Health hazards of the environment : measuring the arm / by Tord Kjellström

by Tord Kjellstrom W henever a dramatic out-break of "pollution dis-ease " occurs , the atten- tion of the world focuses on a severe " symptom " rather than the "disease " itself. The dramatic out- breaks with a mass media appeal only occur under special circum- stances. But the daily exposure of millions to pollution which causes · severe health effects goes unno- ticed and unreported. The under- lying causes tend to be the same ; hazardous chemicals or other agents used or produced by indus- trial or agricultural technologies that have at the same time brought prosperity and development at least to some parts of the community. Towns like Minamata in Japan and Bhopal in India have unwilling- ly become notorious reminders of the side-effects of industrialisation , but the suffering of the victims of pollution disease in those towns 2 must spur us to intensified efforts to prevent pollution disease wherever it occurs. A number of major disease out- breaks caused by environmental hazards have occurred. The exam- ples given overleaf have become prominent partly because of the high numbers of people affected in a local area and partly because of the very dramatic suffering of the community, but also because of the often extensive and detailed health effect studies subsequently carried out. Each dramatic outbreak has triggered epidemiological and other studies, which provide details about the extent of the exposed popula- tion , the numbers initially affected , those with severe long-term health effects, and the prevalence of less severe consequences. These mea- surements of the health effects of pollution are essential as they will pin down the exact causes and will provide the detailed information required to take effective preven- tive action. In situations where the health effects are not so severe or sudden that a dramatic outbreak occurs , epidemiological studies are even more important to measure the true extent of the public health prob- lem. For example , many areas with extensive problems of lead pollu- tion from paint and lead poisoning in children may have few cases of extreme clinical poisoning; the problem may therefore go unde- tected unless specific studies are carried out. Investigations coordinated by WHO have shown that lead pollution is now a greater problem in some developing countries than in the de- veloped countries where lead poi- soning was first well documented. In Mexico City , the median blood lead content among a group of adults was 350 flg/1, whereas in Baltimore , in the United States , the median in a comparable group was 75 flg/1 , a "normal" value. The potential for adverse health effects occurring on a large scale is W ORLD HEALTH, June 1988 clear when we consider the num- bers of people exposed. WHO is co- ordinating a collective effort to monitor the world environment in order to protect human health and preserve essential natural resources . This is known as the Global Environmental Monitoring System (GEMS) , and its work is described in Global Pollution and Fragile world Mankind has learnt the hard way that. today, " no man is an island." Acid rain from industry, chemical and oiltanker spills. the after-effects of manmade and natural disasters-no country is immune from such health haz- ards. The social environment too affects our well-being. Are organ transplants for the few "ethical" when the many lack all medical care? Alcohol, drugs and adoles- cent sex pose intractable prob- lems for society; AIDS adds a new and unwelcome dimension. World Health this month exam- ines just a few of these problems. WOR LD HEALTH, June 1988 WHO's regional office in New Delhi "confronts " a barrage of smoking chimneystacks. Photo WHO/A.S. Kochar Health, a joint publication of WHO and the UN Environment Pro- gramme (U NEP) , obtainable from the Division of Environmental Health at WHO's Geneva headquarters. The air pollution monitoring for GEMS has shown that in many cities , both in developed and developing coun- tries , the ambient air concentra- tions of sulphur dioxide and/or sus- pended particulates exceed air quality guidelines. It is not difficult to calculate that hundreds of mil- lions of people live in areas where the guidelines are exceeded. This problem is compounded by the fact that , in many of the cities with polluted outside air, the in- door air (particularly in kitchens with smoky stoves and poor ventila- tion) is polluted by the same chemi- cals , often at higher concentrations than in the outside air. The severe air pollution that killed 3,000 people in London in 1952 is repli- cated in many kitchens of develop- ing countries , not once in 30 years , but almost every day in the cold season . Since this type of pollution mainly affects elderly women who suffer from pre-existing lung or heart diseases , it may go undetect- ed unless specific epidemiological studies are carried out. The family and the local doctor are likely to consider it " natural" that in the cold winter grandmother with her poor lungs gets worse and eventu- ally dies. Had she been breathing clean air, she might have lived happily for many more years. One difficulty about measuring the health effects of environmental hazards is to detect the effects at an early stage. In an exposed popula- tion, extreme consequences such as clinical disease and death occur only among a small proportion of those exposed , whereas a much larger number of people may have less severe symptoms or physiologi- cal changes that can only be measured by specific tests. Differ- ent effects can also occur in an indi- vidual patient at different times, and it often takes some time for a chemical pollutant to accumulate in the body to the extent that the more severe effects occur. In the meantime , more subtle effects have started but may go unnoticed. Cover : Fire in a Sw iss chemical plant beside the Rhine decimated the fish population for hundreds of miles downstream. Photo Keystone ©· IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor : Christiane Viedma This Month's Theme Editor: Valery Abramov Art Editor:· Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English, French.. Portuguese, Russian and Spanish, and four times a year in Arabic and Farsi . The German edition is obtainable from: German Green Cross, Schuhmarkt 4, 3550 Marburg, FRG. