dwellings, even when they are cognizant of life-threatening harm to them and the well-being of their families. In determining solutions to some of these issues, one way may be through increasing community sustainability (CS). These initiatives involve, as Villamagna and Giesecke (2014) suggest, provision of information and tools and a sustainable sense of home (Williams 2010). The term CS most often refers to “liveable cities,” but the emphasis should be on reasonable safety and security for returning people in rural areas too.
Expanding on this, and from an alternative perspective, is the two million displacements of Nigerian citizens. Lake Chad is a major resource in the area, but as a result of climate change, it has been shrinking, and this is due to overuse of water and land (Nett and Ruttinger 2016). People who leave areas such as these are often driven away for a number of reasons, and this is not exclusive to environmental migration resulting from climate change. For instance, water flooding was used by the Islamic State (terrorist organization) to expel people from their homes in Iraq and Syria (Lossow 2016), and severe landslides in 2014 as a result of extreme weather events in Afghanistan meant the displacement of many families (Nett and Ruttinger 2016) when homes were destroyed. These landslides continue to pose a very real threat to over three million people (Reliefweb 2017a). Similarly, in Nigeria, the insurgency and ruthless violence by the Islamist extremist group Boko Haram from 2009 resulted in “the pillaging of villages, destruction of public buildings, systematic abduction, imprisonment, rape and forced marriage of girls and women, and forced recruitment or execution of boys and men” (Amnesty International 2015). Threats such as these particularly affect women and children. Aside from fleeing homes and the impact of this on people’s health and well-being, the consequence of these common types of ecological insults is that they create fragility, which in turn enables terrorist groups to thrive and operate freely (Nett and Ruttinger 2016). The depletion of natural resources also impacts negatively on livelihoods (e.g., agriculture) meaning that recruitment to terrorist groups becomes easier. We cannot begin to consider sustainable development in instances such as these, until the safety and relative freedom “from direct and indirect threats of violence” (Williams 2010) have been considered in their totality. This needs to be through multidisciplinary approaches alongside a continued need to move away from broader levels of influence, such as government and state, to individual- and community-level solutions.
Bioterrorism is another threat whereby intentional sabotage through chemical or infrastructure damage, such as the bombing of dams, is used as a weapon (Nett and Ruttinger 2016). In 2014 the flood gates of a dam in Iraq were closed and diverted destroying more than 100,000 houses, killing livestock, 200 km of fertile farmland, and near enough the entire harvest (United Nations Security Council 2017). Sixty thousand people were displaced. It is commonplace that mass migration impacts negatively on ecosystems, with some referring to these movements as potentially threatening biospheres. The exodus of such large groups of refugees and migrants impacts on the carrying capacity of land (Adger et al. 2015) creating further environmental risks. This is more often than not due to mass mobility from rural to urban areas with movement affecting natural habitat and species. As Pecl et al. (2017) contest in a review of evidence, “climate-driven changes in species distributions, or ‘range shifts,’ affect human well-being both directly... and indirectly, by degrading ecosystem health” (p. 4). According to World Wildlife Fund since 1970, the population of wildlife has halved, with the human population doubling. The effects of extinction are occurring 100 times faster than they would without human life (WWF 2018). The concerns for the sustainability of environmental health are not exclusively related to human life, as a global community there is a responsibility to ensure plant and animal life is also sustained and protected. There is an inevitable reciprocal relationship between plant, animal, and human life. The direct impact on well-being includes, as examples, changes in food supply and emerging diseases. Still water is a breeding ground for mosquitoes. Equally, the competition for scarce resources leads to conflict and the breakdown of communities.
Naturally, these types of breakdowns are not only associated with problems encountered by mass mobility. They are also implicit in other situations such as extreme weather. Germanwatch is a think tank that has been operational since 1991 with a sole focus on equity and preservation of livelihoods. Their remit is to consider the impact of the economics and politics of the North and the associated worldwide consequences. In 2016, Burck et al. along with Germanwatch analyzed severe weather-related loss events with the most recent data available from 2014 (1995–2014). Their focus was not on geological events (earthquakes, eruptions, or tsunamis) but only on weather-related events, as these have more relevance to climate change. These weather-related losses impacted on communities through storms, floods, and temperature extremes, such as heat and cold waves. In 2014 the Philippines experienced a catalogue of tropical storms, floods, and landslides. The worst typhoon, Rammasun, resulted in the destruction of over 100,000 houses and damage to 400,000 others, including the death of 100 people. The same typhoon destroyed 37,000 houses (Reliefweb 2014). Additionally, avalanches pose a significant threat both internationally and in Europe. In February 2017, for example, several causalities (including 194 deaths) and damage to homes and livelihoods took place following two avalanches in Afghanistan. These were in Badakhshan and Nooristan with 6752 families affected across the country. More than 20,000 ha of arable land was submerged in flood water following flash floods (Reliefweb 2017b).
Rees (2016) predicts that “the darkest prognosis for the next millennium is that bio, cyber or environmental catastrophes could foreclose humanity’s immense potential, leaving a depleted biosphere.” Dwellings are essential place(s) and space(s) for healthy living and habitat; however the “impact of shocks caused by economic crises, conflict, disease outbreaks and natural” (UN 2017a, p. 3), as well as terrorism, mean that significant issues arise when structures are damaged, destroyed, or deemed unsafe (fully or partially). The emotional connection of home as being one that is safe and secure is evident. If a home or dwelling is relatively safe, it also affords physical security. If this is achieved, then well-being may follow, but, beforehand, there is a need for some sense of control and a concerted effort toward community sustainability.
Thoughts on Sustainable Environmental Health
The entry has alluded to the vast scope of environmental health factors and has highlighted a small number of key issues related to the topic. To grasp the true nature of environmental health and sustainability, it is imperative to consider other key sustainability goals. There is no element of human life that is unaffected by environmental health factors and as such there is no quick fix solution to improving environmental health in a sustainable manner. There are however some key considerations to draw from the prior discussion. For sustainable growth health should be featured in all policy approaches across governmental agencies. Sustainability in respect of environmental health should be connected to issues as wide as energy renewal, development of public transport, development of clean fuels and technologies, improvement of living and working conditions, and reducing occupational exposures, improving healthcare and education, improving sanitation and access to clean water, and addressing consumption patterns. The list is not exhaustive; in fact it could be regarded as limitless in its content. The UN (2018b) emphasize these aspects as priorities for sustainable global development.
The entry has emphasized factors related specifically to rapid urbanization and drawn examples from the vast array of global challenges related to this. The objective for the global community given the predicted mass urbanization is to ensure sustainable urban growth so that the benefits are shared equally and responsibly; policy has to focus on the poor and vulnerable in these situations. The UN have identified further targets to be considered; these include creating and maintaining improved links between rural and urban communities to sustain and develop better economic, environmental, and social links. Initiatives to address land usage particularly in relation agriculture and green spaces are prerequisites to sustainable population increases. It is therefore equally important that the global community develops initiatives that include ethical family planning programs. The planet cannot sustain the current predicted increases in population, and so global responsibility for exponential population increase is therefore a policy imperative.
Finally, the entry considered the complexity of defining home. The transience of communities in contemporary societies offers many benefits including increased employment opportunities and is redefining what home is to an individual. However, migration also brings with it challenges both environmental and socioeconomic, and migration is not always brought about by choices. The effects of war, famine, poverty, and ecological disasters are key drivers to mass migration. Any solution to these issues requires global consensus and action rather than a limited, nationalistic, and isolationist approach.
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