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necess- ari ly reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Measuring the harm by Tord Kjellstrom . . . . . . . 2 Seven-out-of-ten for Effort by Brian Appleton . . . . . . . . . . . . 6 Healthy Cities by John Ashton . . . . . . . . . . . . . . 9 One man's meat, another man's becquerel by Valery Abramov . . . . . . . . . . . 12 Mal.aria in the Solomons by John Madeley . . . . . . . .... .'. 14 Images of health . ... , . . . . 16-17 City lifestyles by Rene Diekstra . . . . . . . . . . . . . 18 Organ transplants : are they ethical? by F.rancisco Vilardell . . . . . . . . . . 20 Teenage pregnancy in the Americas by Cesar A Chelala . . . . . . . . . . . 22 Heartbeat Wales by Jqhn Catford . . . . . . . . . . . . . . 24 Battles won- but not yet the war ! by Anatolij Martynov . . . . . . . . . . 26 AIDS and the law by Hamida H. Sheikh . . . . . . . . . 28 News Page . . . . . . . . . . . . . . . . . 30 The severe cadmium poisoning in Toyama, Japan, took 10 to 20 years to develop in most patients. But be- fore the clinical disease started, they had kidney damage which could only be detected by special urine tests. When eventually such tests were used in systematic epide- miological studies, hundreds of cases of "slight" or "suspected" cadmium poisoning were found. In the outbreak of "toxic oil syn- drome" in Spain, it took only a week after exposure to contami- nated oil for signs of severe poison- ing to develop. Even then, most patients went through different stages of less severe poisoning, and thousands of cases with diffuse symptoms or physiological changes were found in epidemiological studies after the initial outbreak. The studies also linked the poisonings to the con- sumption of low quality food oil, and were able to show that the withdrawals of all stocks of this oil stopped this epidemic of "pollution disease." Accurate measurement of the health effects of environmental hazards are essential if we are to tackle the hazards occurring in the workplace. Traditionally the term "occupational disease" was used to classify well-defined, characteristic and often severe syndromes caused by specific hazards at work. As in 4 WORLD HEALTH, June 1988 Crude oil powers much of the world's industries. But oil spills from wrecked tankers can strike a body-blow at the fishing industry. Such a spill, off the Breton coast of France in 1978, also killed thousands of birds (below). Photos L. Sirman © Facing page: A lowflying aircraft sprays insecticide over crops in Ethio- pia. It also sprays the cows! Photo WHO/FAO the case of "environmental dis- eases," only a small proportion of those affected would qualify for the diagnosis. Classical lead poisoning is a severe disease, causing chronic damage to the nervous system. But research shows that a much larger number of exposed workers have less severe changes in the function- ing of the nervous system-a situa- tion which precedes severe poison- ing. This information has been used to propose safety limits (for in- stance, WHO's recommendations for maximum permissible concentra- tions) that prevent the less severe effects, thereby ensuring that the more severe effects are also prevented. In the case of asbestos, the char- acteristic "occupational disease" is asbestosis, to which we may add the cancer mesothelioma, which occurs among people exposed to asbestos. But the asbestos dust also causes lung-cancer and the epidemiologi- cal data indicate that, in a typical exposed group, there will be more cases of lung-cancer due to asbestos than of asbestosis and mesothelio- ma. The measurement of health ef- fects helps us to see the true health impact of this industrial material. It also helps the victims to get recog- nition for the cause of their plight, which may be of great importance for the family's welfare in terms of workers' compensation, insur- ance payments and social security payments. WHO is strengthening its support to countries in the field of environ- mental and occupational epidemi- ology in order to encourage and facilitate timely and valuable mea- surements of the health effects of environmental hazards. A network has been established for communi- cation and cooperation between institutions and individuals work- ing in this field. More than 500 scientists from all WHO's six regions have joined this network. Training programmes for public health staff have been developed and WHO coordinates inter-country research projects. All these activi- ties aim at providing decision-mak- ers with much better information, and then translating the informa- tion into effective action for prevention. The control of environmental health hazards often involves tak- ing difficult decisions that have great financial or organizational im- plications. The preventive actions W ORLD HEALTH, June 1988 need to be well-justified and the impact of these actions has to be monitored. Environmental and occupational epidemiology is there- Location and year London, 1952 Toyama, Japan 1950s Iraq 1972 Madrid, Spain 1981 Severe air pollution SUiptwr di()Xide and suspend,.e.d par.ticul(ltem·atter (SfM) . fore an essential component in carrying through WHO's Health for all strategy in the field of environmental health. • 5